Medicare Program; CY 2018 Updates to the Quality Payment Program, 30010-30500 [2017-13010]
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Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Centers for Medicare & Medicaid
Services
42 CFR Part 414
[CMS–5522–P]
RIN 0938–AT13
Medicare Program; CY 2018 Updates to
the Quality Payment Program
Centers for Medicare &
Medicaid Services (CMS), HHS.
ACTION: Proposed rule.
AGENCY:
The Medicare Access and
CHIP Reauthorization Act of 2015
(MACRA) established the Quality
Payment Program for eligible clinicians.
Under the Quality Payment Program,
eligible clinicians can participate via
one of two tracks: Advanced Alternative
Payment Models (APMs); or the Meritbased Incentive Payment System
(MIPS). We began implementing the
Quality Payment Program through
rulemaking for calendar year (CY) 2017.
This rule provides proposed updates for
the second and future years of the
Quality Payment Program.
DATES: To be assured consideration,
comments must be received at one of
the addresses provided below, no later
than 5 p.m. on August 21, 2017.
ADDRESSES: In commenting, please refer
to file code CMS–5522–P. Because of
staff and resource limitations, we cannot
accept comments by facsimile (FAX)
transmission. You may submit
comments in one of four ways (please
choose only one of the ways listed):
1. Electronically. You may submit
electronic comments on this regulation
to https://www.regulations.gov. Follow
the ‘‘Submit a comment’’ instructions.
2. By regular mail. You may mail
written comments to the following
address ONLY: Centers for Medicare &
Medicaid Services, Department of
Health and Human Services, Attention:
CMS–5522–P, P.O. Box 8013, Baltimore,
MD 21244–8013.
Please allow sufficient time for mailed
comments to be received before the
close of the comment period.
3. By express or overnight mail. You
may send written comments to the
following address ONLY: Centers for
Medicare & Medicaid Services,
Department of Health and Human
Services, Attention: CMS–5522–P, Mail
Stop C4–26–05, 7500 Security
Boulevard, Baltimore, MD 21244–1850.
4. By hand or courier. Alternatively,
you may deliver (by hand or courier)
your written comments ONLY to the
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SUMMARY:
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following addresses prior to the close of
the comment period:
a. For delivery in Washington, DC—
Centers for Medicare & Medicaid
Services, Department of Health and
Human Services, Room 445–G, Hubert
H. Humphrey Building, 200
Independence Avenue SW.,
Washington, DC 20201.
(Because access to the interior of the
Hubert H. Humphrey Building is not
readily available to persons without
Federal government identification,
commenters are encouraged to leave
their comments in the CMS drop slots
located in the main lobby of the
building. A stamp-in clock is available
for persons wishing to retain a proof of
filing by stamping in and retaining an
extra copy of the comments being filed.)
b. For delivery in Baltimore, MD—
Centers for Medicare & Medicaid
Services, Department of Health and
Human Services, 7500 Security
Boulevard, Baltimore, MD 21244–1850.
If you intend to deliver your
comments to the Baltimore address, call
telephone number (410) 786–7195 in
advance to schedule your arrival with
one of our staff members. Comments
erroneously mailed to the addresses
indicated as appropriate for hand or
courier delivery may be delayed and
received after the comment period. For
information on viewing public
comments, see the beginning of the
SUPPLEMENTARY INFORMATION section.
FOR FURTHER INFORMATION CONTACT:
Molly MacHarris, (410) 786–4461, for
inquiries related to MIPS.
Benjamin Chin, (410) 786–0679, for
inquiries related to APMs.
SUPPLEMENTARY INFORMATION:
Table of Contents
I. Executive Summary and Background
II. Provisions of the Proposed Regulations
A. Introduction
B. Definitions
C. MIPS Program Details
D. Overview of Incentives for Participation
in Advanced Alternative Payment
Models
III. Collection of Information Requirements
IV. Response to Comments
V. Regulatory Impact Analysis
A. Statement of Need
B. Overall Impact
C. Changes in Medicare Payments
D. Impact on Beneficiaries
E. Regulatory Review Costs
F. Accounting Statement
Acronyms
Because of the many terms to which
we refer by acronym in this rule, we are
listing the acronyms used and their
corresponding meanings in alphabetical
order below:
ABCTM
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Achievable Benchmark of Care
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ACO Accountable Care Organization
API Application Programming Interface
APM Alternative Payment Model
APRN Advanced Practice Registered Nurse
ASC Ambulatory Surgical Center
ASPE HHS’ Office of the Assistant
Secretary for Planning and Evaluation
BPCI Bundled Payments for Care
Improvement
CAH Critical Access Hospital
CAHPS Consumer Assessment of
Healthcare Providers and Systems
CBSA Core Based Statistical Area
CEHRT Certified EHR technology
CFR Code of Federal Regulations
CHIP Children’s Health Insurance Program
CJR Comprehensive Care for Joint
Replacement
COI Collection of Information
CPR Customary, Prevailing, and Reasonable
CPS Composite Performance Score
CPT Current Procedural Terminology
CQM Clinical Quality Measure
CY Calendar Year
eCQM Electronic Clinician Quality Measure
ED Emergency Department
EHR Electronic Health Record
EP Eligible Professional
ESRD End-Stage Renal Disease
FFS Fee-for-Service
FR Federal Register
FQHC Federally Qualified Health Center
GAO Government Accountability Office
HIE Health Information Exchange
HIPAA Health Insurance Portability and
Accountability Act of 1996
HITECH Health Information Technology for
Economic and Clinical Health
HPSA Health Professional Shortage Area
HHS Department of Health & Human
Services
HRSA Health Resources and Services
Administration
IHS Indian Health Service
IT Information Technology
LDO Large Dialysis Organization
MACRA Medicare Access and CHIP
Reauthorization Act of 2015
MEI Medicare Economic Index
MIPAA Medicare Improvements for
Patients and Providers Act of 2008
MIPS Merit-based Incentive Payment
System
MLR Minimum Loss Rate
MSPB Medicare Spending per Beneficiary
MSR Minimum Savings Rate
MUA Medically Underserved Area
NPI National Provider Identifier
OCM Oncology Care Model
ONC Office of the National Coordinator for
Health Information Technology
PECOS Medicare Provider Enrollment,
Chain, and Ownership System
PFPMs Physician-Focused Payment Models
PFS Physician Fee Schedule
PHI Protected Health Information
PHS Public Health Service
PQRS Physician Quality Reporting System
PTAC Physician-Focused Payment Model
Technical Advisory Committee
QCDR Qualified Clinical Data Registry
QP Qualifying APM Participant
QRDA Quality Reporting Document
Architecture
QRUR Quality and Resource Use Reports
RBRVS Resource-Based Relative Value
Scale
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RFI Request for Information
RHC Rural Health Clinic
RIA Regulatory Impact Analysis
RVU Relative Value Unit
SGR Sustainable Growth Rate
TCPI Transforming Clinical Practice
Initiative
TIN Tax Identification Number
VBP Value-Based Purchasing
VM Value-Based Payment Modifier
VPS Volume Performance Standard
I. Executive Summary and Background
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A. Overview
This proposed rule would make
payment and policy changes to the
Quality Payment Program. The
Medicare Access and CHIP
Reauthorization Act of 2015 (MACRA)
(Pub. L. 114–10, enacted April 16, 2015)
amended title XVIII of the Social
Security Act (the Act) to repeal the
Medicare sustainable growth rate (SGR),
to reauthorize the Children’s Health
Insurance Program, and to strengthen
Medicare access by improving physician
and other clinician payments and
making other improvements.
The MACRA advances a forwardlooking, coordinated framework for
clinicians to successfully take part in
the Quality Payment Program that
rewards value and outcomes in one of
two ways:
• Advanced Alternative Payment
Models (Advanced APMs).
• Merit-based Incentive Payment
System (MIPS).
These policies are collectively
referred to as the Quality Payment
Program. Recognizing that the Quality
Payment Program represents a major
milestone in the way that we bring
quality measurement and improvement
together with payment, we have taken
efforts to review existing policies to
identify how to move the program
forward in the least burdensome manner
possible. Our goal is to support patients
and clinicians in making their own
decisions about health care using data
driven insights, increasingly aligned
and meaningful quality measures, and
technology that allows clinicians to
focus on providing high quality
healthcare for their patients. We believe
our existing APMs alongside the
proposals in this proposed rule provide
opportunities that support state
flexibility, local leadership, regulatory
relief and innovative approaches to
improve quality accessibility and
affordability. By driving changes in how
care is delivered, we believe the Quality
Payment Program supports eligible
clinicians in improving the health of
their patients and increasing care
efficiency. To implement this vision, the
Quality Payment Program emphasizes
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high-value care and patient outcomes
while minimizing burden on eligible
clinicians; the Program is also designed
to be flexible, transparent, and
structured to improve over time with
input from clinicians, patients, and
other stakeholders. We have sought and
continue to seek feedback from the
health care community through various
public avenues such as rulemaking,
listening sessions and stakeholder
engagement. Last year, when we
engaged in rulemaking to establish
policies for effective implementation of
the Quality Payment Program, we did so
with the explicit understanding that
technology, infrastructure, physician
support systems, and clinical practices
will change over the next few years. For
more information, see the Merit-based
Incentive Payment System (MIPS) and
Alternative Payment Model (APM)
Incentive under the Physician Fee
Schedule, and Criteria for PhysicianFocused Payment Models final rule with
comment period (81 FR 77008,
November 4, 2016), hereinafter referred
to as the ‘‘CY 2017 Quality Payment
Program final rule.’’ In addition, we are
aware of the diversity among clinician
practices in their experience with
quality-based payments. As a result of
these factors, we expect the Quality
Payment Program to evolve over
multiple years in order to achieve our
national goals. To date, we have laid the
groundwork for expansion toward an
innovative, outcome-focused, patientcentered, resource-effective health
system that leverages health information
technology to support clinicians and
patients and builds collaboration across
care settings. This proposed rule is the
next part of a staged approach to
develop policies that are reflective of
system capabilities and grounded in our
core strategies to drive progress and
reform efforts. We commit to continue
evolving these policies.
CMS strives to put patients first,
ensuring that they can make decisions
about their own healthcare along with
their clinicians. We want to ensure
innovative approaches to improve
quality, accessibility and affordability
while paying particular attention to
improving clinicians and beneficiaries
experience when interacting with CMS
programs. The Quality Payment
Program aims to (1) support care
improvement by focusing on better
outcomes for patients, decreased
clinician burden, and preservation of
independent clinical practice; (2)
promote adoption of APMs that align
incentives for high-quality, low-cost
care across healthcare stakeholders; and
(3) advance existing delivery system
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reform efforts, including ensuring a
smooth transition to a healthcare system
that promotes high-value, efficient care
through unification of CMS legacy
programs.
We previously finalized the transition
year Quality Payment Program policies
in the CY 2017 Quality Payment
Program final rule. In that final rule, we
implemented policies to improve
physician and other clinician payments
by changing the way Medicare
incorporates quality measurement into
payments and by developing new
policies to address and incentivize
participation in APMs. The final rule
established the Quality Payment
Program and its two interrelated
pathways: Advanced APMs, and the
MIPS. The final rule established
incentives for participation in Advanced
APMs, supporting the goals of
transitioning from fee-for-service (FFS)
payments to payments for quality and
value, including approaches that focus
on better care, smarter spending, and
healthier people. The final rule
included definitions and processes to
identify Qualifying APM Participants
(QPs) in Advanced APMs and outlined
the criteria for use by the PhysicianFocused Payment Model Technical
Advisory Committee (PTAC) in making
comments and recommendations to the
Secretary on proposals for physicianfocused payment models (PFPMs).
The final rule also established
policies to implement MIPS, a program
for certain eligible clinicians that makes
Medicare payment adjustments based
on performance on quality, cost and
other measures and activities, and that
consolidates components of three
precursor programs—the Physician
Quality Reporting System (PQRS), the
Physician Value-based Payment
Modifier (VM), and the Medicare
Electronic Health Record (EHR)
Incentive Program for eligible
professionals (EPs). As prescribed by
MACRA, MIPS focuses on the following:
quality—including a set of evidencebased, specialty-specific standards; cost;
practice-based improvement activities;
and use of certified electronic health
record (EHR) technology (CEHRT) to
support interoperability and advanced
quality objectives in a single, cohesive
program that avoids redundancies.
In this proposed rule, we are building
and improving Quality Payment
Program policies that will be familiar to
stakeholders and are designed to
integrate easily across clinical practices
during the second and future years of
implementation. We strive to continue
our focus on priorities that can drive
improvements toward better patient
outcomes without creating undue
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burden for clinicians. In this proposed
rule, we also address elements of
MACRA that were not included in the
first year of the program, including
virtual groups, facility-based
measurement, and improvement
scoring. We also include proposals to
continue implementing elements of
MACRA that do not take effect in the
first or second year of the Quality
Payment Program, including policies
related to the All-Payer Combination
Option for identifying QPs and
assessing eligible clinicians’
participation in Other Payer Advanced
APMs. To provide unity and
consistency across the two paths of the
Quality Payment Program, MIPS and
APMs, in this proposed rule we have
referred to the second year of the
program as ‘‘Quality Payment Program
Year 2.’’
B. Quality Payment Program Strategic
Objectives
As discussed in the CY 2017 Quality
Payment Program final rule (81 FR
77010), after extensive outreach with
clinicians, patients and other
stakeholders, we created six strategic
objectives to drive continued progress
and improvement. These objectives
guided our final policies and will guide
our future rulemaking in order to
design, implement, and evolve a Quality
Payment Program that aims to improve
health outcomes, promote efficiency,
minimize burden of participation, and
provide fairness and transparency in
operations. These strategic objectives
are as follows: (1) To improve
beneficiary outcomes and engage
patients through patient-centered
Advanced APM and MIPS policies; (2)
to enhance clinician experience through
flexible and transparent program design
and interactions with easy-to-use
program tools; (3) to increase the
availability and adoption of Advanced
APMs; (4) to promote program
understanding and maximize
participation through customized
communication, education, outreach
and support that meet the needs of the
diversity of physician practices and
patients, especially the unique needs of
small practices; (5) to improve data and
information sharing to provide accurate,
timely, and actionable feedback to
clinicians and other stakeholders; and
(6) to promote IT systems capabilities
that meet the needs of users and are
seamless, efficient and valuable on the
front and back-end. We also believe it is
important to ensure the Quality
Payment Program maintains operational
excellence as the program develops.
Therefore we are adding a seventh
objective, specifically to ensure
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operational excellence in program
implementation and ongoing
development. More information on
these objectives and the Quality
Payment Program can be found at
www.qpp.cms.gov.
With these objectives, we recognize
that the Quality Payment Program
provides new opportunities to improve
care delivery by supporting and
rewarding clinicians as they find new
ways to engage patients, families, and
caregivers and to improve care
coordination and population health
management. In addition, we recognize
that by developing a program that is
flexible instead of one-size-fits-all,
clinicians will be able to choose to
participate in a way that is best for
them, their practice, and their patients.
For eligible clinicians interested in
APMs, we believe that by setting
ambitious yet achievable goals, eligible
clinicians will move with greater
certainty toward these new approaches
of delivering care. APMs are a vital part
of bending the Medicare cost curve by
encouraging the delivery of highquality, low-cost care. To these ends,
and to allow this program to work for
all stakeholders, we further recognize
that we must provide ongoing
education, support, and technical
assistance so that clinicians can
understand program requirements, use
available tools to enhance their
practices, and improve quality and
progress toward participation in APMs
if that is the best choice for their
practice. Finally, we understand that we
must achieve excellence in program
management, focusing on customer
needs, promoting problem-solving,
teamwork, and leadership to provide
continuous improvements in the
Quality Payment Program.
C. One Quality Payment Program
Clinicians have told us that they do
not separate their patient care into
domains, and that the Quality Payment
Program needs to reflect typical clinical
workflows in order to achieve its goal of
better patient care. Advanced APMs, the
focus of one pathway of the Quality
Payment Program, contribute to better
care and smarter spending by allowing
physicians and other clinicians to
deliver coordinated, customized, highvalue care to their patients in a
streamlined and cost-effective manner.
Within MIPS, the second pathway of the
Quality Payment Program, we believe
that integration into typical clinical
workflows can best be accomplished by
making connections across the four
statutory pillars of the MIPS incentive
structure—quality, clinical practice
improvement activities (referred to as
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‘‘improvement activities’’), meaningful
use of CEHRT (referred to as ‘‘advancing
care information’’), and resource use
(referred to as ‘‘cost’’)—and by
emphasizing that the Quality Payment
Program is at its core about improving
the quality of patient care.
Although there are two separate
pathways within the Quality Payment
Program, the Advanced APM and MIPS
tracks both contribute toward the goal of
seamless integration of the Quality
Payment Program into clinical practice
workflows. Advanced APMs promote
this seamless integration by way of
payment methodology and design that
incentivize care coordination, and the
MIPS builds the capacity of eligible
clinicians across the four pillars of MIPS
to prepare them for participation in
MIPS APMs and Advanced APMs in
later years of the Quality Payment
Program. Indeed, the bedrock of the
Quality Payment Program is high-value,
patient-centered care, informed by
useful feedback, in a continuous cycle
of improvement. The principal way that
MIPS measures quality of care is
through a set of clinical quality
measures (CQMs) from which MIPS
eligible clinicians can select. The CQMs
are evidence-based, and the vast
majority are created or supported by
clinicians. Over time, the portfolio of
quality measures will grow and develop,
driving towards outcomes that are of the
greatest importance to patients and
clinicians and away from process, or
‘‘check the box’’ type measures.
Through MIPS, we have the
opportunity to measure quality, not only
through evidence-based quality
measures, but also by accounting for
activities that clinicians themselves
identify: namely, practice-driven quality
improvement. MIPS also requires us to
assess whether CEHRT is used
meaningfully. Based on significant
feedback, this area was simplified to
support the exchange of patient
information, engagement of patients in
their own care through technology, and
the way technology specifically
supports the quality goals selected by
the practice. The cost performance
category was simplified and weighted at
zero percent of the final score for the
transition year of CY 2017 to allow
clinicians an opportunity to ease into
the Quality Payment Program. We
further note the cost performance
category requires no separate
submissions for participation which
minimizes burden on clinicians. The
assessment of cost is a vital part of
ensuring that clinicians are providing
Medicare beneficiaries with high-value
care. Given the primary focus on value,
we indicated in the CY 2017 Quality
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Payment Program final rule our
intention to align cost measures with
quality measures over time in the
scoring system (81 FR 77010). That is,
we established special policies for the
first year of the Quality Payment
Program, which enabled a ramp-up and
gradual transition with less financial
risk for clinicians in the transition year.
We called this approach ‘‘pick your
pace’’ and allowed clinicians and
groups to participate in MIPS through
flexible means while avoiding a
negative payment adjustment. In this
proposed rule, we continue the slow
ramp-up of the Quality Payment
Program by establishing special policies
for Program Year 2 aimed at
encouraging successful participation in
the program while reducing burden,
reducing the number of clinicians
required to participate, and preparing
clinicians for the CY 2019 performance
period (CY 2021 payment year).
D. Summary of the Major Provisions
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1. Quality Payment Program Year 2
We believe the second year of the
Quality Payment Program should build
upon the foundation that has been
established which provides a trajectory
for clinicians to value-based care. This
trajectory provides to clinicians the
ability to participate in the program
through two pathways: MIPS and
Advanced APMs. As we indicated in the
CY 2017 Quality Payment Program final
rule (81 FR 77011), we believed that a
second transition period would be
necessary to build upon the iterative
learning and development period as we
build towards a steady state. We
continue to believe this to be true and
have therefore crafted our policies to
extend flexibilities into Quality
Payment Program Year 2.
2. Small Practices
The support of small, independent
practices remains an important thematic
objective for the implementation of the
Quality Payment Program and is
expected to be carried throughout future
rulemaking. For MIPS performance
periods occurring in 2017, many small
practices are excluded from new
requirements due to the low-volume
threshold, which was set at less than or
equal to $30,000 in Medicare Part B
allowed charges or less than or equal to
100 Medicare Part B patients. We have
heard feedback, however, from many
small practices that challenges still exist
in their ability to participate in the
program. We are proposing additional
flexibilities including: Implementing the
virtual groups provisions; increasing the
low-volume threshold to less than or
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equal to $90,000 in Medicare Part B
allowed charges or less than or equal to
200 Medicare Part B patients; adding a
significant hardship exception from the
advancing care information performance
category for MIPS eligible clinicians in
small practices; and providing bonus
points that are added to the final scores
of MIPS eligible clinicians who are in
small practices. We believe that these
additional flexibilities and reduction in
barriers will further enhance the ability
of small practices to participate
successfully in the Quality Payment
Program.
In keeping with the objectives to
provide education about the Quality
Payment Program and maximize
participation, and as mandated by the
statute, during a period of 5 years, $100
million in funding was provided for
technical assistance to be available to
provide guidance and assistance to
MIPS eligible clinicians in small
practices through contracts with
regional health collaboratives, and
others. Guidance and assistance on the
MIPS performance categories or the
transition to APM participation will be
available to MIPS eligible clinicians in
practices of 15 or fewer clinicians with
priority given to practices located in
rural areas or medically underserved
areas (MUAs), and practices with low
MIPS final scores. More information on
the technical assistance support
available to small practices can be found
at https://qpp.cms.gov/docs/
QPP_Support_for_Small_Practices.pdf.
As discussed in section V.C. of this
proposed rule, we have also performed
an updated regulatory impact analysis,
accounting for flexibilities, many of
which are continuing into the Quality
Payment Program Year 2, that have been
created to ease the burden for small and
solo practices. We estimate that at least
80 percent of clinicians in small
practices with 1–15 clinicians will
receive a positive or neutral MIPS
payment adjustment. We refer readers to
section V.C. of this proposed rule for
details on how this estimate was
developed.
3. Summary of Major Provisions for
Advanced Alternative Payment Models
(Advanced APMs)
a. Overview
APMs represent an important step
forward in our efforts to move our
healthcare system from volume-based to
value-based care. APMs that meet the
criteria to be Advanced APMs provide
the pathway through which eligible
clinicians, who would otherwise fall
under the MIPS, can become Qualifying
APM Participants (QPs), thereby earning
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incentive payments for their Advanced
APM participation. In the CY 2017
Quality Payment Program final rule (81
FR 77516), we estimated that 70,000 to
120,000 eligible clinicians would be
QPs for payment year 2019 based on
Advanced APM participation in
performance year 2017. With new
Advanced APMs expected to be
available for participation in 2018,
including the Medicare ACO Track 1
Plus (1+) Model, and the reopening of
the application process to new
participants for some current Advanced
APMs, such as the Next Generation
ACO Model and Comprehensive
Primary Care Plus Model, we anticipate
higher numbers of QPs in subsequent
years of the program. We currently
estimate that approximately 180,000 to
245,000 eligible clinicians may become
QPs for payment year 2020 based on
Advanced APM participation in
performance year 2018.
b. Advanced APMs
In the CY 2017 Quality Payment
Program final rule (81 FR 77408), to be
considered an Advanced APM, we
finalized that an APM must meet all
three of the following criteria, as
required under section 1833(z)(3)(D) of
the Act: (1) The APM must require
participants to use CEHRT; (2) The APM
must provide for payment for covered
professional services based on quality
measures comparable to those in the
quality performance category under
MIPS and; (3) The APM must either
require that participating APM Entities
bear risk for monetary losses of a more
than nominal amount under the APM,
or be a Medical Home Model expanded
under section 1115A(c) of the Act.
We are proposing to maintain the
generally applicable revenue-based
nominal amount standard at 8 percent
of the estimated average total Parts A
and B revenue of eligible clinicians in
participating APM Entities for QP
Performance Periods 2019 and 2020.
c. Qualifying APM Participant (QP) and
Partial QP Determination
QPs are eligible clinicians in an
Advanced APM who have met a
threshold for a certain percentage of
their patients or payments through an
Advanced APM. QPs are excluded from
MIPS for the year, and receive a 5
percent APM Incentive Payment for
each year they are QPs beginning in
2019 through 2024. The statute sets
thresholds for the level of participation
in Advanced APMs required for an
eligible clinician to become a QP for a
year. For Advanced APMs that start or
end during the Medicare QP
Performance Period and operate
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continuously for a minimum of 60 days
during the Medicare QP Performance
Period for the year, we are proposing to
make QP determinations using payment
or patient data only for the dates that
APM Entities were able to participate in
the Advanced APM per the terms of the
Advanced APM, not for the full
Medicare QP Performance Period.
Eligible clinicians who participate in
Advanced APMs but do not meet the QP
or Partial QP thresholds are subject to
MIPS reporting requirements and
payment adjustments.
d. All-Payer Combination Option
The All-Payer Combination Option,
which uses a calculation based on both
the Medicare Option and the eligible
clinician’s participation in Other Payer
Advanced APMs to conduct QP
determinations, is applicable beginning
in performance year 2019. To become a
QP through the All-Payer Combination
Option, an eligible clinician must
participate in an Advanced APM with
CMS, as well as an Other Payer
Advanced APM. We identify Other
Payer Advanced APMs based on
information submitted to us by eligible
clinicians, APM Entities, and in some
cases by payers, including states and
Medicare Advantage Organizations. In
addition, the eligible clinician or the
APM Entity must submit information to
CMS so that we can determine whether
other payer arrangements are Other
Payer Advanced APMs and whether the
eligible clinician meets the requisite QP
threshold of participation. To be an
Other Payer Advanced APM, as set forth
in section 1833(z)(2)(B)(ii) and (C)(ii) of
the Act and implemented in the CY
2017 Quality Payment Program final
rule, a payment arrangement with a
payer (for example, payment
arrangements authorized under Title
XIX, Medicare Health Plan payment
arrangements, and payment
arrangements in CMS Multi-Payer
Models) must meet all three of the
following criteria: (1) CEHRT is used; (2)
the payment arrangement must require
the use of quality measures comparable
to those in the quality performance
category under MIPS and; (3) the
payment arrangement must either
require the APM Entities to bear more
than nominal financial risk if actual
aggregate expenditures exceed expected
aggregate expenditures, or be a
Medicaid Medical Home Model that
meets criteria comparable to Medical
Home Models expanded under section
1115A(c) of the Act.
We are proposing modifications
pertaining to the third criterion that the
payment arrangement must either
require the APM Entities to bear more
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than nominal financial risk if actual
aggregate expenditures exceed expected
aggregate expenditures; or be a
Medicaid Medical Home Model that
meets criteria comparable to Medical
Home Models expanded under section
1115A(c) of the Act. Specifically, we are
proposing to add a revenue-based
nominal amount standard in addition to
the benchmark-based nominal amount
standard that would be applicable only
to payment arrangements in which risk
is expressly defined in terms of revenue.
We are proposing modifications to our
methodologies to determine whether
eligible clinicians will meet the QP
thresholds using the All-Payer
Combination Option. Specifically, we
are proposing to conduct all QP
determinations under the All-Payer
Combination Option at the individual
eligible clinician level and are seeking
comment on any possible exceptions to
this proposed policy that would be
warranted, such as a determination
based on APM Entity group
performance under the All-Payer
Combination Option for eligible
clinicians participating in CMS MultiPayer Models. We are also proposing to
establish an All-Payer QP Performance
Period to assess participation in Other
Payer Advanced APMs under the AllPayer Combination Option, and to
rename the QP Performance Period we
established in rulemaking last year as
the Medicare QP Performance Period.
We are proposing to modify the
information submission requirements
for the All-Payer Combination Option.
Specifically, we are proposing
modifications to the information we
require to make APM Entity or eligible
clinician initiated determinations of
Other Payer Advanced APMs after the
All-Payer QP Performance Period, as
well as the information we require to
perform QP determinations under the
All-Payer Combination Option. We are
also proposing policies on the handling
of information submitted for purposes of
assessment under the All-Payer
Combination Option.
We are proposing a Payer Initiated
Other Payer Advanced APM
Determination Process, which would
allow certain other payers, including
payment arrangements authorized under
Title XIX, Medicare Health Plans, and
payers with payment arrangements in
CMS Multi-Payer Models, to request
that we determine whether their other
payer arrangements are Other Payer
Advanced APMs starting prior to the
2019 All-Payer QP Performance Period
and each year thereafter.
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e. Physician-Focused Payment Models
(PFPMs)
The PTAC is an 11-member federal
advisory committee that is an important
avenue for the creation of innovative
payment models. The PTAC is charged
with reviewing stakeholders’ proposed
PFPMs, and making comments and
recommendations to the Secretary
regarding whether they meet the PFPM
criteria established by the Secretary
through rulemaking in the CY 2017
Quality Payment Program final rule.
PTAC comments and recommendations
will be reviewed by the CMS Innovation
Center and the Secretary, and we will
post a detailed response to them on the
CMS Web site. We are seeking
comments on broadening the definition
of PFPM to include payment
arrangements that involve Medicaid or
the Children’s Health Insurance
Program (CHIP) as a payer even if
Medicare is not included as a payer.
This broadened definition might be
more inclusive of potential PFPMs that
could focus on areas not generally
applicable to the Medicare population,
and could engage more stakeholders in
designing PFPMs. In addition, as we
gain experience with public submission
of PFPM proposals to the PTAC, we are
seeking comments on the Secretary’s
criteria and stakeholders’ needs in
developing PFPM proposals aimed at
meeting the criteria.
4. Summary of Major Provisions for the
Merit-Based Incentive Payment System
(MIPS)
For Quality Payment Program Year 2
which is the second year of the MIPS
and includes the performance periods in
2018 and the 2020 MIPS payment year,
we are proposing the following policies:
a. Quality
We previously finalized that the
quality performance category would
comprise 60 percent of the final score
for the transition year and 50 percent of
the final score for the 2020 MIPS
payment year (81 FR 77100). For the
2020 MIPS payment year, now we are
proposing to maintain a 60 percent
weight for the quality performance
category contingent upon our proposal
to reweight the cost performance
category to zero for the 2020 MIPS
payment year as discussed in section
II.C.6.b.(2) in this proposed rule. Quality
measures are selected annually through
a call for quality measures, and a final
list of quality measures will be
published in the Federal Register by
November 1 of each year. Except as
discussed in section II.C.6.b.(3)(a)(iii) of
this proposed rule with regard to the
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CAHPS for MIPS survey, we are not
proposing any changes to the
submission criteria for quality measures
in this proposed rule. We are proposing
for the CAHPS for MIPS survey for the
Quality Payment Program Year 2 and
future years that the survey
administration period would, at a
minimum, span over 8 weeks and
would end no later than February 28th
following the applicable performance
period. In addition, we are proposing for
the Quality Payment Program Year 2
and future years to remove two
Summary Survey Modules (SSM),
specifically, ‘‘Helping You to Take
Medication as Directed’’ and ‘‘Between
Visit Communication’’ from the CAHPS
for MIPS survey.
For the 2018 MIPS performance
period, we previously finalized that the
data completeness threshold would
increase to 60 percent for data
submitted on quality measures using
QCDRs, qualified registries, via EHR, or
Medicare Part B claims. We noted that
these thresholds for data submitted on
quality measures using QCDRs,
qualified registries, via EHR, or
Medicare Part B claims would increase
for performance periods occurring in
2019 and future years. However, as
discussed in section II.C.6.b. of this
proposed rule, we are proposing for the
2018 MIPS performance period to
maintain the transition year data
completeness threshold of 50 percent
for data submitted on quality measures
using QCDRs, qualified registries, EHR,
or Medicare Part B claims to provide an
additional year for individual MIPS
eligible clinicians and groups to gain
experience with the MIPS before
increasing the data completeness
threshold. However, we are proposing to
increase the data completeness
threshold for the 2021 MIPS payment
year to 60 percent for data submitted on
quality measures using QCDRs,
qualified registries, EHR, or Medicare
Part B claims. We anticipate that for
performance periods going forward, as
MIPS eligible clinicians gain experience
with the MIPS, we would further
increase these thresholds over time.
b. Improvement Activities
Improvement activities are those that
support broad aims within healthcare
delivery, including care coordination,
beneficiary engagement, population
management, and health equity. In
response to comments from experts and
stakeholders across the healthcare
system, improvement activities were
given relative weights of high and
medium. For the 2020 MIPS payment
year, we previously finalized that the
improvement activities performance
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category would comprise 15 percent of
the final score (81 FR 77179). For
performance periods occurring in 2018,
we are not proposing any changes in
improvement activities scoring as
discussed in the CY 2017 Quality
Payment Program final rule (81 FR
77312).
As discussed in the appendices of this
proposed rule, we are proposing new
improvement activities (Table F) and
improvement activities with changes
(Table G) for the 2018 MIPS
performance period and future years for
inclusion in the Improvement Activities
Inventory. Activities proposed in this
section would apply for the 2018 MIPS
performance period and future
performance periods unless further
modified via notice and comment
rulemaking. We refer readers to Table H
of the CY 2017 Quality Payment
Program final rule for a list of all the
previously finalized improvement
activities (81 FR 77817 through 77831).
As discussed in section II.C.6.e.3.(c)
of this proposed rule, we are proposing
to expand our definition of how we will
recognize an individual MIPS eligible
clinician or group as being a certified
patient-centered medical home or
comparable specialty practice. We
finalized at § 414.1380(b)(3)(iv) in the
CY 2017 Quality Payment Program final
rule that a certified patient-centered
medical home includes practice sites
with current certification from a
national program, regional or state
program, private payer or other body
that administers patient-centered
medical home accreditation. We are
proposing in section II.C.6.e.(3)(b) of
this proposed rule that eligible
clinicians in practices that have been
randomized to the control group in the
CPC+ model would also receive full
credit as a Medical Home Model. In
addition, for group reporters, for the
2018 MIPS performance period and
future performance periods, we are
proposing to require that at least 50
percent of the practice sites within a
TIN must be recognized as a certified or
recognized patient-centered medical
home or comparable specialty practice
to receive full credit in the improvement
activities performance category.
As discussed in section II.C.6.f.(2)(d)
of this proposed rule, in recognition of
improvement activities as supporting
the central mission of a unified Quality
Payment Program, we propose to
continue to designate activities in the
Improvement Activities Inventory that
will also qualify for the advancing care
information bonus score. This is
consistent with our desire to recognize
that CEHRT is often deployed to
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improve care in ways that our programs
should recognize.
c. Advancing Care Information
For the Quality Payment Program
Year 2, the advancing care information
performance category comprises 25
percent of the final score. However, if a
MIPS eligible clinician is participating
in a MIPS APM the advancing care
information performance category may
comprise 30 percent or 75 percent of the
final score depending on the availability
of APM quality data for reporting.
Objectives and measures in the
advancing care information performance
category focus on the secure exchange of
health information and the use CEHRT
to support patient engagement and
improved healthcare quality. While we
continue to recommend that physicians
and clinicians migrate to the
implementation and use of EHR
technology certified to the 2015 Edition
so they may take advantage of improved
functionalities, including care
coordination and technical
advancements such as application
programming interfaces, or APIs, we
recognize that some practices may have
challenges in adopting new certified
health IT. Therefore we are proposing
that MIPS eligible clinicians may
continue to use EHR technology
certified to the 2014 Edition for the
performance period in CY 2018. We are
proposing minor modifications to the
advancing care information objectives
and measures and the 2017 advancing
care information transition objectives
and measures. We are also proposing to
add an exclusion for the e-Prescribing
and Health Information Exchange
Objectives. We are proposing to modify
our scoring policy for the Public Health
and Clinical Data Registry Reporting
Objectives and Measures for the
performance score and the bonus score.
We are also proposing to implement
several provisions of the 21st Century
Cures Act (Pub. L. 114–255, enacted on
December 13, 2016) pertaining to
hospital-based MIPS eligible clinicians,
ambulatory surgical center-based MIPS
eligible clinicians, MIPS eligible
clinicians using decertified EHR
technology, and significant hardship
exceptions under the MIPS. We are also
proposing to add a significant hardship
exception for MIPS eligible clinicians in
small practices.
d. Cost
In this proposed rule, we are
proposing to weight the cost
performance category at zero percent of
the final score for the 2020 MIPS
payment year in order to improve
clinician understanding of the measures
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and continue development of episodebased measures that will be used in this
performance category.
For the 2018 MIPS performance
period, we are proposing to adopt for
the cost performance category the total
per capita costs for all attributed
beneficiaries measure and the Medicare
Spending per Beneficiary (MSPB)
measure that were adopted for the 2017
MIPS performance period. For the 2018
MIPS performance period, we are not
proposing to use the 10 episode-based
measures that were adopted for the 2017
MIPS performance period. Although
data on the episode-based measures has
been made available to clinicians in the
past, we are in the process of developing
new episode-based measures with
significant clinician input and believe it
would be more prudent to introduce
these new measures over time. We will
continue to offer performance feedback
on episode-based measures prior to
potential inclusion of these measures in
MIPS to increase clinician familiarity
with the concept as well as specific
episode-based measures.
Specifically, we intend to provide
feedback on these new episode-based
cost measures in the fall of this year for
informational purposes only. We intend
to provide performance feedback on the
MSPB and total per capita cost measures
by July 1, 2018, consistent with section
1848(q)(12) of the Act. In addition, we
intend to offer feedback on another set
of newly developed episode-based cost
measures in 2018 as well. Therefore,
clinicians would have received feedback
on cost measures at several points prior
to the cost performance category
counting as part of the final score.
virtual group as a combination of two or
more TINs composed of a solo
practitioner (a MIPS eligible clinician
(as defined at § 414.1305) who bills
under a TIN with no other NPIs billing
under such TIN) or a group (as defined
at § 414.1305) with 10 or fewer eligible
clinicians under the TIN that elects to
form a virtual group with at least one
other such solo practitioner or group for
a performance period for a year.
To provide support and reduce
burden, we intend to make technical
assistance (TA) available, to the extent
feasible and appropriate, to support
clinicians who choose to come together
as a virtual group for the first 2 years of
virtual group implementation applicable
to the 2018 and 2019 performance years.
Clinicians can access the TA
infrastructure that they may be already
utilizing. For Quality Payment Program
Year 3, we intend to provide an
electronic election process if technically
feasible. Clinicians who do not elect to
contact their designated TA
representative would still have the
option of contacting the Quality
Payment Program Service Center. We
believe that our proposal will create an
election process that is simple and
straightforward.
e. Submission Mechanisms
As discussed in section II.6.a. of this
proposed rule, we are proposing
additional flexibility for submitting
data. Individual MIPS eligible clinicians
or groups would be able to submit
measures and activities, as available and
applicable, via as many mechanisms as
necessary to meet the requirements of
the quality, improvement activities, or
advancing care information performance
categories. We expect that this option
will provide clinicians the ability to
select the measures most meaningful to
them, regardless of the submission
mechanism.
g. MIPS APMs
In the CY 2017 Quality Payment
Program final rule (81 FR 77246), we
finalized that MIPS eligible clinicians
who participate in MIPS APMs will be
scored using the APM scoring standard
instead of the generally applicable MIPS
scoring standard. For the 2018
performance period, we are proposing
modifications to the quality
performance category reporting
requirements and scoring for MIPS
eligible clinicians in most MIPS APMs,
and other modifications to the APM
scoring standard. For purposes of the
APM scoring standard, we are proposing
to add a fourth snapshot date that would
be used only to identify APM Entity
groups participating in those MIPS
APMs that require full TIN
participation. Along with the other APM
Entity groups, these APM Entity groups
would be used for the purposes of
reporting and scoring under the APM
scoring standard described the CY 2017
Quality Payment Program final rule (81
FR 77246).
f. Virtual Groups
There are generally three ways to
participate in MIPS: (1) As an
individual; (2) as a group; and (3) as a
virtual group. In this proposed rule, we
are proposing to establish requirements
for MIPS participation at the virtual
group level. We propose to define a
h. Facility-Based Measurement
For the transition year of MIPS, we
considered an option for facility-based
MIPS eligible clinicians to elect to use
their institution’s performance rates as a
proxy for the MIPS eligible clinician’s
performance in the quality and cost
performance categories. However, we
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did not propose an option for the
transition year of MIPS because there
were several operational considerations
that needed to be addressed before this
option could be implemented. After
consideration of comments received on
the CY 2017 Quality Payment Program
proposed rule (81 FR 28192) and other
comments received, we have decided to
implement facility-based measures for
the 2018 MIPS performance period and
future performance periods to add more
flexibility for clinicians to be assessed
in the context of the facilities at which
they work. As discussed in section
II.C.7.b. of this proposed rule, we are
proposing facility-based measures
policies related to applicable measures,
applicability to facility-based
measurement, group participation, and
facility attribution.
For clinicians whose primary
professional responsibilities are in a
healthcare facility we present a method
to assess performance in the quality and
cost performance categories of MIPS
based on the performance of that facility
in another value-based purchasing
program. While we propose to limit that
opportunity to clinicians who practice
primarily in the hospital, we seek to
expand the program to other valuebased payment programs as appropriate
in the future. We discuss that new
method of scoring in section II.C.7.b.(4)
of this proposed rule.
i. Scoring
In the CY 2017 Quality Payment
Program final rule, we finalized a
unified scoring system to determine a
final score across the 4 performance
categories (81 FR 77273 through 77276).
For the 2018 MIPS performance period,
we propose to build on the scoring
methodology we finalized for the
transition year, focusing on encouraging
MIPS eligible clinicians to meet data
completeness requirements.
For quality performance category
scoring, we are proposing to extend
some of the transition year policies to
the 2018 MIPS performance period and
are also proposing several modifications
to existing policy. For the 2018 MIPS
performance period, we are proposing to
maintain the 3 point floor for measures
that can be reliably scored against a
benchmark. We are also proposing, to
maintain the policy to assign 3 points to
measures that are submitted but do not
have a benchmark or do not meet the
case minimum, which does not apply to
the CMS Web Interface measures and
administrative claims based measures.
For the 2018 MIPS performance period,
we are also proposing to lower the
number of points available for measures
that do not meet the data completeness
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criteria, except for a measure submitted
by a small practice, which we propose
to continue to assign 3 points if the
measure does not meet data
completeness. This does not apply to
CMS Web Interface measures or
administrative claims based measures.
Beginning with the 2018 MIPS
performance period, we are proposing to
add performance standards for scoring
improvement for the quality and cost
performance categories. We are also
proposing a systematic approach to
address topped out quality measures.
For the 2018 MIPS performance
period, we are proposing that 3
performance category scores (quality,
improvement activities, and advancing
care information) would be given weight
in the final score, or be reweighted if a
performance category score is not
available. We are also proposing to add
final score bonuses for small practices
and for MIPS eligible clinicians that
care for complex patients.
We are also proposing that the final
score will be compared against a MIPS
performance threshold of 15 points,
which can be achieved via multiple
pathways and continues the gradual
transition into MIPS.
j. Performance Feedback
We are proposing to provide Quality
Payment Program performance feedback
to eligible clinicians and groups.
Initially, we would provide performance
feedback on an annual basis. In future
years, we aim to provide performance
feedback on a more frequent basis,
which is in line with clinician requests
for timely, actionable feedback that they
can use to improve care.
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k. Targeted Review Process
In the CY 2017 Quality Payment
Program final rule (81 FR 77353), we
finalized a targeted review process
under MIPS wherein a MIPS eligible
clinician or group may request that we
review the calculation of the MIPS
payment adjustment factor and, as
applicable, the calculation of the
additional MIPS payment adjustment
factor applicable to such MIPS eligible
clinician or group for a year. We are not
proposing any changes to this process
for the second year of the MIPS.
l. Third Party Intermediaries
We believe that third party
intermediaries that collect or submit
data on behalf of individual eligible
clinicians and groups participating in
MIPS and allowing for flexible reporting
options, will provide individual MIPS
eligible clinicians and groups with
options to accommodate different
practices and make measurement
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meaningful. In the CY 2017 Quality
Payment Program final rule (81 FR
77362), we finalized that qualified
registries, QCDRs, health IT vendors,
and CMS-approved survey vendors will
have the ability to act as intermediaries
on behalf of individual MIPS eligible
clinicians and groups for submission of
data to CMS across the quality,
improvement activities, and advancing
care information performance
categories. As discussed in section
II.C.10.a.(3) of this proposed rule, we
propose to eliminate the selfnomination submission method of email
and require that QCDRs and qualified
registries submit their self-nomination
applications via a web-based tool for
future program years beginning with
performance periods occurring in 2018.
We are proposing, beginning with the
2019 performance period, a simplified
process in which existing QCDRs or
qualified registries in good standing
may continue their participation in
MIPS by attesting that their approved
data validation plan, cost, approved
QCDR measures (applicable to QCDRs
only), MIPS quality measures, activities,
services, and performance categories
offered in the previous year’s
performance period of MIPS have no
changes. QCDRs and qualified registries
in good standing, may also make
substantive or minimal changes to their
approved self-nomination application
from the previous year of MIPS that
would be submitted during the selfnomination period for CMS review and
approval. By attesting that certain
aspects of their application will remain
the same, as approved from the previous
year, existing QCDRs in good standing
and qualified registries will be spending
less time completing the selfnomination application, as was
previously required. This process will
be conducted on an annual basis.
In addition, we are proposing that the
term ‘‘QCDR measures’’ replace the term
‘‘non-MIPS measures,’’ without
proposing any changes to the definition,
criteria, or requirements that were
finalized in the CY 2017 Quality
Payment Program final rule (81 FR
77375). We are not proposing any
changes to the health IT vendors that
obtain data from CEHRT requirements.
Lastly, we are proposing for future
program years, beginning with
performance periods occurring in 2018
that we remove the April 30th survey
vendor application deadline. We are
proposing for the Quality Payment
Program Year 2 and future years that the
vendor application deadline be January
31st of the applicable performance year
or a later date specified by CMS. We
will notify vendors of the application
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deadline, to become a CMS-approved
survey vendor through additional
communications and postings.
m. Public Reporting
As discussed in section II.C.11. of this
proposed rule, we are proposing public
reporting of certain eligible clinician
and group Quality Payment Program
information, including MIPS and APM
data in an easily understandable format
as required under the MACRA.
n. Eligibility and Exclusion Provisions
of the MIPS Program
In section II.C.1.f. of this proposed
rule, we are proposing to modify the
definition of a non-patient facing MIPS
eligible clinician to apply to virtual
groups. We are also proposing to specify
that groups considered to be non-patient
facing (more than 75 percent of the NPIs
billing under the group’s TIN meet the
definition of a non-patient facing
individual MIPS eligible clinician)
during the non-patient facing
determination period would
automatically have their advancing care
information performance category
reweighted to zero. Additionally, in
section II.C.3.c. of this proposed rule,
we are proposing to modify the lowvolume threshold policy established in
the CY 2017 Quality Payment Program
final rule. As discussed in section
II.C.3.c of this proposed rule, we believe
that increasing the low-volume
threshold to less than or equal to
$90,000 in Medicare Part B charges or
200 or fewer Part-B enrolled Medicare
beneficiaries would further decrease
burden on MIPS eligible clinicians that
practice in rural areas or are part of a
small practice or are solo practitioners.
E. Payment Adjustments
As discussed in section V.C. of this
proposed rule, for the 2020 payment
year based on Advanced APM
participation in 2018 performance
period, we estimate that approximately
180,000 to 245,000 clinicians will
become QPs, and therefore be exempt
from MIPS and qualify for lump sum
incentive payments based on 5 percent
of their Part B allowable charges for
covered professional services. We
estimate that the total lump sum
incentive payments will be between
approximately $590 and $800 million
for the 2020 Quality Payment Program
payment year. This expected growth in
QPs between the first and second year
of the program is due in part to
reopening of CPC+ and Next Generation
ACO for 2018, and the ACO Track 1+
which is projected to have a large
number of participants, with a large
majority reaching QP status.
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Under the policies in this proposed
rule, we estimate that approximately
572,000 eligible clinicians would be
required to participate in MIPS in the
2018 MIPS performance period,
although this number may vary
depending on the number of eligible
clinicians excluded from MIPS based on
their status as QPs or Partial QPs. After
restricting the population to eligible
clinician types who are not newly
enrolled, the proposed increase in the
low-volume threshold is expected to
exclude 585,560 clinicians who do not
exceed the low-volume threshold. In the
2020 MIPS payment year, MIPS
payment adjustments will be applied
based on MIPS eligible clinicians’
performance on specified measures and
activities within three integrated
performance categories; the fourth
category of cost, as previously outlined,
would be weighted to zero in the 2020
MIPS payment year. Assuming that 90
percent of eligible clinicians of all
practice sizes participate in MIPS, we
estimate that MIPS payment
adjustments will be approximately
equally distributed between negative
MIPS payment adjustments ($173
million) and positive MIPS payment
adjustments ($173 million) to MIPS
eligible clinicians, as required by the
statute to ensure budget neutrality.
Positive MIPS payment adjustments will
also include up to an additional $500
million for exceptional performance to
MIPS eligible clinicians whose final
score meets or exceeds the additional
performance threshold of 70 points.
These MIPS payment adjustments are
expected to drive quality improvement
in the provision of MIPS eligible
clinicians’ care to Medicare
beneficiaries and to all patients in the
health care system. However, the
distribution will change based on the
final population of MIPS eligible
clinicians for CY 2020 and the
distribution of scores under the
program. We believe that starting with
these modest initial MIPS payment
adjustments is in the long-term best
interest of maximizing participation and
starting the Quality Payment Program
off on the right foot, even if it limits the
magnitude of MIPS positive adjustments
during the 2018 MIPS performance
period. The increased availability of
Advanced APM opportunities,
including through Medical Home
models, also provides earlier avenues to
earn APM incentive payments for those
eligible clinicians who choose to
participate.
F. Benefits and Costs of Proposed Rule
The Quality Payment Program may
result in quality improvements and
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improvements to the patients’
experience of care as MIPS eligible
clinicians respond to the incentives for
high-quality care provided by MIPS and
implement care quality improvements
in their clinical practices.
We also quantify several costs
associated with this rule. We estimate
that this proposed rule will result in
approximately $857 million in
collection of information-related
burden. We estimate that the
incremental collection of informationrelated burden associated with this
proposed rule is approximately $12.4
million relative to the estimated burden
of continuing the policies the CY 2017
Quality Payment Program final rule,
which is $869 million. We also estimate
regulatory review costs of $4.8 million
for this proposed rule, comparable to
the regulatory review costs of the CY
2017 Quality Payment Program
proposed rule. We estimate that federal
expenditures will include $173 million
in revenue neutral payment adjustments
and $500 million for exceptional
performance payments. Additional
federal expenditures include
approximately $590-$800 million in
APM incentive payments to QPs.
G. Stakeholder Input
In developing this proposed rule, we
sought feedback from stakeholders and
the public throughout the process,
including in the CY 2017 Quality
Payment Program final rule with
comment period, listening sessions,
webinars, and other listening venues.
We received a high degree of interest
from a broad spectrum of stakeholders.
We thank our many commenters and
acknowledge their valued input
throughout the rulemaking process. We
discuss the substance of relevant
comments in the appropriate sections of
this proposed rule, though we were not
able to address all comments or all
issues that all commenters brought forth
due to the volume of comments and
feedback. In general, commenters
continue to support establishment of the
Quality Payment Program and maintain
optimism as we move from pure FFS
Medicare payment towards an enhanced
focus on the quality and value of care.
Public support for our proposed
approach and policies in the proposed
rule focused on the potential for
improving the quality of care delivered
to beneficiaries and increasing value to
the public—while rewarding eligible
clinicians for their efforts.
We thank stakeholders again for their
considered responses throughout our
process, in various venues, including
comments on the Request for
Information Regarding Implementation
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of the Merit-based Incentive Payment
System, Promotion of Alternative
Payment Models, and Incentive
Payments for Participation in Eligible
Alternative Payment Models (herein
referred to as the MIPS and APMs RFI)
(80 FR 59102 through 59113) and the
CY 2017 Quality Payment Program final
rule (81 FR 77008 through 77831). We
intend to continue open communication
with stakeholders, including
consultation with tribes and tribal
officials, on an ongoing basis as we
develop the Quality Payment Program
in future years.
II. Provisions of the Proposed
Regulations and Analysis of and
Responses to Comments
A. Introduction
The Quality Payment Program,
authorized by the Medicare Access and
CHIP Reauthorization Act of 2015
(MACRA) is a new approach for
reforming care across the health care
delivery system for eligible clinicians.
Under the Quality Payment Program,
eligible clinicians can participate via
one of two pathways: Advanced
Alternative Payment Models (APMs); or
the Merit-based Incentive Payment
System (MIPS). We began implementing
the Quality Payment Program through
rulemaking for calendar year (CY) 2017.
This rule provides proposed updates for
the second and future years of the
Quality Payment Program.
B. Definitions
At § 414.1305, subpart O, we propose
to define the following terms:
• All-Payer QP Performance Period.
• Ambulatory Surgical Center (ASC)based MIPS eligible clinician.
• CMS Multi-Payer Model.
• Full TIN APM.
• Improvement Scoring.
• Medicare QP Performance Period.
• Other MIPS APM.
• Virtual group.
We propose to revise the definitions
of the following terms:
• Affiliated practitioner.
• APM Entity.
• Attributed beneficiary.
• Certified Electronic Health Record
Technology (CEHRT).
• Final Score.
• Hospital-based MIPS eligible
clinician.
• Low-volume threshold.
• Medicaid APM.
• Non-patient facing MIPS eligible
clinician.
• Other Payer Advanced APM.
• Rural areas.
We propose to remove the following
terms:
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• Advanced APM Entity.
• QP Performance Period.
These terms and definitions are
discussed in detail in relevant sections
of this proposed rule.
C. MIPS Program Details
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1. MIPS Eligible Clinicians
a. Definition of a MIPS Eligible
Clinician
In the CY 2017 Quality Payment
Program final rule (81 FR77040 through
77041), we defined at § 414.1305 a MIPS
eligible clinician, as identified by a
unique billing TIN and NPI combination
used to assess performance, as any of
the following (excluding those
identified at § 414.1310(b)): A physician
(as defined in section 1861(r) of the
Act), a physician assistant, nurse
practitioner, and clinical nurse
specialist (as such terms are defined in
section 1861(aa)(5) of the Act), a
certified registered nurse anesthetist (as
defined in section 1861(bb)(2) of the
Act), and a group that includes such
clinicians. We established at
§ 414.1310(b) and (c) that the following
are excluded from this definition per the
statutory exclusions defined in section
1848(q)(1)(C)(ii) and (v) of the Act: (1)
QPs; (2) Partial QPs who choose not to
report on applicable measures and
activities that are required to be
reported under MIPS for any given
performance period in a year; (3) lowvolume threshold eligible clinicians;
and (4) new Medicare-enrolled eligible
clinicians. In accordance with sections
1848(q)(1)(A) and (q)(1)(C)(vi) of the
Act, we established at § 414.1310(b)(2)
that eligible clinicians (as defined at
§ 414.1305) who are not MIPS eligible
clinicians have the option to voluntarily
report measures and activities for MIPS.
Additionally, we established at
§ 414.1310(d) that in no case will a
MIPS payment adjustment apply to the
items and services furnished during a
year by eligible clinicians who are not
MIPS eligible clinicians, as described in
§ 414.1310(b) and (c), including those
who voluntarily report on applicable
measures and activities specified under
MIPS.
In the CY 2017 Quality Payment
Program final rule (81 FR 77340), we
noted that the MIPS payment
adjustment applies only to the amount
otherwise paid under Part B with
respect to items and services furnished
by a MIPS eligible clinician during a
year, in which we will apply the MIPS
payment adjustment at the TIN/NPI
level. We have received requests for
additional clarifications on which
specific Part B services are subject to the
MIPS payment adjustment, as well as
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which Part B services are included for
eligibility determinations. We note that
when Part B items or services are
rendered by suppliers that are also MIPS
eligible clinicians, there may be
circumstances in which it is not
operationally feasible for us to attribute
those items or services to a MIPS
eligible clinician at an NPI level in order
to include them for purposes of
applying the MIPS payment adjustment
or making eligibility determinations.
To further clarify, there are
circumstances that involve Part B
prescription drugs and durable medical
equipment where the supplier may also
be a MIPS eligible clinician. In
circumstances in which a MIPS eligible
clinician furnishes a Part B covered item
or service such as prescribing Part B
drugs that are dispensed, administered,
and billed by a supplier that is a MIPS
eligible clinician, or ordering durable
medical equipment that is administered
and billed by a supplier that is a MIPS
eligible clinician, it is not operationally
feasible for us at this time to associate
those billed allowable charges with a
MIPS eligible clinician at an NPI level
in order to include them for purposes of
applying the MIPS payment adjustment
or making eligibility determinations. For
Part B items and services furnished by
a MIPS eligible clinician such as
purchasing and administering Part B
drugs that are billed by the MIPS
eligible clinician, such items and
services may be subject to MIPS
adjustment based on the MIPS eligible
clinician’s performance during the
applicable performance period or
included for eligibility determinations.
For those billed Medicare Part B
allowable charges relating to the
purchasing and administration of Part B
drugs that we are able to associate with
a MIPS eligible clinician at an NPI level,
such items and services furnished by
the MIPS eligible clinician would be
included for purposes of applying the
MIPS payment adjustment or making
eligibility determinations.
b. Group Practice (Group)
As discussed in the CY 2017 Quality
Payment Program final rule (81 FR
77088 through 77831), we indicated that
we will assess performance either for
individual MIPS eligible clinicians or
for groups. We defined a group at
§ 414.1305 as a single Taxpayer
Identification Number (TIN) with two or
more eligible clinicians (including at
least one MIPS eligible clinician), as
identified by their individual NPI, who
have reassigned their Medicare billing
rights to the TIN. We recognize that
MIPS eligible clinicians participating in
MIPS may be part of a TIN that has one
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portion of its NPIs participating in MIPS
according to the generally applicable
scoring criteria while the remaining
portion of its NPIs is participating in a
MIPS APM or an Advanced APM
according to the MIPS APM scoring
standard. In the CY 2017 Quality
Payment Program final rule (81 FR
77058), we noted that except for groups
containing APM participants, we are not
permitting groups to ‘‘split’’ TINs if they
choose to participate in MIPS as a
group. Thus, we would like to clarify
that we consider a group to be either an
entire single TIN or portion of a TIN
that: (1) Is participating in MIPS
according to the generally applicable
scoring criteria while the remaining
portion of the TIN is participating in a
MIPS APM or an Advanced APM
according to the MIPS APM scoring
standard; and (2) chooses to participate
in MIPS at the group level. Also, we
defined an APM Entity group at
§ 414.1305 as a group of eligible
clinicians participating in an APM
Entity, as identified by a combination of
the APM identifier, APM Entity
identifier, TIN, and NPI for each
participating eligible clinician.
c. Small Practices
In the CY 2017 Quality Payment
Program final rule (81 FR 77188), we
defined the term small practices at
§ 414.1305 as practices consisting of 15
or fewer clinicians and solo
practitioners. In section II.C.4.d. of this
proposed rule, we discuss how small
practice status would apply to virtual
groups. Also, in the final rule, we noted
that we would not make an eligibility
determination regarding the size of
small practices, but indicated that small
practices would attest to the size of their
group practice (81 FR 77057). However,
we have since realized that our system
needs to account for small practice size
in advance of a performance period for
operational purposes relating to
assessing and scoring the improvement
activities performance category,
determining hardship exceptions for
small practices as proposed in this
proposed rule, calculating the small
practice bonus for the final score as
proposed in this proposed rule, and
identifying small practices eligible for
technical assistance. As a result, we
believe it is critical to modify the way
in which small practice size would be
determined. To make eligibility
determinations regarding the size of
small practices for performance periods
occurring in 2018 and future years, we
propose that CMS would determine the
size of small practices as described in
this section of the proposed rule. As
noted in the CY 2017 Quality Payment
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Program final rule, the size of a group
(including a small practice) would be
determined before exclusions are
applied (81 FR 77057). We note that
group size determinations are based on
the number of NPIs associated with a
TIN, which would include clinicians
(NPIs) who may be excluded from MIPS
participation and do not meet the
definition of a MIPS eligible clinician.
To make eligibility determinations
regarding the size of small practices for
performance periods occurring in 2018
and future years, we propose that CMS
would determine the size of small
practices by utilizing claims data. For
purposes of this section, we are coining
the term ‘‘small practice size
determination period’’ to mean a 12month assessment period, which
consists of an analysis of claims data
that spans from the last 4 months of a
calendar year 2 years prior to the
performance period followed by the first
8 months of the next calendar year and
includes a 30-day claims run out. This
would allow us to inform small
practices of their status near the
beginning of the performance period as
it pertains to eligibility relating to
technical assistance, applicable
improvement activities criteria, the
proposed hardship exception for small
practices under the advancing care
information performance category, and
the proposed small practice bonus for
the final score.
Thus, for purposes of performance
periods occurring in 2018 and the 2020
MIPS payment year, we would identify
small practices based on 12 months of
data starting from September 1, 2016 to
August 31, 2017. We would not change
an eligibility determination regarding
the size of a small practice once the
determination is made for a given
performance period and MIPS payment
year. We recognize that there may be
circumstances in which the small
practice size determinations made by
CMS do not reflect the real-time size of
such practices. We considered two
options that could address such
potential discrepancies. One option
would include an expansion of the
proposed small practice size
determination period to 24 months with
two 12-month segments of data analysis
(before and during the performance
period), in which CMS would conduct
a second analysis of claims data during
the performance period. Such an
expanded determination period may
better capture the real-time size of small
practices, but determinations made
during the performance period prevent
our system from being able to account
for the assessment and scoring of the
improvement activities performance
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category and identification of small
practices eligible for technical
assistance prior to the performance
period. Specifically, our system needs to
capture small practice determinations in
advance of the performance period in
order for the system to reflect the
applicable requirements for the
improvement activities performance
category and when a small practice
bonus would be applied. A second
option would include an attestation
component, in which a small practice
that was not identified as a small
practice during the proposed small
practice size determination period
would be able to attest to the size of
their group practice prior to the
performance period. However, this
second option would require us to
develop several operational
improvements, such as a manual
process or system that would provide an
attestation mechanism for small
practices, and a verification process to
ensure that only small practices are
identified as eligible for technical
assistance. Since individual MIPS
eligible clinicians and groups are not
required to register to participate in
MIPS (except for groups utilizing the
CMS Web Interface for the Quality
Payment Program or administering the
CAHPS for MIPS survey), requiring
small practices to attest to the size of
their group practice prior to the
performance period could increase
burden on individual MIPS eligible
clinicians and groups that are not
already utilizing the CMS Web Interface
for the Quality Payment Program or
administering the CAHPS for MIPS
survey. We solicit public comment on
the proposal regarding how CMS would
determine small practice size.
d. Rural Area and Health Professional
Shortage Area Practices
In the CY 2017 Quality Payment
Program final rule (81 FR 77188), we
finalized at § 414.1380 that for
individual MIPS eligible clinicians and
groups that are located in rural areas or
geographic HPSAs, to achieve full credit
under the improvement activities
performance category, one highweighted or two medium-weighted
improvement activities are required. In
addition, we defined rural areas at
§ 414.1305 as clinicians in ZIP codes
designated as rural, using the most
recent Health Resources and Services
Administration (HRSA) Area Health
Resource File data set available; and
Health Professional Shortage Areas
(HPSAs) at § 414.1305 as areas
designated under section 332(a)(1)(A) of
the Public Health Service Act. For
technical accuracy purposes, we are
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proposing to modify the definition of a
rural areas at § 414.1305 as ZIP codes
designated as rural, using the most
recent Health Resources and Services
Administration (HRSA) Area Health
Resource File data set available. We
recognize that there are cases in which
an individual MIPS eligible clinician
(including a solo practitioner) or a group
may have multiple practice sites
associated with its TIN and as a result,
it is critical for us to outline the
application of rural area and HPSA
practice designations to such practices.
For performance periods occurring in
2017, we consider an individual MIPS
eligible clinician or a group with at least
one practice site under its TIN in a ZIP
code designated as a rural area or HPSA
to be a rural area or HPSA practice. For
performance periods occurring in 2018
and future years, we believe that a
higher threshold than one practice
within a TIN is necessary to designate
an individual MIPS eligible clinician, a
group, or a virtual group as a rural or
HPSA practice. We recognize that the
establishment of a higher threshold
starting in 2018 would more
appropriately identify groups and
virtual groups with multiple practices
under a group’s TIN or TINs that are
part of a virtual group as rural or HPSA
practices and ensure that groups and
virtual groups are assessed and scored
according to requirements that are
applicable and appropriate. We note
that in the CY 2017 Quality Payment
Program final rule (81 FR 77048 through
77049), we defined a non-patient facing
MIPS eligible clinician at § 414.1305 as
including a group provided that more
than 75 percent of the NPIs billing
under the group’s TIN meet the
definition of a non-patient facing
individual MIPS eligible clinician
during the non-patient facing
determination period. We refer readers
to section II.C.1.e. of this proposed rule
for our proposal to modify the definition
of a non-patient facing MIPS eligible
clinician. We believe that using a
similar threshold for applying the rural
and HPSA designation to an individual
MIPS eligible clinician, a group, or
virtual group with multiple practices
under its TIN or TINs within a virtual
group will add consistency for such
practices across the MIPS as it pertains
to groups and virtual groups obtaining
such statuses. Also, we believe that
establishing a 75 percent threshold
renders an adequate representation of a
group or virtual group where a
significant portion of a group or a
virtual group is identified as having
such status. Therefore, for performance
periods occurring in 2018 and future
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years, we propose that an individual
MIPS eligible clinician, a group, or a
virtual with multiple practices under its
TIN or TINs within a virtual group
would be designated as a rural or HPSA
practice if more than 75 percent of NPIs
billing under the individual MIPS
eligible clinician or group’s TIN or
within a virtual group, as applicable, are
designated in a ZIP code as a rural area
or HPSA. We solicit public comment on
these proposals.
e. Non-Patient Facing MIPS Eligible
Clinicians
Section 1848(q)(2)(C)(iv) of the Act
requires the Secretary, in specifying
measures and activities for a
performance category, to give
consideration to the circumstances of
professional types (or subcategories of
those types determined by practice
characteristics) who typically furnish
services that do not involve face-to-face
interaction with a patient. To the extent
feasible and appropriate, the Secretary
may take those circumstances into
account and apply alternative measures
or activities that fulfill the goals of the
applicable performance category to such
non-patient facing MIPS eligible
clinicians. In carrying out these
provisions, we are required to consult
with non-patient facing MIPS eligible
clinicians.
In addition, section 1848(q)(5)(F) of
the Act allows the Secretary to re-weight
MIPS performance categories if there are
not sufficient measures and activities
applicable and available to each type of
MIPS eligible clinician. We assume
many non-patient facing MIPS eligible
clinicians will not have sufficient
measures and activities applicable and
available to report under the
performance categories under MIPS. We
refer readers to section II.C.6.f.(7) of this
proposed rule for the discussion
regarding how we address performance
category weighting for MIPS eligible
clinicians for whom no measures or
activities are applicable and available in
a given category.
In the CY 2017 Quality Payment
Program final rule (81 FR 77048 through
77049), we defined a non-patient facing
MIPS eligible clinician for MIPS at
§ 414.1305 as an individual MIPS
eligible clinician that bills 100 or fewer
patient-facing encounters (including
Medicare telehealth services defined in
section 1834(m) of the Act) during the
non-patient facing determination
period, and a group provided that more
than 75 percent of the NPIs billing
under the group’s TIN meet the
definition of a non-patient facing
individual MIPS eligible clinician
during the non-patient facing
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determination period. In order to
account for the formation of virtual
groups starting in the 2018 performance
year and how non-patient facing
determinations would apply to virtual
groups, we need to modify the
definition of a non-patient facing MIPS
eligible clinician. Therefore, for
performance periods occurring in 2018
and future years, we propose to modify
the definition of a non-patient facing
MIPS eligible clinician at § 414.1305 to
mean an individual MIPS eligible
clinician that bills 100 or fewer patientfacing encounters (including Medicare
telehealth services defined in section
1834(m) of the Act) during the nonpatient facing determination period, and
a group or virtual group provided that
more than 75 percent of the NPIs billing
under the group’s TIN or within a
virtual group, as applicable, meet the
definition of a non-patient facing
individual MIPS eligible clinician
during the non-patient facing
determination period.
We considered a patient-facing
encounter to be an instance in which
the individual MIPS eligible clinician or
group billed for items and services
furnished such as general office visits,
outpatient visits, and procedure codes
under the PFS. We published the list of
patient-facing encounter codes for
performance periods occurring in 2017
at qpp.cms.gov/resources/education. We
intend to publish the list of patientfacing encounter codes for performance
periods occurring in 2018 at
qpp.cms.gov by the end of 2017. The list
of patient-facing encounter codes is
used to determine the non-patient facing
status of MIPS eligible clinicians.
The list of patient-facing encounter
codes include two general categories of
codes: Evaluation and Management
(E&M) codes; and Surgical and
Procedural codes. E&M codes capture
clinician-patient encounters that occur
in a variety of care settings, including
office or other outpatient settings,
hospital inpatient settings, emergency
departments, and nursing facilities, in
which clinicians utilize information
provided by patients regarding history,
present illness, and symptoms to
determine the type of assessments to
conduct. Assessments are conducted on
the affected body area(s) or organ
system(s) for clinicians to make medical
decisions that establish a diagnosis or
select a management option(s).
Surgical and Procedural codes capture
clinician-patient encounters that
involve procedures, surgeries, and other
medical services conducted by
clinicians to treat medical conditions. In
the case of many of these services,
evaluation and management work is
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included in the payment for the single
code instead of separately reported.
Patient-facing encounter codes from
both of these categories describe direct
services furnished by eligible clinicians
with impact on patient safety, quality of
care, and health outcomes.
For purposes of the non-patient facing
policies under MIPS, the utilization of
E&M codes and Surgical and Procedural
codes allows for accurate identification
of patient-facing encounters, and thus
accurate eligibility determinations
regarding non-patient facing status. As a
result, MIPS eligible clinicians
considered non-patient facing are able
to prepare to meet requirements
applicable to non-patient facing MIPS
eligible clinicians. We propose to
continue applying these policies for
purposes of the 2020 MIPS payment
year and future years.
As described in the CY 2017 Quality
Payment Program final rule, we
established the non-patient facing
determination period for purposes of
identifying non-patient facing MIPS
eligible clinicians in advance of the
performance period and during the
performance period using historical and
performance period claims data. This
eligibility determination process allows
us to begin identifying non-patient
facing MIPS eligible clinicians prior to
or shortly after the start of the
performance period. The non-patient
facing determination period is a 24month assessment period, which
includes a two-segment analysis of
claims data regarding patient-facing
encounters during an initial 12-month
period prior to the performance period
followed by another 12-month period
during the performance period. The
initial 12-month segment of the nonpatient facing determination period
spans from the last 4 months of a
calendar year 2 years prior to the
performance period followed by the first
8 months of the next calendar year and
includes a 60-day claims run out, which
allows us to inform individual MIPS
eligible clinicians and groups of their
non-patient facing status during the
month (December) prior to the start of
the performance period. The second 12month segment of the non-patient facing
determination period spans from the
last 4 months of a calendar year 1 year
prior to the performance period
followed by the first 8 months of the
performance period in the next calendar
year and includes a 60-day claims run
out, which will allow us to inform
additional individual MIPS eligible
clinicians and groups of their nonpatient status during the performance
period.
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day claims run out. This proposal
would only change the duration of the
claims run out, not the 12-month
timeframes used for the first and second
segments of data analysis.
For purposes of the 2020 MIPS
payment year, we would initially
identify individual MIPS eligible
clinicians and groups who are
considered non-patient facing MIPS
eligible clinicians based on 12 months
of data starting from September 1, 2016,
to August 31, 2017. To account for the
identification of additional individual
MIPS eligible clinicians and groups that
may qualify as non-patient facing during
performance periods occurring in 2018,
we would conduct another eligibility
determination analysis based on 12
months of data starting from September
1, 2017, to August 31, 2018.
Similarly, for future years, we would
conduct an initial eligibility
determination analysis based on 12
months of data (consisting of the last 4
months of the calendar year 2 years
prior to the performance period and the
first 8 months of the calendar year prior
to the performance period) to determine
TABLE 1—PERCENTAGES OF DATA
the non-patient facing status of
COMPLETENESS FOR 60-DAY AND individual MIPS eligible clinicians and
30-DAY CLAIMS RUN OUT
groups, and conduct another eligibility
determination analysis based on 12
30-day
60-day
Incurred
months of data (consisting of the last 4
claims
claims
year
months of the calendar year prior to the
run out *
run out *
performance period and the first 8
2015 ..........
97.1%
98.4%
months of the performance period) to
* Note: Completion rates are estimated and determine the non-patient facing status
averaged at aggregated service categories of additional individual MIPS eligible
and may not be applicable to subsets of these clinicians and groups. We would not
totals. For example, completion rates can vary change the non-patient facing status of
by provider due to claim processing practices,
service mix, and post payment review activity. any individual MIPS eligible clinician
Completion rates vary from subsections of a or group identified as non-patient facing
calendar year; later portions of a given cal- during the first eligibility determination
endar year will be less complete than earlier analysis based on the second eligibility
ones. Completion rates vary due to variance in determination analysis. Thus, an
loading patterns due to technical, seasonal,
policy, and legislative factors. Completion individual MIPS eligible clinician or
rates are a function of the incurred date used group that is identified as non-patient
to process claims, and these factors will need facing during the first eligibility
to be updated if claims are processed on a determination analysis would continue
claim from date or other methodology.
to be considered non-patient facing for
For performance periods occurring in the duration of the performance period
2018 and future years, we propose a
and MIPS payment year regardless of
modification to the non-patient facing
the results of the second eligibility
determination period, in which the
determination analysis. We would
initial 12-month segment of the nonconduct the second eligibility
patient facing determination period
determination analysis to account for
would span from the last 4 months of a
the identification of additional,
calendar year 2 years prior to the
previously unidentified individual
performance period followed by the first MIPS eligible clinicians and groups that
8 months of the next calendar year and
are considered non-patient facing.
include a 30-day claims run out; and the
Additionally, in the CY 2017 Quality
second 12-month segment of the nonPayment Program final rule (81 FR
patient facing determination period
77241), we established a policy
would span from the last 4 months of a
regarding the re-weighting of the
calendar year 1 year prior to the
advancing care information performance
performance period followed by the first category for non-patient facing MIPS
8 months of the performance period in
eligible clinicians. Specifically, MIPS
the next calendar year and include a 30- eligible clinicians who are considered to
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However, based on our analysis of
data from the initial segment of the nonpatient facing determination period for
performance periods occurring in 2017
(that is, data spanning from September
1, 2015 to August 31, 2016), we found
that it may not be necessary to include
a 60-day claims run out since we could
achieve a similar outcome for such
eligibility determinations by utilizing a
30-day claims run out. In our
comparison of data analysis results
utilizing a 60-day claims run out versus
a 30-day claims run out, there was a 1
percent decrease in data completeness
(see Table 1 for data completeness
regarding comparative analysis of a 60day and 30-day claims run out). The
small decrease in data completeness
would not negatively impact individual
MIPS eligible clinicians or groups
regarding non-patient facing
determinations. We believe that a 30day claims run out would allow us to
complete the analysis and provide such
determinations in a more timely
manner.
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be non-patient facing will have their
advancing care information performance
category automatically reweighted to
zero (81 FR 77241). For groups that are
considered to be non-patient facing (that
is, more than 75 percent of the NPIs
billing under the group’s TIN meet the
definition of a non-patient facing
individual MIPS eligible clinician)
during the non-patient facing
determination period, we are proposing
in section II.C.7.b.(3) of this proposed
rule to automatically reweight their
advancing care information performance
category to zero.
We propose to continue applying
these policies for purposes of the 2020
MIPS payment year and future years.
We solicit public comment on these
proposals.
f. MIPS Eligible Clinicians Who Practice
in Critical Access Hospitals Billing
Under Method II (Method II CAHs)
In the CY 2017 Quality Payment
Program final rule (81 FR 77049), we
noted that MIPS eligible clinicians who
practice in CAHs that bill under Method
I (Method I CAHs), the MIPS payment
adjustment would apply to payments
made for items and services billed by
MIPS eligible clinicians, but it would
not apply to the facility payment to the
CAH itself. For MIPS eligible clinicians
who practice in Method II CAHs and
have not assigned their billing rights to
the CAH, the MIPS payment adjustment
would apply in the same manner as for
MIPS eligible clinicians who bill for
items and services in Method I CAHs.
As established in the CY 2017 Quality
Payment Program final rule (81 FR
77051), the MIPS payment adjustment
will apply to Method II CAH payments
under section 1834(g)(2)(B) of the Act
when MIPS eligible clinicians who
practice in Method II CAHs have
assigned their billing rights to the CAH.
We refer readers to the CY 2017
Quality Payment Program final rule (81
FR 77049 through 77051) for our
discussion of MIPS eligible clinicians
who practice in Method II CAHs.
g. MIPS Eligible Clinicians Who Practice
in Rural Health Clinics (RHCs) or
Federally Qualified Health Centers
(FQHCs)
As established in the CY 2017 Quality
Payment Program final rule (81 FR
77051 through 77053), services rendered
by an eligible clinician under the RHC
or FQHC methodology, will not be
subject to the MIPS payments
adjustments. As noted, these eligible
clinicians have the option to voluntarily
report on applicable measures and
activities for MIPS, in which the data
received will not be used to assess their
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performance for the purpose of the
MIPS payment adjustment.
We refer readers to the CY 2017
Quality Payment Program final rule (81
FR 77051 through 77053) for our
discussion of MIPS eligible clinicians
who practice in RHCs or FQHCs.
h. MIPS Eligible Clinicians Who
Practice in Ambulatory Surgical Centers
(ASCs), Home Health Agencies (HHAs),
Hospice, and Hospital Outpatient
Departments (HOPDs)
Section 1848(q)(6)(E) of the Act
provides that the MIPS payment
adjustment is applied to the amount
otherwise paid under Part B with
respect to the items and services
furnished by a MIPS eligible clinician
during a year. Some eligible clinicians
may not receive MIPS payment
adjustments due to their billing
methodologies. If a MIPS eligible
clinician furnishes items and services in
an ASC, HHA, Hospice, and/or HOPD
and the facility bills for those items and
services (including prescription drugs)
under the facility’s all-inclusive
payment methodology or prospective
payment system methodology, the MIPS
adjustment would not apply to the
facility payment itself. However, if a
MIPS eligible clinician furnishes other
items and services in an ASC, HHA,
Hospice, and/or HOPD and bills for
those items and services separately,
such as under the PFS, the MIPS
adjustment would apply to payments
made for such items and services. Such
items and services would also be
considered for purposes of applying the
low-volume threshold. Therefore, we
propose that services rendered by an
eligible clinician that are payable under
the ASC, HHA, Hospice, or HOPD
methodology would not be subject to
the MIPS payments adjustments.
However, these eligible clinicians have
the option to voluntarily report on
applicable measures and activities for
MIPS, in which the data received would
not be used to assess their performance
for the purpose of the MIPS payment
adjustment. We note that eligible
clinicians who bill under both the PFS
and one of these other billing
methodologies (ASC, HHA, Hospice,
and/or HOPD) may be required to
participate in MIPS if they exceed the
low-volume threshold and are otherwise
eligible clinicians; in such case, data
reported would be used to determine
their MIPS payment adjustment. We
solicit public comments on this
proposal.
i. MIPS Eligible Clinician Identifier
As described in the CY 2017 Quality
Payment Program final rule (81 FR
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77057), we established that the use of
multiple identifiers that allow MIPS
eligible clinicians to be measured as an
individual or collectively through a
group’s performance and that the same
identifier be used for all four
performance categories. While we have
multiple identifiers for participation
and performance, we established the use
of a single identifier, TIN/NPI, for
applying the MIPS payment adjustment,
regardless of how the MIPS eligible
clinician is assessed.
(1) Individual Identifiers
As established in the CY 2017 Quality
Payment Program final rule (81 FR
77058), we define a MIPS eligible
clinician at § 414.1305 to mean the use
of a combination of unique billing TIN
and NPI combination as the identifier to
assess performance of an individual
MIPS eligible clinician. Each unique
TIN/NPI combination is considered a
different MIPS eligible clinician, and
MIPS performance is assessed
separately for each TIN under which an
individual bills.
(2) Group Identifiers for Performance
As established in the CY 2017 Quality
Payment Program final rule (81 FR
77059), we codified the definition of a
group at § 414.1305 to mean a group that
consists of a single TIN with two or
more eligible clinicians (including at
least one MIPS eligible clinician), as
identified by their individual NPI, who
have reassigned their billing rights to
the TIN.
(3) APM Entity Group Identifier for
Performance
As described in the CY 2017 Quality
Payment Program final rule (81 FR
77060), we established that each eligible
clinician who is a participant of an APM
Entity is identified by a unique APM
participant identifier. The unique APM
participant identifier is a combination of
four identifiers: (1) APM Identifier
(established by CMS; for example,
XXXXXX); (2) APM Entity identifier
(established under the APM by CMS; for
example, AA00001111); (3) TIN(s) (9
numeric characters; for example,
XXXXXXXXX); (4) EP NPI (10 numeric
characters; for example, 1111111111).
We codified the definition of an APM
Entity group at § 414.1305 to mean a
group of eligible clinicians participating
in an APM Entity, as identified by a
combination of the APM identifier,
APM Entity identifier, TIN, and NPI for
each participating eligible clinician.
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2. Exclusions
a. New Medicare-Enrolled Eligible
Clinician
As established in the CY 2017 Quality
Payment Program final rule (81 FR
77061 through 77062), we defined a
new Medicare-enrolled eligible clinician
at § 414.1305 as a professional who first
becomes a Medicare-enrolled eligible
clinician within the PECOS during the
performance period for a year and had
not previously submitted claims under
Medicare such as an individual, an
entity, or a part of a physician group or
under a different billing number or tax
identifier. Additionally, we established
at § 414.1310(c) that these eligible
clinicians will not be treated as a MIPS
eligible clinician until the subsequent
year and the performance period for
such subsequent year. We established at
§ 414.1310(d) that in no case would a
MIPS payment adjustment apply to the
items and services furnished during a
year by new Medicare-enrolled eligible
clinicians for the applicable
performance period.
We used the term ‘‘new Medicareenrolled eligible clinician determination
period’’ to refer to the 12 months of a
calendar year applicable to the
performance period. During the new
Medicare-enrolled eligible clinician
determination period, we conduct
eligibility determinations on a quarterly
basis to the extent that is technically
feasible to identify new Medicareenrolled eligible clinicians that would
be excluded from the requirement to
participate in MIPS for the applicable
performance period.
b. Qualifying APM Participant (QP) and
Partial Qualifying APM Participant
(Partial QP)
In the CY 2017 Quality Payment
Program final rule (81 FR 77062), we
established at § 414.1305 that a QP (as
defined at § 414.1305) is not a MIPS
eligible clinician, and is therefore
excluded from MIPS. Also, we
established that a Partial QP (as defined,
at § 414.1305) who does not report on
applicable measures and activities that
are required to be reported under MIPS
for any given performance period in a
year is not a MIPS eligible clinician.
c. Low-Volume Threshold
Section 1848(q)(1)(C)(ii)(III) of the Act
provides that the definition of a MIPS
eligible clinician does not include MIPS
eligible clinicians who are below the
low-volume threshold selected by the
Secretary under section 1848(q)(1)(C)(iv)
of the Act for a given year. Section
1848(q)(1)(C)(iv) of the Act requires the
Secretary to select a low-volume
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threshold to apply for the purposes of
this exclusion which may include one
or more of the following: (1) The
minimum number, as determined by the
Secretary, of Part B-enrolled individuals
who are treated by the MIPS eligible
clinician for a particular performance
period; (2) the minimum number, as
determined by the Secretary, of items
and services furnished to Part Benrolled individuals by the MIPS
eligible clinician for a particular
performance period; and (3) the
minimum amount, as determined by the
Secretary, of allowed charges billed by
the MIPS eligible clinician for a
particular performance period.
In the CY 2017 Quality Payment
Program final rule (81 FR 77069 through
77070), we defined individual MIPS
eligible clinicians or groups who do not
exceed the low-volume threshold at
§ 414.1305 as an individual MIPS
eligible clinician or group who, during
the low-volume threshold determination
period, has Medicare Part B allowed
charges less than or equal to $30,000 or
provides care for 100 or fewer Part Benrolled Medicare beneficiaries. We
established at § 414.1310(b) that for a
year, MIPS eligible clinicians who do
not exceed the low-volume threshold (as
defined at § 414.1305) are excluded
from MIPS for the performance period
for a given calendar year.
In the CY 2017 Quality Payment
Program final rule (81 FR 77069 through
77070), we defined the low-volume
threshold determination period to mean
a 24-month assessment period, which
includes a two-segment analysis of
claims data during an initial 12-month
period prior to the performance period
followed by another 12-month period
during the performance period. The
initial 12-month segment of the lowvolume threshold determination period
spans from the last 4 months of a
calendar year 2 years prior to the
performance period followed by the first
8 months of the next calendar year and
includes a 60-day claims run out, which
allows us to inform eligible clinicians
and groups of their low-volume status
during the month (December) prior to
the start of the performance period. The
second 12-month segment of the lowvolume threshold determination period
spans from the last 4 months of a
calendar year 1 year prior to the
performance period followed by the first
8 months of the performance period in
the next calendar year and includes a
60-day claims run out, which allows us
to inform additional eligible clinicians
and groups of their low-volume status
during the performance period.
We recognize that individual MIPS
eligible clinicians and groups that are
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small practices or practicing in
designated rural areas face unique
dynamics and challenges such as fiscal
limitations and workforce shortages, but
serve as a critical access point for care
and provide a safety net for vulnerable
populations. Claims data shows that
approximately 15 percent of individual
MIPS eligible clinicians (TIN/NPIs) are
considered to be practicing in rural
areas after applying all exclusions. Also,
we have heard from stakeholders that
MIPS eligible clinicians practicing in
small practices and designated rural
areas tend to have a patient population
with a higher proportion of older adults,
as well as higher rates of poor health
outcomes, co-morbidities, chronic
conditions, and other social risk factors,
which can result in the costs of
providing care and services being
significantly higher compared to nonrural areas. We also have heard from
many solo practitioners and small
practices who still face challenges and
additional resource burden in
participating in the MIPS.
In the CY 2017 Quality Payment
Program final rule, we did not establish
an adjustment for social risk factors in
assessing and scoring performance. In
response to the CY 2017 Quality
Payment Program final rule, we received
public comments indicating that
individual MIPS eligible clinicians and
groups practicing in designated rural
areas would be negatively impacted and
at a disadvantage if assessment and
scoring methodology did not adjust for
social risk factors. Additionally,
commenters expressed concern that
such individual MIPS eligible clinicians
and groups may be disproportionately
more susceptible to lower performance
scores across all performance categories
and negative MIPS payments
adjustments, and as a result, such
outcomes may further strain already
limited fiscal resources and workforce
shortages, and negatively impact access
to care (reduction and/or elimination of
available services).
After the consideration of stakeholder
feedback provided during informal
listening sessions since the publication
of the CY 2017 Quality Payment
Program final rule, we are proposing to
modify the low-volume threshold policy
established in the CY 2017 Quality
Payment Program final rule. We believe
that increasing the dollar amount and
beneficiary count of the low-volume
threshold would further reduce the
number of eligible clinicians that are
required to participate in the MIPS,
which would reduce the burden on
individual MIPS eligible clinicians and
groups practicing in small practices and
designated rural areas. Based on our
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analysis of claims data, we found that
increasing the low-volume threshold to
to exclude individual eligible clinicians
or groups that have Medicare Part B
allowed charges less than or equal to
$90,000 or that provide care for 200 or
fewer Part B-enrolled Medicare
beneficiaries will exclude
approximately 134,000 additional
clinicians from MIPS from the
approximately 700,000 clinicians that
would have been eligible based on the
low-volume threshold that was finalized
in the CY 2017 Quality Payment
Program final rule. Almost half of the
additionally excluded clinicians are in
small practices and approximately 17
percent are clinicians from practices in
designated rural areas. Applying this
criterion decreases the percent of the
MIPS eligible clinicians that come from
small practices. For example, prior to
any exclusions, clinicians in small
practices represent 35 percent of all
clinicians billing Part B services. After
applying the eligibility criteria for the
CY 2017 Quality Payment Program final
rule, MIPS eligible clinicians in small
practices represent approximately 27
percent of the clinicians eligible for
MIPS; however, with the increased lowvolume threshold, approximately 22
percent of the clinicians eligible for
MIPS are from small practices. In our
analysis, the proposed changes to the
low-volume threshold showed little
impact on MIPS eligible clinicians from
practices in designated rural areas.
MIPS eligible clinicians from practices
in designated rural areas account for 15
to 16 percent of the total MIPS eligible
population. We note that, due to data
limitations, we assessed rural status
based on the status of individual TIN/
NPI and did not model any group
definition for practices in designated
rural areas.
We believe that increasing the number
of such individual eligible clinicians
and groups excluded from MIPS
participation would reduce burden and
mitigate, to the extent feasible, the issue
surrounding confounding variables
impacting performance under the MIPS.
Therefore, beginning with the 2018
MIPS performance period, we are
proposing to increase the low-volume
threshold. Specifically, at § 414.1305,
we are proposing to define an
individual MIPS eligible clinician or
group who does not exceed the lowvolume threshold as an individual MIPS
eligible clinician or group who, during
the low-volume threshold determination
period, has Medicare Part B allowed
charges less than or equal to $90,000 or
provides care for 200 or fewer Part Benrolled Medicare beneficiaries. This
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would mean that 37 percent of
individual MIPS eligible clinicians and
groups would be in MIPS based on the
low-volume threshold exclusion (and
the other exclusions). However, 65
percent of Medicare payments would
still be captured under MIPS compared
to 72.2 percent of Medicare payments
under the CY 2017 Quality Payment
Program final rule.
We recognize that increasing the
dollar amount and beneficiary count of
the low-volume threshold would
increase the number of individual MIPS
eligible clinicians and groups excluded
from MIPS. We assessed various levels
of increases and found that $90,000 as
the dollar amount and 200 as the
beneficiary count balances the need to
account for individual MIPS eligible
clinicians and groups who face
additional participation burden while
not excluding a significant portion of
the clinician population.
MIPS eligible clinicians who do not
exceed the low-volume threshold (as
defined at § 414.1305) are excluded
from MIPS for the performance period
with respect to a year. The low-volume
threshold also applies to MIPS eligible
clinicians who practice in APMs under
the APM scoring standard at the APM
Entity level, in which APM Entities do
not exceed the low-volume threshold. In
such cases, the MIPS eligible clinicians
participating in the MIPS APM Entity
would be excluded from the MIPS
requirements for the applicable
performance period and not subject to a
MIPS payment adjustment for the
applicable year. Such an exclusion
would not affect an APM Entity’s QP
determination if the APM Entity is an
Advanced APM.
In the CY 2017 Quality Payment
Program final rule, we established the
low-volume threshold determination
period to refer to the timeframe used to
assess claims data for making eligibility
determinations for the low-volume
threshold exclusion (81 FR 77069
through 77070). We defined the lowvolume threshold determination period
to mean a 24-month assessment period,
which includes a two-segment analysis
of claims data during an initial 12month period prior to the performance
period followed by another 12-month
period during the performance period.
Based on our analysis of data from the
initial segment of the low-volume
threshold determination period for
performance periods occurring in 2017
(that is, data spanning from September
1, 2015 to August 31, 2016), we found
that it may not be necessary to include
a 60-day claims run out since we could
achieve a similar outcome for such
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eligibility determinations by utilizing a
30-day claims run out.
In our comparison of data analysis
results utilizing a 60-day claims run out
versus a 30-day claims run out, there
was a 1 percent decrease in data
completeness. The small decrease in
data completeness would not
substantially impact individual MIPS
eligible clinicians or groups regarding
low-volume threshold determinations.
We believe that a 30-day claims run out
would allow us to complete the analysis
and provide such determinations in a
more timely manner. For performance
periods occurring in 2018 and future
years, we propose a modification to the
low-volume threshold determination
period, in which the initial 12-month
segment of the low-volume threshold
determination period would span from
the last 4 months of a calendar year 2
years prior to the performance period
followed by the first 8 months of the
next calendar year and include a 30-day
claims run out; and the second 12month segment of the low-volume
threshold determination period would
span from the last 4 months of a
calendar year 1 year prior to the
performance period followed by the first
8 months of the performance period in
the next calendar year and include a 30day claims run out. This proposal
would only change the duration of the
claims run out, not the 12-month
timeframes used for the first and second
segments of data analysis.
For purposes of the 2020 MIPS
payment year, we would initially
identify individual eligible clinicians
and groups that do not exceed the lowvolume threshold based on 12 months
of data starting from September 1, 2016
to August 31, 2017. To account for the
identification of additional individual
eligible clinicians and groups that do
not exceed the low-volume threshold
during performance periods occurring
in 2018, we would conduct another
eligibility determination analysis based
on 12 months of data starting from
September 1, 2017 to August 31, 2018.
We would not change the low-volume
status of any individual eligible
clinician or group identified as not
exceeding the low-volume threshold
during the first eligibility determination
analysis based on the second eligibility
determination analysis. Thus, an
individual eligible clinician or group
that is identified as not exceeding the
low-volume threshold during the first
eligibility determination analysis would
continue to be excluded from MIPS for
the duration of the performance period
regardless of the results of the second
eligibility determination analysis. We
established our policy to include two
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eligibility determination analyses in
order to prevent any potential confusion
for an individual eligible clinician or
group to know whether or not
participate in MIPS; also, such policy
makes it clear from the onset as to
which individual eligible clinicians and
groups would be required to participate
in MIPS. We would conduct the second
eligibility determination analysis to
account for the identification of
additional, previously unidentified
individual eligible clinicians and groups
who do not exceed the low-volume
threshold. We note that low-volume
threshold determinations are made at
the individual and group level, and not
at the virtual group level.
We note that section 1848(q)(1)(C)(iv)
of the Act requires the Secretary to
select a low-volume threshold to apply
for the purposes of this exclusion which
may include one or more of the
following: (1) The minimum number, as
determined by the Secretary, of Part Benrolled individuals who are treated by
the MIPS eligible clinician for a
particular performance period; (2) the
minimum number, as determined by the
Secretary, of items and services
furnished to Part B-enrolled individuals
by the MIPS eligible clinician for a
particular performance period; and (3)
the minimum amount, as determined by
the Secretary, of allowed charges billed
by the MIPS eligible clinician for a
particular performance period. We have
established a low-volume threshold that
accounts for the minimum number of
Part-B enrolled individuals who are
treated by a MIPS eligible clinician and
that accounts for the minimum amount
of allowed charges billed by a MIPS
eligible clinician. We have not made
proposals specific to a minimum
number of items and service furnished
to Part-B enrolled individuals by a MIPS
eligible clinician.
In order to expand the ways in which
claims data could be analyzed for
purposes of determining a more
comprehensive assessment of the lowvolume threshold, we have assessed the
option of establishing a low-volume
threshold for items and services
furnished to Part-B enrolled individuals
by a MIPS eligible clinician. We have
considered defining items and services
by using the number of patient
encounters or procedures associated
with a clinician. Defining items and
services by patient encounters would
assess each patient per visit or
encounter with the MIPS eligible
clinician. We believe that defining items
and services by using the number of
patient encounters or procedures is a
simple and straightforward approach for
stakeholders to understand. However,
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we are concerned that using this unit of
analysis could incentivize clinicians to
focus on volume of services rather than
the value of services provided to
patients. Defining items and services by
procedure would tie a specific clinical
procedure rendered to a patient to a
clinician. We solicit public comment on
the methods of defining items and
services furnished by clinicians
described above and alternate methods
of defining items and services.
For the individual MIPS eligible
clinicians and groups that would be
excluded from MIPS participation as a
result of an increased low-volume
threshold, we believe that in future
years it would be beneficial to provide,
to the extent feasible, such individual
MIPS eligible clinicians and groups
with the option to opt-in to MIPS
participation if they might otherwise be
excluded under the low-volume
threshold such as where they only meet
one of the threshold determinations
(including a third determination based
on Part B items and services, if
established). For example, if a clinician
meets the low-volume threshold of
$90,000 in allowed charges, but does
not meet the threshold of 200 patients
or, if established, the threshold
pertaining to Part B items and services,
we believe the clinician should, to the
extent feasible, have the opportunity to
choose whether or not to participate in
the MIPS and be subject to MIPS
payment adjustments. We recognize that
this choice would present additional
complexity to clinicians in
understanding all of their available
options and may impose additional
burden on clinicians by requiring them
to notify CMS of their decision. Because
of these concerns and our desire to
establish options in a way that is a lowburden and user-focused experience for
all MIPS eligible clinicians, we would
not be able to offer this additional
flexibility until performance periods
occurring in 2019. Therefore, as a means
of expanding options for clinicians and
offering them the ability to participate
in MIPS if they otherwise would not be
included, for the purposes of the 2021
MIPS payment year, we propose to
provide clinicians the ability to opt-in to
the MIPS if they meet or exceed one, but
not all, of the low-volume threshold
determinations, including as defined by
dollar amount, beneficiary count or, if
established, items and services. We
request public comment on this
proposal.
We note that there may be additional
considerations we should address for
scenarios in which an individual
eligible clinician or a group does not
exceed the low-volume threshold and
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opts-in to participate in MIPS. We
therefore seek comment on any
additional considerations we should
address when establishing this opt-in
policy. Such as, should we establish
parameters for individual clinicians or
groups who elect to opt-in to participate
in MIPS such as required length of
participation? Additionally, we note
that there is the potential with this optin policy for there to be an impact on
our ability to create quality benchmarks
that meet our sample size requirements.
For example, if particularly small
practices or solo practitioners with low
Part B beneficiary volumes opt-in, such
clinician’s may lack sufficient sample
size to be scored on many quality
measures, especially measures that do
not apply to all of a MIPS eligible
clinician’s patients. We therefore seek
comment on how to address any
potential impact on our ability to create
quality benchmarks that meet our
sample size requirements.
We solicit public comments on these
proposals.
3. Group Reporting
a. Background
As described in the CY 2017 Quality
Payment Program final rule, we
established the following requirements
for groups (81 FR 77072):
• Individual eligible clinicians and
individual MIPS eligible clinicians will
have their performance assessed as a
group as part of a single TIN associated
with two or more eligible clinicians
(including at least one MIPS eligible
clinician), as identified by a NPI, who
have reassigned their Medicare billing
rights to the TIN (at § 414.1310(e)(1)).
• A group must meet the definition of
a group at all times during the
performance period for the MIPS
payment year in order to have its
performance assessed as a group (at
§ 414.1310(e)(2)).
• Individual eligible clinicians and
individual MIPS eligible clinicians
within a group must aggregate their
performance data across the TIN to have
their performance assessed as a group
(at § 414.1310(e)(3)).
• A group that elects to have its
performance assessed as a group will be
assessed as a group across all four MIPS
performance categories (at
§ 414.1310(e)(4)).
As noted in the CY 2017 Quality
Payment Program final rule, we would
not make an eligibility determination
regarding group size, but indicated that
groups would attest to their group size
for purpose of using the CMS Web
Interface or a group identifying as a
small practice (81 FR 77057). In section
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II.C.1.d. of this proposed rule, we are
proposing to modify the way in which
size would be determined for small
practices by establishing a process
under which CMS would utilize claims
data to make small practice size
determinations. Also, in section II.C.4.e.
of this proposed rule, we are proposing
to establish a policy under which CMS
would utilize claims data to determine
group size for groups of 10 or fewer
eligible clinicians seeking to form or
join a virtual group.
As noted in the CY 2017 Quality
Payment Program final rule, a group size
would be determined before exclusions
are applied (81 FR 77057). We note that
group size determinations are based on
the number of NPIs associated with a
TIN, which would include clinicians
(NPIs) who may be excluded from MIPS
participation and do not meet the
definition of a MIPS eligible clinician.
b. Registration
As described in the CY 2017 Quality
Payment Program final rule (81 FR
77072 through 77073), we established,
the following policies:
• A group must adhere to an election
process established and required by
CMS (§ 414.1310(e)(5)), which includes:
++ Groups will not be required to
register to have their performance
assessed as a group except for groups
submitting data on performance
measures via participation in the CMS
Web Interface or groups electing to
report the CAHPS for MIPS survey for
the quality performance category. For all
other data submission mechanisms,
groups must work with appropriate
third party intermediaries as necessary
to ensure the data submitted clearly
indicates that the data represent a group
submission rather than an individual
submission.
++ In order for groups to elect
participation via the CMS Web Interface
or administration of the CAHPS for
MIPS survey, such groups must register
by June 30 of the applicable
performance period (that is, June 30,
2018, for performance periods occurring
in 2018). We note that groups
participating in APMs that require APM
Entities to report using the CMS Web
Interface are not required to register for
the CMS Web Interface or administer
the CAHPS for MIPS survey separate
from the APM.
When groups submit data utilizing
third party intermediaries, such as a
qualified registry, QCDR, or EHR, we are
able to obtain group information from
the third party intermediary and discern
whether the data submitted represents
group submission or individual
submission once the data are submitted.
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In the CY 2017 Quality Payment
Program final rule (81 FR 77072 through
77073), we discussed the
implementation of a voluntary
registration process if technically
feasible. Since the publication of the CY
2017 Quality Payment Program final
rule, we have determined that it is not
technically feasible to develop and
build a voluntary registration process.
Until further notice, we are not
implementing a voluntary registration
process.
Also, in the CY 2017 Quality Payment
Program final rule (81 FR 77075), we
expressed our commitment to pursue
the active engagement of stakeholders
throughout the process of establishing
and implementing virtual groups. We
received public comments in response
to the CY 2017 Quality Payment
Program final rule and additional
stakeholder feedback by hosting several
virtual group listening sessions and
convening user groups. Many
stakeholders requested that CMS
provide an option that would permit a
portion of a group to participate in MIPS
outside the group by reporting as a
separate subgroup or forming a virtual
group. Stakeholders indicated that the
option would measure performance
more effectively, enable groups to
identify areas for improvement at a
granular level that would further
improve quality of care and health
outcomes, and increase coordination of
care.
We recognize that groups, including
multi-specialty groups, have requested
over the years that we make an option
available to them that would allow a
portion of a group to report as a separate
subgroup on measures and activities
that are more applicable to the subgroup
and be assessed and scored accordingly
based on the performance of the
subgroup. In future rulemaking, we
intend to explore the feasibility of
establishing group-related policies that
would permit participation in MIPS at
a subgroup level and create such
functionality through a new identifier.
We solicit public comment on the ways
in which participation in MIPS at the
subgroup level could be established.
4. Virtual Groups
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a. Background
There are generally three ways to
participate in MIPS: (1) Individual-level
reporting; (2) group-level reporting; and
(3) virtual group-level reporting. We
refer readers to sections II.C.1., II.C.3.,
and II.C.5. of this proposed rule for a
discussion of the previously established
requirements for individual- and grouplevel participation and our proposed
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policies for performance periods
occurring in 2018 and future years. In
this rule, we are proposing to establish
requirements for MIPS participation at
the virtual group level.
Section 1848(q)(5)(I) of the Act
provides for the use of voluntary virtual
groups for certain assessment purposes,
including the election of practices to be
a virtual group and the requirements for
the election process. Section
1848(q)(5)(I)(i) of the Act provides that
MIPS eligible clinicians electing to be a
virtual group must: (1) Have their
performance assessed for the quality
and cost performance categories in a
manner that applies the combined
performance of all the MIPS eligible
clinicians in the virtual group to each
MIPS eligible clinician in the virtual
group for the applicable performance
period; and (2) be scored for the quality
and cost performance categories based
on such assessment. Section
1848(q)(5)(I)(ii) of the Act requires, in
accordance with section
1848(q)(5)(I)(iii) of the Act, the
establishment and implementation of a
process that allows an individual MIPS
eligible clinician or a group consisting
of not more than 10 MIPS eligible
clinicians to elect, for a given
performance period, to be a virtual
group with at least one other such
individual MIPS eligible clinician or
group. The virtual group may be based
on appropriate classifications of
providers, such as by geographic areas
or by provider specialties defined by
nationally recognized specialty boards
of certification or equivalent
certification boards.
Section 1848(q)(5)(I)(iii) of the Act
provides that the virtual group election
process must include the following
requirements: (1) An individual MIPS
eligible clinician or group electing to be
in a virtual group must make their
election prior to the start of the
applicable performance period and
cannot change their election during the
performance period; (2) an individual
MIPS eligible clinician or group may
elect to be in no more than one virtual
group for a performance period, and, in
the case of a group, the election applies
to all MIPS eligible clinicians in the
group; (3) a virtual group is a
combination of TINs; (4) the
requirements must provide for formal
written agreements among individual
MIPS eligible clinicians and groups
electing to be a virtual group; and (5)
such other requirements as the Secretary
determines appropriate.
b. Definition of a Virtual Group
As noted above, section
1848(q)(5)(I)(ii) of the Act requires, in
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30027
accordance with section
1848(q)(5)(I)(iii) of the Act, the
establishment and implementation of a
process that allows an individual MIPS
eligible clinician or group consisting of
not more than 10 MIPS eligible
clinicians to elect, for a given
performance period, to be a virtual
group with at least one other such
individual MIPS eligible clinician or
group. Given that section
1848(q)(5)(I)(iii)(V) of the Act provides
that a virtual group is a combination of
TINs, we interpret the references to an
‘‘individual’’ MIPS eligible clinician in
section 1848(q)(5)(I)(ii) of the Act to
mean a solo practitioner, which, for
purposes of section 1848(q)(5)(I) of the
Act, we propose to define as a MIPS
eligible clinician (as defined at
§ 414.1305) who bills under a TIN with
no other NPIs billing under such TIN.
Also, we recognize that a group (TIN)
may include not only NPIs who meet
the definition of a MIPS eligible
clinician, but also NPIs who do not meet
the definition of a MIPS eligible
clinician at § 414.1305 and who are
excluded from MIPS under
§ 414.1310(b) or (c) based on one of four
exclusions (new Medicare-enrolled
eligible clinician; QP; Partial QP who
chooses not to report on measures and
activities under MIPS; and eligible
clinicians that do not exceed the lowvolume threshold). Thus, we interpret
the references to a group ‘‘consisting of
not more than 10’’ MIPS eligible
clinicians in section 1848(q)(5)(I)(ii) of
the Act to mean that a group with 10 or
fewer eligible clinicians (as defined at
§ 414.1305) would be eligible to form or
join a virtual group. For purposes of the
MIPS payment adjustment, the
adjustment would apply only to NPIs in
the virtual group who meet the
definition of a MIPS eligible clinician at
§ 414.1305 and who are not excluded
from MIPS under § 414.1310(b) or (c).
We note that such groups, as defined at
§ 414.1305, would need to include at
least one MIPS eligible clinician in
order to be eligible to join or form a
virtual group. We refer readers to
section II.C.4.g. of this proposed rule for
discussion regarding the assessment and
scoring of groups participating in MIPS
as a virtual group.
We propose to define a virtual group
at § 414.1305 as a combination of two or
more TINs composed of a solo
practitioner (a MIPS eligible clinician
(as defined at § 414.1305) who bills
under a TIN with no other NPIs billing
under such TIN), or a group (as defined
at § 414.1305) with 10 or fewer eligible
clinicians under the TIN that elects to
form a virtual group with at least one
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other such solo practitioner or group for
a performance period for a year.
Lastly, we note that qualifications as
a virtual group for purposes of MIPS do
not change the application of the
physician self-referral law to a financial
relationship between a physician and an
entity furnishing designated health
services, nor does it change the need for
such a financial relationship to comply
with the physician self-referral law.
We note that while entire TINs
participate in a virtual group, including
each NPI under a TIN, and are assessed
and scored collectively as a virtual
group, only NPIs that meet the
definition of a MIPS eligible clinician
would be subject to a MIPS payment
adjustment. However, we note that, as
discussed in section II.C.4.h. of this
proposed rule, any MIPS eligible
clinician who is part of a TIN
participating in a virtual group and
participating in a MIPS APM or
Advanced APM under the MIPS APM
scoring standard would not receive a
MIPS payment adjustment based on the
virtual group’s final score, but would
receive a payment adjustment based on
the MIPS APM scoring standard.
Additionally, we recognize that there
are circumstances in which a TIN may
have one portion of its NPIs
participating under the generally
applicable MIPS scoring criteria while
the remaining portion of NPIs under the
TIN is participating in a MIPS APM or
an Advanced APM under the MIPS
APM scoring standard. In the CY 2017
Quality Payment Program final rule (81
FR 77058), we noted that except for
groups containing APM participants, we
are not permitting groups to ‘‘split’’
TINs if they choose to participate in
MIPS as a group (81 FR 77058). Thus,
we consider a group to mean an entire
single TIN that elects to participate in
MIPS at the group or virtual group level,
including groups that have a portion of
its NPIs participating in a MIPS APM or
an Advanced APM. We note that such
groups would participate in MIPS
similar to other groups.
To clarify, for all groups, including
groups containing participants in a
MIPS APM or an Advanced APM, the
group’s performance assessment
consists of the entire TIN regardless of
whether the group participates in MIPS
as part of a virtual group. Generally, for
groups other than groups containing
participants in a MIPS APM or an
Advanced APM, each MIPS eligible
clinician under the TIN (TIN/NPI)
receives a MIPS adjustment based on
the entire group’s performance
assessment (entire TIN). For groups
containing participants in a MIPS APM
or an Advanced APM, only the portion
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of the TIN that is being scored for MIPS
according to the generally applicable
scoring criteria (TIN/NPI) receives a
MIPS adjustment based on the entire
group’s performance assessment (entire
TIN). The remaining portion of the TIN
that is being scored according to the
APM scoring standard (TIN/NPI)
receives a MIPS adjustment based on
that standard, or may be exempt from
MIPS if they achieve QP or Partial QP
status.
We propose to apply a similar policy
to groups, including groups containing
participants in a MIPS APM or an
Advanced APM, that are participating in
MIPS as part of a virtual group.
Specifically, for groups other than
groups containing participants in a
MIPS APM or an Advanced APM, each
MIPS eligible clinician (TIN/NPI) would
receive a MIPS adjustment based on the
virtual group’s combined performance
assessment (combination of TINs). For
groups containing participants in a
MIPS APM or an Advanced APM, only
the portion of the TIN that is being
scored for MIPS according to the
generally applicable scoring criteria
(TIN/NPI) would receive a MIPS
adjustment based on the virtual group’s
combined performance assessment
(combination of TINs). As discussed in
section II.C.4.h. of this proposed rule,
we are proposing to use waiver
authority to ensure that any participants
in the group who are participating in a
MIPS APM receive their payment
adjustment based on their score under
the APM scoring standard (TIN/NPI).
Such participants may be exempt from
MIPS if they achieve QP or Partial QP
status.
We refer readers to section II.C.4.e. of
this proposed rule for a discussion of
the proposed virtual group election
process and section II.C.4.g. of this
proposed rule for discussion of our
proposals regarding the assessment and
scoring of virtual groups.
We recognize that virtual groups
would each have unique characteristics
and varying patient populations. As
noted in section II.C.4.a. of this
proposed rule, the statute provides the
Secretary with discretion to establish
appropriate classifications regarding the
composition of virtual groups such as by
geographic area or specialty. However,
we believe it is important for virtual
groups to have the flexibility to
determine their own composition at this
time, and, as a result, we are not
proposing to establish any such
classifications regarding virtual group
composition. We further note that the
statute does not limit the number of
TINs that may form a virtual group, and
we are not proposing to establish such
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a limit at this time. We did consider
however proposing to establish such a
limit, such as 50 or 100 participants. In
particular, we are concerned that virtual
groups of too substantial a size (for
example, 10 percent of all MIPS eligible
clinicians in a given specialty or subspecialty) may make it difficult to
compare performance between and
among clinicians. We believe that
limiting the number of virtual group
participants could eventually assist
virtual groups as they aggregate their
performance data across the virtual
group. However, we believe that as we
initially implement virtual groups, it is
important for virtual groups to have the
flexibility to determine their own size,
and thus, a better approach is to not
place such a limit on virtual group size.
We will, however, monitor the ways in
which solo practitioners and groups
with 10 or fewer eligible clinicians form
virtual groups and may propose to
establish appropriate classifications
regarding virtual group composition or
a limit on the number of TINs that may
form a virtual group in future
rulemaking as necessary. We solicit
public comment on these proposals, as
well as our approach of not establishing
appropriate classifications (such as
classification by geographic area or
specialty) regarding virtual group
composition or a limit on the number of
TINs that may form a virtual group at
this time.
In the CY 2017 Quality Payment
Program final rule (81 FR 77073 through
77077), we expressed our commitment
to pursue the active engagement of
stakeholders throughout the process of
establishing and implementing virtual
groups. We received public comments
in response to the CY 2017 Quality
Payment Program final rule and
additional stakeholder feedback by
hosting several virtual group listening
sessions and convening user groups.
Many stakeholders requested that CMS
provide an option that would permit a
portion of a group to participate in MIPS
outside the group by reporting
separately or forming a virtual group.
We refer readers to section II.C.b.3. of
this proposed rule for discussion
regarding a potential option for
addressing such issue.
c. MIPS Virtual Group Identifier for
Performance
To ensure that we have accurately
captured all of the MIPS eligible
clinicians participating in a virtual
group, we propose that each MIPS
eligible clinician who is part of a virtual
group would be identified by a unique
virtual group participant identifier. The
unique virtual group participant
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identifier would be a combination of
three identifiers: (1) Virtual group
identifier (established by CMS; for
example, XXXXXX); (2) TIN (9 numeric
characters; for example, XXXXXXXXX);
and (3) NPI (10 numeric characters; for
example, 1111111111). For example, a
virtual participant identifier could be
VG–XXXXXX, TIN–XXXXXXXXX, NPI–
11111111111. We solicit public
comment on this proposal.
d. Application of MIPS Group Policies
to Virtual Groups
In the CY 2017 Quality Payment
Program final rule (81 FR 77070 through
77072), we finalized various
requirements for groups under MIPS at
§ 414.1310(e), under which groups
electing to report at the group level are
assessed and scored across the TIN for
all four performance categories. We
propose to apply our previously
finalized and proposed group policies to
virtual groups, unless otherwise
specified. We recognize that there are
instances in which we may need to
clarify or modify the application of
certain previously finalized or proposed
group-related policies to virtual groups,
such as the definition of a non-patient
facing MIPS eligible clinician; small
practice, rural area and HPSA
designations; and groups that have a
portion of its NPIs participating in a
MIPS APM or an Advanced APM (see
section II.C.4.b. of this proposed rule).
More generally, such policies may
include those that require a calculation
of the number of NPIs across a TIN
(given that a virtual group is a
combination of TINs), the application of
any virtual group participant’s status or
designation to the entire virtual group,
and the applicability and availability of
certain measures and activities to any
virtual group participant and to the
entire virtual group.
With regard to the applicability of the
non-patient facing policies to virtual
groups, in the CY 2017 Quality Payment
Program final rule (81 FR 77048 through
77049), we defined the term non-patient
facing MIPS eligible clinician at
§ 414.1305 as an individual MIPS
eligible clinician that bills 100 or fewer
patient facing encounters (including
Medicare telehealth services defined in
section 1834(m) of the Act) during the
non-patient facing determination
period, and a group provided that more
than 75 percent of the NPIs billing
under the group’s TIN meet the
definition of a non-patient facing
individual MIPS eligible clinician
during the non-patient facing
determination period. We are proposing
to modify the definition of a non-patient
facing MIPS eligible clinician to include
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clinicians in a virtual group provided
that more than 75 percent of the NPIs
billing under the virtual group’s TINs
meet the definition of a non-patient
facing individual MIPS eligible clinician
during the non-patient facing
determination period. We refer readers
to section II.C.4.f. of this rule for the
proposed modification. We note that
other policies previously established
and proposed in this proposed rule for
non-patient facing groups would apply
to virtual groups. For example, as
discussed in section II.C.1.e. of this
proposed rule, virtual groups
determined to be non-patient facing
would have their advancing care
information performance category
automatically reweighted to zero.
In regard to the application of small
practice status to virtual groups, we are
proposing that a virtual group would be
identified as having a small practice
status if the virtual group does not have
16 or more members of a virtual group
(NPIs). We refer readers to section
II.C.4.d. of this proposed rule for
discussion regarding how small practice
status would apply to virtual groups for
scoring under MIPS. In the CY 2017
Quality Payment Program final rule (81
FR 77188), we defined the term small
practices at § 414.1305 as practices
consisting of 15 or fewer clinicians and
solo practitioners. In section II.C.1.c. of
this proposed rule, we are proposing for
performance periods occurring in 2018
and future years to identify small
practices by utilizing claims data. For
performance periods occurring in 2018,
we would identify small practices based
on 12 months of data starting from
September 1, 2016 to August 31, 2017.
In section II.C.1.e. of this rule, we
propose to determine rural area and
HPSA practice designations for groups
participating in MIPS at the group level.
We note that in section II.C.7.b we
describe our scoring proposals for
practices that are in a rural area or
HPSA practice. For performance periods
occurring in 2018 and future years, we
are proposing that a group with 75
percent or more of the TIN’s practice
sites designated as rural areas or HPSA
practices would be designated as a rural
area or HPSA at the group level. We are
proposing that a virtual group with 75
percent or more of the virtual group’s
TINs designated as rural areas or HPSA
practices would be designated as a rural
area or HPSA practice at the virtual
group level. We note that other policies
previously established and proposed in
this proposed rule for rural area and
HPSA groups would apply to virtual
groups.
We recognize that the measures and
activities available to groups would also
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30029
be available to virtual groups. Virtual
groups would be required to meet the
reporting requirements for each measure
and activity, and the virtual group
would be responsible for ensuring that
their measures and activities are
aggregated across the virtual group (for
example, across their TINs). We note
that other previously established grouprelated policies and proposed policies
in this proposed rule pertaining to the
four performance categories would
apply to virtual groups.
Therefore, we propose to apply MIPS
group policies to virtual groups except
as otherwise specified. We solicit public
comment on this proposal. We are also
interested on receiving feedback on how
such group-related policies previously
established and proposed in this
proposed rule either would or would
not apply to virtual groups. In addition,
we request public comment on any
other policies that may need to be
clarified or modified with respect to
virtual groups, such as those that
require a calculation of the number of
NPIs across a TIN (given that a virtual
group is a combination of TINs), the
application of any virtual group
participant’s status or designation to the
entire virtual group, the application of
the group reporting requirements for the
individual performance categories to
virtual groups, and the applicability and
availability of certain measures and
activities to any virtual group
participant and to the entire virtual
group.
e. Election Process
As noted above, section
1848(q)(5)(I)(iii)(I) and (II) of the Act
provides that the virtual group election
process must include certain
requirements, including that: (1) An
individual MIPS eligible clinician or
group electing to be in a virtual group
must make their election prior to the
start of the applicable performance
period and cannot change their election
during the performance period; and (2)
an individual MIPS eligible clinician or
group may elect to be in no more than
one virtual group for a performance
period, and, in the case of a group, the
election applies to all MIPS eligible
clinicians in the group. We propose to
codify at § 414.1315(a) that a solo
practitioner or a group of 10 or fewer
eligible clinicians must make their
election prior to the start of the
applicable performance period and
cannot change their election during the
performance period. Virtual group
participants may elect to be in no more
than one virtual group for a performance
period and, in the case of a group, the
election applies to all MIPS eligible
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clinicians in the group. For the 2018
performance year and future years, we
are proposing to establish an election
period.
We propose to codify at § 414.1315(b)
that, beginning with performance
periods occurring in 2018, a solo
practitioner, or group of 10 or fewer
eligible clinicians electing to be in a
virtual group must make their election
by December 1 of the calendar year
preceding the applicable performance
period. For example, a solo practitioner
or group would need to make their
election by December 1, 2017 to
participate in MIPS as a virtual group
during the 2018 performance period.
Prior to the election deadline, a virtual
group representative would have the
opportunity to make an election, on
behalf of the members of a virtual group,
regarding the formation of a virtual
group for an applicable performance
period. We intend to publish the
beginning date of the virtual group
election period applicable to the 2018
performance period and future years in
subregulatory guidance.
In order to provide support and
reduce burden, we intend to make
technical assistance (TA) available, to
the extent feasible and appropriate, to
support clinicians who choose to come
together as a virtual group. Clinicians
can access TA infrastructure and
resources that they may already be
utilizing). For Quality Payment Program
year 3, we intend to provide an
electronic election process if technically
feasible. We propose that clinicians who
do not elect to contact their designated
TA representative would still have the
option of contacting the Quality
Payment Program Service Center.
We propose to codify at § 414.1315(c)
a two-stage virtual group election
process, stage 1 of which is optional, for
the applicable 2018 and 2019
performance periods. Stage 1 pertains to
virtual group eligibility determinations.
In stage 1, solo practitioners and groups
with 10 or fewer eligible clinicians
interested in forming or joining a virtual
group would have the option to contact
their designated TA representative or
the Quality Payment Program Service
Center in order to obtain information
pertaining to virtual groups and/or
determine whether or not they are
eligible, as it relates to the practice size
requirement of a solo practitioner or a
group of 10 or fewer eligible clinicians,
to participate in MIPS as a virtual group
(§ 414.1315(a)(1)(i)). We note that
activity involved in stage 1 is not
required, but a resource available to solo
practitioners and groups with 10 or
fewer eligible clinicians; otherwise, solo
practitioners or groups with 10 or fewer
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eligible clinicians that do not engage in
any activity during stage 1, they would
begin the election process at stage 2. For
solo practitioners and groups who
engage in stage 1 and were determined
eligible for virtual group participation,
they would proceed to stage 2. Engaging
in stage 1 would provide solo
practitioners and groups with the option
to confirm whether or not they are
eligible to join or form a virtual group
before going to the lengths of executing
formal written agreements, submitting a
formal election registration, allocating
resources for virtual group
implementation, and other related
activities; whereas, engaging directly in
stage 2 as an initial step, solo
practitioners and groups may have
conducted all such efforts to only have
their election registration be rejected
with no recourse or remaining time to
amend and resubmit.
During stage 1 of the virtual group
election process, we would determine
whether or not a TIN is eligible to form
or join a virtual group. In order for a
solo practitioner to be eligible to form or
join a virtual group, the solo practitioner
would need to be considered a MIPS
eligible clinician (defined at § 414.1305)
who bills under a TIN with no other
NPIs billing under such TIN, and not
excluded from MIPS under
§ 414.1310(b) and (c). In order for a
group to be eligible to form or join a
virtual group, a group would need to
have a TIN size that does not exceed 10
eligible clinicians and not excluded
from MIPS based on the low-volume
threshold exclusion at the group level.
For purposes of determining TIN size
for virtual group participation
eligibility, we coin the term ‘‘virtual
group eligibility determination period’’
and define it to mean an analysis of
claims data during an assessment period
of up to five months that would begin
on July 1 and end as late as November
30 of a calendar year prior to the
performance year and includes a 30-day
claims run out.
To capture a real-time representation
of TIN size, we propose to analyze up
to five months of claims data on a
rolling basis, in which virtual group
eligibility determinations for each TIN
would be updated and made available
monthly. We note that an eligibility
determination regarding TIN size is
based on a relative point in time within
the five-month virtual group eligibility
determination period, and not an
eligibility determination made at the
end of such five-month determination
period. If at any time a TIN is
determined to be eligible to participate
in MIPS as part of a virtual group, the
TIN would retain that status for the
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duration of the election period and the
applicable performance period. TINs
could determine their status by
contacting their designated TA
representative or the Quality Payment
Program Service Center; otherwise, the
TIN’s status would be determined at the
time that the TIN’s virtual group
election is submitted. For example, if a
group contacted their designated TA
representative or the Quality Payment
Program Service Center on October 20,
2017, the claims data analysis would
include the months of July through
September of 2017, and if determined
not to exceed 10 eligible clinicians, such
TIN’s size status would be identified at
such time and would be retained for the
duration of the election period and the
2018 performance period. If another
group contacted their designated TA
representative or the Quality Payment
Program Service Center on November
20, 2017, the claims data analysis would
include the months of July through
October of 2017, and if determined not
to exceed 10 eligible clinicians, such
TIN’s size status would be identified at
such time and would be retained for the
duration of the election period and the
2018 performance period.
We believe such a virtual group
determination period process provides a
relative representation of real-time
group size for purposes of virtual group
eligibility and allows groups to know
their real-time size status immediately
and plan accordingly for virtual group
implementation. It is anticipated that
starting in September of each calendar
year prior to the applicable performance
year beginning in 2018, groups would
be able to contact their designated TA
representative or the Quality Payment
Program Service Center and inquire
about virtual group participation
eligibility. We note that TIN size
determinations are based on the number
of NPIs associated with a TIN, which
would include clinicians (NPIs)
excluded from MIPS participation and
who do not meet the definition of a
MIPS eligible clinician.
For groups that do not choose to
participate in stage 1 of the election
process (that is, the group does not
request an eligibility determination), we
will make an eligibility determination
during stage 2 of the election process. If
a group began the election process at
stage 2 and if its TIN size is determined
not to exceed 10 eligible clinicians and
not excluded based on the low-volume
threshold exclusion at the group level,
the group is determined eligible to
participate in MIPS as part of a virtual
group, and such virtual group eligibility
determination status would be retained
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for the duration of the election period
and applicable performance period.
Stage 2 pertains to virtual group
formation. For stage two, we propose
the following:
• TINs comprising a virtual group
must establish a written formal
agreement between each member of a
virtual group prior to an election
(§ 414.1315(c)(2)(i)).
• On behalf of a virtual group, the
official designated virtual group
representative must submit an election
by December 1 of the calendar year prior
to the start of the applicable
performance period.
(§ 414.1315(c)(2)(ii)). We anticipate this
election will occur via email to the
Quality Payment Program Service
Center using the following email
address: MIPS_VirtualGroups@
cms.hhs.gov.
• The submission of a virtual group
election must include, at a minimum,
information pertaining to each TIN and
NPI associated with the virtual group
and contact information for the virtual
group representative
(§ 414.1315(c)(2)(iii). A virtual group
representative would submit the
following type of information: each TIN
associated with the virtual group; each
NPI associated with a TIN that is part of
the virtual group; name of the virtual
group representative; affiliation of the
virtual group representative to the
virtual group; contact information for
the virtual group representative; and
confirm through acknowledgment that a
written formal agreement has been
established between each member of the
virtual group prior to election and each
member of the virtual group is aware of
participating in MIPS as a virtual group
for an applicable performance period.
Each member of the virtual group must
retain a copy of the virtual group’s
written agreement. We note that the
virtual group agreement is subject to the
MIPS data validation and auditing
requirements as described in section
II.C.9.c. of this rule.
• Once an election is made, the
virtual group representative must
contact their designated CMS contact to
update any election information that
changed during an applicable
performance period one time prior to
the start of an applicable submission
period (§ 414.1315(c)(2)(iv)). We
anticipate that virtual groups will use
the Quality Payment Program Service
Center as their designated CMS contact;
however, we will define this further in
subregulatory guidance.
For stage 2 of the election process, we
would review all submitted election
information; confirm whether or not
each TIN within a virtual group is
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eligible to participate in MIPS as part of
a virtual group; identify the NPIs within
each TIN participating in a virtual group
that are excluded from MIPS in order to
ensure that such NPIs would not receive
a MIPS payment adjustment or, when
applicable and when information is
available, would receive a payment
adjustment based on a MIPS APM
scoring standard; calculate the lowvolume threshold at the individual and
group levels in order to determine
whether or not a solo practitioner or
group is eligible to participate in MIPS
as part of a virtual group; and notify
virtual groups as to whether or not they
are considered official virtual groups for
the applicable performance period. For
virtual groups that are determined to
have met the virtual group formation
criteria and identified as an official
virtual group participating in MIPS for
an applicable performance period, we
would contact the official designated
virtual group representative via email
notifying the virtual group of its official
virtual group status and issuing a virtual
group identifier for performance (as
described in section II.C.4.c. of this
proposed rule) that would accompany
the virtual group’s submission of
performance data during the submission
period.
In regard to virtual group
determinations pertaining to the lowvolume threshold, we recognize that
such determinations are made at the
individual and group level, but not at
the virtual group level. The low-volume
threshold determinations are applicable
to the way in which individual eligible
clinicians and groups participate in
MIPS as individual MIPS eligible
clinicians (solo practitioners) or groups.
For example, if an individual MIPS
eligible clinician is part of a practice
that is participating in MIPS at the
individual level (reporting at the
individual level), then the low-volume
threshold determination is made at the
individual level. Whereas, if an
individual MIPS eligible clinician is
part of a practice that is participating in
MIPS at the group level (reporting at the
group level), then the low-volume
threshold determination at the group
level would be applicable to such MIPS
eligible clinician regardless of the lowvolume threshold determination made
at the individual level because such
individual MIPS eligible clinician is
part of a group reporting at the group
level and the low-volume threshold
determinations for groups applies to the
group as a whole. Similarly, if a solo
practitioner or a group with 10 or fewer
eligible clinicians seeks to participate in
MIPS at the virtual group level
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30031
(reporting at the virtual group level),
then the low-volume threshold
determination at the individual or group
level would be applicable to such solo
practitioner or group with 10 or fewer
eligible clinicians. Thus, solo
practitioners (individual MIPS eligible
clinicians) or groups with 10 or fewer
eligible clinicians that are determined
not to exceed the low-volume threshold
at the individual or group level would
not be eligible to participate in MIPS as
an individual, group, or virtual group.
As we engaged in various discussions
with stakeholders during the
rulemaking process through listening
sessions and user groups, stakeholders
indicated that many solo practitioners
and small groups have limited resources
and technical capacities, which may
make it difficult for the entities to form
virtual groups without sufficient time
and technical assistance. Depending on
the resources and technical capacities of
the entities, stakeholders conveyed that
it may take entities 3 to 18 months to
prepare to participate in MIPS as a
virtual group. The majority of
stakeholders indicated that virtual
groups would need at least 6 to 12
months prior to the start of the 2018
performance period to form virtual
groups, prepare health IT systems, and
train staff to be ready for the
implementation of virtual group related
activities by January 1, 2018.
We recognize that for the first year of
virtual group formation and
implementation prior to the start of the
2018 performance period, the timeframe
for virtual groups to make an election by
registering would be relatively short,
particularly from the date we issue the
publication of a final rule toward the
end of the 2017 calendar year. To
provide solo practitioners and groups
with 10 or fewer eligible clinicians with
additional time to assemble and
coordinate resources, and form a virtual
group prior to the start of the 2018
performance period, we are providing
virtual groups with an opportunity to
make an election prior to the
publication of our final rule. We intend
for the virtual group election process to
be available as early as mid-September
of 2017; we will publicize the specific
opening date via subregulatory
guidance. Virtual groups would have
from mid-September to December 1,
2017 to make an election for the 2018
performance year. In regard to our
proposed policies pertaining to virtual
group implementation (for example,
definition of a virtual group and
election process requirements), we
intend to closely align with the statutory
requirements in order to establish clear
expectations for solo practitioners and
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small groups, and have an opportunity
to begin the preparation of forming
virtual groups in advance of the
publication of our final rule. However,
any MIPS eligible clinicians applying to
be a virtual group that does not meet all
finalized virtual group requirements
would not be permitted to participate in
MIPS as a virtual group.
As previously noted, groups
participating in a virtual group would
have the size of their TIN determined
for eligibility purposes. The virtual
group size would be determined one
time for each performance period. We
recognize that the size of a group may
fluctuate during a performance period
with eligible clinicians and/or MIPS
eligible clinicians joining or leaving a
group. For groups within a virtual group
that are determined to have a group size
of 10 eligible clinicians or less based on
the one time determination per
applicable performance year, any new
eligible clinicians or MIPS eligible
clinicians that join the group during the
performance period would participate
in MIPS as part of the virtual group. In
such cases, we recognize that a group
may exceed 10 eligible clinicians
associated with its TIN during an
applicable performance period, but at
the time of election, such group would
have been determined eligible to form or
join a virtual group given that the TIN
did not have more than 10 eligible
clinicians associated with its TIN. As
previously noted, the virtual group
representative would need to contact
the Quality Payment Program Service
Center to update the virtual group’s
information that was provided during
the election period if any information
changed during an applicable
performance period one time prior to
the start of an applicable submission
period (for example, include new NPIs
who joined a TIN that is part of a virtual
group). Virtual groups must re-register
before each performance period.
The statute provides that a solo
practitioner (TIN/NPI) and a group with
10 or fewer eligible clinicians may elect
to be in no more than one virtual group
for a performance period. We note that
such a solo practitioner or a group that
is part of a virtual group may not elect
to be in more than one virtual group for
a performance period. Also, the statute
determines that a virtual group election
by the group for an applicable
performance period applies to all MIPS
eligible clinicians in the group. In the
case of a TIN within a virtual group
being acquired or merged with another
TIN, or no longer operating as a TIN (for
example, a group practice closes) during
a performance period, such solo
practitioner or group’s performance data
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would continue to be attributed to the
virtual group. The remaining members
of a virtual group would continue to be
part of the virtual group even if only one
solo practitioner or group remains. We
consider a TIN that is acquired or
merged with another TIN, or no longer
operating as a TIN (e.g., a group practice
closes) to mean a TIN that no longer
exists or operates under the auspices of
such TIN during a performance year.
As outlined in section
1848(q)(5)(I)(iii) of the Act and
previously noted, a virtual group is a
combination of TINs, which would
include at least two separate TINs
associated with a solo practitioner (TIN/
NPI), or a group with 10 or fewer
eligible clinicians and another such solo
practitioner, or group. However, given
that a virtual group must be a
combination of TINs, we recognize that
the composition of a virtual group could
include, for example, one solo
practitioner (NPI) who is practicing
under multiple TINs, in which the solo
practitioner would be able to form a
virtual group with his or her own self
based on each TIN assigned to the solo
practitioner. For the number of TINs
able to form a virtual group, we note
that there is not a limit to the number
of TINs able to comprise a virtual group.
f. Virtual Group Agreements
The statute provides for formal
written agreements among the MIPS
eligible clinicians electing to form a
virtual group. We propose that each
virtual group member would be
required to execute formal written
agreements with each other virtual
group member to ensure that
requirements and expectations of
participation in MIPS are clearly
articulated, understood, and agreed
upon. We note that a virtual group may
not include a solo practitioner or group
as part of the virtual group unless an
authorized person of the TIN has
executed a formal written agreement.
During the election process and
submission of a virtual group election,
a designated virtual group
representative would be required to
confirm through acknowledgement that
an agreement is in place between each
member of the virtual group. An
agreement would be executed for at
least one performance period. If a NPI
joins or leaves a TIN, or a change is
made to a TIN that impacts the
agreement itself, such as a legal business
name change, during the applicable
performance year, a virtual group would
be required to update the agreement to
reflect such changes and submit changes
to CMS via the Quality Payment
Program Service Center.
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We propose, at § 414.1315(c)(3), that a
formal written agreement between each
member of a virtual group must include
the following elements:
• Expressly state the only parties to
the agreement are the TINs and NPIs of
the virtual group (at § 414.1315(c)(3)(i)).
For example, the agreement may not be
between a virtual group and another
entity, such as an independent practice
association (IPA) or management
company that in turn has an agreement
with one or more TINs within the
virtual group. Similarly, virtual groups
should not use existing contracts
between TINs that include third parties.
• Be executed on behalf of the TINs
and the NPIs by individuals who are
authorized to bind the TINs and the
NPIs, respectively at
§ 414.1315(c)(3)(ii)).
• Expressly require each member of
the virtual group (including each NPI
under each TIN) to agree to participate
in MIPS as a virtual group and comply
with the requirements of the MIPS and
all other applicable laws and regulations
(including, but not limited to, federal
criminal law, False Claims Act, antikickback statute, civil monetary
penalties law, Health Insurance
Portability and Accountability Act, and
physician self-referral law) at
§ 414.1315(c)(3)(iii)).
• Require each TIN within a virtual
group to notify all NPIs associated with
the TIN of their participation in the
MIPS as a virtual group at
§ 414.1315(c)(3)(iv)).
• Set forth the NPI’s rights and
obligations in, and representation by,
the virtual group, including without
limitation, the reporting requirements
and how participation in MIPS as a
virtual group affects the ability of the
NPI to participate in the MIPS outside
of the virtual group at
§ 414.1315(c)(3)(v)).
• Describe how the opportunity to
receive payment adjustments will
encourage each member of the virtual
group (including each NPI under each
TIN) to adhere to quality assurance and
improvement at § 414.1315(c)(3)(vi)).
• Require each member of the virtual
group to update its Medicare enrollment
information, including the addition and
deletion of NPIs billing through a TIN
that is part of a virtual group, on a
timely basis in accordance with
Medicare program requirements and to
notify the virtual group of any such
changes within 30 days after the change
at § 414.1315(c)(3)(vii)).
• Be for a term of at least one
performance period as specified in the
formal written agreement at
§ 414.1315(c)(3)(viii)).
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• Require completion of a close-out
process upon termination or expiration
of the agreement that requires the TIN
(group part of the virtual group) or NPI
(solo practitioner part of the virtual
group) to furnish all data necessary in
order for the virtual group to aggregate
its data across the virtual group at
§ 414.1315(c)(3)(ix)).
As part of the virtual group election
ICR, we filed a 60-day notice on June 14,
2017 (82 FR 27257), which includes an
agreement template that could be used
by virtual groups and will be made
available via subregulatory guidance.
The agreement template is not required,
but serves as a model agreement that
could be utilized by virtual groups. The
agreement template includes all
necessary elements required for such an
agreement.
We solicit public comment on these
proposals.
Through the formal written
agreements, we want to ensure that all
members of a virtual group are aware of
their participation in a virtual group. As
noted above, formal written agreements
must include a provision that requires
each TIN within a virtual group to
notify all NPIs associated with the TIN
regarding their participation in the
MIPS as a virtual group in order to
ensure that each member of a virtual
group is aware of their participation in
the MIPS as a virtual group. We want to
implement an approach that considers a
balance between the need to ensure that
all members of a virtual group are aware
of their participation in a virtual group
and the minimization of administration
burden. We solicit public comment on
approaches for virtual groups to ensure
that all members of a virtual group are
aware of their participation in the
virtual group.
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g. Reporting Requirements
As we noted in this proposed rule, we
believe virtual groups should generally
be treated under the MIPS as groups.
Therefore, for MIPS eligible clinicians
participating at the virtual group level,
we propose the following requirements:
• Individual eligible clinicians and
individual MIPS eligible clinicians who
are part of a TIN participating in MIPS
at the virtual group level would have
their performance assessed as a virtual
group at § 414.1315(d)(1).
• Individual eligible clinicians and
individual MIPS eligible clinicians who
are part of a TIN participating in MIPS
at the virtual group level would need to
meet the definition of a virtual group at
all times during the performance period
for the MIPS payment year (at § 414.
1315(d)(2)).
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• Individual eligible clinicians and
individual MIPS eligible clinicians who
are part of a TIN participating in MIPS
at the virtual group level must aggregate
their performance data across multiple
TINs in order for their performance to
be assessed as a virtual group (at
§ 414.1315(d)(3)).
• MIPS eligible clinicians that elect to
participate in MIPS at the virtual group
level would have their performance
assessed at the virtual group level across
all four MIPS performance categories (at
§ 414.1315(d)(4)).
• Virtual groups would need to
adhere to an election process
established and required by CMS (at
§ 414.1315(d)(5)).
We solicit public comment on these
proposals.
h. Assessment and Scoring for the MIPS
Performance Categories
As noted above, section
1848(q)(5)(I)(i) of the Act provides that
eligible clinicians electing to be a virtual
group will: (1) Have their performance
assessed for the quality and cost
performance categories in a manner that
applies the combined performance of all
eligible clinicians in the virtual group to
each MIPS eligible clinician (except for
those participating in a MIPS APM or an
Advanced APM under the MIPS APM
scoring standard) in the virtual group
for a performance period of a year; and
(2) be scored based on the assessment of
the combined performance described
above regarding the quality and cost
performance categories for a
performance period. We believe it is
critical for virtual groups to be assessed
and scored at the virtual group level for
all performance categories; it eliminates
the burden of virtual group members
having to report as a virtual group and
separately outside of a virtual group.
Additionally, we believe that the
assessment and scoring at the virtual
group level provides for a
comprehensive measurement of
performance, shared responsibility, and
an opportunity to effectively and
efficiently coordinate resources to also
achieve performance under the
improvement activities and the
advancing care information performance
categories. We propose at § 414.1315
that virtual groups would be assessed
and scored across all four MIPS
performance categories at the virtual
group level for a performance period of
a year.
In the CY 2017 Quality Payment
Program final rule (81 FR 77319 through
77329), we established the MIPS final
score methodology, which will apply to
virtual groups. We refer readers to
sections II.C.7.b. and II.C.8. of this
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proposed rule for scoring policies that
would apply to virtual groups.
As previously noted, we propose to
allow solo practitioners and groups with
10 or fewer eligible clinicians that have
elected to be part of a virtual group to
have their performance measured and
aggregated at the virtual group level
across all four performance categories;
however, we would apply payment
adjustments at the individual TIN/NPI
level. Each TIN/NPI would receive a
final score based on the virtual group
performance, but the payment
adjustment would still be applied at the
TIN/NPI level. We would assign the
virtual group score to all TIN/NPIs
billing under a TIN in the virtual group
during the performance period.
During the performance year, we
recognize that NPIs in a TIN that has
joined a virtual group may also be
participants in an APM. The TIN, as
part of the virtual group, must submit
performance data for all eligible
clinicians associated with the TIN,
including those participating in APMs,
to ensure that all eligible clinicians
associated with the TIN are being
measured under MIPS.
For participants in MIPS APMs, we
propose to use our authority under
section 1115A(d)(1) for MIPS APM
authorized under section 1115A of the
Act, and under section 1899(f) for the
Shared Savings Program, to waive the
requirement under section 1848
(q)(2)(5)(I)(i)(II) of the Act that requires
performance category scores from
virtual group reporting must be used to
generate the composite score upon
which the MIPS payment adjustment is
based for all TIN/NPIs in the virtual
group. Instead, we would use the score
assigned to the MIPS eligible clinician
based on the applicable APM Entity
score to determine MIPS payment
adjustments for all MIPS eligible
clinicians that are part of an APM Entity
participating in a MIPS APM, in
accordance with § 414.1370, instead of
determining MIPS payment adjustments
for these MIPS eligible clinicians using
the composite score of their virtual
group.
APMs seek to deliver better care at
lower cost and to test new ways of
paying for care and measuring and
assessing performance. In the CY 2017
Quality Payment Program final rule, we
established policies to the address
concerns we have expressed in regard to
the application of certain MIPS policies
to MIPS eligible clinicians in MIPS
APMs (81 FR 77246 through 77269). In
section II.C.6.g. of this proposed rule,
we reiterate those concerns and propose
additional policies for the APM scoring
standard. We believe it is important to
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consistently apply the APM scoring
standard under MIPS for eligible
clinicians participating in MIPS APMs
in order to avoid potential
misalignments between the evaluation
of performance under the terms of the
MIPS APM and evaluation of
performance on measures and activities
under MIPS, and to preserve the
integrity of the initiatives we are testing.
Therefore, we believe it is necessary to
waive the requirement to only use the
virtual group scores under section
1848(q)(5)(I)(i)(II) of the Act, and instead
to apply the score under the APM
scoring standard for eligible clinicians
in virtual groups who are also in an
APM Entity participating in an APM.
We note that MIPS eligible clinicians
who are participants in both a virtual
group and a MIPS APM would be
assessed under MIPS as part of the
virtual group and under the APM
scoring standard as part of an APM
Entity group, but would receive their
payment adjustment based only on the
APM Entity score. In the case of an
eligible clinician participating in both a
virtual group and an Advanced APM
who has achieved QP status, the
clinician would be assessed under MIPS
as part of the virtual group, but would
still be excluded from the MIPS
payment adjustment as a result of his or
her QP status. We refer readers to
section II.C.6.g.(2) of this proposed rule
for further discussion regarding the
waiver and the CY 2017 Quality
Payment Program final rule (81 FR
77013) for discussion regarding the
timeframe used for determining QP
status.
5. MIPS Performance Period
In the CY 2017 Quality Payment
Program final rule (81 FR 77085), we
finalized at § 414.1320(b)(1) that for
purposes of the MIPS payment year
2020, the performance period for the
quality and cost performance categories
is CY 2018 (January 1, 2018 through
December 31, 2018). For the
improvement activities and advancing
care information performance
categories, we finalized at
§ 414.1320(b)(2) that for purposes of the
MIPS payment year 2020, the
performance period for the
improvement activities and advancing
care information performance categories
is a minimum of a continuous 90-day
period within CY 2018, up to and
including the full CY 2018 (January 1,
2018, through December 31, 2018). We
are not proposing any changes to these
policies.
We also finalized at § 414.1325(f)(2) to
use claims with dates of service during
the performance period that must be
processed no later than 60 days
following the close of the performance
period for purposes of assessing
performance and computing the MIPS
payment adjustment. Lastly, we
finalized that individual MIPS eligible
clinicians or groups who report less
than 12 months of data (due to family
leave, etc.) would be required to report
all performance data available from the
applicable performance period (for
example, CY 2018 or a minimum of a
continuous 90-day period within CY
2018).
We are proposing at § 414.1320(c) and
(c)(1) that for purposes of the MIPS
payment year 2021 and future years, for
the quality and cost performance
categories, the performance period
under MIPS would be the full calendar
year (January 1 through December 31)
that occurs 2 years prior to the
applicable payment year. For example,
for the MIPS payment year 2021, the
performance period would be CY 2019
(January 1, 2019 through December 31,
2019), and for the MIPS payment year
2022 the performance period would be
CY 2020 (January 1, 2020 through
December 31, 2020).
We are proposing at § 414.1320(d) and
(d)(1) that for purposes of the MIPS
payment year 2021, the performance
period for the improvement activities
and advancing care information
performance categories would be a
minimum of a continuous 90-day period
within the calendar year that occurs 2
years prior to the applicable payment
year, up to and including the full CY
2019 (January 1, 2019 through December
31, 2019).
We request comments on our
proposals for the performance period for
MIPS payment year 2021 and future
years.
6. MIPS Performance Category Measures
and Activities
a. Performance Category Measures and
Reporting
(1) Submission Mechanisms
We finalized in the CY 2017 Quality
Payment Program final rule (81 FR
77094) at § 414.1325(a) that individual
MIPS eligible clinicians and groups
must submit measures and activities, as
applicable, for the quality, improvement
activities, and advancing care
information performance categories. For
the cost performance category, we
finalized that each individual MIPS
eligible clinician’s and group’s cost
performance would be calculated using
administrative claims data. As a result,
individual MIPS eligible clinicians and
groups are not required to submit any
additional information for the cost
performance category. For individual
eligible clinicians and groups that are
not MIPS eligible clinicians, such as
physical therapists, but elect to report to
MIPS, we will calculate administrative
claims-based cost measures and quality
measures, if data are available. We
finalized in the CY 2017 Quality
Payment Program final rule (81 FR
77094 through 77095) multiple data
submission mechanisms for MIPS,
which provide individual MIPS eligible
clinicians and groups with the
flexibility to submit their MIPS
measures and activities in a manner that
best accommodates the characteristics of
their practice, as indicated in Tables 2
and 3. Table 2 summarizes the data
submission mechanisms for individual
MIPS eligible clinicians that we
finalized at § 414.1325(b) and (e). Table
3 summarizes the data submission
mechanisms for groups that are not
reporting through an APM that we
finalized at § 414.1325(c) and (e).
TABLE 2—DATA SUBMISSION MECHANISMS FOR MIPS ELIGIBLE CLINICIANS REPORTING INDIVIDUALLY
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[TIN/NPI]
Performance category/submission combinations
accepted
Quality .................................................................
Cost .....................................................................
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Individual reporting data submission mechanisms
Claims.
QCDR.
Qualified registry.
EHR.
Administrative claims.1
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TABLE 2—DATA SUBMISSION MECHANISMS FOR MIPS ELIGIBLE CLINICIANS REPORTING INDIVIDUALLY—Continued
[TIN/NPI]
Performance category/submission combinations
accepted
Advancing Care Information ................................
Improvement Activities ........................................
Individual reporting data submission mechanisms
Attestation.
QCDR.
Qualified registry.
EHR.
Attestation.
QCDR.
Qualified registry.
EHR.
TABLE 3—DATA SUBMISSION MECHANISMS FOR MIPS ELIGIBLE CLINICIANS REPORTING AS GROUPS (TIN)
Performance category/submission combinations
accepted
Group reporting data submission mechanisms
Quality .................................................................
QCDR.
Qualified registry.
EHR.
CMS Web Interface (groups of 25 or more).
CMS-approved survey vendor for CAHPS for MIPS (must be reported in conjunction with another data submission mechanism).
and
Administrative claims (for all-cause hospital readmission measure; no submission required).
Administrative claims.1
Attestation.
QCDR.
Qualified registry.
EHR.
CMS Web Interface (groups of 25 or more).
Attestation.
QCDR.
Qualified registry.
EHR.
CMS Web Interface (groups of 25 or more).
Cost .....................................................................
Advancing Care Information ................................
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Improvement Activities ........................................
We finalized at § 414.1325(d) that
individual MIPS eligible clinicians and
groups may elect to submit information
via multiple mechanisms; however, they
must use the same identifier for all
performance categories, and they may
only use one submission mechanism per
performance category. In response to the
CY 2017 Quality Payment Program final
rule (81 FR 77089), we received
comments supportive of the use of
multiple submission mechanisms for a
single performance category due to the
flexibility it would provide clinicians.
Another commenter supported such an
approach because they believed that the
scoring of only one submission
mechanism per performance category
may influence which quality measures a
MIPS eligible clinician chooses to report
given that the commenter believed only
a limited number of measures relevant
1 Requires no separate data submission to CMS:
Measures are calculated based on data available
from MIPS eligible clinicians’ billings on Medicare
Part B claims. NOTE: Claims differ from
administrative claims as they require MIPS eligible
clinicians to append certain billing codes to
denominator eligible claims to indicate the required
quality action or exclusion occurred.
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to one’s practice might be available
through a particular submission
mechanism. The commenter also
believed that such flexibility would
encourage continued participation in
MIPS.
We are proposing to revise
§ 414.1325(d) for purposes of the 2020
MIPS payment year and future years,
beginning with performance periods
occurring in 2018, to allow individual
MIPS eligible clinicians and groups to
submit data on measures and activities,
as applicable, via multiple data
submission mechanisms for a single
performance category (specifically, the
quality, improvement activities, or
advancing care information performance
category). Under this proposal,
individual MIPS eligible clinicians and
groups that have fewer than the required
number of measures and activities
applicable and available under one
submission mechanism could be
required to submit data on additional
measures and activities via one or more
additional submission mechanisms, as
necessary, provided that such measures
and activities are applicable and
available to them to receive the
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maximum number of points under a
performance category. We considered an
approach that would require MIPS
eligible clinicians to first submit data on
as many required measures and
activities as possible via one submission
mechanism before submitting data via
an additional submission mechanism,
but we believe that such an approach
would limit flexibility.
If an individual MIPS eligible
clinician or group submits the same
measure through two different
mechanisms, each submission would be
calculated and scored separately. We do
not have the ability to aggregate data on
the same measure across submission
mechanisms. We would only count the
submission that gives the clinician the
higher score, thereby avoiding the
double count. We refer readers to
section II.C.7. of this proposed rule,
which further outlines how we propose
to score measures and activities
regardless of submission mechanism.
We believe that this flexible approach
would help individual MIPS eligible
clinicians and groups with reporting, as
it provides more options for the
submission of data for the applicable
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performance categories. For example, an
individual MIPS eligible clinician or
group submitting data on four
applicable and available quality
measures via EHR may not be able to
receive the maximum number of points
available under the quality performance
category. However, with this proposed
modification, the MIPS eligible clinician
could meet the requirement to report six
quality measures by submitting data on
two additional quality measure via
another submission mechanism, such as
claims or qualified registry. This would
enable the MIPS eligible clinician to
receive the maximum number of points
available under the quality performance
category. We believe that by providing
this flexibility, we would be allowing
MIPS eligible clinicians the flexibility to
choose the measures and activities that
are most meaningful to them, regardless
of the submission mechanism. We are
aware that this proposal for increased
flexibility in data submission
mechanisms may increase complexity
and in some instances additional costs
for clinicians, as they may need to
establish relationships with additional
data submission mechanism vendors in
order to report additional measures and/
or activities for any given performance
category. We would like to clarify that
the requirements for the performance
categories remain the same, regardless
of the number of submission
mechanisms used. It is also important to
note for the improvement activities and
advancing care information performance
categories, that using multiple data
submission mechanisms (for example,
attestation and the qualified registry)
may limit our ability to provide realtime feedback. While we strive to
provide flexibility to individual MIPS
eligible clinicians and groups, we would
like to note that our goal within the
MIPS program is to minimize
complexity and administrative burden
to individual MIPS eligible clinicians
and groups. We request comments on
this proposal.
As discussed in section II.C.4. of this
proposed rule, we are proposing to
generally apply our previously finalized
and proposed group policies to virtual
groups. With respect to data submission
mechanisms, we are proposing that
virtual groups would be able to use a
different submission mechanism for
each performance category, and would
be able to utilize multiple submission
mechanisms for the quality performance
category, beginning with performance
periods occurring in 2018. However,
virtual groups would be required to
utilize the same submission mechanism
for the improvement activities and the
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advancing care information performance
categories.
For those MIPS eligible clinicians
participating in a MIPS APM, who are
on an APM Participant List on at least
one of the three snapshot dates as
finalized in the CY 2017 Quality
Payment Program Final Rule (81 FR
77444 through 77445), or for MIPS
eligible clinicians participating in a full
TIN MIPS APM, who are on an APM
Participant List on at least one of the
four snapshot dates as discussed in
section II.C.6.g.(2) of this proposed rule,
the APM scoring standard applies. We
refer readers to § 414.1370 and the CY
2017 Quality Payment Program final
rule (81 FR 77246), which describes
how MIPS eligible clinicians
participating in APM entities submit
data to MIPS in the form and manner
required, including separate approaches
to the quality and cost performance
categories applicable to MIPS APMs. We
are not proposing any changes to how
APM entities in MIPS APMs and their
participating MIPS eligible clinicians
submit data to MIPS.
(2) Submission Deadlines
In the CY 2017 Quality Payment
Program final rule (81 FR 77097), we
finalized submission deadlines by
which all associated data for all
performance categories must be
submitted for the submission
mechanisms described in this rule.
As specified at § 414.1325(f)(1), the
data submission deadline for the
qualified registry, QCDR, EHR, and
attestation submission mechanisms is
March 31 following the close of the
performance period. The submission
period will begin prior to January 2
following the close of the performance
period, if technically feasible. For
example, for performance periods
occurring in 2018, the data submission
period will occur prior to January 2,
2019, if technically feasible, through
March 31, 2019. If it is not technically
feasible to allow the submission period
to begin prior to January 2 following the
close of the performance period, the
submission period will occur from
January 2 through March 31 following
the close of the performance period. In
any case, the final deadline will remain
March 31, 2019.
At § 414.1325(f)(2), we specified that
for the Medicare Part B claims
submission mechanism, data must be
submitted on claims with dates of
service during the performance period
that must be processed no later than 60
days following the close of the
performance period. Lastly, for the CMS
Web Interface submission mechanism,
at § 414.1325(f)(3), we specified that the
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data must be submitted during an 8week period following the close of the
performance period that will begin no
earlier than January 2, and end no later
than March 31. For example, the CMS
Web Interface submission period could
span an 8-week timeframe beginning
January 16 and ending March 13. The
specific deadline during this timeframe
will be published on the CMS Web site.
We are not proposing any changes to the
submission deadlines in this proposed
rule.
b. Quality Performance Criteria
(1) Background
Sections 1848(q)(1)(A)(i) and (ii) of
the Act require the Secretary to develop
a methodology for assessing the total
performance of each MIPS eligible
clinician according to performance
standards and, using that methodology,
to provide for a final score for each
MIPS eligible clinician. Section
1848(q)(2)(A)(i) of the Act requires us to
use the quality performance category in
determining each MIPS eligible
clinician’s final score, and section
1848(q)(2)(B)(i) of the Act describes the
measures and activities that must be
specified under the quality performance
category.
The statute does not specify the
number of quality measures on which a
MIPS eligible clinician must report, nor
does it specify the amount or type of
information that a MIPS eligible
clinician must report on each quality
measure. However, section
1848(q)(2)(C)(i) of the Act requires the
Secretary, as feasible, to emphasize the
application of outcomes-based
measures.
Sections 1848(q)(1)(E) of the Act
requires the Secretary to encourage the
use of QCDRs, and section
1848(q)(5)(B)(ii)(I) of the Act requires
the Secretary to encourage the use of
CEHRT and QCDRs for reporting
measures under the quality performance
category under the final score
methodology, but the statute does not
limit the Secretary’s discretion to
establish other reporting mechanisms.
Section 1848(q)(2)(C)(iv) of the Act
generally requires the Secretary to give
consideration to the circumstances of
non-patient facing MIPS eligible
clinicians and allows the Secretary, to
the extent feasible and appropriate, to
apply alternative measures or activities
to such clinicians.
As discussed in the CY 2017 Quality
Payment Program final rule (81 FR
77098 through 77099), we finalized
MIPS quality criteria that focus on
measures that are important to
beneficiaries and maintain some of the
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flexibility from PQRS, while addressing
several of the comments we received in
response to the CY 2017 Quality
Payment Program proposed rule and the
MIPS and APMs RFI.
• To encourage meaningful
measurement, we finalized allowing
individual MIPS eligible clinicians and
groups the flexibility to determine the
most meaningful measures and data
submission mechanisms for their
practice.
• To simplify the reporting criteria,
we aligned the submission criteria for
several of the data submission
mechanisms.
• To reduce administrative burden
and focus on measures that matter, we
lowered the required number of the
measures for several of the data
submission mechanisms, yet still
required that certain types of measures,
particularly outcome measures, be
reported.
• To create alignment with other
payers and reduce burden on MIPS
eligible clinicians, we incorporated
measures that align with other national
payers.
• To create a more comprehensive
picture of a practice’s performance, we
also finalized the use of all-payer data
where possible.
As beneficiary health is always our
top priority, we finalized criteria to
continue encouraging the reporting of
certain measures such as outcome,
appropriate use, patient safety,
efficiency, care coordination, or patient
experience measures. However, as
discussed in the CY 2017 Quality
Payment Program final rule (81 FR
77098), we removed the requirement for
measures to span across multiple
domains of the NQS. We continue to
believe the NQS domains are extremely
important, and we encourage MIPS
eligible clinicians to continue to strive
to provide care that focuses on: Effective
clinical care, communication and care
coordination, efficiency and cost
reduction, person and caregivercentered experience and outcomes,
community and population health, and
patient safety. While we do not require
that MIPS eligible clinicians select
measures across multiple domains, we
encourage them to do so. In addition,
we believe the MIPS program overall,
with the focus on the quality, cost,
improvement activities, and advancing
care information performance
categories, will naturally cover many
elements in the NQS.
(2) Contribution to Final Score
For MIPS payment year 2019, the
quality performance category will
account for 60 percent of the final score,
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subject to the Secretary’s authority to
assign different scoring weights under
section 1848(q)(5)(F) of the Act. Section
1848(q)(2)(E)(i)(I)(aa) of the Act states
that the quality performance category
will account for 30 percent of the final
score for MIPS. However, section
1848(q)(2)(E)(i)(I)(bb) of the Act
stipulates that for the first and second
years for which MIPS applies to
payments, the percentage of the final
score applicable for the quality
performance category will be increased
so that the total percentage points of the
increase equals the total number of
percentage points by which the
percentage applied for the cost
performance category is less than 30
percent. Section 1848(q)(2)(E)(i)(II)(bb)
of the Act requires that, for the
transition year for which MIPS applies
to payments, not more than 10 percent
of the final score shall be based on the
cost performance category. Furthermore,
section 1848(q)(2)(E)(i)(II)(bb) of the Act
states that, for the second year for which
MIPS applies to payments, not more
than 15 percent of the final score shall
be based on the cost performance
category.
In the CY 2017 Quality Payment
Program final rule (81 FR 77100), we
finalized at § 414.1330(b) that, for MIPS
payment years 2019 and 2020, 60
percent and 50 percent, respectively, of
the MIPS final score will be based on
the quality performance category. For
the third and future years, 30 percent of
the MIPS final score will be based on
the quality performance category.
As discussed in section II.C.6.d. of
this proposed rule, we are proposing to
weight the cost performance category at
zero percent for the second MIPS
payment year (2020). In accordance
with section 1848(q)(5)(E)(i)(I)(bb) of the
Act, for the first 2 years, the percentage
of the MIPS final score that would
otherwise be based on the quality
performance category (that is, 30
percent) must be increased by the same
number of percentage points by which
the percentage based on the cost
performance category is less than 30
percent. Therefore, if our proposal to
reweight the cost performance category
for MIPS payment year 2020 is
finalized, we would need to inversely
reweight the quality performance
category for the same year. Accordingly,
we are proposing to modify
§ 414.1330(b)(2) to reweight the
percentage of the MIPS final score based
on the quality performance category for
MIPS payment year 2020 as may be
necessary to account for any
reweighting of the cost performance
category, if finalized. For example, if
our proposal to reweight the cost
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performance category to zero percent for
MIPS payment year 2020 is finalized,
then we would modify § 414.1330(b)(2)
to provide that performance in the
quality performance category will
comprise 60 percent of a MIPS eligible
clinician’s final score for MIPS payment
year 2020. We refer readers to section
II.C.6.d. for more information on the
cost performance category.
As also discussed in section II.C.6.d.
of this proposed rule, we note that by
reweighting the cost performance
category to zero percent in performance
period 2018, there will be a sharp
increase in the cost performance
category to a 30 percent weight in
performance period 2019. In order to
assist MIPS eligible clinicians and
groups in obtaining additional comfort
with measurement based on the cost
performance category, we considered
maintaining our previously-finalized
cost performance category weight of 10
percent for the 2018 performance
period. However, in our discussions
with some MIPS eligible clinicians and
clinician societies, eligible clinicians
expressed their desire to down-weight
the cost performance category to zero
percent for an additional year with full
knowledge that the cost performance
category weight is set at 30 percent
under the statute for the 2021 MIPS
payment year. The clinicians we spoke
with preferred our proposed approach
and noted that they are actively
preparing for full cost performance
category implementation and would be
prepared for the 30 percent statutory
weight for the cost performance category
for the 2021 MIPS payment year.
We intend to provide an initial
opportunity for clinicians to review
their performance based on the new
episode-based measures at some point
in the fall of 2017, as the measures are
developed and as the information is
available. We note that this feedback
will be specific to the new episodebased measures that are developed
under the process described above and
may be presented in a different format
than MIPS eligible clinicians’
performance feedback as described in
section II.C.9.a. of this proposed rule.
However, our intention is to align the
feedback as much as possible to ensure
clinicians receive opportunities to
review their performance on potential
new episode-based measures for the cost
performance category prior to the
proposed 2019 MIPS performance
period. We are unable to offer a list of
new episode-based measures on which
we will provide feedback because that
will be determined in our ongoing
development work described above. We
are concerned that continuing to
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provide feedback on the older episodebased measures along with feedback on
new episode-based measures will be
confusing and a poor use of resources.
Because we are focusing on
development of new episode-based
measures, our feedback on episodebased measures that were previously
developed will discontinue after 2017 as
these measures would no longer be
maintained or reflect changes in
diagnostic and procedural coding. As
described in section II.C.9.a. of this
proposed rule, we intend to provide
feedback on these new measures as they
become available in a new format
around summer 2018, in addition to the
fall 2017 feedback discussed previously.
We note that the feedback provided in
the summer of 2018 will go to those
MIPS eligible clinicians for whom we
are able to calculate the episode-based
measures, which means it would be
possible that a clinical may not receive
feedback on episode-based measures in
both the fall of 2017 and the summer of
2018. We believe that receiving
feedback on the new episode-based
measures, along with the previouslyfinalized total per capita cost and MSPB
measures, will support clinicians in
their readiness for the proposed 2019
MIPS performance period.
Section 1848(q)(5)(B)(i) of the Act
requires the Secretary to treat any MIPS
eligible clinician who fails to report on
a required measure or activity as
achieving the lowest potential score
applicable to the measure or activity.
Specifically, under our finalized scoring
policies, an individual MIPS eligible
clinician or group that reports on all
required measures and activities could
potentially obtain the highest score
possible within the performance
category, assuming they perform well on
the measures and activities they report.
An individual MIPS eligible clinician or
group who does not submit data on a
required measure or activity would
receive a zero score for the unreported
items in the performance category (in
accordance with section 1848(q)(5)(B)(i)
of the Act). The individual MIPS
eligible clinician or group could still
obtain a relatively good score by
performing very well on the remaining
items, but a zero score would prevent
the individual MIPS eligible clinician or
group from obtaining the highest
possible score within the performance
category.
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(3) Quality Data Submission Criteria
(a) Submission Criteria
(i) Submission Criteria for Quality
Measures Excluding Groups Reporting
via the CMS Web Interface and the
CAHPS for MIPS Survey
In the CY 2017 Quality Payment
Program final rule (81 FR 77114), we
finalized at § 414.1335(a)(1) that
individual MIPS eligible clinicians
submitting data via claims and
individual MIPS eligible clinicians and
groups submitting data via all
mechanisms (excluding the CMS Web
Interface and the CAHPS for MIPS
survey) are required to meet the
following submission criteria. For the
applicable period during the
performance period, the individual
MIPS eligible clinician or group will
report at least six measures, including at
least one outcome measure. If an
applicable outcome measure is not
available, the individual MIPS eligible
clinician or group will be required to
report one other high priority measure
(appropriate use, patient safety,
efficiency, patient experience, and care
coordination measures) in lieu of an
outcome measure. If fewer than six
measures apply to the individual MIPS
eligible clinician or group, then the
individual MIPS eligible clinician or
group would be required to report on
each measure that is applicable. We
defined ‘‘applicable’’ to mean measures
relevant to a particular MIPS eligible
clinician’s services or care rendered. As
discussed in section II.C.7.a.(2)(e)., we
will only make determinations as to
whether a sufficient number of
measures are applicable for claimsbased and registry submission
mechanisms; we will not make this
determination for EHR and QCDR
submission mechanisms, for example.
Alternatively, the individual MIPS
eligible clinician or group will report
one specialty measure set, or the
measure set defined at the subspecialty
level, if applicable. If the measure set
contains fewer than six measures, MIPS
eligible clinicians will be required to
report all available measures within the
set. If the measure set contains six or
more measures, MIPS eligible clinicians
will be required to report at least six
measures within the set. Regardless of
the number of measures that are
contained in the measure set, MIPS
eligible clinicians reporting on a
measure set will be required to report at
least one outcome measure or, if no
outcome measures are available in the
measure set, the MIPS eligible clinician
will report another high priority
measure (appropriate use, patient safety,
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efficiency, patient experience, and care
coordination measures) within the
measure set in lieu of an outcome
measure. MIPS eligible clinicians may
choose to report measures in addition to
those contained in the specialty
measure set and will not be penalized
for doing so, provided that such MIPS
eligible clinicians follow all
requirements discussed here.
In accordance with
§ 414.1335(a)(1)(ii), individual MIPS
eligible clinicians and groups will select
their measures from either the set of all
MIPS measures listed or referenced in
Table A of the Appendix in this
proposed rule or one of the specialty
measure sets listed in Table B of the
Appendix in this proposed rule. We
note that some specialty measure sets
include measures grouped by
subspecialty; in these cases, the measure
set is defined at the subspecialty level.
Previously finalized quality measures
may be found in the CY 2017 Quality
Payment Program final rule (81 FR
77558 through 77816).
We also finalized the definition of a
high priority measure at § 414.1305 to
mean an outcome, appropriate use,
patient safety, efficiency, patient
experience, or care coordination quality
measure. Except as discussed in section
II.C.6.b.(3)(a) of this proposed rule with
regard to the CMS Web Interface and the
CAHPS for MIPS survey, we are not
proposing any changes to the
submission criteria or definitions
established for measures in this
proposed rule.
In the CY 2017 Quality Payment
Program final rule (81 FR 77114), we
solicited comments regarding adding a
requirement to our finalized policy that
patient-facing MIPS eligible clinicians
would be required to report at least one
cross-cutting measure in addition to the
high priority measure requirement for
further consideration for the Quality
Payment Program Year 2 and future
years. For clarification, we consider a
cross-cutting measure to be any measure
that is broadly applicable across
multiple clinical settings and individual
MIPS eligible clinicians or groups
within a variety of specialties. We
specifically requested feedback on how
we could construct a cross-cutting
measure requirement that would be
most meaningful to MIPS eligible
clinicians from different specialties and
that would have the greatest impact on
improving the health of populations. We
received conflicting feedback on adding
a future requirement for MIPS eligible
clinicians to report at least one crosscutting measure in the Quality Payment
Program Year 2 and future years.
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Many commenters agreed that crosscutting measures are applicable across
multiple clinical settings and that MIPS
eligible clinicians within a variety of
specialties should report at least one
cross-cutting measure. Some stated that
cross-cutting measures promote shared
accountability and improve the health
of populations. Others recommended
we continue to work with stakeholders
and specialists, including solo and
small practices, to develop cross-cutting
measures for all settings, whether they
be patient-facing or non-patient facing
practices that are patient-centric (that is,
following the patient and not the site of
care) and recommended the term
‘‘patient-centered measures’’ rather than
‘‘cross-cutting measures.’’ In addition,
some commenters stated we should
consider measures that are
multidisciplinary, foster crosscollaboration within virtual groups,
improve patient outcomes, target highcost areas, target areas with gaps in care,
and include individual patient
preferences in shared decision-making.
A few commenters provided specific
measures that they recommended
utilizing as cross-cutting measures, such
as: Screening for Hepatitis C;
Controlling High Blood Pressure;
Tobacco Use Cessation Counseling and
Treatment; Advance Care Planning; or
Medication Reconciliation. One
commenter recommended we utilize
shared accountability measures around
surgical goals of care, shared decision
making relying on some form of risk
estimation such as a risk calculator,
medication reconciliation, and a shared
plan of care across clinicians. Another
commenter suggested that instead of
having a cross-cutting measure
requirement, we could use health IT as
a cross-cutting requirement.
Specifically, the commenter noted we
could require that at least one measure
using end-to-end electronic reporting, or
that at least one measure be tied to an
improvement activity the clinician is
performing. Other commenters
suggested that we provide bonus points
to practices that elect to submit data on
cross-cutting measures and hold
harmless from any future cross-cutting
measure requirements MIPS eligible
clinicians who have less than 15
instances in the measure denominator
during the performance period, allow
MIPS eligible clinicians to use highpriority measures in the place of a crosscutting measure if necessary, and apply
the guiding principles listed in NQF’s
‘‘Attribution: Principles and
Approaches’’ final report which may be
found at https://www.qualityforum.org/
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ProjectDescription.aspx?projectID=
80808.
Other commenters appreciated our
decision not to finalize the requirement
to report a cross-cutting measure in the
transition year and requested that we
not require cross-cutting measures in
the future, as they believed it is
administratively burdensome for
clinicians and QCDRs and removes
focus and resources from quality
measures that are more relevant to MIPS
eligible clinicians’ scope of practice and
important to their patients’ treatment
and outcomes. They stated that PQRS
demonstrated the challenge of
identifying cross-cutting measures that
are truly meaningful across different
specialties and that truly have an impact
on improving the health of populations.
Some stated we should focus on highpriority measures over cross-cutting
measures. A few commenters did not
agree that cross-cutting measures were
relevant and stated they should not be
a requirement in MIPS until all MIPS
eligible clinicians can successfully meet
the current requirements. Others did not
agree that QCDRs should be required to
submit cross-cutting measures because
they believed that Congress did not
intend for QCDRs to submit clinical
process measures, that implementation
may be complicated by practices that
upgrade their health IT, and vendors
have indicated it would take 12 to 18
months to implement system changes to
support capture of cross-cutting
measures. They also questioned the
value of investing additional time and
resources in this effort, especially if
these cross-cutting measures are
ultimately found to be topped out or
removed. Others believed we should
delay implementation until the Quality
Payment Program Year 3 in order to
allow MIPS eligible clinicians to focus
on implementing new CEHRT
requirements and modifying their
processes to address lessons learned
from reporting in the first 2 years.
Except as discussed in section
II.C.6.b.(3)(a)(iii). of this proposed rule
with regard to the CAHPS for MIPS
survey, we are not proposing any
changes to the submission criteria for
quality measures in this proposed rule.
We thank the commenters for their
feedback and will take the comments
into consideration in future rulemaking.
We welcome additional feedback on
meaningful ways to incorporate crosscutting measurement into MIPS and the
Quality Payment Program generally.
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(ii) Submission Criteria for Quality
Measures for Groups Reporting via the
CMS Web Interface
In the CY 2017 Quality Payment
Program final rule (81 FR 77116), we
finalized at § 414.1335(a)(2) the
following criteria for the submission of
data on quality measures by registered
groups of 25 or more eligible clinicians
who want to report via the CMS Web
Interface. For the applicable 12-month
performance period, the group would be
required to report on all measures
included in the CMS Web Interface
completely, accurately, and timely by
populating data fields for the first 248
consecutively ranked and assigned
Medicare beneficiaries in the order in
which they appear in the group’s
sample for each module or measure. If
the sample of eligible assigned
beneficiaries is less than 248, then the
group would report on 100 percent of
assigned beneficiaries. A group would
be required to report on at least one
measure for which there is Medicare
patient data. Groups reporting via the
CMS Web Interface are required to
report on all of the measures in the set.
Any measures not reported would be
considered zero performance for that
measure in our scoring algorithm. In
addition, we are proposing to clarify
that these criteria apply to groups of 25
or more eligible clinicians. Specifically,
we propose to revise § 414.1335(a)(2)(i)
to provide criteria applicable to groups
of 25 or more eligible clinicians, report
on all measures included in the CMS
Web Interface. The group must report on
the first 248 consecutively ranked
beneficiaries in the sample for each
measure or module.
In the CY 2017 Quality Payment
Program final rule (81 FR 77116), we
finalized to continue to align the 2019
CMS Web Interface beneficiary
assignment methodology with the
attribution methodology for two of the
measures that were formerly in the VM:
The population quality measure
discussed in the CY 2017 Quality
Payment Program proposed rule (81 FR
28188) and total per capita cost for all
attributed beneficiaries discussed in the
CY 2017 Quality Payment Program
proposed rule (81 FR 28196). When
establishing MIPS, we also finalized a
modified attribution process to update
the definition of primary care services
and to adapt the attribution to different
identifiers used in MIPS. These changes
are discussed in the CY 2017 Quality
Payment Program proposed rule (81 FR
28196). We note that groups reporting
via the CMS Web Interface may also
report the CAHPS for MIPS survey and
receive bonus points for submitting that
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measure. We are not proposing any
changes to the submission criteria for
quality measures for groups reporting
via the CMS Web Interface in this
proposed rule.
(iii) Performance Criteria for Quality
Measures for Groups Electing To Report
Consumer Assessment of Healthcare
Providers and Systems (CAHPS) for
MIPS Survey
In the CY 2017 Quality Payment
Program final rule (81 FR 77100), we
finalized at § 414.1335(a)(3) the
following criteria for the submission of
data on the CAHPS for MIPS survey by
registered groups via CMS-approved
survey vendor: For the applicable 12month performance period, a group that
wishes to voluntarily elect to participate
in the CAHPS for MIPS survey measure
must use a survey vendor that is
approved by CMS for a particular
performance period to transmit survey
measures data to CMS. The CAHPS for
MIPS survey counts for one measure
towards the MIPS quality performance
category and, as a patient experience
measure, also fulfills the requirement to
report at least one high priority measure
in the absence of an applicable outcome
measure. In addition, groups that elect
this data submission mechanism must
select an additional group data
submission mechanism (that is,
qualified registries, QCDRs, EHR, etc.)
in order to meet the data submission
criteria for the MIPS quality
performance category. The CAHPS for
MIPS survey will count as one patient
experience measure, and the group will
be required to submit at least five other
measures through one other data
submission mechanism. A group may
report any five measures within MIPS
plus the CAHPS for MIPS survey to
achieve the six measures threshold. We
are not proposing any changes to the
performance criteria for quality
measures for groups electing to report
the CAHPS for MIPS survey in this
proposed rule.
In the CY 2017 Quality Payment
Program final rule (see 81 FR 77120), we
finalized retaining the CAHPS for MIPS
survey administration period that was
utilized for PQRS of November to
February. However, this survey
administration period has become
operationally problematic for the
administration of MIPS. In order to
compute scoring, we must have the
CAHPS for MIPS survey data earlier
than the current survey administration
period deadline allows. Therefore, we
are proposing for the Quality Payment
Program Year 2 and future years that the
survey administration period would, at
a minimum, span over 8 weeks and
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would end no later than February 28th
following the applicable performance
period. In addition, we propose to
further specify the start and end
timeframes of the survey administration
period through our normal
communication channels.
In addition, as discussed in the CY
2017 Quality Payment Program final
rule (81 FR 77116), we anticipated
exploring the possibility of updating the
CAHPS for MIPS survey under MIPS,
specifically not finalizing all of the
proposed Summary Survey Measures
(SSMs). The CAHPS for MIPS survey
currently consists of the core CAHPS
Clinician & Group (CG–CAHPS) Survey
developed by the Agency for Healthcare
Research and Quality (AHRQ), plus
additional survey questions to meet
CMS’s program needs. We are proposing
for the Quality Payment Program Year 2
and future years to remove two SSMs,
specifically, ‘‘Helping You to Take
Medication as Directed’’ and ‘‘Between
Visit Communication’’ from the CAHPS
for MIPS survey. We are proposing to
remove the SSM entitled ‘‘Helping You
to Take Medication as Directed’’ due to
low reliability. In 2014 and 2015, the
majority of groups had very low
reliability on this SSM. Furthermore,
based on analyses conducted of SSMs in
an attempt to improve their reliability,
removing questions from this SSM did
not result in any improvements in
reliability. The SSM, ‘‘Helping You to
Take Medication as Directed,’’ has also
never been a scored measure with the
Medicare Shared Savings Program
CAHPS for Accountable Care
Organizations (ACOs) Survey. We refer
readers to the CY 2014 Physician Fee
Schedule final rule for a discussion on
the CAHPS for ACO survey scoring (79
FR 67909 through 67910) and measure
tables (79 FR 67916 through 67917). The
SSM entitled ‘‘Between Visit
Communication’’ currently contains
only one question. This question could
also be considered related to other SSMs
entitled: ‘‘Care Coordination’’ or
‘‘Courteous and Helpful Office Staff,’’
but does not directly overlap with any
of the questions under that SSM.
However, we are proposing to remove
this SSM in order to maintain
consistency with the Medicare Shared
Savings Program which, utilizes the
CAHPS for Accountable Care
Organizations (ACOs) Survey. The SSM
entitled ‘‘Between Visit
Communication’’ has never been a
scored measure with the Medicare
Shared Savings Program CAHPS for
ACOs Survey.
In addition to public comments we
receive, we will also take into
consideration analysis we will be
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conducting before finalizing this
proposal. Specifically, we will review
the findings of the CAHPS for ACO
survey pilot, which was administered
from November 2016 through February
2017. The CAHPS for ACO survey pilot
utilized a survey instrument which did
not contain the two SSMs we are
proposing for removal from the CAHPS
for MIPS survey. For more information
on the other SSMs within the CAHPS
for MIPS survey, please see the
explanation of the CAHPS for PQRS
survey in the CY 2016 PFS final rule
with comment period (80 FR 71142
through 71143).
TABLE 4—PROPOSED SUMMARY SURVEY MEASURES (SSMS) INCLUDED
IN THE CAHPS FOR MIPS SURVEY
Summary survey measures (SSMs)
Getting Timely Care, Appointments, and Information.
How Well Providers Communicate.
Patient’s Rating of Provider.
Access to Specialists.
Health Promotion and Education.
Shared Decision-Making.
Health Status and Functional Status.
Courteous and Helpful Office Staff.
Care Coordination.
Stewardship of Patient Resources.
We are seeking comment on
expanding the patient experience data
available for the CAHPS for MIPS
survey. Currently, the CAHPS for MIPS
survey is available for groups to report
under the MIPS. The patient experience
survey data that is available on
Physician Compare is highly valued by
patients and their caregivers as they
evaluate their health care options.
However, in user testing with patients
and caregivers in regard to the Physician
Compare Web site, the users regularly
ask for more information from patients
like them in their own words. Patients
regularly request that we include
narrative reviews of individual
clinicians and groups on the Web site.
AHRQ is fielding a beta version of the
CAHPS Patient Narrative Elicitation
Protocol (https://www.ahrq.gov/cahps/
surveys-guidance/item-sets/elicitation/
index.html). This includes five openended questions designed to be added to
the CG CAHPS survey, after which the
CAHPS for MIPS survey is modeled.
These five questions have been
developed and tested in order to capture
patient narratives in a scientifically
grounded and rigorous way, setting it
apart from other patient narratives
collected by various health systems and
patient rating sites. More scientifically
rigorous patient narrative data would
not only greatly benefit patients in their
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decision for healthcare, but it would
also greatly aid individual MIPS eligible
clinicians and groups as they assess
how their patients experience care. We
are seeking comment on adding these
five open-ended questions to the
CAHPS for MIPS survey in future
rulemaking. Beta testing is an ongoing
process, and we anticipate reviewing
the results of that testing in
collaboration with AHRQ before
proposing changes to the CAHPS for
MIPS survey.
We are requiring, where possible, allpayer data for all reporting mechanisms,
yet certain reporting mechanisms are
limited to Medicare Part B data.
Specifically, the CAHPS for MIPS
survey currently relies on sampling
protocols based on Medicare Part B
billing; therefore, only Medicare Part B
beneficiaries are sampled through that
methodology. In the CY 2017 Quality
Payment Program proposed rule (81 FR
28189), we requested comments on
ways to modify the methodology to
assign and sample patients for these
mechanisms using data from other
payers. We received mixed feedback on
the use of all-payer data overall. The full
discussion of the comments and the
responses can be found in the CY 2017
Quality Payment Program final rule (81
FR 77123 through 77125). We are
requesting additional comments on
ways to modify the methodology to
assign and sample patients using data
from other payers for reporting
mechanisms that are currently limited
to Medicare Part B data. In particular,
we are seeking comment on the ability
of groups to provide information on the
patients to whom they provide care
during a calendar year, whether it
would be possible to identify a list of
patients seen by individual clinicians in
the group, and what type of patient
contact information groups would be
able to provide. Further, we would like
to seek comment on the challenges
groups may anticipate in trying to
provide this type of information,
especially for vulnerable beneficiary
populations, such as those lacking
stable housing. We are also seeking
comment on EHR vendors’ ability to
provide information on the patients who
receive care from their client groups.
(b) Data Completeness Criteria
In the CY 2017 Quality Payment
Program final rule (81 FR 77125), we
finalized data completeness criteria for
the transition year and MIPS payment
year 2020. We finalized at § 414.1340
the data completeness criteria below for
performance periods occurring in 2017.
• Individual MIPS eligible clinicians
or groups submitting data on quality
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measures using QCDRs, qualified
registries, or via EHR must report on at
least 50 percent of the individual MIPS
eligible clinician or group’s patients that
meet the measure’s denominator
criteria, regardless of payer for the
performance period. In other words, for
these submission mechanisms, we
expect to receive quality data for both
Medicare and non-Medicare patients.
For the transition year, MIPS eligible
clinicians whose measures fall below
the data completeness threshold of 50
percent would receive 3 points for
submitting the measure.
• Individual MIPS eligible clinicians
submitting data on quality measures
data using Medicare Part B claims,
would report on at least 50 percent of
the Medicare Part B patients seen during
the performance period to which the
measure applies. For the transition year,
MIPS eligible clinicians whose
measures fall below the data
completeness threshold of 50 percent
would receive 3 points for submitting
the measure.
• Groups submitting quality measures
data using the CMS Web Interface or a
CMS-approved survey vendor to report
the CAHPS for MIPS survey must meet
the data submission requirements on the
sample of the Medicare Part B patients
CMS provides.
In addition, we finalized an increased
data completeness threshold of 60
percent for MIPS for performance
periods occurring in 2018 for data
submitted on quality measures using
QCDRs, qualified registries, via EHR, or
Medicare Part B claims. We noted that
these thresholds for data submitted on
quality measures using QCDRs,
qualified registries, via EHR, or
Medicare Part B claims would increase
for performance periods occurring in
2019 and onward.
We are proposing to modify the
previously established data
completeness criteria for MIPS payment
year 2020. Specifically, we would like
to provide an additional year for
individual MIPS eligible clinicians and
groups to gain experience with MIPS
before increasing the data completeness
thresholds for data submitted on quality
measures using QCDRs, qualified
registries, via EHR, or Medicare Part B
claims. We are concerned about the
unintended consequences of
accelerating the data completeness
threshold so quickly, which may
jeopardize MIPS eligible clinicians’
ability to participate and perform well
under the MIPS, particularly those
clinicians who are least experienced
with MIPS quality measure data
submission. We want to ensure that an
appropriate yet achievable level of data
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30041
completeness is applied to all MIPS
eligible clinicians. We continue to
believe it is important to incorporate
higher data completeness thresholds in
future years to ensure a more accurate
assessment of a MIPS eligible clinician’s
performance on quality measures and to
avoid any selection bias. Therefore, we
propose, below, a 60 percent data
completeness threshold for MIPS
payment year 2021. We strongly
encourage all MIPS eligible clinicians to
perform the quality actions associated
with the quality measures on their
patients. The data submitted for each
measure is expected to be representative
of the individual MIPS eligible
clinician’s or group’s overall
performance for that measure. The data
completeness threshold of less than 100
percent is intended to reduce burden
and accommodate operational issues
that may arise during data collection
during the initial years of the program.
We are providing this notice to MIPS
eligible clinicians so that they can take
the necessary steps to prepare for higher
data completeness thresholds in future
years.
Therefore, we propose to revise the
data completeness criteria for the
quality performance category at
§ 414.1340(a)(2) to provide that MIPS
eligible clinicians and groups
submitting quality measures data using
the QCDR, qualified registry, or EHR
submission mechanism must submit
data on at least 50 percent of the
individual MIPS eligible clinician’s or
group’s patients that meet the measure’s
denominator criteria, regardless of
payer, for MIPS payment year 2020. We
also propose to revise the data
completeness criteria for the quality
performance category at § 414.1340(b)(2)
to provide that MIPS eligible clinicians
and groups submitting quality measures
data using Medicare Part B claims, must
submit data on at least 50 percent of the
applicable Medicare Part B patients seen
during the performance period to which
the measure applies for MIPS payment
year 2020. We further propose at
§ 414.1340(a)(3), that MIPS eligible
clinicians and groups submitting quality
measures data using the QCDR,
qualified registry, or EHR submission
mechanism must submit data on at least
60 percent of the individual MIPS
eligible clinician or group’s patients that
meet the measure’s denominator
criteria, regardless of payer for MIPS
payment year 2021. We also propose at
§ 414.1340(b)(3), that MIPS eligible
clinicians and groups submitting quality
measures data using Medicare Part B
claims, must submit data on at least 60
percent of the applicable Medicare Part
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B patients seen during the performance
period to which the measure applies for
MIPS payment year 2021. We would
like to note that we anticipate for future
MIPS payment years we will propose to
increase the data completeness
threshold for data submitted using
QCDRs, qualified registries, EHR
submission mechanisms, or Medicare
Part B claims. As MIPS eligible
clinicians gain experience with the
MIPS, we would propose to steadily
increase these thresholds for future
years through rulemaking. In addition,
we are seeking comment on what data
completeness threshold should be
established for future years.
In the CY 2017 Quality Payment
Program final rule (81 FR 77125 through
77126), we finalized our approach of
including all-payer data for the QCDR,
qualified registry, and EHR submission
mechanisms because we believed this
approach provides a more complete
picture of each MIPS eligible clinician’s
scope of practice and provides more
access to data about specialties and
subspecialties not currently captured in
PQRS. In addition, those clinicians who
utilize a QCDR, qualified registry, or
EHR submission must contain a
minimum of one quality measure for at
least one Medicare patient. We are not
proposing any changes to these policies
in this proposed rule. As noted in the
CY 2017 Quality Payment Program final
rule, those MIPS eligible clinicians who
fall below the data completeness
thresholds will receive 3 points for the
specific measures that fall below the
data completeness threshold in the
transition year of MIPS only. For the
Quality Payment Program Year 2, we are
proposing that MIPS eligible clinicians
would receive 1 point for measures that
fall below the data completeness
threshold, with an exception for small
practices of 15 or fewer who would still
receive 3 points for measures that fail
data completeness. We refer readers to
section II.C.6.b.(3)(b) of this proposed
rule for our proposed policies on
instances when MIPS eligible clinicians’
measures fall below the data
completeness threshold.
(c) Summary of Data Submission
Criteria
Table 5 reflects our proposed quality
data submission criteria for MIPS
payment year 2020 via Medicare Part B
claims, QCDR, qualified registry, EHR,
CMS Web Interface, and the CAHPS for
MIPS survey. It is important to note that
while we finalized at § 414.1325(d) in
the CY 2017 Quality Payment Program
final rule that individual MIPS eligible
clinicians and groups may only use one
submission mechanism per performance
category, in section II.C.6.a.(1) of this
rule, we are proposing to revise
§ 414.1325(d) for purposes of the 2020
MIPS payment year and future years to
allow individual MIPS eligible
clinicians and groups to submit
measures and activities, as applicable,
via as many submission mechanisms as
necessary to meet the requirements of
the quality, improvement activities, or
advancing care information performance
categories. We refer readers to section
II.C.6.a.(1) of this proposed rule for
further discussion of this proposal.
TABLE 5—SUMMARY OF PROPOSED QUALITY DATA SUBMISSION CRITERIA FOR MIPS PAYMENT YEAR 2020 VIA PART B
CLAIMS, QCDR, QUALIFIED REGISTRY, EHR, CMS WEB INTERFACE, AND THE CAHPS FOR MIPS SURVEY
Performance period
Submission
mechanism
Clinician type
Submission criteria
Data completeness
Report at least six measures including one
outcome measure, or if an outcome measure is not available report another high priority measure; if less than six measures
apply then report on each measure that is
applicable. Individual MIPS eligible clinicians would have to select their measures
from either the set of all MIPS measures
listed or referenced in Table A or one of
the specialty measure sets listed in Table
B of the Appendix in this proposed rule.
Report at least six measures including one
outcome measure, or if an outcome measure is not available report another high priority measure; if less than six measures
apply then report on each measure that is
applicable. Individual MIPS eligible clinicians, groups, or virtual groups would
have to select their measures from either
the set of all MIPS measures listed or referenced in Table A or one of the specialty
measure sets listed in Table B of the Appendix in this proposed rule.
Report on all measures included in the CMS
Web Interface; AND populate data fields
for the first 248 consecutively ranked and
assigned Medicare beneficiaries in the
order in which they appear in the group’s
or virtual group’s sample for each module/
measure. If the pool of eligible assigned
beneficiaries is less than 248, then the
group or virtual group would report on 100
percent of assigned beneficiaries.
50 percent of individual MIPS eligible
clinician’s Medicare
Part B patients for
the performance period.
Individual MIPS eligible clinicians.
Part B Claims .............
Jan 1–Dec 31 ............
Individual MIPS eligible clinicians,
groups or virtual
groups.
QCDR, Qualified Registry, & EHR.
Jan 1–Dec 31 ............
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Jan 1–Dec 31 ............
Groups or virtual
groups.
CMS Web Interface ...
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50 percent of individual MIPS eligible
clinician’s, group’s,
or virtual group’s
patients across all
payers for the performance period.
Sampling requirements for the
group’s or virtual
group’s Medicare
Part B patients.
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TABLE 5—SUMMARY OF PROPOSED QUALITY DATA SUBMISSION CRITERIA FOR MIPS PAYMENT YEAR 2020 VIA PART B
CLAIMS, QCDR, QUALIFIED REGISTRY, EHR, CMS WEB INTERFACE, AND THE CAHPS FOR MIPS SURVEY—Continued
Performance period
Jan 1–Dec 31 ............
Submission
mechanism
CAHPS for MIPS Survey.
Groups or virtual
groups.
As discussed in section II.C.4.d. of
this proposed rule, we are proposing to
generally apply our previously finalized
and proposed group policies to virtual
groups.
(4) Application of Quality Measures to
Non-Patient Facing MIPS Eligible
Clinicians
In the CY 2017 Quality Payment
Program final rule (81 FR 77127), we
finalized at § 414.1335 that non-patient
facing MIPS eligible clinicians would be
required to meet the applicable
submission criteria that apply for all
MIPS eligible clinicians for the quality
performance category. We are not
proposing any changes to this policy in
this proposed rule.
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(5) Application of Facility-Based
Measures
Section 1848(q)(2)(C)(ii) of the Act
provides that the Secretary may use
measures used for payment systems
other than for physicians, such as
measures used for inpatient hospitals,
for purposes of the quality and cost
performance categories. However, the
Secretary may not use measures for
hospital outpatient departments, except
in the case of items and services
furnished by emergency physicians,
radiologists, and anesthesiologists. We
refer readers to section II.C.7.a.(4) of this
proposed rule for a full discussion of
our proposals regarding the application
of facility-based measures.
(6) Global and Population-Based
Measures
In the CY 2017 Quality Payment
Program final rule (81 FR 77136), we
did not finalize all of our proposals on
global and population-based measures
as part of the quality score. Specifically,
we did not finalize our proposal to use
the acute and chronic composite
measures of the AHRQ Prevention
Quality Indicators (PQIs). We agreed
with commenters that additional
enhancements, including the addition of
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Submission criteria
CMS-approved survey vendor would need to
be paired with another reporting mechanism to ensure the minimum number of
measures is reported. CAHPS for MIPS
survey would fulfill the requirement for one
patient experience measure towards the
MIPS quality data submission criteria.
CAHPS for MIPS survey would only count
for one measure under the quality performance category.
Clinician type
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risk adjustment, needed to be made to
these measures prior to inclusion in
MIPS. We did, however, calculate these
measures at the TIN level, through the
QRURs released in September 2016, and
this data can be used by MIPS eligible
clinicians for informational purposes.
We did finalize the all-cause hospital
readmissions (ACR) measure from the
VM Program as part of the quality
measure domain for the MIPS total
performance score. We finalized this
measure with the following
modifications. We did not apply the
ACR measure to solo practices or small
groups (groups of 15 or less). We did
apply the ACR measure to groups of 16
or more who meet the case volume of
200 cases. A group was scored on the
ACR measure even if it did not submit
any quality measures, if it submitted in
other performance categories.
Otherwise, the group was not scored on
the readmission measure if it did not
submit data in any of the performance
categories. In our transition year
policies, the readmission measure alone
would not produce a neutral to positive
MIPS payment adjustment since in
order to achieve a neutral to positive
MIPS payment adjustment, an
individual MIPS eligible clinician or
group must submit information on one
of the three performance categories as
discussed in the CY 2017 Quality
Payment Program final rule (81 FR
77329). In addition, the ACR measure in
the MIPS transition year CY 2017 was
based on the performance period
(January 1, 2017 through December 31,
2017). However, for MIPS eligible
clinicians who did not meet the
minimum case requirements, the ACR
measure was not applicable. We are not
proposing any changes for the global
and population-based measures in this
proposed rule. As discussed in section
II.C.4.d. of this rule, we are proposing to
generally apply our previously finalized
and proposed group policies to virtual
groups.
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Data completeness
Sampling requirements for the
group’s or virtual
group’s Medicare
Part B patients.
c. Selection of MIPS Quality Measures
for Individual MIPS Eligible Clinicians
and Groups Under the Annual List of
Quality Measures Available for MIPS
Assessment
(1) Background and Policies for the Call
for Measures and Measure Selection
Process
Under section 1848(q)(2)(D)(i) of the
Act, the Secretary, through notice and
comment rulemaking, must establish an
annual list of MIPS quality measures
from which MIPS eligible clinicians
may choose for purposes of assessment
for a performance period. The annual
list of MIPS quality measures must be
published in the Federal Register no
later than November 1 of the year prior
to the first day of a performance period.
Updates to the annual list of MIPS
quality measures must be published in
the Federal Register no later than
November 1 of the year prior to the first
day of each subsequent performance
period. Updates may include the
addition of new MIPS quality measures,
substantive changes to MIPS quality
measures, and removal of MIPS quality
measures. MIPS eligible clinicians
reporting on the quality performance
category are required to use the most
recent version of the clinical quality
measure (CQM) electronic specifications
as indicated in the CY 2017 Quality
Payment Program final rule (81 FR
77291). For purposes of the 2018 MIPS
performance period, the spring 2017
version of the eCQM annual update to
the measure specifications and any
applicable addenda are available on the
electronic clinical quality improvement
(eCQI) Resource Center Web site at
https://ecqi.healthit.gov. The CMS
Quality Measure Development Plan
(MDP) serves as a strategic framework
for the future of the clinician quality
measure development to support MIPS
and APMs. The MDP is available on the
CMS Web site and highlights known
measurement gaps and recommends
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approaches to close those gaps through
development, use, and refinement of
quality measures that address
significant variation in performance
gaps. We encourage stakeholders to
develop additional quality measures for
MIPS that would address the gaps.
Under section 1848(q)(2)(D)(ii) of the
Act, the Secretary must solicit a ‘‘Call
for Quality Measures’’ each year.
Specifically, the Secretary must request
that eligible clinician organizations and
other relevant stakeholders identify and
submit quality measures to be
considered for selection in the annual
list of MIPS quality measures, as well as
updates to the measures. Under section
1848(q)(2)(D)(ii) of the Act, eligible
clinician organizations are professional
organizations as defined by nationally
recognized specialty boards of
certification or equivalent certification
boards. However, we do not believe
there needs to be any special restrictions
on the type or make-up of the
organizations that submit measures for
consideration through the call for
measures. Any such restriction would
limit the type of quality measures and
the scope and utility of the quality
measures that may be considered for
inclusion under the MIPS.
As we described previously in the CY
2017 Quality Payment Program final
rule (81 FR 77137), we will accept
quality measures submissions at any
time, but only measures submitted
during the timeframe provided by us
through the pre-rulemaking process of
each year will be considered for
inclusion in the annual list of MIPS
quality measures for the performance
period beginning 2 years after the
measure is submitted. This process is
consistent with the pre-rulemaking
process and the annual call for
measures, which are further described at
(https://www.cms.gov/Medicare/
Quality-Initiatives-Patient-AssessmentInstruments/QualityMeasures/Pre-RuleMaking.html).
Submission of potential quality
measures, regardless of whether they
were previously published in a
proposed rule or endorsed by an entity
with a contract under section 1890(a) of
the Act, which is currently the National
Quality Forum, is encouraged. The
annual Call for Measures process allows
eligible clinician organizations and
other relevant stakeholder organizations
to identify and submit quality measures
for consideration. Presumably,
stakeholders would not submit
measures for consideration unless they
believe that the measure is applicable to
clinicians and can be reliably and
validly measured at the individual
clinician level. The NQF-convened
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Measure Application Partnership (MAP)
provides an additional opportunity for
stakeholders to provide input on
whether or not they believe the
measures are applicable to clinicians as
well as feasible, scientifically
acceptable, and reliable and valid at the
clinician level. Furthermore, we must go
through notice and comment
rulemaking to establish the annual list
of quality measures, which gives
stakeholders an additional opportunity
to review the measures and provide
input on whether or not they believe the
measures are applicable to clinicians, as
well as feasible, scientifically
acceptable, and reliable and valid at the
clinician level. Additionally, we are
required by statute to submit new
measures to an applicable specialtyappropriate, peer-reviewed journal.
As previously noted, we encourage
the submission of potential quality
measures regardless of whether such
measures were previously published in
a proposed rule or endorsed by an entity
with a contract under section 1890(a) of
the Act. However, we propose to request
that stakeholders apply the following
considerations when submitting quality
measures for possible inclusion in
MIPS:
• Measures that are not duplicative of
an existing or proposed measure.
• Measures that are beyond the
measure concept phase of development
and have started testing, at a minimum,
with strong encouragement and
preference for measures that complete
or are near completion of reliability and
validity testing.
• Measures that include a data
submission method beyond claimsbased data submission.
• Measures that are outcome-based
rather than clinical process measures.
• Measures that address patient safety
and adverse events.
• Measures that identify appropriate
use of diagnosis and therapeutics.
• Measures that address the domain
for care coordination.
• Measures that address the domain
for patient and caregiver experience.
• Measures that address efficiency,
cost, and resource use.
• Measures that address significant
variation in performance.
We will apply these considerations
when considering quality measures for
possible inclusion in MIPS.
In addition, we note that we are likely
to reject measures that do not provide
substantial evidence of variation in
performance; for example, if a measure
developer submits data showing a small
variation in performance among a group
already composed of high performers,
such evidence would not be substantial
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enough to assure us that sufficient
variation in performance exists. We also
note that we are likely to reject
measures that are not outcome-based
measures, unless (1) there is substantial
documented and peer reviewed
evidence that the clinical process
measured varies directly with the
outcome of interest and (2) it is not
possible to measure the outcome of
interest in a reasonable timeframe.
We also note that retired measures
that were in one of CMS’s previous
quality programs, such as the Physician
Quality Reporting System (PQRS)
program, will likely be rejected if
proposed for inclusion. This includes
measures that were retired due to being
topped out, as defined below. For
example, measures may be retired due
to attaining topped out status because of
high performance, or measures that are
retired due to a change in the evidence
supporting their use.
In the CY 2017 Quality Payment
Program final rule (81 FR 77153), we
established that we will categorize
measures into the six NQS domains
(patient safety, person- and caregivercentered experience and outcomes,
communication and care coordination,
effective clinical care, community/
population health, and efficiency and
cost reduction). We intend to submit
future MIPS quality measures to the
NQF-convened Measure Application
Partnership’s (MAP), as appropriate,
and we intend to consider the MAP’s
recommendations as part of the
comprehensive assessment of each
measure considered for inclusion under
MIPS.
In the CY 2017 Quality Payment
Program final rule (81 FR 77155), we
established that we use the Call for
Quality Measures process as a forum to
gather the information necessary to draft
the journal articles for submission from
measure developers, measure owners
and measure stewards since we do not
always develop measures for the quality
programs. The submission of this
information does not preclude us from
conducting our own research using
Medicare claims data, Medicare survey
results, and other data sources that we
possess. We submit new measures for
publication in applicable specialtyappropriate, peer-reviewed journals
before including such measures in the
final annual list of quality measures.
In the CY 2017 Quality Payment
Program final rule (81 FR 77158), we
established at § 414.1330(a)(2) that for
purposes of assessing performance of
MIPS eligible clinicians on the quality
performance category, we use quality
measures developed by QCDRs. In the
circumstances where a QCDR wants to
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use a QCDR measure for inclusion in the
MIPS program for reporting, those
measures go through a CMS approval
process during the QCDR selfnomination period. We also established
that we post the quality measures for
use by QCDRs by no later than January
1 for performance periods occurring in
2018 and future years.
Previously finalized MIPS quality
measures can be found in the CY 2017
Quality Payment Program final rule (81
FR 77558 through 77675). Updates may
include the proposal to add new MIPS
quality measures, including measures
selected 2 years ago during the Call for
Measures process. The new MIPS
quality measures proposed for inclusion
in MIPS for the 2018 performance
period and future years are found in
Table A. The proposed new and
modified MIPS specialty sets for the
2018 performance period and future
years are listed in Table B, and include
existing measures that are proposed
with modifications, new measures, and
measures finalized in the CY 2017
Quality Payment Program final rule. We
note that the modifications made to the
specialty sets may include the removal
of certain quality measures that were
previously finalized. The specialty
measure sets should be used as a guide
for eligible clinicians to choose
measures applicable to their specialty.
To clarify, some of the MIPS specialty
sets have further defined subspecialty
sets, each of which is effectively a
separate specialty set. In instances
where an individual MIPS eligible
clinician or group reports on a specialty
or subspecialty set, if the set has less
than six measures, that is all the
clinician is required to report. MIPS
eligible clinicians are not required to
report on the specialty measure sets, but
they are suggested measures for specific
specialties. Throughout measure
utilization, measure maintenance
should be a continuous process done by
the measure owners, to include
environmental scans of scientific
literature about the measure. New
information gathered during this
ongoing review may trigger an ad hoc
review. The specialty measure sets in
Table B of the Appendix, include
existing measures that are proposed
with modifications, new measures, and
measures that were previously finalized
in the CY 2017 Quality Payment
Program final rule. Please note that
these specialty specific measure sets are
not all inclusive of every specialty or
subspecialty. On January 25, 2017, we
announced that we would be accepting
recommendations for potential new
specialty measure sets for year 2 of
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MIPS under the Quality Payment
Program. These recommendations were
based on the MIPS quality measures
finalized in the CY 2017 Quality
Payment Program final rule, and include
recommendations to add or remove the
current MIPS quality measures from the
specialty measure sets. The current
specialty measure sets can be found on
the Quality Payment Program Web site
at https://qpp.cms.gov/measures/
quality. All specialty measure sets
submitted for consideration were
assessed to ensure that they met the
needs of the Quality Payment Program.
As a result, we propose to add new
quality measures to MIPS (Table A),
revise the specialty measure sets in
MIPS (Table B), remove specific MIPS
quality measures only from specialty
sets (Table C.1), and propose to remove
specific MIPS quality measures from the
MIPS program for the 2018 performance
period (Table C.2). The aforementioned
measure tables can be found in the
Appendix of this proposed rule. In
addition, we are proposing to also
remove cross cutting measures from
most of the specialty sets. Specialty
groups and societies reported that cross
cutting measures may or may not be
relevant to their practices, contingent on
the eligible clinicians or groups. CMS
chose to retain the cross cutting
measures in Family Practice, Internal
Medicine and Pediatrics specialty sets
because they are frequently used in
these practices. The proposed 2017
cross cutting measures, (81 FR 28447
through 28449), were compiled and
placed in a separate table for eligible
clinicians to elect to use or not, for
reporting. To clarify, the cross-cutting
measures are intended to provide
clinicians with a list of measures that
are broadly applicable to all clinicians
regardless of the clinician’s specialty.
Even though it is not required to report
on cross-cutting measures, it is provided
as a reference to clinicians who are
looking for additional measures to
report outside their specialty. We
continue to consider cross-cutting
measures to be an important part of our
quality measure programs, and seek
comment on ways to incorporate crosscutting measures into MIPS in the
future. The proposed Table of CrossCutting Measures can be found in Table
D of the Appendix.
For MIPS quality measures that are
undergoing substantive changes, we
propose to identify measures including,
but not limited to measures that have
had measure specification, measure
title, and domain changes. MIPS quality
measures with proposed substantive
changes can be found at Table E of the
Appendix.
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The measures that would be used for
the APM scoring standard and our
authority for waiving certain measure
requirements are described in section
II.C.6.g.(3)(b)(ii) and the measures that
would be used to calculate a quality
score for the APM scoring standard are
proposed in Tables 14, 15, and 16.
We also seek comment for this rule,
on whether there are any MIPS quality
measures that commenters believe
should be classified in a different NQS
domain than what is being proposed, or
that should be classified as a different
measure type (for example, process vs.
outcome) than what is being proposed
in this rule.
(2) Topped Out Measures
As defined in the CY 2017 Quality
Payment Program final rule at (81 FR
77136), a measure may be considered
topped out if measure performance is so
high and unvarying that meaningful
distinctions and improvement in
performance can no longer be made.
Topped out measures could have a
disproportionate impact on the scores
for certain MIPS eligible clinicians, and
provide little room for improvement for
the majority of MIPS eligible clinicians.
We refer readers to section II.C.7.a.(2)(c)
of this proposed rule for additional
information regarding the scoring of
topped out measures.
We noted in the CY 2017 Quality
Payment Program final rule that we
anticipate removing topped out
measures over time and sought
comment on what point in time we
should remove topped out measures
from MIPS (81 FR 77286). We received
the following comments.
Many commenters recommended that
we retain topped out quality measures
for 2 or more years because commenters
believed they serve to motivate
continued high-quality care; more
clinicians may participate in MIPS
compared to prior programs such as
PQRS, and thus there may be more
performance variation in MIPS showing
that the measure is not actually topped
out; declines in performance will not be
captured if a measure is eliminated; it
will help provide stability and
encourage reporting in the early years of
the MIPS program; removing topped out
measures could further limit the number
of measures available to specialists; and
providing eligible clinicians and the
public with information about high
performance is as important as
informing them about deficits.
A few commenters recommended that
we publish information about topped
out and potentially topped out measures
prior to the performance period to allow
clinicians time to adjust their reporting
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strategies, with one commenter noting
that improvement may be rewarded in
addition to achievement. One
commenter recommended pushing back
the baseline performance period for the
purpose of identifying topped out
measures to 2018 because in the
transition year it is unclear how many
eligible clinicians will be reporting at
different times and for what time period
they will report.
Finally, a few commenters
recommended that we consider
specialty, case mix, and rural location
before determining that a measure is
topped out, specifically whether there is
still room for improvement among
certain specialist groups and to ensure
that rural provider improvement is
recognized. One commenter
recommended that we determine topped
out measures based on reporting in the
Quality Payment Program rather than
PQRS or value modifier reporting
because the commenter believed using
historical performance disadvantages
small groups. A few commenters
requested that the process for
identifying and determining the removal
of topped out measures be transparent,
evidence-based, patient-centered, and
include feedback from all appropriate
stakeholders, including the medical
community and measures owner. A few
commenters specifically recommended
that determining whether to remove a
topped out measure be part of a
rulemaking process while another
commenter suggested that we seek out
stakeholder input from the Measure
Applications Partnership (MAP) on
whether a measure should be removed,
awarded lower points, or remain with
benchmarks as a flat percentage.
We propose a 3-year timeline for
identifying and proposing to remove
topped out measures. After a measure
has been identified as topped out for
three consecutive years, we may
propose to remove the measure through
comment and rulemaking for the 4th
year. Therefore, in the 4th year, if
finalized through rulemaking, the
measure would be removed and would
no longer be available for reporting
during the performance period. This
proposal provides a path toward
removing topped out measures over
time, and will apply to the MIPS quality
measures. QCDR measures that
consistently are identified as topped out
according to the same timeline as
proposed below, would not be approved
for use in year 4 during the QCDR selfnomination review process, and would
not go through the comment and
rulemaking process described below.
We propose to phase in this policy
starting with a select set of six highly
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topped out measures identified in
section II.C.7.a.(2)(c) of this proposed
rule. In section II.C.7.a.(2)(c) of this
proposed rule, we are also proposing to
phase in special scoring for measures
identified as topped out in the
published benchmarks for two
consecutive performance periods,
starting with the select set of highly
topped out measures for the 2018 MIPS
performance period. An example
illustrating the proposed timeline for
the removal and special scoring of
topped out measures, as it would be
applied to the select set of highly
topped out measures identified in
section II.C.7.a.(2)(c), is as follows:
• Year 1: The measures are identified
as topped out in the benchmarks
published for the 2017 MIPS
performance Period. The 2017
benchmarks are posted on the Quality
Payment Program Web site: https://
qpp.cms.gov/resources/education.
• Year 2: Measures are identified as
topped out in the benchmarks published
for the 2018 MIPS performance period.
We refer readers to section II.C.7.a.(2)(c)
of this proposed rule for additional
information regarding the scoring of
topped out measures.
• Year 3: Measures are identified as
topped out in the benchmarks published
for the 2019 MIPS performance period.
The measures identified as topped out
in the benchmarks published for the
2019 MIPS performance period and the
previous two consecutive performance
periods would continue to have special
scoring applied for the 2019 MIPS
performance period and would be
considered, through notice-andcomment rulemaking, for removal for
the 2020 MIPS performance period.
• Year 4: Topped out measures that
are finalized for removal are no longer
available for reporting. For example, the
measures in the set of highly topped out
measures identified as topped out for
the 2017, 2018 and 2019 MIPS
performance periods, and if
subsequently finalized for removal will
not be available on the list of measures
for the 2020 MIPS performance period
and future years.
For all other measures, the timeline
would apply starting with the
benchmarks for the 2018 MIPS
performance period. Thus, the first year
any other topped out measure could be
proposed for removal would be in
rulemaking for the 2021 MIPS
performance period, based on the
benchmarks being topped out in the
2018, 2019, and 2020 MIPS performance
periods. If the measure benchmark is
not topped out during one of the three
MIPS performance periods, then the
lifecycle would stop and start again at
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year 1 the next time the measure
benchmark is topped out.
We seek comment on the above
proposed timeline, specifically
regarding the number of years before a
topped out measure is identified and
considered for removal, and under what
circumstances we should remove
topped out measures once they reach
that point. For example, should we
automatically remove topped out
measures after they are identified for the
proposed number of years or should we
review measures identified for removal
and consider certain criteria before
removing the measure? If so what
criteria should be considered? We
would like to note that if for some
reason a measure benchmark is topped
out for only one submission mechanism
benchmark, then we would remove that
measure from the submission
mechanism, but not remove the measure
from other submission mechanisms
available for submitting that measure.
We also seek comment on whether
topped out Summary Survey Measures
(SSMs), if topped out, should be
considered for removal from the
Consumer Assessment of Healthcare
Providers and Systems (CAHPS) for
MIPS Clinician or Group Survey
measure due to high, unvarying
performance within the SSM, or
whether there is another alternative
policy that could be applied for topped
out SSMs within the CAHPS for MIPS
Clinician or Group Survey measure.
In the CY 2017 Quality Payment
Program final rule, we state that we do
not believe it would be appropriate to
remove topped out measures from the
CMS Web Interface for the Quality
Payment Program because the CMS Web
Interface measures are used in MIPS and
in APMs, such as the Shared Savings
Program. Removing topped out
measures from the CMS Web Interface
would not be appropriate because we
have aligned policies where possible,
with the Shared Savings Program, such
as using the Shared Savings Program
benchmarks for the CMS Web Interface
measures (81 FR 77285). In the CY 2017
Quality Payment Program final rule, we
also finalized that MIPS eligible
clinicians reporting via the CMS Web
Interface must report all measures
included in the CMS Web Interface (81
FR 77116). Thus, if a CMS Web Interface
measure is topped out, the CMS Web
Interface reporter cannot select other
measures. We refer readers to section
II.C.7.a.(2) of this proposed rule for
information on scoring policies with
regards to topped out measures from the
CMS Web Interface for the Quality
Payment Program. We are not proposing
to include CMS Web Interface measures
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(3) Non-Outcome Measures
In the CY 2017 Quality Payment
Program final rule, we sought comment
on whether we should remove nonoutcomes measures for which
performance cannot reliably be scored
against a benchmark (for example,
measures that do not have 20 reporters
with 20 cases that meet the data
completeness standard) for 3 years in a
row (81 FR 77288).
A few commenters recommended that
measures that cannot be scored against
a benchmark should be removed from
the MIPS score. One commenter
recommended that non-outcome
measures that are unscorable should be
given a weight of zero or re-weighted in
the performance category. One
commenter supported removing nonoutcomes measures for which
performance cannot reliably be scored
against a benchmark for 3 years in a
row. One commenter believed it would
also be appropriate to remove outcomes
measures under a separate more
protracted timeline because the
commenter believed the reporting of
outcome measures is more difficult and
expected to increase at a slower pace,
while maintaining outcome measures
would encourage the testing and
availability of such measures.
Based on the need for CMS to further
assess this issue, we are not proposing
to remove non-outcome measures in this
proposed rule. However, we seek
comment on what the best timeline for
removing both non-outcome and
outcome measures that cannot be
reliably scored against a benchmark for
3 years. We intend to revisit this issue
and make proposals in future
rulemaking.
(4) Quality Measures Determined To Be
Outcome Measures
Under the MIPS, individual MIPS
eligible clinicians are generally required
to submit at least one outcome measure,
or, if no outcome measure is available,
one high priority measure. As such, our
determinations as to whether a measure
is an outcome measure is of importance
to stakeholders. We utilize the following
as a basis to determine if a measure is
considered an outcome measure:
• Measure Steward and National
Quality Forum (NQF) designation—For
most measures, we will utilize the
designation as determined by the
measure steward and the measure’s
NQF designation to determine if it is an
outcome measure or not. If this is not
clear, we will consider the following
step.
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• Utilization of the CMS Blueprint
definitions for outcome measures:
https://www.cms.gov/Medicare/QualityInitiatives-Patient-AssessmentInstruments/MMS/Downloads/
Blueprint-130.pdf. An outcome of care
is a health state of a patient resulting
from health care. Outcome measures are
supported by evidence that the measure
has been used to detect the impact of
one or more clinical interventions.
Clinical analysts are utilized to evaluate
the measure.
We also note that patient-reported
outcome measures are considered
outcome measures, as they measure the
health of the patient directly resulting
from the health care provided.
Efficiency measures are not considered
outcome measures, as they are
measuring the cost of care associated
with a specific level of care, but we do
note that efficiency is considered a high
priority measure.
After a MIPS quality measure is
established in the program, it is
generally only reviewed again if there
are significant changes to a measure for
the next program year that might
warrant a change to the designation of
outcome or not. In most cases, these
updates are significant enough that they
are usually presented as a new measure
from the measure owner. New measures
to the program will follow the criteria
outlined above. QCDR measures
however, are reviewed on a yearly basis
(during the fall) regardless if there is a
significant change or not. We refer
readers to section II.C.10.a. for
additional information on the QCDR
self-nomination and measures review
and approval process.
We seek comment on the criteria and
process outlined above on how we
designate outcome measures.
Specifically are there additional criteria
we should take into consideration when
we determine if a measure meets the
criteria of an outcome measure? Should
we use different criteria for MIPS
measures versus QCDR measures?
d. Cost Performance Category
(1) Background
(a) General Overview
Measuring cost is an integral part of
measuring value as part of MIPS. In
implementing the cost performance
category for the transition year (2017
MIPS performance period/2019 MIPS
payment year), we started with
measures that had been used in
previous programs but noted our intent
to move towards episode-based
measurement as soon as possible,
consistent with the statute and the
feedback from the clinician community.
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Specifically, we adopted 2 measures
that had been used in the VM: The total
per capita costs for all attributed
beneficiaries measure (referred to as the
total per capita cost measure) and the
MSPB measure (81 FR 77166 through
77168). We also adopted 10 episodebased measures that had previously
been included in the Supplemental
Quality and Resource Use Reports
(sQRURs) (81 FR 77171 through 77174).
At § 414.1325(e), we finalized that all
measures used under the cost
performance category would be derived
from Medicare administrative claims
data and, thus, participation would not
require additional data submission. We
finalized a reliability threshold of 0.4 for
measures in the cost performance
category (81 FR 77170). We also
finalized a case minimum of 35 for the
MSPB measure (81 FR 77171) and 20 for
the total per capita cost measure (81 FR
77170) and each of the 10 episode-based
measures (81 FR 77175) in the cost
performance category to ensure the
reliability threshold is met.
For the transition year, we finalized a
policy to weight the cost performance
category at zero percent in the final
score in order to give clinicians more
opportunity to understand the
attribution and the scoring methodology
and gain more familiarity with the
measures through performance feedback
(81 FR 77165 through 77166) so that
clinicians may be able to act to improve
their performance. In the CY 2017
Quality Payment Program final rule, we
finalized a cost performance category
weight of 10 percent for the 2020 MIPS
payment year (81 FR 77165). For the
2021 MIPS payment year and beyond,
the cost performance category will have
a weight of 30 percent of the final score
as required by section
1848(q)(5)(E)(i)(II)(aa) of the Act.
For descriptions of the statutory basis
and our existing policies for the cost
performance category, we refer readers
to the CY 2017 Quality Payment
Program final rule (81 FR 77162 through
77177).
As finalized at § 414.1370(g)(2), the
cost performance category is weighted at
zero percent for MIPS eligible clinicians
scored under the MIPS APM scoring
standard because many MIPS APM
models incorporate cost measurement in
other ways. For more on the APM
scoring standard, see II.C.6.E. of this
proposed rule.
(2) Weighting in the Final Score
We are proposing at § 414.1350(b)(2)
to change the weight of the cost
performance category from 10 percent to
zero percent for the 2020 MIPS payment
year. We continue to have concerns
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about the level of familiarity and
understanding of cost measures among
clinicians. We will use this additional
year in which the score in the cost
performance category does not count
towards the final score for outreach to
increase understanding of the measures
so that clinicians will be more
comfortable with their role in reducing
costs for their patients. In addition, we
will use this additional year to develop
more episode-based measures, which
are cost measures that are focused on a
clinical conditions or procedures. We
intend to propose in future rulemaking
to adopt episode-based measures
currently in development.
Although we believe reducing this
weight is appropriate given the level of
understanding of the measures and the
scoring standards, we note that section
1848(q)(5)(E)(i)(II)(aa) of the Act
requires the cost performance category
be assigned a weight of 30 percent of the
MIPS final score beginning in the 2021
MIPS payment year. We recognize that
assigning a zero percent weight to the
cost performance category for the 2020
MIPS payment year may not provide a
smooth enough transition for integrating
cost measures into MIPS and may not
provide enough encouragement to
clinicians to review their performance
on cost measures. This policy could
reduce understanding of the measures
when we reach the 2021 MIPS payment
year and the cost performance category
will be used to determine 30 percent of
the final score for MIPS eligible
clinicians, when in the two previous
years it was weighted at zero. Therefore,
we also seek comment on keeping the
weight of the cost performance category
at 10 percent for the 2020 MIPS
payment year.
In our discussions with clinicians and
clinician societies, clinicians expressed
their desire to down-weight the cost
performance category to zero percent for
an additional year with full knowledge
that the cost performance category
weight is set at 30 percent under the
statute for the 2021 MIPS payment year.
The clinicians we spoke with preferred
a low weighting and noted that they are
actively preparing for cost performance
category implementation and would be
prepared for the 30 percent statutory
weight for the cost performance category
for the 2021 MIPS payment year. We
intend to continue to provide education
to clinicians to help them prepare for
the upcoming 30 percent weight.
We invite public comments on this
proposal of a zero percent weighting for
the cost performance category and the
alternative option of 10 percent
weighting for the cost performance
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category for the 2020 MIPS payment
year.
(3) Cost Criteria
(a) Measures Proposed for the MIPS Cost
Performance Category
(i) Background
Under § 414.1350(a), we specify cost
measures for a performance period to
assess the performance of MIPS eligible
clinicians on the cost performance
category. For the 2017 MIPS
performance period, we will utilize 12
cost measures that are derived from
Medicare administrative claims data.
Two of these measures, the MSPB
measure and total per capita cost
measure, have been used in the VM (81
FR 77166 through 77168), and the
remaining 10 are episode-based
measures that were included in the
sQRURs in 2014 and 2015 (81 FR 77171
through 77174).
Section 1848(r) of the Act specifies a
series of steps and activities for the
Secretary to undertake to involve the
physician, practitioner, and other
stakeholder communities in enhancing
the infrastructure for cost measurement,
including for purposes of MIPS. Section
1848(r)(2) of the Act requires the
development of care episode and patient
condition groups, and classification
codes for such groups, and provides for
care episode and patient condition
groups to account for a target of an
estimated one-half of expenditures
under Parts A and B (with this target
increasing over time as appropriate).
Section 1848(r) of the Act requires us to
consider several factors when
establishing these groups. For care
episode groups, we must consider the
patient’s clinical problems at the time
items and services are furnished during
an episode of care, such as clinical
conditions or diagnoses, whether
inpatient hospitalization occurs, the
principal procedures or services
furnished, and other factors determined
appropriate by the Secretary. For patient
condition groups, we must consider the
patient’s clinical history at the time of
a medical visit, such as the patient’s
combination of chronic conditions,
current health status, and recent
significant history (such as
hospitalization and major surgery
during a previous period), and other
factors determined appropriate.
Section 1848(r)(2) of the Act requires
us to post on the CMS Web site a draft
list of care episode and patient
condition groups and codes for
solicitation of input from stakeholders,
and subsequently, post on the CMS Web
site an operational list of such groups
and codes. In December 2016, we
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published the Episode-Based Cost
Measure Development for the Quality
Program (https://www.cms.gov/
Medicare/Quality-Initiatives-PatientAssessment-Instruments/Value-BasedPrograms/MACRA-MIPS-and-APMs/
Episode-Based-Cost-MeasureDevelopment-for-the-Quality-PaymentProgram.pdf) and requested input on a
draft list of care episode and patient
condition groups and codes as required
by section 1848(r)(2)(E) and (F) of the
Act. We additionally requested feedback
on our overall approach to cost measure
development, including several pages of
specific questions on the proposed
approach for clinicians and stakeholders
to provide feedback on. This feedback
will be used to modify our cost measure
development and ensure that our
approach is continually informed by
stakeholder feedback. We are currently
reviewing the feedback that was
recently received on that posting and
will share plans to work with clinicians
and others on the further developments
of these episodes in the future.
We will be posting the operational list
of care episode and patient condition
groups in December 2017, as required
by section 1848(r)(2)(G) of the Act.
Section 1848(r)(2)(H) of the Act also
requires that not later than November 1
of each year (beginning with 2018), the
Secretary shall, through rulemaking,
revise the operational list as the
Secretary determines may be
appropriate.
(ii) Total Per Capita Cost and MSPB
Measures
For the 2018 MIPS performance
period and future performance periods,
we are proposing to include in the cost
performance category the total per
capita cost measure and the MSPB
measure as finalized for the 2017 MIPS
performance period. We refer readers to
the description of these measures in the
CY 2017 Quality Payment Program final
rule (81 FR 77164 through 77171). We
are proposing to include the total per
capita cost measure because it is a
global measure of all Medicare Part A
and Part B costs during the performance
period. MIPS eligible clinicians are
familiar with the total per capita cost
measure because the measure has been
used in the VM since the 2015 payment
adjustment period and performance
feedback has been provided through the
annual QRUR since 2013 (for a subset of
groups that had 20 or more eligible
professionals, based on 2014
performance) and to all groups in the
annual QRUR since 2014 (based on 2013
performance) and mid-year QRUR since
2015. We are proposing to use the MSPB
measure because many MIPS eligible
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clinicians will be familiar with the
measure from the VM, where it has been
included since the 2016 payment
adjustment period and in annual QRUR
since 2014 (based on 2013 performance)
and the mid-year QRUR since 2015, or
its hospital-specified version, which has
been a part of the Hospital VBP Program
since 2015, based on 2013 performance.
In addition to familiarity, these two
measures cover a large number of
patients and provide an important
measurement of clinician contribution
to the overall population that a clinician
encounters.
We are not proposing any changes to
the methodologies for payment
standardization, risk adjustment, and
specialty adjustment for these measures
and refer readers to the CY 2017 Quality
Payment Program final rule (81 FR
77164 through 77171) for more
information about these methodologies.
We will continue to evaluate cost
measures that are included in MIPS on
a regular basis and anticipate that
measures could be added or removed,
subject to rulemaking under applicable
law, as measure development continues.
We will also maintain the measures that
are used in the cost performance
category by updating specifications, risk
adjustment, and attribution as
appropriate. We anticipate including a
list of cost measures for a given
performance period in annual
rulemaking.
We invite public comments on these
proposals.
(iii) Episode-Based Measures
Episode-based measures differ from
the total per capita cost measure and
MSPB measure because their
specifications only include services that
are related to the episode of care for a
clinical condition or procedure (as
defined by procedure and diagnosis
codes), as opposed to including all
services that are provided to a patient
over a given period of time. For the 2018
MIPS performance period, we are not
proposing to include in the cost
performance category the 10 episodebased measures that we adopted for the
2017 MIPS performance period in the
CY 2017 Quality Payment Program final
rule (81 FR 77171 through 77174). We
instead will work to develop new
episode-based measures, with
significant clinician input, for future
performance periods.
We received extensive comments on
our proposal to include 41 of these
episode-based measures for the 2017
MIPS performance period, which we
responded to in the CY 2017 Quality
Payment Program final rule (81 FR
77171 through 77174). We also received
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additional comments after publication
of that final rule with comment period
about the decision to include 10
episode-based measures for the 2017
MIPS performance period. Although
comments were generally in favor of the
inclusion of episode-based measures in
the future, there was also overwhelming
stakeholder interest in more clinician
involvement in the development of
these episode-based measures as
required by section 1848(r)(2) of the Act.
Although there was an opportunity for
clinician involvement in the
development of some of the episodebased measures included for the 2017
MIPS performance period, it was not as
extensive as the process we are
currently using to develop episodebased measures. We believe that the
new episode-based measures, which we
intend to propose in future rulemaking
to include in the cost performance
category for the 2019 MIPS performance
period, will be substantially improved
by more extensive stakeholder feedback
and involvement in the process.
Thus far, stakeholder feedback has
been sought in several ways. First,
stakeholder feedback has been sought
through various public postings. In
October 2015 and April 2016, pursuant
to section 1848(r)(2)(B) and (C) of the
Act, we gathered input from
stakeholders on the episode groups
previously developed under section
1848(n)(9)(A) of the Act that has been
used to inform the process of
constructing the new episode-based cost
measures. This feedback emphasized
several key aspects of cost measure
development such as attribution, risk
adjustment, and alignment with quality
measurement and patient outcomes.
Stakeholders have also emphasized that
feedback related to cost measures
should be actionable and timely. In
addition, a draft list of care episode and
patient condition groups, along with
trigger codes, was posted for comment
in December 2016 (https://
www.cms.gov/Medicare/QualityInitiatives-Patient-AssessmentInstruments/Value-Based-Programs/
MACRA-MIPS-and-APMs/EpisodeBased-Cost-Measure-Development-forthe-Quality-Payment-Program.pdf) as
required by section 1848(r)(2)(E) of the
Act and comments were accepted as
required by section 1848(r)(2)(F) of the
Act.
This draft list of care episode and
patient condition groups and trigger
codes was informed by engagement with
clinicians from over 50 clinician
specialty societies through a Clinical
Committee formed to participate in cost
measure development. The Clinical
Committee work has provided input
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from a diverse array of clinicians on
identifying conditions and procedures
for episode groups. Moving forward, the
Clinical Committee will recommend
which services or claims would be
counted in episode costs. This will
ensure that cost measures in
development are directly informed by a
substantial number of clinicians and
members of specialty societies.
In addition, a technical expert panel
has met 3 times to provide oversight and
guidance for our development of
episode-based cost measures. The
technical expert panel has offered
recommendations for defining an
episode group, assigning costs to the
group, and attributing episode groups to
clinicians. This expert feedback has
been built into the current cost measure
development process.
As this process continues, we are
continuing to seek input from
clinicians. Earlier this year, we opened
an opportunity to submit the names of
clinicians to participate in this process.
This process remains open to additional
individuals. We believe that episodebased measures will benefit from this
comprehensive approach to
development. In addition, because it is
possible that the new episode-based
measures under development could
address similar conditions as those in
the episode-based measures finalized for
the 2017 MIPS performance period, we
believe that it would be better to focus
attention on the new episode-based
measures, so that clinicians would not
receive feedback or scores from two
measures for the same patient condition
or procedure. Recognizing that under
section 1848(q)(5)(E)(i)(II)(aa) of the Act,
we must assign a weight of 30 percent
to the cost performance category for the
2021 MIPS payment year, we will
endeavor to have as many episode-based
measures available as possible for the
proposed 2019 MIPS performance
period.
We plan to include episode-based
measures in the cost performance
category in future years as they are
developed and would propose new
measures in future rulemaking.
Although we are not proposing to
include any episode-based measures in
calculating the cost performance
category score for the 2020 MIPS
payment year, we do plan to continue
to provide confidential performance
feedback to clinicians on their
performance on episode-based measures
developed under the processes required
by section 1848(r)(2) of the Act as
appropriate in order to increase
familiarity with the concept of episodebased measurement as well as the
specific episodes that could be included
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in determining the cost performance
category score in the future. Because
these measures will be generated based
on claims data like other cost measures,
we will not collect any additional data
from clinicians. As we develop new
episode-based measures, we believe it is
likely that they would cover similar
clinical topics to those that are in the
previously developed episode-based
measures because of our intent to
address common clinical conditions
with episode-based measures. We aim to
provide an initial opportunity for
clinicians to review their performance
based on the new episode-based
measures at some point in the fall of
2017, as the measures are developed
and as the information is available. We
note that this feedback will be specific
to the new episode-based measures that
are developed under the process
described above and may be presented
in a different format than MIPS eligible
clinicians’ performance feedback as
described in section II.C.9.a. of this
proposed rule. However, our intention
is to align the feedback as much as
possible to ensure clinicians receive
opportunities to review their
performance on potential new episodebased measures for the cost performance
category prior to the proposed 2019
MIPS performance period. We are
unable to offer a list of new episodebased measures on which we will
provide feedback because that will be
determined in our ongoing development
work described above. We are
concerned that continuing to provide
feedback on the older episode-based
measures along with feedback on new
episode-based measures will be
confusing and a poor use of resources.
Because we are focusing on
development of new episode-based
measures, our feedback on episodebased measures that were previously
developed will discontinue after 2017 as
these measures would no longer be
maintained or reflect changes in
diagnostic and procedural coding. As
described in section II.C.9.a. of this
proposed rule, we intend to provide
feedback on these new measures as they
become available in a new format
around summer 2018. We note that the
feedback provided in the summer of
2018 will go to those MIPS eligible
clinicians for whom we are able to
calculate the episode-based measures,
which means it would be possible a
clinician may not receive feedback on
episode-based measures in both the fall
of 2017 and the summer of 2018. We
believe that receiving feedback on the
new episode-based measures, along
with the previously-finalized total per
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capita cost and MSPB measures, will
support clinicians in their readiness for
the proposed 2019 MIPS performance
period.
As previously finalized in the CY
2017 Quality Payment Program final
rule (81 FR 77173), the episode-based
measures that we are not proposing for
the 2018 MIPS performance period will
be used for determining the cost
performance category score for the 2019
MIPS payment year, although the cost
performance category score will be
weighted at zero percent in that year.
We invite public comments on this
proposal.
(iv) Attribution
In the CY 2017 Quality Payment
Program final rule, we changed the list
of primary care services that had been
used to determine attribution for the
total per capita cost measure by adding
transitional care management (CPT
codes 99495 and 99496) codes and a
chronic care management code (CPT
code 99490) (81 FR 77169). In the CY
2017 Physician Fee Schedule final rule,
we changed the payment status for two
existing CPT codes (CPT codes 99487
and 99489) that could be used to
describe care management from B
(bundled) to A (active) meaning that the
services would be paid under the
Physician Fee Schedule (81 FR 80349).
The services described by these codes
are substantially similar to those
described by the chronic care
management code that we added to the
list of primary care services beginning
with the 2017 performance period. We
therefore propose to add CPT codes
99487 and 99489, both describing
complex chronic care management, to
the list of primary care services used to
attribute patients under the total per
capita cost measure.
We are not proposing any changes to
the attribution methods for the MSPB
measure and refer readers to the CY
2017 Quality Payment Program final
rule (81 FR 77168 through 77169) for
more information.
We invite public comment on our
proposals.
(v) Reliability
In the CY 2017 Quality Payment
Program final rule (81 FR 77169 through
77170), we finalized a reliability
threshold of 0.4 for measures in the cost
performance category. Reliability is an
important evaluation for cost measures
to ensure that differences in
performance are not the result of
random variation. Statistically,
reliability depends on performance
variation for a measure across clinicians
(‘‘signal’’), the random variation in
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performance for a measure within a
clinician’s attributed beneficiaries
(‘‘noise’’), and the number of
beneficiaries attributed to the clinician.
High reliability for a measure suggests
that comparisons of relative
performance among clinicians are likely
to be stable over different performance
periods and that the performance of one
clinician on the measure can be
confidently distinguished from another.
As an example of the statistical concept
of reliability, a test in which the same
individual received very different scores
depending on how the included
questions are framed would not be
reliable. Potential reliability values
range from 0.00 to 1.00, where 1.00
(highest possible reliability) signifies
that all variation in the measure’s rates
is the result of variation in differences
in performance across clinicians,
whereas 0.0 (lowest possible reliability)
signifies that all variation could be a
result of measurement error. The 0.4
reliability threshold that we adopted for
the cost performance category measures
in MIPS means that the majority of
MIPS eligible clinicians and groups who
meet the case minimum required for
scoring under a measure have measure
reliability scores that exceed 0.4. We
generally consider reliability levels
between 0.4 and 0.7 to indicate
‘‘moderate’’ reliability and levels above
0.7 to indicate ‘‘high’’ reliability.
We addressed comments we received
on the CY 2017 Quality Payment
Program proposed rule (81 FR 77169
through 77171), that expressed concern
that our 0.4 reliability threshold was too
low. Many commenters recommended
that cost measures be included only
when they could meet the standard of
‘‘high’’ reliability (0.7 or above). Many
commenters on the CY 2017 Quality
Payment Program final rule made
similar comments. Commenters
emphasized the importance of
reliability; however, we have also seen
commenters incorrectly refer to
measures as being 40 percent reliable.
Reliability is not a percentage but is
instead a coefficient so a measure with
0.4 reliability does not reflect that it is
only correct for 40 percent of those
measured. We encourage a review of our
analysis of reliability for the total per
capita cost measure (80 FR 71282) and
MSPB (81 FR 77169 through 77171).
Reliability is an important evaluation
tool for an individual measure, but it is
only one element of evaluation.
Reliability generally increases as we
increase the case size but a high
reliability may also reflect low variation.
A measure in which all clinicians
perform at nearly the same rate would
be reliable but not valuable in a program
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that attempts to recognize and reward
differential performance. A measure in
which there is very little variation
provides little value in a program like
MIPS given the devotion of resources to
developing and maintaining that
measure over other potential measures.
Reliability must also be considered in
the context of a measurement system
like MIPS which incorporates other
elements of measurement. We
understand and appreciate the concerns
that have been expressed about
reliability of measures. Medicine,
however, always has a certain amount of
variability which may affect the
reliability score. We want strong
reliability, but not at the expense of
losing valuable information about
clinicians. We are concerned that
placing too much of an emphasis on
reliability calculations could limit the
applicability of cost measures to large
group practices who, by nature of their
size, have larger patient populations,
thus depriving solo clinicians and
individual reporters from being
rewarded for efforts to better manage
patients. Therefore, we are not
proposing any adjustments to our
reliability policies, but we will continue
to evaluate reliability as we develop
new measures and to ensure that our
measures meet an appropriate standard.
(b) Attribution for Individuals and
Groups
We are not proposing any changes for
how we attribute cost measures to
individual and group reporters. We refer
readers to the CY 2017 Quality Payment
Program final rule for more information
(81 FR 77175 through 77176).
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(c) Incorporation of Cost Measures With
SES or Risk Adjustment
Both measures proposed for inclusion
in the cost performance category for the
2018 MIPS performance period are risk
adjusted at the measure level. Although
the risk adjustment of the 2 measures is
not identical, in both cases it is used to
recognize the higher risk associated
with demographic factors (such as age)
or certain clinical conditions. We
recognize that the risks accounted for
with this adjustment are not the only
potential attributes that could lead to a
higher cost patient. Stakeholders have
pointed to many other factors such as
income level, race, and geography that
they believe contribute to increased
costs. These issues and our plans for
attempting to address them are
discussed in length in section
II.C.7.b.(1)(a) of this rule.
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(d) Incorporation of Cost Measures With
ICD–10 Impacts
In section II.C.7.a.(1)(c) of this
proposed rule, we discuss our proposal
to assess performance on any measures
impacted by ICD–10 updates based only
on the first 9 months of the 12-month
performance period. Because the total
per capita cost and MSPB measures
include costs from all Medicare Part A
and B services, regardless of the specific
ICD–10 codes that are used on claims,
and do not assign patients based on
ICD–10, we do not anticipate that any
measures for the cost performance
category would be affected by this ICD–
10 issue during the 2018 MIPS
performance period. However, as we
continue our plans to expand cost
measures to incorporate episode-based
measures, ICD–10 changes could
become important. Episode-based
measures may be opened (triggered) by
and may assign services based on ICD–
10 codes. Therefore, a change to ICD–10
coding could have a significant effect on
an episode-based measure. Changes to
ICD–10 codes will be incorporated into
the measure specifications on a regular
basis through the measure maintenance
process.
(e) Application of Measures to NonPatient Facing MIPS Eligible Clinicians
We are not proposing changes to the
policy we finalized in the CY 2017
Quality Payment Program final rule (81
FR 77176) that we will attribute cost
measures to non-patient facing MIPS
eligible clinicians who have sufficient
case volume, in accordance with the
attribution methodology.
Section 1848(q)(2)(C)(iv) of the Act
requires the Secretary to consider the
circumstances of professional types who
typically furnish services without
patient facing interaction (non-patient
facing) when determining the
application of measures and activities.
In addition, this section allows the
Secretary to apply alternative measures
or activities to non-patient facing MIPS
eligible clinicians that fulfill the goals of
a performance category. Section
1848(q)(5)(F) of the Act allows the
Secretary to re-weight MIPS
performance categories if there are not
sufficient measures and activities
applicable and available to each type of
MIPS eligible clinician involved.
We believe that non-patient facing
clinicians are an integral part of the care
team and that their services do
contributed to the overall costs but at
this time we believe it better to focus on
the development of a comprehensive
system of episode-based measures
which focus on the role of patient-facing
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clinicians. Accordingly, for the 2018
MIPS performance period, we are not
proposing alternative cost measures for
non-patient facing MIPS eligible
clinicians or groups. This means that
non-patient facing MIPS eligible
clinicians or groups are unlikely to be
attributed any cost measures that are
generally attributed to clinicians who
have patient-facing encounters with
patients. Therefore, we anticipate that,
similar to MIPS eligible clinicians or
groups that do not meet the required
case minimums for any cost measures,
many non-patient facing MIPS eligible
clinicians may not have sufficient cost
measures applicable and available to
them and would not be scored on the
cost performance category under MIPS.
We continue to consider opportunities
to develop alternative cost measures for
non-patient facing clinicians and solicit
comment on this topic to inform our
future rulemaking.
(f) Facility-Based Measurement as it
Relates to the Cost Performance
Category
In section II.C.7.a.(4) of this proposed
rule, we discuss our proposal to
implement section 1848(q)(2)(C)(ii) of
the Act by assessing clinicians who
meet certain requirements and elect
participation based on the performance
of their associated hospital in the
Hospital VBP Program. We refer readers
to that section for full details on our
proposals related to facility-based
measurement, including the measures
and how the measures are scored, for
the cost performance category.
e. Improvement Activity Criteria
(1) Background
Section 1848(q)(2)(C)(v)(III) of the Act
defines an improvement activity as an
activity that relevant eligible clinician
organizations and other relevant
stakeholders identify as improving
clinical practice or care delivery, and
that the Secretary determines, when
effectively executed, is likely to result in
improved outcomes. Section
1848(q)(2)(B)(iii) of the Act requires the
Secretary to specify improvement
activities under subcategories for the
performance period, which must
include at least the subcategories
specified in section 1848(q)(2)(B)(iii)(I)
through (VI) of the Act, and in doing so
to give consideration to the
circumstances of small practices, and
practices located in rural areas and
geographic health professional shortage
areas (HPSAs).
Section 1848(q)(2)(C)(iv) of the Act
generally requires the Secretary to give
consideration to the circumstances of
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non-patient facing individual MIPS
eligible clinicians or groups and allows
the Secretary, to the extent feasible and
appropriate, to apply alternative
measures and activities to such
individual MIPS eligible clinicians and
groups.
Section 1848(q)(2)(C)(v) of the Act
required the Secretary to use a request
for information (RFI) to solicit
recommendations from stakeholders to
identify improvement activities and
specify criteria for such improvement
activities, and provides that the
Secretary may contract with entities to
assist in identifying activities,
specifying criteria for the activities, and
determining whether individual MIPS
eligible clinicians or groups meet the
criteria set. For a detailed discussion of
the feedback received from the MIPS
and APMs RFI, see the CY 2017 Quality
Payment Program 2017 final rule (81 FR
77177).
We defined improvement activities at
§ 414.1305 as an activity that relevant
MIPS eligible clinicians, organizations
and other relevant stakeholders identify
as improving clinical practice or care
delivery and that the Secretary
determines, when effectively executed,
is likely to result in improved outcomes.
In the CY 2017 Quality Payment
Program final rule (81 FR 77199), we
solicited comments on activities that
would advance the usage of health IT to
support improvement activities. We
received several comments in support of
the concept to include emerging
certified health IT capabilities as part of
the activities in the Improvement
Activities Inventory and several
commenters supported our assessment
that using CEHRT can aid in improving
clinical practices and help healthcare
organizations achieve success on
numerous improvement activities, as
well as the continued integration of
improvement activities and advancing
clinical information. However, several
commenters expressed concern about
health IT-associated burdens and costs
and recommended that we also continue
to offer diverse activities that do not rely
on emerging capabilities of certified
health IT, as they are not universally
available or may only be offered as high
cost add-on capabilities. Some
commenters also requested that we be
less prescriptive in our requirements for
the use of health IT.
In response to the comments, we will
continue to focus on incentivizing the
use of health IT, telehealth, and
connection of patients to communitybased services. The use of health IT is
an important aspect of care delivery
processes described in many of the
proposed new improvement activities in
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Table F in the Appendix of this
proposed rule, and in Table H: Finalized
Improvement Activities Inventory that
we finalized in the CY 2017 Quality
Payment Program final rule (81 FR
77817 through 77831). In that same final
rule, we also finalized a policy to allow
MIPS eligible clinicians to achieve a
bonus in the advancing care information
performance category when they use
functions included in CEHRT to
complete eligible activities from the
Improvement Activities Inventory.
Please refer to section II.C.6.f.(2)(d) of
this proposed rule for details on how
improvement activities using CEHRT
relate to the objectives and measures of
the advancing care information and
improvement activities performance
categories. We are not proposing any
changes to these policies for
incentivizing the use of health IT in this
proposed rule; however, we will
continue to consider including emerging
certified health IT capabilities as part of
activities within the Improvement
Activities Inventory in future years.
In addition, as noted previously, we
believe a key goal of the Quality
Payment Program is to establish a
program that allows for close alignment
of the four performance categories.
Although we are not proposing any
specific new policies, we seek comment
on how we might provide flexibility for
MIPS eligible clinicians to effectively
demonstrate improvement through
health IT usage while also measuring
such improvement. We welcome public
comment on these considerations.
(2) Contribution to the Final Score
In the CY 2017 Quality Payment
Program final rule (81 FR 77179 through
77180), we finalized at § 414.1355 that
the improvement activities performance
category would account for 15 percent
of the final score. We also finalized at
§ 414.1380(b)(3)(iv) criteria for
recognition as a certified-patient
centered medical home or comparable
specialty practice. We are proposing to
clarify the term ‘‘certified’’ patientcentered medical home finalized at
§ 414.1380(b)(3)(iv). It has come to our
attention that the common terminology
utilized in the general medical
community for ‘‘certified’’ patientcentered medical home is ‘‘recognized’’
patient-centered medical home.
Therefore, in order to provide clarity we
are proposing that the term
‘‘recognized’’ be accepted as equivalent
to the term ‘‘certified’’ when referring to
the requirements for a patient-centered
medical home to receive full credit for
the improvement activities performance
category for MIPS. Specifically, we
propose to revise § 414.1380(b)(3)(iv) to
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provide that a MIPS eligible clinician or
group in a practice that is certified or
recognized as a patient-centered
medical home or comparable specialty
practice, as determined by the Secretary,
receives full credit for performance on
the improvement activities performance
category. For purposes of § 414.1380
(b)(3)(iv), ‘‘full credit’’ means that the
MIPS eligible clinician or group has met
the highest potential category score of
40 points. A practice is certified or
recognized as a patient-centered
medical home if it meets any of the
criteria specified under
§ 414.1380(b)(3)(iv).
In the CY 2017 Quality Payment
Program final rule (81 FR 77198), we
requested commenters’ specific
suggestions for additional activities or
activities that may merit additional
points beyond the ‘‘high’’ level. Several
commenters urged us to increase the
overall number of high-weighted
activities in this performance category.
Some commenters recommended
additional criteria for designating highweighted activities, such as an
improvement activity’s impact on
population health, medication
adherence, and shared decision-making
tools, and encouraged us to be more
transparent in our weighting decisions.
Several commenters recommended that
we weight registry-related activities as
high, and suggested that we award
individual MIPS eligible clinicians and
groups in APMs full credit in this
performance category. The commenters
also offered many recommendations for
changing current medium-weighted
activities to high and offered many
specific suggestions for new highweighted improvement activities.
In response to the comments, we are
proposing new, high-weighted activities
in Table F in the Appendix of this
proposed rule. As explained in the CY
2017 Quality Payment Program final
rule (81 FR 77194), we believe that high
weighting should be used for activities
that directly address areas with the
greatest impact on beneficiary care,
safety, health, and well-being. We are
not proposing changes to this approach
in this proposed rule; however, we will
take these suggested additional criteria
into consideration for designating highweighted activities in future
rulemaking. For MIPS eligible clinicians
participating in MIPS APMs, we
finalized a policy to reduce reporting
burden through the APM scoring
standard for this category to recognize
improvement activities work performed
through participation in MIPS APMs.
This policy is codified at
§ 414.1370(g)(3), and we refer readers to
the CY 2017 Quality Payment Program
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final rule for further details on reporting
and scoring this category under the
APM Scoring Standard (81 FR 77259
through 77260).
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(3) Improvement Activities Data
Submission Criteria
(a) Submission Mechanisms
In the CY 2017 Quality Payment
Program final rule (81 FR 77180), we
discussed that for the transition year of
MIPS we would allow for submission of
data for the improvement activities
performance category using the
qualified registry, EHR, QCDR, CMS
Web Interface, and attestation data
submission mechanisms through
attestation. Specifically, we finalized a
policy that regardless of the data
submission method, with the exception
of MIPS eligible clinicians in MIPS
APMs, all individual MIPS eligible
clinicians or groups must select
activities from the Improvement
Activities Inventory. In addition, we
finalized at § 414.1360 that for the
transition year of MIPS, all individual
MIPS eligible clinicians or groups, or
third party intermediaries such as
health IT vendors, QCDRs and qualified
registries that submit on behalf of an
individual MIPS eligible clinician or
group, must designate a ‘‘yes’’ response
for activities on the Improvement
Activities Inventory. In the case where
an individual MIPS eligible clinician or
group is using a health IT vendor,
QCDR, or qualified registry for their data
submission, the individual MIPS
eligible clinician or group will certify all
improvement activities were performed
and the health IT vendor, QCDR, or
qualified registry would submit on their
behalf. We would like to maintain
stability in the Quality Payment
Program and continue this policy into
future years. Therefore, we are
proposing at § 414.1360 that for
purposes of the transition year of MIPS
and future years all individual MIPS
eligible clinicians or groups, or third
party intermediaries such as health IT
vendors, QCDRs and qualified registries
that submit on behalf of an individual
MIPS eligible clinician or group, must
designate a ‘‘yes’’ response for activities
on the Improvement Activities
Inventory. In the case where an
individual MIPS eligible clinician or
group is using a health IT vendor,
QCDR, or qualified registry for their data
submission, the MIPS eligible clinician
or group will certify all improvement
activities were performed and the health
IT vendor, QCDR, or qualified registry
would submit on their behalf. In
addition, as discussed in section
II.C.4.d. of this proposed rule, we are
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proposing to generally apply our
previously finalized and proposed
group policies to virtual groups.
We would like to note that while we
finalized at § 414.1325(d) in the CY
2017 Quality Payment Program final
rule that individual MIPS eligible
clinicians and groups may only use one
submission mechanism per performance
category, in section II.C.6.a.(1) of this
proposed rule, we are proposing to
revise § 414.1325(d) for purposes of the
2020 MIPS payment year and future
years to allow individual MIPS eligible
clinicians and groups to submit
measures and activities, as applicable,
via as many submission mechanisms as
necessary to meet the requirements of
the quality, improvement activities, or
advancing care information performance
categories. We refer readers to section
II.C.6.a.(1) of this proposed rule for
further discussion of this proposal.
We also included a designation
column in the Improvement Activities
Inventory at Table H in the Appendix of
the CY 2017 Quality Payment Program
final rule (81 FR 77817) that indicated
which activities qualified for the
advancing care information bonus
finalized at § 414.1380. In future
updates to the Improvement Activities
Inventory we intend to continue to
indicate which activities qualify for the
advancing care information performance
category bonus.
In the CY 2017 Quality Payment
Program final rule (81 FR 77181), we
clarified that if one MIPS eligible
clinician (NPI) in a group completed an
improvement activity, the entire group
(TIN) would receive credit for that
activity. In addition, we specified that
all MIPS eligible clinicians reporting as
a group would receive the same score
for the improvement activities
performance category if at least one
clinician within the group is performing
the activity for a continuous 90 days in
the performance period. As discussed in
section II.C.4.d. of this proposed rule,
we are proposing to generally apply our
previously finalized and proposed
group policies to virtual groups. We are
not proposing any changes to this policy
in this proposed rule. However, we are
requesting comment on whether we
should establish a minimum threshold
(for example, 50 percent) of the
clinicians (NPIs) that must complete an
improvement activity in order for the
entire group (TIN) to receive credit in
the improvement activities performance
category in future years. In addition, we
are requesting comments on
recommended minimum threshold
percentages and whether we should
establish different thresholds based on
the size of the group. For example, in
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30053
considering different thresholds we
could attribute recognition as a certified
or recognized patient-centered medical
home or comparable specialty practice
at the individual TIN/NPI level, and
attribute this designation to the group
under which they bill if they are
participating in MIPS as a group or as
part of a virtual group. A group or
virtual group consisting of 100 NPIs
could have a reporting threshold of 50
percent while a group consisting of 10
NPIs could have a lower reporting
threshold of 10 percent. We are
concerned that while establishing any
specific threshold for the percentage of
NPIs in a TIN that must participate in
an improvement activity for credit will
incentivize some groups to move closer
to the threshold, it may have the
unintended consequence of
incentivizing groups who are exceeding
the threshold to gravitate back toward
the threshold. Therefore, we are
requesting comments on how to set this
threshold while maintaining the goal of
promoting greater participation in an
improvement activity.
Additionally, we noted in the CY
2017 Quality Payment Program final
rule (81 FR 77197) that we intended, in
future years, to score the improvement
activities performance category based on
performance and improvement, rather
than simple attestation. We seek
comment on how we could measure
performance and improvement; we are
especially interested in ways to measure
performance without imposing
additional burden on eligible clinicians,
such as by using data captured in
eligible clinicians’ daily work.
(b) Submission Criteria
In the CY 2017 Quality Payment
Program final rule (81 FR 77185), we
finalized at § 414.1380 to set the
improvement activities submission
criteria under MIPS, to achieve the
highest potential score, at two highweighted improvement activities or four
medium-weighted improvement
activities, or some combination of high
and medium-weighted improvement
activities. While the minimum reporting
period for one improvement activity is
90 days, the maximum frequency with
which an improvement activity may be
reported would be once during the 12month performance period. In addition,
as discussed in section II.C.4.d. of this
proposed rule, we are proposing to
generally apply our previously finalized
and proposed group policies to virtual
groups.
We established exceptions to the
above for: small practices; practices
located in rural areas; practices located
in geographic HPSAs; non-patient facing
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individual MIPS eligible clinicians or
groups; and individual MIPS eligible
clinicians and groups that participate in
a MIPS APM or a patient-centered
medical home submitting in MIPS.
Specifically, for individual MIPS
eligible clinicians and groups that are
small practices, practices located in
rural areas or geographic HPSAs, or
non-patient facing individual MIPS
eligible clinicians or groups, to achieve
the highest score, one high-weighted or
two medium-weighted improvement
activities are required. For these
individual MIPS eligible clinicians and
groups, in order to achieve one-half of
the highest score, one medium-weighted
improvement activity is required.
Under the APM scoring standard, all
clinicians identified on the Participation
List of an APM receive at least one-half
of the highest score applicable to the
MIPS APM. To develop the
improvement activities score assigned to
each MIPS APM, we compare the
requirements of the specific MIPS APM
with the list of activities in the
Improvement Activities Inventory and
score those activities in the same
manner that they are otherwise scored
for MIPS eligible clinicians. If by our
assessment the MIPS APM does not
receive the maximum improvement
activities performance category score
then the APM entity can submit
additional improvement activities. All
other individual MIPS eligible
clinicians or groups that we identify as
participating in APMs that are not MIPS
APMs will need to select additional
improvement activities to achieve the
improvement activities highest score.
We refer readers to section II.C.6.g. of
this proposed rule for further discussion
of the APM scoring standard.
We also provided full credit for the
improvement activities performance
category, as required by law, for an
individual MIPS eligible clinician or
group that has received certification or
accreditation as a patient-centered
medical home or comparable specialty
practice from a national program or
from a regional or state program, private
payer or other body that administers
patient-centered medical home
accreditation and certifies 500 or more
practices for patient-centered medical
home accreditation or comparable
specialty practice certification, or for an
individual MIPS eligible clinician or
group that is a participant in a medical
home model.
We also noted in the CY 2017 Quality
Payment Program final rule that
practices may receive this designation at
a practice level and that TINs may be
comprised of both undesignated
practices and designated practices (81
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FR 77178). We finalized at
§ 414.1380(b)(3)(viii) that to receive full
credit as a certified patient-centered
medical home or comparable specialty
practice, a TIN that is reporting must
include at least one practice that is a
certified patient-centered medical home
or comparable specialty practice. We
also indicated that we would continue
to have more stringent requirements in
future years, and would lay the
groundwork for expansion towards
continuous improvement over time (81
FR 77189). We received many
comments on the CY 2017 Quality
Payment Program final rule regarding
our transition year policy that only one
practice site within a TIN needs to be
certified as a patient-centered medical
home for the entire TIN to receive full
credit in the improvement activities
performance category. While several
commenters supported our transition
year policy, others disagreed and
suggested to move to a more stringent
requirement in future years while still
offering some flexibility. Accordingly,
we propose to revise § 414.1380(b)(3)(x)
to provide that for the 2020 MIPS
payment year and future years, to
receive full credit as a certified or
recognized patient-centered medical
home or comparable specialty practice,
at least 50 percent of the practice sites
within the TIN must be recognized as a
patient-centered medical home or
comparable specialty practice. This is
an increase to the requirement that only
one practice site within a TIN needs to
be certified as a patient-centered
medical home, but does not require
every site be certified, which could be
overly restrictive given that some sites
within a TIN may be in the process of
being certified as patient-centered
medical homes. In addition, we believe
a 50 percent threshold is achievable
which is supported by a study of
physician-owned primary care groups in
a recent Annals of Family Medicine
article (Casalino, et al., 2016) https://
www.annfammed.org/content/14/1/
16.full. For nearly all groups in this
study (sampled with variation in size
and geographic area) at least 50 percent
of the practice sites within the group
had a medical home designation. If the
group is unable to meet the 50 percent
threshold then the individual MIPS
eligible clinician may choose to receive
full credit as a certified patient-centered
medical home or comparable specialty
practice by reporting as an individual
for all performance categories. In
addition, as discussed in section
II.C.4.d. of this proposed rule, we are
proposing to generally apply our
previously finalized and proposed
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group policies to virtual groups.
Further, we welcome suggestions on an
appropriate threshold for the number of
NPIs within the TIN that must be
recognized as a certified patientcentered medical home or comparable
specialty practice to receive full credit
in the improvement activities
performance category.
We have determined that the
Comprehensive Primary Care Plus
(CPC+) APM design satisfies the
requirements to be designated as a
medical home model, as defined in
§ 414.1305, and is therefore a certified
or recognized patient-centered medical
home for purposes of the improvement
activities performance category. The
CPC+ model meets the criteria to be an
Advanced APM. CPC+ eligibility criteria
for practices include, but are not limited
to, the use of CEHRT and care delivery
activities such as: Assigning patients to
clinician panels; providing 24/7
clinician access; and supporting quality
improvement activities. Control groups
in CPC+ are required to meet the same
eligibility criteria as those selected to be
active participants in the model. For
Round 2 of CPC+, CMS is randomly
assigning accepted practices into the
intervention group or a control group.
Practices accepted into CPC+ and
randomized into the control group have
satisfied the requirements for
participation in CPC+, a medical home
model, and we believe that the MIPS
eligible clinicians in the control group
should therefore receive full credit for
the improvement activities performance
category. In addition, the practices
randomized to the CPC+ control group
must sign a Participation Agreement
with us; the agreement will require
practices in a control group to maintain
a Practitioner Roster of all MIPS eligible
clinicians in the practice.
Accordingly, we are proposing that
MIPS eligible clinicians in practices that
have been randomized to the control
group in the CPC+ APM would receive
full credit as a medical home model,
and therefore a certified patientcentered medical home, for the
improvement activities performance
category. MIPS eligible clinicians who
attest that they are in practices that have
been randomized to the control group in
the CPC+ APM would receive full credit
for the improvement activities
performance category for each
performance period in which they are
on the Practitioner Roster, the official
list of eligible clinicians participating in
a practice in the CPC+ control group.
The inclusion of MIPS eligible
clinicians in practices that have been
randomized into the CPC+ control group
recognizes that they have met the
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requirements to receive full credit for
performance in the improvement
activities performance category as a
medical home model, and will help
ensure more equitable treatment of the
CPC+ control group by allowing
clinicians in the control group that have
met the criteria for participation in the
CPC+ APM to receive the same
recognition as those actively
participating in the CPC+ intervention
group.
We request comments on these
proposals.
(c) Required Period of Time for
Performing an Activity
In the CY 2017 Quality Payment
Program final rule (81 FR 77186), we
specified at § 414.1360 that MIPS
eligible clinicians or groups must
perform improvement activities for at
least 90 consecutive days during the
performance period for improvement
activities performance category credit.
Activities, where applicable, may be
continuing (that is, could have started
prior to the performance period and are
continuing) or be adopted in the
performance period as long as an
activity is being performed for at least
90 days during the performance period.
In addition, as discussed in section
II.C.4.d. of this proposed rule, we are
proposing to generally apply our
previously finalized and proposed
group policies to virtual groups. We are
not proposing any changes to the
required period of time for performing
an activity for the improvement
activities performance category in this
proposed rule.
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(4) Application of Improvement
Activities to Non-Patient Facing
Individual MIPS Eligible Clinicians and
Groups
In the CY 2017 Quality Payment
Program final rule (81 FR 77187), we
specified at § 414.1380(b)(3)(vii) that for
non-patient facing individual MIPS
eligible clinicians or groups, to achieve
the highest score one high-weighted or
two medium-weighted improvement
activities are required. For these
individual MIPS eligible clinicians and
groups, in order to achieve one-half of
the highest score, one medium-weighted
improvement activity is required. We
are not proposing any changes to the
application of improvement activities to
non-patient facing individual MIPS
eligible clinicians and groups for the
improvement activities performance
category in this proposed rule.
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(5) Special Consideration for Small,
Rural, or Health Professional Shortage
Areas Practices
In the CY 2017 Quality Payment
Program final rule (81 FR 77188), we
finalized at § 414.1380(b)(3)(vii) that one
high-weighted or two medium-weighted
improvement activities are required for
individual MIPS eligible clinicians and
groups that are small practices or
located in rural areas, or geographic
HPSAs, to achieve full credit. In
addition, we specified at § 414.1305 that
a rural area means ZIP codes designated
as rural, using the most recent HRSA
Area Health Resource File data set
available. Lastly, we finalized the
following definitions at § 414.1305: (1)
Small practices is defined to mean
practices consisting of 15 or fewer
clinicians and solo practitioners; and (2)
Health Professional Shortage Areas
(HPSA) refers to areas as designated
under section 332(a)(1)(A) of the Public
Health Service Act. We are not
proposing any changes to the special
consideration for small, rural, or health
professional shortage areas practices for
the improvement activities performance
category in this proposed rule.
(6) Improvement Activities
Subcategories
In the CY 2017 Quality Payment
Program final rule (81 FR 77190), we
finalized at § 414.1365 that the
improvement activities performance
category will include the subcategories
of activities provided at section
1848(q)(2)(B)(iii) of the Act. In addition,
we finalized at § 414.1365 the following
additional subcategories: Achieving
Health Equity; Integrated Behavioral
and Mental Health; and Emergency
Preparedness and Response. We are not
proposing any changes to the
improvement activities subcategories for
the improvement activities performance
category in this proposed rule.
(7) Improvement Activities Inventory
(a) Proposed Approach on the Annual
Call for Activities Process for Adding
New Activities
In Table H in the Appendix of the CY
2017 Quality Payment Program final
rule (81 FR 77817), we finalized the
Improvement Activities Inventory for
MIPS. In addition, through
subregulatory guidance we provided an
informal process for submitting new
improvement activities for potential
inclusion in the comprehensive
Improvement Activities Inventory for
the Quality Payment Program Year 2.
During this transition period we
received input from various MIPS
eligible clinicians and organizations
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30055
suggesting possible new activities via a
nomination form that was posted on the
CMS Web site at https://www.cms.gov/
Medicare/Quality-Initiatives-PatientAssessment-Instruments/MMS/
CallForMeasures.html. We are
proposing new activities and changes to
the Improvement Activities Inventory in
Tables F and G of the Appendix of this
proposed rule.
For the Quality Payment Program
Year 3 and future years, we are
proposing to formalize an Annual Call
for Activities process for adding
possible new activities to the
Improvement Activities Inventory. We
believe this is a way to engage eligible
clinician organizations and other
relevant stakeholders, including
beneficiaries, in the identification and
submission of improvement activities
for consideration. We propose that
individual MIPS eligible clinicians or
groups and other relevant stakeholders
may recommend activities for potential
inclusion in the Improvement Activities
Inventory via a similar nomination form
utilized in the transition year of MIPS
found on the Quality Payment Program
Web site at www.qpp.cms.gov. As part of
the process, individual MIPS eligible
clinicians, groups, and other relevant
stakeholders would be able to nominate
additional improvement activities that
we may consider adding to the
Improvement Activities Inventory.
Individual MIPS eligible clinicians and
groups and relevant stakeholders would
be able to provide an explanation via
the nomination form of how the
improvement activity meets all the
criteria we have identified in section
II.C.6.e.(7)(b) of this proposed rule. The
2018 proposed new improvement
activities and the 2018 proposed
improvement activities with changes
can be found in Tables F and G of the
Appendix of this proposed rule and will
be available on the CMS Web site.
We request comments on this
proposed annual Call for Activities
process.
(b) Criteria for Nominating New
Improvement Activities for the Annual
Call for Activities
We propose for the Quality Payment
Program Year 2 and future years that
stakeholders would apply one or more
of the following criteria when
submitting improvement activities in
response to the Annual Call for
Activities:
• Relevance to an existing
improvement activities subcategory (or a
proposed new subcategory);
• Importance of an activity toward
achieving improved beneficiary health
outcome;
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• Importance of an activity that could
lead to improvement in practice to
reduce health care disparities;
• Aligned with patient-centered
medical homes;
• Activities that may be considered
for an advancing care information
bonus;
• Representative of activities that
multiple individual MIPS eligible
clinicians or groups could perform (for
example, primary care, specialty care);
• Feasible to implement, recognizing
importance in minimizing burden,
especially for small practices, practices
in rural areas, or in areas designated as
geographic HPSAs by HRSA;
• Evidence supports that an activity
has a high probability of contributing to
improved beneficiary health outcomes;
or
• CMS is able to validate the activity.
We note that in future rulemaking,
activities that overlap with other
performance categories may be included
if such activities support the key goals
of the program.
We request comments on this
proposal.
(c) Submission Timeline for Nominating
New Improvement Activities for the
Annual Call for Activities
It is our intention that the nomination
and acceptance process will, to the best
extent possible, parallel the Annual Call
for Measures process already conducted
for MIPS quality measures. Aligned
with this approach, we propose to
accept submissions for prospective
improvement activities at any time
during the performance period for the
Annual Call for Activities and create an
Improvement Activities under Review
(IAUR) list. This list will be considered
by us and may include federal partners
in collaboration with stakeholders. The
IAUR list will be analyzed with
consideration of the proposed criteria
for inclusion of improvement activities
in the Improvement Activities
Inventory. In addition, we propose that
for the Annual Call for Activities, only
activities submitted by March 1 would
be considered for inclusion in the
Improvement Activities Inventory for
the performance periods occurring in
the following calendar year. This
proposal is slightly different than the
Call for Measures timeline. The Annual
Call for Measures requires a 2-year
implementation timeline because the
measures being considered for inclusion
in MIPS undergo the pre-rulemaking
process with review by the Measures
Application Partnership (MAP). We are
not proposing that improvement
activities undergo MAP review.
Therefore, our intention is to close the
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Annual Call for Activities submissions
by March 1 before the applicable
performance period, which will enable
us to propose the new improvement
activities for adoption in the same year’s
rulemaking cycle for implementation in
the following year. For example, an
improvement activity submitted prior to
March 1, 2018, would be considered for
performance periods occurring in 2019.
In addition, we propose that we will
add new improvement activities to the
inventory through notice-and-comment
rulemaking. In future years we
anticipate developing a process and
establishing criteria for identifying
activities for removal from the
Improvement Activities Inventory
through the Annual Call for Activities
process. We are requesting comments on
what criteria should be used to identify
improvement activities for removal from
the Improvement Activities Inventory.
the advancing care information
performance category measures and
allow MIPS eligible clinicians to earn
credit in the improvement activities
performance category, while receiving a
bonus in the advancing care information
performance category as well. We are
seeking suggestions on how a health IT
subcategory within the improvement
activities performance category could be
structured to afford MIPS eligible
clinicians with flexible opportunities to
gain experience in using CEHRT and
other health IT to improve their
practice. Should the current policies
where improvement activities earn
bonus points within the advancing care
information performance category be
enhanced? Are there additional policies
that should be explored in future
rulemaking? We welcome public
comment on this potential health IT
subcategory.
(8) Approach for Adding New
Subcategories
In the CY 2017 Quality Payment
Program final rule (81 FR 77197), we
finalized the following criteria for
adding a new subcategory to the
improvement activities performance
category:
• The new subcategory represents an
area that could highlight improved
beneficiary health outcomes, patient
engagement and safety based on
evidence.
• The new subcategory has a
designated number of activities that
meet the criteria for an improvement
activity and cannot be classified under
the existing subcategories.
• Newly identified subcategories
would contribute to improvement in
patient care practices or improvement in
performance on quality measures and
cost performance categories.
We are not proposing any changes to
the approach for adding new
subcategories for the improvement
activities performance category in this
proposed rule. However, we are
proposing that in future years of the
Quality Payment Program we will add
new improvement activities
subcategories through notice-andcomment rulemaking. In addition, we
are seeking comments on new
improvement activities subcategories.
A number of stakeholders have
suggested that a separate subcategory for
improvement activities specifically
related to health IT would make it easier
for MIPS eligible clinicians and vendors
to understand and earn points toward
their final score through the use of
health IT. Such a health IT subcategory
could include only improvement
activities that are specifically related to
(9) CMS Study on Burdens Associated
With Reporting Quality Measures
In the CY 2017 Quality Payment
Program final rule (81 FR 77195), we
finalized specifics regarding the CMS
Study on Improvement Activities and
Measurement including the study
purpose, study participation credit and
requirements, and the study procedure.
We are modifying the name of the study
in this proposed rule to the ‘‘CMS study
on burdens associated with reporting
quality measures’’ to more accurately
reflect the purpose of the study. The
study assesses clinician burden and data
submission errors associated with the
collection and submission of clinician
quality measures for MIPS, enrolling
groups of different sizes and individuals
in both rural and non-rural settings and
also different specialties. We also noted
that study participants would receive
full credit in the improvement activities
performance category after successfully
electing, participating, and submitting
data to the study coordinators at CMS
for the full calendar year (81 FR 77196).
We requested comment on the study,
and received generally supportive
feedback for the study.
We are not proposing any changes to
the study purpose. We are proposing
changes to the study participation credit
and requirements sample size, how the
study sample is categorized into groups,
and the frequency of quality data
submission, focus groups, and surveys.
In addition to performing descriptive
statistics to compare the trends in errors
and burden between study years 2017
and 2018, we would like to perform a
more rigorous statistical analysis with
the 2018 data, which will require a
larger sample size. We propose this
increase in the sample size for 2018 to
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provide the minimum sample needed to
get a significant result with adequate
power for the following investigation.
Specifically, we are interested in
whether there are any significant
differences in quality measurement data
submission errors and/or clinician
burdens between rural clinicians
submitting either individually or as a
group, and urban clinicians submitting
as an individual or as a group. A
statistical power analysis was performed
and a total sample size of 118 will be
adequate for the main objective of the
study. However, allowance will be made
to account for attrition and other
additional (or secondary) analysis.
This analysis would be compared at
different sizes of practices (<3 eligible
clinicians, between 3–8 eligible
clinicians, etc.). This assessment is
important since it facilitates tracing the
root causes of measurement burdens
and data submission errors that may be
associated with any sub-group of
clinician practice. This comparison may
further break the sample down into
more than four categories and a much
larger sample size is a requisite for
significant results with adequate
probability of certainty.
The sample size for performance
periods occurring in 2017 consisted of
42 MIPS groups as stated by MIPS
criteria from the following seven
categories:
• 10 urban individual or groups of <3
eligible clinicians.
• 10 rural individual or groups of <3
eligible clinicians.
• 10 groups of 3–8 eligible clinicians.
• 5 groups of 8–20 eligible clinicians.
• 3 groups of 20–100 eligible
clinicians.
• 2 groups of 100 or greater eligible
clinicians.
• 2 specialty groups.
We are proposing to increase the
sample size for the performance periods
occurring in 2018 to a minimum of:
• 20 urban individual or groups of <3
eligible clinicians—(broken down into
10 individuals & 10 groups).
• 20 rural individual or groups of <3
eligible clinicians—(broken down into
10 individuals & 10 groups).
• 10 groups of 3–8 eligible clinicians.
• 10 groups of 8–20 eligible
clinicians.
• 10 groups of 20–100 eligible
clinicians.
• 10 groups of 100 or greater eligible
clinicians.
• 6 groups of >20 eligible clinicians
reporting as individuals—(broken down
into 3 urban & 3 rural).
• 6 specialty groups—(broken down
into 3 reporting individually & 3
reporting as a group).
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• Up to 10 non-MIPS eligible
clinicians reporting as a group or
individual (any number of individuals
and any group size).
In addition, we are proposing changes
to the study procedures. In the
transition year of MIPS, study
participants were required to attend a
monthly focus group to share lessons
learned in submitting quality data along
with providing survey feedback to
monitor effectiveness. However, an
individual MIPS eligible clinician or
group who chooses to report all 6
measures within a period of 90 days
may not need to be a part of all of the
focus groups and survey sessions after
their first focus group and survey
following the measurement data
submission. This is because they may
have nothing new to contribute in terms
of discussion of errors or clinician
burdens. This also applies to MIPS
eligible clinicians that submit only three
MIPS measures within the performance
period, if they submitted all three
measures within the 90-day period or at
one submission. All study participants
would participate in surveys and focus
group meetings at least once after each
measures data submission. For those
who elect to report data for a 90-day
period, we would make further
engagement optional. Therefore, we are
proposing that for Quality Payment
Program Year 2 and future years that
study participants would be required to
attend as frequently as four monthly
surveys and focus group sessions
throughout the year, but certain study
participants would be able to attend less
frequently.
Further, the CY 2017 study requires
study measurement data to be collected
at baseline and at every 3 months
(quarterly basis) afterwards for the
duration of the calendar year. It also
calls for a minimum requirement of
three MIPS quality measures four times
within the year. We believe this is
inconsistent with clinicians reporting a
full year’s data as we believe some study
participants may choose to submit data
for all measures at one time, or
alternatively, may choose to submit data
up to six times during the 1-year period.
We are proposing for the Quality
Payment Program Year 2 and future
years to offer study participants
flexibility in their submissions so that
they could submit once, as can occur in
the MIPS program, and participate in
study surveys and focus groups while
still earning improvement activities
credit.
It must be noted that although the
aforementioned activities constitute an
information collection request as
defined in the implementing regulations
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30057
of the Paperwork Reduction Act of 1995
(5 CFR 1320), the associated burden is
exempt from application of the
Paperwork Reduction Act. Specifically,
section 1848(s)(7) of the Act, as added
by section 102 of the MACRA (Pub. L.
114–10) states that Chapter 35 of title
44, United States Code, shall not apply
to the collection of information for the
development of quality measures. Our
goals for new measures are to develop
new high quality, low cost measures
that are meaningful, easily
understandable and operable, and also,
reliably and validly measure what they
purport. This study shall inform us (and
our contractors) on the root causes of
clinicians’ performance measure data
collection and data submission burdens
and challenges that hinders accurate
and timely quality measurement
activities. In addition, this study will
inform us on the characteristic attributes
that our new measures must possess to
be able to accurately capture and
measure the priorities and gaps MACRA
aims for, as described in the Quality
Measures Development Plan.2 This
study, therefore, serves as the initial
stage of developing new measures and
also adapting existing measures. We
believe that understanding clinician’s
challenges and skepticisms, and
especially, understanding the factors
that undermine the optimal functioning
and effectiveness of quality measures
are requisites of developing measures
that are not only measuring what it
purports but also that are user friendly
and understandable for frontline
clinicians—our main stakeholders in
measure development. This will lead to
the creation of practice-derived, tested
measures that reduces burden and
create a culture of continuous
improvement in measure development.
We request comments on our study on
burdens associated with reporting
quality measures proposals regarding
sample size for the performance periods
occurring in 2018, study procedures for
the performance periods occurring in
2018 and future years, and data
submissions for the performance
periods occurring in 2018 and future
years.
f. Advancing Care Information
Performance Category
(1) Background
Section 1848(q)(2)(A) of the Act
includes the meaningful use of CEHRT
as a performance category under the
MIPS. We refer to this performance
2 https://www.cms.gov/Medicare/QualityInitiatives-Patient-Assessment-Instruments/ValueBased-Programs/MACRA-MIPS-and-APMs/FinalMDP.pdf (assessed: 06/02/2017).
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category as the advancing care
information performance category, and
it is reported by MIPS eligible clinicians
as part of the overall MIPS program. As
required by sections 1848(q)(2) and (5)
of the Act, the four performance
categories of the MIPS shall be used in
determining the MIPS final score for
each MIPS eligible clinician. In general,
MIPS eligible clinicians will be
evaluated under all four of the MIPS
performance categories, including the
advancing care information performance
category.
(2) Scoring
Section 1848(q)(5)(E)(i)(IV) of the Act
states that 25 percent of the MIPS final
score shall be based on performance for
the advancing care information
performance category. We established at
§ 414.1380(b)(4) that the score for the
advancing care information performance
category would be comprised of a base
score, performance score, and potential
bonus points for reporting on certain
measures and activities. For further
explanation of our scoring policies for
the advancing care information
performance category, we refer readers
to 81 FR 77216–77227.
mstockstill on DSK30JT082PROD with PROPOSALS2
(a) Base Score
For the CY 2018 performance period,
we are not proposing any changes to the
base score methodology as established
in the CY 2017 Quality Payment
Program final rule (81 FR 77217–77223).
We established the policy that MIPS
eligible clinicians must report a
numerator of at least one for the
numerator/denominator measures, or a
‘‘yes’’ response for the yes/no measure
in order to earn the 50 percentage points
in the base score. In addition, if the base
score requirements are not met, a MIPS
eligible clinician would receive a score
of zero for the ACI performance
category.
(b) Performance Score
In the CY 2017 Quality Payment
Program final rule (81 FR 77223 through
77226), we finalized that MIPS eligible
clinicians can earn 10 percentage points
in the performance score for meeting the
Immunization Registry Reporting
Measure. We believe we should modify
this policy because we have learned that
there are areas of the country where
immunization registries are not
available, and we did not intend to
disadvantage MIPS eligible clinicians
practicing in those areas. Thus, we are
proposing to modify the scoring of the
Public Health and Clinical Data Registry
Reporting objective beginning with the
performance period in CY 2018. We
propose if a MIPS eligible clinician
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fulfills the Immunization Registry
Reporting Measure, the MIPS eligible
clinician would earn 10 percentage
points in the performance score. If a
MIPS eligible clinician cannot fulfill the
Immunization Registry Reporting
Measure, we are proposing that the
MIPS eligible clinician could earn 5
percentage points in the performance
score for each public health agency or
clinical data registry to which the
clinician reports for the following
measures, up to a maximum of 10
percentage points: Syndromic
Surveillance Reporting; Electronic Case
Reporting; Public Health Registry
Reporting; and Clinical Data Registry
Reporting. A MIPS eligible clinician
who chooses to report to more than one
public health agency or clinical data
registry may receive credit in the
performance score for the submission to
more than one agency or registry;
however, the MIPS eligible clinician
would not earn more than a total of 10
percentage points for such reporting.
We further propose similar flexibility
for MIPS eligible clinicians who choose
to report the measures specified for the
Public Health Reporting Objective of the
2018 Advancing Care Information
Transition Objective and Measure set.
(In section II.C.6.f.(6)(b) of this proposed
rule, we are proposing to allow MIPS
eligible clinicians to report using the
2018 Advancing Care Information
Transition Objectives and Measures in
2018.) We propose if a MIPS eligible
clinician fulfills the Immunization
Registry Reporting Measure, the MIPS
eligible clinician would earn 10
percentage points in the performance
score. If a MIPS eligible clinician cannot
fulfill the Immunization Registry
Reporting Measure, we are proposing
that the MIPS eligible clinician could
earn 5 percentage points in the
performance score for each public
health agency or specialized registry to
which the clinician reports for the
following measures, up to a maximum
of 10 percentage points: Syndromic
Surveillance Reporting; Specialized
Registry Reporting. A MIPS eligible
clinician who chooses to report to more
than one specialized registry or public
health agency to submit syndromic
surveillance data may earn 5 percentage
points in the performance score for
reporting to each one, up to a maximum
of 10 percentage points.
By proposing to expand the options
for fulfilling the Public Health and
Clinical Data Registry Reporting and the
Public Health Reporting objectives, we
believe that we are adding flexibility so
that additional MIPS eligible clinicians
can successfully fulfill this objective
and earn 10 percentage points in the
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performance score. We are not
proposing to change the maximum
performance score that a MIPS eligible
clinician can earn; it remains at 90
percent.
We are inviting public comment on
these proposals.
(c) Bonus Score
In the CY 2017 Quality Payment
Program final rule (81 FR 77220 through
77226), for the Public Health and
Clinical Data Registry Reporting
objective and the Public Health
Reporting objective, we finalized that
MIPS eligible clinicians who report to
one or more public health agencies or
clinical data registries beyond the
Immunization Registry Reporting
Measure will earn a bonus score of 5
percentage points in the advancing care
information performance category. (In
section II.C.6.f.(6)(b) of this proposed
rule, we are proposing to allow MIPS
eligible clinicians to report using the
2018 Advancing Care Information
Transition Objectives and Measures in
2018.) Based on our proposals above to
allow MIPS eligible clinicians who
cannot fulfill the Immunization Registry
Reporting Measure to earn additional
points in the performance score, we
believe we should modify this policy so
that MIPS eligible clinicians cannot earn
points in both the performance score
and bonus score for reporting to the
same public health agency or clinical
data registry. We are proposing to
modify our policy beginning with the
performance period in CY 2018. We are
proposing that a MIPS eligible clinician
may only earn the bonus score of 5
percentage points for reporting to at
least one additional public health
agency or clinical data registry that is
different from the agency/agencies or
registry/or registries to which the MIPS
eligible clinician reports to earn a
performance score. For example, if a
MIPS eligible clinician reports to a
public health agency and a clinical data
registry for the performance score, they
could earn the bonus score of 5
percentage points by reporting to a
different agency or registry that the
clinician did not identify for purposes
of the performance score. A MIPS
eligible clinician would not receive
credit under both the performance score
and bonus score for reporting to the
same agency or registry.
We are proposing that for the
Advancing Care Information Objectives
and Measures, a bonus of 5 percentage
points would be awarded if the MIPS
eligible clinician reports ‘‘yes’’ for any
one of the following measures
associated with the Public Health and
Clinical Data Registry Reporting
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Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
objective: Syndromic Surveillance
Reporting; Electronic Case Reporting;
Public Health Registry Reporting; or
Clinical Data Registry Reporting. We are
proposing that for the 2018 Advancing
Care Information Transition Objectives
and Measures, a bonus of 5 percent
would be awarded if the MIPS eligible
clinician reports ‘‘yes’’ for any one of
the following measures associated with
the Public Health Reporting objective:
Syndromic Surveillance Reporting or
Specialized Registry Reporting. We are
proposing that to earn the bonus score,
the MIPS eligible clinician must be in
active engagement with one or more
additional public health agencies or
clinical data registries that is/are
different from the agency or registry that
they identified to earn a performance
score.
We are inviting public comment on
this proposal.
(d) Improvement Activities Bonus Score
Under the Advancing Care Information
Performance Category
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In the CY 2017 Quality Payment
Program final rule (81 FR 77202), we
discussed our approach to the
measurement of the use of health IT to
allow MIPS eligible clinicians and
groups the flexibility to implement
health IT in a way that supports their
clinical needs. In addition, we
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discussed the need to move toward
measurement of health IT use with
respect to its contribution to effective
care coordination and improving
outcomes for patients. We stated that
this approach would allow us to more
directly link health IT adoption and use
to patient outcomes, moving MIPS
beyond the measurement of EHR
adoption and process measurement and
into a more patient-focused health IT
program. Toward that end, we adopted
a policy to award a bonus score to MIPS
eligible clinicians who use CEHRT to
complete certain activities in the
improvement activities performance
category based on our belief that the use
of CEHRT in carrying out these
activities could further the outcomes of
clinical practice improvement.
We adopted a final policy to award a
10 percent bonus for the advancing care
information performance category if a
MIPS eligible clinician attests to
completing at least one of the
improvement activities we have
specified using CEHRT (81 FR 77209).
We refer readers to Table 8 in the CY
2017 Quality Payment Program final
rule (81 FR 77202–77209) for a list of
the improvement activities eligible for
the advancing care information
performance category bonus. In this
proposed rule, we are proposing to
expand this policy beginning with the
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30059
CY 2018 performance period by
identifying additional improvement
activities in Table 6 that would be
eligible for the advancing care
information performance category bonus
score if they are completed using
CEHRT functionality. The activities
eligible for the bonus score would
include those listed in Table 6, as well
as those listed in Table 8 in last year’s
final rule. We refer readers to the
Improvement Activities section of this
proposed rule (section II.C.6.e. of this
proposed rule) for a discussion of the
proposed new improvement activities
and proposed changes to the
improvement activities for 2018.
Ten percentage points is the
maximum bonus a MIPS eligible
clinician would receive if they attest to
using CEHRT for one or more of the
activities we have identified as eligible
for the bonus. This bonus is intended to
support progression toward holistic
health IT use and measurement;
attesting to even one improvement
activity demonstrates that the MIPS
eligible clinician is working toward this
holistic approach to the use of their
CEHRT. The weight of the improvement
activity for the improvement activities
performance category has no effect on
the bonus awarded in the advancing
care information performance category.
We invite comment on this proposal.
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TABLE 6: Proposed New Improvement Activities Eligible for the Advancing Care
Information Performance Category Bonus Beginning with
the 2018 Performance Period
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A MIPS eligible clinician providing unscheduled care (such
as an emergency room, urgent care, or other unplanned
encounter) attests that, for greater than 75 percent of case
visits that result from a clinically significant adverse drug
event, the MIPS eligible clinician transmits information,
including through the use of health IT to the patient's
primary care clinician regarding both the unscheduled visit
and the nature of the adverse drug event within 48 hours. A
clinically significant adverse event is defined as a
medication-related harm or injury such as side-effects,
supratherapeutic effects, allergic reactions, laboratory
abnormalities, or medication errors requiring
urgent/emergent evaluation, treatment, or hospitalization.
A MIPS eligible clinician would attest that they are
consulting specified applicable appropriate use criteria
(AUC) through a qualified clinical decision support
mechanism for all advanced diagnostic imaging services
ordered. This activity is for clinicians that are early
adopters of the Medicare AUC program (e.g., 2018
performance year) and for clinicians that begin the program
in future years as will be required by CFR §414.94
(authorized by the Protecting Access to Medicare Act of
2014). Qualified mechanisms will be able to provide a
report to the ordering clinician that can be used to assess
patterns of image-ordering and improve upon those patterns
to ensure that patients are receiving the most appropriate
ima in for their individual condition.
For at-risk outpatient Medicare beneficiaries, individual
MIPS eligible clinicians and groups must attest to
implementation of systematic preventive approaches in
clinical practice for at least 75 percent of medical records
with documentation of screening patients for abnormal
blood glucose according to current U.S. Preventive Services
Task Force (USPSTF) and/or Americans Diabetes
Association (ADA) guidelines.
For at-risk outpatient Medicare beneficiaries, individual
MIPS eligible clinicians and groups must attest to
implementation of systematic preventive approaches in
clinical practice for at least 75 percent of medical records
with documentation of referring eligible patients with
prediabetes to a CDC-recognized diabetes prevention
program operating under the framework of the National
Diabetes Prevention Program.
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Promote use of patient-reported outcome tools
Demonstrate performance of activities for employing
patient-reported outcome (PRO) tools and corresponding
collection of PRO data (e.g., use of PQH -2 or PHQ-9 and
PROMIS instruments) such as patient reported Wound
Quality of Life (QoL), patient reported Wound Outcome,
and patient reported Nutritional Screening.
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Develop pathways to neighborhood/community-based
resources to support patient health goals that could include
one or more of the following:
• Maintain formal (referral) links to communitybased chronic disease self-management support
programs, exercise programs and other wellness
resources with the potential for bidirectional flow
of information;
• Including through the use of tools that facilitate
electronic connnunication between settings;
• Screen patients for health-harming legal needs;
and/or
Provide a guide to available connnunity resources.
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a
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§
-s
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Send a
Summary of
Care
.::
The primary care and behavioral health practices use the
same electronic health record system for shared patients or
have an established bidirectional flow of primary care and
behavioral health records.
.::
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0
0
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t Summary of
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0
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p.,
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Participation in a Perioperative Surgical Home (PSH) that
provides a patient-centered, physician-led, interdisciplinary,
and team-based system of coordinated patient care, which
coordinates care from pre-procedure assessment through the
acute care episode, recovery, and post-acute care. This
activity allows for reporting of strategies and processes
related to care coordination of patients receiving surgical or
procedural care within a PSH. The clinician must perform
one or more of the following care coordination activities:
•
Coordinate with care managers/navigators in
preoperative clinic to plan and implementation
comprehensive post discharge plan of care;
• Deploy perioperative clinic and care processes to
reduce post-operative visits to emergency rooms;
•
Implement evidence-informed practices and
standardize care across the entire spectrum of
surgical patients; or
•
Implement processes to ensure effective
communications and education of patients' postdischar e instructions.
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Reconciliation
Health
Information
Exchange
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In the CY 2017 Quality Payment
Program final rule (81 FR 77210 through
77211), we established a performance
period for the advancing care
information performance category to
align with the overall MIPS performance
period of one full year to ensure all four
performance categories are measured
and scored based on the same period of
time. We believe this will lower
reporting burden, focus clinician quality
improvement efforts and align
administrative actions so that MIPS
eligible clinicians can use common
systems and reporting pathways. We
stated for the first and second
performance periods of MIPS (CYs 2017
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and 2018), we will accept a minimum
of 90 consecutive days of data and
encourage MIPS eligible clinicians to
report data for the full year performance
period. We are maintaining this policy
as finalized for the performance period
in CY 2018, and will accept a minimum
of 90 consecutive days of data in CY
2018. We are proposing the same policy
for the advancing care information
performance category for the
performance period in CY 2019, Quality
Payment Program Year 3, and would
accept a minimum of 90 consecutive
days of data in CY 2019. We refer
readers to section II.C.5. in this
proposed rule for additional information
on the MIPS performance period.
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(4) Certification Requirements
In the CY 2017 Quality Payment
Program final rule (81 FR 77211 through
77213), we outlined the requirements
for MIPS eligible clinicians using
CEHRT during the CY 2017 performance
period for the advancing care
information performance category as it
relates to the objectives and measures
they select to report, and also outlined
requirements for the CY 2018
performance period. We additionally
adopted a definition of CEHRT at
§ 414.1305 for MIPS eligible clinicians
that is based on the definition that
applies in the EHR Incentive Programs
under § 495.4.
For the CY 2017 performance period,
we adopted a policy by which MIPS
eligible clinicians may use EHR
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Advancing Care Information
Performance Category
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technology certified to either the 2014
or 2015 Edition certification criteria, or
a combination of the two. For the CY
2018 performance period, we previously
stated that MIPS eligible clinicians must
use EHR technology certified to the
2015 Edition to meet the objectives and
measures specified for the advancing
care information performance category.
We received significant comments
and feedback from stakeholders
requesting that we extend the use of
2014 Edition CEHRT beyond CY 2017
into CY 2018 and even CY 2019. Many
commenters noted the lack of products
certified to the 2015 Edition. Others
stated that switching from the 2014
Edition to the 2015 Edition requires a
large amount of time and planning and
if it is rushed there is a potential risk to
patient health. Some commenters noted
the significant burden of combining
outputs from multiple CEHRTs. A few
mentioned that the cost to switch to the
2015 Edition is prohibitive for smaller
practices.
Our experience with the transition
from EHR technology certified to the
2011 Edition to EHR technology
certified to the 2014 Edition did make
us aware of the many issues associated
with the adoption of EHR technology
certified to a new Edition. These
include the time that will be necessary
to effectively deploy EHR technology
certified to the 2015 Edition standards
and certification criteria and to make
the necessary patient safety, staff
training, and workflow investments to
be prepared to report for the advancing
care information performance category
for 2018. We understand and appreciate
these concerns, and are working in
collaboration with our federal partners
at the Office of the National Coordinator
for Health Information Technology
(ONC) to monitor progress on the 2015
Edition upgrade.
As noted in the FY 2018 Inpatient
Prospective Payment Systems for Acute
Care Hospitals and the Long-Term Care
Hospital Prospective Payment System
proposed rule (referred to as the FY
2018 IPPS/LTCH PPS proposed rule) (82
FR 20136), ONC is working with health
IT developers to analyze and monitor
the status of developer readiness for
2015 Edition technology. As part of
these analyses, ONC also reviewed
health IT being certified to 2015 Edition
by health IT developers who have
products that were certified for the 2014
Edition and were used by EHR Incentive
Program participants to attest. This
analysis compared the pace of 2014
Edition certification with the pace of
2015 Edition certification to date. As of
the beginning of the second quarter of
CY 2017, ONC confirmed that at least 53
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percent of eligible clinicians and 80
percent of eligible hospitals have 2015
Edition certified EHR technology
available based on previous EHR
Incentive Programs attestation data.
Based on these data, and as compared
to the transition from 2011 Edition to
2014 Edition, it appears that the
transition from the 2014 Edition to the
2015 Edition is on schedule for the CY
2018 performance period.
However, the analysis also considered
market trends such as consolidation and
the number of large and small
developers covering various groups of
participants and the potential impact on
readiness. The eligible hospital market
is fairly concentrated, with nearly 98
percent of eligible hospital EHR
Incentive Program participants using
health IT from the top ten developers
(ranked by market share) with a
significant majority of that coverage by
the top five developers. For hospitals,
some developers representing a smaller
market share also have certified health
IT already available and are not
expected to have a release schedule
much different from their larger
competitors. Considering market factors
and using previous EHR Incentive
Programs attestation data, ONC
estimates that at least 85 percent of
eligible hospitals would have EHR
technology certified to the 2015 Edition
available for use by the end of CY 2017
for program participation in 2018. In the
FY 2018 IPPS/LTCH PPS proposed rule
(82 FR 20136), we proposed to shorten
the EHR reporting period to a minimum
of any continuous 90-day period within
CY 2018 for eligible hospitals and
CAHs, as well as EPs who attest for a
state’s Medicaid EHR Incentive
Program, to allow additional time for
successful implementation of EHR
technology certified to the 2015 Edition
in CY 2018.
For MIPS eligible clinicians, the
concern of potential impact on
participation readiness when reviewing
these market factors may be more
significant. As noted in the FY 2018
IPPS/LTCH PPS proposed rule (82 FR
20136), historical data indicates eligible
professionals were more likely to use a
wider range of certified health IT,
including those which individually
make up a smaller segment of the
overall market. Therefore, when market
factors are taken into account, there
exists a larger proportion of readiness
that is unknown due to the wider range
of certified health IT which may be used
by MIPS eligible clinicians. This
necessitated a more conservative
approach for MIPS eligible clinician
readiness. That estimate is that 74
percent of MIPS eligible clinicians will
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be ready to participate in MIPS using
2015 Edition certified EHR technologies
by January 1, 2018.
However, subsequent to the
preliminary analysis, ONC has
continued to monitor readiness and to
receive feedback from stakeholders on
factors influencing variations in the
development and implementation
timelines for developers supporting
different segments of the market, as well
as the relationship between the
developer readiness timeline and
participant readiness. This continuing
analysis supports a potential need for a
longer implementation timeline for
MIPS eligible clinicians. Stakeholder
feedback suggests that while the
estimate for known readiness remains
the same, readiness among the
remaining MIPS eligible clinicians may
not be on the same timeline. About one
quarter of eligible professional EHR
Incentive Program participants in prior
years used certified health IT from small
developers that each has an historical
market share of 1 percent or less.
Therefore, MIPS eligible clinicians will
need a significant number of smaller
developers to reach the same readiness
on the same timeline as larger
companies in order to support program
participants seeking to upgrade to the
2015 Edition. However, small
developers generally offer a limited
number or type of products, and may
have more limited resources to dedicate
to upgrade development, testing and
certification, and implementation,
which may affect availability and
timing. In addition, the same factors
may impact the capacity of some
developers to support participants
during the process and therefore the
timeline for participant readiness would
also potentially be longer. This is
supported by historical analysis as a
smaller percentage of eligible
professionals used 2014 Edition
certified EHR technology for
participation in the EHR Incentive
Programs during the 2014 calendar year
than eligible hospitals and CAHs for the
same year. For this reason, we believe
additional flexibility for MIPS eligible
clinicians is essential to support
successful participation in the
advancing care information performance
category.
We continue to believe that there are
many benefits for switching to EHR
technology certified to the 2015 Edition.
As noted in the FY 2018 IPPS/LTCH
PPS proposed rule (82 FR 20136), the
2015 Edition health IT certification
criteria enables health information
exchange through new and enhanced
certification criteria standards, and
through implementation specifications
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for interoperability. The 2015 Edition
also incorporates changes that are
designed to spur innovation and
provide more choices to health care
providers and patients for the exchange
of electronic health information,
including new Application
Programming Interface (API)
certification criteria. APIs are required
for patient engagement measures within
the advancing care information
category; however, they may also be
enabled by a health care provider or
organization for their own use of third
party applications with their CEHRT,
such as for quality improvement. An
API can also be enabled by a health care
provider to give patients access to their
health information through a third-party
application with more flexibility than is
often found in many current patient
portals. From the MIPS eligible clinician
perspective, an API could complement
a patient portal or could also potentially
make one unnecessary if patients are
able to use software applications
designed to interact with an API that
could support their ability to view,
download, and transmit their health
information to a third party. In addition,
the 2015 Edition health IT transitions of
care certification criterion rigorously
assesses a product’s ability to create and
receive a Consolidated-Clinical
Document Architecture (C–CDA)
formatted documents. The ONC also
adopted certification criteria that both
support interoperability in other settings
and use cases, such as the Common
Clinical Data Set summary record, data
segmentation for privacy, and care plan
certification criteria (80 FR 62603).
However, in light of the conservative
readiness estimates for MIPS eligible
clinicians, and in line with our
commitment to supporting small
practices, solo practitioners and
specialties which may be more likely to
use certified health IT offered by small
developers, we are proposing that MIPS
eligible clinicians may use EHR
technology certified to either the 2014
or 2015 Edition certification criteria, or
a combination of the two for the CY
2018 performance period. We propose
to amend § 414.1305 to reflect this
change. We further note, that to
encourage new participants to adopt
certified health IT and to incentivize
participants to upgrade their technology
to 2015 Edition products which better
support interoperability across the care
continuum, we are proposing to offer a
bonus of 10 percentage points under the
advancing care information performance
category for MIPS eligible clinicians
who report the Advancing Care
Information Objectives and Measures for
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the performance period in CY 2018
using only 2015 Edition CEHRT. We are
proposing to amend
§ 414.1380(b)(4)C)(3) to reflect this
change. We are proposing this one-time
bonus for CY 2018 to support and
recognize MIPS eligible clinicians and
groups that invest in implementing
certified EHR technology in their
practice. Specifically, we intend this
bonus to support new participants that
may be adopting health IT for the first
time in CY 2018 and do not have 2014
Edition technology available to use or
that may have no prior experience with
meaningful use objectives and
measures. We believe this bonus will
help recognize their investment to adopt
health IT and support their participation
in the advancing care information
performance category in MIPS. In
addition, we believe this bonus will
help to incentivize participants to
continue the process of upgrading from
2014 Edition to 2015 Edition, especially
small practices where the investment in
updated workflows and implementation
may present unique challenges. We
intend this bonus to support and
recognize their efforts to engage with the
advancing care information measures
using technology certified to the 2015
Edition, which include more robust
measures using updated standards and
functions which support
interoperability. We seek comment on
this proposed bonus. Specifically, we
seek comment on if the percentage of
the bonus is appropriate, or whether it
should be limited to new participants in
MIPS and small practices.
This bonus is not available to MIPS
eligible clinicians who use a
combination of the 2014 and 2015
Editions. We note that with the addition
of the 2015 Edition CEHRT bonus of 10
percentage points, MIPS eligible
clinicians would be able to earn a bonus
score of up to 25 percentage points in
CY 2018 under the advancing care
information performance category, an
increase from the 15 percentage point
bonus score available in CY 2017.
To facilitate readers in identifying the
requirements of CEHRT for the
Advancing Care Information Objectives
and Measures, we are including Table 8
in section II.C.6.f.(6)(a) which lists the
2015 Edition and 2014 Edition
certification criteria required to meet the
objectives and measures.
We invite comments on these
proposals.
(5) Scoring Methodology Considerations
Section 1848(q)(5)(E)(i)(IV) of the Act
states that 25 percent of the MIPS final
score shall be based on performance for
the advancing care information
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30065
performance category. Further, section
1848(q)(5)(E)(ii) of the Act, provides that
in any year in which the Secretary
estimates that the proportion of eligible
professionals (as defined in section
1848(o)(5) of the Act) who are
meaningful EHR users (as determined
under section 1848(o)(2) of the Act) is
75 percent or greater, the Secretary may
reduce the applicable percentage weight
of the advancing care information
performance category in the MIPS final
score, but not below 15 percent, and
increase the weightings of the other
performance categories such that the
total percentage points of the increase
equals the total percentage points of the
reduction. We note that section
1848(o)(5) of the Act defines an eligible
professional as a physician, as defined
in section 1861(r) of the Act.
In CY 2017 Quality Payment Program
final rule (81 FR 77226–77227), we
established a final policy, for purposes
of applying section 1848(q)(5)(E)(ii) of
the Act, to estimate the proportion of
physicians as defined in section 1861(r)
of the Act who are meaningful EHR
users as those physician MIPS eligible
clinicians who earn an advancing care
information performance category score
of at least 75 percent for a performance
period. We established that we will base
this estimation on data from the relevant
performance period, if we have
sufficient data available from that
period. For example, if feasible, we
would consider whether to reduce the
applicable percentage weight of the
advancing care information performance
category in the MIPS final score for the
2019 MIPS payment year based on an
estimation using the data from the 2017
performance period. We stated that we
will not include in the estimation
physicians for whom the advancing care
information performance category is
weighted at zero percent under section
1848(q)(5)(F) of the Act, which we
relied on in the CY 2017 Quality
Payment Program final rule (81 FR
77226 through 77227) to establish
policies under which we would weigh
the advancing care information
performance category at zero percent of
the final score. In addition, we are
proposing not to include in the
estimation physicians for whom the
advancing care information performance
category would be weighted at zero
percent under our proposal in section
II.C.6.f.(7) of this proposed rule to
implement certain provisions of the 21st
Century Cures Act (that is, physicians
who are determined hospital-based or
ambulatory surgical center-based, or
who are granted an exception based on
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significant hardship or decertified EHR
technology.
We are considering modifications to
the policy we established in last year’s
rulemaking to base our estimation of
physicians who are meaningful EHR
users for a MIPS payment year (for
example, 2019) on data from the
relevant performance period (for
example, 2017). We are concerned that
if in future rulemaking we decide to
propose to change the weight of the
advancing care information performance
category based on our estimation, such
a change may cause confusion to MIPS
eligible clinicians who are adjusting to
the MIPS program and believe this
performance category will make up 25
percent of the final score for the 2019
MIPS payment year. The earliest we
would be able to make our estimation
based on 2017 data and propose in
future rulemaking to change the weight
of the advancing care information
performance category for the 2019 MIPS
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payment year would be in mid-2018, as
the deadline for data submission is
March 31, 2018. We are requesting
public comments on whether this
timeframe is sufficient, or whether a
more extended timeframe would be
preferable. We are proposing to modify
our existing policy such that we would
base our estimation of physicians who
are meaningful EHR users for a MIPS
payment year on data from the
performance period that occurs four
years before the MIPS payment year. For
example, we would use data from the
2017 performance period to estimate the
proportion of physicians who are
meaningful EHR users for purposes of
reweighting the advancing care
information performance category for
the 2021 MIPS payment year.
We invite comments on this proposal.
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(6) Objectives and Measures
(a) Advancing Care Information
Objectives and Measures Specifications
We are proposing to maintain for the
CY 2018 performance period the
Advancing Care Information Objectives
and Measures as finalized in the CY
2017 Quality Payment Program final
rule (81 FR 77227 through 77229) with
the modifications proposed below. As
we noted (81 FR 77227), these objectives
and measures were adapted from the
Stage 3 objectives and measures
finalized in the 2015 EHR Incentive
Programs final rule (80 FR 62829
through 62871), however, we did not
maintain the previously established
thresholds for MIPS. For a more detailed
discussion of the Stage 3 objectives and
measures, including explanatory
material and defined terms, we refer
readers to the 2015 EHR Incentive
Programs final rule (80 FR 62829
through 62871).
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TABLE 7: 2018 Performance Period Advancing Care Information Performance Category
Scoring Methodology
Advancing Care Information Objectives and Measures
.....
eJJ=
=~
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0 ·=
Q.=
~0"'
~
Protect Patient
Health
Information
Electronic
Prescribing
e-Prescribing
Required
0
Provide Patient Access
Required
Up to 10%
Not Required
Up to 10%
View, Download, or Transmit
(VDT)
Secure Messaging
Not Required
Up to 10%
Not Required
Up to 10%
Not Required
Up to 10%
Send a Summary of Care
Required
Upto 10%
Request/Accept Summary of
Care
Clinical Information
Reconciliation
Immunization Registry Reporting
Required
Up to 10%
Not Required
Up to 10%
Not Required
0 or 10%
Syndromic Surveillance
Reporting
Electronic Case Reporting
Not Required
0 or 5%*
Not Required
0 or 5%*
Not Required
0 or 5%*
Clinical Data Registry Reporting
Public Health and
Clinical Data
Registry
Reporting
Yes/No
Statement
Public Health Registry Reporting
Health
Information
Exchange
0
Patient-Generated Health Data
Coordination of
Care Through
Patient
Engagement
Required
Patient-Specific Education
Patient Electronic
Access
Security Risk Analysis
Not Required
0 or 5%*
Numerator/
Denominator
Numerator/
Denominator
Numerator/
Denominator
Numerator/
Denominator
Numerator/
Denominator
Numerator/
Denominator
Numerator/
Denominator
Numerator/
Denominator
Numerator/
Denominator
Yes/No
Statement
Yes/No
Statement
Yes/No
Statement
Yes/No
Statement
Yes/No
Statement
. • \ ·.· ' ·· •
·. • .··
• ·•. ..·
• . ·• /.
5% bonus
. . ...
·.·:
. .
..
Yes/No
Statement
10% bonus
Yes/No
Statement
Report using only 2015 Edition CEHRT
10% bonus
Based upon
measures
submitted
* A MIPS eligible clinician who cannot fulfill the Immumzatwn Registry Reportmg Measure may earn 5% for each
public health agency or clinical data registry to which the clinician reports, up to a maximum of 10% under the
performance score.
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Bonus {up to 2~.%
· .·.
··.··
Report to one or more additional public health
agencies or clinical data registries beyond those
identified for the performance score
Report improvement activities using CEHRT
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Objective: Protect Patient Health
Information.
Objective: Protect electronic protected
health information (ePHI) created or
maintained by the CEHRT through the
implementation of appropriate
technical, administrative, and physical
safeguards.
Security Risk Analysis Measure:
Conduct or review a security risk
analysis in accordance with the
requirements in 45 CFR 164.308(a)(1),
including addressing the security (to
include encryption) of ePHI data created
or maintained by CEHRT in accordance
with requirements in 45 CFR
164.312(a)(2)(iv) and 164.306(d)(3),
implement security updates as
necessary, and correct identified
security deficiencies as part of the MIPS
eligible clinician’s risk management
process.
Objective: Electronic Prescribing.
Objective: Generate and transmit
permissible prescriptions electronically.
E-Prescribing Measure: At least one
permissible prescription written by the
MIPS eligible clinician is queried for a
drug formulary and transmitted
electronically using CEHRT.
• Denominator: Number of
prescriptions written for drugs requiring
a prescription to be dispensed other
than controlled substances during the
performance period; or number of
prescriptions written for drugs requiring
a prescription to be dispensed during
the performance period.
• Numerator: The number of
prescriptions in the denominator
generated, queried for a drug formulary,
and transmitted electronically using
CEHRT.
Objective: Patient Electronic Access.
Objective: The MIPS eligible clinician
provides patients (or patient-authorized
representative) with timely electronic
access to their health information and
patient-specific education.
Provide Patient Access Measure: For
at least one unique patient seen by the
MIPS eligible clinician: (1) The patient
(or the patient-authorized
representative) is provided timely
access to view online, download, and
transmit his or her health information;
and (2) The MIPS eligible clinician
ensures the patient’s health information
is available for the patient (or patientauthorized representative) to access
using any application of their choice
that is configured to meet the technical
specifications of the Application
Programing Interface (API) in the MIPS
eligible clinician’s CEHRT.
• Denominator: The number of
unique patients seen by the MIPS
eligible clinician during the
performance period.
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• Numerator: The number of patients
in the denominator (or patient
authorized representative) who are
provided timely access to health
information to view online, download,
and transmit to a third party and to
access using an application of their
choice that is configured meet the
technical specifications of the API in the
MIPS eligible clinician’s CEHRT.
Definition of timely—Beginning with
the 2018 performance period, we are
proposing to define ‘‘timely’’ as within
4 business days of the information being
available to the MIPS eligible clinician.
This definition of timely is the same as
we adopted under the EHR Incentive
Programs (80 FR 62815).
Patient-Specific Education Measure:
The MIPS eligible clinician must use
clinically relevant information from
CEHRT to identify patient-specific
educational resources and provide
electronic access to those materials to at
least one unique patient seen by the
MIPS eligible clinician.
• Denominator: The number of
unique patients seen by the MIPS
eligible clinician during the
performance period.
• Numerator: The number of patients
in the denominator who were provided
electronic access to patient-specific
educational resources using clinically
relevant information identified from
CEHRT during the performance period.
Objective: Coordination of Care
Through Patient Engagement.
Objective: Use CEHRT to engage with
patients or their authorized
representatives about the patient’s care.
View, Download, Transmit (VDT)
Measure: During the performance
period, at least one unique patient (or
patient-authorized representatives) seen
by the MIPS eligible clinician actively
engages with the EHR made accessible
by the MIPS eligible clinician. A MIPS
eligible clinician may meet the measure
by either (1) view, download or transmit
to a third party their health information;
or (2) access their health information
through the use of an API that can be
used by applications chosen by the
patient and configured to the API in the
MIPS eligible clinician’s CEHRT; or (3)
a combination of (1) and (2).
Proposed change to the View,
Download, Transmit (VDT) Measure:
During the performance period, at least
one unique patient (or patientauthorized representatives) seen by the
MIPS eligible clinician actively engages
with the EHR made accessible by the
MIPS eligible clinician by either (1)
viewing, downloading or transmitting to
a third party their health information; or
(2) accessing their health information
through the use of an API that can be
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used by applications chosen by the
patient and configured to the API in the
MIPS eligible clinician’s CEHRT; or (3)
a combination of (1) and (2). We are
proposing this change because we
erroneously described the actions in the
measure (viewing, downloading or
transmitting; or accessing through an
API) as being taken by the MIPS eligible
clinician rather than the patient or the
patient-authorized representatives. This
change would align the measure
description with the requirements of the
numerator and denominator. We
propose this change would apply
beginning with the performance period
in 2017.
• Denominator: Number of unique
patients seen by the MIPS eligible
clinician during the performance
period.
• Numerator: The number of unique
patients (or their authorized
representatives) in the denominator who
have viewed online, downloaded, or
transmitted to a third party the patient’s
health information during the
performance period and the number of
unique patients (or their authorized
representatives) in the denominator who
have accessed their health information
through the use of an API during the
performance period.
Secure Messaging Measure: For at
least one unique patient seen by the
MIPS eligible clinician during the
performance period, a secure message
was sent using the electronic messaging
function of CEHRT to the patient (or the
patient-authorized representative), or in
response to a secure message sent by the
patient (or the patient-authorized
representative).
• Denominator: Number of unique
patients seen by the MIPS eligible
clinician during the performance
period.
• Numerator: The number of patients
in the denominator for whom a secure
electronic message is sent to the patient
(or patient-authorized representative) or
in response to a secure message sent by
the patient (or patient-authorized
representative), during the performance
period.
Patient-Generated Health Data
Measure: Patient-generated health data
or data from a non-clinical setting is
incorporated into the CEHRT for at least
one unique patient seen by the MIPS
eligible clinician during the
performance period.
• Denominator: Number of unique
patients seen by the MIPS eligible
clinician during the performance
period.
• Numerator: The number of patients
in the denominator for whom data from
non-clinical settings, which may
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include patient-generated health data, is
captured through the CEHRT into the
patient record during the performance
period.
Objective: Health Information
Exchange
Objective: The MIPS eligible clinician
provides a summary of care record
when transitioning or referring their
patient to another setting of care,
receives or retrieves a summary of care
record upon the receipt of a transition
or referral or upon the first patient
encounter with a new patient, and
incorporates summary of care
information from other health care
clinician into their EHR using the
functions of CEHRT.
Proposed Change to the Objective:
The MIPS eligible clinician provides a
summary of care record when
transitioning or referring their patient to
another setting of care, receives or
retrieves a summary of care record upon
the receipt of a transition or referral or
upon the first patient encounter with a
new patient, and incorporates summary
of care information from other health
care providers into their EHR using the
functions of CEHRT.
We inadvertently used the term
‘‘health care clinician’’ and are
proposing to replace it with the more
appropriate term ‘‘health care provider’’.
We are proposing this change would
apply beginning with the performance
period in 2017.
Send a Summary of Care Measure:
For at least one transition of care or
referral, the MIPS eligible clinician that
transitions or refers their patient to
another setting of care or health care
clinician (1) creates a summary of care
record using CEHRT; and (2)
electronically exchanges the summary
of care record.
Proposed Change to the Send a
Summary of Care Measure: For at least
one transition of care or referral, the
MIPS eligible clinician that transitions
or refers their patient to another setting
of care or health care provider (1)
creates a summary of care record using
CEHRT; and (2) electronically
exchanges the summary of care record.
We inadvertently used the term
‘‘health care clinician’’ and are
proposing to replace it with the more
appropriate term ‘‘health care provider’’.
We are proposing this change would
apply beginning with the 2017
performance period.
• Denominator: Number of transitions
of care and referrals during the
performance period for which the MIPS
eligible clinician was the transferring or
referring clinician.
• Numerator: The number of
transitions of care and referrals in the
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denominator where a summary of care
record was created using CEHRT and
exchanged electronically.
Request/Accept Summary of Care
Measure: For at least one transition of
care or referral received or patient
encounter in which the MIPS eligible
clinician has never before encountered
the patient, the MIPS eligible clinician
receives or retrieves and incorporates
into the patient’s record an electronic
summary of care document.
• Denominator: Number of patient
encounters during the performance
period for which a MIPS eligible
clinician was the receiving party of a
transition or referral or has never before
encountered the patient and for which
an electronic summary of care record is
available.
• Numerator: Number of patient
encounters in the denominator where an
electronic summary of care record
received is incorporated by the clinician
into the CEHRT.
Clinical Information Reconciliation
Measure: For at least one transition of
care or referral received or patient
encounter in which the MIPS eligible
clinician has never before encountered
the patient, the MIPS eligible clinician
performs clinical information
reconciliation. The MIPS eligible
clinician must implement clinical
information reconciliation for the
following three clinical information
sets: (1) Medication. Review of the
patient’s medication, including the
name, dosage, frequency, and route of
each medication; (2) Medication allergy.
Review of the patient’s known
medication allergies; (3) Current
Problem list. Review of the patient’s
current and active diagnoses.
• Denominator: Number of transitions
of care or referrals during the
performance period for which the MIPS
eligible clinician was the recipient of
the transition or referral or has never
before encountered the patient.
• Numerator: The number of
transitions of care or referrals in the
denominator where the following three
clinical information reconciliations
were performed: Medication list;
medication allergy list; and current
problem list.
Objective: Public Health and Clinical
Data Registry Reporting.
Objective: The MIPS eligible clinician
is in active engagement with a public
health agency or clinical data registry to
submit electronic public health data in
a meaningful way using CEHRT, except
where prohibited, and in accordance
with applicable law and practice.
Immunization Registry Reporting
Measure: The MIPS eligible clinician is
in active engagement with a public
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health agency to submit immunization
data and receive immunization forecasts
and histories from the public health
immunization registry/immunization
information system (IIS).
We note that the functionality to be
bi-directional is part of EHR technology
certified to the 2015 Edition (80 FR
62554). It means that in addition to
sending the immunization record to the
immunization registry, the CEHRT must
be able to receive and display a
consolidated immunization history and
forecast.
Syndromic Surveillance Reporting
Measure: The MIPS eligible clinician is
in active engagement with a public
health agency to submit syndromic
surveillance data from a non-urgent care
ambulatory setting where the
jurisdiction accepts syndromic data
from such settings and the standards are
clearly defined.
Proposed Change to the Syndromic
Surveillance Reporting Measure: The
MIPS eligible clinician is in active
engagement with a public health agency
to submit syndromic surveillance data.
We are proposing this change because
we inadvertently finalized the measure
description that we had proposed for
Stage 3 of the EHR Incentive Program
(80 FR 82866) and not the measure
description that we finalized (80 FR
82970). The proposed change aligns
with the measure description finalized
for Stage 3.
Electronic Case Reporting Measure:
The MIPS eligible clinician is in active
engagement with a public health agency
to electronically submit case reporting
of reportable conditions.
Public Health Registry Reporting
Measure: The MIPS eligible clinician is
in active engagement with a public
health agency to submit data to public
health registries.
Clinical Data Registry Reporting
Measure: The MIPS eligible clinician is
in active engagement to submit data to
a clinical data registry.
We note that we have split the
Specialized Registry Reporting Measure
that we adopted under the 2017
Advancing Care Information Transition
Objectives and Measures into two
separate measures, Public Health
Registry and Clinical Data Registry
Reporting to better define the registries
available for reporting. We want to
continue to encourage those MIPS
eligible clinicians who have already
started down the path of reporting to a
specialized registry to continue to
engage in public health and clinical data
registry reporting. Therefore, we
propose to allow MIPS eligible
clinicians and groups to continue to
count active engagement in electronic
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public health reporting with specialized
registries. We propose to allow these
registries to be counted for purposes of
reporting the Public Health Registry
Reporting Measure or the Clinical Data
Registry Reporting Measure beginning
with the 2018 performance period. A
MIPS eligible clinician may count a
specialized registry if the MIPS eligible
clinician achieved the phase of active
engagement as described under ‘‘active
engagement option 3: production’’ in
the 2015 EHR Incentive Programs final
rule with comment period (80 FR 62862
through 62865), meaning the clinician
has completed testing and validation of
the electronic submission and is
electronically submitting production
data to the public health agency or
clinical data registry.
As noted previously, to facilitate
readers in identifying the requirements
of CEHRT for the Advancing Care
Information Objectives and Measures,
we are including the following Table 8,
which includes the 2015 Edition and
2014 Edition certification criteria
required to meet the objectives and
measures.
TABLE 8—ADVANCING CARE INFORMATION OBJECTIVES AND MEASURES AND CERTIFICATION CRITERIA FOR 2014 AND
2015 EDITIONS
Measure
2015 Edition
2014 Edition
Protect Patient Health
Information.
Electronic Prescribing ..
Security Risk Analysis
Patient Electronic Access.
Provide Patient Access.
Patient Specific Education.
View, Download, or
Transmit (VDT).
Coordination of Care
Through Patient Engagement.
Coordination of Care
Through Patient Engagement.
Secure Messaging .....
The requirements are a part of CEHRT specific to each certification criterion.
§ 170.315(b)(3) (Electronic Prescribing).
§ 170.315(a)(10) (Drug-Formulary and Preferred Drug List checks.
§ 170.315(e)(1) (View, Download, and Transmit to 3rd Party). § 170.315(g)(7) (Application Access—Patient Selection).
§ 170.315(g)(8) (Application Access—Data
Category Request). § 170.315(g)(9) (Application Access—All Data Request) The
three criteria combined are the ‘‘API’’ certification criteria.
§ 170.315(a)(13) (Patient-specific Education
Resources).
§ 170.315(e)(1) (View, Download, and Transmit to 3rd Party). § 170.315(g)(7) (Application Access—Patient Selection).
§ 170.315(g)(8) (Application Access—Data
Category Request). § 170.315(g)(9) (Application Access—All Data Request) The
three criteria combined are the ‘‘API’’ certification criteria.
§ 170.315(e)(2) (Secure Messaging) ..............
The requirements are included in the Base
EHR Definition.
§ 170.314(b)(3) (Electronic Prescribing).
§ 170.314(a)(10) (Drug-Formulary and Preferred Drug List checks.
§ 170.314(e)(1) (View, Download, and Transmit to 3rd Party).
Patient Electronic Access.
Coordination of Care
Through Patient Engagement.
Health Information Exchange.
Send a Summary of
Care.
Health Information Exchange.
Request/Accept Summary of Care.
§ 170.315(b)(1) (Transitions of Care) .............
Health Information Exchange.
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Objective
Clinical Information
Reconciliation.
§ 170.315(b)(2) (Clinical Information Reconciliation and Incorporation).
Public Health and Clinical Data Registry
Reporting.
Public Health and Clinical Data Registry
Reporting.
Immunization Registry
Reporting.
§ 170.315(f)(1) (Transmission to Immunization
Registries).
Syndromic Surveillance Reporting.
§ 170.315(f)(2) (Transmission to Public Health
Agencies—Syndromic Surveillance) Urgent
Care Setting Only.
Public Health and Clinical Data Registry
Reporting.
Electronic Case Reporting.
§ 170.315(f)(5) (Transmission to Public Health
Agencies—Electronic Case Reporting).
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Patient-Generated
Health Data.
19:16 Jun 29, 2017
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§ 170.315(e)(3) (Patient Health Information
Capture) Supports meeting the measure,
but is NOT required to be used to meet the
measure. The certification criterion is part
of the CEHRT definition beginning in 2018.
§ 170.315(b)(1) (Transitions of Care) .............
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§ 170.314(a)(13) (Patient-specific Education
Resources).
§ 170.314(e)(1) (View, Download, and Transmit to 3rd Party).
§ 170.314(e)(3) (Secure Messaging).
N/A.
§ 170.314(b)(2) (Transitions of Care-Create
and Transmit Transition of Care/Referral
Summaries or § 170.314(b)(8) (Optional—
Transitions of Care).
§ 170.314(b)(1) (Transitions of Care-Receive,
Display and Incorporate Transition of Care/
Referral Summaries or § 170.314(b)(8)
(Optional-Transitions of Care).
§ 170.314(b)(4) (Clinical Information Reconciliation or § 170.314(b)(9) (Optional—
Clinical Information Reconciliation and Incorporation).
N/A.
§ 170.314(f)(3) (Transmission to Public Health
Agencies—Syndromic Surveillance) or
§ 170.314(f)(7) (Optional-Ambulatory Setting Only-Transmission to Public Health
Agencies—Syndromic Surveillance).
N/A.
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TABLE 8—ADVANCING CARE INFORMATION OBJECTIVES AND MEASURES AND CERTIFICATION CRITERIA FOR 2014 AND
2015 EDITIONS—Continued
Objective
Measure
2015 Edition
2014 Edition
Public Health and Clinical Data Registry
Reporting.
Public Health Registry
Reporting.
Public Health and Clinical Data Registry
Reporting.
Clinical Data Registry
Reporting.
EPs may choose one or more of the following: § 170.315(f)(4) (Transmission to
Cancer Registries).
§ 170.315(f)(7) (Transmission to Public Health
Agencies—Health Care Surveys).
No 2015 Edition health IT certification criteria
at this time.
§ 170.314(f)(5) (Optional—Ambulatory Setting
Only—Cancer Case Information and
§ 170.314(f)(6) (Optional—Ambulatory Setting Only—Transmission to Cancer Registries).
N/A.
We are inviting public comment on
these proposals.
(b) 2017 and 2018 Advancing Care
Information Transition Objectives and
Measures Specifications
TABLE 9—ADVANCING CARE INFORMATION PERFORMANCE CATEGORY SCORING METHODOLOGY FOR 2018 ADVANCING
CARE INFORMATION TRANSITION OBJECTIVES AND MEASURES
2018 Advancing Care Information
Transition Objective
2018 Advancing Care Information
Transition Measure
Required/
not required
for base score
(50%)
Performance
Score
(up to 90%)
Protect Patient Health Information .............
Electronic Prescribing ................................
Security Risk Analysis ..............................
E-Prescribing ............................................
Required ........
Required ........
0 .....................
0 .....................
Patient Electronic Access ..........................
Provide Patient Access .............................
Required ........
Up to 20 .........
View, Download, or Transmit (VDT) .........
Not Required
Up to 10 .........
Patient-Specific Education .........................
Patient-Specific Education ........................
Not Required
Up to 10 .........
Secure Messaging .....................................
Secure Messaging ....................................
Not Required
Up to 10 .........
Health Information Exchange .....................
Health Information Exchange ...................
Required ........
Up to 20 .........
Medication Reconciliation ..........................
Medication Reconciliation .........................
Not Required
Up to 10 .........
Public Health Reporting .............................
Immunization Registry Reporting .............
Syndromic Surveillance Reporting ...........
Specialized Registry Reporting ................
Not Required
Not Required
Not Required
0 or 10 ...........
0 or 5 * ...........
0 or 5 * ...........
Yes/No Statement.
Numerator/Denominator.
Numerator/Denominator.
Numerator/Denominator.
Numerator/Denominator.
Numerator/Denominator.
Numerator/Denominator.
Numerator/Denominator.
Yes/No Statement.
Yes/No Statement.
Yes/No Statement.
5 bonus ..........
Yes/No Statement.
10 bonus ........
Yes/No Statement.
Reporting
requirement
Bonus up to 15%
Report to one or more additional public health agencies or clinical data registries beyond those identified
for the performance score.
Report improvement activities using CEHRT ................................................................................................
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* A MIPS eligible clinician who cannot fulfill the Immunization Registry Reporting measure may earn 5% for each public health agency or clinical data registry to which the clinician reports, up to a maximum of 10% under the performance score.
In the CY 2017 Quality Payment
Program final rule (81 FR 77229 through
77237), we finalized the 2017
Advancing Care Information Transition
Objectives and Measures for MIPS
eligible clinicians using EHR technology
certified to the 2014 Edition. We noted
(81 FR 77229 that these objectives and
measures have been adapted from the
Modified Stage 2 objectives and
measures finalized in the 2015 EHR
Incentive Programs final rule (80 FR
62793 through 62825); however, we did
not maintain the previously established
thresholds for MIPS. For a more detailed
discussion of the Modified Stage 2
Objectives and Measures, including
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explanatory material and defined terms,
we refer readers to the 2015 EHR
Incentive Programs final rule (80 FR
62793 through 62825). We are proposing
to make several modifications identified
and described below to the 2017
Advancing Care Information Transition
Objectives and Measures for the
advancing care information performance
category of MIPS for the 2017 and 2018
performance periods. These
modifications would not require
changes to EHR technology that has
been certified to the 2014 Edition.
We finalized the 2017 Advancing Care
Information Transition Objectives and
Measures only for the 2017 performance
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period because these objectives and
measures are for MIPS eligible
clinicians using EHR technology
certified to the 2014 Edition. Because
we are proposing in section II.C.6.f.(4) to
continue to allow the use of EHR
technology certified to the 2014 Edition
in the 2018 performance period, we are
also proposing to allow MIPS eligible
clinicians to report the Advancing Care
Information Transition Objectives and
Measures in 2018.
Objective: Protect Patient Health
Information.
Objective: Protect electronic protected
health information (ePHI) created or
maintained by the CEHRT through the
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implementation of appropriate
technical, administrative, and physical
safeguards.
Security Risk Analysis Measure:
Conduct or review a security risk
analysis in accordance with the
requirements in 45 CFR 164.308(a)(1),
including addressing the security (to
include encryption) of ePHI data created
or maintained by CEHRT in accordance
with requirements in 45 CFR
164.312(a)(2)(iv) and 164.306(d)(3), and
implement security updates as
necessary and correct identified security
deficiencies as part of the MIPS eligible
clinician’s risk management process.
Objective: Electronic Prescribing.
Objective: MIPS eligible clinicians
must generate and transmit permissible
prescriptions electronically.
E-Prescribing Measure: At least one
permissible prescription written by the
MIPS eligible clinician is queried for a
drug formulary and transmitted
electronically using CEHRT.
• Denominator: Number of
prescriptions written for drugs requiring
a prescription to be dispensed other
than controlled substances during the
performance period; or number of
prescriptions written for drugs requiring
a prescription to be dispensed during
the performance period.
• Numerator: The number of
prescriptions in the denominator
generated, queried for a drug formulary,
and transmitted electronically using
CEHRT.
Objective: Patient Electronic Access.
Objective: The MIPS eligible clinician
provides patients (or patient-authorized
representative) with timely electronic
access to their health information and
patient-specific education.
Proposed Modification to the
Objective: We are proposing to modify
this objective beginning with the 2017
performance period by removing the
word ‘‘electronic’’ from the description
of timely access as it was erroneously
included in the final rule (81 FR 77228).
It was our intention to align the
objective with the objectives for Patient
Specific Education and Patient
Electronic Access adopted under
modified Stage 2 in the 2015 EHR
Incentive Programs final rule (80 FR
62809 and 80 FR 62815), which do not
include the word ‘‘electronic’’. The
word ‘‘electronic’’ was also not included
in the certification specifications for the
2014 Edition, § 170.314(a)(15) (Patientspecific education resources) and
§ 170.314(e)(1) (View, download, and
transmit to third party).
Provide Patient Access Measure: At
least one patient seen by the MIPS
eligible clinician during the
performance period is provided timely
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access to view online, download, and
transmit to a third party their health
information subject to the MIPS eligible
clinician’s discretion to withhold
certain information.
• Denominator: The number of
unique patients seen by the MIPS
eligible clinician during the
performance period.
• Numerator: The number of patients
in the denominator (or patient
authorized representative) who are
provided timely access to health
information to view online, download,
and transmit to a third party.
View, Download, Transmit (VDT)
Measure: At least one patient seen by
the MIPS eligible clinician during the
performance period (or patientauthorized representative) views,
downloads or transmits their health
information to a third party during the
performance period.
• Denominator: Number of unique
patients seen by the MIPS eligible
clinician during the performance
period.
• Numerator: The number of unique
patients (or their authorized
representatives) in the denominator who
have viewed online, downloaded, or
transmitted to a third party the patient’s
health information during the
performance period.
Objective: Patient-Specific Education.
Objective: The MIPS eligible clinician
provides patients (or patient authorized
representative) with timely electronic
access to their health information and
patient-specific education.
Proposed Change to the Objective:
The MIPS eligible clinician uses
clinically relevant information from
CEHRT to identify patient-specific
educational resources and provide those
resources to the patient. We
inadvertently finalized the description
of the Patient Electronic Access
objective for the Patient-Specific
Education Objective, so that the PatientSpecific Education Objective had the
wrong description. We are proposing to
correct this error by adopting the
description of the Patient-Specific
Education Objective adopted under
modified Stage 2 in the 2015 EHR
Incentive Programs final rule (80 FR
62809 and 80 FR 62815). We are
proposing this change would apply
beginning with the performance period
in 2017.
Patient-Specific Education Measure:
The MIPS eligible clinician must use
clinically relevant information from
CEHRT to identify patient-specific
educational resources and provide
access to those materials to at least one
unique patient seen by the MIPS eligible
clinician.
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• Denominator: The number of
unique patients seen by the MIPS
eligible clinician during the
performance period.
• Numerator: The number of patients
in the denominator who were provided
access to patient-specific educational
resources using clinically relevant
information identified from CEHRT
during the performance period.
Objective: Secure Messaging.
Objective: Use CEHRT to engage with
patients or their authorized
representatives about the patient’s care.
Secure Messaging Measure: For at
least one patient seen by the MIPS
eligible clinician during the
performance period, a secure message
was sent using the electronic messaging
function of CEHRT to the patient (or the
patient-authorized representative), or in
response to a secure message sent by the
patient (or the patient authorized
representative) during the performance
period.
• Denominator: Number of unique
patients seen by the MIPS eligible
clinician during the performance
period.
• Numerator: The number of patients
in the denominator for whom a secure
electronic message is sent to the patient
(or patient-authorized representative) or
in response to a secure message sent by
the patient (or patient-authorized
representative), during the performance
period.
Objective: Health Information
Exchange.
Objective: The MIPS eligible clinician
provides a summary of care record
when transitioning or referring their
patient to another setting of care,
receives or retrieves a summary of care
record upon the receipt of a transition
or referral or upon the first patient
encounter with a new patient, and
incorporates summary of care
information from other health care
clinicians into their EHR using the
functions of CEHRT.
Proposed Change to the Objective:
The MIPS eligible clinician provides a
summary of care record when
transitioning or referring their patient to
another setting of care, receives or
retrieves a summary of care record upon
the receipt of a transition or referral or
upon the first patient encounter with a
new patient, and incorporates summary
of care information from other health
care providers into their EHR using the
functions of CEHRT.
We inadvertently used the term
‘‘health care clinician’’ and are
proposing to replace it with the more
appropriate term ‘‘health care provider’’.
We are proposing this change would
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apply beginning with the performance
period in 2017.
Health Information Exchange
Measure: The MIPS eligible clinician
that transitions or refers their patient to
another setting of care or health care
clinician (1) uses CEHRT to create a
summary of care record; and (2)
electronically transmits such summary
to a receiving health care clinician for
at least one transition of care or referral.
Proposed Change to the Measure: The
MIPS eligible clinician that transitions
or refers their patient to another setting
of care or health care provider (1) uses
CEHRT to create a summary of care
record; and (2) electronically transmits
such summary to a receiving health care
provider for at least one transition of
care or referral.
This change reflects the change
proposed to the Health Information
Exchange objective replacing ‘‘health
care clinician’’ with ‘‘health care
provider’’. We are proposing this change
would apply beginning with the
performance period in 2017.
• Denominator: Number of transitions
of care and referrals during the
performance period for which the EP
was the transferring or referring health
care clinician.
Proposed Change to the Denominator:
Number of transitions of care and
referrals during the performance period
for which the MIPS eligible clinician
was the transferring or referring health
care provider. This change reflects the
change proposed to the Health
Information Exchange Measure
replacing ‘‘health care clinician’’ with
‘‘health care provider’’. We also
inadvertently referred to the EP in the
description and are replacing ‘‘EP’’ with
‘‘MIPS eligible clinician’’. We are
proposing this change would apply
beginning with the performance period
in 2017.
• Numerator: The number of
transitions of care and referrals in the
denominator where a summary of care
record was created using CEHRT and
exchanged electronically.
Medication Reconciliation
Objective: Medication Reconciliation.
Proposed Objective: We are proposing
to add a description of the Medication
Reconciliation Objective beginning with
the CY 2017 performance period, which
we inadvertently omitted from the CY
2017 Quality Payment Program
proposed and final rules, as follows:
Proposed Objective: The MIPS eligible
clinician who receives a patient from
another setting of care or provider of
care or believes an encounter is relevant
performs medication reconciliation.
This description aligns with the
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objective adopted for Modified Stage 2
at 80 FR 62811.
Medication Reconciliation Measure:
The MIPS eligible clinician performs
medication reconciliation for at least
one transition of care in which the
patient is transitioned into the care of
the MIPS eligible clinician.
• Denominator: Number of transitions
of care or referrals during the
performance period for which the MIPS
eligible clinician was the recipient of
the transition or referral or has never
before encountered the patient.
• Numerator: The number of
transitions of care or referrals in the
denominator where the following three
clinical information reconciliations
were performed: Medication list,
Medication allergy list, and current
problem list.
Proposed Modification to the Numerator
Proposed Numerator: The number of
transitions of care or referrals in the
denominator where medication
reconciliation was performed.
We are proposing to modify the
numerator by removing medication list,
medication allergy list, and current
problem list. These three criteria were
adopted for Stage 3 (80 FR 62862) but
not for Modified Stage 2 (80 FR 62811).
We are proposing this change would
apply beginning with the performance
period in 2017.
Objective: Public Health Reporting.
Objective: The MIPS eligible clinician
is in active engagement with a public
health agency or clinical data registry to
submit electronic public health data in
a meaningful way using CEHRT, except
where prohibited, and in accordance
with applicable law and practice.
Immunization Registry Reporting
Measure: The MIPS eligible clinician is
in active engagement with a public
health agency to submit immunization
data.
Syndromic Surveillance Reporting
Measure: The MIPS eligible clinician is
in active engagement with a public
health agency to submit syndromic
surveillance data.
Specialized Registry Reporting
Measure: The MIPS eligible clinician is
in active engagement to submit data to
a specialized registry.
We invite public comments on these
proposals.
(c) Exclusions
We are proposing to add exclusions to
the measures associated with the Health
Information Exchange and Electronic
Prescribing objectives required for the
base score. We propose these exclusions
would apply beginning with the CY
2017 performance period. In the CY
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30073
2017 Quality Payment Program final
rule (81 FR 77237 through 77238), we
did not finalize any exclusions for the
measures specified for the advancing
care information performance category
as we believe that the MIPS exclusion
criteria and that the advancing care
information performance category
scoring methodology together
accomplish the same end as the
previously established exclusions for
the majority of the advancing care
information performance category
measures. We further noted that it was
not necessary to finalize the proposed
exclusion for the Immunization Registry
Reporting Measure because MIPS
eligible clinicians have the flexibility to
choose whether to report the measure
because it is part of the performance
score of the advancing care information
performance category. However, we
understand that many MIPS eligible
clinicians may not achieve a base score
because they cannot fulfill the measures
associated with the Health Information
Exchange objective in the base score
because they seldom refer or transition
patients, and we believe that the
implementation burden of the objective
is too high to require of those with only
a small number of referrals or
transitions. Similarly, we understand
that many MIPS eligible clinicians do
not often write prescriptions in their
practice or lack prescribing authority,
and thus could not meet the Eprescribing Measure and would also fail
to earn a base score. As this was not our
intention, we are proposing to establish
exclusions for these measures, as
described below.
Proposed Exclusion for the EPrescribing Objective and Measure: In
the CY 2017 Quality Payment Program
final rule (81 FR 28237 through 28238),
we established a policy that MIPS
eligible clinicians who write fewer than
100 permissible prescriptions in a
performance period may elect to report
their numerator and denominator (if
they have at least one permissible
prescription for the numerator), or they
may report a null value. This policy has
confused MIPS eligible clinicians as a
null value would appear to indicate a
MIPS eligible clinician has failed the
measure and thus not would not achieve
a base score. We are proposing to
change this policy beginning with the
CY 2017 performance period and
propose to establish an exclusion for the
e-Prescribing Measure. MIPS eligible
clinicians who wish to claim this
exclusion would select ‘‘yes’’ to the
exclusion and submit a null value for
the measure, thereby fulfilling the
requirement to report this measure as
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part of the base score. It is important
that a MIPS eligible clinician actually
claims the exclusion if they wish to
exclude the measure. If a MIPS eligible
clinician does not claim the exclusion,
they would fail the measure and not
earn a base score or any score in the
advancing care information performance
category.
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Advancing Care Information Objective
and Measure.
Objective: Electronic Prescribing.
Objective: Generate and transmit
permissible prescriptions electronically.
E-Prescribing Measure: At least one
permissible prescription written by the
MIPS eligible clinician is queried for a
drug formulary and transmitted
electronically using CEHRT.
• Denominator: Number of
prescriptions written for drugs requiring
a prescription to be dispensed other
than controlled substances during the
performance period; or number of
prescriptions written for drugs requiring
a prescription to be dispensed during
the performance period.
• Numerator: The number of
prescriptions in the denominator
generated, queried for a drug formulary,
and transmitted electronically using
CEHRT.
Proposed Exclusion: Any MIPS
eligible clinician who writes fewer than
100 permissible prescriptions during the
performance period.
2017 and 2018 Advancing Care
Information Transition Objective and
Measure
Objective: Electronic Prescribing.
Objective: MIPS eligible clinicians
must generate and transmit permissible
prescriptions electronically.
E-Prescribing Measure: At least one
permissible prescription written by the
MIPS eligible clinician is queried for a
drug formulary and transmitted
electronically using CEHRT.
• Denominator: Number of
prescriptions written for drugs requiring
a prescription to be dispensed other
than controlled substances during the
performance period; or number of
prescriptions written for drugs requiring
a prescription to be dispensed during
the performance period.
• Numerator: The number of
prescriptions in the denominator
generated, queried for a drug formulary,
and transmitted electronically using
CEHRT.
Proposed Exclusion: Any MIPS
eligible clinician who writes fewer than
100 permissible prescriptions during the
performance period.
Proposed Exclusion for the Health
Information Exchange Objective and
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Measures: We are proposing to add
exclusions for the measures associated
with the Health Information Exchange
Objective. Stakeholders have expressed
concern through public comments on
the CY 2017 Quality Payment Program
proposed rule and other inquiries to us
that some MIPS eligible clinicians are
unable to meet the measures associated
with the Health Information Exchange
Objective, which are required for the
base score, because they do not
regularly refer or transition patients in
the normal course of their practice. As
we did not intend to disadvantage those
MIPS eligible clinicians and prevent
them from earning a base score, we are
proposing the exclusions.
Advancing Care Information Objective
and Measures
Objective: Health Information
Exchange.
Objective: The MIPS eligible clinician
provides a summary of care record
when transitioning or referring their
patient to another setting of care,
receives or retrieves a summary of care
record upon the receipt of a transition
or referral or upon the first patient
encounter with a new patient, and
incorporates summary of care
information from other health care
clinician into their EHR using the
functions of CEHRT.
We note that we proposed above to
replace ‘‘health care clinician’’ with
‘‘health care provider’’.
Send a Summary of Care Measure:
For at least one transition of care or
referral, the MIPS eligible clinician that
transitions or refers their patient to
another setting of care or health care
clinician (1) creates a summary of care
record using CEHRT; and (2)
electronically exchanges the summary
of care record.
We note that we proposed above to
replace ‘‘health care clinician’’ with
‘‘health care provider’’.
• Denominator: Number of transitions
of care and referrals during the
performance period for which the MIPS
eligible clinician was the transferring or
referring clinician.
• Numerator: The number of
transitions of care and referrals in the
denominator where a summary of care
record was created using CEHRT and
exchanged electronically.
Proposed Exclusion: Any MIPS
eligible clinician who transfers a patient
to another setting or refers a patient
fewer than 100 times during the
performance period.
Request/Accept Summary of Care
Measure: For at least one transition of
care or referral received or patient
encounter in which the MIPS eligible
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clinician has never before encountered
the patient, the MIPS eligible clinician
receives or retrieves and incorporates
into the patient’s record an electronic
summary of care document.
• Denominator: Number of patient
encounters during the performance
period for which a MIPS eligible
clinician was the receiving party of a
transition or referral or has never before
encountered the patient and for which
an electronic summary of care record is
available.
• Numerator: Number of patient
encounters in the denominator where an
electronic summary of care record
received is incorporated by the clinician
into the CEHRT.
Proposed Exclusion: Any MIPS
eligible clinician who receives
transitions of care or referrals or has
patient encounters in which the MIPS
eligible clinician has never before
encountered the patient fewer than 100
times during the performance period.
2017 and 2018 Advancing Care
Information Transition Objective and
Measures
Objective: Health Information
Exchange.
Objective: The MIPS eligible clinician
provides a summary of care record
when transitioning or referring their
patient to another setting of care,
receives or retrieves a summary of care
record upon the receipt of a transition
or referral or upon the first patient
encounter with a new patient, and
incorporates summary of care
information from other health care
clinicians into their EHR using the
functions of CEHRT.
We note that we are proposing above
to replace ‘‘health care clinician’’ with
‘‘health care provider’’.
Health Information Exchange
Measure: The MIPS eligible clinician
that transitions or refers their patient to
another setting of care or health care
clinician (1) uses CEHRT to create a
summary of care record; and (2)
electronically transmits such summary
to a receiving health care clinician for
at least one transition of care or referral.
We note that we are proposing above
to replace ‘‘health care clinician’’ with
‘‘health care provider’’.
• Denominator: Number of transitions
of care and referrals during the
performance period for which the EP
was the transferring or referring health
care clinician.
We note that we are proposing above
to replace ‘‘health care clinician’’ with
‘‘health care provider’’.
• Numerator: The number of
transitions of care and referrals in the
denominator where a summary of care
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record was created using CEHRT and
exchanged electronically.
Proposed Exclusion: Any MIPS
eligible clinician who transfers a patient
to another setting or refers a patient
fewer than 100 times during the
performance period.
We are inviting public comment on
these proposals.
(7) Additional Considerations
mstockstill on DSK30JT082PROD with PROPOSALS2
(a) 21st Century Cures Act
As we noted in the CY 2017 Quality
Payment Program final rule (81 FR
77238), section 101(b)(1)(A) of the
MACRA amended section 1848(a)(7)(A)
of the Act to sunset the meaningful use
payment adjustment at the end of CY
2018. Section 1848(a)(7) of the Act
includes certain statutory exceptions to
the meaningful use payment adjustment
under section 1848(a)(7)(A) of the Act.
Specifically, section 1848(a)(7)(D) of the
Act exempts hospital-based EPs from
the application of the payment
adjustment under section 1848(a)(7)(A)
of the Act. In addition, section
1848(a)(7)(B) of the Act provides that
the Secretary may, on a case-by-case
basis, exempt an EP from the
application of the payment adjustment
under section 1848(a)(7)(A) of the Act if
the Secretary determines, subject to
annual renewal, that compliance with
the requirement for being a meaningful
EHR user would result in a significant
hardship, such as in the case of an EP
who practices in a rural area without
sufficient internet access. The last
sentence of section 1848(a)(7)(B) of the
Act also provides that in no case may an
exemption be granted under
subparagraph (B) for more than 5 years.
The MACRA did not maintain these
statutory exceptions for the advancing
care information performance category
of the MIPS. Thus, we had previously
stated that the provisions under sections
1848(a)(7)(B) and (D) of the Act are
limited to the meaningful use payment
adjustment under section 1848(a)(7)(A)
of the Act and do not apply in the
context of the MIPS.
Following the publication of the CY
2017 Quality Payment Program final
rule, the 21st Century Cures Act (Pub.
L. 114–255) was enacted on December
13, 2016. Section 4002(b)(1)(B) of the
21st Century Cures Act amended section
1848(o)(2)(D) of the Act to state that the
provisions of sections 1848(a)(7)(B) and
(D) of the Act shall apply to assessments
of MIPS eligible clinicians under section
1848(q) of the Act with respect to the
performance category described in
subsection (q)(2)(A)(iv) (the advancing
care information performance category)
in an appropriate manner which may be
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similar to the manner in which such
provisions apply with respect to the
meaningful use payment adjustment
made under section 1848(a)(7)(A) of the
Act. As a result of this legislative
change, we believe that the general
exceptions described under sections
1848(a)(7)(B) and (D) of the Act are
applicable under the MIPS program. We
include below proposals to implement
these provisions as applied to
assessments of MIPS eligible clinicians
under section 1848(q) of the Act with
respect to the advancing care
information performance category.
(i) MIPS Eligible Clinicians Facing a
Significant Hardship
In the CY 2017 Quality Payment
Program final rule (81 FR 77240 through
77243), we recognized that there may
not be sufficient measures applicable
and available under the advancing care
information performance category to
MIPS eligible clinicians facing a
significant hardship, such as those who
lack sufficient internet connectivity,
face extreme and uncontrollable
circumstances, lack control over the
availability of CEHRT, or do not have
face-to-face interactions with patients.
We relied on section 1848(q)(5)(F) of the
Act to establish a final policy to assign
a zero percent weighting to the
advancing care information performance
category in the final score if there are
not sufficient measures and activities
applicable and available to MIPS
eligible clinicians within the categories
of significant hardship noted above (81
FR 77243). Additionally, under the final
policy (81 FR 77243), we did not impose
a limitation on the total number of MIPS
payment years for which the advancing
care information performance category
could be weighted at zero percent, in
contrast with the 5-year limitation on
significant hardship exceptions under
the Medicare EHR Incentive Program as
required by section 1848(a)(7)(B) of the
Act.
We are not proposing substantive
changes to this policy; however, as a
result of the changes in the law made by
the 21st Century Cures Act discussed
above, we will not rely on section
1848(q)(5)(F) of the Act and instead are
proposing to use the authority in the last
sentence of section 1848(o)(2)(D) of the
Act for significant hardship exceptions
under the advancing care information
performance category under MIPS.
Section 1848(o)(2)(D) of the Act, as
amended by section 4002(b)(1)(B) of the
21st Century Cures Act, states in part
that the provisions of section
1848(a)(7)(B) of the Act shall apply to
assessments of MIPS eligible clinicians
with respect to the advancing care
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30075
information performance category in an
appropriate manner which may be
similar to the manner in which such
provisions apply with respect to the
payment adjustment made under
section 1848(a)(7)(A) of the Act. We
would assign a zero percent weighting
to the advancing care information
performance category in the MIPS final
score for a MIPS payment year for MIPS
eligible clinicians who successfully
demonstrate a significant hardship
through the application process. We
would use the same categories of
significant hardship and application
process as established in the CY 2017
Quality Payment Program final rule (81
FR 77240–77243). We would
automatically reweight the advancing
care information performance category
to zero percent for a MIPS eligible
clinician who lacks face-to-face patient
interaction and is classified as a nonpatient facing MIPS eligible clinician
without requiring an application. If a
MIPS eligible clinician submits an
application for a significant hardship
exception or is classified as a nonpatient facing MIPS eligible clinician,
but also reports on the measures
specified for the advancing care
information performance category, they
would be scored on the advancing care
information performance category like
all other MIPS eligible clinicians, and
the category would be given the
weighting prescribed by section
1848(q)(5)(E) of the Act regardless of the
MIPS eligible clinician’s score.
We believe this policy would be an
appropriate application of the
provisions of section 1848(a)(7)(B) of the
Act to MIPS eligible clinicians and is
similar to the manner in which those
provisions apply with respect to the
payment adjustment made under
section 1848(a)(7)(A) of the Act. Under
the Medicare EHR Incentive Program an
approved hardship exception exempted
an EP from the payment adjustment. We
believe that weighting the advancing
care information performance category
to zero percent is similar in effect to an
exemption from the requirements of that
performance category.
As required under section
1848(a)(7)(B) of the Act, eligible
professionals were not granted
significant hardship exceptions for the
payment adjustments under the
Medicare EHR Incentive Program for
more than 5 years. We propose not to
apply the 5-year limitation under
section 1848(a)(7)(B) of the Act to
significant hardship exceptions for the
advancing care information performance
category under MIPS. We believe this
proposal is an appropriate application
of the provisions of section 1848(a)(7)(B)
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mstockstill on DSK30JT082PROD with PROPOSALS2
of the Act to MIPS eligible clinicians
due to our desire to reduce clinician
burden, promote the greatest level of
participation in the MIPS program, and
maintain consistency with the policies
established in last year’s final rule (81
FR 77243). In the Medicare EHR
Incentive Program, we received many
applications for significant hardship
exceptions and approved most of them,
which we believe indicates many
eligible professionals were unable to or
would have struggled to satisfy the
requirements of meaningful use. We
believe that there will be a continued
need for significant hardship exceptions
in order to provide clinicians with the
necessary flexibility to participate in the
MIPS program that best matches their
available resources and circumstances,
which may not change during a 5-year
time period. For example, a clinician in
an area without internet connectivity
may continue to lack connectivity for
more than 5 years. In addition, in the
CY 2017 Quality Payment Program final
rule (81 FR 77242 through 77243), we
noted that we had received comments
expressing appreciation that CMS
moved away from the 5-year limitation
to significant hardship exceptions.
We solicit comments on the proposed
use of the authority provided in the 21st
Century Cures Act in section
1848(o)(2)(D) of the Act as it relates to
application of significant hardship
exceptions under MIPS and the
proposal not to apply a 5-year limit to
such exceptions.
(ii) Significant Hardship Exception for
MIPS Eligible Clinicians in Small
Practices
Section 1848(q)(2)(B)(iii) of the Act
requires the Secretary to give
consideration to the circumstances of
small practices (consisting of 15 or
fewer professionals) and practices
located in rural areas and geographic
HPSAs in establishing improvement
activities under MIPS. In the CY 2017
Quality Payment Program final rule (81
FR 77187 through 77188), we finalized
that for MIPS eligible clinicians and
groups that are in small practices or
located in rural areas, or geographic
health professional shortage areas
(HPSAs), to achieve full credit under the
improvement activities category, one
high-weighted or two medium-weighted
improvement activities are required.
While there is no corresponding
statutory provision for the advancing
care information performance category,
we believe that special consideration
should also be available for MIPS
eligible clinicians located in small
practices. Through comments received
on the CY 2017 Quality Payment
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19:16 Jun 29, 2017
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Program proposed rule (81 FR 28161–
28586), we heard many concerns about
the impact of MIPS on eligible
clinicians in small practices. Some
commenters stated that there was not a
meaningful exclusion for small practices
that cannot afford the upfront
investments (including investments in
EHR technology) (81 FR 77066). Many
noted there are still many small
practices that have not adopted EHRs
due to the administrative and financial
burden. Some expressed concern that
small group and solo practices would be
driven out of business because of the
potential negative payment adjustments
under MIPS (81 FR 77055). A few
commenters were concerned about the
impact of MACRA on small practices
and asked CMS to remain sensitive to
this concern and offer special
opportunities for MIPS eligible
clinicians in areas threatened by access
problems (81 FR 77055).
Based on these concerns, we are
proposing a significant hardship
exception for the advancing care
information performance category for
MIPS eligible clinicians who are in
small practices, under the authority in
section 1848(o)(2)(D) of the Act, as
amended by section 4002(b)(1)(B) of the
21st Century Cures Act (see discussion
of the statutory authority for significant
hardship exceptions in section
II.C.6.f.(7)(ii). We are proposing that this
hardship exception would be available
to MIPS eligible clinicians in small
practices as defined under § 414.1305
(15 or fewer clinicians and solo
practitioners). We are proposing in
section II.C.1.e. of this proposed rule,
that CMS would make eligibility
determinations regarding the size of
small practices for performance periods
occurring in 2018 and future years. We
are proposing to reweight the advancing
care information performance category
to zero percent of the MIPS final score
for MIPS eligible clinicians who qualify
for this hardship exception. We are
proposing this exception would be
available beginning with the 2018
performance period and 2020 MIPS
payment year. We are proposing a MIPS
eligible clinician seeking to qualify for
this exception would submit an
application in the form and manner
specified by us by December 31st of the
performance period or a later date
specified by us. We are also proposing
MIPS eligible clinicians seeking this
exception must demonstrate in the
application that there are overwhelming
barriers that prevent the MIPS eligible
clinician from complying with the
requirements for the advancing care
information performance category. In
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accordance with section 1848(a)(7)(B) of
the Act, the exception would be subject
to annual renewal. Under our proposal
in section II.C.6.f.(7)(a), the 5-year
limitation under section 1848(a)(7)(B) of
the Act would not apply to this
significant hardship exception for MIPS
eligible clinicians in small practices.
We believe that applying the
significant hardship exception in this
way would be appropriate given the
challenges small practices face as
described by the commenters. In
addition, we believe this application
would be similar to the manner in
which the exception applies with
respect to the payment adjustment made
under section 1848(a)(7)(A) of the Act
because weighting the advancing care
information performance category to
zero percent is similar in effect to an
exemption from the requirements of that
performance category.
While we would be making this
significant hardship exception available
to small practices in particular, we are
considering whether other categories or
types of clinicians might similarly
require an exception. We solicit
comment on what those categories or
types are, why such an exception is
required, and any data available to
support the necessity of the exception.
We note that supporting data would be
particularly helpful to our consideration
of whether any additional exceptions
would be appropriate.
We are seeking comments on these
proposals.
(iii) Hospital-Based MIPS Eligible
Clinicians
In the CY 2017 Quality Payment
Program final rule (81 FR 77238 through
77240), we defined a hospital-based
MIPS eligible clinician under § 414.1305
as a MIPS eligible clinician who
furnishes 75 percent or more of his or
her covered professional services in
sites of service identified by the Place of
Service (POS) codes used in the HIPAA
standard transaction as an inpatient
hospital (POS 21), on-campus outpatient
hospital (POS 22), or emergency room
(POS 23) setting, based on claims for a
period prior to the performance period
as specified by CMS. We intend to use
claims with dates of service between
September 1 of the calendar year 2 years
preceding the performance period
through August 31 of the calendar year
preceding the performance period, but
in the event it is not operationally
feasible to use claims from this time
period, we will use a 12-month period
as close as practicable to this time
period. We discussed our assumption
that MIPS eligible clinicians who are
determined hospital-based do not have
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sufficient advancing care information
measures applicable to them, and we
established a policy to reweight the
advancing care information performance
category to zero percent of the MIPS
final score for the MIPS payment year in
accordance with section 1848(q)(5)(F) of
the Act (81 FR 77240).
We are not proposing substantive
changes to this policy; however, as a
result of the changes in the law made by
the 21st Century Cures Act discussed
above, we will not rely on section
1848(q)(5)(F) of the Act and instead are
proposing to use the authority in the last
sentence of section 1848(o)(2)(D) of the
Act for exceptions for hospital-based
MIPS eligible clinicians under the
advancing care information performance
category. Section 1848(o)(2)(D) of the
Act, as amended by section
4002(b)(1)(B) of the 21st Century Cures
Act, states in part that the provisions of
section 1848(a)(7)(D) of the Act shall
apply to assessments of MIPS eligible
clinicians with respect to the advancing
care information performance category
in an appropriate manner which may be
similar to the manner in which such
provisions apply with respect to the
payment adjustment made under
section 1848(a)(7)(A) of the Act. We
would assign a zero percent weighting
to the advancing care information
performance category in the MIPS final
score for a MIPS payment year for
hospital-based MIPS eligible clinicians
as previously defined. A hospital-based
MIPS eligible clinician would have the
option to report the advancing care
information measures for the
performance period for the MIPS
payment year for which they are
determined hospital-based. However, if
a MIPS eligible clinician who is
determined hospital-based chooses to
report on the advancing care
information measures, they would be
scored on the advancing care
information performance category like
all other MIPS eligible clinicians, and
the category would be given the
weighting prescribed by section
1848(q)(5)(E) of the Act regardless of
their score.
We believe this policy would be an
appropriate application of the
provisions of section 1848(a)(7)(D) of
the Act to MIPS eligible clinicians and
is similar to the manner in which those
provisions apply with respect to the
payment adjustment made under
section 1848(a)(7)(A) of the Act. Under
the Medicare EHR Incentive Program an
approved hardship exception exempted
an EP from the payment adjustment. We
believe that weighting the advancing
care information performance category
to zero percent is similar in effect to an
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exemption from the requirements of that
performance category.
We propose to amend § 414.1380(c)(1)
and (2) of the regulation text to reflect
this proposal.
We request comments on the
proposed use of the authority provided
in the 21st Century Cures Act in section
1848(o)(2)(D) of the Act as it relates to
hospital-based MIPS eligible clinicians.
(iv) Ambulatory Surgical Center (ASC)—
Based MIPS Eligible Clinicians
Section 16003 of the 21st Century
Cures Act amended section
1848(a)(7)(D) of the Act to provide that
no payment adjustment may be made
under section 1848(a)(7)(A) of the Act
for 2017 and 2018 in the case of an
eligible professional who furnishes
substantially all of his or her covered
professional services in an ambulatory
surgical center (ASC). Section
1848(a)(7)(D)(iii) of the Act provides
that determinations of whether an
eligible professional is ASC-based may
be made based on the site of service as
defined by the Secretary or an
attestation, but shall be made without
regard to any employment or billing
arrangement between the eligible
professional and any other supplier or
provider of services. Section
1848(a)(7)(D)(iv) of the Act provides that
the ASC-based exception shall no longer
apply as of the first year that begins
more than 3 years after the date on
which the Secretary determines,
through notice and comment
rulemaking, that CEHRT applicable to
the ASC setting is available.
Under section 1848(o)(2)(D) of the
Act, as amended by section
4002(b)(1)(B) of the 21st Century Cures
Act, the ASC-based provisions of
section 1848(a)(7)(D) of the Act shall
apply to assessments of MIPS eligible
clinicians under section 1848(q) of the
Act with respect to the advancing care
information performance category in an
appropriate manner which may be
similar to the manner in which such
provisions apply with respect to the
payment adjustment made under
section 1848(a)(7)(A) of the Act. We
believe our proposals set forth below for
ASC-based MIPS eligible clinicians are
an appropriate application of the
provisions of section 1848(a)(7)(D) of
the Act to MIPS eligible clinicians.
Under the Medicare EHR Incentive
Program an approved hardship
exception exempted an EP from the
payment adjustment. We believe that
weighting the advancing care
information performance category to
zero percent is similar in effect to an
exemption from the requirements of that
performance category.
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30077
To align with our hospital-based
MIPS eligible clinician policy, we are
proposing to define at § 414.1305 an
ASC-based MIPS eligible clinician as a
MIPS eligible clinician who furnishes
75 percent or more of his or her covered
professional services in sites of service
identified by the Place of Service (POS)
code 24 used in the HIPAA standard
transaction based on claims for a period
prior to the performance period as
specified by us. We request comments
on this proposal and solicit comments
as to whether other POS codes should
be used to identify a MIPS eligible
clinician’s ASC-based status or if an
alternative methodology should be used.
We note that the ASC-based
determination will be made
independent of the hospital-based
determination.
To determine a MIPS eligible
clinician’s ASC-based status, we are
proposing to use claims with dates of
service between September 1 of the
calendar year 2 years preceding the
performance period through August 31
of the calendar year preceding the
performance period, but in the event it
is not operationally feasible to use
claims from this time period, we would
use a 12-month period as close as
practicable to this time period. For
example, for the 2018 performance
period (2020 MIPS payment year), we
would use the data available at the end
of October 2017 for Medicare claims
with dates of service between
September 1, 2016 through August 31,
2017, to determine whether a MIPS
eligible clinician is considered ASCbased under our proposed definition.
We are proposing this timeline to allow
us to notify MIPS eligible clinicians of
their ASC-based status prior to the start
of the performance period and to align
with the hospital-based MIPS eligible
clinician determination period. For the
2019 MIPS payment year, we would not
be able to notify MIPS eligible clinicians
of their ASC-based status until after the
final rule is published, which we
anticipate would be later in 2017. We
expect that we would provide this
notification through QPP.cms.gov.
For MIPS eligible clinicians who we
determine are ASC-based, we propose to
assign a zero percent weighting to the
advancing care information performance
category in the MIPS final score for the
MIPS payment year. However, if a MIPS
eligible clinician who is determined
ASC-based chooses to report on the
advancing care information measures
for the performance period for the MIPS
payment year for which they are
determined ASC-based, we propose they
would be scored on the advancing care
information performance category like
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all other MIPS eligible clinicians, and
the performance category would be
given the weighting prescribed by
section 1848(q)(5)(E) of the Act
regardless of their advancing care
information performance category score.
We are proposing these ASC-based
policies would apply beginning with the
2017 performance period/2019 MIPS
payment year.
We propose to amend § 414.1380(c)(1)
and (2) of the regulation text to reflect
these proposals.
We request comments on these
proposals.
(v) Exception for MIPS Eligible
Clinicians Using Decertified EHR
Technology
Section 4002(b)(1)(A) of the 21st
Century Cures Act amended section
1848(a)(7)(B) of the Act to provide that
the Secretary shall exempt an eligible
professional from the application of the
payment adjustment under section
1848(a)(7)(A) of the Act with respect to
a year, subject to annual renewal, if the
Secretary determines that compliance
with the requirement for being a
meaningful EHR user is not possible
because the CEHRT used by such
professional has been decertified under
ONC’s Health IT Certification Program.
Section 1848(o)(2)(D) of the Act, as
amended by section 4002(b)(1)(B) of the
21st Century Cures Act, states in part
that the provisions of section
1848(a)(7)(B) of the Act shall apply to
assessments of MIPS eligible clinicians
with respect to the advancing care
information performance category in an
appropriate manner which may be
similar to the manner in which such
provisions apply with respect to the
payment adjustment made under
section 1848(a)(7)(A) of the Act.
We are proposing that a MIPS eligible
clinician may demonstrate through an
application process that reporting on the
measures specified for the advancing
care information performance category
is not possible because the CEHRT used
by the MIPS eligible clinician has been
decertified under ONC’s Health IT
Certification Program. We are proposing
that if the MIPS eligible clinician’s
demonstration is successful and an
exception is granted, we would assign a
zero percent weighting to the advancing
care information performance category
in the MIPS final score for the MIPS
payment year. In accordance with
section 1848(a)(7)(B) of the Act, the
exception would be subject to annual
renewal, and in no case may a MIPS
eligible clinician be granted an
exception for more than 5 years. We are
proposing this exception would be
available beginning with the CY 2018
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performance period and the 2020 MIPS
payment year.
We are proposing that a MIPS eligible
clinician may qualify for this exception
if their CEHRT was decertified either
during the performance period for the
MIPS payment year or during the
calendar year preceding the
performance period for the MIPS
payment year. We believe that this
timeframe is appropriate because the
loss of certification may prevent a MIPS
eligible clinician from reporting for the
advancing care information performance
category because it will require that the
MIPS eligible clinician switch to an
alternate CEHRT, a process that we
believe may take up to 2 years. For
example, for the 2020 MIPS payment
year, if the MIPS eligible clinician’s
EHR technology was decertified during
the CY 2018 performance period or
during CY 2017, the MIPS eligible
clinician may qualify for this exception.
In addition, we are proposing that the
MIPS eligible clinician must
demonstrate in their application and
through supporting documentation if
available that the MIPS eligible clinician
made a good faith effort to adopt and
implement another CEHRT in advance
of the performance period. We are
proposing a MIPS eligible clinician
seeking to qualify for this exception
would submit an application in the form
and manner specified by us by
December 31st of the performance
period, or a later date specified by us.
We believe that applying the
exception in this way is an appropriate
application of the provisions of section
1848(a)(7)(B) of the Act to MIPS eligible
clinicians given that weighting the
advancing care information performance
category to zero percent is similar in
effect to an exemption from the
requirements of that performance
category. Under the Medicare EHR
Incentive Program an approved
hardship exception exempted an EP
from the payment adjustment. We
believe that weighting the advancing
care information performance category
to zero percent is similar in effect to an
exemption from the requirements of that
performance category.
The ONC Health IT Certification
Program: Enhanced Oversight and
Accountability final rule (‘‘EOA final
rule’’) (81 FR 72404), effective December
19, 2016, created a regulatory
framework for the ONC’s direct review
of health information technology (health
IT) certified under the ONC Health IT
Certification Program, including, when
necessary, requiring the correction of
non-conformities found in health IT
certified under the Program and/or
terminating certifications issued to
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certified health IT. Prior to the EOA
final rule, ONC-Authorized Certification
Bodies (ONC–ACBs) had the only
authority to terminate or revoke
certification of health IT under the
program, which they used on previous
occasions. On September 23, 2015, we
posted an FAQ discussing the
requirements for using a decertified
CEHRT.3
Once all administrative processes, if
any, are complete, then notice of a
‘‘termination of certification’’ is listed
on the of the Certified Health IT Product
List (CPHL) Web page.4 As appropriate,
ONC will also publicize the termination
of certification of health IT through
other communication channels (for
example, ONC list serv(s)). Further,
when ONC terminates the certification
of a health IT product, the health IT
developer is required to notify all
potentially affected customers in a
timely manner.
We further note that in comparison to
termination actions taken by ONC and
ONC–ACBs, a health IT developer may
voluntarily withdraw a certification that
is in good standing under the ONC
Health IT Certification Program. A
voluntary withdrawal may be the result
of the health IT developer going out of
business, the developer no longer
supporting the product, or for other
reasons that are not in response to
ONC–ACB surveillance, ONC direct
review, or a finding of non-conformity
by ONC or an ONC–ACB.5 In such
instances, ONC will list these products
on the ‘‘Inactive Certificates’’ 6 Web
page of the CHPL.
We propose to amend § 414.1380(c)(1)
and (2) of the regulation text to reflect
these proposals. We are seeking
comments on these proposals.
(b) Hospital-Based MIPS Eligible
Clinicians
In the CY 2017 Quality Payment
Program final rule (81 FR 77238 through
77240, we defined a hospital-based
MIPS eligible clinician as a MIPS
eligible clinician who furnishes 75
percent or more of his or her covered
professional services in sites of services
identified by the Place of Service (POS)
codes used in the HIPAA standard
transaction as an inpatient hospital
(POS 21), on campus outpatient hospital
3 https://questions.cms.gov/faq.php?isDept=
0&search=decertify&searchType=keyword&
submitSearch=1&id=5005.
4 The list is available at https://chpl.healthit.gov/
#/decertifications/products.
5 For further descriptions of certification statuses,
please consult the CHPL Public User Guide.
6 The ‘‘Inactive Certificates’’ Web page is
available at https://chpl.healthit.gov/#/
decertifications/inactive.
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(POS 22) or emergency room (POS 23)
setting, based on claims for a period
prior to the performance period as
specified by CMS.
We are proposing to modify our
policy to include covered professional
services furnished by MIPS eligible
clinicians in an off-campus-outpatient
hospital (POS 19) in the definition of
hospital-based MIPS eligible clinician.
POS 19 was developed in 2015 in order
to capture the numerous physicians that
are paid for a portion of their services
in an ‘‘off campus-outpatient hospital’’
versus an on campus-outpatient
hospital, (POS 22). We also believe that
these MIPS eligible clinicians would not
typically have control of the
development and maintenance of their
EHR systems, just like those who bill
using POS 22. We propose to add POS
19 to our existing definition of a
hospital-based MIPS eligible clinician
beginning with the performance period
in 2018.
We invite comment on this proposal.
(c) Nurse Practitioners, Physician
Assistants, Clinical Nurse Specialists,
and Certified Registered Nurse
Anesthetists
In the CY 2017 Quality Payment
Program final rule (81 FR 77243–77244),
we discussed our belief that certain
types of MIPS eligible clinicians (NPs,
PAs, CNSs, and CRNAs) may lack
experience with the adoption and use of
CEHRT. Because many of these nonphysician clinicians are not eligible to
participate in the Medicare or Medicaid
EHR Incentive Program, we stated that
we have little evidence as to whether
there are sufficient measures applicable
and available to these types of MIPS
eligible clinicians under the advancing
care information performance category.
We established a policy under section
1848(q)(5)(F) of the Act to assign a
weight of zero to the advancing care
information performance category in the
MIPS final score if there are not
sufficient measures applicable and
available to NPs, PAs, CRNAs, and
CNSs. We will assign a weight of zero
only in the event that an NP, PA, CRNA,
or CNS does not submit any data for any
of the measures specified for the
advancing care information performance
category. We encouraged all NPs, PAs,
CRNAs, and CNSs to report on these
measures to the extent they are
applicable and available, however, we
understand that some NPs, PAs, CRNAs,
and CNSs may choose to accept a
weight of zero for this performance
category if they are unable to fully
report the advancing care information
measures. These MIPS eligible
clinicians may choose to submit
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advancing care information measures
should they determine that these
measures are applicable and available to
them; however, we noted that if they
choose to report, they will be scored on
the advancing care information
performance category like all other
MIPS eligible clinicians and the
performance category will be given the
weighting prescribed by section
1848(q)(5)(E) of the Act regardless of
their advancing care information
performance category score.
We stated that this approach is
appropriate for the first MIPS
performance period based on the
payment consequences associated with
reporting, the fact that many of these
types of MIPS eligible clinicians may
lack experience with EHR use, and our
current uncertainty as to whether we
have adopted sufficient measures that
are applicable and available to these
types of MIPS eligible clinicians. We
noted that we would use the first MIPS
performance period to further evaluate
the participation of these MIPS eligible
clinicians in the advancing care
information performance category and
would consider for subsequent years
whether the measures specified for this
category are applicable and available to
these MIPS eligible clinicians. At this
time we have no additional information
because the first MIPS performance
period is currently underway, and thus
we propose the same policy for NPs,
PAs, CRNAs, and CNSs for the 2018
performance period as well. We still
intend to evaluate the participation of
these MIPS eligible clinicians in the
advancing care information performance
category for 2017 and expect to adopt
measures applicable and available to
them in subsequent years.
We are seeking comment on how the
advancing care information performance
category could be applied to NPs, PAs,
CRNAs, and CNSs in future years of
MIPS, and the types of measures that
would be applicable and available to
these types of MIPS eligible clinicians.
In addition, through the Call for
Measures Process we are seeking new
measures that may be more broadly
applicable to these additional types of
MIPS eligible clinicians in future
program years. For more information on
the Call for Measures, see https://
www.cms.gov/Medicare/QualityInitiatives-Patient-AssessmentInstruments/MMS/
CallForMeasures.html.
We are inviting public comment on
these proposals.
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(d) Scoring for MIPS Eligible Clinicians
in Group Practices
In any of the situations described in
the sections above, we would assign a
zero percent weighting to the advancing
care information performance category
in the MIPS final score for the MIPS
payment year if the MIPS eligible
clinician meets certain specified
requirements for this weighting. We
noted that these MIPS eligible clinicians
may choose to submit advancing care
information measures; however, if they
choose to report, they will be scored on
the advancing care information
performance category like all other
MIPS eligible clinicians and the
performance category will be given the
weighting prescribed by section
1848(q)(5)(E) of the Act regardless of
their advancing care information
performance category score. This policy
includes MIPS eligible clinicians
choosing to report as part of a group
practice or part of a virtual group.
Group practices as defined at
§ 414.1310(e)(1) are required to
aggregate their performance data across
the TIN in order for their performance
to be assessed as a group (81 FR 77058).
Additionally, groups that elect to have
their performance assessed as a group
will be assessed as a group across all
four MIPS performance categories. By
reporting as part of a group practice,
MIPS eligible clinicians are subscribing
to the data reporting and scoring
requirements of the group practice. We
note that the data submission criteria for
groups reporting advancing care
information performance category
described in the CY 2017 Quality
Payment Program final rule (81 FR
77215) state that group data should be
aggregated for all MIPS eligible
clinicians within the group practice.
This includes those MIPS eligible
clinicians who may qualify for a zero
percent weighting of the advancing care
information performance category due
to the circumstances as described above,
such as a significant hardship or other
type of exception, hospital-based or
ASC-based status, or certain types of
non-physician practitioners (NPs, PAs,
CNSs, and CRNAs). If these MIPS
eligible clinicians report as part of a
group practice or virtual group, they
will be scored on the advancing care
information performance category like
all other MIPS eligible clinicians and
the performance category will be given
the weighting prescribed by section
1848(q)(5)(E) of the Act regardless of the
group practice’s advancing care
information performance category score.
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(e) Timeline for Submission of
Reweighting Applications
In the CY 2017 Quality Payment
Program final rule (81 FR77240–77243),
we established the timeline for the
submission of applications to reweight
the advancing care information
performance category in the MIPS final
score to align with the data submission
timeline for MIPS. We established that
all applications for reweighting the
advancing care information performance
category be submitted by the MIPS
eligible clinician or designated group
representative in the form and manner
specified by us. All applications may be
submitted on a rolling basis, but must be
received by us no later than the close of
the submission period for the relevant
performance period, or a later date
specified by us. An application would
need to be submitted annually to be
considered for reweighting each year.
The Quality Payment Program
Exception Application will be used to
apply for the following exceptions:
Insufficient Internet Connectivity;
Extreme and Uncontrollable
Circumstances; Lack of Control over the
Availability of CEHRT; Decertification
of CEHRT; and Small Practice.
We are proposing to change the
submission deadline for the application
as we believe that aligning the data
submission deadline with the
reweighting application deadline could
disadvantages MIPS eligible clinicians.
We are proposing to change the
submission deadline for the CY 2017
performance period to December 31,
2017, or a later date specified by us. We
believe this change would help MIPS
eligible clinicians by allowing them to
learn whether their application is
approved prior to the data submission
deadline for the CY 2017 performance
period, March 31, 2018. We plan to have
the application available in mid-2017.
We encourage MIPS eligible clinicians
to apply early as we expect to process
the applications on a rolling basis. We
note that if a MIPS eligible clinician
submits data for the advancing care
information category after an
application has been submitted, the data
would be scored, the application would
be considered voided and the advancing
care information performance category
would not be reweighted.
We further propose that the
submission deadline for the 2018
performance period will be December
31, 2018, or a later date as specified by
us. We believe this would help MIPS
eligible clinicians by allowing them to
learn whether their application is
approved prior to the data submission
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deadline for the CY 2018 performance
period, March 31, 2019.
We request comments on these
proposals.
g. APM Scoring Standard for MIPS
Eligible Clinicians in MIPS APMs
(1) Overview
Under section 1848(q)(1)(C)(ii)(1) of
the Act, Qualifying APM Participants
(QPs) are not MIPS eligible clinicians
and are thus excluded from MIPS
reporting requirements and payment
adjustments. Similarly, under section
1848(q)(1)(c)(ii)(II) of the Act, Partial
Qualifying APM Participants (Partial
QPs) are also not MIPS eligible
clinicians unless they opt to report and
be scored under MIPS. All other eligible
clinicians, including those participating
in MIPS APMs, are MIPS eligible
clinicians and subject to MIPS reporting
requirements and payment adjustments
unless they are excluded on another
basis such as being newly enrolled in
Medicare or not exceeding the low
volume threshold.
In the CY 2017 Quality Payment
Program final rule (81 FR 77246–77269,
77543), we finalized the APM scoring
standard, which is designed to reduce
reporting burden for participants in
certain APMs by minimizing the need
for them to make duplicative data
submissions for both MIPS and their
respective APMs. We also sought to
ensure that eligible clinicians in APM
Entities that participate in certain types
of APMs that assess their participants
on quality and cost are assessed as
consistently as possible across MIPS
and their respective APMs. Given that
many APMs already assess their
participants on cost and quality of care
and require engagement in certain
improvement activities, we believe that
without the APM scoring standard,
misalignments could be quite common
between the evaluation of performance
under the terms of the APM and
evaluation of performance on measures
and activities under MIPS.
In the CY 2017 Quality Payment
Program final rule (81 FR 77249), we
identified the types of APMs for which
the APM scoring standard would apply
as MIPS APMs. We finalized that to be
a MIPS APM, an APM must satisfy the
following criteria: (1) APM Entities
participate in the APM under an
agreement with CMS or by law or
regulation; (2) the APM requires that
APM Entities include at least one MIPS
eligible clinician on a Participation List;
and (3) the APM bases payment
incentives on performance (either at the
APM Entity or eligible clinician level)
on cost/utilization and quality
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measures. We specified that we will
post the list of MIPS APMs prior to the
first day of the MIPS performance year
for each year (81 FR 77250). We
finalized in the regulation at
§ 414.1370(b) that for a new APM to be
a MIPS APM, its first performance year
must start on or before the first day of
the MIPS performance year. A list of
MIPS APMs is available at
www.qpp.cms.gov.
We established in the regulation at
§ 414.1370(c) that the MIPS performance
year under § 414.1320 of the regulations
applies for the APM scoring standard.
We finalized that under section
§ 414.1370(f) of our regulations on the
APM scoring standard, MIPS eligible
clinicians will be scored at the APM
Entity group level and each eligible
clinician will receive the APM Entity
group’s final score. The MIPS payment
adjustment is applied at the TIN/NPI
level for each of the MIPS eligible
clinicians in the APM Entity. The MIPS
final score is comprised of the four
MIPS performance category scores, as
described in our regulation at
§ 414.1370(g): quality, cost,
improvement activities, and advancing
care information. Both the Medicare
Shared Savings Program and Next
Generation ACO Model are MIPS APMs
for the CY 2017 performance year. For
these two MIPS APMs, in accordance
with our regulation at § 414.1370(h), the
MIPS performance category scores are
weighted as follows: Quality at 50
percent; cost at zero percent;
improvement activities at 20 percent;
and advancing care information at 30
percent of the final score. For all other
MIPS APMs for the CY 2017
performance year, quality and cost are
each weighted at zero percent,
improvement activities at 25 percent,
and advancing care information at 75
percent of the final score.
As explained in the following
sections, we propose to: Add an APM
participant assessment date for full TIN
APMs; add the CAHPS for ACOs survey
to the Shared Savings Program and Next
Generation ACO quality measures
included for scoring under the MIPS
APM quality performance category;
define Other MIPS APMs; and add
scoring for quality improvement to the
MIPS APM quality performance
category for MIPS APMs beginning in
2018. We also propose a Quality
Payment Program 2018 performance
year quality scoring methodology for
Other MIPS APMs, and describe the
scoring methodology for quality
improvement for Other MIPS APMs as
applicable.
In reviewing these proposals, we
remind readers that the APM scoring
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standard is built upon the generally
applicable MIPS scoring standard, but
provides for special policies to address
the unique circumstances of MIPS
eligible clinicians who are in APM
Entities participating in MIPS APMs.
For the cost, improvement activities,
and advancing care information
performance categories, unless a
separate policy has been established or
is being proposed for the APM scoring
standard, the generally applicable MIPS
policies would be applicable.
Additionally, unless we include a
proposal to adopt a unique policy for
the APM scoring standard, we propose
to adopt the same generally applicable
MIPS policies proposed elsewhere in
this proposed rule, and would treat the
APM Entity group as the group for
purposes of MIPS. For the quality
performance category, however, the
APM scoring standard we propose is
presented as a separate, unique
standard, and therefore generally
applicable MIPS policies would not be
applied to the quality performance
category under the APM scoring
standard unless specifically stated. We
seek comment on whether there may be
potential conflicts or inconsistencies
between the generally applicable MIPS
policies and those under the APM
scoring standard, particularly where
these could impact our goals to reduce
duplicative and potentially incongruous
reporting requirements and performance
evaluations that could undermine our
ability to test or evaluate MIPS APMs,
or whether certain generally applicable
MIPS policies should be made explicitly
applicable to the APM scoring standard.
(2) Assessment Dates for Inclusion of
MIPS Eligible Clinicians in APM Entity
Groups Under the APM Scoring
Standard
In the CY 2017 Quality Payment
Program final rule, we specified in the
regulation at § 414.1370(e) that the APM
Entity group for purposes of scoring
under the APM scoring standard is
determined in the manner prescribed at
§ 414.1425(b)(1), which provides that
eligible clinicians who are on a
Participation List on at least one of three
dates (March 31, June 30, and August
31) would be considered part of the
APM Entity group. Under these
regulations, MIPS eligible clinicians
who are not on a Participation List on
one of these three assessment dates are
not scored under the APM scoring
standard. Instead, they would need to
submit data to MIPS through one of the
MIPS data submission mechanisms and
their performance would be assessed
either as individual MIPS eligible
clinicians or as a group according to the
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generally applicable MIPS reporting and
scoring criteria.
We will continue to use the three
assessment dates of March 31, June 30,
and August 31 to identify MIPS eligible
clinicians who are on an APM Entity’s
Participation List and determine the
APM Entity group that is used for
purposes of the APM scoring standard.
Beginning in the 2018 performance year,
we propose to add a fourth assessment
date of December 31 to identify those
MIPS eligible clinicians who participate
in a full TIN APM. We propose to define
full TIN APM at § 414.1305 to mean an
APM where participation is determined
at the TIN level, and all eligible
clinicians who have assigned their
billing rights to a participating TIN are
therefore participating in the APM. An
example of a full TIN APM is the Shared
Savings Program which requires all
individuals and entities that have
reassigned their right to receive
Medicare payment to the TIN of an ACO
participant to participate in the ACO
and comply with the requirements of
the Shared Savings Program.
If an eligible clinician elects to
reassign their billing rights to a TIN
participating in a full TIN APM, the
eligible clinician is necessarily
participating in the full TIN APM. We
propose to add this fourth date of
December 31 only for eligible clinicians
in a full TIN APM, and only for
purposes of applying the APM scoring
standard. We are not proposing to use
this additional assessment date of
December 31 for purposes of QP
determinations. Therefore, we propose
to amend § 414.1370(e) to identify the
four assessment dates that would be
used to identify the APM Entity group
for purposes of the APM scoring
standard, and to specify that the
December 31 date would be used only
to identify eligible clinicians on the
APM Entity’s Participation List for a
MIPS APM that is a full TIN APM in
order to add them to the APM Entity
group that is scored under the APM
scoring standard.
We propose to use this fourth
assessment date of December 31 to
extend the APM scoring standard to
only those MIPS eligible clinicians
participating in MIPS APMs that are full
TIN APMs, ensuring that an eligible
clinician who joins the full TIN APM
late in the performance year would be
scored under the APM scoring standard.
We considered proposing to use the
fourth assessment date more broadly for
all MIPS APMs. However, we believe
that this approach would have allowed
MIPS eligible clinicians to
inappropriately leverage the fourth
assessment date to avoid reporting and
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30081
scoring under the generally applicable
MIPS scoring standard when they were
part of the MIPS APM for only a very
limited portion of the performance year.
That is, for MIPS APMs that allow split
TIN participation, it would be possible
for eligible clinicians to briefly join a
MIPS APM principally in order to
benefit from the APM scoring standard,
despite having limited opportunity to
contribute to the APM Entity’s
performance in the MIPS APM. In
contrast, we believe MIPS eligible
clinicians would be less likely to join a
full TIN APM principally to avail
themselves of the APM scoring
standard, since doing so would require
either that the entire TIN join the MIPS
APM or the administratively
burdensome act of the eligible clinician
reassigning their billing rights to the
TIN of an entity participating in the full
TIN APM.
We will continue to use only the three
dates of March 31, June 30, and August
31 to determine, based on Participation
Lists, the MIPS eligible clinicians who
participate in MIPS APMs that are not
full TIN APMs. We seek comment on
the proposed addition of the fourth date
of December 31 to assess Participation
Lists to identify MIPS eligible clinicians
who participate in MIPS APMs that are
full TIN APMs for purposes of the APM
scoring standard.
(3) Calculating MIPS APM Performance
Category Scores
In the CY 2017 Quality Payment
Program final rule, we established a
scoring standard for MIPS eligible
clinicians participating in MIPS APMs
to reduce participant reporting burden
by reducing the need for eligible
clinicians participating in these types of
APMs to make duplicative data
submissions for both MIPS and their
respective APMs (81 FR 77246 through
77271). In accordance with section
1848(q)(1)(D)(i) of the Act, we proposed
to assess the performance of a group of
MIPS eligible clinicians in an APM
Entity that participates in one or more
MIPS APMs based on their collective
performance as an APM Entity group, as
defined at § 414.1305.
In addition to reducing reporting
burden, we sought to ensure that
eligible clinicians in MIPS APMs are not
assessed in multiple ways on the same
performance activities. Depending on
the terms of the particular MIPS APM,
we believe that misalignments could be
common between the evaluation of
performance on quality and cost under
MIPS versus under the terms of the
APM. We believe requiring eligible
clinicians in MIPS APMs to submit data,
be scored on measures, and be subject
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to payment adjustments that are not
aligned between MIPS and an APM
could potentially undermine the
validity of testing or performance
evaluation under the APM. We also
believe imposition of MIPS reporting
requirements would result in reporting
activity that provides little or no added
value to the assessment of eligible
clinicians, and could confuse eligible
clinicians as to which CMS incentives
should take priority over others in
designing and implementing care
improvement activities.
(a) Cost Performance Category
In the CY 2017 Quality Payment
Program final rule, for MIPS eligible
clinicians participating in MIPS APMs,
we used our authority to waive
requirements under the Medicare statute
to reduce the scoring weight for the cost
performance category to zero (81 FR
77258, 77262, and 77266). We did this
for MIPS APMs authorized under
section 1115A of the Act using our
authority under section 1115A(d)(1) of
the Act to waive the requirement under
section 1848(q)(5)(E)(i)(II) of the Act that
specifies the scoring weight for the cost
performance category. Having reduced
the cost performance category weight to
zero, we further used our authority
under section 1115A(d)(1) of the Act to
waive the requirements under sections
1848(q)(2)(B)(ii) and 1848(q)(2)(A)(ii) of
the Act to specify and use, respectively,
cost measures in calculating the MIPS
final score for MIPS eligible clinicians
participating in Other MIPS APMs (81
FR 77261 through 77262 and 77265
through 77266). Similarly, for MIPS
eligible clinicians participating in the
Medicare Shared Savings Program, we
used our authority under section 1899(f)
of the Act to waive the same
requirements of section 1848 of the Act
for the MIPS cost performance category
(81 FR 77257 through 77258). We
finalized this policy because: (1) APM
Entity groups are already subject to cost
and utilization performance assessment
under the MIPS APMs; (2) MIPS APMs
usually measure cost in terms of total
cost of care, which is a broader
accountability standard that inherently
encompasses the purpose of the claimsbased measures that have relatively
narrow clinical scopes, and MIPS APMs
that do not measure cost in terms of
total cost of care may depart entirely
from MIPS measures; and (3) the
beneficiary attribution methodologies
differ for measuring cost under APMs
and MIPS, leading to an unpredictable
degree of overlap (for eligible clinicians
and for CMS) between the sets of
beneficiaries for which eligible
clinicians would be responsible that
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would vary based on the unique APM
Entity characteristics such as which and
how many eligible clinicians comprise
an APM Entity group. We believe that
with an APM Entity’s finite resources
for engaging in efforts to improve
quality and lower costs for a specified
beneficiary population, measurement of
the population identified through the
APM must take priority in order to
ensure that the goals and the model
evaluation associated with the APM are
as clear and free of confounding factors
as possible. The potential for different,
conflicting results across APMs and
MIPS assessments may create
uncertainty for MIPS eligible clinicians
who are attempting to strategically
transform their respective practices and
succeed under the terms of the APM.
We are not proposing changes to these
policies.
We welcome comment on our
proposal to continue to waive the
weighting of the cost performance
category for the 2020 payment year
forward.
(i) Measuring Improvement in the Cost
Performance Category
In setting performance standards with
respect to measures and activities in
each MIPS performance category,
section 1848(q)(3)(B) of the Act requires
us to consider, historical performance
standards, improvement, and the
opportunity for continued
improvement. Section 1848(q)(5)(D)(i)(I)
requires us to introduce the
measurement of improvement into
performance scores in the cost
performance category for MIPS eligible
clinicians for the 2020 MIPS Payment
Year if data sufficient to measure
improvement are available. Section
1848(q)(5)(D)(i)(II) permits us to take
into account improvement in the case of
performance scores in other
performance categories. Given that we
have in effect waivers of the scoring
weight for the cost performance
category, and of the requirement to
specify and use cost measures in
calculating the MIPS final score for
MIPS eligible clinicians participating in
MIPS APMs, and for the same reasons
that we initially waived those
requirements, we propose to use our
authority under section 1115A(d)(1) of
the Act for MIPS APMs authorized
under section 1115A of the Act and
under section 1899(f) of the Act for
MIPS APMs under the Medicare Shared
Savings Program, to waive the
requirement under section
1848(q)(5)(D)(i)(I) of the Act to take
improvement into account for
performance scores in the cost
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performance category beginning with
the 2018 MIPS performance year.
We seek comment on this proposal.
(b) Quality Performance Category
(i) Web Interface Reporters: Shared
Savings Program and Next Generation
ACO Model
(A) Quality Measures
We finalized in the CY 2017 Quality
Payment Program final rule that under
the APM scoring standard, participants
in the Shared Savings Program and Next
Generation ACO Model would be
assessed for the purposes of generating
a MIPS APM quality performance
category score based exclusively on
quality measures submitted using the
CMS Web Interface (81 FR 77256 and
77261). In the CY 2017 Quality Payment
Program final rule, we recognized that
ACOs in both the Shared Savings
Program and Next Generation ACO
Model use the CMS Web Interface to
submit data on quality measures, and
that the measures they would report
were also MIPS measures for 2017. For
the Shared Savings Program and the
Next Generation ACO Model, we
finalized a policy to use quality
measures and data submitted by the
participant ACOs to the CMS Web
Interface (as required under the rules for
these initiatives) and MIPS benchmarks
for these measures to score quality for
MIPS eligible clinicians in these MIPS
APMs at the APM Entity level (81 FR
77256, 77261). For these MIPS APMs,
which we refer to as Web Interface
reporters going forward, we established
that quality performance data that are
not submitted to the CMS Web Interface,
for example the CAHPS for ACOs
survey and claims-based measures, will
not be included in the MIPS APM
quality performance category score for
2017.
(aa) Addition of New Measures
For the Shared Savings Program and
Next Generation ACO Model, we
propose to score the CAHPS for ACOs
survey, in addition to the CMS Web
Interface measures that are used to
calculate the MIPS APM quality
performance category score for the
Shared Savings Program and Next
Generation ACO Model, beginning in
the 2018 performance year. The CAHPS
for ACOs survey is already required in
the Shared Savings Program and Next
Generation ACO Model, and including
the CAHPS for ACOs survey would
better align the measures on which
participants in these MIPS APMs are
assessed under the APM scoring
standard with the measures used to
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assess participants’ quality performance
under the APM.
We did not initially propose to
include the CAHPS for ACOs survey as
part of the MIPS APM quality
performance category scoring for the
Shared Savings Program and Next
Generation ACO Model because we
believed that the CAHPS for ACOs
survey would not be collected and
scored in time to produce a MIPS
quality performance category score.
However, operational efficiencies have
recently been introduced that have
made it possible to score the CAHPS for
ACOs survey on the same timeline as
the CAHPS for MIPS survey. Under our
proposal, the CAHPS for ACOs survey
would be added to the total number of
quality performance category measures
available for scoring in these MIPS
APMs.
While the CAHPS for ACOs survey is
new to MIPS APM scoring, the CG–
CAHPS survey upon which it is based
is also the basis for the CAHPS for MIPS
survey, which was included on the
MIPS final list for the 2017 performance
year. For a further discussion of the
CAHPS for ACOs survey, and the way
it will be scored, we refer readers to
II.C.6.b.(3)(a)(ii) of this proposed rule,
30083
which describes the identical CAHPS
for MIPS survey and its scoring method
that will be used for MIPS in the 2018
performance year. We note that
although each question in the CAHPS
for ACOs survey can also be found in
the CAHPS for MIPS survey, the CAHPS
for ACOs survey will have one fewer
survey question the SSM entitled
‘‘Between Visit Communication’’, which
has never been a scored measure with
the Medicare Shared Savings Program
CAHPS for ACOs Survey and which we
believe to be inappropriate for use by
ACOs.
TABLE 10—WEB INTERFACE REPORTERS: SHARED SAVINGS PROGRAM AND NEXT GENERATION ACO MODEL NEW
MEASURE
Measure name
NQF/quality
number
(if applicable)
CAHPS for ACOs .........
N/A ...............
National quality
strategy domain
Patient/Caregiver Experience.
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(B) Calculating Quality Scores
We refer readers to section
II.C.7.a.(1)(h)(ii) of this proposed rule
for our summary of finalized policies
and proposed changes related to
calculating the MIPS quality
performance category percent score for
MIPS eligible clinicians, including APM
Entity groups reporting through the
CMS Web Interface. Those policies and
proposed changes in section
II.C.7.a.(1)(h)(ii) of this proposed rule
would apply in the same manner under
the APM scoring standard except as
otherwise noted in this section of the
proposed rule. However, we propose not
to subject MIPS APM Web Interface
reporters to a 3 point floor because we
do not believe it is necessary to apply
this transition year policy to eligible
clinicians participating in previously
established MIPS APMs.
(C) Incentives to Report High Priority
Measures
In the CY 2017 Quality Payment
Program final rule, we finalized that for
CMS Web Interface reporters, we will
apply bonus points based on the
finalized set of measures reportable
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Measure description
Primary measure
steward
Consumer Assessment of Healthcare Providers and Systems
(CAHPS) surveys for Accountable Care Organizations (ACOs) in the
Medicare Shared Savings Program (SSP) and Next Generation
ACOs ask consumers about their experiences with health care. The
CAHPS for ACOs Survey is collected from a sample of beneficiaries
who get the majority of their care from an ACO, and the questions
address care received from a named clinician within the ACO.
Survey measures include:
—Getting Timely Care, Appointments, and Information.
—How Well Your Providers Communicate.
—Patients’ Rating of Providers.
—Access to Specialists.
—Health Promotion and Education.
—Shared Decision Making.
—Health Status/Functional Status.
—Stewardship of Patient Resources.
Agency for Healthcare
Research and Quality (AHRQ)
through the CMS Web Interface. (81 FR
77291 through 77294). We will assign
two bonus points for reporting two or
more outcome or patient experience
measures and one bonus point for
reporting any other high priority
measure, beyond the first high priority
measure. We note that in addition to the
measures required by the APM to be
submitted through the CMS Web
Interface, APM Entities in the Shared
Savings Program and Next Generation
ACO Models must also report the
CAHPS for ACOs survey and we
propose that beginning for the 2020
payment year forward they may receive
bonus points under the APM scoring
standard for submitting that measure.
Participants in MIPS APMs, like all
MIPS eligible clinicians, are also subject
to the 10 percent cap on bonus points
for reporting high priority measures.
APM Entities reporting through the
CMS Web Interface will only receive
bonus points if they submit a high
priority measure with a performance
rate that is greater than zero, provided
that the measure meets the case
minimum requirements.
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(D) Scoring Quality Improvement
Beginning in the CY 2018
performance year, section
1848(q)(5)(D)(i)(I) of the Act requires us
to score improvement for the MIPS
quality performance category for MIPS
eligible clinicians, including those
participating in MIPS APMs, if data
sufficient to measure quality
improvement are available. We propose
to calculate the quality improvement
score using the methodology described
in section II.C.7.a.(1)(i) for scoring
quality improvement for eligible
clinicians submitting quality measures
via the CMS Web Interface. We believe
aligning the scoring methodology used
for all CMS Web Interface submissions
will minimize confusion among MIPS
eligible clinicians receiving a MIPS
score, including those participating in
MIPS APMs.
(E) Total Quality Performance Category
Score for CMS Web Interface Reporters
We propose to calculate the total
quality percent score for MIPS eligible
clinicians using the CMS Web Interface
according to the methodology described
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in section II.C.7.a.(1)(h)(2) of this
proposed rule.
We seek comment on our proposed
quality performance category scoring
methodology for CMS Web Interface
reporters.
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(ii) Other MIPS APMs
We propose to define the term Other
MIPS APM at § 414.1305 as a MIPS
APM that does not require reporting
through the CMS Web Interface. We
propose to add this definition as we
believe it will be useful in discussing
our policies for the APM scoring
standard. In the 2018 MIPS performance
period, Other MIPS APMs will include
the Comprehensive ESRD Care Model,
the Comprehensive Primary Care Plus
Model (CPC+), and the Oncology Care
Model.
(A) Quality Measures
In the CY 2017 Quality Payment
Program final rule, we explained that
current MIPS APMs have requirements
regarding the number of quality
measures, measure specifications, as
well as the measure reporting method(s)
and frequency of reporting, and have an
established mechanism for submission
of these measures to us within the
structure of the specific MIPS APM. We
explained that operational
considerations and constraints
interfered with our ability to use the
quality measure data from some MIPS
APMs for the purpose of satisfying MIPS
data submission requirements for the
quality performance category for the
first performance year. We concluded
that there was insufficient time to
adequately implement changes to the
current MIPS APM quality measure data
collection timelines and infrastructure
in the first performance year to conduct
a smooth hand-off to the MIPS system
that would enable use of APM quality
measure data to satisfy the MIPS quality
performance category requirements in
the first MIPS performance year (81 FR
77264). Out of concern that subjecting
MIPS eligible clinicians who participate
in MIPS APMs to multiple, potentially
duplicative or inconsistent performance
assessments could undermine the
validity of testing or performance
evaluation under the MIPS APMs; and
that there was insufficient time to make
adjustments in operationally complex
systems and processes related to the
alignment, submission and collection of
APM quality measures for purposes of
MIPS, we used our authority under
section 1115A(d)(1) to waive certain
requirements of section 1848(q).
We finalized that for the first MIPS
performance year only, for MIPS eligible
clinicians participating in APM Entities
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in Other MIPS APMs, the weight for the
quality performance category is zero (81
FR 77268). To avoid risking adverse
operational or program evaluation
consequences for MIPS APMs while we
worked toward incorporating MIPS
APM quality measures into scoring for
future performance years, we used the
authority provided by section
1115A(d)(1) of the Act to waive the
quality performance category weight
required under section 1848(q)(5)(E)(i)(I)
of the Act, and we indicated that with
the reduction of the quality performance
category weight to zero, it was
unnecessary to establish for MIPS APMs
a final list of quality measures as
required under section 1848(q)(2)(D) of
the Act or to specify and use quality
measures in determining the MIPS final
score for these MIPS eligible clinicians.
As such, we further waived the
requirements under sections
1848(q)(2)(D), 1848(q)(2)(B)(i) and
1848(q)(2)(A)(i) of the Act to establish a
final list of quality measures (using
certain criteria and processes); and to
specify and use, respectively, quality
measures in calculating the MIPS final
score for the first MIPS performance
year.
In the CY 2017 Quality Payment
Program final rule, we anticipated that
beginning with the second MIPS
performance year, the APM quality
measure data submitted to us during the
MIPS performance year would be used
to derive a MIPS quality performance
score for APM Entities in all MIPS
APMs.
We also anticipated that it may be
necessary to propose policies and
waivers of requirements of the statute,
such as section 1848(q)(2)(D) of the Act,
to enable the use of non-MIPS quality
measures in the quality performance
category score. We anticipated that by
the second performance year we would
have had sufficient time to resolve
operational constraints related to use of
separate quality measure systems and to
adjust quality measure data submission
timelines. Accordingly, we stated our
intention to, in future rulemaking, use
our section 1115A(d)(1) waiver
authority to establish that the quality
measures and data that are used to
evaluate performance for APM Entities
in MIPS APMs would be used to
calculate a MIPS quality performance
score under the APM scoring standard.
We have since designed the means to
overcome the operational constraints
that prevented us from scoring quality
under the APM scoring standard in the
first performance year, and we propose
to adopt quality measures for use under
the APM scoring standard, and begin
collecting MIPS APM quality measure
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performance data in order to generate a
MIPS quality performance category
score for APM Entities participating in
MIPS APMs beginning with the 2018
performance year.
(aa) APM Measures for MIPS
In the CY 2017 Quality Payment
Program final rule, we explained the
concerns that led us to express our
intent to use the quality measures and
data that apply in the MIPS APM for
purposes of the APM scoring standard,
including concerns about the
application of multiple, potentially
duplicative or inconsistent performance
assessments that could negatively
impact our ability to evaluate MIPS
APMs (81 FR 77246). Additionally, the
quality and cost/utilization measures
that are used to calculate performancebased payments in MIPS APMs may
vary from one MIPS APM to another.
Factors such as the type and quantity of
measures required, the MIPS APM’s
particular measure specifications, how
frequently the measures must be
reported, and the mechanisms used to
collect or submit the measures all add
to the diversity in the quality and cost/
utilization measures used to evaluate
performance among MIPS APMs. Given
these concerns and the differences
between and among the quality
measures used to evaluate performance
within MIPS APMs as opposed to those
used more generally under MIPS, we
propose to use our authority under
section 1115A(d)(1) of the Act to waive
requirements under section
1848(q)(2)(D) of the Act, which requires
the Secretary to use certain criteria and
processes to establish an annual MIPS
final list of quality measures from which
all MIPS eligible clinicians may choose
measures for purposes of assessment,
and instead to establish a MIPS APM
quality measure list for purposes of the
APM scoring standard. The MIPS APM
quality measure list would be adopted
as the final list of MIPS quality
measures under the APM scoring
standard, and would reflect the quality
measures that are used to evaluate
performance on quality within each
MIPS APM.
The MIPS APM quality measure list
we propose in Table 13, would define
distinct measure sets for participants in
each MIPS APM for purposes of the
APM scoring standard, based on the
measures that are used by the APM, and
for which data will be collected by the
close of the MIPS submission period.
The measure sets on the MIPS APM
measure list would represent all
possible measures which may
contribute to an APM Entity’s MIPS
score for the MIPS quality performance
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category, and may include measures
that are the same as or similar to those
used by MIPS. However, measures may
ultimately not be used for scoring if a
measure’s data becomes inappropriate
or unavailable for scoring; for example,
if a measure’s clinical guidelines are
changed or the measure is otherwise
modified by the APM during the
performance year, the data collected
during that performance year would not
be uniform, and as such may be
rendered unusable for purposes of the
APM scoring standard (See Tables 14,
15, and 16).
(B) Measure Requirements for Other
MIPS APMs
Because the quality measure sets for
each Other MIPS APM are unique, we
propose to calculate the MIPS quality
performance category score using APMspecific quality measures. For purposes
of the APM scoring standard, we will
score only measures that: (1) Are tied to
payment as described under the terms of
the APM, (2) are available for scoring
near the close of the MIPS submission
period, (3) have a minimum of 20 cases
available for reporting, and (4) have an
available benchmark. We discuss each
of these requirements for Other MIPS
APM quality measures below.
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(aa) Tied to Payment
For purposes of the APM scoring
standard, we will consider a measure to
be tied to payment if an APM Entity
group will receive a payment
adjustment or other incentive payment
under the terms of the APM, based on
the APM Entity’s performance on the
measure.
(bb) Available for Scoring
Some MIPS APM quality measure
results are not available until late in the
calendar year subsequent to the MIPS
performance year, which would prevent
us from including them in the MIPS
APM quality performance category score
due to the larger programmatic
timelines for providing MIPS eligible
clinician performance feedback by July
and issuing budget-neutral MIPS
payment adjustments. Consequently, we
propose to only use the MIPS APM
quality measure data that are submitted
by the close of the MIPS submission
period and are available for scoring in
time for inclusion to calculate a MIPS
quality performance category score.
Measures are to be submitted according
to requirements under the terms of the
APM; the measure data will then be
aggregated and prepared for submission
to MIPS for the purpose of creating a
MIPS quality performance category
score.
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We believe using the Other MIPS
APMs’ quality measure data that have
been submitted no later than the close
of the MIPS submission period and have
been processed and made available to
MIPS for scoring in time to calculate a
MIPS quality performance category
score is consistent with our intent to
decrease duplicative reporting for MIPS
eligible clinicians who would otherwise
need to report quality measures to both
MIPS and their APM. Going forward,
these are the measures to which we are
referring when we limit scoring to
measures that are available near the
close of the MIPS submission period.
(cc) 20 Case Minimum
We also believe that a 20 case
minimum, in alignment with the one
finalized generally under MIPS in the
CY 2017 Quality Payment Program final
rule (81 FR 77288), is necessary to
ensure the reliability of the measure
data submitted, as explained the CY
2017 Quality Payment Program final
rule.
As under the general policy for MIPS,
when an APM Entity reports a quality
measure that includes less than 20
cases, that measure would receive a null
score for that measure’s achievement
points, and the measure would be
removed from both the numerator and
the denominator of the MIPS quality
performance category percentage. We
propose to apply this policy under the
APM scoring standard.
(dd) Available Benchmark
An APM Entity’s score on each
quality measure would be calculated in
part by comparing the APM Entity’s
performance on the measure with a
benchmark performance score.
Therefore, we would need all scored
measures to have a benchmark available
by the time that the MIPS quality
performance category score is
calculated, in order to make that
comparison.
We propose that, for the APM scoring
standard, the benchmark score used for
a quality measure would be the
benchmark used in the MIPS APM for
calculation of the performance based
payments, where such a benchmark is
available. If the APM does not produce
a benchmark score for a reportable
measure that is included on the APM
measures list, we would use the
benchmark score for the measure that is
used for the MIPS quality performance
category generally (outside of the APM
scoring standard) for that performance
year, provided the measure
specifications for the measure are the
same under both the MIPS final list and
the APM measures list. If neither the
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30085
APM nor MIPS has a benchmark
available for a reported measure, the
APM Entity that reported that measure
would receive a null score for that
measure’s achievement points, and the
measure would be removed from both
the numerator and the denominator of
the quality performance category
percentage.
(C) Calculating the Quality Performance
Category Percent Score
Eligible clinicians who participate in
Other MIPS APMs are subject to specific
quality measure reporting requirements
within these APMs. To best align with
APM design and objectives, we propose
that the minimum number of required
measures to be reported for the APM
scoring standard would be the
minimum number of quality measures
that are required by the MIPS APM and
are collected and available in time to be
included in the calculation for the APM
Entity score under the APM scoring
standard. For example, if an Other MIPS
APM requires participating APM
Entities to report nine of 14 quality
measures by a specific date and the
APM Entity misses the MIPS
submission deadline, then for the
purposes of calculating an APM Entity
quality performance category score, the
APM Entity would receive a zero for
those measures. An APM Entity that
does not submit any APM quality
measures by the MIPS submission
deadline would receive a zero for its
MIPS APM quality performance
category percent score for the
performance year.
We propose that if an APM Entity
submits some, but not all of the
measures required by the MIPS APM by
the close of the MIPS submission
period, the APM Entity would receive
points for the measures that were
submitted, but would receive a score of
zero for each remaining measure
between the number of measures
reported and the number of measures
required by the APM that were available
for scoring.
For example, if an APM Entity in the
above hypothetical MIPS APM submits
quality performance data on three of the
APM’s measures, instead of the required
nine, the APM Entity would receive
quality points in the APM scoring
standard quality performance category
percent score for the three measures it
submitted, but would receive zero
points for each of the six remaining
measures that were required under the
terms of the MIPS APM. On the other
hand, if an APM Entity reports on more
than the minimum number of measures
required to be reported under the MIPS
APM and the measures meet the other
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criteria for scoring, only the measures
with the highest scores, up to the
number of measures required to be
reported under the MIPS APM, would
be counted; however, any bonus points
earned by reporting on measures beyond
the minimum number of required
measures would be awarded.
If a measure is reported but fails to
meet the 20 case minimum or does not
have a benchmark available, there
would be a null score for that measure,
and it would be removed from both the
numerator and the denominator, so as
not to negatively affect the APM Entity’s
quality performance category score.
We propose to assign bonus points for
reporting high priority measures or
measures with end-to-end CEHRT
reporting as described for general MIPS
scoring in the CY 2017 Quality Payment
Program final rule (81 FR 77297 through
77299).
(aa) Quality Measure Benchmarks
An APM Entity’s MIPS quality
measure score will be calculated by
comparing the APM Entity’s
performance on a given measure with a
benchmark performance score. We
propose that the benchmark score used
for a quality measure would be the
benchmark used by the MIPS APM for
calculation of the performance based
payments within the APM, if possible,
in order to best align the measure
performance outcomes between the
APM and MIPS programs. If the MIPS
APM does not produce a benchmark
score for a reportable measure that will
be available at the close of the MIPS
submission period, the benchmark score
for the measure that is used for the
MIPS quality performance category
generally for that performance year
would be used, provided the measure
specifications are the same for both. If
neither the APM nor MIPS has a
benchmark available for a reported
measure, the APM Entity that reported
that measure will receive a null score
for that measure’s achievement points,
and the measure will be removed from
both the numerator and the
denominator of the quality performance
category percentage.
We are proposing that for measures
that are pay for reporting or which do
not measure performance on a
continuum of performance, we will
consider these measures to be lacking a
benchmark and they will be treated as
such. For example, if a model only
requires that an APM Entity must
surpass a threshold and does not
measure APM Entities on performance
beyond surpassing a threshold, we
would not consider such a measure to
measure performance on a continuum.
We propose to score quality measure
performance under the APM scoring
standard using a percentile distribution,
separated by decile categories, as
described in the finalized MIPS quality
scoring methodology (81 FR 77282
through 77284). For each benchmark,
we will calculate the decile breaks for
measure performance and assign points
based on the benchmark decile range
into which the APM Entity’s measure
performance falls.
We propose to use a graduated pointsassignment approach, where a measure
is assigned a continuum of points out to
one decimal place, based on its place in
the decile. For example, a raw score of
55 percent would fall within the sixth
decile of 41.0 percent to 61.9 percent
and would receive between 6.0 and 6.9
points.
We seek comment on this proposed
method.
TABLE 11—BENCHMARK DECILE DISTRIBUTION
Sample quality
measure
(%)
Sample benchmark decile
Example
Example
Example
Example
Example
Example
Example
Example
Example
Example
Benchmark
Benchmark
Benchmark
Benchmark
Benchmark
Benchmark
Benchmark
Benchmark
Benchmark
Benchmark
Decile
Decile
Decile
Decile
Decile
Decile
Decile
Decile
Decile
Decile
1 .................................................................................................................................
2 .................................................................................................................................
3 .................................................................................................................................
4 .................................................................................................................................
5 .................................................................................................................................
6 .................................................................................................................................
7 .................................................................................................................................
8 .................................................................................................................................
9 .................................................................................................................................
10 ...............................................................................................................................
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(bb) Assigning Quality Measure Points
Based on Achievement
For the APM scoring standard quality
performance category, we propose that
each APM Entity that reports on quality
measures would receive between 1 and
10 achievement points for each measure
reported that can be reliably scored
against a benchmark, up to the number
of measures that are required to be
reported by the APM. Because measures
that lack benchmarks or 20 reported
cases are removed from the numerator
and denominator of the quality
performance category percentage, it is
unnecessary to include a point-floor for
scoring of Other MIPS APMs. Similarly,
because the quality measures reported
by the MIPS APM for MIPS eligible
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clinicians under the APM scoring
standard are required to be submitted to
the APM under the terms of
participation in the APM, and the MIPS
eligible clinicians do not select their
APM measures, there will be no cap on
topped out measures for MIPS APM
participants being scored under the
APM scoring standard, which differs
from the policy for other MIPS eligible
clinicians proposed at section
II.C.7.a.(2)(c) of this proposed rule.
Beginning in the 2018 MIPS
performance year, we propose that APM
Entities in MIPS APMs, like other MIPS
eligible clinicians, would be eligible to
receive bonus points for the MIPS
quality performance category for
reporting on high priority measures or
measures submitted via CEHRT (for
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Graduated
points
(with no floor)
0–9.9
10.0–17.9
18.0–22.9
23.0–35.9
36.0–40.9
41.0–61.9
62.0–68.9
69.0–78.9
79.0–84.9
85.0–100
1.0–1.9
2.0–2.9
3.0–3.9
4.0–4.9
5.0–5.9
6.0–6.9
7.0–7.9
8.0–8.9
9.0–9.9
10.0
example, end-to-end submission)
according to the criteria described in
section II.C.7.a.(1) of this proposed rule.
For each Other MIPS APM, we propose
to identify whether any of their
available measures meets the criteria to
receive a bonus, and add the bonus
points to the quality achievement
points. Further, we propose that the
total number of awarded bonus points
may not exceed 10 percent of the APM
Entity’s total available achievement
points for the MIPS quality performance
category score.
To generate the APM Entity’s quality
performance category percentage,
achievement points would be added to
any applicable bonus points, and then
divided by the total number of available
achievement points, with a cap of 100
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percent. For more detail on the MIPS
quality performance category percentage
score calculation, we refer readers to
section II.C.7.a.(1) of this proposed rule.
Under the APM scoring standard for
Other MIPS APMs, the number of
available achievement points would be
the number of measures required under
the terms of the APM and available for
scoring multiplied by ten. If, however,
an APM Entity reports on a required
measure that fails the 20 case minimum
requirement, or which has no available
benchmark for that performance year,
the measure would receive a null score
and all points from that measure would
be removed from both the numerator
and the denominator.
For example, if an APM Entity reports
on four out of four measures required to
be reported by the MIPS APM, and
receives an achievement score of five on
each and no bonus points, the APM
Entity’s quality performance category
percentage would be [(5 points × 4
measures) + 0 bonus points]/(4
measures × 10 max available points), or
50 percent. If, however, one of those
measures failed the 20 case minimum
requirement or had no benchmark
available, that measure would have a
null value and would be removed from
both the numerator and denominator to
create a quality performance category
percentage of [(5 points × 3 measures) +
0 bonus points]/(3measures × 10 max
available points), or 50 percent.
If an APM Entity fails to meet the 20
case minimum on all available APM
measures, that APM Entity would have
its quality performance category score
reweighted to zero, as described below.
We request comment on the above
proposals for calculating the quality
category percent score.
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(D) Quality Improvement Scoring
Beginning in the 2018 performance
year, we propose to score improvement
as well as achievement in the quality
performance category.
For the APM scoring standard, we
propose that the quality improvement
percentage points would be awarded
based on the following formula:
Quality Improvement Score = (Absolute
Improvement/Previous Year Quality
Performance Category Percent Score
Prior to Bonus Points)/10
For a more detailed discussion of
improvement scoring for the quality
performance category under the APM
scoring standard, we refer readers to the
discussion on calculating improvement
at the quality performance category
level for MIPS at section II.C.7.a.(1)(i) of
this proposed rule.
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(E) Calculating Total Quality
Performance Category Score
the advancing care information
performance category.
We propose that the APM Entity’s
total quality performance category score
would be equal to [(achievement points
+ bonus points)/total available
achievement points] + quality
improvement score. The APM Entity’s
total quality performance category score
may not exceed 100 percent. We request
comment on the above proposed quality
scoring methodology.
We seek comment on the proposed
quality performance category scoring
methodology for APM Entities
participating in Other MIPS APMs.
(i) Special Circumstances
As described in the CY 2017 Quality
Payment Program final rule (81 FR
77238–77245), under the generally
applicable MIPS scoring standard, we
will assign a weight of zero percent to
the advancing care information
performance category in the final score
for MIPS eligible clinicians who meet
specific criteria: hospital-based MIPS
eligible clinicians, MIPS eligible
clinicians who are facing a significant
hardship, and certain types of nonphysician practitioners (NPs, PAs,
CRNAs, CNSs) who are MIPS eligible
clinicians. In section II.C.7.a.(6) of this
proposed rule, we are also proposing to
include in this weighting policy ASCbased MIPS eligible clinicians and MIPS
eligible clinicians who are using
decertified EHR technology.
Under the APM scoring standard, we
propose that if a MIPS eligible clinician
who qualifies for a zero percent
weighting of the advancing care
information performance category in the
final score is part of a TIN that includes
one or more MIPS eligible clinicians
who do not qualify for a zero percent
weighting, we would not apply the zero
percent weighting to the qualifying
MIPS eligible clinician, and the TIN
would still be required to report on
behalf of the group, although the TIN
would not need to report data for the
qualifying MIPS eligible clinician. All
MIPS eligible clinicians in the TIN
would count towards the TIN’s weight
when calculating an aggregated APM
Entity score for the advancing care
information performance category.
If, however, the MIPS eligible
clinician is a solo practitioner and
qualifies for a zero percent weighting, or
if all MIPS eligible clinicians in a TIN
qualify for the zero percent weighting,
the TIN would not be required to report
on the advancing care information
performance category, and if the TIN
chooses not to report that TIN would be
assigned a weight of 0 when calculating
the APM Entity’s advancing care
information performance category score.
If advancing care information data are
reported by one or more TINs in an
APM Entity, an advancing care
information performance category score
will be calculated for, and will be
applicable to, all MIPS eligible
clinicians in the APM Entity group. If
all MIPS eligible clinicians in all TINs
in an APM Entity group qualify for a
zero percent weighting of have the
advancing care information performance
category, or in the case of a solo
practitioner who comprises an entire
(c) Improvement Activities Performance
Category
As finalized in the CY 2017 Quality
Payment Program final rule, for all MIPS
APMs we will assign the same
improvement activities score to each
APM Entity based on the activities
involved in participation in a MIPS
APM. APM Entities will receive a
minimum of one half of the total
possible points. This policy is in
accordance with section
1848(q)(5)(C)(ii) of the Act. In the event
that the assigned score does not
represent the maximum improvement
activities score, the APM Entity group
will have the opportunity to report
additional improvement activities to
add points to the APM Entity level
score.
(d) Advancing Care Information
Performance Category
In the CY 2017 Quality Payment
Program final rule, we finalized our
policy to attribute one score to each
MIPS eligible clinician in an APM
Entity group by looking for both
individual and group TIN level data
submitted for a MIPS eligible clinician,
and using the highest available score (81
FR 77268). We will then use these
scores to create an APM Entity’s score
based on the average of the highest
scores available for all MIPS eligible
clinicians in the APM Entity group. If an
individual or TIN did not report on the
advancing care information performance
category, they will contribute a zero to
the APM Entity’s aggregate score. Each
MIPS eligible clinician in an APM
Entity group will receive one score,
weighted equally with the scores of
every other MIPS eligible clinician in
the APM Entity group, and we will use
these to calculate a single APM Entitylevel advancing care information
performance category score.
We refer readers to section II.C.6.f.(6)
of this proposed rule for our summary
of proposed changes related to scoring
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APM Entity and qualifies for zero
percent weighting, the advancing care
information performance category
would be weighted at zero percent of
the final score, and the advancing care
information performance category’s
weight would be redistributed to the
quality performance category.
(4) Calculating Total APM Entity Score
(a) Performance Category Weighting
As discussed in section II.C.6.g.(3)(a)
of this proposed rule, we propose to
continue to use our authority to waive
sections 1848(q)(2)(B)(ii) and
1848(q)(2)(A)(ii) of the Act to specify
and use, respectively, cost measures;
and to maintain the cost performance
category weight of zero under the APM
scoring standard for the 2018
performance period and subsequent
MIPS performance periods. Because the
cost performance category would be
reweighted to zero that weight would
need to be redistributed to other
performance categories. We propose to
use our authority under section
1115A(d)(1) to waive requirements
under sections 1848(q)(5)(E)(i)(I)(bb),
1848(q)(5)(E)(i)(III) and
1848(q)(5)(E)(i)(IV) of the Act that
prescribe the weights, respectively, for
the quality, improvement activities, and
ACI performance categories. We propose
to weight the quality performance
category score to 50 percent, the
improvement activities performance
category to 20 percent, and the
advancing care information performance
category to 30 percent of the final score
for all APM Entities in Other MIPS
APMs. We propose these weights to
align the Other MIPS APM performance
category weights with those assigned to
the Web Interface reporters, which we
adopted as explained in the CY 2017
Quality Payment Program final rule at
81 FR 77262 through 77263. We believe
it is appropriate to align the
performance category weights for APM
Entities in MIPS APMs that require
reporting through the Web Interface
with those in Other MIPS APMs. By
aligning the performance category
weights among all MIPS APMs, we
would create greater scoring parity
among the MIPS eligible clinicians in
MIPS APMs who are being scored under
the APM scoring standard. These
proposals are summarized in Table 12.
TABLE 12—APM SCORING STANDARD PERFORMANCE CATEGORY WEIGHTS—BEGINNING FOR THE 2018 PERFORMANCE
PERIOD
Performance
category
weight
(%)
MIPS performance
category
APM entity submission requirement
Performance category score
Quality ............................
The APM Entity will be required to submit quality
measures to CMS as required by the MIPS
APM. Measures available at the close of the
MIPS submission period will be used to calculate the MIPS quality performance category
score. If the APM Entity does not submit any
APM required measures by the MIPS submission deadline, the APM Entity will be assigned
a zero.
The APM Entity group will not be assessed on
cost under MIPS.
MIPS eligible clinicians do not need to report improvement activities data; if the CMS-assigned
improvement activities score is below the maximum improvement activities score APM Entities will have the opportunity to submit additional improvement activities to raise the APM
Entity improvement activity score.
CMS will assign the same quality category performance score to each TIN/NPI in an APM
Entity group based on the APM Entity’s total
quality score, derived from available APM
quality measures.
50
N/A ........................................................................
0
CMS will assign the same improvement activities
score to each APM Entity based on the activities involved in participation in the MIPS APM.
APM Entities will receive a minimum of one
half of the total possible points. In the event
that the assigned score does not represent the
maximum improvement activities score, the
APM Entity will have the opportunity to report
additional improvement activities to add points
to the APM Entity level score.
We will attribute the same score to each MIPS
eligible clinician in the APM Entity group. This
score will be the highest score attributable to
the TIN/NPI combination of each MIPS eligible
clinician, which may be derived from either
group or individual reporting. The scores attributed to each MIPS eligible clinicians will be
averaged for a single APM Entity score.
20
Cost ...............................
Improvement Activities ..
mstockstill on DSK30JT082PROD with PROPOSALS2
Advancing Care Information.
Each MIPS eligible clinician in the APM Entity
group is required to report advancing care information to MIPS through either group TIN or
individual reporting.
It is possible that there could be
instances where an Other MIPS APM
has no measures available to score for
the quality performance category for a
MIPS performance period; for example,
it is possible that none of the Other
MIPS APM’s measures would be
available for calculating a quality
performance category score by or shortly
after the close of the MIPS submission
period because the measures were
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removed due to changes in clinical
practice guidelines. In addition, as
explained in section II.C.6.g.(3)(d)(i) of
this proposed rule, the MIPS eligible
clinicians in an APM Entity may qualify
for a zero percent weighting for the
advancing care information performance
category. In such instances, under the
APM scoring standard, we propose to
reweight the affected performance
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30
category to zero, in accordance with
section 1848(q)(5)(F) of the Act.
If the quality performance category is
reweighted to zero, we propose to
reweight the improvement activities and
advancing care information performance
categories to 25 and 75 percent,
respectively. If the advancing care
information performance category is
reweighted to zero, the quality
performance category weight would be
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increased to 80 percent. These proposals
are summarized in Table 13.
TABLE 13—APM SCORING STANDARD PERFORMANCE CATEGORY WEIGHTS FOR OTHER MIPS APMS WITH
PERFORMANCE CATEGORIES WEIGHTED TO 0—BEGINNING FOR THE 2018 PERFORMANCE PERIOD
Performance
category
weight
(no quality)
(%)
MIPS performance
category
APM entity submission requirement
Performance category score
Quality .......................
The APM Entity would not be assessed
on quality under MIPS if no quality data
are available at the close of the MIPS
submission period. The APM Entity will
submit quality measures to CMS as required by the MIPS APM.
The APM Entity group will not be assessed on cost under MIPS.
MIPS eligible clinicians do not need to report improvement activities data unless
the CMS-assigned improvement activities scores is below the maximum improvement activities score.
CMS will assign the same quality category performance score to each TIN/
NPI in an APM Entity group based on
the APM Entity’s total quality score, derived from available APM quality measures.
N/A ............................................................
Cost ...........................
Improvement Activities.
Advancing Care Information.
Each MIPS eligible clinician in the APM
Entity group reports advancing care information to MIPS through either group
TIN or individual reporting.
We seek comment on the proposed
reweighting for APM Entities
participating in MIPS APMs.
(c) Small Practice Bonus
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(b) Risk Factor Score
Section 1848(q)(1)(G) of the Act
requires us to consider risk factors in
our scoring methodology. Specifically,
that section provides that the Secretary,
on an ongoing basis, shall, as the
Secretary determines appropriate and
based on individuals’ health status and
other risk factors, assess appropriate
adjustments to quality measures, cost
measures, and other measures used
under MIPS and assess and implement
appropriate adjustments to payment
adjustments, final scores, scores for
performance categories, or scores for
measures or activities under the MIPS.
We refer readers to II.C.7.b.(1) of this
proposed rule for a description of the
risk factor adjustment and its
application to APM Entities.
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CMS will assign the same improvement
activities score to each APM Entity
group based on the activities involved
in participation in the MIPS APM.
APM Entities will receive a minimum of
one half of the total possible points. In
the event that the assigned score does
not represent the maximum improvement activities score, the APM Entity
will have the opportunity to report additional improvement activities to add
points to the APM Entity level score.
We will attribute the same score to each
MIPS eligible clinician in the APM Entity group. This score will be the highest
score attributable to the TIN/NPI combination of each MIPS eligible clinician,
which may be derived from either
group or individual reporting. The
scores attributed to each MIPS eligible
clinicians will be averaged for a single
APM Entity score.
We believe an adjustment for eligible
clinicians in small practices (referred to
herein as the small practice bonus) is
appropriate to recognize barriers faced
by small practices, such as unique
challenges related to financial and other
resources, environmental factors, and
access to health information technology,
and to incentivize eligible clinicians in
small practices to participate in the
Quality Payment Program and to
overcome any performance discrepancy
due to practice size.
We refer readers to section II.C.7.b.(2)
of this proposed rule for a discussion of
the small practice adjustment and its
application to APM Entities.
(d) Final Score Methodology
In the CY 2017 Quality Payment
Program final rule, we finalized the
methodology for calculating a final
score of 0–100 based on the four
performance categories (81 FR 77320).
We refer readers to section II.C.7.c. of
this proposed rule for a discussion of
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Performance
category
weight (no advancing care
information)
(%)
0
80
0
0
25
20
75
0
the changes we are proposing for the
final score methodology.
(5) MIPS APM Performance Feedback
In the CY 2017 Quality Payment
Program final rule (81 FR 77270), we
finalized that all MIPS eligible
clinicians scored under the APM
scoring standard will receive
performance feedback as specified
under section 1848(q)(12) of the Act on
the quality and cost performance
categories to the extent applicable,
based on data collected in the
September 2016 QRUR, unless they did
not have data included in the September
2016 QRUR. Those eligible clinicians
without data included in the September
2016 QRUR will not receive any
performance feedback until performance
data is available for feedback.
Beginning with the 2018 performance
year, we propose that MIPS eligible
clinicians whose MIPS payment
adjustment is based on their score under
the APM scoring standard will receive
performance feedback as specified
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mstockstill on DSK30JT082PROD with PROPOSALS2
under section 1848(q)(12) of the Act for
the quality, advancing care information,
and improvement activities performance
categories to the extent data are
available for the MIPS performance
year. Further, we propose that in cases
where performance data are not
available for a MIPS APM performance
category because the MIPS APM
performance category has been weighted
to zero for that performance year, we
would not provide performance
feedback on that MIPS performance
category.
We believe that with an APM Entity’s
finite resources for engaging in efforts to
improve quality and lower costs for a
specified beneficiary population, the
incentives of the APM must take
priority over those offered by MIPS in
order to ensure that the goals and
evaluation associated with the APM are
as clear and free of confounding factors
as possible. The potential for different,
conflicting messages in performance
feedback provided by the APMs and
that provided by MIPS may create
uncertainty for MIPS eligible clinicians
who are attempting to strategically
transform their respective practices and
succeed under the terms of the APM.
Accordingly, under section 1115A(d)(1)
and section 1899(f), for all performance
years we propose to waive—for MIPS
eligible clinicians participating in MIPS
APMs—the requirement under section
1848(q)(12)(A)(i)(I) of the Act to provide
performance feedback for the cost
performance category.
We request comment on these
proposals to waive requirements for
performance feedback on the cost
performance category indefinitely, and
for the other performance categories in
years for which the weight for those
categories has been reweighted to zero.
(6) Summary of Proposals
In summary, we have proposed the
following in this section:
• We propose to amend the regulation
at § 414.1370(e) to identify the four
assessment dates that would be used to
identify the APM Entity group for
purposes of the APM scoring standard,
and to specify that the December 31 date
will be used only to identify eligible
clinicians on the APM Entity’s
Participation List for a MIPS APM that
is a full TIN APM in order to add them
to the APM Entity group that is scored
under the APM scoring standard. We
propose to use this fourth assessment
date of December 31 to extend the APM
scoring standard to only those MIPS
eligible clinicians participating in MIPS
APMs that are full TIN APMs, ensuring
that an eligible clinician who joins the
full TIN APM late in the performance
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year would be scored under the APM
scoring standard.
• We propose to continue to weight
the cost performance category under the
APM scoring standard for Web Interface
reporters at zero percent for the 2020
payment year forward.
• Aligned with our proposal to
weight the cost performance category at
zero percent, we propose not to take
improvement into account for
performance scores in the cost
performance category for Web Interface
reporters beginning with the 2020 MIPS
Payment Year.
• We propose to score the CAHPS for
ACOs survey, in addition to the CMS
Web Interface measures that are used to
calculate the MIPS APM quality
performance category score for Web
Interface reporters including the Shared
Savings Program and Next Generation
ACO Model), beginning in the 2018
performance year.
• We propose that, beginning for the
2018 performance year, eligible
clinicians in MIPS APMs that are Web
Interface reporters may receive bonus
points under the APM scoring standard
for submitting the CAHPS for ACOs
survey.
• We propose to calculate the quality
improvement score for MIPS eligible
clinicians submitting quality measures
via the CMS Web Interface using the
methodology described in section
II.C.7.a.(1)(i).
• We propose to calculate the total
quality percent score for MIPS eligible
clinicians using the CMS Web Interface
according to the methodology described
in section II.C.7.a.(1)(h)(2) of this
proposed rule.
• We propose to establish a separate
MIPS final list of quality measures for
each Other MIPS APM that would be
the quality measure list used for
purposes of the APM scoring standard.
• We propose to calculate the MIPS
quality performance category score for
Other MIPS APMs using MIPS APMspecific quality measures. For purposes
of the APM scoring standard, we would
score only measures that: (1) Are tied to
payment as described under the terms of
the APM, (2) are available for scoring
near the close of the MIPS submission
period, (3) have a minimum of 20 cases
available for reporting, and (4) have an
available benchmark.
• We propose to only use the MIPS
APM quality measure data that are
submitted by the close of the MIPS
submission period and are available for
scoring in time for inclusion to calculate
a MIPS quality performance category
score.
• We propose that, for the APM
scoring standard, the benchmark score
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used for a quality measure would be the
benchmark used in the MIPS APM for
calculation of the performance based
payments, where such a benchmark is
available. If the APM does not produce
a benchmark score for a reportable
measure that is included on the APM
measures list, we would use the
benchmark score for the measure that is
used for the MIPS quality performance
category generally (outside of the APM
scoring standard) for that performance
year, provided the measure
specifications for the measure are the
same under both the MIPS final list and
the APM measures list.
• We propose that the minimum
number of quality measures required to
be reported for the APM scoring
standard would be the minimum
number of quality measures that are
required within the MIPS APM and are
collected and available in time to be
included in the calculation for the APM
Entity score under the APM scoring
standard. We propose that if an APM
Entity submits some, but not all of the
measures required by the MIPS APM by
the close of the MIPS submission
period, the APM Entity would receive
points for the measures that were
submitted, but would receive a score of
zero for each remaining measure
between the number of measures
reported and the number of measures
required by the APM that were available
for scoring.
• We propose that the benchmark
score used for a quality measure would
be the benchmark used by the MIPS
APM for calculation of the performance
based payments within the APM, if
possible, in order to best align the
measure performance outcomes between
the two programs. We are proposing that
for measures that are pay for reporting
or which do not measure performance
on a continuum of performance, we will
consider these measures to be lacking a
benchmark and they will be treated as
such.
• We propose to score quality
measure performance under the APM
scoring standard using a percentile
distribution, separated by decile
categories, as described in the finalized
MIPS quality scoring methodology. We
propose to use a graduated pointsassignment approach, where a measure
is assigned a continuum of points out to
one decimal place, based on its place in
the decile.
• We propose that each APM Entity
that reports on quality measures would
receive between 1 and 10 achievement
points for each measure reported that
can be reliably scored against a
benchmark, up to the number of
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measures that are required to be
reported by the APM.
• We propose that APM Entities in
MIPS APMs, like other MIPS eligible
clinicians, would be eligible to receive
bonus points for the MIPS quality
performance category for reporting on
high priority measures or measures
submitted via CEHRT. For each Other
MIPS APM, we propose to identify
whether any of their available measures
meets the criteria to receive a bonus,
and add the bonus points to the quality
achievement points.
• Beginning in the 2018 performance
year, we propose to score improvement
as well as achievement in the quality
performance category. For the APM
scoring standard, we propose that the
improvement percentage points would
be awarded based on the following
formula:
Quality Improvement Score = (Absolute
Improvement/Previous Year Quality
Performance Category Percent Score
Prior to Bonus Points)/10.
• We propose that the APM Entity’s
total quality performance category score
would be equal to [(achievement points
+ bonus points)/total available
achievement points] + quality
improvement score.
• Under the APM scoring standard,
we propose that if a MIPS eligible
clinician who qualifies for a zero
percent weighting of the advancing care
information performance category in the
final score is part of a TIN that includes
one or more MIPS eligible clinicians
who do not qualify for a zero percent
weighting, we would not apply the zero
percent weighting to the qualifying
MIPS eligible clinician, and the TIN
would still be required to report on
behalf of the group, although the TIN
would not need to report data for the
qualifying MIPS eligible clinician.
• We propose to maintain the cost
performance category weight of zero for
Other MIPS APMs under the APM
scoring standard for the 2020 MIPS
payment year and subsequent MIPS
payment years. Because the cost
performance category would be
reweighted to zero that weight would
need to be redistributed to other
performance categories. We propose to
align the Other MIPS APM performance
category weights with those proposed
for Web Interface reporters and weight
the quality performance category to 50
percent, the improvement activities
performance category to 20 percent, and
the advancing care information
performance category to 30 percent of
the APM Entity final score.
• It is possible that none of the Other
MIPS APM’s measures would be
available for calculating a quality
performance category score by or shortly
after the close of the MIPS submission
period, for example, due to changes in
clinical practice guidelines. In addition,
the MIPS eligible clinicians in an APM
Entity may qualify for a zero percent
weighting for the advancing care
information performance category. In
such instances, under the APM scoring
standard, we propose to reweight the
affected performance category to zero.
• Beginning with the 2018
performance year, we propose that MIPS
eligible clinicians whose MIPS payment
adjustment is based on their score under
the APM scoring standard will receive
performance feedback as specified
under section 1848(q)(12) of the Act for
the quality, advancing care information,
and improvement activities performance
categories to the extent data are
available for the MIPS performance
year. Further, we propose that in cases
where the MIPS APM performance
category has been weighted to zero for
that performance year, we would not
provide performance feedback on that
MIPS performance category.
The following tables represent the
measures being introduced for notice
and comment, and would serve as the
measure set used by participants in the
identified MIPS APMs in order to create
a MIPS score under the APM scoring
standard, as described in section
II.C.6.g.(3)(b)(ii)(A) of this proposed
rule. Once this list is finalized, no
measures may be added to this list.
TABLE 14—MIPS APM MEASURES LIST—ONCOLOGY CARE MODEL
NQF/Quality
number
(if applicable)
National quality strategy
domain
Measure description
Risk-adjusted proportion of
patients with all-cause
hospital admissions within
the 6-month episode.
Risk-adjusted proportion of
patients with all-cause ED
visits or observation stays
that did not result in a
hospital admission within
the 6-month episode.
Proportion of patients who
died who were admitted
to hospice for 3 days or
more.
Oncology: Medical and Radiation—Pain Intensity
Quantified.
NA ................
Effective Clinical Care .........
Percentage of OCM-attributed FFS beneficiaries who
were had an acute-care hospital stay during the
measurement period.
NA ................
Effective Clinical Care .........
Percentage of OCM-attributed FFS beneficiaries who
had an ER visit that did not result in a hospital stay
during the measurement period.
NA ................
Effective Clinical Care .........
Percentage of OCM-attributed FFS beneficiaries who
died and spent at least 3 days in hospice during the
measurement time period.
NA
0384/143 ......
Person and Caregiver Centered Experience.
Physician Consortium for
Performance Improvement Foundations (PCPI).
Oncology: Medical and Radiation—Plan of Care for
Pain.
0383/144 ......
Person and Caregiver Centered Experience.
Preventive Care and
Screening: Screening for
Depression and FollowUp Plan.
0418/134 ......
Community/Population
Health.
Percentage of patient visits, regardless of patient age,
with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is
quantified.
Percentage of visits for patients, regardless of age, with
a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain
with a documented plan of care to address pain.
Percentage of patients aged 12 and older screened for
depression on the date of the encounter using an age
appropriate standardized depression screening tool
AND if positive, a follow-up plan is documented on the
date of the positive screen.
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NA
American Society of Clinical
Oncology.
Centers for Medicare &
Medicaid Services.
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TABLE 14—MIPS APM MEASURES LIST—ONCOLOGY CARE MODEL—Continued
NQF/Quality
number
(if applicable)
National quality strategy
domain
Measure description
Patient-Reported Experience of Care.
NA ................
Person and Caregiver Centered Experience.
NA
Prostate Cancer: Adjuvant
Hormonal Therapy for
High or Very High Risk
Prostate Cancer.
0390/104 ......
Effective Clinical Care .........
Adjuvant chemotherapy is
recommended or administered within 4 months
(120 days) of diagnosis to
patients under the age of
80 with AJCC III (lymph
node positive) colon cancer.
Combination chemotherapy
is recommended or administered within 4
months (120 days) of diagnosis for women under
70 with AJCC T1cN0M0,
or Stage IB—III hormone
receptor negative breast
cancer.
Trastuzumab administered
to patients with AJCC
stage I (T1c)—III and
human epidermal growth
factor receptor 2 (HER2)
positive breast cancer
who receive adjuvant
chemotherapy.
Breast Cancer: Hormonal
Therapy for Stage I
(T1b)—IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive
Breast Cancer.
Documentation of Current
Medications in the Medical Record.
0223 .............
Communication and Care
Coordination.
Summary/Survey Measures may include:
—Overall measure of patient experience ..................
—Exchanging Information with Patients ...................
—Access ....................................................................
—Shared Decision Making ........................................
—Enabling Self-Management ....................................
—Affective Communication .......................................
Percentage of patients, regardless of age, with a diagnosis of prostate cancer at high or very high risk of recurrence receiving external beam and radiotherapy to
the prostate who were prescribed adjuvant hormonal
therapy (GnRH [gonadotropin releasing hormone]
agonist or antagonist).
Percentage of patients under the age of 80 with AJCC
III (lymph node positive) colon cancer for whom adjuvant chemotherapy is recommended and not received
or administered within 4 months (120 days) of diagnosis.
0559 .............
Communication and Care
Coordination.
Percentage of female patients, age >18 at diagnosis,
who have their first diagnosis of breast cancer
(epithelial malignancy), at AJCC stage T1cN0M0
(tumor greater than 1 cm), or Stage IB—III, whose primary tumor is progesterone and estrogen receptor
negative recommended for multiagent chemotherapy
(recommended or administered) within 4 months (120
days) of diagnosis.
Commission on Cancer,
American College of Surgeons.
1858/450 ......
Efficiency and Cost Reduction.
Proportion of female patients (aged 18 years and older)
with AJCC stage I (Tlc)—Ill, human epidermal growth
factor receptor 2 (HER2) positive breast cancer receiving adjuvant chemotherapy.
American Society of Clinical
Oncology.
0387 .............
Communication and Care
Coordination.
Percentage of female patients aged 18 years and older
with Stage I (T1b) through IIIC, ER or PR positive
breast cancer who were prescribed tamoxifen or
aromatase inhibitor (AI) during the 12-month reporting
period.
AMA-convened Physician
Consortium for Performance Improvement.
0419/130 ......
Patient Safety ......................
Percentage of visits for patients aged 18 years and older
for which the eligible clinician attests to documenting a
list of current medications using all immediate resources available on the date of the encounter. This
list must include ALL known prescriptions, over-the
counters, herbals, and vitamin/mineral/dietary AND
must contain the medications’ name, dosage, frequency and route of administration.
Centers for Medicare &
Medicaid Services.
Measure name
Primary measure steward
American Urological Association Education and Research.
Commission on Cancer,
American College of Surgeons.
TABLE 15—MIPS APM MEASURES LIST—COMPREHENSIVE ESRD CARE
NQF/Quality
number
(if applicable)
National quality strategy
domain
Measure description
ESCO Standardized Mortality Ratio.
0101/154 ......
Patient Safety ......................
Falls: Screening, Risk Assessment and Plan of
Care to Prevent Future
Falls.
Advance Care Plan .............
0101/154 ......
Communication and Coordination.
0326/47 ........
Patient Safety ......................
Falls: Risk Assessment: Percentage of patients aged 65
years and older with a history of falIs who had a risk
assessment for falls completed within for Quality 12
months.
Falls: Risk Assessment: Percentage of patients aged 65
years and older with a history of falIs who had a risk
assessment for falls completed within for Quality 12
months.
Percentage of patients aged 65 years and older who
have an advance care plan or surrogate decision
maker documented in the medical record or documentation in the medical record that an advance care
plan was discussed but the patient did not wish or
was not able to name a surrogate decision maker or
provide an advance care plan.
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National Committee for
Quality Assurance.
National Committee for
Quality Assurance.
National Committee for
Quality Assurance.
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TABLE 15—MIPS APM MEASURES LIST—COMPREHENSIVE ESRD CARE—Continued
NQF/Quality
number
(if applicable)
National quality strategy
domain
Measure description
ICH-CAHPS: Nephrologists’
Communication and Caring.
0258 .............
Person and Caregiver Centered Experience and
Outcome.
ICH-CAHPS: ICH-CAHPS:
Rating of Dialysis Center.
0258 .............
Person and Caregiver Centered Experience and
Outcome.
ICH-CAHPS: Quality of Dialysis Center Care and
Operations.
0258 .............
.............................................
ICH-CAHPS: Providing Information to Patients.
0258 .............
.............................................
ICH-CAHPS: Rating of Kidney Doctors.
0258 .............
.............................................
ICH-CAHPS: Rating of Dialysis Center Staff.
ICH-CAHPS: Rating of Dialysis Center.
0258 .............
.............................................
Medication Reconciliation
Post Discharge.
0554 .............
Communication and Care
Coordination.
Diabetes Care: Eye Exam ...
0055/117 ......
Effective Clinical Care .........
Diabetes Care: Foot Exam ..
0056/163 ......
Effective Clinical Care .........
Influenza Immunization for
the ESRD Population.
0041/110,
0226.
Community/Population
Health.
Pneumococcal Vaccination
Status.
0043/111 ......
Community/Population
Health.
Summary/Survey Measures may include:
—Getting timely care, appointments, and information.
—How well providers communicate ..........................
—Patients’ rating of provider .....................................
—Access to specialists ..............................................
—Health promotion and education ............................
—Shared decision-making ........................................
—Health status and functional status .......................
—Courteous and helpful office staff ..........................
—Care coordination ...................................................
—Between visit communication ................................
—Helping you to take medications as directed, and
—Stewardship of patient resources ..........................
Comparison of services and quality of care that dialysis
facilities provide from the perspective of ESRD patients receiving in-center hemodialysis care. Patients
will assess their dialysis providers, including
nephrologists and medical and non-medical staff, the
quality of dialysis care they receive, and information
sharing about their disease.
Comparison of services and quality of care that dialysis
facilities provide from the perspective of ESRD patients receiving in-center hemodialysis care. Patients
will assess their dialysis providers, including
nephrologists and medical and non-medical staff, the
quality of dialysis care they receive, and information
sharing about their disease.
Comparison of services and quality of care that dialysis
facilities provide from the perspective of ESRD patients receiving in-center hemodialysis care. Patients
will assess their dialysis providers, including
nephrologists and medical and non-medical staff, the
quality of dialysis care they receive, and information
sharing about their disease.
Comparison of services and quality of care that dialysis
facilities provide from the perspective of ESRD patients receiving in-center hemodialysis care. Patients
will assess their dialysis providers, including
nephrologists and medical and non-medical staff, the
quality of dialysis care they receive, and information
sharing about their disease.
Comparison of services and quality of care that dialysis
facilities provide from the perspective of ESRD patients receiving in-center hemodialysis care. Patients
will assess their dialysis providers, including
nephrologists and medical and non-medical staff, the
quality of dialysis care they receive, and information
sharing about their disease.
The percentage of discharges from any inpatient facility
(e.g. hospital, skilled nursing facility, or rehabilitation
facility) for patients 18 years of age and older seen
within 30 days following the discharge in the office by
the physicians, prescribing practitioner, registered
nurse, or clinical pharmacist providing on-going care
for whom the discharge medication list was reconciled
with the current medication list in the outpatient medical record. This measure is reported as three rates
stratified by age group:
• Reporting Criteria 1: 18–64 years of age.
• Reporting Criteria 2: 65 years and older.
• Total Rate: All patients 18 years of age and Older.
Percentage of patients 18–75 years of age with diabetes
who had a retinal or dilated eye exam by an eye care
professional during the measurement period or a negative retinal exam (no evidence of retinopathy) in the
12 months prior to the measurement period.
Percentage of patients 18–75 years of age with diabetes
(type 1 and type 2) who received a foot exam (visual
inspection and sensory exam with mono filament and
a pulse exam) during the previous measurement year.
Percentage of patients aged 6 months and older seen
for a visit between October 1 and March 31 who received an influenza immunization OR who reported
previous receipt of an influenza immunization.
Percentage of patients 65 years of age and older who
have ever received a pneumococcal vaccine.
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Primary measure steward
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Agency for Healthcare Research and Quality.
Agency for Healthcare Research and Quality.
Agency for Healthcare Research and Quality.
Agency for Healthcare Research and Quality.
Agency for Healthcare Research and Quality.
Agency for Healthcare Research and Quality.
National Committee for
Quality Assurance.
National Committee for
Quality Assurance.
National Committee for
Quality Assurance.
Kidney Care Quality Alliance (KCQA).
National Committee for
Quality Assurance.
30094
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TABLE 15—MIPS APM MEASURES LIST—COMPREHENSIVE ESRD CARE—Continued
NQF/Quality
number
(if applicable)
Measure name
National quality strategy
domain
Screening for Clinical Depression and Follow-Up
Plan.
0418/134 ......
Community/Population
Health.
Tobacco Use: Screening
and Cessation Intervention.
0028/226 ......
Community/Population
Health.
Measure description
Primary measure steward
Percentage of patients aged 12 and older screened for
depression on the date of the encounter and using an
age appropriate standardized depression screening
tool AND if positive, a follow-up plan is documented
on the date of the positive screen.
Percentage of patients aged 18 years and older who
were screened for tobacco use one or more times
within 24 months AND who received cessation counseling intervention if identified as a tobacco user.
Centers for Medicare and
Medicaid Services.
Physician Consortium for
Performance Improvement Foundations (PCPI).
TABLE 16—MIPS APM MEASURES LIST—COMPREHENSIVE PRIMARY CARE PLUS (CPC+)
NQF/Quality
number
(if applicable)
National quality strategy
domain
Measure description
Depression Remission at
Twelve Months.
0710/370 ......
Effective Clinical Care .........
Controlling High Blood Pressure.
0018/236 ......
Effective Clinical Care .........
Diabetes: Eye Exam ............
0055/117 ......
Effective Clinical Care .........
Diabetes: Hemoglobin A1c
(HbA1c) Poor Control
(>9%).
Use of High-Risk Medications in the Elderly.
0059/001 ......
Effective Clinical Care .........
0022/238 ......
Patient Safety ......................
Dementia: Cognitive Assessment.
NA/281 .........
Effective Clinical Care .........
Falls: Screening for Future
Fall Risk.
0101/318 ......
Patient Safety ......................
Initiation and Engagement
of Alcohol and Other Drug
Dependence Treatment.
0004/305 ......
Effective Clinical Care .........
Closing the Referral Loop:
Receipt of Specialist Report.
Cervical Cancer Screening
NA/374 .........
Communication and Care
Coordination.
0032/309 ......
Effective Clinical Care .........
0034/113 ......
Effective Clinical Care .........
0028/226 ......
Community/Population
Health.
Patients age 18 and older with major depression or
dysthymia and an initial Patient Health Questionnaire
(PHQ–9) score greater than nine who demonstrate remission at twelve months (+/¥ 30 days after an index
visit) defined as a PHQ–9 score less than five. This
measure applies to both patients with newly diagnosed and existing depression whose current PHQ–9
score indicates a need for treatment.
Percentage of patients 18–85 years of age who had a
diagnosis of hypertension and whose blood pressure
was adequately controlled (<140/90 mmHg) during the
measurement period.
Percentage of patients 18–75 years of age with diabetes
who had a retinal or dilated eye exam by an eye care
professional during the measurement period or a negative retinal exam (no evidence of retinopathy) in the
12 months prior to the measurement period.
Percentage of patients 18–75 years of age with diabetes
who had hemoglobin A1c >9.0% during the measurement period.
Percentage of patients 66 years of age and older who
were ordered high-risk medications. Two rates are reported.
a. Percentage of patients who were ordered at least
one high-risk medication.
b. Percentage of patients who were ordered at least
two different high-risk medications.
Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least
once within a 12-month period.
Percentage of patients 65 years of age and older who
were screened for future fall risk at least once during
the measurement period.
Percentage of patients 13 years of age and older with a
new episode of alcohol and other drug (AOD) dependence who received the following. Two rates are reported.
a. Percentage of patients who initiated treatment
within 14 days of the diagnosis.
b. Percentage of patients who initiated treatment
and who had two or more additional services with
an AOD diagnosis within 30 days of the initiation
visit.
Percentage of Patients with referrals, regardless of age,
for which the referring provider receives a report from
the provider to whom the patient was referred.
Percentage of women 21–64 years of age, who were
screened for cervical cancer using either of the following criteria.
• Women age 21–64 who had cervical cytology
performed every 3 years.
• Women age 30–64 who had cervical cytology/
human papillomavirus (HPV) co-testing performed
every 5 years.
Percentage of patients, 50–75 years of age who had appropriate screening for colorectal cancer.
Percentage of patients aged 18 years and older who
were screened for tobacco use one or more times
within 24 months AND who received cessation counseling intervention if identified as a tobacco user.
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Colorectal Cancer Screening.
Preventive Care and
Screening: Tobacco Use:
Screening and Cessation
Intervention.
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Primary measure steward
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Minnesota Community
Measurement
National Committee for
Quality Assurance
National Committee for
Quality Assurance
National Committee for
Quality Assurance
National Committee for
Quality Assurance
Physician Consortium for
Performance Improvement Foundation (PCPI)
National Committee for
Quality Assurance
National Committee for
Quality Assurance
Centers for Medicare and
Medicaid Services
National Committee for
Quality Assurance
National Committee for
Quality Assurance
Physician Consortium for
Performance Improvement Foundations (PCPI)
30095
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TABLE 16—MIPS APM MEASURES LIST—COMPREHENSIVE PRIMARY CARE PLUS (CPC+)—Continued
NQF/Quality
number
(if applicable)
National quality strategy
domain
Measure description
Breast Cancer Screening ....
2372/112 ......
Effective Clinical Care .........
Preventive Care and
Screening: Influenza Immunization.
0041/110 ......
Community/Population
Health.
Pneumonia Vaccination Status for Older Adults.
Diabetes: Medical Attention
for Nephropathy.
0043/111 ......
0062/119 ......
Community/Population
Health.
Effective Clinical Care .........
Ischemic Vascular Disease
(IVD): Use of Aspirin or
Another.
0068/204 ......
Effective Clinical Care .........
Hypertension: Improvement
in Blood Pressure.
NA/373 .........
Effective Clinical Care .........
Preventive Care and
Screening: Screening for
Depression and FollowUp Plan.
0418/134 ......
Community/Population
Health.
Diabetes: Foot Exam ...........
0056/163 ......
Effective Clinical Care .........
Statin Therapy for the Prevention and Treatment of
Cardiovascular Disease.
NA/438 .........
Not provided in the measure
Inpatient Hospital Utilization
(IHU).
NA ................
.............................................
Emergency Department Utilization (EDU).
NA ................
.............................................
Preventive Care and
Screening: Body Mass
Index (BMI) Screening
and Follow-Up Plan.
0421 .............
Community/Population
Health.
CAHPS ................................
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Measure name
CPC+ specific; different than
CAHPS for
MIPS.
.............................................
Percentage of women 50–74 years of age who had a
mammogram to screen for breast cancer.
Percentage of patients aged 6 months and older seen
for a visit between October 1 and March 31 who received an influenza immunization OR who reported
previous receipt of an influenza immunization.
Percentage of patients 65 years of age and older who
have ever received a pneumococcal vaccine.
The percentage of patients 18–75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period.
Percentage of patients 18 years of age and older who
were diagnosed with acute myocardial infarction
(AMI), coronary artery bypass graft (CABG) or
percutaneous coronary interventions (PCI) in the 12
months prior to the measurement period, or who had
an active diagnosis of ischemic vascular disease (IVD)
during the measurement period, and who had documentation of use of aspirin or another antiplatelet during the measurement period.
Percentage of patients aged 18–85 years of age with a
diagnosis of hypertension whose blood pressure improved during the measurement period.
Percentage of patients aged 12 years and older
screened for depression on the date of the encounter
using an age appropriate standardized depression
screening tool AND if positive, a follow-up plan is documented on the date of the positive screen.
The percentage of patients 18–75 years of age with diabetes (type 1 and type 2) who received a foot exam
(visual inspection and sensory exam with mono filament and a pulse exam) during the measurement year.
Percentage of the following patients—all considered at
high risk of cardiovascular events—who were prescribed or were on statin therapy during the measurement period:
* Adults aged ≥21 years who were previously diagnosed with or currently have an active diagnosis
of clinical atherosclerotic cardiovascular disease
(ASCVD); OR
* Adults aged ≥21 years who have ever had a fasting or direct low-density lipoprotein cholesterol
(LDL-C) level ≥190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia; OR
* Adults aged 40–75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70–
189 mg/dL.
For members 18 years of age and older, the risk-adjusted ratio of observed to expected acute inpatient
discharges during the measurement year reported by
Surgery, Medicine, and Total.
For members 18 years of age and older, the risk-adjusted ratio of observed to expected emergency department (ED) visits during the measurement year.
Percentage of patients aged 18 years and older with a
BMI documented during the current encounter or during the previous six months AND with a BMI outside
of normal parameters, a follow-up plan is documented
during the encounter or during the previous six
months of the current encounter. Normal Parameters:
Age 18 years and older BMI ≥18.5 and <25 kg/m2.
CG-CAHPS Survey 3.0 ....................................................
7. MIPS Final Score Methodology
For the 2020 MIPS payment year, we
intend to build on the scoring
methodology we finalized for the
transition year, which allows for
accountability and alignment across the
performance categories and minimizes
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burden on MIPS eligible clinicians,
while continuing to prepare MIPS
eligible clinicians for the performance
threshold required for the 2021 MIPS
payment year. Our rationale for our
scoring methodology continues to be
grounded in the understanding that the
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Primary measure steward
National Committee for
Quality Assurance
PCPI(R) Foundation
(PCPI[R])
National Committee for
Quality Assurance
National Committee for
Quality Assurance
National Committee Quality
Assurance
Centers for Medicare &
Medicaid Services (CMS)
Centers for Medicare &
Medicaid Services (CMS)
National Committee for
Quality Assurance
Quality Insights
National Committee for
Quality Assurance
National Committee for
Quality Assurance
Centers for Medicare &
Medicaid Services (CMS)
AHRQ
MIPS scoring system has many
components and numerous moving
parts.
As we continue to move forward in
implementing the MIPS program, we
strive to balance the statutory
requirements and programmatic goals
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with the ease of use, stability, and
meaningfulness for MIPS eligible
clinicians, while also emphasizing
simplicity and scoring that is
understandable for MIPS eligible
clinicians. In this section, we propose
refinements to the performance
standards, the methodology for
determining a score for each of the four
performance categories (the
‘‘performance category score’’), and the
methodology for determining a final
score based on the performance category
scores.
We intend to continue the transition
of MIPS by proposing the following
policies:
• Continuation of many transition
year scoring policies in the quality
performance category, with an
adjustment to the number of
achievement points available for
measures that fail to meet the data
completeness criteria, to encourage
MIPS eligible clinician to meet data
completeness while providing an
exception for small practices;
• An improvement scoring
methodology that rewards MIPS eligible
clinicians who improve their
performance in the quality and cost
performance categories;
• A new scoring option for the quality
and cost performance categories that
allows facility-based MIPS eligible
clinicians to be scored based on their
facility’s performance;
• Special considerations for MIPS
eligible clinicians in small practices or
those who care for complex patients;
and
• Policies that allow multiple
pathways for MIPS eligible clinicians to
receive a neutral to positive MIPS
payment adjustment.
We believe these sets of proposed
policies will help clinicians smoothly
transition from the transition year to the
2021 MIPS payment year, for which the
performance threshold (which
represents the final score that would
earn a neutral MIPS adjustment) will be
either the mean or median (as selected
by the Secretary) of the MIPS final
scores for all MIPS eligible clinicians
from a previous period specified by the
Secretary.
Unless otherwise noted, for purposes
of this section II.C.7. on scoring, the
term ‘‘MIPS eligible clinician’’ will refer
to MIPS eligible clinicians that submit
data and are scored at either the
individual- or group-level, including
virtual groups, but will not refer to
MIPS eligible clinicians who elect
facility-based scoring. The scoring rules
for facility-based measurement are
discussed in section II.C.7.a.(4). of this
proposed rule. We also note that the
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APM scoring standard applies to APM
Entities in MIPS APMs, and those
policies take precedence where
applicable; however, where those
policies do not apply, scoring for MIPS
eligible clinicians as described in this
section II.C.7. on scoring will apply. We
refer readers to section II.C.6.g. of this
proposed rule for additional information
about the APM scoring standard.
a. Converting Measures and Activities
Into Performance Category Scores
(1) Policies That Apply Across Multiple
Performance Categories
The detailed policies and proposals
for scoring the four performance
categories are described in detail in
section II.C.7.a. of this proposed rule.
However, as the four performance
categories collectively create a single
MIPS final score, there are several
policies that apply across categories,
which we discuss in section II.C.7.a.(1)
of this proposed rule.
(a) Performance Standards
In accordance with section 1848(q)(3)
of the Act, in the CY 2017 Quality
Payment Program final rule, we
finalized performance standards for the
four performance categories. We refer
readers to the CY 2017 Quality Payment
Program final rule for a description of
the performance standards against
which measures and activities in the
four performance categories are scored
(81 FR 77271 through 77272).
As discussed in section
II.C.7.a.(1)(b)(i) of this proposed rule, we
are proposing to add an improvement
scoring standard to the quality and cost
performance categories starting for the
2020 MIPS payment year.
(b) Policies Related to Scoring
Improvement
(i) Background
In accordance with section
1848(q)(5)(D)(i) of the Act, beginning
with the 2020 MIPS payment year, if
data sufficient to measure improvement
are available, the final score
methodology shall take into account
improvement of the MIPS eligible
clinician in calculating the performance
score for the quality and cost
performance categories and may take
into account improvement for the
improvement activities and advancing
care information performance
categories. In addition, section
1848(q)(3)(B) of the Act provides that
the Secretary, in establishing
performance standards for measures and
activities for the MIPS performance
categories, shall consider: Historical
performance standards; improvement;
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and the opportunity for continued
improvement. Section 1848(q)(5)(D)(ii)
of the Act also provides that
achievement may be weighted higher
than improvement.
In the CY 2017 Quality Payment
Program final rule, we summarized
public comments received on the
proposed rule regarding potential ways
to incorporate improvement into the
scoring methodology moving forward,
including approaches based on
methodologies used in the Hospital VBP
Program, the Shared Savings Program,
and Medicare Advantage 5-star Ratings
Program (81 FR 77306 through 77308).
We did not finalize a policy at that time
on this topic and indicated we would
take comments into account in
developing a proposal for future
rulemaking.
When considering the applicability of
these programs to MIPS, we looked at
the approach that was used to measure
improvement for each of the programs
and how improvement was incorporated
into the overall scoring system. An
approach that focuses on measure-level
comparison enables a more granular
assessment of improvement because
performance on a specific measure can
be considered and compared from year
to year. All options that we considered
last year use a standard set of measures
that do not provide for choice of
measures to assess performance;
therefore, they are better structured to
compare changes in performance based
on the same measure from year to year.
The aforementioned programs do not
use a category-level approach; however,
we believe that a category-level
approach would provide a broader
perspective, particularly in the absence
of a standard set of measures, because
it would allow for a more flexible
approach that enables MIPS eligible
clinicians to select measures and data
submission mechanisms that can change
from year to year and be more
appropriate to their practice in a given
year.
We believe that both approaches are
viable options for measuring
improvement. Accordingly, we believe
that an appropriate approach for
measuring improvement for the quality
performance category and the cost
performance category should consider
the unique characteristics of each
performance category rather than
necessarily applying a uniform
approach across both performance
categories. For the quality performance
category, clinicians are offered a variety
of different measures which can be
submitted by different mechanisms,
rather than a standard set of measures
or a single data submission mechanism.
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For the cost performance category,
however, clinicians are scored on the
same set of cost measures to the extent
each measure is applicable and
available to them; clinicians cannot
choose which cost measures they will
be scored on. In addition, all of the cost
measures are derived from
administrative claims data with no
additional submission required by the
clinician.
When considering the applicability of
these programs to MIPS, we also
considered how scoring improvement is
incorporated into the overall scoring
system, including when only
achievement or improvement is
incorporated into a final score or when
improvement and achievement are both
incorporated into a final score.
We considered whether we could
adapt the Hospital VBP Program’s
general approach for assessing
improvement to MIPS and note that
many commenters, in response to the
CY 2017 Quality Payment Program
proposed rule, recommended this
methodology for MIPS because it is
familiar to the health care community.
However, we decided that the Hospital
VBP Program’s improvement scoring
methodology, which compares changes
in performance based on the same
measure from year to year, is not fully
translatable to MIPS for the quality
performance category and the cost
performance category. The scoring
methodology used to assess
achievement in the Hospital VBP
Program, as required by section
1886(o)(5)(B)(ii) of the Act, does not
reward points for achievement in the
same method as MIPS, because
hospitals that fall below the
achievement threshold (the median
performance during the benchmark
period) are not awarded achievement
points. We refer readers to the Hospital
Inpatient VBP Program Final Rule (76
FR 26516 through 26525) for additional
discussion of the Hospital VBP
Program’s scoring methodology. In
addition, the Hospital VBP Program
requires the use of either the
achievement score or the improvement
points, but not both, for the Program’s
performance scoring calculation.
Adopting the Hospital VBP Program
method for MIPS would require
significant changes to the scoring
methodology used for the quality and
cost performance categories. For the
quality performance category, there are
a wide variety of measures available in
MIPS, and clinicians have flexibility in
selecting measures and submission
mechanisms, with the potential for
clinicians to select different measures
from year to year, which would affect
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our ability to capture performance
changes at the measure level.
We continue to believe that flexibility
for clinicians to select meaningful
measures is appropriate for MIPS,
especially for the quality performance
category. The Hospital VBP Program
methodology, which relies on consistent
measures from year to year in order to
track improvement, would limit our
ability to measure improvement in
MIPS.
We also considered adopting the
Shared Savings Program’s approach for
assessing improvement, where
participants can receive bonus points
for improving on quality measures over
time. The Shared Savings Program
methodology could be adopted without
an underlying change to the scoring of
achievement in the quality and cost
performance categories with an
approach that considers both
achievement and improvement in its
overall scoring calculation and would
align MIPS and the Shared Savings
Program. However, we believe that the
Shared Savings Program’s improvement
methodology would not be appropriate
for the MIPS quality performance
category because we are again
concerned about the wide variety of
quality measures available in MIPS and
the flexibility clinicians have in
selecting measures and submission
mechanisms that could affect our ability
to capture performance changes at the
measure level. We seek to balance a
system that allows for meaningful
measurement to clinicians and
accommodates the various practice
types by allowing for a choice of
measures and submission mechanisms
that may differ from year to year for the
quality performance category. However,
as we discuss in section II.C.7.a.(3)(a) of
this proposed rule, we do believe the
Shared Savings Program measure level
methodology could be translated for
cost measures in the cost performance
category.
Finally, we also considered adopting
the Medicare Advantage Program’s 5Star Rating approach for assessing
improvement, where Medicare
Advantage contracts are rated on quality
and performance measures. Under this
approach, we would identify an overall
‘‘improvement measure score’’ by
comparing the underlying numeric data
for measures from the prior year with
the data from measures for the
performance period. To obtain an
‘‘improvement measure score’’ MIPS
eligible clinicians would need to have
data for both years in at least half of the
required measures for the quality
performance category (81 FR 77307). We
are again concerned that the wide
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variety of measures available in MIPS
and the flexibility clinicians have in
selecting different measures and
submission mechanisms from year to
year could affect our ability to capture
performance changes at the measure
level, particularly for the quality
performance category. Accordingly, we
do not believe this is an appropriate
approach for the quality performance
category. Although this approach could
be considered for the cost performance
category, we believe that the Shared
Savings Program is more analogous to
MIPS and that the improvement
methodology used in that program is
one with which more stakeholders in
MIPS would be familiar.
After taking all of this into
consideration, we are proposing two
different approaches for scoring
improvement from year to year. As
described in section II.C.7.a.(2)(i)(i) of
this proposed rule, we are proposing to
measure improvement at the
performance category level for the
quality performance category score.
Because clinicians can elect the
submission mechanisms and quality
measures that are most meaningful to
their practice, and these choices can
change from year to year, we want a
flexible methodology that allows for
improvement scoring even when the
quality measures change. This is
particularly important as we encourage
MIPS eligible clinicians to move away
from topped out measures and toward
more outcome measures. We do not
want the flexibility that is offered to
MIPS eligible clinicians in the quality
performance category to limit clinicians’
ability to move towards outcome
measures, or limit our ability to measure
improvement. Our proposal for taking
improvement into account as part of the
quality performance category score is
addressed in detail in sections
II.C.7.a.(2)(i) through II.C.7.a.(2)(j) of
this proposed rule.
We believe that there is reason to
adopt a different methodology for
scoring improvement for the cost
performance category from that used for
the quality performance category. In
contrast to the quality performance
category, for the cost performance
category, MIPS eligible clinicians do not
have a choice in measures or
submission mechanisms; rather, all
MIPS eligible clinicians are assessed on
all measures based on the availability
and applicability of the measure to their
practice, and all measures are derived
from administrative claims data.
Therefore, for the cost performance
category, we propose in section
II.C.7.a.(3)(a)(i) of this proposed rule to
measure improvement at the measure
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level. We also note, that while we are
statutorily required to measure
improvement for the cost performance
category beginning with the second
MIPS payment year if data sufficient to
measure improvement is available, we
are also proposing at II.C.6.d.(2) of this
proposed rule to weight the cost
performance category at zero percent for
the 2018 MIPS performance period/2020
MIPS payment year. Therefore, the
improvement score for the cost
performance category would not affect
the MIPS final score for the 2018 MIPS
performance period/2020 MIPS
payment year and would be for
informational purposes only.
We are not proposing to score
improvement in the improvement
activities performance category or the
advancing care information performance
category at this time, though we may
address improvement scoring for these
performance categories in future
rulemaking.
We propose to amend
§ 414.1380(a)(1)(i) to add that
improvement scoring is available for
performance in the quality performance
category and for the cost performance
category at § 414.1380(a)(1)(ii) beginning
with the 2020 MIPS payment year.
We invite public comment on our
proposals to score improvement for the
quality and cost performance categories
starting with the 2020 MIPS payment
year.
(ii) Data Sufficiency Standard To
Measure Improvement
Section 1848(q)(5)(D)(i) of the Act
requires us to measure improvement for
the quality and cost performance
categories of MIPS if data sufficient to
measure improvement are available,
which we interpret to mean that we
would measure improvement when we
can identify data from a current
performance period that can be
compared to data from a prior
performance period or data that
compares performance from year to
year. In section II.C.7.a.(2)(i)(ii) of this
proposed rule, we propose for the
quality performance category that we
would measure improvement when data
are available because there is a
performance category score for the prior
performance period. In section
II.C.7.a.(3)(a)(i) of this proposed rule, we
propose for the cost performance
category that we would measure
improvement when data are available
which is when there is sufficient case
volume to provide measurable data on
measures in subsequent years with the
same identifier. We refer readers to the
noted sections for details on these
proposals.
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(c) Scoring Flexibility for ICD–10
Measure Specification Changes During
the Performance Period
The quality and cost performance
categories rely on measures that use
detailed measure specifications that
include ICD–10–CM/PCS (‘‘ICD–10’’)
code sets. We annually issue new ICD–
10 coding updates, which are effective
from October 1, through September 30
(https://www.cms.gov/Medicare/Coding/
ICD10/ICD10Ombudsmanand
ICD10CoordinationCenterICC.html). As
part of this update, codes are added as
well as removed from the ICD–10 code
set.
To provide scoring flexibility for
MIPS eligible clinicians and groups for
measures impacted by ICD–10 coding
changes in the final quarter of the
Quality Payment Program performance
period—which may render the measures
no longer comparable to the historical
benchmark—we propose at
§ 414.1380(b)(1)(xviii) and
§ 414.1320(c)(2) to provide that we will
assess performance on measures
considered significantly impacted by
ICD–10 updates based only on the first
9 months of the 12-month performance
period (for example, January 1, 2018
through September 30, 2018, for the
2018 MIPS performance period). We
believe it would be appropriate to assess
performance for significantly impacted
measures based on the first 9 months of
the performance period, rather than the
full 12 months, because the indicated
performance for the last quarter could
be affected by the coding changes rather
than actual differences in performance.
Performance on measures that are not
significantly impacted by changes to
ICD–10 codes would continue to be
assessed on the full 12-month
performance period (January 1 through
December 31).
Any measure that relies on an ICD–10
code which is added, modified, or
removed, such as in the measure
numerator, denominator, exclusions, or
exceptions, could have an impact on the
indicated performance on the measure,
although the impact may not always be
significant. We propose an annual
review process to analyze the measures
that have a code impact and assess the
subset of measures significantly
impacted by ICD–10 coding changes
during the performance period.
Depending on the data available, we
anticipate that our determination as to
whether a measure is significantly
impacted by ICD–10 coding changes
would include these factors: A more
than 10 percent change in codes in the
measure numerator, denominator,
exclusions, and exceptions; guideline
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changes or new products or procedures
reflected in ICD–10 code changes; and
feedback on a measure received from
measure developers and stewards. We
considered an approach where we
would consider any change in ICD–10
coding to impact performance on a
measure and thus only rely on the first
9 months of the 12-month performance
period for such measures. However, we
believe such an approach would be too
broad and truncate measurement for too
many measures where performance may
not be significantly affected. We believe
that our proposed approach ensures the
measures on which individual MIPS
eligible clinicians and groups will have
their performance assessed are accurate
for the performance period and are
consistent with the benchmark set for
the performance period.
We propose to publish on the CMS
Web site which measures are
significantly impacted by ICD–10
coding changes and would require the
9-month assessment. We propose to
publish this information by October 1st
of the performance period if technically
feasible, but by no later than the
beginning of the data submission
period, which is January 1, 2019 for the
2018 performance period.
We request comment on the proposal
to address ICD–10 measures
specification changes during the
performance period by relying on the
first 9 months of the 12-month
performance period. We also request
comment on potential alternate
approaches to address measures that are
significantly impacted due to ICD–10
changes during the performance period,
including the factors we might use to
determine whether a measure is
significantly impacted.
(2) Scoring the Quality Performance
Category for Data Submission via
Claims, Data Submissions via EHR,
Third Party Data Submission Options,
CMS Web Interface, and Administrative
Claims
Many comments submitted in
response to the CY 2017 Quality
Payment Program final rule requested
additional clarification on our finalized
scoring methodology for the 2019 MIPS
payment year. To provide further clarity
to MIPS eligible clinicians about the
transition year scoring policies, before
describing our proposed scoring policies
for the 2020 MIPS payment year, we
provide a summary of the scoring
policies finalized in the CY 2017
Quality Payment Program final rule
along with examples of how they apply
under several scenarios.
In the CY 2017 Quality Payment
Program final rule (81 FR 77286 through
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77287), we finalized that the quality
performance category would be scored
by assigning achievement points to each
submitted measure, which we refer to in
this section of the proposed rule as
‘‘measure achievement points’’ and we
propose to amend various paragraphs in
§ 414.1380(b)(1) to use this term in place
of ‘‘achievement points’’. MIPS eligible
clinicians can also earn bonus points for
certain measures (81 FR 77293 through
77294; 81 FR 77297 through 77299),
which we refer to as ‘‘measure bonus
points’’, and we propose to amend
§ 414.1380(b)(1)(xiii) (which we propose
to redesignate as § 414.1380(b)(1)(xiv) in
this proposed rule),7
§ 414.1380(b)(1)(xiv) (which we propose
to redesignate as § 414.1380(b)(1)(xv) in
this proposed rule), and
§ 414.1380(b)(1)(xv) (which we propose
to redesignate as § 414.1380(b)(1)(xvii)
in this proposed rule) to use this term
in place of ‘‘bonus points’’. The measure
achievement points assigned to each
measure would be added with any
measure bonus points and then divided
by the total possible points
(§ 414.1380(b)(1)(xv) (which we propose
to redesignate as § 414.1380(b)(1)(xvii)).
In this section of the proposed rule we
refer to the total possible points as ‘‘total
available measure achievement points’’,
and we propose to amend
§ 414.1380(b)(1)(xv) to use this term in
place of ‘‘total possible points’’. We also
propose to amend these terms in
§ 414.1380(b)(1)(xiii)(D) (which we
propose to redesignate as
§ 414.1380(b)(1)(xiv)(D) in this proposed
rule), and § 414.1380(b)(1)(xiv) (which
we propose to redesignate as
§ 414.1380(b)(1)(xv) in this proposed
rule).
This resulting quality performance
category score is a fraction from zero to
1, which can be formatted as a percent;
therefore, for this section, we will
present the quality performance
category score as a percent and refer to
it as ‘‘quality performance category
percent score.’’ We also propose to
amend § 414.1380(b)(1)(xv) (which we
propose to redesignate as
§ 414.1380(b)(1)(xvii) in this proposed
rule) to use this term in place of
‘‘quality performance category score’’.
Thus, the formula for the quality
performance category percent score that
we will use in this section is as follows:
(total measure achievement points +
total measure bonus points)/total
7 In section II.C.7.a.(2)(c) of this proposed rule, we
propose a new provision to be codified at
§ 414.1380(b)(1)(xiii), and in section II.C.7.a.(2)(i) of
this proposed rule, we propose a new provision to
be codified at § 414.1380(b)(1)(xvi). As a result, we
propose as well that the remaining paragraphs be
redesignated in order following the new provisions.
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available measure achievement
points = quality performance
category percent score.
In the CY 2017 Quality Payment
Program final rule, we finalized that for
the quality performance category, an
individual MIPS eligible clinician or
group that submits data on quality
measures via EHR, QCDR, qualified
registry, claims, or a CMS-approved
survey vendor for the CAHPS for MIPS
survey will be assigned measure
achievement points for 6 measures (1
outcome or, if an outcome measure is
not available, other high priority
measure and the next 5 highest scoring
measures) as available and applicable,
and will receive applicable measure
bonus points for all measures submitted
that meet the bonus criteria (81 FR
77282 through 77301).
In addition, for groups of 16 or more
clinicians who meet the case minimum
of 200, we will also automatically score
the administrative claims-based allcause hospital readmission measure as a
seventh measure (81 FR 77287). For
individual MIPS eligible clinicians and
groups for whom the readmission
measure does not apply, the
denominator is generally 60 (10
available measure achievement points
multiplied by 6 available measures). For
groups for whom the readmission
measure applies, the denominator is
generally 70 points.
If we determined that a MIPS eligible
clinician has fewer than 6 measures
available and applicable, we will score
only the number of measures that are
available and adjust the denominator
accordingly to the total available
measure achievement points (81 FR
77291). We refer readers to section
II.C.7.a.(2)(e) of this proposed rule, for a
description of the validation process to
determine measure availability.
For the 2019 MIPS payment year, a
MIPS eligible clinician that submits
quality measure data via claims, EHR, or
third party data submission options
(that is, QCDR, qualified registry, EHR,
or CMS-approved survey vendor for the
CAHPS for MIPS survey), can earn
between 3 and 10 measure achievement
points for quality measures submitted
for the performance period of greater
than or equal to 90 continuous days
during CY 2017. A MIPS eligible
clinician can earn measure bonus points
(subject to a cap) if they submit
additional high priority measures with a
performance rate that is greater than
zero, and that meet the case minimum
and data completeness requirements, or
submit a measure using an end-to-end
electronic pathway. An individual MIPS
eligible clinician that has 6 or more
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30099
quality measures available and
applicable will have 60 total available
measure achievement points. For
example, as shown in Table 17, if an
individual MIPS eligible clinician
submits 7 measures, including one
required outcome measure and 2
additional high priority measures, the
MIPS eligible clinician will be assigned
points based on achievement for the
required outcome measure and the next
5 measures with the highest number of
measure achievement points. In this
example, the second high priority
measure has the lowest number of
measure achievement points and
therefore is not included in the total
measure achievement points calculated
(81 FR 77300), but the MIPS eligible
clinician will still receive a bonus point
for submitting a high priority measure
(81 FR 77291 through 77294). We note
that in the CY 2017 Quality Payment
Program proposed rule, we proposed
that bonus points would be available for
high priority measures that are not
scored (not included in the top 6
measures for the quality performance
category score) as long as the measure
has the required case minimum, data
completeness, and has a performance
rate greater than zero, because we
believed these qualities would allow us
to include the measure in future
benchmark development (81 FR 28255).
Although we received public comments
on this policy, responded to those
comments, and reiterated this proposal
in the CY 2017 Quality Payment
Program final rule (81 FR 77292), we
would like to clarify that our policy to
assign measure bonus points for high
priority measures, even if the measure’s
achievement points are not included in
the total measure achievement points
for calculating the quality performance
category percent score, as long as the
measure has the required case
minimum, data completeness, and has a
performance rate greater than zero,
applies beginning with the transition
year. We propose to amend
§ 414.1380(b)(1)(xiii)(A) (which we
propose to redesignate as
§ 414.1380(b)(1)(xiv)(A)) to state that
measure bonus points may be included
in the calculation of the quality
performance category percent score
regardless of whether the measure is
included in the calculation of the total
measure achievement points. We also
propose a technical correction to the
second sentence of that paragraph to
state that to qualify for measure bonus
points, each measure must be reported
with sufficient case volume to meet the
required case minimum, meet the
required data completeness criteria, and
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not have a zero percent performance
rate.
TABLE 17—EXAMPLE CALCULATION OF THE QUALITY PERFORMANCE CATEGORY PERCENT SCORE FOR AN INDIVIDUAL FOR
THE TRANSITION YEAR
Measure
bonus points *
Total available
measure
achievement
points
3 .......................................
6 .......................................
n/a
n/a
10
10
6
6
6
4
3
.......................................
.......................................
.......................................
.......................................
(not included for
achievement).
n/a
n/a
n/a
1
1
10
10
10
10
n/a
31 .....................................
2
60
Measure achievement
points
Measure 1
quired).
Measure 2
Measure 3
Measure 4
Measure 5
Measure 6
Measure 7
(Outcome—re.........................
.........................
.........................
.........................
(High priority) ..
(High priority) ..
Total ...........................
Performance category
percent score
(measure achievement points from 6 measures +
measure bonus points)/total available measure
achievement points.
(31+2)/60 = 55%
* Assumes the measures meet the required case minimum, data completeness, and has performance greater than zero. Assumes no bonus
points for end-to-end electronic submission. This example does not apply to CMS Web Interface Reporters because individuals are not able to
submit data via that mechanism.
A group of 16 or more clinicians will
also be automatically scored on the
hospital readmission measure if they
meet the case minimum. Table 18
illustrates an example of a group that
submitted the 6 required quality
measures, including an additional high
priority measure, and received 3
measure achievement points for each
submitted measure and the all-cause
readmission measure.
TABLE 18—EXAMPLE CALCULATION OF THE QUALITY PERFORMANCE CATEGORY PERCENT SCORE FOR A GROUP OF 16
OR MORE CLINICIANS, NON-CMS WEB INTERFACE REPORTER FOR THE TRANSITION YEAR
Measure
achievement
points
Measure
bonus points *
Total available
measure
achievement
points
Measure 1 (Outcome—required).
Measure 2 (High priority) ........
Measure 3 ...............................
Measure 4 ...............................
Measure 5 ...............................
Measure 6 ...............................
Measure 7—(readmission
measure with 200+ cases).
3
n/a
10
3
3
3
3
3
3
1
n/a
n/a
n/a
n/a
n/a
10
10
10
10
10
10
Total .................................
21
1
70
Performance category percent score
(measure achievement points from 7 measures + measure
bonus points)/total available measure achievement points.
(21+1)/70 = 31.4%
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* Assumes the measures meet the required case minimum, data completeness, and has performance greater than zero. Assumes no bonus
points for end-to-end electronic submission.
In the CY 2017 Quality Payment
Program final rule, we also finalized
scoring policies specific to groups of 25
or more that submit their quality
performance measures using the CMS
Web Interface (81 FR 77278 through
77306).
Although we are not proposing to
change the basic scoring system that we
finalized in the CY 2017 Quality
Payment Program final rule for the 2020
MIPS payment year, we are proposing
several modifications to scoring the
quality performance category, including
adjusting scoring for measures that do
not meet the data completeness criteria,
adding a method for scoring measures
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submitted via multiple mechanisms,
adding a method for scoring selected
topped out measures, and adding a
method for scoring improvement. We
also note that in section II.C.7.a.(4) of
this proposed rule, we are also
proposing an additional option for
facility-based scoring for the quality
performance category.
(a) Quality Measure Benchmarks
We are not proposing to change the
policies on benchmarking finalized in
the CY 2017 Quality Payment Program
final rule and codified at paragraphs
(b)(1)(i) through (iii) of § 414.1380;
however, we are proposing a technical
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correction to paragraphs (i) and (ii) to
clarify that measure benchmark data are
separated into decile categories based
on percentile distribution, and that,
other than using performance period
data, performance period benchmarks
are created in the same manner as
historical benchmarks using decile
categories based on a percentile
distribution and that each benchmark
must have a minimum of 20 individual
clinicians or groups who reported on
the measure meeting the data
completeness requirement and case
minimum case size criteria and
performance greater than zero. We refer
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readers to the discussion at 81 FR 77282
for more details on that policy.
We note that in section II.C.2.c. of this
proposed rule, we are proposing to
increase the low-volume threshold
which, because we include MIPS
eligible clinicians and comparable
APMs that meet our benchmark criteria
in our measure benchmarks, could have
an impact on our MIPS benchmarks,
specifically by reducing the number of
individual eligible clinicians and groups
that meet the definition of a MIPS
eligible clinician and contribute to our
benchmarks. Therefore, we seek
feedback on whether we should broaden
the criteria for creating our MIPS
benchmarks to include PQRS and any
data from MIPS, including voluntary
reporters, that meet our benchmark
performance, case minimum and data
completeness criteria when creating our
benchmarks.
In the CY 2017 Quality Payment
Program final rule, we did not stratify
benchmarks by practice characteristics,
such as practice size, because we did
not believe there was a compelling
rationale for such an approach, and we
believed that stratifying could have
unintended negative consequences for
the stability of the benchmarks, equity
across practices, and quality of care for
beneficiaries (81 FR 77282). However,
we sought comment on any rationales
for or against stratifying by practice size
we may not have considered. We note
that we do create separate benchmarks
for each of the following submission
mechanisms: EHR submission options;
QCDR and qualified registry submission
options; claims submission options;
CMS Web Interface submission options;
CMS-approved survey vendor for
CAHPS for MIPS submission options;
and administrative claims submission
options (for measures derived from
claims data, such as the all-cause
hospital readmission measure) (81 FR
77282).
Several commenters who responded
to our solicitation of comment in the
final rule supported stratifying measure
benchmarks by practice size because the
commenters believed it would help
small practices, which have limited
resources compared to larger practices,
and because quality measures may have
characteristics that are less favorable to
small groups. One commenter
recommended that we stratify by
practice size during the 5 years in which
technical assistance is available. One
commenter recommended that we
develop criteria for determining when a
benchmark should be stratified by group
size, and another commenter
recommended if we do not stratify
benchmarks by practice size, we adjust
MIPS payment adjustments for practice
size. Several commenters recommended
that we stratify benchmarks beyond
practice size and include adjustments
for disease severity and socioeconomic
status of patients, specialty or subspecialty, geographic region, and/or site
of service. One commenter specifically
suggested that we use peer comparison
groups when establishing measure
benchmarks.
After consideration of the comments
we received, we are not proposing to
change our policies related to stratifying
benchmarks by practice size for the
2020 MIPS payment year. For many
measures, the benchmarks may not need
stratification as they are only
meaningful to certain specialties and
only expected to be submitted by those
certain specialists. We would like to
further clarify that in the majority of
instances our current benchmarking
approach only compares like clinicians
to like clinicians. We continue to
believe that stratifying by practice size
could have unintended negative
consequences for the stability of the
benchmarks, equity across practices,
and quality of care for beneficiaries.
However, we seek comment on methods
by which we could stratify benchmarks,
while maintaining reliability and
stability of the benchmarks, to use in
developing future rulemaking for future
performance and payment years.
Specifically, we seek comment on
methods for stratifying benchmarks by
specialty or by place of service. We also
request comment on specific criteria to
consider for stratifying measures, such
as how we should stratify submissions
by multi-specialty practices or by
practices that operate in multiple places
of service.
(b) Assigning Points Based on
Achievement
In the CY 2017 Quality Payment
Program final rule, we finalized at
§ 414.1380(b)(1) that a MIPS quality
measure must have a measure
benchmark to be scored based on
performance. MIPS quality measures
that do not have a benchmark (for
example, because fewer than 20 MIPS
eligible clinicians or groups submitted
data that met our criteria to create a
reliable benchmark) will not be scored
based on performance (81 FR 77286).
We are not proposing any changes to
this policy, but we are proposing a
technical correction to the regulatory
text at § 414.1380(b)(1) to delete the
term ‘‘MIPS’’ before ‘‘quality measure’’
in third sentence of that paragraph and
to delete the term MIPS before ‘‘quality
measures’’ in the fourth sentence of that
paragraph because this policy applies to
all quality measures, including the
measures finalized for the MIPS
program and the quality measures
submitted through a QCDR that have
been approved for MIPS.
We are also not proposing to change
the policies to score quality measure
performance using a percentile
distribution, separated by decile
categories and assign partial points
based on the percentile distribution
finalized in the CY 2017 Quality
Payment Program final rule and codified
at paragraphs (b)(1)(ix), (x), and (xi) of
§ 414.1380; however, we propose a
technical correction to paragraph (ix) to
clarify that measures are scored against
measure benchmarks. We refer readers
to the discussion at 81 FR 77286 for
more details on those policies.
For illustration, Table 19 provides an
example of assigning points for
performance based on benchmarks
using a percentile distribution,
separated by decile categories. The
example is of the benchmarks for
Measure 130 Documentation of Current
Medications in the Medical Record,
which is based on our 2015 benchmark
file for the 2017 MIPS performance
period.
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TABLE 19—EXAMPLE OF ASSIGNING POINTS FOR PERFORMANCE BASED ON A BENCHMARK, SEPARATED BY DECILES
Measure ID #130 (documentation of current medications in
the medical record) *
Submission mechanism
Claims performance benchmark
Decile
Decile
Decile
Decile
1
3
4
5
or 2 (3 points) ..............................................................................................
(3.0–3.9 points) ...........................................................................................
(4.0–4.9 points) ...........................................................................................
(5.0–5.9 points) ...........................................................................................
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<96.11
96.11–98.73
98.74–99.64
99.65–99.99
E:\FR\FM\30JNP2.SGM
EHR performance
benchmark
<76.59
76.59–87.88
87.89–92.73
92.74–95.35
30JNP2
Registry/QCDR
benchmark
<61.27
61.27–82.11
82.12–91.71
91.72–96.86
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TABLE 19—EXAMPLE OF ASSIGNING POINTS FOR PERFORMANCE BASED ON A BENCHMARK, SEPARATED BY DECILES—
Continued
Measure ID #130 (documentation of current medications in
the medical record) *
Submission mechanism
Claims performance benchmark
Decile
Decile
Decile
Decile
Decile
6 (6.0–6.9 points) ...........................................................................................
7 (7.0–7.9 points) ...........................................................................................
8 (8.0–8.9 points) ...........................................................................................
9 (9.0–9.9 points) ...........................................................................................
10 (10 points) .................................................................................................
—
—
—
—
100
EHR performance
benchmark
95.36 –97.08
97.09–98.27
98.28–99.12
99.13–99.75
>= 99.76
Registry/QCDR
benchmark
96.87–99.30
99.31 –99.99
—
—
100
* Based on our historical benchmark file for the 2017 MIPS performance period.
mstockstill on DSK30JT082PROD with PROPOSALS2
In Table 19, the cells with ‘‘—’’
represent where there is a cluster at the
top of benchmark distribution. For
example, for the claims benchmark, over
50 percent of the MIPS eligible
clinicians submitting that measure had
a performance rate of 100 percent based
on 2015 PQRS data. Because of the
cluster, clinicians who are at the 6, 7,
8, and 9th decile all would have
performance rates of 100 percent and
would all receive a score of 10 points,
indicated by dashes for those deciles.
Based on this clustered distribution,
those clinicians with performance of
99.99 percent fall into decile 5 and
receive points in the range from 5.0 to
5.9 points. For this measure, the
benchmark for each submission
mechanism is topped out.
We note that for quality measures for
which baseline period data is available,
we will publish the numerical baseline
period benchmarks with deciles prior to
the start of the performance period (or
as soon as possible thereafter) (81 FR
77282). For quality measures for which
there is no comparable data from the
baseline period, we will publish the
numerical performance period
benchmarks after the end of the
performance period (81 FR 77282). We
will also publish further explanation of
how we calculate partial points at
qpp.cms.gov.
(i) Floor for Scored Quality Measures
For the 2017 MIPS performance
period, we also finalized at
§ 414.1380(b)(1) a global 3-point floor
for each scored quality measure, as well
as for the hospital readmission measure
(if applicable), such that MIPS eligible
clinicians would receive between 3 and
10 measure achievement points for each
submitted measure that can be reliably
scored against a benchmark, which
requires meeting the case minimum and
data completeness requirements (81 FR
77286 through 77287). Likewise, for
measures without a benchmark based on
the baseline period, we stated that we
would continue to assign between 3 and
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10 measure achievement points for
performance years after the first
transition year because it would help to
ensure that the MIPS eligible clinicians
are protected from a poor performance
score that they would not be able to
anticipate (81 FR 77282; 81 FR 77287).
For measures with benchmarks based on
the baseline period, we stated the 3point floor was for the transition year
and that we would revisit the 3-point
floor in future years (81 FR 77286
through 77287).
For the 2018 MIPS performance
period, we propose to again apply a 3point floor for each measure that can be
reliably scored against a benchmark
based on the baseline period, and to
amend § 414.1380(b)(1) accordingly. We
refer readers to section II.C.7.a.(2)(h)(ii)
of this rule, for our proposal to score
measures in the CMS Web Interface for
the Quality Payment Program for which
performance is below the 30th
percentile. We will revisit the 3-point
floor for such measures again in future
rulemaking.
We invite public comment on this
proposal to again apply this 3-point
floor for quality measures that can be
reliably scored against a baseline
benchmark in the 2018 MIPS
performance period.
(ii) Additional Policies for the CAHPS
for MIPS Measure Score
In the CY 2017 Quality Payment
Program final rule, we finalized a policy
for the CAHPS for MIPS measure, such
that each Summary Survey Measure
(SSM) will have an individual
benchmark, that we will score each SSM
individually and compare it against the
benchmark to establish the number of
points, and the CAHPS score will be the
average number of points across SSMs
(81 FR 77284).
As described in section
II.C.6.b.(3)(a)(iii) of this proposed rule,
we are proposing to remove two SSMs
from the CAHPS for MIPS survey,
which would result in the collection of
10 SSMs in the CAHPS for MIPS survey.
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Eight of those 10 SSMs have had high
reliability for scoring in prior years, or
reliability is expected to improve for the
revised version of the measure, and they
also represent elements of patient
experience for which we can measure
the effect one practice has compared to
other practices participating in MIPS.
The ‘‘Health Status and Functional
Status’’ SSM, however, assesses
underlying characteristics of a group’s
patient population characteristics and is
less of a reflection of patient experience
of care with the group. Moreover, to the
extent that health and functional status
reflects experience with the practice,
case-mix adjustment is not sufficient to
separate how much of the score is due
to patient experience versus due to
aspects of the underlying health of
patients. The ‘‘Access to Specialists’’
SSM has low reliability; historically it
has had small sample sizes, and
therefore, the majority of groups do not
achieve adequate reliability, which
means there is limited ability to
distinguish between practices’
performance.
For these reasons, we propose not to
score the ‘‘Health Status and Functional
Status’’ SSM and the ‘‘Access to
Specialists’’ SSM beginning with the
2018 MIPS performance period. Despite
not being suitable for scoring, both
SSMs provide important information
about patient care. Qualitative work
suggests that ‘‘Access to Specialists’’ is
a critical issue for Medicare FFS
beneficiaries. The survey is also a useful
tool for assessing beneficiaries’ selfreported health status and functional
status, even if this measure is not used
for scoring practices’ care experiences.
Therefore, we believe that continued
collection of the data for these two
SSMs is appropriate even though we do
not propose to score them.
Other than these two SSMs, we
propose to score the remaining 8 SSMs
because they have had high reliability
for scoring in prior years, or reliability
is expected to improve for the revised
version of the measure, and they also
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represent elements of patient experience
for which we can measure the effect one
practice has compared to other practices
participating in MIPS. Table 20
summarizes the proposed SSMs
included in the CAHPS for MIPS survey
and illustrates application of our
proposal to score only 8 measures.
TABLE 20—PROPOSED SSM FOR CAHPS FOR MIPS SCORING
Proposed for inclusion
in the CAHPS for
MIPS survey?
Summary survey measure
Getting Timely Care, Appointments, and Information ..................................................................
How Well Providers Communicate ...............................................................................................
Patient’s Rating of Provider ..........................................................................................................
Health Promotion & Education ......................................................................................................
Shared Decision Making ...............................................................................................................
Stewardship of Patient Resources ................................................................................................
Courteous and Helpful Office Staff ...............................................................................................
Care Coordination .........................................................................................................................
Health Status and Functional Status ............................................................................................
Access to Specialists ....................................................................................................................
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We invite comment on our proposal
not to score the ‘‘Health Status and
Functional Status’’ and ‘‘Access to
Specialists’’ SSMs beginning with the
2018 MIPS performance period.
We note that in section
II.C.6.g.(3)(b)(i)(A) of this proposed rule,
we are proposing to add the CAHPS for
ACOs survey as an available measure for
calculating the MIPS APM score for the
Shared Savings Program and Next
Generation ACO Model. We refer
readers participating in ACOs to section
II.C.6.g.(3)(b) of this proposed rule for
the CAHPS for ACOs scoring
methodology.
(c) Identifying and Assigning Measure
Achievement Points for Topped Out
Measures
Section 1848(q)(3)(B) of the Act
requires that, in establishing
performance standards with respect to
measures and activities, we consider,
among other things, the opportunity for
continued improvement. We finalized
in the CY 2017 Quality Payment
Program final rule that we would
identify topped out process measures as
those with a median performance rate of
95 percent or higher (81 FR 77286). For
non-process measures we finalized a
topped out definition similar to the
definition used in the Hospital VBP
Program: Truncated Coefficient of
Variation is less than 0.10 and the 75th
and 90th percentiles are within 2
standard errors (81 FR 77286). When a
measure is topped out, a large majority
of clinicians submitting the measure
performs at or very near the top of the
distribution; therefore, there is little or
no room for the majority of MIPS
eligible clinicians who submit the
measure to improve. We understand
that every measure we have identified
as topped out may offer room for
improvement for some MIPS eligible
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clinicians; however, we believe asking
clinicians to submit measures that we
have identified as topped out and
measures for which they already excel
is an unnecessary burden that does not
add value or improve beneficiary
outcomes.
Based on 2015 historic benchmark
data,8 approximately 45 percent of the
quality measure benchmarks currently
meet the definition of topped out, with
some submission mechanisms having a
higher percent of topped out measures
than others. Approximately 70 percent
of claims measures are topped out, 10
percent of EHR measures are topped
out, and 45 percent of registry/QCDR
measures are topped out.
In the CY 2017 Quality Payment
Program final rule, we finalized that for
the 2019 MIPS payment year, we would
score topped out quality measures in the
same manner as other measures (81 FR
77286). We finalized that we would not
modify the benchmark methodology for
topped out measures for the first year
that the measure has been identified as
topped out, but that we would modify
the benchmark methodology for topped
out measures beginning with the 2020
MIPS payment year, provided that it is
the second year the measure has been
identified as topped out. As described
in detail later in this section, we are
proposing a phased in approach to
apply special scoring to topped out
measures, beginning with the 2018
MIPS performance period (2020 MIPS
payment year), rather than modifying
the benchmark methodology for topped
out measures as indicated in the CY
2017 Quality Payment Program final
rule.
8 The topped out determination is calculated on
historic performance data and the percentage of
topped out measures may change when evaluated
for the most applicable annual period.
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Proposed for inclusion
in CAHPS for MIPS
scoring?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes.
Yes.
Yes.
Yes.
Yes.
Yes.
Yes.
Yes.
No.
No.
..............................
..............................
..............................
..............................
..............................
..............................
..............................
..............................
..............................
..............................
In the CY 2017 Quality Payment
Program final rule, we sought comment
on how topped out measures should be
scored provided that it is the second
year the measure has been identified as
topped out (81 FR 77286). We suggested
three possible options: (1) Score the
measures using a mid-cluster approach;
(2) remove topped out measures; or (3)
apply a flat percentage in building the
benchmarks for topped out measures.
Flat percentages assign points based
directly on the percentage of
performance rather than by a percentile
distribution by decile. Flat-rate would
provide high scores to virtually all
clinicians submitting the measure
because performance rates tend to be
high. Cluster-based benchmarks for
topped out measures are based on a
percentile distribution, but because
many submitters are clustered at the top
of performance, there can be large drops
in points assigned for relatively small
differences in performance. The current
top of the cluster approach can result in
many clinicians receiving 10 points. A
mid-cluster approach would limit the
maximum number of points a topped
out measure can achieve based on how
clustered the score are, and could still
result in large drops, although less than
with the top of the cluster approach, in
points assigned for relatively small
differences in performance. We also
noted in the CY 2017 Quality Payment
Program final rule that we anticipate
removing topped out measures over
time and sought comment on what point
in time we should remove topped out
measures from MIPS (81 FR 77286). The
comments and our proposed policy for
removing topped out measures are
described in section II.C.6.c.(2) of this
proposed rule.
In response to our request for
comment in the CY 2017 Quality
Payment Program final rule, a few
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commenters believed that we should not
score topped out measures differently
from other measures because
commenters believed changing the
scoring could reduce quality, add
complexity to the program, and reduce
incentives to participate in MIPS.
Several commenters recommended that
if we do score topped out measures
differently, we use flat percentages
rather than cluster-based benchmarks,
with a few commenters noting that
using flat percentages could help ensure
those with high performance on a
measure are not penalized as low
performers and another noting that
allowing high scorers to earn maximum
or near maximum points is similar to
the approach in the Shared Savings
Program. A few commenters
recommended that we publish
information about topped out and
potentially topped out measures prior to
the performance period to allow
clinicians time to adjust their reporting
strategies, with one commenter noting
that improvement may be rewarded in
addition to achievement. One
commenter recommended pushing back
the baseline performance period for
identifying topped out measures to the
2018 MIPS performance period because
in the transition year it is unclear how
many eligible clinicians will be
reporting at different times and for what
period they will report.
As described in section II.C.6.c.(2) of
this proposed rule, we are proposing a
lifecycle for topped out measures by
which, after a measure benchmark is
identified as topped out in the
published benchmark for 2 years, in the
third consecutive year it is identified as
topped out it will be considered for
removal through notice-and-comment
rulemaking or the QCDR approval
process and may be removed from the
benchmark list in the fourth year,
subject to the phased in approach
described in section II.C.6.c.(2) of this
proposed rule.
As part of the lifecycle for topped out
measures, we also propose in this
section II.C.7.a.(2)(c) of this proposed
rule, a method to phase in special
scoring for topped out measure
benchmarks starting with the 2018 MIPS
performance period, provided that is the
second consecutive year the measure
benchmark is identified as topped out in
the benchmarks published for the
performance period. This special
scoring would not apply to measures in
the CMS Web Interface, as explained
later in this section. The phased-in
approach described in this section
represents our first step in methodically
implementing special scoring for topped
out measures.
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We are not proposing to remove
topped out measures for the 2018 MIPS
performance period because we
recognize that there are currently a large
number of topped out measures and
removing them may impact the ability
of some MIPS eligible clinicians to
submit 6 measures and may impact
some specialties more than others. We
note, however, that as described in
section II.C.6.c.(2) of this proposed rule,
we are proposing a timeline for
removing topped out measures in future
years. We believe this provides MIPS
eligible clinicians the ability to
anticipate and plan for the removal of
specific topped out measures, while
providing measure developers time to
develop new measures.
We note that because we create a
separate benchmark for each submission
mechanism available for a measure, a
benchmark for one submission
mechanism for the measure may be
identified as topped out while another
submission mechanism’s benchmark
may not be topped out. The topped out
designation and special scoring apply
only to the specific benchmark that is
topped out, not necessarily every
benchmark for a measure. For example,
the benchmark for the claims
submission mechanism may be topped
out for a measure, but the benchmark for
the EHR submission mechanisms for
that same measure may not be topped
out. In this case, the topped out scoring
would only apply to measures
submitted via the claims submission
mechanism, which has the topped out
benchmark. We also describe in section
II.C.6.c.(2) of this proposed rule that,
similarly, only the submission
mechanism that is topped out for the
measure would be removed.
We propose to cap the score of topped
out measures at 6 measure achievement
points. We are proposing a 6-point cap
for multiple reasons. First, we believe
applying a cap to the current method of
scoring a measure against a benchmark
is a simple approach that can easily be
predicted by clinicians. Second, the cap
will create incentives for clinicians to
submit other measures for which they
can improve and earn future
improvement points. Third, considering
our proposed topped out measure
lifecycle, we believe this cap would
only be used for a few years and the
simplicity of a cap on the current
benchmarks would outweigh the
cluster-based options or applying a cap
on benchmarks based on flat-percentage,
which are more complicated. The
rationale for a 6-point cap is that 6
points is the median score for any
measure as it represents the start of the
6th decile for performance and
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represents the spot between the bottom
5 deciles and start of the top 5 deciles.
We believe this proposed capped
scoring methodology will incentivize
MIPS eligible clinicians to begin
submitting non-topped out measures
without performing below the median
score. This methodology also would not
impact scoring for those MIPS eligible
clinicians that do not perform near the
top of the measure and therefore have
significant room to improve on the
measure. We may also consider
lowering the cap below 6 points in
future years, especially if we remove the
3-point floor for performance in future
years.
We note that although we are
proposing a new methodology for
assigning measure achievement points
for topped out measures, we are not
changing the policy for awarding
measure bonus points for topped out
measures. Topped out measures will
still be eligible for measure bonus points
if they meet the required criteria. We
refer readers to sections II.C.7.a.(2)(f)
and II.C.7.a.(2)(g) of this proposed rule
for more information about measure
bonus points.
We request comments on our proposal
to score topped out measures differently
by applying a 6-point cap, provided it
is the second consecutive year the
measure is identified as topped out.
Specifically, we seek feedback on
whether 6 points is the appropriate cap
or whether we should consider another
value. We also seek comment on other
possible options for scoring topped out
measures that would meet our policy
goals to encourage clinicians to begin to
submit measures that are not topped out
while also providing stability for MIPS
eligible clinicians.
While we believe it is important to
score topped out measures differently
because they could have a
disproportionate impact on the scores
for certain MIPS eligible clinicians and
topped out measures provide little room
for improvement for the majority of
MIPS eligible clinicians who submit
them, we also recognize that numerous
measure benchmarks are currently
identified as topped out and special
scoring for topped out measures could
impact some specialties more than
others. Therefore, we considered ways
to phase in special scoring for topped
out measures in a way that will begin
to apply special scoring, but would not
overwhelm any one specialty and would
also provide additional time to evaluate
the impact of topped out measures
before implementing it for all topped
out measures, while also beginning to
encourage submission of measures that
are not topped out.
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We believe the best way to
accomplish this is by applying special
topped out scoring to a select number of
measures for the 2018 performance
period and to then apply the special
topped out scoring to all topped out
measures for the 2019 performance
period, provided it is the second
consecutive year the measure is topped
out. We believe this approach allows us
time to further evaluate the impact of
topped out measures and allows for a
methodical way to phase in topped out
scoring.
We identified measures we believe
should be scored with the special
topped out scoring for the 2018
performance period by using the
following set criteria, which are only
intended as a way to phase in our
topped-out measure policy for selected
measures and are not intended to be
criteria for use in future policies:
• Measure is topped out and there is
no difference in performance between
decile 3 through decile 10. We applied
this limitation because, based on
historical data, there is no room for
improvement for over 80 percent of
MIPS eligible clinicians that reported on
these measures.
• Process measures only because we
want to continue to encourage reporting
on high priority outcome measures, and
the small subset of structure measures
was confined to only three specialties.
• MIPS measures only (which does
not include measures that can only be
reported through a QCDR) given that
QCDR measures go through a separate
process for approval and because we
want to encourage use of QCDRs
required by section 1848(q)(1)(E) of the
Act.
• Measure is topped out for all
mechanisms by which the measure can
be submitted. Because we create a
30105
separate benchmark for each submission
mechanism available for a measure, a
benchmark for one submission
mechanism for the measure may be
identified as topped out while another
submission mechanism’s benchmark
may not be topped out. For example, the
benchmark for the claims submission
mechanism may be topped out for a
measure, but the benchmark for the EHR
submission mechanisms for that same
measure may not be topped out. We
decided to limit our criteria to only
measures that were topped out for all
measures for simplicity and to avoid
confusion about what scoring is applied
to a measure.
• Measure is in a specialty set with at
least 10 measures, because 2 measures
in the pathology specialty set, which
only has 8 measures total would have
been included.
Applying these criteria results in the
6 measures as listed in Table 21.
TABLE 21—TOPPED OUT MEASURES PROPOSED FOR SPECIAL SCORING FOR THE 2018 MIPS PERFORMANCE PERIOD
Measure name
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We propose to apply the special
topped out scoring method that we
finalize for the 2018 performance period
to only the 6 measures in Table 21 for
the 2018 performance period, provided
they are again identified as topped out
in the benchmarks for the 2018
performance period. If these measures
are not identified as topped out in the
benchmarks published for the 2018
performance period, they will not be
scored differently because they would
not be topped out for a second
consecutive year.
We seek comment on our proposal to
apply special topped out scoring only to
the 6 measures identified in Table 21 for
the 2018 performance period.
Starting with the 2019 performance
period, we propose to apply the special
topped out scoring method to all topped
19:16 Jun 29, 2017
Topped out for
all submission
mechanisms
21
Process ..........
Yes .................
224
Process ..........
Yes .................
23
Process ..........
Yes .................
262
Process ..........
Yes .................
General Surgery, Orthopedic Surgery, Otolaryngology, Thoracic Surgery, Plastic Surgery.
n/a.
359
Process ..........
Yes .................
Diagnostic Radiology.
52
Perioperative Care: Selection of Prophylactic
Antibiotic—First OR Second Generation
Cephalosporin.
Melanoma: Overutilization of Imaging Studies
in Melanoma.
Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients).
Image Confirmation of Successful Excision of
Image—Localized Breast Lesion.
Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computerized Tomography (CT)
Imaging Description.
Chronic Obstructive Pulmonary Disease
(COPD): Inhaled Bronchodilator Therapy.
VerDate Sep<11>2014
Measure type
Process ..........
Yes .................
n/a.
Measure ID
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out measures, provided it is the second
(or more) consecutive year the measure
is identified as topped out. We seek
comment on our proposal to apply
special topped out scoring to all topped
out measures, provided it is the second
(or more) consecutive year the measure
is identified as topped out.
We illustrate the lifecycle for scoring
and removing topped out measures
based on our proposals as follows:
• Year 1: Measure benchmarks are
identified as topped out, which in this
example would be in the benchmarks
published for the 2017 MIPS
performance period.
• Year 2: Measure benchmarks are
identified as topped out, which in this
example would be in the benchmarks
published for the 2018 MIPS
performance period. Measures
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Specialty set
General Surgery, Orthopedic Surgery, Otolaryngology, Thoracic Surgery, Plastic Surgery.
Dermatology.
identified in Table 21 have special
scoring applied, provided they are
identified as topped out for the 2018
MIPS performance period, meaning it is
the second consecutive year they are
identified as topped out.
• Year 3: Measure benchmarks are
identified as topped out in the
benchmarks published for the 2019
MIPS performance period. All measure
benchmarks identified as topped out for
the second (or more) consecutive year
have special scoring applied for the
2019 MIPS performance period. In Year
3 we would also consider removal of the
select set of topped out measures
identified in Table 21, through notice
and comment rulemaking, provided
they are identified as topped out during
the previous two (or more) consecutive
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years. In our example, Year 3 would be
the 2019 performance period.
• Year 4: Measure benchmarks are
identified as topped out in the
benchmarks published for the 2020
MIPS performance period. Measure
benchmarks identified as topped out for
a second (or more) consecutive year
continue to have special scoring
applied. Topped out measures finalized
for removal for the 2020 MIPS
performance period are no longer
available for reporting.
An example of applying the proposed
scoring cap compared to scoring applied
for the 2017 MIPS performance period
is provided in Table 22.
TABLE 22—PROPOSED SCORING FOR TOPPED OUT MEASURES* STARTING IN THE CY 2018 MIPS PERFORMANCE PERIOD
COMPARED TO THE TRANSITION YEAR SCORING
Measure 1
(topped out)
Measure 2
(topped out)
Measure 3
(topped out)
2017 MIPS performance period
Scoring.
10 measure
achievement
points.
10 measure
achievement
points.
10 measure
achievement
points.
Proposed Capped
Scoring applied.
6 measure
achievement
points.
6 measure
achievement
points.
6 measure
achievement
points.
Notes ....................
Topped out measures scored with 6-point measure achievement point cap. Cap
does not impact score if the MIPS eligible clinician’s score is below the cap.
Scoring policy
Measure 4
(topped out)
4 measure
achievement
points (did not
get max score).
4 measure
achievement
points.
Measure 5
(not topped out)
Measure 6
(not topped out)
Quality Cate-gory
Percent Score *
10 measure
achievement
points.
5 measure
achievement
points.
49/60 = 81.67%.
10 measure
achievement
points.
5 measure
achievement
points.
37/60 = 61.67%.
Still possible to earn maximum measure achievement points on the nontopped out measures.
mstockstill on DSK30JT082PROD with PROPOSALS2
* This example would only apply to the 6 measures identified in Table 21 for the CY 2018 MIPS Performance Period. This example also excludes bonus points and
improvement scoring proposed in section II.C.7.a.(2)(i) of this proposed rule.
Together the proposed policies for
phasing in capped scoring and removing
topped out measures are intended to
provide an incentive for MIPS eligible
clinicians to begin to submit measures
that are not topped out while also
providing stability by allowing MIPS
eligible clinicians who have few
alternative measures to continue to
receive standard scoring for most
topped out measures for an additional
year, and not perform below the median
score for those 6 measures that receive
special scoring. It also provides MIPS
eligible clinicians the ability to
anticipate and plan for the removal of
specific topped out measures, while
providing measure developers time to
develop new measures.
We propose to add a new paragraph
at § 414.1380(b)(1)(xiii) to codify our
proposal for the lifecycle for removing
topped out measures.
We also propose to add at
§ 414.1380(b)(1)(xiii)(A) that for the
2018 MIPS performance period, the 6
measures identified in Table 21 will
receive a maximum of 6 measure
achievement points, provided that the
measure benchmarks are identified as
topped out again in the benchmarks
published for the 2018 MIPS
performance period. We also propose to
add at § 414.1380(b)(1)(xiii)(B) that
beginning with the 2019 MIPS
performance period, measure
benchmarks, except for measures in the
CMS Web Interface, that are identified
as topped out for two 2 or more
consecutive years will receive a
maximum of 6 measure achievement
points in the second consecutive year it
is identified as topped out, and beyond.
We specifically seek comment on
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whether the proposed policy to cap the
score of topped out measures beginning
with the 2019 performance period
should apply to SSMs in the CAHPS for
MIPS survey measure or whether there
is another alternative policy that could
be applied for the CAHPS for MIPS
survey measure due to high, unvarying
performance within the SSM. We note
that we would like to encourage groups
to report the CAHPS for MIPS survey as
it incorporates beneficiary feedback.
We stated in the CY 2017 Quality
Payment Program final rule that we do
not believe it would be appropriate to
remove topped out measures from the
CMS Web Interface for the Quality
Payment Program because the CMS Web
Interface measures are used in MIPS and
in APMs such as the Shared Savings
Program and because we have aligned
policies, where possible, with the
Shared Savings Program, such as using
the Shared Savings Program
benchmarks for the CMS Web Interface
measures (81 FR 77285). In the CY 2017
Quality Payment Program final rule, we
also finalized that MIPS eligible
clinicians submitting via the CMS Web
Interface must submit all measures
included in the CMS Web Interface (81
FR 77116). Thus, if a CMS Web Interface
measure is topped out, the CMS Web
Interface submitter cannot select other
measures. Because of the lack of ability
to select measures, we are not proposing
to apply a special scoring adjustment to
topped out measures for CMS Web
Interface for the Quality Payment
Program.
Additionally, because the Shared
Savings Program incorporates a
methodology for measures with high
performance into the benchmark, we do
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not believe capping benchmarks from
the CMS Web Interface for the Quality
Payment Program is appropriate. We
finalized in the CY 2017 Quality
Payment Program final rule at
§ 414.1380(b)(1)(ii)(A) to use
benchmarks from the corresponding
reporting year of the Shared Savings
Program. The Shared Savings Program
adjusts some benchmarks to a flat
percentage when the 60th percentile is
equal to or greater than 80.00 percent for
individual measures (78 FR 74759
through 74763), and, for other measures,
benchmarks are set using flat
percentages when the 90th percentile
for a measure are equal to or greater
than 95.00 percent (79 FR 67925). Thus,
we are not proposing to apply the
topped out measure cap to measures in
the CMS Web Interface for the Quality
Payment Program.
We seek comment on this proposal
not to apply the topped out measure cap
to measures in the CMS Web Interface
for the Quality Payment Program.
(d) Case Minimum Requirements and
Measure Reliability and Validity
To help ensure reliable measurement,
in the CY 2017 Quality Payment
Program final rule (81 FR 77288), we
finalized a 20-case minimum for all
quality measures except the all-cause
hospital readmission measure. For the
all-cause hospital readmission measure,
we finalized in the CY 2017 Quality
Payment Program final rule a 200-case
minimum and finalized to apply the allcause hospital readmission measure
only to groups of 16 or more clinicians
that meet the 200-case minimum
requirement (81 FR 77288).
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We are not proposing any changes to
these policies.
For the 2019 MIPS payment year, we
finalized in the CY 2017 Quality
Payment Program final rule that if the
measure is submitted but is unable to be
scored because it does not meet the
required case minimum, does not have
a benchmark, or does not meet the data
completeness requirement, the measure
would receive a score of 3 points (81 FR
77288 through 77289). We identified
two classes of measures for the
transition year. Class 9 1 measures are
measures that can be scored based on
performance because they have a
benchmark, meet the case minimum
requirement, and meet the data
completeness standard. We finalized
that Class 1 measures would receive 3
to 10 points based on performance
compared to the benchmark (81 FR
77289). Class 2 measures are measures
that cannot be scored based on
performance because they do not have
a benchmark, do not have at least 20
cases, or the submitted measure does
not meet data completeness criteria. We
finalized that Class 2 measures, which
do not include measures submitted with
the CMS Web Interface or
administrative claims-based measures,
receive 3 points (81 FR 77289).
We propose to maintain the policy to
assign 3 points for measures that are
submitted but do not meet the required
case minimum or does not have a
benchmark for the 2020 MIPS payment
year and amend § 414.1380(b)(1)(vii)
accordingly.
We also propose a change to the
policy for scoring measures that do not
meet the data completeness requirement
for the 2020 MIPS payment year.
To encourage complete reporting, we
are proposing that in the 2020 MIPS
payment year, measures that do not
meet data completeness standards will
receive 1 point instead of the 3 points
that were awarded in the 2019 MIPS
payment year. We propose lowering the
point floor to 1 for measures that do not
meet data completeness standards for
several reasons. First, we want to
encourage complete reporting because
data completeness is needed to reliably
measure quality. Second, unlike case
minimum and availability of a
benchmark, data completeness is within
the direct control of the MIPS eligible
clinician. In the future, we intend that
measures that do not meet the
completeness criteria will receive zero
points; however, we believe that during
the second year of transitioning to
MIPS, clinicians should continue to
receive at least 1 measure achievement
point for any submitted measure, even
if the measure does not meet the data
completeness standards.
We are concerned, however, that data
completeness may be harder to achieve
for small practices. For example, small
practices tend to have small case
volume and missing one or two cases
could cause the MIPS eligible clinician
to miss the data completeness standard
as each case may represent multiple
percentage points for data completeness.
For example, for a small practice with
only 20 cases for a measure, each case
is worth 5 percentage points, and if they
miss reporting just 11 or more cases,
they would fail to meet the data
completeness threshold, whereas for a
practice with 200 cases, each case is
worth 0.5 percentage points towards
data completeness and the practice
would have to miss more than 100 cases
30107
to fail to meet the data completeness
criteria. Applying 1 point for missing
data completeness based on missing a
relatively small number of cases could
disadvantage these clinicians, who may
have additional burdens for reporting in
MIPS, although we also recognize that
failing to report on 10 or more patients
is undesirable. In addition, we know
that many small practices may have less
experience with submitting quality
performance category data and may not
yet have systems in place to ensure they
can meet the data completeness criteria.
Thus, we are also proposing an
exception to the proposed policy for
measures submitted by small practices,
as defined in § 414.1305. We propose
that these clinicians would continue to
receive 3 points for measures that do not
meet data completeness.
Therefore, we propose to revise Class
2 measures to include only measures
that cannot be scored based on
performance because they do not have
a benchmark or do not have at least 20
cases. We also propose to create Class 3
measures, which are measures that do
not meet the data completeness
requirement. We propose that the
revised Class 2 measure would continue
to receive 3 points. The proposed Class
3 measures would receive 1 point,
except if the measure is submitted by a
small practice in which case the Class
3 measure would receive 3 points.
However, consistent with the policy
finalized in the CY 2017 Quality
Payment Program final rule, these
policies for Class 2 and Class 3
measures would not apply to measures
submitted with the CMS Web Interface
or administrative claims-based
measures. A summary of the proposals
is provided in Table 23.
TABLE 23—QUALITY PERFORMANCE CATEGORY: SCORING MEASURES BASED ON PERFORMANCE
Description in transition year
Scoring rules in 2017 MIPS
performance period
Description proposed for
2018 MIPS
performance period
Proposed for 2018 MIPS
performance period
Class 1 ..............
mstockstill on DSK30JT082PROD with PROPOSALS2
Measure type
Measures that can be scored
based on performance.
Measures that were submitted or calculated that
met the following criteria:
(1) The measure has a
benchmark;
(2) Has at least 20
cases; and
(3) Meets the data completeness standard
(generally 50 percent.)
3 to 10 points based on performance compared to the
benchmark.
Same as transition year ........
Same as transition year.
3 to 10 points based on performance compared to the
benchmark.
9 References to ‘‘Classes’’ of measures in this
section II.C.7.a.(2)(d) are intended only to
characterize the measures for ease of discussion.
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TABLE 23—QUALITY PERFORMANCE CATEGORY: SCORING MEASURES BASED ON PERFORMANCE—Continued
Measure type
Description in transition year
Scoring rules in 2017 MIPS
performance period
Description proposed for
2018 MIPS
performance period
Proposed for 2018 MIPS
performance period
Class 2 ..............
Measures that cannot be
scored based on performance. Measures that were
submitted, but fail to meet
one of the Class 1 criteria.
The measure either
3 points .................................
* This Class 2 measure policy does not apply to CMS
Web Interface measures
and administrative claims
based measures.
Measures that were submitted and meet data completeness, but does not
have one or both of the following:
(1) a benchmark
(2) at least 20 cases
3 points
*This Class 2 measure policy
would not apply to CMS
Web Interface measures
and administrative claims
based measures.
(1) does not have a
benchmark,
(2) does not have at
least 20 cases, or
(3) does not meet data
completeness criteria.
n/a .........................................
n/a .........................................
Measures that were submitted, but do not meet
data completeness criteria,
regardless of whether they
have a benchmark or meet
the case minimum.
1 point except for small practices, which would receive
3 points.
*This Class 3 measure policy
would not apply to CMS
Web Interface measures
and administrative claims
based measures.
mstockstill on DSK30JT082PROD with PROPOSALS2
Class 3 ..............
We propose to amend
§ 414.1380(b)(1)(vii) to assign 3 points
for measures that do not meet the case
minimum or do not have a benchmark
in the 2020 MIPS payment year, and to
assign 1 point for measures that do not
meet data completeness requirements,
unless the measure is submitted by a
small practice, in which case it would
receive 3 points.
We invite comment on our proposal
to assign 1 point to measures that do not
meet data completeness criteria, with an
exception for measures submitted by
small practices.
We are not proposing to change the
methodology we use to score measures
submitted via the CMS Web Interface
that do not meet the case minimum, do
not have a benchmark, or do not meet
the data completeness requirement
finalized in the CY 2017 Quality
Payment Program final rule and codified
at paragraph (b)(1)(viii) of § 414.1380.
However, we note that as described in
section II.C.7.a.(2)(h)(ii) of this proposed
rule, we are proposing to add that CMS
Web Interface measures with a
benchmark that are redesignated from
pay for performance to pay for reporting
by the Shared Savings Program will not
be scored. We refer readers to the
discussion at 81 FR 77288 for more
details on our previously finalized
policy.
We are also not proposing any
changes to the policy to not include
administrative claims measures in the
quality performance category percent
score if the case minimum is not met or
if the measure does not have a
benchmark finalized in the CY 2017
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Quality Payment Program final rule and
codified at paragraph (b)(1)(viii) of
§ 414.1380. We refer readers to the
discussion at 81 FR 77288 for more
details on that policy.
To clarify the exclusion of measures
submitted via the CMS Web Interface
and based on administrative claims
from the policy changes proposed to be
codified at paragraph (b)(1)(vii)
previously, we are amending paragraph
(b)(1)(vii) to make it subject to
paragraph (b)(1)(viii), which codifies the
exclusion.
(e) Scoring for MIPS Eligible Clinician
That Do Not Meet Quality Performance
Category Criteria
In the CY 2017 Quality Payment
Program final rule, we finalized that
MIPS eligible clinicians who fail to
submit a measure that is required to
satisfy the quality performance category
submission criteria would receive zero
points for that measure (81 FR 77291).
For each required measure that is not
submitted, a MIPS eligible clinician
would receive zero points out of 10. For
example, if a MIPS eligible clinician had
6 measures available and applicable but
submitted only 4 measures, the MIPS
eligible clinician would be assigned
zero out of 10 measure achievement
points for the 2 missing measures,
which would be calculated into their
performance category percent score.
We are not proposing any changes to
the policy to assign zero points for
failing to submit a measure that is
required in this proposed rule.
In the CY 2017 Quality Payment
Program final rule, we also finalized
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implementation of a validation process
for claims and registry submissions to
validate whether MIPS eligible
clinicians have 6 applicable and
available measures, whether an outcome
measure is available or whether another
high priority measure is available if an
outcome measure is not available (81 FR
77290 through 77291).
We are not proposing any changes to
apply a process to validate whether
MIPS eligible clinicians that submit
measures via claims and registry
submissions have measures available
and applicable. As stated in the CY 2017
Quality Payment Program final rule (81
FR 77290), we did not intend to
establish a validation process for QCDRs
because we expect that MIPS eligible
clinicians that enroll in QCDRs will
have sufficient meaningful measures to
meet the quality performance category
criteria (81 FR 77290 through 77291).
We do not propose any changes to this
policy.
We also stated that if a MIPS eligible
clinician did not have 6 measures
relevant within their EHR to meet the
full specialty set requirements or meet
the requirement to submit 6 measures,
the MIPS eligible clinician should select
a different submission mechanism to
meet the quality performance category
requirements and should work with
their EHR vendors to incorporate
applicable measures as feasible (81 FR
77290 through 77291). Under our
proposals in section II.C.6.a.(1) of this
proposed rule to allow measures to be
submitted and scored via multiple
mechanisms within a performance
category, we anticipate that MIPS
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eligible clinicians that submit fewer
than 6 measures via EHR will have
sufficient additional measures available
via a combination of submission
mechanisms to submit the measures
required to meet the quality
performance category criteria. For
example, the MIPS eligible clinician
could submit 2 measures via EHR and
supplement that with 4 measures via
QCDR or registry.
Therefore, given our proposal to score
multiple mechanisms, if a MIPS eligible
clinician submits any quality measures
via EHR or QCDR, we would not
conduct a validation process because we
expect these MIPS eligible clinicians to
have sufficient measures available to
meet the quality performance category
requirements.
Given our proposal in section
II.C.7.a.(2)(h) of this proposed rule to
score measures submitted via multiple
mechanisms, we propose to validate the
availability and applicability of
measures only if a MIPS eligible
clinician submits via claims submission
options only, registry submission
options only, or a combination of claims
and registry submission options. In
these cases, we propose that we will
apply the validation process to
determine if other measures are
available and applicable broadly across
claims and registry submission options.
We will not check if there are measures
available via EHR or QCDR submission
options for these reporters. We note that
groups cannot report via claims and
therefore groups and virtual groups will
only have validation applied across
registries. We would validate the
availability and applicability of a
measure through a clinically related
measure analysis based on patient type,
procedure, or clinical action associated
with the measure specifications. For us
to recognize fewer than 6 measures, an
individual MIPS eligible clinician must
submit exclusively using claims or
qualified registries or a combination of
the two, and a group or virtual group
must submit exclusively using qualified
registries. Given our proposal in section
II.C.7.a.(2)(h) of this proposed rule to
score measures submitted via multiple
mechanisms, validation will be
conducted first by applying the
clinically related measure analysis for
the individual measure and then, to the
extent technically feasible, validation
will be applied to check for available
measures available via both claims and
registries.
We recognize that in extremely rare
instances there may be a MIPS eligible
clinician who may not have available
and applicable quality measures. For
example, a subspecialist who focuses on
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a very targeted clinical area may not
have any measures available. However,
in many cases, the clinician may be part
of a broader group or would have the
ability to select some of the crosscutting measures that are available.
Given the wide array of submission
options, including QCDRs which have
the flexibility to develop additional
measures, we believe this scenario
should be extremely rare. If we are not
able to score the quality performance
category, we may reweight their score
according to the reweighting policies
described in section II.C.7.b.(3)(b) and
II.C.7.b.(3)(d) of this proposed rule. We
note that we anticipate this will be a
rare circumstance given our proposals to
allow measures to be submitted and
scored via multiple mechanisms within
a performance category and to allow
facility-based measurement for the
quality performance category.
(f) Incentives To Report High Priority
Measures
In the CY 2017 Quality Payment
Program final rule, we finalized that we
would award 2 bonus points for each
outcome or patient experience measure
and 1 bonus point for each additional
high priority measure that is reported in
addition to the 1 high priority measure
that is already required to be reported
under the quality performance category
submission criteria, provided the
measure has a performance rate greater
than zero, and the measure meets the
case minimum and data completeness
requirements (81 FR 77293). High
priority measures were defined as
outcome, appropriate use, patient safety,
efficiency, patient experience and care
coordination measures, as identified in
Tables A and E in the Appendix of the
CY 2017 Quality Payment Program final
rule (81 FR 77558 and 77686). We also
finalized that we will apply measure
bonus points for the CMS Web Interface
for the Quality Payment Program based
on the finalized set of measures
reportable through that submission
mechanism (81 FR 77293). We note that
in addition to the 14 required measures,
CMS Web Interface reporters may also
report the CAHPS for MIPS survey and
receive measure bonus points for
submitting that measure.
We are not proposing any changes to
these policies for awarding measure
bonus points for reporting high priority
measures in this proposed rule.
In the CY 2017 Quality Payment
Program final rule, we finalized a cap on
high priority measure bonus points at 10
percent of the denominator (total
possible measure achievement points
the MIPS eligible clinician could receive
in the quality performance category) of
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the quality performance category for the
first 2 years of MIPS (81 FR 77294).
Groups that submit via the CMS Web
Interface for the Quality Payment
Program are also subject to the 10
percent cap on high priority measure
bonus points. We are not proposing any
changes to the cap on measure bonus
points for reporting high priority
measures, which is codified at
§ 414.1380(b)(1)(xiv)(D) 10, in this
proposed rule.
(g) Incentives to Use CEHRT To Support
Quality Performance Category
Submissions
Section 1848(q)(5)(B)(ii) of the Act
outlines specific scoring rules to
encourage the use of CEHRT under the
quality performance category. For more
of the statutory background and
description of the proposed and
finalized policies, we refer readers to
the CY 2017 Quality Payment Program
final rule (81 FR 77294 through 77299).
In the CY 2017 Quality Payment
Program final rule at
§ 414.1380(b)(1)(xiv), we codified that 1
bonus point is available for each quality
measure submitted with end-to-end
electronic reporting, under certain
criteria described below (81 FR 77297).
We also finalized a policy capping the
number of bonus points available for
electronic end-to-end reporting at 10
percent of the denominator of the
quality performance category percent
score, for the first 2 years of the program
(81 FR 77297). For example, when the
denominator is 60, the number of
measure bonus points will be capped at
6 points. We also finalized that the
CEHRT bonus would be available to all
submission mechanisms except claims
submissions. Specifically, MIPS eligible
clinicians who report via qualified
registries, QCDRs, EHR submission
mechanisms, or the CMS Web Interface
for the Quality Payment Program, in a
manner that meets the end-to-end
reporting requirements, may receive 1
bonus point for each reported measure
with a cap as described (81 FR 77297).
We are not proposing changes to these
policies related to bonus points for
using CEHRT for end-to-end reporting
in this proposed rule. However, we are
seeking comment on the use of health IT
in quality measurement and how HHS
can encourage the use of certified EHR
technology in quality measurement as
established in the statute. What other
incentives within this category for
reporting in an end-to-end manner
could be leveraged to incentivize more
clinicians to report electronically? What
format should these incentives take? For
10 Redesignated
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example, should clinicians who report
all of their quality performance category
data in an end-to-end manner receive
additional bonus points than those who
report only partial electronic data? Are
there other ways that HHS should
incentivize providers to report
electronic quality data beyond what is
currently employed? We welcome
public comment on these questions.
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(h) Calculating Total Measure
Achievement and Measure Bonus Points
In section II.C.7.a.(2)(i) of this
proposed rule, we are proposing a new
methodology to reward improvement
based on achievement, from 1 year to
another, which requires modifying the
calculation of the quality performance
category percent score. In this section
II.C.7.a.(2)(h) of the proposed rule, we
are summarizing the policies for
calculating the total measure
achievement points and total measure
bonus points, prior to scoring
improvement and the final quality
performance category percent score. We
note that we will refer to policies
finalized in the CY 2017 Quality
Payment Program final rule that apply
to the quality performance category
score, which is referred to as the quality
performance category percent score in
this proposed rule, in this section. We
are also proposing some refinements to
address the ability for MIPS eligible
clinicians to submit quality data via
multiple submission mechanisms.
(i) Calculating Total Measure
Achievement and Measure Bonus Points
for Non-CMS Web Interface Reporters
In the CY 2017 Quality Payment
Program final rule (81 FR 77300), we
finalized that if a MIPS eligible clinician
elects to report more than the minimum
number of measures to meet the MIPS
quality performance category criteria,
then we will only include the scores for
the measures with the highest number
of assigned points, once the first
outcome measure is scored, or if an
outcome measure is not available, once
another high priority measure is scored.
We are not proposing any changes to the
policy to score the measures with the
highest number of assigned points in
this proposed rule; however, we are
proposing refinements to account for
measures being submitted across
multiple submission mechanisms.
In the CY 2017 Quality Payment
Program final rule, we sought comment
on whether to score measures submitted
across multiple submission mechanisms
(81 FR 77275). As described in section
II.C.6.a.(1) of this proposed rule, we are
proposing that MIPS eligible clinicians
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be able to submit measures within a
performance category via multiple
submission mechanisms. In the CY 2017
Quality Payment Program final rule, we
also sought comment on what approach
we should use to combine the scores for
quality measures from multiple
submission mechanisms into a single
aggregate score for the quality
performance category (81 FR 77275).
Examples of possible scoring options
were a weighted average score on
quality measures submitted through two
or more different mechanisms or taking
the highest scores for any submitted
measure regardless of how the measure
is submitted. A few comments received
in response to the CY 2017 Quality
Payment Program final rule did not
support developing different weights for
different submission methods. One
commenter recommended that we take
the highest score for any submitted
measure, regardless of submission
mechanisms, or alternatively, calculate
independent scores that would each
contribute equally to the final score.
After consideration of the comments
we received, we are proposing,
beginning with the 2018 MIPS
performance period, a method to score
quality measures if a MIPS eligible
clinician submits measures via more
than one of the following submission
mechanisms: Claims, qualified registry,
EHR or QCDR submission options. We
believe that allowing MIPS eligible
clinicians to be scored across these data
submission mechanisms in the quality
performance category will provide
additional options for MIPS eligible
clinicians to report the measures
required to meet the quality
performance category criteria, and
encourage MIPS eligible clinicians to
begin using electronic submission
mechanisms, even if they may not have
6 measures to report via a single
electronic submission mechanism alone.
We note that we also continue to score
the CMS-approved survey vendor for
CAHPS for MIPS submission options in
conjunction with other submission
mechanisms (81 FR 77275) as noted in
Table 24.
We propose to score measures across
multiple mechanisms using the
following rules:
• As with the rest of MIPS, we will
only score measures within a single
identifier. For example, as codified in
§ 414.1310(e), eligible clinicians and
MIPS eligible clinicians within a group
aggregate their performance data across
the TIN in order for their performance
to be assessed as a group. Therefore,
measures can only be scored across
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multiple mechanisms if reported by the
same individual MIPS eligible clinician,
group, virtual group or APM Entity, as
described in Table 24.
• We do not propose to aggregate
measure results across different
submitters to create a single score for an
individual measure (for example, we are
not going to aggregate scores from
different TINs within a virtual group
TIN to create a single virtual group score
for the measures; rather, virtual groups
must perform that aggregation across
TINs prior to data submission to CMS).
Virtual groups are treated like other
groups and must report all of their
measures at the virtual group level, for
the measures to be scored. Data
completeness and all the other criteria
will be evaluated at the virtual group
level. Then the same rules apply for
selecting which measures are used for
scoring. In other words, if a virtual
group representative submits some
measures via a qualified registry and
other measures via EHR, but an
individual TIN within the virtual group
also submits measures, we will only use
the scores from the measures that were
submitted at the virtual group level,
because the TIN submission does not
use the virtual group identifier. This is
consistent with our other scoring
principles, where, for virtual groups, all
quality measures are scored at the
virtual group level.
• Separately, as also described in
Table 24, because CMS Web Interface
and facility-based measurement each
have a comprehensive set of measures
that meet the proposed MIPS
submission requirements, we do not
propose to combine CMS Web Interface
measures or facility-based measurement
with other group submission
mechanisms (other than CAHPS for
MIPS, which can be submitted in
conjunction with the CMS Web
Interface). We refer readers to section
II.C.7.a.(2)(h)(ii) of this proposed rule
for discussion of calculating the total
measure achievement and measure
bonus points for CMS Web Interface
reporters and to section II.C.7.a.(4) of
this proposed rule for a description of
our proposed policies on facility-based
measurement. We list these submission
mechanisms in Table 24, to illustrate
that CMS Web Interface submissions
and facility-based measurement cannot
be combined with other submission
options, except that the CAHPS for
MIPS survey can be combined with
CMS Web Interface, as described in
section II.C.7.a.(2)(h)(ii) of this proposed
rule.
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TABLE 24—SCORING ALLOWED ACROSS MULTIPLE MECHANISMS BY SUBMISSION MECHANISM
[Determined by MIPS identifier and submission mechanism]
MIPS identifier and submission mechanisms
When can quality measures be scored across multiple mechanisms?
Individual eligible clinician reporting via claims, EHR, QCDR, and registry submission options.
Group reporting via EHR, QCDR, registry, and the CAHPS for MIPS
survey.
Virtual group reporting via EHR, QCDR, registry, and the CAHPS for
MIPS survey.
Group reporting via CMS Web Interface ..................................................
Virtual group reporting via CMS Web Interface .......................................
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Individual or group reporting facility-based measures .............................
MIPS APMs reporting Web Interface or other quality measures .............
• If a MIPS eligible clinician submits
the same measure via 2 different
submission mechanisms, we will score
each mechanism by which the measure
is submitted for achievement and take
the highest measure achievement points
of the 2 mechanisms.
• Measure bonus points for high
priority measures would be added for
all measures submitted via all the
different submission mechanisms
available, even if more than 6 measures
are submitted, but high priority measure
bonus points are only available once for
each unique measure (as noted by the
measure number) that meets the criteria
for earning the bonus point. For
example, if a MIPS eligible clinician
submits 8 measures—6 process and 2
outcome—and both outcome measures
meet the criteria for a high priority
bonus (meeting the required data
completeness, case minimum, and has a
performance rate greater than zero), the
outcome measure with the highest
measure achievement points would be
scored as the required outcome measure
and then the measures with the next 5
highest measure achievement points
will contribute to the final quality score.
This could include the second outcome
measure but does not have to. Even if
the measure achievement points for the
second outcome measure are not part of
the quality performance category
percent score, measure bonus points
would still be available for submitting a
second outcome measure and meeting
the requirement for the high priority
measure bonus points. The rationale for
providing measure bonus points for
measures that do not contribute measure
achievement points to the quality
performance category percent score is
that it would help create better
benchmarks for outcome and other high
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Can combine claims, EHR, QCDR, and registry.
Can combine EHR, QCDR, registry, and CAHPS for MIPS survey.
Can combine EHR, QCDR, registry, and CAHPS for MIPS survey.
Cannot be combined with other submission mechanisms, except for
the CAHPS for MIPS survey.
Cannot be combined with other submission mechanisms, except for
the CAHPS for MIPS survey.
Cannot be combined with other submission mechanisms.
MIPS APMs are subject to separate scoring standards and cannot be
combined with other submission mechanisms.
priority measures by encouraging
clinicians to report them even if they
may not have high performance on the
measure. We also want to encourage
MIPS eligible clinicians to submit to us
all of their available MIPS data, not only
the data that they or their intermediary
deem to be their best data. We believe
it will be in the best interest of all MIPS
eligible clinicians that we determine
which measures will result in the
clinician receiving the highest MIPS
score. If the same measure is submitted
through multiple submission
mechanisms, we would apply the bonus
points only once to the measure. We
propose to amend § 414.1380(b)(1)(xiv)
(as redesignated from
§ 414.1380(b)(1)(xiii)) to add paragraph
(b)(1)(xiv)(E) that if the same high
priority measure is submitted via two or
more submission mechanisms, as
determined using the measure ID, the
measure will receive high priority
measure bonus points only once for the
measure. The total measure bonus
points for high-priority measures would
still be capped at 10 percent of the total
possible measure achievement points.
• Measure bonus points that are
available for the use of end-to-end
electronic reporting would be calculated
for all submitted measures across all
submission mechanisms, including
measures that cannot be reliably scored
against a benchmark. If the same
measure is submitted through multiple
submission mechanisms, then we would
apply the bonus points only once to the
measure. For example, if the same
measure is submitted using end-to-end
reporting via both a QCDR and EHR
reporting mechanism, the measure
would only get a measure bonus point
one time. We propose to amend
§ 414.1380(b)(1)(xv) (as redesignated) to
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add that if the same measure is
submitted via two or more submission
mechanisms, as determined using the
measure ID, the measure will receive
measure bonus points only once for the
measure. The total measure bonus
points for end-to-end electronic
reporting would still be capped at 10
percent of the total available measure
achievement points.
Although we provide a policy to
account for scoring in those
circumstances when the same measure
is submitted via multiple mechanisms,
we anticipate that this will be a rare
circumstance and do not encourage
clinicians to submit the same measure
via multiple mechanisms. Table 25
illustrates how we would assign total
measure achievement points and total
measure bonus points across multiple
submission mechanisms under our
proposal. In this example, a MIPS
eligible clinician elects to submit
quality data via 3 submission
mechanisms: 3 Measures via registry, 4
measures via claims, and 5 measures via
EHR. The 3 registry measures are also
submitted via claims (as noted by the
same measure letter in this example).
The EHR measures do not overlap with
either the registry or claims measures. In
this example, we assign measure
achievement and bonus points for each
measure. If the same measure (as
determined by measure ID) is submitted,
then we use the highest achievement
points for that measure. For the bonus
points, we assess which of the outcome
measures meets the outcome measure
requirement and then we identify any
other unique measures that qualify for
the high priority bonus. We also identify
the unique measures that qualify for
end-to-end electronic reporting bonus.
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TABLE 25—EXAMPLE OF ASSIGNING TOTAL MEASURE ACHIEVEMENT AND BONUS POINTS FOR AN INDIVIDUAL MIPS
ELIGIBLE CLINICIAN THAT SUBMITS MEASURES ACROSS MULTIPLE SUBMISSION MECHANISMS
Measure achievement points
6 Scored
measures
High priority
measure bonus
points
Measure A (Outcome) ..........................
7.1 ........................................................
7.1 (Outcome
measure with
highest achievement points).
(required outcome
measure does
not receive
bonus points).
Measure B ............................................
6.2 (points not considered because it
is lower than the 8.2 points for the
same claims measure).
5.1 (points not considered because it
is lower than the 6.0 points for the
same claims measure).
...............................
Incentive for
CEHRT measure
bonus points
1
No bonus points
because the registry submission
of the same
measure satisfies requirement
for outcome
measure.
Registry
Measure C (high priority patient safety
measure that meets requirements for
additional bonus points).
Claims
Measure A (Outcome) ..........................
4.1 (points not considered because it
is lower than the 7.1 points for the
same measure submitted via a registry).
...............................
Measure B ............................................
Measure C (High priority patient safety
measure that meets requirements for
additional bonus points).
8.2 ........................................................
6.0 ........................................................
8.2
6.0 .........................
Measure D (outcome measure <50%
of data submitted).
1.0 ........................................................
1.0 .........................
No bonus (Bonus
applied to the
registry measure).
(no high priority
bonus points because below
data completeness).
EHR (using end-to-end)
Reporting that
meets CEHRT
bonus point criteria
Measure E ............................................
Measure F .............................................
Measure G ............................................
Measure H ............................................
Measure I (high priority patient safety
measure that is below case minimum).
5.1
5.0
4.1
4.2
3.0
........................................................
........................................................
........................................................
........................................................
........................................................
35.6 ......................................................
Quality Performance Category Percent
Score Prior to Improvement Scoring.
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1
5.1 .........................
5.0 .........................
...............................
4.2 .........................
...............................
1 (below 10%
cap1).
..............................................................
...............................
...............................
...............................
...............................
(no high priority
bonus points because below
case minimum).
5 (below 10% cap).
1
1
1
1
1
(35.6 + 1 + 5)/60 = 69.33%
In this example the cap would be 6 points, which is 10 percent of the total available measure achievement points of 60.
We propose to amend
§ 414.1380(b)(1)(xii) to add paragraph
(A) to state that if a MIPS eligible
clinician submits measures via claims,
qualified registry, EHR, or QCDR
submission options, and submits more
than the required number of measures,
they are scored on the required
measures with the highest assigned
measure achievement points. MIPS
eligible clinicians that report a measure
via more than 1 submission mechanism
can be scored on only 1 submission
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mechanism, which will be the
submission mechanism with the highest
measure achievement points. Groups
that submit via these submission
mechanisms may also submit and be
scored on CMS-approved survey vendor
for CAHPS for MIPS submission
mechanisms.
We invite comments on our proposal
to calculate the total measure
achievement points by using the
measures with the 6 highest measure
achievement points across multiple
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submission mechanisms. We invite
comments on our proposal that if the
same measure is submitted via 2 or
more mechanisms, we will only take the
one with the highest measure
achievement points. We invite
comments on our proposal to assign
high priority measure bonus points to
all measures, with performance greater
than zero, that meet case minimums,
and that meet data completeness
requirements, regardless of submission
mechanism and to assign measure
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bonus points for each unique measure
submitted using end-to-end electronic
reporting. We invite comments on our
proposal that if the same measure is
submitted using 2 different
mechanisms, the measure will receive
measure bonus points once.
We are not proposing any changes to
our policy that if a MIPS eligible
clinician does not have any scored
measures, then a quality performance
category percent score will not be
calculated as finalized in the CY 2017
Quality Payment Program final rule at
81 FR 77300. We refer readers to the
discussion at 81 FR 77299 through
77300 for more details on that policy.
As stated in section II.C.7.a.(2)(e) of this
proposed rule, we anticipate that it will
be only in rare case that a MIPS eligible
clinician does not have any scored
measures and a quality performance
category percent score cannot be
calculated.
(ii) Calculating Total Measure
Achievement and Measure Bonus Points
for CMS Web Interface Reporters
In the CY 2017 Quality Payment
Program final rule, we finalized that
CMS Web Interface reporters are
required to report 14 measures, 13
individual measures, and a 2component measure for diabetes (81 FR
77302 through 77305). We note that for
the transition year, 3 measures did not
have a benchmark in the Shared Savings
Program. Therefore, for the transition
year, CMS Web Interface reporters are
scored on 11 of the total 14 required
measures, provided that they report all
14 required measures.
In the CY 2017 Quality Payment
Program final rule, we finalized a global
floor of 3 points for all CMS Web
Interface measures submitted in the
transition year, even with measures at
zero percent performance rate, provided
that these measures have met the data
completeness criteria, have a benchmark
and meet the case minimum
requirements (82 FR 77305). Therefore,
measures with performance below the
30th percentile will be assigned a value
of 3 points during the transition year to
be consistent with the floor established
for other measures and because the
Shared Savings Program does not
publish benchmarks below the 30th
percentile (82 FR 77305). We stated that
we will reassess scoring for measures
below the 30th percentile in future
years.
We propose to continue to assign 3
points for measures with performance
below the 30th percentile, provided the
measure meets data completeness, has a
benchmark, and meets the case
minimum requirements for the 2018
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MIPS performance year; we make this
proposal in order to continue to align
with the 3-point floor for other measures
and because the Shared Savings
Program does not publish benchmarks
with values below the 30th percentile.
We will reassess this policy again next
year through rulemaking.
We are not proposing any changes to
our previously finalized policy to
exclude from scoring CMS Web
Interface measures that are submitted
but that do not meet the case minimum
requirement or that lack a benchmark,
or to our policy that measures that are
not submitted and measures submitted
below the data completeness
requirements will receive a zero score
(82 FR 77305). However, to further
increase alignment with the Shared
Savings Program, we propose to also
exclude CMS Web Interface measures
from scoring if the measure is
redesignated from pay for performance
to pay for reporting for all Shared
Savings Program ACOs, although we
will recognize the measure was
submitted. While the Shared Savings
Program designates measures that are
pay for performance in advance of the
reporting year, the Shared Savings
Program may redesignate a measure as
pay for reporting under certain
circumstances (see 42 CFR
425.502(a)(5)). Therefore, we propose to
amend § 414.1380(b)(1)(viii) to add that
CMS Web Interface measures that have
a measure benchmark but are
redesignated as pay for reporting for all
Shared Savings Program ACOs by the
Shared Savings Program will not be
scored, as long as the data completeness
requirement is met.
We invite comment on our proposal
to not score CMS Web Interface
measures redesignated as pay for
reporting by the Shared Savings
Program.
We also note that, while we did not
state explicitly in the CY 2017 Quality
Payment Program final rule, groups that
choose to report quality measures via
the CMS Web Interface may, in addition
to the 14 required measures, also submit
the CAHPS for MIPS survey in the
quality performance category (81 FR
77094 through 77095; 81 FR 77292). If
they do so, they can receive bonus
points for submitting this high priority
measure and will be scored on it as an
additional measure. Therefore, we
propose to amend § 414.1380(b)(1)(xii)
to add paragraph (B) to state that groups
that submit measures via the CMS Web
Interface may also submit and be scored
on CMS-approved survey vendor for
CAHPS for MIPS submission options.
In addition, groups of 16 or more
eligible clinicians that meet the case
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minimum for administrative claims
measures will automatically be scored
on the all-cause hospital readmission
measure and have that measure score
included in their quality category
performance percent score.
We are not proposing any changes to
calculating the total measure
achievement points and measure bonus
points for CMS Web Interface measures
in this proposed rule, although we are
proposing to add improvement to the
quality performance category percent
score for such submissions (as well as
other submission mechanisms) in
section II.C.7.a.(2)(j) of this proposed
rule.
(i) Scoring Improvement for the MIPS
Quality Performance Category Percent
Score
(i) Calculating Improvement at the
Quality Performance Category Level
In the CY 2017 Quality Payment
Program final rule, we noted that we
consider achievement to mean how a
MIPS eligible clinician performs relative
to performance standards, and
improvement to mean how a MIPS
eligible clinician performs compared to
the MIPS eligible clinician’s own
previous performance on measures and
activities in the performance category
(81 FR 77274). We also solicited public
comments in the CY 2017 Quality
Payment Program proposed rule on
potential ways to incorporate
improvement in the scoring
methodology. In section II.C.7.a.(1)(b)(i)
of this proposed rule, we explain why
we believe that the options set forth in
the CY 2017 Quality Payment Program
proposed rule, including the Hospital
VBP Program, the Shared Savings
Program, and Medicare Advantage 5-star
Ratings Program, were not fully
translatable to MIPS. Beginning with the
2018 MIPS performance period, we
propose here to score improvement as
well as achievement in the quality
performance category level when data is
sufficient. We believe that scoring
improvement at the performance
category level, rather than measuring
improvement at the measure level, for
the quality performance category would
allow improvement to be available to
the broadest number of MIPS eligible
clinicians because we are connecting
performance to previous MIPS quality
performance as a whole rather than
changes in performance for individual
measures. Just as we believe it is
important for a MIPS eligible clinician
to have the flexibility to choose
measures that are meaningful to their
practice, we want them to be able to
adopt new measures without concern
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about losing the ability to be measured
on improvement. In addition, we are
encouraging MIPS eligible clinicians to
select more outcome measures and to
move away from topped out measures.
We do not want to remove the
opportunity to score improvement from
those who select different measures
between performance periods for the
quality performance category; therefore,
we are proposing to measure
improvement at the category level
which can be calculated with different
measures.
We propose at § 414.1380(b)(1)(xvi)(E)
to define an improvement percent score
to mean the score that represents
improvement for the purposes of
calculating the quality performance
category percent score. We also propose
at § 414.1380(b)(1)(xvi)(C) that an
improvement percent score would be
assessed at the quality performance
category level and included in the
calculation of the quality performance
category percent score. When we
evaluated different improvement
scoring options, we saw two general
methods for incorporating
improvement. One method measures
both achievement and improvement and
takes the higher of the two scores for
each measure that is compared. The
Hospital VBP Program incorporates
such a methodology. The second
method is to calculate an achievement
score and then add an improvement
score if improvement is measured. The
Shared Savings Program utilizes a
similar methodology for measuring
improvement. For the quality
performance category, we are proposing
to calculate improvement at the category
level and believe adding improvement
to an existing achievement percent score
would be the most straight-forward and
simple way to incorporate
improvement. For the purpose of
improvement scoring methodology, the
term ‘‘quality performance category
achievement percent score’’ means the
total measure achievement points
divided by the total possible available
measure achievement points, without
consideration of bonus points or
improvement adjustments and is
discussed in section II.C.7.a.(2)(i)(iv) of
this proposed rule.
Consistent with bonuses available in
the quality performance category, we
propose at § 414.1380(b)(1)(xvi)(B) that
the improvement percent score may not
total more than 10 percentage points.
We invite public comments on these
proposals.
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(ii) Data Sufficiency Standard To
Measure Improvement for Quality
Performance Category
Section 1848(q)(5)(D)(i) of the Act
stipulates that beginning with the
second year to which the MIPS applies,
if data sufficient to measure
improvement is available then we shall
measure improvement for the quality
performance category. Measuring
improvement requires a direct
comparison of data from one Quality
Payment Program year to another.
Starting with the 2020 MIPS payment
year, we propose that a MIPS eligible
clinician’s data would be sufficient to
score improvement in the quality
performance category if the MIPS
eligible clinician had a comparable
quality performance category
achievement percent score for the MIPS
performance period immediately prior
to the current MIPS performance period;
we explain our proposal to identify how
we will identify ‘‘comparable’’ quality
performance category achievement
percent scores below. We believe that
this approach would allow
improvement to be broadly available to
MIPS eligible clinicians and encourage
continued participation in the MIPS
program. Moreover, this approach
would encourage MIPS eligible
clinicians to focus on efforts to improve
the quality of care delivered. We note
that, by measuring improvement based
only on the overall quality performance
category achievement percent score,
some MIPS eligible clinicians and
groups may generate an improvement
score simply by switching to measures
on which they perform more highly,
rather than actually improving at the
same measures. We will monitor how
frequently improvement is due to actual
improvement versus potentially
perceived improvement by switching
measures and will address through
future rulemaking, as needed. We also
solicit comment on whether we should
require some level of year to year
consistency when scoring improvement.
We propose that ‘‘comparability’’ of
quality performance category
achievement percent scores would be
established by looking first at the
submitter of the data. As discussed in
more detail in section II.C.7.a.(2)(i)(i) of
this proposed rule, we are comparing
results at the category, rather than the
performance measure level because we
believe that the performance category
score from 1 year is comparable to the
performance category score from the
prior year, even if the measures in the
performance category have changed
from year to year.
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We propose to compare results from
an identifier when we receive
submissions with that same identifier
(either TIN/NPI for individual, or TIN
for group, APM entity, or virtual group
identifier) for two consecutive
performance periods. However, if we do
not have the same identifier for two
consecutive performance periods, we
propose a methodology to create a
comparable performance category score
that can be used for improvement
measurement. Just as we do not want to
remove the opportunity to earn an
improvement score from those who
elect new measures between
performance periods for the quality
performance category, we also do not
want to restrict improvement for those
MIPS eligible clinicians who elect to
participate in MIPS using a different
identifier.
There are times when submissions
from a particular individual clinician or
group of clinicians use different
identifiers between 2 years. For
example, a group of 20 MIPS eligible
clinicians could choose to submit as a
group (using their TIN identifier) for the
current performance period. If the group
also submitted as a group for the
previous year’s performance period, we
would simply compare the group scores
associated with the previous
performance period to the current
performance period (following the
methodology explained in section
II.C.7.a.(2)(i)(iv) of this proposed rule).
However, if the group members had
previously elected to submit to MIPS as
individual clinicians, we would not
have a group score at the TIN level from
the previous performance period to
which to compare the current
performance period.
In circumstances where we do not
have the same identifier for two
consecutive performance periods, we
propose to identify a comparable score
for individual submissions or calculate
a comparable score for group, virtual
group, and APM entity submissions. For
individual submissions, if we do not
have a quality performance category
achievement percent score for the same
individual identifier in the immediately
prior period, then we propose to apply
the hierarchy logic that is described in
section II.C.8.a.(2) of this proposed rule
to identify the quality performance
category achievement score associated
with the final score that would be
applied to the TIN/NPI for payment
purposes. For example, if there is no
historical score for the TIN/NPI, but
there is a TIN score (because in the
previous period the TIN submitted as a
group), then we would use the quality
performance category achievement
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percent score associated with the TIN’s
prior performance. If the NPI had
changed TINs and there was no
historical score for the same TIN/NPI,
then we would take the highest prior
score associated with the NPI.
When we do not have a comparable
TIN group, virtual group, or APM Entity
score, we propose to calculate a score
based on the individual TIN/NPIs in the
practice for the current performance
period. For example, in a group of 20
clinicians that previously participated
in MIPS as individuals, but now want
to participate as a group, we would not
have a comparable TIN score to use for
scoring improvement. We believe
however it is still important to provide
to the MIPS eligible clinicians the
improvement points they have earned.
Similarly, in cases where a group of
clinicians previously participated in
MIPS as individuals, but now
participates as a new TIN, or a new
virtual group, or a new APM Entity
submitting data in the performance
period, we would not have a
comparable TIN, virtual group, or APM
Entity score to use for scoring
improvement. Therefore, we propose to
calculate a score by taking the average
of the individual quality performance
category achievement scores for the
MIPS eligible clinicians that were in the
group for the current performance
period. If we have more than one quality
performance category achievement
percent score for the same individual
identifier in the immediately prior
period, then we propose to apply the
hierarchy logic that is described in
section II.C.8.a.(2) of this proposed rule
to identify the quality performance
category score associated with the final
score that would be applied to the TIN/
NPI for payment purposes. We would
30115
exclude any TIN/NPI’s that did not have
a final score because they were not
eligible for MIPS. We would include
quality performance category
achievement percent scores of zero in
the average.
There are instances where we would
not be able to measure improvement
due to lack of sufficient data. For
example, if the MIPS eligible clinicians
did not participate in MIPS in the
previous performance period because
they were not eligible for MIPS, we
could not calculate improvement
because we would not have a previous
quality performance category
achievement percent score.
Table 26 summarizes the different
cases when a group or individual would
be eligible for improvement scoring
under this proposal.
TABLE 26—ELIGIBILITY FOR IMPROVEMENT SCORING EXAMPLES
Current MIPS
performance
period identifier
Scenario
Prior MIPS
performance
period identifier
(with score greater
than zero)
Eligible for
improvement
scoring
No change in identifier ..........................
Individual (TIN A/
NPI 1).
Individual (TIN A/
NPI 1).
Yes .......................
No change in identifier ..........................
Group (TIN A) .......
Group (TIN A) .......
Yes .......................
Individual is with same group, but selects to submit as an individual
whereas previously the group submitted as a group.
Individual changes practices, but submitted to MIPS previously as an individual.
Individual changes practices and has
multiple scores in prior performance
period.
Group does not have a previous group
score from prior performance period.
Individual (TIN A/
NPI 1).
Group (TIN A) .......
Yes .......................
Individual (TIN B/
NPI).
Individual (TIN A/
NPI).
Yes .......................
Individual (TIN C/
NPI).
Group (TIN A/NPI);
Individual (TIN
B/NPI).
Individual scores
(TIN A/NPI 1,
TIN A/NPI 2, TIN
A/NPI 3, etc.).
Yes .......................
Virtual group does not have previous
group score from prior performance
period.
Virtual Group (Virtual Group Identifier A) (Assume
virtual group has
2 TINs with 2 clinicians.).
Individual (TIN A/
NPI 1).
Individuals (TIN A/
NPI 1, TIN A/
NPI 2, TIN B/
NPI 1, TIN B/
NPI 2).
Yes .......................
Individual was not
eligible for MIPS
and did not voluntarily submit
any quality
measures to
MIPS.
No .........................
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Individual does not have a quality performance
category
achievement
score for the prior performance period.
Group (TIN A) .......
We propose at
§ 414.1380(b)(1)(xvi)(A) to state that
improvement scoring is available when
the data sufficiency standard is met,
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Yes .......................
which means when data are available
and a MIPS eligible clinician or group
has a quality performance category
achievement percent score for the
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Data comparability
Current individual score is compared
to individual score from prior performance period.
Current group score is compared to
group score from prior performance
period.
Current individual score is compared
to the group score associated with
the TIN/NPI from the prior performance period.
Current individual score is compared
to the individual score from the prior
performance period.
Current individual score is compared
to highest score from the prior performance period.
The current group score is compared
to the average of the scores from
the prior performance period of individuals who comprise the current
group.
The current group score is compared
to the average of the scores from
the prior performance period of individuals who comprise the current
group.
The individual quality performance
category score is missing for the
prior performance period and not eligible for improvement scoring.
previous performance period. We also
propose at § 414.1380(b)(1)(xvi)(A)(1)
that data must be comparable to meet
the requirement of data sufficiency,
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which means that the quality
performance category achievement
percent score is available for the current
performance period and the previous
performance period and, therefore,
quality performance category
achievement percent scores can be
compared. We also propose at
§ 414.1380(b)(1)(xvi)(A)(2) that quality
performance category achievement
percent scores are comparable when
submissions are received from the same
identifier for two consecutive
performance periods. We also propose
an exception at
§ 414.1380(b)(1)(xvi)(A)(3) that if the
identifier is not the same for 2
consecutive performance periods, then
for individual submissions, the
comparable quality performance
category achievement percent score is
the quality performance category
achievement percent score associated
with the final score from the prior
performance period that will be used for
payment. For group, virtual group, and
APM entity submissions, the
comparable quality performance
category achievement percent score is
the average of the quality performance
category achievement percent score
associated with the final score from the
prior performance period that will be
used for payment for each of the
individuals in the group. As noted
above, these proposals are designed to
offer improvement scoring to all MIPS
eligible clinicians with sufficient data in
the prior MIPS performance period. We
invite public comments on our
proposals as they relate to data
sufficiency for improvement scoring.
We also seek comment on an
alternative to this proposal: Whether we
should restrict improvement to those
who submit quality performance data
using the same identifier for two
consecutive MIPS performance periods.
We believe this option would be simpler
to apply, communicate and understand
than our proposal is, but this alternative
could have the unintended consequence
of not allowing improvement scoring for
certain MIPS eligible clinicians, groups,
virtual groups and APM entities.
(iii) Additional Requirement for Full
Participation To Measure Improvement
for Quality Performance Category
To receive a quality performance
category improvement percent score
greater than zero, we are also proposing
that MIPS eligible clinicians must fully
participate, which we propose in
§ 414.1380(b)(1)(xvi)(F) to mean
compliance with § 414.1330 and
§ 414.1340, in the current performance
year. Compliance with those referenced
regulations entails the submission of all
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required measures, including meeting
data completeness, for the quality
performance category for the current
performance period. For example, for
MIPS eligible clinicians submitting via
QCDR, full participation would
generally mean submitting 6 measures
including 1 outcome measure if an
outcome measure is available or 1 high
priority measure if an outcome measure
is not available, and meeting the 50
percent data completeness criteria for
each of the 6 measures.
We believe that improvement is most
meaningful and valid when we have a
full set of quality measures. A
comparison of data resulting from full
participation of a MIPS eligible clinician
from 1 year to another enables a more
accurate assessment of improvement
because the performance being
compared is based on the applicable
and available measures for the
performance periods and not from
changes in participation. While we are
not requiring full participation for both
performance periods, requiring full
participation for the current
performance period means that any
future improvement scores for a
clinician or group would be derived
solely from changes in performance and
not because the clinician or group
submitted more measures. We propose
at § 414.1380(b)(1)(xvi)(C)(5) that the
quality improvement percent score is
zero if the clinician did not fully
participate in the quality performance
category for the current performance
period.
Because we want to award
improvement for net increases in
performance and not just improved
participation in MIPS, we want to
measure improvement above a floor for
the 2018 MIPS performance period, to
account for our transition year policies.
We considered that MIPS eligible
clinicians who chose the ‘‘test’’ option
of the ‘‘pick your pace’’ approach for the
transition year may not have submitted
all the required measures and, as a
result, may have a relatively low quality
performance category achievement score
for the 2017 MIPS performance period.
Due to the transition year policy to
award at least 3 measure achievement
points for any submitted measure via
claims, EHR, QCDR, qualified registry,
and CMS-approved survey vendor for
CAHPS for MIPS, and the 3-point floor
for the all-cause readmission measure (if
the measure applies), a MIPS eligible
clinician that submitted some data via
these mechanisms on the required
number of measures would
automatically have a quality
performance category achievement score
of at least 30 percent because they
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would receive at least 3 of 10 possible
measure achievement points for each
required measure. For example, if a solo
practitioner submitted 6 measures and
received 3 points for each measure, then
the solo practitioner would have 18
measure achievement points out of a
possible 60 total possible measure
achievement points (3 measure
achievement points × 6 measures). The
quality performance category
achievement percent score is 18/60
which equals 30 percent. For groups
with 16 or more clinicians that
submitted 6 measures and receive 3
measure achievement points for each
submitted measure as well as the allcause hospital readmission measure,
then the group would have 21 measure
achievement points out of 70 total
possible measure achievement points or
a quality performance category
achievement percent score of 21/70
which equals 30 percent (3 measure
achievement points × 7 measures). For
the CMS Web Interface submission
option, MIPS eligible clinicians that
fully participate by submitting and
meeting data completeness for all
measures, would also be able to achieve
a quality performance category
achievement percent score of at least 30
percent, as each scored measure would
receive 3 measure achievement points
out of 10 possible measure achievement
points.
Therefore, we propose at
§ 414.1380(b)(1)(xvi)(C)(4) that if a MIPS
eligible clinician has a previous year
quality performance category score less
than or equal to 30 percent, we would
compare 2018 performance to an
assumed 2017 quality performance
category achievement percent score of
30 percent. In effect, for the MIPS 2018
performance period, improvement
would be measured only if the
clinician’s 2018 quality performance
category achievement percent score for
the quality performance category
exceeds 30 percent. We believe this
approach appropriately recognizes the
participation of MIPS eligible clinicians
who participated in the transition year
and accounts for MIPS eligible
clinicians who participated minimally
and may otherwise be awarded for an
increase in participation rather than an
increase in achievement performance.
We invite public comment on these
proposals.
(iv) Measuring Improvement Based on
Changes in Achievement
To calculate improvement with a
focus on quality performance, we are
proposing to focus on improvement
based on achievement performance and
would not consider measure bonus
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points in our improvement algorithm.
Bonus points may be awarded for
reasons not directly related to
performance such as the use of end-toend electronic reporting. We believe
that improvement points should be
awarded based on improvement related
to achievement. Accordingly, we are
proposing to use an individual MIPS
eligible clinician’s or group’s total
measure achievement points from the
prior MIPS performance period without
the bonus points the individual MIPS
eligible clinician or group may have
received, to calculate improvement.
Therefore, to measure improvement at
the quality performance category level,
we will use the quality performance
category achievement percent score
excluding measure bonus points (and
any improvement score) for the
applicable years. We propose at
§ 414.1380(b)(1)(xvi)(D) to call this
score, which is based on achievement
only, the ‘‘quality performance category
achievement percent score’’ which is
calculated using the following formula:
Quality performance category
achievement percent score = total
measure achievement points/total
available measure achievement
points.
Table 27 illustrates how the quality
performance category achievement
percent score is calculated. For
simplicity, we assume the MIPS eligible
clinician received 6 measure
30117
achievement points for each of the
submitted 6 required measures in the
current performance period, which
equals 36 total measure achievement
points. This is compared to the previous
performance period when the MIPS
eligible clinician received only 5
measure achievement points per
measure, for 30 total measure
achievement points. The quality
performance category achievement
percent score is represented in line 2.
For improvement, performance in the
current 2018 MIPS performance period
(60 percent) is compared to the
performance category achievement
percent score in the 2017 MIPS
performance period (50 percent).
TABLE 27—COMPARISON OF QUALITY PERFORMANCE CATEGORY ACHIEVEMENT PERCENT SCORES
Current MIPS performance period
(1) Total Measure Achievement Points ..............
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(2) Quality Performance Category Achievement
Percent Score (measure achievement points/
60 for this example).
The current MIPS performance period
quality performance category
achievement percent score is compared
to the previous performance period
quality performance category
achievement percent score. If the
current score is higher, the MIPS
eligible clinician may qualify for an
improvement percent score to be added
into the quality performance category
percent score for the current
performance year.
We propose to amend the regulatory
text at § 414.1380(b)(1)(xvi) to state that
improvement scoring is available to
MIPS eligible clinicians and groups that
demonstrate improvement in
performance in the current MIPS
performance period compared to the
performance in the previous MIPS
performance period, based on
achievement. Bonus points or
improvement percent score adjustments
made to the category score in the prior
or current performance period are not
taken into account when determining
whether an improvement has occurred
or the size of any improvement percent
score.
We invite public comment on our
proposal to award improvement based
on changes in the quality performance
category achievement percent score.
(v) Improvement Scoring Methodology
for the Quality Performance Category
We believe the improvement scoring
methodology that we are proposing for
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Previous MIPS performance period
6 measure achievement points × 6 measures
= 36 total measure achievement points.
36/60 = 60 percent ..........................................
5 measure achievement points × 6 measures
= 30 total measure achievement points.
30/60 = 50 percent.
the quality performance category
recognizes the rate of increase in quality
performance category scores of MIPS
eligible clinicians from one performance
period to another performance period so
that a higher rate of improvement
results in a higher improvement percent
score. We believe this is particularly
true for those clinicians with lower
performance who will be incentivized to
begin improving with the opportunity to
increase their improvement significantly
and achieve a higher improvement
percent score.
We propose to award an
‘‘improvement percent score’’ based on
the following formula:
Improvement percent score = (increase
in quality performance category
achievement percent score from
prior performance period to current
performance period/prior year
quality performance category
achievement percent score) * 10
percent.
percent score) * 10 percent = 2
percentage points. Another way to
explain the logic is a 20 percent rate of
improvement for achievement (for
example increasing the achievement
percent score 10 percentage points
which is 20 percent higher than the
original 50 percent achievement percent
score) is worth a 2 percentage point
increase to the quality performance
category achievement percent score.
We believe that this improvement
scoring methodology provides an easily
explained and applied approach that is
consistent for all MIPS eligible
clinicians. Additionally, it provides
additional incentives for MIPS eligible
clinicians who are lower performers to
improve performance. We believe that
providing larger incentives for MIPS
eligible clinicians with lower quality
performance category scores to improve
will not only increase the quality
performance category scores but also
will have the greatest impact on
improving quality for beneficiaries.
We also propose that the
improvement percent score cannot be
negative (that is, lower than zero
percentage points). The improvement
percent score would be zero for those
who do not have sufficient data or who
are not eligible under our proposal for
improvement points. For example, as
noted in section II.C.7.a.(2)(i)(ii) of this
proposed rule, a MIPS eligible clinician
would not be eligible for improvement
if the clinician was not eligible for MIPS
Using the example from Table 27, the
quality performance category
achievement percent score for the
current performance period is 60
percent, and the previous performance
period achievement percent score is 50
percent. The increase in achievement is
10 percentage points (60 percent—50
percent). Therefore, the improvement
percent score is 10 percent (increase in
achievement)/50 percent (previous
performance period achievement
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in the prior performance period and did
not have a quality performance category
achievement percent score. We are also
proposing to cap the size of the
improvement award at 10 percentage
points, which we believe appropriately
rewards improvement and does not
outweigh percentage points available
through achievement. In effect, 10
recognition and award for the largest
increases in performance improvement.
Table 28 illustrates examples of the
proposed improvement percent scoring
methodology, which is based on rate of
increase in quality performance category
achievement percent scores.
percentage points under our proposed
formula would represent 100 percent
improvement—or doubling of
achievement measure points—over the
immediately preceding period. For the
reasons stated, we anticipate that this
amount will encourage participation by
individual MIPS eligible clinicians and
groups and will provide an appropriate
TABLE 28—IMPROVEMENT SCORING EXAMPLES BASED ON RATE OF INCREASE IN QUALITY PERFORMANCE CATEGORY
ACHIEVEMENT PERCENT SCORES
Year 1 quality
performance
category achievement
percent score
Individual Eligible Clinician #1 (Pick your
Pace Test Option).
Individual Eligible Clinician #2.
Individual Eligible Clinician #3.
Individual Eligible Clinician #4.
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Increase in
achievement
Rate of improvement
Improvement percent
score
5% (Will substitute
30% which is the
lowest score a clinician can achieve
with complete reporting in year 1.).
60% .............................
50
20% Because the year
1 score is below
30%, we measure
improvement above
30%.
20%/30%= 0.67 ...........
0.67*10% = 6.7% No
cap needed.
66
6% ...............................
6%/60%= 0.10 .............
90% .............................
93
3% ...............................
3%/90%= 0.033 ...........
30% .............................
70
40% .............................
40%/30%=1.33 ............
0.10*10% = 1.0% No
cap needed.
0.033*10% = 0.3% No
cap needed.
1.33*10%=13.3%
Apply cap at 10%.
We also considered an alternative to
measuring the rate of improvement. The
alternative would use band levels to
determine the improvement points for
MIPS eligible clinicians who qualify for
improvement points. Under the band
level methodology, a MIPS eligible
clinician’s improvement points would
be determined by an improvement in
the quality performance category
achievement percent score from 1 year
to the next year to determine
improvement in the same manner as set
forth in the rate of improvement
methodology. However, for the band
level methodology, an improvement
percent score would then be assigned by
taking into account a portion (50, 75 or
100 percent) of the improvement in
achievement, based on the clinician’s
performance category achievement
percent score for the prior year. Bands
would be set for category achievement
percent scores, with increases from
lower category achievement scores
earning a larger portion (percentage) of
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the improvement points. Under this
alternative, simple improvement
percentage points for improvement are
awarded to MIPS eligible clinicians
whose category scores improved across
years according to the band level, up to
a maximum of 10 percent of the total
score.
In Table 29, we illustrate the band
levels we considered as part of this
alternative proposal. The chart depicts
the band level and the improvement
points allotted for the increases in
improvement scores that fall within the
transition year score range.
TABLE 29—BAND LEVEL AND IMPROVEMENT POINTS ALLOTTED FOR
DETERMINING IMPROVEMENT PERCENT SCORES
Transition year
score range
% Credit for each percent
increase in achievement
1–50 ...............
100% of increase in achievement.
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TABLE 29—BAND LEVEL AND IMPROVEMENT POINTS ALLOTTED FOR
DETERMINING IMPROVEMENT PERCENT SCORES—Continued
Transition year
score range
% Credit for each percent
increase in achievement
51–75 .............
75% of increase in achievement.
50% of increase in achievement.
75–100 ...........
Table 30 illustrates examples of the
improvement scoring methodology
based on band levels. Generally, this
methodology would generate a higher
improvement percent score for
clinicians; however, we believe the
policy we proposed would provide a
score that better represents true
improvement at the performance
category level, rather than comparing
simple increases in performance
category scores.
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TABLE 30—EXAMPLES OF IMPROVEMENT SCORING METHODOLOGY BASED ON BAND LEVELS
Year 2 quality
performance
category
achievement
percent score
Year 1 quality
performance category
achievement percent
score
Individual Eligible Clinician #1 (Pick your Pace
Test Option).
Individual Eligible Clinician #2.
Individual Eligible Clinician #3.
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Band for
improvement
adjustment
Improvement percent
score (after applying the
cap)
5% (Will substitute 30%
which is the lowest
score a clinician can
achieve with complete
reporting in year 1.)
60% .................................
50%
20% Because the year 1
score is below 30%,
we measure improvement above 30%.
100%
20%*100%= 20% which
is capped at 10%.
66%
6% ...................................
75%
90% .................................
93%
3% ...................................
50%
6%*75%= 4.5% No cap
needed
3%*50%= 1.5% No cap
needed
In addition, we considered another
alternative that would adopt the
improvement scoring methodology of
the Shared Savings Program11 for CMS
Web Interface submissions in the
quality performance category, but
decided to not adopt this approach.
Under the Shared Savings Program
approach, eligible clinicians and groups
that submit through the CMS Web
Interface would have been required to
submit on the same set of quality
measures, and we would have awarded
improvement for all eligible clinicians
or groups who submitted complete data
in the prior year. As Shared Savings
Program and Next Generation ACOs
report using the CMS Web Interface,
using the same improvement score
approach would align MIPS with these
other programs. We believed it could be
beneficial to align improvement
between the programs because it would
align incentives for those who
participate in the Shared Savings
Program or ACOs. The Shared Savings
Program approach would test each
measure for statistically significant
improvement or statistically significant
decline. We would sum the number of
measures with a statistically significant
improvement and subtract the number
of measures with a statistically
significant decline to determine the Net
Improvement. We would next divide the
Net Improvement in each domain by the
number of eligible measures in the
domain to calculate the Improvement
Score. We would cap the number of
possible improvement percentage points
at 10.
11 For additional information on the Shared
Savings Program’s scoring methodology, we refer
readers to the Quality Measurement Methodology
and Resources, September 2016, Version 1 and the
Medicare Shared Savings Program Quality Measure
Benchmarks for the 2016 and 2017 Reporting Years
(available at https://www.cms.gov/Medicare/
Medicare-Fee-for-Service-Payment/
sharedsavingsprogram/Downloads/MSSP–QMBenchmarks-2016.pdf.)
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We considered the Shared Savings
Program methodology because it would
promote alignment with ACOs. We
ultimately decided not to adopt this
scoring methodology because we believe
having a single performance category
level approach for all quality
performance category scores encourages
a uniformity in our approach to
improvement scoring and simplifies the
scoring rules for MIPS eligible
clinicians. It also allows us greater
flexibility to compare performance
scores across the diverse submission
mechanisms, which makes
improvement scoring more broadly
available to eligible clinicians and
groups that elect different ways of
participating in MIPS.
We propose to add regulatory text at
§ 414.1380(b)(1)(xvi)(C)(3) to state that
an improvement percent score cannot be
negative (that is, lower than zero
percentage points). We also propose to
add regulatory text at
§ 414.1380(b)(1)(xvi)(C)(1) to state that
improvement scoring is awarded based
on the rate of increase in the quality
performance category achievement
percent score of individual MIPS
eligible clinicians or groups from the
current MIPS performance period
compared to the score in the year
immediately prior to the current MIPS
performance period. We also propose to
add regulatory text at
§ 414.1380(b)(1)(xvi)(C)(2) to state that
an improvement percent score is
calculated by dividing the increase in
the quality performance category
achievement percent score of an
individual MIPS eligible clinician or
group, which is calculated by
comparing the quality performance
category achievement percent score the
current MIPS performance period to the
quality performance category
achievement percent score from the
MIPS performance period in the year
immediately prior to the current MIPS
performance period, by the prior year
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quality performance category
achievement percent score, and
multiplying by 10 percent.
We invite public comments on our
proposal to calculate improvement
scoring using a methodology that
awards improvement points based on
the rate of improvement and,
alternatively, on rewarding
improvement at the band level or using
the Shared Saving Program approach for
CMS Web Interface submissions.
(j) Calculating the Quality Performance
Category Percent Score Including
Improvement
In the CY 2017 Quality Payment
Program final rule, we finalized at
§ 414.1380(b)(1)(xv) that the quality
performance category score is the sum
of all points assigned for the measures
required for the quality performance
category criteria plus bonus points,
divided by the sum of total possible
points (81 FR 77300). Using the
terminology proposed in section
II.C.7.a.(2) of this proposed rule, this
formula can be represented as:
Quality performance category percent
score = (total measure achievement
points + measure bonus points)/
total available measure achievement
points.
We propose to incorporate the
improvement percent score, which is
proposed in section II.C.7.a.(2)(i)(i) of
this proposed rule, into the quality
performance category percent score. We
propose to amend § 414.1380(b)(1)(xv)
(redesignated as § 414.1380(b)(1)(xvii))
to add the improvement percent score
(as calculated pursuant to proposed
paragraph (b)(1)(xvi)(A) through (F)) to
the quality performance score. We also
propose to amend § 414.1380(b)(1)(xv)
(redesignated as § 414.1380(b)(1)(xvii))
to amend the text that states the quality
performance category percent score
cannot exceed the total possible points
for the quality performance category to
clarify that the total possible points for
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the quality performance category cannot
exceed 100 percentage points. Thus, the
calculation for the proposed quality
performance category percent score
including improvement, can be
summarized in the following formula:
Quality performance category percent
score = ([total measure achievement
points + measure bonus points]/
total available measure achievement
points) + improvement percent
score, not to exceed 100 percent.
This same formula and logic will be
applied for both CMS Web Interface and
Non-CMS Web Interface reporters.
Table 31 illustrates an example of
calculating the quality performance
category percent score including
improvement for a non-CMS Web
Interface reporter. In this example, an
individual MIPS eligible clinician
received measure achievement points
for their 6 required measures, and
received 6 measure bonus points.
Because this is an individual clinician
and the administrative claims based
measure is not applicable, the total
available measure achievement points
for this clinician is 60. The
improvement percent score would be
calculated based on the proposal in
section II.C.7.a.(2)(i) of this proposed
rule; Table 31 does not illustrate the
underlying calculations for the
improvement percent score. To
calculate the quality performance
category percent score, the total
measures achievement points would be
summed with the total measure bonus
points and then divided by the total
available measure achievement points.
The improvement percent score would
be added to that calculation. The
resulting quality performance category
percent score cannot exceed 100
percentage points.
TABLE 31—EXAMPLE OF SCORING THE QUALITY PERFORMANCE CATEGORY PERCENT SCORE INCLUDING IMPROVEMENT
Total measure
achievement
points
Total measure
bonus points
Total available
measure
achievement
points
Individual Eligible Clinician .........
35.6
6
60
Individual Eligible Clinician (did
not submit in Year 1).
Individual Eligible Clinician (with
maximum improvement).
35.6
6
60
50
6
60
We note that the quality performance
category percent score is then
multiplied by the performance category
weight for calculating the final score.
We invite public comment on this
overall methodology and formula for
calculating the quality performance
category percent score.
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(3) Scoring the Cost Performance
Category
We score the cost performance
category using a methodology that is
generally consistent with the
methodology used for the quality
performance category. In the CY 2017
Quality Payment Program final rule (81
FR 77309), we codified at
§ 414.1380(b)(2) that a MIPS eligible
clinician receives 1 to 10 achievement
points for each cost measure attributed
to the MIPS eligible clinician based on
the MIPS eligible clinician’s
performance compared to the measure
benchmark. We establish a single
benchmark for each cost measure and
base those benchmarks on the
performance period (81 FR 77309).
Because we base the benchmarks on the
performance period, we will not be able
to publish the actual numerical
benchmarks in advance of the
performance period (81 FR 77309). We
develop a benchmark for a cost measure
only if at least 20 groups (for those MIPS
eligible clinicians participating in MIPS
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Calculation prior to
improvement
(35.6 + 6)/60 =
69.33%.
(35.6 + 6)/60 =
69.33%.
(50 + 6)/60 =
93.33%.
as a group practice) or TIN/NPI
combinations (for those MIPS eligible
clinicians participating in MIPS as an
individual) can be attributed the case
minimum for the measure (81 FR
77309). If a benchmark is not developed,
the cost measure is not scored or
included in the performance category
(81 FR 77309). For each set of
benchmarks, we calculate the decile
breaks based on cost measure
performance during the performance
period and assign 1 to 10 achievement
points for each measure based on which
benchmark decile range the MIPS
eligible clinician’s performance on the
measure is between (81 FR 77309
through 77310). We also codified at
§ 414.1380(b)(2)(iii) that a MIPS eligible
clinician’s cost performance category
score is the equally-weighted average of
all scored cost measures (81 FR 77311).
In the CY 2017 Quality Payment
Program final rule (81 FR 77311), we
adopted a final policy to not calculate
a cost performance category score if a
MIPS eligible clinician or group is not
attributed any cost measures because
the MIPS eligible clinician or group has
not met the case minimum requirements
for any of the cost measures or a
benchmark has not been created for any
of the cost measures that would
otherwise be attributed to the clinician
or group. We inadvertently failed to
include this policy in the regulation text
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Improvement
percent score
(%)
1.9
0
10
Quality
performance
category percent
score
69.33% + 1.9% =
71.23%
69.33% + 0% =
69.33%
93.33% + 10% =
103.33%, which
is capped at
100%
and are proposing to codify it under
§ 414.1380(b)(2)(v).
For more of the statutory background
and descriptions of our current policies
for the cost performance category, we
refer readers to the CY 2017 Quality
Payment Program final rule (81 FR
77308 through 77311).
In section II.C.7.a.(3)(a) of this
proposed rule, we propose to add
improvement scoring to the cost
performance category scoring
methodology starting with the 2020
MIPS payment year. We do not propose
any changes to the methodology for
scoring achievement in the cost
performance category for the 2020 MIPS
payment year other than the method
used for facility-based measurement
described in II.C.7.a.(4) of this proposed
rule. We are proposing a change in
terminology to refer to the ‘‘cost
performance category percent score in
order to be consistent with the
terminology used in the quality
performance category. In section
II.C.7.a.(2) of this proposed rule, we
propose to calculate a ‘‘quality
performance category percent score’’
which is reflective of performance in the
quality performance category based on
dividing the sum of total measure
achievement points and bonus points by
the total available measure achievement
points. We propose to revise
§ 414.1380(b)(2)(iii) to provide that a
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MIPS eligible clinician’s cost
performance category percent score is
the sum of the following, not to exceed
100 percent: The total number of
achievement points earned by the MIPS
eligible clinician divided by the total
number of available achievement points
(which can be expressed as a
percentage); and the cost improvement
score. This terminology change to refer
to the score as a percentage is consistent
with the change in section II.C.7.a.(2) for
the quality performance category. We
discuss our proposals for improvement
scoring in the cost performance category
in section II.C.7.b.3.(a) of this proposed
rule.
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(a) Measuring Improvement
(i) Calculating Improvement at the Cost
Measure Level
In section II.C.7.a.(1)(b) of this
proposed rule, we propose to make
available to MIPS eligible clinicians and
groups a method of measuring
improvement in the quality and cost
performance categories. In section
II.C.7.a.(2)(i) of this proposed rule, for
the quality performance category, we
propose to assess improvement on the
basis of the score at the performance
category level. For the cost performance
category, similar to the quality
performance category, we propose at
§ 414.1380(b)(2)(iv) that improvement
scoring is available to MIPS eligible
clinicians and groups that demonstrate
improvement in performance in the
current MIPS performance period
compared to their performance in the
immediately preceding MIPS
performance period (for example,
demonstrating improvement in the 2018
MIPS performance period over the 2017
MIPS performance period).
In section II.C.7.a.(2)(i) of this
proposed rule, we note the various
challenges associated with attempting to
measure improvement in the quality
performance category at the measure
level, given the many opportunities
available to clinicians to select which
measures to report. The cost
performance category is not subject to
this same issue of measure selection.
Cost measures are calculated based on
Medicare administrative claims data
maintained by CMS, without any
additional data input from or reporting
by clinicians, and MIPS eligible
clinicians are not given the opportunity
to select which cost measures apply to
them. We believe that there are
advantages to measuring cost
improvement at the measure level.
Principally, MIPS eligible clinicians
could see their performance on each
cost measure and better understand how
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practice improvement changes can drive
changes for each specific cost measure.
Additionally, as discussed in section
II.C.7.a.(1)(b)(i) of this proposed rule,
other Medicare value-based purchasing
programs generally assess performance
improvement at the measure level.
Therefore, we propose at section
§ 414.1380(b)(2)(iv)(A) to measure cost
improvement at the measure level for
the cost performance category.
As described in section
II.C.7.a.(1)(b)(ii) of this proposed rule,
we believe that we would have data
sufficient to measure improvement
when we can measure performance in
the current performance period
compared to the prior performance
period. Due to the differences in our
proposals for measuring improvement
for the quality and cost performance
categories, such as measuring
improvement at the measure level
versus the performance category level,
we are proposing a different data
sufficiency standard for the cost
performance category than for the
quality performance category, which is
proposed in section II.C.7.a.(2)(i)(ii) of
this proposed rule. First, for data
sufficient to measure improvement to be
available for the cost performance
category, the same cost measure(s)
would need to be specified for the cost
performance category for 2 consecutive
performance periods. For the 2020 MIPS
payment year, only 2 cost measures, the
MSPB measure and the total per capita
cost measure, would be eligible for
improvement scoring. For a measure to
be scored in either performance period,
a MIPS eligible clinician would need to
have a sufficient number of attributed
cases to meet or exceed the case
minimum for the measure.
In addition, a clinician would have to
report for MIPS using the same
identifier (TIN/NPI combination for
individuals, TIN for groups, or virtual
group identifiers for virtual groups) and
be scored on the same measure(s) for 2
consecutive performance periods. We
wish to encourage action on the part of
clinicians in reviewing and
understanding their contribution to
patient costs. For example, a clinician
who is shown to have lower
performance on the MSPB measure
could focus on the efficient use of postacute care and be able to see that
improvement reflected in the cost
improvement score in future years. This
review could highlight opportunities for
better stewardship of healthcare costs
such as better recognition of
unnecessary costs related to common
ordering practices. For these reasons, we
believe that improvement should be
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evaluated only when there is a
consistent identifier.
Therefore, for the cost performance
category, we are proposing at
§ 414.1380(b)(2)(iv)(B) that we would
calculate a cost improvement score only
when data sufficient to measure
improvement is available. We are
proposing that sufficient data would be
available when a MIPS eligible clinician
participates in MIPS using the same
identifier in 2 consecutive performance
periods and is scored on the same cost
measure(s) for 2 consecutive
performance periods (for example, in
the 2017 MIPS performance period and
the 2018 MIPS performance period). If
the cost improvement score cannot be
calculated because sufficient data is not
available, we are proposing to assign a
cost improvement score of zero
percentage points. While the total
available cost improvement score would
be limited at first because only 2 cost
measures would be included in both the
first and second performance periods of
the program (total per capita cost and
MSPB), more opportunities for
improvement scoring would be
available in the future as additional cost
measures, including episode-based
measures, are added in future
rulemaking. MIPS eligible clinicians
would be able to review their
performance feedback and make
improvements compared to the score in
their previous feedback.
We invite public comments on these
proposals.
(ii) Improvement Scoring Methodology
In section II.C.7.a.(1)(b)(i) of this
proposed rule, we discuss a number of
different programs and how they
measure improvement at the category or
measure level as part of their scoring
systems. For example, the Hospital
Value-Based Purchasing (VBP) Program
awards either measure improvement or
measure achievement, but not both. In
the proposed method for the quality
performance category, we compare the
overall rate of achievement on all the
underlying measures in the quality
performance category and measure a
rate of overall improvement to calculate
an improvement percent score. We then
add the improvement percent score after
taking into account measure
achievement points and measure bonus
points as described in proposed
§ 414.1380(b)(1)(xvii). In reviewing the
methodologies that are specified in
section II.C.7.a.(1)(b)(i) of this proposed
rule that include consideration of
improvement at the measure level, we
noted that the methodology used in the
Shared Savings Program would best
reward achievement and improvement
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for the cost performance category
because this program includes measures
for clinicians, the methodology is
straightforward, and it only recognizes
significant improvement. We propose to
quantify improvement in the cost
performance category by comparing the
number of cost measures with
significant improvement in performance
and the number of cost measures with
significant declines in performance. We
propose at § 414.1380(b)(2)(iv)(C) to
determine the cost improvement score
by subtracting the number of cost
measures with significant declines from
the number of cost measures with
significant improvement, and then
dividing the result by the number of
cost measures for which the MIPS
eligible clinician or group was scored in
both performance periods, and then
multiplying the result by the maximum
cost improvement score. For the 2020
MIPS payment year, improvement
scoring would be possible for the total
per capita cost measure and the MSPB
measure as those 2 measures would be
available for 2 consecutive performance
periods under our proposals in section
II.C.6.d.(3)(a). As in our proposed
quality improvement methodology, we
propose at § 414.1380(b)(2)(iv)(D) that
the cost improvement score could not be
lower than zero, and therefore, could
only be positive.
We propose to determine whether
there was a significant improvement or
decline in performance between the 2
performance periods by applying a
common standard statistical test, a ttest, as is used in the Shared Savings
Program (79 FR 67930 through 67931).
The t-test’s statistical significance and
the t-test’s effect size are the 2 primary
outputs of the t-test. Statistical
significance indicates whether the
difference between sample averages is
likely to represent an actual difference
between populations and the effect size
indicates whether that difference is
large enough to be practically
meaningful. Statistical significance
testing in this case assesses how
unlikely it is that differences as large as
those observed would be due to chance
when the performance is actually the
same. The test recognizes and
appropriately adjusts measures at both
high and low levels of performance for
statistically significant levels of change.
However, as an alternative, we welcome
public comments on whether we should
consider instead adopting an
improvement scoring methodology that
measures improvement in the cost
performance category the same way we
propose to do in the quality
performance category; that is, using the
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rate of improvement and without
requiring statistical significance. We
refer readers to section II.C.7.a.(2)(i) of
this proposed rule for our proposal
related to measuring improvement in
the quality performance category.
Section 1848(q)(5)(D)(ii) of the Act
specifies that the Secretary may assign
a higher scoring weight under
subparagraph (F) with respect to the
achievement of a MIPS eligible clinician
than with respect to any improvement
of such clinician with respect to a
measure, activity, or category described
in paragraph (2). We believe that there
are many opportunities for clinicians to
actively work on improving their
performance on cost measures, through
more active care management or
reductions in certain services. However,
we recognize that most clinicians are
still learning about their opportunities
in cost measurement. We aim to
continue to educate clinicians about
opportunities in cost measurement and
continue to develop opportunities for
robust feedback and measures that
better recognize the role of clinicians.
Since MIPS is still in its beginning years
and we understand that clinicians are
working hard to understand how we
measure costs for purposes of the cost
performance category, as well as how
we score their performance in all other
aspects of the program, we believe
improvement scoring in the cost
performance category should be limited
to avoid creating additional confusion.
Based on these considerations, we
propose in section II.C.6.d.(2) of this
proposed rule to weight the cost
performance category at zero percent for
the 2020 MIPS payment year/2018 MIPS
performance period. With the entire cost
performance category proposed to be
weighted at zero percent, we believe
that the focus of clinicians should be on
achievement as opposed to
improvement, and therefore we propose
at § 414.1380(b)(2)(iv)(E) that although
improvement would be measured
according to the method described
above, the maximum cost improvement
score for the 2020 MIPS payment year
would be zero percentage points.
Section 1848(q)(5)(D)(ii) of the Act
provides discretion for the Secretary to
assign a higher scoring weight under
subparagraph (F), which refers to
section 1848(q)(5)(F) of the Act, with
respect to achievement than with
respect to improvement. Section
1848(q)(5)(F) of the Act provides if there
are not sufficient measures and
activities applicable and available to
each type of MIPS eligible clinician, the
Secretary shall assign different scoring
weights (including a weight of zero) for
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measures, activities, and/or performance
categories. When read together, we
interpret sections 1848(q)(5)(D)(ii) and
1848(q)(5)(F) of the Act to provide
discretion to the Secretary to assign a
scoring weight of zero for improvement
on the measures specified for the cost
performance category. Under the
improvement scoring methodology we
have proposed, we believe a maximum
cost improvement score of zero would
be effectively the same as a scoring
weight of zero. As a result of our
proposal, the cost improvement score
would not contribute to the cost
performance category percent score
calculated for the 2020 MIPS payment
year. In other words, we would
calculate a cost improvement score, but
the cost improvement score would not
contribute any points to the cost
performance category percent score for
the 2020 MIPS payment year.
In section II.C.6.d.(2) of this proposed
rule, we consider an alternative to make
no changes to the previously finalized
weight of 10 percent for the cost
performance category for the 2020 MIPS
payment year. If we finalize this
alternative, we believe that
improvement should be given weight
towards the cost performance category
percent score, but it should still be
limited. Therefore, we propose that if
we maintain a weight of 10 percent for
the cost performance category for the
2020 MIPS payment year, the maximum
cost improvement score available in the
cost performance category would be 1
percentage point out of 100 percentage
points available for the cost
performance category percent score. If a
clinician were measured on only one
measure consistently from one
performance period to the next and met
the requirements for improvement, the
clinician would receive one
improvement percentage point in the
cost performance category percent score.
If a clinician were measured on 2
measures consistently, improved
significantly on one, and did not show
significant improvement on the other (as
measured by the t-test method described
above), the clinician would receive 0.5
improvement percentage points.
We invite comments on these
proposals as well as alternative ways to
measure changes in statistical
significance for the cost measure.
(b) Calculating the Cost Performance
Category Percent Score With
Achievement and Improvement
In section II.C.7.a.(1)(b) of this
proposed rule, we evaluated different
improvement scoring options used in
other CMS programs. In those programs,
we saw 2 general methods for
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incorporating improvement. One
method measures both achievement and
improvement and takes the higher of the
2 scores for each measure that is
compared. The Hospital VBP Program
incorporates such a methodology. The
second method is to calculate an
achievement score and then add an
improvement score if improvement is
measured. The Shared Savings Program
utilizes a similar methodology for
measuring improvement. For the cost
performance category, we are proposing
to evaluate improvement at the measure
level, unlike the quality performance
category where we are proposing to
evaluate improvement at the
performance category level. For both the
quality performance category and the
cost performance category, we are
proposing to add improvement to an
existing category percent score. We
believe this is the most straight-forward
and simple way to incorporate
improvement. It is also consistent with
other Medicare programs that reward
improvement.
As noted in section II.7.b.(3) of this
proposed rule, we have proposed a
change in terminology to express the
cost performance category percent score
as a percentage. We propose to revise
§ 414.1380(b)(2)(iii) to provide that a
MIPS eligible clinician’s cost
performance category percent score is
the sum of the following, not to exceed
100 percent: The total number of
achievement points earned by the MIPS
eligible clinician divided by the total
number of available achievement points
(which can be expressed as a
percentage); and the cost improvement
score. With these two proposed changes,
the formula would be (Cost
Achievement Points/Available Cost
Achievement Points) + (Cost
Improvement Score) = (Cost
Performance Category Percent Score).
We invite public comments on these
proposals.
In Table 32, we provide an example
of cost performance category percent
scores along with the determination of
improvement or decline. For illustrative
purposes, we are using the alternative
proposal of a maximum cost
improvement score of 1. This example
is for group reporting where the group
is measured on both the total per capita
cost measure and the MSPB measure for
2 consecutive performance periods.
TABLE 32—EXAMPLE OF ASSESSING ACHIEVEMENT AND IMPROVEMENT IN THE COST PERFORMANCE CATEGORY
Measure
achievement
points earned
by the group
Measure
Total per Capita Cost Measure .......................................................................
MSPB Measure ................................................................................................
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In this example, there are 20 total
possible measure achievement points
and 14.6 measure achievement points
earned by the group, and the group
improved on one measure but not the
other, with both measures being scored
in each performance period. The cost
improvement score would be
determined as follows: ((1 measure with
significant improvement¥zero
measures with significant decline)/2
measures) * 1 percentage point = 0.5
percentage points. Under the proposed
revised formula, the cost performance
category percent score would be (14.6/
20) + 0.5% = 73.5%.
As discussed in section II.C.7.b.(2) of
this proposed rule, in determining the
MIPS final score, the cost performance
category percent score is multiplied by
the cost performance category weight.
For the 2020 MIPS payment year, if we
finalize the cost performance category
weight of zero percent, then the cost
performance category percent score will
not contribute to the final score.
(4) Facility-Based Measures Scoring
Option for the 2020 MIPS Payment Year
for the Quality and Cost Performance
Categories
(a) Background
Section 1848(q)(2)(C)(ii) of the Act
provides that the Secretary may use
measures used for payment systems
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8.2
6.4
other than for physicians, such as
measures for inpatient hospitals, for
purposes of the quality and cost
performance categories. However, the
Secretary may not use measures for
hospital outpatient departments, except
in the case of items and services
furnished by emergency physicians,
radiologists, and anesthesiologists. In
the MIPS and APMs RFI (80 FR 59108),
we sought comment on how we could
best use this authority. We refer readers
to the CY 2017 Quality Payment
Program final rule (81 FR 77127) for a
summary of these comments.
As noted in the CY 2017 Quality
Payment Program proposed rule (81 FR
28192), we considered an option for
facility-based MIPS eligible clinicians to
elect to use their institution’s
performance rates as a proxy for the
MIPS eligible clinician’s quality score.
However, we did not propose an option
for the transition year of MIPS because
there were several operational
considerations that we believed needed
to be addressed before this option could
be implemented. We requested
comments on the following issues: (1)
Whether we should attribute a facility’s
performance to a MIPS eligible clinician
for purposes of the quality and cost
performance categories and under what
conditions such attribution would be
appropriate and representative of the
MIPS eligible clinician’s performance;
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Total possible
measure
achievement
points
10
10
Significant
improvement
from prior
performance
period
Yes
No
Significant
decline from
prior
performance
period
No
No
(2) possible criteria for attributing a
facility’s performance to a MIPS eligible
clinician for purposes of the quality and
cost performance categories; (3) the
specific measures and settings for which
we can use the facility’s quality and cost
data as a proxy for the MIPS eligible
clinician’s quality and cost performance
categories; and (4) if attribution should
be automatic or if an individual MIPS
eligible clinician or group should elect
for it to be done and choose the facilities
through a registration process.
As noted in the CY 2017 Quality
Payment Program final rule (81 FR
77127 through 77130), the majority of
the comments we received supported
attributing a facility’s performance to a
MIPS eligible clinician for purposes of
the quality and cost performance
categories. Some commenters opposed
using a facility’s quality and cost
performance as a proxy for MIPS
eligible clinicians. Many of these
commenters expressed the view that
facility scores do not represent the
individual MIPS eligible clinician’s
performance. In addition, we received
suggestions on how we should attribute
a facility’s performance to a MIPS
eligible clinician, as well as comments
suggesting that attribution should be
voluntary and that the facility’s
measures should be relevant to the
MIPS eligible clinician. A full
discussion of the comments we received
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and our responses can be found in the
CY 2017 Quality Payment Program final
rule (81 FR 77127 through 77130).
In addition, we have received ongoing
feedback from various stakeholder
associations and individuals regarding
facility-based measurement for MIPS
eligible clinicians, which included:
Support for MIPS eligible clinicians
being able to choose to be assessed in
this manner; several groups’ preference
that value-based purchasing and quality
reporting program measure data be used
for facility-based scoring; support for a
‘‘hybrid’’ approach where MIPS eligible
clinicians could select both clinicianbased measures and facility-based
measures for purposes of MIPS scoring;
and a suggested 2-year pilot program
before expanding facility-based scoring
more broadly with an emphasis on no
negative impact on those who are
measured in this fashion. We took this
feedback, as well as the comments
discussed in the CY 2017 Quality
Payment Program final rule, into
consideration when developing
proposals for the application of facilitybased measures.
(b) Facility-Based Measurement
We believe that facility-based
measurement is intended to reduce
reporting burden on facility-based MIPS
eligible clinicians by leveraging existing
quality data sources and value-based
purchasing experiences and aligning
incentives between facilities and the
MIPS eligible clinicians who provide
services there. In addition, we believe
that facility-based MIPS eligible
clinicians contribute substantively to
their respective facilities’ performance
on facility-based measures of quality
and cost, and that their performance
may be better reflected by their
facilities’ performance on such
measures.
Medicare operates both pay-forreporting programs and pay-forperformance programs. Pay-forreporting programs incentivize the act of
reporting data on quality and/or other
measures and activities, typically by
applying a downward payment
adjustment to facilities or clinicians, as
applicable, that fail to submit data as
required by the Secretary. This type of
program does not adjust payments based
on performance. In contrast, pay-forperformance programs, such as VBP
programs, score facilities or clinicians,
as applicable, on their performance on
specified quality and/or other measures
and activities and adjust payments
based on that performance. Pay-forperformance programs, such as VBP
programs, are more analogous to MIPS
given its focus on performance and not
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just reporting. For this reason, we
believe that facility-based measurement
under MIPS should be based on pay-forperformance programs rather than payfor-reporting programs.
Many Medicare payment systems
include a pay-for-performance program,
such as the Hospital VBP Program, the
Skilled Nursing Facility VBP Program
(SNF VBP), the End Stage Renal Disease
Quality Incentive Program (ESRD QIP),
and the Home Health Value-Based
Purchasing Program (HHVBP). We
believe that clinicians play a role in
contributing to quality performance in
all of these programs. However, we
believe that a larger and more diverse
group of clinicians contributes to
quality in the inpatient hospital setting
than in other settings in which we might
begin to implement this measurement
option. In addition, the inpatient
hospital setting has a mature valuebased purchasing program, first
established to adjust payment for
hospitals in FY 2013 (76 FR 26489).
Therefore, we believe it is appropriate to
implement this scoring option in a
limited fashion in the first year of
incorporating additional facility-based
measures under MIPS by focusing on
inpatient hospital measures that are
used for certain pay-for-performance
programs as facility-based measures.
The inpatient hospital setting
includes three distinct pay-forperformance programs: The Hospital
VBP Program, the Hospital
Readmissions Reduction Program
(HRRP), and the Hospital-Acquired
Condition Reduction Program (HACRP).
We believe that the Hospital VBP
Program is most analogous to the MIPS
program at this time because the
Hospital VBP Program compares
facilities on a series of different
measures that intend to capture the
breadth of care provided in a facility. In
contrast, the HACRP and HRRP each
focus on a single type of outcome for
patients treated in a hospital (safety and
readmissions, respectively), though we
note that these outcomes are critically
important to health care improvement.
The payment adjustments associated
with those 2 programs are intended to
provide negative adjustments for poor
performance but do not similarly reward
high performance. In contrast, the
Hospital VBP Program compares
performance among hospitals and
rewards high performers and provides
negative adjustments to poor
performers.
We also considered program timing
when determining what Hospital VBP
Program year to use for facility-based
measurement for the 2020 MIPS
payment year. Quality measurement for
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the FY 2019 Hospital VBP Program’s
performance period will be concluded
by December 31, 2017 (we refer readers
to the finalized FY 2019 performance
periods in the FY 2017 Inpatient
Prospective Payment System/Long-Term
Care Hospital Prospective Payment
System Final Rule, 81 FR 57002), and
the Hospital VBP Program scoring
reports (referred to as the Percentage
Payment Summary Reports) will be
provided to participating hospitals not
later than 60 days prior to the beginning
of FY 2019, pursuant to the Hospital
VBP Program’s statutory requirement at
section 1886(o)(8) of the Act. We further
note that hospitals must meet case and
measure minimums during the
performance period to receive a Total
Performance Score under that Program.
We discuss eligibility for facility-based
measurement in section II.C.7.b.(4)(c) of
this proposed rule, and we note that the
determination of the applicable hospital
will be made on the basis of a period
that overlaps with the applicable
Hospital VBP Program performance
period. Although Hospital VBP Program
measures have different measurement
periods, the FY 2019 measures all
overlap from January to June in 2017,
which also overlaps with our first 12month period to determine MIPS
eligibility.
We believe that MIPS eligible
clinicians electing the facility-based
measurement option under MIPS should
be able to consider as much information
as possible when making that decision,
including how their attributed hospital
performed in the Hospital VBP Program
because an individual clinician is a part
of the clinical team in the hospital,
rather than the sole clinician
responsible for care as tracked by
quality measures. Therefore, we
concluded that we should be as
transparent as possible with MIPS
eligible clinicians about their potential
facility-based scores before they begin
data submission for the MIPS
performance period since this policy
option is intended to minimize
reporting burdens on clinicians that are
already participating in quality
improvement efforts through other CMS
programs. We expect that MIPS eligible
clinicians that would consider facilitybased scoring would generally be aware
of their hospital’s performance on its
quality measures, but believe that
providing this information directly to
clinicians ensures that such clinicians
are fully aware of the implications of
their scoring elections under MIPS.
However, we note that this policy could
conceivably place non-facility-based
MIPS eligible clinicians at a competitive
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disadvantage since they would not have
any means by which to ascertain their
MIPS measure scores in advance. We
view that compromise as a necessity to
maximize transparency, and we request
comment on whether this notification in
advance of the conclusion of the MIPS
performance period is appropriate, or if
we should consider notifying facilitybased clinicians later in the MIPS
performance period or even after its
conclusion. Notification after the MIPS
performance period would prevent
facility-based clinicians from being able
to compare their expected MIPS
performance category scores under the
facility-based measurement option with
their expected scores under the options
available to all MIPS eligible clinicians
and pick the higher of the two. Since
higher performance category scores may
result in a higher final score and a
higher MIPS payment adjustment, there
is a substantial incentive for a clinician
to undertake this comparison, a
comparison unavailable to non-facilitybased peers.
The performance periods proposed in
section II.C.5. of this proposed rule for
the 2020 MIPS payment year occur in
2018, with data submission for most
mechanisms starting in January 2019.
To provide potential facility-based
scores to clinicians by the time the data
submission period for the 2018 MIPS
performance period begins assuming
that timeframe is operationally feasible),
we believe that the FY 2019 program
year of the Hospital VBP Program, as
well as the corresponding performance
periods, is the most appropriate
program year to use for purposes of
facility-based measurement under the
quality and cost performance categories
for the 2020 MIPS payment year.
However, we note also that Hospital
VBP performance periods can run for
periods as long as 36 months, and for
some FY 2019 Hospital VBP Program
measures, the performance period
begins in 2014. We request comment on
whether this lengthy performance
period duration should override our
desire to include all Hospital VBP
Program measures as discussed further
below. We propose at
§ 414.1380(e)(6)(iii) that the
performance period for facility-based
measurement is the performance period
for the measures for the measures
adopted under the value-based
purchasing program of the facility of the
year specified.
We considered whether we should
include the entire set of Hospital VBP
Program measures for purposes of
facility-based measurement under MIPS
or attempt to differentiate those which
may be more influenced by clinicians’
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contribution to quality performance
than others. However, we believe that
clinicians have a broad and important
role as part of the healthcare team at a
hospital and that attempting to
differentiate certain measures
undermines the team-based approach of
facility-based measurement. We propose
at § 414.1380(e)(6)(i) that the quality and
cost measures are those adopted under
the value-based purchasing program of
the facility program for the year
specified.
Therefore, we propose for the 2020
MIPS payment year to include all the
measures adopted for the FY 2019
Hospital VBP Program on the MIPS list
of quality measures and cost measures.
Under this proposal, we consider the FY
2019 Hospital VBP Program measures to
meet the definition of additional
system-based measures provided in
section 1848(q)(2)(C)(ii) of the Act, and
we propose at § 414.1380(e)(1)(i) that
facility-based measures available for the
2018 MIPS performance period are the
measures adopted for the FY 2019
Hospital VBP Program year authorized
by section 1886(o) of the Act and
codified in our regulations at §§ 412.160
through 412.167. Measures in the FY
2019 Hospital VBP Program have
different performance periods as noted
in Table 33.
We request comments on these
proposals. We also request comments on
what other programs, if any, we should
consider including for purposes of
facility-based measurement under MIPS
in future program years.
(c) Facility-Based Measurement
Applicability
(i) General
The percentage of professional time a
clinician spends working in a hospital
varies considerably. Some clinicians
may provide services in the hospital
regularly, but also treat patients
extensively in an outpatient office or
another environment. Other clinicians
may practice exclusively within a
hospital. Recognizing the various levels
of presence of different clinicians
within a hospital environment, we seek
to limit the potential applicability of
facility-based measurement to those
MIPS eligible clinicians with a
significant presence in the hospital.
In the CY 2017 Quality Payment
Program final rule (81 FR 77238 through
77240), we adopted a definition of
‘‘hospital-based MIPS eligible clinician’’
under § 414.1305 for purposes of the
advancing care information performance
category. Section 414.1305 defines a
hospital-based MIPS eligible clinician as
a MIPS eligible clinician who furnishes
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75 percent or more of his or her covered
professional services in sites of service
identified by the POS codes used in the
HIPAA standard transaction as an
inpatient hospital, on-campus
outpatient hospital, or emergency room
setting, based on claims for a period
prior to the performance period as
specified by CMS. We considered
whether we should simply use this
definition to determine eligibility for
facility-based measurement under MIPS.
However, we are concerned that this
definition could include many
clinicians that have limited or no
presence in the inpatient hospital
setting. We have noted that hospitalbased clinicians may not have control
over important aspects of the certified
EHR technology that is available in the
hospital setting (81 FR 77238). In that
regard, there is little difference between
outpatient and inpatient hospital
settings. But we are proposing to
determine a MIPS eligible clinician’s
quality performance category score and
cost performance category score based
on a hospital’s Hospital VBP
performance, which is based on
inpatient services. Section
1848(q)(2)(C)(ii) of the Act limits our
ability to incorporate measures used for
hospital outpatient departments. Our
proposal at section II.C.6.f.(7)(a)(i) of
this proposed rule to expand the
definition of a hospital-based MIPS
eligible clinician for the advancing care
information performance category to
include clinicians who practice
primarily in off-campus outpatient
hospitals could include clinicians that
practice many miles away from the
hospital in practices which are owned
by the hospital, but do not substantially
contribute to the hospital’s Hospital
VBP Program performance. As we
discuss further in this section, the
measures used in the Hospital VBP
Program are focused on care provided in
the inpatient setting. We do not believe
it is appropriate for a MIPS eligible
clinician to use a hospital’s Hospital
VBP Program performance for MIPS
scoring if they did not provide services
in that setting.
Therefore, we believe establishing a
different definition for purposes of
facility-based measurement is necessary
to implement this option. We also note
that, since we are seeking comments
above on other programs to consider
including for purposes of facility-based
measurement in future years, we believe
establishing a separate definition that
could be expanded as needed for this
purpose is appropriate. We propose at
§ 414.1380(e)(2) that a MIPS eligible
clinician is eligible for facility-based
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measurement under MIPS if they are
determined facility-based as an
individual. We propose at
§ 414.1380(e)(2)(i) that a MIPS eligible
clinician is considered facility-based as
an individual if the MIPS eligible
clinician furnishes 75 percent or more
of their covered professional services (as
defined in section 1848(k)(3)(A) of the
Act) in sites of service identified by the
POS codes used in the HIPAA standard
transaction as an inpatient hospital, as
identified by POS code 21, or an
emergency room, as identified by POS
code 23, based on claims for a period
prior to the performance period as
specified by CMS. We understand that
the services of some clinicians who
practice solely in the hospital are billed
using place of service codes such as
code 22, reflecting an on-campus
outpatient hospital for patients who are
in observation status. Because there are
limits on the length of time a Medicare
patient may be seen under observation
status, we believe that these clinicians
would still furnish 75 percent or more
of their covered professional services
using POS code 21, but seek comment
on whether a lower or higher threshold
of inpatient services would be
appropriate. We do not propose to
include POS code 22 in determining
whether a clinician is facility-based
because many clinicians who bill for
services using this POS code may work
on a hospital campus but in a capacity
that has little to do with the inpatient
care in the hospital. In contrast, we
believe those who provide services in
the emergency room or the inpatient
hospital clearly contribute to patient
care that is captured as part of the
Hospital VBP Program because many
patients who are admitted are admitted
through the emergency room. We seek
comments on whether POS 22 should be
included in determining if a clinician is
facility-based and how we might
distinguish those clinicians who
contribute to inpatient care from those
who do not. We note that the inclusion
of any POS code in our definition is
pending technical feasibility to link a
clinician to a facility under the method
described in section II.C.7.b.(4)(d) of
this proposed rule.
We note that this more limited
definition would mean that a clinician
who is determined to be facility-based
likely would also be determined to be
hospital-based for purposes of the
advancing care information performance
category, because this proposed
definition of facility-based is narrower
than the hospital-based definition
established for that purpose. Clinicians
would be determined to be facility-
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based through an evaluation of covered
professional services between
September 1 of the calendar year 2 years
preceding the performance period
through August 31 of the calendar year
preceding the performance period with
a 30-day claims run out. For example,
for the 2020 MIPS payment year, where
we have adopted a performance period
of CY 2018 for the quality and cost
performance categories, we would use
the data available at the end of October
2017 to determine whether a MIPS
eligible clinician is considered facilitybased by our definition. At that time,
those data would include Medicare
claims with dates of service between
September 1, 2016 and August 31, 2017.
In the event that it is not operationally
feasible to use claims from this exact
time period, we would use a 12-month
period as close as practicable to
September 1 of the calendar year 2 years
preceding the performance period and
August 31 of the calendar year
preceding the performance period. This
determination would allow clinicians to
be made aware of their eligibility for
facility-based measurement near the
beginning of the MIPS performance
period. We believe that this definition
allows us to identify MIPS eligible
clinicians who are significant
contributors to facilities’ care for
Medicare beneficiaries and other
patients for purposes of facility-based
measurement.
We also recognize that in addition to
the variation in the percentage of time
a clinician is present in the hospital,
there is also great variability in the types
of services that clinicians perform.
Some may be responsible for overall
management of patients throughout
their stay, others may perform a
procedure, and others may serve a role
in supporting diagnostics. We
considered whether certain clinicians
should be identified as eligible for this
facility-based measurement option
based on characteristics in addition to
their percentage of covered professional
services furnished in the inpatient
hospital or emergency room setting,
such as by requiring a certain specialty
such as hospital medicine or by limiting
eligibility to those who served in
patient-facing roles. However, we
believe that all MIPS eligible clinicians
with a significant presence in the
facility play a role in the overall
performance of a facility, and therefore,
are not proposing at this time to further
limit this option based on
characteristics other than the percentage
of covered professional services
furnished in an inpatient hospital or
emergency room setting. Additionally,
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we believe that allowing facility-based
MIPS eligible clinicians the most
flexibility possible, while still being
able to accurately measure the value of
care those clinicians provide, as we
continue implementation of the Quality
Payment Program is paramount in
ensuring that clinicians understand the
program and its effects on the care they
provide.
We request comments on this
proposal.
(ii) Facility-Based Measurement Group
Participation
We are also proposing at
§ 414.1380(e)(2) that a MIPS eligible
clinician is eligible for facility-based
measurement under MIPS if they are
determined facility-based as part of a
group. We are proposing at
§ 414.1380(e)(2)(ii) that a facility-based
group is a group in which 75 percent or
more of the MIPS eligible clinician NPIs
billing under the group’s TIN are
eligible for facility-based measurement
as individuals as defined in
§ 414.1380(e)(2)(i). We also considered
an alternative proposal in which a
facility-based group would be a group
where the TIN overall furnishes 75
percent or more of its covered
professional services (as defined in
section 1848(k)(3)(A) of the Act) in sites
of service identified by the POS codes
used in the HIPAA standard transaction
as an inpatient hospital, as identified by
POS code 21, or the emergency room, as
identified by POS code 23, based on
claims for a period prior to the
performance period as specified by
CMS. Groups would be determined to
be facility-based through an evaluation
of covered professional services
between September 1 of the calendar
year 2 years preceding the performance
period through August 31 of the
calendar year preceding the
performance period with a 30 day
claims run out period (or if not
operationally feasible to use claims from
this exact time period, a 12-month
period as close as practicable to
September 1 of the calendar year 2 years
preceding the performance period and
August 31 of the calendar year
preceding the performance period).
We request comments on our proposal
and alternative proposal.
(d) Facility Attribution for FacilityBased Measurement
Many MIPS eligible clinicians provide
services at more than one hospital, so
we must develop a method to identify
which hospital’s scores should be
associated with that MIPS eligible
clinician under this facility-based
measurement option. We considered
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whether a clinician should be required
to identify for us the hospital with
which they were affiliated, but felt that
such a requirement would add
unnecessary administrative burden in a
process that we believe was intended to
reduce burden. We also considered
whether we could combine scores from
multiple hospitals, but believe that such
a combination would reduce the
alignment between a single hospital and
a clinician or group and could be
confusing for participants. We believe
we must establish a reasonable
threshold for a MIPS eligible clinician’s
participation in clinical care at a given
facility to allow that MIPS eligible
clinician to be scored using that
facility’s measures. We do not believe it
to be appropriate to allow MIPS eligible
clinicians to claim credit for facilities’
measures if the MIPS eligible clinician
does not participate meaningfully in the
care provided at a given facility.
Therefore, we propose at
§ 414.1380(e)(5) that MIPS eligible
clinicians who elect facility-based
measurement would receive scores
derived from the value-based
purchasing score (using the
methodology described in section
II.B.7.b.4 of this proposed rule) for the
facility at which they provided services
for the most Medicare beneficiaries
during the period of September 1 of the
calendar year 2 years preceding the
performance period through August 31
of the calendar year preceding the
performance period with a 30 day
claims run out. This mirrors our period
of determining if a clinician is eligible
for facility-based measurement and also
overlaps with parts of the performance
period for the applicable Hospital VBP
program measures. For the first year, the
value-based purchasing score for the
facility is the FY 2019 Hospital VBP
Program’s Total Performance Score. In
cases in which there was an equal
number of Medicare beneficiaries
treated at more than one facility, we
propose to use the value-based
purchasing score from the facility with
the highest score.
(e) Election of Facility-Based
Measurement
Stakeholders have expressed a strong
preference that facility-based
measurement be a voluntary process,
and we agree with this preference
considering our general goal in making
MIPS as flexible as possible. Therefore,
we propose at § 414.1380(e)(3) that
individual MIPS eligible clinicians or
groups who wish to have their quality
and cost performance category scores
determined based on a facility’s
performance must elect to do so. We
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propose that those clinicians or groups
who are eligible for and wish to elect
facility-based measurement would be
required to submit their election during
the data submission period as
determined at § 414.1325(f) through the
attestation submission mechanism
established for the improvement
activities and advancing care
information performance categories. If
technically feasible, we would let the
MIPS eligible clinician know that they
were eligible for facility-based
measurement prior to the submission
period, so that MIPS eligible clinicians
would be informed if this option is
available to them.
We also considered an alternative
approach of not requiring an election
process but instead automatically
applying facility-based measurement to
MIPS eligible clinicians and groups who
are eligible for facility-based
measurement, if technically feasible.
Under this approach, we would
calculate a MIPS eligible clinician’s
facility-based measurement score based
on the hospital’s (as identified using the
process described in section II.C.6.b. of
this proposed rule) performance using
the methodology described in section
II.C.7.a.2.b. of this proposed rule, and
automatically use that facility-based
measurement score for the quality and
cost performance category scores if the
facility-based measurement score is
higher than the quality and cost
performance category scores as
determined based on data submitted by
the MIPS eligible clinician through any
available reporting mechanism. This
facility-based measurement score would
be calculated even if an individual
MIPS eligible clinician or group did not
submit any data for the quality
performance category. This option
would reduce burden for MIPS eligible
clinicians by not requiring them to elect
facility-based measurement, but is
contrary to stakeholders’ request for a
voluntary policy. Additionally, under
this option, our considerations about
Hospital VBP Program timing would be
less applicable. That is, we explained
our rationale for specifying the FY 2019
Hospital VBP Program above, in part to
ensure that MIPS eligible clinicians are
informed about their potential facilitybased scores prior to the conclusion of
the MIPS performance period. However,
under an automatic process, we could
consider automatically using other
Hospital VBP Program years’ scores. For
example, we could apply FY 2020
Hospital VBP Program scores instead of
FY 2019. We intend in general to align
Hospital VBP and MIPS performance
periods when feasible, and the timing
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considerations we described above led
us to conclude that FY 2019 was the
most appropriate Hospital VBP Program
year for the first year of the facilitybased measurement option under MIPS,
and selecting other years would result
in further divergence between the MIPS
performance period and the Hospital
VBP Program’s performance periods. We
are also concerned that a method that
does not require active selection may
result in MIPS eligible clinicians being
scored on measures at a facility and
being unaware that such scoring is
taking place. We are also concerned that
such a method could provide an
advantage to those facility-based
clinicians who do not submit quality
measures in comparison to those who
work in other environments. We also
note that this option may not be
technically feasible for us to implement
for the 2018 MIPS performance period.
We invite comments on this proposal
and alternate proposal.
(e) Facility-Based Measures
For the FY 2019 program year, the
Hospital VBP Program has adopted 13
quality and efficiency measures. The
Hospital VBP Program currently
includes 4 domains: Person and
community engagement, clinical care,
safety, and efficiency and cost
reduction. These domains align with
many MIPS high priority measures
(outcome, appropriate use, patient
safety, efficiency, patient experience,
and care coordination measures) in the
quality performance category and the
efficiency and cost reduction domain
closely aligns with our cost performance
category. We believe this set of
measures covering 4 domains and
composed primarily of measures that
would be considered high priority
under the MIPS quality performance
category capture a broad picture of
hospital-based care. For example, the
HCAHPS survey under the Hospital
VBP Program is a patient experience
measure, which would make it a highpriority measure under MIPS.
Additionally, the Hospital VBP Program
has adopted several measures of clinical
outcomes in the form of 30-day
mortality measures, and clinical
outcomes are a high-priority topic for
MIPS. The Hospital VBP Program
includes several measures in a Safety
domain, which meets our definition of
patient safety measures as high-priority.
Therefore, we propose that facilitybased individual MIPS eligible
clinicians or groups that are attributed
to a hospital would be scored on all the
measures on which the hospital is
scored for the Hospital VBP Program via
the Hospital VBP Program’s Total
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Performance Score (TPS) scoring
methodology.
The Hospital VBP Program’s FY 2019
measures, and their associated
performance periods, have been
reproduced in Table 33 (see 81 FR
56985 and 57002).
TABLE 33—FY 2019 HOSPITAL VBP PROGRAM MEASURES
Short name
Domain/measure name
NQF No.
Performance period
Person and Community Engagement Domain
HCAHPS .............................
Hospital Consumer Assessment of Healthcare Providers
and Systems (HCAHPS) (including Care Transition
Measure).
0166 (0228)
CY 2017
0230
July 1, 2014—June 30, 2017
0229
July 1, 2014—June 30, 2017
0468
July 1, 2014—June 30, 2017
1550
January 1, 2015—June 30,
2017
0138
CY 2017
0139
CY 2017
0753
CY 2017
1716
CY 2017
1717
CY 2017
0531
0469
July 1, 2015—June 30 2017
CY 2017
Clinical Care Domain
MORT–30–AMI ...................
MORT–30–HF .....................
MORT–30–PN ....................
THA/TKA .............................
Hospital 30-Day, All-Cause, Risk-Standardized Mortality
Rate (RSMR) Following Acute Myocardial Infarction
(AMI) Hospitalization.
Hospital 30-Day, All-Cause, Risk-Standardized Mortality
Rate (RSMR) Following Heart Failure (HF) Hospitalization.
Hospital 30-Day, All-Cause, Risk-Standardized Mortality
Rate (RSMR) Following Pneumonia Hospitalization.
Hospital-Level Risk-Standardized Complication Rate
(RSCR) Following Elective Primary Total Hip Arthroplasty
(THA) and/or Total Knee Arthroplasty (TKA).
Safety Domain
CAUTI .................................
CLABSI ...............................
Colon and Abdominal
Hysterectomy SSI.
MRSA Bacteremia ..............
CDI ......................................
PSI–90* ...............................
PC–01 .................................
National Healthcare Safety Network (NHSN) Catheter-Associated Urinary Tract Infection (CAUTI) Outcome Measure.
National Healthcare Safety Network (NHSN) Central LineAssociated Bloodstream Infection (CLABSI) Outcome
Measure.
American College of Surgeons—Centers for Disease Control and Prevention (ACS–CDC) Harmonized Procedure
Specific Surgical Site Infection (SSI) Outcome Measure.
National Healthcare Safety Network (NHSN) Facility-wide
Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure.
National Healthcare Safety Network (NHSN) Facility-wide
Inpatient Hospital-onset Clostridium difficile Infection
(CDI) Outcome Measure.
Patient Safety for Selected Indicators (Composite Measure)
Elective Delivery ....................................................................
Efficiency and Cost Reduction Domain
MSPB ..................................
Payment-Standardized Medicare Spending Per Beneficiary
(MSPB).
2158
CY 2017
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* PSI–90 has been proposed in the FY 2018 IPPS/LTCH PPS proposed rule for removal beginning with the FY 2019 program year.
We note that the Patient Safety
Composite Measure (PSI–90) was
proposed for removal beginning with
the FY 2019 measure set in the FY 2018
IPPS/LTCH proposed rule (82 FR 19970)
due to issues with calculating the
measure score. If the proposal to remove
that measure from the hospital measure
set is finalized, we would remove the
measure from the list of those adopted
for facility-based measurement in the
MIPS program.
We propose at § 414.1380(e)(4) that
there are no data submission
requirements for the facility-based
measures used to assess performance in
the quality and cost performance
categories, other than electing the
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option through attestation as proposed
in section II.C.7.a.(4)(e). We also refer
readers to section II.C.7. of this
proposed rule for further details on how
we will incorporate scoring for facilitybased measurements into MIPS.
(f) Scoring Facility-Based Measurement
(i) Hospital VBP Program Scoring
As we discuss above in subsection (b),
we believe that the Hospital VBP
Program represents the most appropriate
value-based purchasing program with
which to begin implementation of the
facility-based measurement option
under MIPS.
Section 1886(o) of the Act, as added
by section 3001(a)(1) of the Affordable
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Care Act, requires the Secretary to
establish a hospital value-based
purchasing program (the Hospital VBP
Program) under which value-based
incentive payments are made in a fiscal
year to hospitals that meet performance
standards established for a performance
period for such fiscal year. These valuebased incentive payments are funded
through a reduction to participating
hospitals’ base-operating DRG payment
amounts, with the amount of the
reduction specified by statute. For the
FY 2019 program year, that reduction
will be equal to 2 percent. Participating
hospitals then receive value-based
incentive payments depending on their
performance on measures adopted
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under the Program. For more detail on
the statutory background and history of
the Hospital VBP Program’s
implementation, we refer readers to 81
FR 56979.
As noted previously, the FY 2019
Hospital VBP Program will score
participating hospitals on 13 measures
covering 4 domains of care, although as
discussed in the FY 2018 IPPS/LTCH
proposed rule (82 FR 19970), we have
proposed to remove the PSI 90 Patient
Safety Composite measure from the FY
2019 measure set. For each of the
measures, performance standards are
established for the applicable fiscal year
that include levels of achievement and
improvement. For the FY 2019 program
year, the achievement threshold and
benchmark are calculated using baseline
period data with respect to that fiscal
year, with the achievement threshold for
each of these measures being the
median of hospital performance on the
measure during the baseline period and
the benchmark for each of these
measures being the arithmetic mean of
the top decile of hospital performance
during the baseline period. The
achievement threshold and benchmark
for the MSPB measure are calculated
using the same methodology, except
that we use performance period data
instead of baseline period data in our
calculations. We then calculate hospital
performance on each measure during
the performance period for which they
have sufficient data and calculate a
measure score based on that
performance as compared with the
performance standards that apply to the
measure. For achievement scoring, those
hospitals that perform below (or above
in the case of measures for which a
lower rate is better) the level of the
achievement threshold are not awarded
any achievement points. Those that
perform between the level of the
achievement threshold and the
benchmark are awarded points based on
the relative performance of the hospital,
according to formulas specified by the
Hospital VBP Program (see the Hospital
Inpatient VBP Program final rule, 76 FR
26518 through 26519). Those hospitals
whose performance meets or exceeds
the benchmark are awarded 10
achievement points for the measure.
Hospitals are also provided the
opportunity to receive improvement
points based on their improvement
between the baseline period for the
measure and the performance period. A
hospital is awarded between 0 and 10
points for achievement and 0 and 9
points for improvement, and is awarded
the higher of the 2 scores for each
individual measure. There are no floors
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established for scoring and no bonus
points are available in this scoring
system.
Points awarded for measures within
each domain are summed to reach the
unweighted domain score. We note for
the person and community engagement
domain only, the domain score consists
of a base score and a consistency score.
The base score is based on the greater
of improvement or achievement points
for each of the 8 HCAHPS survey
dimensions. Consistency points are
awarded based on a hospital’s lowest
HCAHPS dimension score during the
performance period relative to national
hospital scores on that dimension
during the baseline period. The domain
scores are then weighted according to
domain weights specified each Program
year, then summed to reach the Total
Performance Score, which is converted
to a value-based incentive payment
percentage that is used to adjust
payments to each hospital for inpatient
services furnished during the applicable
program year. For the FY 2019 program
year, all 4 domains will be weighted
equally. We refer readers to 81 FR 57005
and 81 FR 79857 through 79858 for
additional information on the Hospital
VBP Program’s performance standards,
as well as the QualityNet Web site for
certain technical updates to the
performance standards.
(ii) Applying Hospital VBP Program
Scoring to the MIPS Quality and Cost
Performance Categories
We considered several methods to
incorporate facility-based measures into
scoring for the 2020 MIPS payment year,
including selecting hospitals’ measure
scores, domain scores, and the Hospital
VBP Program Total Performance Scores
to form the basis for the cost and quality
performance category scores for
individual MIPS eligible clinicians and
groups that are eligible to participate in
facility-based measurement. Although
each of these approaches may have
merit, we have proposed the option that
we believe provides the fairest
comparison between performance in the
2 programs and will best allow us to
expand the opportunity to other
programs in the future.
Unlike MIPS, the Hospital VBP
Program does not have performance
categories. There are instead four
domains of measures. We considered
whether we should try to identify
certain domains or measures that were
more closely aligned with those
identified in the quality performance
category or the cost performance
category. We also considered whether
we should limit the application of
facility-based measurement to the
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quality performance category and
calculate the cost performance category
score as we do for other clinicians.
However, we believe that value-based
purchasing programs are generally
constructed to assess an overall picture
of the care provided by the facility,
taking into account both the costs and
the quality of care provided. Given our
focus on alignment between quality and
cost, we also do not believe it is
appropriate to measure quality on one
unit (a hospital) and cost on another
(such as an individual clinician or TIN).
Therefore, we propose at § 414.1380(e)
that facility-based scoring is available
for the quality and cost performance
categories and that the facility-based
measurement scoring standard is the
MIPS scoring methodology applicable
for those who meet facility-based
eligibility requirements and who elect
facility-based measurement.
(iii) Benchmarking Facility-Based
Measures
Measures in the MIPS quality
performance category are benchmarked
to historical performance on the basis of
performance during the 12-month
calendar year that is 2 years prior to the
performance period for the MIPS
payment year. If a historical benchmark
cannot be established, a benchmark is
calculated during the performance
period. In the cost performance
category, benchmarks are established
during the performance period because
changes in payment policies year to year
can make it challenging to compare
performance on cost measure year to
year. Although we propose a different
performance period for MIPS eligible
clinicians in facility-based
measurement, the baseline period used
for creating MIPS benchmarks is
generally consistent with this approach.
We note that the Hospital VBP Program
uses measures for the same fiscal year
even if those measures do not have the
same performance period length, but the
baseline period closes well before the
performance period. The MSPB is
benchmarked in a manner that is similar
to measures in the MIPS cost
performance category. The MSPB only
uses a historical baseline period for
improvement scoring and bases its
achievement threshold and benchmark
solely on the performance period (81 FR
57002). We propose at
§ 414.1380(e)(6)(ii) that the benchmarks
for facility-based measurement are those
that are adopted under the value-based
purchasing program of the facility for
the year specified.
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(iv) Assigning MIPS Performance
Category Scores Based on Hospital VBP
Performance
Performance measurement in the
Hospital VBP Program and MIPS is
quite different in part due to the design
and the maturity of the programs. As
noted above, the Hospital VBP Program
only assigns achievement points to a
hospital for its performance on a
measure if the hospital’s performance
during the performance period meets or
exceeds the median of hospital
performance on that measure during the
applicable baseline period, whereas
MIPS assigns achievement points to all
measures that meet the required data
completeness and case minimums. In
addition, the Hospital VBP Program has
removed many process measures and
topped out measures since its first
program year (FY 2013), while both
process and topped out measures are
available in MIPS. With respect to the
FY 2017 program year, for example, the
median Total Performance Score for a
hospital in Hospital VBP was 33.88 out
of 100 possible points. If we were to
simply assign the Hospital VBP Total
Performance Score for a hospital to a
clinician, the performance of those
MIPS eligible clinicians electing facilitybased measurement would likely be
lower than most who participated in the
MIPS program, particularly in the
quality performance category.
We believe that we should recognize
relative performance in the facility
programs that reflects their different
designs. Therefore, we propose at
§ 414.1380(e)(6)(iv) that the quality
performance category score for facilitybased measurement is reached by
determining the percentile performance
of the facility determined in the valuebased purchasing program for the
specified year as described under
§ 414.1380(e)(5) and awarding a score
associated with that same percentile
performance in the MIPS quality
performance category score for those
clinicians who are not scored using
facility-based measurement. We also
propose at § 414.1380(e)(6)(v) that the
cost performance category score for
facility-based measurement is
established by determining the
percentile performance of the facility
determined in the value-based
purchasing program for the specified
year as described in § 414.1380(e)(5) and
awarding the number of points
associated with that same percentile
performance in the MIPS cost
performance category score for those
clinicians who are not scored using
facility-based measurement. For
example, if the median Hospital VBP
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Program Total Performance Score was
35 out of 100 possible points and the
median quality performance category
percent score in MIPS was 75 percent
and the median cost performance
category score was 50 percent, then a
clinician or group that is evaluated
based on a hospital that received an
Hospital VBP Program Total
Performance Score of 35 points would
receive a score of 75 percent for the
quality performance category and 50
percent for the cost performance
category. The percentile distribution for
both the Hospital VBP Program and
MIPS would be based on the
distribution during the applicable
performance periods for each of the
programs and not on a previous
benchmark year.
We believe this proposal offers a fairer
comparison of the performance among
participants in MIPS and the Hospital
VBP Program compared to other options
we considered and provides an
objective means to normalize
differences in measured performance
between the programs. In addition, we
believe this method will make it simpler
to apply the concept of facility-based
measurement to additional programs in
the future.
We welcome public comments on this
proposal.
(v) Scoring Improvement for FacilityBased Measurement
The Hospital VBP Program includes a
methodology for recognizing
improvement on individual measures
which is then incorporated into the total
performance score for each participating
hospital. A hospital’s performance on a
measure is compared to a national
benchmark as well as its own
performance from a corresponding
baseline period.
In this proposed rule, we have
proposed to consider improvement in
the quality and cost performance
categories. In section II.C.7.a.(2)(i) of
this proposed rule, we propose to
measure improvement in the quality
performance category based on
improved achievement for the
performance category percent score and
award improvement even if, under
certain circumstances, a clinician moves
from one identifier to another from 1
year to the next. For those who may be
measured under facility-based
measurement, improvement is already
captured in the scoring method used by
the Hospital VBP Program, so we do not
believe it is appropriate to separately
measure improvement using the
proposed MIPS methodology. Although
the improvement methodology is not
identical, a hospital that demonstrated
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improvement in the individual
measures would in turn receive a higher
score through the Hospital VBP Program
methodology, so that improvement is
reflected in the underlying Hospital
VBP Program measurement. In addition,
improvement is already captured in the
distribution of MIPS performance scores
that is used to translate Hospital VBP
Total Performance Score into a MIPS
quality performance category score.
Therefore, we are not proposing any
additional improvement scoring for
facility-based measurement for either
the quality or cost performance
category.
Because we intend to allow clinicians
the flexibility to elect facility-based
measurement on an annual basis, some
clinicians may be measured through
facility-based measurement in 1 year
and through another MIPS method in
the next. Because the first MIPS
performance period in which a clinician
could switch from facility-based
measurement to another MIPS method
would be in 2019, we seek comment on
how to assess improvement for those
that switch from facility-based scoring
to another MIPS method. We request
comment on whether it is appropriate to
include measurement of improvement
in the MIPS quality performance
category for facility-based measured
clinicians and groups given that the
Hospital VBP Program already takes
improvement into account in its scoring
methodology.
In section II.C.7.a.(3)(a) of this
proposed rule, we discuss our proposal
to measure improvement in the cost
performance category at the measure
level. We propose that clinicians under
facility-based measurement would not
be eligible for a cost improvement score
in the cost performance category. As in
the quality performance category, we
believe that a clinician participating in
facility-based measurement in
subsequent years would already have
improvement recognized as part of the
Hospital VBP Program methodology and
should therefore not be given additional
credit. In addition, because we propose
to limit measurement of improvement to
those MIPS eligible clinicians that
participate in MIPS using the same
identifier and are scored on the same
cost measure(s) in 2 consecutive
performance periods, those MIPS
eligible clinicians who elect facilitybased measurement would not be
eligible for a cost improvement score in
the cost performance category under our
proposed methodology because they
would not be scored on the same cost
measure(s) for 2 consecutive
performance periods.
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We invite comments on these
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(vi) Bonus Points for Facility-Based
Measurement
MIPS eligible clinicians that report on
quality measures are eligible for bonus
points for the reporting of additional
outcome and high priority measures
beyond the one that is required. 2 bonus
points are awarded for each additional
outcome or patient experience measure,
and one bonus point is awarded for each
additional other high priority measure.
These bonus points are intended to
encourage the use of measures that are
more impactful on patients and better
reflect the overall goals of the MIPS
program. Many of the measures in the
Hospital VBP Program meet the criteria
that we have adopted for high-priority
measures. We support measurement that
takes clinicians’ focus away from
clinical process measures; however, our
proposed scoring method described
above is based on a percentile
distribution of scores within the quality
and cost performance categories that
already accounts for bonus points. For
this reason, we are not proposing to
calculate additional high priority bonus
points for facility-based measurement.
We note that clinicians have an
additional opportunity to receive bonus
points in the quality performance
category score for using end-to-end
electronic submission of quality
measures. The Hospital VBP Program
does not capture whether or not
measures are reported using end-to-end
electronic reporting. In addition, our
proposed facility-based scoring method
described above is based on a percentile
distribution of scores within the quality
and cost performance categories that
already accounts for bonus points. For
this reason, we are not proposing to
calculate additional end-to-end
electronic reporting bonus points for
facility-based measurement.
We welcome public comments on our
approach.
(vii) Special Rules for Facility-Based
Measurement
Some hospitals do not receive a Total
Performance Score in a given year in the
Hospital VBP Program, whether due to
insufficient quality measure data, failure
to meet requirements under the Hospital
Inpatient Quality Reporting Program, or
other reasons. In these cases, we would
be unable to calculate a facility-based
score based on the hospital’s
performance, and facility-based
clinicians would be required to
participate in MIPS via another method.
Most hospitals which do not receive a
Total Performance Score in the Hospital
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VBP Program are routinely excluded,
such as hospitals in Maryland. In such
cases, facility-based clinicians would
know well in advance that the hospital
would not receive a Total Performance
Score, and that they would need to
participate in MIPS through another
method. However, we are concerned
that some facility-based clinicians may
provide services in hospitals which they
expect will receive a Total Performance
Score but do not due to various rare
circumstances such as natural disasters.
In section II.C.7.b.(3)(c) of this proposed
rule, we propose a process for
requesting a reweighting assessment for
the quality, cost and improvement
activities performance categories due to
extreme and uncontrollable
circumstances, such as natural disasters.
We propose that MIPS eligible
clinicians who are facility-based and
affected by extreme and uncontrollable
circumstances, such as natural disasters,
may apply for reweighting.
In addition, we note that hospitals
may submit correction requests to their
Total Performance Scores calculated
under the Hospital VBP Program, and
may also appeal the calculations of their
Total Performance Scores, subject to
Hospital VBP Program requirements
established in prior rulemaking. We
intend to use the final Hospital VBP
Total Performance Score for the facilitybased measurement option under MIPS.
In the event that a hospital obtains a
successful correction or appeal of its
Total Performance Score, we would
update MIPS eligible clinicians’ quality
and cost performance category scores
accordingly, as long as the update could
be made prior to the application of the
MIPS payment adjustment for the
relevant MIPS payment year. We
welcome public comments on whether
a different deadline should be
considered.
Additionally, although we wish to tie
the hospital and clinician performance
as closely together as possible for
purposes of the facility-based scoring
policy, we do not wish to disadvantage
those clinicians and groups that select
this measurement method. In section
II.C.7.a.(2) of this proposed rule, we
propose to retain a policy equivalent to
the 3-point floor for all measures with
complete data in the quality
performance category scored against a
benchmark in the 2020 MIPS payment
year. However, the Hospital VBP
Program does not have a corresponding
scoring floor. Therefore, we propose to
adopt a floor on the Hospital VBP
Program Total Performance Score for
purposes of facility-based measurement
under MIPS so that any score in the
quality performance category, once
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translated into the percentile
distribution described above, that would
result in a score of below 30 percent
would be reset to a score of 30 percent
in the quality performance category. We
believe that this adjustment is important
to maintain consistency with our other
policies. There is no similar floor
established for measures in the cost
performance category under MIPS, so
we do not propose any floor for the cost
performance category for facility-based
measurement.
Some MIPS eligible clinicians who
select facility-based measurement could
have sufficient numbers of attributed
patients to meet the case minimums for
the cost measures established under
MIPS. Although there is no additional
data reporting for cost measures, we
believe that, to facilitate the relationship
between cost and quality measures, they
should be evaluated covering the same
population as opposed to comparing a
hospital population and a population
attributed to an individual clinician or
group. In addition, we believe that
including additional cost measures in
the cost performance category score for
MIPS eligible clinicians who elect
facility-based measurement would
reduce the alignment of incentives
between the hospital and the clinician.
Thus, we are proposing at
§ 414.1380(e)(6)(v)(A) that MIPS eligible
clinicians who elect facility-based
measurement would not be scored on
other cost measures specified for the
cost performance category, even if they
meet the case minimum for a cost
measure.
If a clinician or a group elects facilitybased measurement but also submits
quality data through another MIPS
mechanism, we propose to use the
higher of the two scores for the quality
performance category and base the score
of the cost performance category on the
same method (that is, if the facilitybased quality performance category
score is higher, facility-based
measurement is used for quality and
cost). Since this policy may result in a
higher final score, it may provide
facility-based clinicians with a
substantial incentive to elect facilitybased measurement, whether or not the
clinician believes such measures are the
most accurate or useful measures of that
clinician’s performance. Therefore, this
policy may create an unfair advantage
for facility-based clinicians over nonfacility-based clinicians, since nonfacility-based clinicians would not have
the opportunity to use the higher of two
scores. Therefore, we seek comment on
whether this proposal to use the higher
score is the best approach to score the
performance of facility-based clinicians
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(5) Scoring the Improvement Activities
Performance Category
Section 1848(q)(5)(C) of the Act
specifies scoring rules for the
improvement activities performance
category. For more of the statutory
background and description of the
proposed and finalized policies, we
refer readers to the CY 2017 Quality
Payment Program final rule (81 FR
77311 through 77319). We have also
codified certain requirements for the
improvement activities performance
category at § 414.1380(b)(3). Based on
these criteria, we finalized at
§ 414.1380(b)(3) in the CY 2017 Quality
Payment Program final rule the scoring
methodology for this category, which
assigns points based on certified
patient-centered medical home
participation or comparable specialty
practice participation, APM
participation, and the improvement
activities reported by the MIPS eligible
clinician (81 FR 77312). A MIPS eligible
clinician’s performance will be
evaluated by comparing the reported
improvement activities to the highest
possible score (40 points). We are not
proposing any changes to the scoring of
the improvement activities performance
category in this proposed rule.
(a) Assigning Points to Reported
Improvement Activities
We will assign points for each
reported improvement activity within 2
categories: Medium-weighted and highweighted activities. Each mediumweighted activity is worth 10 points
toward the total category score of 40
points, and each high-weighted activity
is worth 20 points toward the total
category score of 40 points. These points
are doubled for small practices,
practices in rural areas, or practices
located in geographic HPSAs, and nonpatient facing MIPS eligible clinicians.
We refer readers to § 414.1380(b)(3) and
the CY 2017 Quality Payment Program
final rule (81 FR 78312) for further
detail on improvement activities
scoring.
Activities will be weighted as high
based on the extent to which they align
with activities that support the certified
patient-centered medical home, since
that is consistent with the standard
under section 1848(q)(5)(C)(i) of the Act
for achieving the highest potential score
for the improvement activities
performance category, as well as with
our priorities for transforming clinical
practice (81 FR 77311). Additionally,
activities that require performance of
multiple actions, such as participation
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in the Transforming Clinical Practice
Initiative (TCPI), participation in a MIPS
eligible clinician’s state Medicaid
program, or an activity identified as a
public health priority (such as emphasis
on anticoagulation management or
utilization of prescription drug
monitoring programs) are justifiably
weighted as high (81 FR 77311 through
77312).
We refer readers to Table 26 of the CY
2017 Quality Payment Program final
rule for a summary of the previously
finalized improvement activities that are
weighted as high (81 FR 77312 through
77313), and we refer readers to Table H
of the same final rule, for a list of all the
previously finalized improvement
activities, both medium- and highweighted (81 FR 77817 through 77831).
Please refer to Table F and Table G in
the appendices of this proposed rule for
proposed additions and changes to the
Improvement Activities Inventory for
the 2020 MIPS payment year and future
years. Activities included in these
proposed tables would apply for the
2020 MIPS payment year and future
years unless further modified via notice
and comment rulemaking. Consistent
with our unified scoring system
principles, we finalized in the CY 2017
Quality Payment Program final rule that
MIPS eligible clinicians will know in
advance how many potential points
they could receive for each
improvement activity (81 FR 77311
through 77319).
(b) Improvement Activities Performance
Category Highest Potential Score
At § 414.1380(b)(3), we finalized that
we will require a total of 40 points to
receive the highest score for the
improvement activities performance
category (81 FR 77315). For more of the
statutory background and description of
the proposed and finalized policies, we
refer readers to the CY 2017 Quality
Payment Program final rule (81 FR
77314 through 77315).
For small practices, practices in rural
areas and geographic HPSA practices
and non-patient facing MIPS eligible
clinicians, the weight for any activity
selected is doubled so that these
practices and eligible clinicians only
need to select one high- or two mediumweighted activities to achieve the
highest score of 40 points (81 FR 77312).
In accordance with section
1848(q)(5)(C)(ii) of the Act, we codified
at § 414.1380(b)(3)(ix) that individual
MIPS eligible clinicians or groups who
are participating in an APM (as defined
in section 1833(z)(3)(C) of the Act) for
a performance period will automatically
earn at least one half of the highest
potential score for the improvement
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activities performance category for the
performance period. In addition, MIPS
eligible clinicians that are participating
in MIPS APMs will be assigned an
improvement activity score, which may
be higher than one half of the highest
potential score. This assignment is
based on the extent to which the
requirements of the specific model meet
the list of activities in the Improvement
Activities Inventory. For a further
description of improvement activities
and the APM scoring standard for MIPS,
we refer readers to the CY 2017 Quality
Payment Program final rule (81 FR
77246). For all other individual MIPS
eligible clinicians or groups, we refer
readers to the scoring requirements for
individual MIPS eligible clinicians and
groups in the CY 2017 Quality Payment
Program final rule (81 FR 77270). An
individual MIPS eligible clinician or
group is not required to perform
activities in each improvement activities
subcategory or participate in an APM to
achieve the highest potential score in
accordance with section
1848(q)(5)(C)(iii) of the Act (81 FR
77178).
In the CY 2017 Quality Payment
Program final rule, we also finalized
that individual MIPS eligible clinicians
and groups that successfully participate
and submit data to fulfill the
requirements for the CMS Study on
Improvement Activities and
Measurement will receive the highest
score for the improvement activities
performance category (81 FR 77315). We
refer readers to section II.C.6.e.(7) of this
proposed rule for further detail on this
study.
(c) Points for Certified Patient-Centered
Medical Home or Comparable Specialty
Practice
Section 1848(q)(5)(C)(i) of the Act
specifies that a MIPS eligible clinician
who is in a practice that is certified as
a patient-centered medical home or
comparable specialty practice for a
performance period, as determined by
the Secretary, must be given the highest
potential score for the improvement
activities performance category for the
performance period. Accordingly, at
§ 414.1380(b)(3)(iv), we specify that a
MIPS eligible clinician who is in a
practice that is certified as a patientcentered medical home, including a
Medicaid Medical Home, Medical Home
Model, or comparable specialty practice,
will receive the highest potential score
for the improvement activities
performance category (81 FR 77196
through 77180).
We are not proposing any changes to
the scoring of the patient-centered
medical home or comparable specialty
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practice; although we are proposing a
change to how groups qualify for this
activity. We refer readers to section
II.C.6.e. of this proposed rule for a
discussion of the requirements for
certified patient-centered medical home
practices or comparable specialty
practices.
(d) Calculating the Improvement
Activities Performance Category Score
In the CY 2017 Quality Payment
Program final rule (81 FR 77318), we
finalized that individual MIPS eligible
clinicians and groups must earn a total
of 40 points to receive the highest score
for the improvement activities
performance category. To determine the
improvement activities performance
category score, we sum the points for all
of a MIPS eligible clinician’s reported
activities and divide by the
improvement activities performance
category highest potential score of 40. A
perfect score will be 40 points divided
by 40 possible points, which equals 100
percent. If MIPS eligible clinicians have
more than 40 improvement activities
points we will cap the resulting
improvement activities performance
category score at 100 percent.
Section 1848(q)(2)(B)(iii) of the Act
requires the Secretary to give
consideration to the circumstances of
small practices and practices located in
rural areas and in geographic HPSAs (as
designated under section 332(a)(1)(A) of
the PHS Act) in defining activities.
Section 1848(q)(2)(C)(iv) of the Act also
requires the Secretary to give
consideration to non-patient facing
MIPS eligible clinicians. Further,
section 1848(q)(5)(F) of the Act allows
the Secretary to assign different scoring
weights for measures, activities, and
performance categories, if there are not
sufficient measures and activities
applicable and available to each type of
eligible clinician.
Accordingly, we finalized that the
following scoring applies to MIPS
eligible clinicians who are a non-patient
facing MIPS eligible clinician, a small
practice (consisting of 15 or fewer
professionals), a practice located in a
rural area, or practice in a geographic
HPSA or any combination thereof:
• Reporting of one medium-weighted
activity will result in 20 points or onehalf of the highest score.
• Reporting of two medium-weighted
activities will result in 40 points or the
highest score.
• Reporting of one high-weighted
activity will result in 40 points or the
highest score.
The following scoring applies to MIPS
eligible clinicians who are not a nonpatient facing clinician, a small practice,
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a practice located in a rural area, or a
practice in a geographic HPSA:
• Reporting of one medium-weighted
activity will result in 10 points which
is one-fourth of the highest score.
• Reporting of two medium-weighted
activities will result in 20 points which
is one-half of the highest score.
• Reporting of three mediumweighted activities will result in 30
points which is three-fourths of the
highest score.
• Reporting of four medium-weighted
activities will result in 40 points which
is the highest score.
• Reporting of one high-weighted
activity will result in 20 points which
is one-half of the highest score.
• Reporting of two high-weighted
activities will result in 40 points which
is the highest score.
• Reporting of a combination of
medium-weighted and high-weighted
activities where the total number of
points achieved are calculated based on
the number of activities selected and the
weighting assigned to that activity
(number of medium-weighted activities
selected × 10 points + number of highweighted activities selected × 20 points)
(81 FR 78318).
We also finalized in the CY 2017
Quality Payment Program final rule that
certain activities in the improvement
activities performance category will also
qualify for a bonus under the advancing
care information performance category
(81 FR 78318). This bonus will be
calculated under the advancing care
information performance category and
not under the improvement activities
performance category. We refer readers
to section II.C.6.f.5.(d) of this proposed
rule for further details. For more
information about our finalized
improvement activities scoring policies
and for several sample scoring charts,
we refer readers to the CY 2017 Quality
Payment Program final rule (81 FR
78319). Finally, in that same final rule,
we codified at § 414.1380(b)(3)(ix) that
MIPS eligible clinicians participating in
APMs that are not certified patientcentered medical homes will
automatically earn a minimum score of
one-half of the highest potential score
for the performance category, as
required by section 1848(q)(5)(C)(ii) of
the Act. For any other MIPS eligible
clinician who does not report at least
one activity, including a MIPS eligible
clinician who does not identify to us
that they are participating in a certified
patient-centered medical home or
comparable specialty practice, we will
calculate a score of zero points (81 FR
77319).
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(e) Self-Identification Policy for MIPS
Eligible Clinicians
We also noted in the CY 2017 Quality
Payment Program final rule (81 FR
77319), that individual MIPS eligible
clinicians or groups participating in
APMs would not be required to selfidentify as participating in an APM, but
that all MIPS eligible clinicians would
be required to self-identify if they were
part of a certified patient-centered
medical home or comparable specialty
practice, a non-patient facing MIPS
eligible clinician, a small practice, a
practice located in a rural area, or a
practice in a geographic HPSA or any
combination thereof, and that we would
validate these self-identifications as
appropriate. However, beginning with
the 2018 MIPS performance period, we
are proposing to no longer require these
self-identifications for a non-patient
facing MIPS eligible clinician, a small
practice, a practice located in a rural
area, or a practice in a geographic HPSA
or any combination thereof because it is
technically feasible for us to identify
these MIPS eligible clinicians during
attestation to the performance of
improvement activities following the
performance period. We define these
MIPS eligible clinicians in the CY 2017
Quality Payment Program final rule (81
FR 77540), and they are discussed in
this proposed rule in section II.C.1. of
this proposed rule. However, MIPS
eligible clinicians that are part of a
certified patient-centered medical home
or comparable specialty practice are still
required to self-identify for the 2018
MIPS performance period, and we will
validate these self-identifications as
appropriate. We refer readers to section
II.C.6.e.3.(c) of this proposed rule for the
criteria for recognition as a certified
patient-centered medical home or
comparable specialty practice.
(6) Scoring the Advancing Care
Information Performance Category
We refer readers to section II.C.6.f. of
this proposed rule with comment
period, where we discuss scoring the
advancing care information performance
category.
b. Calculating the Final Score
For a description of the statutory basis
and our policies for calculating the final
score for MIPS eligible clinicians, we
refer readers to the discussion in the CY
2017 Quality Payment Program final
rule (81 FR 77319 through 77329) and
§ 414.1380. In this proposed rule, we
propose to add a complex patient
scoring bonus and add a small practice
bonus to the final score. In addition, we
review the final score calculation for the
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refinements to the reweighting policies.
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(1) Accounting for Risk Factors
Section 1848(q)(1)(G) of the Act
requires us to consider risk factors in
our scoring methodology. Specifically,
that section provides that the Secretary,
on an ongoing basis, shall, as the
Secretary determines appropriate and
based on individuals’ health status and
other risk factors, assess appropriate
adjustments to quality measures, cost
measures, and other measures used
under MIPS and assess and implement
appropriate adjustments to payment
adjustments, final scores, scores for
performance categories, or scores for
measures or activities under the MIPS.
In doing this, the Secretary is required
to take into account the relevant studies
conducted under section 2(d) of the
Improving Medicare Post-Acute Care
Transformation (IMPACT) Act of 2014
and, as appropriate, other information,
including information collected before
completion of such studies and
recommendations. We refer readers to
our discussion of risk factors for the
transition year of MIPS (81 FR 77320
through 77321).
In this section, we summarize our
efforts related to social risk and the
relevant studies conducted under
section 2(d) of the IMPACT Act of 2014.
We also propose some short-term
adjustments to address patient
complexity.
(a) Considerations for Social Risk
We understand that social risk factors
such as income, education, race and
ethnicity, employment, disability,
community resources, and social
support (certain factors of which are
also sometimes referred to as
socioeconomic status (SES) factors or
socio-demographic status (SDS) factors)
play a major role in health. One of our
core objectives is to improve beneficiary
outcomes, including reducing health
disparities, and we want to ensure that
all beneficiaries, including those with
social risk factors, receive high quality
care. In addition, we seek to ensure that
the quality of care furnished by
providers and suppliers is assessed as
fairly as possible under our programs
while ensuring that beneficiaries have
adequate access to excellent care.
We have been reviewing reports
prepared by the Office of the Assistant
Secretary for Planning and Evaluation
(ASPE) and the National Academies of
Sciences, Engineering, and Medicine on
the issue of accounting for social risk
factors in CMS’ value-based purchasing
and quality reporting programs, and
considering options on how to address
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the issue in these programs. On
December 21, 2016, ASPE submitted the
first of several Reports to Congress on a
study it was required to conduct under
section 2(d) of the IMPACT Act of 2014.
The first study analyzed the effects of
certain social risk factors in Medicare
beneficiaries on quality measures and
measures of resource use used in one or
more of nine Medicare value-based
purchasing programs.12 The report also
included considerations for strategies to
account for social risk factors in these
programs. A second report due October
2019 will expand on these initial
analyses, supplemented with nonMedicare datasets to measure social risk
factors. In a January 10, 2017 report
released by the National Academies of
Sciences, Engineering, and Medicine,
that body provided various potential
methods for accounting for social risk
factors, including stratified public
reporting.13
As noted in the FY 2017 IPPS/LTCH
PPS final rule (81 FR 56974), the NQF
has undertaken a 2-year trial period in
which certain new measures and
measures undergoing maintenance, and
measures endorsed with the condition
that they enter the trial period can be
assessed to determine whether risk
adjustment for selected social risk
factors is appropriate for these
measures. This trial entails temporarily
allowing inclusion of social risk factors
in the risk-adjustment approach for
these measures. At the conclusion of the
trial, NQF will issue recommendations
on the future inclusion of social risk
factors in risk adjustment for these
quality measures, and we will closely
review its findings.
As we continue to consider the
analyses and recommendations from
these and any future reports, and await
the results of the NQF trial on risk
adjustment for quality measures, we are
continuing in this proposed rule to work
with stakeholders in this process. As we
have previously communicated, we are
concerned about holding providers to
different standards for the outcomes of
their patients with social risk factors
because we do not want to mask
potential disparities or minimize
incentives to improve the outcomes for
disadvantaged populations. Keeping
this concern in mind, while we sought
12 Office of the Assistant Secretary for Planning
and Evaluation. 2016. Report to Congress: Social
Risk Factors and Performance Under Medicare’s
Value-Based Purchasing Programs. Available at
https://aspe.hhs.gov/pdf-report/report-congresssocial-risk-factors-and-performance-undermedicares-value-based-purchasing-programs.
13 National Academies of Sciences, Engineering,
and Medicine. 2017. Accounting for social risk
factors in Medicare payment. Washington, DC: The
National Academies Press.
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input on this topic previously, we
continue to seek public comment on
whether we should account for social
risk factors in the MIPS, and if so, what
method or combination of methods
would be most appropriate for
accounting for social risk factors in the
MIPS. Examples of methods include:
Adjustment of MIPS eligible clinician
scores (for example, stratifying the
scores of MIPS eligible clinicians based
on the proportion of their patients who
are dual eligible); confidential reporting
of stratified measure rates to MIPS
eligible clinicians; public reporting of
stratified measure results; risk
adjustment of a particular measure as
appropriate based on data and evidence;
and redesigning payment incentives (for
instance, rewarding improvement for
clinicians caring for patients with social
risk factors or incentivizing clinicians to
achieve health equity). We are seeking
comments on whether any of these
methods should be considered, and if
so, which of these methods or
combination of methods would best
account for social risk factors in MIPS,
if any.
In addition, we are seeking public
comment on which social risk factors
might be most appropriate for stratifying
measure scores and/or potential risk
adjustment of a particular measure.
Examples of social risk factors include,
but are not limited to the following:
Dual eligibility/low-income subsidy;
race and ethnicity; and geographic area
of residence. We are seeking comment
on which of these factors, including
current data sources where this
information would be available, could
be used alone or in combination, and
whether other data should be collected
to better capture the effects of social
risk. We will take commenters’ input
into consideration as we continue to
assess the appropriateness and
feasibility of accounting for social risk
factors in MIPS. We note that any such
changes would be proposed through
future notice and comment rulemaking.
We look forward to working with
stakeholders as we consider the issue of
accounting for social risk factors and
reducing health disparities in CMS
programs. Of note, implementing any of
the above methods would be taken into
consideration in the context of how this
and other CMS programs operate (for
example, data submission methods,
availability of data, statistical
considerations relating to reliability of
data calculations, among others), we
also welcome comment on operational
considerations. CMS is committed to
ensuring that its beneficiaries have
access to and receive excellent care, and
that the quality of care furnished by
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providers and suppliers is assessed
fairly in CMS programs.
(b) Complex Patient Bonus
While we work with stakeholders on
these issues as we have described, we
are proposing, under the authority
within section 1848(q)(1)(G) of the Act,
which allows us to assess and
implement appropriate adjustments to
payment adjustments, MIPS final scores,
scores for performance categories, or
scores for measures or activities under
MIPS, to implement a short-term
strategy for the Quality Payment
Program to address the impact patient
complexity may have on final scores.
The overall goal when considering a
bonus for complex patients is two-fold:
(1) To protect access to care for complex
patients and provide them with
excellent care; and (2) to avoid placing
MIPS eligible clinicians who care for
complex patients at a potential
disadvantage while we review the
completed studies and research to
address the underlying issues. We used
the term ‘‘patient complexity’’ to take
into account a multitude of factors that
describe and have an impact on patient
health outcomes; such factors include
the health status and medical conditions
of patients, as well as social risk factors.
We believe that as the number and
intensity of these factors increase for a
single patient, the patient may require
more services, more clinician focus, and
more resources in order to achieve
health outcomes that are similar to those
who have fewer factors. In developing
the policy for the complex patient
bonus, we assessed whether there was a
MIPS performance discrepancy by
patient complexity using two wellestablished indicators in the Medicare
program. Our proposal is intended to
address any discrepancy, without
masking performance. Because this
bonus is intended to be a short-term
strategy, we are proposing the bonus
only for the 2018 MIPS performance
period (2020 MIPS payment year) and
will assess on an annual basis whether
to continue the bonus and how the
bonus should be structured.
When considering approaches for a
complex patient bonus, we reviewed
evidence to identify how indicators of
patient complexity have an impact on
performance under MIPS as well as
availability of data to implement the
bonus. Specifically, we identified two
potential indicators for complexity:
Medical complexity as measured
through Hierarchical Condition
Category (HCC) risk scores, and social
risk as measured through the proportion
of patients with dual eligible status. We
identified these indicators because they
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are common indicators of patient
complexity in the Medicare program
and the data is readily available. As
discussed below, both of these
indicators have been used in Medicare
programs to account for risk and both
data elements are already publicly
available for individual NPIs in the
Medicare Physician and Other Supplier
Public Use File (referred to as the
Physician and Other Supplier PUF)
(https://www.cms.gov/researchstatistics-data-and-systems/statisticstrends-and-reports/medicare-providercharge-data/physician-and-othersupplier.html). While we recognize that
these indicators are interrelated (as dual
eligible status is one of the factors
included in calculation of HCC risk
scores), we intend for the sake of
simplicity to implement one of these
indicators for the 2020 MIPS payment
year.
We believe that average HCC risk
scores are a valid proxy for medical
complexity that have been used by other
CMS programs. The HCC model was
developed by CMS as a risk-adjustment
model that uses hierarchical condition
categories to assign risk scores to
Medicare beneficiaries. Those scores
estimate how Medicare beneficiaries’
FFS spending will compare to the
overall average for the entire Medicare
population. According to the Physician
and Other Supplier PUF methodological
overview, published in January of
2017,14 the average risk score is set at
1.08; beneficiaries with scores greater
than that are expected to have aboveaverage spending, and vice versa. Risk
scores are based on a beneficiary’s age
and sex; whether the beneficiary is
eligible for Medicaid, first qualified for
Medicare on the basis of disability, or
lives in an institution (usually a nursing
home); and the beneficiary’s diagnoses
from the previous year. The HCC model
was designed for risk adjustment on
larger populations, such as the enrollees
in an MA plan, and generates more
accurate results when used to compare
groups of beneficiaries rather than
individuals. For more information on
the HCC risk score, see: https://
www.cms.gov/Medicare/Health-Plans/
MedicareAdvtgSpecRateStats/RiskAdjustors.html.
HCC risk scores have been used in the
VM to apply an additional upward
payment adjustment of +1.0x for
clinicians whose attributed patient
population has an average risk score
that is in the top 25 percent of all
14 https://www.cms.gov/Research-Statistics-Dataand-Systems/Statistics-Trends-and-Reports/
Medicare-Provider-Charge-Data/Downloads/
Medicare-Physician-and-Other-Supplier-PUFMethodology.pdf.
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beneficiary risk scores (77 FR 69325
through 69326). CMS proposes and
announces changes to the HCC risk
adjustment model as part of the
announcement of payment policies for
Medicare Advantage plans under
section 1853 of the Act; the proposals
and announcements are posted at
https://www.cms.gov/Medicare/HealthPlans/MedicareAdvtgSpecRateStats/
Announcements-and-Documents.html.
A mean HCC risk score for a MIPS
eligible clinician can be calculated by
averaging the HCC risk scores for the
beneficiaries cared for by the clinician.
In considering options for a complex
patient bonus, we explored the use of
average HCC risk scores while
recognizing that ‘‘complexity’’ is one of
several drivers of that metric. We
believe that using the HCC risk score as
a proxy for patient complexity is a
helpful starting point, and will explore
methods for further distinguishing
complexity from other reasons a
clinician could receive a high average
HCC risk score.
In addition to medical complexity,
patient complexity includes social risk
factors, and we considered identifying
patients dually eligible for Medicare and
Medicaid, which we believe is a proxy
for social risk factors. A ratio of
beneficiaries seen by a MIPS eligible
clinician who are dual eligible can be
calculated using claims data based on
the proportion of unique patients who
are dually eligible for Medicare and fulland partial-benefit Medicaid (referred to
herein as ‘‘dual eligible status’’) seen by
the MIPS eligible clinician during the
performance year among all unique
Medicare beneficiaries seen during the
performance year. Dual eligible
Medicare beneficiaries are qualified to
receive Medicare and Medicaid benefits.
In the Physician and Other Supplier
PUF, beneficiaries are classified as
Medicare and Medicaid entitlement if in
any month in the given calendar year
they were receiving full or partial
Medicaid benefits.15 Dual eligibility has
been used in the Medicare Advantage 5star methodology 16 and stratification by
proportion of dual eligibility status is
proposed for the Hospital Readmissions
Reduction Program (82 FR 19959
through 19961).
15 https://www.cms.gov/Research-Statistics-Dataand-Systems/Statistics-Trends-and-Reports/
Medicare-Provider-Charge-Data/Downloads/
Medicare-Physician-and-Other-Supplier-PUFMethodology.pdf.
16 Centers for Medicare & Medicaid Services.
Medicare 2017 Part C & D Star Rating Technical
Notes. Available at https://www.cms.gov/Medicare/
Prescription-Drug-Coverage/PrescriptionDrug
CovGenIn/Downloads/2017-Part-C-and-D-MedicareStar-Ratings-Data-v04-04-2017-.zip.
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We evaluated both indicators (average
HCC risk score and proportion dual
eligible status) using the 2015 Physician
and Other Supplier PUF. We
incorporated these factors into our
scoring model that uses historical PQRS
data to simulate scores for MIPS eligible
clinicians including estimates for the
quality, advancing care information, and
improvement activities performance
categories, and the small practice bonus
that is proposed in section II.C.7.b.(1)(c)
of this proposed rule. The scoring model
is described in more detail in the
regulatory impact analysis in section
V.C. of this proposed rule. For HCC, we
merged the average HCC risk score by
NPI with each TIN/NPI in our
population. We calculated a dual
eligible ratio by taking a proportion of
dual eligible beneficiaries and divided
by total beneficiaries for each NPI. We
created group level scores by taking an
average of NPI scores weighted by the
number of beneficiaries. We divided
clinicians and groups into quartiles
based on average HCC risk score and
percent of duals. To assess whether
there was a difference in MIPS
simulated scores by these two variables,
we analyzed the effect of average HCC
risk score and dual eligible ratio
separately for groups and individuals.
When looking at individuals, we
focused on individuals that reported 6
or more measures (removing individuals
who reported no measures or who
reported less than 6 measures). We
restricted our analysis to individuals
who reported 6 or more measures
because we wanted to look at
differences in performance for those
who reported the required 6 measures,
rather than differences in scores due to
incomplete reporting.
We observed modest correlation
between these two indicators. Using the
Physician and Other Supplier PUF (after
restricting to those clinicians that we
estimate to be MIPS eligible in our
scoring model described in section V.C
of this proposed rule), the correlation
coefficient for these two factors is 0.487
(some correlation is expected due to the
inclusion of dual eligible status in the
HCC risk model). The correlation
between average HCC risk scores and
proportion of patients with dual eligible
status indicates that while there is
overlap between these two indicators,
they cannot be used interchangeably.
We also assessed the correlation of
these indicators with MIPS final scores
based on performance and the small
practice bonus for MIPS eligible
clinicians, as well as variations by
practice size, submission mechanism,
and specialty. Average MIPS simulated
scores (prior to any complex patient
bonus) varied from 82.73 (fourth HCC
quartile, highest risk) to 87.14 (first HCC
quartile, lowest risk) for group reporters,
and from 82.36 (fourth HCC quartile,
highest risk) to 86.39 (first HCC quartile,
lowest risk) for individual reporters who
reported 6 or more measures (see Table
34). When reviewing average HCC risk
scores by practice size, we found that
MIPS eligible clinicians in larger
practices had slightly higher risk scores
than those in small practices (average
HCC risk score of 1.82 for practices with
100 or more clinicians, compared with
1.61 for practices with 1–15 clinicians)
(see Table 35) and that the average HCC
risk score varied by specialty, with
nephrology having the highest average
HCC risk score (3.05) and dermatology
having the lowest (1.24). The average
HCC risk score for family medicine was
1.58 (see Table 36).
We also ranked MIPS eligible
clinicians by proportion of patients with
dual eligibility (see Table 34).
Performance for MIPS eligible clinicians
ranged from 82.35 in the fourth dual
quartile (highest proportion dual
eligible patients) to 89.49 in the second
dual quartile (second lowest proportion
dual eligible patients) for group
reporters. Performance for MIPS eligible
clinicians reporting individually who
reported 6 or more measures ranged
from 83.08 in the fourth dual quartile
(highest proportion dual eligible
patients) to 86.80 in the first dual
quartile (lowest proportion dual eligible
patients).
TABLE 34—MIPS SIMULATED SCORE * BY HCC RISK QUARTILE AND DUAL ELIGIBLE RATIO QUARTILE
Individuals
with 6+
measures **
HCC Quartile
Quartile 1—Lowest Average HCC Risk Score .................................................................................................
Quartile 2 ..........................................................................................................................................................
Quartile 3 ..........................................................................................................................................................
Quartile 4—Highest Average HCC Risk Score ................................................................................................
Dual Eligible Ratio
Quartile 1—Lowest Proportion of Dual Status .................................................................................................
Quartile 2 ..........................................................................................................................................................
Quartile 3 ..........................................................................................................................................................
Quartile 4—Highest Proportion of Dual Status ................................................................................................
Group
86.39
84.89
83.31
82.36
87.14
88.41
86.76
82.73
86.80
83.76
82.63
83.08
88.03
89.49
85.39
82.35
* The simulated score includes estimated quality, advancing care information, and improvement activities performance categories without complex patient bonus. Simulated score does include small practice bonus proposed in II.C.7.b.(1)(c) of this proposed rule.
** We restricted this column to individuals who reported 6 or more measures to assess differences in performance for those who reported the
required 6 measures and to not consider changes due to incomplete reporting.
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TABLE 35—AVERAGE HCC RISK SCORE AND DUAL ELIGIBLE RATIO BY PRACTICE SIZE
Average HCC
risk score
Practice size
1–15 clinicians .........................................................................................................................................................
16–24 clinicians .......................................................................................................................................................
25–99 clinicians .......................................................................................................................................................
100 or more clinicians .............................................................................................................................................
Total ..................................................................................................................................................................
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1.61
1.70
1.72
1.82
1.75
Dual eligible
ratio
(%)
24.90
26.20
27.50
26.90
26.60
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TABLE 36—AVERAGE HCC RISK SCORE AND DUAL ELIGIBLE RATIO BY SPECIALTY
Average
HCC risk
score
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Specialty *
Total .........................................................................................................................................................................
Addiction Medicine ...................................................................................................................................................
Allergy/Immunology .................................................................................................................................................
Anesthesiology .........................................................................................................................................................
Anesthesiology Assistant .........................................................................................................................................
Cardiac Electrophysiology .......................................................................................................................................
Cardiac Surgery .......................................................................................................................................................
Cardiovascular Disease (Cardiology) ......................................................................................................................
Certified Clinical Nurse Specialist ...........................................................................................................................
Certified Registered Nurse Anesthetist (CRNA) .....................................................................................................
Chiropractic ..............................................................................................................................................................
Clinic or Group Practice ..........................................................................................................................................
Colorectal Surgery (Proctology) ..............................................................................................................................
Critical Care (Intensivists) ........................................................................................................................................
Dermatology .............................................................................................................................................................
Diagnostic Radiology ...............................................................................................................................................
Emergency Medicine ...............................................................................................................................................
Endocrinology ..........................................................................................................................................................
Family Medicine * .....................................................................................................................................................
Gastroenterology .....................................................................................................................................................
General Practice ......................................................................................................................................................
General Surgery ......................................................................................................................................................
Geriatric Medicine ....................................................................................................................................................
Geriatric Psychiatry ..................................................................................................................................................
Gynecological Oncology ..........................................................................................................................................
Hand Surgery ...........................................................................................................................................................
Hematology ..............................................................................................................................................................
Hematology-Oncology .............................................................................................................................................
Hospice and Palliative Care ....................................................................................................................................
Infectious Disease ...................................................................................................................................................
Internal Medicine .....................................................................................................................................................
Interventional Cardiology .........................................................................................................................................
Interventional Pain Management .............................................................................................................................
Interventional Radiology ..........................................................................................................................................
Maxillofacial Surgery ................................................................................................................................................
Medical Oncology ....................................................................................................................................................
Nephrology ...............................................................................................................................................................
Neurology .................................................................................................................................................................
Neuropsychiatry .......................................................................................................................................................
Neurosurgery ...........................................................................................................................................................
Nuclear Medicine .....................................................................................................................................................
Nurse Practitioner ....................................................................................................................................................
Obstetrics & Gynecology .........................................................................................................................................
Ophthalmology .........................................................................................................................................................
Optometry ................................................................................................................................................................
Oral Surgery (Dentist only) ......................................................................................................................................
Orthopedic Surgery ..................................................................................................................................................
Osteopathic Manipulative Medicine .........................................................................................................................
Otolaryngology .........................................................................................................................................................
Pain Management ....................................................................................................................................................
Pathology .................................................................................................................................................................
Pediatric Medicine ...................................................................................................................................................
Peripheral Vascular Disease ...................................................................................................................................
Physical Medicine and Rehabilitation ......................................................................................................................
Physician Assistant ..................................................................................................................................................
Physician, Sleep Medicine .......................................................................................................................................
Plastic and Reconstructive Surgery ........................................................................................................................
Podiatry ....................................................................................................................................................................
Preventive Medicine ................................................................................................................................................
Psychiatry ................................................................................................................................................................
Pulmonary Disease ..................................................................................................................................................
Radiation Oncology .................................................................................................................................................
Rheumatology ..........................................................................................................................................................
Sports Medicine .......................................................................................................................................................
Surgical Oncology ....................................................................................................................................................
Thoracic Surgery .....................................................................................................................................................
Urology .....................................................................................................................................................................
Vascular Surgery .....................................................................................................................................................
1.75
1.77
1.38
1.78
1.94
1.85
1.93
1.85
1.78
1.77
1.27
1.57
1.70
2.06
1.24
1.78
1.94
1.78
1.58
1.70
1.60
1.83
1.93
1.92
1.76
1.39
1.95
1.92
1.93
2.35
1.84
1.79
1.50
2.18
1.90
1.94
3.05
1.79
1.76
1.68
1.91
1.78
1.63
1.37
1.33
1.82
1.44
1.62
1.50
1.57
1.71
1.95
1.83
1.76
1.69
1.70
1.74
1.72
1.80
1.80
2.00
1.79
1.65
1.54
1.92
1.94
1.56
2.22
Dual eligible
ratio
(%)
26.60
37.00
19.70
26.00
26.50
23.20
25.10
25.30
31.20
25.50
19.10
30.60
22.10
28.50
11.90
26.50
34.10
24.70
25.80
24.20
35.80
27.10
29.60
39.30
24.20
17.80
25.80
24.90
26.90
31.60
28.10
22.90
26.90
28.80
30.20
23.50
33.00
27.40
30.30
24.70
26.10
28.60
26.20
18.70
24.80
29.20
20.50
29.70
21.10
29.50
23.70
31.10
23.10
27.00
26.40
23.20
23.60
27.70
27.60
39.50
27.20
22.20
23.40
22.70
25.10
26.30
20.30
26.80
* Specialty descriptions as self-reported on Part B claims. Note that all categories are mutually exclusive, including General Practice and Family Practice. ‘Family Medicine’ is used here for physicians listed as ‘Family Practice’ in Part B claims.
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Based on our assessment of these two
indicators, we generally see high
average simulated scores 17 that are
above 80 points for each quartile based
on average HCC risk score or proportion
of dual status patients (see Table 34). As
discussed in II.C.8.d. of this proposed
rule, 70 points is the proposed
additional performance threshold at
which MIPS eligible clinicians can
receive the additional adjustment factor
for exceptional performance. However,
even though the simulated scores are
high, we also generally see a very
modest decrease in simulated scores of
4.0 points (for individuals who report 6
or more measures) and 4.4 points (for
groups) from the top quartile to the
bottom quartile for the average patient
HCC risk score and from 3.7 (for
individuals who report 6 or more
measures) and 5.7 points (for groups)
from the top quartile to the bottom
quartile for dual eligible ratio. While we
are transitioning into MIPS and evolving
our scoring policies, we want to ensure
safeguards and access for these
vulnerable patients; therefore, we are
proposing to apply a small complex
patient bonus to final scores used for the
2020 MIPS payment year. As we stated
earlier, we intend to start with one
dimension of patient complexity for
simplicity. For the 2020 MIPS payment
year, we are proposing a complex
patient bonus based on the average HCC
risk score because this is the indicator
that clinicians are familiar with from the
VM.
We propose at § 414.1380(c)(3) to add
a complex patient bonus to the final
score for the 2020 MIPS payment year
for MIPS eligible clinicians that submit
data (as explained below) for at least
one performance category. We propose
at § 414.1380(c)(3)(i) to calculate an
average HCC risk score, using the model
adopted under section 1853 of the Act
for Medicare Advantage risk adjustment
purposes, for each MIPS eligible
clinician or group, and to use that
average HCC risk score as the complex
patient bonus. We would calculate the
average HCC risk score for a MIPS
eligible clinician or group by averaging
HCC risk scores for beneficiaries cared
for by the MIPS eligible clinician or
clinicians in the group during the
second 12-month segment of the
eligibility period, which spans from the
last 4 months of a calendar year 1 year
prior to the performance period
followed by the first 8 months of the
performance period in the next calendar
year (September 1, 2017 to August 31,
2018 for the 2018 MIPS performance
17 Scores are simulated prior to any complex
patient bonus.
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period) as described in section II.C.3.c.
of this proposed rule. We propose the
second 12-month segment of the
eligibility period to align with other
MIPS policies and to ensure we have
sufficient time to determine the
necessary calculations. The second
period 12-month segment overlaps 8months with the MIPS performance
period which means that many of the
patients in our complex patient bonus
would have been cared for by the
clinician, group, virtual group or APM
Entity during the MIPS performance
period.
HCC risk scores for beneficiaries
would be calculated based on the
calendar year immediately prior to the
performance period. For the 2018 MIPS
performance period, the HCC risk scores
would be calculated based on
beneficiary services from the 2017
calendar year. We chose this approach
because CMS uses prior year diagnoses
to set Medicare Advantage rates
prospectively every year and has
employed this approach in the VM (77
FR 69317–8). Additionally, this
approach mitigates the risk of
‘‘upcoding’’ to get higher expected costs,
which could happen if concurrent risk
adjustments were incorporated. We
realize using the 2017 calendar year to
assess beneficiary HCC risk scores
overlaps by 4-months with the 12month data period to identify
beneficiaries (which is September 1,
2017 to August 31, 2018 for the 2018
MIPS performance period); however, we
annually calculate the beneficiary HCC
risk score and use it for multiple
purposes (like the Physician and Other
Supplier PUF).
For MIPS APMs and virtual groups,
we propose at § 414.1380(c)(3)(ii) to use
the beneficiary weighted average HCC
risk score for all MIPS eligible
clinicians, and if technically feasible,
TINs for models and virtual groups
which rely on complete TIN
participation, within the APM Entity or
virtual group, respectively, as the
complex patient bonus. We would
calculate the weighted average by taking
the sum of the individual clinician’s (or
TIN’s as appropriate) average HCC risk
score multiplied by the number of
unique beneficiaries cared for by the
clinician and then divide by the sum of
the beneficiaries cared for by each
individual clinician (or TIN as
appropriate) in the APM Entity or
virtual group.
We propose at § 414.1380(c)(3)(iii)
that the complex patient bonus cannot
exceed 3 points. This value was selected
because the differences in performance
we observed between simulated scores
between the first and fourth quartiles of
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average HCC risk scores was
approximately 4 points for individuals
and approximately 5 points for groups.
We considered whether we should
apply a set number of points to those in
a specific quartile (for example, for the
highest risk quartile only), but did not
want to restrict the bonus to only certain
MIPS eligible clinicians. Rather than
assign points based on quartile, we
believed that adding the average HCC
risk score directly to the final score
would achieve our goal of accounting
for patient complexity without masking
low performance and does provide a
modest effect on the final score. The
95th percentile of HCC values for
individual clinicians was 2.91 which we
rounded to 3 for simplicity. We believe
applying this bonus to the final score is
appropriate because caring for complex
and vulnerable patients can affect all
aspects of a practice and not just
specific performance categories. It may
also create a small incentive to provide
access to complex patients.
Finally, we propose that the MIPS
eligible clinician, group, virtual group
or APM Entity must submit data on at
least one measure or activity in a
performance category during the
performance period to receive the
complex patient bonus. Under this
proposal, MIPS eligible clinicians
would not need to meet submissions
requirements for the quality
performance category in order to receive
the bonus (they could instead submit
improvement activities or advancing
care information measures only or
submit fewer than the required number
of measures for the quality performance
category).
Based on our data analysis, we
estimate that this bonus on average
would range from 1.16 points in the first
quartile based on HCC risk scores to
2.49 points in the fourth quartile for
individual reporters submitting 6 or
more measures, and 1.26 points in the
first quartile to 2.23 points in the fourth
quartile for group reporters. For
example, a MIPS eligible clinician with
a final score of 55.11 with an average
HCC risk score of 2.01 would receive a
final score of 57.12. We propose in
section II.C.7.b.(2) of this proposed rule
that if the result of the calculation is
greater than 100 points, then the final
score would be capped at 100 points.
We also seek comment on an
alternative complex patient bonus
methodology, similarly for the 2020
MIPS payment year only. Under the
alternative, we would apply a complex
patient bonus based on a ratio of
patients who are dual eligible, because
we believe that dual eligible status is a
common indicator of social risk for
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which we currently have data available.
We believe the advantage of this option
is its relative simplicity and that it
creates a direct incentive to care for dual
eligible patients, who are often
medically complex and have concurrent
social risk factors. In addition, whereas
the HCC risk scores rely on the
diagnoses a beneficiary receives which
could be impacted by variations in
coding practices among clinicians, the
dual eligibility ratio is not impacted by
variations in coding practices. For this
alternative option, we would calculate a
dual eligible ratio (including both full
and partial Medicaid beneficiaries) for
each MIPS eligible clinician based on
the proportion of unique patients who
have dual eligible status seen by the
MIPS eligible clinician among all
unique patients seen during the second
12-month segment of the eligibility
period, which spans from the last 4
months of a calendar year 1 year prior
to the performance period followed by
the first 8 months of the performance
period.
For MIPS APMs and virtual groups,
we would use the average dual eligible
patient ratio for all MIPS eligible
clinicians, and if technically feasible,
TINs for models and virtual groups
which rely on complete TIN
participation, within the APM entity or
virtual group, respectively.
Under this alternative option, we
would identify dual eligible status
(numerator of the ratio) using data on
dual-eligibility status sourced from the
state Medicare Modernization Act
(MMA) files, which are files each state
submits to CMS with monthly Medicaid
eligibility information. We would use
dual-eligibility status data from the state
MMA files because it is the best
available data for identifying dual
eligible beneficiaries. Under this
alternative option, an individual would
be counted as a full-benefit or partialbenefit dual patient if the beneficiary
was identified as a full-benefit or
partial-benefit dual in the state MMA
files at the conclusion of the second 12month segment of the eligibility
determination period.
We would define the proportion of
full benefit or partial dual eligible
beneficiaries as the proportion of dual
eligible patients among all unique
Medicare patients seen by the MIPS
eligible clinician or group during the
second 12-month segment of the
eligibility period which spans from the
last 4 months of a calendar year prior to
the performance period followed by the
first 8 months of the performance period
in the next calendar year (September 1,
2017 to August 31, 2018 for the 2018
MIPS performance period) as described
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in section II.C.3.c. of this proposed rule,
to identify MIPS eligible clinicians for
calculation of the complex patient
bonus. This date range aligns with the
second low-volume threshold
determination and also represents care
provided during the performance
period.
We would propose to multiply the
dual eligible ratio by 5 points to
calculate a complex patient bonus for
each MIPS eligible clinician. For
example, a MIPS eligible clinician who
sees 400 patients with dual eligible
status out of 1000 total Medicare
patients seen during the second 12month segment of the eligibility period
would have a complex patient ratio of
0.4, which would be multiplied by 5
points for a complex patient bonus of 2
points toward the final score. We
believe this approach is simple to
explain and would be available to all
clinicians who care for dual eligible
beneficiaries. We also believe a complex
patient bonus ranging from 1 to 5 points
(with most MIPS eligible clinicians
receiving a bonus between 1 and 3
points) is appropriate because, in our
analysis, we estimated differences in
performance between the 1st and 4th
quartiles of dual eligible ratios to be
approximately 3 points for individuals
and approximately 6 points for groups.
A bonus of less than 5 points would
help to mitigate the impact of caring for
patients with social risk factors while
not masking poor performance. Using
this approach, we estimate that the
bonus would range from 0.45 (first dual
quartile) to 2.42 (fourth dual quartile)
for individual reporters, and from 0.63
(first dual quartile) to 2.19 (fourth dual
quartile) for group reporters. Under this
alternative option, we would also
include the complex patient bonus in
the calculation of the final score. Again,
we propose in section II.C.7.b.(2) of this
proposed rule that if the result of the
calculation is greater than 100 points,
then the final score would be capped at
100 points. We seek comments on our
proposed bonus for complex patients
based on average HCC risk scores, and
our alternative option using a ratio of
dual eligible patients in lieu of average
HCC risk scores. We reiterate that the
complex patient bonus is intended to be
a short-term solution, which we plan to
revisit on an annual basis, to incentivize
clinicians to care for patients with
medical complexity. We may consider
alternate adjustments in future years
after methods that more fully account
for patient complexity in MIPS have
been developed. We also seek comments
on alternative methods to construct a
complex patient bonus.
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30139
(c) Small Practice Bonus for the 2020
MIPS Payment Year
Eligible clinicians and groups who
work in small practices are a crucial
part of the health care system. The
Quality Payment Program provides
options designed to make it easier for
these MIPS eligible clinicians and
groups to report on performance and
quality and participate in advanced
alternative payment models for
incentives. We have heard directly from
clinicians in small practices that they
face unique challenges related to
financial and other resources,
environmental factors, and access to
health information technology. We
heard from many commenters that the
Quality Payment Program advantages
large organizations because such
organizations have more resources
invested in the infrastructure required
to track and report measures to MIPS.
Based on our scoring model, which is
described in the regulatory impact
analysis in section V.C. of this proposed
rule, practices with more than 100
clinicians may perform better in the
Quality Payment Program, on average
compared to smaller practices. We
believe this trend is due primarily to
two factors: Participation rates and
submission mechanism. Based on the
most recent PQRS data available,
practices with 100 or more MIPS
eligible clinicians have participated in
the PQRS at a higher rate than small
practices (99.4 percent compared to 69.7
percent, respectively). As we indicate in
our regulatory impact analysis in
section V.C. of this proposed rule, we
believe participation rates based only on
historic 2015 quality data submitted
under PQRS significantly underestimate
the expected participation in MIPS
particularly for small practices.
Therefore, we have modeled the
regulatory impact analysis using
minimum participation assumptions of
80 percent and 90 percent participation
for each practice size category (1–15
clinicians, 16–24 clinicians, 25–99
clinicians, and 100 or more clinicians).
However, even with these enhanced
participation assumptions, MIPS
eligible clinicians in small practices
would have lower participation than
MIPS eligible clinicians in larger
practices as 80 or 90 percent
participation is still much lower than
the 99.4 percent participation for MIPS
eligible clinicians in practices with 100
or more clinicians.
In addition, practices with 100 or
more MIPS eligible clinicians are more
likely to report as a group, rather than
individually, which reduces burden to
individuals within those practices due
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to the unified nature of group reporting.
Specifically, 63.1 percent of practices
with 100 or more MIPS eligible
clinicians are reporting via CMS Web
Interface (either through the Shared
Savings Program or as a group practice)
compared to 20.5 percent of small
practices (the CMS Web Interface
reporting mechanism is only available
to small practices participating in the
Shared Saving Program or Next
Generation ACO Model.) 18
These two factors have financial
implications based on the MIPS scoring
model described in section V.C. of this
proposed rule. Looking at the combined
impact performance, we see consistent
trends for small practices in various
scenarios. A combined impact of
performance measurement looks at the
aggregate net percent change (the
combined impact of MIPS negative and
positive adjustments in the final score).
In analyzing the combined impact
performance, we see MIPS eligible
clinicians in small practices
consistently have a lower combined
impact performance than larger
practices based on actual historical data
and after we apply the 80 and 90
percent participation assumptions.
Due to these challenges, we believe an
adjustment to the final score for MIPS
eligible clinicians in small practices
(referred to herein as the ‘‘small practice
bonus’’) is appropriate to recognize
these barriers and to incentivize MIPS
eligible clinicians in small practices to
participate in the Quality Payment
Program and to overcome any
performance discrepancy due to
practice size. To receive the small
practice bonus, we propose that the
MIPS eligible clinician must participate
in the program by submitting data on at
least one performance category in the
2018 MIPS performance period.
Therefore, MIPS eligible clinicians
would not need to meet submission
requirements for the quality
performance category in order to receive
the bonus (they could instead submit
improvement activities or advancing
care information measures only or
submit fewer than the required number
of measures for the quality performance
category). Additionally, we propose that
group practices, virtual groups, or APM
Entities that consist of a total of 15 or
fewer clinicians may receive the small
practice bonus.
We propose at § 414.1380(c)(4) to add
a small practice bonus of five points to
the final score for MIPS eligible
clinicians who participate in MIPS for
the 2018 MIPS performance period and
18 Groups must have at least 25 clinicians to
participate in Web Interface.
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are in small practices or virtual groups
or APM entities with 15 or fewer
clinicians (the entire virtual group or
APM entity combined must include 15
or fewer clinicians to qualify for the
bonus). We believe a bonus of 5 points
is appropriate to acknowledge the
challenges small practices face in
participating in MIPS, and to help them
achieve the performance threshold
proposed at section II.C.8.c. of this
proposed rule at 15 points for the 2020
MIPS payment year, as this bonus
represents one-third of the total points
needed to meet or exceed the
performance threshold and receive a
neutral to positive payment adjustment.
With a small practice bonus of 5 points,
small practices could achieve this
performance threshold by reporting 2
quality measures or 1 quality measure
and 1 improvement activity.19 We
believe that a higher bonus (for
example, a bonus that would meet or
exceed the performance threshold) is
not ideal because it might discourage
small practices from actively
participating in MIPS or could mask
poor performance. We propose in
section II.C.7.b.(2) of this proposed rule
that if the result of the calculation is
greater than 100 points, then the final
score would be capped at 100 points.
This bonus is intended to be a shortterm strategy to help small practices
transition to MIPS, therefore, we are
proposing the bonus only for the 2018
MIPS performance period (2020 MIPS
payment year) and will assess on an
annual basis whether to continue the
bonus and how the bonus should be
structured.
We are inviting public comment on
our proposal to apply a small practice
bonus for the 2020 MIPS payment year.
We also considered applying a bonus
for MIPS eligible clinicians that practice
in either a small practice or a rural area.
However, on average, we saw less than
a one point difference between scores
for MIPS eligible clinicians who
practice in rural areas and those who do
19 Assuming the small practice did not submit
advancing care information and applied for the
hardship exception and had the advancing care
information performance category weight
redistributed to quality, the small practice would
have a final score with 85 percent weight from the
quality performance category score and 15 percent
from improvement activities. With the proposed
scoring for small practices, submitting one measure
one time would provide at least 3 measure
achievement points out of 60 total available
measure points. With 85 percent quality
performance category weight, each quality measure
would be worth at least 4.25 point towards the final
score. ((3/60) × 85% × 100= 4.25 points). For
improvement activities, each medium weighted
activity is worth 20 out of 40 possible points which
translates to 7.5 points to the file score. (20/40) ×
15% × 100 = 7.5 points).
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not. Therefore, we are not proposing to
extend the final score bonus to those
who practice in a rural area, but plan to
continue to monitor the Quality
Payment Program’s impacts on the
performance of those who practice in
rural areas. We also seek comment on
the application of a rural bonus in the
future, including available evidence
demonstrating differences in clinician
performance based on rural status. If we
implement a bonus for practices located
in rural areas, we would use the
definition for rural specified in section
II.C.1. of this proposed rule for
individuals and groups (including
virtual groups).
(2) Final Score Calculation
With the proposed addition of the
complex patient and small practice
bonuses, we propose to use the formula
at § 414.1380(c) to calculate the final
score for all MIPS eligible clinicians,
groups, virtual groups, and MIPS APMs
starting with the 2020 MIPS payment
year.
We propose to revise the final score
calculation at § 414.1380(c) to reflect
this updated formula. We also propose
to revise the policy finalized in the CY
2017 Quality Payment Program final
rule to assign MIPS eligible clinicians
with only 1 scored performance
category a final score that is equal to the
performance threshold (81 FR 77326
through 77328) (we note that we
inadvertently failed to codify this policy
in § 414.1380(c)). We are proposing this
revision to the policy to account for our
proposal in section II.C.7.b.(3)(c) of this
proposed rule for extreme and
uncontrollable circumstances which, if
finalized, could result in a scenario
where a MIPS eligible clinician is not
scored on any performance categories.
To reflect this proposal, we propose to
add to § 414.1380(c) that a MIPS eligible
clinician with fewer than 2 performance
category scores would receive a final
score equal to the performance
threshold.
With the proposed addition of the
complex patient and small practice
bonuses, we also propose to strike the
following phrase from the final score
definition at § 414.1305: ‘‘The final
score is the sum of each of the products
of each performance category score and
each performance category’s assigned
weight, multiplied by 100.’’ We believe
this portion of the definition would be
incorrect and redundant of the proposed
revised regulation at § 414.1380(c).
We invite public comment on the
proposed final score methodology and
associated revisions to regulation text.
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(3) Final Score Performance Category
Weights
(a) General Weights
Section 1848(q)(5)(E)(i) of the Act
specifies weights for the performance
categories included in the MIPS final
score: In general, 30 percent for the
quality performance category, 30
percent for the cost performance
category, 25 percent for the advancing
care information performance category,
and 15 percent for the improvement
activities performance category.
However, that section also specifies
different weightings for the quality and
cost performance categories for the first
and second years for which the MIPS
applies to payments. Section
1848(q)(5)(E)(i)(II)(bb) of the Act
specifies that for the transition year, not
more than 10 percent of the final score
will be based on the cost performance
category, and for the 2020 MIPS
payment year, not more than 15 percent
will be based on the cost performance
category. Under section
1848(q)(5)(E)(i)(I)(bb) of the Act, the
weight of the quality performance
category for each of the first 2 years will
increase by the difference of 30 percent
minus the weight specified for the cost
performance category for the year.
In the CY 2017 Quality Payment
Program final rule, we established the
weights of the cost performance
category as 10 percent of the final score
(81 FR 77166) and the quality
performance category as 50 percent of
the final score (81 FR 77100) for the
2020 MIPS payment year. However, we
are proposing in section II.C.6.d. of this
proposed rule to change the weight of
the cost performance category to zero
percent and in section II.C.6.b. of this
proposed rule to change the weight of
the quality performance category to 60
percent for the 2020 MIPS payment
year. We refer readers to sections
II.C.6.b. and II.C.6.d. of this proposed
rule for further information on the
policies related to the weight of the
quality and cost performance categories,
including our rationale for our proposed
weighting for each category.
As specified in section 1848(q)(5)(E)(i)
of the Act, the weights for the other
performance categories are 25 percent
for the advancing care information
performance category and 15 percent for
the improvement activities performance
category. Section 1848(q)(5)(E)(ii) of the
Act provides that in any year in which
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the Secretary estimates that the
proportion of eligible professionals (as
defined in section 1848(o)(5) of the Act)
who are meaningful EHR users (as
determined in section 1848(o)(2) of the
Act) is 75 percent or greater, the
Secretary may reduce the applicable
percentage weight of the advancing care
information performance category in the
final score, but not below 15 percent.
For more on our policies concerning
section 1848(q)(5)(E)(ii) of the Act and
a review of our proposal for reweighting
the advancing care information
performance category in the event that
the proportion of MIPS eligible
clinicians who are meaningful EHR
users is 75 percent or greater starting
with the 2019 MIPS performance
period, we refer readers to section
II.C.6.f.(5) of this proposed rule.
Table 37 summarizes the weights
specified for each performance category
under section 1848(q)(5)(E)(i) of the Act
and in accordance with our policies in
the CY 2017 Quality Payment Program
final rule as codified at
§§ 414.1380(c)(1), 414.1330(b),
414.1350(b), 414.1355(b), and
414.1375(a), and with our proposals in
section II.C.6. of this proposed rule.
TABLE 37—FINALIZED AND PROPOSED WEIGHTS BY MIPS PERFORMANCE CATEGORY *
Performance category
Quality ..................................................................................................................
Cost ......................................................................................................................
Improvement Activities .........................................................................................
Advancing Care Information** .............................................................................
2021 MIPS
payment year
and beyond
(final)
(%)
2020 MIPS
payment year
(proposed)
(%)
Transition year
(final)
(%)
60
0
15
25
60
0
15
25
30
30
15
25
* In sections II.C.6.b. and II.C.6.c., we propose to maintain the same weights from the transition year for the 2020 MIPS payment year for quality and cost (60 percent and zero percent, respectively).
**As described in section II.C.6.f. of this proposed rule, the weight for advancing care information could decrease (not below 15 percent) starting with the 2021 MIPS payment year if the Secretary estimates that the proportion of physicians who are meaningful EHR users is 75 percent or
greater.
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(b) Flexibility for Weighting
Performance Categories
Under section 1848(q)(5)(F) of the
Act, if there are not sufficient measures
and activities applicable and available
to each type of MIPS eligible clinician
involved, the Secretary shall assign
different scoring weights (including a
weight of zero) for each performance
category based on the extent to which
the category is applicable and for each
measure and activity based on the
extent to which the measure or activity
is applicable and available to the type
of MIPS eligible clinician involved. For
the 2020 MIPS payment year, we
propose to assign a scoring weight of
zero percent to a performance category
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and redistribute its weight to the other
performance categories in the following
scenarios.
For the quality performance category,
we propose that having sufficient
measures applicable and available
means that we can calculate a quality
performance category percent score for
the MIPS eligible clinician because at
least one quality measure is applicable
and available to the MIPS eligible
clinician. Based on the volume of
measures available to MIPS eligible
clinicians via the multiple submission
mechanisms, we generally believe there
will be at least one quality measure
applicable and available to every MIPS
eligible clinician. Given that we
generally believe there will be at least
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one quality measure applicable and
available to every MIPS eligible
clinician, if we receive no quality
performance category submission from a
MIPS eligible clinician, the MIPS
eligible clinician generally will receive
a performance category score of zero (or
slightly above zero if the all-cause
hospital readmission measure applies
because the clinician submits data for a
performance category other than the
quality performance category).20
20 As discussed in the CY 2017 Quality Payment
Program final rule (81 FR 77300), groups of 16 or
more eligible clinicians that meet the applicable
case minimum requirement are automatically
scored on the all-cause readmission measure, even
if they do not submit any other data under the
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However, as described in section
II.C.7.a.(2)(e) of this proposed rule, there
may be rare instances that we believe
could affect only a very limited subset
of MIPS eligible clinicians (as well as
groups and virtual groups) that may
have no quality measures available and
applicable and for whom we receive no
quality performance category
submission (and for whom the all-cause
hospital readmission measure does not
apply). In those instances, we would not
be able to calculate a quality
performance category percent score.
The proposed quality performance
category scoring policies for the 2020
MIPS payment year continue many of
the special scoring policies from the
transition year which would enable us
to determine a quality performance
category percent score whenever a MIPS
eligible clinician has submitted at least
1 quality measure. In addition, MIPS
eligible clinicians that do not submit
quality measures when they have them
available and applicable would receive
a quality performance category percent
score of zero percent. It is only in the
rare scenarios when we determine that
a MIPS eligible clinician does not have
any relevant quality measures available
to report or the MIPS eligible clinician
is approved for reweighting the quality
performance category based on extreme
and uncontrollable circumstances as
proposed in section II.C.7.b.(3)(c) of this
proposed rule, that we would reweight
the quality performance category.
Therefore, we continue to believe that
we will not be able to calculate a score
for the quality performance category
only in the rare scenarios when a MIPS
eligible clinician does not have any
relevant quality measures available to
report.
For the cost performance category, we
continue to believe that having
sufficient measures applicable and
available means that we can reliably
calculate a score for the cost measures
that adequately captures and reflects the
performance of a MIPS eligible
clinician, and that MIPS eligible
clinicians who are not attributed enough
cases to be reliably measured should not
be scored for the cost performance
category (81 FR 77322 through 77323).
We established a policy that if a MIPS
eligible clinician is not attributed a
sufficient number of cases for a measure
(in other words, has not met the
required case minimum for the
measure), or if a measure does not have
a benchmark, then the measure will not
quality performance category, provided that they
submit data under one of the other performance
categories. If such groups do not submit data under
any performance category, the readmission measure
is not scored.
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be scored for that clinician (81 FR
77323). If we do not score any cost
measures for a MIPS eligible clinician in
accordance with this policy, then the
clinician would not receive a cost
performance category percent score.
Because we have proposed in section
II.C.6.d. of this proposed rule to set the
weight of the cost performance category
to zero percent of the final score for the
2020 MIPS payment year, we are not
proposing to redistribute the weight of
the cost performance category to any
other performance categories for the
2020 MIPS payment year. In the event
we do not finalize this proposal, we are
proposing to redistribute the weight of
the cost performance category as
described in section II.C.7.b.(3)(d) of
this proposed rule.
For the improvement activities
performance category, we believe that
all MIPS eligible clinicians will have
sufficient activities applicable and
available; however, as discussed in
section II.C.7.b.(3)(c) of this proposed
rule, we believe there are limited
extreme and uncontrollable
circumstances, such as natural disasters,
where a clinician is unable to report
improvement activities. Barring these
circumstances, we are not proposing
any changes that would affect our
ability to calculate an improvement
activities performance category score.
We refer readers to section II.C.6.f. of
this proposed rule for a detailed
discussion of our proposals and policies
under which we would not score the
advancing care information performance
category and would assign a weight of
zero percent to that category for a MIPS
eligible clinician.
We invite public comment on our
interpretation of sufficient measures
available and applicable in the
performance categories.
(c) Extreme and Uncontrollable
Circumstances
In the CY 2017 Quality Payment
Program final rule (81 FR 77241 through
77243), we discussed our belief that
extreme and uncontrollable
circumstances, such as a natural disaster
in which an EHR or practice location is
destroyed, can happen at any time and
are outside a MIPS eligible clinician’s
control. We stated that if a MIPS eligible
clinician’s CEHRT is unavailable as a
result of such circumstances, then the
measures specified for the advancing
care information performance category
may not be available for the MIPS
eligible clinician to report. We
established a policy allowing a MIPS
eligible clinician affected by extreme
and uncontrollable circumstances to
submit an application to us to be
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considered for reweighting of the
advancing care information performance
category under section 1848(q)(5)(F) of
the Act. Although we are proposing in
section II.C.6.f. of this proposed rule to
use the authority in the last sentence of
section 1848(o)(2)(D) of the Act, as
amended by section 4002(b)(1)(B) of the
21st Century Cures Act, as the authority
for this policy, rather than section
1848(q)(5)(F) of the Act, we continue to
believe that extreme and uncontrollable
circumstances could affect the
availability of a MIPS eligible clinician’s
CEHRT and the measures specified for
the advancing care information
performance category.
While we did not propose or finalize
a similar reweighting policy for other
performance categories in the transition
year, we believe a similar reweighting
policy may be appropriate for the
quality, cost, and improvement
activities performance categories
beginning with the 2020 MIPS payment
year. For these performance categories,
we propose to define ‘‘extreme and
uncontrollable circumstances’’ as rare
(that is, highly unlikely to occur in a
given year) events entirely outside the
control of the clinician and of the
facility in which the clinician practices
that cause the MIPS eligible clinician to
not be able to collect information that
the clinician would submit for a
performance category or to submit
information that would be used to score
a performance category for an extended
period of time (for example, 3 months
could be considered an extended period
of time with regard to information a
clinician would collect for the quality
performance category). For example, a
tornado or fire destroying the only
facility in which a clinician practices
likely would be considered an ‘‘extreme
and uncontrollable circumstance;’’
however, neither the inability to renew
a lease—even a long or extended lease—
nor a facility being found not compliant
with federal, state, or local building
codes or other requirements would be
considered ‘‘extreme and uncontrollable
circumstances.’’ We propose that we
would review both the circumstances
and the timing independently to assess
the availability and applicability of
measures and activities independently
for each performance category. For
example, in 2018 the performance
period for improvement activities is
only 90 days, whereas it is 12 months
for the quality performance category, so
an issue lasting 3 months may have
more impact on the availability of
measures for the quality performance
category than for the improvement
activities performance category, because
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the MIPS eligible clinician, conceivably,
could participate in improvement
activities for a different 90-day period.
We believe that extreme and
uncontrollable circumstances, such as
natural disasters, may affect a clinician’s
ability to access or submit quality
measures via all submission
mechanisms (effectively rendering the
measures unavailable to the clinician) as
well as the availability of numerous
improvement activities. In addition,
damage to a facility where care is
provided due to a natural disaster, such
as a hurricane, could result in practice
management and clinical systems that
are used for the collection or submission
of data to be down, thus impacting a
clinician’s ability to submit necessary
information via Qualified Registry,
QCDR, CMS Web Interface, or claims.
This policy would not include issues
that third party intermediaries, such as
EHRs, Qualified Registries, or QCDRs,
might have submitting information to
MIPS on behalf of a MIPS eligible
clinician. Instead, this policy is geared
towards events, such as natural
disasters, that affect the MIPS eligible
clinician’s ability to submit data to the
third party intermediary, which in turn,
could affect the ability of the clinician
(or the third party intermediary acting
on their behalf) to successfully submit
measures and activities to MIPS.
We also propose to use this policy for
measures which we derive from claims
data, such as the all-cause hospital
readmission measure and the cost
measures. Other programs, such as the
Hospital VBP Program, allow hospitals
to submit exception applications when
‘‘a hospital is able to continue to report
data on measures . . . but can
demonstrate that its Hospital VBP
Program measure rates are negatively
impacted as a result of a natural disaster
or other extraordinary circumstance
and, as a result, the hospital receives a
lower value-based incentive payment’’
(78 FR 50705). For the Hospital VBP
Program, we ‘‘interpret[ed] the
minimum numbers of cases and
measures requirement in the Act to
enable us to not score . . . all applicable
quality measure data from a
performance period and, thus, exclude
the hospital from the Hospital VBP
Program for a fiscal year during which
the hospital has experienced a disaster
or other extraordinary circumstance’’
(78 FR 50705). Hospitals that request
and are granted an exception are
exempted from the Program entirely for
the applicable year.
For the 2020 MIPS payment year, we
would score quality measures and
assign points even for those clinicians
who do not meet the case minimums for
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the quality measures they submit.
However, we established a policy not to
score a cost measure unless a MIPS
eligible clinician has met the required
case minimum for the measure (81 FR
77323), and not to score administrative
claims measures, such as the all-cause
hospital readmission measure, if they
cannot be reliably scored against a
benchmark (81 FR 77288 through
77289). Even if the required case
minimums have been met and we are
able to reliably calculate scores for the
measures that are derived from claims,
we believe a MIPS eligible clinician’s
performance on those measures could
be adversely impacted by a natural
disaster or other extraordinary
circumstance, similar to the issues we
identified for the Hospital VBP Program.
For example, the claims data used to
calculate the cost measures or the allcause hospital readmission measure
could be significantly affected if a
natural disaster caused wide-spread
injury or health problems for the
community, which could not have been
prevented by high-value healthcare. In
such cases, we believe that the measures
are available to the clinician, but are
likely not applicable, because the
extreme and uncontrollable
circumstance has disrupted practice and
measurement processes. Therefore, we
believe an approach similar to Hospital
VBP Program is warranted under MIPS,
and we are proposing that we would
exempt a MIPS eligible clinician from
all quality and cost measures calculated
from administrative claims data if the
clinician is granted an exception for the
respective performance categories based
on extreme and uncontrollable
circumstances.
Beginning with the 2020 MIPS
payment year, we propose that we
would reweight the quality, cost, and/or
improvement activities performance
categories if a MIPS eligible clinician,
group, or virtual group’s request for a
reweighting assessment based on
extreme and uncontrollable
circumstances is granted. We propose
that MIPS eligible clinicians could
request a reweighting assessment if they
believe extreme and uncontrollable
circumstances affect the availability and
applicability of measures for the quality,
cost, and improvement activities
performance categories. To the extent
possible, we would seek to align the
requirements for submitting a
reweighting assessment for extreme and
uncontrollable circumstances with the
requirements for requesting a significant
hardship exception for the advancing
care information performance category.
For example, we propose to adopt the
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same deadline (December 31, 2018 for
the 2018 MIPS performance period) for
submission of a reweighting assessment
(see section II.C.6.f. of this proposed
rule), and we would encourage the
requests to be submitted on a rolling
basis. We propose the reweighting
assessment must include the nature of
the extreme and uncontrollable
circumstance, including the type of
event, date of the event, and length of
time over which the event took place,
performance categories impacted, and
other pertinent details that impacted the
ability to report on measures or
activities to be considered for
reweighting of the quality, cost, or
improvement activities performance
categories (for example, information
detailing how exactly the event
impacted availability and applicability
of measures). If we finalize the policy to
allow reweighting based on extreme and
uncontrollable circumstances beginning
with the 2020 MIPS payment year, we
would specify the form and manner in
which these reweighting applications
must be submitted outside of the
rulemaking process after the final rule is
published.
For virtual groups, we propose to ask
the virtual group to submit a
reweighting assessment for extreme and
uncontrollable circumstances similar to
groups, and we would evaluate whether
sufficient measures and activities are
applicable and available to the majority
of TINs in the virtual group. We are
proposing that a majority of TINs in the
virtual group would need to be
impacted before we grant an exception.
We still find it important to measure the
performance of virtual group members
unaffected by an extreme and
uncontrollable circumstance even if
some of the virtual group’s TINs are
affected.
We also seek comment on what
additional factors we should consider
for virtual groups. This reweighting
assessment due to extreme and
uncontrollable circumstances for the
quality, cost, and improvement
activities would not be available to APM
Entities in the APM scoring standard for
the following reasons. First, all MIPS
eligible clinicians scored under the
APM scoring standard will
automatically receive an improvement
activities category score based on the
terms of their participation in a MIPS
APM and need not report anything for
this performance category. Second, the
cost performance category has no weight
under the APM scoring standard.
Finally, for the quality performance
category, each MIPS APM has its own
rules related to quality measures and we
believe any decisions related to
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availability and applicability of
measures should reside within the
model. As noted in II.C.6.g.(2)(d) of this
proposed rule, MIPS APM entities
would be able to request reweighting of
the advancing care information
performance category.
If we finalize these proposals for
reweighting the quality, cost, and
improvement activities performance
categories based on extreme and
uncontrollable circumstances, then it
would be possible that one or more of
these performance categories would not
be scored and would be weighted at
zero percent of the final score for a
MIPS eligible clinician. We propose to
assign a final score equal to the
performance threshold if fewer than two
performance categories are scored for a
MIPS eligible clinician. This is
consistent with our policy finalized in
the CY 2017 Quality Payment Program
final rule that because the final score is
a composite score, we believe the
intention of section 1848(q)(5) of the Act
is for MIPS eligible clinicians to be
scored based on multiple performance
categories (81 FR 77326 through 77328).
We request comment on our extreme
and uncontrollable circumstances
proposals. We also seek comment on the
types of the extreme and uncontrollable
circumstances we should consider for
this policy given the general parameters
we describe in this section.
(d) Redistributing Performance Category
Weights
In the CY 2017 Quality Payment
Program final rule, we codified at
§ 414.1380(c)(2) that we will assign
different scoring weights for the
performance categories if we determine
there are not sufficient measures and
activities applicable and available to
MIPS eligible clinicians (81 FR 77327).
We also finalized a policy to assign
MIPS eligible clinicians with only one
scored performance category a final
score that is equal to the performance
threshold, which means the clinician
would receive a MIPS payment
adjustment factor of zero percent for the
year (81 FR 77326 through 77328). We
are proposing in section II.C.7.b.(2) of
this proposed rule to refine this policy
such that a MIPS eligible clinician with
fewer than 2 performance category
scores would receive a final score equal
to the performance threshold. This
refinement is to account for our
proposal in section II.C.7.b.(3)(c) of this
proposed rule for extreme and
uncontrollable circumstances which, if
finalized, could result in a scenario
where a MIPS eligible clinician is not
scored on any performance categories.
We refer readers to the CY 2017 Quality
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Payment Program final rule for a
description of our policies for
redistributing the weights of the
performance categories (81 FR 77325
through 77329). For the 2020 MIPS
payment year, we propose to
redistribute the weights of the
performance categories in a manner that
is similar to the transition year.
However, we are also proposing new
scoring policies to incorporate our
proposals for extreme and
uncontrollable circumstances.
In section II.C.6.f. of this proposed
rule, we are proposing to use the
authority in the last sentence of section
1848(o)(2)(D) of the Act, as amended by
section 4002(b)(1)(B) of the 21st Century
Cures Act, as the authority for certain
policies under which we would assign
a scoring weight of zero percent for the
advancing care information performance
category, and to amend § 414.1380(c)(2)
to reflect our proposals. We are not,
however, proposing substantive changes
to the policy established in the CY 2017
Quality Payment Program final rule to
redistribute the weight of the advancing
care information performance category
to the other performance categories for
the transition year (81 FR 77325 through
77329).
For the 2020 MIPS payment year, if
we assign a weight of zero percent for
the advancing care information
performance category for a MIPS eligible
clinician, we propose to continue our
policy from the transition year and
redistribute the weight of the advancing
care information performance category
to the quality performance category
(assuming the quality performance
category does not qualify for
reweighting). We believe redistributing
the weight of the advancing care
information performance category to the
quality performance category (rather
than redistributing to both the quality
and improvement activities performance
categories) is appropriate because MIPS
eligible clinicians have more experience
reporting quality measures through the
PQRS program, and measurement in
this performance category is more
mature.
If we do not finalize our proposal at
section II.C.6.d. of this proposed rule to
weight the cost performance category at
zero percent (which means the weight of
the cost performance category is greater
than zero percent), then we propose to
not redistribute the weight of any other
performance categories to the cost
performance category. We believe this is
consistent with our policy of
introducing cost measurement in a
deliberate fashion and recognition that
clinicians are more familiar with other
elements of MIPS. In the rare and
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unlikely scenario where a MIPS eligible
clinician qualifies for reweighting of the
quality performance category percent
score (because there are not sufficient
quality measures applicable and
available to the clinician or the clinician
is facing extreme and uncontrollable
circumstances) and the MIPS eligible
clinician is eligible to have the
advancing care information performance
category reweighted to zero and the
MIPS eligible clinician has sufficient
cost measures applicable and available
to have a cost performance category
percent score that is not reweighted,
then we would redistribute the weight
of the quality and advancing care
information performance categories to
the improvement activities performance
category and would not redistribute the
weight to the cost performance category.
If we finalize the cost performance
category weight at zero percent for the
2020 MIPS payment year, then we
would set the final score at the
performance threshold because the final
score would be based on improvement
activities which would not be a
composite of two or more performance
category scores.
For the 2020 MIPS payment year, if
we do not finalize the proposal to set
the cost performance category a zero
percent weight, and if a MIPS eligible
clinician does not receive a cost
performance category percent score
because there are not sufficient cost
measures applicable and available to the
clinician or the clinician is facing
extreme and uncontrollable
circumstances, we propose to
redistribute the weight of the cost
performance category to the quality
performance category. In the rare
scenarios where a MIPS eligible
clinician does not receive a quality
performance category percent score
because there are not sufficient quality
measures applicable and available to the
clinician or the clinician is facing
extreme and uncontrollable
circumstances, we propose to
redistribute the weight of the cost
performance category equally to the
remaining performance categories that
are not reweighted.
In the rare event a MIPS eligible
clinician is not scored on at least one
measure in the quality performance
category because there are not sufficient
measures applicable and available or the
clinician is facing extreme and
uncontrollable circumstances, we
propose for the 2020 MIPS payment
year to continue our policy from the
transition year and redistribute the 60
percent weight of the quality
performance category so that the
performance category weights are 50
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percent for the advancing care
information performance category and
50 percent for the improvement
activities performance category
(assuming these performance categories
do not qualify for reweighting). While
clinicians have more experience
reporting advancing care information
measures, we believe equal weighting to
both the improvement activities and
advancing care information is
appropriate for simplicity. Additionally,
in the absence of quality measures, we
believe increasing the relative weight of
the improvement activities performance
category is appropriate because both
improvement activities and advancing
care information have elements of
quality and care improvement which are
important to emphasize. Should the cost
performance category have available
and applicable measures and the cost
performance category weight is not zero,
but either the improvement activities or
advancing care information performance
category is reweighted to zero percent,
then we would redistribute the weight
of the quality performance category to
the remaining performance category that
is not weighted at zero percent. We
would not redistribute the weight to the
cost performance category.
We believe that all MIPS eligible
clinicians will have sufficient
improvement activities applicable and
available. It is possible that a MIPS
eligible clinician might face extreme
and uncontrollable circumstances that
render the improvement activities not
applicable or available to the clinician;
however, in that scenario, we believe it
is likely that the measures specified for
the other performance categories also
would not be applicable or available to
the clinician based on the
circumstances. In the rare event that the
improvement activities performance
category would qualify for reweighting
based on extreme and uncontrollable
circumstances, and the other
performance categories would not also
qualify for reweighting, we propose to
redistribute the improvement activities
performance category weight to the
quality performance category consistent
with the redistribution policies for the
cost and advancing care information
performance categories. Should the cost
performance category have available
and applicable measures and the cost
performance category weight is not
finalized at zero percent, and the quality
performance category is reweighted to
zero percent, then we would
redistribute the weight of the
improvement activities performance
category to the advancing care
information performance category.
Table 38 summarizes the potential
reweighting scenarios based on our
proposals for the 2020 MIPS payment
year should the cost performance
category be weighted at zero percent.
TABLE 38—PROPOSED PERFORMANCE CATEGORY REDISTRIBUTION POLICIES FOR THE 2020 MIPS PAYMENT YEAR IF THE
COST PERFORMANCE CATEGORY WEIGHT IS ZERO PERCENT
Weighting
for the
2020 MIPS
payment year
(%)
Performance category
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Quality ..............................................................................................................
Cost ..................................................................................................................
Improvement Activities .....................................................................................
Advancing Care Information ............................................................................
In response to our final policy to
redistribute the advancing care
information performance category
weight solely to the quality performance
category in the CY 2017 Quality
Payment Program final rule (81 FR
77327), we received some comments
expressing concern that this would
place undue emphasis on the quality
performance category. Commenters
expressed the belief that this policy
would particularly affect non-patient
facing MIPS eligible clinicians who
have limited available measures, and
would limit the ability to fairly compare
different specialties that are reweighted
differently. One reason for the
discrepancy is that MIPS eligible
clinicians that submit data to the
advancing care information performance
category can readily achieve a base
score of 50 percent if they meet the
requirements for the base score
measures, whereas the quality
performance category does not start at
the same base. Commenters also
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Reweight
scenario if no
advancing
care
information
performance
category score
(%)
60
0
15
25
expressed the belief that specialties with
few quality measures available to them
will be unfairly impacted by this
reweighting policy, by putting a
disproportionate weight on just a few
quality measures. Commenters
suggested we redistribute the weight of
the advancing care information
performance category to the
improvement activities performance
category because the improvement
activities performance category allows
for the most flexibility. One commenter
recommended redistributing the weight
of the advancing care information
performance category to both the quality
and improvement activities performance
categories.
We continue to have concerns about
increasing the weight of the
improvement activities performance
category, given that this performance
category is based on attestation only and
is not connected to a predecessor CMS
program like the other MIPS
performance categories. However, based
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85
0
15
0
Reweight
scenario if no
quality
performance
category
percent score
0
0
50
50
Reweight
scenario if no
improvement
activities
performance
category score
(%)
75
0
0
25
on the comments we received, we
considered an alternative approach for
the 2020 MIPS payment year to
redistribute the weight of the advancing
care information performance category
to the quality and improvement
activities performance categories, to
minimize the impact of the quality
performance category on the final score.
For this approach, we would
redistribute 15 percent to the quality
performance category (60 percent + 15
percent = 75 percent) and 10 percent to
the improvement activities performance
category (15 percent + 10 percent = 25
percent). We considered redistributing
the weight of the advancing care
information performance category
equally to the quality and improvement
activities performance categories.
However, for simplicity, we wanted to
redistribute the weights in increments of
5 points. Because MIPS eligible
clinicians have more experience
reporting quality measures and because
these measures are more mature, under
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this alternative option, we would
redistribute slightly more to the quality
performance category (15 percent vs. 10
percent). Should the cost performance
category have available and applicable
measures and the cost performance
category weight is not finalized at zero
percent and the quality performance
category is reweighted to zero percent,
then we would redistribute the weight
of the advancing care information
performance category to the
improvement activities performance
category. This alternative approach,
assuming the cost performance category
weight is zero percent is detailed in
Table 39.
TABLE 39—ALTERNATIVE OPTION FOR REWEIGHTING THE ADVANCING CARE INFORMATION PERFORMANCE CATEGORY FOR
THE 2020 MIPS PAYMENT YEAR IF THE COST PERFORMANCE CATEGORY WEIGHT IS ZERO PERCENT
Weighting for
the 2020 MIPS
payment year
(%)
Performance
category
Reweight
scenario if no
advancing care
information
performance
category score
(%)
60
0
15
25
75
0
25
0
Quality ..................................................................................................................................................................
Cost ......................................................................................................................................................................
Improvement Activities .........................................................................................................................................
Advancing Care Information ................................................................................................................................
We invite comments on our proposal
for weighting the performance
categories for the 2020 MIPS payment
year and our alternative option for
reweighting the advancing care
information performance category.
8. MIPS Payment Adjustments
a. Payment Adjustment Identifier and
Final Score Used in Payment
Adjustment Calculation
(1) Payment Adjustment Identifier
For purposes of applying the MIPS
payment adjustment under section
1848(q)(6)(E) of the Act, we finalized a
policy in the CY 2017 Quality Payment
Program final rule to use a single
identifier, TIN/NPI, for all MIPS eligible
clinicians, regardless of whether the
TIN/NPI was measured as an individual,
group or APM Entity group (81 FR
77329 through 77330). In other words,
a TIN/NPI may receive a final score
based on individual, group, or APM
Entity group performance, but the MIPS
payment adjustment would be applied
at the TIN/NPI level.
We are not proposing any changes to
the MIPS payment adjustment
identifier.
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(2) Final Score Used in Payment
Adjustment Calculation
In CY 2017 Quality Payment Program
final rule (81 FR 77330 through 77332),
we finalized a policy to use a TIN/NPI’s
historical performance from the
performance period associated with the
MIPS payment adjustment. We also
proposed the following policies, and,
although we received public comments
on them and responded to those
comments, we inadvertently failed to
state that we were finalizing these
policies, although it was our intention
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to do so. Thus, we clarify that the
following final policies apply beginning
with the transition year. For groups
submitting data using the TIN identifier,
we will apply the group final score to
all the TIN/NPI combinations that bill
under that TIN during the performance
period. For individual MIPS eligible
clinicians submitting data using TIN/
NPI, we will use the final score
associated with the TIN/NPI that is used
during the performance period. For
eligible clinicians in MIPS APMs, we
will assign the APM Entity group’s final
score to all the APM Entity Participant
Identifiers that are associated with the
APM Entity. For eligible clinicians that
participate in APMs for which the APM
scoring standard does not apply, we will
assign a final score using either the
individual or group data submission
assignments.
In the case where a MIPS eligible
clinician starts working in a new
practice or otherwise establishes a new
TIN that did not exist during the
performance period, there would be no
corresponding historical performance
information or final score for the new
TIN/NPI. In cases where there is no final
score associated with a TIN/NPI from
the performance period, we will use the
NPI’s performance for the TIN(s) the NPI
was billing under during the
performance period. If the MIPS eligible
clinician has only one final score
associated with the NPI from the
performance period, then we will use
that final score. In the event that an NPI
bills under multiple TINs in the
performance period and bills under a
new TIN in the MIPS payment year, we
finalized a policy of taking the highest
final score associated with that NPI in
the performance period (81 FR 77332).
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In some cases, a TIN/NPI could have
more than one final score associated
with it from the performance period, if
the MIPS eligible clinician submitted
duplicative data sets. In this situation,
the MIPS eligible clinician has not
changed practices; rather, for example, a
MIPS eligible clinician has a final score
for an APM Entity and a final score for
a group TIN. If a MIPS eligible clinician
has multiple final scores, the following
hierarchy will apply. If a MIPS eligible
clinician is a participant in MIPS APM,
then the APM Entity final score would
be used instead of any other final score.
If a MIPS eligible clinician has more
than one APM Entity final score, we
will apply the highest APM Entity final
score to the MIPS eligible clinician. If a
MIPS eligible clinician reports as a
group and as an individual and not as
an APM Entity, we will calculate a final
score for the group and individual
identifier and use the highest final score
for the TIN/NPI (81 FR 77332).
For a further description of our
policies, we refer readers to the CY 2017
Quality Payment Program final rule (81
FR 77330 through 77332).
In addition to the above policies from
the CY 2017 Quality Payment Program
final rule, beginning with the 2020
MIPS payment year, we are proposing to
modify the policies to address the
addition of virtual groups. Section
1848(q)(5)(I)(i) of the Act provides that
MIPS eligible clinicians electing to be a
virtual group must: (1) Have their
performance assessed for the quality
and cost performance categories in a
manner that applies the combined
performance of all the MIPS eligible
clinicians in the virtual group to each
MIPS eligible clinician in the virtual
group for the applicable performance
period; and (2) be scored for the quality
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and cost performance categories based
on such assessment. Therefore, when
identifying a final score for payment
adjustments, we must prioritize a virtual
group final score over other final scores
such as individual and group scores.
Because we also wish to encourage
movement towards APMs, we will
prioritize using the APM Entity final
score over any other score for a TIN/
NPI, including a TIN/NPI that is in a
virtual group. If a TIN/NPI is in both a
virtual group and a MIPS APM, we
propose to use the waiver authority for
Innovation Center models under section
1115A(d)(1) of the Act and the Shared
Savings Program waiver authority under
section 1899(f) of the Act to waive
section 1848(q)(5)(I)(i)(I) and (II) of the
Act. As discussed in section II.C.4.h. of
this proposed rule, the use of waiver
authority is to avoid creating competing
incentives between MIPS and the APM.
We want MIPS eligible clinicians to
focus on the requirements of the APM
to ensure that the models produce valid
results that are not confounded by the
incentives created by MIPS.
We also propose to modify our
hierarchy to state that if a MIPS eligible
30147
clinician is not in an APM Entity and is
in a virtual group, the MIPS eligible
clinician would receive the virtual
group final score over any other final
score. Our policies remain unchanged
for TIN/NPIs who are not in an APM
Entity or virtual group.
We invite public comment on our
proposals.
Table 40 illustrates the previously
finalized and newly proposed policies
for determining which final score to use
when more than one final score is
associated with a TIN/NPI.
TABLE 40—HIERARCHY FOR FINAL SCORE WHEN MORE THAN ONE FINAL SCORE IS ASSOCIATED WITH A TIN/NPI
Example
Final score used to determine payment adjustments
TIN/NPI has more than one APM Entity final score ................................
TIN/NPI has an APM Entity final score that is not a virtual group score
and also has a group final score.
TIN/NPI has an APM Entity final score and also has a virtual group
score.
TIN/NPI has a virtual group score and an individual final score .............
TIN/NPI has a group final score and an individual final score, but no
APM Entity final score and is not in a virtual group.
Table 41 illustrates the previously
finalized policies that apply if there is
no final score associated with a TIN/NPI
The highest of the APM Entity final scores.
APM Entity final score.
APM Entity final score.
Virtual group score.
The highest of the group or individual final score.
from the performance period, such as
when a MIPS eligible clinician starts
working in a new practice or otherwise
establishes a new TIN.
TABLE 41—NO FINAL SCORE ASSOCIATED WITH A TIN/NPI
MIPS eligible
clinician
(NPI 1)
Performance period final score
TIN/NPI billing in MIPS payment year
(yes/no)
Final score used to determine payment
adjustments
TIN A/NPI 1 .........
90 ...........................................................
TIN B/NPI 1 .........
70 ...........................................................
90 (Final score for TIN A/NPI 1 from
the performance period).
n/a (no claims are billed under TIN B/
NPI 1).
TIN C/NPI 1 ........
n/a (NPI 1 was not part of TIN C during
the performance period).
Yes (NPI 1 is still billing under TIN A in
the MIPS payment year).
No (NPI 1 has left TIN B and no longer
bills under TIN B in the MIPS payment year).
Yes (NPI 1 has joined TIN C and is billing under TIN C in the MIPS payment year).
b. MIPS Payment Adjustment Factors
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For a description of the statutory
background and further description of
our policies, we refer readers to the CY
2017 Quality Payment Program final
rule (81 FR 77332 through 77333).
We are not proposing any changes to
these policies.
c. Establishing the Performance
Threshold
Under section 1848(q)(6)(D)(i) of the
Act, for each year of the MIPS, the
Secretary shall compute a performance
threshold with respect to which the
final scores of MIPS eligible clinicians
are compared for purposes of
determining the MIPS payment
adjustment factors under section
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1848(q)(6)(A) of the Act for a year. The
performance threshold for a year must
be either the mean or median (as
selected by the Secretary, and which
may be reassessed every 3 years) of the
final scores for all MIPS eligible
clinicians for a prior period specified by
the Secretary. Section 1848(q)(6)(D)(iii)
of the Act outlines a special rule for the
initial 2 years of MIPS, which requires
the Secretary, prior to the performance
period for such years, to establish a
performance threshold for purposes of
determining the MIPS payment
adjustment factors under section
1848(q)(6)(A) of the Act and an
additional performance threshold for
purposes of determining the additional
MIPS payment adjustment factors under
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90 (No final score for TIN C/NPI 1, so
use the highest final score associated with NPI 1 from the performance period).
section 1848(q)(6)(C) of the Act, each of
which shall be based on a period prior
to the performance period and take into
account data available for performance
on measures and activities that may be
used under the performance categories
and other factors determined
appropriate by the Secretary. We
codified the term performance threshold
at § 414.1305 as the numerical threshold
for a MIPS payment year against which
the final scores of MIPS eligible
clinicians are compared to determine
the MIPS payment adjustment factors.
We codified at § 414.1405(b) that a
performance threshold will be specified
for each MIPS payment year. We refer
readers to the CY 2017 Quality Payment
Program final rule for further discussion
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of the performance threshold (81 FR
77333 through 77338). In accordance
with the special rule set forth in section
1848(q)(6)(D)(iii) of the Act, we
finalized a performance threshold of 3
points for the transition year (81 FR
77334 through 77338).
Our goal was to encourage
participation and provide an
opportunity for MIPS eligible clinicians
to become familiar with the MIPS
Program. We determined that it would
have been inappropriate to set a
performance threshold that would result
in downward adjustments to payments
for many clinicians who may not have
had time to prepare adequately to
succeed under MIPS. By providing a
pathway for many clinicians to succeed
under MIPS, we believed that we would
encourage early participation in the
program, which may enable more robust
and thorough engagement with the
program over time. We set the
performance threshold at a low number
to provide MIPS eligible clinicians an
opportunity to achieve a minimum level
of success under the program, while
gaining experience with reporting on
the measures and activities and
becoming familiar with other program
policies and requirements. We believed
if we set the threshold too high, using
a new formula that is unfamiliar and
confusing to clinicians, many could be
discouraged from participating in the
first year of the program, which may
lead to lower participation rates in
future years. Additionally, we believed
this flexibility is particularly important
to reduce the burden for MIPS eligible
clinicians in small or solo practices. We
believed that active participation of
MIPS eligible clinicians in MIPS will
improve the overall quality, cost, and
care coordination of services provided
to Medicare beneficiaries. In accordance
with section 1848(q)(6)(D)(iii) of the
Act, we took into account available data
regarding performance on measures and
activities, as well as other factors we
determined appropriate. We refer
readers to 81 FR 77333 through 77338
for details on our analysis. We also
stated our intent to increase the
performance threshold in the 2020 MIPS
payment year, and that, beginning in the
2021 MIPS payment year, we will use
the mean or median final score from a
prior period as required by section
1848(q)(6)(D)(i) of the Act (81 FR
77338).
For the 2020 MIPS payment year, we
again want to use the flexibility
provided in section 1848(q)(6)(D)(iii) to
help transition MIPS eligible clinicians
to the 2021 MIPS payment year, when
the performance threshold will be the
mean or median of the final scores for
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all MIPS eligible clinicians from a prior
period. We want to encourage continued
participation and the collection of
meaningful data by MIPS eligible
clinicians. A higher performance
threshold would help MIPS eligible
clinicians strive to achieve more
complete reporting and better
performance and prepare MIPS eligible
clinicians for the 2021 MIPS payment
year. However, a performance threshold
set too high could also create a
performance barrier, particularly for
MIPS eligible clinicians who did not
previously participate in PQRS or the
EHR Incentive Programs. We have heard
from stakeholders requesting that we
continue a low performance threshold
and from stakeholders requesting that
we ramp up the performance threshold
to help MIPS eligible clinicians prepare
for the 2021 MIPS payment year and to
meaningfully incentivize higher
performance. Given our desire to
provide a meaningful ramp between the
transition year’s 3-point performance
threshold and the 2021 MIPS payment
year performance threshold using the
mean or median of the final scores for
all MIPS eligible clinicians for a prior
period, we are proposing to set the
performance threshold at 15 points for
the 2020 MIPS payment year.
We propose a performance threshold
of 15 points because it represents a
meaningful increase in performance
threshold, compared to 3 points in the
transition year, while maintaining
flexibility for MIPS eligible clinicians in
the pathways available to achieve this
performance threshold. For example,
submitting the maximum number of
improvement activities could qualify for
a score for 15 points (40 out 40 possible
points for the improvement activity
which is worth 15 percent of the final
score). The performance threshold could
also be met by full participation in the
quality performance category: By
submitting all required measures with
the necessary data completeness, MIPS
eligible clinicians would earn at least a
quality performance category percent
score of 30 percent (which is 3 measure
achievement points out of 10 measure
points for each required measure).
If the quality performance category is
weighted at 60 percent, then the quality
performance category would be 30
percent × 60 percent × 100 which equals
18 points toward the final score and
exceeds the performance threshold.
Finally, a MIPS eligible clinician could
achieve a final score of 15 points
through an advancing care information
performance category score of 60
percent or higher (60 percent advancing
care information performance category
score × 25 percent for the advancing
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care information performance category
weight × 100 equals 15 points towards
the final score). We refer readers to
section II.C.8.g.(2) of this proposed rule
for complete examples of how MIPS
eligible clinician could exceed the
performance threshold. We believe the
proposed performance threshold would
mitigate concerns from MIPS eligible
clinicians about participating in the
program for the second year. However,
we remain concerned that moving from
a performance threshold of 15 points for
the 2020 MIPS payment year to a
performance threshold of the mean or
median of the final scores for all MIPS
eligible clinicians for a prior period for
the 2021 MIPS payment year may be a
steep jump.
By the 2021 MIPS payment year,
MIPS eligible clinicians would likely
need to submit most of the required
information and perform well on the
measures and activities to receive a
positive MIPS payment adjustment.
Therefore, we also seek comment on
setting the performance threshold either
lower or higher than the proposed 15
points for the 2020 MIPS payment year.
A performance threshold lower than the
proposed 15 points for the 2020 MIPS
payment year presents the potential for
a significant increase in the final score
a MIPS eligible clinician must earn to
meet the performance threshold in the
2021 MIPS payment year, as well as
providing for a potentially smaller total
amount of negative MIPS payment
adjustments upon which the total
amount of the positive MIPS payment
adjustments would depend due to the
budget neutrality requirement under
section 1848(q)(6)(F)(ii) of the Act. A
performance threshold higher than the
proposed 15 points would increase the
final score required to receive a neutral
MIPS payment adjustment, which may
be particularly challenging for small
practices, even with the proposed
addition of the small practice bonus. A
higher performance threshold would
also allow for potentially higher positive
MIPS payment adjustments for those
who exceed the performance threshold.
We considered an alternative of
setting a performance threshold of 6
points, which could be met by
submitting two quality measures with
required data completeness or one highweighted improvement activity. While
this lower performance threshold may
provide a sharp increase to the required
performance threshold in MIPS
payment year 2021 (the mean or median
of the final scores for all MIPS eligible
clinicians for a prior period), it would
continue to reward clinicians for
participation in MIPS as they transition
into the program.
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We also considered an alternative of
setting the performance threshold at 33
points, which would require full
participation both in improvement
activities and in the quality performance
category (either for a small group or for
a large group that meets data
completeness standards) to meet the
performance threshold. Such a
threshold would make the step to the
required mean or median performance
threshold in MIPS payment year 2021
less steep, but could present further
challenges to clinicians who have not
previously participated in legacy quality
reporting programs.
As required by section
1848(q)(6)(D)(iii) of the Act, for the
purposes of determining the
performance threshold, we considered
data available for performance on
measures and activities that may be
used under the MIPS performance
categories. Specifically, we updated our
scoring model using 2019 MIPS
payment year eligibility data from the
initial 12-month period to identify
potential MIPS eligible clinicians who
are physicians (doctors of medicine,
doctors of osteopathy, chiropractors,
dentists, optometrists, and podiatrists),
nurse practitioners, physician assistants,
certified registered nurse anesthetists,
and clinical nurse specialists, and who
exceeded the low-volume threshold. We
estimated newly enrolled Medicare
clinicians who would be excluded from
MIPS by using clinicians (identified by
NPI) that have Part B charges in the
eligibility file, but no Part B charges in
2015. To exclude QPs from our scoring
model, we used a preliminary version of
the file used for the predictive
qualifying Alternative Payment Model
participants analysis made available on
qpp.cms.gov on June 2, 2017 and
prepared using claims for services
between January 1, 2016 through August
31, 2016. We assumed that all partial
QPs would participate in MIPS and
included them in our scoring model.
We used 2014 and 2015 PQRS and
2015 VM data to estimate scores for the
quality performance category, using the
published benchmarks for the 2017
MIPS performance period. We used
2015 and 2016 Medicare and Medicaid
EHR Incentive files to estimate
advancing care information performance
category scores. We also modeled an
improvement activities performance
category score using assumptions based
on prior PQRS and EHR Incentive
Program participation. We did not
model any cost measures as we
proposed in section II.C.6.d.(2) of this
proposed rule to weight the cost
performance category at zero percent.
We refer readers to the regulatory
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impact analysis in section V.C. of this
proposed rule for a detailed description
of our scoring model and data sources.
Using 2015 PQRS data, we
determined which of these MIPS
eligible clinicians participated in PQRS
and estimated participation rates for the
MIPS quality performance category
based on PQRS participation, which is
the performance category that accounts
for the largest share (a minimum of 60
percent) of the 2020 MIPS payment year
final score. We noted that 92.4 percent
of the estimated MIPS eligible clinicians
submitted data to PQRS, but the
participation rate was lower for MIPS
eligible clinicians in small practices at
69.7 percent. While we believe many of
the policies in this proposed rule and
the technical assistance for small
practices would help increase
participation, we believe it is important
to keep the performance threshold low
so that these small practices can learn
to participate and perform well in MIPS
for future years without excessive
financial risk.
We invite public comments on the
proposal to set the performance
threshold at 15 points, and also seek
comment on setting the performance
threshold at the alternative of 6 points
or at 33 points for the 2020 MIPS
payment year.
We also seek public comments on
principles and considerations for setting
the performance threshold beginning
with the 2021 MIPS payment year,
which will be the mean or median of the
final scores for all MIPS eligible
clinicians from a prior period.
d. Additional Performance Threshold
for Exceptional Performance
Section 1848(q)(6)(D)(ii) of the Act
requires the Secretary to compute, for
each year of the MIPS, an additional
performance threshold for purposes of
determining the additional MIPS
payment adjustment factors for
exceptional performance under
paragraph (C). For each such year, the
Secretary shall apply either of the
following methods for computing the
additional performance threshold: (1)
The threshold shall be the score that is
equal to the 25th percentile of the range
of possible final scores above the
performance threshold determined
under section 1848(q)(6)(D)(i) of the Act;
or (2) the threshold shall be the score
that is equal to the 25th percentile of the
actual final scores for MIPS eligible
clinicians with final scores at or above
the performance threshold for the prior
period described in section
1848(q)(6)(D)(i) of the Act.
We codified at § 414.1305 the
definition of additional performance
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30149
threshold as the numerical threshold for
a MIPS payment year against which the
final scores of MIPS eligible clinicians
are compared to determine the
additional MIPS payment adjustment
factors for exceptional performance. We
also codified at § 414.1405(d) that an
additional performance threshold will
be specified for each of the MIPS
payment years 2019 through 2024. We
refer readers to the CY 2017 Quality
Payment Program final rule for further
discussion of the additional
performance threshold (81 FR 77338
through 77339).
Based on the special rule for the
initial 2 years of MIPS in section
1848(q)(6)(D)(iii) of the Act, for the
transition year, we decoupled the
additional performance threshold from
the performance threshold and
established the additional performance
threshold at 70 points. We selected a 70point numerical value for the additional
performance threshold, in part, because
it would require a MIPS eligible
clinician to submit data for and perform
well on more than one performance
category (except in the event the
advancing care information performance
category is reweighted to zero percent
and the weight is redistributed to the
quality performance category making
the quality performance category worth
85 percent of the final score). Under
section 1848(q)(6)(C) of the Act, a MIPS
eligible clinician with a final score at or
above the additional performance
threshold will receive an additional
MIPS payment adjustment factor and
may share in the $500,000,000 available
for the year under section
1848(q)(6)(F)(iv) of the Act. We believed
these additional incentives should only
be available to those clinicians with
very high performance on the MIPS
measures and activities. We took into
account the data available and the
modeling described in section
II.E.7.c.(1) of the CY 2017 Quality
Payment Program final rule in selecting
the additional performance threshold
for the transition year (81 FR 77338
through 77339).
As we discussed in section II.C.8.c. of
this proposed rule, we are relying on the
special rule under section
1848(q)(6)(D)(iii) of the Act to establish
the performance threshold at 15 points
for 2020 MIPS payment year. We are
proposing to again decouple the
additional performance threshold from
the performance threshold. Because we
do not have actual MIPS final scores for
a prior performance period, if we do not
decouple the additional performance
threshold from the performance
threshold, then we would have to set
the additional performance threshold at
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the 25th percentile of possible final
scores above the performance threshold.
With a performance threshold set at 15
points, the range of total possible points
above the performance threshold is 16
to 100 points. The 25th percentile of
that range is 36.25 points, which is
barely more than one third of the
possible 100 points in the MIPS final
score. We do not believe it would be
appropriate to lower the additional
performance threshold to 36.25 points,
as we do not believe a final score of
36.25 points demonstrates exceptional
performance by a MIPS eligible
clinician. We believe these additional
incentives should only be available to
those clinicians with very high
performance on the MIPS measures and
activities. Therefore, we are relying on
the special rule under section
1848(q)(6)(D)(iii) of the Act to set the
additional performance threshold at 70
points for the 2020 MIPS payment year,
which is higher than the 25th percentile
of the range of the possible final scores
above the performance threshold.
We took into account the data
available and the modeling described in
section II.C.8.c. of this proposed rule to
estimate final scores for the 2020 MIPS
payment year. We believe 70 points is
appropriate because it requires a MIPS
eligible clinician to submit data for and
perform well on more than one
performance category (except in the
event the advancing care information
measures are not applicable and
available to a MIPS eligible clinician).
Generally, a MIPS eligible clinician
could receive a maximum score of 60
points for the quality performance
category, which is below the 70-point
additional performance threshold. In
addition, 70 points is at a high enough
level that MIPS eligible clinicians must
submit data for the quality performance
category to achieve this target. For
example, if a MIPS eligible clinician
gets a perfect score for the improvement
activities and advancing care
information performance categories, but
does not submit quality measures data,
then the MIPS eligible clinician would
only receive 40 points (0 points for
quality + 15 points for improvement
activities + 25 points for advancing care
information), which is below the
additional performance threshold. We
believe the additional performance
threshold at 70 points maintains the
incentive for excellent performance
while keeping the focus on quality
performance. Finally, we believe
keeping the additional performance
threshold at 70 points maintains
consistency with the 2019 MIPS
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payment year which helps to simplify
the overall MIPS framework.
We invite public comment on these
proposals. We also seek feedback on
whether we should raise the additional
performance threshold to a higher
number which would in many instances
require the use of an EHR for those to
whom the advancing care information
performance category requirements
would apply. In addition, a higher
additional performance threshold would
incentivize better performance and
would also allow MIPS eligible
clinicians to receive a higher additional
MIPS payment adjustment.
We also seek public comment on
which method we should use to
compute the additional performance
threshold beginning with the 2021 MIPS
payment year. Section 1848(q)(6)(D)(ii)
of the Act requires the additional
performance threshold to be the score
that is equal to the 25th percentile of the
range of possible final scores above the
performance threshold for the year, or
the score that is equal to the 25th
percentile of the actual final scores for
MIPS eligible clinicians with final
scores at or above the performance
threshold for the prior period described
in section 1848(q)(6)(D)(i) of the Act.
For example, should we use the lower
of the two options, which would result
in more MIPS eligible clinicians
receiving an additional MIPS payment
adjustment for exceptional
performance? Or should we use the
higher of the options, which would
restrict the additional MIPS payment
adjustment for exceptional performance
to those with the higher final scores?
Since a fixed amount is available for a
year under section 1848(q)(6)(F)(iv) of
the Act to fund the additional MIPS
payment adjustments, the more
clinicians that receive an additional
MIPS payment adjustment, the lower
the average clinician’s additional MIPS
payment adjustment will be.
e. Scaling/Budget Neutrality
We codified at § 414.1405(b)(3) that a
scaling factor not to exceed 3.0 may be
applied to positive MIPS payment
adjustment factors to ensure budget
neutrality such that the estimated
increase in aggregate allowed charges
resulting from the application of the
positive MIPS payment adjustment
factors for the MIPS payment year
equals the estimated decrease in
aggregate allowed charges resulting from
the application of negative MIPS
payment adjustment factors for the
MIPS payment year. We refer readers to
the CY 2017 Quality Payment Program
final rule for further discussion of
budget neutrality (81 FR 77339).
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We are not proposing any changes to
the scaling and budget neutrality
requirements as they are applied to
MIPS payment adjustment factors in
this proposed rule.
f. Additional Adjustment Factors
We refer readers to the CY 2017
Quality Payment Program final rule for
further discussion of the additional
MIPS payment adjustment factor (81 FR
77339 through 77340). We are not
proposing any changes to determine the
additional MIPS payment adjustment
factors.
g. Application of the MIPS Payment
Adjustment Factors
(1) Application to the Medicare Paid
Amount
Section 1848(q)(6)(E) of the Act
provides that for items and services
furnished by a MIPS eligible clinician
during a year (beginning with 2019), the
amount otherwise paid under Part B for
such items and services and MIPS
eligible clinician for such year, shall be
multiplied by 1 plus the sum of the
MIPS payment adjustment factor
determined under section 1848(q)(6)(A)
of the Act divided by 100, and as
applicable, the additional MIPS
payment adjustment factor determined
under section 1848(q)(6)(C) of the Act
divided by 100.
We codified at § 414.1405(e) the
application of the MIPS payment
adjustment factors. For each MIPS
payment year, the MIPS payment
adjustment factor, and if applicable the
additional MIPS payment adjustment
factor, are applied to Medicare Part B
payments for items and services
furnished by the MIPS eligible clinician
during the year.
We are proposing to apply the MIPS
payment adjustment factor, and if
applicable, the additional MIPS
payment adjustment factor, to the
Medicare paid amount for items and
services paid under Part B and
furnished by the MIPS eligible clinician
during the year. This proposal is
consistent with the approach taken for
the value-based payment modifier (77
FR 69308 through 69310) and would
mean that beneficiary cost-sharing and
coinsurance amounts would not be
affected by the application of the MIPS
payment adjustment factor and the
additional MIPS payment adjustment
factor. The MIPS payment adjustment
applies only to the amount otherwise
paid under Part B for items and services
furnished by a MIPS eligible clinician
during a year. Please refer to the CY
2017 Quality Payment Program final
rule at 81 FR 77340 and section II.C.3.c.
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of this proposed rule for further
discussion and our proposals regarding
which Part B covered items and services
would be subject to the MIPS payment
adjustment.
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(2) Example of Adjustment Factors
Figure A provides an example of how
various final scores would be converted
to an adjustment factor, and potentially
an additional adjustment factor, using
the statutory formula and based on
proposed policies. In Figure A, the
performance threshold is 15 points. The
applicable percentage is 5 percent for
2020. The adjustment factor is
determined on a linear sliding scale
from zero to 100, with zero being the
lowest negative applicable percentage
(negative 5 percent for the 2020 MIPS
payment year), and 100 being the
highest positive applicable percentage.
However, there are two modifications to
this linear sliding scale. First, there is an
exception for a final score between zero
and one-fourth of the performance
threshold (zero and 3.75 points based on
the proposed performance threshold for
the 2020 MIPS payment year). All MIPS
eligible clinicians with a final score in
this range would receive the lowest
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negative applicable percentage (negative
5 percent for the 2020 MIPS payment
year). Second, the linear sliding scale
line for the positive MIPS adjustment
factor is adjusted by the scaling factor
(as discussed in section II.C.8.e. of this
proposed rule). If the scaling factor is
greater than zero and less than or equal
to 1.0, then the adjustment factor for a
final score of 100 would be less than or
equal to 5 percent. If the scaling factor
is above 1.0, but less than or equal to
3.0, then the adjustment factor for a
final score of 100 would be higher than
5 percent. Only those MIPS eligible
clinicians with a final score equal to 15
points (which is the performance
threshold in this example) would
receive a neutral MIPS payment
adjustment. Because our proposed
policies have set the performance
threshold at 15 points, we anticipate
that the scaling factor would be less
than 1.0 and the payment adjustment for
MIPS eligible clinicians with a final
score of 100 points would be less than
5 percent.
Figure A of this proposed rule
illustrates an example slope. In this
example, the scaling factor for the
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30151
adjustment factor is 0.22, which is much
lower than 1.0. In this example, MIPS
eligible clinicians with a final score
equal to 100 would have an adjustment
factor of 1.10 percent (5 percent × 0.22).
The additional performance threshold
is 70 points. An additional adjustment
factor of 0.5 percent starts at the
additional performance threshold and
increases on a linear sliding scale up to
10 percent times a scaling factor that is
greater than zero and less than or equal
to 1.0. The scaling factor will be
determined so that the estimated
aggregate increase in payments
associated with the application of the
additional adjustment factors is equal to
$500,000,000. In Figure A of this
proposed rule, the example scaling
factor for the additional adjustment
factor is 0.183. Therefore, MIPS eligible
clinicians with a final score of 100
would have an additional adjustment
factor of 1.83 percent (10 percent ×
0.183). The total adjustment for a MIPS
eligible clinician with a final score
equal to 100 would be 1 + 0.0110 +
0.0183 = 1.0293, for a total positive
MIPS payment adjustment of 2.93
percent.
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The final MIPS payment adjustments
would be determined by the distribution
of final scores across MIPS eligible
clinicians and the performance
threshold. More MIPS eligible clinicians
above the performance threshold means
the scaling factors would decrease
because more MIPS eligible clinicians
receive a positive MIPS payment
adjustment. More MIPS eligible
clinicians below the performance
threshold means the scaling factors
would increase because more MIPS
eligible clinicians would have negative
MIPS payment adjustments and
relatively fewer MIPS eligible clinicians
receive positive MIPS payment
adjustments.
Table 42 illustrates the changes in
payment adjustments from the
transition year to the 2020 MIPS
payment year based on the proposals in
this proposed rule as well as the
statutorily-required increase in the
applicable percent as required by
section 1848(q)(6)(B) of the Act.
TABLE 42—ILLUSTRATION OF POINT SYSTEM AND ASSOCIATED ADJUSTMENTS COMPARISON BETWEEN TRANSITION YEAR
AND THE 2020 MIPS PAYMENT YEAR
2020 MIPS payment year
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Final score
points
MIPS adjustment
0.0–0.75 ..............
0.76–2.99 ............
Negative 4 percent ....................................................
Negative MIPS payment adjustment greater than
negative 4 percent and less than 0 percent on a
linear sliding scale.
0 percent adjustment .................................................
Positive MIPS payment adjustment greater than 0
percent on a linear sliding scale multiplied by a
scaling factor to preserve budget neutrality.
The linear sliding scale ranges from greater than 0
to 4 percent for scores from 3.01 to 100.00.
3.00 .....................
3.01–69.99 ..........
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Final score
points
Fmt 4701
0.0–3.75
3.76–14.99
15.00
15.01–69.99
........................
Sfmt 4702
MIPS adjustment
Negative 5 percent.
Negative MIPS payment adjustment greater than
negative 5 percent and less than 0 percent on a
linear sliding scale.
0 percent adjustment.
Positive MIPS payment adjustment greater than 0
percent on a linear sliding scale multiplied by a
scaling factor to preserve budget neutrality.
The linear sliding scale ranges from greater than 0
to 5 percent for scores from 15.01 to 100.00.
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30153
TABLE 42—ILLUSTRATION OF POINT SYSTEM AND ASSOCIATED ADJUSTMENTS COMPARISON BETWEEN TRANSITION YEAR
AND THE 2020 MIPS PAYMENT YEAR—Continued
Transition year
2020 MIPS payment year
Final score
points
MIPS adjustment
70.00–100 ...........
Positive MIPS payment adjustment on a linear sliding scale multiplied by a scaling factor to preserve
budget neutrality AND additional MIPS payment
adjustment for exceptional performance. (Additional MIPS payment adjustment starting at 0.5
percent and increasing on a linear sliding scale to
10 percent multiplied by a scaling factor.)
The linear sliding scale ranges from greater than 0
to 4 percent for scores from 3.01 to 100.00.
We have provided the following
examples for the 2020 MIPS payment
year to demonstrate scenarios in which
MIPS eligible clinicians can achieve a
final score at or above the performance
threshold of 15 points.
Example 1: MIPS Eligible Clinician in
Small Practice Submits 1 Quality
Measure and 1 Improvement Activity
In the example illustrated in Table 43,
a MIPS eligible clinician in a small
practice reporting individually meets
the performance threshold by reporting
one measure one time via claims and
one medium-weight improvement
activity. The practice does not submit
data for the advancing care information
performance category, but does submit a
significant hardship exception
application which is approved;
therefore, the weight for the advancing
care information performance category
is reweighted to the quality performance
category due to proposed reweighting
policies discussed in section II.C.7.b,(3)
of this proposed rule. We also assume
the small practice has a cost
performance category percent score of
50 percent, although the cost
performance category percent score will
Final score
points
70.00–100
........................
MIPS adjustment
Positive MIPS payment adjustment on a linear sliding scale multiplied by a scaling factor to preserve
budget neutrality AND additional MIPS payment
adjustment for exceptional performance. (Additional MIPS payment adjustment starting at 0.5
percent and increasing on a linear sliding scale to
10 percent multiplied by a scaling factor.)
The linear sliding scale ranges from greater than 0
to 5 percent for scores from 15.01 to 100.00.
not contribute to the final score. Finally,
we assume the average HCC score for
the beneficiaries seen by the MIPS
eligible clinician is 1.5.
There are several special scoring rules
which affect MIPS eligible clinicians in
a small practice:
• 3 measure achievement points for
each quality measure even if the
measure does not meet data
completeness standards. We refer
readers to section II.C.7.a.(2)(d) of this
proposed rule for discussion of this
policy. Therefore, a quality measure
submitted one time would receive 3
points. Because the measure is
submitted via claims, it does not qualify
for the end-to-end electronic reporting
bonus, nor would it qualify for the highpriority bonus because it is the only
measure submitted. However, because
the MIPS eligible clinician does not
meet full participation requirements, the
MIPS eligible clinician does not qualify
for improvement scoring. We refer you
to section II.C.7.a.(2)(i)(iii) of this
proposed rule for a discussion on full
participation requirements. Therefore,
the quality performance category is (3
measure achievement points + zero
measure bonus points)/60 total available
measure points + zero improvement
percent score which is 5 percent.
• The advancing care information
performance category weight is
redistributed to quality so that the
quality performance category percent
score is worth 85 percent of the final
score. We refer you to section
II.C.7.b.(3)(d) of this proposed rule for a
discussion of this proposed policy.
• MIPS eligible clinicians in small
practices qualify for special scoring for
improvement activities so a medium
weighted activity is worth 20 points out
of a total 40 possible points for the
improvement activities performance
category. We refer you to section
II.C.6.e.(5) of this proposed rule for a
discussion of this proposed policy.
• MIPS eligible clinicians in small
practices qualify for the 5 point small
practice bonus which is applied to the
final score. We refer you to section
II.C.7.b.(1)(c) of this proposed rule for a
discussion of this proposed policy.
This MIPS eligible clinician exceeds
the performance threshold of 15 points
(but does not exceed the additional
performance threshold). This score is
summarized in Table 43.
TABLE 43—SCORING EXAMPLE 1, MIPS ELIGIBLE CLINICIAN IN A SMALL PRACTICE
Performance
score
Category
weight
Earned points
([B]*[C]*100)
[A]
[B]
[C]
[D]
Quality .........................................................................................................
Cost .............................................................................................................
Improvement Activities ................................................................................
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Performance category
85% ................................
0% ..................................
15% ................................
Advancing Care Information .......................................................................
5% ..................................
50% ................................
20 out of 40 points—
50%.
Missing ...........................
Subtotal (Before Bonuses) ..................................................................
........................................
........................................
11.75
Complex Patient Bonus ..............................................................................
Small Practice Bonus .................................................................................
........................................
........................................
........................................
........................................
1.5
5
Final Score (not to exceed 100) ..........................................................
........................................
........................................
18.25
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Example 2: Group Submission Not in a
Small Group
In the example illustrated in Table 44,
a MIPS eligible clinician in a medium
size practice participating in MIPS as a
group meets 75 percent of the quality
score and 100 percent for the advancing
care information and improvement
activities performance categories. There
are many paths for a practice to receive
a 75 percent score in the quality
performance category, so for simplicity
we are assuming the score has been
calculated. Both the performance
threshold and the additional
performance threshold are exceeded.
Again, for simplicity, we assume the
average HCC score for the group is 1.5.
In this example, the group practice does
not qualify for any special scoring, yet
is able to exceed the additional
performance threshold and achieve the
additional adjustment factor.
TABLE 44—SCORING EXAMPLE 2, MIPS ELIGIBLE CLINICIAN IN A MEDIUM PRACTICE
Performance category
Performance
score
Category
weight
Earned points
([B]*[C]*100)
[A]
[B]
[C]
[D]
Quality .........................................................................................................................
Cost .............................................................................................................................
Improvement Activities ................................................................................................
60%
0%
15%
45
0
15
Advancing Care Information ........................................................................................
75% ................................
50% ................................
40 out of 40 points—
100%.
100% ..............................
25%
25
Subtotal (Before Bonuses) ...................................................................................
........................................
........................
85
Complex Patient Bonus ...............................................................................................
Small Practice Bonus ..................................................................................................
........................................
........................................
........................
........................
1.5
0
Final Score (not to exceed 100) ..........................................................................
........................................
........................
86.5
Example 3: Non-Patient Facing MIPS
Eligible Clinician
In the example illustrated in Table 45,
an individual MIPS eligible clinician
that is non-patient facing and not in a
small practice meets 50 percent of the
quality score and 50 percent for 1
medium-weighted for improvement
activity. Again, there are many paths for
a practice to receive a 50 percent score
in the quality performance category, so
for simplicity we are assuming the score
has been calculated. Because the MIPS
eligible clinician is non-patient facing,
they qualify for special scoring for
improvement activities, they receive 20
points (out of 40 possible points) for the
medium weighted activity. Also, this
individual did not submit advancing
care information measures and qualifies
for the automatic reweighting of the
advancing care information performance
category to quality. The non-patient
facing MIPS eligible clinician has an
average HCC score of 1.5, but as the
MIPS eligible clinician is not in a small
practice, the MIPS eligible clinician
does not qualify for the small practice
bonus.
In this example, the performance
threshold is exceeded while the
additional performance threshold is not.
TABLE 45—SCORING EXAMPLE 2, NON-PATIENT FACING MIPS ELIGIBLE CLINICIAN
Performance
score
Category
weight
Earned points
([B]*[C]*100)
[A]
[B]
[C]
[D]
Quality .........................................................................................................................
Cost .............................................................................................................................
Improvement Activities ................................................................................................
50% ................................
50% ................................
20 out of 40 points for 1
medium weight activity—50%.
0% ..................................
60%
0%
15%
30
0
7.5
Advancing Care Information ........................................................................................
25%
0
Subtotal (Before Bonuses) ...................................................................................
........................................
........................
37.5
Complex Patient Bonus ...............................................................................................
Small Practice Bonus ..................................................................................................
........................................
........................................
........................
........................
1.5
0
Final Score (not to exceed 100) ..........................................................................
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Performance category
........................................
........................
39
We note that these examples are not
intended to be exhaustive of the types
of participants nor the opportunities for
reaching and exceeding the performance
threshold.
9. Review and Correction of MIPS Final
Score
a. Feedback and Information To
Improve Performance
(1) Performance Feedback
As we have stated previously in the
CY 2017 Quality Payment Program final
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rule (81 FR 77345), we will continue to
engage in user research with front-line
clinicians to ensure we are providing
the performance feedback data in a userfriendly format, and that we are
including the data most relevant to
clinicians. Any suggestions from user
research would be considered as we
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develop the systems needed for
performance feedback, which would
occur outside of the rulemaking process.
Over the past year, we have
conducted numerous user research
sessions to determine what the
community most needs in performance
feedback. In summary we have found
the users want the following:
(1) To know as soon as possible how
I am performing based on my submitted
data so that I have confidence that I
performed the way I thought I would.
(2) To be able to quickly understand
how and why my payments will be
adjusted so that I can understand how
my business will be impacted.
(3) To be able to quickly understand
how I can improve my performance so
that I can increase my payment in future
program years.
(4) To know how I am performing
over time so I can improve the care I am
providing patients in my practice.
(5) To know how my performance
compares to my peers.
Based on that research, we have
already begun development of real-time
feedback on data submission and
scoring where technically feasible (some
scoring requires all clinician data be
submitted, and therefore, cannot occur
until the end of the submission period).
By ‘‘real-time’’ feedback, we mean
instantaneous feedback; for example,
when a clinician submits their data via
our Web site or a third party submits
data via our Application Program
Interface (API), they will know
immediately if their submission was
successful.
We will continue to provide
information for stakeholders who wish
to participate in user research via our
education and communication
channels. Suggestions can also be sent
via the ‘‘Contact Us’’ information on
qpp.cms.gov. However, we note that
suggestions provided through this
channel will not be considered
comments on this proposed rule. To
submit comments on this proposed rule,
please see the explanation of how to
submit such comments and relevant
deadlines explained at the beginning of
this proposed rule.
(a) MIPS Eligible Clinicians
Under section 1848(q)(12)(A)(i) of the
Act, we are at a minimum required to
provide MIPS eligible clinicians with
timely (such as quarterly) confidential
feedback on their performance under
the quality and cost performance
categories beginning July 1, 2017, and
we have discretion to provide such
feedback regarding the improvement
activities and advancing care
information performance categories.
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Beginning July 1, 2018, we are
proposing to provide performance
feedback to MIPS eligible clinicians and
groups for the quality and cost
performance categories for the 2017
performance period, and if technically
feasible, for the improvement activities
and advancing care information
performance categories. We propose to
provide this performance feedback at
least annually, and as, technically
feasible, we would provide it more
frequently, such as quarterly. If we are
able to provide it more frequently, we
would communicate the expected
frequency to our stakeholders via our
education and outreach communication
channels.
Based on public comments
summarized and responded to in the CY
2017 Quality Payment Program final
rule (81 FR 77347), we also propose that
the measures and activities specified for
the CY 2017 performance period (for all
four MIPS performance categories),
along with the final score, would be
included in the performance feedback
provided on or about July 1, 2018. We
request comment on these proposals.
For cost measures, since we can
measure performance using any 12month period of prior claims data, we
request comment on whether it would
be helpful to provide more frequent
feedback on the cost performance
category using rolling 12-month periods
or quarterly snapshots of the most
recent 12-month period; how frequent
that feedback should be; and the format
in which we should make it available to
clinicians and groups. In addition, as
described in sections II.C.6.b. and
II.C.6.d. of this proposed rule, we intend
to provide cost performance feedback in
the fall of 2017 and the summer of 2018
on new episode-based cost measures
that are currently under development by
CMS. With regard to the format of
feedback on cost measures, we are
considering utilizing the parts of the
Quality and Resource Use Reports
(QRURs) that user testing has revealed
beneficial while making the overall look
and feel usable to clinicians. We request
comment whether that format is
appropriate or if other formats or
revisions to that format should be used
to provide performance feedback on cost
measures.
(b) MIPS APMs
We are proposing that MIPS eligible
clinicians who participate in MIPS
APMs would receive performance
feedback in 2018 and future years of the
Quality Payment Program, as
technically feasible. Please refer to
section II.C.6.g.(5) of this proposed rule
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for additional information related to this
proposal.
(c) Voluntary Clinician and Group
Reporting
As noted in the CY 2017 Quality
Payment Program final rule (81 FR
77071), eligible clinicians who are not
included in the definition of a MIPS
eligible clinician during the first 2 years
of MIPS (or any subsequent year) may
voluntarily report on measures and
activities under MIPS, but will not be
subject to the payment adjustment. In
the final rule (81 FR 77346), we
summarized public comments
requesting that eligible clinicians who
are not required, but who voluntarily
report on measures and activities under
MIPS, should receive the same access to
performance feedback as MIPS eligible
clinicians, and indicated that we would
take the comments into consideration in
the future development of performance
feedback. We propose to furnish
performance feedback to eligible
clinicians and groups that do not meet
the definition of a MIPS eligible
clinician but voluntarily report on
measures and activities under MIPS. We
propose that this would begin with data
collected in performance period 2017,
and would be available beginning July
1, 2018. Based on user and market
research, we believe that making this
information available would provide
value in numerous ways. First, it would
help clinicians who are excluded from
MIPS in the 2017 performance period,
but who may be considered MIPS
eligible clinicians in future years, to
prepare for participation in the Quality
Payment Program when there are
payment consequences associated with
participation. Second, it would give all
clinicians equal access to the CMS
claims and benchmarking data available
in performance feedback. And third, it
would allow clinicians who may be
interested in participating in an APM to
make a more informed decision.
We request comments on this
proposal.
(2) Mechanisms
Under section 1848(q)(12)(A)(ii) of the
Act, the Secretary may use one or more
mechanisms to make performance
feedback available, which may include
use of a web-based portal or other
mechanisms determined appropriate by
the Secretary. For the quality
performance category, described in
section 1848(q)(2)(A)(i) of the Act, the
feedback shall, to the extent an eligible
clinician chooses to participate in a data
registry for purposes of MIPS (including
registries under sections 1848(k) and
(m) of the Act), be provided based on
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performance on quality measures
reported through the use of such
registries. For any other performance
category (that is, cost, improvement
activities, or advancing care
information), the Secretary shall
encourage provision of feedback
through qualified clinical data registries
(QCDRs) as described in section
1848(m)(3)(E) of the Act.
As previously stated in the CY 2017
Quality Payment Program final rule (81
FR 77347 through 77349), we will use
a CMS-designated system as the
mechanism for making performance
feedback available, which we expect
will be a web-based application. We
expect to use a new and improved
format for the next performance
feedback, anticipated to be released
around July 1, 2018. It will be provided
via the Quality Payment Program Web
site (qpp.cms.gov), and we intend to
leverage additional mechanisms, such
as health IT vendors, registries, and
QCDRs to help disseminate data and
information contained in the
performance feedback to eligible
clinicians, where applicable.
We are also seeking comment on how
health IT, either in the form of an EHR
or as a supplemental module, could
better support the feedback related to
participation in the Quality Payment
Program and quality improvement in
general. Specifically—
• Are there specific health IT
functionalities that could contribute
significantly to quality improvement?
• Are there specific health IT
functionalities that could be part of a
certified EHR technology or made
available as optional health IT modules
in order to support the feedback loop
related to Quality Payment Program
participation or participation in other
HHS reporting programs?
• In what other ways can health IT
support clinicians seeking to leverage
quality data reports to inform clinical
improvement efforts? For example, are
there existing or emerging tools or
resources that could leverage an API to
provide timely feedback on quality
improvement activities?
• Are there opportunities to expand
existing tracking and reporting for use
by clinicians, for example expanding
the feedback loop for patient
engagement tools to support remote
monitoring of patient status and access
to education materials?
We welcome public comment on
these questions.
We intend to continue to leverage
third party intermediaries as a
mechanism to provider performance
feedback. In the CY 2017 Quality
Payment Program final rule (81 FR
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77367 through 77386) we finalized that
at least 4 times per year, qualified
registries and QCDRs will provide
feedback on all of the MIPS performance
categories that the qualified registry or
QCDR reports to us (improvement
activities, advancing care information,
and/or quality performance category).
The feedback should be given to the
individual MIPS eligible clinician or
group (if participating as a group) at the
individual participant level or group
level, as applicable, for which the
qualified registry or QCDR reports. The
qualified registry or QCDR is only
required to provide feedback based on
the MIPS eligible clinician’s data that is
available at the time the performance
feedback is generated. In regard to third
party intermediaries, we also noted we
would look to propose ‘‘real time’’
feedback as soon as it is technically
feasible.
Per the policies finalized in the CY
2017 Quality Payment Program final
rule (81 FR 77367 through 77386), we
continue to require qualified registries
and QCDRs, as well as encourage other
third party intermediaries (such as
health IT vendors that submit data to us
on behalf of a MIPS eligible clinician or
group), to provide performance feedback
to individual MIPS eligible clinicians
and groups via the third party
intermediary with which they are
already working. We also understand
that performance feedback is valuable to
individual clinicians and groups, and
seek feedback from third party
intermediaries on when ‘‘real-time’’
feedback could be provided.
Additionally, we plan to continue to
work with third party intermediaries as
we continue to develop the mechanisms
for performance feedback, to see where
we may be able to develop and
implement efficiencies for the Quality
Payment Program. We are exploring
options with an API, which could allow
authenticated third party intermediaries
to access the same data that we use to
provide confidential feedback to the
individual clinicians and groups on
whose behalf the third party
intermediary reports for purposes of
MIPS, in accordance with applicable
law, including, but not limited to, the
HIPAA Privacy and Security Rules. Our
goal is to enable individual clinicians
and groups to more easily access their
feedback via the mechanisms and
relationships they already have
established. We are seeking comments
on this approach as we continue to
develop performance feedback
mechanisms. We refer readers to section
II.C.10. of this proposed rule for
additional information on Third Party
Data Submission.
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(3) Receipt of Information
Section 1848(q)(12)(A)(v) of the Act,
states that the Secretary may use the
mechanisms established under section
1848(q)(12)(A)(ii) of the Act to receive
information from professionals. This
allows for expanded use of the feedback
mechanism to not only provide
feedback on performance to MIPS
eligible clinicians, but to also receive
information from professionals.
In the CY 2017 Quality Payment
Program final rule (81 FR 77350), we
discussed that we intended to explore
the possibility of adding this feature to
the CMS-designated system, such as a
portal, in future years under MIPS.
Although we are not making any
specific proposals at this time, we are
again seeking comment on the features
that could be developed for the
expanded use of the feedback
mechanism. This could be a feature
where eligible clinicians and groups can
send their feedback (for example, if they
are experiencing issues accessing their
data, technical questions about their
data, etc.) to us through the Quality
Payment Program Service Center or the
Quality Payment Program Web site. We
appreciate that eligible clinicians and
groups may have questions regarding
the Quality Payment Program
information contained in their
performance feedback. To assist eligible
clinicians and groups, we intend to
utilize existing resources, such as a
helpdesk or offer technical assistance, to
help address questions with the goal of
linking these resource features to the
Quality Payment Program Web site and
Service Center.
(4) Additional Information—Type of
Information
Section 1848(q)(12)(B)(i) of the Act
states that beginning July 1, 2018, the
Secretary shall make available to MIPS
eligible clinicians information about the
items and services for which payment is
made under Title 18 that are furnished
to individuals who are patients of MIPS
eligible clinicians by other suppliers
and providers of services. This
information may be made available
through mechanisms determined
appropriate by the Secretary, such as the
CMS-designated system that would also
provide performance feedback. Section
1848(q)(12)(B)(ii) of the Act specifies
that the type of information provided
may include the name of such
providers, the types of items and
services furnished, and the dates that
items and services were furnished.
Historical data regarding the total, and
components of, allowed charges (and
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other figures as determined appropriate
by the Secretary) may also be provided.
We propose, beginning with the
performance feedback provided around
July 1, 2018, to make available to MIPS
eligible clinicians and eligible clinicians
information about the items and
services for which payment is made
under Title 18 that are furnished to
individuals who are patients of MIPS
eligible clinicians and eligible clinicians
by other suppliers and providers of
services. We propose to include as
much of the following data elements as
technically feasible: The name of such
suppliers and providers of services; the
types of items and services furnished
and received; the dollar amount of
services provided and received; and the
dates that items and services were
furnished. We propose that the
additional information would include
historical data regarding the total, and
components of, allowed charges (and
other figures as determined
appropriate). We propose that this
information be provided on the
aggregate level; with the exception of
data on items and services, as we could
consider providing this data at the
patient level, if clinicians find that level
of data to be useful, although we note
it may contain personally identifiable
information and protected health
information. We propose the date range
for making this information available
would be based on what is most helpful
to clinicians, such as the most recent
data we have available, which as
technically feasible would be provided
from a 3 to 12-month period. We
propose to make this information
available via the Quality Payment
Program Web site, and as technically
feasible, as part of the performance
feedback. Finally, because data on items
and services furnished is generally kept
confidential, we propose that access
would be provided only after secure
credentials are obtained. We request
comment on these proposals.
(5) Performance Feedback Template
As we have previously indicated (81
FR 77352), we intend to do as much as
we can of the development of the
template for performance feedback by
working with the stakeholder
community in a transparent manner. We
believe this will encourage stakeholder
commentary and make sure the result is
the best possible format(s) for feedback.
To continue with our collaborative
goal of working with the stakeholder
community, we seek comment on the
structure, format, content (for example,
detailed goals, data fields, and elements)
that would be useful for MIPS eligible
clinicians and groups to include in
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performance feedback, including the
data on items and services furnished, as
discussed above. Additionally, we
understand the term ‘‘performance
feedback’’ may not be meaningful to
clinicians or groups to clearly denote
what this data might imply. Therefore,
we seek comment on what to term
‘‘performance feedback.’’ User testing to
date has provided some considerations
for a name in the Quality Payment
Program, such as Progress Notes,
Reports, Feedback, Performance
Feedback, or Performance Reports.
Any suggestions on the template to be
used for performance feedback or what
to call ‘‘performance feedback’’ can be
submitted to the Quality Payment
Program Web site at qpp.cms.gov.
b. Targeted Review
In the CY 2017 Quality Payment
Program final rule (81 FR 77546), we
finalized at § 414.1385 that MIPS
eligible clinicians or groups may request
a targeted review of the calculation of
the MIPS payment adjustment factor
under section 1848(q)(6)(A) of the Act
and, as applicable, the calculation of the
additional MIPS payment adjustment
factor under section 1848(q)(6)(C) of the
Act applicable to such MIPS eligible
clinician or group for a year. We note
MIPS eligible clinicians who are scored
under the APM scoring standard
described in section II.C.6.g. of this
proposed rule may request this targeted
review. Although we are not proposing
any changes to the targeted review
process, we are providing information
on the process that was finalized in the
CY 2017 Quality Payment Program final
rule (81 FR 77353 through 77358).
(1) MIPS eligible clinicians and
groups have a 60-day period to submit
a request for targeted review, which
begins on the day we make available the
MIPS payment adjustment factor, and if
applicable the additional MIPS payment
adjustment factor, for the MIPS payment
year and ends on September 30 of the
year prior to the MIPS payment year or
a later date specified by us.
(2) We will respond to each request
for targeted review timely submitted
and determine whether a targeted
review is warranted. Examples under
which a MIPS eligible clinician or group
may wish to request a targeted review
include, but are not limited to:
• The MIPS eligible clinician or
group believes that measures or
activities submitted to us during the
submission period and used in the
calculations of the final score and
determination of the adjustment factors
have calculation errors or data quality
issues. These submissions could be with
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or without the assistance of a third party
intermediary; or
• The MIPS eligible clinician or
group believes that there are certain
errors made by us, such as performance
category scores were wrongly assigned
to the MIPS eligible clinician or group
(for example, the MIPS eligible clinician
or group should have been subject to the
low-volume threshold exclusion and
should not have received a performance
category score).
(3) The MIPS eligible clinician or
group may include additional
information in support of their request
for targeted review at the time the
request is submitted. If we request
additional information from the MIPS
eligible clinician or group, it must be
provided and received by us within 30
days of the request. Non-responsiveness
to the request for additional information
may result in the closure of the targeted
review request, although the MIPS
eligible clinician or group may submit
another request for targeted review
before the deadline.
(4) Decisions based on the targeted
review are final, and there is no further
review or appeal.
c. Data Validation and Auditing
In the CY 2017 Quality Payment
Program final rule (81 FR 77546 through
77547), we finalized at § 414.1390(a)
that we will selectively audit MIPS
eligible clinicians and groups on a
yearly basis. If a MIPS eligible clinician
or group is selected for audit, the MIPS
eligible clinician or group will be
required to do the following in
accordance with applicable law and
timelines we establish:
(1) Comply with data sharing
requests, providing all data as requested
by us or our designated entity. All data
must be shared with us or our
designated entity within 45 days of the
data sharing request, or an alternate
timeframe that is agreed to by us and the
MIPS eligible clinician or group. Data
will be submitted via email, facsimile,
or an electronic method via a secure
Web site maintained by us.
(2) Provide substantive, primary
source documents as requested. These
documents may include: Copies of
claims, medical records for applicable
patients, or other resources used in the
data calculations for MIPS measures,
objectives, and activities. Primary
source documentation also may include
verification of records for Medicare and
non-Medicare beneficiaries where
applicable. We are not proposing any
changes to the requirements in section
§ 414.1390(a).
We indicated in the CY 2017 Quality
Payment Program final rule that all
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MIPS eligible clinicians and groups that
submit data to us electronically must
attest to the best of their knowledge that
the data submitted to us is accurate and
complete (81 FR 77362). We also
indicated in the final rule that
attestation requirements would be part
of the submission process (81 FR
77360). We neglected to codify this
requirement in regulation text of the CY
2017 Quality Payment Program final
rule. Additionally, after further
consideration since the final rule, the
requirement is more in the nature of a
certification, rather than an attestation.
Thus, we are proposing to revise
§ 414.1390 to add a new paragraph (b)
that requires all MIPS eligible clinicians
and groups that submit data and
information to CMS for purposes of
MIPS to certify to the best of their
knowledge that the data submitted to
CMS is true, accurate, and complete. We
also propose that the certification by the
MIPS eligible clinician or group must
accompany the submission.
We also indicated in the CY 2017
Quality Payment Program final rule that
if a MIPS eligible clinician or group is
found to have submitted inaccurate data
for MIPS, we would reopen and revise
the determination in accordance with
the rules set forth at §§ 405.980 through
405.984 (81 FR 77362). We neglected to
codify this policy in regulation text of
the CY 2017 Quality Payment Program
final rule and further, we did not
include § 405.986, which is also an
applicable rule in our reopening policy.
We also finalized our approach to
recoup incorrect payments from the
MIPS eligible clinician by the amount of
any debts owed to us by the MIPS
eligible clinician and likewise, we
would recoup any payments from the
group by the amount of any debts owed
to us by the group. Thus, we are
proposing to revise § 414.1390 to add a
new paragraph (c) that states we may
reopen and revise a MIPS payment
determination in accordance with the
rules set forth at §§ 405.980 through
405.986.
In the CY 2017 Quality Payment
Program, we also indicated that MIPS
eligible clinicians and groups should
retain copies of medical records, charts,
reports and any electronic data utilized
for reporting under MIPS for up to 10
years after the conclusion of the
performance period (81 FR 77360). We
neglected to codify this policy in
regulation text of the CY 2017 Quality
Payment Program final rule. Thus, we
are proposing to revise § 414.1390 to
add a new paragraph (d) that states that
all MIPS eligible clinicians or groups
that submit data and information to
CMS for purposes of MIPS must retain
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such data and information for a period
of 10 years from the end the MIPS
Performance Period.
Finally, we indicated in the CY 2017
Quality Payment Program final rule,
that, in addition to recouping any
incorrect payments, we intend to use
data validation and audits as an
educational opportunity for MIPS
eligible clinicians and groups and we
note that this process will continue to
include education and support for MIPS
eligible clinicians and groups selected
for an audit.
10. Third Party Data Submission
In developing MIPS, our goal is to
develop a program that is meaningful,
understandable, and flexible for
participating MIPS eligible clinicians.
Flexible reporting options will provide
eligible clinicians with options to
accommodate different practices and
make measurement meaningful. We
believe that allowing eligible clinicians
to participate in MIPS through the use
of third party intermediaries that will
collect or submit data on their behalf,
will help us accomplish our goal of
implementing a flexible program. We
strongly encourage all third party
intermediaries to work with their MIPS
eligible clinicians to ensure the data
submitted are representative of the
individual MIPS eligible clinician’s or
group’s overall performance for that
measure or activity.
For purposes of this section, we use
the term third party to refer to a
qualified registry, QCDR, a health IT
vendor or other third party that obtains
data from a MIPS eligible clinician’s
Certified Electronic Health Record
Technology, or a CMS approved survey
vendor. In the CY 2017 Quality Payment
Program final rule (81 FR 77363), we
finalized at § 414.1400(a)(1) that MIPS
data may be submitted by third party
intermediaries on behalf of a MIPS
eligible clinician or group by: (1) A
qualified registry; (2) a QCDR; (3) a
health IT vendor; or (4) a CMS approved
survey vendor. Additionally, we
finalized at § 414.1400(a)(3) that third
party intermediaries must meet all the
criteria designated by us as a condition
of their qualification or approval to
participate in MIPS as a third party
intermediary. Lastly, as finalized at
§ 414.1400(a)(3)(ii), all submitted data
must be submitted in the form and
manner specified by us.
We are proposing to revise
§ 414.1400(a)(1) to state that MIPS data
may be submitted by third party
intermediaries on behalf of an
individual MIPS eligible clinician,
group, or virtual group. See section
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II.C.4. of this rule for more information
related to virtual groups.
Additionally, we believe it is
important that the MIPS data submitted
by third party intermediaries is true,
accurate, and complete. To that end, we
are proposing to add a requirement at
§ 414.1400(a)(5) stating that all data
submitted to CMS by a third party
intermediary on behalf of a MIPS
eligible clinician, group or virtual group
must be certified by the third party
intermediary to the best of its
knowledge as true, accurate, and
complete. We also propose that this
certification occur at the time of the
submission and accompany the
submission. We solicit comments on
this proposal.
As more clinicians participate in
value based payment arrangements with
multiple payers, we believe third-party
intermediaries will play an important
role in calculating quality measures,
reporting once to all payers, and sharing
actionable feedback to clinicians. A
robust ecosystem of third-party
intermediaries would more reliably
calculate measures using data across
clinical practices caring for the same
patients and reduce burden by
streamlining reporting to all payers and
offering timely feedback to clinicians
that is easier to act on in addressing
gaps in care. Third-party intermediaries
can also take the burden off clinical
practices by integrating various types of
health care data, including
administrative data from payers, other
utilization data, cost data, and clinical
data derived from health IT systems, to
provide front-line clinicians and others
with a comprehensive view of the cost
and quality of the care they are
delivering.
We are continuing to explore how we
can further encourage those third-party
intermediaries that provide
comprehensive data services to support
eligible clinicians participating in both
MIPS and APMs. For instance, should
we consider implementing additional
incentives for eligible clinicians to use
a third-party intermediary which has
demonstrated substantial participation
from additional payers and/or other
clinical data sources across practices
caring for a cohort of Medicare
beneficiaries within a given geographic
area? Should these incentives also
include expectations that structured,
standardized data be shared with third
party intermediaries? Should there be
additional refinements to the approach
to qualifying third party intermediaries
which evaluate the degree to which
these intermediaries can deliver
longitudinal information on a patient to
participating clinicians, for example, a
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virtual care team of primary and
specialty physicians? Should there be a
special designation for registries that
would convey the availability of
longitudinal clinical data for robust
measurement and feedback? We seek
comment on these and other ideas
which can further advance the role of
intermediaries and reduce clinician
burden by enabling a streamlined
reporting and feedback system.
a. Qualified Clinical Data Registries
(QCDRs)
In the CY 2017 Quality Payment
Program final rule (81 FR 77364), we
finalized the definition and capabilities
of a QCDR. We are not proposing any
changes to the definition or the
capabilities of a QCDR in this proposed
rule, and refer readers to the CY 2017
Quality Payment Program final rule for
a detailed discussion of the definition
and capabilities of a QCDR.
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(1) Establishment of an Entity Seeking
To Qualify as a QCDR
In the CY 2017 Quality Payment
Program final rule (81 FR 77365), we
finalized the criteria to establish an
entity seeking to qualify as a QCDR. We
are not proposing any changes to the
criteria in this proposed rule, and refer
readers to the CY 2017 Quality Payment
Program final rule for the criteria to
qualify as a QCDR.
(2) Self-Nomination Period
In the CY 2017 Quality Payment
Program final rule (81 FR 77365 through
77366), we finalized the self-nomination
period for the 2018 performance period
and for future years of the program to
be from September 1 of the year prior
to the applicable performance period
until November 1 of the same year. As
an example, the self-nomination period
for the 2018 performance period will
begin on September 1, 2017, and will
end on November 1, 2017. Entities that
desire to qualify as a QCDR for the
purposes of MIPS for a given
performance period will need to selfnominate for that year and provide all
information requested by us at the time
of self-nomination. Having qualified as
a QCDR in a prior year does not
automatically qualify the entity to
participate in MIPS as a QCDR in
subsequent performance periods.
Furthermore, prior performance of the
QCDR (when applicable) will be taken
into consideration in approval of their
self-nomination. For example, a QCDR
may choose not to continue
participation in the program in future
years, or the QCDR may be precluded
from participation in a future year due
to multiple data or submission errors as
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noted below. Finally, QCDRs may want
to update or change the measures or
services or performance categories they
intend to provide. We believe an annual
self-nomination process is the best
process to ensure accurate information
is conveyed to MIPS eligible clinicians
and accurate data is submitted to MIPS.
However, we do understand that some
QCDRs have no changes to the measure
and/or activity inventory they offer to
their clients and intend to participate in
the MIPS for many years. Because of
this, we are proposing, beginning with
the 2019 performance period, a
simplified process in which existing
QCDRs in good standing may continue
their participation in MIPS, by attesting
that the QCDR’s approved data
validation plan, cost, measures,
activities, services, and performance
categories offered in the previous year’s
performance period of MIPS have
minimal or no changes and will be used
for the upcoming performance period.
Specifically, existing QCDRs in good
standing may attest during the selfnomination period that they have no
changes to their approved selfnomination application from the
previous year of MIPS. In addition, the
existing QCDRs may decide to make
minimal changes to their approved selfnomination application from the
previous year, which would be
submitted by the QCDR for CMS review
and approval by the close of the selfnomination period. Minimal changes
may include limited changes to their
performance categories, adding or
removing MIPS quality measures, and
adding or updating existing services
and/or cost information. Existing
QCDRs in good standing, may also
submit for CMS review and approval,
substantive changes to measure
specifications for existing QCDR
measures that were approved the
previous year, or submit new QCDR
measures for CMS review and approval
without having to complete the entire
self-nomination application process,
which is required to be completed by a
new QCDR. By attesting that certain
aspects of their approved application
from the previous year have not
changed, existing QCDRs in good
standing would be spending less time
completing the entire self-nomination
form, as was previously required on a
yearly basis. We are proposing such a
simplified process to reduce the burden
of self-nomination for those existing
QCDRs who have previously
participated in MIPS, and are in good
standing (not on probation or
disqualified, as described below) and to
allow for sufficient time for us to review
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data submissions and to make
determinations on the standing of the
QCDRs. We note that substantive
changes to existing QCDR measure
specifications or any new QCDR
measures would have to be submitted
for CMS review and approval by the
close of the self-nomination period. This
proposed process will allow existing
QCDRs in good standing to avoid
completing the entire application
annually, as is required in the existing
process, and in alignment with the
existing timeline. We request comments
on this proposal. In the development of
this proposal, we had reviewed the
possibility of offering a multi-year
approval, where QCDRs would be
approved for a 2-year increment of time.
We are concerned that utilizing a multiyear approval process in which QCDRs
would be approved for 2 continuous
years using the same fixed services they
had for the first year, would not provide
the QCDR with the flexibility to add or
remove services and/or measures or
activities based on their QCDR
capabilities for the upcoming program
year. Furthermore, another concern with
a multi-year approval process is the
concern for those QCDRs who perform
poorly during the first year, and who
should be placed on probation or
disqualified (as described below). We
request comments on this alternative.
We finalized to require other
information (described below) of QCDRs
at the time of self-nomination. If an
entity becomes qualified as a QCDR,
they will need to sign a statement
confirming this information is correct
prior to listing it on their Web site. Once
we post the QCDR on our Web site,
including the services offered by the
QCDR, we will require the QCDR to
support these services or measures for
its clients as a condition of the entity’s
qualification as a QCDR for purposes of
MIPS. Failure to do so will preclude the
QCDR from participation in MIPS in the
subsequent year.
For future years, beginning with the
2018 performance period, we are
proposing that self-nomination
information must be submitted via a
web-based tool, and to eliminate the
submission method of email. We will
provide further information on the webbased tool at www.qpp.cms.gov. We
request comments on this proposal.
(3) Information Required at the Time of
Self-Nomination
In the CY 2017 Quality Payment
Program final rule (81 FR 77366 through
77367), we finalized the information a
QCDR must provide to us at the time of
self-nomination. We are proposing to
replace the term non-MIPS measures
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with QCDR measures for future program
years, beginning with the 2018
performance period. We note that
although we are proposing a change in
the term referring to such measures, we
are not proposing any other changes to
the information a QCDR must provide to
us at the time of self-nomination
finalized in the CY 2017 Quality
Payment Program final rule. We refer
readers to the CY 2017 Quality Payment
Program final rule for specific
information requirements.
(4) QCDR Criteria for Data Submission
In the CY 2017 Quality Payment
Program final rule (81 FR 77367 through
77374), we finalized that a QCDR must
perform specific functions to meet the
criteria for data submission. While we
are not proposing any changes to the
criteria for data submission in this
proposed rule, we would like to note the
following as clarifications to existing
criteria. Specifically, a QCDR—
• Must have in place mechanisms for
the transparency of data elements and
specifications, risk models, and
measures. That is, we expect that the
QCDR measures, and their data
elements (that is, specifications)
comprising these measures be listed on
the QCDR’s Web site unless the measure
is a MIPS measure, in which case the
specifications will be posted by us.
QCDR measure specifications should be
provided at a level of detail that is
comparable to what is posted by us on
the CMS Web site for MIPS quality
measures specifications.
• Approved QCDRs may post the
MIPS quality measure specifications on
their Web site, if they so choose. If the
MIPS quality measure specifications are
posted by the QCDRs, they must
replicate exactly the same as the MIPS
quality measure specifications posted
on the CMS Web site.
• Enter into and maintain with its
participating MIPS eligible clinicians an
appropriate Business Associate
agreement that complies with the
HIPAA Privacy and Security Rules.
Ensure that the Business Associate
agreement provides for the QCDR’s
receipt of patient-specific data from an
individual MIPS eligible clinician or
group, as well as the QCDR’s disclosure
of quality measure results and
numerator and denominator data or
patient specific data on Medicare and
non-Medicare beneficiaries on behalf of
MIPS eligible clinicians and groups.
• Must provide timely feedback at
least 4 times a year, on all of the MIPS
performance categories that the QCDR
will report to us. We refer readers to
section II.C.9.a. of this proposed rule for
additional information on third party
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intermediaries and performance
feedback.
• For purposes of distributing
performance feedback to MIPS eligible
clinicians, we encourage QCDRs to
assist MIPS eligible clinicians in the
update of their email addresses in CMS
systems—including PECOS and the
Identity and Access System—so that
they have access to feedback as it
becomes available on www.qpp.cms.gov
and have documentation from the MIPS
eligible clinician authorizing the release
of his or her email address.
As noted in the CY 2017 Quality
Payment Program final rule (81 FR
77370), we will on a case-by-case basis
allow QCDRs and qualified registries to
request review and approval for
additional MIPS measures throughout
the performance period. We would like
to explain that this flexibility would
only apply for MIPS measures; QCDRs
will not be able to request additions of
any new QCDR measures throughout the
performance period. QCDRs will not be
able to retire any measures they are
approved for during the performance
period. Should a QCDR encounter an
issue regarding the safety or change in
evidence for a measure during the
performance period, they must inform
CMS of said issue and indicate whether
they will or will not be reporting on the
measure, and we will review measure
issues on a case-by-case basis. Any
measures QCDRs wish to retire would
need to be retained until the next
annual self-nomination process and
applicable performance period.
(5) QCDR Measure Specifications
Criteria
In the CY 2017 Quality Payment
Program final rule (81 FR 77374 through
77375), we specified at § 414.1400(f)
that the QCDR must provide specific
QCDR measures specifications criteria.
We generally intend to apply a process
similar to the one used for MIPS
measures to QCDR measures that have
been identified as topped out. We are
not proposing any changes to the QCDR
measure specifications criteria as
finalized in the CY2017 Quality
Payment Program final rule. We would
like to note that for QCDR quality
measures, we encourage alignment with
our measures development plan, but
will consider all QCDR measures
submitted by the QCDR. For MIPS
measures, we would also like to note
that CMS expects that a QCDR reporting
on MIPS measures retain and use the
MIPS specifications as they exist for the
performance period.
We would like to clarify that we will
likely not approve retired measures that
were previously in one of CMS’s quality
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programs, such as the Physician Quality
Reporting System (PQRS) program, if
proposed as QCDR measures. This
includes measures that were retired due
to being topped out (as defined in
section II.C.6.c.(2) of this proposed rule)
due to high-performance or measures
retired due to a change in the evidence
supporting the use of the measure.
We seek comment for future
rulemaking, on requiring QCDRs that
develop and report on QCDR measures,
must fully develop and test (that is,
conduct reliability and validity testing)
their QCDR measures, by the time of
submission of the new measure during
the self-nomination process.
Beginning with the 2018 performance
period and for future program years, we
propose that QCDR vendors may seek
permission from another QCDR to use
an existing measure that is owned by
the other QCDR. If a QCDR would like
report on an existing QCDR measure
that is owned by another QCDR, they
must have permission from the QCDR
that owns the measure that they can use
the measure for the performance period.
Permission must be granted at the time
of self-nomination, so that the QCDR
that is using the measure can include
the proof of permission for CMS review
and approval for the measure to be used
in the performance period. The QCDR
measure owner (QCDR vendor) would
still own and maintain the QCDR
measure, but would allow other
approved QCDRs to utilize their QCDR
measure with proper notification. This
proposal will help to harmonize
clinically similar measures and limit the
use of measures that only slightly differ
from another. We invite comments on
this proposal.
We would like to clarify from the CY
2017 Quality Payment Program final
rule (81 FR 77375) that the QCDR must
publicly post the measure specifications
no later than 15 calendar days following
our approval of these measures
specifications for each QCDR measure it
intends to submit for MIPS.
We refer readers to the CY 2017
Quality Payment Program final rule for
the QCDR measure specifications
criteria.
(6) Identifying QCDR Quality Measures
In the CY 2017 Quality Payment
Program final rule (81 FR 77375 through
77377), we finalized the definition and
types of QCDR quality measures for
purposes of QCDRs submitting data for
the MIPS quality performance category.
We are not proposing any changes to the
criteria on how to identify QCDR quality
measures in this proposed rule. We
would like to clarify that QCDRs are not
limited to reporting on QCDR measures,
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and may also report on MIPS measures
as indicated above in the QCDR data
submission criteria section.
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(7) Collaboration of Entities To Become
a QCDR
In the CY 2017 Quality Payment
Program final rule (81 FR 77377), we
finalized policy on the collaboration of
entities to become a QCDR. We are not
proposing any changes to this policy in
this proposed rule, and would refer
readers to the CY 2017 Quality Payment
Program final rule for the criteria.
In response to the CY 2017 Quality
Payment Program final rule,
commenters recommended that we
work with QCDRs to determine a more
reasonable cycle for self-nomination,
measure selection, and reporting
because the current process is
burdensome. Commenters also
recommended that we not disqualify
QCDRs that do not have the capability
to allow MIPS eligible clinicians to
report across all performance categories
using only one submission mechanism,
and noted that the ability for QCDRs to
report their own measures allows MIPS
eligible clinicians the ability to
implement measures that are more
clinically meaningful and up-to-date
than those measures that may be
available in the MIPS measure set. We
would like to note that we are proposing
above, a simplified self-nomination and
measure selection process available to
existing QCDRs that are in good
standing, beginning in the third year of
the Quality Payment Program. We
would also like to explain that QCDRs
are not required to report on all
performance categories across the MIPS
program, and would not be disqualified
for not being able to report data across
on performance categories only using
one mechanism. We thank the
commenters for their support with
regards to allowing QCDRs to nominate
and report on QCDR measures that may
be specialty related. We thank the
commenters for their feedback and will
take their comments into consideration
in future rule making.
b. Health IT Vendors That Obtain Data
From MIPS Eligible Clinicians’ Certified
EHR Technology (CEHRT)
In the CY 2017 Quality Payment
Program final rule 81 FR 77382, we
finalized definitions and criteria around
health IT vendors that obtain data from
MIPS eligible clinicians CEHRT. We
note that, for this proposed rule, a
health IT vendor that serves as a third
party intermediary to collect or submit
data on behalf MIPS eligible clinicians
may or may not also be a ‘‘health IT
developer.’’ Under the ONC Health IT
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Certification Program (Program), (80 FR
62604), a health IT developer
constitutes a vendor, self-developer, or
other entity that presents health IT for
certification or has health IT certified
under the Program. The use of ‘‘health
IT developer’’ is consistent with the use
of the term ‘‘health IT’’ in place of
‘‘EHR’’ or ‘‘EHR technology’’ under the
Program (see 80 FR 62604; and section
II.C.6.f. of this proposed rule).
Throughout this proposed rule, we use
the term ‘‘health IT vendor’’ to refer to
entities that support the health IT
requirements of a clinician participating
in the Quality Payment Program.
We are not proposing any changes to
this policy in this proposed rule, and
would refer readers to the CY 2017
Quality Payment Program final rule for
the criteria. However we seek comment
for future rulemaking regarding the
potential shift to seeking alternatives
which might fully replace the QRDA III
format in the Quality Payment Program
in future program years.
c. Qualified Registries
In the CY 2017 Quality Payment
Program final rule (81 FR 77382 through
77386), we finalized the definition and
capability of qualified registries. We are
not proposing any changes to the
definition or the capabilities of qualified
registries in this final rule, and refer
readers to the CY 2017 Quality Payment
Program final rule for the detailed
definition and capabilities of a qualified
registry.
(1) Establishment of an Entity Seeking
To Qualify as a Registry
In the CY 2017 Quality Payment
Program final rule (81 FR 77383), we
finalized the requirements for the
establishment of an entity seeking to
qualify as a registry. We are not
proposing any changes to the criteria
regarding the establishment of an entity
seeking to qualify as a registry criteria
in this proposed rule, and refer readers
to the final rule for the criteria for
establishing an entity seeking to qualify
as a registry.
(2) Self-Nomination Period
For the 2018 performance period, and
for future years of the program, we
finalized at § 414.1400(g) a selfnomination period from September 1 of
the year prior to the applicable
performance period, until November 1
of the same year. For example, for the
2018 performance period, the selfnomination period would begin on
September 1, 2017, and end on
November 1, 2017. Entities that desire to
qualify as a qualified registry for
purposes of MIPS for a given
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performance period will need to provide
all requested information to us at the
time of self-nomination and would need
to self-nominate for that performance
period. Having previously qualified as a
qualified registry does not automatically
qualify the entity to participate in
subsequent MIPS performance periods.
Furthermore, prior performance of the
qualified registry (when applicable) will
be taken into consideration in approval
of their self-nomination. For example, a
qualified registry may choose not to
continue participation in the program in
future years, or the qualified registry
may be precluded from participation in
a future year, due to multiple data or
submission errors as noted below. As
such, we believe an annual selfnomination process is the best process
to ensure accurate information is
conveyed to MIPS eligible clinicians
and accurate data is submitted to MIPS.
However, we do understand that some
qualified registries have no changes to
the measures and/or activity inventory
they offer to their clients and intend to
participate in MIPS for many years.
Because of this, we are proposing,
beginning with the 2019 performance
period, a simplified process in which
existing qualified registries in good
standing may continue their
participation in MIPS by attesting that
the qualified registry’s approved data
validation plan, cost, approved MIPS
quality measures, services, and
performance categories offered in the
previous year’s performance period of
MIPS have minimal or no changes and
will be used for the upcoming
performance period. Specifically,
existing qualified registries in good
standing may attest during the selfnomination period that they have no
changes to their approved selfnomination application from the
previous year of MIPS. In addition, the
existing qualified registry may decide to
make minimal changes to their selfnomination application from the
previous year, which would be
submitted by the qualified registry for
CMS review and approval by the close
of the self-nomination period. Minimal
changes may include limited changes to
their performance categories, adding or
removing MIPS quality measures, and
adding or updating existing services
and/or cost information. By attesting
that certain aspects of their approved
application from the previous year have
not changed, existing qualified registries
will be spending less time completing
the entire self-nomination form, as was
previously required on a yearly basis.
We are proposing such a simplified
process to reduce the burden of self-
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nomination for those existing qualified
registries who have previously
participated in MIPS, and are in good
standing (not on probation or
disqualified, as described below) and to
allow for sufficient time for us to review
data submissions and to make
determinations on the standing of
qualified registries. This proposed
process will allow existing qualified
registries in good standing to avoid
completing the entire application
annually, as is required in the existing
process, and in alignment with the
existing timeline. We request comments
on this proposal. In the development of
this proposal, we had reviewed the
possibility of offering a multi-year
approval, where qualified registries
would be approved for a 2-year
increment of time. We are concerned
that utilizing a multi-year approval
process in which qualified registries
would be approved for 2 continuous
program years using the same fixed
services they had for the first year,
would not provide the qualified registry
with the flexibility to add or remove
services and or measures based on their
capabilities for the upcoming program
year. Furthermore, another concern with
a multi-year approval process is the
concern for those qualified registries
who perform poorly during the first
year, who should be placed on
probation or disqualified (as described
below). We are proposing that this
process be conducted on a yearly basis,
from September 1 of the year prior to
the applicable performance period until
November 1 of the same year, starting in
2018, aligning with the annual selfnomination period in order to ensure
that only those qualified registries who
are in good standing utilize this process.
We believe that this annual process will
provide qualified registries with the
flexibility to make minor changes to
their services should they wish to do so.
We request comments on this proposal.
We also seek comment to potentially
allow for qualified registries to utilize a
multi-year approval process, in which
they would be approved for a
continuous 2-year increment since
qualified registries can only make minor
changes (for example, including a
performance category, or a MIPS quality
measure, all of which are already
considered a part of the MIPS program).
We finalized to require further
information of qualified registries at the
time of self-nomination. If an entity
becomes qualified as a qualified
registry, they would need to sign a
statement confirming this information is
correct prior to us listing their
qualifications on their Web site. Once
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we post the qualified registry on our
Web site, including the services offered
by the qualified registry, we would
require the qualified registry to support
these services/measures for its clients as
a condition of the entity’s qualification
as a qualified registry for purposes of
MIPS. Failure to do so will preclude the
qualified registry from participation in
MIPS in the subsequent performance
year.
For the 2018 performance period and
beyond, we are proposing that selfnomination information must be
submitted via a web-based tool, and to
eliminate the submission method of
email. We will provide further
information on the web-based tool at
www.qpp.cms.gov. We request
comments on this proposal.
(3) Information Required at the Time of
Self-Nomination
We finalized in the CY 2017 Quality
Payment Program final rule (81 FR
77384) that a qualified registry must
provide specific information to us at the
time of self-nomination. We are not
proposing any changes to the
information required at the time of selfnomination in this proposed rule, and
refer readers to the final rule for specific
information requirements.
(4) Qualified Registry Criteria for Data
Submission
In the CY 2017 Quality Payment
Program final rule (81 FR 77386), we
finalized the criteria for qualified
registry data submission. We are not
proposing any changes to the data
submission criteria in this proposed
rule, and refer readers to the final rule
for specific criteria regarding qualified
registry data submission. We would like
to note two clarifications to the existing
criteria:
• Enter into and maintain with its
participating MIPS eligible clinicians an
appropriate Business Associate
agreement that complies with the
HIPAA Privacy and Security Rules.
Ensure that the Business Associate
agreement provides for the Qualified
Registry’s receipt of patient-specific data
from an individual MIPS eligible
clinician or group, as well as the
Qualified Registry’s disclosure of
quality measure results and numerator
and denominator data or patient specific
data on Medicare and non-Medicare
beneficiaries on behalf of individual
MIPS eligible clinicians and groups.
• We had finalized that timely
feedback be provided at least four times
a year, on all of the MIPS performance
categories that the qualified registry will
report to us. We refer readers to section
II.C.9.a. of this proposed rule for
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additional information on third party
intermediaries and performance
feedback.
We had received comments in
response to the CY 2017 Quality
Payment Program final rule from
commenters who expressed concern
that the 3 percent acceptable error rate
for qualified registries is too low.
Commenters recommended we analyze
reporting for the transition year and
increase the error rate to 5 percent at the
minimum because qualified registries
may make a small number of errors
given that 2017 is the first year of MIPS
and that removing qualified registries
due to a low error threshold could hurt
clinicians. We thank the commenters for
their feedback and will take the
comments into consideration in future
rulemaking.
As indicated in the CY 2017 Quality
Payment Program final rule (81 FR
77370), we will on a case-by-case basis
allow qualified registries to request
review and approval for additional
MIPS measures throughout the
performance period. Any new measures
that are approved by us will be added
to the information related to the
qualified registry on the CMS Web site,
as technically feasible. We anticipate
only being able to update this
information on the Web site on a
quarterly basis, as technically feasible.
d. CMS-Approved Survey Vendors
In the CY 2017 Quality Payment
Program final rule (81 FR 77386), we
finalized the definition, criteria,
required forms, and vendor business
requirements needed to participate in
MIPS as a survey vendor. We refer
readers to the CY 2017 Quality Payment
Program final rule for specific details on
requirements. We have heard from some
groups that it would be useful to have
a final list of CMS-approved survey
vendors to inform their decision on
whether or not to participate in the
CAHPS for MIPS survey. Therefore,
beginning with the 2018 performance
period and for future program years, we
propose to remove the April 30th survey
vendor application deadline because
this deadline is within the timeframe of
when groups can elect to participate in
the CAHPS for MIPS survey. In order to
provide a final list of CMS-approved
survey vendors earlier in the timeframe
during which groups can elect to
participate in the CAHPS for MIPS
survey, an earlier vendor application
deadline would be necessary. This
could be accomplished by having a
rolling application period, where
vendors would be able to submit an
application by the end of the first
quarter. However, in addition to
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submitting a vendor application,
vendors must also complete vendor
training and submit a Quality Assurance
Plan and we need to allow sufficient
time for these requirements as well.
Therefore, we propose for the Quality
Payment Program Year 2 and future
years that the vendor application
deadline would be January 31st of the
applicable performance year or a later
date specified by CMS. This proposal
would allow us to adjust the application
deadline beyond January 31st on a year
to year basis, based on program needs.
We will notify vendors of the
application deadline to become a CMSapproved survey vendor through
additional communications and
postings. We request comments on this
proposal and other alternatives that
would allow us to provide a final list of
CMS-approved survey vendors early in
the timeframe during which groups can
elect to participate in the CAHPS for
MIPS survey.
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e. Probation and Disqualification of a
Third Party Intermediary
At § 414.1400(k), we finalized the
process for placing third party
intermediaries on probation and for
disqualifying such entities for failure to
meet certain standards established by us
(81 FR 77386). Specifically, we
proposed that if at any time we
determine that a third party
intermediary (that is, a QCDR, health IT
vendor, qualified registry, or CMSapproved survey vendor) has not met all
of the applicable criteria for
qualification, we may place the third
party intermediary on probation for the
current performance period or the
following performance period, as
applicable.
In addition, we finalized that we
require a corrective action plan from the
third party intermediary to address any
deficiencies or issues and prevent them
from recurring. We finalized that the
corrective action plan must be received
and accepted by us within 14 days of
the CMS notification to the third party
intermediary of the deficiencies or
probation. Failure to comply with these
corrective action plan requirements
would lead to disqualification from
MIPS for the subsequent performance
period.
We finalized for probation to mean
that, for the applicable performance
period, the third party intermediary
must meet all applicable criteria for
qualification and approval and also
must submit a corrective action plan for
remediation or correction of any
deficiencies identified by CMS that
resulted in the probation (81 FR 77548).
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In addition, we finalized that if the
third party intermediary has data
inaccuracies including (but not limited
to) TIN/NPI mismatches, formatting
issues, calculation errors, data audit
discrepancies affecting in excess of 3
percent (but less than 5 percent) of the
total number of MIPS eligible clinicians
or groups submitted by the third party
intermediary, we would annotate the
listing of qualified third party
intermediaries on the CMS Web site,
noting that the third party intermediary
furnished data of poor quality and
would place the entity on probation for
the subsequent performance period.
Further, we finalized if the third party
intermediary does not reduce their data
error rate below 3 percent for the
subsequent performance period, the
third party intermediary would
continue to be on probation and have
their listing on the CMS Web site
continue to note the poor quality of the
data they are submitting for MIPS for
one additional performance period.
After 2 years on probation, the third
party intermediary would be
disqualified for the subsequent
performance period. Data errors
affecting in excess of 5 percent of the
MIPS eligible clinicians or groups
submitted by the third party
intermediary may lead to the
disqualification of the third party
intermediary from participation for the
following performance period. In
placing the third party intermediary on
probation; we would notify the third
party intermediary of the identified
issues, at the time of discovery of such
issues.
In addition, we finalized that if the
third party intermediary does not
submit an acceptable corrective action
plan within 14 days of notification of
the deficiencies and correct the
deficiencies within 30 days or before the
submission deadline—whichever is
sooner, we may disqualify the third
party intermediary from participating in
MIPS for the current performance
period or the following performance
period, as applicable.
We note that MIPS eligible clinicians
are ultimately responsible for the data
that are submitted by their third party
intermediaries and expect that MIPS
eligible clinicians and groups should
ultimately hold their third party
intermediaries accountable for accurate
reporting. We will consider cases of
vendors leaving the marketplace during
the performance period on a case by
case basis, but would note that we will
not consider cases prior to the
performance period. We would
however, need proof that the MIPS
eligible clinician had an agreement in
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place with the vendor at the time of
their withdrawal from the marketplace.
We are not proposing any changes to the
process of probation and
disqualification of a third party
intermediary in this proposed rule.
Commenters on the final rule
requested that we provide opportunities
for MIPS eligible clinicians and groups
that discover an issue with their third
party intermediary to change reporting
methods and/or third party
intermediaries without restriction on
the eligible clinicians. We thank the
commenters for their feedback and will
take the comments into consideration in
future rulemaking.
f. Auditing of Third Party Intermediaries
Submitting MIPS Data
In the CY 2017 Quality Payment
Program final rule (81 FR 77389), we
finalized at § 414.1400(j) that any third
party intermediary (that is, a QCDR,
health IT vendor, qualified registry, or
CMS-approved survey vendor) must
comply with the following procedures
as a condition of their qualification and
approval to participate in MIPS as a
third party intermediary:
(1) The entity must make available to
us the contact information of each MIPS
eligible clinician or group on behalf of
whom it submits data. The contact
information will include, at a minimum,
the MIPS eligible clinician or group’s
practice phone number, address, and if
available, email;
(2) The entity must retain all data
submitted to us for MIPS for a minimum
of 10 years; and
(3) For the purposes of auditing, we
may request any records or data retained
for the purposes of MIPS for up to 6
years and 3 months.
We are proposing to change
§ 414.1400(j)(2) to clarify that the entity
must retain all data submitted to us for
purposes of MIPS for a minimum of 10
years from the end of the MIPS
performance period.
11. Public Reporting on Physician
Compare
This section contains the approach for
public reporting on Physician Compare
for the CY 2018 Quality Payment
Program final rule, including MIPS,
APMs, and other information as
required by the MACRA and building
on the MACRA public reporting policies
previously finalized (81 FR 77390
through 77399).
Physician Compare draws its
operating authority from section
10331(a)(1) of the Affordable Care Act.
As required by section 10331(a)(1) of the
Affordable Care Act, by January 1, 2011,
we developed a Physician Compare
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Internet Web site with information on
physicians enrolled in the Medicare
program under section 1866(j) of the
Act, as well as information on other EPs
who participate in the PQRS under
section 1848 of the Act. More
information about Physician Compare
can be accessed on the Physician
Compare Initiative Web site at https://
www.cms.gov/medicare/qualityinitiatives-patient-assessmentinstruments/physician-compareinitiative/.
The first phase of Physician Compare
was launched on December 30, 2010
(https://www.medicare.gov/
physiciancompare). Since the initial
launch, Physician Compare has been
continually improved and more
information has been added. In
December 2016, the site underwent a
complete user-informed, evidencedbased redesign to further enhance
usability and functionality on both
desktop computers and mobile devices
and to begin to prepare the site for the
inclusion of more data as required by
the MACRA.
Currently, Web site users can view
information about approved Medicare
clinicians, such as: Name; Medicare
primary and secondary specialties;
practice locations; group affiliations;
hospital affiliations that link to the
hospital’s profile on Hospital Compare
as available; Medicare assignment
status; education; residency; and,
American Board of Medical Specialties
(ABMS), American Osteopathic
Association (AOA), and American
Board of Optometry (ABO) board
certification information. For groups,
users can view group names, specialties,
practice locations, Medicare assignment
status, and affiliated clinicians. In
December 2016, we also added
indicators on the results page to show
those clinicians and groups that had
performance scores available to view.
We also included an indicator on profile
pages to show those Medicare clinicians
and groups that satisfactorily or
successfully participated in a CMS
quality program to indicate their
commitment to quality.
Consistent with section 10331(a)(2) of
the Affordable Care Act, Physician
Compare phased in public reporting of
performance scores that provide
comparable information on quality and
patient experience measures for
reporting periods beginning January 1,
2012. To the extent that scientifically
sound measures are developed and are
available, Physician Compare is
required to include, to the extent
practicable, the following types of
measures for public reporting: Measures
collected under PQRS and an
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assessment of efficiency, patient health
outcomes, and patient experience, as
specified. The first set of quality
measures were publicly reported on
Physician Compare in February 2014.
Currently, Physician Compare publicly
reports 91 group-level measures
collected through either the Web
Interface or registry for groups
participating in 2015 under the PQRS,
19 quality measures for ACOs
participating in the 2015 Shared Savings
Program or Pioneer ACO program, and
90 individual clinician-level measures
collected either through claims or
registry for individual EPs participating
in 2015 under the PQRS. In addition, 31
total individual clinician-level Qualified
Clinical Data Registry (QCDR) nonPQRS measures are publicly available
either through Physician Compare
profile pages or 2015 QCDR Web sites.
A complete history of public reporting
on Physician Compare is detailed in the
CY 2016 PFS final rule (80 FR 71117
through 71122).
As finalized in the CY 2015 and CY
2016 PFS final rules (79 FR 67547 and
80 FR 70885, respectively), Physician
Compare will continue to expand public
reporting. This expansion includes
publicly reporting both individual
eligible professional (now referred to as
eligible clinician) and group-level QCDR
measures starting with 2016 data
available for public reporting in late
2017, as well as the inclusion of a
benchmark and 5-star rating in late 2017
based on 2016 data (80 FR 71125 and
71129), among other additions.
This expansion will continue under
the MACRA. Sections 1848(q)(9)(A) and
(D) of the Act facilitate the continuation
of our phased approach to public
reporting by requiring the Secretary to
make available on the Physician
Compare Web site, in an easily
understandable format, individual MIPS
eligible clinician and group
performance information, including:
• The MIPS eligible clinician’s final
score;
• The MIPS eligible clinician’s
performance under each MIPS
performance category (quality, cost,
improvement activities, and advancing
care information);
• Names of eligible clinicians in
Advanced APMs and, to the extent
feasible, the names of such Advanced
APMs and the performance of such
models; and,
• Aggregate information on the MIPS,
posted periodically, including the range
of final scores for all MIPS eligible
clinicians and the range of the
performance of all MIPS eligible
clinicians for each performance
category.
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Initial plans to publicly report this
performance information on Physician
Compare were finalized in the CY 2017
Quality Payment Program final rule (81
FR 77390). The proposals related to
each of these requirements for year 2 of
the Quality Payment Program are
addressed below in this section.
Section 1848(q)(9)(B) of the Act also
requires that this information indicate,
where appropriate, that publicized
information may not be representative
of the eligible clinician’s entire patient
population, the variety of services
furnished by the eligible clinician, or
the health conditions of individuals
treated. The information mandated for
Physician Compare under section
1848(q)(9) of the Act will generally be
publicly reported consistent with
sections 10331(a)(2) and 10331(b) of the
Affordable Care Act, and like all
measure data included on Physician
Compare, will be comparable. In
addition, section 10331(b) of the
Affordable Care Act requires that we
include, to the extent practicable,
processes to ensure that data made
public are statistically valid, reliable,
and accurate, including risk adjustment
mechanisms used by the Secretary. In
addition to the public reporting
standards identified in the Affordable
Care Act—statistically valid and reliable
data that are accurate and comparable—
we have established a policy that, as
determined through user testing, the
data we disclose generally should
resonate with and be accurately
interpreted by Web site users to be
included on Physician Compare profile
pages. Together, we refer to these
conditions as the Physician Compare
public reporting standards (80 FR 71118
through 71120). Section 10331(d) of the
Affordable Care Act also requires us to
consider input from multi-stakeholder
groups, consistent with sections
1890(b)(7) and 1890A of the Act. We
continue to receive general input from
stakeholders on Physician Compare
through a variety of means, including
rulemaking and different forms of
stakeholder outreach (for example,
Town Hall meetings, Open Door
Forums, webinars, education and
outreach, Technical Expert Panels, etc.).
In addition, section 1848(q)(9)(C) of
the Act requires the Secretary to provide
an opportunity for MIPS eligible
clinicians to review the information that
will be publicly reported prior to such
information being made public. This is
generally consistent with section
10331(a)(2) of the Affordable Care Act,
under which we have established a 30day preview period for all measurement
performance data that allows physicians
and other eligible clinicians to view
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their data as it will appear on the Web
site in advance of publication on
Physician Compare (80 FR 77392).
Section 1848(q)(9)(C) of the Act also
requires that MIPS eligible clinicians be
able to submit corrections for the
information to be made public. We
finalized a policy to extend the current
Physician Compare 30-day preview
period for MIPS eligible clinicians
starting with data from the 2017 MIPS
performance period, which is available
for public reporting in late 2018.
Therefore, we finalized a 30-day
preview period in advance of the
publication of data on Physician
Compare (81 FR 77392).
We will coordinate data review and
any relevant data resubmission or
correction between Physician Compare
and the four performance categories of
MIPS. All data available for public
reporting—measure rates, scores, and
attestations, etc.—are available for
review and correction during the
targeted review process, which will
begin at least 30 days in advance of the
publication of new data. Data under
review is not publicly reported until the
review is complete. All corrected
measure rates, scores, and attestations
submitted as part of this process are
available for public reporting. The
technical details of the process are
communicated directly to affected MIPS
eligible clinicians and groups and
detailed outside of rulemaking with
specifics made public on the Physician
Compare Initiative page on
www.cms.gov and communicated
through Physician Compare and other
CMS listservs (81 FR 77391).
In addition, section 1848(q)(9)(D) of
the Act requires that aggregate
information on the MIPS be periodically
posted on the Physician Compare Web
site, including the range of final scores
for all MIPS eligible clinicians and the
range of performance for all MIPS
eligible clinicians for each performance
category.
Lastly, section 104(e) of the MACRA
requires the Secretary to make publicly
available, on an annual basis, in an
easily understandable format,
information for physicians and, as
appropriate, other eligible clinicians
related to items and services furnished
to people with Medicare, and to
include, at a minimum:
• Information on the number of
services furnished under Part B, which
may include information on the most
frequent services furnished or groupings
of services;
• Information on submitted charges
and payments for Part B services; and,
• A unique identifier for the
physician or other eligible clinician that
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is available to the public, such as an
NPI.
The information is further required to
be made searchable by at least specialty
or type of physician or other eligible
clinician; characteristics of the services
furnished (such as, volume or groupings
of services); and the location of the
physician or other eligible clinician.
In accordance with section 104(e) of
the MACRA, we finalized a policy in the
CY 2016 PFS final rule (80 FR 71130)
to add utilization data to the Physician
Compare downloadable database.
Utilization data is currently available at
https://www.cms.gov/Research-StatisticsData-and-Systems/Statistics-Trendsand-Reports/Medicare-Provider-ChargeData/Physician-and-OtherSupplier.html. This information is
integrated on the Physician Compare
Web site via the downloadable database
each year using the most current data,
starting with the 2016 data, targeted for
initial release in late 2017 (80 FR
71130). Not all available data will be
included. The specific HCPCS codes
included are to be determined based on
analysis of the available data, focusing
on the most used codes. Additional
details about the specific HCPCS codes
that are included in the downloadable
database will be provided to
stakeholders in advance of data
publication. All data available for public
reporting—on the public-facing Web site
pages or in the downloadable
database—are available for review
during the 30-day preview period.
We propose to revise the public
reporting regulation at § 414.1395(a), to
more completely and accurately
reference the data available for public
reporting on Physician Compare. We
propose to modify § 414.1395(a) to
remove from the heading and text
references to ‘‘MIPS’’ and ‘‘public Web
site’’ and instead reference ‘‘Quality
Payment Program’’ and ‘‘Physician
Compare’’. Specifically, proposed
§ 414.1395(a) reads as follows: ‘‘Public
reporting of eligible clinician and group
Quality Payment Program information.
For each program year, CMS posts on
Physician Compare, in an easily
understandable format, information
regarding the performance of eligible
clinicians or groups under the Quality
Payment Program.’’ We also propose to
add paragraphs (b), (c), and (d) at
§ 414.1395, to capture previously
established policies for Physician
Compare relating to the public reporting
standards, first year measures, and the
30-day preview period. Specifically, at
proposed § 414.1395(b), we propose
that, with the exception of data that
must be mandatorily reported on
Physician Compare, for each program
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year, we rely on the established public
reporting standards to guide the
information available for inclusion on
Physician Compare. The public
reporting standards require data
included on Physician Compare to be
statistically valid, reliable, and accurate;
be comparable across reporting
mechanisms; and, meet the reliability
threshold. And, to be included on the
public facing profile pages, the data
must also resonate with Web site users,
as determined by CMS. At proposed
§ 414.1395(c), we propose to codify our
policy regarding first year measures:
‘‘For each program year, CMS does not
publicly report any first year measure,
meaning any measure in its first year of
use in the quality and cost performance
categories. After the first year, CMS
reevaluates measures to determine when
and if they are suitable for public
reporting.’’ At proposed § 414.1395(d),
we propose to specify the 30-day
preview period rule: ‘‘For each program
year, CMS provides a 30-day preview
period for any clinician or group with
Quality Payment Program data before
the data are publicly reported on
Physician Compare.’’
We believe section 10331 of the
Affordable Care Act supports the
overarching goals of the MACRA by
providing the public with quality
information that will help them make
informed decisions about their health
care, while encouraging clinicians to
improve the quality of care they provide
to their patients. In accordance with
section 10331 of the Affordable Care
Act, section 1848(q)(9) of the Act, and
section 104(e) of the MACRA, we plan
to continue to publicly report
performance information on Physician
Compare. As such, we propose the
inclusion of the following information
on Physician Compare.
a. Final Score, Performance Categories,
and Aggregate Information
Sections 1848(q)(9)(A) and (D) of the
Act require that we publicly report on
Physician Compare the final score for
each MIPS eligible clinician,
performance of each MIPS eligible
clinician for each performance category,
and periodically post aggregate
information on the MIPS, including the
range of final scores for all MIPS eligible
clinicians and the range of performance
of all the MIPS eligible clinicians for
each performance category. We finalized
such data for public reporting on
Physician Compare for the transition
year (81 FR 77393), and we are now
proposing to add these data each year to
Physician Compare for each MIPS
eligible clinician or group, either on the
profile pages or in the downloadable
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database, as technically feasible.
Statistical testing and user testing, as
well as consultation of the Physician
Compare Technical Expert Panel, will
determine how and where these data are
best reported on Physician Compare. As
the MACRA requires that this
information be available for public
reporting on Physician Compare, we are
proposing to include it each year
moving forward, as technically feasible.
We request comment on this proposal to
publicly report on Physician Compare
the final score for each MIPS eligible
clinician or group, performance of each
MIPS eligible clinician or group for each
performance category, and periodically
post aggregate information on the MIPS,
including the range of final scores for
and the range of performance of all the
MIPS eligible clinicians or groups for
each performance category, as
technically feasible.
A detailed discussion of proposals
related to each performance category of
MIPS data follows.
b. Quality
As detailed in the CY 2017 Quality
Payment Program final rule (81 FR
77395), and consistent with the existing
policy that makes all current PQRS
measures available for public reporting,
we finalized a decision to make all
measures under the MIPS quality
performance category available for
public reporting on Physician Compare
in the transition year of the Quality
Payment Program, as technically
feasible. This included all available
measures reported via all available
submission methods, and applied to
both MIPS eligible clinicians and
groups.
Also consistent with current policy,
although all measures will be available
for public reporting, not all measures
will be made available on the publicfacing Web site profile pages. As
explained in the CY 2017 Quality
Payment Program final rule (81 FR
77394), providing too much information
can overwhelm Web site users and lead
to poor decision making. Therefore,
consistent with section
1848(q)(9)(A)(i)(II) of the Act, all
measures in the quality performance
category that meet the statistical public
reporting standards will be included in
the downloadable database, as
technically feasible. We also finalized a
policy that a subset of these measures
will be publicly reported on the Web
site’s profile pages, as technically
feasible, based on Web site user testing.
Statistical testing and user testing will
determine how and where measures are
reported on Physician Compare. In
addition, we adopted our existing policy
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of not publicly reporting first year
measures, meaning new measures that
have been in use for less than 1 year,
regardless of submission method used,
for this MIPS quality performance
category. After a measure’s first year in
use, we will evaluate the measure to see
if and when the measure is suitable for
public reporting (81 FR 77395).
Currently, there is a minimum sample
size requirement of 20 patients for
performance data to be included on
Physician Compare. We previously
sought comment on moving away from
this requirement and moving to a
reliability threshold for public
reporting. In general, commenters
supported a minimum reliability
threshold. As a result, we finalized
instituting a minimum reliability
threshold for public reporting data on
Physician Compare starting with 2017
data available for public report in late
2018 and each year moving forward (81
FR 77395).
The reliability of a measure refers to
the extent to which the variation in the
performance rate is due to variation in
quality of care as opposed to random
variation due to sampling. Statistically,
reliability depends on performance
variation for a measure across entities,
the random variation in performance for
a measure within an entity’s panel of
attributed patients, and the number of
patients attributed to the entity. High
reliability for a measure suggests that
comparisons of relative performance
across entities, such as eligible
clinicians or groups, are likely to be
stable and consistent, and that the
performance of one entity on the quality
measure can confidently be
distinguished from another. We will
conduct analyses to determine the
reliability of the data collected and use
this to calculate the minimum reliability
threshold for the data. Once an
appropriate minimum reliability
threshold is determined, we will only
publicly report those performance rates
for any given measure that meet the
minimum reliability threshold. We note
that reliability standards for public
reporting and reliability for scoring need
not align; reliability for public reporting
is unique because, for example, public
reporting requires ensuring additional
protections to maintain confidentiality.
In addition, because publicly reported
measures can be compared across
clinicians and across groups, it is
particularly important for the most
stringent reliability standards to be in
place to ensure differences in
performance scores reflect true
differences in quality of care to promote
accurate comparisons by the public. For
further information on reliability as it
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relates to scoring of cost measures see
section II.C.7.a.(3) of this proposed rule.
In the CY 2017 Quality Payment
Program final rule, we established that
we will include the total number of
patients reported on each measure in
the downloadable database to facilitate
transparency and more accurate
understanding and use of the data (81
FR 77395). We will begin publishing the
total number of patients reported on
each measure in the downloadable
database with 2017 data available for
public reporting in late 2018 and for
each year moving forward.
Understanding that we will continue
our policies to not publicly report first
year quality measures, that we will only
report those measures that meet the
reliability threshold and meet the public
reporting standards, and include the
total number of patients reported on for
each measure in the downloadable
database, we are again proposing to
make all measures under the MIPS
quality performance category available
for public reporting on Physician
Compare, as technically feasible. This
would include all available measures
reported via all available submission
methods for both MIPS eligible
clinicians and groups, for 2018 data
available for public reporting in late
2019, and for each year moving forward,
these data are required by the MACRA
to be available for public reporting on
Physician Compare, continuing to
publicly report these data ensures
continued transparency and provides
people with Medicare and their
caregivers valuable information they can
use to make informed health care
decisions. We request comment on this
proposal.
In addition, we seek comment on
expanding the patient experience data
available for public reporting on
Physician Compare. Currently, the
Consumer Assessment of Healthcare
Providers and Systems (CAHPS) for
MIPS survey is available for groups to
report under the MIPS. This patient
experience survey data is highly valued
by patients and their caregivers as they
evaluate their health care options.
However, in testing with patient and
caregivers, they regularly ask for more
information from patients like them in
their own words. Patients regularly
request we include narrative reviews of
clinicians and groups on the Web site.
The Agency for Healthcare Research and
Quality (AHRQ) is fielding a beta
version of the CAHPS Patient Narrative
Elicitation Protocol (https://
www.ahrq.gov/cahps/surveys-guidance/
item-sets/elicitation/). This
includes five open-ended questions
designed to be added to the Clinician &
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Groups CAHPS survey, which CAHPS
for MIPS is molded after. These five
questions have been developed and
tested to work to capture patient
narratives in a scientifically grounded
and rigorous way, setting it apart from
other patient narratives collected by
various health systems and patient
rating sites. More scientifically rigorous
patient narrative data would not only
greatly benefit patients, but it would
also greatly aid clinicians and groups as
they work to assess how their patients
experience care. We are seeking
comment on potentially public
reporting these five open-ended
questions for the CAHPS for MIPS
survey on Physician Compare as a
consideration in future rulemaking. We
direct readers to the Quality
Performance Criteria in section
II.C.6.b.(3)(a) of this proposed rule for
additional information related to
seeking comment on adding these
questions to the CAHPS for MIPS
survey.
c. Cost
Consistent with section
1848(q)(9)(A)(i)(II) of the Act, we
finalized in the CY 2017 Quality
Payment Program final rule a decision
to make all measures under the MIPS
cost performance category available for
public reporting on Physician Compare
(81 FR 77396). This included all
available measures reported via all
available submission methods, and
applied to both MIPS eligible clinicians
and groups. However, as noted in the
final rule, we may not have data
available for public reporting in the
transition year of the Quality Payment
Program for the cost performance
category (2017 data available for public
reporting in late 2018).
As discussed in the final rule (81 FR
77395), cost data are difficult for
patients to understand and, as a result,
publicly reporting these measures could
lead to significant misinterpretation and
misunderstanding. For this reason, we
are again proposing to include on
Physician Compare a sub-set of cost
measures that meet the public reporting
standards, either on profile pages or in
the downloadable database, if
technically feasible, for 2018 data
available for public reporting in late
2019, and for each year moving forward.
These data are required by the MACRA
to be available for public reporting on
Physician Compare, but we want to
ensure we only share those cost
measures that can help patients and
caregivers make informed health care
decisions on profile pages. For
transparency purposes, the cost
measures that meet all other public
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reporting standards would be included
in the downloadable database.
Statistical testing and Web site user
testing would determine how and where
measures are reported on Physician
Compare to minimize passing the
complexity of these measures on to
patients and to ensure those measures
included are accurately understood and
correctly interpreted. Under this
proposal, we note that the policies we
previously mentioned regarding first
year measures, the minimum reliability
threshold, and all public reporting
standards would apply. This proposal
applies to all available measures
reported via all available submission
methods, and applies to both MIPS
eligible clinicians and groups. We
request comment on this proposal.
d. Improvement Activities
Consistent with section
1848(q)(9)(A)(i)(II) of the Act, we
finalized a decision to make all
activities under the MIPS improvement
activities performance category
available for public reporting on
Physician Compare (81 FR 77396). This
included all available improvement
activities reported via all available
submission methods, and applied to
both MIPS eligible clinicians and
groups.
Consistent with the policy finalized
for the transition year, we are again
proposing to include a subset of
improvement activities data on
Physician Compare that meet the public
reporting standards, either on the profile
pages or in the downloadable database,
if technically feasible, for 2018 data
available for public reporting in late
2019, and for each year moving forward.
This again includes all available
activities reported via all available
submission methods, and applies to
both MIPS eligible clinicians and
groups. For those eligible clinicians or
groups that successfully meet the
improvement activities performance
category requirements this information
may be posted on Physician Compare as
an indicator. This information is
required by the MACRA to be available
for public reporting on Physician
Compare, but the improvement
activities performance category is a new
field of data for Physician Compare so
concept and Web site user testing is still
needed to ensure these data are
understood by stakeholders. Therefore,
we again propose that statistical testing
and user testing would determine how
and where improvement activities are
reported on Physician Compare.
For the transition year, we proposed
to exclude first year activities from
public reporting. First year activities are
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any improvement activities in their first
year of use. Starting with year 2 (2018
data available for public reporting in
late 2019), we propose publicly
reporting first year activities if all other
reporting criteria are satisfied. This
evolution in our Quality Payment
Program public reporting plan provides
an opportunity to make more valuable
information public given that
completion of or participation in
activities the first year they are available
is different from reporting first year
quality or cost measures. Clinicians and
groups can learn from the first year of
quality and cost data, understand why
their performance rate is what it is, and
take time to improve. A waiting period
for indicating completion or
participation in an improvement
activity is unlikely to produce the same
benefit. We request comments on these
proposals.
e. Advancing Care Information
Since the beginning of the EHR
Incentive Programs in 2011, participant
performance data has been publicly
available in the form of public use files
on the CMS Web site. In the 2015 EHR
Incentive Programs final rule (80 FR
62901), we addressed comments
requesting that we not only continue
this practice but also include a wider
range of information on participation
and performance. In that rule, we stated
our intent to publish the performance
and participation data on Stage 3
objectives and measures of meaningful
use in alignment with quality programs
which utilize publicly available
performance data such as Physician
Compare. At this time there is only an
indicator on Physician Compare profile
pages to show that an eligible clinician
successfully participated in the current
Medicare EHR Incentive Program.
As MIPS will include advancing care
information as one of the four MIPS
performance categories, we decided,
consistent with section 1848(q)(9)(i)(II)
of the Act, to include more information
on an eligible clinician’s or group’s
performance on the objectives and
measures of meaningful use on
Physician Compare for the transition
year (81 FR 77387). An important
consideration was that to meet the
public reporting standards, the data
added to Physician Compare must
resonate with Medicare patients and
their caregivers. Testing to date has
shown that people with Medicare value
the use of certified EHR technology and
see EHR use as something that if used
well can improve the quality of their
care. In addition, we believe the
inclusion of indicators for clinicians
and groups who achieve high
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performance in key care coordination
and patient engagement activities
provide significant value for patients
and their caregivers as they make health
care decisions.
Consistent with our transition year
final policy, and understanding the
value of this information to Web site
users, we are again proposing to include
an indicator on Physician Compare for
any eligible clinician or group who
successfully meets the advancing care
information performance category, as
technically feasible. Also, as technically
feasible, we propose to include
additional indicators, including but not
limited to, objectives, activities, or
measures specified in section II.C.6.f. of
this proposed rule, such as, identifying
if the eligible clinician or group scores
high performance in patient access, care
coordination and patient engagement, or
health information exchange. These
proposals would apply to 2018 data
available for public reporting in late
2019, and for each year moving forward,
as this information is required by the
MACRA to be available for public
reporting on Physician Compare. We
also propose that any advancing care
information objectives, activities, or
measures would need to meet the public
reporting standards applicable to data
posted on Physician Compare, either on
the profile pages or in the downloadable
database. This would include all
available objectives, activities, or
measures reported via all available
submission methods, and would apply
to both MIPS eligible clinicians and
groups. Statistical testing and Web site
user testing would determine how and
where objectives and measures are
reported on Physician Compare. As with
improvement activities, we are also
proposing to allow first year advancing
care information objectives, activities,
and measures to be available for public
reporting starting in year 2 (2018 data
available for public reporting in late
2019). Again, especially if we are
including an indicator over a
performance rate, the benefits of waiting
1 year are not the same and thus, we
believe it is more important to make
more information available for public
reporting as the Quality Payment
Program matures. We request comment
on these proposals.
f. Achievable Benchmark of Care
(ABCTM)
Benchmarks are important to ensuring
that the quality data published on
Physician Compare are accurately
understood. A benchmark allows Web
site users to more easily evaluate the
information published by providing a
point of comparison between groups
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and between clinicians. In an effort to
find the best possible methodology for
Physician Compare, we embarked on a
year-long information gathering and
stakeholder outreach effort in advance
of the CY 2016 PFS rule process. We
reached out to stakeholders, including
specialty societies, consumer advocacy
groups, physicians and other clinicians,
measure experts, and quality measure
specialists, as well as other CMS Quality
Programs. Based on this outreach and
the recommendation of our Technical
Expert Panel, we proposed and
ultimately finalized (80 FR 71129) a
decision to publicly report on Physician
Compare an item, or measure-level,
benchmark using the Achievable
Benchmark of Care (ABCTM) 21
methodology annually based on the
PQRS performance rates most recently
available by reporting mechanism. As a
result, in late 2017, we expect to
publicly report a benchmark based on
the 2016 PQRS performance rates for
each measure by each available
reporting mechanism. The specific
measures the benchmark will be
calculated for will be determined once
the data are available and analyzed. As
with all data, the benchmark will only
be applied to those measures deemed to
meet the established public reporting
standards.
We believe ABCTM is a well-tested,
data-driven methodology that allows us
to account for all of the data collected
for a quality measure, evaluate who the
top performers are, and then use that to
set a point of comparison for all of those
groups or clinicians who report the
measure.
ABCTM starts with the pared-mean,
which is the mean of the best
performers on a given measure for at
least 10 percent of the patient
population—not the population of
reporters. To find the pared-mean, we
will rank order physicians or groups (as
appropriate per the measure being
evaluated) in order from highest to
lowest performance score. We will then
subset the list by taking the best
performers moving down from best to
worst until we have selected enough
reporters to represent 10 percent of all
patients in the denominator across all
reporters for that measure.
We finalized that the benchmark
would be derived by calculating the
total number of patients in the highest
scoring subset receiving the intervention
or the desired level of care, or achieving
the desired outcome, and dividing this
21 Kiefe CI, Weissman NW., Allison JJ, Farmer R,
Weaver M, Williams OD. Identifying achievable
benchmarks of care: concepts and methodology.
International Journal of Quality Health Care. 1998
Oct; 10(5):443–7.
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number by the total number of patients
that were measured by the top
performing doctors. This would produce
a benchmark that represents the best
care provided to the top 10 percent of
patients by measure, by reporting
mechanism.
An Example: A clinician reports on
how many patients with diabetes she
has given foot exams. There are four
steps to establishing the benchmark for
this measure.
(1) We look at the total number of
patients with diabetes for all clinicians
who reported this diabetes measure.
(2) We rank clinicians that reported
this diabetes measure from highest
performance score to lowest
performance score to identify the set of
top clinicians who treated at least 10
percent of the total number of patients
with diabetes.
(3) We count how many of the
patients with diabetes who were treated
by the top clinicians also got a foot
exam.
(4) This number is divided by the
total number of patients with diabetes
who were treated by the top clinicians,
producing the ABCTM benchmark.
To account for low denominators,
ABCTM suggests the calculation of an
adjusted performance fraction (AFP)
using a Bayesian Estimator or use of
another statistical methodology. After
analysis, we have determined that the
use of a beta binomial model adjustment
is most appropriate for the type of data
we are working with. The beta binomial
method moves extreme values toward
the average for a given measure, while
the Bayesian Estimator moves extreme
values toward 50 percent. Using the beta
binomial method is a more
methodologically sophisticated
approach to address the issue of extreme
values based on small sample sizes.
This ensures that all clinicians are
accounted for and appropriately figured
in to the benchmark.
The benchmarks for Physician
Compare developed using the ABCTM
methodology will be based on the
current year’s data, so the benchmark
will be appropriate regardless of the
unique circumstances of data collection
or the measures available in a given
reporting year. We also finalized (80 FR
71129) a decision to use the ABCTM
methodology to generate a benchmark
which will be used to systematically
assign stars for the Physician Compare
5-star rating. The details of how the
benchmark will be specifically used to
determine the 5-star categories for all
applicable measures is being
determined in close collaboration with
stakeholders, CMS programs, measure
experts, and the Physician Compare
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Technical Expert Panel. We expect to
publicly report the benchmark and 5star rating for the first time on Physician
Compare in late 2017 using the 2016
PQRS performance scores for both
clinicians and groups.
As a result of stakeholder feedback
asking that we consider one consistent
approach for benchmarking and parsing
the data based on the benchmark across
the Quality Payment Program, we did
consider an alternative approach. We
reviewed the benchmark and decile
breaks being used to assign points and
determine payment under MIPS (see
II.C.7.a.(2)(b) of this proposed rule).
This approach was not considered ideal
for public reporting for several reasons.
A primary concern was that the decile
approach when used for public
reporting would force a star rating
distribution inconsistent with the raw
distribution of scores on a given
measure. If applied to star ratings, there
would need to be an equal distribution
of clinicians in each of the star rating
categories.
Using the ABCTM methodology for the
benchmark sets the 5-star rating at the
performance rate that is the best
achievable rate in the current clinical
climate based on the current set of
measures and the current universe of
reporters. The star ratings are then
derived from there consistent with the
raw score distribution. In this way, if
the majority of clinicians performed
well on a measure, the majority would
receive a high star rating. If we used the
decile approach some clinicians would
be reported as having a ‘‘low’’ star rating
despite their relative performance on
the measure.
It is not always ideal to use the same
methodology across the program as
scoring for payment purposes may be
designed in a somewhat different way
that may incorporate factors that are not
necessarily as applicable for public
reporting, while the key consideration
for public reporting is that the
methodology used best helps patients
and caregivers easily interpret the data
accurately. Testing with Web site users
has shown that the star rating based on
the ABCTM benchmark helps patients
and caregivers interpret the data
accurately.
ABCTM has been historically well
received by the clinicians and entities it
is measuring because the benchmark
represents quality while being both
realistic and achievable; it encourages
continuous quality improvement; and, it
is shown to lead to improved quality of
care.22 23 24 Appreciating this and the
22 Kiefe CI, Weissman NW., Allison JJ, Farmer R,
Weaver M, Williams OD. Identifying achievable
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support this methodology received in
previous rulemaking and throughout
our outreach process to date, we are
again proposing to use the ABCTM
methodology to determine a benchmark
for the quality, cost, improvement
activities, and advancing care
information data, as feasible and
appropriate, by measure and by
reporting mechanism for each year of
the Quality Payment Program, starting
with the transition year data (2017 data
available for public reporting in late
2018). We are also proposing to use this
benchmark to determine a 5-star rating
for each MIPS measure, as feasible and
appropriate. As previously finalized,
only those measures that meet the
public reporting standards would be
considered and the benchmark would
be based on the most recently available
data. The details of how the benchmark
will translate to the 5-star rating will be
determined in consultation with
stakeholders.
We believe that displaying the
appropriate and relevant MIPS data in
this user-friendly format provides more
opportunities to present these data to
people with Medicare in a way that is
most likely to be accurately understood
and interpreted. We request comment
on these proposals.
g. Voluntary Reporting
In CY 2017 Quality Payment Program
proposed rule (81 FR 28291), we
solicited comment on the advisability
and technical feasibility of including on
Physician Compare data voluntarily
reported by eligible clinicians and
groups that are not subject to MIPS
payment adjustments, such as exempt
clinician types and those clinicians
practicing through Rural Health Centers
(RHCs), Federally Qualified Health
Centers (FQHCs), etc., to be addressed
through separate notice-and-comment
rulemaking.
Overall, comments received were
favorable. Stakeholders generally
support clinicians and groups being
permitted to have data available for
public reporting when submitting these
data voluntarily under MIPS. As a
result, we are now proposing that
starting with year 2 of the Quality
benchmarks of care: concepts and methodology.
International Journal of Quality Health Care. 1998
Oct; 10(5):443–7.
23 Kiefe CI, Allison JJ, Williams O, Person SD,
Weaver MT, Weissman NW. Improving Quality
Improvement Using Achievable Benchmarks For
Physician Feedback: A Randomized Controlled
Trial. JAMA. 2001;285(22):2871–2879.
24 Wessell AM, Liszka HA, Nietert PJ, Jenkins RG,
Nemeth LS, Ornstein S. Achievable benchmarks of
care for primary care quality indicators in a
practice-based research network. American Journal
of Medical Quality 2008 Jan–Feb;23(1):39–46.
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Payment Program (2018 data available
for public reporting in 2019) and for
each year moving forward, to make
available for public reporting all data
submitted voluntarily across all MIPS
performance categories, regardless of
submission method, by clinician and
groups not subject to the MIPS payment
adjustments, as technically feasible.
If a clinician or group chooses to
submit quality, cost, improvement
activity, or advancing care information,
these data would become available for
public reporting. However, because
these data would be submitted
voluntarily, we propose that during the
30-day preview period these clinicians
and groups would have the option to
opt out of having their data publicly
reported on Physician Compare. If
clinicians and groups do not actively
opt out at this time, their data would be
available for inclusion on Physician
Compare if the data meet all previously
stated public reporting standards and
the minimum reliability threshold. As
clinicians and groups not required to
report under MIPS, particularly in the
first years of the Quality Payment
Program, are taking additional steps to
show their commitment to quality care,
we want to ensure they have the
opportunity to report their data and
have it included on Physician Compare.
We request comment on this proposal.
h. APM Data
Section 1848(q)(9)(A)(ii) of the Act
requires us to publicly report names of
eligible clinicians in Advanced APMs
and, to the extent feasible, the names
and performance of Advanced APMs.
We see this as an opportunity to
continue to build on the ACO reporting
we are now doing on Physician
Compare. At this time, if a clinician or
group submitted quality data as part of
an ACO, there is an indicator on the
clinician’s or group’s profile page
indicating this. In this way, it is known
which clinicians and groups took part in
an ACO. Also, currently, all ACOs have
a dedicated page on the Physician
Compare Web site to showcase their
data. For the transition year of the
Quality Payment Program, we decided
to use this model as a guide as we add
APM data to Physician Compare.
Specifically, we finalized a policy to
indicate on eligible clinician and group
profile pages of Physician Compare
when the eligible clinician or group is
participating in an APM (81 FR 77398).
We also finalized a decision to link
eligible clinicians and groups to their
APM’s data, as technically feasible,
through Physician Compare. The
finalized policy provides the
opportunity to publicly report data for
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both Advanced APMs and APMs that
are not considered Advanced APMs for
the transition year, as technically
feasible.
At the outset, APMs will be very new
concepts for Medicare patients and their
caregivers. In these early years,
indicating who participated in APMs
and testing language to accurately
explain that to Web site users provides
useful and valuable information as we
continue to evolve Physician Compare.
As we come to understand how to best
explain this concept to patients and
their caregivers, we can continue to
assess how to most fully integrate these
data on the Web site. Understanding
this and understanding the value of
adding APM data to Physician Compare,
we are again proposing to publicly
report names of eligible clinicians in
Advanced APMs and the names and
performance of Advanced APMs and
APMs that are not considered Advanced
APMs related to the Quality Payment
Program starting with year 2 (2018 data
available for public reporting in late
2019), and for each year moving
forward, as technically feasible. In
addition, we again propose to continue
to find ways to more clearly link
clinicians and groups and the APMs
they participate in on Physician
Compare, as technically feasible. We
request comment on these proposals.
i. Stratification by Social Risk Factors
We understand that social risk factors
such as income, education, race and
ethnicity, employment, disability,
community resources, and social
support play a major role in health. One
of our core objectives is to improve the
outcomes of people with Medicare, and
we want to ensure that complex
patients, as well as those with social
risk factors receive excellent care. In
addition, we seek to ensure that all
clinicians are treated as fairly as
possible within all CMS programs. In
the CY 2017 Quality Payment Program
final rule (81 FR 77395), we noted that
we would review the first of several
reports by the Office of the Assistant
Secretary for Planning and Evaluation
(ASPE).25 In addition, we have been
reviewing the report of the National
Academies of Sciences, Engineering,
and Medicine on the issue of accounting
for social risk factors in CMS programs.
ASPE’s first report, as required by the
Improving Medicare Post-Acute Care
Treatment (IMPACT) Act, was released
25 ASPE, ‘‘Report to Congress: Social Risk Factors
and Performance Under Medicare’s Value-Based
Purchasing Programs.’’ 21 Dec 2016. Available at
https://aspe.hhs.gov/pdf-report/report-congresssocial-risk-factors-and-performance-undermedicares-value-based-purchasing-programs.
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on December 21, 2016, and analyzed the
effects of social risk factors of people
with Medicare on clinician performance
under nine Medicare value-based
purchasing programs. A second report
due October 2019 will expand on these
initial analyses, supplemented with
non-Medicare datasets to measure social
risk factors. The National Academies of
Sciences, Engineers, and Medicine
released its fifth and final report on
January 10, 2017, and provided various
potential methods for accounting for
social risk factors, including stratified
public reporting, as well as
recommended next steps.26
As we continue to consider the
analyses and recommendations from
these and any future reports, we look
forward to working with stakeholders in
this process. Therefore, we seek
comment only on accounting for social
risk factors through public reporting on
Physician Compare. Specifically, we
seek comment on stratified public
reporting by risk factors and ask for
feedback on which social risk factors or
indicators should be used and from
what sources. Examples of social risk
factor indicators include but are not
limited to dual eligibility/low-income
subsidy, race and ethnicity, social
support, and geographic area of
residence. We also seek comment on the
process for accessing or receiving the
necessary data to facilitate stratified
reporting. Finally, we seek comment on
whether strategies such as confidential
reporting of stratified rates using social
risk factor indicators should be
considered in the initial years of the
Quality Payment Program in lieu of
publicly reporting stratified
performance rates for quality and cost
measures under the MIPS on Physician
Compare. We seek comment only on
these items for possible consideration in
future rulemaking.
j. Board Certification
Finally, we propose adding additional
Board Certification information to the
Physician Compare Web site. Board
Certification is the process of reviewing
and certifying the qualifications of a
physician or clinician by a board of
specialists in the relevant field. We
currently include ABMS, AOA, and
ABO data as part of clinician profiles on
Physician Compare. We appreciate that
there are additional, well respected
boards that are not included in the
ABMS, AOA, and ABO data currently
available on Physician Compare that
26 National Academies of Sciences, Engineering,
and Medicine. 2017. Accounting for social risk
factors in Medicare payment. Washington, DC: The
National Academies Press.
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represent clinicians and specialties
represented on the Web site. Such board
certification information is of interest to
users as it provides additional
information to use to evaluate and
distinguish between clinicians on the
Web site, which can help in making an
informed health care decision. The more
data of immediate interest that is
included on Physician Compare, the
more users will come to the Web site
and find quality data that can help them
make informed decisions. Please note
we are not endorsing any particular
boards.
Another board, the American Board of
Wound Medicine and Surgery
(ABWMS), has shown interest in being
added to Physician Compare and have
demonstrated that they have the data to
facilitate inclusion of this information
on the Web site. We believe this board
fills a gap for a specialty that is not
currently covered by the ABMS, so we
propose to add ABWMS Board
Certification information to Physician
Compare.
Additionally, for all years moving
forward, for any board that would like
to be considered to be added to the
Physician Compare Web site, we
propose to establish a process for
reviewing interest from these boards as
it is brought to our attention on a caseby-case basis, and selecting boards as
possible sources of additional board
certification information for Physician
Compare. We further propose that, for
purposes of CMS’s selection, the board
would need to demonstrate that it: Fills
a gap in currently available board
certification information listed on
Physician Compare, can make the
necessary data available, and if
appropriate, can make arrangements and
enter into agreements to share the
needed information for inclusion on
Physician Compare. We propose that
boards contact the Physician Compare
support team at PhysicianCompare@
Westat.com to indicate interest and
initiate the review and discussion
process. Once decisions are made, they
will be communicated via the CMS.gov
Physician Compare initiative Web page
and via the Physician Compare listserv.
We request comments on these
proposals.
D. Overview of the APM Incentive
1. Overview
Section 1833(z) of the Act requires
that an incentive payment be made to
QPs for participation in Advanced
APMs. In the CY 2017 Quality Payment
Program final rule (81 FR 77399 through
77491), we finalized policies relating to
the following topics:
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• Beginning in 2019, if an eligible
clinician participated sufficiently in an
Advanced APM during the QP
Performance Period, that eligible
clinician may become a QP for the year.
Eligible clinicians who are QPs are
excluded from the MIPS reporting
requirements in the performance year
and payment adjustment for the
payment year.
• For years from 2019 through 2024,
QPs receive a lump sum incentive
payment equal to 5 percent of their prior
year’s payments for Part B covered
professional services. Beginning in
2026, QPs receive a higher update under
the PFS for the year than non-QPs.
• For 2019 and 2020, eligible
clinicians may become QPs only
through participation in Advanced
APMs.
• For 2021 and later, eligible
clinicians may become QPs through a
combination of participation in
Advanced APMs and Other Payer
Advanced APMs (which we refer to as
the All-Payer Combination Option).
In this proposed rule, we discuss
proposals for clarifications and
modifications to some of the policies
that we previously finalized, and
provide additional details and proposals
regarding the All-Payer Combination
Option.
2. Terms and Definitions
As we continue to develop the
Quality Payment Program, we have
identified the need to propose
additions, deletions, and changes to
some of the previously finalized
definitions. A list of these definitions is
available in the CY 2017 Quality
Payment Program final rule (81 FR
77537 through 77540).
As we discuss in section II.D.6.d.(2)(a)
of this proposed rule, we propose to
change the timeframe of the QP
Performance Period under the All-Payer
Combination Option so that it would
begin on January 1 and end on June 30
of the calendar year that is 2 years prior
to the payment year. We propose to add
the definition of All-Payer QP
Performance Period using this
timeframe. We also propose to add the
definition of Medicare QP Performance
Period, which would begin on January
1 and end on August 31 of the calendar
year that is 2 years prior to the payment
year. We would replace the definition
we established in the CY 2017 Quality
Payment Program final rule for QP
Performance Period with the definitions
of All-Payer QP Performance Period and
Medicare QP Performance Period. To
update the regulation to incorporate this
proposal, we also propose to remove
‘‘QP Performance Period’’ each time it
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occurs in our regulations and replace it
with either ‘‘All-Payer QP Performance
Period’’ or ‘‘Medicare QP Performance
Period’’ as relevant. As we discuss in
section II.D.6.d.(3)(a) of this proposed
rule, we propose to make QP
determinations under the All-Payer
Combination Option at the eligible
clincian level only. In connection with
our proposals to calculate Threshold
Scores for QP determinations under the
All-Payer Combination Option, we do
not anticipate having or receiving
information about attributed
beneficiaries as we do under the
Medicare Option. This is because, under
the All-Payer Combination Option, APM
Entities or eligible clinicians would
only submit aggregate payment and
patient data. We would not have
anything similar to a Participation List
or an Affiliated Practitioner List for
Other Payer Advanced APMs.
Therefore, we are proposing to change
the definition of attributed beneficiary
so that it only applies to Advanced
APMs, not to Other Payer Advanced
APMs. We seek comment on these
proposals.
We seek comment on these terms,
including how we have defined the
terms, the relationship between terms,
any additional terms that we should
formally define to clarify the
explanation and implementation of this
program, and potential conflicts with
other terms we use in similar contexts.
We also seek comment on the naming of
the terms and whether there are ways to
name or describe their relationships to
one another that make the definitions
more distinct and easier to understand.
For instance, we would consider
options for a framework of definitions
that might more intuitively distinguish
between APMs and Other Payer
Advanced APMs and between APMs
and Advanced APMs.
3. Regulation Text Changes
a. Clarifications and Corrections
We propose to revise the definition of
APM Entity in the regulation at
§ 414.1305 to clarify that a ‘‘payment
arrangement with a non-Medicare
payer’’ is an other payer arrangement as
defined in § 414.1305. We propose to
make technical changes to the definition
of Medicaid APM in § 414.1305 to
clarify that these arrangements must
meet the Other Payer Advanced APM
criteria set forth in § 414.1420, and not
just the criteria under § 414.1420(a) as
provided under the current definition.
To consolidate our regulations and
avoid unnecessarily defining a term, we
propose to remove the defined term for
Advanced APM Entity in § 414.1305
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and to replace ‘‘Advanced APM Entity’’
where it appears throughout the
regulations with ‘‘APM Entity.’’ We also
propose to make this substitution in the
definitions of Affiliated Practitioner and
Attributed Beneficiary in § 414.1305.
Similarly, we propose to replace
‘‘Advanced APM Entity group’’ with
‘‘APM Entity group’’ where it appears
throughout our regulations. We note
that these proposed changes are
technical, and would not have a
substantive effect on our policies.
We propose technical changes to
correct the references in the first
sentence of the regulation at § 414.1415
to refer to the financial risk standard
under paragraph (c)(1) or (2) and the
nominal amount standard under
paragraph (c)(3) or (4). Due to
typographical errors, the current
regulation refers to paragraphs (d)(1)
through (4), and there is no paragraph
(d) in this section. We also propose to
correct typographical errors in
§ 414.1420(a)(3)(i), (ii), (d) and (d)(1). In
§ 414.1420(d), we propose to correct the
reference to the ‘‘nominal risk standard’’
to instead refer to the ‘‘nominal amount
standard.’’ We propose technical, nonsubstantive clarifications in
§§ 414.1425(a)(1) through (3),
414.1425(b)(2), and 414.1435(d). We
also propose to correct a typographical
error in § 414.1460(b) to refer to
participation ‘‘during a Medicare QP
Performance Period’’ instead of ‘‘during
the QP Performance Periods.’’
b. Changes to § 414.1460
We propose to reorganize and revise
the monitoring and program integrity
provisions at § 414.1460. We propose
changes to paragraphs (a), (b), and (d) in
this section of the proposed rule as
these policies apply to both the
Medicare Option and the All-Payer
Combination Option. We discuss
proposed changes to paragraph (c) of
§ 414.1460 in sections II.D.6.c.(7) and
II.D.6.d.(4) of this proposed rule, and
changes to paragraph (e) of § 414.1460
in sections II.D.6.c.(7)(b) and
II.D.6.d.(4)(c), as the policies in these
paragraphs only apply to the All-Payer
Combination Option.
We finalized in the CY 2017 Quality
Payment Program final rule at
§ 414.1460(d) that for any QPs who are
terminated from an Advanced APM or
found to be in violation of any federal,
state, or tribal statute, regulation, or
binding guidance during the QP
Performance Period or Incentive
Payment Base Period or terminated after
these periods as a result of a violation
occurring during either period we may
rescind such eligible clinician’s QP
determinations and, if necessary, recoup
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part or all of any such eligible
clinician’s APM Incentive Payment or
deduct such amount from future
payments to such individuals. We also
finalized that we may reopen and
recoup any payments that were made in
error (81 FR 77555). We recognize that
rescinding QP determinations and
reopening and recouping APM Incentive
Payments are separate policies and for
this reason, we propose to reorganize
§ 414.1460 so that paragraph (b) sets
forth our policy on rescinding QP
determinations and paragraph (d) sets
forth our policy on reopening and
recouping APM Incentive Payments. We
propose to revise § 414.1460(b) to
provide when we may rescind a QP
determination. In addition, we propose
to remove the last sentence of
§ 414.1460(d), which provides that an
APM Incentive Payment will be
recouped if an audit reveals a lack of
support for attested statements provided
by eligible clinicians and APM Entitles.
We believe that this provision is
duplicative of the immediately
preceding sentence, which permits us to
reopen and recoup any erroneous
payments in accordance with existing
procedures set forth at §§ 405.980
through 405.986 and 405.370 through
405.379. We propose to codify our
recoupment policy at § 414.1460(d)(2),
which provides that we may reopen,
revise, and recoup an APM Incentive
Payment that was made in error in
accordance with procedures similar to
those set forth at §§ 405.980 through
405.986 and 405.370 through 405.379 or
as established under the relevant APM.
In the CY 2017 Quality Payment
Program final rule, we indicated at
§ 414.1460(b) that CMS may reduce or
deny an APM Incentive Payment to
eligible clinicians who are terminated
by APMs or whose APM Entities are
terminated by APMs for noncompliance with all Medicare
conditions of participation or the terms
of the relevant Advanced APMs in
which they participate during the QP
Performance Period. We also finalized at
§ 414.1460(a) that for QPs who CMS
determines are not in compliance with
all Medicare conditions of participation
and the terms of the relevant Advanced
APMs in which they participate during
the QP Performance Period, there may
be a reduction or denial of the APM
Incentive Payment. We propose to
consolidate our policy on reducing and
denying APM Incentive Payments and
redesignate it to § 414.1460(d)(1). Thus,
we propose to remove provisions
regarding reducing and denying APM
Incentive Payments from paragraphs (a)
and (b) of § 414.1460, and revise
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paragraph (d) to discuss when CMS may
reduce or deny an APM Incentive
Payment to an eligible clinician. We
solicit comment on these proposals.
4. Advanced APMs
a. Overview
In the CY 2017 Quality Payment
Program final rule (81 FR 77408), we
finalized the criteria that define an
Advanced APM based on the
requirements set forth in sections
1833(z)(3)(C) and (D) of the Act. An
Advanced APM is an APM that:
• Requires its participants to use
certified EHR technology (CEHRT) (See
81 FR 77409–44414);
• Provides for payment for covered
professional services based on quality
measures comparable to measures under
the quality performance category under
MIPS (See 81 FR 77414–77418); and
• Either requires its participating
APM Entities to bear financial risk for
monetary losses that are in excess of a
nominal amount, or the APM is a
Medical Home Model expanded under
section 1115A(c) of the Act (See 81 FR
77418–77431).
APMs may offer multiple options or
tracks with variations in CEHRT use
requirements, quality-based payments,
and the level of financial risk; or
multiple tracks designed for different
types of participant organizations, and
we finalized in the CY 2017 Quality
Payment Program final rule (81 FR
77406) that we will consider different
tracks or options within an APM
separately for purposes of making
Advanced APM determinations.
b. Bearing Financial Risk for Monetary
Losses
In the CY 2017 Quality Payment
Program final rule (81 FR 77418), we
divided the discussion of this criterion
into two main elements: (1) What it
means for an APM Entity to bear
financial risk for monetary losses under
an APM); and (2) what levels of risk we
would consider to be in excess of a
nominal amount. For each of these
elements, we established a generally
applicable standard and a Medical
Home Model standard.
As we discussed in the CY 2017
Quality Payment Program final rule, we
believe that it is important to maintain
the distinction between Medical Home
Models and other APMs because we
believe that Medical Home Models are
categorically different than other types
of APMs, as supported by specific
provisions in the statute enabling
unique treatment of Medical Home
Models. Also, Medical Home Model
participants tend to be smaller in size
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and have lower Medicare revenues
relative to total Medicare spending than
other APM Entities, which affects their
ability to bear substantial risk,
especially in relation to total cost of
care. We believe that the meaning of
nominal financial risk varies according
to context, and that smaller practices
participating in Medical Home Models,
as a category, experience risk differently
than much larger, multispecialty
focused organizations do. Historically,
Medical Home Model participants have
not been required to bear financial risk,
which means the assumption of any
new financial risk presents a new
challenge for these entities (81 FR
77420–77421). For these reasons, we
finalized special standards for Medical
Home Models that are exceptions to the
generally applicable financial risk and
nominal amount standards.
(1) Medical Home Model Eligible
Clinician Limit
In the CY 2017 Quality Payment
Program final rule, we finalized that
beginning in the 2018 Medicare QP
Performance Period, the Medical Home
Model financial risk standard would
only apply to APM Entities that
participate in Medical Home Models
and that have fewer than 50 eligible
clinicians in the organization through
which the APM Entity is owned and
operated (81 FR 77430). Under this
policy, in a Medical Home Model that
otherwise meets the criteria to be an
Advanced APM, the Medical Home
Model financial risk standard would be
applicable only for those APM Entities
owned and operated by organizations
with fewer than 50 eligible clinicians.
We note this policy does not apply to
Medical Home Models expanded under
section 1115A of the Act.
We are proposing to exempt from this
requirement any APM Entities enrolled
in Round 1 of the Comprehensive
Primary Care Plus Model (CPC+).
We finalized the Medical Home
Model eligible clinician limit after
practices applied and signed agreements
with CMS to participate in CPC+ Round
1. As such, practices applying to
participate in CPC+ Round 1 were not
necessarily aware of the eligible
clinician limit policy and will have
already participated in CPC+ for one
year without this requirement applying
to them by the beginning of CY 2018.
Thus, to permit continued and
uninterrupted testing of CPC+ in
existing regions, we believe it is
necessary to exempt practices
participating in CPC+ Round 1 from this
requirement. Additionally, since in
future all APM Entities would know
about this requirement prior to their
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enrollment and in order to ensure that
large APM entities that are able to bear
more risk enroll in such higher risk
models, we are also proposing that
CPC+ participants who enroll in the
future (for example, in CPC+ Round 2)
will not be exempt from this
requirement. While this creates a small
difference between the incentives for
large APM Entities in different cohorts
to participate in CPC+, we believe an
APM Entity should seek to enroll in an
APM, including an Advanced APM,
primarily based on the framework of
that APM itself, rather than the
possibility of other associated payments
such as the Advanced APM incentive
payment. Additionally, we note that any
eligible clinicians in APM Entities
participating in CPC+ that do not
achieve QP status for the year would be
scored under MIPS using the APM
scoring standard, meaning minimal
additional burden would be required for
such MIPS eligible clinicians.
We seek comment on these proposals.
(2) Nominal Amount of Risk
We finalized in the CY 2017 Quality
Payment Program final rule (81 FR
77427) that an APM would meet the
generally applicable nominal amount
standard if, under the terms of the APM,
the total annual amount that an APM
Entity potentially owes us or foregoes is
equal to at least:
• For QP Performance Periods in
2017 and 2018, 8 percent of the average
estimated total Medicare Parts A and B
revenue of participating APM Entities
(the revenue-based standard); or
• For all QP Performance Periods, 3
percent of the expected expenditures for
which an APM Entity is responsible
under the APM (the benchmark-based
standard).
We also finalized in the CY 2017
Quality Payment Program final rule (81
FR 77428) that to be an Advanced APM,
a Medical Home Model must require
that the total annual amount that an
Advanced APM potentially owes us or
foregoes under the Medical Home
Model be at least the following amounts
in a given performance year:
• In 2017, 2.5 percent of the APM
Entity’s total Medicare Parts A and B
revenue.
• In 2018, 3 percent of the APM
Entity’s total Medicare Parts A and B
revenue.
• In 2019, 4 percent of APM Entity’s
total Medicare Parts A and B revenue.
• In 2020 and later, 5 percent of the
APM Entity’s total Medicare Parts A and
B revenue.
Both the generally applicable and
Medical Home Model revenue-based
nominal amount standards state the
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standard in terms of average estimated
total Medicare Parts A and B revenue of
participating APM Entities. We
recognize that this language may be
ambiguous as to whether it is intended
to include payments to all providers and
suppliers in an APM Entity or only
payments directly to the APM Entity
itself. To eliminate this potential
ambiguity, we propose to amend
§§ 414.1415(c)(3)(i)(A) and (c)(4)(i)(A)
through (D) to more clearly define the
generally applicable revenue-based
nominal amount standard and the
Medical Home Model revenue-based
nominal amount standard as a
percentage of the average estimated total
Medicare Parts A and B revenue of
providers and suppliers in participating
APM Entities. Under this proposed
policy, when assessing whether an APM
meets the generally applicable revenuebased nominal amount standard, where
total risk under the model is not
expressly defined in terms of revenue,
we would calculate the estimated total
Medicare Parts A and B revenue of
providers and suppliers at risk for each
APM Entity. We would then calculate
an average of all the estimated total
Medicare Parts A and B revenue of
providers and suppliers at risk for each
APM Entity, and if that average
estimated total Medicare Parts A and B
revenue at risk for all APM Entities was
equal to or greater than 8 percent, the
APM would satisfy the generally
applicable revenue-based nominal
amount standard.
We request comment on this proposal.
(a) Generally Applicable Revenue-Based
Nominal Amount Standard
In the CY 2017 Quality Payment
Program final rule we finalized the
amount of the generally applicable
revenue-based nominal amount
standard for the first two QP
Performance Periods only, and we
sought comment on what the revenuebased nominal amount standard should
be for the third and subsequent QP
Performance Periods. Specifically, we
sought comment on: (1) Setting the
revenue-based standard for 2019 and
later at up to 15 percent of revenue; or
(2) setting the revenue-based standard at
10 percent so long as risk is at least
equal to 1.5 percent of expected
expenditures for which an APM Entity
is responsible under an APM (81 FR
77427).
Many commenters requested that we
not raise the revenue-based nominal
amount standard for 2019 and beyond.
Some commenters stated that
maintaining the 8 percent revenuebased nominal amount standard for
2019 would allow for stability and
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predictability for eligible clinicians
participating in certain APMs. Other
commenters noted that increasing the
revenue-based nominal amount
standard may reduce or discourage
eligible clinicians from participating in
Advanced APMs and that the added
complexity of requiring that a 10
percent revenue-based standard also be
equivalent to at least 1.5 percent of
expected expenditures would be
confusing for participants and other
stakeholders. A few commenters
suggested that we only consider
increasing the revenue-based nominal
amount standard after we review how
the finalized standard affects
participation in Advanced APMs.
We agree that maintaining the
revenue-based nominal amount
standard at 8 percent of the average
estimated total Medicare Parts A and B
revenue of providers and suppliers in
participating APM Entities would
provide stability and clarity for eligible
clinicians and APM Entities. We also
continue to believe that 8 percent of the
average estimated total Medicare Parts A
and B revenue of providers and
suppliers in participating APM Entities
represents a reasonable standard to
determine what constitutes a more than
nominal amount of financial risk. We
believe that the continued testing and
evaluation of APMs with two-sided risk
will yield critical information about the
best way to structure financial
incentives and financial risk, and this
information may have bearing on what
constitutes a more than nominal amount
of risk. Therefore, we will continue to
evaluate the revenue-based nominal
amount standard in light of
participation in Advanced APMs before
considering any increase in later years.
After considering public comments
submitted on the potential options for
increasing the revenue-based nominal
amount standard for Medicare QP
Performance Periods 2019 and later, we
propose to maintain the current
revenue-based nominal amount
standard at 8 percent of the average
estimated total Medicare Parts A and B
revenue of all providers and suppliers
in participating APM Entities for the
2019 and 2020 Medicare QP
Performance Periods, and to address the
standard for Medicare QP Performance
Periods after 2020 through subsequent
rulemaking. We seek comment on
whether we should consider either a
lower or higher revenue-based nominal
amount standard for the 2019 and 2020
Medicare QP Performance Periods, and
on the amount and structure of the
revenue-based nominal amount
standard for Medicare QP Performance
Periods 2021 and later.
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We also seek comment on whether we
should consider a different, potentially
lower, revenue-based nominal amount
standard only for small practices and
those in rural areas that are not
participating in a Medical Home Model
for the 2019 and 2020 Medicare QP
Performance Periods. For the purposes
of the Quality Payment Program, we use
the definition of small practices and
rural areas in § 414.1305. Specifically,
we seek comment on whether such a
standard should apply only to small
and, or rural practices that are
participants in an APM, or also small
and, or rural practices that join larger
APM Entities in order to participate in
APMs. We also seek comment on how
we should decide where a practice is
located in order to determine whether it
is operating in a rural area as rural area
is defined in § 414.1305 of our
regulations. We believe that a different,
potentially lower, revenue-based
nominal amount standard for the 2019
and 2020 Medicare QP Performance
Periods specifically for small practices
and those in rural areas that are not
participating in a Medical Home Model
may allow for their increased
participation in Advanced APMs, which
may help increase the quality and
coordination of care beneficiaries
receive as a result. We believe such a
standard should not apply to small and,
or rural practices participating in a
Medical Home Model because
participants in Medical Home Models
with fewer than 50 eligible clinicians in
their parent organization benefit from
the lower Medical Home Model nominal
amount standard. We also note that
such a standard may have certain
disadvantages, including reducing the
likelihood that potential Advanced
APMs will ultimately result in
reductions in the growth of Medicare
expenditures and increasing the
complexity of the generally applicable
nominal amount standard.
(b) Medical Home Model Nominal
Amount Standard
In the CY 2017 Quality Payment
Program final rule, we finalized that if
the financial risk arrangement under the
Medical Home Model is not based on
revenue (for example, it is based on total
cost of care or a per beneficiary per
month dollar amount), we will make a
determination for the APM based on the
risk under the Medical Home Model
compared to the average estimated total
Parts A and B revenue of its
participating APM Entities using the
most recently available data (81 FR
77428).
We received comments suggesting
that few APM Entities in Medical Home
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Models have had experience with
financial risk, and that many would be
financially challenged to provide
sufficient care or even remain a viable
business if they were faced with the
kinds of substantial disruptions in
revenue that can accompany financial
risk arrangements. Some commenters
indicated that taking on the level of risk
required under our finalized policy
would still represent an increase in total
risk that is too great in magnitude and
premature for the many APM Entities in
Medical Home Models that have little
experience with financial risk.
We recognize these concerns,
however, we still believe that a final
Medical Home Model nominal amount
standard of 5 percent is the appropriate
target for the standard, and that
ultimately setting the standard at 5
percent of Parts A and B revenue of
providers and suppliers in participating
APM Entities would strike the
appropriate balance to reflect the
meaning of ‘‘nominal’’ in the Medical
Home Model context. We continue to
believe that the meaning of the term
‘‘nominal’’ depends on the situation in
which it is applied, so it is appropriate
to consider the characteristics of
Medical Home Models and their
participating APM Entities in setting the
nominal amount standard for Medical
Home Models.
We have reconsidered the incremental
annual increases in the nominal amount
standard that we finalized to occur over
several years from 2.5 percent to 5
percent. We recognize that establishing
an even more gradual increase in risk
for Medical Home Models with a lower
risk floor for the 2018 Medicare QP
Performance Period may be better suited
to the circumstances of many APM
Entities in Medical Home Models that
have little experience with risk. We also
reiterate, as we note for the generally
applicable nominal amount standard,
that the terms and conditions in the
particular APM govern the actual risk
that participants experience; the
nominal amount standard merely sets a
floor on the level of risk required for the
APM to be considered an Advanced
APM. To that end, we believe a small
reduction of risk in the Medical Home
Model nominal amount standard
beginning in the 2018 Medicare QP
Performance Period, along with a more
gradual progression toward the 5
percent nominal amount standard,
would allow for greater flexibility at the
APM level in setting financial risk
thresholds that would encourage more
participation in Medical Home Models
and be more sustainable for the type of
APM Entities that would potentially
participate in Medical Home Models.
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Therefore, we are proposing that to be
an Advanced APM, a Medical Home
Model must require that the total annual
amount that an APM Entity potentially
owes us or foregoes under the Medical
Home Model be at least the following:
• For Medicare QP Performance
Period 2018, 2 percent of the average
estimated total Medicare Parts A and B
revenue of all providers and suppliers
in participating APM Entities.
• For Medicare QP Performance
Period 2019, 3 percent of the average
estimated total Medicare Parts A and B
revenue of all providers and suppliers
in participating APM Entities.
• For Medicare QP Performance
Period 2020, 4 percent of the average
estimated total Medicare Parts A and B
revenue of all providers and suppliers
in participating APM Entities.
• For Medicare QP Performance
Periods 2021 and later, 5 percent of the
average estimated total Medicare Parts A
and B revenue of all providers and
suppliers in participating APM Entities.
We seek comment on this proposal.
c. Summary of Proposals
In summary, we are making the
following proposals in this section:
• We are proposing to amend our
regulation at § 414.1415(c)(3)(i)(A) and
(c)(4)(i)(A) through (D) to more clearly
define the generally applicable revenuebased nominal amount standard and the
Medical Home Model revenue-based
nominal amount standard as a
percentage of the average estimated total
Medicare Parts A and B revenue of all
providers and suppliers in participating
APM Entities.
• We are proposing to amend our
regulation at § 414.1415(c)(2) to any
APM Entities enrolled in an Advanced
APM qualifying under the Medical
Home Model standard as of January 1,
2017, to exempt Round 1 of the CPC+
Model from the requirement that
beginning in the 2018 Medicare QP
Performance Period, the Medical Home
Model financial risk standard applies
only to an APM Entity that is
participating in a Medical Home Model
if it has fewer than 50 eligible clinicians
in its parent organization.
• We are proposing to amend our
regulation at § 414.1415(c)(3)(i)(A) to
provide that the generally applicable
revenue-based nominal amount
standard remain at 8 percent of the
average estimated total Medicare Parts A
and B revenue of providers and
suppliers in participating APM Entities
for the 2019 and 2020 Medicare QP
Performance Periods, and to address the
standard for Medicare QP Performance
Periods after 2020 through subsequent
rulemaking.
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• We are proposing to amend our
regulation at § 414.1415(c)(4)(i)(A)
through (D) to provide that, to be an
Advanced APM, a Medical Home Model
must require that the total annual
amount that an APM Entity potentially
owes us or foregoes under the Medical
Home Model be at least the following
amounts:
++ For Medicare QP Performance
Period 2018, 2 percent of the average
estimated total Medicare Parts A and B
revenue of all providers and suppliers
in participating APM Entities.
++ For Medicare QP Performance
Period 2019, 3 percent of the average
estimated total Medicare Parts A and B
revenue of all providers and suppliers
in participating APM Entities.
++ For Medicare QP Performance
Period 2020, 4 percent of the average
estimated total Medicare Parts A and B
revenue of all providers and suppliers
in participating APM Entities.
++ For Medicare QP Performance
Periods 2021 and later, 5 percent of the
average estimated total Medicare Parts A
and B revenue of all providers and
suppliers in participating APM Entities.
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5. Qualifying APM Participant (QP) and
Partial QP Determination
We finalized policies relating to QP
and Partial QP determinations in the CY
2017 Quality Payment Program final
rule (See 81 FR 77433 through 77450).
We finalized that the QP Performance
Period will run from January 1 through
August 31 of the calendar year that is 2
years prior to the payment year (81 FR
77446). As we discuss in section
II.D.6.(d)(2)(a)of this proposed rule, we
propose to refer to this time period for
the Medicare Option as the Medicare QP
Performance Period.
a. Advanced APMs Starting or Ending
During a Medicare QP Performance
Period
We acknowledge that there may be
Advanced APMs that start after January
1 of the Medicare QP Performance
Period for a year. There may also be
Advanced APMs that end prior to the
August 31 end of the Medicare QP
Performance Period for a year. By
‘‘start’’ and ‘‘end,’’ in this context, we
mean that the period of active testing of
the model starts or ends such that there
is no opportunity for any APM Entity to
participate in the Advanced APM before
it starts, or to participate in it after it
ends. We consider the active testing
period to mean the dates within the
performance period specific to the
model, which is also the time period for
which we consider payment amounts or
patient counts through the Advanced
APM when we make QP determinations.
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An Advanced APM is in active testing
if APM Entities are furnishing services
to beneficiaries and those services will
count toward the APM Entity’s
performance in the Advanced APM.
Active testing does not include, for
example, the period of time after an
APM Entity has stopped furnishing
services to beneficiaries under the terms
of the Advanced APM but is waiting for
calculation or receipt of a performancebased payment. We note that we tie this
policy to the timeframe during which
APM Entities, rather than eligible
clinicians, participate in an Advanced
APM. To the extent the participation of
APM Entities and eligible clinicians is
not the same, we believe it is more
appropriate and consistent with other
policies relating to the APM incentive,
and to APMs in general, to base the
active testing period for an APM on the
activities of the APM Entities because
they are the participants directly subject
to the terms of the Advanced APM,
including the specified performance
period for the Advanced APM. For
example, in a model like CJR, where we
identify eligible clinicians for QP
determinations based on the Affiliated
Practitioner List, it would be possible
for APM Entities to be participating in
active testing of the Advanced APM
without any Affiliated Practitioners for
a period of time. In that case, we would
consider the dates the APM Entities
were able to be in active testing for CJR,
as opposed to the dates when eligible
clinicians began participating as
Affiliated Practitioners. If a specific
APM Entity joins an Advanced APM
after the January 1 start and before the
August 31 end of a Medicare QP
Performance Period, but other APM
Entities participate during the entire
Medicare QP Performance Period (from
January 1 through August 31), then we
would consider the Advanced APM to
be in active testing for the entire
Medicare QP Performance Period.
For example, the performance period
for an Advanced APM may start on May
1, which is after the first QP
determination date (March 31) and
before the second QP determination
date (June 30) during the Medicare QP
Performance Period. If we were to
calculate Threshold Scores in such an
Advanced APM using data in the
denominator for all attribution-eligible
beneficiaries from January through June
30, which would include data for the
period before the Advanced APM is
actively tested, the APM Entities, or, as
applicable, individual eligible clinicians
in that Advanced APM, are less likely
to achieve a QP threshold on either the
June 30 or the final August 31
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determination date for the year. This
outcome would be a direct result of our
operational decisions to begin the
performance period for the Advanced
APM on May 1, which is outside of the
control of both the participating APM
Entities and eligible clinicians. As such,
participants in Advanced APMs that
start or end during the Medicare QP
Performance Period for the year could
be disadvantaged for purposes of QP
determinations. This is because the
numerator of the Threshold Score
calculation would include payment
amounts or patient counts from only the
period before the QP determination date
during which the Advanced APM was
actively tested, while the denominator
would include payment amounts or
patient counts for the entire Medicare
QP performance period up to the QP
determination date.
We propose to modify our policies
regarding the timeframe(s) for which
payment amount and patient count data
are included in the QP payment amount
and patient count threshold calculations
for Advanced APMs that start after
January 1 or end before August 31 in a
given Medicare QP Performance Period.
In these situations, we would calculate
QP Threshold Scores using only data in
the numerator and denominator for the
dates that APM Entities were able to
participate in active testing of the
Advanced APM, per the terms of the
Advanced APM, so long as APM
Entities were able to participate in the
Advanced APM for 60 or more
continuous days during the Medicare
QP Performance Period. We propose to
add this policy at § 414.1425(c)(6) of our
regulations. The QP Threshold Score
would be calculated at the APM Entity
level or the Affiliated Practitioner level
as set forth in § 414.1425(b); this change
would not affect our established policy
as to which list of eligible clinicians, the
Participation List or Affiliated
Practitioner List, would be used.
This proposed change would not
affect how we make QP and Partial QP
determinations for eligible clinicians
who participate in multiple Advanced
APMs as set forth by §§ 414.1425(c)(4)
and 414.1425(d)(2). We propose to make
those calculations using the full
Medicare QP Performance Period even if
the eligible clinician participates in one
or more Advanced APMs that start or
end during the Medicare QP
Performance Period. We believe that
this policy appropriately reflects the
participation of the individual eligible
clinician in multiple Advanced APMs
and is consistent with our general
framework for making QP
determinations. For these QP
determinations, we would include
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patients or payments through all
Advanced APMs the eligible clinician
participates in for a Medicare QP
Performance Period, including any
Advanced APMs that are in active
testing for less than 60 continuous days.
This policy accounts for the eligible
clinician’s flexibility in participating in
Advanced APMs while combining that
participation to potentially meet the QP
threshold.
With the exception of QP
determinations for individual eligible
clinicians who participate in multiple
Advanced APMs, we believe it is
appropriate to require that an Advanced
APM must be actively tested for a
minimum of 60 continuous days during
the Medicare QP Performance Period in
order for the payment amount or patient
count data to be considered for purposes
of QP determinations for the year
because it is important that the QP
determination be based on a measure of
meaningful participation in an
Advanced APM. For example, if an
Advanced APM started on August 30,
we do not believe a QP determination
made based on only 2 days of payment
amount or patient count data in the
numerator and denominator would
reflect a meaningful assessment of
participation in an Advanced APM. We
have chosen a minimum of 60
continuous days because it is the
shortest amount of time between two
snapshot dates: June 30 and August 31.
We believe this amount of time is
sufficient for purposes of measuring
participation in an Advanced APM. We
seek comment on whether it would be
more appropriate to require that the
Advanced APM be in active testing for
at least 90 days, since 90 days is the
shortest possible length of time we
would use to make a QP determination
(if the QP determination is based on
January 1 through March 31).
Under this proposal, we would make
QP determinations for all QP
determination snapshot dates that fall
after the Advanced APM meets the
minimum time requirement of 60
continuous days, whether the Advanced
APM starts or ends during the Medicare
QP Performance Period. We would not
make a QP or Partial QP determination
for participants in Advanced APMs that
are not actively tested for a period of at
least 60 continuous days during the
Medicare QP Performance Period. For
example, for an Advanced APM that
starts its performance period on June 1,
we would not make any QP Threshold
Score calculations for the June 30
snapshot date because the Advanced
APM would not yet have been actively
tested for 60 consecutive days. We
would wait until the August 31
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snapshot date because this would be the
first snapshot where the Advanced APM
was active for 60 or more continuous
days. The QP determination would be
made based on payment amounts or
patient counts from the June 1 start date
to August 31 in both the numerator and
the denominator. For an Advanced APM
that starts on or before January 1 and
ends active testing on June 1, we would
make QP determinations on each
snapshot date, but those determinations
would be made based only on payment
amounts or patient counts from January
1 to June 1. Although the Advanced
APM would not be actively tested
between June 30 and August 31, we
would still make another QP Threshold
Score calculation for APM Entities or
eligible clinicians who had not met the
QP Threshold in case the additional
time for claims run out would give us
more accurate information. For an
Advanced APM that started on August
30 of a year, we would not make a QP
determination for that year because the
APM would not be actively tested for 60
continuous days during the Medicare
QP Performance Period.
We believe that this proposal allows
us to properly measure performance in
Advanced APMs without penalizing
APM Entities or eligible clinicians for
start or end dates that are wholly
outside of their control. We believe this
policy is needed to match the data used
to assess Advanced APM participation
for purposes of the APM incentive
payment with the timeframe during
which the Advanced APM is actively
tested and to accurately reflect the
participation of APM Entities and
eligible clinicians. This proposed policy
would not apply to Other Payer
Advanced APMs because eligible
clinicians have more control over the
start and end dates of payment
arrangements with Other Payers, such as
through contract negotiations, than they
do over our start and end dates, which
we exclusively determine.
This proposed policy would not apply
to APM Entities that had the
opportunity to participate in the
Advanced APM track of an APM during
the entire Medicare QP Performance
Period, but did not do so until partway
through the Medicare QP Performance
Period. For example, Oncology Care
Model (OCM), has two risk tracks: Onesided and two-sided risk. Only the twosided risk track is an Advanced APM.
APM Entities participating in OCM now
have the opportunity to change their
risk track from one-sided to two-sided
risk, to take effect on either January 1 or
July 1 of the applicable calendar year.
Applying this proposed policy to OCM,
an APM Entity participating in OCM
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that requests two-sided risk to take
effect beginning on July 1, 2018, would
be considered a participant in and
Advanced APM as of July 1, but would
be subject to a QP determination based
on payment and patient count data for
the full Medicare QP Performance
Period because that APM Entity had the
opportunity to elect two-sided risk
beginning on January 1, 2018. In this
scenario, the APM Entity has control
over its participation in an Advanced
APM, and could choose to be in the
Advanced APM for the full Medicare QP
Performance Period.
We clarify that this proposed policy
for Advanced APMs that start or end
during the Medicare QP Performance
Period does not apply to the CEHRT
Track (Track 1) of the Comprehensive
Care for Joint Replacement Model (CJR)
because we have determined that Track
1 of CJR is an Advanced APM for the
2017 QP Performance Period. Therefore,
we will include episodes ending on or
after January 1, 2017 in QP
determinations as set forth in our
regulations at § 414.1425.
b. Participation in Multiple Advanced
APMs
We propose to edit § 414.1425(c)(4)
and (d)(4) to better reflect our intended
policy for QP determinations and Partial
QP determinations for eligible clinicians
who are included in more than one
APM Entity group and none of the APM
Entity groups in which the eligible
clinician is included meets the
corresponding QP or Partial QP
threshold, or who are Affiliated
Practitioners. As we explained in the CY
2017 Quality Payment Program final
rule (81 FR 77446–7), eligible clinicians
may become QPs through any of the
assessments conducted for the three
snapshot dates: March 31, June 30, and
August 31. If the APM Entity group
meets the QP threshold under this first
assessment, then all eligible clinicians
in the APM Entity group will be QPs
unless the APM Entity’s participation in
the Advanced APM is voluntarily or
involuntarily terminated before the end
of the Medicare QP Performance Period,
or in the event of eligible clinician or
APM Entity program integrity violation.
We stated these same procedures apply
to the QP determination made for
individual eligible clinicians on an
APM Entity’s Affiliated Practitioner List
or individual eligible clinicians in
multiple Advanced APMs whose APM
Entity groups did not meet the QP
threshold.
We propose to amend our regulation
to make clear that under
§ 414.1425(c)(4), if an eligible clinician
is a determined to be a QP based on
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participation in multiple Advanced
APMs, but any of the APM Entities in
which the eligible clinician participates
voluntarily or involuntarily terminates
from the Advanced APM before the end
of the Medicare QP Performance Period,
the eligible clinician is not a QP. We
propose to make the same clarification
for Partial QP determinations under
§ 414.1425(d)(4). These clarifying edits
specify that this policy applies within
the context of QP and Partial QP
determinations based on participation
in multiple Advanced APMs, not all QP
determinations. Accordingly, for
example, if an eligible clinician is a QP
through participation in both of two
Advanced APMs under § 414.1425(b)(1),
and one APM Entity voluntarily or
involuntarily terminates from one of
those Advanced APMs, the eligible
clinician is still a QP. However, if the
eligible clinician is a QP through
participation in multiple Advanced
APMs under § 414.1425(c)(4), and any
APM Entity that eligible clinician
participates in that counts towards the
QP determination voluntarily or
involuntarily terminates, the eligible
clinician is no longer a QP. We seek
comment on these proposals.
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c. Summary of Proposals
In summary, we are making the
following proposals in this section:
• We propose to calculate QP
Threshold Scores for Advanced APMs
that are actively tested continuously for
a minimum of 60 days during the
Medicare QP Performance Period and
start or end during the Medicare QP
Performance Period using only the dates
that APM Entities were able to
participate in the Advanced APM per
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the terms of the Advanced APM, not the
full Medicare QP Performance Period.
• We propose to make QP
determinations under § 414.1425(c)(4),
for eligible clinicians participating in
multiple Advanced APMs using the full
Medicare QP Performance Period even if
the eligible clinician participates in one
or more Advanced APMs that start or
end during the Medicare QP
Performance Period.
• We propose to amend our
regulation to make clear that under
§ 414.1425(c)(4), if an eligible clinician
is determined to be a QP based on
participation in multiple Advanced
APMs, but any of the APM Entities in
which the eligible clinician participates
voluntarily or involuntarily terminates
from the Advanced APM before the end
of the Medicare QP Performance Period,
the eligible clinician is not a QP.
6. All-Payer Combination Option
a. Overview
Section 1833(z)(2)(B)(ii) of the Act
requires that beginning in payment year
2021, in addition to the Medicare
Option, eligible clinicians may become
QPs through the Combination All-Payer
and Medicare Payment Threshold
Option, which we refer to as the AllPayer Combination Option. In the CY
2017 Quality Payment Program final
rule (81 FR 77459), we finalized our
overall approach to the All-Payer
Combination Option. The Medicare
Option focuses on participation in
Advanced APMs, and we make
determinations under this option based
on Medicare Part B covered professional
services attributable to services
furnished through an APM Entity. The
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30177
All-Payer Combination Option does not
replace or supersede the Medicare
Option; instead, it would allow eligible
clinicians to become QPs by meeting the
QP thresholds through a pair of
calculations that assess Medicare Part B
covered professional services furnished
through Advanced APMs, and a
combination of both Medicare Part B
covered professional services furnished
through Advanced APMs and services
furnished through Other Payer
Advanced APMs. We finalized that
beginning in payment year 2021, we
will conduct QP determinations
sequentially so that the Medicare
Option is applied before the All-Payer
Combination Option (81 FR 77438). An
eligible clinician only needs to be a QP
under either the Medicare Option or the
All-Payer Combination Option to be a
QP for the payment year. The All-Payer
Combination Option encourages eligible
clinicians to participate in payment
arrangements with payers other than
Medicare that have payment designs
that satisfy the Other Payer Advanced
APM criteria. It also encourages
sustained participation in Advanced
APMs across multiple payers.
We finalized that the QP
determinations under the All-Payer
Combination Option are based on
payment amounts or patient counts as
illustrated in Tables 46, 47, and Figures
K1 and K2 (See 81 FR 77460 through
77461). We also finalized that, in
making QP determinations, we will use
the Threshold Score that is most
advantageous to the eligible clinician
toward achieving QP status for the year,
or if QP status is not achieved, Partial
QP status for the year (81 FR 77475).
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TABLE 46: QP Payment Amount Thresholds- All-Payer Combination Option
All-Payer Combination Option- Payment Amount Method
Payment Year
2019
2020
2021
2022
QPPayment
N/A
N/A
50% 25%
50%
Amount
Threshold
Partial QP
Payment Amount
Threshold
N/A
N/A
40%
20%
40%
~~
.....
§· ~
.: ..,
>--3
0
g.
>--3
0
g.
(])
s
25%
2023
75%
25%
2024 and later
75%
25%
20%
50%
20%
50%
~~
.....
§· ~
.: ..,
s
(il
>--3
0
g.
(])
~~
.....
§· ~
.: ..,
(])
s
(il
>--3
0
g.
20%
~~
.....
§· ~
.: ..,
(])
s
(il
(il
TABLE 47: QP Patient Count Thresholds- All-Payer Combination Option
Partial QP Patient
Count Threshold
N/A
N/A
25%
10%
>--3
0
.......
e:..
2022
35%
20%
2023
50%
20%
2024 and later
50%
20%
25%
10%
35%
10%
35%
~~
.....
§· ~
(])
.: e;
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s (])
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>--3
0
.......
e:..
~~
.....
§· ~
(])
.: e;
s (])
E:\FR\FM\30JNP2.SGM
>--3
0
.......
e:..
~~
.....
§· ~
(])
.: e;
s (])
30JNP2
>--3
0
.......
e:..
10%
~~
.....
§· ~
(])
.: e;
s (])
EP30JN17.006
All-Payer Combination Option- Patient Count Method
Payment Year
2019
2020
2021
QP Patient Count N/A
N/A
35%
20%
Threshold
Unlike the Medicare Option, where
we have access to all of the information
necessary to determine whether an APM
meets the criteria to be an Advanced
APM, we cannot identify whether an
other payer arrangement meets the
criteria to be an Other Payer Advanced
APM without receiving the required
information from an external source.
Similarly, we do not have the necessary
payment amount and patient count
information to determine under the AllPayer Combination Option whether an
eligible clinician meets the payment
amount or patient count threshold to be
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a QP without receiving the required
information from an external source.
We finalized the process that eligible
clinicians can use to seek a QP
determination under the All-Payer
Combination Option (81 FR 77478
through 77480):
• The eligible clinician submits to
CMS sufficient information on all
relevant payment arrangements with
other payers;
• Based upon that information CMS
determines that at least one of those
payment arrangements is an Other Payer
Advanced APM; and
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30179
• The eligible clinician meets the
relevant QP thresholds by having
sufficient payments or patients
attributed to a combination of
participation in Other Payer Advanced
APMs and Advanced APMs.
We address the following topics in
this section of the proposed rule: (1)
Other Payer Advanced APM Criteria; (2)
Determination of Other Payer Advanced
APMs; and (3) Calculation of All-Payer
Combination Option Threshold Scores
and QP Determinations.
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b. Other Payer Advanced APM Criteria
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(1) In General
Our goal is to align the Advanced
APM criteria under the Medicare Option
and the Other Payer Advanced APM
criteria under the All-Payer
Combination Option as permitted by
statute and as feasible and appropriate.
We believe this alignment will help
simplify the Quality Payment Program
and encourage participation in Other
Payer Advanced APMs.
In the CY 2017 Quality Payment
Program final rule, we finalized that, in
general, an other payer arrangement
with any payer other than traditional
Medicare, including Medicare Health
Plans, which include Medicare
Advantage, Medicaid-Medicaid Plans,
1876 and 1833 Cost Plans, and Programs
of All Inclusive Care for the Elderly
(PACE) plans, will be an Other Payer
Advanced APM if it meets all three of
the following criteria:
• The other payer arrangement
requires at least 50 percent of
participating eligible clinicians in each
APM Entity (or each hospital if
hospitals are the APM participants) to
use Certified EHR Technology (CEHRT)
to document and communicate clinical
care (81 FR 77464 through 77465);
• The other payer arrangement
requires that quality measures
comparable to measures under the MIPS
quality performance category apply,
which means measures that are
evidence-based, reliable and valid; and,
if available, at least one measure must
be an outcome measure (81 FR 77466);
and
• The other payer arrangement either:
(1) Requires APM Entities to bear more
than nominal financial risk if actual
aggregate expenditures exceed expected
aggregate expenditures (under either the
generally applicable or Medicaid
Medical Home Model standards for
nominal amount of financial risk, as
applicable); or (2) is a Medicaid Medical
Home Model that meets criteria
comparable to Medical Home Models
expanded under section 1115A(c) of the
Act (81 FR 77466 through 77467).
(2) Other Payer Medical Home Models
In the CY 2017 Quality Payment
Program final rule we finalized
definitions of Medical Home Model and
Medicaid Medical Home Model at
§ 414.1305. The statute does not define
‘‘medical homes,’’ but sections
1848(q)(5)(C)(i),
1833(z)(2)(B)(iii)(II)(cc)(BB),
1833(z)(2)(C)(iii)(II)(cc)(BB), and
1833(z)(3)(D)(ii)(II) of the Act make
medical homes an instrumental piece of
the Quality Payment Program.
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We recognize that there may be
medical homes that are operated by
other payers that may be appropriately
considered medical home models under
the All-Payer Combination Option.
Examples of these arrangements may
include those aligned with the
Comprehensive Primary Care Plus
(CPC+) model. Therefore, we seek
comment on whether we should define
the term Other Payer Medical Home
Model as an other payer arrangement
that is determined by CMS to have the
following characteristics:
• The other payer arrangement has a
primary care focus with participants
that primarily include primary care
practices or multispecialty practices that
include primary care physicians and
practitioners and offer primary care
services. For the purposes of this
provision, primary care focus means the
inclusion of specific design elements
related to eligible clinicians practicing
under one more of the following
Physician Specialty Codes: 01 General
Practice; 08 Family Medicine; 11
Internal Medicine; 16 Obstetrics and
Gynecology; 37 Pediatric Medicine; 38
Geriatric Medicine; 50 Nurse
Practitioner; 89 Clinical Nurse
Specialist; and 97 Physician Assistant;
• Empanelment of each patient to a
primary clinician; and
• At least four of the following:
++ Planned coordination of chronic
and preventive care.
++ Patient access and continuity of
care.
++ Risk-stratified care management.
++ Coordination of care across the
medical neighborhood.
++ Patient and caregiver engagement.
++ Shared decision-making.
++ Payment arrangements in addition
to, or substituting for, fee-for-service
payments (for example, shared savings
or population-based payments).
Similar to Medical Home Models and
Medicaid Medical Home Models, we
believe that Other Payer Medical Home
Models could be considered unique
types of other payer arrangements for
purposes of the Quality Payment
Program. We anticipate that participants
in these arrangements may generally be
more limited in their ability to bear
financial risk than other entities because
they may be smaller and predominantly
include primary care practitioners,
whose revenues are a smaller fraction of
the patients’ total cost of care than those
of other eligible clinicians. Because of
these factors, we believe it may be
appropriate to determine whether an
Other Payer Medical Home Model
satisfies the financial risk criterion by
using special Other Payer Medical
Home Model financial risk and nominal
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amount standards, which could be
different from the generally applicable
Other Payer Advanced APM standards
and would be identical to the Medicaid
Medical Home Model financial risk and
nominal amount standards.
We are particularly interested in, and
seek comment on, whether there are
payment arrangements that currently
exist that would meet this definition.
We encourage commenters to note
whether such payment arrangements
would meet the existing generally
applicable Other Payer Advanced APM
financial risk and nominal amount
standards. We also request comments on
any special considerations that might be
relevant when establishing a definition
for a medical home model standard for
payers with payment arrangements that
would not fit under the Medical Home
Model or Medicaid Medical Home
Model definitions, including how the 50
clinician cap discussed in section
II.D.4.b.(1) of this proposed rule for the
Medical Home Model nominal amount
standard would apply.
(3) Financial Risk for Monetary Losses
In the CY 2017 Quality Payment
Program final rule we finalized policies
to assess whether an other payer
arrangement requires participating APM
Entities to bear more than nominal
financial risk if aggregate expenditures
exceed expected aggregated
expenditures (more than nominal
financial risk for monetary losses). This
Other Payer Advanced APM criterion
has two components: A financial risk
standard and a nominal amount
standard. The financial risk standard
defines what it means for an APM Entity
to bear financial risk if actual aggregate
expenditures exceed expected aggregate
expenditures under an other payer
arrangement. We finalized a generally
applicable financial risk standard and a
Medicaid Medical Home Model
financial risk standard for Other Payer
Advanced APMs. (See 81 FR 77466
through 77474).
We finalized that for an other payer
arrangement to meet the generally
applicable financial risk standard for
Other Payer Advanced APMs, if an APM
Entity’s actual aggregate expenditures
exceed expected aggregate expenditures
during a specified performance period,
the payer must:
• Withhold payment of services to the
APM Entity and/or the APM Entity’s
eligible clinicians;
• Reduce payment rates to APM
Entity and/or the APM Entity’s eligible
clinicians; or
• Require direct payments by the
APM Entity to the payer (81 FR 77467).
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We also finalized that for a Medicaid
Medical Home Model to be an Other
Payer Advanced APM, if the APM
Entity’s actual aggregate expenditures
exceed expected aggregate expenditures
during a specified performance period,
the Medicaid Medical Home Model
must:
• Withhold payment of services to the
APM Entity and/or the APM Entity’s
eligible clinicians;
• Reduce payment rates to APM
Entity and/or the APM Entity’s eligible
clinicians;
• Require direct payments by the
APM Entity to the payer; or
• Require the APM Entity to lose the
right to all or part of an otherwise
guaranteed payment or payments (81 FR
77468 through 77469).
(a) Generally Applicable Nominal
Amount Standard
(i) Marginal Risk and Minimum Loss
Rate
The generally applicable nominal
amount standard that we finalized in
the CY 2017 Quality Payment Program
final rule (81 FR 77471) for Other Payer
Advanced APMs differs from the
generally applicable nominal amount
standard for Advanced APMs in two
ways.
First, the finalized generally
applicable Advanced APM nominal
amount standard only requires an APM
to meet one measure of risk—total risk
(81 FR 77424). The finalized generally
applicable Other Payer Advanced APM
nominal amount standard involves
assessment of the following three
measures of risk:
• Marginal risk—the percentage of the
amount by which actual expenditures
exceed expected expenditures for which
an APM Entity would be liable under
the payment arrangement.
• Minimum loss rate—a percentage
by which actual expenditures may
exceed expected expenditures without
triggering financial risk.
• Total risk—the maximum potential
payment for which an APM Entity could
be liable under a payment arrangement.
We note that as described in the CY
2017 Quality Payment Program final
rule (81 FR 77426), although we did not
formally adopt marginal risk or
minimum loss rate criteria for Advanced
APMs, we pointed out that all current
Advanced APMs would meet these
standards, and that we intend that all
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future Advanced APMs would meet the
three measures of risk as well.
Therefore, we do not expect the
application of the different criteria
between Advanced APMs and Other
Payer Advanced APMs to produce
meaningfully different results in terms
of actual risk faced by participants.
Second, the finalized generally
applicable Advanced APM nominal
amount standard allows for total risk to
be defined in one of two ways, based on
expected expenditures (the benchmarkbased standard) or based on revenue
(the revenue-based standard) (81 FR
77427). In contrast, the finalized Other
Payer Advanced APM generally
applicable nominal amount standard is
only based on expected expenditures
(81 FR 77471).
In the CY 2017 Quality Payment
program final rule, we sought comments
on using the expected expenditures
approach for the generally applicable
Other Payer Advanced APM nominal
amount standard.
Table 48 lists the requirements of the
generally applicable nominal amount
standards as finalized in the CY 2017
Quality Payment Program final rule (81
FR 77427 and 77471).
TABLE 48—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
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Generally Applicable Nominal Amount Standard
We do not propose to modify the
marginal risk and minimum loss rate
requirements as we finalized in the CY
2017 Quality Payment Program final
rule as part of the generally applicable
nominal amount standard for Other
Payer Advanced APMs. We continue to
believe that using these measures of risk
will ensure that payment arrangements
involving other payers and APM
Entities or eligible clinicians cannot be
engineered in such a way as to provide
eligible clinicians an avenue to QP
status through an Other Payer Advanced
APM that technically meets the
financial risk criterion but carries a very
low risk of losses based on performance.
Because we do not have direct control
over the design of Other Payer
Advanced APMs, we believe the use of
a multi-factor nominal amount standard
to assess financial risk provides greater
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Other Payer Advanced APMs
For 2017 and 2018, nominal amount of risk
must be at least equal to either:
• 8 percent of average estimated total of
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 which the
APM Entity is responsible.
assurance that Other Payer Advanced
APMs will involve true financial risk in
accordance with statutory requirements.
Including marginal risk and a minimal
loss rate as components of the nominal
amount standard assures that the
payment arrangements that we could
determine are Other Payer Advanced
APMs and could contribute to the
attainment of QP status are similarly
rigorous to Advanced APMs. We request
additional comments on this approach,
and on whether there are potential
alternative approaches to achieving
these goals.
(ii) Revenue-Based Generally Applicable
Nominal Amount Standard
We propose to add a revenue-based
nominal amount standard to the
generally applicable nominal amount
standard for Other Payer Advanced
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APMs that is parallel to the revenuebased nominal amount standard for
Advanced APMs. Specifically, we
propose that an other payer arrangement
would meet the revenue-based nominal
amount standard we are proposing if,
under the terms of the other payer
arrangement, the total amount that an
APM Entity potentially owes the payer
or foregoes is equal to at least: For the
2019 and 2020 All-Payer QP
Performance Periods, 8 percent of the
total combined revenues from the payer
of providers and suppliers in
participating APM Entities. We would
use this standard for other payer
arrangements where financial risk is
expressly defined in terms of revenue in
the payment arrangement. We seek
comment on this proposal.
For Advanced APMs, we may
determine that an APM still meets the
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revenue-based generally applicable
nominal amount standard, even if risk is
not explicitly defined in terms of
revenue, by comparing model downside
risk to the estimated average Medicare
revenue of model participants. Because
we have direct access to Medicare
claims data, we can estimate such an
average. For other payers, we do not
have similar direct access to claims
data. As such, there are significant
operational challenges to identifying
whether an other payer arrangement
would satisfy the revenue-based
nominal amount standard when the
other payer arrangement does not define
risk explicitly in terms of revenue. We
do not have direct access to other payer
revenue data, so we could not do this
calculation without significant
assistance from the relevant payer. For
this reason, we propose that the
revenue-based standard would only be
applied to other payer arrangements in
which risk is explicitly defined in terms
of revenue, as specified in an agreement
covering the other payer arrangement.
We propose that under the generally
applicable nominal amount standard for
Other Payer Advanced APMs, an other
payer arrangement would need to meet
either the benchmark-based nominal
amount standard or the revenue-based
nominal amount standard, and need not
meet both. We believe this proposed
approach to the nominal amount
standard would expand the
opportunities for other payer
arrangements to meet the generally
applicable nominal amount standard,
and would allow closer alignment
between Medicare and other payers as
new payment arrangements are
introduced and evolve. As with the
revenue-based nominal amount
standard for Advanced APMs, which we
discuss in section II.D.4.b.(2)(a) of this
proposed rule, we seek comment on
whether we should consider either a
lower or higher revenue-based nominal
amount standard for the 2019 and 2020
All-Payer QP Performance Periods, and
on the amount and structure of the
revenue-based nominal amount
standard for All-Payer QP Performance
Periods 2021 and later.
We also seek comment on whether we
should consider a different, potentially
lower, revenue-based nominal amount
standard only for small practices and
those in rural areas that are not
participating in a Medicaid Medical
Home Model for the 2019 and 2020 AllPayer QP Performance Periods. For the
purposes of the Quality Payment
Program, we use the definition of small
practices and rural areas in § 414.1305.
We believe that a different, potentially
lower, revenue-based nominal amount
standard for the 2019 and 2020 AllPayer QP Performance Periods
specifically for small and rural
organizations may allow for their
increased participation in Advanced
APMs, which may help increase the
quality and coordination of care
beneficiaries receive as a result.
Specifically, we seek comment on
whether such a standard should apply
only to small and, or, rural practices
that are participants in an APM, or also
to small and/or rural practices that join
larger APM Entities to participate in
APMs. We also seek comment on how
we should decide where a practice is
located to determine whether it is
operating in a rural area is defined in
§ 414.1305.
(b) Medicaid Medical Home Model
Nominal Amount Standard
In the CY 2017 Quality Payment
Program final rule (81 FR 77472), in
addition to the financial risk standard
for Medicaid Medical Home Models, we
finalized that to be an Other Payer
Advanced APM, a Medicaid Medical
Home Model must require that the total
annual amount that an APM Entity
potentially owes or foregoes be at least
the following amounts in a given
performance year:
• In 2019, 4 percent of the APM
Entity’s total revenues under the payer.
• In 2020 and later, 5 percent of the
APM Entity’s total revenues under the
payer.
Table 49 lists the requirements of the
Medicaid Medical Home Model nominal
amount standards as finalized in the CY
2017 Quality Payment Program final
rule (81 FR 77428 and 77472).
TABLE 49—MEDICAID MEDICAL HOME MODEL NOMINAL AMOUNT STANDARDS FOR ADVANCED APMS AND OTHER PAYER
ADVANCED APMS FINALIZED IN THE CY 2017 QUALITY PAYMENT PROGRAM FINAL RULE
Medical Home Model
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Nominal Amount Standard .................................
As we have discussed in section
II.D.4.b.(2)(b) of this proposed rule
regarding APM Entities in Medical
Home Models, we have also received
comments that few APM Entities in
Medical Home Models and Medicaid
Medical Home Models have had
experience with financial risk, and that
many would be financially challenged
to provide sufficient care or even remain
a viable business in the event of
substantial disruptions in revenue. We
understand these concerns that the
gradual increase in risk over time may
be unmanageable for some APM
Entities; however, we still believe that a
final Medicaid Medical Home Model
nominal amount standard of 5 percent
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Medicaid Medical Home Model
Nominal amount of risk must be:
• In 2017, 2.5 percent ..............................
• In 2018, 3 percent .................................
• In 2019, 4 percent
• In 2020 and later, 5 percent
is appropriate and that setting the
standard at 5 percent of the APM
Entity’s total revenue under the payer
appropriately reflects the meaning of
nominal in the Medicaid Medical Home
Model context.
We have reconsidered the incremental
annual increases in the standard over
several years. Our policy finalized in the
CY 2017 Quality Payment Program final
rule set forth what we envisioned was
a gradually increasing but achievable
amount of risk that would apply over
time. In general, we still believe this to
be true, but recognize that establishing
an even more gradual increase in risk
for Medicaid Medical Home Models
may better suit many APM Entities in
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Nominal amount of risk must be:
• In 2019, 4 percent.
• In 2020 and later, 5 percent.
Medicaid Medical Home Models that
have little experience with risk. To that
end, we believe a small reduction of risk
in the Medicaid Medical Home Model
nominal amount standard beginning in
the 2019 All-Payer QP Performance
Period may allow for greater flexibility
in setting financial risk thresholds that
would encourage more participation in
Medicaid Medical Home Models and be
more sustainable for the type of APM
Entities that would potentially
participate in Medicaid Medical Home
Models.
Therefore, we are proposing that, to
be an Other Payer Advanced APM, a
Medicaid Medical Home Model must
require that the total annual amount that
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an APM Entity potentially owes or
foregoes under the Medicaid Medical
Home Model must be at least:
• For All-Payer QP Performance
Period 2019, 3 percent of the APM
Entity’s total revenue under the payer.
• For All-Payer QP Performance
Period 2020, 4 percent of the APM
Entity’s total revenue under the payer.
• For All-Payer QP Performance
Period 2021 and later, 5 percent of the
APM Entity’s total revenue under the
payer.
We seek comment on this proposal.
(4) Summary of Proposals
In summary, we are proposing the
following:
• We propose that an other payer
arrangement would meet the revenuebased nominal amount standard we are
proposing if, under the terms of the
other payer arrangement, the total
amount that an APM Entity potentially
owes the payer or foregoes is equal to
at least: for the 2019 and 2020 All-Payer
QP Performance Periods, 8 percent of
the total combined revenues from the
payer of providers and suppliers in
participating APM Entities.
• We are proposing that to be an
Other Payer Advanced APM, a Medicaid
Medical Home Model must require that
the total annual amount that an APM
Entity potentially owes or foregoes
under the Medicaid Medical Home
Model must be at least:
++ For All-Payer QP Performance
Period 2019, 3 percent of the APM
Entity’s total revenue under the payer.
++ For All-Payer QP Performance
Period 2020, 4 percent of the APM
Entity’s total revenue under the payer.
++ For All-Payer QP Performance
Period 2021 and later, 5 percent of the
APM Entity’s total revenue under the
payer.
c. Determination of Other Payer
Advanced APMs
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(1) Overview
In the CY 2017 Quality Payment
Program final rule, we established a
prospective Advanced APM
determination process (81 FR 77408).
This prospective approach was
implemented to ensure that APM
Entities and eligible clinicians were
aware of which APMs met the
Advanced APM criteria prior to the first
QP Performance Period, and because we
have a general goal of providing notice,
when possible, of which models are
Advanced APMs prior to the beginning
of the Medicare QP Performance Period.
We were able to perform Advanced
APM determinations within the time
period between the effective date of the
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CY 2017 Quality Payment Program final
rule and the beginning of the first QP
Performance Period because we already
possessed all of the information
necessary.
For other payer arrangements, we
specified that an APM Entity or eligible
clinician must submit, by a date and in
a manner determined by us, information
necessary to identify whether a given
payment arrangement satisfies the Other
Payer Advanced APM criteria (81 FR
77480). We finalized that we will
identify Medicaid APMs and Medicaid
Medical Home Models that meet the
Other Payer Advanced APM criteria
before the beginning of the QP
Performance Period (81 FR 77478
through 77480). We also sought
comment on the overall process for
reviewing payment arrangements to
determine whether they are Other Payer
Advanced APMs, and we also sought
comment on whether we should create
a separate pathway to identify whether
other payer arrangements with Medicaid
as a payer meet the Other Payer
Advanced APM criteria (81 FR 77463).
(a) Payer Initiated Other Payer
Advanced APM Determination Process
(Payer Initiated Process)
We propose to allow certain other
payers, including payers with payment
arrangements authorized under Title
XIX, Medicare Health Plan payment
arrangements, and payers with payment
arrangements in CMS Multi-Payer
Models to request that we determine
whether their other payer arrangements
are Other Payer Advanced APMs
starting prior to the 2019 All-Payer QP
Performance Period and each year
thereafter. We propose to generally refer
to this process as the Payer Initiated
Other Payer Advanced APM
Determination Process (Payer Initiated
Process). We believe that establishing
this Payer Initiated Process would be
beneficial to APM Entities and eligible
clinicians because it would help reduce
their reporting burden, and it would
provide us with the most complete
information on payment arrangements.
In addition, we believe the Other Payer
Advanced APM determinations made
via the Payer Initiated Process could be
completed prior to the All-Payer QP
Performance Period, and we could
therefore provide APM Entities and
eligible clinicians with information that
may help them plan their participation
in Other Payer Advanced APMs.
When referring to Medicare Health
Plans in the context of the Payer
Initiated Process, we include in the term
Medicare Advantage and certain types
of plans including Medicare-Medicaid
Plans, 1876 and 1833 Cost Plans, and
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30183
Programs of All Inclusive Care for the
Elderly (PACE) Plans.
If a payer requests that we determine
whether a payment arrangement
authorized under Title XIX, a Medicare
Health Plan payment arrangement, or a
payment arrangement in a CMS MultiPayer Model is an Other Payer
Advanced APM, and the payer uses the
same other payer arrangement in other
commercial lines of business, we
propose to allow the payer to
concurrently request that we determine
whether those other payer arrangements
are Other Payer Advanced APMs as
well. We will make Other Payer
Advanced APM determinations for each
individual payment arrangement.
We propose that these Other Payer
Advanced APM determinations would
be in effect for only one year at a time.
Payers would need to submit payment
arrangement information each year in
order for us to make an Other Payer
Advanced APM determination in each
year. We believe this approach is
appropriate since payment
arrangements can change from year to
year, and also since we may modify
aspects of the Other Payer Advanced
APM criteria from one year to the next.
We seek comment on this approach, and
we are exploring ways to streamline this
process over time.
We propose to allow remaining other
payers, including commercial and other
private payers, to request that we
determine whether other payer
arrangements are Other Payer Advanced
APMs starting in 2019 prior to the 2020
All-Payer QP Performance Period and
annually each year thereafter. We
believe that phasing in the Payer
Initiated Process would allow us to gain
experience with the determination
process on a limited basis with payers
where we have the strongest
relationships and existing processes that
we believe can help facilitate submitting
this information. We anticipate making
improvements and refinements to this
process, which we believe will help us
facilitate receiving this information from
the remaining other payers.
We propose that the Payer Initiated
Process would be voluntary for all
payers. We propose that the Payer
Initiated Process would generally
involve the same steps for each payer
type as listed below for each All-Payer
QP Performance Period, and we
elaborate on details within this
framework that are specific to payer
type in the following subsections:
Guidance and Submission Form: We
intend to make guidance available
regarding the Payer Initiated Process for
each payer type prior to the first
Submission Period, which would occur
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during 2018. We intend to develop a
submission form (which we refer to as
the Payer Initiated Submission Form)
that would be used by payers to request
Other Payer Advanced APM
determinations, and we intend to make
this Payer Initiated Submission Form
available to payers prior to the first
Submission Period. We propose that
payers would be required to use the
Payer Initiated Submission Form to
request that we make an Other Payer
Advanced APM determination. We
intend for the Payer Initiated
Submission Form to include questions
that are applicable to all payment
arrangements and some that are specific
to a particular type of payment
arrangements, and we intend for it to
include a way for payers to attach
supporting documentation. We propose
that payers may submit requests for
review of multiple other payer
arrangements through the Payer
Initiated Process, though we would
make separate determinations as to each
other payer arrangement and a payer
would be required to use a separate
Payer Initiated Submission Form for
each other payer arrangement. Payers
may submit other payer arrangements
with different tracks within that
arrangement as one request along with
information specific to each track.
Submission Period: We propose that
the Submission Period opening date and
Submission Deadline would vary by
payer type to align with existing CMS
processes for payment arrangements
authorized under Title XIX, Medicare
Health Plan payment arrangements, and
payers with payment arrangements in
CMS Multi-Payer Models to the extent
possible and appropriate. We are
proposing these dates based on
operational timelines that take into
account the time necessary to review
submitted information, to align with
other relevant deadlines in the Quality
Payment Program to the extent possible,
and to provide payers with as much
notice of what is required in the Payer
Initiated Process and as much time to
complete any Payer Initiated
Submission Form as possible.
CMS Determination: Upon the timely
receipt of a Payer Initiated Submission
Form, we would use the information
submitted to determine whether the
other payer arrangement meets the
Other Payer Advanced APM criteria. We
propose that if we determine that the
payer has submitted incomplete or
inadequate information, we would
inform the payer and allow the payer to
submit additional information no later
than 10 business days from the date we
inform the payer. For each other payer
arrangement for which the payer does
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not submit sufficient information, we
would not make a determination in
response to that request submitted via
the Payer Initiated Submission Form. As
a result, the other payer arrangement
would not be considered an Other Payer
Advanced APM for the year. These
determinations are final and not subject
to reconsideration.
CMS Notification: We intend to notify
payers of our determinations for each
request as soon as practicable after the
relevant Submission Deadline. APM
Entities or eligible clinicians may
submit information regarding an other
payer arrangement for a subsequent AllPayer QP Performance Period even if we
have determined that the other payer
arrangement is not an Other Payer
Advanced APM for a prior year.
CMS Posting of Other Payer Advanced
APMs: We intend to post on the CMS
Web site a list (which we refer to as the
Other Payer Advanced APM List) of all
other payer arrangements that we
determine to be Other Payer Advanced
APMs. Prior to the start of the relevant
All-Payer QP Performance Period, we
intend to post the Other Payer
Advanced APMs that we determine
through the Payer Initiated Process and
Other Payer Advanced APMs under
Title XIX that we determine through the
Eligible Clinician Initiated Process.
After the All-Payer QP Performance
Period, we would update this list to
include Other Payer Advanced APMs
that we determine based on other
requests through the Eligible Clinician
Initiated Process.
We believe that this proposed Payer
Initiated Process would encourage
greater participation in Other Payer
Advanced APMs, particularly because it
would allow us to post a list of at least
some of the Other Payer Advanced
APMs before the start of the All-Payer
QP Performance Period as discussed in
section II.D.6.d.(2)(a) of this proposed
rule. We also believe that payers are
well positioned to compile and submit
to us the information we require to
make Other Payer Advanced APM
determinations because they develop
other payer arrangements. We seek
comment on these proposals.
We note that we will seek OMB
approval for the proposed Payer
Initiated Submission Form separately
from this rulemaking process. In
accordance with the Paperwork
Reduction Act (PRA), we will publish
the required 60-day public notice and
30-day public notice. In addition, the
entire information collection request
and all associated forms will be made
available for public review prior to OMB
submission.
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(b) APM Entity or Eligible Clinician
Initiated Other Payer Advanced APM
Determination Process (Eligible
Clinician Initiated Process)
In the CY 2017 Quality Payment
Program final rule, we finalized that
APM Entities and eligible clinicians in
payment arrangements with other
payers would have an opportunity to
request determinations of whether an
other payer arrangement(s) is an Other
Payer Advanced APM after the QP
Performance Period (81 FR 77480). At
that time, APM Entities and eligible
clinicians would know which payment
arrangements they participated in
during the preceding QP Performance
Period. We clarify that both APM
Entities and eligible clinicians may
request Other Payer Advanced APM
determinations through this process,
and we refer to this process as the
Eligible Clinician Initiated Process.
We propose that through the Eligible
Clinician Initiated Process, APM
Entities and eligible clinicians
participating in other payer
arrangements would have an
opportunity to request that we
determine for the year whether those
other payer arrangements are Other
Payer Advanced APMs. The Eligible
Clinician Initiated Process could also be
used to request determinations before
the beginning of an All-Payer QP
Performance Period for other payer
arrangements authorized under Title
XIX, as we discuss in section
II.D.6.(c)(2)(b) of this proposed rule. The
Eligible Clinician Initiated Process
would not be necessary for, or
applicable to, other payer arrangements
that are already determined to be Other
Payer Advanced APMs through the
Payer Initiated Process.
Guidance and Submission Form: We
intend to make guidance available
regarding the Eligible Clinician Initiated
Process for each payer type prior to the
first Submission Period, which would
occur during 2018. We intend to
develop a submission form (which we
refer to as the Eligible Clinician Initiated
Submission Form) that would be used
by APM Entities or eligible clinicians to
request Other Payer Advanced APM
determinations, and we intend to make
this Eligible Clinician Initiated
Submission Form available to APM
Entities and eligible clinicians prior to
the first Submission Period. We propose
that APM Entities and eligible clinicians
would be required to use the Eligible
Clinician Initiated Submission Form to
request that we make an Other Payer
Advanced APM determination. We
intend for the Eligible Clinician
Initiated Submission Form to include
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questions that are applicable to all other
payer arrangements and some that are
specific to a particular type of other
payer arrangements, and we intend for
it to include a way for APM Entities or
eligible clinicians to attach supporting
documentation. We propose that APM
Entities or eligible clinicians may
submit requests for review of multiple
other payer arrangements through the
Eligible Clinician Initiated Process,
though we would make separate
determinations as to each other payer
arrangement, and an APM Entity or
eligible clinician would be required to
use a separate Eligible Clinician
Initiated Submission Form for each
other payer arrangement. APM Entities
or eligible clinicians may submit other
payer arrangements with different tracks
within that arrangement as one request
along with information specific to each
track.
Submission Period: In general, we
propose that APM Entities or eligible
clinicians may request Other Payer
Advanced APM determinations
beginning on August 1 of the same year
as the relevant All-Payer QP
Performance Period. We discuss our
proposal to establish the All-Payer QP
Performance Period in section
II.D.6.d.(2)(a) of this proposed rule. We
propose that the Submission Deadline
for requesting Other Payer Advanced
APM determinations, as well as to
request QP determinations under the
All-Payer Combination Option, is
December 1 of the same year as the
relevant All-Payer QP Performance
Period.
CMS Determination: Upon timely
receipt of an Eligible Clinician Initiated
Submission Form, we would use the
information submitted to determine
whether the other payer arrangement
meets the Other Payer Advanced APM
criteria. We propose that, if we
determine that the APM Entity or
eligible clinician has submitted
incomplete or inadequate information,
we would inform the APM Entity or
eligible clinician and allow the APM
Entity or eligible clinician to submit
additional information no later than 10
business days from the date we inform
the APM Entity or eligible clinician. For
each other payer arrangement for which
the APM Entity or eligible clinician
does not submit sufficient information,
we would not make a determination in
response to that request submitted via
the Eligible Clinician Initiated
Submission Form. As a result, the other
payer arrangement would not be
considered an Other Payer Advanced
APM for the year. These determinations
are final and not subject to
reconsideration.
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CMS Notification: We propose to
notify APM Entities and eligible
clinicians of our determinations for each
other payer arrangement for which a
determination was requested as soon as
practicable after the Submission
Deadline.
We note that APM Entities and
eligible clinicians who submit complete
Eligible Clinician Initiated Submission
Forms by September 1 of the calendar
year of the relevant All-Payer QP
Performance Period may allow for us to
make Other Payer Advanced APM
determinations and inform APM
Entities or eligible clinicians of those
determinations prior to the December 1
QP Determination Submission Deadline.
If we determine that an other payer
arrangement is not an Other Payer
Advanced APM, notifying APM Entities
or eligible clinicians of such a
determination may help them avoid the
burden of submitting payment amount
and patient count information for that
payment arrangement. We intend to
make these early notifications to the
extent possible. We propose that APM
Entities or eligible clinicians may
submit information regarding an other
payer arrangement for a subsequent AllPayer QP Performance Period even if we
have determined that the other payer
arrangement is not an Other Payer
Advanced APM for a prior year.
CMS Posting of Other Payer Advanced
APMs: We intend to post on the CMS
Web site a list (which we refer to as the
Other Payer Advanced APM List) of all
of the other payer arrangements that we
determine to be Other Payer Advanced
APMs. Prior to the start of the relevant
All-Payer QP Performance Period, we
intend to post the Other Payer
Advanced APMs that we determine
through the Payer Initiated Process and
Other Payer Advanced APMs under
Title XIX that we determine through the
Eligible Clinician Initiated Process.
After the All-Payer QP Performance
Period, we would update this list to
include Other Payer Advanced APMs
that we determine based on other
requests through the Eligible Clinician
Initiated Process.
We seek comment on these proposals.
We note that we will seek OMB
approval for the proposed Eligible
Clinician Initiated Submission Form
separately from this rulemaking process.
In accordance with the Paperwork
Reduction Act (PRA), we will publish
the required 60-day public notice and
30-day public notice. In addition, the
entire information collection request
and all associated forms will be made
available for public review prior to OMB
submission.
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(2) Medicaid APMs and Medicaid
Medical Home Models
In this section, we discuss how
payers, APM Entities, and eligible
clinicians may request that we
determine whether payment
arrangements authorized under Title
XIX of the Act are Medicaid APMs or
Medicaid Medical Home Models that
meet the Other Payer Advanced APM
criteria. There are some differences
between the determination process for
other payer arrangements where
Medicaid is the payer and the process
for other payer arrangements with other
types of payers. These differences stem
in part from the requirements specified
in sections 1833(z)(2)(B)(ii)(bb) and
1833(z)(2)(C)(ii)(bb) of the Act for the
All-Payer Combination Option for QP
determinations. We interpret those
statutory provisions to direct us, when
making QP determinations under the
All-Payer Combination Option, to
exclude from the calculation of ‘‘all
other payments’’ any payments made (or
patients under the patient count
method) under Title XIX in a state in
which there is no available Medicaid
APM (which by definition at § 414.1305
meets the Other Payer Advanced APM
criteria) or Medicaid Medical Home
Model that meets the Other Payer
Advanced APM criteria. We believe that
our interpretation of the statute to
exclude, when appropriate as discussed
in section II.D.6.(d)(3)(c) of this
proposed rule, Medicaid APMs or
Medicaid Medical Home Models that
meet the Other Payer Advanced APM
criteria, is appropriate to carry out the
terms of the statute while avoiding
circumstances that could unfairly
impact the ability of eligible clinicians
to plan ahead and position themselves
to attain QP status. Our interpretation
leads us to exclude Title XIX payments
or patients from the denominator of QP
calculations when eligible clinicians
had no opportunity to participate in a
Medicaid APM or Medicaid Medical
Home Model that meets the Other Payer
Advanced APM criteria.
To implement this requirement, we
need to determine which states have no
available Medicaid APMs or Medicaid
Medical Home Models that meet the
Other Payer Advanced APM criteria
during a given All-Payer QP
Performance Period as described in
section II.D.6.c.(2)(b) of the proposed
rule. We believe that it is important for
us to make this determination prior to
the All-Payer QP Performance Period,
and to announce the Medicaid APMs
and Medicaid Medical Home Models
that meet the Other Payer Advanced
APM criteria and the locations where
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they are available, so that eligible
clinicians can assess whether their Title
XIX payments and patients would be
excluded under the All-Payer
Combination Option for that particular
performance year. If, for a given state,
we receive no requests to make
determinations for other payer
arrangements that could be Medicaid
APMs or Medicaid Medical Home
Models that are Other Payer Advanced
APMs for the year through either the
Payer Initiated Process or the Eligible
Clinician Initiated Process, we would
assume that there are no Medicaid
APMs or Medicaid Medical Home
Models that meet the Other Payer
Advanced APM criteria in that state for
the relevant All-Payer QP Performance
Period. Accordingly, we would exclude
Title XIX payments and patients from
the All-Payer Combination Option
calculations for eligible clinicians in
that state.
(a) Payer Initiated Process
We propose that any states and
territories (which we refer to as states)
that have in place a state plan under
Title XIX may request that we determine
prior to the All-Payer QP Performance
Period whether other payer
arrangements authorized under Title
XIX are Medicaid APMs or Medicaid
Medical Home Models that meet the
Other Payer Advanced APM criteria, in
other words, are Other Payer Advanced
APMs, under the Payer Initiated
Process. States include the 50 states, the
District of Columbia, the
Commonwealth of Puerto Rico, the
Virgin Islands, Guam, American Samoa,
and the Northern Mariana Islands.
We propose to allow states to request
determinations for both Medicaid feefor-service and Medicaid managed care
plan payment arrangements. States often
use managed care plan contracts to
implement payment arrangements, and
a substantial portion of the Medicaid
beneficiary population receives their
health care services through Medicaid
managed care plans. We expect that
states would work closely with their
managed care plans to identify and
collect relevant information. However,
we propose to accept requests regarding
payment arrangements authorized under
Title XIX under the Payer Initiated
Process only from the state, not from a
Medicaid managed care plan, as states
are responsible ultimately for the
administration of their Medicaid
programs. Details specific to the Payer
Initiated Process for payment
arrangements authorized under Title
XIX are explained below.
Guidance and Submission Form: We
intend to make guidance available
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regarding the Payer Initiated Process for
each payer type prior to the first
Submission Period, which would occur
during 2018. We intend to develop a
submission form (which we refer to as
the Payer Initiated Submission Form)
that would be used by payers to request
Other Payer Advanced APM
determinations, and we intend to send
this Payer Initiated Submission Form to
states prior to the first Submission
Period. We propose that payers would
be required to use the Payer Initiated
Submission Form to request that we
make an Other Payer Advanced APM
determination. We intend for the Payer
Initiated Submission Form to include
questions that are applicable to all other
payer arrangements and some that are
specific to payment arrangements
authorized under Title XIX, and we
intend for it to include a way for payers
to attach supporting documentation. We
propose that payers may submit
requests for review of multiple other
payer arrangements through the Payer
Initiated Process, though we would
make separate determinations as to each
other payer arrangement, and a payer
would be required to use a separate
Payer Initiated Submission Form for
each other payer arrangement. Payers
may submit other payer arrangements
with different tracks within that
arrangement as one request along with
information specific to each track.
We intend to work with states as they
prepare and submit Payer Initiated
Submission Forms for our review. In
completing the Payer Initiated
Submission Form, states could refer to
information we already possess on their
payment arrangements to support their
request for a determination. This
information could include, for example,
submissions that states typically make
to us to obtain authorization to modify
their Medicaid payment arrangements,
such as a State Plan Amendment or an
1115 demonstration’s waiver
application, Special Terms and
Conditions document, implementation
protocol document, or other document
describing the 1115 demonstration
arrangements approved by CMS.
Submission Period: We propose that
the Submission Period for the Payer
Initiated Process for use by states to
request Other Payer Advanced APM
determinations for other payer
arrangements authorized under Title
XIX will open on January 1 of the
calendar year prior to the relevant AllPayer QP Performance Period for which
we would make the determination for a
Medicaid APM or a Medicaid Medical
Home Model that is an Other Payer
Advanced APM. We propose that the
Submission Deadline for these
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submissions is April 1 of the year prior
to the All-Payer QP Performance Period
for which we would make the
determination. As we discuss in section
II.D.6.c.(2) of this proposed rule, we
need to determine Medicaid APMs and
Medicaid Medical Home Models that
are Other Payer Advanced APMs prior
to the start of the All-Payer QP
Performance Period in order to apply
the Title XIX exclusions where
appropriate. We propose these dates for
this reason, as well as to provide time
for APM Entities and eligible clinicians
to review the Medicaid APMs and
Medicaid Medical Home Models that
are Other Payer Advanced APMs on the
Other Payer Advanced APM list.
CMS Determination: Upon the timely
receipt of a Payer Initiated Submission
Form, we would use the information
submitted to determine whether the
other payer arrangement meets the
Other Payer Advanced APM criteria. We
propose that, if we determine that the
state has submitted incomplete or
inadequate information, we would
inform the state and allow the state to
submit additional information no later
than 10 business days from the date we
inform the state. For each other payer
arrangement for which the state does
not submit sufficient information, we
would not make a determination in
response to that request submitted via
the Payer Initiated Submission Form. As
a result, the other payer arrangement
would not be considered an Other Payer
Advanced APM for the year. These
determinations are final and not subject
to reconsideration.
CMS Notification: We propose to
notify states of our determinations for
each request as soon as practicable after
the relevant Submission Deadline. We
propose that states may submit
information regarding an other payer
arrangement for a subsequent All-Payer
QP Performance Period even if we have
determined that the other payer
arrangement is not an Other Payer
Advanced APM for a prior year.
CMS Posting of Other Payer Advanced
APMs: We intend to post on the CMS
Web site a list (which we refer to as the
Other Payer Advanced APM List) of all
other payer arrangements that we
determine to be Other Payer Advanced
APMs. Prior to the start of the relevant
All-Payer QP Performance Period, we
intend to post the Other Payer
Advanced APMs that we determine
through the Payer Initiated Process and
Other Payer Advanced APMs under
Title XIX that we determine through the
Eligible Clinician Initiated Process.
After the All-Payer QP Performance
Period, we would update this list to
include Other Payer Advanced APMs
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that we determine based on other
requests through the Eligible Clinician
Initiated Process.
We intend to implement ongoing
assistance through existing
conversations or negotiations as states
design and develop new payment
arrangements that may be identified as
Other Payer Advanced APMs. As states
begin discussions with us regarding the
development of other payer
arrangements through the different legal
authorities available under Title XIX or
Title XI of the Act, we would help states
consider and address the Other Payer
Advanced APM criteria.
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(b) Eligible Clinician Initiated Process
We believe that, to appropriately
implement the Title XIX exclusions, it
is not feasible to allow APM Entities
and eligible clinicians to request
determinations for Title XIX payment
arrangements after the conclusion of the
All-Payer QP Performance Period for the
year, as we are allowing APM Entities
and eligible clinicians to do for other
payers. To do so would mean that a
single clinician requesting a
determination for a previously unknown
Medicaid APM or Medicaid Medical
Home Model that meets the Other Payer
Advanced APM criteria could
unexpectedly affect QP threshold
calculations for every other clinician in
that state (or county) as described in
section II.D.6.d.(3) of this proposed rule.
Thus, we would be unable to provide
timely notice of the presence of a
Medicaid APM or Medicaid Medical
Home Model that meets the Other Payer
Advanced APM criteria to all other
eligible clinicians in the state whose QP
determinations under the All-Payer
Combination Option could be affected.
To avoid this scenario, we propose to
require that APM Entities and eligible
clinicians may request determinations
for any Medicaid payment arrangements
in which they are participating at an
earlier point, prior to the All-Payer QP
Performance Period. This would allow
all clinicians in a given state or county
to know before the beginning of the
performance period whether their Title
XIX payments and patients would be
excluded from the all-payer calculations
that are used for QP determinations for
the year under the All-Payer
Combination Option. Details specific to
the Eligible Clinician Initiated Process
for payment arrangements authorized
under Title XIX are explained below.
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Guidance and Submission Form: We
intend to make guidance available
regarding the Eligible Clinician Initiated
Process for payment arrangements
authorized under Title XIX prior to the
first Submission Period, which would
occur during 2018. We intend to
develop a submission form (which we
refer to as the Eligible Clinician Initiated
Submission Form) that would be used
by APM Entities or eligible clinicians to
request Other Payer Advanced APM
determinations, and we intend to make
this Eligible Clinician Initiated
Submission Form available to APM
Entities and eligible clinicians prior to
the first Submission Period. We propose
that APM Entities and eligible clinicians
would be required to use the Eligible
Clinician Initiated Submission Form to
request that we make an Other Payer
Advanced APM determination. We
intend for the Eligible Clinician
Initiated Submission Form to include
questions that are applicable to all other
payer arrangements and some that are
specific to payment arrangements made
under Title XIX, and we intend for it to
include a way for APM Entities or
eligible clinicians to attach supporting
documentation. We propose that APM
Entities or eligible clinicians may
submit requests for review of multiple
other payer arrangements through the
Eligible Clinician Initiated Process,
though we would make separate
determinations as to each other payer
arrangement and an APM Entity or
eligible clinician would be required to
use a separate Eligible Clinician
Initiated Submission Form for each
other payer arrangement. APM Entities
or eligible clinicians may submit other
payer arrangements with different tracks
within that arrangement as one request
along with information specific to each
track.
Submission Period: We propose that
APM Entities or eligible clinicians may
submit Eligible Clinician Initiated
Forms for payment arrangements
authorized under Title XIX beginning
on September 1 of the calendar year
prior to the All-Payer QP Performance
Period. We also propose that the
Submission Deadline is November 1 of
the calendar year prior to the All-Payer
QP Performance Period.
CMS Determination: Upon the timely
receipt of an Eligible Clinician Initiated
Submission Form, we would use the
information submitted to determine
whether the other payer arrangement
meets the Other Payer Advanced APM
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30187
criteria. We propose that if we
determine that the APM Entity or
eligible clinician has submitted
incomplete or inadequate information,
we would inform the APM Entity or
eligible clinician and allow the APM
Entity or eligible clinician to submit
additional information no later than 10
business days from the date we inform
the APM Entity or eligible clinician. For
each other payer arrangement for which
the APM Entity or eligible clinician
does not submit sufficient information,
we would not make a determination in
response to that request submitted via
the Eligible Clinician Initiated
Submission Form. As a result, the other
payer arrangement would not be
considered an Other Payer Advanced
APM for the year. These determinations
are final and not subject to
reconsideration.
CMS Notification: We propose to
notify APM Entities and eligible
clinicians of our determinations for each
other payer arrangement for which a
determination was requested as soon as
practicable after the relevant
Submission Deadline. We propose that
APM Entities or eligible clinicians may
submit information regarding an other
payer arrangement for a subsequent AllPayer QP Performance Period even if we
have determined that the other payer
arrangement is not an Other Payer
Advanced APM for a prior year.
CMS Posting of Other Payer Advanced
APMs: We intend to post on the CMS
Web site a list (which we refer to as the
Other Payer Advanced APM List) of all
of the other payer arrangements that we
determine to be Other Payer Advanced
APMs. Prior to the start of the relevant
All-Payer QP Performance Period, we
intend to post the Other Payer
Advanced APMs that we determine
through the Payer Initiated Process and
Other Payer Advanced APMs under
Title XIX that we determine through the
Eligible Clinician Initiated Process.
After the All-Payer QP Performance
Period, we would update this list to
include Other Payer Advanced APMs
that we determine based on other
requests through the Eligible Clinician
Initiated Process.
(c) Summary
The proposed timeline for both the
Payer Initiated and Eligible Clinician
Initiated Other Payer Advanced APM
Determination Processes for payment
arrangements authorized under Title
XIX are summarized in Table 50.
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TABLE 50—OTHER PAYER ADVANCED APM DETERMINATION PROCESS FOR PAYMENT ARRANGEMENTS AUTHORIZED
UNDER TITLE XIX FOR ALL-PAYER QP PERFORMANCE PERIOD 2019
Payer Initiated Process
Medicaid ...........
Date
Eligible Clinician (EC) initiated process *
Guidance sent to states, then Submission
Period Opens.
Submission Period Closes .........................
CMS contacts states and Posts Other
Payer Advanced APM List.
Jan. 2018 .........
Guidance made available to ECs—Submission Period Opens.
Submission Period Closes .........................
CMS contacts ECs and states and Posts
Other Payer Advanced APM List.
April 2018 .........
Sept. 2018 ........
Date
Sept. 2018.
Nov. 2018.
Dec. 2018.
* Note that APM Entities or eligible clinicians may use the Eligible Clinician Initiated Process.
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(3) CMS Multi-Payer Models
For purposes of carrying out the
Quality Payment Program, we propose
to define the term CMS-Multi Payer
Model at § 414.1305 of our regulations
as an Advanced APM that CMS
determines, per the terms of the
Advanced APM, has at least one other
payer arrangement that is designed to
align with the terms of that Advanced
APM. Examples of CMS Multi-Payer
Models include the Comprehensive
Primary Care Plus (CPC+) Model, the
Oncology Care Model (OCM) (2-sided
risk arrangement), and the Vermont AllPayer ACO Model.
Other payer arrangements that are in
a CMS Multi-Payer Model, by
definition, are not APMs and thus
cannot be Advanced APMs under the
Medicare Option. We recognize, though,
that these other payer arrangements
could be Other Payer Advanced APMs.
We therefore propose that beginning in
the first All-Payer QP Performance
Period, payers with other payer
arrangements in a CMS Multi-Payer
Model may request that we determine
whether those aligned other payer
arrangements are Other Payer Advanced
APMs.
Because there may be differences
among the other payer arrangements
that are aligned with an Advanced APM
in a CMS Multi-Payer Model, we
propose to make separate
determinations about each of those
other payer arrangements on an
individual basis. In other words, an
other payer arrangement aligned with an
Advanced APM in a CMS Multi-Payer
Model is not automatically an Other
Payer Advanced APM by virtue of its
alignment.
We acknowledge that there can be
payment arrangements authorized under
Title XIX or Medicare Health Plan
payment arrangements that are aligned
with a CMS Multi-Payer Model. We
propose that payers, APM Entities, or
eligible clinicians who want to request
that we determine whether those
arrangements are Other Payer Advanced
APMs would use the processes specified
for payment arrangements authorized
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under Title XIX and Medicare Health
Plan payment arrangements discussed
in sections II.D.6.c.(2) and II.D.6.c.(4) of
this proposed rule.
(a) Payer Initiated Process
Details specific to the Payer Initiated
Process for payment arrangements in
CMS Multi-Payer Models are explained
below.
Guidance and Submission Form: We
intend to make guidance available
regarding the Payer Initiated Process for
other payer arrangements in CMS MultiPayer Models prior to the first
Submission Period, which would occur
during 2018. We intend to develop a
submission form (which we refer to as
the Payer Initiated Submission Form)
that would be used by payers to request
Other Payer Advanced APM
determinations, and we intend to make
this Payer Initiated Submission Form
available to payers prior to the first
Submission Period. We propose that
payers would be required to use the
Payer Initiated Submission Form to
request that we make an Other Payer
Advanced APM determination. We
intend for the Payer Initiated
Submission Form to include questions
that are applicable to all other payer
arrangements and some that are specific
to other payer arrangements in CMS
Multi-Payer Models, and we intend for
it to include a way for payers to attach
supporting documentation. We propose
that payers may submit requests for
review of multiple other payer
arrangements through the Payer
Initiated Process, though we would
make separate determinations as to each
other payer arrangement and a payer
would be required to use a separate
Payer Initiated Submission Form for
each other payer arrangement. Payers
may submit other payer arrangements
with different tracks within that
arrangement as one request along with
information specific to each track.
Submission Period: We propose that
the submission period would open on
January 1 of the calendar year prior to
the relevant All-Payer QP Performance
Period. We also propose that the
submission period would close on June
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30 of the calendar year prior to the
relevant All-Payer QP Performance
Period.
CMS Determination: Upon the timely
receipt of a Payer Initiated Submission
Form, we would use the information
submitted to determine whether the
other payer arrangement meets the
Other Payer Advanced APM criteria. We
propose that if we determine that the
payer has submitted incomplete or
inadequate information, we would
inform the payer and allow the payer to
submit additional information no later
than 10 business days from the date we
inform the payer. For each other payer
arrangement for which the payer does
not submit sufficient information, we
would not make a determination in
response to that request submitted via
the Payer Initiated Submission Form. As
a result, the other payer arrangement
would not be considered an Other Payer
Advanced APM for the year. These
determinations are final and not subject
to reconsideration.
CMS Notification: We propose to
notify payers of our determinations for
each request as soon as practicable after
the relevant Submission Deadline. We
propose that payers may submit
information regarding an other payer
arrangement for a subsequent All-Payer
QP Performance Period even if we have
determined that the other payer
arrangement is not an Other Payer
Advanced APM for a prior year.
CMS Posting of Other Payer Advanced
APMs: We intend to post on the CMS
Web site a list (which we refer to as the
Other Payer Advanced APM List) of all
other payer arrangements that we
determine to be Other Payer Advanced
APMs. Prior to the start of the relevant
All-Payer QP Performance Period, we
intend to post the Other Payer
Advanced APMs that we determine
through the Payer Initiated Process and
Other Payer Advanced APMs under
Title XIX that we determine through the
Eligible Clinician Initiated Process.
After the All-Payer QP Performance
Period, we would update this list to
include Other Payer Advanced APMs
that we determine based on other
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requests through the Eligible Clinician
Initiated Process.
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(b) Eligible Clinician Initiated Process
Details specific to the Eligible
Clinician Initiated Process for payment
arrangements in CMS Multi-Payer
Models are explained below.
Guidance and Submission Form: We
intend to make guidance available
regarding the Eligible Clinician Initiated
Process for payment arrangements in
CMS Multi-Payer Models prior to the
first Submission Period, which would
occur during 2019. We intend to
develop a submission form (which we
refer to as the Eligible Clinician Initiated
Submission Form) that would be used
by APM Entities or eligible clinicians to
request Other Payer Advanced APM
determinations, and we intend to make
this Eligible Clinician Initiated
Submission Form available to APM
Entities and eligible clinicians prior to
the first Submission Period. We propose
that APM Entities and eligible clinicians
would be required to use the Eligible
Clinician Initiated Submission Form to
request that we make an Other Payer
Advanced APM determination. We
intend for the Eligible Clinician
Initiated Submission Form to include
questions that are applicable to all other
payer arrangements and some that are
specific to other payer arrangements in
CMS Multi-Payer Models, and we
intend for it to include a way for APM
Entities or eligible clinicians to attach
supporting documentation. We propose
that APM Entities or eligible clinicians
may submit requests for review of
multiple other payer arrangements
through the Eligible Clinician Initiated
Process, though we would make
separate determinations as to each other
payer arrangement. An APM Entity or
eligible clinician would be required to
use a separate Eligible Clinician
Initiated Submission Form for each
other payer arrangement. APM Entities
or eligible clinicians may submit other
payer arrangements with different tracks
within that arrangement as one request
along with information specific to each
track.
Submission Period: We propose that
APM Entities or eligible clinicians may
request Other Payer Advanced APM
determinations beginning on August 1
of the same year as the relevant AllPayer QP Performance Period. We
discuss our proposal to establish the
All-Payer QP Performance Period in
section II.D.6.(d)(2)(a) of this proposed
rule. We propose that the Submission
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Deadline for requesting Other Payer
Advanced APM determinations, as well
as to request QP determinations under
the All-Payer Combination Option, is
December 1 of the same year as the
relevant All-Payer QP Performance
Period.
CMS Determination: Upon the timely
receipt of an Eligible Clinician Initiated
Submission Form, we would use the
information submitted to determine
whether the other payer arrangement
meets the Other Payer Advanced APM
criteria. We propose that if we
determine that the APM Entity or
eligible clinician has submitted
incomplete or inadequate information,
we would inform the APM Entity or
eligible clinician and allow the APM
Entity or eligible clinician to submit
additional information no later than 10
business days from the date we inform
the APM Entity or eligible clinician. For
each other payer arrangement for which
the APM Entity or eligible clinician
does not submit sufficient information,
we would not make a determination in
response to that request submitted via
the Eligible Clinician Initiated
Submission Form. As a result, the other
payer arrangement would not be
considered an Other Payer Advanced
APM for the year. These determinations
are final and not subject to
reconsideration.
CMS Notification: We propose to
notify APM Entities and eligible
clinicians of our determinations for each
other payer arrangement for which a
determination was requested as soon as
practicable after the relevant
Submission Deadline. We note that
APM Entities and eligible clinicians
who submit complete Eligible Clinician
Initiated Submission Forms by
September 1 of the calendar year of the
relevant All-Payer QP Performance
Period may allow for us to make Other
Payer Advanced APM determinations
and inform APM Entities or eligible
clinicians of those determinations prior
to the December 1 QP Determination
Submission Deadline. If we determine
that an other payer arrangement is not
an Other Payer Advanced APM,
notifying APM Entities or eligible
clinicians of such a determination may
help them avoid the burden of
submitting payment amount and patient
count information for that payment
arrangement. We intend to make these
early notifications to the extent possible.
We propose that APM Entities or
eligible clinicians may submit
information regarding an other payer
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Sfmt 4702
30189
arrangement for a subsequent All-Payer
QP Performance Period even if we have
determined that the other payer
arrangement is not an Other Payer
Advanced APM for a prior year.
CMS Posting of Other Payer Advanced
APMs: We intend to post on the CMS
Web site a list (which we refer to as the
Other Payer Advanced APM List) of all
of the other payer arrangements that we
determine to be Other Payer Advanced
APMs. Prior to the start of the relevant
All-Payer QP Performance Period, we
intend to post the Other Payer
Advanced APMs that we determine
through the Payer Initiated Process and
Other Payer Advanced APMs under
Title XIX that we determine through the
Eligible Clinician Initiated Process.
After the All-Payer QP Performance
Period, we would update this list to
include Other Payer Advanced APMs
that we determine based on other
requests through the Eligible Clinician
Initiated Process.
(c) State All-Payer Models
Some CMS Multi-Payer Models
involve an agreement with a state to test
an APM and one or more associated
other payer arrangements in that state
where the state prescribes uniform
payment arrangements across statebased payers. As such, we believe it
may be appropriate and efficient for
states, rather than any other payer, to
submit information to us on these
payment arrangements for purposes of
an Other Payer Advanced APM
determination.
We propose that, in CMS Multi-Payer
Models where a state prescribes uniform
payment arrangements across all payers
statewide, the state would submit on
behalf of payers in the Payer Initiated
Process for Other Payer Advanced
APMs; we would seek information for
the determination from the state, rather
than individual payers. The same Payer
Initiated Process and timeline described
above for CMS Multi-Payer Models
would apply. We seek comment on this
proposal. Additionally, we seek
comment regarding the effectiveness of
taking a similar approach in cases where
the state does not require uniform
payment arrangements across payers.
(d) Summary
The proposed timelines for both the
Payer Initiated and Eligible Clinician
Initiated Other Payer Advanced APM
Determination Processes for payment
arrangements in CMS Multi-Payer
Models are summarized in Table 51.
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TABLE 51—OTHER PAYER ADVANCED APM DETERMINATION PROCESS FOR CMS MULTI-PAYER MODELS FOR ALL-PAYER
QP PERFORMANCE PERIOD 2019
Payer Initiated Process
CMS MultiPayer Models.
Date
Eligible Clinician (EC)
initiated process *
Guidance made available to payers—Submission Period Opens.
Submission Period Closes .........................
CMS contacts payers and Posts Other
Payer Advanced APM Lists.
Jan. 2018 .........
Guidance made available to ECs—Submission Period Opens.
Submission Period Closes .........................
CMS contacts ECs and Posts Other Payer
Advanced APM List.
June 2018 ........
Sept. 2018 ........
Date
Aug. 2019.
Dec. 2019.
Dec. 2019.
mstockstill on DSK30JT082PROD with PROPOSALS2
* Note that APM Entities or eligible clinicians may use the Eligible Clinician Initiated Process.
(4) Medicare Health Plans
The Medicare Option for QP
determinations under sections
1833(z)(2)(A), (2)(B)(i), and (2)(C)(i) of
the Act, is based only on the percentage
of Part B payments for covered
professional services, or patients, that is
attributable to payments through an
Advanced APM. As such, payment
amounts or patient counts under
Medicare Health Plans, including
Medicare Advantage, MedicareMedicaid Plans, 1876 and 1833 Cost
Plans, and Programs of All Inclusive
Care for the Elderly (PACE) plans,
cannot be included in the QP
determination calculations under the
Medicare Option. (See 81 FR 77473
through 77474). Instead, eligible
clinicians who participate in Other
Payer Advanced APMs, including those
with Medicare Advantage as a payer,
could begin receiving credit for that
participation through the All-Payer
Combination Option in 2021 based on
the performance in the 2019 All-Payer
QP Performance Period.
In light of these statutory limitations,
we have received feedback in support of
creating a way for those participating or
who could participate in Advanced
APMs that include Medicare Advantage
to receive credit for that participation in
QP determinations under the Medicare
Option. We are considering
opportunities to address this issue. We
seek comment on such opportunities,
including potential models and uses of
our waiver and demonstration
authorities.
Under the All-Payer Combination
Option, eligible clinicians can become
QPs based in part on payment amounts
or patient counts associated with payer
arrangements through Medicare Health
Plans, provided that such arrangements
meet the criteria to be Other Payer
Advanced APMs. We note that the
financial relationship between the
Medicare Health Plan and CMS is not
relevant to the Other Payer Advanced
APM determination. Rather, because QP
determinations are made for eligible
clinicians, only the payment
arrangement between a Medicare Health
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Plan and an eligible clinician is relevant
when determining whether a payment
arrangement is an Other Payer
Advanced APM.
(a) Payer Initiated Process
We propose that Medicare Health
Plans may request that we determine
whether their payment arrangements are
Other Payer Advanced APMs prior to
the All-Payer QP Performance Period,
by submitting information
contemporaneously with the annual
bidding process for Medicare Advantage
contracts (that is., submitted by the first
Monday in June of the year prior to the
payment and coverage year). Because
this is a process in which many
Medicare Health Plans currently
participate, we believe it will be the
least burdensome approach for
Medicare Health Plans.
Details specific to the Payer Initiated
Process for Medicare Health Plan
payment arrangements are explained
below.
Guidance and Submission Form: We
intend to make guidance available
regarding the Payer Initiated Process for
Medicare Health Plan payment
arrangements prior to the first
Submission Period, which would occur
during 2018. We intend to make
guidance available on or around the
time of release of the Part C and D
Advance Notice and Draft Call Letter the
year prior to the relevant All-Payer QP
Performance Period. We intend to
develop a submission form (which we
refer to as the Payer Initiated
Submission Form) that would be used
by payers to request Other Payer
Advanced APM determinations, and we
intend to make this Payer Initiated
Submission Form available to payers
prior to the first Submission Period.
This form would be built into the Health
Plan Management System (HPMS),
which payers currently use for the
annual bidding process. We propose
that payers would be required to use the
Payer Initiated Submission Form to
request that we make an Other Payer
Advanced APM determination. We
intend for the Payer Initiated
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Fmt 4701
Sfmt 4702
Submission Form to include questions
that are applicable to all other payer
arrangements and some that are specific
to Medicare Health Plan payment
arrangements, and we intend for it to
include a way for payers to attach
supporting documentation. We propose
that payers may submit requests for
review of multiple other payer
arrangements through the Payer
Initiated Process, though we would
make separate determinations as to each
other payer arrangement and a payer
would be required to use a separate
Payer Initiated Submission Form for
each other payer arrangement. Payers
may submit other payer arrangements
with different tracks within that
arrangement as one request along with
information specific to each track.
Submission Period: We propose that
the Submission Period would begin and
end at the same time as the annual bid
timeframe. We propose the Submission
Period would begin when the bid
packages are sent out to plans in April
of the year prior to the relevant AllPayer QP Performance Period. We also
propose that the Submission Deadline
would be the annual bid deadline,
which would be the first Monday in
June in the year prior to the relevant
All-Payer QP Performance Period.
CMS Determination: Upon the timely
receipt of a Payer Initiated Submission
Form, we would use the information
submitted to determine whether the
other payer arrangement meets the
Other Payer Advanced APM criteria. We
propose that if we determine that the
payer has submitted incomplete or
inadequate information, we would
inform the payer and allow the payer to
submit additional information no later
than 10 business days from the date we
inform the payer. For each other payer
arrangement for which the payer does
not submit sufficient information, we
would not make a determination in
response to that request submitted via
the Payer Initiated Submission Form. As
a result, the other payer arrangement
would not be considered an Other Payer
Advanced APM for the year. These
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Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
mstockstill on DSK30JT082PROD with PROPOSALS2
determinations are final and not subject
to reconsideration.
CMS Notification: We propose to
notify payers of our determinations for
each request as soon as practicable after
the relevant Submission Deadline. We
propose that payers may submit
information regarding an other payer
arrangement for a subsequent All-Payer
QP Performance Period even if we have
determined that the other payer
arrangement is not an Other Payer
Advanced APM for a prior year.
CMS Posting of Other Payer Advanced
APMs: We intend to post on the CMS
Web site a list (which we refer to as the
Other Payer Advanced APM List) of all
other payer arrangements that we
determine to be Other Payer Advanced
APMs. Prior to the start of the relevant
All-Payer QP Performance Period, we
intend to post the Other Payer
Advanced APMs that we determine
through the Payer Initiated Process and
Other Payer Advanced APMs under
Title XIX that we determine through the
Eligible Clinician Initiated Process.
After the All-Payer QP Performance
Period, we would update this list to
include Other Payer Advanced APMs
that we determine based on other
requests through the Eligible Clinician
Initiated Process.
(b) Eligible Clinician Initiated Process
Details specific to the Payer Initiated
Process for Medicare Health Plan
payment arrangements are explained
below.
Guidance and Submission Form: We
intend to make guidance available
regarding the Eligible Clinician Initiated
Process for Medicare Health Plan
payment arrangements prior to the first
Submission Period, which would occur
during 2019. We intend to develop a
submission form (which we refer to as
the Eligible Clinician Initiated
Submission Form) that would be used
by APM Entities or eligible clinicians to
request Other Payer Advanced APM
determinations, and we intend to make
this Eligible Clinician Initiated
Submission Form available to APM
Entities and eligible clinicians prior to
the first Submission Period. We propose
that APM Entities and eligible clinicians
would be required to use the Eligible
Clinician Initiated Submission Form to
request that we make an Other Payer
Advanced APM determination. We
intend for the Eligible Clinician
Initiated Submission Form to include
questions that are applicable to all other
payer arrangements and some that are
specific to Medicare Health Plan
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19:16 Jun 29, 2017
Jkt 241001
payment arrangements, and we intend
for it to include a way for APM Entities
or eligible clinicians to attach
supporting documentation. We propose
that APM Entities or eligible clinicians
may submit requests for review of
multiple other payer arrangements
through the Eligible Clinician Initiated
Process, though we would make
separate determinations as to each other
payer arrangement and an APM Entity
or eligible clinician would be required
to use a separate Eligible Clinician
Initiated Submission Form for each
other payer arrangement. APM Entities
or eligible clinicians may submit other
payer arrangements with different tracks
within that arrangement as one request
along with information specific to each
track.
Submission Period: We propose that
APM Entities or eligible clinicians may
request Other Payer Advanced APM
determinations beginning on August 1
of the same year as the relevant AllPayer QP Performance Period. We
discuss our proposal to establish the
All-Payer QP Performance Period in
section II.D.6.(d)(2)(a) of this proposed
rule. We propose that the Submission
Deadline for requesting Other Payer
Advanced APM determinations, as well
as to request QP determinations under
the All-Payer Combination Option, is
December 1 of the same year as the
relevant All-Payer QP Performance
Period.
CMS Determination: Upon the timely
receipt of an Eligible Clinician Initiated
Submission Form, we would use the
information submitted to determine
whether the other payer arrangement
meets the Other Payer Advanced APM
criteria. We propose that if we
determine that the APM Entity or
eligible clinician has submitted
incomplete or inadequate information,
we would inform the APM Entity or
eligible clinician and allow the APM
Entity or eligible clinician to submit
additional information no later than 10
business days from the date we inform
the APM Entity or eligible clinician. For
each other payer arrangement for which
the APM Entity or eligible clinician
does not submit sufficient information,
we would not make a determination in
response to that request submitted via
the Eligible Clinician Initiated
Submission Form. As a result, the other
payer arrangement would not be
considered an Other Payer Advanced
APM for the year. These determinations
are final and not subject to
reconsideration.
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Frm 00183
Fmt 4701
Sfmt 4702
30191
CMS Notification: We propose to
notify APM Entities and eligible
clinicians of our determinations for each
other payer arrangement for which a
determination was requested as soon as
practicable after the relevant
Submission Deadline. We note that
APM Entities and eligible clinicians
who submit complete Eligible Clinician
Initiated Submission Forms by
September 1 of the calendar year of the
relevant All-Payer QP Performance
Period may allow for us to make Other
Payer Advanced APM determinations
and inform APM Entities or eligible
clinicians of those determinations prior
to the December 1 QP Determination
Submission Deadline. If we determine
that an other payer arrangement is not
an Other Payer Advanced APM,
notifying APM Entities or eligible
clinicians of such a determination may
help them avoid the burden of
submitting payment amount and patient
count information for that payment
arrangement. We intend to make these
early notifications to the extent possible.
We propose that APM Entities or
eligible clinicians may submit
information regarding an other payer
arrangement for a subsequent All-Payer
QP Performance Period even if we have
determined that the other payer
arrangement is not an Other Payer
Advanced APM for a prior year.
CMS Posting of Other Payer Advanced
APMs: We intend to post on the CMS
Web site a list (which we refer to as the
Other Payer Advanced APM List) of all
of the other payer arrangements that we
determine to be Other Payer Advanced
APMs. Prior to the start of the relevant
All-Payer QP Performance Period, we
intend to post the Other Payer
Advanced APMs that we determine
through the Payer Initiated Process and
Other Payer Advanced APMs under
Title XIX that we determine through the
Eligible Clinician Initiated Process.
After the All-Payer QP Performance
Period, we would update this list to
include Other Payer Advanced APMs
that we determine based on other
requests through the Eligible Clinician
Initiated Process.
(c) Summary
The proposed timeline for both the
Payer Initiated and Eligible Clinician
Initiated Other Payer Advanced APM
Determination Processes for Medicare
Health Plan payment arrangements are
summarized in Table 52.
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Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
TABLE 52—OTHER PAYER ADVANCED APM DETERMINATION PROCESS FOR MEDICARE HEALTH PLAN PAYMENT
ARRANGEMENTS FOR ALL-PAYER QP PERFORMANCE PERIOD 2019
Payer Initiated Process
Medicare Health
Plans.
Date
Eligible Clinician (EC) initiated process *
Guidance sent to Medicare Health Plans—
Submission Period Opens.
Submission Period Closes .........................
CMS contacts Medicare Health Plans and
Posts Other Payer Advanced APM List.
April 2018 .........
Guidance made available to ECs—Submission Period Opens.
Submission Period Closes .........................
CMS contacts ECs and Posts Other Payer
Advanced APM List.
June 2018 ........
Sept. 2018 ........
Date
Aug. 2019.
Dec. 2019.
Dec. 2019.
* Note that APM Entities or eligible clinicians may use the Eligible Clinician Initiated Process.
(5) Remaining Other Payers
mstockstill on DSK30JT082PROD with PROPOSALS2
(a) Payer Initiated Process
We propose to allow the remaining
other payers not specifically addressed
in proposals above, including
commercial and other private payers
that are not states, Medicare Health
Plans or payers with arrangements that
are aligned with a CMS Multi-Payer
Model, to request that we determine
whether other payer arrangements are
Other Payer Advanced APMs starting
prior to the 2020 All-Payer QP
Performance Period and each year
thereafter. We seek comment on this
proposal, and we also seek comment on
potential challenges to these other
payers submitting information to us for
Other Payer Advanced APM
determinations. We intend to discuss
this process in more detail in future
rulemaking.
(b) Eligible Clinician Initiated Process
We propose that APM Entities and
eligible clinicians may request that we
determine whether an other payer
arrangement with one of these other
payers is an Other Payer Advanced
APM beginning 2019 All-Payer QP
Performance Period as explained below.
Guidance and Submission Form: We
intend to make guidance available
regarding the Eligible Clinician Initiated
Process for remaining other payer
arrangements prior to the first
Submission Period, which would occur
during 2019. We intend to develop a
submission form (which we refer to as
the Payer Initiated Submission Form)
that would be used by APM Entities or
eligible clinicians to request Other Payer
Advanced APM determinations, and we
intend to make this Eligible Clinician
Initiated Submission Form available to
APM Entities and eligible clinicians
prior to the first Submission Period. We
propose that APM Entities and eligible
clinicians would be required to use the
Eligible Clinician Initiated Submission
Form to request that we make an Other
Payer Advanced APM determination.
We intend for the Eligible Clinician
Initiated Submission Form to include
questions that are applicable to all other
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19:16 Jun 29, 2017
Jkt 241001
payer arrangements and some that are
specific to remaining other payer
arrangements, and we intend for it to
include a way for APM Entities or
eligible clinicians to attach supporting
documentation. We propose that APM
Entities or eligible clinicians may
submit requests for review of multiple
other payer arrangements through the
Eligible Clinician Initiated Process,
though we would make separate
determinations as to each other payer
arrangement and an APM Entity or
eligible clinician would be required to
use a separate Eligible Clinician
Initiated Submission Form for each
other payer arrangement. APM Entities
or eligible clinicians may submit other
payer arrangements with different tracks
within that arrangement as one request
along with information specific to each
track.
Submission Period: We propose that
APM Entities or eligible clinicians may
request Other Payer Advanced APM
determinations beginning on August 1
of the same year as the relevant AllPayer QP Performance Period. We
discuss our proposal to establish the
All-Payer QP Performance Period in
section II.D.6.(d)(2)(a) of this proposed
rule. We propose that the Submission
Deadline for requesting Other Payer
Advanced APM determinations, as well
as to request QP determinations under
the All-Payer Combination Option, is
December 1 of the same year as the
relevant All-Payer QP Performance
Period.
CMS Determination: Upon the timely
receipt of an Eligible Clinician Initiated
Submission Form, we would use the
information submitted to determine
whether the other payer arrangement
meets the Other Payer Advanced APM
criteria. We propose that if we
determine that the APM Entity or
eligible clinician has submitted
incomplete or inadequate information,
we would inform the APM Entity or
eligible clinician and allow the APM
Entity or eligible clinician to submit
additional information no later than 10
business days from the date we inform
the APM Entity or eligible clinician. For
each other payer arrangement for which
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Frm 00184
Fmt 4701
Sfmt 4702
the APM Entity or eligible clinician
does not submit sufficient information,
we would not make a determination in
response to that request submitted via
the Eligible Clinician Initiated
Submission Form. As a result, the other
payer arrangement would not be
considered an Other Payer Advanced
APM for the year. These determinations
are final and not subject to
reconsideration.
CMS Notification: We propose to
notify APM Entities and eligible
clinicians of our determinations for each
other payer arrangement for which a
determination was requested as soon as
practicable after the relevant
Submission Deadline. We note that
APM Entities and eligible clinicians
who submit complete Eligible Clinician
Initiated Submission Forms by
September 1 of the calendar year of the
relevant All-Payer QP Performance
Period may allow for us to make Other
Payer Advanced APM determinations
and inform APM Entities or eligible
clinicians of those determinations prior
to the December 1 QP Determination
Submission Deadline. If we determine
that an other payer arrangement is not
an Other Payer Advanced APM,
notifying APM Entities or eligible
clinicians of such a determination may
help them avoid the burden of
submitting payment amount and patient
count information for that payment
arrangement. We intend to make these
early notifications to the extent possible.
We propose that APM Entities or
eligible clinicians may submit
information regarding an other payer
arrangement for a subsequent All-Payer
QP Performance Period even if we have
determined that the other payer
arrangement is not an Other Payer
Advanced APM for a prior year.
CMS Posting of Other Payer Advanced
APMs: We intend to post on the CMS
Web site a list (which we refer to as the
Other Payer Advanced APM List) of all
of the other payer arrangements that we
determine to be Other Payer Advanced
APMs. Prior to the start of the relevant
All-Payer QP Performance Period, we
intend to post the Other Payer
Advanced APMs that we determine
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through the Payer Initiated Process and
Other Payer Advanced APMs under
Title XIX that we determine through the
Eligible Clinician Initiated Process.
After the All-Payer QP Performance
Period, we would update this list to
include Other Payer Advanced APMs
that we determine based on other
requests through the Eligible Clinician
Initiated Process.
We seek comments on these
proposals.
30193
(c) Summary
The proposed timeline for both the
Payer Initiated and Eligible Clinician
Initiated Other Payer Advanced APM
Determination Processes for payment
arrangements for remaining other payers
are summarized in Table 53.
TABLE 53—OTHER PAYER ADVANCED APM DETERMINATION PROCESS FOR REMAINING OTHER PAYER PAYMENT
ARRANGEMENTS FOR ALL-PAYER QP PERFORMANCE PERIOD 2019
Eligible Clinician (EC) initiated process *
Remaining Other Payers ..........................
Date
Guidance made available to ECs—Submission Period Opens ................................
Submission Period Closes ........................................................................................
CMS contacts ECs and Posts Other Payer Advanced APM List .............................
Aug. 2019.
Dec. 2019.
Dec. 2019.
* Note that APM Entities or eligible clinicians may use the Eligible Clinician Initiated Process.
(6) Timeline for the Proposed Other
Payer Advanced APM Determination
Processes
The proposed timeline for both the
proposed Payer Initiated and Eligible
Clinician Initiated Other Payer
Advanced APM Determination
Processes for all payer types is
presented in Table 54.
TABLE 54—TIMELINE FOR OTHER PAYER ADVANCED APM DETERMINATION PROCESS FOR THE 2019 QP PERFORMANCE
PERIOD BY PAYER TYPE *
Year
Date
2018 ...
January ...............
April .....................
June ....................
July–August .........
September ...........
November ............
December ............
2019 ...
August .................
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September ...........
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Payment arrangements
authorized under
Title XIX
Payment arrangements in CMS
Multi-Payer Models
Guidance sent to
Guidance made available to
states—Submispayers—Submission Pesion Period Opens.
riod Opens.
Submission Period
..............................................
Closes for states.
Guidance made
available to ECs—
Submission Period
Opens for ECs.
CMS makes Other
Payer Advanced
APM Determinations for states.
CMS posts Other
Payer Advanced
APM List.
Submission Period
Closes for ECs.
CMS posts Other
Payer Advanced
APM List.
Submission Period
Opens for ECs.
.................................
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PO 00000
Submission Period Closes
for Payers.
CMS makes Other Payer
Advanced APM Determinations for payers.
Medicare Health Plan
payment arrangements
Remaining other payer
payment arrangements
..............................................
Guidance sent to Medicare
Health Plans—Submission
Period Opens.
Submission Period Closes
for Medicare Health Plans.
CMS posts Other Payer Advanced APM List.
CMS makes Other Payer
Advanced APM Determinations for Medicare
Health Plans.
CMS posts Other Payer Advanced APM List.
..............................................
..............................................
..............................................
..............................................
Submission Period Opens
for ECs.
Latest time where ECs can
request Other Payer Advanced APM determinations to get notification
prior to close of data submission period.
Submission Period for QP
determination data opens.
Submission Period Opens
for ECs.
Latest time where ECs can
request Other Payer Advanced APM determinations to get notification
prior to close of data submission period.
Submission Period for QP
determination data opens.
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Submission Period Opens
for ECs.
Latest time where ECs can
request Other Payer Advanced APM determinations to get notification
prior to close of data submission period.
Submission Period for QP
determination data opens.
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TABLE 54—TIMELINE FOR OTHER PAYER ADVANCED APM DETERMINATION PROCESS FOR THE 2019 QP PERFORMANCE
PERIOD BY PAYER TYPE *—Continued
Date
Payment arrangements
authorized under
Title XIX
Payment arrangements in CMS
Multi-Payer Models
Medicare Health Plan
payment arrangements
Remaining other payer
payment arrangements
December ............
.................................
Submission Period Closes
for EC requests for Other
Payer Advanced APM determinations and QP determination data.
CMS makes Other Payer
Advanced APM Determinations for ECs.
CMS posts Other Payer Advanced APM List.
Submission Period Closes
for EC requests for Other
Payer Advanced APM determinations and QP determination data.
CMS makes Other Payer
Advanced APM Determinations for ECs.
CMS posts Other Payer Advanced APM List.
Submission Period Closes
for EC requests for Other
Payer Advanced APM determinations and QP determination data.
CMS makes Other Payer
Advanced APM Determinations for ECs.
CMS posts Other Payer Advanced APM List.
Year
* The process repeats beginning in 2019 for the 2020 QP Performance Period.
(7) Submission of Information for Other
Payer Advanced APM Determinations
In the CY 2017 Quality Payment
Program final rule, we finalized that to
be assessed under the All-Payer
Combination Option, APM Entities or
eligible clinicians must submit, in a
manner and by a date that we specify,
payment arrangement information
necessary to assess whether the other
payer arrangement meets the Other
Payer Advanced APM criteria (81 FR
77480).
(a) Required Information
As we discuss in sections II.D.6.c.(1)
through II.D.6.c.(5) of this proposed
rule, we propose to allow for certain
types of payers as well as APM Entities
or eligible clinicians to request that we
determine whether certain other payer
arrangements are Other Payer Advanced
APMs.
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(i) Payer Initiated Process
We intend to create a Payer Initiated
Submission Form that would allow
payers to submit the information
necessary for us to determine whether a
payment arrangement is an Other Payer
Advanced APM. We propose that, for
each other payer arrangement a payer
requests us to determine whether it is an
Other Payer Advanced APM, the payer
must use, complete, and submit the
Payer Initiated Submission Form by the
relevant deadline.
For us to make these determinations,
we propose to require that payers
submit the following information for
each other payer arrangement:
• Arrangement name;
• Brief description of the nature of
the arrangement;
• Term of the arrangement
(anticipated start and end dates);
• Participant eligibility criteria;
• Locations (nationwide, state, or
county) where this other payer
arrangement will be available;
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• Evidence that the CEHRT criterion
set forth in § 414.1420(b) is satisfied;
• Evidence that the quality measure
criterion set forth in § 414.1420(c) is
satisfied; including an outcome
measure;
• Evidence that the financial risk
criterion set forth in § 414.1420(d) is
satisfied; and
• Other documentation as may be
necessary for us to determine that the
other payer arrangement is an Other
Payer Advanced APM.
We propose that the Payer Initiated
Submission Form would allow payers to
include descriptive language for each of
the required information elements. We
are proposing to require the name and
description of the arrangement, nature
of the arrangement, term of the
arrangement, eligibility criteria, and
location(s) where the arrangement will
be available so that we can verify
whether eligible clinicians who may tell
us that they participate in such
arrangements are eligible to do so. We
require evidence that all of the Other
Payer Advanced APM criteria are met in
order for us to determine whether the
arrangement is an Other Payer
Advanced APM. We propose that a
submission for an Other Payer
Advanced APM determination
submitted by the payer is complete only
if all of these information elements are
submitted to us.
We propose to require that payers
submit documentation that supports the
information they provided in the Payer
Initiated Submission Form and that is
sufficient to enable us to determine
whether the other payer arrangement is
an Other Payer Advanced APM.
Examples of such documentation would
include contracts and other relevant
documents that govern the other payer
arrangement that verify each required
information element, copies of their full
contracts governing the arrangement, or
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some other documents that detail and
govern the payment arrangement.
(ii) Eligible Clinician Initiated Process
We intend to create an Eligible
Clinician Initiated Submission Form
that would allow for APM Entities or
eligible clinicians to submit the
information necessary for us to
determine whether a payment
arrangement is an Other Payer
Advanced APM. We propose that, for
each other payer arrangement an APM
Entity or eligible clinician requests us to
determine whether it is an Other Payer
Advanced APM, the APM Entity or
eligible clinician must use, complete,
and submit the Eligible Clinician
Initiated Submission Form by the
relevant deadline.
For us to make these determinations,
we propose to require that the APM
Entity or eligible clinician submit the
following information for each other
payer arrangement:
• Arrangement name;
• Brief description of the nature of
the arrangement;
• Term of the arrangement
(anticipated start and end dates);
• Locations (nationwide, state, or
county) where this other payer
arrangement will be available;
• Evidence that the CEHRT criterion
set forth in § 414.1420(b) is satisfied;
• Evidence that the quality measure
criterion set forth in § 414.1420(c) is
satisfied, including an outcome
measure;
• Evidence that the financial risk
criterion set forth in § 414.1420(d) is
satisfied; and
• Other documentation as may be
necessary for us to determine whether
the other payer arrangement is an Other
Payer Advanced APM.
We propose that the Eligible Clinician
Initiated Submission Form would allow
APM Entities and eligible clinicians to
include descriptive language for each of
the required information elements. We
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are proposing to require the name and
description of the arrangement, nature
of the arrangement, term of the
arrangement, eligibility criteria, and, in
the case of Title XIX arrangements only,
location(s) where the arrangement will
be available. We require evidence that
all of the Other Payer Advanced APM
criteria are met in order for us to
determine that the arrangement is an
Other Payer Advanced APM. We
propose that a submission for an Other
Payer Advanced APM determination
submitted by the APM Entity or eligible
clinician is complete only if all of these
information elements are submitted to
us.
We propose to require that APM
Entities or eligible clinicians submit
documentation that supports the
information they provided in the
Eligible Clinician Initiated Submission
Form and that is sufficient to enable us
to determine whether the other payer
arrangement is an Other Payer
Advanced APM. Examples of such
documentation would include contracts
and other relevant documents that
govern the other payer arrangement that
verify each required information
element, copies of their full contracts
governing the arrangement, or some
other documents that detail and govern
the payment arrangement. In addition to
requesting that we determine whether
one or more other payer arrangements
are Other Payer Advanced APMs for the
year, APM Entities or eligible clinicians
may also inform us that they are
participating in an other payer
arrangement that we determine to be an
Other Payer Advanced APM for the
year. To do so, we propose that an APM
Entity or eligible clinician would
indicate, upon submission of Other
Payer Advanced APM participation data
for purposes of QP determination,
which Other Payer Advanced APMs
they participated in during the AllPayer QP Performance Period, and
include copies of participation
agreements or similar contracts (or
relevant portions of them) to document
their participation in those payment
arrangements.
We acknowledge that there is some
burden associated with requesting Other
Payer Advanced APM determinations.
We seek comment on ways to reduce
burden on states, payers, APM Entities,
and eligible clinicians while still
allowing us to receive the information
necessary to make such determinations.
(b) Certification and Program Integrity
(i) Payer Initiated Process
We believe that it is important that
the information submitted by payers
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through the Payer Initiated Process is
true, accurate, and complete. To that
end, we propose to add a new
requirement at § 414.1445(d) stating that
a payer that submits information
pursuant to § 414.1445(c) must certify to
the best of its knowledge that the
information it submitted to us through
the Payer Initiated Process is true,
accurate, and complete. Additionally,
we propose that this certification must
accompany the Payer Initiated
Submission Form and any supporting
documentation that payers submit to us
through this process.
We propose to revise and clarify the
monitoring and program integrity
provisions at § 414.1460. First, we
propose to modify § 414.1460(c) to
specify that information submitted by
payers for purposes of the All-Payer
Combination Option may be subject to
audit by us. We anticipate that the
purpose of any such audit would be to
verify the accuracy of an Other Payer
Advanced APM determination. We seek
comment on how this might be done
with minimal burden to payers. Second,
we propose at § 414.1460(e)(1) to require
payers who choose to submit
information through the Payer Initiated
Process to such books, contracts,
records, documents, and other evidence
as necessary to audit an Other Payer
Advanced APM determination. We
propose that such information must be
maintained for 10 years after
submission. We also propose at
§ 414.1460(e)(3) that such information
and supporting documentation must be
provided to us upon request. We request
comments on this proposal, including
comment on the length of time payers
typically maintain such information. We
also seek comment on how this might be
done with minimal burden to payers.
(ii) Eligible Clinician Initiated Process
In the CY 2017 Quality Payment
Program final rule, we finalized a
requirement at § 414.1445(b)(3) that
payers must attest to the accuracy of
information submitted by eligible
clinicians (81 FR 77480). After
publication of the final rule, we
received comments from stakeholders
opposing this requirement. Commenters
noted that payers may not have any
existing relationship with us, that
payers do not have any direct stake in
the QP status of eligible clinicians, and
that there may be operational and legal
barriers to payers attesting to this
information. In consideration of these
comments, we propose to eliminate the
requirement at § 414.1445(b)(3) that
payers attest that the information
submitted by eligible clinicians is
accurate. Instead, as discussed in
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30195
section II.D.6.c.(7)(b)(i) of this rule, we
are proposing that payers must certify
only the information they submit
directly to us.
In the CY 2017 Quality Payment
Program final rule, we finalized a
requirement at § 414.1460(c) that
eligible clinicians and APM Entities
must attest to the accuracy and
completeness of data submitted to meet
the requirements under the All-Payer
Combination Option. We believe this
requirement would be more
appropriately placed in the regulatory
provisions that discuss the submission
of information related to requests for
Other Payer Advanced APM
determinations. Accordingly, we are
proposing to remove this requirement at
§ 414.1460(c) and proposing at
§ 414.1445(d) that an APM Entity or
eligible clinician that submits
information pursuant to § 414.1445(c)
must certify to the best of its knowledge
that the information it submitted to us
is true, accurate, and complete. In the
case of information submitted by the
APM Entity, we propose that the
certification be made by a person with
the authority to bind the APM Entity.
We also propose that this certification
accompany the Eligible Clinician
Initiated Submission Form and any
supporting documentation that eligible
clinicians submit to us through this
process. We note that under
§ 414.1460(c), APM Entities or eligible
clinicians may be subject to audit of the
information and supporting
documentation provided under the
certification. In section II.D.6.c.(7)(b) of
this rule, we discuss our proposal to add
a similar certification requirement at
§ 414.1440(f)(2) for QP determinations.
We note that we propose to remove the
last sentence of § 414.1460(c) regarding
record retention and address the record
retention issue only in the maintenance
of records provision at § 414.1460(e).
Finally, we are proposing to clarify
the nature of the information subject to
the record retention requirements at
§ 414.1460(e). Specifically, we propose
that an APM Entity or eligible clinician
must maintain such books, contracts,
records, documents, and other evidence
as necessary to enable the audit of an
Other Payer Advanced APM
determination, QP determination, and
the accuracy of an APM Incentive
Payment.
(iii) Outcome Measure
For both Advanced APMs and Other
Payer Advanced APMs, we want to
encourage the use of outcome measures
for quality performance assessment. We
also recognize there is a lack of
appropriate outcome measures for use
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by certain specialties and take that into
consideration when interpreting the
requirement that an Other Payer
Advanced APM is one under which
MIPS-comparable quality measures
apply. Therefore, in the CY 2017
Quality Payment Program final rule, we
finalized at § 414.1420(c)(3) that to meet
the quality measure use criterion to be
an Other Payer Advanced APM, the
other payer arrangement must use an
outcome measure if there is an
applicable outcome measure on the
MIPS quality measure list; but if there
is no outcome measure available for use
in the other payer arrangement, the
APM Entity must attest that there is no
applicable measure on the MIPS quality
measure list. While we are not
proposing substantive changes to this
policy, we are making technical
revisions to our regulations to codify
this policy at § 414.1445(c)(3) and we
clarify that a payer, APM entity, or
eligible clinician must certify that there
is no applicable measure on the MIPS
quality measure list if the payment
arrangement does not use an outcome
measure.
(c) Use of Information Submitted
We intend to post, on a CMS Web site,
only the following information about
other payer arrangements that we
determine are Other Payer Advanced
APMs: The names of payers with Other
Payer Advanced APMs as specified in
either the Payer Initiated or Eligible
Clinician Initiated Submission Form,
the location(s) in which the Other Payer
Advanced APMs are available whether
at the nationwide, state, or county level,
and the names of the specific Other
Payer Advanced APMs.
We believe that making this
information publicly available is
particularly important for Medicaid
APMs and Medicaid Medical Home
Models so that eligible clinicians can
assess whether their Medicaid payments
and patients would be excluded in
calculations under the All-Payer
Combination Option. More generally,
we believe that making this information
publicly available would help eligible
clinicians to identify which of their
other payer arrangements are Other
Payer Advanced APMs so they can
include information on those Other
Payer Advanced APMs in their requests
for QP determinations; and to learn
about, and potentially join, Other Payer
Advanced APMs that may be available
to them. We seek comment on whether
posting this information would be
helpful to APM Entities or eligible
clinicians.
In the CY 2017 Quality Payment
Program final rule, we finalized that, to
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the extent permitted by federal law, we
would maintain confidentiality of
certain information that APM Entities or
eligible clinicians submit for purposes
of Other Payer Advanced APM
determinations to avoid dissemination
of potentially sensitive contractual
information or trade secrets (81 FR
77478 through 77480).
We propose that, with the exception
of the specific information we propose
to make publicly available as stated
above, the information a payer submits
to us through the Payer Initiated Process
and the information an APM Entity or
eligible clinician submits to us through
the Eligible Clinician Initiated Process
would be kept confidential to the extent
permitted by federal law, in order to
avoid dissemination of potentially
sensitive contractual information or
trade secrets.
We seek comment on this proposal.
(d) Use of Certified EHR Technology
(CEHRT)
In the CY 2017 Quality Payment
Program final rule, we finalized that to
be an Other Payer Advanced APM, the
other payer arrangement must require at
least 50 percent of participating eligible
clinicians in each APM Entity to use
Certified EHR Technology (CEHRT) to
document and communicate clinical
care (81 FR 77465).
We believe that some other payer
arrangements, particularly those for
which eligible clinicians may request
determinations as Other Payer
Advanced APMs, may only require
CEHRT use at the individual eligible
clinician level in the contract the
eligible clinician has with the payer. We
also believe that it may be challenging
for eligible clinicians to submit
information sufficient for us to
determine that at least 50 percent of
eligible clinicians under the other payer
arrangement are required to use CEHRT
to document and communicate clinical
care.
To address this issue, we propose that
we would presume that an other payer
arrangement would satisfy the 50
percent CEHRT use criterion if we
receive information and documentation
from the eligible clinician through the
Eligible Clinician Initiated Process
showing that the other payer
arrangement requires the requesting
eligible clinician(s) to use CEHRT to
document and communicate clinician
information. We seek comment on this
proposal. We also seek comment on
what kind of requirements for CEHRT
currently exist in other payer
arrangements, particularly if they are
written to apply at the eligible clinician
level.
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(8) Summary of Proposals
In summary, we are proposing the
following:
Payer Initiated Process
• We propose to allow certain other
payers, including payers with payment
arrangements authorized under Title
XIX, Medicare Health Plan payment
arrangements, and payers with payment
arrangements in CMS Multi-Payer
Models to request that we determine
whether their other payer arrangements
are Other Payer Advanced APMs
starting prior to the 2019 All-Payer QP
Performance Period and each year
thereafter. We propose to allow
remaining other payers, including
commercial and other private payers, to
request that we determine whether other
payer arrangements are Other Payer
Advanced APMs starting in 2019 prior
to the 2020 All-Payer QP Performance
Period, and annually each year
thereafter. We propose to generally refer
to this process as the Payer Initiated
Other Payer Advanced APM
Determination Process (Payer Initiated
Process), and we propose that the Payer
Initiated Process would generally
involve the same steps for each payer
type for each All-Payer QP Performance
Period. If a payer uses the same other
payer arrangement in other commercial
lines of business, we propose to allow
the payer to concurrently request that
we determine whether those other payer
arrangements are Other Payer Advanced
APMs as well.
• We propose that these Other Payer
Advanced APM determinations would
be in effect for only one year at a time.
• We propose that the Payer Initiated
Process would be voluntary for all
payers.
• We propose that payers would be
required to use the Payer Initiated
Submission Form to request that we
make an Other Payer Advanced APM
determination. We propose that the
Submission Period opening date and
Submission Deadline would vary by
payer type to align with existing CMS
processes for payment arrangements
authorized under Title XIX, Medicare
Health Plan payment arrangements, and
payers with payment arrangements in
CMS Multi-Payer Models to the extent
possible and appropriate.
• We propose that if we determine
that the payer has submitted incomplete
or inadequate information, we would
inform the payer and allow the payer to
submit additional information no later
than 10 business days from the date we
inform the payer. For each other payer
arrangement for which the payer does
not submit sufficient information, we
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would not make a determination in
response to that request submitted via
the Payer Initiated Submission Form.
• Title XIX (Medicaid): We propose
that any states and territories (‘‘states’’)
that have in place a state plan under
Title XIX may request that we determine
prior to the All-Payer QP Performance
Period whether other payer
arrangements authorized under Title
XIX are Other Payer Advanced APMs
under the Payer Initiated Process. We
propose to allow states to request
determinations for both Medicaid feefor-service and Medicaid managed care
plan payment arrangements. We
propose that the Submission Period for
the Payer Initiated Process for use by
states to request Other Payer Advanced
APM determinations for other payer
arrangements authorized under Title
XIX will open on January 1 of the
calendar year prior to the relevant AllPayer QP Performance Period for which
we would make the determination for a
Medicaid APM or a Medicaid Medical
Home Model that is an Other Payer
Advanced APM. We propose that the
Submission Deadline for these
submissions is April 1 of the year prior
to the All-Payer QP Performance Period
for which we would make the
determination.
• CMS Multi-Payer Models: We
propose that payers with other payer
arrangements aligned with a CMS MultiPayer Model may request that we
determine whether their aligned other
payer arrangements are Other Payer
Advanced APMs. We propose that
payers with other payer arrangements in
a CMS Multi-Payer Model may request
that we determine prior to the All-Payer
QP Performance Period whether those
other payer arrangements are Other
Payer Advanced APMs. We propose that
payers that want to request that we
determine whether those arrangements
are Other Payer Advanced APMs would
use the processes specified for payment
arrangements authorized under Title
XIX and Medicare Health Plan payment
arrangements. We propose that the
submission period would open on
January 1 of the calendar year prior to
the relevant All-Payer QP Performance
Period. We also propose that the
submission period would close on June
30 of the calendar year prior to the
relevant All-Payer QP Performance
Period. We propose that, in CMS MultiPayer Models where a state prescribes
uniform payment arrangements across
all payers statewide, the state would
submit on behalf of payers in the Payer
Initiated Process for Other Payer
Advanced APMs; we would seek
information for the determination from
the state, rather than individual payers.
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The same Payer Initiated Process and
timeline described above for CMS
Multi-Payer Models would apply.
• Medicare Health Plans: We propose
that the Submission Period would begin
and end at the same time as the annual
bid timeframe. We propose the
Submission Period would begin when
the bid packages are sent out to plans
in April of the year prior to the relevant
All-Payer QP Performance Period. We
also propose that the Submission
Deadline would be the annual bid
deadline, which would be the first
Monday in June in the year prior to the
relevant All-Payer QP Performance
Period.
• Remaining Other Payers: We
propose to allow the remaining other
payers not specifically addressed in
proposals above, including commercial
and other private payers that are not
states, Medicare Health Plans, or payers
with arrangements that are aligned with
a CMS Multi-Payer Model, to request
that we determine whether their other
payer arrangements are Other Payer
Advanced APMs starting prior to the
2020 All-Payer QP Performance Period
and each year thereafter.
Eligible Clinician Initiated Process
• We propose that through the
Eligible Clinician Initiated Process,
APM Entities and eligible clinicians
participating in other payer
arrangements would have an
opportunity to request that we
determine for the year whether those
other payer arrangements are Other
Payer Advanced APMs. The Eligible
Clinician Initiated Process could also be
used to request determinations before
the beginning of an All-Payer Payer QP
Performance Period for other payer
arrangements authorized under Title
XIX.
• We propose that APM Entities or
eligible clinicians would be required to
use the Eligible Clinician Initiated
Submission Form to request that we
make an Other Payer Advanced APM
determination.
• We propose that if we determine
that the APM Entity or eligible clinician
has submitted incomplete or inadequate
information, we would inform the payer
and allow the payer to submit
additional information no later than 10
business days from the date we inform
the APM Entity or eligible clinician. For
each other payer arrangement for which
the APM Entity or eligible clinician
does not submit sufficient information,
we would not make a determination in
response to that request submitted via
the Eligible Clinician Initiated
Submission Form.
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30197
• Title XIX (Medicaid): We propose
that for the first All-Payer QP
Performance Period, APM Entities and
eligible clinicians may submit
information on payment arrangements
authorized under Title XIX to request
that we determine whether those
arrangements are Medicaid APMs or
Medicaid Medical Home Models that
meet the Other Payer Advanced APM
criteria prior to the All-Payer QP
Performance Period. We propose that
APM Entities or eligible clinicians may
submit Eligible Clinician Initiated
Forms for payment arrangements
authorized under Title XIX beginning
on September 1 of the calendar year
prior to the All-Payer QP Performance
Period. We also propose that the
Submission Deadline is November 1 of
the calendar year prior to the All-Payer
QP Performance Period.
• CMS Multi-Payer Models: We
propose that through the Eligible
Clinician Initiated Process, APM
Entities and eligible clinicians
participating in other payer
arrangements in CMS Multi-Payer
Models may request that we determine
whether those other payer arrangements
are Other Payer Advanced APMs. We
propose that APM Entities or eligible
clinicians may request Other Payer
Advanced APM determinations
beginning on August 1 of the same year
as the relevant All-Payer QP
Performance Period. We propose that
the Submission Deadline for requesting
Other Payer Advanced APM
determinations, as well as to request QP
determinations under the All-Payer
Combination Option, is December 1 of
the same year as the relevant All-Payer
QP Performance Period.
• Medicare Health Plans: We propose
that through the Eligible Clinician
Initiated Process, APM Entities and
eligible clinicians participating in other
payer arrangements in Medicare Health
Plans would have an opportunity to
request that we determine whether
those other payer arrangements that are
not already determined to be Other
Payer Advanced APMs through the
Payer Initiated Process are Other Payer
Advanced APMs. We propose that APM
Entities or eligible clinicians may
request Other Payer Advanced APM
determinations beginning on August 1
of the same year as the relevant AllPayer QP Performance Period. We
propose that the Submission Deadline
for requesting Other Payer Advanced
APM determinations, as well as to
request QP determinations under the
All-Payer Combination Option, is
December 1 of the same year as the
relevant All-Payer QP Performance
Period.
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• Remaining Other Payers: We
propose that through the Eligible
Clinician Initiated Process APM Entities
and eligible clinicians participating in
other payer arrangements through one of
these other payers is an Other Payer
Advanced APM. We propose that APM
Entities or eligible clinicians may
request Other Payer Advanced APM
determinations beginning on August 1
of the same year as the relevant AllPayer QP Performance Period. We
propose that the Submission Deadline
for requesting Other Payer Advanced
APM determinations, as well as to
request QP determinations under the
All-Payer Combination Option, is
December 1 of the same year as the
relevant All-Payer QP Performance
Period.
Submission of Information for Other
Payer Advanced APM Determinations
• We propose that, for each other
payer arrangement a payer requests us
to determine whether it is an Other
Payer Advanced APM, all payers must
complete and submit the Payer Initiated
Submission Form by the relevant
Submission Deadline. We propose that
the Payer Initiated Submission Form
would allow payers to include
descriptive language for each of the
required information elements. We are
proposing to require the name and
description of the arrangement, nature
of the arrangement, term of the
arrangement, eligibility criteria, and
location(s) where the arrangement will
be available so that we can verify
whether eligible clinicians who may tell
us that they participate in such
arrangements are eligible to do so. We
propose to require that payers submit
documentation that supports the
information they provided in the Payer
Initiated Submission Form and that is
sufficient to enable us to determine
whether the other payer arrangement is
an Other Payer Advanced APM.
• We propose that, for each other
payer arrangement an APM Entity or
eligible clinician requests us to
determine whether it is an Other Payer
Advanced APM, all payers must
complete and submit the Eligible
Clinician Initiated Submission Form by
the relevant deadline. We propose that
the Eligible Clinician Initiated
Submission Form would allow APM
Entities or eligible clinicians to include
descriptive language for each of the
required information elements. We are
proposing to require the name and
description of the arrangement, nature
of the arrangement, term of the
arrangement, eligibility criteria, and
location(s) where the arrangement will
be available so that we can verify
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whether eligible clinicians who may tell
us that they participate in such
arrangements are eligible to do so. We
propose to require that APM Entities or
eligible clinicians submit
documentation that supports the
information they provided in the
Eligible Clinician Initiated Submission
Form and that is sufficient to enable us
to determine whether the other payer
arrangement is an Other Payer
Advanced APM.
• We propose that, for each other
payer arrangement a payer requests us
to determine whether it is an Other
Payer Advanced APM, the payer must
complete and submit the Payer Initiated
Submission Form by the relevant
deadline.
• We propose that, for each other
payer arrangement an APM Entity or
eligible clinician requests us to
determine whether it is an Other Payer
Advanced APM, the APM Entity or
eligible clinician must complete and
submit the Eligible Clinician Initiated
Submission Form by the relevant
deadline.
• We propose to add a new
requirement at § 414.1445(d) stating that
a payer that submits information
pursuant to § 414.1445(c) must certify to
the best of its knowledge that the
information submitted to us through the
Payer Initiated Process is true, accurate,
and complete. Additionally, we propose
that this certification must accompany
the Payer Initiated Submission Form
and any supporting documentation that
payers submit to us through this
process.
• We also propose to revise the
monitoring and program integrity
provisions at § 414.1460 to ensure the
integrity of the Payer Initiated Process.
Specifically, we are proposing to require
payers that choose to submit
information through the Payer Initiated
Process to maintain such books,
contracts, records, documents, and other
evidence as necessary to audit an Other
Payer Advanced APM determination
and that such information and
supporting documentation must be
maintained for 10 years after submission
and must be provided to CMS upon
request. We also propose to specify that
information submitted by payers for
purposes of the All-Payer Combination
Option may be subject to audit by CMS.
• We are proposing to remove the
requirement at § 414.1445(b)(3) that
payers must attest to the accuracy of
information submitted by eligible
clinicians. We are also proposing to
remove the attestation requirement at
§ 414.1460(c) and add a requirement at
§ 414.1445(d) that an APM Entity or
eligible clinician that submits
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information pursuant to § 414.1445(c)
must certify to the best of its knowledge
that the information it submitted to us
is true, accurate, and complete. We also
propose that this certification must
accompany the submission.
• We propose to remove the record
retention requirement at § 414.1445(c)
and only address the record retention
issue at § 414.1445(e) stating that APM
Entities and eligible clinicians must
maintain such books, contracts, records,
documents, and other evidence as
necessary to enable the audit of an
Other Payer Advanced APM
determination, QP determination, and
the accuracy of an APM Incentive
Payment.
• We propose that, with the exception
of the specific information we propose
to make publicly available as stated
above, the information a payer submits
to us through the Payer Initiated Process
and the information an APM Entity or
eligible clinician submits to us through
the Eligible Clinician Initiated Process
would be kept confidential to the extent
permitted by federal law, in order to
avoid dissemination of potentially
sensitive contractual information or
trade secrets.
• We propose that we would initially
presume that an other payer
arrangement would satisfy the 50
percent CEHRT use criterion if we
receive information and documentation
from the APM Entity or eligible
clinician through the Eligible Clinician
Initiated Process showing that the other
payer arrangement requires the
requesting eligible clinician(s) to use
CEHRT to document and communicate
clinical information.
d. Calculation of All-Payer Combination
Option Threshold Scores and QP
Determinations
(1) Overview
In the CY 2017 Quality Payment
Program final rule, we finalized our
overall approach to the All-Payer
Combination Option (81 FR 77463).
Beginning in 2021, in addition to the
Medicare Option, an eligible clinician
may alternatively become a QP through
the All-Payer Combination Option, and
an eligible clinician need only meet the
QP threshold under one of the two
options to be a QP for the payment year
(81 FR 77459). We finalized that we will
conduct the QP determination
sequentially so that the Medicare
Option is applied before the All-Payer
Combination Option (81 FR 77439).
We finalized that we will calculate
Threshold Scores under the Medicare
Option through both the payment
amount and patient count methods,
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compare each Threshold Score to the
relevant QP and Partial QP thresholds,
and use the most advantageous score to
make QP determinations (81 FR 77457).
We finalized the same approach for the
All-Payer Combination Option (81 FR
77475).
Sections 1833(z)(2)(B)(ii)(I) and
(C)(ii)(I) of the Act specify that the all
payer portion of the Threshold Score
calculations under the All-Payer
Combination Option is based on the
sum of payments for Medicare Part B
covered professional services furnished
by the eligible clinician and, with
certain exceptions, all other payments
regardless of payer. We finalized that we
would include such payments in the
numerator and denominator, and we
would exclude the following excepted
categories of payments made to the
eligible clinician and associated patients
from the calculations:
• By the Secretary of Defense;
• By the Secretary of Veterans Affairs;
and
• Under Title XIX in a state in which
no Medicaid Medical Home Model or
APM is available under the state plan.
We finalized this exclusion of
payments under Title XIX to mean that
Medicaid payments and patients should
be excluded from the all-payer
calculation under the All-Payer
Combination Option, unless:
++ A state has in operation at least
one Medicaid APM or Medicaid
Medical Home Model that is determined
to be an Other Payer Advanced APM;
and
++ The relevant APM Entity is
eligible to participate in at least one of
such Other Payer Advanced APMs
during the QP Performance Period,
regardless of whether the APM Entity
actually participates in such Other
Payer Advanced APMs.
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(2) Timing of QP Determinations Under
the All-Payer Combination Option
In the CY 2017 Quality Payment
Program final rule, we finalized that the
QP Performance Period for both the
Medicare Option and the All-Payer
Combination Option would begin on
January 1 and end on August 31 of the
calendar year that is 2 years prior to the
payment year (81 FR 77446–77447).
(a) All-Payer QP Performance Period
and Medicare QP Performance Period
Upon further consideration, we
propose to establish a separate QP
Performance Period for the All-Payer
Combination Option, which would
begin on January 1 and end on June 30
of the calendar year that is 2 years prior
to the payment year. We propose to
define this term in § 414.1305 as the All-
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Payer QP Performance Period. The QP
Performance Period for the Medicare
Option will remain the same as
previously finalized, so it would begin
on January 1 and end on August 31 of
the calendar year that is 2 years to the
payment year. We propose to define this
term in § 414.1305 as the Medicare QP
Performance Period.
We are proposing to establish the AllPayer QP Performance Period because,
to make QP determinations under the
All-Payer Combination Option, we first
need to collect information on eligible
clinicians’ payments and patients with
all other payers. In order to provide
eligible clinicians with timely QP
determination that would enable them
to make their own timely decisions for
purposes of MIPS based on their QP
status for the year, we need to collect
this information by December 1 of the
QP performance year. We are concerned
that eligible clinicians would not be
able to submit the necessary payment
and patient information from all of their
other payers for the period from January
1 through August 31 before the
December 1 Information Submission
Deadline. For the Medicare Option, we
allow for a 90 day claims run out period
before gathering the necessary payment
amount and patient count information.
We believe the same claims run out
timeframe should be adopted for other
payers. If we were to maintain the
current QP Performance Period through
August 31 eligible clinicians would be
required to submit their other payer
payment and patient information to us
on or very near the end of the 90 day
claims run out period leaving them with
little or no time to prepare the
submission. We also believe that an
additional 60 days after the claims run
out is a reasonable amount of time for
the eligible clinician to collect and
submit the payment and patient data.
We seek comment on this proposal,
specifically as to an appropriate claims
run out standard for other payers.
If we retained the current QP
Performance Period and instead delayed
the submission deadline to allow
eligible clinicians time comparable to
the time provided under the Medicare
Option to fully collect and submit this
information, QP determinations under
the All-Payer Combination Option
would likely not be complete before the
end of the MIPS reporting period, which
would undermine our goal of giving
eligible clinicians information about
their QP status prior to the end of the
MIPS reporting period.
Alternatively, we are considering
whether to establish the All-Payer QP
Performance Period from January 1
through March 31 of the calendar year
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30199
that is 2 years prior to the payment year.
We believe this option would provide
the most ample time possible for eligible
clinicians to prepare and submit
information to enable us to make a QP
determination under the All-Payer
Combination Option. In the CY 2017
Quality Payment Program final rule, we
finalized a snapshot approach that
allows an eligible clinician to attain QP
status based on Advanced APM
participation from January 1 through
March 31 under the Medicare Option.
Since QP determinations under the
Medicare Option can be based on
participation information for January 1
through March 31 of a year, we believe
this alternative performance period
under the All-Payer Combination
Option would not be inconsistent with
the policy that we finalized last year,
and seek comment on this alternative
approach. We seek comments on the
establishment of a January 1 through
March 31 All-Payer QP Performance
Period and whether additional
requirements may be needed to ensure
the appropriate inplementation of this
proposal.
We seek comment on the proposed
All-Payer QP Peformance Period from
January 1 through June 30 of the year
that is 2 years prior to the payment year,
and a possible alternative All-Payer QP
Performance Period that would be from
January 1 through March 31. If we do
not finalize the proposed or alternative
All-Payer QP Performance Period, we
would retain the QP Performance Period
that we finalized in the CY 2017 Quality
Payment Program final rule, which is
from January 1 through August 31 of the
calendar year that is 2 years prior to the
payment year. We are particularly
concerned about the potential delay or
run out from other payers that may
affect the ability of APM entities or
eligible clinicians to gather and submit
the necessary payment amount and
patient count information for the
applicable All-Payer QP Performance
Period by the December 1 All-Payer QP
Determination Submission Deadline. At
the same time, we recognize the need to
balance this concern with the benefit of
collecting Other Payer Advanced APM
participation information over a
meaningful period of time. We seek
comment on the feasibility or difficulty
in gathering and submitting this
information for each of the potential
performance period time frames.
(b) Alignment of Time Periods Assessed
Under the Medicare Option and the AllPayer Combination Option
In the CY 2017 Quality Payment
Program final rule, we finalized that we
will make QP determinations under the
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Medicare Option using three snapshot
dates during the QP Performance Period
on March 31, June 30, and August 31
(81 FR 77446 through 77447).
Consistent with our proposal to make
the All-Payer QP Performance Period
from January 1 through June 30 of the
calendar year that is 2 years prior to the
payment year, we propose to make QP
determinations based on eligible
clinicians’ participation in Advanced
APMs and Other Payer Advanced APMs
between January 1 through March 31
and January 1 through June 30 under the
All-Payer Combination Option.
We also propose that an eligible
clinician would need to meet the
relevant QP or Partial QP Threshold
under the All-Payer Combination
Option, and we would use data for the
same time periods for Medicare
payments or patients and that of other
payers. For example, we would not
assess an eligible clinician under the
All-Payer Combination Option using
their Advanced APM payment amount
and patient count information from
January 1 through March 31 and their
Other Payer Advanced APM payment
amount and patient count information
from January 1 through June 30. We are
proposing to align the time period
assessed for the for the Medicare and
other payer portions of the calculations
under the All-Payer Combination
Option because we believe that would
support the principle that QP
determinations should be based on an
eligible clinician’s performance over a
single period of time, and that lack of
alignment, comingling participation
information from multiple time periods
for the purposes of making QP
determinations, would not
appropriately reflect the structure of QP
assessment using the All-Payer
Combination Option. We seek comment
on this proposal.
(c) Notification of QP Determinations
Under the All-Payer Combination
Option
Our goal, under both the Medicare
Option and the All-Payer Combination
Option, is to notify eligible clinicians of
their QP status at a time that gives any
Partial QPs time to decide whether to
report to MIPS and gives those eligible
clinicians who are not QPs or Partial
QPs sufficient notice of the need to
report to MIPS. For the All-Payer
Combination Option, we also believe it
is important to provide eligible
clinicians as much information as
possible about their QP status under the
Medicare Option prior to the proposed
All-Payer Information Submission
Deadline, as subsequently discussed in
section II.D.6.d.(4)(b) of this proposed
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rule. We therefore propose to inform
eligible clinicians of their QP status
under the All-Payer Combination
Option as soon as practicable after the
proposed All-Payer Information
Submission Deadline.
(3) QP Determinations Under the AllPayer Combination Option
In the CY 2017 Quality Payment
Program final rule, we finalized that,
similar to the Medicare Option, we will
calculate the Threshold Scores used to
make QP determinations under the AllPayer Combination Option at the APM
Entity group level unless certain
exceptions apply (81 FR 77478).
(a) QP Determinations at the Individual
Eligible Clinician Level
Upon further consideration, we
propose to make QP determinations
under the All-Payer Combination
Option at the individual eligible
clinician level only. We believe that
there will likely be significant
challenges associated with making QP
determinations under the All-Payer
Combination Option at the APM Entity
group level as we finalized through
rulemaking last year.
As we explained in the CY 2017
Quality Payment Program final rule, an
APM Entity faces the risks and rewards
of participation in an Advanced APM as
a single unit and is responsible for
performance metrics that are aggregated
to the APM Entity group level as
determined by the Advanced APM
unless that APM Entity falls under the
exception specified in § 414.1425(b)(1)
for eligible clinicians on Affiliated
Practitioner Lists. Because of this, we
believe it is generally preferable to make
QP determinations at the APM Entity
level unless we are making QP
determinations for eligible clinicians
identified on Affiliated Practitioner
Lists as specified at § 414.1425(b)(1); or
we are making QP determinations for
eligible clinicians participating in
multiple APM Entities, none of which
reach the QP Threshold as a group as
specified at § 414.1425(c)(4) (81 FR
77439). However, under the All-Payer
Combination Option, we believe in
many instances that the eligible
clinicians in the APM Entity group we
would identify and use to make QP
determinations under the Medicare
Option would likely have little, if any,
common group-level participation in
Other Payer Advanced APMs. The
eligible clinicians in the same APM
Entity group would not necessarily have
agreed to share risks and rewards for
Other Payer Advanced APM
participation as an APM Entity group,
particularly when eligible clinicians
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may participate in Other Payer
Advanced APMs at different rates
within an APM Entity group (or not at
all).
Eligible clinicians may participate in
Other Payer Advanced APMs whose
participants do not completely overlap,
or do not overlap at all, with the APM
Entity the eligible clinician is part of.
Therefore, we believe that looking at
participation in Other Payer Advanced
APMs at the individual eligible
clinician level may be a more
meaningful way to assess their
participation across multiple payers. In
addition, those risks and rewards
associated with participation in Other
Payer Advanced APMs may vary
significantly among eligible clinicians
depending on the Other Payer
Advanced APMs in which they
participate. Specifically, we are
concerned that if we were to make AllPayer Combination Option QP
determinations at the APM Entity level,
the denominator in QP threshold
calculations could include all other
payments and patients from eligible
clinicians who had no, or limited, Other
Payer Advanced APM participation,
thereby disadvantaging those eligible
clinicians who did have significant
Other Payer Advanced APM
participation. By contrast, this scenario
is unlikely to occur when making QP
determinations at the APM Entity level
under the Medicare Option because all
eligible clinicians in the APM Entity
group would be contributing to the APM
Entity’s performance under the
Advanced APM. For these reasons, we
believe it would be most appropriate to
make all QP determinations under the
All-Payer Combination Option at the
individual eligible clinician level.
We seek comment on this proposal,
specifically on the possible extent to
which APM Entity groups in Advanced
APMs could agree to be assessed
collectively for performance in Other
Payer Advanced APMs. We also seek
comment on whether there is variation,
and the extent of that variation, among
eligible clinicians within an APM Entity
group in their participation in other
payer arrangements that we may
determine to be Other Payer Advanced
APMs We seek comment on whether
there are circumstances in which QP
determinations should be made at a
group level under the All-Payer
Combination Option.
If we were to establish a mechanism
for making QP determinations at the
APM Entity group level, we anticipate
that there could be significant
challenges in obtaining the information
necessary at the APM Entity group level
under the All-Payer Combination
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clinicians who meet the criteria to be
assessed individually under the
Medicare Option.
(b) Use of Individual or APM Entity
Group Information for Medicare
Payment Amounts and Patient Count
Calculations Under the All-Payer
Combination Option
Because we are proposing to make QP
determinations at the individual eligible
clinician level only, we are proposing to
use the individual eligible clinician
payment amounts and patient counts for
the Medicare calculations in the AllPayer Combination Option. We believe
that matching the information we use at
the same level for all payment amounts
and patient counts for both the
Medicare and all-payer calculations
under the All-Payer Combination
Option is most consistent with sections
1833(z)(2)(B)(ii) and (C)(ii) of the Act
because these provisions require
calculations that add together the
payments or patients from Medicare and
all other payers (except those excluded).
We note however that we would use the
APM Entity group level payment
amounts and patient counts for all
Medicare Option Threshold Scores,
unless we are making QP
determinations for Affiliated
Practitioner Lists as specified at
§ 414.1425(b)(1) or we are making QP
determinations for eligible clinicians
participating in multiple APM Entities,
none of which reach the QP Threshold
as a group as specified at
§ 414.1425(c)(4) (81 FR 77439).
If we were to use the APM Entity
group level payment amounts and
patient counts for Medicare and
individual eligible clinician payment
amounts and patient counts for other
payers, we would combine APM Entity
group level Medicare information with
individual eligible clinician level other
payer information. In most instances
this would disproportionately
underweight the eligible clinicians’
activities in Other Payer Advanced
APMs relative to their activities in
Advanced APMs when calculating
Threshold Scores under the All-Payer
Combination Option. We do not believe
that this underweighting would be
consistent with sections 1833(z)(2)(B)(ii)
and (c)(11) of the Act.
We recognize that in many cases an
individual eligible clinician’s Medicare
Threshold Scores would likely differ
from Threshold Scores calculated at the
APM Entity group level, which would
benefit those eligible clinicians whose
individual Threshold Scores would be
higher than the group Threshold Scores
and disadvantage those eligible
clinicians whose individual Threshold
Scores are equal to or lower than the
group Threshold Scores. In situations
where eligible clinicians are assessed
under the Medicare Option as an APM
Entity group, and receive a Medicare
Threshold Score at the group level, we
believe that the Medicare portion of
their All-Payer Combination Option
should not be lower than the Medicare
Threshold Score that they received by
participating in an APM Entity group.
To accomplish this outcome, we
propose a modified methodology. When
the eligible clinician’s Medicare
Threshold Score calculated at the
individual level would be a lower
percentage than the one that is
calculated at the APM Entity group level
we would apply a weighted
methodology. This methodology would
allow us to apply the APM Entity group
level Medicare Threshold Score (if
higher than the individual eligible
clinician level Medicare Threshold
Score), to the eligible clinician, under
either the payment amount or patient
count method, but weighted to reflect
the individual eligible clinician’s
Medicare volume.
We would multiply the eligible
clinician’s APM Entity group Medicare
Threshold Score by the total Medicare
payments or patients made to that
eligible clinician as follows:
As an example of how this weighting
methodology would apply under the
payment amount method for payment
year 2021, consider the following APM
Entity group with two clinicians, one of
whom participates in Other Payer
Advanced APMs and one who does not.
TABLE 55—WEIGHTING METHODOLOGY EXAMPLE—PAYMENT AMOUNT METHOD
Medicare—Advanced
APM Payments
Clinician A ........................................
Clinician B ........................................
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Medicare—Total
Payments
$150
150
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APM Payments
$200
800
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$0
760
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Other Payer—Total
Payments
$500
1,200
EP30JN17.250
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Option. When we make QP
determinations at the APM Entity group
level under the Medicare Option, we
can do so more easily because we
receive Participation Lists and we also
have the claims data necessary to
identify the payment or patient data that
belong in the numerator and
denominator of the Threshold Score
calculations for QP Determinations.
To make QP determinations at the
APM Entity group level under the AllPayer Combination Option, we would
need to collect for each APM Entity
group all of the payment amount and
patient count information for all eligible
clinicians as discussed in section
II.D.6.d.(4)(a) of this proposed rule. We
anticipate also needing Participation
Lists or similar documentation to
identify eligible clinicians within each
APM Entity group that participate in an
Other Payer Advanced APM. We seek
comment on whether APM Entities in
Other Payer Advanced APMs could
report this information at the APM
Entity group level to facilitate our
ability to make QP determinations at the
group level.
We note that when an Affiliated
Practitioner List defines the eligible
clinicians to be assessed for QP
determination in the Advanced APM,
we make QP determinations under the
Medicare Option at the individual level
only. To promote consistency with the
Medicare Option where possible, if in
response to comments on this proposed
rule we adopt a mechanism to make QP
determinations under the All-Payer
Combination Option at the APM Entity
group level, we propose that eligible
clinicians who meet the criteria to be
assessed individually under the
Medicare Option would still be assessed
at the individual level only under the
All-Payer Combination Option. We seek
comment on whether there are
alternative approaches to making QP
determinations under the All-Payer
Combination Option for eligible
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TABLE 55—WEIGHTING METHODOLOGY EXAMPLE—PAYMENT AMOUNT METHOD—Continued
300
In this example, the APM Entity
group Medicare Threshold Score is
$300/$1000, or 30 percent. Eligible
Clinicians A and B would not be QPs
under the Medicare Option, but
Clinician B could request that we make
a QP determination under the All-Payer
Combination Option since the APM
Entity group exceeded the 25 percent
minimum Medicare payment amount
threshold under that option.
If we calculate Clinician B’s payments
individually as proposed, we would
calculate the Threshold Score as
follows:
Because Clinician B’s Threshold
Score is less than the 50 percent QP
Payment Amount Threshold, Clinician
B would not be a QP based on this
result. However, if we apply the
weighting methodology, we would
calculate the Threshold Score as
follows:
Based upon this Threshold Score,
Clinician B would be a QP under the
All-Payer Combination Option.
We would calculate the eligible
clinician’s Threshold Scores both
individually and with this weighted
methodology, and then use the most
advantageous score when making a QP
determination. We believe that this
approach promotes consistency between
the Medicare Option and the All-Payer
Combination Option to the extent
possible. We seek comment on this
approach.
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(c) Title XIX Excluded Payments and
Patients
Sections 1833(z)(2)(B)(ii)(I)(bb) and
1833(z)(2)(C)(ii)(I)(bb) of the Act direct
us to exclude payments made under
Title XIX in a state where no Medicaid
Medical Home Model or Medicaid APM
is available under that state program. To
carry out this exclusion, in the CY 2017
Quality Payment Final Rule, we
finalized that for both the payment
amount and patient count methods,
Title XIX payments or patients will be
excluded from the numerator and
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1,000
Other Payer—Advanced
APM Payments
Other Payer—Total
Payments
........................................
........................................
denominator for the QP determination
unless:
(1) A state has in operation at least
one Medicaid APM or Medicaid
Medical Home Model that is determined
to be an Other Payer Advanced APM;
and
(2) The relevant APM Entity is eligible
to participate in at least one of such
Other Payer Advanced APMs during the
QP Performance Period, regardless of
whether the APM Entity actually
participates in such Other Payer
Advanced APMs (81 FR 77475).
For purposes of the discussion below
on the exclusion of Title XIX payments
and patients in QP determinations,
when we refer to Medicaid APMs or
Medicaid Medical Home Models, we
mean to refer to those that are Other
Payer Advanced APMs. We also
discussed that if a state operates such an
Other Payer Advanced APM at a substate level such that eligible clinicians
who do not practice in the area are not
eligible to participate, Medicaid
payments or patients should not be
included in those eligible clinicians’ QP
calculations because no Medicaid
Medical Home Model or Medicaid APM
was available for their participation (81
FR 77475).
We propose that we will use the
county level to determine whether a
state operates a Medicaid APM or a
Medicaid Medical Home Model at a substate level. We believe that the county
level is appropriate as in our
experience, the county level is the most
common geographic unit used by states
when creating payment arrangements
under Title XIX at the sub-state level.
We believe that applying this exclusion
at the county level would allow us to
carry out this exclusion in accordance
with the statute in a way that would not
penalize eligible clinicians who have no
Medicaid APMs or Medicaid Medical
Home Models available to them. We
seek comment on this proposal.
We propose that, in states where a
Medicaid APM or Medicaid Medical
Home Model only exists in certain
counties, we would exclude Title XIX
data from an eligible clinician’s QP
calculations unless the county where
the eligible clinician saw the most
patients during the relevant All-Payer
QP Performance Period was a county
where a Medicaid APM or Medicaid
Medical Home Model determined to be
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an Other Payer Advanced APM was
available. We would require eligible
clinicians to identify and certify the
county where they saw the most
patients during the relevant All-Payer
QP Performance Period. If this county is
not in a county where a Medicaid APM
or Medicaid Medical Home Model was
available during the All-Payer QP
Performance Period, then Title XIX
payments would be excluded from the
eligible clinician’s QP calculations. We
are proposing this approach to ensure
that, before including Title XIX payment
or patient count information in
calculating QP determinations, eligible
clinicians have a meaningful
opportunity to participate in a Medicaid
APM or Medicaid Medical Home Model
determined to be an Other Payer
Advanced APM in a manner that would
allow for both positive and negative
contributions to their QP threshold
score under the All-Payer Combination
Option. We seek comments on this
proposal.
As we discuss in section II.D.6.c.(3) of
this proposed rule, we need to
determine whether there are Medicaid
APMs and Medicaid Medical Home
Models available in each state prior to
end of the All-Payer QP Performance
Period in order to properly implement
the statutory exclusion of Title XIX
payments and patients, which is why
we finalized in the CY 2017 Quality
Payment Program final rule that we will
identify Medicaid APMs and Medicaid
Medical Home Models that are Other
Payer Advanced APMs prior to the QP
Performance Period (81 FR 77478).
In addition to excluding payments
based on county-level geography, we
propose to exclude Title XIX payments
and patients from the QP determination
calculation when the only Medicaid
APMs and Medicaid Medical Home
Models available in a given county are
not available to the eligible clinician in
question based on their specialty. We
believe that this proposal is consistent
with the statutory requirement to
exclude Title XIX data from the
calculations when no Medicaid APM or
Medicaid Medical Home Model is
available. In cases where participation
in such a model is limited to eligible
clinicians in certain specialties, we do
not believe the Medicaid APM or
Medicaid Medical Home Model would
effectively be available to eligible
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clinicians who are not in those
specialties. We therefore believe it
would be inappropriate and inequitable
to include Title XIX payments and
patients in such eligible clinicians’ QP
determination calculations. We propose
to identify Medicaid APM or Medicaid
Medical Home Models that are only
open to certain specialties through
questions asked of states in the Payer
Initiated Process and of APM Entities
and eligible clinicians in the Eligible
Clinician Initiated Process. We would
exclude Title XIX data from an eligible
clinician’s QP calculations unless the
eligible clinician practiced under one of
the specialty codes eligible to
participate in a Medicaid APM or
Medicaid Medical Home Model that was
available in the county where the
eligible clinician saw the most patients.
We would use the method generally
used in the Quality Payment Program to
identify an eligible clinician’s specialty
or specialties. We seek comment on this
proposal.
We also wish to clarify that payment
arrangements offered by MedicareMedicaid Plans, operating under the
Financial Alignment Initiative for
Medicare-Medicaid Enrollees, will not
be considered to be either Medicaid
APMs or Medicaid Medical Home
Models, and that the presence of such
payment arrangements in a state will
not preclude the exclusion of Title XIX
payment and patients in the All-Payer
Combination Option calculations for
eligible clinicians in that state if no
Medicaid APM or Medicaid Medical
Home Model is otherwise in operation
in the state. Medicare-Medicaid Plans
are limited to certain MedicareMedicaid enrollees, and enter into
payment arrangements that do not
uniformly segregate Title XVIII and Title
XIX funds. As such, payments to
eligible clinicians in Medicare-Medicaid
plans cannot consistently be attributed
to funding under either Title XVIII or
XIX. Additionally, given that Medicare
is generally the primary payer for
services furnished by eligible clinicians
to dual Medicare-Medicaid enrollees,
any possible segregable Title XIX
funding for professional services
through these payment arrangements
would be de minimus. We do not
believe it would be appropriate to
consider these payment arrangements
exclusively focused on this population
as Medicaid APMs or Medicaid Medical
Home Models.
(d) Payment Amount Method
In the CY 2017 Quality Payment
Program final rule, we finalized that we
will calculate an All-Payer Combination
Option Threshold Score for eligible
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clinicians in an APM Entity using the
payment amount method (81 FR 77476
through 77477). We finalized that the
numerator will be the aggregate of all
payments from all payers, except those
excluded, to the APM Entity’s eligible
clinicians, or the eligible clinician in the
event of an individual eligible clinician
assessment, under the terms of all Other
Payer Advanced APMs during the QP
Performance Period. We finalized that
the denominator will be the aggregate of
all payments from all payers, except
excluded payments, to the APM Entity’s
eligible clinicians, or the eligible
clinician in the event of an individual
eligible clinician assessment during the
QP Performance Period.
We finalized that we will calculate
the Threshold Score by dividing the
numerator value by the denominator
value, which will result in a percent
value Threshold Score. We will
compare that Threshold Score to the
finalized QP Payment Amount
Threshold and the Partial QP Payment
Amount Threshold and determine the
QP status of the eligible clinicians for
the payment year (81 FR 77475).
We propose to maintain the policies
we finalized for the payment amount
method as finalized, with some
proposed modifications. We propose
these changes to facilitate the
implementation of the payment amount
method while providing eligible
clinicians with some flexibility in
choosing the timeframe for making QP
determinations. To carry out our
proposal to make QP determinations at
the eligible clinician level only, we
propose that the numerator would be
the aggregate of all payments from all
payers, except those excluded,
attributable to the eligible clinician
only, under the terms of all Advanced
APMs and Other Payer Advanced APMs
from either January 1 through March 31
or January 1 through June 30 of the AllPayer QP Performance Period. We also
propose that the denominator would be
the aggregate of all payments from all
payers, except excluded payments, to
the eligible clinician from either January
1 through March 31, or January 1
through June 30 of the All-Payer QP
Performance Period. We seek comment
on this approach.
(e) Patient Count Method
We finalized that the Threshold Score
calculation for the patient count method
would include patients for whom the
eligible clinicians in an APM Entity
furnish services and receive payment
under the terms of an Other Payer
Advanced APM, except for those that
are excluded (81 FR 77477 through
77478). We finalized that the numerator
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30203
would be the number of unique patients
to whom eligible clinicians in the APM
Entity furnish services that are included
in the aggregate expenditures used
under the terms of all their Other Payer
Advanced APMs during the QP
Performance Period plus the patient
count numerator for Advanced APMs
(81 FR 77477 through 77478). We
finalized that the denominator would be
the number of unique patients to whom
eligible clinicians in the APM Entity
furnish services under all payers, except
those excluded (81 FR 77477 through
77478). We finalized that we will
calculate the Threshold Score by
dividing the numerator value by the
denominator value, which will result in
a percent value Threshold Score (81 FR
77477 through 77478). We will compare
that Threshold Score to the finalized QP
Patient Count Threshold and the Partial
QP Patient Count Threshold and
determine the QP status of the eligible
clinicians for the payment year (81 FR
77477 through 77478). We finalized that
we would count each unique patient
one time in the numerator and one time
in the denominator (81 FR 77477
through 77478).
We intend to carry out QP
determinations using the patient count
method as finalized with some proposed
modifications. We propose these
changes to facilitate the implementation
of the patient count method while
providing eligible clinicians with some
flexibility in choosing the timeframe for
making QP determinations. To carry out
our proposal to make QP determinations
at the eligible clinician level only, we
propose to count each unique patient
one time in the numerator and one time
in the denominator across all payers to
align with our finalized policy for
patient counts at the eligible clinician
level. We propose that the numerator
would be the number of unique patients
the eligible clinician furnishes services
to under the terms of all of their
Advanced APMs or Other Payer
Advanced APMs from either January 1
through March 31, or January 1 through
June 30 of the All-Payer QP Performance
Period. We propose that the
denominator would be the number of
unique patients the eligible clinician
furnishes services to under all payers,
except those excluded from either
January 1 through March 31, or January
1 through June 30 of the All-Payer QP
Performance Period. We seek comment
on this approach.
(4) Submission of Information for QP
Determinations Under the All-Payer
Combination Option
In the CY 2017 Quality Payment
Program final rule, we finalized that
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either APM Entities or individual
eligible clinicians must submit by a date
and in a manner determined by us: (1)
Payment arrangement information
necessary to assess whether each other
payer arrangement is an Other Payer
Advanced APM, including information
on financial risk arrangements, use of
CEHRT, and payment tied to quality
measures; (2) for each payment
arrangement, the amounts of payments
for services furnished through the
arrangement, the total payments from
the payer, the numbers of patients
furnished any service through the
arrangement (that is, patients for whom
the eligible clinician is at risk if actual
expenditures exceed expected
expenditures), and (3) the total number
of patients furnished any service
through the arrangement (81 FR 77480).
We also finalized that if we do not
receive sufficient information to
complete our evaluation of an other
payer arrangement and to make QP
determinations, we would not assess the
eligible clinicians under the All-Payer
Combination Option (81 FR 77480).
(a) Required Information
In order for us to make QP
determinations for an eligible clinician
under the All-Payer Combination
Option, we need information for all of
the Other Payer Advanced APMs in
which an eligible clinician participated
during the All-Payer QP Performance
Period. Eligible clinicians can
participate in other payer arrangements
that we determine are Other Payer
Advanced APMs through the Payer
Initiated Process, through the Eligible
Clinician Initiated Process, or both. We
discuss the submission of information
that pertains to Other Payer Advanced
APM determinations in section
II.D.6.c.(7)(a) of this proposed rule.
In order for us to make QP
determinations under the All-Payer
Combination Option using either the
payment amount or patient count
method, we would need to receive all of
the payment amount and patient count
information: (1) Attributable to the
eligible clinician through every Other
Payer Advanced APM; and (2) for all
other payments or patients, except from
excluded payers, made or attributed to
the eligible clinician during the AllPayer QP Performance Period. We
clarify that eligible clinicians will not
need to submit Medicare payment or
patient information for QP
determinations under the All-Payer
Combination Option.
To make calculations for the snapshot
dates as proposed in section
II.D.6.d.(4)(b) of this proposed rule, we
will need this payment amount and
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patient count information from January
1 through June 30 of the calendar year
2 years prior to the payment year. We
will need this payment amount and
patient count information submitted in
a way that allows us to distinguish
information from January 1 through
March 31 and from January 1 through
June 30 so that we can make QP
determinations based on the two
snapshot dates as discussed above.
To meet the need for information in
a way that we believe minimizes
reporting burden, we propose to collect
this payment amount and patient count
information aggregated for the two
proposed snapshot time frames: From
January 1 through March 31 and from
January 1 through June 30. We seek
comment on this approach, particularly
as to the feasibility of submitting
information in this way and suggestions
on how to further minimize reporting
burden. Alternatively, if we finalize an
All-Payer QP Performance Period of
January 1 through March 31, we would
need payment amount and patient count
information only from January 1
through March 31. If we retain the
current finalized QP Performance
Period, we would need information
aggregated for three snapshot
timeframes: From January 1 through
March 31, January 1 through June 30,
and January 1 through August 31.
As we discuss in section II.D.6.d.(3)(a)
of this proposed rule, we are proposing
to make QP determinations under the
All-Payer Combination Option only at
the eligible clinician level. As a result,
we propose that all of this payment and
patient information must be submitted
at the eligible clinician level, and not at
the APM Entity group level as we
finalized in rulemaking last year.
To minimize reporting burden on
individual eligible clinicians and to
allow eligible clinicians to submit
information to us as efficiently as
possible, we propose to allow eligible
clinicians to have APM Entities submit
this information on behalf of any of the
eligible clinicians in the APM Entity
group at the individual eligible clinician
level. We seek comments on these
proposals, particularly regarding the
feasibility of APM Entities reporting this
information for some or all of the
eligible clinicians in the APM Entity
group.
Additionally, we propose that if an
APM Entity or eligible clinician submits
sufficient information only for the
payment amount or patient count
method, but not for both, we will make
a QP determination based on the one
method for which we receive sufficient
information. We believe that this
proposal is consistent with our overall
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approach, particularly because we have
finalized that we will use the more
advantageous of the Threshold Scores to
make QP determinations (81 FR 77475).
We clarify that APM Entities or eligible
clinicians can submit information to
allow us to use both the payment
amount and patient count methods.
To facilitate and ease burden for
information submissions, we also
propose to create a form that APM
Entities or eligible clinicians would be
able to use to submit this payment
amount and patient count information.
APM Entities and eligible clinicians
would be required to use this form for
submitting the payment and patient
information.
We seek comment on these proposals.
(b) QP Determination Submission
Deadline
We propose that APM Entities or
eligible clinicians must submit all of the
required information about the Other
Payer Advanced APMs in which they
participate, including those for which
there is a pending request for an Other
Payer Advanced APM determination, as
well as the payment amount and patient
count information sufficient for us to
make QP determinations by December 1
of the calendar year that is 2 years to
prior to the payment year, which we
refer to as the QP Determination
Submission Deadline.
We believe that December 1 is the
latest date in the year that we could
receive information, and be able to
complete QP determinations and notify
eligible clinicians of their QP status in
time for them to report to MIPS as
needed. We also proposed this date for
the QP Determination Submission
Deadline to provide eligible clinicians
requesting QP determinations under the
All-Payer Combination Option as much
time as possible to gather and submit
information.
In the CY 2017 Quality Payment
Program final rule, we finalized that
without sufficient information we will
not make QP determinations under the
All-Payer Combination Option (81 FR
77480). As such, we will not make QP
determinations for an eligible clinician
under the All-Payer Combination
Option if we do not receive information
sufficient to make a QP determination
under either the payment amount or
patient count method by the QP
Determination Submission Deadline.
We seek comment on these proposals.
(c) Certification and Program Integrity
We propose that a new requirement
be added at § 414.1440(f)(2) stating that
the APM Entity or eligible clinician that
submits information to request a QP
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determination under the All-Payer
Combination Option must certify to the
best of its knowledge that the
information that they submitted to us is
true, accurate, and complete. In the case
of information submitted by the APM
Entity, we propose that the certification
must be made by an individual with the
authority to legally bind the APM
Entity. This certification would
accompany the Eligible Clinician
Initiated Submission Form, which both
eligible clinicians and APM Entities use
for the Eligible Clinician Initiated
Process. We seek comment on these
proposals.
We propose to revise the monitoring
and program integrity provisions at
§ 414.1460 to further promote the
integrity of the All-Payer Combination
Option. In the CY 2017 Quality Payment
Program final rule, we finalized at
§ 414.1460(e) that an APM Entity or
eligible clinician that submits
information to us under § 414.1445 for
assessment under the All-Payer
Combination Option must maintain
such books contracts records,
documents, and other evidence for a
period of 10 years from the final date of
the QP Performance Period or from the
date of completion of any audit,
evaluation, or inspection, whichever is
later (81 FR 77555). We also finalized at
§ 414.1460(c) that eligible clinicians and
APM Entities must maintain copies of
any supporting documentation related
to the All-Payer Combination Option for
at least 10 years (81 FR 77555). We
propose to revise § 414.1460(e) to apply
to information submitted to us under
§ 414.1440 for QP determinations. We
also propose to add paragraph (3) to
§ 414.1460(e) stating that an APM Entity
or eligible clinician who submits
information to us under § 414.1445 or
§ 414.1440 must provide such
information and supporting
documentation to us upon request. We
seek comments on these proposals.
(d) Use of Information
In the CY 2017 Quality Payment
Program final rule, we finalized that, to
the extent permitted by federal law, we
will maintain confidentiality of the
information and data that APM Entities
and eligible clinicians submit to support
Other Payer Advanced APM
determinations in order to avoid
dissemination of potentially sensitive
contractual information or trade secrets
(81 FR 77479 through 77480).
We believe that it is similarly
appropriate for us to maintain the
confidentiality of information submitted
to us for the purposes of QP
determinations to the extent permitted
by federal law. Therefore, we propose
that, to the extent permitted by federal
law, we will maintain confidentiality of
the information that APM Entities or
eligible clinicians submit to us for
purposes of QP determinations under
the All-Payer Combination Option, in
order to avoid dissemination of
potentially sensitive contractual
information or trade secrets.
30205
(5) Example
In Tables 56 and 57, we provide
examples where an eligible clinician is
in a Medicare ACO Model that we have
determined to be an Advanced APM, a
commercial ACO arrangement, and a
Medicaid APM from January 1 through
June 30, 2019. We would use the
information below to determine that
eligible clinician’s QP status for
payment year 2021.
We would calculate the Threshold
Scores for the APM Entity group in the
Advanced APM under the Medicare
Option. For the payment amount
method, as shown in Table 56, the APM
Entity group would not attain QP status
under the Medicare Option, which for
payment year 2021 requires a QP
payment amount Threshold Score of 50
percent. The APM Entity group would
also fail to attain Partial QP status under
the Medicare Option, which for
payment year 2021 requires a Partial QP
payment amount Threshold Score of 40
percent. For the patient count method,
as shown in Table 57, the APM Entity
group would not attain QP status under
the Medicare Option, which for
payment year 2021 requires a QP patient
count Threshold Score of 35 percent.
The APM Entity group would not attain
Partial QP status under the Medicare
Option, which for payment year 2021
requires a Partial QP patient count
Threshold Score of 25 percent.
TABLE 56—ALL-PAYER COMBINATION OPTION EXAMPLE—PAYMENT AMOUNT METHOD
Payer
Payments to
group/eligible
clinician
by payer
(in dollars)
Level
Total
payments to
group/eligible
clinician by payer
(in dollars)
Threshold
score
(percentage)
Medicare Option
Advanced APM (Medicare) ..........................................................
APM Entity Group .....
300,000
1,000,000
30
All-Payer Combination Option
Advanced APM (Medicare) ..........................................................
Other Payer Advanced APM (Commercial) .................................
Medicaid APM ..............................................................................
Eligible Clinician ........
Eligible Clinician ........
Eligible Clinician ........
20,000
20,000
80,000
50,000
50,000
100,000
........................
........................
........................
Totals for All-Payer Combination Option ..............................
Eligible Clinician ........
120,000
200,000
60
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TABLE 57—ALL-PAYER COMBINATION OPTION EXAMPLE—PATIENT COUNT METHOD
Payer
Patients of
group/eligible
clinician
by payer
Level
Total
patients of
group/eligible
clinician
by payer
Threshold
score
(percentage)
Medicare Option
Advanced APM (Medicare) ..........................................................
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TABLE 57—ALL-PAYER COMBINATION OPTION EXAMPLE—PATIENT COUNT METHOD—Continued
Payer
Patients of
group/eligible
clinician
by payer
Level
Total
patients of
group/eligible
clinician
by payer
Threshold
score
(percentage)
All-Payer Combination Option
Advanced APM (Medicare) ..........................................................
Other Payer Advanced APM (Commercial) .................................
Medicaid APM ..............................................................................
Eligible Clinician ........
Eligible Clinician ........
Eligible Clinician ........
200
100
500
1,000
500
1,000
........................
........................
........................
Totals for All-Payer Combination Option ..............................
Eligible Clinician ........
800
2,500
32
Partial QP patient count Threshold
under the All-Payer Combination
Option, which for payment year 2021 is
40 percent. We would use the more
advantageous score, so the eligible
clinician would be a QP for payment
year 2021.
Alternatively, if we were to use the
APM Entity weighted methodology for
calculation of a Threshold Score using
the payment amount method as
described in section II.D.6.d.(3)(d) of
this proposed rule, we would apply the
weighting methodology as follows:
adjustments (81 FR 77449). To promote
alignment with the Medicare Option
and to simplify requirements when
possible, we propose that eligible
clinicians who are Partial QPs for the
year under the All-Payer Combination
Option would make the election
whether to report to MIPS and then be
subject to MIPS reporting requirements
and payment adjustments. We seek
comment on this approach.
(6) Partial QP Election To Report to
MIPS
To summarize, we are proposing the
following:
• We propose to establish the AllPayer QP Performance Period, which
would begin on January 1 and end on
June 30 of the calendar year that is 2
years prior to the payment year.
• We propose to make QP
determinations based on eligible
clinicians’ participation in Advanced
APMs and Other Payer Advanced APMs
for two time periods: Between January
1 through March 31 and between
January 1 through June 30 of the AllPayer QP Performance Period under the
All-Payer Combination Option. We
propose to use data for the same time
periods for Medicare payments or
patients and that of other payers. We
also propose the eligible clinicians must
request QP determinations under the
All-Payer Combination Option and must
submit to CMS payment amount and
patient count data from other payers to
support the determination.
• We propose to notify eligible
clinicians of their QP status under the
All-Payer Combination Option as soon
as practicable after the proposed QP
Determination Submission Deadline.
• We propose to make QP
determinations under the All-Payer
Combination Option at the individual
eligible clinician level only.
• We propose to use the individual
eligible clinician payment amounts and
patient counts for Medicare in the All-
In the 2017 Quality Payment Program
final rule, we finalized under the
Medicare Option that, in the cases
where the QP determination is made at
the individual eligible clinician level, if
the eligible clinician is determined to be
a Partial QP, the eligible clinician will
make the election whether to report to
MIPS and then be subject to MIPS
reporting requirements and payment
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(7) Summary Proposals
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notified of this as we share information
on a regular basis on their QP status
under each snapshot. For payment year
2021, the eligible clinicians in this APM
Entity group would submit their
payment amount or patient count data
from all payers to calculate their
Threshold Score under the All-Payer
Combination Option.
In this example, the eligible clinician
score exceeds the QP payment amount
Threshold under the All-Payer
Combination Option, which for
payment year 2021 is 50 percent, but the
eligible clinician only exceeds the
The eligible clinician would obtain a
Threshold Score of 58 percent. This
would be slightly below the Threshold
Score obtained from the individual
eligible clinician payment count
calculation, but it would still exceed the
QP payment amount Threshold of 50
percent under the All-Payer
Combination Option. Based upon this
Threshold Score, the eligible clinician
would be a QP under the All-Payer
Combination Option.
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The APM Entity group did not attain
QP or Partial QP status under either the
payment amount or patient count
method under the Medicare Option.
However, because under both methods
of calculation, the APM Entity group
meets or exceeds the required Medicare
threshold for the year under the AllPayer Combination Option of 25 percent
and 20 percent, respectively, eligible
clinicians within the APM Entity group
would be eligible to obtain QP status
through the All-Payer Combination
Option. The eligible clinicians in the
APM Entity group would have been
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Payer Combination Option. We propose
that when the eligible clinician’s
Medicare Threshold Score calculated at
the individual level would be a lower
percentage than the one that is
calculated at the APM Entity group
level, we would apply a weighted
methodology.
• We propose that we will determine
whether a state operates a Medicaid
APM or a Medicaid Medical Home
Model that has been determined to be
an Other Payer Advanced APM at a substate level. We propose that we will use
the county level to determine whether a
state operates a Medicaid APM or a
Medicaid Medical Home Model an
Other Payer Advanced APM at a substate level.
• We propose that in a state where we
determine there are one or more
Medicaid APMs or Medicaid Medical
Home Models that are Other Payer
Advanced APMs in operation, but only
in certain counties, or only for eligible
clinicians in certain specialties, we
would further evaluate whether those
Medicaid APMs or Medicaid Medical
Home Models were available to each
eligible clinician for whom we make a
QP determination under the All-Payer
Combination Option. We would identify
the county in which the eligible
clinician practices by having the eligible
clinician submit that information to
identify the county where they saw the
most patients during the relevant AllPayer QP Performance Period when they
request a QP determination. We also
propose that if the eligible clinician’s
practice is in a county, or in a specialty,
in which there is no Medicaid APM or
Medicaid Medical Home Model in
operation, all of that eligible clinician’s
Medicaid payments and patients would
be excluded from the numerator and
denominator of the calculations under
the payment amount or patient count
method, respectively. We also propose
to identify Medicaid APM or Medicaid
Medical Home Models that are only
open to certain specialties through
questions asked of states in the Payer
Initiated Process and of eligible
clinicians in the Eligible Clinician
Initiated Process. We would use the
method generally used in the Quality
Payment Program to identify an eligible
clinician’s specialty or specialties.
• For the payment amount method
we would first make a calculation under
the Medicare Option using all Medicare
payments for the APM Entity. If the
minimum threshold score for the
Medicare Option were met, we would
make calculations under the All-Payer
Combination Option. We propose that
under the All-Payer Combination
Option the numerator would be the
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aggregate of all payments from all
payers, except those excluded, that are
made or attributable to the eligible
clinician, under the terms of all
Advanced APMs and Other Payer
Advanced APMs. We also propose that
the denominator would be the aggregate
of all payments from all payers, except
those excluded, that are made or
attributed to the eligible clinician.
• For the patient count method under
the All-Payer Combination Option, we
propose to count each unique patient
one time in the numerator and one time
in the denominator across all payers to
align with our finalized policy for
patient counts at the eligible clinician
level. We propose that the numerator
would be the number of unique patients
the eligible clinician furnishes services
to under the terms of all of their
Advanced APMs or Other Payer
Advanced APMs. We propose that the
denominator would be the number of
unique patients the eligible clinician
furnishes services to under all payers,
except those excluded.
• We propose to collect the necessary
payment amount and patient count
information for QP determinations
under the All-Payer Combination
Option aggregated for the two proposed
snapshot timeframes: From January 1
through March 31 and from January 1
through June 30. We propose that APM
Entities may submit this information on
behalf of any of the eligible clinicians in
the APM Entity group at the individual
eligible clinician level.
• We propose that if an APM Entity
or eligible clinician submits sufficient
information for either the payment
amount or patient count method, but
not for both, we will make a QP
determination based on the one method
for which we receive sufficient
information.
• We propose that APM Entities or
eligible clinicians must submit all of the
required information about the Other
Payer Advanced APMs in which they
participate, including those for which
there is a pending request for an Other
Payer Advanced APM determination, as
well as the payment amount and patient
count information sufficient for us to
make QP determinations by December 1
of the calendar year that is 2 years to
prior to the payment year, which we
refer to as the QP Determination
Submission Deadline.
• We propose that an APM Entity or
eligible clinician who submits
information to request a QP
determination under the All-Payer
Combination Option must certify to the
best of its knowledge that the
information submitted is true, accurate
and complete. In the case of information
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submitted by the APM Entity, we
propose that the certification be made
by an executive of the APM Entity. We
also propose that this certification must
accompany the form that APM Entities
or eligible clinicians submit to us when
requesting that we make QP
determinations under the All-Payer
Combination Option.
• We propose that APM Entities and
eligible clinicians that submit
information to CMS under § 414.1445
for assessment under the All-Payer
Combination Option or § 414.1440 for
QP determinations must maintain such
books, contracts, records, documents,
and other evidence as necessary to
enable the audit of an Other Payer
Advanced APM determination, QP
determinations, and the accuracy of
APM Incentive Payments for a period of
10 years from the end of the All-Payer
QP Performance Period or from the date
of completion of any audit, evaluation,
or inspection, whichever is later.
• We propose that APM Entities and
eligible clinicians that submit
information to us under § 414.1445 or
§ 414.1440 must provide such
information and supporting
documentation to us upon request.
• We propose that, to the extent
permitted by federal law, we will
maintain confidentiality of the
information that an APM Entity or
eligible clinician submits to us for
purposes of QP determinations under
the All-Payer Combination Option, to
avoid dissemination of potentially
sensitive contractual information or
trade secrets.
• We propose that eligible clinicians
who are Partial QPs for the year under
the All-Payer Combination Option
would make the election whether to
report to MIPS and then be subject to
MIPS reporting requirements and
payment adjustments.
We seek comment on these proposals.
7. Physician-Focused Payment Models
(PFPMs)
a. Overview
Section 1868(c) of the Act established
an innovative process for individuals
and stakeholder entities (stakeholders)
to propose physician-focused payment
models (PFPMs) to the PhysicianFocused Payment Model Technical
Advisory Committee (PTAC). The
PTAC, established under section
1868(c)(1)(A) of the Act, is a federal
advisory committee comprised of 11
members that provides advice to the
Secretary. A copy of the PTAC’s charter,
established on January 5, 2016, is
available at https://aspe.hhs.gov/
charter-physician-focused-paymentmodel-technical-advisory-committee.
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Section 1868(c)(2)(C) of the Act
requires the PTAC to review
stakeholders’ proposed PFPMs, prepare
comments and recommendations
regarding whether such proposed
PFPMs meet the PFPM criteria
established by the Secretary, and submit
those comments and recommendations
to the Secretary. Section 1868(c)(2)(D) of
the Act requires the Secretary to review
the PTAC’s comments and
recommendations on proposed PFPMs
and to post ‘‘a detailed response’’ to
those comments and recommendations
on the CMS Web site.
b. Definition of PFPM
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(1) Definition of PFPM
In the CY 2017 Quality Payment
Program final rule (81 FR 77555), we
defined PFPM at § 414.1465 as an
Alternative Payment Model in which:
Medicare is a payer; eligible clinicians
that are eligible professionals as defined
in section 1848(k)(3)(B) of the Act are
participants and play a core role in
implementing the APM’s payment
methodology; and the APM targets the
quality and costs of services that eligible
clinicians participating in the
Alternative Payment Model provide,
order, or can significantly influence.
In the CY 2017 Quality Payment
Program final rule (81 FR 77496) we
finalized the requirement that PFPMs be
tested as APMs with Medicare as a
payer. We stated that a PFPM could
include other payers in addition to
Medicare, but that other payer
arrangements and Other Payer
Advanced APMs are not PFPMs.
Therefore, PFPM proposals would need
to include Medicare as a payer.
In this proposed rule, we seek
comment on whether to broaden the
definition of PFPM to include payment
arrangements that involve Medicaid or
the Children’s Health Insurance
Program (CHIP) as a payer, even if
Medicare is not included as a payer. A
PFPM would then include Medicaid,
CHIP, or Medicare (or some
combination of these) as a payer. A
PFPM might still include other payers
in addition to Medicaid, CHIP, or
Medicare; however, an other payer
arrangement or Other Payer Advanced
APM that includes only private payers,
including a Medicare Advantage plan,
would not be a PFPM. Medicare
Advantage and other private plans paid
to act as insurers on the Medicare
program’s behalf are considered to be
private payers. The inclusion of
Medicaid or CHIP as a payer would not
imply the waiver of any requirements
under Title XIX or Title XXI; PFPMs
with Medicaid or CHIP as a payer would
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be required to follow all applicable
regulations and requirements relevant to
the approach they propose except those
for which waivers are expressly
provided under the terms of the PFPM
in the event, and at the time, that the
PFPM is implemented.
We believe broadening the definition
of PFPM to include payment
arrangements with Medicaid and CHIP,
even if Medicare is not included in the
payment arrangement, may complement
the policies we are proposing within
this rule for the All-Payer Combination
Option. Broadening the definition of
PFPM could potentially provide an
opportunity for stakeholders to propose
PFPMs to the PTAC that could be Other
Payer Advanced APMs, and
participation in such Other Payer
Advanced APMs would contribute to an
eligible clinician’s ability to become a
QP through the All-Payer Combination
Option.
The PTAC’s charge is to review
submitted proposals and provide
comments and recommendations to the
Secretary regarding whether the
proposals meet the PFPM criteria
established by the Secretary. The
Secretary is then charged with
reviewing and posting on the CMS Web
site a detailed response to the PTAC’s
comments and recommendations.
Because the Secretary does not have
authority to direct the design or
development of payment arrangements
that might be tested with private payers,
we seek comment on, if we were to
broaden the definition of PFPM,
including in the scope of PFPMs only
payment arrangements or models for
which the Secretary and CMS could
take subsequent action following the
statutory PTAC review process.
We seek comment on whether
broadening the definition of PFPMs
would be inclusive of potential PFPMs
that could focus on areas not generally
applicable to the Medicare population,
such as pediatric issues or maternal
health and whether changing the
definition of PFPM may engage more
stakeholders in designing PFPMs that
include more populations beyond
Medicare FFS beneficiaries. We seek
comment on how the PFPM criteria
could be applied to these payment
arrangements. We seek comment on
whether including more issues and
populations fits within the PTAC’s
charge and whether stakeholders are
interested in the opportunity to allow
the PTAC to apply its expertise to a
broader range of proposals for PFPMs.
The current definition of PFPM
specifies that a PFPM is an APM. In the
CY 2017 Quality Payment Program final
rule (81 FR 77406), we noted that APM
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is defined under section 1833(z)(3)(C) of
the Act as any of the following: (1) A
model under section 1115A of the Act
(other than a health care innovation
award); (2) the Shared Savings Program
under section 1899 of the Act; (3) a
demonstration under section 1866C of
the Act; or (4) a demonstration required
by federal law. If a payment
arrangement is a PFPM it must also be
an APM. Under our current regulation,
a model that does not meet the
definition of APM is not a PFPM.
However, a payment arrangement with
Medicaid or CHIP as the payer, but not
Medicare, would not necessarily meet
the definition of APM. Therefore, we
seek comment on whether we should, in
tandem with potentially broadening the
scope of PFPMs to include payment
arrangements with Medicaid and CHIP,
require that a PFPM be an APM or a
payment arrangement operated under
legal authority for Medicaid or CHIP
payment arrangements.
In the CY 2017 Quality Payment
Program final rule (81 FR 77494), we
stated that we anticipate PFPMs that are
recommended by the PTAC and tested
by CMS will be tested using section
1115A authority, although a model or
payment arrangement does not need to
be tested under section 1115A of the Act
to be a PFPM. APMs tested under
sections 1115A or 1866C of the Act, or
demonstrations required by federal law,
may include Medicaid or CHIP, but not
necessarily Medicare, as a payer. We
believe that because Medicaid and CHIP
payment arrangements may be operated
under other legal authorities than those
included in the definition of APM, such
as section 1115(a) waivers, section
1915(b) and (c) waivers, and state plan
amendments, we may need to consider
broadening the PFPM definition beyond
APMs to correspond with potentially
including Medicaid or CHIP as the only
payer. We note that were our policy to
change, PFPMs that are Medicaid or
CHIP payment arrangements that fall
outside the definition of APM would
need to follow the processes and meet
the requirements associated with the
legal authorities on which they are
based.
We believe it is important for PFPMs
to include innovative payment
methodologies. For that reason, we
continue to believe that the definition of
PFPM, as well as the PFPM criteria we
established through rulemaking should
apply exclusively to payment
arrangements, and not to arrangements
focused on care delivery reform without
a payment reform component. We
believe there are various statutory
authorities outside of those specified in
the definition of APM that might allow
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Medicaid and CHIP payment
arrangements to be structured to address
payment reform. We seek comment on
whether states and stakeholders see
value in having the definition of PFPM
broadened to include payment
arrangements with Medicaid or CHIP
but not Medicare as a payer, and
whether they see value in having
proposals for PFPMs with Medicaid or
CHIP but not Medicare as a payer go
through the PTAC’s review process.
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(2) Relationship Between PFPMs and
Advanced APMs
Section 1868(c) of the Act does not
require PFPMs to meet the criteria to be
an Advanced APM for purposes of the
incentives for participation in Advanced
APMs under section 1833(z) of the Act,
and we did not define PFPMs solely as
Advanced APMs. Stakeholders may
therefore propose as PFPMs either
Advanced APMs or Medical Home
Models, or other APMs. If we were to
broaden the definition to include
payment arrangements with Medicaid or
CHIP but not Medicare as a payer,
stakeholders could propose as PFPMs
Medicaid APMs, Medicaid Medical
Home Models, or other payer
arrangements involving Medicaid or
CHIP as a payer. We recognize that both
stakeholders and the PTAC may want to
discuss whether a proposed PFPM
would be an Advanced APM in their
proposals, comments, and
recommendations.
c. PTAC Review Process of PFPM
Proposals With Medicaid or CHIP as a
Payer
In the CY 2017 Quality Payment
Program final rule (81 FR 77491 through
77492), we described the roles of the
Secretary, the PTAC, and CMS as they
relate to PFPMs and the PTAC’s review
process. We believe that expanding the
definition of PFPM to include Medicaid
or CHIP as a payer, even when Medicare
is not involved, might encourage
innovation in additional areas and that
stakeholders and states may benefit
from the PTAC’s review process.
We intend to continue to give serious
consideration to proposed PFPMs
recommended by the PTAC. Section
1868(c) of the Act does not require us
to test proposals that are recommended
by the PTAC. In the CY 2017 Quality
Payment Program final rule (81 FR
77491), we explained that without being
able to predict the volume, quality, or
appropriateness of the proposed PFPMs
on which the PTAC will make
comments and recommendations, we
are not in a position to commit to test
all such models. We continue to believe
this is the case. In addition, we
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acknowledge that any PFPMs with
Medicaid or CHIP as a payer, as we are
seeking comment on, could not be
tested without significant coordination
and cooperation with the state(s)
involved. We could not ensure the
agreement of the state(s) for which a
PFPM is proposed with Medicaid or
CHIP as a payer, and therefore, similar
to models with Medicare as the payer,
we could not commit to testing these
proposed payment arrangements. The
Secretary and CMS must retain the
ability to make final decisions on which
PFPMs, whether they include Medicare
as a payer or only include Medicaid or
CHIP, are tested using section 1115A or
section 1866C authority, and if so, when
they are tested. Proposed PFPMs that
the PTAC recommends to the Secretary
but that are not immediately tested by
us may be considered for testing at a
later time.
We also could not speak to the length
of time it would take a state to
implement a PFPM with Medicaid or
CHIP as a payer, or whether it would be
shorter than the normal process for
implementing a payment arrangement
using Title XIX, Title XXI, or any other
relevant legal authority.
The decision to test a model
recommended by the PTAC that
includes Medicare, Medicaid, or CHIP
as a payer and is tested under section
1115A authority would not require
submission of a second proposal to us;
we would review the proposal
submitted to the PTAC along with
comments from the PTAC and the
Secretary, and any other resources we
believe would be useful. In order to
further evaluate or proceed to test a
proposed PFPM based on a
recommendation from the PTAC under
section 1115A authority, we may seek to
obtain additional information based on
the contents of the proposal. After a
PFPM proposal has been recommended
by the PTAC, if it is selected for further
evaluation or testing under section
1115A authority, we may work with the
individual stakeholders who submitted
their proposals to consider design
elements for testing the PFPM and make
changes as necessary, to the extent that
we are involved in the design and
testing or operation of the PFPM. We
note that if a PFPM we select for testing
under section 1115A authority requires
those interested to apply in order to
participate, the stakeholder who
submitted the proposal for a model to be
established would still have to apply in
order to participate in that model.
PFPMs with Medicaid or CHIP as a
payer operated under legal authority
other than 1115A would need to meet
the requirements for that legal authority.
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We believe that proposed PFPMs that
include Medicare as a payer and that
meet all of the PFPM criteria and are
recommended by the PTAC may need
less time to go through the development
process; however, we cannot guarantee
that the development process would be
shortened, or estimate by how much it
would be shortened. These processes
depend on the nature of the PFPM’s
design, and any attempt to impose a
deadline on them would not benefit
stakeholders because it would not allow
us to tailor the review and development
process to the needs of the proposed
PFPM. We could not speak to the length
of time it would take a state to
implement a PFPM with Medicaid or
CHIP as a payer, or whether it would be
shorter than the normal process. This
would be true for Medicaid or CHIP
payment arrangements tested using any
legal authorities.
d. PFPM Criteria
In the CY 2017 Quality Payment
Program final rule (81 FR 77496), we
finalized the Secretary’s criteria for
PFPMs as required by section
1868(c)(2)(A) of the Act. The PFPM
criteria are for the PTAC’s use in
discharging its duties under section
1868(c)(2)(C) of the Act to make
comments and recommendations to the
Secretary on proposed PFPMs.
We seek comment on the Secretary’s
criteria, including, but not limited to,
whether the criteria are appropriate for
evaluating PFPM proposals and are
clearly articulated. In addition, we seek
comment on stakeholders’ needs in
developing PFPM proposals that meet
the Secretary’s criteria. In particular, we
want to know whether stakeholders
believe there is sufficient guidance
available on what constitutes a PFPM,
the relationship between PFPMs, APMs,
and Advanced APMs; and on how to
access data, or how to gather supporting
evidence for a PFPM proposal.
e. Summary
In summary, we seek comment on
changing the definition of PFPM to
include payment arrangements with
Medicare, Medicaid or CHIP, or any
combination of these, as a payer; and we
seek comment on revising the definition
to require that a PFPM be an APM or a
payment arrangement operated under
legal authority for Medicaid or CHIP
payment arrangements. We also seek
comments on the Secretary’s criteria
more broadly and stakeholders’ needs in
developing PFPM proposals that meet
the Secretary’s criteria.
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III. Collection of Information
Requirements
Under the Paperwork Reduction Act
of 1995 (PRA), we are required to
publish a 60-day notice in the Federal
Register and solicit public comment
before a collection of information
requirement is submitted to the Office of
Management and Budget (OMB) for
review and approval. To fairly evaluate
whether an information collection
should be approved by OMB, section
3506(c)(2)(A) of the PRA requires that
we solicit comment on the following
issues:
• The need for the information
collection and its usefulness in carrying
out the proper functions of our agency.
• The accuracy of our burden
estimates.
• The quality, utility, and clarity of
the information to be collected.
• Our effort to minimize the
information collection burden on the
affected public, including the use of
automated collection techniques.
We are soliciting public comment on
each of the required issues under
section 3506(c)(2)(A) of the PRA for the
following information collection
requirements (ICRs).
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Summary and Overview
The Quality Payment Program aims to
do the following: (1) Support care
improvement by focusing on better
outcomes for patients, decreased
clinician burden, and preservation of
independent clinical practice; (2)
promote adoption of alternative
payment models that align incentives
across healthcare stakeholders; and (3)
advance existing delivery system reform
efforts, including ensuring a smooth
transition to a healthcare system that
promotes high-value, efficient care
through unification of CMS legacy
programs.
The CY 2017 Quality Payment
Program final rule established policies
to implement MIPS, a program for
certain eligible clinicians that makes
Medicare payment adjustments based
on performance on quality, cost and
other measures and activities, and that
consolidates components of three
precursor programs—the PQRS, the VM,
and the Medicare EHR Incentive
Program for eligible professionals. As
prescribed by MACRA, MIPS focuses on
the following: Quality—including a set
of evidence-based, specialty-specific
standards; cost; practice-based
improvement activities; and use of
CEHRT to support interoperability and
advanced quality objectives in a single,
cohesive program that avoids
redundancies.
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In the CY 2017 Quality Payment
Program final rule, we estimated a
reduction in burden hours of 1,066,658
and reduction of burden costs of $7.4
million relative to the legacy programs
it replaced (81 FR 77513). The total
existing burden for the previously
approved information collections
related to the CY 2017 Quality Payment
Program final rule was approximately
11 million hours and a total labor cost
of reporting of $1.311 million. The
streamlining and simplification of data
submission structures in the transition
year resulted in a reduction in burden
relative to the approved information
collections for the legacy programs
(PQRS and EHR Incentive Program for
Eligible Professionals), which
represented approximately 12 million
hours for a total labor cost of reporting
of $1.318 million. We estimate that the
policies proposed in this rule would
result in further reduction of 132,620
burden hours and a further reduction in
burden cost of $12.4 million relative to
a baseline of continuing the policies in
the CY 2017 Quality Payment Program
final rule. The Quality Payment Program
Year 2 reduction in burden based on
this rule reflects several proposed
policies, including our proposal for
significant hardship or other type of
exception, including a new significant
hardship exception for small practices
for the advancing care information
performance category; our proposal to
use a shorter version of the CAHPS for
MIPS survey; our proposal to allow
election of facility-based measurement
for applicable MIPS eligible clinicians,
thereby eliminating the need for
additional quality data submission
processes; and our proposal to allow
MIPS eligible clinicians to form virtual
groups which would create efficiencies
in data submission.
In addition to the decline in burden
due to the policies proposed in this rule,
we anticipate further reduction in
burden as a result of policies set forth
in the CY 2017 Quality Payment
Program final rule, including greater
clinician familiarity with the measures
and data submission methods set in
their second year of participation,
operational improvements streamlining
registration and data submission, and
continued growth in the number of QPs
that are excluded from MIPS. This
expected growth is due in part to
reopening of CPC+ and Next Generation
ACO for 2018, and the ACO Track 1+
which is projected to have a large
number of participants, with a large
majority reaching QP status. We
estimate that there will be between
180,000 and 245,000 eligible clinicians
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that will become QPs for the 2018
performance period compared to
110,159 eligible clinicians that are
estimated to become QPs during the
2017 performance period, an increase of
between 69,841 and 134,841. This
expected growth is due in part to
reopening of CPC+ and Next Generation
ACO for 2018, and the ACO Track 1+ in
response to public comments. These
models are projected to have a large
number of participants, the majority of
whom are expected to reach QP status.
Additional enrollees in currently active
and new Advanced APMs are both
considered in the growth estimate.
Our estimates assume clinicians who
participated in the 2015 PQRS and who
are not QPs in Advanced APMs in the
2017 Quality Payment Program
performance period will continue to
submit quality data as either MIPS
eligible clinicians or voluntary reporters
in the 2018 Quality Payment Program
performance period. Our participation
estimates are reflected in Table 65 for
the quality performance category, Table
76 for the advancing information
performance category, and Table 78 for
the improvement activities performance
category. We estimate that 36 percent of
the 975,723 ineligible or excluded
clinicians are expected to report
voluntarily because they reported under
PQRS. We expect them to continue to
submit because (a) the collection and
submission of quality data has been
integrated into their clinician practice;
and (b) the clinician types that were
ineligible from MIPS in years 1 and 2
may potentially become eligible in the
future.
We also assume that previous PQRS
participants who are not QPs will also
submit under the improvement
activities performance category, and
will submit under the advancing care
information performance category
unless they receive a significant
hardship or other type of exception,
including a new significant hardship
exception for small practices or are
automatically assigned a weighting of
zero percent for the advancing care
information performance category. We
are excluding the 110,159 QPs
identified using a preliminary version of
the file used for predictive qualifying
Alternative Payment Model participants
analysis made available on qpp.cms.gov
on June 2, 2017 and prepared using
claims for services between January 1,
2016 through August 31, 2016. Because
we do not have an estimated
participation status by TIN/NPI for
clinicians who join Advanced APMs in
2017 and 2018, we cannot model the
exclusion of the additional estimated
69,841 to 134,841 QPs clinicians that
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Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
will become QPs for the 2018
performance period. Hence, these
burden estimates may overstate the total
burden for data submission under the
quality, advancing care information, and
improvement activities performance
categories.
Our burden estimates assume that 36
percent of clinicians who do not exceed
the low- volume threshold or are not
eligible clinician types will voluntarily
submit quality data under MIPS because
they submitted quality data under the
PQRS. Hence, the proposed changes in
low-volume threshold will increase our
estimate of the proportion of clinicians
who will submit data voluntarily, but
will not affect the estimated number of
respondents. Section II.C.2.c. of this rule
proposes a low-volume threshold of less
than or equal to $90,000 in allowed
Medicare Part B charges or less than or
equal to 200 Medicare patients. The CY
2017 Quality Payment Program final
rule established a low-volume threshold
of less than or equal to $30,000 in
allowed Medicare Part B charges or less
than or equal to 100 Medicare patients.
The revised MIPS requirements and
burden estimates for all ICRs listed
below (except for CAHPS for MIPS and
virtual groups election) were submitted
as a request for revision of OMB control
number 0938–1314. The CAHPS for
MIPS ICR was submitted as a request for
revision of OMB control number 0938–
1222. The virtual groups ICR has a 60
data day Federal Register notice (82 FR
27257) published on June 14, 2017. ICRcomments related to virtual group
election are due on or before August 14,
2017.
A. Wage Estimates
To derive wage estimates, we used
data from the U.S. Bureau of Labor
Statistics’ (BLS) May 2016 National
Occupational Employment and Wage
Estimates for all salary estimates (https://
www.bls.gov/oes/current/oes_nat.htm).
Table 58 in this proposed rule presents
the mean hourly wage (calculated at 100
percent of salary), the cost of fringe
benefits and overhead, and the adjusted
hourly wage.
As indicated, we are adjusting our
employee hourly wage estimates by a
factor of 100 percent. This is necessarily
a rough adjustment, both because fringe
benefits and overhead costs vary
30211
significantly from employer to
employer, and because methods of
estimating these costs vary widely from
study to study. Nonetheless, there is no
practical alternative, and we believe that
doubling the hourly wage to estimate
total cost is a reasonably accurate
estimation method. We have selected
the occupations in Table 58 based on a
study (Casalino et al., 2016) that
collected data on the staff in physician’s
offices involved in the quality data
submission process.27
In addition, to calculate time costs for
beneficiaries who elect to complete the
CAHPS for MIPS survey, we have used
wage estimates for Civilian, All
Occupations, using the same BLS data
discussed in this section of the
proposed rule. We have not adjusted
these costs for fringe benefits and
overhead because direct wage costs
represent the ‘‘opportunity cost’’ to
beneficiaries themselves for time spent
completing the survey. To calculate
time costs for virtual groups to prepare
their written formal agreements, we
have used wage estimates for Legal
Support Workers, All Others.
TABLE 58—ADJUSTED HOURLY WAGES USED IN BURDEN ESTIMATES
Occupation title
Occupational
code
Billing and Posting Clerks ................................................................................
Computer Systems Analysts ............................................................................
Physicians ........................................................................................................
Practice Administrator (Medical and Health Services Managers) ...................
Licensed Practical Nurse (LPN) ......................................................................
Legal Support Workers, All Other ....................................................................
Civilian, All Occupations ..................................................................................
Mean hourly
wage
($/hr.)
43–3021
15–1121
29–1060
11–9111
29–2061
23–2099
Not applicable
$18.06
44.05
101.04
52.58
21.56
31.81
23.86
Fringe benefits
and overhead
($/hr.)
$18.06
44.05
101.04
52.58
21.56
31.81
N/A
Adjusted
hourly wage
($/hr.)
$36.12
88.10
202.08
105.16
43.12
63.62
23.86
Source: Occupational Employment and Wage Estimates May 2016, U.S. Department of Labor, Bureau of Labor Statistics. https://www.bls.gov/
oes/current/oes_nat.htm.
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B. Framework for Understanding the
Burden of MIPS Data Submission
Because of the wide range of
information collection requirements
under MIPS, Table 59 presents a
framework for understanding how the
organizations permitted or required to
submit data on behalf of clinicians
varies across the types of data, and
whether the clinician is a MIPS eligible
clinician, MIPS APM participant, or an
Advanced APM participant. As shown
in the first row of Table 59, MIPS
eligible clinicians that are not in MIPS
APMs and other clinicians voluntarily
submitting data will submit data either
27 Lawrence P. Casalino et al., ‘‘US Physician
Practices Spend More than $15.4 Billion Annually
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as individuals, groups, or virtual groups
to the quality, advancing care
information, and improvement activities
performance categories. For MIPS
APMs, the organizations submitting data
on behalf of participating MIPS eligible
clinicians will vary across categories of
data, and in some instances across
APMs. For the 2018 MIPS performance
period, the quality data submitted by
Shared Savings Program ACOs, Next
Generation ACOs, and Other MIPS
APMs on behalf of their participant
eligible clinicians will fulfill any MIPS
submission requirements for the quality
performance category.
For the advancing care information
performance category, billing TINs will
submit data on behalf of participants
who are MIPS eligible clinicians. For
the improvement activities performance
category, we will assume no reporting
burden for MIPS APM participants
because we will assign the improvement
activities performance category score at
the MIPS APM level and all APM Entity
groups in the same MIPS APM will
receive the same score. Advanced APM
participants who are determined to be
Partial QPs may incur additional burden
if they elect to participate in MIPS,
which is discussed in more detail in
section II.D.5. of this proposed rule.
to Report Quality Measures,’’ Health Affairs, 35, no.
3 (2016): 401–406.
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Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
TABLE 59—CLINICIANS OR ORGANIZATIONS SUBMITTING MIPS DATA ON BEHALF OF CLINICIANS, BY TYPE OF DATA AND
CATEGORY OF CLINICIAN
Type of data submitted
Category of clinician
Advancing care
information performance
category
Quality performance
category
MIPS Eligible Clinicians
(not in MIPS APMs) and
other clinicians voluntarily submitting data.
As group, virtual groups,
or individual clinicians.
Facility-based clinicians
and groups that elect facility-based measurement.
Clinicians and groups
electing facility-based
measurement will receive a quality score
based on their facility’s
Hospital VBP data submission. The burden has
been previously counted
under the Hospital VBP
rule, and is not included
in burden estimates here.
ACOs submit to the CMS
Each group TIN in the
Web Interface on behalf
APM Entity reports adof their participating
vancing care information
MIPS eligible clinicians.
to MIPS.29
[Not included in burden
estimate because quality
data submission to fulfill
requirements of the
Shared Savings Program and Next Generation ACO models are not
subject to the Paperwork
Reduction Act.] 28
MIPS APM Entities submit Each MIPS eligible clinito MIPS on behalf of
cian in the APM Entity
their participating MIPS
reports advancing care
eligible clinicians [Not ininformation to MIPS
cluded in burden estithrough either group TIN
mate because quality
or individual reporting.
data submission to fulfill
[The burden estimates
requirements of Innovaassume group TIN-level
tion Center models are
reporting.]
not subject to the Paperwork Reduction Act.].
Eligible Clinicians participating in the Shared
Savings Program or
Next Generation ACO
Model (both MIPS
APMs).
mstockstill on DSK30JT082PROD with PROPOSALS2
Eligible Clinicians participating in Other MIPS
APMs.
28 Sections and 3021 and 3022 of the Affordable
Care Act state the Shared Savings Program and
testing, evaluation, and expansion of Innovation
Center models are not subject to the Paperwork
Reduction Act (42 U.S.C. 1395jjj and 42 U.S.C.
1315a(d)(3), respectively).
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As group, virtual groups,
or individuals. Clinicians
who practice primarily in
a hospital, ambulatory
surgical center based
clinicians, non-patient
facing clinicians, PAs,
NPs, CNSs and CRNAs
are automatically eligible
for a zero percent
weighting for the advancing care information
performance category.
Clinicians approved for
significant hardship exceptions are also eligible
for a zero percent
weighting.
Facility-based clinicians
may be eligible for a
zero percent weighting
for the advancing care
information category.
Improvement activities
performance category
Other data submitted on
behalf of MIPS eligible
clinician
As group, virtual groups,
or individual clinicians.
Groups electing to use a
CMS-approved survey
vendor to administer
CAHPS must register.
Groups electing to submit
via CMS Web Interface
for the first time must
register.
Virtual groups must register via email.
As groups, virtual groups,
or individual clinicians.
Facility-based clinicians
that elect facility-based
measurement make the
election online.
CMS will assign the same
improvement activities
performance category
score to each APM Entity group based on the
activities involved in participation in the Shared
Savings Program.30
[The burden estimates
assume no improvement
activity reporting burden
for APM participants.]
Advanced APM Entities
will make election for
participating MIPS eligible clinicians.
CMS will assign the same
improvement activities
performance category
score to each APM Entity based on the activities
involved in participation
in the MIPS APM. [The
burden estimates assume no improvement
activities performance
category reporting burden for APM participants.]
Advanced APM Entities
will make election for
participating eligible clinicians.
29 For MIPS APMs other than the Shared Savings
Program, both group TIN and individual clinician
advancing care information data will be accepted.
If both group TIN and individual scores are
submitted for the same MIPS APM Entity, CMS
would take the higher score for each TIN/NPI. The
TIN/NPI scores are then aggregated for the APM
Entity score.
30 APM Entities participating in MIPS APMs do
not need to submit improvement activities data
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The policies finalized in the CY 2017
Quality Payment Program final rule and
proposed in this rule create some
additional data collection requirements
unless the CMS-assigned improvement activities
scores is below the maximum improvement
activities score.
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not listed in Table 59. These additional
data collections, some of which were
previously approved by OMB under
control numbers 0938–1314 and 0938–
1222 are as follows:
• Self-nomination of new and
returning QCDRs and registries (0938–
1314).
• CAHPS for MIPS survey completion
by beneficiaries (0938–1222).
• Approval process for new and
returning CAHPS for MIPS survey
vendors.
• Call for new improvement
activities.
• Other Payer Advanced APM
identification: other payer initiated
process.
• Opt out of performance data display
on Physician Compare for voluntary
reporters under MIPS.
C. ICR Regarding Burden for Virtual
Group Election (§ 414.1315)
As described in section II.C.4.b. of
this proposed rule, virtual groups are
defined by a combination of two or
more TINs and must report as a virtual
group on measures in all quality,
improvement activities, and advancing
care information performance categories
as virtual groups. Virtual groups may
submit data through any of the
mechanisms available to groups. We
refer to section II.C.4. on additional
requirements for virtual groups.
We propose an optional 2-stage
process for enrollment. In stage 1, MIPS
eligible clinicians have the option to
request a determination of their
eligibility to form a virtual group before
they form a group and begin the stage
2 submission of an election to
participate in a virtual group. For
clinicians or groups that do not choose
to participate in stage 1 of the election
process, we will make an eligibility
determination during stage 2 of the
election process. We refer readers to
section II.C.4.e. of this proposed rule for
a discussion of the proposed virtual
group election process.
As proposed in II.C.4.e. of this
proposed rule, the submission of a
virtual group election must include, at
a minimum, detailed information
pertaining to each TIN and NPI
associated with the virtual group and
detailed information for the virtual
group representative, as well as
confirmation of a written formal
agreement between members of the
virtual group.
We assume that virtual group
participation will be relatively low in
the first year because we have heard
from stakeholders that they need at least
3–6 months to form groups and
establish agreements before signing up.
We are not able to give them that much
time in the first year, rather closer to 60
days. Because of this we expect the
number of virtual groups will be very
small in the first year of virtual group
implementation. Our assumptions for
participation in a virtual group are
shown in Table 60. We assume that only
those eligible clinicians that reported
historically will participate in virtual
groups in the first year because of the
limited lead time to create processes.
Also, while virtual groups may use the
same submission mechanisms as
groups, we are estimating based on
stakeholder feedback that the 16 virtual
groups reflected in Table 60 will report
by registry. Table 60 also shows that we
estimate that approximately 765 MIPS
eligible clinicians will decide to join 16
virtual groups for the 2018 MIPS
performance period. The virtual groups
could range in size from a few clinicians
to hundreds of clinicians, as long as
each participant is a solo practice or TIN
with 10 or fewer eligible clinicians. In
order to estimate the number of
clinicians available to participate in
virtual groups, we used the data
prepared to support the 2017
performance period initial
determination of clinician eligibility
(available via the NPI lookup on
qpp.cms.gov) using a date range of
September 1, 2015–August 31, 2016. We
also used the initial small practice
determinations made on the same date
range. We estimated the number of
clinicians who would not participate
30213
due to being a QP using a version of the
file used for the predictive qualifying
Alternative Payment Model participants
(QP) analysis made available on
qpp.cms.gov on June 2, 2017 and
prepared using claims for services
between January 1, 2016 through August
31, 2016. We assume an average of 5
TINs per virtual group with an average
of 9.5 clinicians in each TINs across
each virtual group or approximately 48
eligible clinicians per virtual group (5
TINs × 9.5 clinicians per TIN). For
purposes of this burden estimate for the
2018 MIPS performance period, we
assumed that approximately one percent
of eligible clinicians will participate in
approximately 16 virtual groups
consisting of approximately 5 TINs per
virtual group will be formed (765 MIPS
eligible clinicians ÷ 48 eligible
clinicians per virtual group) or 80 TINs
total that will participate in virtual
groups (16 virtual groups × 5 MIPS
eligible clinicians per TIN).
We assume that the virtual election
process will require 10 hours per virtual
group, similar to the burden of the
QCDR or registry self-nomination
process finalized in § 414.1400. We
assume that 8 hours of the 10 burden
hours per virtual group will be
computer systems analyst’s time or the
equivalent with an average labor cost of
$88.10/hour, and an estimated cost of
$704.80 per virtual group ($88.10/hour
× 8 hours). We also assume that 2 hours
of the 10 burden hours per virtual group
will be legal support services
professionals assisting in formulating
the written virtual agreement with an
average labor cost of $63.62/hour, with
a cost of $127.24 per virtual group
($63.62/hour × 2 hours). Therefore, the
total burden cost per virtual group
associated with the election process is
$832.04 ($704.80 + $127.24). We also
assume that 16 new virtual groups will
go through the election process leading
to a total burden of $13,313 ($832.04 ×
16 virtual groups). We estimate that the
total annual burden hours will be 160
(16 virtual groups × 10 hours).
TABLE 60—ESTIMATED BURDEN FOR VIRTUAL GROUP ELECTION PROCESS
mstockstill on DSK30JT082PROD with PROPOSALS2
Burden
estimate
Total Estimated Number of MIPS eligible clinicians in TINs of 10 eligible clinicians or fewer submitting data in MIPS (a) .............
Total Estimated Number of eligible TINs (10 eligible clinicians or fewer) (b) .....................................................................................
Estimated Number of Virtual Groups (c) .............................................................................................................................................
Estimated Total Annual Burden Hours for Virtual Group to prepare written formal agreement (d) ...................................................
Estimated Total Annual Burden Hours for Virtual Group Representative to Submit Application to Form Virtual Group (e) .............
Estimated Total Annual Burden Hours per Virtual Group (f) ..............................................................................................................
Estimated Total Annual Burden Hours for Virtual Groups (g) = (c) * (f) .....................................................................................
Estimate Cost to Prepare Formal Written Agreement (@legal support services professional’s labor rate of $63.62) (h) ................
Estimated Cost to Elect Per Virtual Group (@computer systems analyst’s labor rate of $88.10/hr.) (i) ...........................................
Estimated Total Annual Burden Cost Per Virtual Group (j) ................................................................................................................
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765
80
16
2
8
10
160
$127.24
$704.80
$832.04
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TABLE 60—ESTIMATED BURDEN FOR VIRTUAL GROUP ELECTION PROCESS—Continued
Burden
estimate
Estimated Total Annual Burden Cost (k) = (c) * (j) ......................................................................................................................
While the formation of virtual groups
will result in a burden for virtual group
registration, we also estimate that the
formation of virtual groups will result in
a decline in burden from other forms of
data submission. Because we assume
burden is the same for each organization
(group, virtual group, or eligible
clinician) submitting quality,
improvement activities or advancing
care information performance category
data, virtual groups will reduce burden
by reducing the time needed to prepare
data for submission, review measure
specifications, register or elect to submit
data via a mechanism such as QCDR,
registry, CMS Web Interface, or EHR.
This reduction in burden is described in
each of the quality, improvement
activities, and advancing care
information performance category
sections below.
As stated earlier, the information
collection request for the virtual group
election process will be submitted for
OMB review and approval separately
from this rulemaking process. Please
note that the 60-day Federal Register
notice already published on June 14,
2017 (82 FR 27257) and the related
comment period ends August 14, 2017.
When the 30-day Federal Register
notice publishes, it will not only
announce that we are formally
submitting the information collection
request to OMB but it will also inform
the public on its additional opportunity
to review the information collection
request and submit comments.
D. ICR Regarding Burden for Election of
Facility-Based Measurement
(§ 414.1345)
In section II.C.7.a.(4) of this proposed
rule, we propose that for the 2020 MIPS
payment year (2018 MIPS performance
period), we would allow facility-based
MIPS eligible clinicians to be given a
MIPS score in the quality and cost
performance categories that is based on
the performance of the facility in which
they provide services. We propose at
§ 414.1380(e)(2)(i) that a MIPS eligible
clinician is eligible for facility-based
measurement under MIPS if they
furnish 75 percent or more of their
covered professional services (as
defined in section 1848(k)(3)(A) of the
Act) in sites of service identified by the
place of service codes used in the
HIPAA standard transaction as an
inpatient hospital, as identified by place
of service code 21, and the emergency
room, as identified by place of service
code 23, based on claims for a period
prior to the performance period as
specified by CMS.
These MIPS eligible clinicians may
elect to participate in facility-based
measurement during the performance
period. For the 2020 MIPS payment year
(2018 MIPS performance period), we
will base our assumptions for these
eligible clinicians on the Hospital VBP
Program.
In Table 61, we estimate participation
in facility-based measurement, based on
2015 data from the PQRS and the first
2019 payment year MIPS eligibility and
special status file as described in 81 FR
$13,313
77069 and 77070.31 We estimate 18,207
respondents (17,943 MIPS eligible
clinicians who practice primarily in the
hospital electing as individuals and 264
groups with 75 percent or more of their
clinicians qualifying as clinicians who
practice primarily in the hospital) will
elect facility-based measurement in the
2018 MIPS performance period. We
estimate that the 17,943 individual
clinicians electing facility-based scoring
are comprised of 20 percent (10,353) of
a total of the approximately 51,767 of
clinicians who practice primarily in the
hospital that previously submitted as
individuals in the 2017 MIPS
performance period; 80 percent (7,590)
of a total of 9,488 clinicians who
practice primarily in the hospital that
we estimate will not have submitted in
the 2017 MIPS performance period. We
believe that the 80 percent (7,590) of the
total 9,488 would not have submitted in
the 2017 MIPS performance period
because of the additional effort required
to report MIPS measures in addition to
measures required for the Hospital
Value-Based Purchasing program. We
have heard this from hospitalists and
other clinicians and we believe that the
inclusion of this opportunity within
MACRA was in response to this
concern. We estimate that 20 percent (or
264) of groups that would have
previously submitted on behalf of
clinicians in the 2017 MIPS
performance period will elect facilitybased measurement on behalf of their
12,125 clinicians.
TABLE 61—ESTIMATED NUMBER OF INDIVIDUAL CLINICIANS AND GROUPS WHO PRACTICE PRIMARILY IN THE HOSPITAL TO
ELECT FACILITY-BASED MEASUREMENT
mstockstill on DSK30JT082PROD with PROPOSALS2
Counts
Estimated number of clinicians who practice primarily in the hospital that previously submitted as individuals under the 2017
MIPS performance period to elect facility-based measurement in the 2018 MIPS performance period (a) ..................................
Estimated number of clinicians who practice primarily in the hospital that did not submit under the 2017 MIPS performance period to elect facility-based measurement as individuals in the 2018 MIPS performance period (b) ..............................................
Estimated number of clinicians who practice primarily in the hospital to elect facility-based measurement as individuals in the
2017 MIPS performance period (c) = (a) + (b) ................................................................................................................................
Estimated number of clinicians who practice primarily in the hospital that previously submitted as groups under the 2017 MIPS
performance period to elect facility-based measurement in the 2018 MIPS performance period (d) ............................................
Estimated number of groups who practice primarily in the hospital that previously submitted on behalf of clinicians as groups
under the 2017 MIPS performance period to elect facility-based measurement in the 2018 MIPS performance period (e) ........
Estimated number of respondents that elect facility-based measurements (including individual clinicians who practice primarily in
the hospital electing facility-based measurement and groups electing facility-based measurement) (f) = (c) + (e) ......................
31 The data used for our estimates defined
hospital-based clinicians as those who furnish 75
percent or more of their covered professional
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service in sites of service identified by place service
codes 21, 22, or 23. The proposal defines facilitybased clinicians as those who furnish 75 percent or
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10,353
7,590
17,943
12,125
264
18,207
more of their covered professional service in sites
of service identified by place service codes 21 and
23.
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Although the election of facility-based
measurement generates burden, it will
also result in the reduction of burden in
the quality performance category
because certain clinicians and groups
will no longer be required to submit
data for this category. Hence, our
burden estimates for the quality
performance category consider the
reduction in burden for clinicians who
practice primarily in the hospital that
previously submitted data for this
performance category and elected to use
facility-based measurement. The
reduction in burden is described in the
quality performance category section
below. We assume that there will be no
reduction in burden related to the
advancing care information performance
category because MIPS eligible
clinicians who practice primarily in the
hospital are not required to submit data
for this performance category.
As shown in Table 62, we estimate
that the election to participate via
facility-based measurement will take 1
hour of staff time, comparable to the
CMS Web Interface registration process.
We assume that the staff involved in the
election process to participate via
facility-based measurement will mainly
be billing clerks or their equivalent, who
have an average labor cost of $36.12/
30215
hour. Therefore, assuming the total
burden hours per group or individual
clinician associated with the election
process is 1 hour, the total annual
burden hours are 18,207 (18,207 groups
or individual clinicians × 1 hour). We
estimate that the total cost to groups and
individual clinicians associated with
the election process will be
approximately $36.12 ($36.12 per hour
× 1 hour per group or eligible clinician).
We also assume that 18,207 individual
clinicians or groups will go through the
election process leading to a total
burden of $657,637 ($36.12 × 18,207
clinicians).
TABLE 62—ESTIMATED BURDEN FOR ELECTION TO PARTICIPATE IN FACILITY-BASED MEASUREMENT
Burden
estimate
Estimated number of respondents to elect facility-based measurements (including individual clinicians who practice primarily in
the hospital electing facility-based measurement and groups electing facility-based measurement) (a) .......................................
Estimated number of Burden Hours Per Group or Eligible Clinician to Elect Facility-based Measurement (b) ................................
Estimated Total Annual Burden Hours (c) = (a) * (b) ..................................................................................................................
Estimated Cost Per Clinician or Group Practice to Elect Facility-Based Measurement (@billing clerk’s labor rate of $36.12/hr.)
(d) .....................................................................................................................................................................................................
Estimated Total Annual Burden Cost (e) = (c) * (d) ....................................................................................................................
mstockstill on DSK30JT082PROD with PROPOSALS2
E. ICRs Regarding Burden for Third
Party Reporting (§ 414.1400)
Under MIPS, quality, advancing care
information, and improvement activities
performance category data may be
submitted via relevant third party
intermediaries, such as qualified
registries, QCDRs and health IT vendors.
The CAHPS for MIPS survey data,
which counts as one quality
performance category measure, can be
submitted via CMS-approved survey
vendors. The burdens associated with
qualified registry and QCDR selfnomination and the CAHPS for MIPS
survey vendor applications are
discussed below.
1. Burden for Qualified Registry and
QCDR Self-Nomination 32
For the 2017 MIPS performance
period, 120 qualified registries and 113
QCDRs were qualified to report quality
measures data for purposes of the PQRS,
an increase from 114 qualified registries
and 69 QCDRs in CY 2016.33 Under
MIPS, we believe that the number of
QCDRs and qualified registries will
continue to increase because: (1) Many
32 We do not anticipate any changes in the
CEHRT process for health IT vendors as we
transition to MIPS. Hence, health IT vendors are not
included in the burden estimates for MIPS.
33 The full list of qualified registries for 2017 is
available at https://qpp.cms.gov/docs/QPP_MIPS_
2017_Qualified_Registries.pdf and the full list of
QCDRs is available at https://qpp.cms.gov/docs/
QPP_2017_CMS_Approved_QCDRs.pdf.
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MIPS eligible clinicians will be able to
use the qualified registry and QCDR for
all MIPS submission (not just for quality
submission) and (2) QCDRs will be able
to provide innovative measures that
address practice needs. Qualified
registries or QCDRs interested in
submitting quality measures results and
numerator and denominator data on
quality measures to us on their
participants’ behalf will need to
complete a self-nomination process to
be considered qualified to submit on
behalf of MIPS eligible clinicians or
groups, unless the qualified registry or
QCDR was qualified to submit on behalf
of MIPS eligible clinicians or groups for
prior program years and did so
successfully.
We estimate that the self-nomination
process for qualifying additional
qualified registries or QCDRs to submit
on behalf of MIPS eligible clinicians or
groups for MIPS will involve
approximately 1 hour per qualified
registry or QCDR to complete the online
self-nomination process. The selfnomination form is submitted
electronically using a web-based tool.
We are proposing to eliminate the
option of submitting the self-nomination
form via email that was available in the
transition year.
In addition to completing a selfnomination statement, qualified
registries and QCDRs will need to
perform various other functions, such as
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18,207
1
18,207
$36.12
$657,637
meeting with CMS officials when
additional information is needed. In
addition, QCDRs calculate their measure
results. QCDRs must possess
benchmarking capability (for non-MIPS
quality measures) that compares the
quality of care a MIPS eligible clinician
provides with other MIPS eligible
clinicians performing the same quality
measures. For non-MIPS measures the
QCDR must provide to us, if available,
data from years prior (for example, 2016
data for the 2018 MIPS performance
period) before the start of the
performance period. In addition, the
QCDR must provide to us, if available,
the entire distribution of the measure’s
performance broken down by deciles.
As an alternative to supplying this
information to us, the QCDR may post
this information on their Web site prior
to the start of the performance period,
to the extent permitted by applicable
privacy laws. The time it takes to
perform these functions may vary
depending on the sophistication of the
entity, but we estimate that a qualified
registry or QCDR will spend an
additional 9 hours performing various
other functions related to being a MIPS
qualified registry or QCDR.
As shown in Table 63, we estimate
that the staff involved in the qualified
registry or QCDR self-nomination
process will mainly be computer
systems analysts or their equivalent,
who have an average labor cost of
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$88.10/hour. Therefore, assuming the
total burden hours per qualified registry
or QCDR associated with the selfnomination process is 10 hours, the
annual burden hours is 2,330 (233 (113
+ 120) QCDRs or qualified registries ×
10 hours). We estimate that the total
cost to a qualified registry or QCDR
associated with the self-nomination
process will be approximately $881.00
($88.10 per hour × 10 hours per
qualified registry). We also estimate that
233 qualified registries or QCDRs will
go through the self-nomination process
leading to a total burden of $205,273
($881.00 × 233).
The burden associated with the
qualified registry and QCDR submission
requirements in MIPS will be the time
and effort associated with calculating
quality measure results from the data
submitted to the qualified registry or
QCDR by its participants and submitting
these results, the numerator and
denominator data on quality measures,
the advancing care information
performance category, and improvement
activities data to us on behalf of their
participants. We expect that the time
needed for a qualified registry to
accomplish these tasks will vary along
with the number of MIPS eligible
clinicians submitting data to the
qualified registry or QCDR and the
number of applicable measures.
However, we believe that qualified
registries and QCDRs already perform
many of these activities for their
participants. We believe the estimate
noted in this section represents the
upper bound of QCDR burden, with the
potential for less additional MIPS
burden if the QCDR already provides
similar data submission services.
Based on the assumptions previously
discussed, we provide an estimate of
total annual burden hours and total
annual cost burden associated with a
qualified registry or QCDR selfnominating to be considered ‘‘qualified’’
to submit quality measures results and
numerator and denominator data on
MIPS eligible clinicians.
TABLE 63—ESTIMATED BURDEN FOR QCDR AND REGISTRY SELF-NOMINATION
Burden
estimate
Estimated number of Qualified registries or QCDRs Self-Nominating (a) ..........................................................................................
Estimated Total Annual Burden Hours Per Qualified Registry or QCDR (b) .....................................................................................
Estimated Total Annual Burden Hours for Qualified Registries or QCDRs (c) = (a) * (b) ..........................................................
Estimated Cost Per Qualified Registry or QCDR (@computer systems analyst’s labor rate of $88.10/hr.) (d) ................................
Estimated Total Annual Burden Cost for Qualified registries or QCDRs (e) = (a) * (d) ..............................................................
2. Burden for CAHPS for MIPS Survey
Vendors
In the CY 2017 Quality Payment
Program final rule (81 FR 77386), we
finalized the definition, criteria,
required forms, and vendor business
requirements needed to participate in
MIPS as a survey vendor. For purposes
of MIPS, we defined a CMS-approved
survey vendor at § 414.1305 as a survey
vendor that is approved by us for a
particular performance period to
administer the CAHPS for MIPS survey
and transmit survey measures data to
us. At § 414.1400(i), we require that
vendors undergo the CMS-approval
process each year in which the survey
vendor seeks to transmit survey
measures data to us. We finalized the
criteria for a CMS-approved survey
vendor for the CAHPS for MIPS survey.
We estimate that it will take a survey
vendor 10 hours to submit the
information required for the CMSapproval process, including the
completion of the Vendor Participation
Form and compiling documentation,
including the quality assurance
plan,that demonstrates that they comply
with Minimum Survey Vendor Business
Requirements. This is comparable to the
burden of the QCDR and qualified
registry self-nomination process. As
shown in Table 64, we assume that the
survey vendor staff involved in
collecting and submitting the
information required for the CAHPS for
MIPS certification will be computer
systems analysts, who have an average
233
10
2,330
$881.00
$205,273
labor cost of $88.10/hour. Therefore,
assuming the total burden hours per
CAHPS associated with the application
process is 10 hours, the annual burden
hours is 150 (15 CAHPS vendors × 10
hours). We estimate that the total cost to
each CAHPS vendor associated with the
application process will be
approximately $881.00 ($88.10 per hour
× 10 hours per CAHPS vendor). We
estimate that 15 CAHPS vendors will go
through the process leading to a total
burden of $13,215 ($881.00 × 15 CAHPS
vendors).
Based on the assumptions previously
discussed, we provide an estimated
number of total annual burden hours
and total annual cost burden associated
with the survey vendor approval
process in Table 64.
TABLE 64—ESTIMATED BURDEN FOR CAHPS SURVEY VENDOR APPLICATION
Burden
estimate
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Estimated number of New CAHPS Vendors Applying (a) ..................................................................................................................
Estimated number of Burden Hours Per Vendor to Apply (b) ............................................................................................................
Estimated Cost Per Vendor Reporting (@computer systems analyst’s labor rate of $88.10/hr.) (c) .................................................
15
10
$881.00
Estimated Total Annual Burden Hours (d) = (a) * (b) ..................................................................................................................
Estimated Total Annual Burden Cost for CAHPS Vendor Application Process (e) = (a) * (c) ....................................................
150
$13,215
F. ICRs Regarding the Quality
Performance Category (§ 414.1330 and
§ 414.1335)
Two groups of clinicians will submit
quality data under MIPS: those who
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submit as MIPS eligible clinicians, and
other clinicians who opt to submit data
voluntarily but will not be subject to
MIPS payment adjustments.
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Historically, the PQRS has never
experienced 100 percent participation;
the participation rate for 2015 was 69
percent. For purposes of these analyses,
we assume that clinicians who
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participated in the 2015 PQRS and who
are not QPs in Advanced APMs in the
2017 Quality Payment Program
performance period will continue to
submit quality data as either MIPS
eligible clinicians or voluntary reporters
in the 2018 MIPS performance period.
In addition, as shown in Table 62,
regarding our burden estimates for
election of facility-based measurement,
we assume that approximately 18,207
individual clinicians or groups will
elect to participate in facility-based
measurement for the 2018 MIPS
performance period and will not be
required to submit any additional
quality performance category data under
MIPS. Based on 2015 data from the
PQRS, the data prepared to support the
2017 performance period initial
determination of clinician and special
status eligibility (available via the NPI
lookup on qpp.cms.gov) using a date
range of September 1, 2015—August 31,
2016, and a version of the file used for
the predictive qualifying Alternative
Payment Model participants analysis
made available on qpp.cms.gov on June
2, 2017 and prepared using claims for
services between January 1, 2016
through August 31, 2016. We estimate
that at least 92 percent of MIPS eligible
clinicians not participating in MIPS
APMs will submit quality performance
category data including those
participating as individual clinicians,
groups, or virtual groups. We assume
that 100 percent of MIPS APM Entities
will submit quality data to CMS as
required under their models.34 We
anticipate that the professionals
submitting data voluntarily will include
clinicians that are ineligible for the
Quality Payment Program, clinicians
that do not exceed the low-volume
threshold, and newly enrolled Medicare
clinicians. Based on those assumptions,
using data from the 2015 PQRS, the data
prepared to support the 2017
performance period initial
determination of clinician and special
status eligibility (available via the NPI
lookup on qpp.cms.gov), and a
preliminary version of the file used for
the predictive QP analysis made
available on qpp.cms.gov on June 2,
2017, we estimate that an additional
292,351 clinicians, or 36 percent of
clinicians excluded from or ineligible
from MIPS, will submit MIPS quality
data voluntarily. Because in the
projected growth in the number of QPs
over time, we are predicting a decline in
34 We estimate that 110,159 clinicians that
participated in the 2015 PQRS will be QPs who will
not be not required to submit MIPS quality
performance category data under MIPS, and are not
included in the numerator or denominator of our
participation rate.
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the rate of voluntary quality data
submission among clinicians excluded
from or ineligible for MIPS relative to
our estimated voluntary reporting rate of
45 percent in the CY 2017 Quality
Payment Program final rule.
Historically, clinicians who are
expected to be QPs in 2018 MIPS
performance period were much more
likely to have submitted quality data
under the 2015 PQRS than other
clinicians excluded from or ineligible
from MIPS. Due to data limitations, our
assumptions about quality performance
category participation for the purposes
of our burden estimates differs from our
assumptions about quality performance
category participation in the impact
analysis.35
Our burden estimates for data
submission combine the burden for
MIPS eligible clinicians and other
clinicians submitting data voluntarily.
Apart from clinicians who practice
primarily in the hospital electing
facility-based measurement and
clinicians that became QPs in the first
QP performance period, we assume that
clinicians will continue to submit
quality data under the same submission
mechanisms that they used under the
2015 PQRS. As discussed in more detail
in the section of this proposed rule
describing the burden for facility-based
measurement (III.D.), we assume that
some eligible clinicians who practice
primarily in the hospital will elect
facility-based measurement, rather than
submit quality data via other
mechanisms. Further, as discussed in
more detail in the section of this
proposed rule describing the burden for
the virtual group application process
(III.C.), we assume that the
approximately 80 TINs that elect to form
the approximately 16 virtual groups will
continue to use the same submission
mechanism as under the 2015 PQRS,
but the submission will be at the virtual
group, rather than group level. Our
burden estimates for the quality
performance category do not include the
burden for the quality data that MIPS
APM Entities submit to fulfill the
requirements of their models. Sections
3021 and 3022 of the Affordable Care
Act state the Shared Savings Program
and the testing, evaluation, and
expansion of Innovation Center models
are not subject to the Paperwork
35 As noted, the COI section of this rule uses the
actual overall average participation rate of 92
percent in quality data submission based on 2015
PQRS data. The RIA section of this rule uses the
actual participation rate for practices with more
than 15 clinicians and assumes a minimum 90
percent participation (standard assumption or 80
percent participation (alternative assumption) for
practices with 1–15 clinicians.
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30217
Reduction Act (42 U.S.C. 1395jjj and 42
U.S.C. 1315a(d)(3), respectively).36
Tables 65, 66, and 67 explain our
revised estimates of the number of
organizations (including groups, virtual
groups, and individual MIPS eligible
clinicians) submitting data on behalf of
clinicians via each of the quality
submission mechanisms. The proposed
policies related to both virtual groups
and facility-based measurement are
reflected, as is the proposed policy to
score quality measures submitted via
multiple submission mechanisms.
Table 65 provides our estimated
counts of clinicians that will submit
quality performance category data as
MIPS individual clinicians, groups, or
virtual groups in the 2018 MIPS
performance period. The first step was
to estimate the number of clinicians to
submit as an individual clinician or
group via each mechanism during the
2017 MIPS performance period using
2015 PQRS data on individuals and
groups submitting through various
mechanisms and excluding clinicians
identified as QPs in a preliminary
version of the file used for the
predictive qualifying APM participants
analysis made available on qpp.cms.gov
on June 2, 2017 and prepared using
claims for services between January 1,
2016 through August 31, 2016. The
second step was to subtract out the
estimated number of clinicians who
practice primarily in the hospital to
elect facility-based scoring as groups or
individuals in the 2018 MIPS
performance period. Further detail on
our methods to estimate the number of
clinicians who practice primarily in the
hospital to elect facility-based scoring as
individual clinicians or groups is
provided on the burden for the election
of facility-based measurement (section
III.D. of this proposed rule).
Based on these methods, Table 65
shows that in the 2018 MIPS
performance period, an estimated
364,002 clinicians will submit as
individuals via claims submission
mechanisms; 225,569 clinicians will
submit as individuals, or as part of
groups or virtual groups via qualified
registry or QCDR submission
mechanisms; 115,241 clinicians will
submit as individuals, or as part of
groups or virtual groups via EHR
submission mechanisms; and 101,939
clinicians will submit as part of groups
via the CMS Web Interface.
Our estimated numbers of clinicians
to submit as individual clinicians,
36 Our estimates do reflect the burden that MIPS
APM participants of submitting advancing care
information data, which is outside the requirements
of their models.
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groups, or virtual groups via each
submission mechanism account for the
policy proposed under section
II.C.6.a.(1) of this rule that individual
clinicians, groups, and virtual groups
can be scored on data submitted via
multiple submission mechanisms.
Hence, the estimated numbers of
individual clinicians, groups, and
virtual groups to submit via the various
submission mechanisms are not
mutually exclusive, and reflect the
occurrence of individual clinicians or
groups that submitted data via multiple
mechanism under the 2015 PQRS.
TABLE 65—ESTIMATED NUMBER OF CLINICIANS SUBMITTING QUALITY PERFORMANCE CATEGORY DATA BY MECHANISM
Claims
Estimated number of clinicians to submit via mechanism (as individual clinicians, groups, or virtual groups) in Quality Payment Program Year 1 (excludes QPs) (a) ............................................................................................
Subtract out: Estimated number of clinicians to submit via mechanism (as
individual clinicians, groups or virtual groups) in Quality Payment Program Year 1 that will opt for facility-based scoring in Quality Payment
Program Year 2 (b) ......................................................................................
Estimated number of clinicians to submit via mechanism (as individual clinicians or groups) in Quality Payment Program Year 2 (excludes QPs and
facility-based measurement) (c) = (a)¥(b) ..................................................
Table 65 provides estimates of the
number of clinicians to submit quality
measures via each mechanism,
regardless of whether they decide to
submit as individual clinicians or as
part of groups or virtual groups. Because
our burden estimates for quality data
submission assume that burden is
reduced when clinicians elect to submit
as part of a group or virtual group, we
also separately estimate the expected
number of clinicians to submit as
QCDR/registry
CMS web
interface
EHR
371,987
236,908
118,395
101,939
7,985
11,339
3,154
0
364,002
225,569
115,241
101,939
individuals or part of groups or virtual
groups.
Table 66 uses methods similar to
those described for Table 65 to estimate
the number of clinicians to submit as
individual clinicians via each
mechanism in Quality Payment Program
Year 2. We estimate that approximately
364,002 clinicians will submit as
individuals via claims submission
mechanisms; approximately 86,046
clinicians will submit as individuals via
qualified registry or QCDR submission
mechanisms; and approximately 60,253
clinicians will submit as individuals via
EHR submission mechanisms.
Individual clinicians cannot elect to
submit via CMS Web Interface.
Consistent with the proposed policy to
allow individual clinicians to be scored
on quality measures submitted via
multiple mechanisms, our columns in
Table 66 are not mutually exclusive.
TABLE 66—ESTIMATED NUMBER OF CLINICIANS SUBMITTING QUALITY PERFORMANCE CATEGORY DATA AS INDIVIDUALS
Claims
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Estimated number of Clinicians to submit data as individuals in Quality Payment Program Year 1 (excludes QPs) (a) ...................................................
Subtract out: Estimated number of clinicians to submit via mechanism as individuals in Quality Payment Program Year 1 that will opt for facilitybased scoring in Quality Payment Program Year 2 (b) ...............................
Estimated number of clinicians to submit via mechanism as individuals in
Quality Payment Program Year 2 (excludes QPs and facility-based measurement) (c) = (a)¥(b) .................................................................................
Table 67 provides our estimated
counts of groups or virtual groups to
submit quality data on behalf of
clinicians via each mechanism in the
2018 MIPS performance period and
reflects our assumption that the
formation of virtual groups will reduce
burden. Except for groups who practice
primarily in the hospital electing
facility-based measurement and groups
comprised entirely of QPs, we assume
that groups that submitted quality data
as groups under the 2015 PQRS will
continue to submit quality data either as
groups or virtual groups via the same
submission mechanisms in the 2018
MIPS performance period. The first step
in estimating the numbers of groups or
virtual groups to submit via each
mechanism in the 2018 MIPS
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interface
EHR
371,987
88,078
60,589
0
7,985
2,032
336
0
364,002
86,046
60,253
0
performance period was to estimate the
number of groups to submit on behalf of
clinicians via each mechanism in the
2017 MIPS performance period. We
used 2015 PQRS data on groups
submitting on behalf of clinicians via
various mechanisms and excluded
groups comprised entirely of QPs in a
preliminary version of the file used for
the predictive qualifying Alternative
Payment Model participants analysis
made available on qpp.cms.gov on June
2, 2017 and prepared using claims for
services between January 1, 2016
through August 31, 2016. The second
step was to subtract out the estimated
number of groups who practice
primarily in the hospital that will elect
facility-based measurement. Further
detail on our methods to estimate the
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QCDR/registry
number of groups who practice
primarily in the hospital to elect
facility-based scoring on behalf of
clinicians is provided in section III.D. of
this proposed rule, on the burden for the
election of facility-based measurement.
The third and fourth steps in Table 67
reflect our assumption that virtual
groups will reduce the burden for
quality data submission by reducing the
number of organizations to submit
quality data on behalf of clinicians. We
assume that 40 groups that previously
submitted on behalf of clinicians via
QCDR or qualified registry submission
mechanisms will elect to form 8 virtual
groups that will submit via QCDR and
qualified registry submission
mechanisms. We assume that another 40
groups that previously submitted on
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behalf of clinicians via EHR submission
mechanisms will elect to form another
8 virtual groups via EHR submission
mechanisms. Hence, the third step in
Table 67 is to subtract out the estimated
number of groups under each
submission mechanism that will elect to
form virtual groups, and the fourth step
in Table 67 is to add in the estimated
number of virtual groups that will
submit on behalf of clinicians via each
submission mechanism.
Specifically, we assumed that 2,455
groups and virtual groups will submit
data via QCDR/registry submission
mechanisms on behalf of 146,676
clinicians; 817 groups and virtual
groups will submit via EHR submission
mechanisms on behalf of 56,772 eligible
clinicians; and 298 groups will submit
data via the CMS Web Interface on
behalf of 102,914 clinicians. Groups
cannot elect to submit via claims
submission mechanism.
TABLE 67—ESTIMATED NUMBER OF GROUPS AND VIRTUAL GROUPS SUBMITTING QUALITY PERFORMANCE CATEGORY
DATA BY MECHANISM ON BEHALF OF CLINICIANS
Claims
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Estimated number of groups to submit via mechanism (on behalf of clinicians) in Quality Payment Program Year 1 (excludes QPs) (a) ..................
Subtract out: Estimated number groups to submit via mechanism on behalf
of clinicians in Quality Payment Program Year 1 that will opt for facilitybased scoring in Quality Payment Program Year 2 (b) ...............................
Subtract out: Estimated number groups to submit via mechanism on behalf
of clinicians in Quality Payment Program Year 1 that will submit as Virtual
Groups in Quality Payment Program Year 2 (c) ..........................................
Add in: Estimated number of virtual groups to submit via mechanism on behalf of clinicians in Quality Payment Program Year 2 (d) ...........................
Estimated number groups to submit via mechanism on behalf of clinicians
in Quality Payment Program Year 2 (e) = (a)¥(b)¥(c) + (d) .....................
These burden estimates have some
limitations. We believe it is difficult to
quantify the burden accurately because
clinicians and groups may have
different processes for integrating
quality data submission into their
practices’ work flows. Moreover, the
time needed for a clinician to review
quality measures and other information,
select measures applicable to their
patients and the services they furnish,
and incorporate the use of quality data
codes into the office workflows is
expected to vary along with the number
of measures that are potentially
applicable to a given clinician’s
practice. Further, these burden
estimates are based on historical rates of
participation in the PQRS program, and
the rate of participation in MIPS are
expected to differ.
We believe the burden associated
with submitting the quality measures
will vary depending on the submission
method selected by the clinician, group,
or virtual group. As such, we break
down the burden estimates by
clinicians, groups, and virtual groups by
the submission method used.
We anticipate that clinicians and
groups using QCDR, qualified registry,
and EHR submission mechanisms will
have the same start-up costs related to
reviewing measure specifications. As
such, we estimate for clinicians, groups,
and virtual groups using any of these
three submission mechanisms a total of
7 staff hours needed to review the
quality measures list, review the various
submission options, select the most
appropriate submission option, identify
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QCDR/registry
0
2,672
928
298
0
185
79
0
0
40
40
0
0
8
8
0
0
2,455
817
298
the applicable measures or specialty
measure sets for which they can report
the necessary information, review the
measure specifications for the selected
measures or measures group, and
incorporate submission of the selected
measures or specialty measure sets into
the office work flows. Building on data
in a recent article, Casalino et al. (2016),
we assume that a range of expertise is
needed to review quality measures: 2
hours of an office administrator’s time,
1 hour of a clinician’s time, 1 hour of
an LPN/medical assistant’s time, 1 hour
of a computer systems analyst’s time,
and 1 hour of a billing clerk’s time.37 In
the CY 2017 Quality Payment Program
final rule we estimated 3 hours for an
administrator’s time for data
submission. Because the new CMS
Application Programming Interface
(API) will be available for EHR, registry
and QCDR, and CMS Web Interface
submission mechanisms, we have
reduced our estimate to 2 hours of an
office administrator’s time for data
submission. This CMS API will
streamline the process of reviewing
measure specifications and submitting
measures for third party submission
37 Our burden estimates are based on prorated
versions of the estimates for reviewing measure
specifications in Lawrence P. Casalino et al., ‘‘US
Physician Practices Spend More than $15.4 Billion
Annually to Report Quality Measures,’’ Health
Affairs, 35, no. 3 (2016): 401–406. The estimates
were annualized to 50 weeks per year, and then
prorated to reflect that Medicare revenue is 30
percent of all revenue paid by insurers, and then
adjusted to reflect that the decrease from 9 required
quality measures under PQRS to 6 required
measures under MIPS.
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CMS Web
interface
EHR
mechanisms. (We have also reduced our
burden estimate for CMS Web Interface
to reflect the new CMS API in a separate
section below.).38
For the claims submission
mechanism, we estimate that the startup cost for a MIPS eligible clinician’s
practice to review measure
specifications is $596.80, including 3
hours of a practice administrator’s time
(3 hours × $105.16=$315.48), 1 hour of
a clinician’s time (1 hour × $202.08/
hour=$202.08), 1 hour of an LPN/
medical assistant’s time (1 hour ×
$43.12), and 1 hour of a billing clerk’s
time (1 hour × $36.12/hour = $36.12).
These start-up costs pertain to the
specific quality submission methods
below, and hence appear in the burden
estimate tables.
For the purposes of our burden
estimates for the claims, qualified
registry and QCDR, and EHR submission
mechanisms, we also assume that, on
average, each clinician, group, or virtual
group will submit 6 quality measures.
Our estimated number of respondents
for the claims and EHR submission
mechanisms increased relative to the
estimates in the CY 2017 Quality
Payment Program final rule because our
estimates now reflect the proposed
policy to allow individual clinicians
and groups to be scored on quality
measures submitted via multiple
mechanisms. Our estimated number of
respondents for the QCDRs and
38 CMS: New API Will Automate MACRA Quality
Measure Data Sharing. https://healthitanalytics.com/
news/cms-new-api-will-automate-macra-qualitymeasure-data-sharing.
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qualified registries submission
mechanisms has declined relative to the
CY 2017 Quality Payment final rule
because our estimates now reflect the
proposed policies allowing certain
eligible clinicians who practice
primarily in the hospital to elect
facility-based measurement, as well as
the proposed policy to allow practices
of 10 or fewer eligible clinicians to
participate as part of a virtual group.
The number of respondents for CMS
Web Interface has declined relative to
the estimates in the CY 2017 Quality
Payment Program final rule because our
estimates now exclude the CMS Web
Interface data submitted by Shared
Savings Program and Pioneer ACOs to
fulfill the requirement of their models.
As noted in this section of the proposed
rule, information collections associated
with the Shared Savings Program and
the testing, evaluation, and expansion of
CMS Innovation Center models are not
subject to the Paperwork Reduction Act.
1. Burden for Quality Data Submission
by Clinicians: Claims-Based Submission
As noted in Table 65, based on 2015
PQRS data, the data prepared to support
the 2017 performance period initial
determination of clinician and special
status eligibility (available via the NPI
lookup on qpp.cms.gov) using a date
range of September 1, 2015–August 31,
2016, and a preliminary version of the
file used for the predictive qualifying
Alternative Payment Model participants
analysis made available on qpp.cms.gov
on June 2, 2017, and prepared using
claims for services between January 1,
2016 through August 31, 2016, we
assume that 364,002 individual
clinicians will submit quality data via
claims. We anticipate the claims
submission process for MIPS will be
operationally similar to the way the
claims submission process functioned
under the PQRS. Specifically, clinicians
will need to gather the required
information, select the appropriate
quality data codes (QDCs), and include
the appropriate QDCs on the claims they
submit for payment. Clinicians will
collect QDCs as additional (optional)
line items on the CMS–1500 claim form
or the electronic equivalent HIPAA
transaction 837–P, approved by OMB
under control number 0938–1197.
The total estimated burden of claimsbased submission will vary along with
the volume of claims on which the
submission is based. Based on our
experience with the PQRS, we estimate
that the burden for submission of
quality data will range from 0.22 hours
to 10.8 hours per clinician. The wide
range of estimates for the time required
for a clinician to submit quality
measures via claims reflects the wide
variation in complexity of submission
across different clinician quality
measures. As shown in Table 68, we
also estimate that the cost of quality
data submission using claims will range
from $19.38 (0.22 hours × $88.10) to
$951.48 (10.8 hours × $88.10). The total
estimated annual cost per clinician
ranges from the minimum burden
estimate of $704.28 to a maximum
burden estimate of $1,636.38. The
burden will involve becoming familiar
with MIPS data submission
requirements. As noted in Table 68, we
believe that the start-up cost for a
clinician’s practice to review measure
specifications totals 7 hours, which
includes 3 hours of a practice
administrator’s time (3 hours × $105.16
= $315.48), 1 hour of a clinician’s time
(1 hour × $202.08/hour = $202.08), 1
hour of an LPN/medical assistant’s time
(1 hour × $43.12 = $43.12), 1 hour of a
computer systems analyst’s time (1 hour
× $88.10 = $88.10), and 1 hour of a
billing clerk’s time (1 hour × $36.12/
hour = $36.12).
Considering both data submission and
start-up costs, the total estimated
burden hours per clinician ranges from
a minimum of 7.22 hours (0.22 + 3 + 1
+ 1 + 1 + 1) to a maximum of 17.8 hours
(10.8 + 3 + 1 + 1 + 1 + 1). The total
estimated annual cost per clinician
ranges from the minimum estimate of
$704.28 ($19.38 + $315.48 + $88.10 +
$43.12 + $36.12 + $202.08) to a
maximum estimate of $1,636.38
($951.48 + $315.48 + $88.10 + $43.12 +
$36.12 + $202.08). Therefore, total
annual burden cost is estimated to range
from a minimum burden estimate of
$256,359,329 (364,002 × $704.28) to a
maximum burden estimate of
$595,645,593 (364,002 × $1,636.38).
Based on the assumptions discussed
in this section of the proposed rule,
Table 68 summarizes the range of total
annual burden associated with
clinicians using the claims submission
mechanism.
TABLE 68—BURDEN ESTIMATE FOR QUALITY PERFORMANCE CATEGORY: CLINICIANS USING THE CLAIMS SUBMISSION
MECHANISM
Minimum
burden
Median
burden
Maximum
burden
estimate
mstockstill on DSK30JT082PROD with PROPOSALS2
Estimated number of Clinicians (a) .............................................................................................
Burden Hours Per Clinician to Submit Quality Data (b) ..............................................................
Estimated number of Hours Office Administrator Review Measure Specifications (c) ...............
Estimated number of Hours Computer Systems Analyst Review Measure Specifications (d) ...
Estimated number of Hours LPN Review Measure Specifications (e) .......................................
Estimated number of Hours Billing Clerk Review Measure Specifications (f) ............................
Estimated number of Hours Clinician Review Measure Specifications (g) .................................
Estimated Annual Burden hours per Clinician (h) = (b) + (c) + (d) + (e) + (f) + (g) ...................
364,002
0.22
3
1
1
1
1
7.22
364,002
1.58
3
1
1
1
1
8.58
364,002
10.8
3
1
1
1
1
17.8
Estimated Total Annual Burden Hours (i) = (a) * (h) ...........................................................
Estimated Cost to Submit Quality Data (@computer systems analyst’s labor rate of $88.10/
hr.) (j) ........................................................................................................................................
Estimated Cost to Review Measure Specifications (@practice administrator’s labor rate of
$105.16/hr.) (k) .........................................................................................................................
Estimated Cost to Review Measure Specifications (@computer systems analyst’s labor rate
of $88.10/hr.) (l) .......................................................................................................................
Estimated Cost to Review Measure Specifications (@LPN’s labor rate of $43.12/hr.) (m) .......
Estimated Cost to Review Measure Specifications (@billing clerk’s labor rate of $36.12/hr.)
(n) .............................................................................................................................................
Estimated Cost to Review Measure Specifications (@physician’s labor rate of $202.08/hr.)
(o) .............................................................................................................................................
Estimated Total Annual Cost Per Clinician (p) = (j) + (k) + (l) + (m) + (n) + (o) ........................
2,628,094
3,123,137
6,479,236
$19.38
$139.20
$951.48
$315.48
$315.48
$315.48
$88.10
$43.12
$88.10
$43.12
88.10
$43.12
$36.12
$36.12
$36.12
$202.08
$704.28
$202.08
$824.10
$202.08
$1,636.38
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TABLE 68—BURDEN ESTIMATE FOR QUALITY PERFORMANCE CATEGORY: CLINICIANS USING THE CLAIMS SUBMISSION
MECHANISM—Continued
Minimum
burden
Estimated Total Annual Burden Cost (q) = (a) * (p) ............................................................
2. Burden for Quality Data Submission
by Individuals, Groups, and Virtual
Groups Using Qualified Registry and
QCDR Submissions
As noted in Table 65 and based on
2015 PQRS data, the data prepared to
support the 2017 performance period
initial determination of clinician and
special status eligibility (available via
the NPI lookup on qpp.cms.gov) using a
date range of September 1, 2015–August
31, 2016, a preliminary version of the
file used for the predictive qualifying
Alternative Payment Model participants
analysis made available on qpp.cms.gov
on June 2, 2017, and prepared using
claims for services between January 1,
2016 through August 31, 2016, we
assume that 225,569 clinicians will
submit quality data as individuals,
groups, or virtual groups via qualified
registry or QCDR submissions. Of these,
we expect 86,046 clinicians, as shown
in Table 66, to submit as individuals
and 2,455 groups, as shown in Table 67,
are expected to submit on behalf of the
remaining 139,523 clinicians. Given that
the number of measures required is the
same for clinicians, groups, and virtual
groups, we expect the burden to be the
same for each respondent submitting
data via qualified registry or QCDR,
whether the clinician is participating in
MIPS as an individual, group or virtual
group.
We estimate that burdens associated
with QCDR submissions are similar to
the burdens associated with qualified
registry submissions. Therefore, we
discuss the burden for both data
submissions together below. For
qualified registry and QCDR
submissions, we estimate an additional
time burden for respondents (individual
clinicians, groups, and virtual groups) to
become familiar with MIPS submission
requirements and, in some cases,
specialty measure sets and QCDR
measures. Therefore, we believe that the
start-up cost for an individual clinician
or group to review measure
specifications and submit quality data to
total $851.35. For review costs, this total
includes 3 hours per respondent to
submit quality data (3 hours × $88.10/
hour = $264.00), 3 hours of a practice
administrator’s time (2 hours × $105.16/
hour = $210.32), 1 hour of a clinician’s
time (1 hours × $202.08/hour =
$202.08), 1 hour of a computer systems
analyst’s time (1 hour × $88.10/hour =
$256,359,329
Median
burden
$299,974,048
Maximum
burden
estimate
$595,645,593
$88.10), 1 hour of an LPN/medical
assistant’s time, (1 hour × $43.12/hour
= $43.12), and 1 hour of a billing clerk’s
time (1 hour × $36.12/hour = $36.12).
Clinicians, groups, and virtual groups
will need to authorize or instruct the
qualified registry or QCDR to submit
quality measures’ results and numerator
and denominator data on quality
measures to us on their behalf. We
estimate that the time and effort
associated with authorizing or
instructing the quality registry or QCDR
to submit this data will be
approximately 5 minutes (0.083 hours)
per clinician or group (respondent) for
a total burden cost of $7.31, at a
computer systems analyst’s labor rate
(.083 hours × $88.10/hour). Hence, we
estimate 9.083 burden hours per
respondent, with annual total burden
hours of 803,855 (9.083 burden hours ×
88,501 respondents). The total estimated
annual cost per respondent is estimated
to be approximately $851.05. Therefore,
total annual burden cost is estimated to
be $75,318,776 (88,501 × $851.05).
Based on these assumptions, we have
estimated the burden for these
submissions.
TABLE 69—BURDEN ESTIMATE FOR QUALITY PERFORMANCE CATEGORY: CLINICIANS (PARTICIPATING INDIVIDUALLY OR AS
PART OF A GROUP OR VIRTUAL GROUP) USING THE QUALIFIED REGISTRY/QCDR SUBMISSION
Burden
estimate
86,046
2,455
88,501
3
2
1
1
1
1
0.083
Estimated Annual Burden Hours Per Respondent (k) = (d) + (e) + (f) + (g) + (h) + (i) + (j) ......................................................
mstockstill on DSK30JT082PROD with PROPOSALS2
Number of clinicians submitting as individuals (a) ..............................................................................................................................
Number of groups or virtual groups submitting via QCDR or registry on behalf of individual clinicians (b) ......................................
Number of Respondents (groups and virtual groups plus clinicians submitting as individuals) (c) = (a) + (b) .................................
Estimated Burden Hours Per Respondent to Report Quality Data (d) ...............................................................................................
Estimated number of Hours Office Administrator Review Measure Specifications (e) ......................................................................
Estimated number of Hours Computer Systems Analyst Review Measure Specifications (f) ...........................................................
Estimated number of Hours LPN Review Measure Specifications (g) ...............................................................................................
Estimated number of Hours Billing Clerk Review Measure Specifications (h) ...................................................................................
Estimated number of Hours Clinician Review Measure Specifications (i) ..........................................................................................
Estimated number of Hours Per Respondent to Authorize Qualified Registry to Report on Respondent’s Behalf) (j) .....................
9.083
Estimated Total Annual Burden Hours (l) = (c) * (k) ...................................................................................................................
Estimated Cost Per Respondent to Submit Quality Data (@computer systems analyst’s labor rate of $88.10/hr.) (m) ...................
Estimated Cost to Review Measure Specifications (@practice administrator’s labor rate of $105.16/hr.) (n) ..................................
Estimated Cost Computer System’s Analyst Review Measure Specifications (@computer systems analyst’s labor rate of $88.10/
hr.) (o) ..............................................................................................................................................................................................
Estimated Cost LPN Review Measure Specifications (@LPN’s labor rate of $43.12/hr.) (p) ............................................................
Estimated Cost Billing Clerk Review Measure Specifications (@clerk’s labor rate of $36.12/hr.) (q) ...............................................
Estimated Cost Clinician Review Measure Specifications (@physician’s labor rate of $202.08/hr.) (r) ............................................
Estimated Burden for Submission Tool Registration etc. (@computer systems analyst’s labor rate of $88.1/hr.) (s) ......................
Estimated Total Annual Cost Per Respondent (t) = (m) + (n) + (o) + (p) + (q) + (r) + (s) .................................................................
803,855
$264.00
$210.32
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$88.10
$43.12
$36.12
$202.08
$7.31
$851.05
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TABLE 69—BURDEN ESTIMATE FOR QUALITY PERFORMANCE CATEGORY: CLINICIANS (PARTICIPATING INDIVIDUALLY OR AS
PART OF A GROUP OR VIRTUAL GROUP) USING THE QUALIFIED REGISTRY/QCDR SUBMISSION—Continued
Burden
estimate
Estimated Total Annual Burden Cost (u) = (c) * (t) .....................................................................................................................
3. Burden for Quality Data Submission
by Clinicians, Groups, and Virtual
Groups: EHR Submission
As noted in Tables 65, 66 and 67,
based on our analysis of 2015 PQRS
data, data prepared to support the 2017
performance period initial
determination of clinician and special
status eligibility (available via the NPI
lookup on qpp.cms.gov) using a date
range of September 1, 2015–August 31,
2016, and a preliminary version of the
file used for the predictive qualifying
Alternative Payment Model participants
QP analysis made available on
qpp.cms.gov on June 2, 2017 and
prepared using claims for services
between the date range January 1, 2016
through August 31, 2016, we assume
that 115,241 clinicians will submit
quality data as individuals or groups via
EHR submissions; 60,253 clinicians are
expected to submit as individuals; and
817 groups are expected to submit on
behalf of 56,772 clinicians. We expect
the burden to be the same for each
respondent submitting data via qualified
registry or QCDR, whether the clinician
is participating in MIPS as an individual
or group.
Under the EHR submission
mechanism, the individual clinician or
group may either submit the quality
measures data directly to us from their
EHR or utilize an EHR data submission
vendor to submit the data to us on the
clinician’s or group’s behalf.
To prepare for the EHR submission
mechanism, the clinician or group must
review the quality measures on which
we will be accepting MIPS data
extracted from EHRs, select the
appropriate quality measures, extract
the necessary clinical data from their
EHR, and submit the necessary data to
the CMS-designated clinical data
warehouse or use a health IT vendor to
submit the data on behalf of the
clinician or group. We assume the
burden for submission of quality
measures data via EHR is similar for
clinicians, groups, and virtual groups
who submit their data directly to us
from their CEHRT and clinicians,
groups, and virtual groups who use an
EHR data submission vendor to submit
the data on their behalf. To submit data
to us directly from their CEHRT,
clinicians, groups, and virtual groups
must have access to a CMS-specified
identity management system which we
believe takes less than 1 hour to obtain.
Once a clinician or group has an
account for this CMS-specified identity
management system, they will need to
extract the necessary clinical data from
their EHR, and submit the necessary
data to the CMS-designated clinical data
warehouse.
We estimate that obtaining an account
on a CMS-specified identity
management system will require 1 hour
per respondent for a cost of $88.10 (1
hour × $88.10/hour), and that
submitting a test data file to us will also
$75,318,776
require 1 hour per respondent for a cost
of $88.10 (1 hour × $88.10/hour). For
submitting the actual data file, we
believe that this will take clinicians or
groups no more than 2 hours per
respondent for a cost of submission of
$176.20 (2 hours × $88.10/hour). The
burden will involve becoming familiar
with MIPS submission. We believe that
the start-up cost for a clinician or group
to submit the test data file and review
measure specifications is a total 7 hours,
1 hour for the test data submission and
6 hours for reviewing measuring which
includes 2 hours of a practice
administrator’s time (2 hours × $105.16/
hour = $210.32), 1 hour of a clinician’s
time (1 hour × $202.08/hour = $202.08),
1 hour of a computer systems analyst’s
time (1 hour × $88.10/hour = $88.10), 1
hour of an LPN/medical assistant’s time
(1 hour × $43.12/hour = $43.12), and 1
hour of a billing clerk’s time (1 hour ×
$36.12/hour = $36.12). Hence, we
estimated 10 total burden hours per
respondent with annual total burden
hours of 610,700 (10 burden hours ×
61,070 respondents). The total estimated
annual cost per respondent is estimated
to be $932.14. Therefore, total annual
burden cost is estimated to be
$56,925,790 = (61,070 respondents ×
$932.14).
Based on the assumptions discussed
in this section of the proposed rule, we
have estimated the burden for the
quality data submission using EHR
submission mechanism below.
TABLE 70—BURDEN ESTIMATE FOR QUALITY PERFORMANCE CATEGORY: CLINICIANS (SUBMITTING INDIVIDUALLY OR AS
PART OF A GROUP OR VIRTUAL GROUP) USING THE EHR SUBMISSION MECHANISM
mstockstill on DSK30JT082PROD with PROPOSALS2
Burden
estimate
Number of clinicians submitting as individuals (a) ..............................................................................................................................
Number of Groups and Virtual Groups submitting via EHR on behalf of individual clinicians (b) .....................................................
Number of Respondents (Groups and Virtual Groups plus clinicians submitting as individuals) (c) = (a) + (b) ...............................
Estimated Burden Hours Per Respondent to Obtain Account in CMS-Specified Identity Management System (d) .........................
Estimated Burden Hours Per Respondents to Submit Test Data File to CMS (e) .............................................................................
Estimated Burden Hours Per Respondent to Submit MIPS Quality Data File to CMS (f) .................................................................
Estimated number of Hours Office Administrator Review Measure Specifications (g) ......................................................................
Estimated number of Hours Computer Systems Analyst Review Measure Specifications (h) ..........................................................
Estimated number of Hours LPN Review Measure Specifications (i) ................................................................................................
Estimated number of Hours Billing Clerk Review Measure Specifications (j) ....................................................................................
Estimated number of Hours Clinicians Review Measure Specifications (k) .......................................................................................
60,253
817
61,070
1
1
2
2
1
1
1
1
Estimated Annual Burden Hours Per Respondent (l) = (d) + (e) + (f) + (g) + (h) + (i) + (j) + (k) ..............................................
10
Estimated Total Annual Burden Hours (m) = (c) * (l) ..................................................................................................................
610,700
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TABLE 70—BURDEN ESTIMATE FOR QUALITY PERFORMANCE CATEGORY: CLINICIANS (SUBMITTING INDIVIDUALLY OR AS
PART OF A GROUP OR VIRTUAL GROUP) USING THE EHR SUBMISSION MECHANISM—Continued
Burden
estimate
Estimated Cost Per Respondent to Obtain Account in CMS-specified identity management system (@computer systems analyst’s labor rate of $88.10/hr.) (n) ....................................................................................................................................................
Estimated Cost Per Respondent to Submit Test Data File to CMS (@computer systems analyst’s labor rate of $88.10/hr.) (o) ...
Estimated Cost Per Respondent to Submit Quality Data (@computer systems analyst’s labor rate of $88.10/hr.) (p) ....................
Estimated Cost to Review Measure Specifications (@practice administrator’s labor rate of $105.16/hr.) (q) ..................................
Estimated Cost to Review Measure Specifications (@computer systems analyst’s labor rate of $88.10/hr.) (r) ..............................
Estimated Cost to Review Measure Specifications (@LPN’s labor rate of $43.12/hr.) (s) ................................................................
Estimated Cost to Review Measure Specifications (@clerk’s labor rate of $36.12/hr.) (t) ................................................................
Estimated Cost to D21Review Measure Specifications (@physician’s labor rate of $202.08/hr.) (u) ...............................................
$88.10
88.10
176.20
210.32
88.10
43.12
36.12
202.08
Estimated Total Annual Cost Per Respondent (v) = (n) + (o) + (p) + (q) + (r) + (s) + (t) + (u) ..................................................
Estimated Total Annual Burden Cost (w) = (c) * (v) ....................................................................................................................
932.14
56,925,790
4. Burden for Quality Data Submission
via CMS Web Interface
Based on 2015 PQRS data and as
shown in Table 67, we assume that 298
groups will submit quality data via the
CMS Web Interface in the 2018 MIPS
performance period. We anticipate that
approximately 252,808 clinicians will
be represented.
The burden associated with the group
submission requirements under the
CMS Web Interface is the time and effort
associated with submitting data on a
sample of the organization’s
beneficiaries that is prepopulated in the
CMS Web Interface. Based on
experience with PQRS GPRO Web
Interface submission mechanism, we
estimate that, on average, it will take
each group 74 hours of a computer
systems analyst’s time to submit quality
measures data via the CMS Web
Interface at a cost of $88.10 per hour, for
a total cost of $6,519 (74 hours × $88.10/
hour). Our estimate of 74 hours for
submission includes the time needed for
each group to populate data fields in the
web interface with information on
approximately 248 eligible assigned
Medicare beneficiaries and then submit
the data (we will partially pre-populate
the CMS Web Interface with claims data
from their Medicare Part A and B
beneficiaries). The patient data either
can be manually entered or uploaded
into the CMS Web Interface via a
standard file format, which can be
populated by CEHRT. Because the CMS
API will streamline the measure
submission process for many groups, we
have reduced our estimate of the
computer system’s analyst time needed
for submission from 79 hours in the CY
2017 Quality Payment Program final
rule to 74 hours. Because each group
must provide data on 248 eligible
assigned Medicare beneficiaries (or all
eligible assigned Medicare beneficiaries
if the pool of eligible assigned
beneficiaries is less than 248), we
assume that entering or uploading data
for one Medicare beneficiary requires
approximately 18 minutes of a computer
systems analyst’s time (74 hours ÷ 248
patients).
The total annual burden hours are
estimated to be 22,052 (298 groups × 74
annual hours), and the total annual
burden cost is estimated to be
$1,942,662 (298 groups × $6,519).
Based on the assumptions discussed
in this section of the proposed rule, we
have calculated the following burden
estimate for groups submitting to MIPS
with the CMS Web Interface.
TABLE 71—BURDEN ESTIMATE FOR QUALITY DATA SUBMISSION VIA THE CMS WEB INTERFACE
Burden
estimate
Estimated number of Eligible Group Practices (a) ..............................................................................................................................
Estimated Total Annual Burden Hours Per Group to Submit (b) ........................................................................................................
298
74
Estimated Total Annual Burden Hours (c) = (a) * (b) ..................................................................................................................
Estimated Cost Per Group to Report (@computer systems analyst’s labor rate of $88.10/hr.) (d) ...................................................
22,052
$88.10
Estimated Total Annual Cost Per Group (e) = (b) * (d) ...............................................................................................................
$6,519
Estimated Total Annual Burden Cost (f) = (a) * (e) .....................................................................................................................
$1,942,662
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By eligible
clinician or
group
Estimated number of Participating Eligible Professionals (g) .............................................................................................................
Average Burden Hours Per Eligible Professional (h) = (c) ÷ (g) ........................................................................................................
Estimated Cost Per Eligible Professional to Report Quality Data (i) = (f) ÷ (g) .................................................................................
5. Burden for Beneficiary Responses to
CAHPS for MIPS Survey
Under MIPS, groups of two or more
clinicians can elect to contract with a
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the CAHPS for MIPS survey as one of
their six required quality measures.
Beneficiaries that choose to respond to
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252,808
0.09
$7.68
the CAHPS for MIPS survey will
experience burden.
The usual practice in estimating the
burden on public respondents to
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surveys such as CAHPS is to assume
that respondent time is valued, on
average, at civilian wage rates. As
previously explained, the BLS data
show the average hourly wage for
civilians in all occupations to be $23.86.
Although most Medicare beneficiaries
are retired, we believe that their time
value is unlikely to depart significantly
from prior earnings expense, and we
have used the average hourly wage to
compute the dollar cost estimate for
these burden hours.
Under the 2018 MIPS performance
period, we assume that 461 groups will
elect to report on the CAHPS for MIPS
survey, which is equal to the number of
groups reporting via CAHPS for the
PQRS for reporting period 2015.39 Table
72 shows the estimated annualized
burden for beneficiaries to participate in
the CAHPS for MIPS Survey. Based on
historical information on the numbers of
CAHPS for PQRS survey respondents,
we assume that an average of 287
beneficiaries will respond per group.
Therefore, the CAHPS for MIPS survey
will be administered to approximately
132,307 beneficiaries per year (461
groups × an average of 287 beneficiaries
per group responding).
We are proposing to use a shorter
version of the CAHPS for MIPS survey
with 58 items, as compared to 81 items
for the version that will be used in the
transition year. The proposed shorter
survey is estimated to require an average
administration time of 12.9 minutes (or
0.22 hours) in English (at a pace of 4.5
items per minute). We assume the
Spanish survey would require 15.5
minutes (assuming 20 percent more
words in the Spanish translation).
Because less than 1 percent of surveys
were administered in Spanish for
reporting year 2016, our burden
estimate reflects the length of the
English survey. Our proposal would
reduce beneficiary burden compared to
the transition year; we estimate that the
81-item survey requires an average
administration time of 18 minutes in
English and 21.6 minutes in Spanish.
Compared to the survey for reporting
year 2016, this is a reduction of 5.1
minutes (18 minutes¥12.9 minutes) in
administration time for the English
version and a reduction of 6.1 (21.6
minutes¥15.5 minutes) minutes in
administration time for the Spanish
version.
Given that we expect approximately
132,307 respondents per year, the
annual total burden hours are estimated
to be 29,108 hours (132,307 respondents
× 0.22 burden hours per respondent).
The estimated total burden annual
burden cost is $694,612 (132,307 ×
$5.25).
TABLE 72—BURDEN ESTIMATE FOR BENEFICIARY PARTICIPATION IN CAHPS FOR MIPS SURVEY
Burden
estimate
Estimated
Estimated
Estimated
Estimated
Estimated
number of Eligible Group Practices Administering CAHPS for Physician Quality Reporting Survey (a) ..........................
number of Beneficiaries Per Group Responding to Survey (b) .........................................................................................
number of Total Beneficiary Respondents (c) = (a) * (b) ..................................................................................................
number of Burden Hours Per Beneficiary Respondent (d) ................................................................................................
Cost Per Beneficiary (@labor rate of $23.86/hr.) (e) .........................................................................................................
461
287
132,307
0.22
$5.25
Estimated Total Annual Burden Hours (f) = (c) * (d) ...................................................................................................................
29,108
Estimated Total Annual Burden Cost for Beneficiaries Responding to CAHPS MIPS (g) = (c) * (e) .........................................
$694,612
6. Burden for Group Registration for
CMS Web Interface
Groups interested in participating in
MIPS using the CMS Web Interface for
the first time must complete an on-line
registration process. After first time
registration, groups will only need to
opt out if they are not going to continue
to submit via the CMS Web Interface. In
Table 73 we estimate that the
registration process for groups under
MIPS involves approximately 1 hour of
administrative staff time per group. We
assume that a billing clerk will be
responsible for registering the group and
that, therefore, this process has an
average computer systems analyst labor
cost of $88.10 per hour. Therefore,
assuming the total burden hours per
group associated with the group
registration process is 1 hour, we
estimate the total cost to a group
associated with the group registration
process to be approximately $88.10
($88.10 per hour × 1 hour per group).
We assume that approximately 10
groups will elect to use the CMS Web
Interface submission mechanism in the
2018 MIPS performance period. The
total annual burden hours are estimated
to be 10 (10 groups × 1 annual hour),
and the total annual burden cost is
estimated to be $881.00 (10 groups ×
$88.10).
TABLE 73—TOTAL ESTIMATED BURDEN FOR GROUP REGISTRATION FOR CMS WEB INTERFACE
Burden
estimate
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Estimated Number of New Groups Registering for CMS Web Interface (a) ......................................................................................
Estimated Annual Burden Hours Per Group (b) .................................................................................................................................
10
1
Estimated Total Annual Burden Hours (c) = (a) * (b) ..................................................................................................................
Estimated Cost per Group to Register for CMS Web Interface @computer systems analyst’s labor rate of $88.10/hr.) (d) ...........
10
$88.10
Estimated Total Annual Burden Cost for CMS Web Interface Group Registration (e) = (a) * (d) ..............................................
$881
39 Because the CAHPS for PQRS survey was
required for groups of 100 or more clinicians under
the PQRS, we expect that group participation in
CAHPS for MIPS survey, which is optional under
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MIPS, may be somewhat lower. Hence, we assume
that the number of groups electing to use the
CAHPS for MIPS survey will be equivalent to the
second highest participation rate for CAHPS for
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PQRS survey, which occurred in year 2015 when
461 groups used the survey. The most popular year
of the CAHPS for PQRS survey was reporting year
2016, when 514 groups used the survey.
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7. Burden for Group Registration for
CAHPS for MIPS Survey
Under MIPS, the CAHPS for MIPS
survey counts for one measure towards
the MIPS quality performance category
and, as a patient experience measure,
also fulfills the requirement to submit at
least one high priority measure in the
absence of an applicable outcome
measure. Groups that wish to administer
the CAHPS for MIPS survey must
register by June of the applicable 12month performance period, and
electronically notify CMS of which
vendor they have selected to administer
the survey on their behalf. In the 2018
MIPS performance period, we assume
that 461 groups will enroll in the MIPS
for CAHPS survey.
As shown in Table 74, we assume that
the staff involved in the group
registration for CAHPS for MIPS Survey
will mainly be computer systems
analysts or their equivalent, who have
an average labor cost of $88.10/hour. We
assume the CAHPS for MIPS Survey
registration burden estimate includes
the time to register for the survey as
well as select the CAHPS for MIPS
Survey vendor. Therefore, assuming the
30225
total burden hours per registration is 1
hour and 0.5 hours to select the CAHPS
for MIPS Survey vendor that will be
used and electronically notify CMS of
their selection, the total burden hours
for CAHPS for MIPS registration is 1.5.
We estimate the total annual burden
hours as 692 (461 groups × 1.5 hours).
We estimate the cost per group for
CAHPS for MIPS Survey registration is
$132.15 ($88.10 × 1.5 hours). We
estimate that the total cost associated
with the registration process is $60,921
($132.15 per hour × 461 hours per
group).
TABLE 74—BURDEN ESTIMATE FOR GROUP REGISTRATION FOR CAHPS FOR MIPS SURVEY
Burden
estimate
Estimated number of Groups Registering for CAHPS (a) ..................................................................................................................
Estimated Total Annual Burden Hours for CAHPS Registration (b) ...................................................................................................
461
1.5
Estimated Total Annual Burden Hours for CAHPS Registration (c) = (a) * (b) ...........................................................................
Estimated Cost to Register for CAHPS@computer systems analyst’s labor rate of $88.10/hr.) (d) .................................................
692
$132.15
Estimated Total Annual Burden Cost for CAHPS Registration (e) = (a) * (d) .............................................................................
$60,921
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G. ICRs Regarding Burden Estimate for
Advancing Care Information Data
(§ 414.1375)
During the 2018 MIPS performance
period, clinicians, groups, and virtual
groups can submit advancing care
information data through qualified
registry, QCDR, EHR, CMS Web
Interface, and attestation data
submission methods. We have worked
to further align the advancing care
information performance category with
other MIPS performance categories. We
anticipate that most organizations will
use the same data submission
mechanism for the advancing care
information and quality performance
categories, and that the clinicians,
practice managers, and computer
systems analysts involved in supporting
the quality data submission will also
support the advancing care information
data submission process. Hence, the
burden estimate for the submission of
advancing care information data below
shows only incremental hours required
above and beyond the time already
accounted for in the quality data
submission process. While this analysis
assesses burden by performance
category and submission mechanism,
we emphasize that MIPS is a
consolidated program and submission
analysis and decisions are expected to
be made for the program as a whole.
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1. Burden for Advancing Care
Information Application
As stated in the CY 2017 Quality
Payment Program final rule, some MIPS
eligible clinicians may not have
sufficient measures applicable and
available to them for the advancing care
information performance category, and
as such, they may apply to have the
advancing care information category reweighted to zero in the following
circumstances: insufficient internet
connectivity, extreme and
uncontrollable circumstances, lack of
control over the availability of CEHRT
(81 FR 77240 through 77243). As
described in section II.C.6.f.(7)(a) of this
proposed rule, we are proposing to
allow MIPS eligible clinicians to apply
to have their advancing care information
performance category re-weighted to
zero through the Quality Payment
Program due to a significant hardship
exception or exception for decertified
EHR technology. We are also proposing
that MIPS eligible clinicians who are in
small practices (15 or fewer clinicians)
may, beginning with the 2018
performance period and 2020 MIPS
payment year, request a reweighting to
zero for the advancing care information
category due to a significant hardship.
We are proposing to rely on section
1848(o)(2)(D) of the Act, as amended by
section 4002(b)(1)(B) of the 21st Century
Cures Act, as our authority for the
significant hardship exceptions.
Table 75 shows the estimated
annualized burden for clinicians to
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apply for a reweighting to zero of their
advancing care information performance
category due to a significant hardship
exception or as a result of a
decertification of an EHR, as well as an
application for significant hardship by
small practices. Based on 2016 data
from the Medicare EHR Incentive
Program and the first 2019 payment year
MIPS eligibility and special status file,
we assume 50,689 respondents (eligible
clinicians, groups, or virtual groups)
will submit a request for reweighting to
zero of their advancing care information
category due to a significant hardship
exception, decertification of an EHR or
significant hardship for small practices
through the Quality Payment Program.
We estimate that 6,699 respondents
(eligible clinicians, groups, or virtual
groups) will submit a request for a
reweighting to zero for the advancing
care information performance category
due to extreme and uncontrollable
circumstances or as a result of a
decertification of an EHR, and 43,990
respondents will submit a request for a
reweighting to zero for the advancing
care information performance category
as a small practice. The application to
request a reweighting to zero for the
advancing care information performance
category due to significant hardship is a
short online form that requires
identifying which type of hardship or if
decertification of an EHR applies and a
description of how the circumstances
impair the ability to submit the
advancing care information data, as well
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as some proof of circumstances beyond
the submitter’s control. The estimate to
submit this application is 0.5 hours of
a computer system analyst’s time. Given
that we expect 50,689 applications per
year, the annual total burden hours are
estimated to be 25,345 hours (50,689
respondents × 0.5 burden hours per
respondent). The estimated total annual
burden is $2,232,850 (50,689 × $44.05).
TABLE 75—BURDEN ESTIMATE FOR APPLICATION FOR ADVANCING CARE INFORMATION REWEIGHTING
Burden
estimate
Number of Eligible Clinicians, Groups, or Virtual Groups Applying Due to Significant Hardship and Other Exceptions (a) .............
Number of Eligible Clinicians, Groups, or Virtual Groups Applying Due to Significant Hardship as Small Practice (b) ...................
Total respondents Due to Hardships, Other Exceptions and Hardships for Small Practices (c) .......................................................
Estimated Burden Hours Per Applicant for Advancing Care Information (d) .....................................................................................
6,699
43,990
50,689
0.5
Estimated Total Annual Burden Hours (e) = (a) * (c) ..................................................................................................................
Estimated Cost Per Applicant for Advancing Care Information (@computer systems analyst’s labor rate of $88.10/hr.) (f) ...........
25,345
$44.05
Estimated Total Annual Burden Cost (g) = (a) * (f) .....................................................................................................................
$2,232,850
2. Number of Organizations Submitting
Advancing Care Information Data on
Behalf of Eligible Clinicians
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A variety of organizations will submit
advancing care information data on
behalf of clinicians. Clinicians not
participating in a MIPS APM can submit
as individuals or as part of a group or
virtual group. Group TINs may submit
advancing care information data on
behalf of clinicians in MIPS APMs, or,
except for participants in the Shared
Savings Program, clinicians in MIPS
APMs may submit advancing care
information performance category data
individually. Because group TINs in
APM Entities will be submitting
advancing care information data to
fulfill the requirements of submitting to
MIPS, we have included MIPS APMs in
our burden estimate for the advancing
care information performance category.
Consistent with the list of APMs that are
MIPS APMs on the QPP Web site,40 we
assume that 5 MIPS APMs that do not
also qualify as Advanced APMs will
operate in the 2018 MIPS performance
period: Track 1 of the Shared Savings
Program, CEC (one-sided risk
arrangement), OCM (one-sided risk
arrangement), and the Comprehensive
Primary Care Plus Model (CPC+).
Further, we assume that group TINs will
submit advancing care information data
on behalf of partial QPs that elect to
participate in MIPS.
As shown in Table 76, based on 2015
data from the Medicare EHR Incentive
Program and the data prepared to
support the 2017 performance period
initial determination of clinician
eligibility and special status
determination (available via the NPI
lookup on qpp.cms.gov) using a date
range of September 1, 2015–August 31,
2016, we estimate that 265,895
individual MIPS eligible clinicians and
301 groups or virtual groups,
representing 106,406 MIPS eligible
clinicians, will submit advancing care
information data. These estimates reflect
that under the policies finalized in CY
2017 Quality Payment Program final
rule, certain MIPS eligible clinicians
will be eligible for automatic
reweighting of their advancing care
information performance category score
to zero, including MIPS eligible
clinicians that practice primarily in the
hospital, physician assistants, nurse
practitioners, clinician nurse specialists,
certified registered nurse anesthetists,
and non-patient facing clinicians. These
estimates also account for the significant
hardships finalized in the CY 2017
Quality Payment Program final rule and
our proposed policies for significant
hardship exceptions, including for MIPS
eligible clinicians in small practices, as
well as exceptions due to decertification
of an EHR. Due to data limitations, our
estimate of the number of clinicians to
submit advancing care information data
does not account for our proposal to rely
on section 1848(o)(2)(D) of the Act, as
amended by section 4002(b)(1)(B) of the
21st Century Cures Act, to assign a
scoring weight of zero percent for the
advancing care information performance
category for MIPS eligible clinicians
who are determined to be based in
ambulatory surgical centers (ASCs).
Further, we anticipate that the 480
Shared Savings Program ACOs will
submit data at the ACO participant
group TIN-level, for a total of 15,945
group TINs. We anticipate that the three
APM Entities electing the one-sided
track in the CEC model will submit data
at the group TIN-level, for an estimated
total of 100 group TINs submitting data.
We anticipate that the 195 APM Entities
in the OCM (one-sided risk
arrangement) will submit data at APM
Entity level, for an estimated total of
6,478 group TINs. Based on a
preliminary version of the file used for
the predictive qualifying Alternative
Payment Model participants analysis
made available on qpp.cms.gov on June
2, 2017, and prepared using claims for
services between January 1, 2016
through August 31, 2016, we estimate 2
APM Entities in the CPC+ model will
submit at the group TIN-level, for an
estimated total of 2 group TINs
submitting data. Based on preliminary
data, we assume that 1 CPC+ APM
entity will submit data because one or
more of its participants is a partial QP,
and that 1 CPC+ APM Entity will submit
data because some of its participants
qualify as either as QPs or partial QPs.
The total estimated number of
respondents is estimated at 288,721.
40 https://qpp.cms.gov/docs/QPP_Advanced_
APMs_in_2017.pdf.
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TABLE 76—ESTIMATED NUMBER OF RESPONDENTS TO SUBMIT ADVANCING CARE INFORMATION PERFORMANCE DATA ON
BEHALF OF CLINICIANS
Estimated
number of
respondents
Estimated
number of
APM entities
Number of Individual clinicians to submit advancing care information (a) .............................................................
Number of groups or virtual groups to submit advancing care information (b) ......................................................
Shared Savings Program ACO Group TINs (c) ......................................................................................................
CEC one-sided risk track participants 41 (d) ............................................................................................................
OCM one-sided risk arrangement Group TINs (e) ..................................................................................................
CPC+ TINs (f) ..........................................................................................................................................................
265,895
301
15,945
100
6,478
2
........................
........................
480
3
195
2
Total (g) = (a) + (b) + (c) + (d) + (e) + (f) ........................................................................................................
288,721
680
3. Burden for Submission of Advancing
Care Information Data
In Table 76, we estimate that up to
approximately 288,721 respondents will
be submitting data under the advancing
care information performance category,
265,895 clinicians, 301 groups or virtual
groups, 15,945 group TINs within the
Shared Savings Program ACOs, 100
group TINs within the APM Entity
participating in CECs in the one-sided
risk track, and 6,478 group TINs within
the OCM (one-sided risk arrangement),
and 2 CPC+ group TINs. We estimate
this is a significant reduction in
respondents from the 2017 MIPS
performance period as a result of our
proposed policy to provide significant
hardship exceptions, including for MIPS
eligible clinicians in small practices, as
well as for situations due to
decertification of an EHR, and our
proposed policy to allow eligible
clinicians to participate as part of a
virtual group.
In the CY 2017 Quality Payment
Program final rule, our burden estimates
assumed all clinicians who submitted
quality data would also submit under
advancing care information. For this
proposed rule, MIPS special status
eligibility data were available to model
exceptions. The majority (214,302) of
the difference in our estimated number
of respondents is due to the availability
of MIPS special status data to identify
clinicians and groups that would also
not need to report advancing care
information data under transition year
policies, including hospital-based
eligible clinicians, clinician types
eligible for automatic reweighting of
their advancing care information
performance category score, non-patient
facing clinicians, and clinicians facing a
significant hardship. The remaining
decline in respondents is due to policies
proposed in this rule, including 25,881
respondents who would be excluded
under the new proposed significant
hardship exception for small practices.
Our burden estimates in the CY 2017
Quality Payment Program final rule
assumed that during the transition year,
3 hours of clinician time would be
required to collect and submit
advancing care information performance
category data. We anticipate that the
year-over-year consistency of data
submission processes, measures, and
activities and the further alignment of
the advancing care information
performance category with other
performance categories will reduce the
clinician time needed under this
performance category in the 2018 MIPS
performance period. Further, for some
practices the staff mix requirements in
the 2018 MIPS performance period may
be driven more by transition to 2015
CEHRT. Therefore, as shown in Table
77, the total burden hours for an
organization to submit data on the
specified Advancing Care Information
Objectives and Measures is estimated to
be 3 incremental hours of a computer
analyst’s time above and beyond the
clinician, practice manager, and
computer system’s analyst time required
to submit quality data. The total
estimated burden hours are 866,163
(288,721 respondents × 3 hours). At a
computer systems analyst’s hourly rate,
the total burden cost is $76,308,960
(288,721 × $264.30/hour).
TABLE 77—ESTIMATED BURDEN FOR ADVANCING CARE INFORMATION PERFORMANCE CATEGORY DATA SUBMISSION
Burden
estimate
288,721
3
Estimated Total Annual Burden Hours (c) = (a) * (b) ..................................................................................................................
Estimated Cost Per Respondent to Submit Advancing Care Information data (@computer systems analyst’s labor rate of
$88.10/hr.) (d) ..................................................................................................................................................................................
866,163
$264.30
Estimated Total Annual Burden Cost (e) = (a) * (d) ....................................................................................................................
mstockstill on DSK30JT082PROD with PROPOSALS2
Number of respondents submitting advancing care information data on behalf of clinicians (a) .......................................................
Estimated Total Annual Burden Hours Per Respondent (b) ...............................................................................................................
$76,308,960
H. ICR Regarding Burden for
Improvement Activities Submission
(§ 414.1355)
Requirements for submitting
improvement activities did not exist in
the legacy programs replaced by MIPS,
and we do not have historical data
which is directly relevant. A variety of
organizations and in some cases,
individual clinicians, will submit
improvement activity performance
category data. For clinicians who are not
part of APMs, we assume that clinicians
submitting quality data as part of a
group or virtual group through the
41 The 3 CEC APM Entities reflected in the burden
estimate are the non-large dialysis organizations
participating in the one-sided risk track.
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QCDR and registry, EHR, and CMS Web
Interface submission mechanisms will
also submit improvement activities data.
Further, we assume that clinicians and
groups that practice primarily in the
hospital that elect facility-based
measurement for the quality
performance category will also submit
improvement activities data. As noted
in section II.C.6.g.(3)(c) of the proposed
rule, MIPS eligible clinicians
participating in MIPS APMs do not need
to submit improvement activities data
unless the CMS-assigned improvement
activities score is below the maximum
improvement activities score. As
represented in Table 78, we estimate
520,654 clinicians will submit
improvement activities as individuals
during the 2018 MIPS performance
period, an estimated 3,818 groups to
submit improvement activities on behalf
of clinicians during the 2018 MIPS
performance period, and an additional
16 virtual groups to submit
improvement activities, resulting in
524,488 total respondents. The burden
estimates assume there will be no
improvement activities burden for MIPS
APM participants. We will assign the
improvement activities performance
category score at the APM level; each
APM Entity within the same MIPS APM
will be assigned the same score.
TABLE 78—ESTIMATED NUMBERS OF ORGANIZATIONS SUBMITTING IMPROVEMENT ACTIVITIES PERFORMANCE CATEGORY
DATA ON BEHALF OF CLINICIANS
Count
Estimated number of clinicians to participate in Improvement Activities data submission as individuals during the 2018 MIPS
performance period (a) ....................................................................................................................................................................
Estimated number of Groups to submit improvement activities on behalf of clinicians during the 2018 MIPS performance period
(b) .....................................................................................................................................................................................................
Estimated number of Virtual Groups to submit improvement activities on behalf of clinicians during the 2018 MIPS performance
period (c) ..........................................................................................................................................................................................
Total number of Respondents (Groups, Virtual Groups, and Individual Clinicians) to submit improvement activities data on
behalf of clinicians during the 2018 MIPS performance period (d) = (a) + (b) + (c) ...............................................................
In Table 79, we estimate that
approximately 524,488 respondents will
be submitting data under the
improvement activities performance
category. Our burden estimates in the
CY 2017 Quality Payment Program final
rule assumed that during the transition
year, 2 hours of clinician time would be
required to submit data on the specified
improvement activities. For this
proposed rule, our burden estimate has
been revised to assume that the total
burden hours to submit data on the
specified improvement activities will be
1 hour of computer system analyst time
in addition to time spent on other
performance categories. Our revised
estimate is based on feedback from
stakeholders that these are activities
they have already been doing and
tracking so there is no additional
development of material needed.
520,654
3,818
16
524,488
Additionally, the same improvement
activity may be reported across multiple
performance periods so many MIPS
eligible clinicians will not have any
additional information to develop for
the 2018 MIPS performance period. The
total estimated burden hours are
524,488 (524,488 responses × 1 hour).
At a computer systems analyst’s hourly
rate, the total burden cost is $46,207,393
(524,488 × $88.10/hour).
TABLE 79—ESTIMATED BURDEN FOR IMPROVEMENT ACTIVITIES SUBMISSION
Burden
estimate
Total number of Respondents (Groups, Virtual Groups, and Individual Clinicians) to submit improvement activities data on behalf of clinicians during the 2018 MIPS performance period (a) .....................................................................................................
Estimated Total Annual Burden Hours Per Respondent (b) ...............................................................................................................
524,488
1
Estimated Total Annual Burden Hours (c) ...................................................................................................................................
Estimated Cost Per Respondent to Submit Improvement Activities (@computer systems analyst’s labor rate of $88.10/hr.) (d) ...
524,488
$88.10
Estimated Total Annual Burden Cost (e) = (a) * (d) ....................................................................................................................
$46,207,393
mstockstill on DSK30JT082PROD with PROPOSALS2
I. ICR Regarding Burden for Nomination
of Improvement Activities § 414.1360)
For the 2018 MIPS performance
period, we are also proposing to allow
clinicians, groups, and other relevant
stakeholders to nominate new
improvement activities using a
nomination form provided on the
Quality Payment Program Web site at
qpp.cms.gov, and to send their proposed
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new improvement activities to us via
email. As shown in Table 80, based on
response to an informal call for new
proposed improvement activities during
the transition year, we estimate that
approximately 150 organizations
(clinicians, groups or other relevant
stakeholders) will nominate new
improvement activities. We estimate it
will take an estimated 0.5 hours per
organization to submit an activity to us,
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including an estimated 0.3 hours per
practice for a practice administrator to
identify and submit an activity to us via
email at a rate of $105.16/hour for a
total of $31.55 per activity and clinician
review time of 0.2 hours at a rate of
$202.08/hour for a total of $40.42 per
activity. We estimate that the total
annual burden cost is $10,796 (150 ×
$71.96).
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TABLE 80—ESTIMATED BURDEN FOR NOMINATION OF IMPROVEMENT ACTIVITIES
Burden
estimate
Number of Organizations Nominating New Improvement Activities (a) ..............................................................................................
Estimated Number of Hours Per Practice Administrator to Identify and Propose Activity (b) ............................................................
Estimated Number of Hours Per Clinician to Identify Activity (c) .......................................................................................................
150
0.30
0.20
Estimated Annual Burden Hours Per Respondent (d) = (b) + (c) ...............................................................................................
0.50
Estimated Total Annual Burden Hours (e) = (a) * (d) ..................................................................................................................
Estimated Cost to Identify and Submit Activity (@practice administrator’s labor rate of $105.16/hr.) (f) ..........................................
Estimated Cost to Identify Improvement Activity (@physician’s labor rate of $202.08/hr.) (g) ..........................................................
75.00
$31.55
$40.42
Estimated Total Annual Cost Per Respondent (h) = (f) + (g) ......................................................................................................
$71.97
Estimated Total Annual Burden Cost (i) = (a) * (h) .....................................................................................................................
$10,796
J. ICRs Regarding Burden for Cost
(§ 414.1350)
K. ICR Regarding Partial QP Elections
(§ 414.1430)
The cost performance category relies
on administrative claims data. The
Medicare Parts A and B claims
submission process is used to collect
data on cost measures from MIPS
eligible clinicians. MIPS eligible
clinicians are not asked to provide any
documentation by CD or hardcopy.
Therefore, under the cost performance
category, we do not anticipate any new
or additional submission requirements
for MIPS eligible clinicians.
APM Entities may face a data
submission burden under MIPS related
to Partial QP elections. Advanced APM
participants will be notified about their
QP or Partial QP status before the end
of the performance period. For
Advanced APMs the burden of partial
QP election would be incurred by a
representative of the participating APM
Entity. For the purposes of this burden
estimate, we assume that all MIPS
eligible clinicians determined to be
Partial QPs will participate in MIPS.
Based on our analyses of a
preliminary version of the file used for
the predictive qualifying Alternative
Payment Model participants analysis
made available on qpp.cms.gov on June
2, 2017, and prepared using claims for
services between January 1, 2016
through August 31, 2016, we assume
that approximately 17 APM Entities will
face the data submission requirement in
the 2018 performance period.
As shown in Table 81, we assume that
17 APM Entities will make the election
to participate as a partial QP in MIPS.
We estimate it will take the APM Entity
representative 15 minutes to make this
election. Using a computer systems
analyst’s hourly labor cost, we estimate
a total burden cost of just $375 (17
participant × $22.03).
TABLE 81—ESTIMATED BURDEN FOR PARTIAL QP ELECTION
Burden
estimate
Number of APM Entities Electing Partial QP Status on behalf of their Participants (a) .....................................................................
Estimated Burden Hours Per Respondent to Elect to Participate as Partial QP (d) ..........................................................................
17
0.25
Estimated Total Annual Burden Hours (e) = (c) * (d) ..................................................................................................................
Estimated Cost Per Respondent to Elect to Participate as Partial QP (@computer systems analyst’s labor rate of $88.10/hr.) (f)
4.25
$22.03
Estimated Total Annual Burden Cost (g) = (c) * (f) .....................................................................................................................
$375
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L. ICRs Regarding Other Payer
Advanced APM Identification: PayerInitiated Process (§ 414.1440)
Beginning in Quality Payment
Program Year 3, the All-Payer
Combination Option will be an available
pathway to QP status for eligible
clinicians participating sufficiently in
Advanced APMs and Other Payer
Advanced APMs. The All-Payer
Combination Option allows for eligible
clinicians to achieve QP status through
their participation in both Advanced
APMs and Other Payer Advanced
APMs. In order to include an eligible
clinician’s participation in Other Payer
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Advanced APMs in their QP threshold
score, we will need to determine if
certain payment arrangements with
other payers meet the criteria to be
Other Payer Advanced APMs. To
provide eligible clinicians with
advanced notice prior to the start of the
2019 QP performance period, and to
allow other payers to be involved
prospectively in the process, we have
outlined in section II.D.6.a. of this
proposed rule a payer-initiated
identification process for identifying
payment arrangements that qualify as
Other Payer Advanced APMs. This
payer-initiated identification process of
Other Payer Advanced APMs will begin
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in CY 2018, and determinations would
be applicable for the Quality Payment
Program Year 3.
As shown in Table 82, we estimate
that 300 other payer arrangements will
be submitted (50 Medicaid payers, 150
MA Organizations, and 100 Multipayers) for identification as Other Payer
Advanced APMs. The estimated burden
to apply is 10 hours per payment
arrangement, for a total annual burden
hours of 3,000 (300 × 100). We estimate
a total cost per payer of $881.00 using
a computer system analyst’s rate of
$88.10/hour (10 × 81.10). The total
annual burden cost for all other payers
is $264,300 (300 × $881.00).
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TABLE 82—BURDEN FOR PROSPECTIVE IDENTIFICATION OF OTHER PAYER ADVANCED APMS
Burden
estimate
Estimated Number of other payer payment arrangements (50 Medicaid, 150 MA Organizations, 100 Multi-payers) (a) .................
Estimated Total Annual Burden Hours Per other payer payment arrangement (b) ...........................................................................
300
10
Estimated Total Annual Burden Hours (c) = (a) * (b) ..................................................................................................................
Estimated Cost Per Other Payer (@computer systems analyst’s labor rate of $88.10/hr.) (d) .........................................................
3,000
$881.00
Estimated Total Annual Burden Cost for Identifying Other Payer Advanced APMs (e) = (a) * (d) ............................................
$264,300
M. ICRs Regarding Burden for Voluntary
Participants to Elect Opt Out of
Performance Data Display on Physician
Compare (§ 414.1395)
We estimate 22,400 clinicians and
groups who will voluntarily participate
in MIPS but will also elect not to
participate in public reporting. Table 83
shows that for these voluntary
participants, they may submit a request
to opt out which is estimated at 0.25
hours of a computer system analyst’s
labor rate of $88.10. The total annual
burden hours for opting out is estimated
at 5,600 hours (22,400 × 0.25). The total
annual burden cost for opting out for all
requesters is estimated at $493,472
(22,400 × $22.03).
TABLE 83—BURDEN FOR VOLUNTARY PARTICIPANTS TO ELECT OPT OUT OF PERFORMANCE DATA DISPLAY ON PHYSICIAN
COMPARE
Burden
estimate
Estimated Number of Voluntary Participants Opting Out of Physician Compare (a) .........................................................................
Estimated Total Annual Burden Hours Per Opt-out Requester (b) ....................................................................................................
22,400
0.25
Estimated Total Annual Burden Hours for Opt-out Requester (c) = (a) * (b) ..............................................................................
Estimated Cost Per Physician Compare Opt-out Request@computer systems analyst’s labor rate of $88.10/hr.) (d) ....................
5,600
$22.03
Estimated Total Annual Burden Cost for Opt-out Requester (e) = (a) * (d) ................................................................................
$493,472
N. Summary of Annual Burden
Estimates
Table 84 includes the total estimated
burden of recordkeeping and data
submission of the proposed rule
9,391,175 hours with total labor cost of
$856,996,819. In order to understand
the burden implications of the proposals
in this rule, we have also estimated a
baseline burden of continuing the
policies and information collections set
forth in the CY 2017 Quality Payment
Program final rule into the 2018
performance period. This estimated
baseline burden of 9,523,975 hours and
a total labor cost of $869,369,094 is
lower than the burden approved for
information collection related to the CY
2017 Quality Payment Program final
rule 42 because we anticipate greater
respondent familiarity with the
measures and data submission methods
in their second year of participation and
because the number of QPs that are
excluded from MIPS is expected to
continue to grow. Further, our estimated
baseline burden estimates reflect the
recent availability of data sources to
more accurately reflect the number of
the organizations exempt from the
advancing care information performance
category.
We estimate that the proposed rule
will reduce burden by 132,620 hours
and $12,372,275 in labor costs relative
to the estimated baseline of continued
transition year policies. The Quality
Payment Program Year 2 reduction in
burden based on proposals in this rule
reflects several proposed policies,
including our proposal for significant
hardship or other type of exception,
including a new significant hardship
exception for small practices for the
advancing care information performance
category. Our burden estimates also
reflect the proposed reduction in the
length of the CAHPS survey; our
proposal to allow clinicians that
practice primarily in the hospital to
elect to use facility-based
measurements, thereby eliminating the
need for additional quality data
submission processes; and our proposal
to allow MIPS eligible clinicians to form
virtual groups, which would create
efficiencies in data submission.
TABLE 84—PROPOSED ANNUAL RECORDKEEPING AND SUBMISSION REQUIREMENTS
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Respondents/
responses
Registration for Virtual Groups ............................................................
Election of Facility-Based Measurement .............................................
QCDR and Registries self-nomination .................................................
CAHPS Survey Vendor Application .....................................................
(Quality Performance Category) Claims Submission Mechanism .......
(Quality Performance Category) Qualified Registry or QCDR Submission Mechanisms.
(Quality Performance Category) EHR-Submission Mechanism ..........
42 The burden estimate for the CY 2017 Quality
Payment Program final rule was 10,940,417 hours
for a total labor cost of $1,349,763,999. For
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Hours per
response
Total annual
burden hours
Frm 00222
Total annual
burden cost
16
18,207
233
15
364,002
88,501
10.0
1.0
10.0
10.0
17.8
9.1
160
18,207
2,330
150
6,479,236
803,855
Varies (See Table 60) ....
36.12 ...............................
88.10 ...............................
88.10 ...............................
Varies (See Table 68) ....
Varies (See Table 69) ....
$13,313
657,637
205,273
13,215
595,645,593
75,318,776
61,070
10.0
610,700
Varies (See Table 70) ....
56,925,790
comparability for the burden estimate in this
proposed rule, the burden estimate for the CY 2017
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Quality Payment Program final rule has been
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TABLE 84—PROPOSED ANNUAL RECORDKEEPING AND SUBMISSION REQUIREMENTS—Continued
Respondents/
responses
(Quality Performance Category) CMS Web Interface Submission
Mechanism.
(Quality Performance Category) Registration and Enrollment for
CMS Web Interface.
(CAHPS for MIPS Survey) Beneficiary Participation ...........................
(CAHPS for MIPS Survey) Group Registration ...................................
§ 414.1375 (Advancing Care Information) Performance Category
Significant Hardships, including for small practices and decertification of EHRs.
(Advancing Care Information Performance Category) Data Submission.
(Improvement Activities Performance Category) Data Submission ....
(Improvement Activities Performance Category) Call for Activities .....
(Partial Qualifying APM Participant (QP) Election) ..............................
Other Payer Advanced APM Identification: Other Payer Initiated
Process.
(Physician Compare) Opt Out for Voluntary Participants ....................
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Total ..............................................................................................
O. Submission of PRA-Related
Comments
We have submitted a copy of this
proposed rule to OMB for its review of
the rule’s information collection and
recordkeeping requirements. These
requirements are not effective until they
have been approved by the OMB.
To obtain copies of the supporting
statement and any related forms for the
proposed collections discussed in this
section of the proposed rule, please visit
our Web site at www.cms.hhs.gov/
PaperworkReductionActof1995, or call
the Reports Clearance Office at 410–
786–1326.
We invite public comments on these
potential information collection
requirements. If you wish to comment,
please submit your comments
electronically as specified in the
ADDRESSES section of this proposed rule
and identify the rule (CMS–5522–P), the
ICR’s CFR citation, CMS ID number, and
OMB control number (0938–1222 for
CAHPS for MIPS and 0938–1314 for all
other ICRs). ICR-related comments are
due August 21, 2017.
We have invited public comments on
the virtual group election process under
a separate Federal Register Notice (82
FR 27257) published on June 14, 2017.
ICR-comments related to virtual group
election are due on or before August 14,
2017. Because of the statutory
requirement for the virtual group
election process to take place prior to
the start of the 2018 MIPS performance
period, we have an earlier deadline for
public comments on the virtual group
election process to allow for earlier
approval date for that information
collection.
IV. Response to Comments
Because of the large number of public
comments we normally receive on
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Hours per
response
Total annual
burden hours
74.0
22,052
88.10 ...............................
1,942,662
10
1.0
10
88.10 ...............................
881
132,307
461
50,689
0.22
1.5
0.5
29,108
692
25,345
23.86 ...............................
88.10 ...............................
88.10 ...............................
694,612
60,921
2,232,850
288,721
3.0
866,163
88.10 ...............................
76,308,960
524,488
150
17
300
1.00
0.5
0.3
10.0
524,488
75
4
3,000
88.10 ...............................
Varies (See Table 80) ....
88.10 ...............................
88.10 ...............................
46,207,393
10,796
375
264,300
22,400
0.3
5,600
88.10 ...............................
493,472
1,551,885
........................
9,391,175
.........................................
856,996,819
V. Regulatory Impact Analysis
A. Statement of Need
This proposed rule is necessary to
make statutorily required policy
changes and other policy updates to the
Merit-based Incentive Payment System
(MIPS) established under MACRA as
well as the policies related to the
Advanced APM provisions of MACRA,
which together are referred to as the
Quality Payment Program. As required
by MACRA, MIPS consolidates several
quality programs, including components
of the Medicare Electronic Health
Record Incentive Program, the Physician
Quality Reporting System (PQRS), and
the Physician Value-Based Payment
Modifier (VM) and Physician Feedback
Program. The MACRA effectively ends
these programs after CY 2018 and
authorizes MIPS’ operation beginning in
CY 2019.
The Quality Payment Program is
structured to improve care quality over
time with input from clinicians,
patients, and other stakeholders. We
have sought and continue to seek
feedback from the health care
community through various public
avenues such as listening sessions,
request for information and rulemaking
where we have received feedback that
many clinical practices are still working
towards implementing the Quality
Payment Program. This proposed rule
for Quality Payment Program Year 2
Frm 00223
Total annual
burden cost
298
Federal Register documents, we are not
able to acknowledge or respond to them
individually. We will consider all
comments we receive by the date and
time specified in the DATES section of
this preamble, and, when we proceed
with a subsequent document, we will
respond to the comments in the
preamble to that document.
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Fmt 4701
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reflects this feedback and includes
several proposals that extend transition
year policies finalized in the CY 2017
Quality Payment Program final rule
with comment period; however, we also
include policies to begin ramping up to
full implementation, since the
performance threshold must be based on
the mean or median of prior year
performance under statute starting in
the 2019 MIPS performance period
(MIPS payment year 2021).
Additionally, we address elements of
MACRA that were not included in the
first year of the program, including
virtual groups, facility-based
measurement, and improvement
scoring. We also include proposals to
continue implementing elements of
MACRA that do not take effect in the
first or second year of the Quality
Payment Program, including policies
related to the All-Payer Combination
Option for the APM incentive.
B. Overall Impact
We have examined the impact of this
proposed rule as required by Executive
Order 12866 on Regulatory Planning
and Review (September 30, 1993),
Executive Order 13563 on Improving
Regulation and Regulatory Review
(February 2, 2013), the Regulatory
Flexibility Act (Pub. L. 96–354 enacted
September 19, 1980) (RFA), section
1102(b) of the Act, section 202 of the
Unfunded Mandates Reform Act of 1995
(Pub. L. 14–04 enacted March 22, 1995),
Executive Order 13132 on Federalism
(August 4, 1999), the Congressional
Review Act (5 U.S.C. 804(2)), and
Executive Order 13771 on Reducing
Regulation and Controlling Regulatory
Costs (January 30, 2017).
Executive Orders 12866 and 13563
direct agencies to assess all costs and
benefits of available regulatory
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alternatives and, if regulation is
necessary, to select regulatory
approaches that maximize net benefits
(including potential economic,
environmental, public health and safety
effects, distributive impacts, and
equity). A regulatory impact analysis
(RIA) must be prepared for major rules
with economically significant effects
($100 million or more in any 1 year). We
estimate, as discussed below in this
section, that the Medicare Part B
provisions included in this proposed
rule will redistribute more than $173
million in budget neutral payments in
the second performance year. In
addition, this proposed rule will
increase government outlays for the
exceptional performance payment
adjustments under MIPS ($500 million),
and incentive payments to QPs
(approximately $590–$800 million).
Overall, this rule will transfer more than
$1 billion in payment adjustments for
MIPS eligible clinicians and incentive
payments to QPs. Therefore, we
estimate that this rulemaking is
‘‘economically significant’’ as measured
by the $100 million threshold, and
hence also a major rule under the
Congressional Review Act. Accordingly,
we have prepared a RIA that, to the best
of our ability, presents the costs and
benefits of the rulemaking.
Executive Order 13771, titled
Reducing Regulation and Controlling
Regulatory Costs, was issued on January
30, 2017. As shown in the discussion of
Table 84 in the Collection of
Information section of this proposed
rule, we estimate that this proposed rule
would reduce the ICR burden by
132,620 hours and would result in a
further reduction in burden costs of
$12.4 million in the Quality Payment
Program Year 2 relative to Quality
Payment Program Year 1. As shown in
the discussion of Regulatory Review
Costs in section V.E. of this proposed
rule, we estimate that total regulatory
review costs associated with the Quality
Payment Program would be
approximately $4.8 million.
The Regulatory Flexibility Act (RFA)
requires agencies to prepare an Initial
Regulatory Flexibility Analysis to
describe and analyze the impact of the
final rule on small entities unless the
Secretary can certify that the regulation
will not have a significant impact on a
substantial number of small entities.
The RFA requires agencies to analyze
options for regulatory relief of small
entities. Note that Small Business
Administration (SBA) standards for
small entities differ than the definition
of a small practice under MIPS finalized
in the CY 2017 Quality Payment
Program final rule under § 414.1305.
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The SBA standard for a small business
is $11 million in average receipts for an
office of clinicians and $7.5 million in
average annual receipts for an office of
other health practitioners. (For details,
see the SBA’s Web site at https://
www.sba.gov/content/tablesmallbusiness-size-standards (refer to
the 620000 series)).
Approximately 95 percent of
practitioners, other providers, and
suppliers are considered to be small
entities either by nonprofit status or by
having annual revenues that qualify for
small business status under the SBA
standards. There are over 1 million
physicians, other practitioners, and
medical suppliers that receive Medicare
payment under the PFS. Because many
of the affected entities are small entities,
the analysis and discussion provided in
this Regulatory Impact Analysis section
as well as elsewhere in this proposed
rule is intended to comply with the
requirement for an Initial Regulatory
Flexibility Analysis (IRFA).
As discussed below, approximately
572,000 MIPS eligible clinicians will be
required to submit data under MIPS. As
shown later in this analysis, however,
potential reductions in Medicare Part B
payment for MIPS eligible clinicians
under the MIPS are a small percentage
of their total Medicare Part B paid
charges—5 percent in the 2020 payment
year—though rising to as high as 9
percent in subsequent years. On
average, clinicians’ Medicare billings
are only approximately 23 percent of
their total revenue,43 so even those
MIPS eligible clinicians that receive a
negative MIPS payment adjustment
under MIPS would rarely face losses in
excess of 3 percent of their total
revenues, the HHS standard for
determining whether an economic effect
is ‘‘significant.’’ (In order to determine
whether a rule meets the RFA threshold
of ‘‘significant’’ impact, HHS has, for
many years, used as a standard adverse
effects that exceed 3 percent of either
revenues or costs.) However, because
there are so many affected MIPS eligible
clinicians, even if only a small
proportion is significantly adversely
affected, the number could be
‘‘substantial.’’ Therefore, we are unable
to conclude that an Initial Regulatory
Flexibility Analysis (IRFA) is not
required. Accordingly, the analysis and
discussion provided in this section, as
well as elsewhere in this final rule with
comment period, together meet the
43 Based on National Health Expenditure Data,
Physicians and Clinical Services Expenditures,
https://www.cms.gov/Research-Statistics-Data-andSystems/Statistics-Trends-and-Reports/
NationalHealthExpendData/NationalHealth
AccountsProjected.html.
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requirements for an IRFA. We note that
whether or not a particular MIPS
eligible clinician or other eligible
clinician is adversely affected would
depend in large part on the performance
of that MIPS eligible clinician or other
eligible clinician, and that CMS will
offer significant technical assistance to
MIPS eligible clinicians and other
eligible clinicians in meeting the new
standards.
For the 2018 MIPS performance
period, this proposed rule has several
key proposals that will provide
regulatory relief for clinicians and
practices and help increase ways for
successful participation. These include
implementing virtual groups, raising the
low volume threshold, continuing to
allow the use of 2014 Edition CEHRT
(Certified Electronic Health Record
Technology), and adding a new
significant hardship exception for the
advancing care information performance
category for MIPS eligible clinicians
who are in small practices, as
summarized in section I.D.4.c. of this
proposed rule.
In addition, section 1102(b) of the Act
requires us to prepare an RIA if a rule
may have a significant impact on the
operations of a substantial number of
small hospitals located in rural areas.
This analysis must conform to the
provisions of section 603 of the RFA.
For purposes of section 1102(b) of the
Act, we define a small hospital located
in a rural area as a hospital that is
located outside of a Metropolitan
Statistical Area for Medicare payment
regulations and has fewer than 100
beds. We are not preparing an analysis
for section 1102(b) of the Act because
we have determined, and the Secretary
certifies, that this proposed rule would
not have a significant impact on the
operations of a substantial number of
small hospitals located in rural areas.
Section 202 of the Unfunded
Mandates Reform Act of 1995 (UMRA)
also requires that agencies assess
anticipated costs and benefits on state,
local, or tribal governments or on the
private sector before issuing any rule
whose mandates require spending in
any 1 year of $100 million in 1995
dollars, updated annually for inflation.
In 2017, that threshold is approximately
$148 million. This proposed rule would
impose no mandates on state, local, or
tribal governments or on the private
sector because participation in Medicare
is voluntary and because physicians and
other clinicians have multiple options
as to how they will participate under
MIPS and discretion over their
performance. Moreover, HHS interprets
UMRA as applying only to unfunded
mandates. We do not interpret Medicare
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payment rules as being unfunded
mandates, but simply as conditions for
the receipt of payments from the federal
government for providing services that
meet federal standards. This
interpretation applies whether the
facilities or providers are private, state,
local, or tribal.
Executive Order 13132 establishes
certain requirements that an agency
must meet when it issues a proposed
rule (and subsequent final rule) that
imposes substantial direct effects on
state and local governments, preempts
state law, or otherwise has Federalism
implications. We have outlined in
section II.D.6.(a) of this proposed rule a
payer-initiated identification process for
identifying which payment
arrangements qualify as Other Payer
Advanced APMs. State Medicaid
programs may elect to participate in the
payer-initiated identification process.
We do not believe any of these policies
impose a substantial direct effect on the
Medicaid program as participation in
the Payer Initiated Determination
Process is voluntary and use of the
Eligible Clinician Initiated
Determination Process is also voluntary.
We have prepared the following
analysis, which together with the
information provided in the rest of this
proposed rule, meets all assessment
requirements. The analysis explains the
rationale for and purposes of this
proposed rule; details the costs and
benefits of the rule; analyzes
alternatives; and presents the measures
we would use to minimize the burden
on small entities. As indicated
elsewhere in this proposed rule, we are
implementing a variety of changes to
our regulations, payments, or payment
policies to implement statutory
provisions. We provide information for
each of the policy changes in the
relevant sections of this proposed rule.
We note that many of the MIPS policies
from the CY 2017 Quality Payment
Program final rule were only defined for
the 2017 MIPS performance period and
2019 MIPS payment year (including the
performance threshold, the performance
category reweighting policies, and many
scoring policies for the quality
performance category) which precludes
us from developing a baseline for the
2018 MIPS performance period and
2020 MIPS payment year if there were
no new regulatory action. We are
unaware of any relevant federal rules
that duplicate, overlap, or conflict with
this proposed rule. The relevant
sections of this proposed rule contain a
description of significant alternatives if
applicable.
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C. Changes in Medicare Payments
Section 101 of the MACRA, (1)
repeals the Sustainable Growth Rate
(SGR) formula for physician payment
updates in Medicare, and (2) requires
that we establish MIPS for eligible
clinicians under which the Secretary
must use a MIPS eligible clinician’s
final score to determine and apply a
MIPS payment adjustment factor to the
clinician’s Medicare Part B payments for
a year.
The largest component of the MACRA
costs is its replacement of scheduled
reductions in physician payments with
payment rates first frozen at 2015 levels
and then increasing at a rate of 0.5
percent a year during CYs 2016 through
2019. The estimates in this RIA take
those legislated rates as the baseline for
the estimates we make as to the costs,
benefits, and transfer effects of this
proposed regulation, with some
proposed data submission provisions for
the 2018 MIPS performance period
taking effect in 2018 and 2019, and the
corresponding positive and negative
payment adjustments taking effect in the
2020 MIPS payment year.
As required by the MACRA, overall
payment rates for services for which
payment is made under the PFS would
remain at the 2019 level through 2025,
but starting in 2019, the amounts paid
to individual MIPS eligible clinicians
and other eligible clinicians would be
subject to adjustment through one of
two mechanisms, depending on whether
the clinician achieves the threshold for
participation in Advanced APMs to be
considered a Qualifying APM
Participant (QP) or Partial QP, or is
instead evaluated under the MIPS.
1. Estimated Incentive Payments to QPs
in Advanced APMs
From 2019 through 2024, eligible
clinicians receiving a sufficient portion
of Medicare Part B payments for covered
professional services or seeing a
sufficient number of Medicare patients
through Advanced APMs as required to
become QPs would receive a lump-sum
APM Incentive Payment equal to 5
percent of their estimated aggregate
payment amounts for Medicare covered
professional services in the preceding
year, as discussed in section II.D. of this
proposed rule.
The APM Incentive Payment is
separate from, and in addition to, the
payment for covered professional
services furnished by an eligible
clinician during that year. Eligible
clinicians who become QPs for a year
would not need to report to MIPS and
would not receive a MIPS payment
adjustment to their Part B payments.
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Eligible clinicians who do not become
QPs, but meet a slightly lower threshold
to become Partial QPs for the year, may
elect to report to MIPS and would then
be scored under MIPS and receive a
MIPS payment adjustment, but do not
receive the APM Incentive Payment. For
the 2018 Medicare QP Performance
Period, we define Partial QPs to be
eligible clinicians in Advanced APMs
who have at least 20 percent, but less
than 25 percent, of their payments for
Part B covered professional services
through an Advanced APM Entity, or
furnish Part B covered professional
services to at least 10 percent, but less
than 20 percent, of their Medicare
beneficiaries through an Advanced APM
Entity. If the Partial QP elects to be
scored under MIPS, they would be
subject to all MIPS requirements and
would receive a MIPS payment
adjustment. This adjustment may be
positive or negative. If an eligible
clinician does not meet either the QP or
Partial QP standards, the eligible
clinician would be subject to MIPS,
would report to MIPS, and would
receive the corresponding MIPS
payment adjustment.
Beginning in 2026, payment rates for
services furnished by clinicians who
achieve QP status for a year would be
increased each year by 0.75 percent for
the year, while payment rates for
services furnished by clinicians who do
not achieve QP status for the year would
be increased by 0.25 percent. In
addition, MIPS eligible clinicians would
receive positive, neutral, or negative
MIPS payment adjustments to their Part
B payments in a payment year based on
performance during a prior performance
period. Although the MACRA
amendments established overall
payment rate and procedure parameters
until 2026 and beyond, this impact
analysis covers only the second
payment year (2020) of the Quality
Payment Program in detail. After 2020,
while overall payment levels will be
partially bounded, we have also
acknowledged in the preamble that the
Department will likely revise its quality
and other payment measures and overall
payment thresholds and other
parameters as clinicians’ behavior
changes.
We estimate that between 180,000 and
245,000 eligible clinicians will become
QPs, therefore be exempt from MIPS,
and qualify for lump sum incentive
payment based on 5 percent of their Part
B allowable charges for covered
professional services, which are
estimated to be between approximately
$11,820 million and $15,770 million in
the 2018 Quality Payment Program
performance year. We estimate that the
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aggregate total of the APM incentive
payment of 5 percent of Part B allowed
charges for QPs would be between
approximately $590 and $800 million
for the 2020 Quality Payment Program
payment year. These estimates reflect
longstanding HHS policy not to attempt
to predict the effects of future
rulemaking in order to maximize future
Secretarial discretion over whether, and
if so how, payment or other rules would
be changed.
We project the number of eligible
clinicians that will be excluded from
MIPS as QPs using several sources of
information. First, the projections are
anchored in the most recently available
public information on Advanced APMs.
The projections reflect APMs that will
be operating in 2018. This proposed rule
indicates which APMs would be
Advanced APMs under proposed
policies, including the Next Generation
ACO Model, Comprehensive Primary
Care Plus (CPC+) Model,
Comprehensive ESRD Care (CEC)
Model, Episode Payment Models (EPM),
Vermont All-Payer ACO Model,44
Comprehensive Care for Joint
Replacement Payment Model (CEHRT
Track), Oncology Care Model (TwoSided Risk Arrangement), ACO Track 1+
Model, the Shared Savings Program
Tracks 2 and 3. We also project
Advanced APM participation based on
applicant counts and estimated
acceptance rates to Advanced APMs
that had open application periods as of
early 2017. We use a preliminary
version of the file used for the
predictive qualifying Alternative
Payment Model participants analysis
made available on qpp.cms.gov on June
2, 2017 and prepared using claims for
services between January 1, 2016
through August 31, 2016, for the first
Medicare QP Performance Period for
2017. We examine the extent to which
Advanced APM participants would
meet the QP thresholds of having at
least 25 percent of their Part B covered
professional services or at least 20
percent of their Medicare beneficiaries
furnished Part B covered professional
services through the Advanced APM
Entity. The preliminary version of this
file followed the methodologies for
group (APM Entity level) determination
of QP status outlined in the CY 2017
Quality Payment Program final rule
with comment period. We also assumed
that during the first Medicare QP
Performance Period, the majority of
eligible clinicians participating in
Advanced APMs would be QPs based
on the preliminary version of this file.
44 Vermont ACOs will be participating in an
Advanced APM during 2018 through a modified
version of the Next Generation ACO Model. The
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2. Estimated Numbers of Clinicians
Eligible for MIPS
Certain clinicians may not be eligible
to participate or may be excluded from
participation in MIPS for various
reasons. For example, the MACRA
requires us to limit eligibility for the
2019 and 2020 MIPS payment years to
specified clinician types. Additionally,
we exclude eligible clinicians with
billings that do not exceed the low
volume threshold as proposed in section
II.C.2.c. of this proposed rule: Those
with $90,000 or less in Part B allowed
charges or 200 or fewer Medicare Part B
patients as measured at the TIN/NPI
level for individual reporting, the TIN
level for group reporting, the APM
Entity level for reporting under the APM
scoring standard. We also exclude those
who are newly enrolled to Medicare and
those eligible clinicians who are QPs.
To estimate the number of clinicians
that are not in MIPS due to an ineligible
clinician type for CY 2018, our scoring
model used the first 2019 Payment Year
MIPS eligibility file as described in 81
FR 77069 and 77070. The data file
included 1.5 million clinicians who had
Medicare Part B claims from September
1, 2015 to August 31, 2016 and included
a 60-day claim run-out. We limited our
analysis to those clinicians identified as
MIPS eligible clinician types for the
2020 MIPS payment year: Doctors of
medicine, doctors of osteopathy,
chiropractors, dentists, optometrists,
podiatrists, nurse practitioners,
physician assistants, certified registered
nurse anesthetists, and clinical nurse
specialists.
We estimated the number of
clinicians excluded for low volume by
comparing the allowed Medicare Part B
charges in the first 2019 MIPS payment
year eligibility file to the proposed low
volume threshold. We used 2015 PQRS
reporting data to determine whether
clinicians have historically reported as
a group and whether to make the lowvolume determination at the individual
(TIN/NPI) or group (TIN) level. We
assumed all Shared Savings Program or
Pioneer ACO participants would exceed
the low volume threshold because the
ACOs have a requirement for a
minimum number of assigned
beneficiaries.
Because of the lack of available data
on which eligible clinicians would elect
to participate as part of a virtual group
under the policies proposed in section
II.C.4 of this proposed rule, the scoring
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model does not reflect the proposed
policies for scoring virtual groups.
We estimated the number of newly
enrolled Medicare clinicians to be
excluded from MIPS by assuming
clinicians (NPIs) are newly enrolled if
they have Part B charges in the
eligibility file, but no Part B charges in
2015. Because of data limitations, this
newly enrolled modeling methodology
is different than the one that will be
used under the policies finalized under
§§ 414.1310 and 414.1315.
To exclude QPs from our scoring
model, we used a preliminary version of
the file used for the predictive
qualifying Alternative Payment Model
participants analysis made available on
qpp.cms.gov on June 2, 2017, and
prepared using claims for services
between January 1, 2016 through August
31, 2016 for the first Medicare QP
Performance Period for 2017 that
included clinicians participating in
Advanced APMs active as of mid-March
2017. We assumed that all partial QPs
would participate in MIPS and included
them in our scoring model. Because of
the expected growth in Advanced APM
participation, the estimated number of
QPs excluded from our model based on
data from the 2017 Quality Payment
Program performance period (74,920) is
lower than the summary level projection
for the 2018 Quality Payment Program
performance period based on the
expected growth in APM participation
(180,000–245,000). This expected
growth is due in part to reopening of
CPC+ and Next Generation ACO for
2018, and the ACO Track 1+ which is
projected to have a large number of
participants, with a large majority
reaching QP status. Hence, our model
may overestimate the fraction of
clinicians and allowed Medicare Part B
charges that will remain subject to MIPS
after the exclusions.
We have estimated the cumulative
effects of these exclusions in Table 85.
We estimate that 65 percent of
clinicians’ $124,029 million in allowed
Medicare Part B charges will be
included in MIPS. Further, we estimate
that approximately 37 percent of
1,548,022 Medicare clinicians billing to
Part B will be included in MIPS.
Table 85 also shows the number of
eligible clinicians remaining in the
scoring model used for this regulatory
impact analysis (554,846) is lower than
the estimated number of eligible
clinicians remaining after exclusions
(572,299). The discrepancy is due to our
scoring model excluding clinicians that
submitted via measures groups under
Vermont Medicare ACO Initiative will be an
Advanced APM beginningin 2019.
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submission mechanism was eliminated
under MIPS.
TABLE 85—PROJECTED NUMBER OF CLINICIANS INELIGIBLE FOR OR EXCLUDED FROM MIPS IN CY 2018, BY REASON *
Count of Medicare
clinicians
(TIN/NPIs)
remaining after
exclusion
Reason for exclusion
Part B allowed
charges remaining
after exclusion
($ in millions)
1,548,022
1,314,733
1,232,779
647,219
572,299
572,299
37%
All Medicare clinicians billing Part B .......................................
Subset to clinician types that are eligible for 2020 MIPS payment year ** ..........................................................................
Exclude newly enrolled clinicians *** .......................................
Additionally, exclude low volume clinicians **** .......................
Additionally, exclude qualifying APM participants (QPs) *****
Total remaining in MIPS after exclusion .................................
Percent eligible clinicians remaining in MIPS after exclusions
Count of
Medicare
clinicians
(TIN/NPIs)
excluded
Part B allowed
charges
excluded
($ in millions)
$124,029
..............................
..............................
$101,733
$101,243
$87,147
$80,658
$80,658
65%
233,289
81,954
585,560
74,920
..............................
..............................
$22,296
$490
$14,096
$6,489
..............................
..............................
Additional Exclusions for Scoring Model
Exclude clinicians who previously submitted measures
groups under 2015 PQRS ...................................................
Percent eligible clinicans remaining in scoring model after
exclusions .............................................................................
554,846
$71,930
17,453
$8,728
36%
58%
..............................
..............................
* Allowed Medicare Part B charges for covered services of the clinician under Part B from September 1, 2015 to August 31, 2016 data. Payments estimated using 2015 or 2016 dollars.
** Section 1848(q)(1)(C) of the Act defines a MIPS eligible clinician for payment years 1 and 2 as a physician, physician’s assistant, nurse
practitioner, or clinical nurse anesthetist, or a group that includes such clinicians.
*** Newly enrolled Medicare clinicians in our scoring model had positive Part B charges between September 1, 2015 and August 31, 2016 but
had no Part B charges for CY2015.
**** Low-volume clinicians have less than or equal to $90,000 in allowed Medicare Part B charges or less than or equal to 200 Medicare patients.
**** QPs have at least 25 percent of their Medicare Part B covered professional services or least 20 percent of their Medicare beneficiaries furnished part B covered professional services through an Advanced APM.
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3. Estimated Impacts on Payments to
MIPS Eligible Clinicians
Our scoring model includes eligible
clinicians who will be required to
submit MIPS data to us in year 1.45 They
are eligible clinicians who (a) are not
QPs participating in Advanced APMs,
(b) exceeded the low volume threshold,
and (c) enrolled as Medicare clinicians
prior to the current performance year.
Payment impacts in this proposed
rule reflect averages by specialty and
practice size based on Medicare
utilization. The payment impact for a
MIPS eligible clinician could vary from
the average and would depend on the
mix of services that the MIPS eligible
clinician furnishes. The average
percentage change in total revenues
would be less than the impact displayed
here because MIPS eligible clinicians
generally furnish services to both
Medicare and non-Medicare patients. In
addition, MIPS eligible clinicians may
receive substantial Medicare revenues
for services under other Medicare
payment systems that would not be
45 Due to data limitations, our scoring model
excluded the 17.453 MIPS eligible clinicians who
submitted quality via the measures groups
mechanism under the 2015 PQRS. The measures
group submission mechanism is not available in
MIPS.
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affected by MIPS payment adjustment
factors.
To estimate the impact of MIPS on
clinicians required to report, we used
the most recently available data,
including 2014 and 2015 PQRS data,
2014 and 2015 CAHPS for PQRS data,
2014 and 2015 VM data, 2015 and 2016
Medicare and Medicaid EHR Incentive
Program data, the data prepared to
support the 2017 performance period
initial determination of clinician and
special status eligibility (available via
the NPI lookup on qpp.cms.gov),
preliminary version of the file used for
the predictive qualifying Alternative
Payment Model participants analysis
made available on qpp.cms.gov on June
2, 2017, and prepared using claims for
services between January 1, 2016
through August 31, 2016 for the first
Medicare QP Performance Period for
2017, the 2017 MIPS published measure
benchmarks, and other available data to
model the scoring provisions described
in this regulation. First, we
arithmetically calculated a hypothetical
final score for each MIPS eligible
clinician based on quality, advancing
care information, and improvement
activities performance categories.
We estimated the quality performance
category score using measures
submitted to PQRS for the 2015
performance period. For quality
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measures submitted via the claims,
EHR, qualified registry, QCDR, and
CMS-approved survey vendor
submission mechanisms, we applied the
published benchmarks developed for
the 2017 MIPS performance period. For
quality measures submitted via Web
Interface, we applied the published
benchmarks developed for the 2017
Shared Savings Program where
available, and did not calculate scores
for measures for which Shared Savings
Program benchmarks did not exist. For
the all-cause hospital readmission
measure we used the 2015 VM analytic
file, which was the most recent data
available, and calculated our own
benchmarks based on 2015 data since
published benchmarks were not yet
available. In order to estimate the
impact of improvement for the quality
performance category, we estimated a
quality performance category percent
score using 2014 PQRS data, 2014
CAHPS for PQRS data, and 2014 VM
data. Because we lack detailed
information on which MIPS eligible
clinicians would elect to submit as part
of a virtual group and which MIPS
eligible clinicians based primarily in
inpatient hospital settings or in
emergency departments would elect
facility-based measurement, the
proposed policies regarding virtual
groups and facility-based measurement
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are not reflected in our scoring model.
Our model applied the MIPS APM
scoring standards proposed in section
II.C.6.g. of this proposed rule to quality
data from MIPS eligible clinicians that
participated in the Shared Savings
Program model in 2015.
We propose in section II.C.6.d.(2) of
this proposed rule, for the cost
performance category to have a zero
percent weight and to not contribute to
the 2020 MIPS payment year final score.
Therefore, we did not include cost
measures in this scoring model.
For the advancing care information
performance category score, we used
data from the 2015 Medicare and
Medicaid EHR Incentive Programs.
Because the EHR Incentive Programs are
based on attestation at the NPI level, the
advancing care information performance
category scores are assigned to
clinicians by their individual national
provider identifier (NPI), regardless of
whether the clinician was part of a
group submission for PQRS. We
assigned a score of 100 percent to MIPS
eligible clinicians who attested in the
2015 Medicare EHR Incentive Program
or received a 2015 incentive payment
from the Medicaid EHR Incentive
Program (after excluding incentive
payments to adopt, implement, and
upgrade). While we had attestation
information for the Medicare EHR
Incentive Program, we did not have
detailed attestation information for the
Medicaid EHR Incentive Program.
Therefore, we used incentive payments
(excluding the adopt implement and
upgrade incentive payments) as a proxy
for attestation in the Medicaid EHR
Incentive Program. Our rationale for
selecting a 100 percent performance
score is that the requirements to achieve
a base score of 50 percent in MIPS are
lower than the EHR Incentive Program
requirements to attest for meaningful
use (which determined whether
program requirements were met on an
all or nothing basis). We anticipate
clinicians who met EHR Incentive
Program requirements for meaningful
use will be able to achieve an advancing
care information performance category
score of 100 percent. Because the
minimum requirements for meaningful
use did not allow partial scoring, we
believe the clinicians who met the
minimum requirements would be able
to achieve an advancing care
information performance category score
of 100 percent. For example, the
minimum requirements to attest to
Modified Stage 2 objectives and
measures for the 2017 Medicare EHR
Incentive Program (assuming no
measure exceptions and an
immunization registry is available)
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would translate into an advancing care
information performance score of 85
percent. Generally, we see that
clinicians have performance greater
than the minimum requirements, which
is the reason we estimated an advancing
care information performance category
score of 100 percent.
For those clinicians who did not attest
in either the 2015 Medicare or Medicaid
EHR Incentive Program, we evaluated
whether the MIPS eligible clinician
could have their advancing care
information performance category score
reweighted. The advancing care
information performance category
weight is set equal to zero percent, and
the weight is redistributed to quality for
non-patient facing clinicians, hospitalbased clinicians, ASC-based clinicians,
NPs, PAs, CRNAs, or CNSs, or those
who request and are approved for a
significant hardship or other type of
exception, including a new significant
hardship exception for small practices,
or clinicians who are granted an
exception based on decertified EHR
technology. We used the non-patient
facing and hospital-based indicators and
specialty and small practice indicators
as calculated in the initial MIPS
eligibility run. Due to data limitations,
we were not able to reweight the
advancing care information performance
category scores of ASC-based clinicians
in our scoring model. For significant
hardship exceptions, we used the 2016
final approved significant hardship file.
If a MIPS eligible clinician did not attest
and did not qualify for a reweighting of
their advancing care information
performance category, the advancing
care information performance category
score was set equal to zero percent.
We modeled the improvement
activities performance category score
based on 2015 APM participation and
historic participation in 2015 PQRS and
2015 Medicare and Medicaid EHR
Incentive Programs. Our model
identified the 2015 Shared Savings
Program participants and assigned them
an improvement activity score of 100
percent, consistent with our policy to
assign a 100 percent improvement
activities performance category score to
Shared Savings Program participants in
Quality Payment Program Payment Year
2019. Due to limitations in 2015 data,
our model did not include 2015
participants in APMs other than the
Shared Savings Program.
Clinicians and groups not
participating in a MIPS APM were
assigned an improvement activities
score based on their performance in the
quality and advancing care information
performance categories. MIPS eligible
clinicians whose 2015 PQRS data meets
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all the MIPS quality submission criteria
(for example, submitting 6 measures
with data completeness, including one
outcome or high priority measures) and
had an estimated advancing care
information performance category score
of 100 percent (if advancing care
information is applicable to them) are
assigned an improvement activities
performance category score of 100
percent. MIPS eligible clinicians who
did not participate in 2015 PQRS or the
2015 Medicare or Medicaid EHR
Incentive Program (if it was applicable),
earned an improvement activity
performance category score of zero
percent, with the rationale that these
clinicians may be less likely to
participate in MIPS if they have not
previously participated in other
programs.
For the remaining MIPS eligible
clinicians not assigned an improvement
activities performance category score of
0 or 100 percent in our model, we
assigned a score that corresponds to
submitting one medium-weighted
improvement activity. The MIPS eligible
clinicians assigned an improvement
activity performance category score
corresponding to a medium-weighted
activity include (a) those who submitted
some quality measures under the 2015
PQRS but did not meet the MIPS quality
submission criteria or (b) those who did
not submit any quality data under the
2015 PQRS who attested under the
Medicare EHR Incentive program or
received an incentive payment
(excluding adopt implement and
upgrade payments) from the Medicaid
EHR Incentive Program. We assumed
that these clinicians may be likely to
partially, but not fully participate, in the
improvement activities category. For
non-patient facing clinicians, clinicians
in a small practice (consisting of 15 or
fewer professionals), clinicians in
practices located in a rural area,
clinicians in a geographic healthcare
professional shortage area (HPSA)
practice or any combination thereof, the
medium weighted improvement activity
was assigned one-half of the total
possible improvement activities
performance category score (20 out of a
40 possible points or 50 percent) The
remaining MIPS eligible clinicians not
assigned an improvement activities
performance category score of 0, 50, or
100 points were assigned a score
corresponding to one medium-weighted
activity (10 out of 40 possible points or
25 percent). Due to lack of available
data, we were not able to identify MIPS
eligible clinicians in patient-centered
medical homes or comparable specialty
societies in our scoring model. The
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policy finalized under § 414.1380(b)(3)
indicates that MIPS eligible clinicians in
a patient centered medical home or a
comparable specialty societies would
qualify for improvement activities
performance category score of 100
percent.
Our model assigns a final score for
each TIN/NPI by multiplying each
performance category score by the
corresponding performance category
weight, adding the products together,
and multiplying the sum by 100 points.
For MIPS eligible clinicians that had
their advancing care information
performance category score reweighted
due to a significant hardship exception
or automatic reweighting, the weight for
the advancing care information
performance category was assigned to
the quality performance category.
The scoring model reflects the
proposed bonuses for complex patients
and small practices in sections
II.C.7.b.(1)(b) and II.C.7.b.(1)(c) of this
proposed rule. Consistent with the
proposal to define complex patients as
those with high medical risk, our
scoring model adds the average
Hierarchical Condition Category (HCC)
score across all the MIPS eligible
clinician’s patients (with a cap of three
points) to the final score. We used the
average HCC risk score calculated for
each NPI in the 2015 Physician and
Other Supplier Public Use File. We also
generated a group average HCC risk
score by weighing the scores for
individual clinicians in each group by
the number of beneficiaries they have
seen. Our scoring model also adds 5
points to the final score for small
practices that had a final score greater
than 0 points. After adding any
applicable bonus for complex patients
and small practices, we set any final
scores that exceeded 100 points to 100.
We then implemented an exchange
function based on the provisions of this
proposed rule to estimate the positive or
negative MIPS payment adjustment
based on the estimated final score and
the estimated Medicare Part B paid
charges. Due to data limitations, we
assumed that the paid amount was 80
percent of Medicare Part B allowed
charges. We iteratively modified the
parameters of the exchange function
distributions of MIPS payment
adjustments that meet statutory
requirements related to the linear
sliding scale, budget neutrality and
aggregate exceptional performance
payment adjustment amounts (as
finalized under § 414.1405). Our model
used a 15-point performance threshold
and a 70-point additional performance
threshold.
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With the extensive changes to policy
and the flexibility that is allowed under
MIPS, estimating impacts of this
proposed rule using only historic 2015
participation assumptions would
significantly overestimate the impact on
clinicians, particularly on clinicians in
practices with 1–15 clinicians, which
have traditionally had lower
participation rates. To assess the
sensitivity of the impact to the
participation rate, we have prepared two
sets of analyses.
The first analysis, which we label as
standard participation assumptions,
relies on the assumption that a
minimum 90 percent of MIPS eligible
clinicians will participate in submitting
quality performance category data to
MIPS, regardless of practice size.
Therefore, we assumed that, on average,
the categories of practices with 1–15
clinicians would have 90 percent
participation in the quality performance
category. This assumption is an increase
from existing historical data. PQRS
participation rates have increased
steadily since the program began; the
2015 PQRS Experience Report showed
an increase in the participation rate
from 15 percent in 2007 to 69 percent
in 2015.46 In 2015, among those eligible
for MIPS, 88.7 percent participated in
the PQRS. In 2015, MIPS eligible
practices of less than 1–15 clinicians
participated in the PQRS at a rate of
69.7 percent. Because practices of 16–24
have a 91.7 percent participation rate
based on historical data, and 25–99
clinicians have a 96.2 percent
participation rate and practices of 100+
clinicians have a 99.4 percent
participation rate, we assumed the
average participation rates of those
categories of clinicians would be the
same as under the 2015 PQRS. Our
assumption of 90 percent average
participation for the categories of
practices with 1–15 clinicians reflects
our belief that small and solo practices
will respond to the finalized policies
and this proposed rule’s flexibility,
reduced data submission burden,
financial incentives, and the support
they will receive through technical
assistance by participating at a rate close
to that of other practice sizes, enhancing
the existing upward trend in quality
data submission rates. Therefore, we
assume that the quality scores assigned
to new participants reflect the
distribution of MIPS quality scores. We
also applied behavioral participation
46 2015 PQRS Experience Report, available at
https://www.cms.gov/Medicare/Quality-InitiativesPatient-Assessment-Instruments/PQRS/Downloads/
2015_PQRS_Experience_Report.pdf.
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assumptions to the improvement
activities performance category.
To simulate the impact of the
standard model assumption, we
randomly select a subset of nonparticipants and substitute the quality
and improvement activity scores of
randomly selected participants. For
example, for a previously nonparticipating clinician, we substitute the
scores of a randomly selected MIPS
eligible clinician with a quality score of
73 percent. The improvement activities
performance category score is then
computed using this alternative quality
score. We did not apply the same
participation assumptions to the
advancing care information performance
category because the category applies
only to a subset of MIPS eligible
clinicians, and, as noted above, would
be weighted at zero percent for nonpatient facing clinicians, hospital-based
clinicians, ASC-based clinicians, NPs,
PAs, CRNAs, or CNSs, and those who
request and are approved for a
significant hardship or other type of
exception, including those in small
practices. Further, we took into account
that advancing care information
performance category participation may
be affected by the cost and time it may
take to acquire and implement certified
EHR technology needed to perform in
that performance category.
The second analysis, which we label
as ‘‘alternative participation
assumptions,’’ assumes a minimum
participation rate in the quality and
improvement activities performance
categories of 80 percent. Because the
2015 PQRS participation rates for
practices of more than 15 clinicians are
greater than 80 percent, this analysis
assumes increased participation for
practices of 1–15 clinicians only.
Practices of more than 15 clinicians are
included in the model at their historic
participation rates.
Table 86 summarizes the impact on
Part B services of MIPS eligible
clinicians by specialty for the standard
participation assumptions.
Table 87 summarizes the impact on
Part B services of MIPS eligible
clinicians by specialty under the
alternative participation assumptions.
Tables 89 and 90 summarize the
impact on Part B services of MIPS
eligible clinicians by practice size for
the standard participation assumptions
(Table 88) and the alternative
participation assumptions (Table 89).
Tables 87 and 89 show that under our
standard participation assumptions, the
vast majority (96.1 percent) of MIPS
eligible clinicians are anticipated to
receive positive or neutral payment
adjustments for the 2020 MIPS payment
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year, with only 3.9 percent receiving
negative MIPS payment adjustments.
Using the alternative participation
assumptions, Tables 88 and 90 show
that 94.3 percent of MIPS eligible
clinicians are expected to receive
positive or neutral payment
adjustments.
The projected distribution of funds
reflects this proposed rule’s emphasis
on increasing more complete reporting
of MIPS eligible clinicians for the
Quality Payment Program Performance
Year 2, which continues the ramp to
more robust participation in future
MIPS performance years.
TABLE 86—MIPS ESTIMATED PAYMENT YEAR 2020 IMPACT ON ESTIMATED PAID AMOUNT BY SPECIALTY, STANDARD
PARTICIPATION ASSUMPTIONS *
mstockstill on DSK30JT082PROD with PROPOSALS2
Provider type, specialty
Number of
MIPS eligible
clinicians
Overall ...............................................
Addiction Medicine ............................
Allergy/Immunology ...........................
Anesthesiology ..................................
Anesthesiology Assistant ..................
Cardiac Electrophysiology .................
Cardiac Surgery ................................
Cardiovascular Disease (Cardiology)
Certified Clinical Nurse Specialist .....
Certified Registered Nurse Anesthetist (CRNA) ...............................
Chiropractic .......................................
Clinic or Group Practice ....................
Colorectal Surgery (Proctology) ........
Critical Care (Intensivists) .................
Dermatology ......................................
Diagnostic Radiology ........................
Emergency Medicine .........................
Endocrinology ....................................
Family Medicine *** ...........................
Gastroenterology ...............................
General Practice ...............................
General Surgery ................................
Geriatric Medicine .............................
Geriatric Psychiatry ...........................
Gynecological Oncology ...................
Hand Surgery ....................................
Hematology .......................................
Hematology-Oncology .......................
Hospice and Palliative Care ..............
Infectious Disease .............................
Internal Medicine ...............................
Interventional Cardiology ..................
Interventional Pain Management ......
Interventional Radiology ....................
Maxillofacial Surgery .........................
Medical Oncology ..............................
Nephrology ........................................
Neurology ..........................................
Neuropsychiatry ................................
Neurosurgery .....................................
Nuclear Medicine ..............................
Nurse Practitioner .............................
Obstetrics & Gynecology ..................
Ophthalmology ..................................
Optometry ..........................................
Oral Surgery (Dentist only) ...............
Orthopedic Surgery ...........................
Osteopathic Manipulative Medicine ..
Otolaryngology ..................................
Pain Management .............................
Pathology ..........................................
Pediatric Medicine .............................
Peripheral Vascular Disease .............
Physical Medicine and Rehabilitation
Physician Assistant ...........................
Physician, Sleep Medicine ................
Plastic and Reconstructive Surgery ..
Podiatry .............................................
Preventive Medicine ..........................
Psychiatry ..........................................
Pulmonary Disease ...........................
Radiation Oncology ...........................
Rheumatology ...................................
Sports Medicine ................................
Surgical Oncology .............................
Thoracic Surgery ...............................
Other .................................................
Urology ..............................................
Vascular Surgery ...............................
Estimated paid
amount (mil)
(80% of
allowed
charges) **
Percent
eligible
clinicians
engaging
with quality
reporting
Percent
eligible
clinicians
with positive
or neutral
payment
adjustment
Percent
eligible
clinicians
with
exceptional
payment adjustment
Percent
eligible
clinicians
with negative
payment
adjustment
Aggregate
impact positive
adjustment
(mil) **
554,846
71
1,692
14,105
588
1,970
1,181
20,025
896
$57,544
3
162
789
7
341
182
3,600
22
96.6
95.8
94.9
97.8
100.0
97.5
98.6
96.5
97.0
96.1
95.8
94.9
95.7
99.8
98.4
98.3
96.8
96.4
76.8
82.4
80.0
74.5
88.4
81.5
85.2
80.9
86.2
3.9
4.2
5.1
4.3
0.2
1.6
1.7
3.2
3.6
673.3
0.0
1.8
7.8
0.1
4.7
2.7
47.2
0.3
¥173.3
0.0
¥0.8
¥3.0
0.0
¥0.4
¥0.2
¥8.5
¥0.2
0.9
¥0.2
0.6
0.6
1.7
1.3
1.4
1.1
0.4
16,600
581
393
1,046
2,730
9,506
27,990
31,503
4,376
54,171
10,910
2,210
14,135
1,394
119
807
1,037
648
6,463
645
4,571
72,692
2,716
1,255
1,181
194
2,530
5,707
11,588
67
3,850
466
50,649
15,587
14,779
4,621
282
17,504
297
6,854
1,475
7,924
4,007
57
5,237
38,378
256
1,986
9,558
221
10,590
8,756
3,049
3,340
792
713
1,738
272
8,590
2,725
259
31
51
97
201
2,510
3,317
1,728
336
3,667
1,204
214
1,143
121
9
80
131
109
2,929
23
497
6,917
491
333
232
5
870
1,073
1,141
6
505
66
1,313
237
6,451
439
7
2,586
22
777
291
770
43
7
734
875
18
170
1,231
11
487
1,111
810
1,126
61
52
203
34
1,596
683
99.3
92.9
97.7
95.7
97.0
91.8
97.0
99.1
97.3
97.0
96.0
91.3
96.6
96.4
91.6
98.4
92.8
98.6
97.5
99.5
94.2
95.9
97.5
90.0
97.0
99.0
98.5
95.1
95.3
91.0
95.3
97.0
98.0
99.0
96.8
94.5
97.5
93.4
96.0
93.7
88.1
96.6
99.6
98.2
91.3
98.7
96.5
94.7
87.3
98.2
93.9
96.2
97.9
97.2
97.0
98.6
97.8
94.9
95.4
95.8
98.0
92.6
97.2
96.2
96.6
91.8
95.7
97.4
97.2
96.9
96.5
90.7
96.6
95.9
89.9
98.3
92.3
98.9
97.2
99.1
94.1
95.3
98.5
89.0
96.1
99.0
98.4
95.2
95.7
91.0
95.2
97.2
97.8
99.1
96.6
94.3
97.9
93.3
94.9
92.5
86.6
95.5
99.6
96.5
90.5
98.4
97.7
94.7
87.0
97.7
93.7
96.2
97.3
97.2
96.8
98.9
98.1
95.6
96.1
96.0
84.7
52.4
96.9
75.6
82.9
69.6
58.8
56.2
80.1
80.7
79.2
74.7
79.4
77.0
76.6
79.4
67.8
83.5
77.3
88.1
78.9
80.0
83.8
62.8
67.9
85.4
78.2
78.2
77.8
72.1
72.9
81.2
87.3
88.3
73.6
69.2
89.1
66.8
79.1
68.5
63.4
65.0
90.2
90.9
68.4
84.1
80.8
77.5
59.2
83.8
75.2
80.0
80.8
80.5
78.7
82.7
82.9
84.6
72.4
73.9
2.0
7.4
2.8
3.8
3.4
8.2
4.3
2.6
2.8
3.1
3.5
9.3
3.4
4.1
10.1
1.7
7.7
1.1
2.8
0.9
5.9
4.7
1.5
11.0
3.9
1.0
1.6
4.8
4.3
9.0
4.8
2.8
2.2
0.9
3.4
5.7
2.1
6.7
5.1
7.5
13.4
4.5
0.4
3.5
9.5
1.6
2.3
5.3
13.0
2.3
6.3
3.8
2.7
2.8
3.2
1.1
1.9
4.4
3.9
4.0
3.1
0.2
0.9
1.2
2.5
27.2
26.3
12.8
4.3
48.1
15.6
1.9
13.9
1.4
0.1
1.0
1.3
1.5
32.4
0.3
5.6
86.1
7.1
3.2
1.8
0.1
9.3
12.9
12.9
0.0
5.5
0.7
16.7
3.0
99.0
5.0
0.1
25.2
0.2
7.5
2.6
6.1
0.5
0.1
6.4
11.2
0.2
1.8
10.0
0.1
4.2
13.8
9.0
15.0
0.7
0.7
2.8
0.4
17.9
7.5
¥0.7
¥0.2
¥0.4
¥0.3
¥0.7
¥10.7
¥6.8
¥2.2
¥1.0
¥11.1
¥2.8
¥1.7
¥3.5
¥0.5
¥0.1
¥0.1
¥0.5
0.0
¥4.5
0.0
¥2.7
¥24.7
¥0.4
¥1.9
¥0.5
0.0
¥0.8
¥3.0
¥5.4
¥0.1
¥1.8
¥0.3
¥7.0
¥0.6
¥5.9
¥1.5
¥0.1
¥9.9
¥0.1
¥3.6
¥2.0
¥4.2
¥0.1
0.0
¥5.0
¥3.0
0.0
¥1.0
¥9.1
0.0
¥4.8
¥3.4
¥1.6
¥2.0
¥0.1
¥0.1
¥0.3
¥0.1
¥3.4
¥2.1
0.9
¥0.1
1.0
0.9
0.9
0.7
0.6
0.6
1.0
1.0
1.1
0.1
0.9
0.8
¥0.7
1.0
0.6
1.4
1.0
1.3
0.6
0.9
1.3
0.4
0.6
1.0
1.0
0.9
0.7
¥0.2
0.7
0.7
0.7
1.0
1.4
0.8
¥0.4
0.6
0.7
0.5
0.2
0.2
1.1
1.0
0.2
0.9
0.9
0.4
0.1
0.8
¥0.1
0.9
0.9
1.2
0.9
1.2
1.2
0.9
0.9
0.8
Notes:
* Standard scoring model assumes that a minimum of 90 percent of clinicians within each practice size category would participate in quality data submission.
VerDate Sep<11>2014
19:16 Jun 29, 2017
Aggregate
impact
negative
payment
adjustment
(mil) **
Combined
impact of
negative
and positive
adjustments
and
exceptional
performance
payment as
percent of
estimated
paid amount
(%)
Jkt 241001
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Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
** 2014, 2015 and 2016 data used to estimate 2018 payment adjustments. Payments estimated using 2015 and 2016 dollars.
*** Specialty descriptions as self-reported on Part B claims. Note that all categories are mutually exclusive, including General Practice and Family Practice. ‘Family Medicine’ is used here for
physicians listed as ‘Family Practice’ in Part B claims.
TABLE 87—MIPS ESTIMATED PAYMENT YEAR 2020 IMPACT ON ESTIMATED PAID AMOUNT BY SPECIALTY, ALTERNATIVE
PARTICIPATION ASSUMPTIONS *
mstockstill on DSK30JT082PROD with PROPOSALS2
Clinician specialty/type
Percent
eligible
clinicians
with
exceptional
payment
adjustment
Percent
eligible
clinicians
with
negative
payment
adjustment
Estimated paid
amount (mil)
(80% of
allowed
charges) **
Percent
eligible
clinicians
engaging with
quality
reporting
554,846
71
1,692
14,105
588
1,970
1,181
20,025
896
$57,544
3
162
789
7
341
182
3,600
22
94.5
94.4
89.4
96.8
100.0
96.9
97.5
94.1
96.0
94.3
94.4
90.0
94.8
99.8
98.0
97.3
94.9
95.4
77.1
83.6
80.5
74.5
88.4
81.6
85.6
81.2
86.3
5.7
5.6
10.0
5.2
0.2
2.0
2.7
5.1
4.6
782.9
0.0
2.0
9.0
0.1
5.6
3.2
54.8
0.3
¥282.9
0.0
¥1.5
¥4.5
0.0
¥0.5
¥0.4
¥15.4
¥0.2
0.9
¥0.2
0.3
0.6
2.0
1.5
1.6
1.1
0.3
16,600
581
393
1,046
2,730
9,506
27,990
31,503
4,376
54,171
10,910
2,210
14,135
1,394
119
807
1,037
648
6,463
645
4,571
72,692
2,716
1,255
1,181
194
2,530
5,707
11,588
67
3,850
466
50,649
15,587
14,779
4,621
282
17,504
297
6,854
1,475
7,924
4,007
57
5,237
38,378
256
1,986
9,558
221
10,590
8,756
3,049
3,340
792
713
1,738
272
8,590
2,725
259
31
51
97
201
2,510
3,317
1,728
336
3,667
1,204
214
1,143
121
9
80
131
109
2,929
23
497
6,917
491
333
232
5
870
1,073
1,141
6
505
66
1,313
237
6,451
439
7
2,586
22
777
291
770
43
7
734
875
18
170
1,231
11
487
1,111
810
1,126
61
52
203
34
1,596
683
98.9
85.0
97.2
92.9
95.9
85.3
96.2
98.8
94.8
95.2
93.5
83.6
94.3
94.3
87.4
98.0
89.9
98.0
96.3
99.4
89.8
93.5
97.0
83.3
95.9
98.5
98.0
91.7
92.1
91.0
92.7
94.0
97.2
98.6
94.0
90.8
96.5
90.1
93.9
88.8
82.2
95.1
99.5
94.7
86.0
98.2
95.7
90.9
76.1
95.9
90.1
93.4
96.9
95.0
96.5
98.2
96.4
93.8
92.9
93.1
97.6
86.1
96.7
94.3
95.7
85.9
94.9
97.2
95.1
95.3
94.4
83.9
94.4
94.0
86.6
97.9
90.0
98.3
96.3
98.9
90.1
93.1
98.2
83.2
94.9
98.5
97.8
92.3
92.9
91.0
92.8
94.4
97.1
98.8
94.0
91.0
96.8
90.4
93.6
88.3
81.6
94.0
99.5
94.7
85.7
97.9
96.9
91.5
77.0
95.5
90.3
93.8
96.4
95.5
96.3
98.5
97.0
94.5
93.9
93.8
84.8
51.2
96.8
75.4
83.2
69.9
58.8
56.2
80.6
80.9
79.5
75.9
79.7
77.3
76.7
79.5
67.7
83.7
77.3
88.1
79.3
80.3
83.8
61.9
68.2
85.9
78.3
78.5
78.0
72.1
73.2
81.6
87.5
88.4
73.9
69.6
89.4
66.7
79.1
68.5
62.9
65.2
90.2
90.7
68.5
84.2
81.0
77.6
58.4
84.8
75.8
80.3
80.9
80.5
78.9
82.6
83.0
84.4
72.5
73.8
2.4
13.9
3.3
5.7
4.3
14.1
5.1
2.8
4.9
4.7
5.6
16.1
5.6
6.0
13.4
2.1
10.0
1.7
3.7
1.1
9.9
6.9
1.8
16.8
5.1
1.5
2.2
7.7
7.1
9.0
7.2
5.6
2.9
1.2
6.0
9.0
3.2
9.6
6.4
11.7
18.4
6.0
0.5
5.3
14.3
2.1
3.1
8.5
23.0
4.5
9.7
6.2
3.6
4.5
3.7
1.5
3.0
5.5
6.1
6.2
3.6
0.1
1.0
1.4
3.0
31.0
32.0
15.6
5.0
55.7
18.2
1.8
16.1
1.6
0.1
1.2
1.5
1.8
38.6
0.4
6.2
99.0
8.4
3.6
2.3
0.1
11.2
14.9
14.5
0.1
6.4
0.8
19.3
3.6
117.0
5.8
0.1
29.3
0.3
8.4
2.8
7.1
0.6
0.1
7.0
13.2
0.3
1.9
10.1
0.1
4.3
15.9
10.8
17.6
0.8
0.8
3.3
0.5
21.2
8.6
¥1.1
¥0.4
¥0.4
¥0.4
¥0.9
¥17.9
¥9.3
¥2.9
¥1.9
¥18.3
¥4.8
¥3.4
¥5.9
¥0.8
¥0.1
¥0.2
¥0.7
¥0.2
¥6.0
0.0
¥4.9
¥40.6
¥0.6
¥3.1
¥0.8
0.0
¥1.1
¥5.6
¥9.0
¥0.1
¥2.8
¥0.5
¥9.8
¥1.0
¥11.1
¥2.6
¥0.1
¥15.2
¥0.1
¥6.3
¥3.2
¥5.4
¥0.1
0.0
¥8.0
¥4.3
¥0.1
¥1.6
¥16.9
¥0.1
¥7.9
¥5.9
¥2.2
¥3.5
¥0.2
¥0.1
¥0.6
¥0.2
¥5.7
¥3.6
1.0
¥0.8
1.2
0.9
1.0
0.5
0.7
0.7
0.9
1.0
1.1
¥0.7
0.9
0.7
¥0.8
1.3
0.7
1.5
1.1
1.6
0.3
0.8
1.6
0.1
0.6
1.1
1.2
0.9
0.5
0.0
0.7
0.5
0.7
1.1
1.6
0.7
¥0.8
0.5
0.7
0.3
¥0.1
0.2
1.2
0.9
¥0.1
1.0
1.1
0.2
¥0.5
0.6
¥0.7
0.9
1.1
1.3
1.1
1.4
1.3
1.0
1.0
0.7
Number of
MIPS eligible
clinicians
Overall ...............................................
Addiction Medicine ............................
Allergy/Immunology ...........................
Anesthesiology ..................................
Anesthesiology Assistant ..................
Cardiac Electrophysiology .................
Cardiac Surgery ................................
Cardiovascular Disease (Cardiology)
Certified Clinical Nurse Specialist .....
Certified Registered Nurse Anesthetist (CRNA) ...............................
Chiropractic .......................................
Clinic or Group Practice ....................
Colorectal Surgery (Proctology) ........
Critical Care (Intensivists) .................
Dermatology ......................................
Diagnostic Radiology ........................
Emergency Medicine .........................
Endocrinology ....................................
Family Medicine *** ...........................
Gastroenterology ...............................
General Practice ...............................
General Surgery ................................
Geriatric Medicine .............................
Geriatric Psychiatry ...........................
Gynecological Oncology ...................
Hand Surgery ....................................
Hematology .......................................
Hematology-Oncology .......................
Hospice and Palliative Care ..............
Infectious Disease .............................
Internal Medicine ...............................
Interventional Cardiology ..................
Interventional Pain Management ......
Interventional Radiology ....................
Maxillofacial Surgery .........................
Medical Oncology ..............................
Nephrology ........................................
Neurology ..........................................
Neuropsychiatry ................................
Neurosurgery .....................................
Nuclear Medicine ..............................
Nurse Practitioner .............................
Obstetrics & Gynecology ..................
Ophthalmology ..................................
Optometry ..........................................
Oral Surgery (Dentist only) ...............
Orthopedic Surgery ...........................
Osteopathic Manipulative Medicine ..
Otolaryngology ..................................
Pain Management .............................
Pathology ..........................................
Pediatric Medicine .............................
Peripheral Vascular Disease .............
Physical Medicine and Rehabilitation
Physician Assistant ...........................
Physician, Sleep Medicine ................
Plastic and Reconstructive Surgery ..
Podiatry .............................................
Preventive Medicine ..........................
Psychiatry ..........................................
Pulmonary Disease ...........................
Radiation Oncology ...........................
Rheumatology ...................................
Sports Medicine ................................
Surgical Oncology .............................
Thoracic Surgery ...............................
Other .................................................
Urology ..............................................
Vascular Surgery ...............................
Percent
eligible
clinicians
with positive
or neutral
payment
adjustment
Combined
impact of
negative
and positive
adjustments
and
exceptional
performance
payment as
percent of
estimated
paid amount
(%)
Aggregate
impact positive
adjustment
(mil) **
Aggregate
impact negative payment
adjustment
(mil) **
* Alternative scoring model assumes that a minimum of 80 percent of clinicians within each practice size category would participate in quality data submission.
** 2014, 2015 and 2016 data used to estimate 2018 payment adjustments. Payments estimated using 2015 and 2016 dollars.
*** Specialty descriptions as self-reported on Part B claims. Note that all categories are mutually exclusive, including General Practice and Family Practice. ‘Family Medicine’ is used here for
physicians listed as ‘Family Practice’ in Part B claims.
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TABLE 88—MIPS ESTIMATED PAYMENT YEAR 2020 IMPACT ON TOTAL ESTIMATED PAID AMOUNT BY PRACTICE SIZE,
STANDARD PARTICIPATION ASSUMPTIONS *
Practice size
Number of
MIPS eligible
clinicians
All practice sizes ...............................
1–15 clinicians ...................................
16–24 clinicians .................................
25–99 clinicians .................................
100 or more clinicians .......................
Estimated paid
amount (mil)
(80% of allowed
charges) **
Percent
eligible
clinicians
engaging with
quality
reporting
$57,544
26,091
3,840
9,814
17,799
Percent
eligible
clinicians
with positive
or neutral
payment
adjustment
96.6
90.0
91.7
96.2
99.4
554,846
114,424
22,296
99,285
318,841
96.1
90.0
89.1
94.9
99.2
Percent
eligible
clinicians
with
exceptional
payment adjustment
Percent
eligible
clinicians
with negative
payment
adjustment
76.8
64.2
52.7
63.7
86.4
Aggregate
impact positive
adjustment
(mil) **
3.9
10.0
10.9
5.1
0.8
673.3
288.2
32.7
94.3
258.1
Aggregate
impact negative payment
adjustment
(mil) **
¥173.3
¥115.1
¥17.9
¥29.9
¥10.4
Combined
impact of
negative and
positive
adjustments
and
exceptional
performance
payment as
percent of
estimated
paid amount
(%)
0.9
0.7
0.4
0.7
1.4
Practice size is the total number of TIN/NPIs in a TIN.
* Standard scoring model assumes that a minimum of 90 percent of clinicians within each practice size category would participate in quality data submission.
** 2014, 2015 and 2016 data used to estimate 2018 payment adjustments. Payments estimated using 2015 and 2016 dollars.
TABLE 89—MIPS ESTIMATED PAYMENT YEAR 2020 IMPACT ON ESTIMATED PAID AMOUNT BY PRACTICE SIZE, ALTERNATE
PARTICIPATION ASSUMPTIONS *
Practice size
Number of
MIPS eligible
clinicians
All practice sizes ...............................
1–15 clinicians ...................................
16–24 clinicians .................................
25–99 clinicians .................................
100 or more clinicians .......................
Estimated paid
amount (mil)
(80% of
allowed
charges)
Percent
eligible
clinicians
engaging with
quality
reporting
$57,544
26,091
3,840
9,814
17,799
Percent
eligible
clinicians
with positive
or neutral
payment
adjustment
94.5
80.0
91.7
96.2
99.4
554,846
114,424
22,296
99,285
318,841
94.3
81.2
89.1
94.9
99.2
Percent
eligible
clinicians
with
exceptional
payment
adjustment
Percent
eligible
clinicians
with negative
payment
adjustment
77.1
64.1
52.7
63.7
86.4
Aggregate
impact positive
adjustment
(mil) **
5.7
18.8
10.9
5.1
0.8
782.9
317.4
40.3
115.2
310.0
Aggregate
impact negative payment
adjustment
(mil) **
¥282.9
¥224.7
¥17.9
¥29.9
¥10.4
Combined
impact of
negative and
positive
adjustments
and
exceptional
performance
payment as
percent of
estimated
paid amount
(%)
0.9
0.4
0.6
0.9
1.7
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Practice size is the total number of TIN/NPIs in a TIN.
* Alternative scoring model assumes that a minimum of 80 percent of clinicians within each practice size category would participate in quality data submission.
** 2014, 2015 and 2016 data used to estimate 2018 payment adjustments. Payments estimated using 2015 and 2016 dollars.
4. Potential Costs of Advancing Care
Information and Improvement Activities
for Eligible Clinicians
We believe that most MIPS eligible
clinicians who can report the advancing
care information performance category
of MIPS have already adopted an EHR
during Stage 1 and 2 of the Medicare or
Medicaid EHR Incentive Programs, and
will have limited additional operational
expenses related to compliance with the
advancing care information performance
category requirements.
MIPS eligible clinicians who did not
participate in the Medicare and
Medicaid EHR Incentive Programs could
potentially face additional operational
expenses for implementation and
compliance with the advancing care
information performance category
requirements.
For some MIPS eligible clinicians, the
advancing care information performance
category will be weighted at zero
percent of the final score. We will
continue our policy that was finalized
in § 414.1375(a) to reweight the
advancing care information performance
category scores for certain MIPS eligible
clinicians, including those who may
have been exempt from the Medicare
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EHR Incentive Program such as
hospital-based clinicians, non-patient
facing clinicians, PAs, NPs, CNs and
CRNAs. Further, as described in section
II.6.f.(7)(a)(iv) of this proposed rule, we
are proposing to rely on section
1848(o)(2)(D) of the Act, as amended by
section 4002(b)(1)(B) of the 21st Century
Cures Act, to assign a scoring weight of
zero percent for the advancing care
information performance category for
MIPS eligible clinicians who are
determined to be based in ambulatory
surgical centers (ASCs). As described in
section II.6.f.(7)(a)(i) of this proposed
rule, we are proposing to rely on section
1848(o)(2)(D) of the Act, as amended by
section 4002(b)(1)(B) of the 21st Century
Cures Act, to allow MIPS eligible
clinicians to apply for a significant
hardship exception and subsequently
have their advancing care information
performance category reweighted to zero
when they are faced with a significant
hardship. Relying on this same
authority, we are also proposing a
significant hardship exception for the
advancing care information performance
category for MIPS eligible clinicians
who are in small practices, as discussed
in section II.6.f.7.(a)(ii) of this proposed
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rule, and are proposing an exception for
MIPS eligible clinicians whose CEHRT
has been decertified under ONC’s
Health IT Certification Program as
discussed in section II.6.f.7.(a)(v) of this
proposed rule. Additionally, we believe
most MIPS eligible clinicians who can
report the advancing care information
performance category of MIPS have
already adopted an EHR during Stage 1
and 2 of the Medicare EHR Incentive
Program. As we have stated with respect
to the Medicare EHR Incentive Program,
we believe that future retrospective
studies on the costs to implement an
EHR and the return on investment (ROI)
will demonstrate efficiency
improvements that offset the actual
costs incurred by MIPS eligible
clinicians participating in MIPS and
specifically in the advancing care
information performance category, but
we are unable to quantify those costs
and benefits at this time. At present,
evidence on EHR benefits in either
improving quality of care or reducing
health care costs is mixed. This is not
surprising since the adoption of EHR as
a fully functioning part of medical
practice is progressing, with numerous
areas of adoption, use, and
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sophistication demonstrating need for
improvement. Even physicians and
hospitals that can meet Medicare EHR
Incentive Program standards have not
necessarily fully implemented all the
functionality of their systems or fully
exploited the diagnostic, prescribing,
and coordination of care capabilities
that these systems promise. Moreover,
many of the most important benefits of
EHR depend on interoperability among
systems and this functionality is still
lacking in many EHR systems.
A recent RAND report prepared for
the ONC reviewed 236 recent studies
that related the use of health IT to
quality, safety, and efficacy in
ambulatory and non-ambulatory care
settings and found that—
‘‘A majority of studies that evaluated
the effects of health IT on healthcare
quality, safety, and efficiency reported
findings that were at least partially
positive. These studies evaluated
several forms of health IT: Metric of
satisfaction, care process, and cost and
health outcomes across many different
care settings. Our findings agree with
previous [research] suggesting that
health IT, particularly those
functionalities included in the Medicare
EHR Incentive Program regulation, can
improve healthcare quality and safety.
The relationship between health IT and
[health care] efficiency is complex and
remains poorly documented or
understood, particularly in terms of
healthcare costs, which are highly
dependent upon the care delivery and
financial context in which the
technology is implemented.’’ 47 Other
recent studies have not found definitive
quantitative evidence of benefits.48
Health IT vendors may face additional
costs in Quality Payment Program Year
2 if they choose to develop additional
capabilities in their systems to submit
advancing care information and
improvement activities performance
category data on behalf of MIPS eligible
clinicians. We request comments that
provide information that would enable
us to quantify the costs, costs savings,
and benefits associated with
implementation and compliance with
the requirements of the advancing care
information performance category.
47 Paul G. Shekelle, et al. Health Information
Technology: An Updated Systematic Review with a
Focus on Meaningful Use Functionalities. RAND
Corporation. 2014.
48 See, for example, Saurabh Rahurkar, et al.,
‘‘Despite the Spread of Health Information
Exchange, There Is Little Information of Its Impact
On Cost, Use, And Quality of Care,’’ Health Affairs,
March 2015; and Hemant K. Bharga and Abhay
Nath Mishra, ‘‘Electronic Medical Records and
Physician Productivity: Evidence from Panel Data
Analysis,’’ Management Science, July 2014.
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Similarly, the costs for
implementation and complying with the
improvement activities performance
category requirements could potentially
lead to higher expenses for MIPS
eligible clinicians. Costs per full-time
equivalent primary care clinician for
improvement activities will vary across
practices, including for some activities
or certified patient-centered medical
home practices, in incremental costs per
encounter, and in estimated costs per
member per month.
Costs may vary based on panel size
and location of practice among other
variables. For example, Magill (2015)
conducted a study of certified patientcentered medical home practices in two
states.49 That study found that costs
associated with a full-time equivalent
primary care clinician, who were
associated with certified patientcentered medical home practices, varied
across practices. Specifically, the study
found an average cost of $7,691 per
month in Utah practices, and an average
of $9,658 in Colorado practices.
Consequently, certified patient-centered
medical home practices incremental
costs per encounter were $32.71 in Utah
and $36.68 in Colorado (Magill, 2015).
The study also found that the average
estimated cost per member, per month,
for an assumed panel of 2,000 patients
was $3.85 in Utah and $4.83 in
Colorado. However, given the lack of
comprehensive historical data for
improvement activities, we are unable
to quantify those costs in detail at this
time. We request comments that provide
information that would enable us to
quantify the costs, costs savings, and
benefits associated implementation of
improvement activities.
D. Impact on Beneficiaries
There are a number of changes in this
proposed rule that would have an effect
on beneficiaries. In general, we believe
that the changes may have a positive
impact and improve the quality and
value of care provided to Medicare
beneficiaries. More broadly, we expect
that over time clinician engagement in
the Quality Payment Program may result
in improved quality of patient care,
resulting in lower morbidity and
mortality. We believe the policies
finalized in the CY 2017 Quality
Payment Program final rule, as well as
policies in this rule will lead to
additional growth in the participation of
both MIPS APMS and Advanced APMs.
APMs promote seamless integration by
way of their payment methodology and
49 Magill et al. ‘‘The Cost of Sustaining a PatientCentered Medical Home: Experience from 2 States.’’
Annals of Family Medicine, 2015; 13:429–435.
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30241
design that incentivize such care
coordination. The policies that are being
proposed regarding the All-Payer
Combination Option and identification
of Other Payer Advanced APMs will
help facilitate both the development and
participation in alternative payment
arrangements in the private and public
sectors. Clinicians can focus their efforts
around the care transformation in either
Advanced APM or MIPS APM models
and know that those efforts will be
aligned with the Quality Payment
Program, either through incentive
payments for QPs or through MIPS
scores calculated based on performance
within the APM assessed at the APM
Entity level.
Several Advanced APMs and MIPS
APMS have shown evidence of
improving the quality of care provided
to beneficiaries and beneficiaries’
experience of care. For example, the
various shared savings initiatives
already operating have demonstrated
the potential for quality programs to
delivers better quality healthcare,
smarter spending, and to put beneficiary
experience at the center. For example,
in August of 2015, we issued 2014
quality and financial performance
results showing that ACOs continue to
improve the quality of care for Medicare
beneficiaries while generating net
savings to the Medicare trust fund, if
shared savings paid out to these ACOs
are not included.50 In 2014, the 20
ACOs in the Pioneer ACO Model and
333 Shared Shavings Program ACOs
generated more than $411 million in
total savings, which includes all ACOs’
savings and losses but does not include
shared savings payments to ACOs.
Additionally, in their first years of
implementation, both Pioneer and
Shared Savings Program ACOs had
higher quality care than Medicare FFS
providers on measures for which
comparable data were available. Shared
Savings Program patients with multiple
chronic conditions and with high
predicted Medicare spending received
better quality care than comparable FFS
patients.51 Between the first and fourth
performance periods, Pioneer ACOs
improved their average quality score
from 71 percent to 92 percent. The
Shared Savings Program ACOs yielded
$465 million in savings to the Medicare
Trust Funds in 2014, not including
shared savings payments paid out to
50 https://www.cms.gov/Newsroom/
MediaReleaseDatabase/Fact-sheets/2015Factsheets-items/2015-08-25.html.
51 J.M. McWilliams et al., ‘‘Changes in Patients’
Experiences in Medicare Accountable Care
Organizations.’’ New England Journal of Medicine
2014; 371:1715–1724, DOI: 10.1056/
NEJMsa1406552.
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ACOs.52 The Shared Savings Program
ACOs generated total program savings
(inclusive of all savings and losses
relative to financial benchmarks, though
not including shared savings payments)
of $429 million for performance year
2015 (PY15).53 Of participating ACOs,
119 Shared Savings Program ACOs
earned shared savings by holding
spending far enough below their
financial benchmarks and meeting
quality standards. No Track 2 ACOs
owed CMS losses. The financial results
were that for (PY15), 83 ACOs had
expenditures lower than their
benchmark, but did not qualify for
shared savings, as they did not meet the
minimum savings rate (MSR), and an
increasing proportion of ACOs have
generated savings above their MSR each
year. For PY15, 31 percent of ACOs (120
of 392) generated savings above their
MSR compared to 28 percent (92 of 333)
in PY14 and 26 percent (58 of 220) in
PY13.54
For Pioneer ACOs, the financial and
quality results continue to be positive,
with several Pioneer ACOs generating
greater savings in the model
performance year 4 (PY4) (2015) and
one ACO generating savings for the first
time. While the cohort of Pioneer ACOs
decreased between PY3 (2014) and PY4,
they still generated total model savings
of over $37 million. It is important to
note that going into PY4, the
benchmarks for the Pioneer ACOs were
re-based, and the Model as a whole
introduced new financial benchmarking
methodologies. Re-basing refers to using
a newer set of baseline years to compute
financial benchmarks; the new
benchmarks are therefore based on
ACOs’ spending during their initial
years of participation in the Pioneer
ACO Model.55
Quality performance improved
considerably from PY3 to PY4 and
across all 4 years of the Pioneer ACO
Model. Overall quality scores for nine of
the 12 Pioneer ACOs were above 90
percent in PY4. All 12 Pioneers
improved their quality scores from PY1
(2012) to PY4 by over 21 percentage
points. The financial results were that
the 12 Pioneer ACOs participating in
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52 ???
53 CMS, ‘‘Medicare Accountable Care
Organizations 2015 Performance Year Quality and
Financial Results.’’ Available at https://
www.cms.gov/Newsroom/MediaReleaseDatabase/
Fact-sheets/2016-Fact-sheets-items/2016-0825.html.
54 CMS, Medicare Accountable Care
Organizations 2015 Performance Year Quality and
Financial Results, https://www.cms.gov/Newsroom/
MediaReleaseDatabase/Fact-sheets/2016-Factsheets-items/2016-08-25.html (last accessed April
14, 2016).
55 Id.
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PY4 were accountable for 461,442
beneficiaries, representing a nearly 24
percent increase in average aligned
beneficiaries per ACO (up to 38,454)
from PY3. PY4 was the first option year
in the Pioneer ACO Model, where
Pioneer ACOs were operating under a
new financial benchmarking
methodology. While the cohort of
Pioneer ACOs decreased by nearly a
third between PY3 and PY4 with several
Pioneer ACOs transitioning to either the
Shared Savings Program or the Next
Generation ACO model Pioneer ACOs
still generated total model savings
(inclusive of all Pioneer ACO savings
and losses relative to financial
benchmarks) of over $37 million. Of the
eight Pioneer ACOs that generated
savings, six generated savings outside a
minimum savings rate and earned
shared savings, and of the four Pioneer
ACOs that generated losses, one
generated losses outside a minimum
loss rate and owed shared losses.56
The results from the third program
year (January through December 2015)
of the original CPC Initiative indicate
that the from 2013 to 2015 CPC
practices transformed their care delivery
—with the biggest improvements in
risk-stratified care management,
expanded access to care, and continuity
of care. The CPC also improved patient
experience slightly. Over the first 3
years, ED visits increased by 2 percent
less for Medicare FFS beneficiaries in
CPC practices relative to those in
comparison practices.57 58
As the early findings from the original
CPC initiative and literature from other
medical home models supported by
payment suggest, we expect to see
improvement in quality and patient
experience of care.59 60 61 62 Under CPC+,
56 Id.
57 Peikes, D., Taylor, E., Dale, S., et al.
‘‘Evaluation of the Comprehensive Primary Care
Initiative: Second Annual Report.’’ Princeton, NJ:
Mathematica Policy Research, April 13, 2016,
available at https://innovation.cms.gov/files/
reports/cpci-evalrpt2.pdf.
58 For more detail see Peikes, D., Anglin, G.,
Taylor, E., et al. ‘‘Evaluation of the Comprehensive
Primary Care Initiative: Third Annual Report.’’
Princeton, NJ: Mathematica Policy Research,
December 2016, available at https://
innovation.cms.gov/Files/reports/cpci-evalrpt3.pdf.
59 Reid, R.J., Fishman, P.A., Yu, O., Ross, T.R.,
Tufano, J.T., Soman, M.P, & Larson, E.B. (2009).
Patient-centered medical home demonstration: A
prospective, quasi-experimental, before and after
evaluation. AJMC, 15(9), e71–e87.
60 Maeng, D.D., Graham, J., Graf, T.R., Liberman,
J.N., Dermes, N.B., Tomcavage, J., et al. (2012).
Reducing long-term cost by transforming primary
care: Evidence from Geisinger’s Medical Home
Model. AJMC, 18(3), 149–155.
61 Nelson, K.M., Helfrich, C., Sun, H., Hebert,
P.L., Liu, C.F., Dolan, E., et al. (2014).
Implementation of the patient-centered medical
home in the Veterans Health Administration:
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a higher proportion of the practice
revenue is de-linked from FFS payment
and there is thus more flexibility for
practices to deliver care without a faceto-face encounter and instead in the
modality that best meets patients’ health
care needs (that is, office visit, virtual
visit, phone call, etc.).63 We anticipate
that CPC+ will allow practices to get off
the ‘‘FFS Treadmill’’ 64 and achieve
incentive neutrality (the incentive to
bring a patient to the office is balanced
with the incentive to provide the
needed care outside of an office
visit).65 66
While maintaining coverage of
Original Medicare services and
beneficiary freedom to choose
providers, ACOs could potentially
enhance care management of the
chronically ill aligned population
through the adoption of leading-edge
technologies, care coordination
techniques, and evidence-based benefit
enhancements that motivate providers
and beneficiaries to optimize care. The
evidence discussed here focuses on the
Next Generation Model elements of
telehealth, home health care, and
reduced cost sharing.
The transition from the inpatient
setting to home is a critical period for
patients, particularly elderly
populations. Studies have examined a
variety of interventions to help smooth
care transitions. Interventions found in
the literature include advance practice
nurse-led comprehensive discharge
planning and home visit follow-up
protocols 67 68 69 and patient coaching
Associations with patient satisfaction, quality of
care, staff burnout, and hospital and emergency
department use. JAMA Intern Med, 174(8), 1350–
1358.
62 DeVries, A., Li, C.H.W., Sridhar, G., Hummel,
J.R., Breidbart, S., & Barron, J.J. (2012). Impact of
medical homes on quality, Healthcare utilization,
and costs. AJMC, 18(9), 534–544.
63 Mechanic, R.E., Santos, P., Landon, B.E., &
Chernew, M.E. (2011). Medical group responses to
global payment: early lessons from the ‘Alternative
Quality Contract’ in Massachusetts. Health Aff
(Millwood), 30(9), 1734–42.
64 Bitton, A., Schwartz, G.R., Stewart, E.E.,
Henderson, D.E., Keohane, C.A., Bates, D.W., &
Schiff, G.D. (2012). Off the hamster wheel?
Qualitative evaluation of a payment-linked patientcentered medical home (PCMH) pilot. Milbank Q,
90(3), 484–515.
65 Ash, A.S., & Ellis, R.P. (2012). Risk-adjusted
payment and performance assessment for primary
care. Med Care, 50(8), 643–53.
66 Vats, S., Ash, A.S., & Ellis, R.P. (2013). Bending
the cost curve? Results from a comprehensive
primary care payment pilot. Med Care, 51(11), 964–
9.
67 Naylor MD, Brooten D, Campbell R, et al.
Comprehensive Discharge Planning and Home
Follow-up of Hospitalized Elders: A Randomized
Clinical Trial. JAMA. 1999;281(7):613–620.
68 Naylor, M. D., Brooten, D. A., Campbell, R. L.,
Maislin, G., McCauley, K. M. and Schwartz, J. S.
(2004), Transitional Care of Older Adults
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accompanied by post-discharge home
visits.70 While the intensity and content
of these interventions vary, the use of a
post-discharge home visit shortly after
leaving the hospital appears to be
effective in engaging and monitoring
patients to decrease readmissions or
emergency room visits. MedPAC has
also noted that there may be a role for
home health services in models that
focus on chronic care needs and care
coordination.71 The Next Generation
ACO Model seeks to encourage ACOs to
engage in post-discharge home visits to
improve ACO patient outcomes by
allowing ACOs to perform and bill for
types of services not currently available
under Original Medicare.
The study of the potential value and
efficacy of telehealth and remote patient
monitoring has become more prevalent
in recent years as technology has
enabled greater utilization of these
services.72 Studies and case studies
from health systems have shown value
in using telehealth platforms for
activities such as e-visits 73 74 and
remote patient monitoring,75 as well as
for higher intensity care through realtime videoconferencing,76 particularly
to enable older adults to receive care
more rapidly from their homes and with
minimal burden. The Next Generation
Model seeks to allow ACOs flexibility in
utilizing telehealth services to improve
Hospitalized with Heart Failure: A Randomized,
Controlled Trial. Journal of the American Geriatrics
Society, 52: 675–684.
69 Stauffer BD, Fullerton C, Fleming N, et al.
Effectiveness and Cost of a Transitional Care
Program for Heart Failure: A Prospective Study
with Concurrent Controls. Arch Intern Med.
2011;171(14):1238–1243.
70 Voss R, Gardner R, Baier R, Butterfield K,
Lehrman S, Gravenstein S. The Care Transitions
Intervention: Translating From Efficacy to
Effectiveness. Arch Intern Med. 2011;171(14):1232–
1237.
71 Report to the Congress: Medicare and the
Health Care Delivery System. March 2013.
72 Joseph Kvedar, Molly Joel Coye and Wendy
Everett, Connected Health: A Review Of
Technologies and Strategies to Improve Patient Care
with Telemedicine and Telehealth, Health Affairs,
33, no.2 (2014):194–199.
73 Patrick T. Courneya, Kevin J. Palattao and Jason
M. Gallagher. HealthPartners’ Online Clinic For
Simple Conditions Delivers Savings Of $88 Per
Episode And High Patient Approval. Health Affairs,
32, no.2 (2013):385–392.
74 Mehrotra A, Paone S, Martich G, Albert SM,
Shevchik GJ. A Comparison of Care at E-visits and
Physician Office Visits for Sinusitis and Urinary
Tract Infection. JAMA Intern Med. 2013;173(1):72–
74.
75 UVA Health System, Tech Firm Collaborate to
Reduce Hospital Readmission Rates. VHQC News.
June 2014.
76 Shah MN, Gillespie SM, et al. High-Intensity
Telemedicine-Enhanced Acute Care for Older
Adults: An Innovative Healthcare Delivery Model.
Journal of the American Geriatrics Society. 2003;
61(11):2000–2007.
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access to the most appropriate care for
ACO beneficiaries.
1. Impact on Other Health Care
Programs and Providers
We estimate that the Quality Payment
Program Year 2 will not have a
significant economic effect on eligible
clinicians and groups and believe that
MIPS policies, along with increasing
participation in APMs over time may
succeed in improving quality and
reducing costs. This may in turn result
in beneficial effects on both patients and
some clinicians, and we intend to
continue focusing on clinician-driven,
patient-centered care.
We propose several policies for the
Quality Payment Program Year 2 to
reduce burden. These include raising
the low volume threshold so that fewer
clinicians in small practices are
required to participate in the MIPS
starting with the 2018 performance
period; including bonus points for
clinicians in small practices; adding a
new significant hardship exception for
the advancing care information
performance category for MIPS eligible
clinicians in small practices;
implementing virtual groups; allowing
MIPS eligible clinicians and groups to
submit measures and activities using as
many submission mechanisms as
necessary to meet the requirements of
the quality, improvement activities, or
advancing care information performance
categories; implementing a voluntary
facility-based scoring mechanism for the
2018 performance period that aligns
with the Hospital Value Based
Purchasing (VBP) Program, and
extending the ability of MIPS eligible
clinicians and groups to use 2014
Edition CEHRT while providing bonus
points for the use of the 2015 Edition of
CEHRT. Additionally, for vendors, we
believe the flexibility to use EHR
technology certified to either the 2014
Edition or the 2015 Edition for the
Quality Payment Program Year 2 is
beneficial as vendors will have
additional time to deploy the updated
software to their customers, which are
the clinicians and other providers.
Clinicians will likewise have additional
time to upgrade and implement the new
functionalities.
In summary, the Quality Payment
Program policies are designed to
promote the delivery of high-value care
for individuals in all practices and areas
with a particular focus on clinicians in
small and solo practices. We believe
each of these proposals will further
reduce burdens on clinicians and
practices and help increase successful
participation. Further, the policies
throughout this proposed rule will focus
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30243
the Quality Payment Program in its
second year on encouraging more
complete data submission and
educating clinicians. The proposed
policies will continue a glide path,
which began in the transition year, to
more robust participation and
performance in future years. The
proposed policy changes are reflected in
the RIA estimates, which show that the
risk for negative MIPS payment
adjustment is minimal for MIPS eligible
clinicians, including small and solo
practices that meet the proposed data
completeness requirements.
2. Alternatives Considered
This proposed rule contains a range of
policies, including many provisions
related to specific statutory provisions.
The preceding preamble provides
descriptions of the statutory provisions
that are addressed, identifies those
policies where discretion has been
exercised, presents our rationale for our
proposed policies and, where relevant,
analyzes alternatives that we
considered. Comment is sought in
section II.C.8.c. of this proposed rule on
policies closely related to this
Regulatory Impact Analysis, including
the performance threshold. We view the
performance threshold as one of the
most important factors affecting the
distribution of payment adjustments
under the Program, and the alternatives
that we considered focus on that policy.
For example, we discuss above that
we modeled the effects of the proposed
rule’s policies using a 15-point
performance threshold and a 70-point
additional performance threshold.
Additionally, we assumed a minimum
90 percent participation rate in each
category of eligible clinicians. We
displayed the results of that modeling in
Table 86 along with subsequent tables.
We tested two additional models
using a performance threshold of 6
points and a performance threshold of
33 points. In both of these cases, we
again modeled a 70-point additional
performance threshold and a minimum
90 percent participation rate in each
category of eligible clinicians in order to
focus the results on the differing
performance thresholds.
Under the 6-point performance
threshold alternative, we estimated that
we would make approximately $663.5
million in positive payment adjustments
(including $500 million in exceptional
performance payments), and conversely,
would make approximately $163.5
million in negative payment
adjustments. These results represent a
roughly $10 million reduction in the
aggregate positive adjustments and a
roughly $10 million reduction in
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aggregate negative payment adjustments
compared to the results displayed above
in Table 86. Under the 6-point
performance threshold, we also
estimated that slightly fewer eligible
clinicians would receive negative
payment adjustments than in the 15point model described further above—
approximately 3.1 percent in this
alternative compared to approximately
3.9 percent in the 15-point model.
Under the 33-point performance
threshold alternative, we estimated that
we would make approximately $743.7
million in positive payment adjustments
(including $500 million in exceptional
performance payments), and conversely,
would make approximately $243.7
million in negative payment
adjustments. These results represent a
roughly $70 million increase in
aggregate positive payment adjustments
and a roughly $70 million increase in
aggregate negative payment adjustments
compared to the results displayed above
in Table 86. Additionally, under the 33point performance threshold alternative,
we estimated that approximately 9.1
percent of eligible clinicians would
receive a negative payment adjustment,
compared to the approximately 3.9
percent that we estimated in the 15point model.
3. Assumptions and Limitations
We would like to note several
limitations to the analyses that
estimated MIPS eligible clinicians’
eligibility, negative MIPS payment
adjustments, and positive payment
adjustments for the 2020 MIPS payment
year based on the data prepared to
support the 2017 performance period
initial determination of clinician and
special status eligibility (available via
the NPI lookup on qpp.cms.gov), the
preliminary version of the file used for
the predictive qualifying APM
participants analysis made available on
qpp.cms.gov on June 2, 2017 and
prepared using claims for services
between January 1, 2016 through August
31, 2016 and 2014 and 2015 data from
legacy programs, including the PQRS,
CAHPS for PQRS, and the VM.
The scoring model cannot fully reflect
MIPS eligible clinicians’ behavioral
responses to MIPS. The scoring model
assumes higher participation in MIPS
quality reporting than under the PQRS.
Other potential behavioral responses are
not addressed in our scoring model. The
scoring model assumes that quality
measures submitted and the distribution
of scores on those measures would be
similar under Quality Payment Program
Payment in the 2020 MIPS payment
year as they were under the 2015 PQRS
program.
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The scoring model does not reflect the
growth in Advanced APM participation
between 2017 and 2018. After applying
the other MIPS exclusions, the scoring
model excluded approximately 74,920
QPs using preliminary QP data for
Quality Payment Program Year 2017,
significantly lower than CMS’ summary
level projected QP counts for Quality
Payment Program Year 2018 (180,000–
245,000). The methods for the summary
level estimates reflect the several new
APMs that we anticipate will be
Advanced APMs in CY 2018, and that
some eligible clinicians will join the
successors of APMs already active in
early 2017.
There are additional limitations to our
estimates. To the extent that there are
year-to-year changes in the data
submission, volume and mix of services
provided by MIPS eligible clinicians,
the actual impact on total Medicare
revenues will be different from those
shown in Tables 86 through 90. Due the
limitations above, there is considerable
uncertainty around our estimates that is
difficult to quantify in detail.
E. Regulatory Review Costs
If regulations impose administrative
costs on private entities, such as the
time needed to read and interpret this
proposed rule, we should estimate the
cost associated with regulatory review.
Due to the uncertainty involved with
accurately quantifying the number of
entities that will review this proposed
rule, we assume that the total number of
commenters on last year’s proposed rule
will be the number of reviewers of this
proposed rule. We acknowledge that
this assumption may understate or
overstate the costs of reviewing this
rule. It is possible that not all
commenters reviewed last year’s rule in
detail, and it is also possible that some
reviewers chose not to comment on the
proposed rule. For these reasons, we
believe that the number of past
commenters would be a fair estimate of
the number of reviewers of this
proposed rule. We welcome any public
comments on the approach in
estimating the number of entities that
will review this proposed rule.
We also recognize that different types
of entities are in many cases affected by
mutually exclusive sections of this
proposed rule. Therefore, for the
purposes of our estimate, we assume
that each reviewer reads approximately
50 percent of the proposed rule. We are
seeking public comments on this
assumption.
Using the wage information from the
BLS for medical and health service
managers (Code 11–9111), we estimate
that the cost of reviewing this proposed
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rule is $105.16 per hour, including
overhead and fringe benefits, which we
assume are 100 percent of the hourly
wage (https://www.bls.gov/oes/2016/
may/naics4_621100.htm). Assuming an
average reading speed, we estimate that
it would take approximately 11.5 hours
for the staff to review half of this
proposed rule. For each commenter that
reviews this proposed rule, the
estimated cost is $1209.34 (11.5 hours ×
$105.16). Therefore, we estimate that
the total cost of reviewing this proposed
rule is $4,873,360 ($1209.34 × 4,000
reviewers). We estimate that the
incremental costs of reviewing this
proposed rule are the same as the CY
2017 Quality Payment Program final
rule.
F. Accounting Statement
As required by OMB Circular A–4
(available at https://
www.whitehouse.gov/omb/circulars/
a004/a-4.pdf), in Table 90 (Accounting
Statement), we have prepared an
accounting statement.
We have not attempted to quantify the
benefits of this proposed rule because of
the many uncertainties as to both
clinician behaviors and resulting effects
on patient health and cost reductions.
For example, the applicable percentage
for MIPS payment adjustments changes
over time, increasing from 4 percent in
2019 to 9 percent in 2022 and
subsequent years, and we are unable to
estimate precisely how physicians will
respond to the increasing payment
adjustments. As noted above, in CY
2020, we estimate that we will
distribute approximately $173 million
in payment adjustments on a budgetneutral basis, which represents the
applicable percent for 2020 required
under section 1848(q)(6)(B)(i) of the Act
and excludes $500 million in additional
MIPS payment adjustments for
exceptional performance.
Further, the addition of new
Advanced APMs and growth in
Advanced APM participation over time
will affect the pool of MIPS eligible
clinicians, and for those that are MIPS
eligible clinicians, may change their
relative performance. The $500 million
available for exceptional performance
and the 5 percent APM Incentive
Payment for QPs are only available from
2019 through 2024. Beginning in 2026,
Medicare PFS payment rates for services
furnished by QPs will receive a higher
update than for services furnished by
non-QPs. However, we are unable to
estimate the number of QPs in those
years, as we cannot project the number
or types of Advanced APMs that will be
made available in those years through
future CMS initiatives proposed and
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implemented in those years, nor the
number of QPs for those future
Advanced APMs.
The percentage of the final score
attributable to each performance
category will change over time and we
will continue to refine our scoring rules.
The improvement activities category
represents a new category for measuring
MIPS eligible clinicians’ performance.
We may also propose policy changes in
future years as we continue
implementing MIPS and as MIPS
eligible clinicians accumulate
experience with the new system.
Moreover, there are interactions
between the MIPS and APM incentive
programs and other shared savings and
incentive programs that we cannot
model or project. Nonetheless, even if
ultimate savings and health benefits
represent only low fractions of current
experience, benefits are likely to be
substantial in overall magnitude.
30245
Table 90 includes our estimate for
MIPS payment adjustments ($173
million), the exceptional performance
payment adjustments under MIPS ($500
million), and incentive payments to QPs
(using the range described in the
preceding analysis, approximately
$590–$800 million). However, of these
three elements, only the negative MIPS
payment adjustments are shown as
estimated decreases.
TABLE 90—ACCOUNTING STATEMENT: TRANSFERS
Category
Transfers
CY 2020 Annualized Monetized Transfers ..............................................
Estimated increase of between $1,263 and $1,473 million in payments
for higher performance under MIPS and to QPs.77
Increased Federal Government payments to physicians, other practitioners and suppliers who receive payment under the Medicare Physician Fee Schedule.
Estimated decrease of $173 million for lower performance under MIPS.
Reduced Federal Government payments to physicians, other practitioners and suppliers who receive payment under the Medicare Physician Fee Schedule.
From Whom to Whom? ............................................................................
CY 2020 Annualized Monetized Transfers ..............................................
From Whom to Whom? ............................................................................
Note: These estimates are identical under both a 7 percent and 3 percent discount rate.
Based on National Health Expenditure
data,78 total Medicare expenditures for
physician and clinical services in 2015
reached $144.3 billion. Expenditures for
physician and clinical services from all
sources reached $634.9 billion. Table 90
shows that the aggregate negative MIPS
payment adjustment for all MIPS
eligible clinicians under MIPS is
estimated at $173 million, which
represents less than 0.2 percent of
Medicare payments for physician and
clinical services and less than 0.1
percent of payments for physician and
clinician services from all sources.
Table 90 also shows that the aggregate
positive payment adjustment for MIPS
eligible clinicians under MIPS is
estimated at $673 million (including
additional MIPS payment adjustments
for exceptional performance), which
represents less than 1 percent of
Medicare expenditures for physician
and clinician services and 0.2 percent of
Medicare expenditures from all sources
for physician and clinical services.
Table 91 summarizes the regulatory
review costs discussed in section V.E. of
this proposed rule, and the collection of
information burden costs calculated in
section III.N. of this proposed rule.
As noted above, we estimate the
regulatory review costs of $4.8 million
for this proposed rule. In Table 91, we
have prepared our analysis of collection
of information burden costs to be
consistent with guidance in accordance
with OMB’s April 2017 guidance on
EO13771. The Order’s guidance directs
agencies to measure certain costs,
including costs associated with
‘‘Medicare quality performance
tracking’’, using the estimates in the CY
2017 Quality Payment Program final
rule as a baseline. The Order notes that
regular updates to certain Medicare
regulations make assessments of the
incremental changes related to
‘‘performance tracking’’ included in a
proposed regulation much more useful
than a comparison against hypotheticals
(such as a program’s hypothetical
discontinuation).
As shown in section III.N. of this
proposed rule, we estimate that this
proposed rule will result in
approximately $857 million in
collection of information-related
burden. However, we estimate that the
incremental collection of informationrelated burden associated with this
proposed rule is an approximately $12.4
million reduction relative to the
baseline burden of continuing the
policies and information collections set
forth in the CY 2017 Quality Program
final rule into CY 2018. Our burden
estimates reflect several proposed that
would reduce burden, including the
proposed reduction in the length of the
CAHPS survey; our proposal to allow
certain hospital-based clinicians to elect
use facility-based measurements,
thereby eliminating the need for
additional quality data submission
processes; and our proposal to allow
MIPS eligible clinicians to form virtual
groups, which would create efficiencies
in data submission; and our proposal for
significant hardship or other type of
exception, including a new significant
hardship exception for small practices
for the advancing care information
performance category.
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TABLE 91—ADDITIONAL COSTS AND BENEFITS
Category of cost or benefits
Costs/benefits
Regulatory Review Costs .........................................................................
Incremental Collection of Information/Paperwork Reduction Act Burden
Estimates.
77 A range of estimates is provided due to
uncertainty about the number of Advanced APM
participants that will meet the QP threshold in
2016.
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$4.8 million.
¥$12.4 million.
78 Physicians and Clinical Services Expenditures,
https://www.cms.gov/Research-Statistics-Data-andSystems/Statistics-Trends-and-Reports/
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TABLE 91—ADDITIONAL COSTS AND BENEFITS—Continued
Category of cost or benefits
Costs/benefits
Benefits of Expanded Advanced and MIPS APM Participation ...............
Improvements in quality, patient experience of care, readmission rates,
access to appropriate care, and total cost of care.
Improvements in quality, patient experience of care, and readmission
rates.
Benefits of MIPS .......................................................................................
Note: These estimates are identical under both a 7 percent and 3 percent discount rate. Incremental information collection costs are total information collection costs associated with this proposed rule minus costs associated with CY 2017 Quality Payment Program final rule.
Table 91 also shows the expected
benefits associated with this proposed
rule. We note that these expected
benefits are qualitative in nature. We
expect that the Quality Payment
Program will result in quality
improvements and improvements to the
patients’ experience of care as MIPS
eligible clinicians respond to the
incentives for high-quality care
provided by the Program and implement
care quality improvements in their
clinical practices. While we cannot
quantify these effects specifically at this
time because we cannot project eligible
clinicians’ behavioral responses to the
incentives offered under the Quality
Payment Program, we nevertheless
believe that changes to clinical care will
result in care quality improvements for
Medicare beneficiaries and other
patients treated by eligible clinicians.
List of Subjects
42 CFR Part 414
Administrative practice and
procedure, Biologics, Drugs, Health
facilities, Health professions, Diseases,
Medicare, Reporting and recordkeeping
requirements.
For the reasons set forth in the
preamble, the Centers for Medicare &
Medicaid Services proposes to amend
42 CFR chapter IV as set forth below:
PART 414—PAYMENT FOR PART B
MEDICAL AND OTHER HEALTH
SERVICES
1. The authority citation for part 414
continues to read as follows:
■
Authority: Secs. 1102, 1871, and 1881(b)(l)
of the Social Security Act (42 U.S.C. 1302,
1395hh, and 1395rr(b)(l)).
2. Section 414.1305 is amended by—
a. Removing the definition of
‘‘Advanced APM Entity’’;
■ b. Revising the definition of
‘‘Affiliated practitioner’’;
■ c. Adding the definitions of ‘‘AllPayer QP Performance Period’’ and
‘‘Ambulatory Surgical Center (ASC)based MIPS eligible clinician’’;
■ d. Revising the definitions of ‘‘APM
Entity’’ and ‘‘Attributed beneficiary’’;
■ e. Amending the definition ‘‘Certified
Electronic Health Record Technology
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■
■
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(CEHRT)’’ by revising paragraphs (1)
introductory text, (1)(iii), and (2)
introductory text;
■ f. Adding the definition of ‘‘CMS
Multi-Payer Model’’;
■ g. Revising the definition of ‘‘Final
Score’’;
■ h. Adding the definitions of ‘‘Full TIN
APM’’;
■ i. Revising the definition of ‘‘Hospitalbased MIPS eligible clinician’’;
■ j. Adding the definitions of
‘‘Improvement scoring’’;
■ k. Revising the definitions of ‘‘Lowvolume threshold’’, and ‘‘Medicaid
APM’’;
■ l. Adding the definitions of ‘‘Medicare
QP Performance Period’’;
■ m. Revising the definition of ‘‘Nonpatient facing MIPS eligible clinician’’;
■ n. Adding the definition or ‘‘Other
MIPS APM’’;
■ o. Revising the definition of ‘‘Other
Payer Advanced APM’’;
■ p. Removing the definition of ‘‘QP
Performance Period’’;
■ q. Revising the definition of ‘‘Rural
areas’’; and
■ r. Adding the definitions of ‘‘Virtual
group’’.
The revisions and additions read as
follows:
§ 414.1305
Definitions.
*
*
*
*
*
Affiliated practitioner means an
eligible clinician identified by a unique
APM participant identifier on a CMSmaintained list who has a contractual
relationship with the APM Entity for the
purposes of supporting the APM
Entity’s quality or cost goals under the
Advanced APM.
All-Payer QP Performance Period
means the time period that CMS will
use to assess the level of participation
by an eligible clinician in Advanced
APMs and Other Payer Advanced APMs
under the All-Payer Combination
Option for purposes of making a QP
determination for the year as specified
in § 414.1440. The All-Payer QP
Performance Period begins on January 1
and ends on June 30 of the calendar year
that is 2 years prior to the payment year.
*
*
*
*
*
Ambulatory Surgical Center (ASC)based MIPS eligible clinician means a
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MIPS eligible clinician who furnishes
75 percent or more of his or her covered
professional services in sites of service
identified by the Place of Service (POS)
codes used in the HIPAA standard
transaction as an ambulatory surgical
center setting based on claims for a
period prior to the performance period
as specified by CMS.
*
*
*
*
*
APM Entity means an entity that
participates in an APM or other payer
arrangement through a direct agreement
with CMS or the payer or through
Federal or State law or regulation.
*
*
*
*
*
Attributed beneficiary means a
beneficiary attributed to the APM Entity
under the terms of the Advanced APM
as indicated on the most recent
available list of attributed beneficiaries
at the time of a QP determination.
*
*
*
*
*
Certified Electronic Health Record
Technology (CEHRT) * * *
(1) For any calendar year before 2019,
EHR technology (which could include
multiple technologies) certified under
the ONC Health IT Certification Program
that meets one of the following:
*
*
*
*
*
(iii) The definition for 2019 and
subsequent years specified in paragraph
(2) of this definition.
(2) For 2019 and subsequent years,
EHR technology (which could include
multiple technologies) certified under
the ONC Health IT Certification Program
that meets the 2015 Edition Base EHR
definition (as defined at 45 CFR
170.102) and has been certified to the
2015 Edition health IT certification
criteria—
*
*
*
*
*
CMS Multi-Payer Model means an
Advanced APM that CMS determines,
per the terms of the Advanced APM, has
at least one other payer arrangement
that is designed to align with the terms
of that Advanced APM.
*
*
*
*
*
Final score means a composite
assessment (using a scoring scale of 0 to
100) for each MIPS eligible clinician for
a performance period determined using
the methodology for assessing the total
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performance of a MIPS eligible clinician
according to performance standards for
applicable measures and activities for
each performance category.
*
*
*
*
*
Full TIN APM means an APM where
participation is determined at the TIN
level, and all eligible clinicians who
have assigned their billing rights to a
participating TIN are therefore
participating in the APM.
*
*
*
*
*
Hospital-based MIPS eligible clinician
means a MIPS eligible clinician who
furnishes 75 percent or more of his or
her covered professional services in
sites of service identified by the place of
service codes used in the HIPAA
standard transaction as an inpatient
hospital, on-campus outpatient hospital,
off campus-outpatient hospital, or
emergency room setting based on claims
for a period prior to the performance
period as specified by CMS.
*
*
*
*
*
Improvement scoring means an
assessment measuring improvement for
each MIPS eligible clinician or group for
a performance period using a
methodology that compares
improvement from one performance
period to another performance period.
*
*
*
*
*
Low-volume threshold means an
individual MIPS eligible clinician or
group who, during the low-volume
threshold determination period, has
Medicare Part B allowed charges less
than or equal to $90,000 or provides
care for 200 or fewer Part B-enrolled
Medicare beneficiaries.
*
*
*
*
*
Medicaid APM means a payment
arrangement authorized by a State
Medicaid program that meets the Other
Payer Advanced APM criteria set forth
in § 414.1420.
*
*
*
*
*
Medicare QP Performance Period
means the time period that CMS will
use to assess the level of participation
by an eligible clinician in Advanced
APMs under the Medicare Option for
purposes of making a QP determination
for the year as specified in § 414.1425.
The Medicare QP Performance Period
begins on January 1 and ends on August
31 of the calendar year that is 2 years
prior to the payment year.
*
*
*
*
*
Non-patient facing MIPS eligible
clinician means an individual MIPS
eligible clinician who bills 100 or fewer
patient-facing encounters (including
Medicare telehealth services defined in
section 1834(m) of the Act) during the
non-patient facing determination
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period, and a group or virtual group
provided that more than 75 percent of
the NPIs billing under the group’s TIN
or within a virtual group, as applicable,
meet the definition of a non-patient
facing individual MIPS eligible clinician
during the non-patient facing
determination period.
*
*
*
*
*
Other MIPS APM means a MIPS APM
that does not require reporting through
the CMS Web Interface.
Other Payer Advanced APM means an
other payer arrangement that meets the
Other Payer Advanced APM criteria set
forth in § 414.1420.
*
*
*
*
*
Rural areas means ZIP codes
designated as rural, using the most
recent Health Resources and Services
Administration (HRSA) Area Health
Resource File data set available.
*
*
*
*
*
Virtual group means a combination of
two or more TINs composed of a solo
practitioner (a MIPS eligible clinician
(as defined at § 414.1305) who bills
under a TIN with no other NPIs billing
under such TIN) or a group (as defined
at § 414.1305) with 10 or fewer eligible
clinicians under the TIN that elects to
form a virtual group with at least one
other such solo practitioner or group for
a performance period of a year.
■ 3. Section 414.1315 is added to read
as follows:
§ 414.1315
Virtual Groups.
(a) Eligibility. A solo practitioner or a
group of 10 or fewer eligible clinicians
must make their election prior to the
start of the applicable performance
period and cannot change their election
during the performance period. Virtual
group participants may elect to be in no
more than one virtual group for a
performance period and, in the case of
a group, the election applies to all MIPS
eligible clinicians in the group.
(b) Election Deadline. A virtual group
representative must make an election,
on behalf of the members of a virtual
group, regarding the formation of a
virtual group for an applicable
performance period, by December 1 of
the calendar year preceding the
applicable performance year.
(c) Election Process. The two-stage
virtual group election process for the
2018 and 2019 performance years is as
follows:
(1) Stage 1: Virtual group eligibility
determination.
(i) Solo practitioners and groups with
10 or fewer eligible clinicians interested
in forming or joining a virtual group
have the option to contact their
designated technical assistance
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30247
representative or the Quality Payment
Program Service Center, as applicable,
in order to obtain information
pertaining to virtual groups and/or
determine whether or not they are
eligible, as it relates to the practice size
requirement of a solo practitioner or a
group of 10 or fewer eligible clinicians,
to participate in MIPS as a virtual group.
(ii) [Reserved]
(2) Stage 2: Virtual group formation.
(i) TINs comprising a virtual group
must establish a written formal
agreement between each member of a
virtual group prior to an election.
(ii) On behalf of a virtual group, the
official designated virtual group
representative must submit an election
by December 1 of the calendar year prior
to the start of the applicable
performance period.
(iii) The submission of a virtual group
election must include, at a minimum,
information pertaining to each TIN and
NPI associated with the virtual group
and contact information for the virtual
group representative.
(iv) Once an election is made, the
virtual group representative must
contact their designated CMS contact to
update any election information that
changed during a performance period
one time prior to the start of an
applicable submission period.
(3) Agreement. Virtual groups must
execute a written formal and contractual
agreement between each member of a
virtual group that includes the following
elements:
(i) Expressly state the only parties to
the agreement are the TINs and NPIs of
the virtual group.
(ii) Be executed on behalf of the TINs
and the NPIs by individuals who are
authorized to bind the TINs and the
NPIs, respectively.
(iii) Expressly require each member of
the virtual group (including each NPI
under each TIN) to agree to participate
in the MIPS as a virtual group and
comply with the requirements of the
MIPS and all other applicable laws and
regulations (including, but not limited
to, federal criminal law, False Claims
Act, anti-kickback statute, civil
monetary penalties law, Health
Insurance Portability and
Accountability Act, and physician selfreferral law).
(iv) Require each TIN within a virtual
group to notify all NPIs associated with
the TIN regarding their participation in
the MIPS as a virtual group.
(v) Set forth the NPI’s rights and
obligations in, and representation by,
the virtual group, including without
limitation, the reporting requirements
and how participation in the MIPS as a
virtual group affects the ability of the
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NPI to participate in the MIPS outside
of the virtual group.
(vi) Describe how the opportunity to
receive payment adjustments will
encourage each member of the virtual
group (including each NPI under each
TIN) to adhere to quality assurance and
improvement.
(vii) Require each member of the
virtual group to update its Medicare
enrollment information, including the
addition and deletion of NPIs billing
through a TIN that is part of a virtual
group, on a timely basis in accordance
with Medicare program requirements
and to notify the virtual group of any
such changes within 30 days after the
change.
(viii) Be for a term of at least one
performance period as specified in the
formal written agreement.
(ix) Require completion of a close-out
process upon termination or expiration
of the agreement that requires the TIN
(group part of the virtual group) or NPI
(solo practitioner part of the virtual
group) to furnish all data necessary in
order for the virtual group to aggregate
its data across the virtual group.
(d) Virtual Group Reporting
Requirements: For TINs participating in
MIPS at the virtual group level—
(1) Individual eligible clinicians and
individual MIPS eligible clinicians who
are part of a TIN participating in MIPS
at the virtual group level would have
their performance assessed as a virtual
group.
(2) Individual eligible clinicians and
individual MIPS eligible clinicians who
are part of a TIN participating in MIPS
at the virtual group level would need to
meet the definition of a virtual group at
all times during the performance period
for the MIPS payment year.
(3) Individual eligible clinicians and
individual MIPS eligible clinicians who
are part of a TIN participating in MIPS
at the virtual group level must aggregate
their performance data across multiple
TINs in order for their performance to
be assessed as a virtual group.
(4) MIPS eligible clinicians that elect
to participate in MIPS at the virtual
group level would have their
performance assessed at the virtual
group level across all four MIPS
performance categories.
(5) Virtual groups would need to
adhere to an election process
established and required by CMS.
■ 4. Section 414.1320 is amended by
adding paragraphs (c) and (d) to read as
follows:
§ 414.1320
MIPS performance period.
*
*
*
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(c) For purposes of the 2021 MIPS
payment year and future years, the
performance period for:
(1) The quality and cost performance
categories is the full calendar year
(January 1 through December 31) that
occurs 2 years prior to the applicable
MIPS payment year.
(2) [Reserved]
(d) For purposes of the 2021 MIPS
payment year, the performance period
for:
(1) The advancing care information
and improvement activities performance
categories is a minimum of a continuous
90-day period within CY 2019, up to
and including the full CY 2019 (January
1, 2019 through December 31, 2019).
(2) [Reserved]
■ 5. Section 414.1325 is amended by
revising paragraphs (c)(6) and (d) to read
as follows:
§ 414.1325
Data submission requirements.
*
*
*
*
*
(c) * * *
(6) A CMS-approved survey vendor
for groups that elect to include the
CAHPS for MIPS survey as a quality
measure. Groups that elect to include
the CAHPS for MIPS survey as a quality
measure must select from the above data
submission mechanisms to submit their
other quality information.
(d) Report measures and activities, as
applicable, via as many submission
mechanisms as necessary to meet the
requirements of the quality,
improvement activities, or advancing
care information performance
categories. MIPS eligible clinicians and
groups may elect to submit measures
and activities, as available and
applicable via multiple mechanisms;
however, they must use the same
identifier for all performance categories.
*
*
*
*
*
■ 6. Section 414.1330 is amended by
revising paragraph (b)(2) to read as
follows:
§ 414.1330
Quality performance category.
*
*
*
*
*
(b) * * *
(2) 60 percent of a MIPS eligible
clinician’s final score for MIPS payment
year 2020.
*
*
*
*
*
■ 7. Section 414.1335 is amended by
revising paragraph (a)(2)(i) to read as
follows:
§ 414.1335 Data submission criteria for the
quality performance category.
(a) * * *
(2) * * *
(i) Criteria applicable to groups of 25
or more eligible clinicians, report on all
measures included in the CMS Web
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Interface. The group must report on the
first 248 consecutively ranked
beneficiaries in the sample for each
measure or module.
*
*
*
*
*
■ 8. Section 414.1340 is amended by
revising paragraphs (a)(2) and (b)(2) and
adding paragraphs (a)(3) and (b)(3) to
read as follows:
§ 414.1340 Data completeness criteria for
the quality performance category.
(a) * * *
(2) At least 50 percent of the MIPS
eligible clinician or group’s patients that
meet the measure’s denominator
criteria, regardless of payer for the MIPS
payment year 2020.
(3) At least 60 percent of the MIPS
eligible clinician or group’s patients that
meet the measure’s denominator
criteria, regardless of payer for MIPS
payment year 2021.
(b) * * *
(2) At least 50 percent of the
applicable Medicare Part B patients seen
during the performance period to which
the measure applies for MIPS payment
year 2020.
(3) At least 60 percent of the
applicable Medicare Part B patients seen
during the performance period to which
the measure applies for MIPS payment
year 2021.
*
*
*
*
*
■ 9. Section 414.1350 is amended by
revising paragraph (b)(2) to read as
follows:
§ 414.1350
Cost performance category.
*
*
*
*
*
(b) * * *
(2) 0 percent of a MIPS eligible
clinicians’ final score for MIPS payment
year 2020.
*
*
*
*
*
■ 10. Section 414.1360 is amended by
revising paragraph (a) introductory text
to read as follows:
§ 414.1360 Data submission criteria for the
improvement activities performance
category.
(a) For purposes of the transition year
of MIPS and future years MIPS eligible
clinicians must submit data on MIPS
improvement activities in one of the
following manners:
*
*
*
*
*
■ 11. Section 414.1370 is amended by—
■ a. Revising paragraphs (b)(4)(i); (e)
and (f);
■ b. Adding paragraphs (g)(1)(i)(A)
through (D), and (g)(1)(ii);
■ c. Revising paragraphs (g)(2), (g)(3)(i),
(g)(4)(i) and (ii) introductory text, (h)
introductory text, (h)(1), (h)(3), (h)(4);
and
■ d. Adding paragraph (h)(5).
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The revisions and additions read as
follows:
§ 414.1370
MIPS.
APM scoring standard under
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*
*
*
*
*
(b) * * *
(4) * * *
(i) New APMs. An APM for which the
first performance year begins after the
first day of the APM scoring standard
performance period for the year.
*
*
*
*
*
(e) APM Entity group determination.
Except as provided in paragraph (e)(1)
of this section, the APM Entity group is
determined in the manner prescribed in
§ 414.1425(b)(1).
(1) Full TIN APM. The APM Entity
group includes an eligible clinician who
is on a Participation List in a Full TIN
APM on December 31 of the APM
scoring standard performance period.
(2) [Reserved]
(f) APM Entity group scoring under
the APM scoring standard. The MIPS
final score calculated for the APM
Entity is applied to each MIPS eligible
clinician in the APM Entity group. The
MIPS payment adjustment is applied at
the TIN/NPI level for each of the MIPS
eligible clinicians in the APM Entity
group.
(1) If a Shared Savings Program ACO
does not report data on quality measures
as required by the Shared Savings
Program under § 425.508 of this chapter,
each ACO participant TIN will be
treated as a unique APM Entity for
purposes of the APM scoring standard.
(2) Virtual groups. MIPS eligible
clinicians who have elected to
participate in a virtual group and who
are also on a MIPS APM Participation
List will be included in the assessment
under MIPS for purposes of producing
a virtual group score and under the
APM scoring standard for purposes of
producing an APM Entity score. The
MIPS payment adjustment for these
eligible clinicians is based solely on
their APM Entity score.
(g) * * *
(1) * * *
(i) * * *
(A) Quality Performance Category
Score. The MIPS Quality Performance
category score for an APM scoring
standard performance period is
calculated for the APM Entity using the
data submitted by the APM Entity
through the CMS Web Interface
according to the terms of the MIPS
APM, including data on measures
submitted through the CMS Web
Interface and other measures specified
by CMS for the APM scoring standard.
(B) Quality Improvement Score.
Beginning in 2018, for an APM Entity
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for which we calculated a Total Quality
Performance category score for the
previous APM scoring standard
performance period, CMS calculates a
Quality Improvement Score for the APM
Entity group as specified in
§ 414.1380(b)(1)(xvi).
(C) Total Quality Performance
Category Score. Beginning in 2018, the
Total Quality Performance category
score is the sum of the Quality
Performance Category Score and the
Quality Improvement Score.
(D) If a Shared Savings Program ACO
does not report on quality measures on
behalf of its participating eligible
clinicians as required by the Shared
Savings Program under § 425.508 of this
chapter, the ACO participant TINs may
report data for the MIPS quality
performance category according to the
MIPS submission and reporting
requirements.
(ii) Other MIPS APMs.
(A) Quality Performance Category
Score. The MIPS Quality Performance
category score for an APM scoring
standard performance period is
calculated for the APM Entity using the
data submitted by the APM Entity based
on measures that we specify through
notice and comment rulemaking for
each MIPS APM from among those used
under the terms of the MIPS APM, and
that are:
(1) Tied to payment;
(2) Available for scoring;
(3) Have a minimum of 20 cases
available for reporting; and
(4) Have an available benchmark.
(B) Quality Improvement Score.
Beginning in 2019, for an APM Entity
for which we calculated a Total Quality
Performance category score for the
previous APM scoring standard
performance period, CMS calculates a
Quality Improvement Score for the APM
Entity group, as specified in
§ 414.1380(b)(1)(xvi).
(C) Total Quality Performance
Category Score. Beginning in 2018, the
Total Quality Performance category
score is the sum of the Quality
Performance category score and the
Quality Improvement Score.
(2) Cost. The cost performance
category weight is zero percent for APM
Entities in MIPS APMs.
(3) * * *
(i) CMS assigns an improvement
activities score for each MIPS APM for
an APM scoring standard performance
period based on the requirements of the
MIPS APM. The assigned improvement
activities score applies to each APM
Entity group for the APM scoring
standard performance period. In the
event that the assigned score does not
represent the maximum improvement
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activities score, an APM Entity may
report additional activities.
*
*
*
*
*
(4) * * *
(i) Each Shared Savings Program ACO
participant TIN must report data on the
Advancing Care Information (ACI)
Performance category separately from
the ACO, as specified in
§ 414.1375(b)(2). The ACO participant
TIN scores are weighted according to
the number of MIPS eligible clinicians
in each TIN as a proportion of the total
number of MIPS eligible clinicians in
the APM Entity group, and then
aggregated to determine an APM Entity
score for the ACI Performance category.
(ii) For APM Entities in MIPS APMs
other than the Shared Savings Program,
CMS uses one score for each MIPS
eligible clinician in the APM Entity
group to derive a single average APM
Entity score for the ACI Performance
category. The score for each MIPS
eligible clinician is the higher of either:
*
*
*
*
*
(h) APM scoring standard
performance category weights. The
performance category weights used to
calculate the MIPS final score for an
APM Entity group for the APM scoring
standard performance period are:
(1) Quality.
(i) For MIPS APMs that require use of
the CMS Web Interface: 50 percent.
(ii) For Other MIPS APMs, 0 percent
for 2017, 50 percent beginning in 2018.
*
*
*
*
*
(3) Improvement activities.
(i) For MIPS APMs that require use of
the CMS Web Interface: 20 percent.
(ii) For Other MIPS APMs, 25 percent
for 2017, 20 percent beginning in 2018.
(4) Advancing care information.
(i) For MIPS APMs that require use of
the CMS Web Interface: 30 percent.
(ii) For Other MIPS APMs, 25 percent
for 2017, 30 percent beginning in 2018.
(5) Reweighting the MIPS Performance
categories for the APM scoring standard.
If CMS determines there are not
sufficient measures or activities
applicable and available to MIPS
eligible clinicians, CMS will assign
weights as follows:
(i) If CMS reweights the Quality
Performance category to 0 percent, the
Improvement Activities Performance
category is reweighted to 25 percent and
the Advancing Care Information
Performance category is reweighted to
75 percent.
(ii) If CMS reweights the Advancing
Care Information Performance category
to 0 percent, the Quality Performance
category is reweighted to 80 percent.
■ 12. Section 414.1375 is amended by
revising paragraphs (a) and (b)(2)(ii) to
read as follows:
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§ 414.1375 Advancing care information
performance category.
*
*
*
*
*
(a) Final score. The advancing care
information performance category
comprises 25 percent of a MIPS eligible
clinician’s final score for the 2019 MIPS
payment year and each MIPS payment
year thereafter, unless a different
scoring weight is assigned by CMS.
(b) * * *
(2) * * *
(ii) May claim an exclusion for each
measure that includes an option for an
exclusion.
*
*
*
*
*
■ 13. Section 414.1380 is revised to read
as follows:
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§ 414.1380
Scoring.
(a) General. MIPS eligible clinicians
are scored under MIPS based on their
performance on measures and activities
in four performance categories. MIPS
eligible clinicians are scored against
performance standards for each
performance category and receive a final
score, composed of their scores on
individual measures and activities, and
calculated according to the final score
methodology.
(1) Measures and activities in the four
performance categories are scored
against performance standards. (i) For
the quality performance category,
measures are scored between zero and
10 points. Performance is measured
against benchmarks. Bonus points are
available for both submitting specific
types of measures and submitting
measures using end-to-end electronic
reporting. Starting with the 2020 MIPS
payment year, improvement scoring is
available in the quality performance
category.
(ii) For the cost performance category,
measures are scored between 1 and 10
points. Performance is measured against
a benchmark. Starting with the 2020
MIPS payment year, improvement
scoring is available in the cost
performance category.
(iii) For the improvement activities
performance category, each
improvement activity is worth a certain
number of points. The points for each
reported activity are summed and
scored against a total potential
performance category score of 40 points.
(iv) For the advancing care
information performance category, the
performance category score is the sum
of a base score, performance score, and
bonus score.
(2) [Reserved]
(b) Performance categories. MIPS
eligible clinicians are scored under
MIPS in four performance categories.
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(1) Quality performance category. For
the 2017 and 2018 performance periods.
MIPS eligible clinicians receive three to
ten measure achievement points for
each scored quality measure in the
quality performance category based on
the MIPS eligible clinician’s
performance compared to measure
benchmarks. A quality measure must
have a measure benchmark to be scored
based on performance. Quality measures
that do not have a benchmark will not
be scored based on performance.
Instead, these measures will receive 3
points for the 2017 MIPS performance
period and either 1 or 3 points for the
2018 MIPS performance period in
accordance with paragraph (b)(1)(vii) of
this section.
(i) Measure benchmarks are based on
historical performance for the measure
based on a baseline period. Each
benchmark must have a minimum of 20
individual clinicians or groups who
reported the measure meeting the data
completeness requirement and
minimum case size criteria and
performance greater than zero.
Benchmark data are separated into
decile categories based on a percentile
distribution. We will restrict the
benchmarks to data from MIPS eligible
clinicians and comparable APM data,
including data from QPs and Partial
QPs.
(ii) As an exception, if there is no
comparable data from the baseline
period, CMS would use information
from the performance period to create
measure benchmarks, as described in
paragraph (b)(1)(i) of this section, which
would not be published until after the
performance period. For the 2017
performance period, CMS would use
information from CY 2017 during which
MIPS eligible clinicians may report for
a minimum of any continuous 90-day
period.
(A) CMS Web Interface submission
uses benchmarks from the
corresponding reporting year of the
Shared Savings Program.
(B) [Reserved]
(iii) Separate benchmarks are used for
the following submission mechanisms:
(A) EHR submission options;
(B) QCDR and qualified registry
submission options;
(C) Claims submission options;
(D) CMS Web Interface submission
options;
(E) CMS-approved survey vendor for
CAHPS for MIPS submission options;
and
(F) Administrative claims submission
options.
(iv) Minimum case requirements for
quality measures are 20 cases, unless a
measure is subject to an exception.
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(v) As an exception, the minimum
case requirements for the all-cause
hospital readmission measure is 200
cases.
(vi) MIPS eligible clinicians failing to
report a measure required under this
category receive zero points for that
measure.
(vii) Subject to paragraph (b)(1)(viii)
of this section, MIPS eligible clinicians
do not receive zero points if the
expected measure is submitted but is
unable to be scored because it does not
meet the required case minimum or if
the measure does not have a measure
benchmark for MIPS payment years
2019 and 2020. Instead, these measures
receive a score of 3 points in MIPS
payment years 2019 and 2020. MIPS
eligible clinicians do not receive zero
points if the expected measure is
submitted but is unable to be scored
because it is below the data
completeness requirement. Instead,
these measures receive a score of 3
points in the 2019 MIPS payment year
and a score of 1 point in the 2020 MIPS
payment year, except if the measure is
submitted by a small practice. Measures
below the data completeness
requirement submitted by a small
practice receive a score of 3 points in
the 2020 MIPS payment year.
(viii) As an exception, the
administrative claims-based measures
and CMS Web Interface measures will
not be scored if these measures do not
meet the required case minimum. For
CMS Web Interface measures, we will
recognize the measure was submitted
but exclude the measure from being
scored. For CMS Web Interface
measures: Measures that do not have a
measure benchmark and measures that
have a measure benchmark but are
redesignated as pay for reporting for all
Shared Savings Program accountable
care organizations by the Shared
Savings Program, CMS will recognize
the measure was submitted but exclude
the measure from being scored as long
as the data completeness requirement is
met. CMS Web Interface measures that
are below the data completeness
requirement will be scored and receive
0 points.
(ix) Measures submitted by MIPS
eligible clinicians are scored against
measure benchmarks using a percentile
distribution, separated by decile
categories.
(x) For each set of benchmarks, CMS
calculates the decile breaks for measure
performance and assigns points based
on which benchmark decile range the
MIPS eligible clinician’s measure rate is
between.
(xi) CMS assigns partial points based
on the percentile distribution.
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(xii) MIPS eligible clinicians are
required to submit measures consistent
with § 414.1335.
(A) MIPS eligible clinicians that
submit measures via claims, qualified
registry, EHR, or QCDR submission
mechanisms, and submit more than the
required number of measures are scored
on the required measures with the
highest measure achievement points.
MIPS eligible clinicians that report a
measure via more than one submission
mechanism can be scored on only one
submission mechanism, which will be
the submission mechanism with the
highest measure achievement points.
Groups that submit via these submission
options may also submit and be scored
on CMS-approved survey vendor for
CAHPS for MIPS submission
mechanisms.
(B) Groups that submit measures via
the CMS Web Interface may also submit
and be scored on CMS-approved survey
vendor for CAHPS for MIPS submission
mechanisms.
(xiii) Topped out quality measures
will be identified on an annual basis
and may be removed from the measure
set for a submission mechanism after
the third consecutive year that a given
measure has been identified as topped
out in connection with that submission
mechanism. CMS will identify topped
out measures in the benchmarks
published for each Quality Payment
Program year. Topped out measures that
have been removed pursuant to this
policy will not be available for reporting
after removal.
(A) For the 2018 MIPS performance
period (2020 MIPS payment year),
selected topped out measures identified
by CMS will receive no more than 6
measure achievement points, provided
that the measure benchmarks for all
submission mechanisms are identified
as topped out in the benchmarks
published for the 2018 MIPS
performance period.
(B) Beginning with the 2019 MIPS
performance period (2021 MIPS
payment year), a measure, except for
measures in the CMS Web Interface,
whose benchmark is identified as
topped out for 2 or more consecutive
years will receive no more than 6
measure achievement points in the
second consecutive year it is identified
as topped out, and beyond.
(xiv) Measure bonus points are
available for measures determined to be
high priority measures when two or
more high priority measures are
reported.
(A) Measure bonus points are not
available for the first reported high
priority measure which is required to be
reported. To qualify for measure bonus
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points, each measure must be reported
with sufficient case volume to meet the
required case minimum, meet the
required data completeness criteria, and
not have a zero percent performance
rate. Measure bonus points may be
included in the calculation of the
quality performance category percent
score regardless of whether the measure
is included in the calculation of the
total measure achievement points.
(B) Outcome and patient experience
measures receive two measure bonus
points.
(C) Other high priority measures
receive one measure bonus point.
(D) Measure bonus points for high
priority measures cannot exceed 10
percent of the total available measure
achievement points for the 2019 and
2020 MIPS payment years.
(E) If the same high priority measure
is submitted via two or more submission
mechanisms, the measure will receive
high priority measure bonus points only
once for the measure.
(xv) One measure bonus point is also
available for each measure submitted
with end-to-end electronic reporting for
a quality measure under certain criteria
determined by the Secretary. Bonus
points cannot exceed 10 percent of the
total available measure achievement
points for the 2019 and 2020 MIPS
payment years. If the same measure is
submitted via 2 or more submission
mechanisms, the measure will receive
measure bonus points only once for the
measure.
(xvi) Improvement scoring is available
to MIPS eligible clinicians that
demonstrate improvement in
performance in the current MIPS
performance period compared to
performance in the year immediately
prior to the current MIPS performance
period based on achievement.
(A) Improvement scoring is available
when the data sufficiency standard is
met, which means when data are
available and a MIPS eligible clinician
has a quality performance category
achievement percent score for the
previous performance period.
(1) Data must be comparable to meet
the requirement of data sufficiency
which means that the quality
performance category achievement
percent score is available for the current
performance period and the previous
performance period and quality
performance category achievement
percent scores can be compared.
(2) Quality performance category
achievement percent scores are
comparable when submissions are
received from the same identifier for
two consecutive performance periods.
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(3) If the identifier is not the same for
2 consecutive performance periods, then
for individual submissions, the
comparable quality performance
category achievement percent score is
the quality performance category
achievement percent score associated
with the final score from the prior
performance period that will be used for
payment. For group, virtual group, and
APM Entity submissions, the
comparable quality performance
category achievement percent score is
the average of the quality performance
category achievement percent score
associated with the final score from the
prior performance period that will be
used for payment for each of the
individuals in the group.
(B) The improvement percent score
may not total more than 10 percentage
points.
(C) The improvement percent score is
assessed at the performance category
level for the quality performance
category and included in the calculation
of the quality performance category
percent score as described in paragraph
(b)(1)(xvii) of this section.
(1) The improvement percent score is
awarded based on the rate of increase in
the quality performance category
achievement percent score of eligible
clinicians from the current MIPS
performance period compared to the
year immediately prior to the current
MIPS performance period.
(2) An improvement percent score is
calculated by dividing the increase in
the quality performance category
achievement percent score from the
prior performance period to the current
performance period by the prior year
quality performance category
achievement percent score multiplied
by 10 percent.
(3) An improvement percent score
cannot be lower than zero percentage
points.
(4) For the 2018 MIPS performance
period, if a MIPS eligible clinician has
a previous year quality performance
category achievement percent score less
than or equal to 30 percent, then the
2018 performance will be compared to
an assumed 2017 quality performance
category achievement percent score of
30 percent.
(5) The improvement percent score is
zero if the MIPS eligible clinician did
not fully participate in the quality
performance category for the current
performance period.
(D) For the purpose of improvement
scoring methodology, the term ‘‘quality
performance category achievement
percent score’’ means the total measure
achievement points divided by the total
available measure achievement points,
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without consideration of measure bonus
points or improvement percent score.
(E) For the purpose of improvement
scoring methodology, the term
‘‘improvement percent score’’ means the
score that represents improvement for
the purposes of calculating the quality
performance category percent score as
described in paragraph (b)(1)(xvii) of
this section.
(F) For the purpose of improvement
scoring methodology, the term ‘‘fully
participate’’ means the MIPS eligible
clinician met all requirements in
§§ 414.1330 and 414.1340.
(xvii) A MIPS eligible clinician’s
quality performance category percent
score is the sum of all the measure
achievement points assigned for the
measures required for the quality
performance category criteria plus the
measure bonus points in paragraph
(b)(1)(xiv) of this section and measure
bonus points in paragraph (b)(1)(xv) of
this section. The sum is divided by the
sum of total available measure
achievement points. The improvement
percent score in paragraph (b)(1)(xvi) of
this section is added to that result. The
quality performance category percent
score cannot exceed 100 percentage
points.
(xviii) Beginning with the 2018 MIPS
performance period, measures
significantly impacted by ICD–10
updates, as determined by CMS, will be
assessed based only on the first 9
months of the 12-month performance
period. For purposes of this paragraph,
CMS will make a determination as to
whether a measure is significantly
impacted by ICD–10 coding changes
during the performance period. CMS
will publish on the CMS Web site which
measures require a 9-month assessment
process by October 1st of the
performance period if technically
feasible, but by no later than the
beginning of the data submission period
at § 414.1325(f)(1).
(2) Cost performance category. A
MIPS eligible clinician receives one to
ten achievement points for each cost
measure attributed to the MIPS eligible
clinician based on the MIPS eligible
clinician’s performance compared to the
measure benchmark.
(i) Cost measure benchmarks are
based on the performance period. Cost
measures must have a benchmark to be
scored.
(ii) A MIPS eligible clinician must
meet the minimum case volume
specified by CMS to be scored on a cost
measure.
(iii) A MIPS eligible clinician cost
performance category percent score is
the sum of the following, not to exceed
100 percent:
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(A) The total number of achievement
points earned by the MIPS eligible
clinician divided by the total number of
available achievement points; and
(B) The cost improvement score, as
determined under paragraph (iv).
(iv) Cost improvement scoring is
available to MIPS eligible clinicians that
demonstrate improvement in
performance in the current MIPS
performance period compared to their
performance in the immediately
preceding MIPS performance period.
(A) The cost improvement score is
determined at the measure level for the
cost performance category.
(B) The cost improvement score is
calculated only when data sufficient to
measure improvement is available.
Sufficient data is available when a MIPS
eligible clinician or group participates
in MIPS using the same identifier in 2
consecutive performance periods and is
scored on the same cost measure(s) for
2 consecutive performance periods. If
the cost improvement score cannot be
calculated because sufficient data is not
available, then the cost improvement
score is zero.
(C) The cost improvement score is
determined by comparing the number of
measures with a statistically significant
change (improvement or decline) in
performance; a change is determined to
be significant based on application of a
t-test. The number of cost measures with
a significant decline is subtracted from
the number of cost measures with a
significant improvement, with the result
divided by the number of cost measures
for which the MIPS eligible clinician or
group was scored for two consecutive
performance periods. The resulting
fraction is then multiplied by the
maximum improvement score.
(D) The cost improvement score
cannot be lower than zero percentage
points.
(E) The maximum cost improvement
score for the 2020 MIPS payment year
is zero percentage points.
(v) A cost performance category
percent score is not calculated if a MIPS
eligible clinician is not attributed any
cost measures because the clinician or
group has not met the case minimum
requirements for any of the cost
measures or a benchmark has not been
created for any of the cost measures that
would otherwise be attributed to the
clinician or group.
(3) Improvement activities
performance category. MIPS eligible
clinicians and groups receive points for
improvement activities based on
patient-centered medical home or
comparable specialty practice
participation, APM participation, and
improvement activities reported by the
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MIPS eligible clinician in comparison to
the highest potential score (40 points)
for a given MIPS year. For purposes of
this paragraph, ‘‘full credit’’ means that
the MIPS eligible clinician or group has
met the highest potential score for the
improvement activities performance
category.
(i) CMS assigns credit for the total
possible category score for each reported
improvement activity based on two
weights: Medium-weighted and highweighted activities.
(ii) Improvement activities with a
high weighting receive credit for 20
points, toward the total possible
category score.
(iii) Improvement activities with a
medium weighting receive credit for 10
points toward the total possible category
score.
(iv) A MIPS eligible clinician or group
in a practice that is certified or
recognized as a patient-centered
medical home or comparable specialty
practice, as determined by the Secretary,
receives full credit for performance on
the improvement activities performance
category. A practice is certified or
recognized as a patient-centered
medical home if it meets any of the
following criteria:
(A) The practice has received
accreditation from one of four
accreditation organizations that are
nationally recognized;
(1) The Accreditation Association for
Ambulatory Health Care;
(2) The National Committee for
Quality Assurance (NCQA);
(3) The Joint Commission; or
(4) The Utilization Review
Accreditation Commission (URAC).
(B) The practice is participating in a
Medicaid Medical Home Model or
Medical Home Model.
(C) The practice is a comparable
specialty practice that has received the
NCQA Patient-Centered Specialty
Recognition.
(D) The practice is a participant or in
a control group in the CPC+ model.
(E) The practice has received
accreditation from other certifying
bodies that have certified a large
number of medical organizations and
meet national guidelines, as determined
by the Secretary. The Secretary must
determine that these certifying bodies
must have 500 or more certified member
practices, and require practices to
include the following:
(1) Have a personal physician/
clinician in a team-based practice.
(2) Have a whole-person orientation.
(3) Provide coordination or integrated
care.
(4) Focus on quality and safety.
(5) Provide enhanced access.
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(v) CMS compares the points
associated with the reported activities
against the highest potential category
score of 40 points.
(vi) A MIPS eligible clinician or
group’s improvement activities category
score is the sum of points for all of their
reported activities, which is capped at
40 points, divided by the highest
potential category score of 40 points.
(vii) Non-patient facing MIPS eligible
clinicians and groups, small practices,
and practices located in rural areas and
geographic HPSAs receive full credit for
improvement activities by selecting one
high-weighted improvement activity or
two medium-weighted improvement
activities. Non-patient facing MIPS
eligible clinicians and groups, small
practices, and practices located in rural
areas and geographic HPSAs receive
half credit for improvement activities by
selecting one medium-weighted
improvement activity.
(viii) For the transition year, to
receive full credit as a certified or
recognized patient-centered medical
home or comparable specialty a TIN that
is reporting must include at least one
practice site which is a certified patientcentered medical home or comparable
specialty practice.
(ix) MIPS eligible clinicians
participating in APMs that are not
patient-centered medical homes for a
performance period shall earn a
minimum score of one-half of the
highest potential score for the
improvement activities performance
category.
(x) For the 2018 MIPS performance
period and future periods, to receive full
credit as a certified or recognized
patient-centered medical home or
comparable specialty practice, CMS
requires that at least 50 percent of the
practice sites within the TIN must be
recognized as a patient-centered
medical home or comparable specialty
practice.
(4) Advancing care information
performance category. (i) A MIPS
eligible clinician’s advancing care
information performance category score
equals the sum of the base score,
performance score, and any applicable
bonus scores. A MIPS eligible clinician
cannot earn the performance score or
base score until they have fulfilled the
base score. The advancing care
information performance category score
will not exceed 100 percentage points.
(A) A MIPS eligible clinician earns a
base score by reporting the numerator
(of at least one) and denominator or a
yes/no statement or an exclusion; as
applicable, for each required measure.
(B) A MIPS eligible clinician earns a
performance score by reporting on
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certain measures specified by CMS.
MIPS eligible clinicians may earn up to
10 or 20 percentage points as specified
by CMS for each measure reported for
the performance score.
(C) A MIPS eligible clinician may earn
the following bonus scores:
(1) A bonus score of 5 percentage
points for reporting to one or more
additional public health agencies or
clinical data registries.
(2) A bonus score of 10 percentage
points for attesting to completing one or
more improvement activities specified
by CMS using CEHRT.
(3) For the 2020 MIPS payment year,
a bonus score of 10 percentage points
for submitting data for the measures for
the base score and the performance
score generated solely from 2015
Edition CEHRT.
(c) Final score calculation. Each MIPS
eligible clinician receives a final score
of 0 to 100 points for a performance
period for a MIPS payment year
calculated per the following formula. If
a MIPS eligible clinician is scored on
fewer than 2 performance categories, he
or she receives a final score equal to the
performance threshold.
Final score = [(quality performance
category percent score × quality
performance category weight) + (cost
performance category percent score ×
cost performance category weight) +
(improvement activities performance
category score × improvement activities
performance category weight) +
(advancing care information
performance category score × advancing
care information performance category
weight)] × 100 + [the complex patient
bonus + the small practice bonus], not
to exceed 100 points.
(1) Performance category weights. The
weights of the performance categories in
the final score are as follows, unless a
different scoring weight is assigned
under paragraph (c)(2) of this section:
(i) Quality performance category
weight is defined under § 414.1330(b).
(ii) Cost performance category weight
is defined under § 414.1350(b).
(iii) Improvement activities
performance category weight is defined
under § 414.1355(b).
(iv) Advancing care information
performance category weight is defined
under § 414.1375(a).
(2) Reweighting the performance
categories. A scoring weight different
from the weights specified in paragraph
(c)(1) of this section, will be assigned to
a performance category, and its weight
as specified in paragraph (c)(1) of this
section, will be redistributed to another
performance category or categories, in
the following circumstances:
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(i) CMS determines there are not
sufficient measures and activities
applicable and available to MIPS
eligible clinicians pursuant to section
1848(q)(5)(F) of the Act.
(ii) CMS estimates that the proportion
of eligible professionals who are
meaningful EHR users is 75 percent or
greater pursuant to section
1848(q)(5)(E)(ii) of the Act.
(iii) A significant hardship exception
or other type of exception is granted to
a MIPS eligible clinician for the
advancing care information performance
category pursuant to section
1848(o)(2)(D) of the Act.
(3) Complex patient bonus. Provided
that the MIPS eligible clinician, group,
virtual group or APM entity submits
data for at least one MIPS performance
category during the applicable
performance period, a complex patient
bonus will be added to the final score
for the 2020 MIPS payment year, as
follows:
(i) For MIPS eligible clinicians and
groups, the complex patient bonus is
equal to the average HCC risk score
assigned to beneficiaries (pursuant to
the HCC risk adjustment model
established by CMS pursuant to section
1853(a)(1) of the Act) seen by the MIPS
eligible clinician or seen by clinicians in
a group.
(ii) For MIPS APMs and virtual
groups, the complex patient bonus is
equal to the beneficiary weighted
average HCC risk score for all MIPS
eligible clinicians and TINs for models
and virtual groups which rely on
complete TIN participation within the
APM entity or virtual group,
respectively.
(iii) The complex patient bonus
cannot exceed 3.0.
(4) Small practice bonus. A small
practice bonus of 5 points will be added
to the final score for the 2020 MIPS
payment year for MIPS eligible
clinicians, and for groups, virtual
groups, and APM Entities that consist of
15 or fewer clinicians, that participate
in the program by submitting data on at
least one performance category in the
2018 MIPS performance period.
(d) Scoring for APM Entities. MIPS
eligible clinicians in APM Entities that
are subject to the APM scoring standard
are scored using the methodology under
§ 414.1370.
(e) Scoring for Facility-Based
Measurement. MIPS eligible clinicians
may elect to be scored under the quality
and cost performance categories using
facility-based measures under the
methodology described in this
paragraph.
(1) General. The facility-based
measurement scoring standard is the
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MIPS scoring methodology applicable
for MIPS eligible clinicians identified as
meeting the requirements in paragraph
(e)(2) and (3) of this section.
(i) For the 2018 MIPS performance
period, the facility-based measures
available are the measures adopted for
the FY 2019 Hospital Value-Based
Purchasing Program as authorized by
section 1886(o) of the Act and codified
in our regulations at § 412.160 through
§ 412.167.
(ii) For the 2020 MIPS payment year,
the scoring methodology applicable for
MIPS eligible clinicians electing facilitybased measurement is the Total
Performance Score methodology
adopted for the Hospital Value-Based
Purchasing Program.
(2) Eligibility for facility-based
measurement. MIPS eligible clinicians
are eligible for facility-based
measurement for a MIPS payment year
if they are determined facility-based as
an individual clinician or as part of a
group, as follows:
(i) Facility-based individual
determination. A MIPS eligible clinician
furnishes 75 percent or more of his or
her covered professional services in
sites of service identified by the place of
service codes used in the HIPAA
standard transaction as an inpatient
hospital or emergency room setting
based on claims for a period prior to the
performance period as specified by
CMS.
(ii) Facility-based group
determination. A facility-based group is
a group in which 75 percent or more of
its MIPS eligible clinicians meet the
requirements under paragraph (e)(2)(i)
of this section.
(3) Election of facility-based
measurement. MIPS eligible clinicians
that meet the criteria described under
paragraph (e)(2) of this section must
elect participation in facility-based
measurement through attestation.
(4) Data submission for facility-based
measurement. There are no data
submission requirements for facilitybased measurement other than electing
the option through attestation as
described in paragraph (e)(3) of this
section.
(5) Determination of applicable
facility score. A facility-based clinician
or group receives a score under the
facility-based measurement scoring
standard derived from the value-based
purchasing score for the facility at
which the clinician or group provided
services to the most Medicare
beneficiaries. If there is an equal
number of Medicare beneficiaries
treated at more than one facility, the
value-based purchasing score for the
highest scoring facility is used.
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(6) MIPS performance category
scoring under the facility-based
measurement scoring standard.
(i) Measures. The quality and cost
measures are those adopted under the
value-based purchasing program of the
facility for the year specified.
(ii) Benchmarks. The benchmarks are
those adopted under the value-based
purchasing program of the facility
program for the year specified.
(iii) Performance Period. The
performance period for facility-based
measurement is the performance period
for the measures adopted under the
value-based purchasing program of the
facility program for the year specified.
(iv) Quality. The quality performance
category percent score is established by
determining the percentile performance
of the facility in the value-based
purchasing program for the specified
year as described in paragraph (e)(5) of
this section and awarding a score
associated with that same percentile
performance in the MIPS quality
performance category percent score [for
those clinicians who are not scored
using facility-based measurement] for
the MIPS payment year.
(v) Cost. The cost performance
category percent score is established by
determining the percentile performance
of the facility in the value-based
purchasing program for the specified
year as described in paragraph (e)(5) of
this section and awarding a score
associated with that same percentile
performance in the MIPS cost
performance category percent score for
those clinicians who are not scored
using facility-based measurement for the
MIPS payment year.
(A) Other Cost Measures. MIPS
eligible clinicians who elect facilitybased measurement are not scored on
cost measures described in paragraph
(b)(2) of this section.
(B) [Reserved]
■ 14. Section 414.1390 is amended by
adding paragraphs (b) through (d) to
read as follows:
§ 414.1390
Data validation and auditing.
*
*
*
*
*
(b) Certification. All MIPS eligible
clinicians and groups that submit data
and information to CMS for purposes of
MIPS must certify to the best of their
knowledge that the data submitted to
CMS is true, accurate, and complete.
Such certification must accompany the
submission.
(c) Reopening. CMS may reopen and
revise a MIPS payment determination in
accordance with the rules set forth at
§§ 405.980 through 405.986 of this
chapter.
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(d) Record Retention. All MIPS
eligible clinicians or groups that submit
data and information to CMS for
purposes of MIPS must retain such data
and information for a period of 10 years
from the end the MIPS Performance
Period.
■ 15. Section 414.1395 is revised to read
as follows:
§ 414.1395
Public reporting.
(a) Public reporting of eligible
clinician and group Quality Payment
Program information. For each program
year, CMS posts on Physician Compare,
in an easily understandable format,
information regarding the performance
of eligible clinicians or groups under the
Quality Payment Program.
(b) Maintain existing public reporting
standards. With the exception of data
that must be mandatorily reported on
Physician Compare, for each program
year, CMS relies on established public
reporting standards to guide the
information available for inclusion on
Physician Compare. The public
reporting standards require data
included on Physician Compare to be
statistically valid, reliable, and accurate;
comparable across reporting
mechanisms; and meet the reliability
threshold. And, to be included on the
public facing profile pages, the data
must also resonate with Web site users,
as determined by CMS.
(c) First year measures. For each
program year, CMS does not publicly
report any first year measure, meaning
any measure in its first year of use in the
quality and cost performance categories.
After the first year, CMS reevaluates
measures to determine when and if they
are suitable for public reporting.
(d) 30-day preview period. For each
program year, CMS provides a 30-day
preview period for any clinician or
group with Quality Payment Program
data before the data are publicly
reported on Physician Compare.
■ 16. Section 414.1400 is amended by—
■ a. Revising paragraph (a)(1)
introductory text;
■ b. Adding paragraph (a)(5);
■ c. Revising paragraphs (b), (e)
introductory text, (e)(3), (f) introductory
text, (f)(1), (f)(2), (g), (i) and (j)(2).
The revisions and additions read as
follows:
§ 414.1400
Third party data submission.
(a) * * *
(1) MIPS data may be submitted by
third party intermediaries on behalf of
a MIPS eligible clinician, group or
virtual group by:
*
*
*
*
*
(5) All data submitted to CMS by a
third party intermediary on behalf of a
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MIPS eligible clinician, group or virtual
group must be certified by the third
party intermediary to the best of its
knowledge as true, accurate, and
complete. Such certification must
accompany the submission.
(b) QCDR self-nomination criteria. For
the 2018 performance period and future
years of the program, QCDRs must selfnominate from September 1 of the prior
year until November 1 of the prior year.
Entities that desire to qualify as a QCDR
for the purposes of MIPS for a given
performance period will need to selfnominate for that performance period
and provide all information requested
by CMS at the time of self-nomination.
Having qualified as a QCDR does not
automatically qualify the entity to
participate in subsequent MIPS
performance periods. Beginning with
the 2019 performance period existing
QCDRs that are in good standing may
attest that certain aspects of their
previous year’s approved selfnomination have not changed and will
be used for the upcoming performance
period. CMS may allow existing QCDRs
in good standing to submit minimal or
substantial changes to their previously
approved self-nomination form, from
the previous year, during the annual
self-nomination period, for CMS review
and approval without having to
complete the entire QCDR selfnomination application process.
*
*
*
*
*
(e) Identifying QCDR quality
measures. For purposes of QCDRs
submitting data for the MIPS quality
performance category, CMS considers
the following types of quality measures
to be QCDR quality measures:
*
*
*
*
*
(3) CAHPS for MIPS survey. Although
the CAHPS for MIPS survey is included
in the MIPS measure set, we consider
the changes that need to be made to the
CAHPS for MIPS survey for reporting by
individual MIPS eligible clinicians (and
not as a part of a group) significant
enough as to treat the CAHPS for MIPS
survey as a QCDR quality measure for
purposes of individual MIPS eligible
clinicians reporting the CAHPS for
MIPS survey via a QCDR.
(f) QCDR measure specifications
criteria. A QCDR must provide
specifications for each measure, activity,
or objective the QCDR intends to submit
to CMS. The QCDR must provide CMS
descriptions and narrative specifications
for each measure, activity, or objective
no later than November 1 of the
applicable performance period for
which the QCDR wishes to submit
quality measures or other performance
category (improvement activities and
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advancing care information) data
starting with the 2018 performance
period and in future program years.
(1) For QCDR quality measures, the
quality measure specifications must
include the following for each measure:
name/title of measures, NQF number (if
NQF-endorsed), descriptions of the
denominator, numerator, and when
applicable, denominator exceptions,
denominator exclusions, risk
adjustment variables, and risk
adjustment algorithms. The narrative
specifications provided must be similar
to the narrative specifications we
provide in our measures list.
(2) For MIPS quality measures, the
QCDR only needs to submit the MIPS
measure numbers or specialty-specific
measure sets (if applicable). CMS
expects that QCDRs reporting on MIPS
measures, retain and use the MIPS
measure specifications as they exist
under the program year.
*
*
*
*
*
(g) Qualified registry self-nomination
criteria. For the 2018 performance
period and future years of the program,
the qualified registry must self-nominate
from September 1 of the prior year until
November 1 of the prior year. Entities
that desire to qualify as a qualified
registry for a given performance period
must self-nominate and provide all
information requested by CMS at the
time of self-nomination. Having
qualified as a qualified registry does not
automatically qualify the entity to
participate in subsequent MIPS
performance periods. Beginning with
the 2019 performance period, existing
qualified registries that are in good
standing may attest that certain aspects
of their previous year’s approved selfnomination have not changed and will
be used for the upcoming performance
period. CMS may allow existing
qualified registries in good standing to
submit minimal or substantive changes
to their previously approved selfnomination form from the previous
year, during the annual self-nomination
period, for CMS review and approval
without having to complete the entire
qualified registry self-nomination
application process.
*
*
*
*
*
(i) CMS-approved survey vendor
application criteria. Vendors are
required to undergo the CMS approval
process for each year in which the
survey vendor seeks to transmit survey
measures data to CMS. Applicants must
adhere to any deadlines specified by
CMS.
(j) * * *
(2) The entity must retain all data
submitted to CMS for purposes of MIPS
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for a minimum of 10 years from the end
of the MIPS Performance Period.
*
*
*
*
*
■ 17. Section 414.1410 is amended by
revising paragraph (b) to read as follows:
§ 414.1410
Advanced APM determination.
*
*
*
*
*
(b) Advanced APM determination
process. CMS determines Advanced
APMs in the following manner:
(1) CMS updates the Advanced APM
list on its Web site at intervals no less
than annually.
(2) CMS will include notice of
whether a new APM is an Advanced
APM in the first public notice of the
new APM.
■ 18. Section 414.1415 is amended by
revising paragraphs (c) introductory
text, (c)(2) introductory text, (c)(3)(i)(A)
and (c)(4) to read as follows:
§ 414.1415
Advanced APM criteria.
*
*
*
*
*
(c) Financial risk. To be an Advanced
APM, an APM must either meet the
financial risk standard under paragraphs
(c)(1) or (2) of this section and the
nominal amount standard under
paragraphs (c)(3) or (4) of this section or
be an expanded Medical Home Model
under Section 1115A(c) of the Act.
*
*
*
*
*
(2) Medical Home Model financial
risk standard. The following standard
applies only for APM Entities that are
participating in Medical Home Models
starting in the 2018 Medicare QP
Performance Period, except for APM
Entities participating in Round 1 of the
Comprehensive Primary Care Plus
(CPC+) Model. This standard applies for
APM Entities that are owned and
operated by an organization with fewer
than 50 eligible clinicians whose
Medicare billing rights have been
reassigned to the TIN(s) of the
organization(s) or any of the
organization’s subsidiary entities. APM
Entities under this standard participate
in a Medical Home Model that, based on
the APM Entity’s failure to meet or
exceed one or more specified
performance standards, which may
include expected expenditures, does
one or more of the following:
*
*
*
*
*
(3) * * *
(i) * * *
(A) For Medicare QP Performance
Periods 2017, 2018, 2019, and 2020, 8
percent of the average estimated total
Medicare Parts A and B revenue of all
providers and suppliers in participating
APM Entities; or
*
*
*
*
*
(4) Medical Home Model nominal
amount standard. (i) For a Medical
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Home Model to be an Advanced APM,
the total annual amount that an APM
Entity potentially owes CMS or foregoes
must be at least the following amounts:
(A) For Medicare QP Performance
Period 2017, 2.5 percent of the average
estimated total Medicare Parts A and B
revenue of all providers and suppliers
in participating APM Entities.
(B) For Medicare QP Performance
Period 2018, 2 percent of the average
estimated total Medicare Parts A and B
revenue of all providers and suppliers
in participating APM Entities;
(C) For Medicare QP Performance
Period 2019, 3 percent of the average
estimated total Medicare Parts A and B
revenue of all providers and suppliers
in participating APM Entities.
(D) For Medicare QP Performance
Period 2020, 4 percent of the average
estimated total Medicare Parts A and B
revenue of all providers and suppliers
in participating APM Entities.
(E) For Medicare QP Performance
Periods 2021 and later, 5 percent of the
average estimated total Medicare Parts A
and B revenue of all providers and
suppliers in participating APM Entities.
(ii) [Reserved]
*
*
*
*
*
■ 19. Section 414.1420 is amended by
revising the section heading and
paragraphs (a) introductory text, (a)(3)(i)
and (ii), (c) introductory heading, (c)(2)
introductory text, (c)(3), (d) introductory
text, (d)(1) introductory text, (d)(3), and
(4) to read as follows:
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§ 414.1420
criteria.
Other payer advanced APM
(a) Other Payer Advanced APM
criteria. A payment arrangement with a
payer other than Medicare is an Other
Payer Advanced APM for an All-Payer
QP Performance Period if CMS
determines that the arrangement meets
the following criteria during an AllPayer QP Performance Period:
*
*
*
*
*
(3) * * *
(i) Requires APM Entities to bear more
than nominal financial risk if actual
aggregate expenditures exceed expected
aggregate expenditures as described in
paragraph (d) of this section; or
(ii) Is a Medicaid Medical Home
Model that meets criteria comparable to
Medical Home Models expanded under
section 1115A(c) of the Act as described
in paragraph (d) of this section.
*
*
*
*
*
(c) Use of quality measures.
*
*
*
*
*
(2) At least one of the quality
measures used in the payment
arrangement must have an evidencebased focus, be reliable and valid, and
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meet at least one of the following
criteria:
* * *
(3) To meet the quality measure use
criterion, a payment arrangement must
use an outcome measure if there is an
applicable outcome measure on the
MIPS quality measure list.
(d) Financial risk. To be an Other
Payer Advanced APM, a payment
arrangement must meet either the
financial risk standard under paragraphs
(d)(1) or (2) of this section and the
nominal amount standard under
paragraphs (d)(3) or (4) of this section,
make payment using a full capitation
arrangement under paragraph (d)(6) of
this section, or be a Medicaid Medical
Home Model with criteria comparable to
an expanded Medical Home Model
under section 1115A(c) of the Act.
(1) Generally applicable financial risk
standard. Except for APM Entities to
which paragraph (d)(2) of this section
applies, to be an Other Payer Advanced
APM, an APM Entity must, based on
whether an APM Entity’s actual
expenditures for which the APM Entity
is responsible under the APM exceed
expected expenditures during a
specified period of performance do one
or more of the following:
*
*
*
*
*
(3) Generally applicable nominal
amount standard. Except for payment
arrangements described in paragraph
(d)(2) of this section, the total amount
an APM Entity potentially owes or
foregoes under a payment arrangement
must be at least:
(i) 8 percent of the total revenue from
the payer of providers and suppliers
participating in each APM Entity in the
payment arrangement if financial risk is
expressly defined in terms of revenue;
or
(ii) At least 3 percent of the expected
expenditures for which an APM Entity
is responsible under the payment
arrangement.
(4) Medicaid Medical Home Model
nominal amount standard. For a
Medicaid Medical Home Model to be an
Other Payer Advanced APM, the total
annual amount that an APM Entity
potentially owes or foregoes must be at
least the following amounts:
(i) For All-Payer QP Performance
Period 2019, 3 percent of the APM
Entity’s total revenue under the payer.
(ii) For All-Payer QP Performance
Period 2020, 4 percent of the APM
Entity’s total revenue under the payer.
(iii) For All-Payer QP Performance
Periods 2021 and later, 5 percent of the
APM Entity’s total revenue under the
payer.
*
*
*
*
*
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20. Section 414.1425 is amended by—
a. Revising paragraphs (a), (b), (c)(3),
and (c)(4)(i) and (c)(4)(ii);
■ b. Redesignating paragraph (c)(6) as
paragraph (c)(4)(iii);
■ c. Revising newly redesignated
paragraph (c)(4)(iii);
■ d. Adding a new paragraph (c)(6);
■ e. Revising paragraphs (d)(1) and (2);
and
■ f. Removing paragraph (d)(4).
The revisions and addition read as
follows:
■
■
§ 414.1425 Qualifying APM participant
determination: In general.
*
*
*
*
*
(a) List used for QP determination. (1)
For Advanced APMs in which all APM
Entities may include eligible clinicians
on a Participation List, the Participation
List is used to identify the APM Entity
group for purposes of QP
determinations, regardless of whether
the APM Entity also has eligible
clinicians on an Affiliated Practitioner
List.
(2) For Advanced APMs in which
APM Entities do not include eligible
clinicians on a Participation List but do
include eligible clinicians on an
Affiliated Practitioner List, the
Affiliated Practitioner List is used to
identify the eligible clinicians for
purposes of QP determinations.
(3) For Advanced APMs in which
some APM Entities may include eligible
clinicians on a Participation List and
other APM Entities may only include
eligible clinicians on an Affiliated
Practitioner List depending on the type
of APM Entity, paragraph (a)(1) of this
section applies to APM Entities that
may include eligible clinicians on a
Participation List, and paragraph (a)(2)
of this section applies to APM Entities
that only include eligible clinicians on
an Affiliated Practitioner List.
(b) Group or individual determination
under the Medicare Option. (1) APM
Entity group determination. Except for
paragraphs (b)(2) and (3) of this section,
for purposes of the QP determinations
for a year, eligible clinicians are
grouped and assessed through their
collective participation in an APM
Entity group that is in an Advanced
APM. To be included in the APM Entity
group for purposes of the QP
determination, an eligible clinician’s
APM participant identifier must be
present on a Participation List of an
APM Entity group on one of the dates:
March 31, June 30, or August 31 of the
Medicare QP Performance Period. An
eligible clinician included on a
Participation List on any one of these
dates is included in the APM Entity
group even if that eligible clinician is
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not included on that Participation List
at one of the prior or later listed dates.
CMS performs QP determinations for
the eligible clinicians in an APM entity
group three times during the Medicare
QP Performance Period using claims
data for services furnished from January
1 through each of the respective QP
determination dates: March 31, June 30,
and August 31. An eligible clinician can
only be determined to be a QP if the
eligible clinician appears on the
Participation List on a date (March 31,
June 30, or August 31) CMS uses to
determine the APM Entity group and to
make QP determinations collectively for
the APM Entity group based on
participation in the Advanced APM.
(2) Affiliated practitioner individual
determination under the Medicare
Option. For Advanced APMs described
in paragraph (a)(2) of this section, QP
determinations are made individually
for each eligible clinician. To be
assessed as an Affiliated Practitioner, an
eligible clinician must be identified on
an Affiliated Practitioner List on one of
the dates: March 31, June 30, or August
31 of the Medicare QP Performance
Period. An eligible clinician included
on an Affiliated Practitioner List on any
one of these dates is assessed as an
Affiliated Practitioner even if that
eligible clinician is not included on the
Affiliated Practitioner List at one of the
prior or later listed dates. For such
eligible clinicians, CMS performs QP
determinations during the Medicare QP
Performance Period using claims data
for services furnished from January 1
through each of the respective QP
determination dates that the eligible
clinician is on the Affiliated Practitioner
List: March 31, June 30, and August 31.
(3) Individual eligible clinician
determination under the All-Payer
Combination Option. Eligible clinicians
are assessed under the All-Payer
Combination Option as set forth in
§ 414.1440.
(c) * * *
(3) An eligible clinician is a QP for a
year under the Medicare Option if the
eligible clinician is in an APM Entity
group that achieves a Threshold Score
that meets or exceeds the corresponding
QP payment amount threshold or QP
patient count threshold for that
Medicare QP Performance Period as
described in § 414.1430(a)(1) and (3). An
eligible clinician is a QP for the year
under the All-Payer Combination
Option if the individual eligible
clinician achieves a Threshold Score
that meets or exceeds the corresponding
QP payment amount threshold or QP
patient count threshold for that AllPayer QP Performance Period as
described in § 414.1430(b)(1) and (3).
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(4) * * *
(i) The eligible clinician is included
in more than one APM Entity group and
none of the APM Entity groups in which
the eligible clinician is included meets
the QP payment amount threshold or
the QP patient count threshold, or the
eligible clinician is an Affiliated
Practitioner; and
(ii) CMS determines that the eligible
clinician individually achieves a
Threshold Score that meets or exceeds
the QP payment amount threshold or
the QP patient count threshold; unless
(iii) Any of the APM Entities in which
the eligible clinician participates
voluntarily or involuntarily terminates
from the Advanced APM before the end
of the Medicare QP Performance Period.
*
*
*
*
*
(6) Advanced APMs that Start or End
During the Medicare QP Performance
Period. (i) Notwithstanding paragraph
(a) of this section and §§ 414.1435 and
414.1440, and except as provided in
paragraph (c)(6)(ii) of this section, CMS
makes QP determinations and Partial
QP determinations for the APM Entity
group or individual eligible clinician
under § 414.1425(b) for Advanced APMs
that start or end during the Medicare QP
Performance Period and that are actively
tested for 60 or more continuous days
during the Medicare QP Performance
Period using claims data for services
furnished during those dates on which
the Advanced APM is actively tested.
For Advanced APMs that start active
testing during the Medicare QP
Performance Period, CMS performs QP
and Partial QP determinations during
the Medicare QP Performance Period
using claims data for services furnished
from the start of active testing of the
Advanced APM through each of the QP
determination dates that occur on or
after the Advanced APM has been
actively tested for 60 or more
continuous days: March 31, June 30,
and August 31. For Advanced APMs
that end active testing during the
Medicare QP Performance Period, CMS
performs QP and Partial QP
determinations using claims data for
services furnished from January 1 or the
start of active testing, whichever occurs
later, through the final day of active
testing of the Advanced APM for each
of the QP determination dates that occur
on or after the Advanced APM has been
actively tested for 60 or more
continuous days during that Medicare
QP Performance Period: March 31, June
30, and August 31.
(ii) For QP determinations specified
under paragraph (c)(4) of this section
and Partial QP determinations under
paragraph (d)(2) of this section, QP
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30257
determinations are made using claims
data for the full Medicare QP
Performance Period even if the eligible
clinician participates in one or more
Advanced APMs that start or end during
the Medicare QP Performance Period.
(d) * * *
(1) An eligible clinician is a Partial QP
for a year under the Medicare Option if
the eligible clinician is in an APM
Entity group that achieves Threshold
Score that meets or exceeds the
corresponding Partial QP payment
amount threshold or Partial QP patient
count threshold for that Medicare QP
Performance Period as described in
§ 414.1430(a)(2) and (4). An eligible
clinician is a Partial QP for the year
under the All-Payer Combination
Option if the individual eligible
clinician achieves a Threshold Score
that meets or exceeds the corresponding
Partial QP payment amount threshold or
Partial QP patient count threshold for
that All-Payer QP Performance Period as
described in § 414.1430(b)(2) and (4).
(2) Notwithstanding paragraph (d)(1)
of this section, an eligible clinician is a
Partial QP for a year if:
(i) The eligible clinician is included
in more than one APM Entity group and
none of the APM Entity groups in which
the eligible clinician is included meets
the corresponding QP or Partial QP
threshold, or the eligible clinician is an
Affiliated Practitioner; and
(ii) CMS determines that the eligible
clinician individually achieves a
Threshold Score that meets or exceeds
the corresponding Partial QP Threshold;
unless
(iii) Any of the APM Entities in which
the eligible clinician participates
voluntarily or involuntarily terminates
from the Advanced APM before the end
of the Medicare QP Performance Period.
*
*
*
*
*
■ 21. Section 414.1435 is amended by
revising paragraphs (a) introductory
text, (a)(1), (2), (b)(1) through (4), (c)(3),
and (d) to read as follows:
§ 414.1435 Qualifying APM participant
determination: Medicare option.
(a) Payment amount method. The
Threshold Score for an APM Entity or
eligible clinician is calculated as a
percent by dividing the value described
under paragraph (a)(1) of this section by
the value described under paragraph
(a)(2) of this section.
(1) Numerator. The aggregate of
payments for Medicare Part B covered
professional services furnished by the
APM Entity group to attributed
beneficiaries during the Medicare QP
Performance Period.
(2) Denominator. The aggregate of
payments for Medicare Part B covered
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professional services furnished by the
APM Entity group to all attributioneligible beneficiaries during the
Medicare QP Performance Period.
*
*
*
*
*
(b) * * *
(1) Numerator. The number of
attributed beneficiaries to whom the
APM Entity group furnishes Medicare
Part B covered professional services or
is furnished services by a Rural Health
Clinic (RHC) or Federally-Qualified
Health Center (FQHC) during the
Medicare QP Performance Period.
(2) Denominator. The number of
attribution-eligible beneficiaries to
whom the APM Entity group or eligible
clinician furnishes Medicare Part B
covered professional services or is
furnished services by a Rural Health
Clinic (RHC) or Federally-Qualified
Health Center (FQHC) during the
Medicare QP Performance Period.
(3) Unique beneficiaries. For each
APM Entity group, a unique Medicare
beneficiary is counted no more than one
time for the numerator and no more
than one time for the denominator.
(4) Beneficiaries count multiple times.
Based on attribution under the terms of
an Advanced APM, a single Medicare
beneficiary may be counted in the
numerator or denominator for multiple
different APM Entity groups.
(c) * * *
(3) When it is not operationally
feasible to use the final attributed
beneficiary list, the attributed
beneficiary list will be taken from the
Advanced APM’s most recently
available attributed beneficiary list at
the end of the Medicare QP Performance
Period.
(d) Use of methods. CMS calculates
Threshold Scores for an APM Entity or
eligible clinician as provided by
§ 414.1425(b) under both the payment
amount and patient count methods for
each Medicare QP Performance Period.
CMS then assigns to the eligible
clinicians included in the APM Entity
group or to the eligible clinician the
score that results in the greater QP
status. QP status is greater than Partial
QP status, and Partial QP status is
greater than no QP status.
■ 22. Section 414.1440 is amended by
revising paragraphs (a)(2), (b), (c), and
(d) and adding paragraphs (e), (f), and
(g) to read as follows:
§ 414.1440 Qualifying APM participant
determination: All-payer combination
option.
(a) * * *
(2) Payments and associated patient
counts under paragraph (a)(1) of this
section, are included in the numerator
and denominator as specified in
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paragraphs (b)(2) and (3) of this section
for an eligible clinician if CMS
determines that there is at least one
Medicaid APM or Medicaid Medical
Home Model that is an Other Payer
Advanced APM available in the county
where the eligible clinician sees the
most patients during the All-Payer QP
Performance Period, and that the
eligible clinician is eligible to
participate in the Other Payer Advanced
APM based on their specialty.
(b) Payment amount method. (1) In
general. The Threshold Score for an
eligible clinician will be calculated by
dividing the value described under the
numerator by the value described under
the denominator as specified in
paragraphs (b)(2) and (3) of this section.
(2) Numerator. The aggregate amount
of all payments from all payers, except
those excluded under paragraph (a) of
this section, attributable to the eligible
clinician under the terms of Advanced
APMs and Other Payer Advanced APMs
during the All-Payer QP Performance
Period. CMS calculates Medicare Part B
covered professional services under the
All-Payer Combination Option at the
eligible clinician level.
(3) Denominator. The aggregate
amount of all payments from all payers,
except those excluded under paragraph
(a) of this section, made to the eligible
clinician during the All-Payer QP
Performance Period. CMS calculates
Medicare Part B covered professional
services under the All-Payer
Combination Option at the eligible
clinician level.
(c) Patient count method. (1) In
general. The Threshold Score for an
eligible clinician is calculated by
dividing the value described under the
numerator by the value described under
the denominator as specified in
paragraphs (c)(2) and (3) of this section.
(2) Numerator. The number of unique
patients to whom the eligible clinician
furnishes services that are included in
the measures of aggregate expenditures
used under the terms of all Advanced
APMs and Other Payer Advanced APMs
during the All-Payer QP Performance
Period.
(3) Denominator. The number of
unique patients to whom the eligible
clinician furnishes services under all
non-excluded payers during the AllPayer QP Performance Period.
(d) QP Determinations under the AllPayer Combination Option. (1) Eligible
clinicians are assessed under the AllPayer Combination Option at the
individual level only. CMS performs QP
determinations following the All-Payer
QP Performance Period using payment
amount and patient count information
submitted to CMS by APM Entities or
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eligible clinicians for January 1 through
March 31 and January 1 through June
30.
(2) If the Medicare Threshold Score
for an eligible clinician is higher when
calculated for the APM Entity group
than when calculated for the individual
eligible clinician, CMS makes the QP
determination under the All-Payer
Combination Option using a weighted
Medicare Threshold Score that will be
factored into an All-Payer Combination
Option Threshold Score calculated at
the individual eligible clinician level.
(e) Information used to calculate
Threshold Scores under the All-Payer
Combination Option. (1) To request a
QP determination under the All-Payer
Combination Option, an APM Entity or
eligible clinician may request that we
evaluate whether a payment
arrangement meets the Other Payer
Advanced APM criteria as set forth in
§ 414.1445(b)(2) and may demonstrate
participation in an Other Payer
Advanced APM determined as a result
of requests made in § 414.1445(a) and
(b)(1) in a form and manner specified by
CMS.
(2) To request a QP determination
under the All-Payer Combination
Option, for each payment arrangement
submitted as set forth in paragraph
(e)(1), the APM Entity or eligible
clinician must include the amount of
revenue for services furnished through
the payment arrangement, the total
revenue received from the all payers
except those excluded as provided in
paragraph (a)(2) of this section, the
number of patients furnished any
service through the arrangement, and
the total number of patients furnished
any services, except those excluded as
provided in paragraph (a)(2) of this
section, during the All-Payer QP
Performance Period.
(f) Requirement to submit sufficient
information. (1) CMS makes a QP
determination with respect to the
eligible clinician under the All-Payer
Combination Option only if the APM
Entity or eligible clinician submits the
information required under paragraphs
(e)(1) and (2) of this section sufficient
for CMS to assess the eligible clinician
under either the payment amount or
patient count as described in paragraphs
(b) and (c) of this section.
(2) Certification. The APM Entity or
eligible clinician who submits
information to request a QP
determination under the All-Payer
Combination Option must certify that
the information submitted to CMS is
true, accurate, and complete. Such
certification must accompany the
submission. In the case of information
submitted by an APM Entity, the
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certification must be made by an
individual with the authority to bind
the APM Entity.
(g) Notification of QP determination.
CMS notifies eligible clinicians
determined to be QPs or Partial QPs for
a year as soon as practicable after QP
calculations are conducted.
■ 23. Section 414.1445 is revised to read
as follows:
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§ 414.1445 Determination of other payer
advanced APMs.
(a) Determination of Medicaid APMs.
Beginning in 2018, at a time determined
by CMS, a state, APM Entity, or eligible
clinician may request, in a form and
manner specified by CMS, that CMS
determine whether a payer arrangement
authorized under Title XIX is either a
Medicaid APM or a Medicaid Medical
Home Model that meets the Other Payer
Advanced APM criteria prior to the AllPayer QP Performance Period.
(b) Determination of Other Payer
Advanced APMs. (1) Determination
prior to the All-Payer QP Performance
Period. Beginning in 2018, a payer with
a Medicare Health Plan payment
arrangement or a payment arrangement
in a CMS Multi-Payer Model may
request, in a form and manner specified
by CMS, that CMS determine whether a
payment arrangement meets the Other
Payer Advanced APM criteria under
§ 414.1420 prior to the All-Payer QP
Performance Period.
(2) Determination following the AllPayer QP Performance Period.
Beginning in 2019, an APM Entity or
eligible clinician may request, in a form
and manner specified by CMS, that CMS
determine whether a payment
arrangement meets the Other Payer
Advanced APM criteria under
§ 414.1420 following the All-Payer QP
Performance Period.
(i) CMS will not determine that a
payment arrangement is a Medicaid
APM or a Medicaid Medical Home
Model that meets the Other Payer
Advanced APM criteria after the end of
the All-Payer QP Performance Period.
(ii) [Reserved]
(c) Information Required for
Determination. (1) For a payer, APM
Entity, or eligible clinician to request
that CMS determine whether a payment
arrangement is an Other Payer
Advanced APM, Medicaid APM, or
Medicaid Medical Home Model that
meets the Other Payer Advanced APM
criteria, a payer, APM Entity, or eligible
clinician must submit payment
arrangement information necessary to
assess the payment arrangement on the
Other Payer Advanced APM criteria
under § 414.1420. If the payer, APM
Entity, or eligible clinician fails to
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submits all of the information required
under this section or does not
supplement information if the need to
do so as identified by CMS, then CMS
will not determine whether the payment
arrangement is an Other Payer
Advanced APM.
(2) If an eligible clinician submits
information showing that a payment
arrangement requires that the eligible
clinician must use CEHRT as defined in
§ 414.1305 to document and
communicate clinical care, CMS will
presume that CEHRT criterion in
§ 414.1420(b) is satisfied for that
payment arrangement.
(3) If a payment arrangement has no
outcome measure, the payer, APM
Entity, or eligible clinician submitting
payment arrangement information to
request a determination of whether a
payment arrangement meets the Other
Payer Advanced APM criteria must
certify that there is no available or
applicable outcome measure on the
MIPS list of quality measures.
(d) Certification. A payer, APM Entity,
or eligible clinician that submits
information pursuant to paragraph (c) of
this section must certify that the
information it submitted to CMS is true,
accurate, and complete. Such
certification must accompany the
submission. In case of information
submitted by an APM Entity, the
certification must be made by an
individual with the authority to bind
the APM Entity.
(e) Timing of Other Payer Advanced
APM determinations. CMS makes Other
Payer Advanced APM determinations
prior to making QP determinations
under § 414.1440.
(f) Notification of Other Payer
Advanced APM determinations. CMS
makes final Other Payer Advanced APM
determinations and notifies the
requesting payer, APM Entity, or
eligible clinician of such determinations
as soon as practicable following the
relevant submission deadline.
■ 24. Section 414.1460 is amended by
revising paragraphs (a) through (e) to
read as follows:
§ 414.1460
integrity.
Monitoring and program
(a) Vetting eligible clinicians. Prior to
payment of the APM Incentive Payment,
CMS determines if eligible clinicians
were in compliance with all Medicare
conditions of participation and the
terms of the relevant Advanced APMs in
which they participated during the
Medicare QP Performance Period. A
determination under this provision is
not binding for other purposes.
(b) Rescinding QP Determinations.
CMS may rescind a QP determination if:
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(1) Any of the information CMS relied
on in making the QP determination was
inaccurate or misleading.
(2) The QP is terminated from an
Advanced APM or Other Payer
Advanced APM during the Medicare QP
Performance Period, All-Payer QP
Performance Period or Incentive
Payment Base Period; or
(3) The QP is found to be in violation
of the terms of the relevant Advanced
APM or any Federal, State, or tribal
statute or regulation during the
Medicare QP Performance Period, AllPayer Performance Period or Incentive
Payment Base Period.
(c) Information submitted for AllPayer Combination Option. Information
submitted by payers, APM Entities, or
eligible clinicians for purposes of the
All-Payer Combination Option may be
subject to audit by CMS.
(d) Reducing, Denying, and Recouping
of APM Incentive Payments.
(1) CMS may reduce or deny an APM
Incentive Payment to an eligible
clinician
(i) Who CMS determines is not in
compliance with all Medicare
conditions of participation and the
terms of the relevant Advanced APM in
which they participate during the
Medicare QP Performance Period, AllPayer QP Performance Period, or
Incentive Payment Base Period;
(ii) Who is terminated by an APM or
Advanced APM during the Medicare QP
Performance Period, All-Payer QP
Performance Period, or Incentive
Payment Base Period; or
(iii) Whose APM Entity is terminated
by an APM or Advanced APM for noncompliance with any Medicare
condition of participation or the terms
of the relevant Advanced APM in which
they participate during the Medicare QP
Performance Period, All-Payer QP
Performance Period, or Incentive
Payment Base Period.
(2) CMS may reopen, revise, and
recoup an APM Incentive Payment that
was made in error in accordance with
procedures similar to those set forth at
§§ 405.980 through § 405.986 and
§§ 405.370 through 405.379 of this
chapter or as established under the
relevant APM.
(e) Maintenance of records. (1) A
payer that submits information to CMS
under § 414.1445 for assessment under
the All-Payer Combination Option must
maintain such books, contracts, records,
documents, and other evidence as
necessary to enable the audit of an
Other Payer Advanced APM
determination. Such information and
supporting documentation must be
maintained for a period of 10 years after
submission.
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(2) An APM Entity or eligible
clinician that submits information to
CMS under § 414.1445 for assessment
under the All-Payer Combination
Option or § 414.1440 for QP
determinations must maintain such
books, contracts, records, documents,
and other evidence as necessary to
enable the audit of an Other Payer
Advanced APM determination, QP
determinations, and the accuracy of
APM Incentive Payments for a period of
10 years from the end of the All-Payer
QP Performance Period or from the date
of completion of any audit, evaluation,
or inspection, whichever is later, unless:
(i) CMS determines there is a special
need to retain a particular record or
group of records for a longer period and
notifies the APM Entity or eligible
clinician at least 30 days before the
formal disposition date; or
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(ii) There has been a termination,
dispute, or allegation of fraud or similar
fault against the APM Entity or eligible
clinician, in which case the APM Entity
or eligible clinician must retain records
for an additional 6 years from the date
of any resulting final resolution of the
termination, dispute, or allegation of
fraud or similar fault.
(3) A payer, APM Entity or eligible
clinician that submits information to
CMS under §§ 414.1440 or 414.1445
must provide such information and
supporting documentation to CMS upon
request.
*
*
*
*
*
PO 00000
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Dated: June 7, 2017.
Seema Verma,
Administrator, Centers for Medicare &
Medicaid Services.
Dated: June 13, 2017.
Thomas E. Price,
Secretary, Department of Health and Human
Services.
Appendix
Note: For previously finalized MIPS
quality measures, we refer readers to Table A
in the Appendix of the CY 2017 Quality
Payment Program final rule (81 FR 77558).
For previously finalized MIPS specialty
measure sets, we refer readers to Table E in
the Appendix of the CY 2017 Quality
Payment Program final rule (81 FR 77686).
Except as otherwise proposed below,
previously finalized measures and specialty
measure sets would continue to apply for the
Quality Payment Program year 2 and future
years.
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TABLE Group A: New Quality Measures Proposed for Inclusion in MIPS for the 2018
Performance Period
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.
.
AlA verage Ch angem B ac k P am t o11 owmg L urn b ar D.
1scect omy /L ammo t omy
..
Category
Description
NQF#:
Not Applicable (NA)
Quality#:
To Be Determined (TBD)
The average change (preoperative to three months postoperative) in back pain for
Description:
patients 18 years of age or older who had lumbar discectomy I laminotomy procedure.
Measure
MN Community Measurement
Steward:
This measure is not a proportion or rate, and as such, does not have a numerator and
denominator, but has an eligible population with a calculated result. The calculated
Numerator:
result is: The average change (preoperative to three months postoperative) in back pain
for all eligible patients.
Patients 18 years of age or older as of January 1 of the measurement period who had a
lumbar discectomy I laminotomy procedure for a diagnosis of disc herniation performed
Denominator: by an eligible provider in an eligible specialty during the measurement period and
whose back pain was measured by the Visual Analog Scale (VAS) within three months
preoperatively AND at three months (6 to 20 weeks) postoperatively.
Patient who has had any additional spine procedures performed on the same date as the
Exclusions:
lumbar discectomy I laminotomy.
Measure Type: Outcome
Measure
Person and Caregiver-Centered Experience and Outcomes
Domain:
High priority
Yes (Patient Experience)
measure:
Data
Submission
Qualified Registry
Method:
CMS proposes to include this measure because it is outcomes focused and provides
measurements related to the variations in improvement after spine surgery. This
measure is useful for patients in evaluating what outcomes can be expected from
Rationale:
surgery and clinicians who can conduct comparisons across results. The MAP has made
a recommendation of conditional support, with the conditions of submission to NQF for
endorsement and verification that testing supports implementation at the individual
clinician level (https:/lwww.qualityforum.orglmapl)
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Category
NQF#:
Quality#:
Description:
Measure
Steward:
.
.
A2Average Ch angem Bac k Pam f o11 owmg Lurn b ar F US IOn
..
Description
Not Applicable (NA)
To Be Determined (TBD)
The average change (preoperative to one year postoperative) in back pain for patients 18
years of age or older who had lumbar spine fusion surgery.
MN Community Measurement
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This measure is not a proportion or rate, and as such, does not have a numerator and
denominator, but has an eligible population with a calculated result.
Numerator:
The calculated result is: The average change (preoperative to one year postoperative) in
back pain for all eligible patients.
Patients 18 years of age or older as of January 1 of the measurement period who had a
lumbar spine fusion surgery performed by an eligible provider in an eligible specialty
Denominator: during the measurement period and whose back pain was measured by the Visual
Analog Scale (VAS) within three months preoperatively AND at one year(+/- 3
months) postoperatively.
Exclusions:
None
Measure Type: Outcome
Measure
Person and Caregiver-Centered Experience and Outcomes
Domain:
High priority
Yes (Patient Experience)
measure:
Data
Qualified Registry
Submission
Method:
CMS proposes to include this measure because it is outcomes focused and provides
measurements related to the variations in improvement after spine surgery in patients.
This measure is an example of quality measurement as the results can be used in
Rationale:
evaluating whether the patient's pain was reduced as a result of the lumbar fusion. The
MAP has made a recommendation of conditional support, with the conditions of
submission to NQF for endorsement and verification that testing supports
implementation at the individual clinician level.(https://www.qualityfomm.org/map/)
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30263
·L
A3Average Ch angem eg p·rn owmg L urn b ar D.
am o
1scect omy /L ammo t omy
..
Description
Not Applicable (NA)
To Be Determined (TBD)
The average change (preoperative to three months postoperative) in leg pain for patients
Description:
18 years of age or older who had lumbar discectomy I laminotomy procedure.
Category
NQF#:
Quality#:
Numerator:
Denominator:
Exclusions:
Measure
Type:
Measure
Domain:
High priority
measure:
Data
Submission
Method:
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Rationale:
VerDate Sep<11>2014
MN Community Measurement
The average change (preoperative to three months postoperative) in leg pain for all
eligible patients.
Patients 18 years of age or older as of January 1 of the measurement period who had a
lumbar discectomy and/or laminotomy procedure for a diagnosis of disc herniation
performed by an eligible provider in an eligible specialty during the measurement
period and whose leg pain was measured by the Visual Analog Scale (VAS) within
three months preoperatively AND at three months (6 to 20 weeks) postoperatively.
Patient had any additional spine procedures performed on the same date as the lumbar
discectomyI laminotomy.
Outcome
Person and Caregiver-Centered Experience and Outcomes
Yes (Patient Experience)
Qualified Registry
CMS proposes to include this measure because it is outcomes focused and provides
measurements related to the variations in improvement after spine surgery. This
measure is useful for clinicians who can conduct comparisons across results. The MAP
has made a recommendation of conditional support, with the conditions of submission
to NQF for endorsement and verification that testing supports implementation at the
individual clinician level.(https://www.qualityforum.org/map/)
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Measure
Steward:
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A.4. Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen
Depnvaf wn Th erapy
.
Category
Description
Not Applicable (NA)
NQF#:
Quality#:
To Be Determined (TBD)
Patients determined as having prostate cancer who are currently starting or undergoing
androgen deprivation therapy (ADT), for an anticipated period of 12 months or greater
Description:
and who receive an initial bone density evaluation. The bone density evaluation must be
prior to the start of ADT or within 3 months of the start of ADT.
Measure
Oregon Urology Institute
Steward:
Patients with a bone density evaluation within the two years prior to the start of or less
Numerator:
than three months after the start of ADT treatment.
Patients determined as having prostate cancer who are currently starting or undergoing
Denominator:
androgen deprivation therapy (ADT), for an anticipated period of 12 months or greater.
None
Exclusions:
Measure Type: Process
Measure
Effective Clinical Care
Domain:
High priority
No
measure:
Data
Submission
EHR
Method:
CMS proposes to include this measure as there are no quality measures that currently
address patients with prostate cancer and a diagnosis of osteoporosis. This measure will
Rationale:
result in better care, reduced fractures, and reduced bone density loss. The MAP has
made a recommendation of conditional support, with the condition for the completion of
N QF endorsement. (https://www .qualityfomm.org/map/)
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"f
ASP reven f IOn ofP os t - 0•peraf 1ve V Omimg (POV) - C om b.maf IOn Th erapy (P e d" t ncs )
1a .
Category
Description
NQF#:
Not Applicable (NA)
Quality#:
To Be Determined (TBD)
Percentage of patients aged 3 through 17 years, who undergo a procedure under general
anesthesia in which an inhalational anesthetic is used for maintenance AND who have
Description:
two or more risk factors for post-operative vomiting (POV), who receive combination
therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of
different classes preoperatively and/or intraoperatively.
Measure
American Society of Anesthesiologists
Steward:
Patients who receive combination therapy consisting of at least two prophylactic
Numerator:
pharmacologic anti-emetic agents of different classes preoperatively and/or
intraoperatively.
All patients, aged 3 through 17 years, who undergo a procedure under general anesthesia
Denominator:
in which an inhalational anesthetic is used for maintenance AND who have two or more
risk factors for POV.
Cases in which an inhalational anesthetic is used only for induction.
Exclusions:
Organ Donors as designated by ASA Physical Status 6
Measure Type: Process
Measure
Effective Clinical Care
Domain:
High priority
No
measure:
Data
Submission
Qualified Registry
Method:
CMS proposes to include this measure because it recognizes the difference in therapy
required for the pediatric population with regards to the prevention of post-operative
vomiting; furthermore, the American Society of Anesthesiologists have verified that
testing supports the implementation of the measure at the individual clinician level. The
Rationale:
MAP has made a recommendation of conditional support, with the conditions of
submission to NQF for endorsement and verification that testing supports implementation
at the individual clinician level.(https://www.qualityfomm.org/map/)
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.
A .. Off M e d"Ia WI EffUSIOn (OME) : S t ernie A nf Imicro b" I s- A vm ance ofi nappropnate use
6
"th
.
.
.
"d
,ys
I IS
1a
Category
Description
NQF#:
657
To Be Determined (TBD)
Quality#:
Percentage of patients aged 2 months through 12 years with a diagnosis ofOME who
Description:
were not prescribed systemic antimicrobials.
Measure
American Academy of Otolaryngology- Head and Neck Surgery Foundation
(AAOHNSF)
Steward:
Patients who were not prescribed systemic antimicrobials.
Numerator:
Denominator:
All patients aged 2 months through 12 years with a diagnosis of OME.
Exclusions:
Documentation ofmedical reason(s) for prescribing systemic antimicrobials.
Measure Type: Process
Measure
Patient Safety, Efficiency and Cost Reduction
Domain:
High priority
Yes (Appropriate Use)
measure:
Data
Submission
Qualified Registry
Method:
CMS proposes to include this measure as it promotes the practice of appropriate
prescription and usage of medications in the care of all beneficiaries to facilitate health
and promote well-being. The MAP has made a recommendation of support for this NQF
Rationale:
endorsed measure. (https ://www .qualityfomm.org/map/)
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30267
A.7. Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and
Interrogation of Ovarian Arteries
Category
NQF#:
Quality#:
Description:
Measure
Steward:
Description
Not Applicable (NA)
To Be Determined (TBD)
Documentation of angiographic endpoints of embolization AND the documentation of
embolization strategies in the presence of unilateral or bilateral absent uterine arteries.
Society of Interventional Radiology
Number of patients undergoing uterine artery embolization for symptomatic leiomyomas
and/or adenomyosis in whom embolization endpoints are documented separately for each
embolized vessel AND ovarian artery angiography or embolization performed in the
presence of variant uterine artery anatomy.
Numerator:
Denominator:
Exclusions:
Embolization endpoints: Complete stasis (static contrast column for at least 5 heartbeats)
I Near-stasis (not static, but contrast visible for at least 5 heartbeats) I Slowed flow
(contrast visible for fewer than 5 heartbeats) I Normal velocity flow with pruning of
distal vasculature I Other [specify] I Not documented
Embolization strategy options for variant uterine artery anatomy: Ovarian artery
angiography, Ovarian artery embolization, Abdominal Aortic angiography, None
All patients undergoing uterine artery embolization for symptomatic leiomyomas and/or
adenomyosis.
SIR Guidance: Any patients that should be excluded from reporting either in the eligible
population (denominator) or from both numerator and denominator (if patient
experiences outcome then exclude from denominator and numerator; if not then include
in denominator). Method to risk adjust measure.
Process
Yes (Patient Safety)
Rationale:
The MAP has made a recommendation of refine and resubmit based on lack of test data.
CMS proposes to include this measure, as field testing has been completed and there are
currently no applicable uterine artery embolization technique measures in CMS quality
programs. (https://www.qualityfomm.org/map/)
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Measure Type:
Measure
Domain:
High priority
measure:
Data
Submission
Method:
30268
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A.S. Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life
Category
NQF#:
Quality#:
Description:
Measure
Steward:
Numerator:
Description
1516
To Be Determined (TBD)
The percentage of children 3-6 years of age who had one or more well-child visits with a
PCP during the measurement year.
National Committee for Quality Assurance
Children who received at least one well-child visit with a PCP during the measurement
year. The measurement year (12 month period).
Children 3-6 years of age during the measurement year.
Denominator:
Numerator Exclusions:
Do not include services rendered during an inpatient or ED visit.
Measure Type:
Measure
Domain:
High priority
measure:
Data
Submission
Method:
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Rationale:
VerDate Sep<11>2014
Preventive services may be rendered on visits other than well-child visits. Well-child
preventive services count toward the measure, regardless of the primary intent of the
visit, but services that are specific to an acute or chronic condition do not count toward
the measure.
Process
Community/Population Health
No
Qualified Registry
This pediatric measure fulfills an important measurement gap for pediatric patients in the
3 through 6 year olds age range; therefore, CMS is proposing its inclusion in the Pediatric
specialty measure set.
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Exclusions:
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30269
A.9. Developmental Screening in the First Three Years of Life
Category
NQF#:
Quality#:
Description:
Measure
Steward:
Description
1448
To Be Determined (TBD)
The percentage of children screened for risk of developmental, behavioral and social
delays using a standardized screening tool in the first three years of life. This is a measure
of screening in the first three years of life that includes three, age-specific indicators
assessing whether children are screened by 12 months of age, by 24 months of age and by
36 months of age.
Oregon Health & Science University
The numerator identifies children who were screened for risk of developmental,
behavioral and social delays using a standardized tool. National recommendations call for
children to be screened at the 9, 18, and 24- OR 30-month well visits to ensure periodic
screening in the first, second, and third years of life. The measure is based on three, agespecific indicators.
Numerator 1: Children in Denominator 1 who had screening for risk of developmental,
behavioral and social delays using a standardized screening tool that was documented by
their first birthday.
Numerator:
Numerator 2: Children in Denominator 2 who had screening for risk of developmental,
behavioral and social delays using a standardized screening tool that was documented by
their second birthday.
Numerator 3: Children in Denominator 3 who had screening for risk of developmental,
behavioral and social delays using a standardized screening tool that was documented by
their third birthday.
Numerator 4: Children in Denominator 4 who had screening for risk of developmental,
behavioral and social delays using a standardized screening tool that was documented by
their first, second or third birthday.
Children who meet the following eligibility requirement:
Age: Children who tum 1, 2 or 3 years of age between January 1 and December 31 of the
measurement year.
Exclusions:
Measure Type:
Measure
Domain:
VerDate Sep<11>2014
Continuous Enrollment: Children who are enrolled continuously for 12 months prior to
child's 1st, 2nd or 3rd birthday.
Allowable Gap: No more than one gap in enrollment of up to 45 days during the
measurement year. To determine continuous enrollment for a Medicaid beneficiary for
whom enrollment is verified monthly, the beneficiary may not have more than a 1-month
gap in coverage (i.e., a beneficiary whose coverage lapses for 2 months (60 days) is not
considered continuously enrolled.
None
Process
Community/Population Health
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Denominator:
30270
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Rationale:
VerDate Sep<11>2014
Description
No
Qualified Registry
This pediatric measure fulfills an important measurement gap related to developmental
screening for pediatric patients in the 1 through 3 year olds age range; therefore, CMS is
proposing its inclusion in the Pediatric specialty measure set.
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Category
High priority
measure:
Data
Submission
Method:
30271
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TABLE Group B: Proposed New and Modified MIPS Specialty Measure Sets for
the 2018 Performance Period
Note: CMS has proposed to modify the specialty measure sets below based upon review of updates made to existing
quality measure specifications, the proposal of adding new measures for inclusion in MIPS, and the feedback
provided by specialty societies. Existing measures with proposed substantive changes are noted with an asterisk (*),
core measures as agreed upon by Core Quality Measure Collaborative (CQMC) are noted with the symbol (§), high
priority measures are noted with an exclamation point(!), and high priority measures that are appropriate use
measures are noted with a double exclamation point(!!) in the colunm.
B 1 All ergy1/1 mmuno ogy
*
0041
0043
0419
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§
VerDate Sep<11>2014
0405
Quality
#
110
111
130
160
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Data
Measure
Submission Type
Method
147v7
Claims,
Web
Interface,
Registry,
EHR
127v6
Claims,
Web
Interface,
Registry,
EHR
68v7
52v6
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EHR
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Process
Process
Process
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National
Quality
Strategy
Domain
.·
Measure Title
And Description
·.
Measure
Steward
·.
Community/
Population
Health
Preventive Care and Screening:
Influenza Immunization:
Percentage of patients aged 6
months and older seen for a visit
between October 1 and March 31
who received an influenza
inununization OR who reported
previous receipt of an influenza
inununization.
Community/
Population
Health
National
Pneumonia Vaccination Status for
Committee
Older Adults:
or
Percentage of patients 65 years of
Quality
age and older who have ever
Assurance
received a pnerunococcal vaccine.
Patient
Safety
Effective
Clinical Care
Sfmt 4725
Documentation of Current
Medications in the Medical
Record:
Percentage of visits for patients
aged 18 years and older for which
the eligible professional attests to
documenting a list of current
medications using all immediate
resources available on the date of
the encounter. This list must include
ALL known prescriptions, over-thecounters, herbals, and
vitamin/mineral/dietary (nutritional)
supplements AND must contain the
medications' name, dosage,
frequency and route of
administration.
HIV/AIDS: Pneumocystis Jiroveci
Pneumonia (PCP) Prophylaxis:
Percentage of patients aged 6 weeks
and older with a diagnosis of
HIV/AIDS who were prescribed
Pneumocystis Jiroveci Pneumonia
(PCP) prophylaxis.
E:\FR\FM\30JNP2.SGM
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Physician
Consortirun
or
Performance
mprovement
PCPI®)
Centers for
Medicare &
Medicaid
Services
National
Committee
or
Quality
Assurance
EP30JN17.021
Indicator
NQF
#
CMSEMeasure
ID
30272
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B 1 All en :y1/1 mmuno ogy ( con f mue d)
*
§
*
Quality
#
#
0028
0022
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N/A
VerDate Sep<11>2014
226
238
317
19:16 Jun 29, 2017
CMS.£~
Measure
ID
Data
Measure
Submission Type
Method
138v6
Claims,
Registry,
EHR,
Web
Interface
156v6
Registry,
EHR
22v6
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EHR
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Process
National
Quality
Strategy
Domain
Community/Po
pulation Health
Process
Patient Safety
Process
Community /Po
pulation Health
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Measure Title
and Description
Preventive Care and
Screening: Tobacco Use:
Screening and Cessation
Intervention:
a. Percentage of patients aged 18
years and older who were
screened for tobacco use one
or more times within 24
months
b. Percentage of patients aged
18 years and older who were
screened for tobacco use and
identified as a tobacco user
who received tobacco
cessation intervention
c. Percentage of patients aged 18
years and older who were
screened for tobacco use one
or more times within 24
months AND who received
cessation counseling
intervention if identified as a
tobacco user.
Use of High-Risk Medications
in the Elderly:
Percentage of patients 65 years
of age and older who were
ordered high-risk medications.
Two rates are reported.
a. Percentage of patients who
were ordered at least one highrisk medication.
b. Percentage of patients who
were ordered at least two of the
same high-risk medications.
Preventive Care and
Screening: Screening for High
Blood Pressure and Follow-Up
Documented:
Percentage of patients aged 18
years and older seen during the
reporting period who were
screened for high blood pressure
AND a recommended follow-up
plan is documented based on the
current blood pressure (BP)
reading as indicated.
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Measure
Steward
Physician
~onsortium
or
Performance
mprovement
foundation
PCPI®)
National
f=ommittee for
puality
f"\ssurance
f=enters for
~edicare &
~edicaid
~ervices
EP30JN17.022
Indicator
NQF
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30273
B.l. Allergy/lmmuno ogy (continued)
Indicator
§
!
NQF
#
2082
2079
*
N/A
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#
338
340
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402
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Data
Submission
Method
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Registry
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Registry
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EHR
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PO 00000
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Measure
Type
putcome
National
Quality
Strategy
Domain
Effective
Clinical
Care
Process
Efficiency
and Cost
Reduction
Process
Communi
cation and
Care
Coordinati
on
Process
Communit
y/
Population
Health
Fmt 4701
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.Measure Title
and Descripti()n
lllV Viral Load
Suppression:
The percentage of patients,
regardless of age, with a
diagnosis ofHlV with a HlV
viral load less than 200
copies/mL at last HlV viral
load test during the
measurement year.
lllV Medical Visit
Frequency: Percentage of
patients, regardless of age with
a diagnosis ofHlV who had at
least one medical visit in each 6
month period of the 24 month
measurement period, with a
minimum of 60 days between
medical visits.
Closing the Referral Loop:
Receipt of Specialist Report:
Percentage of patients with
referrals, regardless of age, for
which the referring provider
receives a report from the
provider to whom the patient
was referred.
Tobacco Use and Help with
Quitting Among
Adolescents:
The percentage of adolescents
12 to 20 years of age with a
primary care visit during the
measurement year for whom
tobacco use status was
documented and received help
with quitting if identified as a
tobacco user.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
Health Resource
and Services
Administration
Health
Resources and
Services
Administration
Centers for
Medicare &
Medicaid
Services
National
Committee for
Quality
Assurance
EP30JN17.023
·.
.•
30274
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.·
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National
Quality
Strategy
Domain
Measure Xitle
and Description
Effective
Clinical
Care
Coronary Artery Bypass Graft
(CABG): Preoperative BetaBlocker in Patients with Isolated
CABG Surgery: Percentage of
isolated Coronary Artery Bypass
Graft (CABG) surgeries for
patients aged 18 years and older
who received a beta-blocker within
24 hours prior to surgical incision.
Sfmt 4725
Measure
Steward
·.··
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Centers for
Medicare
&
Medicaid
Services
EP30JN17.024
Indicator
Quality
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
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!
*
§
N/A
0028
Quality
#
076
226
CMSEMeasure
ID
N/A
138v6
Data
Submission
Method
Claims,
Registry
Claims, Web
Interface,
Registry,
Measure
Type
National Quality
Strategy Domain
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·steward
..
·.
Process
Process
Patient Safety
Community/
Population Health
EHR
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Measure Title
and Description
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Prevention of Central
Venous Catheter
(CVC)-Related
Bloodstream
Infections:
Percentage of patients,
regardless of age, who
undergo central venous
catheter (CVC)
insertion for whom
eve was inserted with
all elements of maximal
sterile barrier technique,
hand hygiene, skin
preparation and, if
ultrasound is used,
sterile ultrasound
techniques followed.
Preventive Care and
Screening: Tobacco
Use: Screening and
Cessation
Intervention:
a. Percentage of patients
aged 1g years and
older who were
screened for tobacco
use one or more
times within 24
months
b. Percentage of patients
aged 18 years and
older who were
screened for tobacco
use and identified as
a tobacco user who
received tobacco
cessation
intervention
c. Percentage of patients
aged 18 years and
older who were
screened for tobacco
use one or more
times within 24
months AND who
received cessation
counseling
intervention if
identified as a
tobacco user.
E:\FR\FM\30JNP2.SGM
30JNP2
American
Society of
Anesthesiologists
Physician
Consortium for
Performance
Improvement
Foundation
(PCPI®)
EP30JN17.025
Indicator
NQF
#
30276
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.
B2 A nes th esw I ogy ( con fmue d)
#
N/A
Quality#
317
CMSE•
MeasureiD
Data Submission
Method
Claims, Registry,
EHR
22v6
MeasUFe
Type
National
Quality
Strategy
Domain
Process
Community/
Population
Health
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Registry
Process
ComnllmityI
Population
Health
N/A
404
N/A
Registry
Intermed
iate
Outcome
Effective
Clinical Care
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Measure Title
and Description
Measure
Steward
.·
Preventive Care and
Screening: Screening
for High Blood
Pressure and FollowUp Documented:
Percentage of patients
aged 18 years and
older seen during the
reporting period who
were screened for
high blood pressure
AND a recommended
follow-up plan is
documented based on
the current blood
pressure (BP) reading
as indicated.
Tobacco Use and
Help with Quitting
Among Adolescents:
The percentage of
adolescents 12 to 20
years of age with a
primary care visit
during the
measurement year for
whom tobacco use
status was
documented and
received help with
quitting if identified
as a tobacco user.
Anesthesiology
Smoking
Abstinence: The
percentage of current
smokers who abstain
from cigarettes prior
to anesthesia on the
day of elective
surgery or procedure.
30JNP2
Centers for
Medicare &
Medicaid
Services
National
Conunittee
for Quality
Assurance
American
Society of
Anesthesiolo
gists
EP30JN17.026
Indicator
NQF
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30277
.
B2 A nes th esw I ogy con mue d)
Indicator .
Quality
NQF
#
#
CMSEMeasure
ID
Data
Submission
Method
Measure
Type
··.
!
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PO 00000
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National
Quality
Strategy
Domain
Outcome
Patient
Safety
Process
Communicat
ion and Care
Coordination
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Measure· Title
and Description
Perioperative Temperature
Management: Percentage of patients,
regardless of age, who undergo
surgical or therapeutic procedures
under general or neuraxial anesthesia
of 60 minutes duration or longer for
whom at least one body temperature
greater than or equal to 35.5 degrees
Celsius (or 95.9 degrees Fahrenheit)
was recorded within the 30 minutes
immediately before or the 15 minutes
immediately after anesthesia end
time.
Post-Anesthetic Transfer of Care
Measure: Procedure Room to a
Post Anesthesia Care Unit (PACU):
Percentage of patients, regardless of
age, who are under the care of an
anesthesia practitioner and are
admitted to a PACU in which a postanesthetic fonnal transfer of care
protocol or checklist which includes
the key transfer of care elements is
utilized.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
American
Society of
Anesthesiolo
gists
American
Society of
Anesthesiolo
gists
EP30JN17.027
I
30278
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.
B2 A nes th esw I ogy ( con fmue d)
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'
N/A
N/A
N/A
VerDate Sep<11>2014
Data
Measure Submission
ID
Method
#
..
!
CMSE~.
Quality
427
430
TBD
19:16 Jun 29, 2017
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N/A
N/A
Jkt 241001
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Registry
Registry
PO 00000
Process
National
Quality
Strategy
Domain
Conununication
and Care
Coordination
Process
Patient Safety
Process
Effective
Clinical Care
Frm 00270
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Measure Title
and Description
Measure
Steward
Post-Anesthetic Transfer of
Care: Use of Checklist or
Protocol for Direct Transfer of
Care from Procedure Room to
Intensive Care Unit (ICU):
Percentage of patients,
regardless of age, who undergo
a procedure under anesthesia
American
and are admitted to an Intensive
Society of
Care Unit (ICU) directly from
Anesthesiologists
the anesthetizing location, who
have a documented use of a
checklist or protocol for the
transfer of care from the
responsible anesthesia
practitioner to the responsible
ICU team or team member.
Prevention of Post-Operative
Nausea and Vomiting
(PONV) - Combination
Therapy:
Percentage of patients, aged 18
years and older, who undergo a
procedure under an inhalational
general anesthetic, AND who
have three or more risk factors
for post-operative nausea and
vomiting (PONV), who receive
combination therapy consisting
of at least two prophylactic
pharmacologic antiemetic agents
of different classes
preoperatively or
inlraoperali vely.
Prevention of Post-Operative
Vomiting (POV) Combination Therapy
(Pediatrics):
Percentage of patients aged 3
through 17 years of age, who
undergo a procedure under
general anesthesia in which an
inhalational anesthetic is used
for maintenance AND who
have two or more risk factors
for post-operative vomiting
(POV), who receive
combination therapy consisting
of at least two prophylactic
pharmacologic anti-emetic
agents of different classes
preoperatively and/or
intraoperatively.
E:\FR\FM\30JNP2.SGM
30JNP2
American
Society of
Anesthesiologists
American
Society of
Anesthesiologists
EP30JN17.028
Indicator
NQF
#
30279
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
NQF
Quality
#
#
CMSRData
Measure Submission
1D
Method
Measure
Type
Quality •
Strategy
Domain
§
0081
005
135v6
Registry,
EHR
Process
Effective
Clinical
Care
§
0067
006
N/A
Registry
Process
Effective
Clinical
Care
§
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Registry,
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Process
Frm 00271
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Effective
Clinical
Care
Effective
Clinical
Care
Sfmt 4725
Measure title
and Description
Measure
Steward
·.
Heart Failure (HF): AngiotensinConverting Enzyme (ACE)
Inhibitor or Angiotensin Receptor
Blocker (ARB) Therapy for Left
Ventricular Systolic Dysfunction
(LVSD):
Percentage of patients aged 18 years
and older with a diagnosis of heart
failure (HF) with a current or prior
left ventricular ejection fraction
(L VEF) < 40% who were prescribed
ACE inhibitor or ARB therapy either
within a 12-month period when seen
in the outpatient setting OR at each
hospital discharge.
Chronic Stable Coronary Artery
Disease: Antiplatelet Therapy:
Percentage of patients aged 18 years
and older with a diagnosis of
coronary artery disease (CAD) seen
within a 12-month period who were
prescribed aspirin or clopidogreL
Coronary Artery Disease (CAD):
Beta-Blocker Therapy-Prior
Myocardial Infarction (MI) or Left
Ventricular Systolic Dysfunction
(LVEF<40%):
Percentage of patients aged 18 years
and older with a diagnosis of
coronary artery disease seen within a
12-month period who also have prior
MI OR a current or prior L VEF <
40% who were prescribed betablocker therapy.
Heart Failure (HF): Beta-Blocker
Therapy for Left Ventricular
Systolic Dysfunction (LVSD):
Percentage of patients aged 18 years
and older with a diagnosis of heart
failure (HF) with a current or prior
left ventricular ejection fraction
(L VEF) < 40% who were prescribed
beta-blocker therapy either within a
12-month period when seen in the
outpatient setting OR at each hospital
discharge.
E:\FR\FM\30JNP2.SGM
30JNP2
Physician
Consortitun tor
Performance
Improvement
Foundation
(PCPI®)
American Heart
Association
Physician
Consortitun for
Performance
Improvement
Foundation
(PCPI®)
Physician
Consortitun for
Performance
Improvement
Foundation
(PCPI®)
EP30JN17.029
Indicator
.B 3 C ar d"10Iogy
National
30280
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B 3 Cardiology (continued)
Quality
#
CMSEData
Measure Submission
1D
Method
0326
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VerDate Sep<11>2014
047
N/A
Claims,
Registry
0066
118
N/A
Registry
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PO 00000
·
Measure
Type
National
Quality
Strategy
Domain
Process
Communication
and Care
Coordination
Process
Effective
Clinical Care
Frm 00272
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Measure Title
and Description
Measure
Steward
·.
Care Plan:
Percentage of patients aged 65
years and older who have an
advance care plan or surrogate
decision maker documented in
the medical record that an
advance care plan was discussed
but the patient did not wish or
was not able to name a surrogate
decision maker or provide an
advance care plan.
Chronic Stable Coronary
Artery Disease: ACE Inhibitor
or ARB Therapy--Diabetes or
Left Ventricular Systolic
Dysfunction (LVEF <40%):
Percentage of patients aged 18
years and older with a diagnosis
of coronary artery disease seen
within a 12-month period who
also have diabetes OR a current
or prior Left Ventricular Ejection
fraction (L YEP) < 40% who
were prescribed ACE inhibitor or
ARB therapy.
E:\FR\FM\30JNP2.SGM
30JNP2
National
Committee for
Quality
Assurance
American
Heart
Association
EP30JN17.030
Indicator
NQF
#
30281
B 3 C ar d" I ogy (con fmue d)
10
Indicato
r
*
§
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F.#
y#
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CMSESubmissio
Measur · ..·
n
eiD
Method
69v6
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EHR, Web
Interface
Claims,
Registry,
EHR
PO 00000
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e
Type
Process
Process
Fmt 4701
.
National Quality
Strategy Domain
Community /Populatio
n Health
Patient Safety
Sfmt 4725
Measure title
and Description
.···
Preventive Care and
Screening: Body
Mass Index (BMI)
Screening and
Follow-Up Plan:
Percentage of patients
aged 18 years and
older with a BMI
documented during
the current encounter
or during the previous
twelve months AND
with a BMI outside of
normal parameters, a
follow-up plan is
documented during
the encounter or
during the previous
twelve months of the
current encounter.
Normal Parameters:
Age 18 years and
olderBMI => 18.5
and< 25 kg/m2.
Documentation of
Current Medications
in the Medical
Record: Percentage
of visits for patients
aged 18 years and
older for which the
eligible clinician
attests to documenting
a list of current
medications using all
immediate resources
available on the date
of the encounter. This
list must include ALL
known prescriptions,
over-the-counters,
herbals, and
vitaminlmineral/dietar
y (nutritional)
supplements AND
must contain the
medications' name,
dosage, frequency and
route of
administration.
E:\FR\FM\30JNP2.SGM
30JNP2
Measur
e
Steward
Centers
for
Medicar
e&
Medicai
d
Services
Centers
for
Medicar
e&
Medicai
d
Services
EP30JN17.031
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30282
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
Indicator
§
*
§
NQF
Quality
#
#
0068
0028
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226
236
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CMSEMeasure
ID
Data
Submission
Method
164v6
Claims,
Web
Interface,
Registry,
EHR
l38v6
Claims,
Registry,
EHR, Web
Interface
165v6
Claims,
Registry,
EHR, Web
Interface
Jkt 241001
PO 00000
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Type
Process
Process
Intermediate
Outcome
Frm 00274
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~Y
( con mue d)
National
Quality
Strategy
Domain
Effective
Clinical
Care
Community
/Population
Health
Effective
Clinical
Care
Sfmt 4725
Measure Title
and D~scription
Ischemic Vascular Disease (IVD):
Use of Aspirin or Another
Antiplatelet:
Percentage of patients 18 years of
age and older who were diagnosed
with acute myocardial infarction
(AMI), coronary artery bypass graft
(CABG) or percutaneous coronary
interventions (PCI) in the 12 months
prior to the measurement period, or
who had an active diagnosis of
ischemic vascular disease (IVD)
during the measurement period, and
who had documentation of use of
aspirin or another antiplatelet during
the measurement period.
Preventive Care and Screening:
Tobacco Use: Screening and
Cessation Intervention:
a. Percentage of patients aged 18
years and older who were screened
for tobacco use one or more times
within 24 months
b. Percentage of patients aged 18
years and older who were screened
for tobacco use and identified as a
tobacco user who received tobacco
cessation intervention
c. Percentage of patients aged 18
years and older who were screened
for tobacco use one or more times
within 24 months AND who
received cessation counseling
intervention if identified as a
tobacco user.
Controlling High Blood Pressure:
Percentage of patients 18-85 years of
age who had a diagnosis of
hypertension and whose blood
pressure was adequately controlled
(<140/90 mmHg) during the
measurement period.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
National
Connnittee for
Quality
Assurance
Physician
Consortium for
Performance
Improvement
Foundation
(PCPI®)
National
Committee for
Quality
Assurance
EP30JN17.032
B 3 C ar d' I
100
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30283
B 3 Cardiology (continued)
*
NQF
#
0022
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#
238
243
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CMSEData
Measure Submission
ID
Method
156v6
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Jkt 241001
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EHR
Registry
PO 00000
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Type
Process
Process
Frm 00275
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National Quality
·Strategy Domain
Patient Safety
Communication
and Care
Coordination
Sfmt 4725
Measure Title
and Des~;ription
Use of High-Risk Medications
in the Elderly:
Percentage of patients 65 years
of age and older who were
ordered high-risk medications.
Two rates are reported.
a. Percentage of patients who
were ordered at least one highrisk medication.
b. Percentage of patients who
were ordered at least two of the
same high-risk medications.
Cardiac Rehabilitation
Patient Referral from an
Outpatient Setting:
Percentage of patients evaluated
in an outpatient setting who
within the previous 12 months
have experienced an acute
myocardial infarction (MI),
coronary artery bypass graft
(CABG) surgery, a
percutaneous coronary
intervention (PC I), cardiac
valve surgery, or cardiac
transplantation, or who have
chronic stable angina (CSA)
and have not already
participated in an early
outpatient cardiac
rehabilitation/secondary
prevention (CR) program for
the qualifying event/diagnosis
who were referred to a CR
program.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
National
Committee for
Quality
Assurance
American
College of
Cardiology
Foundation
EP30JN17.033
Indicator
30284
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B 3 C ar d" I og, (con fmue d)
10
NQF#
Quality .•·
#
CMSEMeasureiD
Data
Submissio.n
Method
N/A
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322
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Measure
Type
National Quality
Strategy Domain
Measure Title
and Description
Measure
Steward
.·
Process
Community/Popu
lation Health
Efficiency
Efficiency and
Cost Reduction
Fmt 4701
Sfmt 4725
E:\FR\FM\30JNP2.SGM
Preventive Care and
Screening:
Screening for High
Blood Pressure and
Follow-Up
Documented:
Percentage of patients
aged 18 years and
older seen during the
reporting period who
were screened for
high blood pressure
AND a recommended
follow-up plan is
documented based on
the current blood
pressure (BP).
Cardiac Stress
Imaging Not
Meeting
Appropriate Use
Criteria:
Preoperative
Evaluation in LowRisk Surgery
Patients:
Percentage of stress
single-photon
emission computed
tomography (SPECT)
myocardial perfusion
imaging (MPI), stress
echocardiogram
(ECHO), cardiac
computed
tomography
angiography (CCTA),
or cardiac magnetic
resonance (CMR)
performed in low risk
surgery patients 18
years or older for
preoperative
evaluation during the
12-month reporting
period.
30JNP2
Centers for
Medicare &
Medicaid
Services
American
College of
Cardiology
EP30JN17.034
Ind.icator
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
Indicator
NQF
#
Quality
#
Data
CMSE·
Measure Submission
Method
ID
Measure
Type
~Y
( con mue d)
NatiQnal
Quality
Strategy
Domain
N/A
323
N/A
Registry
Efficiency
Efficiency
and Cost
Reduction
!!
N/A
324
N/A
Registry
Efficiency
Efficiency
and Cost
Reduction
§
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Claims,
Registry
Process
Effective
Clinical Care
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19:16 Jun 29, 2017
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Measure Title
and Description
Cardiac Stress Imaging Not
Meeting Appropriate Use
Criteria: Routine Testing After
Percutaneous Coronary
Intetvention (PCI):
Percentage of all stress singlephoton emission computed
tomography (SPECT) myocardial
perfusion imaging (MPI), stress
echocardiogram (ECHO), cardiac
computed tomography angiography
(CCTA), and cardiovascular
magnetic resonance (CMR)
performed in patients aged 18 years
and older routinely after
percutaneous coronary intervention
(PCI), with reference to timing of
test after PCI and symptom status.
Cardiac Stress Imaging Not
Meeting Appropriate Use
Criteria: Testing in
Asymptomatic, Low-Risk
Patients: Percentage of all stress
single-photon emission computed
tomography (SPECT) myocardial
perfusion imaging (MPI), stress
echocardiogram (ECHO), cardiac
computed tomography angiography
(CCTA), ami cardiovascular
magnetic resonance (CMR)
performed in asymptomatic, low
coronary heart disease (CHD) risk
patients 18 years and older for
initial detection and risk
assessment
Chronic Anticoagulation
Therapy: Percentage of patients
aged 18 years and older with a
diagnosis of nonvalvular atrial
fibrillation (AF) or atrial flutter
whose assessment of the specified
thromboembolic risk factors
indicate one or more high-risk
factors or more than one moderate
risk factor, as determined by
CHADS2 risk stratification, who
are prescribed warfarin OR another
oral anticoagulant drug that is FDA
approved for the prevention of
thromboembolism.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
American
College of
Cardiology
American
College of
Cardiology
American
College of
Cardiology
EP30JN17.035
B 3 C ar d' I
100
..
30285
30286
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
Indicator
NQF
#
CMSEQuality
Measure
#
..
ID
Data
Submission
Method
Measure
Type
~Y
( con mue d)
National
Quality
Strategy
Domain
!
N/A
344
N/A
Registry
Outcome
N/A
345
N/A
Registry
Outcome
Effective
Clinical
Care
N/A
*
!
N/A
N/A
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Rate of Carotid Artery Stenting
(CAS) for Asymptomatic Patients,
Without Major Complications
(Discharged to Home by PostOperative Day #2):
Percent of asymptomatic patients
undergoing CAS who are discharged
to home no later than post-operative
day #2.
Rate of Postoperative Stroke or
Death in Asymptomatic Patients
Undergoing Carotid Artery
Stenting (CAS):
Percent of asymptomatic patients
undergoing CAS who experience
stroke or death following surgery
while in the hospitaL
Effective
Clinical
Care
!
VerDate Sep<11>2014
373
374
402
431
19:16 Jun 29, 2017
~5v7
50v6
N/A
N/A
Jkt 241001
Intermed
iate
Outcome
EHR
Registry,
EHR
Registry
Registry
PO 00000
Measure Title
and Description
Effective
Clinical
Care
Hypertension: Improvement in
Blood Pressure:
Percentage of patients aged 18-85
years of age with a diagnosis of
hypertension whose blood pressure
improved during the measurement
period.
Process
Communica
tion and
Care
Coordinatio
n
Closing the Referral Loop:
Receipt of Specialist Report:
Percentage of patients with referrals,
regardless of age, for which the
referring provider receives a report
from the provider to whom the
patient was referred.
Process
Process
Frm 00278
Fmt 4701
Community
/Population
IIealth
Population/
Community
Sfmt 4725
Tobacco Use and Help with
Quitting Among Adolescents:
The percentage of adolescents 12 to
20 years of age with a primary care
visit during the measurement year
for whom tobacco use status was
documented and received help with
quitting if identified as a tobacco
user.
Preventive Care and Screening:
Unhealthy Alcohol Use: Screening
& Brief Counseling:
Percentage of patients aged 18 years
and older who were screened for
unhealthy alcohol use using a
systematic screening method at least
once within the last 24 months AND
who received brief counseling if
identified as an unhealthy alcohol
user.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
Society for
Vascular
Surgeons
Society for
Vascular
Surgeons
Centers for
Medicare &
Medicaid
Services
Centers for
Medicare &
Medicaid
Services
National
Committee for
Quality
Assurance
Physician
Consortium for
Performance
Improvement
Foundation
(PCPI)
EP30JN17.036
B 3 C ar d' I
100
30287
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B 3 C ar d" I ogy (con fmue d)
10
ln2014
NQF
#
CMSEMeasure
ID
Quality
#
N/A
438
19:16 Jun 29, 2017
347vl
Jkt 241001
PO 00000
Data
Submission
Method
Web
Interface,
Registry,
EHR
Frm 00279
Measure
Type
Process
Fmt 4701
Sfmt 4725
National
Quality
Strategy
Domain
Effective
Clinical
Care
Measure Title
and Description
··.
Measure
Steward
.
Statin Therapy for the
Prevention and
Treatment of
Cardiovascular
Disease:
Percentage of the
following patients-all
considered at high risk
of cardiovascular
events-who were
prescribed or were on
statin therapy during
the measurement
period:
o Adults aged 2: 21
years who were
previously diagnosed
with or currently have
an active diagnosis of
clinical atherosclerotic
cardiovascular disease
(ASCVD); OR
o Adults aged 2:21 years
who have ever had a
fasting or direct lowdensity lipoprotein
cholesterol (LDL-C)
level2: 190 mg/dL; OR
o Adults aged 40-75
years with a diagnosis
of diabetes with a
fasting or direct LDL-C
level of70-189 mg/dL
E:\FR\FM\30JNP2.SGM
30JNP2
Centers for
Medicare
&
Medicaid
Services
EP30JN17.037
...
30288
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B 3 C ar d" I ogy (con fmue d)
10
...
NQF
#
Q\lality#
.·
!
mstockstill on DSK30JT082PROD with PROPOSALS2
§
VerDate Sep<11>2014
N/A
0071
441
442
19:16 Jun 29, 2017
CMSE- .·
Data .·
Measure
Submission
MethOd
ID ..
Registry
N/A
PO 00000
Intermed
iate
Outcome
Registry
N/A
Jkt 241001
Measure
Type
Process
Frm 00280
Fmt 4701
National Quality
Strategy Domain
Effective Clinical
Care
Effective Clinical
Care
Sfmt 4725
Measure Title
and Description
Ischemic Vascular
Disease All or None
Outcome Measure
(Optimal Control): The
IVD All-or-None Measure
is one outcome measure
(optimal control). The
measure contains four
goals. All four goals
within a measure must be
reached in order to meet
that measure. The
numerator for the all-ornone measure should be
collected from the
organization's total IVD
denominator.
All-or-None Outcome
Measure (Optimal
Control)
• Using the IVD
denominator optimal
results include: Most
recent blood pressure
(BP) measurement is
less than 140/90 mm Hg
• And Most recent
tobacco status is
Tobacco Free
• And Daily Aspirin or
Other Antiplatelet
Unless Contraindicated
And
Statin Use.
Persistent Beta Blocker
Treatment After a Heart
Attack:
The percentage of patients
18 years of age and older
during the measurement
year who were
hospitalized and
discharged from July 1 of
the year prior to the
measurement year to June
30 of the measurement
year with a diagnosis of
acute myocardial
infarction (AMI) and who
received were prescribed
persistent beta-blocker
treatment for six months
after discharge.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
Wisconsin
Collaborativ
e for
Healthcare
Quality
(WCHQ)
National
Committee
for Quality
Assurance
EP30JN17.038
IJidicator
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30289
B.3a. Electrophysiology Cardiac Specialist (Subspecialty Set of B.3 Cardiology)
Note: Each subspecialty set is effectively a separate specialty set. In instances where an Individual MIPS
eligible clinician or group reports on specialty or subspecialty set, if the set has less than six measures that
is all the clinician is required to report.
NQF
#
Quality
#
CMSE~
Data
Measure Submission
Method
ID
Measun::
type
National
Quality
Strategy
N/A
348
N/A
Registry
Outcome
Patient Safety
!
2474
392
N/A
Registry
Outcome
Patient Safety
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N/A
393
19:16 Jun 29, 2017
N/A
Jkt 241001
Registry
PO 00000
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Steward
Domain
!
!
Measure Title
and Description
Outcome
Frm 00281
Fmt 4701
Patient Safety
Sfmt 4725
HRS-3: Implantable
Cardioverter-Defibrillator
(JCD) Complications Rate:
Patients with physician-specific
risk-standardized rates of
procedural complications
following the first time
implantation of an ICD.
HRS-12: Cardiac Tamponade
and/or Pericardiocentesis
Following Atrial Fibrillation
Ablation: Rate of cardiac
tamponade and/or
pericardiocentesis following atrial
fibrillation ablation
This measure is reported as four
rates stratified by age and gender:
o Reporting Age Criteria 1:
Females less than 65 years of age
o Reporting Age Criteria 2: Males
less than 65 years of age
o Reporting Age Criteria 3:
Females 65 years of age and older
o Reporting Age Criteria 4: Males
65 years of age and older.
HRS-9: Infection within 180
Days of Cardiac Implantable
Electronic Device (CIED)
Implantation, Replacement, or
Revision: Infection rate following
CIED device implantation,
replacement, or revision.
E:\FR\FM\30JNP2.SGM
30JNP2
The Heart
Rhythm
Society
The Heart
Rhythm
Society
The Heart
Rhythm
Society
EP30JN17.039
Indicator
30290
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B4 Gas t roen tero ogy
..
Quality
#
#
0326
*
§
mstockstill on DSK30JT082PROD with PROPOSALS2
!
VerDate Sep<11>2014
0421
0419
047
128
130
19:16 Jun 29, 2017
CMSEMeasure
1D
Data
Sqbmission
Method
N/A
Claims,
Registry
69v6
Claims,
Registry,
EHR, Web
Interface
68v7
Claims,
Registry,
EHR
Jkt 241001
PO 00000
Measure
Type
National
Quality
Strategy
Domain
Process
Communication
and Care
Coordination
Process
Community /Pop
ulation Health
Process
Frm 00282
Fmt 4701
Patient Safety
Sfmt 4725
Measure Title
and Description
··.
Care Plan:
Percentage of patients aged 65
years and older who have an
advance care plan or surrogate
decision maker documented in
the medical record that an
advance care plan was
discussed but the patient did not
wish or was not able to name a
surrogate decision maker or
provide an advance care plan.
Preventive Care and
Screening: Body Mass Index
(BMI) Screening and FollowUp Plan:
Percentage of patients aged 18
years and older with a BMl
documented during the current
encounter or during the
previous twelve months AND
with a BMI outside of normal
parameters, a follow-up plan is
documented during the
encounter or during the
previous twelve months of the
current encounter.
Normal Parameters:
Age 18 years and older BMI =>
18.5 and< 25 kg/m2.
Documentation of Current
Medications in the Medical
Record: Percentage of visits
for patients aged 18 years and
older for which the eligible
clinician attests to documenting
a list of current medications
using all innnediate resources
available on the date of the
encounter. This list must
include ALL known
prescriptions, over-thecounters, herbals, and
vitamin/mineral/dietary
(nutritional) supplements AND
must contain the medications'
name, dosage, frequency and
route of administration.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
National
Cmmnittee
for Quality
Assurance
Centers for
Medicare &
Medicaid
Services
Centers for
Medicare &
Medicaid
Services
EP30JN17.040
Indicator
NQF
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30291
B4 Gas t roen t ero ogy ( con fmue d)
NQF
#
CMSEQuality
Measure
#
ID
§
!!
*
§
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§
VerDate Sep<11>2014
0659
0028
N/A
185
226
271
19:16 Jun 29, 2017
N/A
138v6
N/A
Jkt 241001
Data
Submission
Method
Claims,
Registry
Claims,
Registry,
EHR, Web
Interface
Registry
PO 00000
Measure
Type·
Process
National
Quality
Strategy
Domain
Measure Title
and Description
Measure
Steward
Communicat
ion and Care
Coordination
Colonoscopy Interval for Patients
with a History of Adenomatous
Polyps- Avoidance of
Inappropriate Use: Percentage of
patients aged 18 years and older
receiving a surveillance
colonoscopy, with a history of a
prior adenomatous polyp(s) in
previous colonoscopy findings, who
had an interval of 3 or more years
since their last colonoscopy.
Gastroenterol
ogical
Association/
American
Society for
Gastrointestinal
Endoscopy/
American
College of
Gastroenterology
Process
Community/
Population
Health
Process
Effective
Clinical Care
Frm 00283
Fmt 4701
Sfmt 4725
Preventive Care and Screening:
Tobacco Use: Screening and
Cessation Intervention:
a. Percentage of patients aged 18
years and older who were screened
for tobacco use one or more times
within 24 months
b. Percentage of patients aged 18
years and older who were screened
for tobacco use and identified as a
tobacco user who received tobacco
cessation intervention
c. Percentage of patients aged 18
years and older who were screened
for tobacco use one or more times
within 24 months AND who
received cessation counseling
intervention if identified as a
tobacco user.
Inflammatory Bowel Disease
(IBD): Preventive Care:
Corticosteroid Related Iatrogenic
Injury- Bone Loss Assessment:
Percentage of patients aged 18 years
and older with an inflammatory
bowel disease encounter who were
prescribed prednisone equivalents
greater than or equal to 10 mg/day
for 60 or greater consecutive days or
a single prescription equating to
600mg prednisone or greater for all
fills and were documented for risk of
bone loss once during the reporting
year or the previous calendar year.
E:\FR\FM\30JNP2.SGM
30JNP2
Physician
Consortium
for
Performance
Improvement
Foundation
(PCPI®)
American
Gastroenterologial
Association
EP30JN17.041
Indicator
30292
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B4 Gas t roen t ero ogy ( con fmue d)
NQF
#
N/A
N/A
§
!!
§
!
*
mstockstill on DSK30JT082PROD with PROPOSALS2
!
VerDate Sep<11>2014
0658
N/A
N/A
#
275
317
320
343
374
19:16 Jun 29, 2017
CMSEMeasure
ID
Data
Submission
Method
N/A
Registry
22v6
Claims,
Registry,
EHR
N/A
N/A
50v6
Jkt 241001
Claims,
Registry
Registry
Registry,
EHR
PO 00000
.Measure
Type
National
Quality
Strategy
Domain
Process
Effective
Clinical Care
Process
Community
/Population
Health
Process
Outcome
Process
Frm 00284
Fmt 4701
Measure Title
and Description
Inflammatory Bowel Disease
(IBD): Assessment of Hepatitis B
Virus (HBV) Status Before
Initiating Anti-TNF (Tumor
Necrosis Factor) Therapy:
Percentage of patients aged 18
years and older with a diagnosis of
inflammatory bowel disease (IBD)
who had Hepatitis B Virus (HBV)
status assessed and results
interpreted within one year prior to
receiving a first course of anti-TNF
(tumor necrosis factor) therapy.
Preventive Care and Screening:
Screening for High Blood
Pressure and Follow-Up
Documented:
Percentage of patients aged 18
years and older seen during the
reporting period who were screened
for high blood pressure AND a
recommended follow-up plan is
documented based on the current
blood pressure (BP) reading as
indicated.
..
Measure
Steward
American
Gastroenterological
Association
Centers for
Medicare &
Medicaid
Services
Communicat
ion and Care
Coordination
Appropriate Follow-Up Interval
for Normal Colonoscopy in
Average Risk Patients: Percentage
of patients aged 50 to 75 years of
age receiVmg a screerung
colonoscopy without biopsy or
polypectomy who had a
recommended follow-up interval of
at least I 0 years for repeat
colonoscopy documented in their
colonoscopy report.
American
Gastroenterol
ogical
Association/
American
Society for
Gastrointestinal
Endoscopy/
American
College of
GastroenteroloQ;y
Effective
Clinical Care
Screening Colonoscopy Adenoma
Detection Rate Measure: The
percentage of patients age 50 years
or older with at least one
conventional adenoma or colorectal
cancer detected during screening
colonoscopy.
American
College of
Gastruenterology
Communicat
ion and Care
Coordination
Closing the Referral Loop:
Receipt of Specialist Report:
Percentage of patients with
referrals, regardless of age, for
which the referring provider
receives a report from the provider
to whom the patient was referred.
Centers for
Medicare &
Medicaid
Services
Sfmt 4725
E:\FR\FM\30JNP2.SGM
30JNP2
EP30JN17.042
Indicator
Quality
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30293
B4 Gas t roen t ero ogy ( con fmue d)
NQF
#
!
mstockstill on DSK30JT082PROD with PROPOSALS2
§
VerDate Sep<11>2014
N/A
N/A
#
390
401
19:16 Jun 29, 2017
CMSEMeasure
ID
N/A
N/A
Jkt 241001
Data
Submissiop
Method
Registry
Registry
PO 00000
Measure
Type
Process
Process
Frm 00285
Fmt 4701
National
Quality
Strategy
Domain
Person and
CaregiverCentered
Experience
and Outcomes
Effective
Clinical Care
Sfmt 4725
Measure Title
a.nd Description
Measure
Steward
..
Hepatitis C: Discussion and
Shared Decision Making
Surrounding Treatment Options:
Percentage of patients aged 18
years and older with a diagnosis of
hepatitis C with whom a physician
or other qualified healthcare
professional reviewed the range of
treatment options appropriate to
their genotype and demonstrated a
shared decision making approach
with the patient
To meet the measure, there must be
documentation in the patient record
of a discussion between the
physician or other qualified
healthcare professional and the
patient that includes all of the
following: treatment choices
appropriate to genotype, risks and
benefits, evidence of effectiveness,
and patient preferences toward
treatment
Hepatitis C: Screening for
Hepatocellular Carcinoma
(HCC) in Patients with Cirrhosis:
Percentage of patients aged 18
years and older with a diagnosis of
chronic hepatitis C cirrhosis who
underwent imaging with either
ultrasound, contrast enhanced CT
or MRI for hepatocellular
c<:Jn.:inoma (HCC) alleasl once
within the 12 month reporting
period.
E:\FR\FM\30JNP2.SGM
30JNP2
American
Gastroenterological
Association/
Physician
Consortium
for
Performance
Improvement
American
Gastroenterological
Association/
Physician
Consortium
for
Performance
Improvement
EP30JN17.043
llldicator
Quality
30294
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B4 Gas t roen t ero ogy ( con fmue d)
NQF
Quality
#
#
N/A
N/A
2152
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§
!!
VerDate Sep<11>2014
N/A
402
425
431
439
19:16 Jun 29, 2017
Data
CMSEMeasure Submission
m
Method
N/A
N/A
N/A
N/A
Jkt 241001
Registry
Claims,
Registry
Registry
Registry
PO 00000
Measure
Type
Process
Process
Process
Efficienc
y
Frm 00286
Fmt 4701
National
Quality
Strategy
Domain
Measure. Title
and Description
Connmmity
I Population
Health
Tobacco Use and Help with
Quitting Among Adolescents:
The percentage of adolescents 12 to
20 years of age with a primary care
visit during the measurement year for
whom tobacco use status was
documented and received help with
quitting if identified as a tobacco
user.
Effective
Clinical
Care
Photodocumentation of Cecal
Intubation:
The rate of screening and surveillance
colonoscopies for which photo
documentation of landmarks of cecal
intubation is performed to establish a
complete examination.
Connnunity
I Population
Health
Preventive Care and Screening:
Unhealthy Alcohol Use: Screening
& Brief Counseling:
Percentage of patients aged 18 years
and older who were screened for
unhealthy alcohol use using a
systematic screening method at least
once within the last 24 months AND
who received brief counseling if
identified as an unhealthy alcohol
user.
Efficiency
and Cost
Reduction
Sfmt 4725
Age Appropriate Screening
Colonoscopy: The percentage of
patients greater than 85 years of age
who received a screening
colonoscopy from January 1 to
December 31.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
National
Commillee
for Quality
Assurance
f'\merican
Society for
pastrointestinal
~ndoscopy
Physician
Consortium for
Performance
Improvement
Foundation
(PCPI®)
American
Gastroenterological
Association/
American
Society for
Gastrointestinal
Endoscopy/
American
College of
GastroenteroloQ;y
EP30JN17.044
Indicator
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30295
B5 Dermato ogy
Quality
#
#
·.
CMS.EData
Measure Submission
Method
ID
National
Quality
Strategy
Domain
Measure
Type
Measure Title
and Description
0419
130
68v7
Claims,
Registry,
EHR
Process
Patient
Safety
!
0650
137
N/A
Registry
Structure
Communicat
ion and Care
Coordination
!
N/A
138
N/A
Registry
Process
Communicat
ion and Care
Coordination
!!
mstockstill on DSK30JT082PROD with PROPOSALS2
!
0562
224
N/A
Registry
Process
Efficiency
and Cost
Reduction
VerDate Sep<11>2014
19:16 Jun 29, 2017
Jkt 241001
PO 00000
Frm 00287
Fmt 4701
Sfmt 4725
Documentation of Current
Medications in the Medical Record:
Percentage of visits for patients aged
18 years and older for which the
eligible clinician attests to
docmnenting a list of current
medications using all inunediate
resources available on the date of the
encounter. This list must include ALL
known prescriptions, over-thecounters, herbals, and
vitamin/mineral/dietary (nutritional)
supplements AND must contain the
medications' name, dosage,
frequency and route of
administration.
Melanoma: Continuity of CareRecall System: Percentage of
patients, regardless of age, with a
current diagnosis of melanoma or a
history of melanoma whose
information was entered, at least once
within a 12-month period, into a
recall system that includes:
o A target date for the next complete
physical skin exam, AND
o A process to follow up with patients
who either did not make an
appointment within the specified
timeframe or who missed a scheduled
appointment
Melanoma: Coordination of Care:
Percentage of patients visits,
regardless of age, with a new
occmrence of melanoma, who have a
treatment plan documented in the
chart that was communicated to the
physician(s) providing continuing
care within one month of diagnosis.
Melanoma: Overutilization of
Imaging Studies in Melanoma:
Percentage of patients, regardless of
age, with a current diagnosis of stage
0 through IIC melanoma or a history
of melanoma of any stage, without
signs or symptoms suggesting
systemic spread, seen for an office
visit during the one-year
measurement period, for whom no
diagnostic imaging studies were
ordered.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
Centers for
Medicare &
Medicaid
Services
American
Academy of
Dermatology
American
Academy of
Dermatology
American
Academy of
Dermatology
EP30JN17.045
lndicator
NQF
30296
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B5 D ermat oI ogy con fmue d)
*
§
!
0028
CMSEQuality
Measure
#
ID
226
138v6
Data
Submission
·Method
Claims,
Registry,
EHR, Web
Interface
N/A
Registry
317
22v6
Claims,
Registry,
EHR
N/A
mstockstill on DSK30JT082PROD with PROPOSALS2
265
N/A
VerDate Sep<11>2014
N/A
337
N/A
Registry
19:16 Jun 29, 2017
Jkt 241001
PO 00000
Measure
'}'ype
National
Quality
Strategy
Domain
Measure Title
and Description
Process
Community
/Population
Health
Process
Communica
tionand
Care
Coordinatio
n
Process
Community
/Population
Health
Process
Effective
Clinical
Care
Frm 00288
Fmt 4701
Sfmt 4725
Preventive Care and Screening:
Tobacco Use: Screening and
Cessation Intervention:
a. Percentage of patients aged 18
years and older who were screened
for tobacco use one or more times
within 24 months
b. Percentage of patients aged 18
years and older who were screened
for tobacco use and identified as a
tobacco user who received tobacco
cessation intervention
c. Percentage of patients aged 18
years and older who were screened
for tobacco use one or more times
within 24 months AND who
received cessation counseling
intervention if identified as a
tobacco user.
Biopsy Follow-Up:
Percentage of new patients whose
biopsy results have been reviewed
and communicated to the primary
care/reterring physician and patient
by the performing physician.
Preventive Care and Screening:
Screening for High Blood Pressure
and Follow-Up Documented:
Percentage of patients aged 18 years
and older seen during the reporting
period who were screened for high
blood pressure AND a recommended
follow-up plan is documented based
on the curTent blood pressure (BP)
reading as indicated.
Tuberculosis (TB) Prevention for
Psoriasis, Psoriatic Arthritis and
Rheumatoid Arthritis Patients on a
Biological Immune Response
Modifier:
Percentage of patients whose
providers are ensuring active
tuberculosis prevention either through
yearly negative standard tuberculosis
screening tests or are reviewing the
patient's history to detem1ine if they
have had appropriate management for
a recent or prior positive test
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
Physician
Consortium
for
Performance
Improvement
Foundation
(PCPI®)
American
Academy of
Dermatology
Centers for
Medicare &
Medicaid
Services
American
Academy of
Dermatology
EP30JN17.046
Indicator
NQF
#
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30297
B5 D ermat oI ogy con fmue d)
*
!
N/A
N/A
CMSEQuality
Measure
#
ID
374
402
50v6
N/A
Data
Submission
·Method
Registry,
EHR
Registry
Measure
'}'ype
Process
National
Quality
Strategy
Domain
Measure Title
and Description
Connnunicat
ion and Care
Coordination
Closing the Referral Loop:
Receipt of Specialist Report:
Percentage of patients with refenals,
regardless of age, for which the
refening provider receives a report
from the provider to whom the
patient was refened.
Process
Commlmity/
Population
Health
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N/A
410
N/A
Registry
Outcome
N/A
!
Person and
Caregiver
Centered
Experience
and
Outcomes
440
N/A
Registry
Process
Communicat
ion and Care
Coordination
19:16 Jun 29, 2017
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Fmt 4701
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Tobacco Use and Help with
Quitting Among Adolescents:
The percentage of adolescents 12 to
20 years of age with a primary care
visit during the measurement year
for whom tobacco usc status was
documented and received help with
quitting if identified as a tobacco
user.
Psoriasis: Clinical Response to
Oral Systemic or Biologic
Medications :
Percentage of psoriasis patients
receiving oral systemic or biologic
therapy who meet minimal
physician- or patient-reported
disease activity levels. It is implied
that establishment and maintenance
of an established minimum level of
disease control as measured by
physician- and/or patient-reported
outcomes will increase patient
satisfaction with and adherence to
treatment
Basal Cell Carcinoma
(BCC)/Squamous Cell
Carcinoma: Biopsy Reporting
Time- Pathologist to Clinician:
Percentage of biopsies with a
diagnosis of cutaneous Basal Cell
Carcinoma (BCC) and Squamous
Cell Carcinoma (SCC) (including in
situ disease) in which the
pathologist communicates results to
the clinician within 7 days of biopsy
date.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
Centers for
Medicare &
Medicaid
Services
National
Committee
for Quality
Assurance
American
Academy of
Dermatology
American
Academy of
Dermatology
EP30JN17.047
Indicator
NQF
#
30298
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B6 Emergency M e d".
ICllle
!!
!!
!!
#
N/A
0653
0654
0104
§
!!
0058
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N/A
VerDate Sep<11>2014
CMSEQuality
Measure
#
lD
066
091
093
107
116
187
19:16 Jun 29, 2017
146v6
N/A
N/A
161v6
N/A
N/A
Jkt 241001
Data
Submission
Method
Registry,
EHR
Claims,
Registry
Claims,
Registry
EHR
Registry
National
Quality
Strategy
Domain
Measure Title
and Description
Measure
Steward
Process
Efficiency
and Cost
Reduction
Appropriate Testing for Children
with Pharyngitis:
Percentage of children 3-18 years of
age who were diagnosed with
pharyngitis, ordered an antibiotic and
received a group A streptococcus
(strep) test for the episode.
National
Committee
for Quality
Assurance
Process
Effective
Clinical
Care
Acute Otitis Extema (AOE):
Topical Therapy:
Percentage of patients aged 2 years
and older with a diagnosis of AOE
who were prescribed topical
preparations.
American
Academy of
Ololaryngolo
gy-Headand
Neck Surgery
Efficiency
and Cost
Reduction
Acute Otitis Extema (AOE):
Systemic Antimicrobial TherapyAvoidance of Inappropriate Use:
Percentage of patients aged 2 years
and older with a diagnosis of AOE
who were not prescribed systemic
antimicrobial therapy.
American
Academy of
Otolaryngolo
gy-Headand
Neck Surgery
Effective
Clinical
Care
Adult Major Depressive Disorder
(MDD): Suicide Risk Assessment:
Percentage of patients aged 18 years
and older with a diagnosis of major
depressive disorder (MDD) with a
suicide risk assessment completed
during the visit in which a new
diagnosis or recurrent episode was
identified.
Physician
Consortium
for
Performance
Improvement
Foundation
(PCPI®)
Efficiency
and Cost
Reduction
Avoidance of Antibiotic Treatment
in Adults with Acute Bronchitis:
Percentage of adults 18-64 years of
age with a diagnosis of acute
bronchitis who were not dispensed an
antibiotic prescription.
National
Committee
for Quality
Assurance
Effective
Clinical
Care
Stroke and Stroke Rehabilitation:
Thrombolytic Therapy:
Percentage of patients aged 18 years
and older with a diagnosis of acute
ischemic stroke who arrive at the
hospital within two hours of time last
known well and for whom IV t-PA
was initiated within three hours of
time last known well.
American
Heart
Association
Process
Process
Registry
PO 00000
Measure
Type
Process
Process
Frm 00290
Fmt 4701
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Indicator
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..
#
0651
N/A
N/A
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VerDate Sep<11>2014
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N/A
#
254
255
317
331
332
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CMSEData
Measure Submission
Method
ID
N/A
Claims,
Registry
N/A
Claims,
Registry
22v6
N/A
N/A
Jkt 241001
Claims,
Registry,
EHR
Registry
Registry
PO 00000
Measure
Type
National
Quality
Strategy
Domain
Process
Effective
Clinical
Care
Process
Measure Title
and Description
Effective
Clinical
Care
Process
Process
Process
Frm 00291
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Community
/Population
Health
Efficiency
and Cost
Reduction
Efficiency
and Cost
Reduction
Sfmt 4725
Ultrasound Determination of
Pregnancy Location for Pregnant
Patients with Abdominal Pain:
Percentage of pregnant female
patients aged 14 to 50 who present to
the emergency department (ED) with
a chief complaint of abdominal pain
or vaginal bleeding who receive a
trans-abdominal or trans-vaginal
ultrasound to determine pregnancy
location.
Rh Immunoglobulin (Rhogam) for
Rh-Negative Pregnant Women at
Risk of Fetal Blood Exposure:
Percentage ofRh-negative pregnant
women aged 14-50 years at risk of
fetal blood exposure who receive RhImmunoglobulin (Rhogam) in the
emergency department (ED).
Preventive Care and Screening:
Screening for High Blood Pressure
and Follow-Up Documented:
Percentage of patients aged 18 years
and older seen during the reporting
period who were screened for high
blood pressure AND a recommended
follow-up plan is documented based
on the current blood pressure (BP)
reading as indicated.
Adult Sinusitis: Antibiotic
Prescribed for Acute Sinusitis
(Overuse):
Percentage of patients, aged 18 years
and older, with a diagnosis of acute
sinusitis who were prescribed an
antibiotic within 10 days after onset
of svmptoms.
Adult Sinusitis: Appropriate
Choice of Antibiotic: Amoxicillin
With or Without Clavulanate
Prescribed for Patients with Acute
Bacterial Sinusitis (Appropriate
Use):
Percentage of patients aged 18 years
and older with a diagnosis of acute
bacterial sinusitis that were
prest.:ribecl amuxit.:illin, with or
without clavulante, as a first line
antibiotic at the time of diagnosis.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
American
College of
Emergency
Physicians
American
College of
Emergency
Physicians
Centers for
Medicare &
Medicaid
Services
~merican
~cademy of
ptolaryngology~ead and Neck
Surgery
~merican
~cademy of
ptolaryngology~ead and Neck
Surgery
EP30JN17.049
Indicator
NQF·· Quality
30300
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B.6. Emergency Medicine continued)
!!
N/A
N/A
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VerDate Sep<11>2014
N/A
Quality
#
333
415
416
19:16 Jun 29, 2017
CMSE:Measu~
ID
Data
Submission
Method
Measure
Type
Efficienc
N/A
Registry
N/A
Claims,
Registry
Efficienc
N/A
Claims,
Registry
Efficienc
Jkt 241001
PO 00000
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y
y
Frm 00292
Fmt 4701
National
Quality
Strategy
Domain
Efficiency
and Cost
Reduction
Et1iciency
and Cost
Reduction
Efficiency
and Cost
Reduction
Sfmt 4725
Measure Title
and Description
Adult Sinusitis: Computerized
Tomography (CT) for Acute
Sinusitis (Overuse):
Percentage of patients aged 18 years
and older with a diagnosis of acute
sinusitis who had a computerized
tomography (CT) st.:an of the
paranasal sinuses ordered at the time
of diagnosis or received within 28
days after date of diagnosis.
Emergency Medicine: Emergency
Department Utilization of CT for
Minor Blunt Head Trauma for
Patients Aged 18 Years and Older:
Percentage of emergency department
visits for patients aged 18 years and
older who presented within 24 hours
of a minor blunt head trauma with a
Glasgow Coma Scale (GCS) score of
15 and who had a head CT for trauma
ordered by an emergency care
provider who have an indication for a
head CT.
Emergency Medicine: Emergency
Department Utilization of CT for
Minor Blunt Head Trauma for
Patients Aged 2 through 17 Years:
Percentage of emergency department
visits for patients aged 2 through 17
years who presented within 24 hours
of a minor blunt head trauma with a
Glasgow Coma Scale (GCS) score of
15 and who had a head CT for trauma
ordered by an emergency care
provider who are classified as low
risk according to the Pediatric
Emergent.:y Care Applied Researt.:h
Network(PECARN) prediction rules
for traumatic brain injury.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
American
Academy of
Otolaryngology
-Head and
Neck Surgery
American
College of
Emergency
Physicians
American
College of
Emergency
Physicians
EP30JN17.050
Indicator
NQF
#
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30301
B .. F amuv M e dICllle
7
·1
. .
N.QF
#
§
!
0059
#
001
CMSEData
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ID
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122v6
Claims,
Weh
Interface,
Registry,
Measure
Type
Tntennedi
ate
Outcome
National
Quality
Strategy
Domain
Effective
Clinical Care
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EHR
VerDate Sep<11>2014
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PO 00000
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Measure Title
and Description
Diabetes: Hemoglobin Ale
(HbAlc) Poor Control (>9%):
Percentage of patients 18-75 years
of age with diabetes who had
hemoglobinAlc > 9.0% during the
measurement period.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure.
Steward
National
Connnittee for
Quality
Assurance
EP30JN17.051
Indicator
Quality
30302
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
"I
B7F amuy M e d". ( con fmue d)
ICllle
§
§
§
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§
VerDate Sep<11>2014
Quality
#
#
0081
0067
0070
0083
005
006
007
008
19:16 Jun 29, 2017
CMSEMeasqre
ID
135v6
N/A
145v6
144v6
Jkt 241001
Data
Submission
Method
Registry,
EHR
Registry
Registry,
EHR
Registry,
EHR
PO 00000
Measure
Type
Process
Process
Process
Process
Frm 00294
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National
Quality
Strategy
Domain
Measure Title
and Description
Effective
Clinical Care
Heart Failure (HF): AngiotensinConverting Enzyme (ACE)
Inhibitor or Angiotensin Receptor
Blocker (ARB) Therapy for Left
Ventricular Systolic Dysfunction
(LVSD):
Percentage of patients aged 18 years
and older with a diagnosis of heart
failure (HF) with a current or prior
left ventricular ejection fraction
(L VEF) < 40% who were prescribed
ACE inhibitor or ARB therapy
either within a 12-month period
when seen in the outpatient setting
OR at each hospital discharge.
Physician
Consortium for
Performance
Improvement
Foundation
(PCPI®)
Effective
Clinical Care
Chronic Stable Coronary Artery
Disease: Antiplatelet Therapy:
Percentage of patients aged 18 years
and older with a diagnosis of
coronary artery disease (CAD) seen
within a 12-month period who were
prescribed aspirin or clopidogrel.
American
Heart
Association
Effective
Clinical Care
Effective
Clinical Care
Sfmt 4725
Coronary Artery Disease (CAD):
Beta-Blocker Therapy-Prior
Myocardial Infarction (MI) or
Left Ventricular Systolic
Dysfunction (LVEF <40%):
Percentage of patients aged 18 years
and older with a diagnosis of
coronary artery disease seen within a
12-month period who also have
prior MI OR a current or prior
L VEF < 40% who were prescribed
beta-blocker therapy.
Heart Failure (HF): Beta-Blocker
Therapy for Left Ventricular
Systolic Dysfunction (LVSD):
Percentage of patients aged 18 years
and older with a diagnosis of heart
failure (HF) with a current or prior
left ventricular ejection fraction
(L VEF) < 40% who were prescribed
beta-blocker therapy either within a
12-month period when seen in the
outpatient setting OR at each
hospital discharge.
E:\FR\FM\30JNP2.SGM
30JNP2
Meas~Jre
Steward
Physician
Consortium for
Performance
Improvement
Foundation
(PCPI®)
Physician
Consortium for
Performance
Improvement
Foundation
(PCPI®)
EP30JN17.052
Indicator
NQF
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30303
"I
B7F amuy M e d". ( con fmue d)
ICllle
Quality
#
#
105
!
0045
0046
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0326
VerDate Sep<11>2014
009
024
039
047
19:16 Jun 29, 2017
CMSEData
Measure Submission
Method
ID
128v6
EHR
N/A
Claims,
Registry
N/A
N/A
Jkt 241001
Process
Claims,
Registry
Claims,
Registry
PO 00000
Measure
Type
Process
Process
Process
Frm 00295
Fmt 4701
National
Quality
Strategy
Domain
Effective
Clinical Care
Communicat
ion and Care
Coordination
Measure Title
and Description
Anti-Depressant Medication
Management:
Percentage of patients 18 years of
age and older who were treated with
antidepressant medication, had a
diagnosis of major depression, and
who remained on antidepressant
medication treatment.
Two rates are reported
a. Percentage of patients who
remained on an antidepressant
medication for at least 84 days (12
weeks)
b. Percentage of patients who
remained on an antidepressant
medication for at least 180 days (6
months).
Communication with the
Physician or Other Clinician
Managing On-going Care PostFracture for Men and Women
Aged 50 Years and Older:
Percentage of patients aged 50 years
and older treated for a tracture with
documentation of communication,
between the physician treating the
fracture and the physician or other
clinician managing the patient's ongoing care, that a fracture occurred
and that the patient was or should be
considered for osteoporosis
treatment or testing. This measure is
reported by the physician who treats
the fracture and who therefore is
held accountable for the
communication.
Measure
Steward
National
Committee for
Quality
Assurance
National
Cmmnittee for
Quality
Assurance
Effective
Clinical Care
Screening for Osteoporosis for
Women Aged 65-85 Years of Age:
Percentage of female patients aged
65-85 years of age who ever had a
central dual-energy X-ray
absorptiometry (DXA) to check for
osteoporosis.
National
Cmmnittee for
Quality
Assurance
Communicat
ion and Care
Coordination
Care Plan:
Percentage of patients aged 65 years
and older who have an advance care
plan or surrogate decision maker
documented in the medical record or
documentation in the medical record
that an advance care plan was
discussed but the patient did not
wish or was not able to name a
surrogate decision maker or provide
an advance care plan.
National
Cmmnittee for
Quality
Assurance
Sfmt 4725
E:\FR\FM\30JNP2.SGM
30JNP2
EP30JN17.053
Indicator
NQF
30304
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
"I
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ICllle
Quality
#
#
N/A
!
!!
!!
!!
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VerDate Sep<11>2014
N/A
0069
N/A
0653
0654
048
050
065
066
091
093
19:16 Jun 29, 2017
CMSE~
Measure
ID
N/A
Data
Submission
Method
Claims,
Registry
N/A
Claims,
Registry
154v6
Registry,
EHR
146v6
N/A
N/A
Jkt 241001
Registry,
EHR
Claims,
Registry
Claims,
Registry
PO 00000
Measure
Type
National
Quality
Strategy
D6main
Process
Effective
Clinical
Care
Process
Person
and
CaregiverCentered
Experienc
e and
Outcomes
Process
Efficiency
and Cost
Reduction
Measure Title
.and Description
Urinary Incontinence: Assessment
of Presence or Absence of Urinary
Incontinence in Women Aged 65
Years and Older:
Percentage of female patients aged 65
years and older who were assessed
for the presence or absence of urinary
incontinence within 12 months.
Urinary Incontinence: Plan of Care
for Urinary Incontinence in
Women Aged 65 Years and Older:
Percentage of female patients aged 65
years and older with a diagnosis of
urinary incontinence with a
documented plan of care for urinary
incontinence at least once within 12
months.
Appropriate Treatment for
Children with Upper Respiratory
Infection (URI):
Percentage of children 3 months
through 18 years of age who were
diagnosed with upper respiratory
infection (URI) and were not
dispensed an antibiotic prescription
on or three davs after the episode.
Meas:ure
Steward
National
Committee for
Quality
Assurance
National
Committee for
Quality
Assurance
National
Committee for
Quality
Assurance
Process
Efficiency
and Cost
Reduction
Appropriate Testing for Children
with Pharyngitis:
Percentage of children 3-18 years of
age who were diagnosed with
pharyngitis, ordered an antibiotic and
received a group A streptococcus
(strep) test for the episode.
National
Committee for
Quality
Assurance
Process
Effective
Clinical
Care
Acute Otitis Extema (AOE):
Topical Therapy: Percentage of
patients aged 2 years and older with a
diagnosis of AOE who were
prescribed topical preparations.
American
Academy of
Otolaryngology
-Head and
Neck Surgery
Acute Otitis Extema (AOE):
Systemic Antimicrobial TherapyAvoidance of Inappropriate Use:
Percentage of patients aged 2 years
and older with a diagnosis of AOE
who were not prescribed systemic
antimicrobial therapy.
American
Academy of
Otolaryngology
-Head and
Neck Surgery
Process
Frm 00296
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Efficiency
and Cost
Reduction
Sfmt 4725
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EP30JN17.054
Indicator
NQF
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
"I
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ICllle
NQF
Quality
#
#
0104
!
*
NIA
0041
0043
§
*
§
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VerDate Sep<11>2014
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110
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112
113
116
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Data
Measure Submission
Method
ID
16lv6
NIA
147v7
127v6
125v6
130v6
NIA
Jkt 241001
National
Quality
Strategy
Domain
Memmre Title
and Description
Measure
Steward
..
Process
EHR
Claims,
Registry
Claims,
Web
Interface,
Registry,
EHR
Claims,
Web
Interface,
Registry,
EHR
Claims,
Web
Interface,
Registry,
EHR
Claims,
Web
Interface,
Registry,
EHR
EHREHR
Registry
PO 00000
Measure
Type
Effective
Clinical
Care
Adult Major Depressive Disorder
(MDD): Suicide Risk Assessment:
Percentage of patients aged 18 years
and older with a diagnosis of major
depressive disorder (MDD) with a
suicide risk assessment completed
during the visit in which a new
diagnosis or recurrent episode was
identified.
Process
Person and
Caregiver
Centered
Experience
and
Outcomes
Osteoarthritis (OA): Function and
Pain Assessment:
Percentage of patient visits for
patients aged 21 years and older with
a diagnosis of osteoarthritis (OA)
with assessment for function and
pam.
American
Academy of
Orthopedic
Surgeons
Preventive Care and Screening:
Influenza Immunization:
Percentage of patients aged 6 months
and older seen for a visit between
October 1 and March 31 who
received an influenza immunization
OR who reported previous receipt of
an influenza immunization.
Physician
Consortium for
Performance
Improvement
Foundation
(PCPI®)
Process
Community
I Population
Health
Pneumonia Vaccination Status for
Older Adults:
Percentage of patients 65 years of age
and older who have ever received a
pneumococcal vaccine.
National
Committee for
Quality
Assurance
Process
Effective
Clinical
Care
Breast Cancer Screening:
Percentage of women 50 -74 years of
age who had a mammogram to screen
for breast cancer.
National
Committee for
Quality
Assurance
Process
Effective
Clinical
Care
Colo rectal Cancer Screening:
Percentage of patients 50- 75 years
of age who had appropriate screening
for colorectal cancer.
National
Committee for
Quality
Assurance
Efficiency
and Cost
Reduction
Avoidance of Antibiotic Treatment
in Adults with Acute Bronchitis:
Percentage of adults 18-64 years of
age with a diagnosis of acute
bronchitis who were not dispensed an
antibiotic prescription.
National
Committee for
Quality
Assurance
Community
Process
I Population
Health
Process
Frm 00297
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Sfmt 4725
E:\FR\FM\30JNP2.SGM
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Physician
Consortium for
Performance
Improvement
Foundation
(PCPI®)
EP30JN17.055
..
Indicator
30305
30306
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
"I
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ICllle
Indicator
NQF
#
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§
0055
0062
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#
117
119
126
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CMSE-
Data
M:easure Submission
M:ethod
ID
13lv6
134v4
N/A
Jkt 241001
Claims,
Web
Interface,
Registry,
EHR
Registry,
EHR
Registry
PO 00000
M:easure
Type
National
Quality
Strategy
Domain
Process
Effective
Clinical Care
Process
Effective
Clinical Care
Process
Effective
Clinical Care
Frm 00298
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M:easure Title
and Description
Diabetes: Eye Exam:
Percentage of patients 18 - 75 years
of age with diabetes who had a
retinal or dilated eye exam by an eye
care professional during the
measurement period or a negative
retinal exam (no evidence of
retinopathy) in the 12 months prior
to the measurement period.
Diabetes: Medical Attention for
Nephropathy: The percentage of
patients 18-75 years of age with
diabetes who had a nephropathy
screening test or evidence of
nephropathy during the
measurement period.
Diabetes Mellitus: Diabetic Foot
and Ankle Care, Peripheral
Neuropathy -Neurological
Evaluation: Percentage of patients
aged 18 years and older with a
diagnosis of diabetes mellitus who
had a neurological examination of
their lower extremities within 12
months.
E:\FR\FM\30JNP2.SGM
30JNP2
M:easure
Steward
National
Committee for
Quality
Assurance
National
Cmmnittee for
Quality
Assurance
American
Podiatric
Medical
Association
EP30JN17.056
..
30307
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
"I
B7F amuy M e d". ( con fmue d)
ICllle
...
*
§
NQF#
0421
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#
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ID
Claims,
Registry,
EHR, Web
Interface
69v6
Claims,
Registry,
EHR
68v7
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Method
PO 00000
Frm 00299
Measure
Type
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Process
Fmt 4701
National Quality
Strategy Domain
Community /Popul
ation Health
Patient Safety
Sfmt 4725
Measure Title
and Description
Preventive Care and
Screening: Body Mass
Judex (BMI) Screening
and Follow-Up Plan:
Percentage of patients aged
18 years and older with a
BMI documented during the
current encounter or during
the previous 12 months
AND with a BMI outside of
normal parameters, a
follow-up plan is
documented during the
encounter or during the
previous twelve months of
the current encounter.
Normal Parameters:
Age 18 years and older
BMI => 18.5 and< 25
kg/m2.
Documentation of Current
Medications in the
Medical Record:
Percentage of visits for
patients aged 18 years and
older for which the eligible
professional attests to
documenting a list of
current medications using
all inunediate resources
available on the date of the
encounter. This list must
include ALL known
prescriptions, over-thecounters, herbals, and
vitamin/mineral/dietary
(nutritional) supplements
AND must contain the
medications' name, dosage,
frequency and route of
administration.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
Centers
for
Medicare
&
Medicaid
Services
Centers
for
Medicare
&
Medicaid
Services
EP30JN17.057
Indicator
30308
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
"I
B7F amuy M e d". ( con fmue d)
ICllle
0418
Quality
#
134
CMSEMeasure
ID
2v77
Data
Submission
Method
Claims,
Web
Interface,
Registry,
Measure
Type
Process
National
Quality
Strategy
Domain
Connnunity/
Population
Health
EHR
0101
154
N/A
!
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Registry
0101
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Registry
VerDate Sep<11>2014
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Patient Safety
Process
Connnunication
and Care
Coordination
Frm 00300
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Measure Title
and Description
Preventive Care and
Screening: Screening for
Depression and Follow-Up
Plan:
Percentage of patients aged 12
years and older screened for
depression on the date of the
encounter using an age
appropriate standardized
depression screening tool AND
if positive, a follow-up plan is
documented on the date of the
positive screen.
Falls: Risk Assessment:
Percentage of patients aged 65
years and older with a history
of falls who had a risk
assessment for falls completed
within 12 months.
Falls: Plan of Care:
Percentage of patients aged 65
years and older with a history
of falls who had a plan of care
for falls documented within 12
months.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
Centers for
Medicare &
Medicaid
Services
National
Committee for
Quality
Assurance
National
Committee for
Quality
Assurance
EP30JN17.058
Indicator
NQF
#
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30309
"I
B7F amuy M e d". ( con fmue d)
ICllle
§
!
mstockstill on DSK30JT082PROD with PROPOSALS2
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VerDate Sep<11>2014
NQF
Quality
#
#
0056
NA
0068
163
181
204
19:16 Jun 29, 2017
CMSEMeasure
m
Data
Submission
Method
123v6
EHR
N/A
Claims,
Registry
164v6
Claims, Web
Interface,
Registry,
EHR
Jkt 241001
PO 00000
Frm 00301
Measure
Type
Process
National Quality
Strategy Domain
Effective Clinical
Care
Process
Patient Safety
Process
Effective Clinical
Care
Fmt 4701
Sfmt 4725
E:\FR\FM\30JNP2.SGM
Measure Title
and Description
Comprehensive
Diabetes Care: Foot
Exam:
The percentage of
patients 18-75 years of
age with diabetes (type
1 and type 2) who
received a foot exam
(visual inspection and
sensory exam with
mono filament and a
pulse exam) during the
measurement year.
Elder Maltreatment
Screen and FollowUp Plan:
Percentage of patients
aged 65 years and
older with a
documented elder
maltreatment screen
using an Elder
Maltreatment
Screening Tool on the
date of encounter
AND a documented
follow-up plan on the
date of the positive
screen.
Ischemic Vascular
Disease (IVD): Use of
Aspirin or Another
Antiplatelet:
Percentage of patients
18 years of age and
older who were
diagnosed with acute
myocardial infarction
(AMI), coronary artery
bypass graft (CABG)
or percutaneous
coronary interventions
(PCI) in the 12 months
prior to the
measurement period,
or who had an active
diagnosis of ischemic
vascular disease (IVD)
during the
measurement period,
and who had
documentation of use
of aspirin or another
antiplatelet during the
measurement period.
30JNP2
Measure
Steward
National
Connnittee
for Quality
Assurance
Centers for
Medicare &
Medicaid
Services
National
Connnittee
for Quality
Assurance
EP30JN17.059
lndicator
30310
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
"I
B7F amuy M e d". ( con fmue d)
ICllle
Indicator
*
§
*
NQF
#
0028
0022
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VerDate Sep<11>2014
Quality
#
226
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243
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CMSE-
Data
Measure Submission
Method
ID
138v6
Claims,
Registry,
EHR, Web
Interface
156v6
Registry,
EHR
N/A
Jkt 241001
Registry
PO 00000
Measure
Type
National
Quality
Strategy
Domain
Process
Community/
Population
Health
Process
Patient
Safety
Process
Communicat
ion and Care
Coordination
Frm 00302
Fmt 4701
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Measure Title
and Description
Preventive Care and Screening:
Tobacco Use: Screening and
Cessation Intervention:
a. Percentage of patients aged 18
years and older who were
screened for tobacco use one or
more times within 24 months
b. Percentage of patients aged 18
years and older who were
screened for tobacco use and
identified as a tobacco user who
received tobacco cessation
intervention
c. Percentage of patients aged 18
years and older who were
screened for tobacco use one or
more times within 24 months
AND who received cessation
counseling intervention if
identified as a tobacco user.
Use of High-Risk Medications in
the Elderly:
Percentage of patients 65 years of
age and older who were ordered
high-risk medications. Two rates are
reported.
a. Percentage of patients who were
ordered at least one high-risk
medication.
b. Percentage of patients who were
ordered at least two of the same
high-risk medications.
Cardiac Rehabilitation Patient
Referral from an Outpatient
Setting:
Percentage of patients evaluated in
an outpatient setting who within the
previous 12 months have
experienced an acute myocardial
infarction (MI), coronary artery
bypass graft (CABG) surgery, a
percutaneous coronary intervention
(PCI), cardiac valve surgery, or
cardiac transplantation, or who have
chronic stable angina (CSA) and
have not already participated in an
early outpatient cardiac
rehabilitation/secondary prevention
(CR) program for the qualifying
event/diagnosis who were referred
to a CR program.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
Physician
Consortium for
Performance
Improvement
Foundation
(PCPI®)
National
Committee for
Quality
Assurance
American
College of
Cardiology
Foundation
EP30JN17.060
..
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30311
B.7. Family Medicine (continued)
NQF
Quality
#
#
0004
§
0032
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VerDate Sep<11>2014
305
309
317
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.Data
CMSE"
Measure Submisgion
Method
ID
l37v6
Measure Title
and Description
22v6
Claims,
Registry,
EHR
Effective
Clinical
Care
Process
EHR
PO 00000
National
Quality
Strategy
Domain
Process
EHR
124v6
Jkt 241001
Measure
Type
Effective
Clinical
Care
Process
Community
/Population
Health
Frm 00303
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Initiation and Engagement of
Alcohol and Other Drug
Dependence Treatment:
Percentage of patients 13 years of age
and older with a new episode of
alcohol and other drug (AOD)
dependence who received the
following. Two rates are reported.
a. Percentage of patients who initiated
treatment within 14 days of the
diagnosis.
b. Percentage of patients who
initiated treatment and who had two
or more additional services with an
AOD diagnosis within 30 days of the
initiation visit
Cervical Cancer Screening:
Percentage of women 21-64 years of
age who were screened for cervical
cancer using either of the following
criteria:
o Women age 21-64 who had cervical
cytology performed every 3 years
o Women age 30-64 who had cervical
cytology!human papillomavirus
(HPV) co-testing performed every 5
years.
Preventive Care and Screening:
Screening for High Blood Pressure
and Follow-Up Documented:
Percentage of patients aged 18 years
and older seen during the reporting
period who were screened for high
blood pressure AND a recommended
follow-up plan is documented based
on the current blood pressure (BP)
reading as indicated.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
National
Committee for
Quality
Assurance
National
Conunittee for
Quality
Assurance
Centers for
Medicare &
Medicaid
Services
EP30JN17.061
Indicator
30312
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
"I
B7F amuy M e d". ( con fmue d)
ICllle
Quality·
#
·. CMSEData
Measure Submission
Method
ID
321
N/A
!
0005
&
0006
CMSapproved
Survev
Vendor
§
1525
326
N/A
Claims,
Registry
*
§
!!
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VerDate Sep<11>2014
N/A
N/A
331
332
19:16 Jun 29, 2017
N/A
N/A
Jkt 241001
Registry
Registry
PO 00000
Measure
Type
National
Quality
Strategy
Domain
Patient
Engagem
ent!Exper
1ence
Person and
CaregiverCentered
Experience
and
Outcomes
Process
Effective
Clinical
Care
Process
Efficiency
and Cost
Reduction
Process
Efficiency
and Cost
Reduction
Frm 00304
Fmt 4701
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Measure 'fitle
and Description
CAHPS for MIPS
Clinician/Group Smvey:
Summa!}' Survey Measures may
include:
o Getting Timely Care,
Appointments, and Information;
o How well Providers Communicate;
o Patient's Rating of Provider;
o Access to Specialists;
o Health Promotion and Education;
o Shared Decision-Making;
o Health Status and Functional
Status;
o Courteous and Helpful Office
Staff;
o Care Coordination;
o Stewardship of Patient Resources.
Atrial Fibrillation and Atrial
Flutter: Chronic Anticoagulation
Therapy:
Percentage of patients aged 18 years
and older with a diagnosis of
nonvalvular atrial fibrillation (AF)
or atrial flutter whose assessment of
the specified thromboembolic risk
factors indicate one or more highrisk factors or more than one
moderate risk factor, as determined
by CHADS2 risk stratification, who
are prescribed warfarin OR another
oral anticoagulant drug that is FDA
approved for the prevention of
thromboembolism
Adult Sinusitis: Antibiotic
Prescribed for Acute Sinusitis
(Overuse):
Percentage of patients, aged 18
years and older, with a diagnosis of
acute sinusitis who were prescribed
an antibiotic within 10 days after
onset of symptoms.
Adult Sinusitis: Appropriate
Choice of Antibiotic: Amoxicillin
With or Without Clavulanate
Prescribed for Patients with Acute
Bacterial Sinusitis (Appropriate
Use):
Percentage of patients aged 18 years
and older with a diagnosis of acute
bacterial sinusitis that were
prescribed amoxicillin, with or
without clavulante, as a first line
antibiotic at the time of diagnosis.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
Agency for
Healthcare
Research&
Quality
(AHRQ)
American
College of
Cardiology
American
Academy of
Otolaryngology
-Head and
Neck Surgery
American
Academy of
Otolaryngology
-Head and
Neck Surgery
EP30JN17.062
Indicator
NQF
#
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
"I
B7F amuy M e d". ( con fmue d)
ICllle
!!
NQF
#
N/A
Quality
#
333
CMSE-
Data
Measure Submission
Method
ID
N/A
Registry
Measure
Type
National
Quality
Strategy
Domain
Efficiency
Efficiency
and Cost
Reduction
Efficiency
and Cost
Reduction
§
!
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VerDate Sep<11>2014
N/A
334
N/A
Registry
Efficiency
N/A
!!
337
N/A
Registry
Process
Effective
Clinical Care
Outcome
Effective
Clinical Care
Outcome
Person and
CaregiverCentered
Experience
and
Outcomes
2082
N/A
338
342
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N/A
Jkt 241001
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Registry
PO 00000
Frm 00305
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Measure Title
and Description
Adult Sinusitis: Computerized
Tomography (CT) for Acute
Sinusitis (Overuse):
Percentage of patients aged 18 years
and older with a diagnosis of acute
sinusitis who had a computerized
tomography (CT) scan of the
paranasal sinuses ordered at the time
of diagnosis or received within 28
days after dale of diagnosis.
Adult Sinusitis: More than One
Computerized Tomography (CT)
Scan Within 90 Days for Chronic
Sinusitis (Overuse):
Percentage of patients aged 18 years
and older with a diagnosis of
chronic sinusitis who had more than
one CT scan of the paranasal sinuses
ordered or received within 90 days
after the date of diagnosis.
Tuberculosis (TB) Prevention for
Psoriasis, Psoriatic Arthritis and
Rheumatoid Arthritis Patients on
a Biological Immune Response
Modifier:
Percentage of patients whose
providers are ensuring active
tuberculosis prevention either
through yearly negative standard
tuberculosis screening tests or are
reviewing the patient's history to
determine if they have had
appropriate management for a recent
or prior positive test
lllV Viral Load Suppression:
The percentage of patients,
regardless of age, with a diagnosis
ofHIV with a HIV viral load less
than 200 copies/mL at last HTV viral
load test during the measurement
year.
Pain Brought Under Control
Within 48 Hours:
Patients aged 18 and older who
report being uncomfortable because
of pain at the initial assessment
(after admission to palliative care
services) who report pain was
brought to a comfortable level
within 48 hours.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
American
Academy of
Otolaryngology
-Head and
Neck Surgery
American
Academy of
Otolaryngology
-Head and
Neck Surgery
American
Academy of
Dermatology
Health
Resources and
Services
Administration
National
Hospice and
Palliative Care
Organization
EP30JN17.063
..
Indicator
30313
30314
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
"I
B7F amuy M e d". ( con fmue d)
ICllle
Indicator
NQF
#
Quality
#
CMSE-
Data
M:easute Submission
M:ethod
ID
!
0710
370
159v6
Web
Interface,
Registry,
EHR
0712
§
371
160v6
EHR
M;easure
Type
I
Natiomtl
Quality
Strategy
Domain
Outcome
Effective
Clinical Care
Process
Effective
Clinical Care
N/A
*
!
373
65v7
EHR
Intermed
iate
Outcome
N/A
374
50v6
Registry,
EHR
Process
Collllllunication
and Care
Coordination
Process
Person and
CaregiverCentered
Experience and
Outcomes
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VerDate Sep<11>2014
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PO 00000
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Clinical Care
Sfmt 4725
M:easure Title
and Description
Depression Remission at
Twelve Months:
Patients age 18 and older with
major depression or dysthymia
and an initial Patient Health
Questionnaire (PHQ-9) score
greater than nine who
demonstrate remission at twelve
months(+/- 30 days after an
index visit) defined as a PHQ-9
score less than five. This
measure applies to both patients
with newly diagnosed and
existing depression whose
current PHQ-9 score indicates a
need for treatment
Depression Utilization of the
PHQ-9 Tool:
Patients age 18 and older with
the diagnosis of major
depression or dysthymia who
have a Patient Health
Questionnaire (PHQ-9) tool
administered at least once during
a 4-month period in which there
was a qualifying visit
Hypertension: Improvement in
Blood Pressure:
Percentage of patients aged 1885 years of age with a diagnosis
of hypertension whose blood
pressure improved during the
measurement period.
Closing the Referral Loop:
Receipt of Specialist Report:
Percentage of patients with
referrals, regardless of age, for
which the referring provider
receives a report from the
provider to whom the patient
was referred.
Functional Status Assessments
for Congestive Heart Failure:
Percentage of patients 65 years
of age and older with congestive
heart failure who completed
initial and follow-up patientreported functional status
assessments.
E:\FR\FM\30JNP2.SGM
30JNP2
M:easure
Steward
MN
Community
Measurement
MN
Community
Measurement
Centers for
Medicare &
Medicaid
Services
Centers for
Medicare &
Medicaid
Services
Centers for
Medicare &
Medicaid
Services
EP30JN17.064
..
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30315
"I
B7F amuy M e d". ( con fmue d)
ICllle
!
#
1879
N/A
1407
!
mstockstill on DSK30JT082PROD with PROPOSALS2
§
VerDate Sep<11>2014
N/A
N/A
CMSEQuality
Measure
#
ID
383
387
394
398
400
19:16 Jun 29, 2017
N/A
N/A
N/A
N/A
N/A
Jkt 241001
Data
Submission
·Method
Registry
Registry
Registry
Registry
Registry
PO 00000
Measure
'}'ype
National
Quality
Strategy
Domain
Measure Title
and Description
Adherence to Antipsychotic
Medications for Individuals with
Schizophrenia:
Percentage of individuals at least 18
years of age as of the beginning of the
measurement period with
schizophrenia or schizoaffective
disorder who had at least two
prescriptions filled for any
antipsychotic medication and who
had a Proportion of Days Covered
(PDC) of at least 0.8 for antipsychotic
medications during the measurement
period (12 consecutive months).
Annual Hepatitis C Virus (HCV)
Screening for Patients who are
Active Injection Drug Users:
Percentage of patients regardless of
age who are active injection drug
users who received screening for
HCV infection within the 12 month
reporting period
Intermed
iate
Outcome
Patient
Safety
Process
Effective
Clinical
Care
Process
Community
I Population
Health
Outcome
Effective
Clinical
Care
Process
Effective
Clinical
Care
Frm 00307
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Immunizations for Adolescents:
The percentage of adolescents 13
years of age who had the
recommended immunizations by their
13th birthday.
Optimal Asthma Control:
Composite measure of the percentage
of pediatric and adult patients whose
asthma is well-controlled as
demonstrated by one of three age
appropriate patient reported outcome
tools.
One-Time Screening for Hepatitis
C Virus (HCV) for Patients at
Risk:
Percentage of patients aged 18 years
and older with one or more of the
following: a history of injection drug
use, receipt of a blood transfusion
prior to 1992, receiving maintenance
hemodialysis OR birthdate in the
years 1945-1965 who received onetime screening for hepatitis C virus
(HCV) infection.
E:\FR\FM\30JNP2.SGM
30JNP2
MeasU:re
Steward
National
Committee
for Quality
Assurance
Physician
Consortium for
Performance
Improvement
Foundation
(PCPI®)
National
Committee for
Quality
Assurance
MN
Community
Measurement
Physician
Consortium for
Performance
Improvement
Foundation
(PCPI®)
EP30JN17.065
Indicator
NQF
30316
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
"I
B7F amuy M e d". ( con fmue d)
ICllle
§
#
N/A
CMSEQuality
Measure
#
ID
401
N/A
Data
Submission
·MetJtod
Registry
Measure
'}'ype
Process
National
Quality
Strategy
Domain
Measure Title
and Description
Hepatitis C: Screening for
Hepatocellular Carcinoma (HCC)
in Patients with Cirrhosis:
Percentage of patients aged 18 years
and older with a diagnosis of chronic
hepatitis C cirrhosis who underwent
imaging with either ultrasound,
contrast enhanced CT or MRI for
hepatocellular carcinoma (HCC) at
least once within the 12 month
reporting period.
Effective
Clinical
Care
N/A
Registry
Process
408
N/A
Registry
Process
Effective
Clinical
Care
N/A
412
N/A
Registry
Process
Effective
Clinical
Care
N/A
VerDate Sep<11>2014
402
N/A
mstockstill on DSK30JT082PROD with PROPOSALS2
N/A
Commlmity
I Population
Health
414
N/A
Registry
Process
Effective
Clinical
Care
19:16 Jun 29, 2017
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PO 00000
Frm 00308
Fmt 4701
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MeasU:rc
Steward
American
Gastroenterolo
gical
Association/
American
Society for
Gastrointestinal
Endoscopy/
American
College of
Gastroenterology
Tobacco Use and Help with
Quitting Among Adolescents:
The percentage of adolescents 12 to
20 years of age with a primary care
visit during the measurement year for
whom tobacco usc status was
documented and received help with
quitting if identified as a tobacco
user.
Opioid Therapy Follow-up
Evaluation:
All patients 18 and older prescribed
opiates for longer than six weeks
duration who had a follow-up
evaluation conducted at least every
three months during Opioid Therapy
documented in the medical record.
Documentation of Signed Opioid
Treatment Agreement:
All patients 18 and older prescribed
opiates for longer than six weeks
duration who signed an opioid
treatment agreement at least once
during Opioid Therapy documented
in the medical record.
Evaluation or Interview for Risk of
Opiuid Misuse:
All patients 18 and older prescribed
opiates for longer than six weeks
duration evaluated for risk of opioid
misuse using a brief validated
instrument (e.g. Opioid Risk Tool,
SOAPPSOAPP-R) or patient
interview documented at least once
during Opioid Therapy in the medical
record.
E:\FR\FM\30JNP2.SGM
30JNP2
National
Committee for
Quality
Assurance
American
Academy of
Neurology
American
Academy of
Neurology
American
Academy of
Neurology
EP30JN17.066
Indicator
NQF
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30317
"I
B7F amuy M e d". ( con fmue d)
ICllle
#
0053
2152
*
N/A
Quality
#
418
431
438
CMSEData
Measure Submission
·Metltod
ID
N/A
N/A
347vl
Claims,
Registry
Registry
Web
Interface,
Registry,
Measure
'}'ype
Process
mstockstill on DSK30JT082PROD with PROPOSALS2
19:16 Jun 29, 2017
Jkt 241001
PO 00000
Measure Title
and Description
Effective
Clinical
Care
Process
Community
I Population
Health
Process
Effective
Clinical
Care
EHR
VerDate Sep<11>2014
National
Quality
Strategy
Domain
Frm 00309
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Osteoporosis Management in
Women Who Had a Fracture:
The percentage of women age 50-85
who suffered a fracture and who
either had a bone mineral density test
or received a prescription for a drug
to treat osteoporosis in the six months
after the fracture.
Preventive Care and Screening:
Unhealthy Alcohol Use: Screening
& Brief Counseling:
Percentage of patients aged 18 years
and older who were screened for
unhealthy alcohol use using a
systematic screening method at least
once within the last 24 months AND
who received brief counseling if
identified as an unhealthy alcohol
user.
Statin Therapy for the Prevention
and Treatment of Cardiovascular
Disease:
Percentage ofthe following
patients-all considered at high risk
of cardiovascular events-who were
prescribed or were on statin therapy
during the measurement period:
• Adults aged C: 21 years who were
previously diagnosed with or
currently have an active diagnosis of
clinical atherosclerotic cardiovascular
disease (ASCVD); OR
• Adults aged C:21 years who have
ever had a fasting or direct lowdensity lipoprotein cholesterol (LDLC) level C: 190 mg/dL; OR
• Adults aged 40-75 years with a
diagnosis of diabetes with a fasting or
direct LDL-C level of70-189 mg/dL
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
National
Committee for
Quality
Assurance
Physician
Consortium for
Performance
Improvement
Foundation
(PCPl®)
Centers for
Medicare &
Medicaid
Services
EP30JN17.067
Indicator
NQF
30318
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
"I
B7F amuy M e d". ( con fmue d)
ICllle
#
Quality
#
CMSEData
Measure Submission
·Met}lod
ID
!
N/A
441
N/A
§
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442
N/A
§
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N/A
Jkt 241001
Measure
Type
Registry
Intermediate
Outcome
Registry
Process
Registry
Registry
PO 00000
National
Quality
Strategy
Domain
Effective
Clinical
Care
Effective
Clinical
Care
Process
Patient
Safety
Process
Efficienc
y and
Cost
Reductio
n
Frm 00310
Fmt 4701
Sfmt 4725
Measure Title
and Description
Ischemic Vascular Disease All or
None Outcome Measure (Optimal
Control): The TVD All-or-None
Measure is one outcome measure
(optimal control). The measure
contains four goals. All four goals
within a measure must be reached in
order to meet that measure. The
numerator for the all-or-none
measure should he collected from
the organization's total IVD
denominator.
All-or-None Outcome Measure
(Optimal Control)
• Using the IVD denominator
optimal results include: Most
recent blood pressure (BP)
measurement is less than 140/90
mmiig
• And Most recent tobacco status is
Tobacco Free
• And Daily Aspirin or Other
Antiplatelet Unless
Contraindicated
• And Statin Use.
Persistent Beta Blocker
Treatment After a Heart Attack:
The percentage of patients 18 years
of age and older during the
measurement year who were
hospitalized and discharged from
July 1 of the year prior to the
measurement year to June 30 of the
measurement year with a diagnosis
of acute myocardial infarction
(AMI) and who received were
prescribed persistent beta-blocker
treatment for six months after
discharge.
Non-Recommended Cervical
Cancer Screening in Adolescent
Females:
The percentage of adolescent
females 16-20 years of age screened
mmecessarily for cervical cancer.
Medication Management for
People with Asthma (MMA):
The percentage of patients 5-64
years of age during the measurement
year who were identified as having
persistent asthma and were
dispensed appropriate medications
that they remained on for at least
75% oftheir treatment period.
E:\FR\FM\30JNP2.SGM
30JNP2
MeasU:re
Steward
Wisconsin
Collaborative
for Healthcare
Quality
(WCHQ)
National
Committee for
Quality
Assurance
National
Cmmnittee for
Quality
Assurance
National
Cmmnittee for
Quality
Assurance
EP30JN17.068
Indicator
NQF
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30319
"I
B7F amuy M e d". ( con fmue d)
ICllle
§
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#
#
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TBD
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CMSE:Measu~
ID
N/A
N/A
Jkt 241001
Data
Submission
Method
Registry
Registry
PO 00000
Measure
Type
National
Quality
Strategy
Domain
Process
Community/
Population
Health
Process
Patient
Safety,
Efliciency
and Cost
Reduction
Frm 00311
Fmt 4701
Sfmt 4725
Measure Title
a:nd Description
Chlamydia Screening and
Follow-up: The percentage of
female adolescents 16 years of age
who had a chlamydia screening test
with proper follow-up during the
measurement period.
Otitis Media with Effusion
(OME): Systemic
Antimicrobials- Avoidance of
Inappropriate Use:
Percentage of patients aged 2
months tlu·ough 12 years vvitl1 a
diagnosis of OME who were not
prescribed systemic antimicrobials.
E:\FR\FM\30JNP2.SGM
30JNP2
MeasU:re
Steward
National
Cmmnittee for
Quality
Assurance
American
Academy of
Otolaryngology
-Head and
Neck Surgery
Foundation
(AAOHNSF)
EP30JN17.069
.Indicator
NQF
30320
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B.S. Internal Medicine
§
!
Quality
#
#
0059
001
CMSEData
Measure Submission
ID
Method
122v6
§
0081
005
135v6
§
0067
006
N/A
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007
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145v6
Jkt 241001
Claims,
Web
Interface,
Registry,
EHR
Registry,
EHR
Registry
Registry,
EHR
PO 00000
Measure
Type
National
Quality
Strategy
Domain
Measure Title
and Description
Effective
IntermediE
Clinical
te
Care
Outcome
Process
Effective
Clinical Care
Process
Effective
Clinical Care
Process
Frm 00312
Fmt 4701
Effective
Clinical Care
Sfmt 4725
Diabetes: Hemoglobin Ale
(HbAlc) Poor Control (>9%):
Percentage of patients 18-75 years
of age with diabetes who had
hemoglobin Ale> 9.0% during the
measurement period.
Heart Failure (HF): AngiotensinConverting Enzyme (ACE)
Inhibitor or Angiotensin Receptor
Blocker (ARB) Therapy for Left
Ventricular Systolic Dysfunction
(LVSD):
Percentage of patients aged 18 years
and older with a diagnosis of heart
failure (HF) with a current or prior
left ventricular ejection fraction
(L VEF) < 40% who were
prescribed ACE inhibitor or ARB
therapy either within a 12-month
period when seen in the outpatient
setting OR at each hospital
discharge.
Chronic Stable Coronary Artery
Disease (CAD): Antiplatelet
Therapy: Percentage of patients
aged 18 years and older with a
diagnosis of coronary artery disease
(CAD) seen within a 12-month
period who were prescribed aspirin
or clopidogrel.
Coronary Artery Disease (CAD):
Beta-Blocker Therapy-Prior
Myocardial Infarction (MI) or
Left Ventricular Systolic
Dysfunction (LVEF <40%):
Percentage of patients aged 18 years
and older with a diagnosis of
coronary artery disease seen within
a 12-month period who also have
prior MI OR a cunent or prior
L VEF < 40% who were prescribed
beta-blocker therapy.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
National
Committee for
Quality
Assurance
Physician
Consortium for
Performance
Improvement
Foundation
(PCPI®)
American Heart
Association
Physician
Consortium for
Performance
Improvement
Foundation
(PCPI®)
EP30JN17.070
lndicator
NQF
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30321
B.S. Internal Medicine (continued)
.·
NQF
#
#
CMSEMeasure
Data
Submission
ID
Method
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008
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009
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024
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Jkt 241001
Measure
Type
National
Quality
Strategy
Domain
Measure Title
and Description
EHR
Process
Effective
Clinical
Care
EHR
Process
Effective
Clinical
Care
Process
Communic
ation
and Care
Coordinatio
n
Registry,
Claims,
Registry
PO 00000
Frm 00313
Fmt 4701
Sfmt 4725
Heart Failure (HF): Beta-Blocker
Therapy for Left Ventricular
Systolic Dysfunction (LVSD):
Percentage of patients aged 18 years
and older with a diagnosis of heart
failure (HF) with a current or prior
lett ventricular ejection traction
(L VEF) < 40% who were prescribed
beta-blocker therapy either within a
12-month period when seen in the
outpatient setting OR at each hospital
discharge.
Anti-Depressant Medication
Management:
Percentage of patients 18 years of
age and older who were treated with
antidepressant medication, had a
diagnosis of major depression, and
who remained on antidepressant
medication treatment
Two rates are reported
a. Percentage of patients who
remained on an antidepressant
medication for at least 84 days (12
weeks)
b. Percentage of patients who
remained on an antidepressant
medication for at least 180 days (6
months).
Communication with the Physician
or Other Clinician Managing Ongoing Care Post-Fracture for Men
and Women Aged 50 Years and
Older:
Percentage of patients aged 50 years
and older treated for a fracture with
documentation of communication,
between the physician treating the
fracture and the physician or other
clinician managing the patient's ongoing care, that a fracture occurred
and that the patient was or should be
considered for osteoporosis treatment
or testing. This measure is reported
by the physician who treats the
fracture and who therefore is held
accountable for the communication.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
Physician
Consortium
For
Performance
Improvement
National
Committee for
Quality
Assurance
National
Conm1ittee for
Quality
Assurance
EP30JN17.071
Indicator
Quality
30322
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B.S. Internal Medicine (continued)
#
0046
0326
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Measure Submission
·Method
ID
N/A
Claims,
Registry
N/A
Claims,
Registry
N/A
Claims,
Registry
N/A
Jkt 241001
Claims,
Registry
PO 00000
Measure
'}'ype
National
Quality
Strategy
Domain
Process
Effective
Clinical Care
Process
Communication
and Care
Coordination
Process
Effective
Clinical Care
Process
Person and
Caregiver
Centered
Experience and
Outcomes
Frm 00314
Fmt 4701
Sfmt 4725
Measure Title
and Description
Screening for Osteoporosis for
Women Aged 65-85 Years of
Age:
Percentage of female patients
aged 65-85 years of age who
ever had a central dual-energy
X-ray absorptiometry (DXA) to
check for osteoporosis.
Care Plan:
Percentage of patients aged 65
years and older who have an
advance care plan or surrogate
decision maker documented in
the medical record or
documentation in the medical
record that an advance care plan
was discussed but the patient did
not wish or was not able to name
a surrogate decision maker or
provide an advance care plan.
Urinary Incontinence:
Assessment of Presence or
Absence of Urinary
Incontinence in Women Aged
65 Years and Older:
Percentage of female patients
aged 65 years and older who
were assessed for the presence or
absence of urinary incontinence
within 12 months.
Urinary Incontinence: Plan of
Care for Urinary Incontinence
in Women Aged 65 Years and
Older:
Percentage of female patients
aged 65 years and older with a
diagnosis of urinary
incontinence with a documented
plan of care for urinary
incontinence at least once within
12 months.
E:\FR\FM\30JNP2.SGM
30JNP2
MeasU:re
Steward
National
Cmmnittee for
Quality
Assurance
National
Cmmnittee for
Quality
Assurance
National
Committee for
Quality
Assurance
National
Cmmnittee for
Quality
Assurance
EP30JN17.072
Indicator
NQF
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30323
B.S. Internal Medicine (continued)
·.
!!
!!
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#
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Method
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Measure ID
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093
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Claims,
Registry
N/A
Claims,
Registry
131v6
Claims, Web
Interface,
Registry,
EHR
134v6
Registry,
EHR
Jkt 241001
PO 00000
Frm 00315
Measure
Type
National Quality
Stra,tegy Domain
Measure Title
and. Description
.···
Process
\
Effective Clinical
Care
Process
Etliciency and
Cost Reduction
Process
Effective Clinical
Care
Process
Effective Clinical
Care
Fmt 4701
Measure
Steward
Sfmt 4725
Acute Otitis Extema
(AOE): Topical
Therapy: Percentage of
patients aged 2 years
and older with a
diagnosis of AOE who
were prescribed topical
preparations.
Acute Otitis Extema
(AOE): Systemic
Antimicrobial
Therapy- Avoidance
oflnappropriate Use:
Percentage of patients
aged 2 years and older
with a diagnosis of
AOE who were not
prescribed systemic
antimicrobial therapv.
Diabetes: Eye Exam:
Percentage of patients
18 - 75 years of age
with diabetes who had a
retinal or dilated eye
exam by an eye care
professional during the
measurement period or
a negative retinal exam
(no evidence of
retinopathy) in the 12
months prior to the
measurement period.
Diabetes: Medical
Attention for
Nephropathy:
The percentage of
patients 18-75 years of
age with diabetes who
had a nephropathy
screening test or
evidence of
nephropathy during the
measurement period.
E:\FR\FM\30JNP2.SGM
30JNP2
American
Academy of
Otolaryngology
-Head and Neck
Surgery
American
Academy of
Otolaryngology
-Head and Neck
Surgery
National
Committee for
Quality
Assurance
National
Committee for
Quality
Assurance
EP30JN17.073
Indicator
30324
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B.S. Internal Medicine (continued)
...
Indicator
NQF
#
Quality#
..
0417
*
§
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Method
N/A
Registry
69v6
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Registry,
EHR, Web
Interface
68v7
Claims,
Registry,
EHR
Jkt 241001
PO 00000
Frm 00316
Measure
Type
Measure Title
aJtd Description
National Quality
Strategy Domain
Measure
Steward
..·
Process
Effective Clinical
Care
Process
Community/
Population Health
Process
Fmt 4701
Patient Safety
Sfmt 4725
Diabetes Mellitus: Diabetic
Foot and Ankle Care,
Peripheral NeuropathyNeurological Evaluation:
Percentage of patients aged
1R years and older with a
diagnosis of diabetes mellitus
who had a neurological
examination of their lower
extremities within 12 months.
Preventive Care and
Screening: Body Mass
Index (BMI) Screening and
Follow-Up Plan:
Percentage of patients aged
18 years and older with a
BMI documented during the
current encounter or during
the previous twelve months
AND with a BMI outside of
normal parameters, a followup plan is documented during
the encounter or during the
previous twelve months of the
current encounter.
Normal Paran1eters:
Age 18 years and older BMI
=> 18.5 and< 25 kg/m2.
Documentation of Current
Medications in the Medical
Record:
Percentage of visits for
patients aged 18 years and
older for which the eligible
professional attests to
documenting a list of current
medications using all
inmlediate resources available
on the date of the encounter.
This list must include ALL
known prescriptions, overthe-counters, herbals, and
vitamin/mineral/dietary
(nutritional) supplements
AND must contain the
medications' name, dosage,
frequency and route of
administration.
E:\FR\FM\30JNP2.SGM
30JNP2
American
Podiatric
Medical
Association
Centers for
Medicare &
Medicaid
Services
Centers for
Medicare &
Medicaid
Services
EP30JN17.074
...
30325
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B.S. Internal Medicine (continued)
NQF#
0418
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Web
Interface,
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Process
National
Quality
Strategy
Domain
Connnunity
I Population
Health
EHR
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Registry
Frm 00317
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Patient
Safety
Process
Connnunic
ation and
Care
Coordinatio
n
Sfmt 4725
E:\FR\FM\30JNP2.SGM
Measure Title
and Description
Preventive Care
and Screening:
Screening for
Depression and
Follow-Up Plan:
Percentage of
patients aged 12
years and older
screened for
depression on the
date of the
encounter using an
age appropriate
standardized
depression
screening tool AND
if positive, a followup plan is
documented on the
date of the positive
screen.
Falls: Risk
Assessment:
Percentage of
patients aged 65
years and older with
a history of falls
who had a risk
assessment for falls
completed within 12
months.
Falls: Plan of
Care:
Percentage of
patients aged 65
years and older with
a history of falls
who had a plan of
care for falls
documented within
12 months.
30JNP2
I
Measure
Steward
Centers for
Medicare
&
Medicaid
Services
National
Connnittee
for Quality
Assurance
National
Connnittee
for Quality
Assurance
EP30JN17.075
Indicator
Data
CMSE~
Quality
Submission
#
•·· MeasureiD
Method
30326
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B.S. Internal Medicine (continued)
Indicator
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#
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163
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Method
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N/A
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Registry
PO 00000
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Type
Process
Process
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National
Quality
Strategy
Domain
Effective
Clinical Care
Patient Safety
Measure Title
and Description
.·
Measure
Steward
..
Comprehensive
Diabetes Care:
Foot Exam:
The percentage of
patients 18-75 years
of age with diabetes
(type 1 and type 2)
who received a foot
exam (visual
inspection and
sensory exam with
mono filament and a
pulse exam) during
the measurement
year.
Elder
Maltreatment
Screen and FollowUp Plan:
Percentage of
patients aged 65
years and older with
a documented elder
maltreatment screen
using an Elder
Maltreatment
Screening Tool on
the date of encounter
AND a documented
follow-up plan on
the date of the
positive screen.
E:\FR\FM\30JNP2.SGM
30JNP2
National
Committee
for Quality
Assurance
Centers for
Medicare &
Medicaid
Services
EP30JN17.076
...
30327
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B 8 Interna I Medicine (continued)
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#
#
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Submission
Method
Claims,
Web
Interface,
Registry,
EHR
Frm 00319
Measure
Type
Process
Fmt 4701
Sfmt 4725
National
Quality
Strategy
Domain
Effective
Clinical Care
.·
Measure Title
and Des~ription
Measure
Steward
Ischemic Vascular
Disease (IVD): Use
of Aspirin or
Another
Antiplatelet:
Percentage of
patients 18 years of
age and older who
were diagnosed with
acute myocardial
infarction (AMI),
coronary artery
bypass graft
(CABG) or
percutaneous
coronary
interventions (PCI)
in the 12 months
prior to the
measurement period,
or who had an active
diagnosis of
ischemic vascular
disease (IVD)
during the
measurement period,
and who had
documentation of
use of aspirin or
another antiplatelet
during the
measurement period.
National
Committee
for Quality
Assurance
·.
E:\FR\FM\30JNP2.SGM
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EP30JN17.077
Indicator
CMSE.,
Measure
ID
30328
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B.S. Internal Medicine (continued)
Indicator
NQF
#
*
§
*
0028
0022
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Metlwd
138v6
Claims,
Registry,
EHR, Web
Interface
156v6
EHR,
Registry
N/A
Jkt 241001
Registry
PO 00000
Measure
Type
National
Quality
Strategy
Domain
Process
Community/
Population
Health
Process
Patient
Safety
Process
Communicat
ion and Care
Coordination
Frm 00320
Fmt 4701
Sfmt 4725
Measure Title
and Description
Preventive Care and Screening:
Tobacco Use: Screening and
Cessation Intervention:
a. Percentage of patients aged 18
years and older who were
screened for tobacco use one or
more times within 24 months
b. Percentage of patients aged 18
years and older who were
screened for tobacco use and
identified as a tobacco user who
received tobacco cessation
intervention
c. Percentage of patients aged 18
years and older who were screened
for tobacco use one or more times
within 24 months AND who
received cessation counseling
intervention if identified as a
tobacco user.
Use of High-Risk Medications in
the Elderly:
Percentage of patients 65 years of
age and older who were ordered
high-risk medications. Two rates are
reported.
a. Percentage of patients who were
ordered at least one high-risk
medication.
b. Percentage of patients who were
ordered at least two of the same
high-risk medications.
Cardiac Rehabilitation Patient
Referral from an Outpatient
Setting:
Percentage of patients evaluated in
an outpatient setting who within the
previous 12 months have
experienced an acute myocardial
infarction (MI), coronary artery
bypass graft (CABG) surgery, a
percutaneous coronary intervention
(PCI), cardiac valve surgery, or
cardiac transplantation, or who have
chronic stable angina (CSA) and
have not already participated in an
early outpatient cardiac
rehabilitation/secondary prevention
(CR) program for the qualifying
event/diagnosis who were referred
to a CR program.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure.
Steward
Physician
Consortium for
Performance
Improvement
Foundation
(PCPI®)
National
Committee for
Quality
Assurance
American
College of
Cardiology
Foundation
EP30JN17.078
CMSE-
Quality
Measure
#
ID
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30329
B.S. Internal Medicine (continued)
Quality
#
#
0004
§
0032
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CMSE:Measu~
ID
137vG
Data
Submission
Method
22v6
Claims,
Registry,
EHR
Effective
Clinical
Care
Process
EHR
PO 00000
National
Quality
Strategy
Domain
Process
EHR
124v6
Jkt 241001
Measure
Type
Effective
Clinical
Care
Process
Community/
Population
Health
Frm 00321
Fmt 4701
Sfmt 4725
Measure Title
a:nd Description
Initiation and Engagement of
Alcohol and Other Drug
Dependence Treatment:
Percentage of patients 13 years of
age and older with a new episode
of alcohol and other drug (AOD)
dependence who received the
following. Two rates are reported.
a. Percentage of patients who
initiated treatment within 14 days
of the diagnosis.
b. Percentage of patients who
initiated treatment and who had
two or more additional services
with an AOD diagnosis within 30
days of the initiation visit.
Cervical Cancer Screening:
Percentage of women 21--64 years
of age who were screened for
cervical cancer using either of the
following criteria:
o Women age 21--64 who had
cervical cytology performed every
3 years
o Women age 30--64 who had
cervical cytology/human
papillomavirus (HPV) co-testing
performed every 5 years.
Preventive Care and Screening:
Screening for High Blood
Pressure and Follow-Up
Documented:
Percentage of patients aged 18
years and older seen during the
reporting period who were
screened for high blood pressure
AND a recommended follow-up
plan is documented based on the
current blood pressure (BP)
reading as indicated.
E:\FR\FM\30JNP2.SGM
30JNP2
MeasU:re
Steward
National
Committee for
Quality
Assurance
National
Committee for
Quality
Assurance
Centers for
Medicare &
Medicaid
Services
EP30JN17.079
Indicator
NQF
30330
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B.S. Internal Medicine (continued)
Quality
#
#
CMSEData
Measure Submission
ID
Method
§
!
0005
&
0006
321
N/A
CMSapproved
Survey
Vendor
§
1525
326
N/A
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Registry
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Measure
Type.
National
Quality
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Measure Title
and Description
Measure
Steward
Domain
Patient
Engagem
ent!Exper
1ence
Person and
CaregiverCentered
Experience
and
Outcomes
Process
Effective
Clinical Care
Fmt 4701
Sfmt 4725
CAHPS for MIPS
Clinician/Group Smvey:
Summaa Survey Measures may
include:
o Getting Timely Care,
Appointments, and Information;
o How well Providers
Communicate;
o Patient's Rating of Provider;
o Access to Specialists;
o Health Promotion and Education;
o Shared Decision-Making;
o Health Status and Functional
Status;
o Courteous and Helpful Office
Staff;
o Care Coordination;
o Stewardship of Patient
Resources.
Atrial Fibrillation and Atrial
Flutter: Chronic
Anticoagulation Therapy:
Percentage of patients aged 18
years and older with a diagnosis of
nonvalvular atrial fibrillation (AF)
or atrial flutter whose assessment
ofthe specified thromboembolic
risk factors indicate one or more
high-risk factors or more than one
moderate risk factor, as
determined by CHADS2 risk
stratification, who are prescribed
warfarin OR another oral
anticoagulant drug that is FDA
approved for the prevention of
thromboembolism.
E:\FR\FM\30JNP2.SGM
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Agency for
Healthcare
Research&
Quality
(AHRQ)
American
College of
Cardiology
EP30JN17.080
Indicator
NQF
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B.S. Internal Medicine (continued)
...
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#
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N/A
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Method
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PO 00000
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Type
Process
Process
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National Quality
Strategy Domain
Efficiency and
Cost Reduction
Efficiency and
Cost Reduction
Sfmt 4725
Measure Title
and Description
Adult Sinusitis:
Antibiotic
Prescribed for
Acute Sinusitis
(Overuse):
Percentage of
patients, aged 18
years and older, with
a diagnosis of acute
sinusitis who were
prescribed an
antibiotic within 10
days after onset of
symptoms.
Adult Sinusitis:
Appropriate Choice
of Antibiotic:
Amoxicillin With or
Without
Clavulanate
Prescribed for
Patients with Acute
Bacterial Sinusitis
(Appropriate Usc):
Percentage of
patients aged 18
years and older with
a diagnosis of acute
bacterial sinusitis that
were prescribed
amoxicillin, with or
without clavulante, as
a first line antibiotic
at the time of
diagnosis.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
American
Academy of
Otolaryngolog
y-Headand
Neck Surgery
American
Academy of
Otolaryngolog
y-Headand
Neck Surgery
EP30JN17.081
Indicator
30332
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B.S. Internal Medicine (continued)
!!
Quality
#
#
N/A
333
Cl\1SE-
Data
Measure Submission
Method
ID
N/A
Measure
Type
National
Quality
Strategy
Domain
Registry
Efficiency
Efficiency and Cost
Reduction
§
!
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Efficiency
Efficiency and Cost
Reduction
337
N/A
Registry
Process
Effective
Clinical
Care
Outcome
Effective
Clinical
Care
Outcome
Person and
CaregiverCentered
Experience
and
Outcomes
2082
N/A
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Measure Title
and Description
Adult Sinusitis: Computerized
Tomography (CT) for Acute
Sinusitis (Overuse):
Percentage of patients aged 18 years
and older with a diagnosis of acute
sinusitis who had a computerized
tomography (CT) scan of the
paranasal sinuses ordered at the time
of diagnosis or received within 28
days after date of diagnosis.
Adult Sinusitis: More than One
Computerized Tomography (CT)
Scan Within 90 Days for Chronic
Sinusitis (Overuse):
Percentage of patients aged 18 years
and older with a diagnosis of
chronic sinusitis who had more than
one CT scan of the paranasal sinuses
ordered or received within 90 days
after the date of diagnosis.
Tuberculosis (TB) Prevention for
Psoriasis, Psoriatic Arthritis and
Rheumatoid Arthritis Patients on
a Biological Immune Response
Modifier:
Percentage of patients whose
providers are ensuring active
tuberculosis prevention either
through yearly negative standard
tuberculosis screening tests or are
reviewing the patient's history to
determine if they have had
appropriate management for a recent
or prior positive test.
lllV Viral Load Suppression:
The percentage of patients,
regardless of age, with a diagnosis
ofHlV with a HlV viral load less
than 200 copies/mL at last HTV viral
load test during the measurement
year.
Pain Brought Under Control
Within 48 Hours:
Patients aged 18 and older who
report being uncomfortable because
of pain at the initial assessment
(after admission to palliative care
services) who report pain was
brought to a comfortable level
within 48 hours.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
American
Academy of
Otolaryngology
-Head and
Neck Surgery
American
Academy of
Otolaryngology
-Head and
Neck Surgery
American
Academy of
Dermatology
Health
Resources and
Services
Administration
National
Hospice and
Palliative Care
Organization
EP30JN17.082
Indicator
NQF
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30333
B.S. Internal Medicine (continued)
Quality
#
CMSE· ..·.·
Measure
ID
Data
Submission
Method
!
0710
370
159v6
Web
Interface,
Registry,
EHR
0712
§
371
lGOvG
EHR
Measure
Type
Outcome
Process
National
Quality
Strategy
Domain
Effective
Clinical Care
Effective
Clinical Care
N/A
*
!
373
65v7
EHR
Intermed
iate
Outcome
N/A
374
50v6
Registry,
EHR
Process
Cmurnunication
and Care
Coordination
Process
Person and
CaregiverCentered
Experience and
Outcomes
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Effective
Clinical Care
Sfmt 4725
Measure Title
and J)escription
Depression Remission at
Twelve Months:
Patients age 18 and older with
major depression or dysthymia
and an initial Patient Health
Questionnaire (PHQ-9) score
greater than nine who
demonstrate remission at twelve
months (+/- 30 days after an
index visit) defined as a PHQ-9
score less than five. This
measure applies to both patients
with newly diagnosed and
existing depression whose
current PHQ-9 score indicates a
need for treatment
Depression Utilization of the
PHQ-9 Tool:
Patients age 18 and older with
the diagnosis of major
depression or dysthymia who
have a Patient Health
Questionnaire (PHQ-9) tool
administered at least once
during a 4-month period in
which there was a qualifying
visit
Hypertension: Improvement
in Blood Pressure:
Percentage of patients aged 1885 years of age with a diagnosis
of hypertension whose blood
pressure improved during the
measurement period.
Closing the Referral Loop:
Receipt of Specialist Report:
Percentage of patients with
referrals, regardless of age, for
which the referring provider
receives a report from the
provider to whom the patient
was referred.
Functional Status Assessments
for Congestive Heart Failure:
Percentage of patients 65 years
of age and older with congestive
heart failure who completed
initial and follow-up patientreported functional status
assessments.
E:\FR\FM\30JNP2.SGM
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Steward
MN
Community
Measurement
MN
Community
Measurement
Centers for
Medicare &
Medicaid
Services
Centers for
Medicare &
Medicaid
Services
Centers for
Medicare &
Medicaid
Services
EP30JN17.083
Indicator
NQF
#
30334
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B.S. Internal Medicine (continued)
NQF
#
Qualily
#
·.
!
1879
383
CMSEData
Measure Submission
Method
m
N/A
Registry
Measure
Type
Intermed
iate
Outcome
National
Quality
Strategy
Domain
Patient
Safety
N/A
!
§
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N/A
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Effective
Clinical
Care
N/A
398
N/A
Registry
Outcome
Effective
Clinical
Care
N/A
N/A
400
401
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PO 00000
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Effective
Clinical
Care
Effective
Clinical
Care
Sfmt 4725
Measure Title
and Description
Adherence to Antipsychotic
Medications for Individuals with
Schizophrenia:
Percentage of individuals at least 18
years of age as of the beginning of the
measurement period with
schizophrenia or schizoaffective
disorder who had at least two
prescriptions filled for any
antipsychotic medication and who
had a Proportion of Days Covered
(PDC) of at least 0.8 for antipsychotic
medications during the measurement
period (12 consecutive months).
Annual Hepatitis C Virus (HCV)
Screening for Patients who are
Active Injection Drug Users:
Percentage of patients regardless of
age who are active injection drug
users who received screening for
HCV infection within the 12 month
reporting period.
Optimal Asthma Control:
Composite measure ofthe
percentage of pediatric and adult
patients whose asthma is wellcontrolled as demonstrated by one
of three age appropriate patient
reported outcome tools.
One-Time Screening for Hepatitis
C Virus (HCV) for Patients at
Risk:
Percentage of patients aged 18 years
and older with one or more of the
following: a history of injection drug
use, receipt of a blood transfusion
prior to 1992, receiving maintenance
hemodialysis OR birthdate in the
years 1945-1965 who received onetilne screening for hepatitis C virus
(HCV) infection.
Hepatitis C: Screening for
Hepatocellular Carcinoma (HCC)
in Patients with Cirrhosis:
Percentage of patients aged 18 years
and older with a diagnosis of chronic
hepatitis C cirrhosis who underwent
ilnaging with either ultrasound,
contrast enhanced CT or MRI for
hepatocellular carcinoma (HCC) at
least once within the 12 month
reporting period.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
National
Committee
for Quality
Assurance
Physician
Consortium
for
Performance
Improvement
Foundation
(PCPI®)
Milmesota
Community
Measurement
Physician
Consortium
for
Performance
Improvement
Foundation
(PCPI®)
American
Gastroenterological
Association/
American
Society for
Gastrointestinal
Endoscopy/
American
College of
Gastroenterology
EP30JN17.084
Indicator
30335
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B.S. Internal Medicine (continued)
NQF
#
N/A
#
·
..
402
ID
Data
Submission
Method
Measure
Type
National
Quality
Strategy
Domain
N/A
Registry
Process
Community/
Population
Health
VerDate Sep<11>2014
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N/A
Registry
Process
Effective
Clinical
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N/A
Registry
Process
Effective
Clinical
Care
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Measure Title
and Description
Tobacco Use and Help with
Quitting Among Adolescents:
The percentage of adolescents 12
to 20 years of age with a primary
care visit during the measurement
year for whom tobacco use status
was documented and received help
with quitting if identified as a
tobacco user.
Opioid Therapy Follow-up
Evaluation:
All patients 18 and older
prescribed opiates for longer than
six weeks duration who had a
follow-up evaluation conducted at
least every three months during
Opioid Therapy documented in the
medical record.
Documentation of Signed Opioid
Treatment Agreement:
All patients 18 and older
prescribed opiates for longer than
six weeks duration who signed an
opioid treatment agreement at least
once during Opioid Therapy
documented in the medical record.
E:\FR\FM\30JNP2.SGM
30JNP2
·.
Measure
Steward
National
Committee
for Quality
Assurance
American
Academy of
Neurology
American
Academy of
Neurology
EP30JN17.085
Indicator
CMS!.Measure
Quality
30336
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B.S. Internal Medicine (continued)
ln2014
431
19:16 Jun 29, 2017
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Jkt 241001
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Frm 00328
Process
Fmt 4701
Community/
Population
Health
Sfmt 4725
Measure Title
and Description
Evaluation or
Interview for Risk
of Opioid Misuse:
All patients 18 and
older prescribed
opiates for longer
than six weeks
duration evaluated
for risk of opioid
misuse using a brief
validated instrument
(e.g. Opioid Risk
Tool, SOAAP-R) or
patient interview
documented at least
once during Opioid
Therapy in the
medical record.
Osteoporosis
Management in
Women Who Had
a Fracture:
The percentage of
women age 50-85
who suffered a
fracture and who
either had a bone
mineral density test
or received a
prescription for a
drug to treat
osteoporosis in the
six months after the
fracture.
Preventive Care
and Screening:
Unhealthy Alcohol
Use: Screening &
Brief Counseling:
Percentage of
patients aged 18
years and older who
were screened for
unhealthy alcohol
useusmg a
systematic screening
method at least once
within the last 24
months AND who
received brief
counseling if
identified as an
unhealthy alcohol
user.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
American
Academy of
Neurology
National
Committee
for Quality
Assurance
Physician
Consortium
for
Performance
Improvement
Foundation
(PCPI®)
EP30JN17.086
...
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30337
B.8 Internal Medicine (continued)
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#
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N/A
0071
#
438
441
442
19:16 Jun 29, 2017
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Measure Submission
Method
ID
.·
347vl
N/A
N/A
Jkt 241001
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Type
Web
Interface,
Registry,
EHR
Process
Registry
Intermed
iate
Outcome
Registry
Process
PO 00000
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Fmt 4701
National
Quality
Strategy
Domain
Measure· Title
and Description
Statin Therapy for the Prevention
and Treatment of Cardiovascular
Disease:
Percentage of the following patients:
all considered at high risk of
cardiovascular events who were
prescribed or were on statin therapy
during the measurement period:
o Adults aged 2: 21 years who were
previously diagnosed with or
Effective
currently have an active diagnosis of
Clinical Care
clinical athero-sclerotic
cardiovascular disease(ASCVD);
OR
o Adults aged 2:21 years who have
ever had a fasting or direct lowdensity lipoprotein cholesterol
(LDL-C) level2: 190 mg/dL; OR
o Adults aged 40-75 years with a
~iagnosis of diabetes with a fasting or
~irect LDL-C level of70-189 mg/dL
~schemic Vascular Disease All or
~one Outcome Measure (Optimal
Control): The IVD All-or- None
~easure is one outcome measure
optimal control). The measure
ontains four goals. All four goals
~ithin a measure must be reached in
prder to meet that measure. The
~mmerator for the ali-or-none measure
should be collected from the
prganization's total IVD denominator.
Effective
Clinical Care P,.l!-or-None Outcome Measure
Optimal Control)
• Using the IVD denominator optimal
results include: Most recent blood
pressure (BP) measurement is less
than 140/90 mm Hg
• And Most recent tobacco status is
Tobacco Free
• And Daily Aspirin or Other
Antiplatelet Unless Contraindicated
And Statin Use.
Persistent Beta Blocker
Treatment After a Heart Attack:
!The percentage of patients 18 years of
~ge and older during the measurement
~ear who were hospitalized and
~ischarged from July 1 of the year prior
Effective
Clinical Care o the measurement year to June 30 of
~e measurement year with a diagnosis
pf acute myocardial infarction (AMI)
~nd who received were prescribed
persistent beta-blocker treatment for six
~onths after discharge.
Sfmt 4725
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
Centers for
Medicare &
Medicaid
Services
Wisconsin
Collaborative
for Healthcare
Quality
(WCHQ)
National
Cmmnittee
for Quality
Assurance
EP30JN17.087
Indicator
Quality
30338
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B.8 Internal Medicine (continued)
Indicator
§
!!
§
!
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VerDate Sep<11>2014
NQF
#
N/A
1799
N/A
Quality
#
443
444
447
19:16 Jun 29, 2017
CMSE~
Measure
ID
N/A
NA
N/A
Jkt 241001
Data
Submission
Method
Registry
Registry
Registry
PO 00000
Measure
Type
National
Quality
Strategy
Domain
Process
Patient
Safety
Process
Efficiency
and Cost
Reduction
Process
Community
I
Population
Health
Frm 00330
Fmt 4701
Sfmt 4725
Measure Title
and Description
· ..
Non-Recommended Cervical Cancer
Screening in Adolescent Females:
The percentage of adolescent females
16-20 years of age screened
llllllecessarily for cervical cancer.
Medication Management for
People with Asthma (MMA):
T11e percentage of patients 5-64 years
of age during the measurement year
who were identified as having
persistent asthma and were dispensed
appropriate medications that they
remained on for at least 75% of their
treatment period.
Chlamydia Screening and Followup: The percentage of female
adolescents 16 years of age who had a
chlamydia screening test with proper
follow-up during the measurement
period.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
National
Committee
for Quality
Assurance
National
C OJ1llllittee
for Quality
Assurance
National
Cm=ittee
for Quality
Assurance
EP30JN17.088
I
30339
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B 9 Ob st et ncs /G
.
~vneco ogy
Indicator
NQF
#
Quality
#
CMSE-
Data
Measure Submission
Method
ID
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!
VerDate Sep<11>2014
0326
047
N/A
N/A
!
Claims,
Registry
048
N/A
Claims,
Registry
N/A
050
19:16 Jun 29, 2017
N/A
Jkt 241001
Claims,
Registry
PO 00000
Measure
Type
National
Quality
Strategy
Domain
Process
Conununication
and Care
Coordination
Process
Effective
Clinical Care
Process
Person and
CaregiverCentered
Experience and
Outcomes
Frm 00331
Fmt 4701
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Measure Title
and Description
· ..
Care Plan:
Percentage of patients aged 65
years and older who have an
advance care plan or surrogate
decision maker documented in
the medical record or
documentation in the medical
record that an advance care plan
was discussed but the patient did
not wish or was not able to name
a surrogate decision maker or
provide an advance care plan.
Urinary Incontinence:
Assessment of Presence or
Absence of Urinary
Incontinence in Women Aged
65 Y cars and Older:
Percentage of female patients
aged 65 years and older who
were assessed for the presence or
absence of urinary incontinence
within 12 months.
Urinary Incontinence: Plan of
Care for Urinary Incontinence
in Women Aged 65 Years and
Older:
Percentage of female patients
aged 65 years and older with a
diagnosis of urinary
incontinence with a documented
plan of care for urinary
incontinence at least once within
12 months.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
National
Committee
for Quality
Assurance
National
Committee
for Quality
Assurance
National
Conm1ittee
for Quality
Assurance
EP30JN17.089
I
30340
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B 9 Ob stet ncs /G
.
~yneco ogy ( con f mue d)
Indicator
NQF
#
*
§
*
§
0041
2372
0421
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112
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130
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Data
Submission
Method
147v7
Claims,
Web
Interface,
Registry,
EHR
125v6
Claims,
Web
Interface,
Registry,
EHR
69v6
68v7
Jkt 241001
Claims,
Registry,
EHR, Web
Interface
Claims,
Registry,
EHR,
PO 00000
National
Quality
Strategy
Domain
Measure Title
and Description
Process
Conununity
I Population
Health
Preventive Care and Screening:
Influenza Immunization:
Percentage of patients aged 6 months
and older seen for a visit between
October 1 and March 31 who
received an influenza inununization
OR who reported previous receipt of
an influenza inununization.
Physician
Consortium
for
Performance
Improvement
Foundation
(PCPI®)
Process
Effective
Clinical
Care
Breast Cancer Screening:
Percentage of women 50- 74 years of
age who had a mannnogram to screen
for breast cancer.
National
Committee
for Quality
Assurance
Measure
Type
Process
Conununity
I Population
Health
Process
Patient
Safety
Frm 00332
Fmt 4701
Sfmt 4725
Preventive Care and Screening:
Body Mass Index (BMI) Screening
and Follow-Up Plan:
Percentage of patients aged 1R years
and older with a BMI documented
during the current encounter or
during the previous twelve months
AND with a BMI outside of normal
parameters, a follow-up plan is
documented during the encounter or
during the previous twelve months of
the current encounter.
Normal Parameters:
Age 18 years and older BMI => 18.5
and< 25 kglm2.
Documentation of Current
Medications in the Medical Record:
Percentage of visits for patients aged
18 years and older for which the
eligible professional attests to
documenting a list of current
medications using all inunediate
resources available on the date of the
encounter. This list must include ALL
known prescriptions, over-thecounters, herbals, and
vitamin/mineral/dietary (nutritional)
supplements AND must contain the
medications' name, dosage,
frequency and route of
administration.
E:\FR\FM\30JNP2.SGM
30JNP2
·.
Measure
Steward
Centers for
Medicare &
Medicaid
Services
Centers for
Medicare &
Medicaid
Services
EP30JN17.090
CMSE-
Quality
Measure
#
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30341
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Quality
#
#
0028
226
CMSEData
Measure Submission
ID
·Method
National
Quality
Strategy
Domain
Measure
'}'ype
Measure Title
and Description
138v6
Claims,
Registry,
EHR, Web
Interface
Process
Intcrmcd ~ffcctivc
~linical Care
iate
Outcome
Process
0018
236
165v6
Claims,
Web
Interface,
Registry,
EHR
N/A
265
N/A
Registry
~ommunity/
Population
~ealth
~ommunicat
on and Care
~oordination
§
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Effective
Clinical
Care
Process
Community
I
Population
Health
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Preventive Care and Screening:
Tobacco Use: Screening and
Cessation Intervention:
a. Percentage of patients aged 18
years and older who were screened
for tobacco use one or more times
within 24 months
b. Percentage of patients aged 18
years and older who were screened
for tobacco use and identified as a
tobacco user who received tobacco
cessation intervention
c. Percentage of patients aged 18
years and older who were screened
for tobacco use one or more times
within 24 months AND who
received cessation counseling
intervention if identified as a
tobacco user.
Controlling High Blood Pressure:
Percentage of patients 18-85 years of
age who had a diagnosis of
hypertension and whose blood
pressure was adequately controlled
(<140/90mmHg) during the
measurement period.
Biopsy Follow Up: Percentage of
new patients whose biopsy results
have been reviewed and
communicated to the primary
care/referring physician and patient
by the performing physician.
Cervical Cancer Screening:
Percentage of women 21-64 years of
age who were screened for cervical
cancer using either of the following
criteria:
o Women age 21-64 who had cervical
cytology performed every 3 years
o Women age 30-64 who had cervical
cytology /human papillomavirus
(HPV) co-testing pertormed every 5
years.
Chlamydia Screening for Women:
Percentage of women 16-24 years of
age who were identified as sexually
active and who had at least one test
for chlamydia during the
measurement period.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
Physician
Consortium
for
Performance
Improvement
Foundation
(PCPI®)
National
Committee
for Quality
Assurance
American
Academy of
Dermatology
National
Committee
for Quality
Assurance
National
Committee
for Quality
Assurance
EP30JN17.091
.Indicator
NQF
30342
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#
Qualily
#
CMSEMeasure
ID
·.
Data
Submission
Method
317
22v6
Claims,
Registry,
EHR
NIA
369
158v6
EHR
NIA
374
50v6
National
Quality
Strategy
Domain
Registry,
EHR
Process
Community
I
Population
Health
Process
NIA
*
!
Measure
Type ..
Effective
Clinical
Care
Process
Communic
ation and
Care
Coordinatio
n
NIA
Registry
Process
418
NIA
Claims,
Registry
Process
Effective
Clinical
Care
2063
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Community
I
Population
Health
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NIA
Claims,
Registry
Process
Patient
Safety
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Measure Title
and Description
Preventive Care and Screening:
Screening for High Blood
Pressure and Follow-Up
Documented: Percentage of
patients aged 18 years and older
seen during the reporting period
who were screened for high blood
pressure AND a recommended
follow-up plan is documented based
on the current blood pressure (BP)
reading as indicated.
Pregnant women that had HBsAg
testing:
This measure identifies pregnant
women who had a HBsAg (hepatitis
B) test during their pregnancy.
Closing the Referral Loop:
Receipt of Specialist Report:
Percentage of patients with referrals,
regardless of age, for which the
referring provider receives a report
from the provider to whom the
patient was referred.
Tobacco Use and Help with
Quitting Among Adolescents:
The percentage of adolescents 12 to
20 years of age with a primary care
visit during the measurement year
for whom tobacco use status was
documented and received help with
quitting if identified as a tobacco
user.
Osteoporosis Management in
Women Who Had a Fracture:
The percentage of women age 50-85
who suffered a fracture and who
either had a bone mineral density
test or received a prescription for a
drug to treat osteoporosis in the six
months after the fracture.
Performing Cystoscopy at the
Time of Hysterectomy for Pelvic
Organ Prolapse to Detect Lower
Urinary Tract Injury:
Percentage of patients who lmdergo
cystoscopy to evaluate for lower
urinary tract injury at the time of
hysterectomy for pelvic organ
prolapse.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
Centers for
Medicare &
Medicaid
Services
Optumlnsight
Centers for
Medicare &
Medicaid
Services
National
Committee
for Quality
Assurance
National
Cmmnittee
for Quality
Assurance
American
Urogynecolog
ical Society
EP30JN17.092
Indicator
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30343
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B 9 Ob stet ncs /G
""'neco ogy con mue d)
Quali,ty
#
#
CMSE- ·.
Measure
ID
Data
Submission
Method
Measure
Typt:
N/A
428
N/A
Registry
Process
N/A
429
N/A
Claims,
Registry
Process
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National
Quality
Strategy
Domain
Effective
Clinical
Care
Patient
Safety
Communit
y/
Population
Health
Sfmt 4725
1
Measure Title
and De~cription
Pelvic Organ Prolapse:
Preoperative Assessment of
Occult Stress Urinary
Incontinence:
Percentage of patients undergoing
appropriate preoperative
evaluation of stress urinmy
incontinence prior to pelvic organ
prolapse surgery per
ACOG/AUGS/AUA guidelines.
Pelvic Organ Prolapse:
Preoperative Screening for
Uterine Malignancy:
Percentage of patients who are
screened for uterine malignancy
prior to vaginal closure or
obliterative surgery for pelvic
organ prolapse.
Preventive Care and Screening:
Unhealthy Akuhul Use:
Screening & Brief Counseling:
Percentage of patients aged 18
years and older who were
screened for unhealthy alcohol use
using a systematic screening
method at least once within the
last 24 months AND who received
brief counseling if identified as an
unhealthy alcohol user.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure Steward
American
Urogynecologic
Society
American
Urogynecologic
Society
Physician
Consortium for
Perfom1ance
Improvement
Foundation
(PC PI®)
EP30JN17.093
Indicator
NQF
30344
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·.
NQF
#
Quality
#
CMSE"
Measure
ID
Measure
Type
National Quality
Strategy
Domain
432
N/A
Registry
Outcome
Patient Safety
!
N/A
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N/A
Registry
Outcome
Patient Safety
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Patient Safety
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Measu.re Title
and Description
Proportion of Patients
Sustaining a Bladder
Injury at the Time of
any Pelvic Organ
Prolapse Repair:
Percentage of patients
undergoing any surgery to
repair pelvic organ
prolapse who sustains an
injury to the bladder
recognized either during
or within I month after
surgery.
Proportion of Patients
Sustaining a Bowel
Injury at the Time of
any Pelvic Organ
Prolapse Repair:
Percentage of patients
undergoing surgical repair
of pelvic organ prolapse
that is complicated by a
bowel injury at the time of
index surgery that is
recognized
intraoperatively or within
I month after surgery.
Proportion of Patients
Sustaining A Ureter
Injury at the Time of
any Pelvic Organ
Prolapse Repair:
Percentage of patients
undergoing pelvic organ
prolapse repairs who
sustain an injury to the
ureter recognized either
during or within 1 month
after surgery.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
American
Urogynecolo
gic Society
American
Urogynecolo
gic Society
American
Urogynecolo
gic Society
EP30JN17.094
Indicator
Data
Submission
Method
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#
#
CMSE~
Measure
lD
Data
Submission
Method
Measure
Type
National
Qqality
Strategy
Domain
N/A
443
N/A
Registry
Process
Patient
Safety
N/A
447
N/A
Registry
Process
Community/
Population
Health
0567
448
N/A
Process
Patient
Safety
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Measure Title
and Description
Measure
Steward
..
Non-Recommended Cervical
Cancer Screening in Adolescent
Females:
The percentage of adolescent
females 16-20 years of age screened
urmecessarily for cervical cancer.
Chlamydia Screening and Followup:
The percentage of female
adolescents 16 years of age who had
a chlamydia screening test with
proper follow-up during the
measurement period.
Appropriate Work Up Prior to
Endometrial Ablation:
Percentage of women, aged 18 years
and older, who undergo endometrial
sampling or hysteroscopy with
biopsy and results documented
before undergoing an endometrial
ablation.
E:\FR\FM\30JNP2.SGM
30JNP2
National
Conmrittee
for Quality
Assurance
National
Comnrittee
for Quality
Assurance
Health
BenchmarksIMS Health
EP30JN17.095
Indicator
Quality
30346
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CMSE~
Data
Measure Submission
ID
.MethOd
Measure
Type
1
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014
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Registry,
EHR
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Claims,
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Quality
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Domain
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Effective
Clinical
Care
Process
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Clinical
Care
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Measure Title
and Description
Measure
Steward
.·
Primary Open-Angle Glaucoma
(POAG): Optic Nerve Evaluation:
Percentage of patients aged 18 years
and older with a diagnosis of primary
open-angle glaucoma (POAG) who
have an optic nerve head evaluation
during one or more office visits
within 12 months.
Age-Related Macular
Degeneration (AMD): Dilated
Macular Examination:
Percentage of patients aged 50 years
and older with a diagnosis of agerelated macular degeneration (AMD)
who had a dilated macular
examination performed which
included documentation of the
presence or absence of macular
thickening or hemorrhage AND the
level of macular degeneration severity
during one or more office visits
within 12 months.
E:\FR\FM\30JNP2.SGM
30JNP2
Physician
Consortium
for
Pertormance
Improvement
Foundation
(PCPI®)
American
Academy of
Ophthahuolog
y
EP30JN17.096
·.
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#
018
019
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130
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.CMSEMeasure
ID
167v6
Data
Submission
Metho11
EHR
Process
142v6
Claims,
Registry,
EHR
13lv6
Claims,
Web
Interface,
Registry,
EHR
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Claims,
Registry,
EHR,
Jkt 241001
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Type
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Process
Process
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National
Quality
Strategy
Domain
.
Measure Title
and Description
Diabetic Retinopathy:
Documentation of Presence or
Absence of Macular Edema and
Level of Severity of Retinopathy:
Percentage of patients aged 18 years
EtTective and older with a diagnosis of diabetic
Clinical
retinopathy who had a dilated macular
Care
or fundus exam performed which
included documentation of the level
of severity of retinopathy and the
presence or absence of macular edema
during one or more office visits
within 12 months.
Diabetic Retinopathy:
Communication with the Physician
Managing Ongoing Diabetes Care:
Percentage of patients aged 18 years
Communi and older with a diagnosis of diabetic
cation and retinopathy who had a dilated macular
Care
or fundus exam performed with
Coordinati documented communication to the
on
physician who manages the ongoing
care of the patient with diabetes
mellitus regarding the findings of the
macular or fundus exam at least once
within 12 months.
Diabetes: Eye Exam:
Percentage of patients 18- 75 years of
age with diabetes who had a retinal or
EtTective dilated eye exam by an eye care
Clinical
professional during the measurement
Care
period or a negative retinal exam (no
evidence of retinopathy) in the 12
months prior to the measurement
period.
Documentation of Current
Medications in the Medical Record:
Percentage of visits for patients aged
18 years and older for which the
eligible professional attests to
documenting a list of current
medications using all immediate
Patient
resources available on the date of the
Safety
encounter. This list must include ALL
known prescriptions, over-thecounters, herbals, and
vitamin/mineral/dietary (nutritional)
supplements AND must contain the
medications' name, dosage, frequency
and route of administration.
Sfmt 4725
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30JNP2
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Steward
Physician
Consortium
for
Performance
Improvement
Foundation
(PCPI®)
Physician
Consortium
for
Performance
Improvement
Foundation
(PCPI®)
National
Cmmnittee
for Quality
Assurance
Centers for
Medicare &
Medicaid
Services
EP30JN17.097
I
30348
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B 10 0 'PIhth aImo ogy ( con fmue d)
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Indicator
NQF
#
CMSEQuality
Measure
#
ID
Data
Submission
Method
..
Measure.
Type
National
Quality
Strategy
Domain
Measure Title
and Description
Measure
Steward
.·
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N/A
Claims,
Registry
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132v6
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EIIR
Registry,
EHR
PO 00000
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Effective
Clinical Care
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Coordination
Outcome
Outcome
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Clinical Care
Patient
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American
Academy of
Ophthalmol
ogy
American
Academy of
Ophthalmol
ogy
Physician
Consortium
for
Performanc
e
lmproveme
nt
Foundation
(PCPl
0566
Claims,
Registry
Age-Related Macular Degeneration
(AMD): Counseling on Antioxidant
Supplement:
Percentage of patients aged 50 years and
older with a diagnosis of age-related
macular degeneration (AMD) or their
caregiver(s) who were counseled within
12 months on the benefits and/or risks of
the Age-Related Eye Disease Study
(AREDS) formulation for preventing
progression of AMD.
Primary Open-Angle Glaucoma
(POAG): Reduction oflntraocular
Pressure (lOP) by 15% OR
Documentation of a Plan of Care:
Percentage of patients aged 18 years
and older with a diagnosis of primary
open-angle glaucoma (POAG) whose
glaucoma treatment has not failed (the
most recent lOP was reduced by at least
15% from the pre- intervention level)
OR if the most recent lOP was not
reduced by at least 15% from the preintervention level, a plan of care was
documented within 12 months.
Cataracts: 20/40 or Better Visual
Acuity within 90 Days Following
Cataract Surgery:
Percentage of patients aged 18 years and
older with a diagnosis of uncomplicated
cataract who had cataract surgery and no
significant ocular conditions impacting
the visual outcome of surgery and had
best-corrected visual acuity of20/40 or
better (distance or near) achieved within
90 days following the cataract surgery.
Cataracts: Complications within 30
Days Following Cataract Surgery
Requiring Additional Surgical
Procedures:
Percentage of patients aged 18 years and
older with a diagnosis of uncomplicated
cataract who had cataract surgery and
had any of a specified list of surgical
procedures in the 30 days following
cataract surgery which would indicate the
occurrence of any of the following major
complications: retained nuclear
fragments, endophthahnitis, dislocated or
wrong power lOL, retinal detachment, or
wound dehiscence.
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B.lO. Ophthalmology (continued)
*
§
Quality·.
#
#
0028
226
CMSE-
Data
Measure Submission
Method
ID
138v6
Claims,
Registry,
EHR, Web
Interface
Measure
Type
National
Quality
Strategy
Domain
Process
Community/
Population
Health
!
1536
303
N/A
Registry
Outcome
Person
CaregiverCentered
Experience
and
Outcomes
*
!
N/A
374
50v6
Registry,
EHR
Process
Communicat
ion and Care
Coordination
Outcome
Effective
Clinical Care
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Measure Title
and Description
Preventive Care and Screening:
Tobacco Use: Screening and
Cessation Intervention:
a. Percentage of patients aged 18
years and older who were
screened for tobacco use one or
more times within 24 months
b. Percentage of patients aged 18
years and older who were screened
for tobacco use and identified as a
tobacco user who received tobacco
cessation intervention
c. Percentage of patients aged 18
years and older who were screened
for tobacco use one or more times
within 24 months AND who
received cessation counseling
intervention if identified as a
tobacco user.
Cataracts: Improvement in
Patient's Visual Function within 90
Days Following Cataract Surgery:
Percentage of patients aged 18 years
and older who had cataract surgery
and had improvement in visual
function achieved within 90 days
following the cataract surgery, based
on completing a pre-operative and
post-operative visual function survey.
Closing the Referral Loop: Receipt
of Specialist Report:
Percentage of patients with referrals,
regardless of age, for which the
referring provider receives a report
from the provider to whom the patient
was referred.
Adult Primary Rhegmatogenous
Retinal Detachment Surgery: No
Return to the Operating Room
Within 90 Days of Surgery:
Patients aged 18 years and older who
had surgery for primary
rhegmatogenous retinal detachment
who did not require a return to the
operating room within 90 days of
surgery.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
Physician
Consortium
for
Performance
Improvement
Foundation
(PCPT®)
American
Academy of
Ophthalmolog
y
Centers for
Medicare &
Medicaid
Services
American
Academy of
Ophthalmolog
y
EP30JN17.099
Indicator
NQF
30350
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#
385
388
389
402
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CMS.EMeasure
ID
N/A
N/A
N/A
N/A
Jkt 241001
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Measure
Submission
Type
Method I
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Registry
Registry
Registry
PO 00000
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Outcome
Outcome
Process
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National
Quality
Strategy
Domain
Measure Title
and Description
Adult Primary Rhegmatogenous
Retinal Detachment Surgery:
Visual Acuity Improvement Within
90 Days of Surgery:
EtTective
Patients aged 18 years and older who
Clinical
had surgery for primary
Care
rhegmatogenous retinal detachment
and achieved an improvement in their
visual acuity, from their preoperative
level, within 90 days of surgery in the
operative eye.
Cataract Surgery with IntraOperative Complications
(Unplanned Rupture of Posterior
Capsule Requiring Unplanned
Patient
Vitrectomy:
Safety
Percentage of patients aged 18 years
and older who had cataract surgery
performed and had an unplanned
rupture of the posterior capsule
requiring vitrectomy.
Cataract Surgery: Difference
Between Planned and Final
Refraction:
EtTective
Percentage of patients aged 18 years
Clinical
and older who had cataract surgery
Care
performed and who achieved a final
refraction within+/- 0.5 diopters of
their planned (target) refraction.
Tobacco Use and Help with
Quitting Among Adolescents:
The percentage of adolescents 12 to
Comrnunit
20 years of age with a primary care
y/
visit during the measurement year for
Population
whom tobacco use status was
Health
documented and received help with
quitting if identified as a tobacco
user.
Sfmt 4725
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
American
Academy of
Ophthalmolog
y
American
Academy of
Ophthalmolog
y
American
Academy of
Ophthalmolog
y
National
Committee
for Quality
Assurance
EP30JN17.100
.Indicator
NQF
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30351
B 11 0 rth ope d" surgery
IC
Data
Submission:
Method
NQF
!
0045
024
N/A
!!
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021
N/A
Claims,
Registry
N/A
Claims,
Registry
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#
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PO 00000
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Type
Process
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Quality
Strategy
Domajn ·
Communicati
on and Care
Coordination
Process
Process
Frm 00343
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Measure Title
and Description
Communication with the Physician
or Other Clinician Managing Ongoing Care Post-Fracture for Men
and Women Aged 50 Years and
Older:
Percentage of patients aged 50 years
and older treated for a fracture with
documentation of communication,
between the physician treating the
fracture and the physician or other
clinician managing the patient's ongoing care, that a fracture occurred
and that the patient was or should be
considered for osteoporosis treatment
or testing. This measure is reported
by the physician who treats the
fracture and who therefore is held
accountable for the communication.
Perioperative Care: Selection of
Prophylactic Antibiotic- First OR
Second Generation Cephalosporin:
Percentage of surgical patients aged
18 years and older undergoing
Patient Safety procedures with the indications for a
first OR second generation
cephalosporin prophylactic antibiotic,
who had an order for a first OR
second generation cephalosporin for
antimicrobial prophylaxis.
Perioperative Care: Venous
Thromboembolism (VTE)
Prophylaxis (When Indicated in
ALL Patients):
Percentage of surgical patients aged 18
years and older undergoing procedures
for which venous thromboembolism
(VTE) prophylaxis is indicated in all
Patient Safety
patients, who had an order tor Low
Molecular Weight Heparin (LMWH),
Low-Dose Unfractionated Heparin
(LDUH), adjusted-dose warfarin,
fondaparinux or mechanical prophy laxi
to be given within 24 hours prior to
incision time or within 24 hours after
surgery end time.
Sfmt 4725
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
National
Committee
for Quality
Assurance
American
Society of
Plastic
Surgeons
American
Society of
Plastic
Surgeons
EP30JN17.101
CMSEMeasure
Indica
tor
30352
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IC
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~QF
tor
#
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Measure
ID
Data
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Method
Measure
Type
National
Quality
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Domain
Measure Title
and Description
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!
0097
046
N/A
Claims, Web
Interface,
Registry
Process
Connnunicat
ion and Care
Coordination
0326
§
047
N/A
Claims,
Registry
Process
Connnunicat
ion and Care
Coordination
VerDate Sep<11>2014
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Medication Reconciliation Post~
Discharge: The percentage of
discharges from any inpatient facility
(e.g. hospital, skilled nursing facility,
or rehabilitation facility) for patients
18 years and older of age seen within
30 days following discharge in the
office by the physician, prescribing
practitioner, registered nurse, or
clinical pharmacist providing ongoing care for whom the discharge
medication list was reconciled with
the current medication list in the
outpatient medical record.
This measure is reported as three
rates stratified by age group:
o Reporting Criteria 1: 18-64 years of
age
o Reporting Criteria 2: 65 years and
older
o Total Rate: All patients 18 years of
age and older.
Care Plan:
Percentage of patients aged 65 years
and older who have an advance care
plan or surrogate decision maker
documented in the medical record
that an advance care plan was
discussed but the patient did not wish
or was not able to name a surrogate
decision maker or provide an advance
care plan.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
National
Committee
for Quality
Assurance
National
Committee
for Quality
Assurance
EP30JN17.102
CMS
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30353
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IC
Indica
tor
!
*
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§
NQF Quality
# •
#
N/A
0421
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E-:
Measur
eiD.
Data
Submission ··
Method
Claims,
Registry
69v6
Claims, Web
Interface,
Registry, EHR
PO 00000
Measure
Type
Process
N/A
Jkt 241001
National
Quality
Strategy
Domain
Person and
CaregiverCentered
Experience
and
Outcomes
Process
Community/
Population
Health
Frm 00345
Fmt 4701
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..·
Measure Title
and Description
Osteoarthritis (OA): Function and
Pain Assessment:
Percentage of patient visits for patients
aged 21 years and older with a
diagnosis of osteoarthritis (OA) with
assessment for function and pain.
Preventive Care and Screening:
Body Mass Index (BMI) Screening
and Follow-Up Plan:
Percentage of patients aged 18 years
and older with a BMI documented
during the current encounter or during
the previous twelve months AND with
a BMI outside of normal parameters, a
follow-up plan is documented during
the encounter or during the previous
twelve months of the current
encounter.
Nonnal Parameters: Age 18 years and
older BMI => 18.5 and< 25 kg/m2.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
American
Academy of
Orthopedic
Surgeons
Centers for
Medicare &
Medicaid
Services
EP30JN17.103
CMS
30354
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IC
!
Quality
#
.#
0419
130
CMSEMeasure
ID
68v7
Data
Submission
Method
Claims,
Registry,
Measure
Type
National
Quality
Strategy
Domain
Process
Patient Safety
Process
Communication
and Care
Coordination
Process
Community/
Population
Health
EHR
!
0420
0418
!
!
0101
0101
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N/A
VerDate Sep<11>2014
131
134
154
155
178
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N/A
Claims,
Registry
2v7
Claims,
Web
Interface,
Registry,
EHR
N/A
Claims,
Registry
N/A
Claims,
Registry
N/A
Jkt 241001
Registry
PO 00000
Process
Patient Safety
Process
Communication
and Care
Coordination
Process
Frm 00346
Fmt 4701
Effective
Clinical Care
Sfmt 4725
Measure Title
and Description
Documentation of Current
Medications in the Medical
Record:
Percentage of visits for patients
aged 18 years and older for which
the eligible professional attests to
documenting a list of current
medications using all immediate
resources available on the date of
the encounter. This list must
include ALL known prescriptions,
over-the-counters, herbals, and
vitamin/mineral/dietary
(nutritional) supplements AND
must contain the medications'
name, dosage, frequency and route
of administration.
Pain Assessment and Follow-Up:
Percentage of visits for patients
aged 18 years and older with
documentation of a pain
assessment using a standardized
tool(s) on each visit AND
documentation of a follow-up plan
when pain is present.
Preventive Care and Screening:
Screening for Depression and
Follow-Up Plan:
Percentage of patients aged 12
years and older screened for
depression on the date of the
encounter using an age appropriate
standardized depression screening
tool AND if positive, a follow-up
plan is documented on the date of
the positive screen.
Falls: Risk Assessment:
Percentage of patients aged 65
years and older with a history of
falls who had a risk assessment for
falls completed within 12 months.
Falls: Plan of Care:
Percentage of patients aged 65
years and older with a history of
falls who had a plan of care for
falls documented within 12
months.
Rheumatoid Arthritis (RA):
Functional Status Assessment:
Percentage of patients aged 18
years and older with a diagnosis of
rheumatoid arthritis (RA) for
whom a functional status
assessment was performed at least
once within 12 months.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
Centers for
Medicare&
Medicaid
Services
Centers for
Medicare&
Medicaid
Services
Centers for
Medicare&
Medicaid
Services
National
Committee
for Quality
Assurance
National
Committee
for Quality
Assurance
American
College of
Rheumatol
ogy
EP30JN17.104
Indicator
NQF
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30355
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#
#
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NIA
*
§
0028
NIA
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180
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317
318
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CMSE~
Measure
ID
NIA
Data
Submission
Method
Registry
NIA
Registry
138v6
Claims,
Web
Interface,
Registry,
EHR
22v6
Claims,
Registry,
EHR
139v6
EHR, Web
Intertace
Jkt 241001
PO 00000
Measure
Type
Process
Process
National
Quality
Strategy
Domain
Measure Title
and Description
Effective
Clinical
Care
Effective
Clinical
Care
Process
ConmmnityI
Population
Health
Process
ConmmnityI
Population
Health
Process
Patient
Safety
Frm 00347
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Rheumatoid Arthritis (RA):
Assessment and Classification of
Disease Prognosis:
Percentage of patients aged 18 years
and older with a diagnosis of
rheumatoid arthritis (RA) who have an
assessment and classification of disease
prognosis at least once within 12
months.
Rheumatoid Arthritis (RA):
Glucocorticoid Management
Percentage of patients aged 18 years
and older with a diagnosis of
rheumatoid arthritis (RA) who have
been assessed for glucocorticoid use
and, for those on prolonged doses of
prednisone 2: 10 mg daily (or
equivalent) with improvement or no
change in disease activity,
documentation of glucocorticoid
management plan within 12 months.
Preventive Care and Screening:
Tobacco Use: Screening and
Cessation Intervention:
a. Percentage of patients aged 18 years
and older who were screened for
tobacco use one or more times within
24 months
b. Percentage of patients aged 18 years
and older who were screened for
tobacco use and identified as a
tobacco user who received tobacco
cessation intervention
Percentage of patients aged 18 years
and older who were screened for
tobacco use one or more times within
24 months AND who received
cessation counseling intervention if
identified as a tobacco user.
Preventive Care and Screening:
Screening for High Blood Pressure
and Follow-Up Documented:
Percentage of patients aged 18 years
and older seen during the reporting
period who were screened for high
blood pressure AND a recommended
follow-up plan is documented based on
the current blood pressure (BP) reading
as indicated.
Falls: Screening for Future Fall
Risk:
Percentage of patients 65 years of age
and older who were screened for future
fall risk during the measurement
period.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
American
College of
Rheumatolog
y
American
College of
Rheumatolo
gy
Physician
Consortium
for
Performance
Improvemen
t Foundation
(PCPI®)
Centers for
Medicare&
Medicaid
Services
National
Committee
for Quality
Assurance
EP30JN17.105
Indicator
N:QF
30356
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IC
I
!
!
!
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VerDate Sep<11>2014
#
N/A
N/A
N/A
N/A
N/A
Quality
#
350
351
352
353
358
19:16 Jun 29, 2017
CMSEData
Measure Submission
ID
·Method
N/A
N/A
N/A
N/A
N/A
Jkt 241001
Registry
Registry
Registry
Registry
Registry
PO 00000
National
Quality
Strategy
Domain
Measure
'}'ype
Process
Process
Process
Process
Process
Frm 00348
Measure Title
and. Description
Total Knee Replacement: Shared
Decision-Making: Trial of
Conservative (Non-surgical)
Therapy:
rommunication Percentage of patients regardless of age
undergoing a total knee replacement with
~nd Care
roordination
documented shared decision-making with
discussion of conservative (non-surgical)
therapy (e.g. nonsteroidal antiinflammatory dmgs (NSAIDs),
analgesics, weight loss, exercise,
injections) prior to the procedure.
Total Knee Replacement: Venous
Thromboembolic and Cardiovascular
Risk Evaluation:
Percentage of patients regardless of age
undergoing a total knee replacement who
Patient
are evaluated for the presence or absence
Safety
of venous Urromboembolic and
cardiovascular risk factors within 30 days
prior to the procedure (e.g. history of
Deep Vein Thrombosis (DVT),
Pulmonary Embolism (PE), Myocardial
Infarction (Ml), Arrhythmia and Stroke).
Total Knee Replacement: Preoperative
Antibiotic Infusion with Proximal
Tourniquet:
Patient
Percentage of patients regardless of age
Safety
undergoing a total knee replacement who
had the prophylactic antibiotic
completely infused prior to the inflation
of the proximal tourniquet
Total Knee Replacement:
Identification of Implanted Prosthesis
in Operative Report:
Percentage of patients regardless of age
undergoing a total knee replacement
Patient
whose operative report identifies the
Safety
prosthetic implant specifications
including the prosthetic implant
manufacturer, the brand name ofthe
prosthetic implant and the size of each
prosthetic implant.
Patient-Centered Surgical Risk
Assessment and Communication:
Person and
Percentage of patients who underwent a
Caregivernon-emergency surgery who had their
personalized risks of postoperative
Centered
Experience
complications assessed by their surgical
and
team prior to surgery using a clinical
Outcomes
data-based, patient-specific risk
calculator and who received personal
discussion of those risks with the
surgeon.
Fmt 4701
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E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
American
Associatio
n of Hip
and Knee
Surgeons
American
Associatio
nofHip
audKnee
Surgeons
American
Associatio
n of Hip
and Knee
Surgeons
American
Associatio
nofHip
and Knee
Surgeons
American
Associatio
n of Hip
and Knee
Surgeons
EP30JN17.106
Indicator
NQF
30357
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IC
NQF
#
*
!
*
!
!
N/A
N/A
N/A
N/A
N/A
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N/A
VerDate Sep<11>2014
#
374
375
376
402
408
412
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CMSEData
Measure Submission
m
Method
50v6
66v6
56v6
N/A
N/A
N/A
Jkt 241001
Registry,
EHR
EIIR
Process
Process
EHR
Process
Registry
Registry
Registry
PO 00000
Measure
Type
National
Quality
Strategy
Domain
Connmmication
and Care
Coordination
Person and
CaregiverCentered
Experience and
Outcomes
Person and
CaregiverCentered
Experience and
Outcomes
Process
Community/
Population
Health
Process
Effective
Clinical Care
Process
Effective
Clinical Care
Frm 00349
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Measure Title
and Descriptian
Closing the Referral Loop:
Receipt of Specialist Report:
Percentage of patients with referrals,
regardless of age, for which the
referring provider receives a report
from the provider to whom the
patient was referred.
Functional Status Assessment for
Total Knee Replacement:
Changes to the measure description:
Percentage of patients 18 years of
age and older who received an
elective primary total knee
arthroplasty (TKA) who completed
baseline and follow-up patientreported and completed a functional
status assessment within 90 days
prior to the surgery and in the 270365 days after the surgery.
Functional Status Assessment for
Total Hip Replacement:
Percentage of patients 18 years of
age and older with who received an
elective primary total hip
arthroplasty (THA) who completed
baseline and follow-up patientreported and completed a functional
status assessment within 90 days
prior to the surgery and in the 270365 days after the surgery.
Tobacco Use and Help with
Quitting Among Adolescents:
The percentage of adolescents 12 to
20 years of age with a primary care
visit during the measurement year for
whom tobacco use status was
documented and received help with
quitting if identified as a tobacco
user.
Opioid Therapy Follow-up
Evaluation:
All patients 18 and older prescribed
opiates for longer than six weeks
duration who had a follow-up
evaluation conducted at least every
three months during Opioid Therapy
documented in the medical record.
Documentation of Signed Opioid
Treatment Agreement:
All patients 18 and older prescribed
opiates for longer than six weeks
duration who signed an opioid
treatment agreement at least once
during Opioid Therapy documented
in the medical record.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
Centers
for
Medicare
&
Medicaid
Services
Centers
for
Medicare
&
Medicaid
Services
Centers
for
Medicare
&
Medicaid
Services
National
Committe
e for
Quality
Assurance
American
Academy
of
Neurology
American
Academy
of
Neurology
EP30JN17.107
Indicator
Quality
30358
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B 11 0 rth ope d" surgery con fmue d)
IC
NIA
0053
NIA
NIA
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NIA
VerDate Sep<11>2014
m
414
418
TBD
TBD
TBD
19:16 Jun 29, 2017
Data
Submission
Method
NIA
Registry
NIA
Claims,
Registry
NIA
NIA
NIA
Jkt 241001
Registry
Registry
Registry
PO 00000
Measure
Type
National
Quality
Strategy
Domain
Mca~urc
Title
and Description
Process
Effective
Clinical
Care
Process
Effective
Clinical
Care
Outcome
Person and
CaregiverCentered
Experience
and
Outcomes
Outcome
Person and
CaregiverCentered
Experience
and
Outcomes
Outcome
Person and
CaregiverCentered
Experience
and
Outcomes
Frm 00350
Fmt 4701
Sfmt 4725
· ..
Evaluation or Interview for Risk of
Opioid Misuse:
All patients 18 and older prescribed
opiates for longer than six weeks
duration evaluated for risk of opioid
misuse using a brief validated
instrument (e.g. Opioid Risk Tool,
SOAAP-R) or patient interview
documented at least once during
Opioid Therapy in the medical record
Osteoporosis Management in
Women Who Had a Fracture:
The percentage of women age 50-85
who suffered a fracture and who
either had a bone mineral density test
or received a prescription for a drug
to treat osteoporosis in the six months
after the fracture
Average Change in Back Pain
Following Lumbar Discectomy I
Laminotomy:
The average change (preoperative to
three months postoperative) in back
pain for patients 18 years of age or
older who had lumbar discectomy
/laminotomy procedure
Average Change in Back Pain
Following Lumbar Fusion:
The average change (preoperative to
one year postoperative) in back pain
for patients 18 years of age or older
who had lumbar spine fusion surgery
Average Change in Leg Pain
Following Lumbar Discectomy I
Laminotomy:
The average change (preoperative to
three months postoperative) in leg pain
for patients 18 years of age or older
who had lumbar discectomy I
laminotomy procedure
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
American
Academy of
Neurology
National
Committee
for Quality
Assurance
MN
Community
Measurement
MN
Community
Measurement
MN
Community
Measurement
EP30JN17.108
Indicator
NQF'
#
CMSEQuality
Measure
#
30359
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NQF
#
!!
0268
#
021
CMSEData
Measure Submission
Method
TD
N/A
Claims,
Registry
Process
Process
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!!
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0239
023
N/A
Claims,
Registry
0326
!
047
N/A
Claims,
Registry
154v6
Registry,
EHR
0069
065
19:16 Jun 29, 2017
Measure
Type
Jkt 241001
PO 00000
Process
Process
Frm 00351
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National
Quality
Strategy
Domain
Measure Title
and Description
Perioperative Care: Selection of
Prophylactic Antibiotic- First OR
Second Generation Cephalosporin:
Percentage of surgical patients aged
18 years and older undergoing
Patient
procedures with the indications for a
Safety
first OR second generation
cephalosporin prophylactic antibiotic,
who had an order for a first OR
second generation cephalosporin for
antimicrobial prophy !axis
Periuperative Care: Venous
Thromboembolism (VTE)
Prophylaxis (When Indicated in
ALL Patients):
Percentage of surgical patients aged
18 years and older undergoing
procedures for which venous
thromboembolism (VTE) prophylaxis
Patient
is indicated in all patients, who had
Safety
an order for Low Molecular Weight
Heparin (LMWH), Low-Dose
Unfractionated Heparin (LDUH),
adjusted-dose warfarin, fondaparinux
or mechanical prophy !axis to be
given within 24 hours prior to
incision time or within 24 hours after
surgery end time
Care Plan:
Percentage of patients aged 65 years
and older who have an advance care
Communica
plan or surrogate decision maker
tionand
documented in the medical record that
Care
an advance care plan was discussed
Coordinatio
but the patient did not wish or was not
n
able to name a surrogate decision
maker or provide an advance care
plan.
Appropriate Treatment for
Children with Upper Respiratory
Infection (URI):
Efficiency
Percentage of children 3 months
and Cost
through 18 years of age who were
Reduction
diagnosed with upper respiratory
infection (URI) and were not
dispensed an antibiotic prescription
on or three days after the episode
Sfmt 4725
E:\FR\FM\30JNP2.SGM
30JNP2
·.
Measure
Steward
American
Society of
Plastic
Surgeons
American
Society of
Plastic
Surgeons
National
Committee
for Quality
Assurance
National
Cmmnittee
for Quality
Assurance
EP30JN17.109
Indicator
Quality
30360
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B 12 Ot o Iarym o ogy ( con fmue d)
Indicator
!!
!!
*
NQF'
#
0653
0654
0041
0043
*
§
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VerDate Sep<11>2014
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0419
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#
091
093
110
111
128
130
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CMSE~
Data
Measure Submission
ID
Method
NIA
NIA
147v7
Claims,
Registry
Claims,
Registry
Claims,
Web
Intertace,
Registry,
EHR
127v6
Claims,
Web
Intertace,
Registry,
EHR
69v6
Claims,
Registry,
EHR, Web
Intertace
68v7
Claims,
Registry,
EHR
Jkt 241001
PO 00000
Measure
Type
National
Quality
Strategy
Domain
Process
Effective
Clinical
Care
Process
Measure Title
and Description
Efficiency
and Cost
Reduction
Process
Community
I Population
Health
Process
Conmmnity
I Population
Health
Process
Conmmnity
/Population
Health
Process
Patient
Safety
Frm 00352
Fmt 4701
Sfmt 4725
Measure
Steward
Acute Otitis Externa (AOE): Topical
Therapy:
Percentage of patients aged 2 years and
older with a diagnosis of AOE who
were prescribed topical preparations
Acute Otitis Externa (AOE):
Systemic Antimicrobial TherapyAvoidance of Inappropriate Use:
Percentage of patients aged 2 years and
older with a diagnosis of AOE who
were not prescribed systemic
antimicrobial therapy
Preventive Care and Screening:
Influenza Immunization:
Percentage of patients aged 6 months
and older seen for a visit between
October 1 and March 31 who received
an influenza immunization OR who
reported previous receipt of an
influenza immunization
Pneumonia Vaccination Status for
Older Adults:
Percentage of patients 65 years of age
and older who have ever received a
pneumococcal vaccine
Preventive Care and Screening:
Body Mass Index (BMI) Screening
and Follow-Up Plan:
Percentage of patients aged 18 years
and older with a BMI documented
during the current encounter or during
the previous twelve months AND with
a BMI outside of normal parameters, a
follow-up plan is documented during
the encounter or during the previous
twelve months of the current
encounter.
Normal Parameters:
Age 18 years and older BMI => 18.5
and< 25 kglm2
Documentation of Current
Medications in the Medical Record:
Percentage of visits for patients aged
18 years and older for which the
eligible clinician attests to
documenting a list of current
medications using all immediate
resources available on the date of the
encounter. This list must include ALL
known prescriptions, over-thecounters, herbals, and
vitamin/mineral/dietary (nutritional)
supplements AND must contain the
medications' name, dosage, frequency
and route of administration.
American
Academy of
Otolaryngology
Head and Neck
Surgery
E:\FR\FM\30JNP2.SGM
30JNP2
American
Academy of
Otolaryngology
Head and Neck
Surgery
Physician
Consorti1m1 for
Performance
Improvement
Foundation
(PC PilE)
National
Committee for
Quality
Assurance
Centers for
Medicare &
Medicaid
Services
Centers for
Medicare &
Medicaid
Services
EP30JN17.110
··.
I.
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30361
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NQF
#
!
!
*
§
0101
0101
0028
#
154
155
226
CMSEMeasure
ID
N/A
Data
Submission
Method
Claims,
Registry
N/A
Claims,
Registry
138v6
Claims,
Registry,
EHR,Web
Interface
Measure
Type
National
Quality
Strategy
Domain
Measure Title
and Description
Process
Patient
Safety
Process
Communica
tion and
Care
Coordinatio
n
Process
Community
/Population
Health
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tion and
Care
Coordinatio
n
276
N/A
Registry
Process
Effective
Clinical
Care
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Falls: Risk Assessment:
Percentage of patients aged 65 years
and older with a history of falls who
had a risk assessment for falls
completed within 12 months
Falls: Plan of Care:
Percentage of patients aged 65 years
and older with a history of falls who
had a plan of care for falls
documented within 12 months
Preventive Care and Screening:
Tobacco Use: Screening and
Cessation Intervention:
a. Percentage of patients aged 18
years and older who were screened
for tobacco use one or more times
within 24 months
b. Percentage of patients aged 18
years and older who were screened
for tobacco use and identified as a
tobacco user who received tobacco
cessation intervention
c. Percentage of patients aged 18
years and older who were screened
for tobacco use one or more times
within 24 months AND who
received cessation counseling
intervention if identified as a
tobacco user.
Biopsy Follow Up:
Percentage of new patients whose
biopsy results have been reviewed
and communicated to the primary
care/referring physician and patient
by the performing physician
Sleep Apnea: Assessment of Sleep
Symptoms:
Percentage of visits for patients aged
18 years and older with a diagnosis of
obstructive sleep apnea that includes
documentation of an assessment of
sleep symptoms, including presence
or absence of snoring and daytime
sleepiness
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Stewttrd
National
Committee for
Quality
Assurance
National
Committee for
Quality
Assurance
Physician
Consortium for
Performance
Improvement
Foundation
(PCPI®)
American
Academy of
Dermatology
American
Academy of
Sleep Medicine
EP30JN17.111
Indicator
Quality
30362
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
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NQF
#
CMSEQuality
Measure
#
1D
Data
Submission
Method
M~a~ure
Type
National
Quality
Strategy
Domain
N/A
Process
Effective
Clinical
Care
278
N/A
Registry
Process
Effective
Clinical
Care
279
N/A
Registry
Process
Effective
Clinical
Care
N/A
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277
317
22v6
Registry
Process
Cmmnunity
/Population
IIealth
Process
Efficiency
and Cost
Reduction
N/A
331
19:16 Jun 29, 2017
N/A
Registry
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Measure Title
and Description
Measure Steward
..
Sleep Apnea: Severity Assessment
at Initial Diagnosis:
Percentage of patients aged 18 years
and older with a diagnosis of
obstmctive sleep apnea who had an
apnea hypopnea index (AHI) or a
respiratmy disturbance index (RDI)
measured at the time of initial
diaQ,nosis
Sleep Apnea: Positive Airway
Pressure Therapy Prescribed:
Percentage of palienls aged 18 years
and older with a diagnosis of
moderate or severe obstmctive sleep
apnea who were prescribed positive
airwav pressure therapy
Sleep Apnea: Assessment of
Adherence to Positive Airway
Pressure Therapy:
Percentage of visits for patients aged
18 years and older with a diagnosis
of obstr1.rctive sleep apnea who were
prescribed positive airway pressure
therapy who had documentation that
adherence to positive airway
pressure therapy was objectively
measured
Preventive Care and Screening:
Screening for High Blood
Pressure and Follow-Up
Documented:
Percentage of patients aged 18 years
and older seen during the reporting
period who were screened for high
blood pressure AND a
recommended tallow-up plan is
documented based on the current
blood pressure (BP) reading as
indicated.
Adult Sinusitis: Antibiotic
Prescribed for Acute Sinusitis
(Overuse):
Percentage of patients, aged 18
years and older, with a diagnosis of
acute sinusitis who were prescribed
an antibiotic within 10 days after
onset of svmptoms
E:\FR\FM\30JNP2.SGM
30JNP2
American Academy
of Sleep Medicine
American Academy
of Sleep Medicine
American Academy
of Sleep Medicine
Centers for Medicare
& Medicaid Services
American Academy
of
Otolaryngology-Head
and Neck Surgery
EP30JN17.112
Indicator
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30363
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!I
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#
NIA
N/A
N/A
N/A
N/A
#
332
333
334
357
358
19:16 Jun 29, 2017
CMS:E~
Data
Measure
Submission
Method
ID
NIA
NIA
NIA
NIA
N/A
Jkt 241001
Measure
National
Quality
Type
Strategy
,'
Measure Title
and Description
Meas\]re Steward
Domain
Efficienc
y and
Cost
Reductio
n
Adult Sinusitis: Appropriate Choice of
Antibiotic: Amoxicillin With or
Without Clavulanate Prescribed for
Patients with Acute Bacterial Sinusitis
(Appropriate Use):
Percentage of patients aged 18 years and
older with a diagnosis of acute bacterial
sinusitis that were prescribed
amoxicillin, with or without clavulante,
as a first line antibiotic at the time of
diagnosis
Adult Sinusitis: Computerized
Tomography (CT) for Acute Sinusitis
(Overuse):
Percentage of patients aged 18 years and
older with a diagnosis of acute sinusitis
who had a computerized tomography
(CT) scan of the paranasal sinuses
ordered at the time of diagnosis or
received within 28 days after date of
diagnosis
Adult Sinusitis: More than One
Computerized Tomography (CT) Scan
Within 90 Days for Chronic Sinusitis
(Overuse): Percentage of patients aged 18
years and older with a diagnosis of chronic
sinusitis who had more than one CT scan
of the paranasal sinuses ordered or
received within 90 days after the date of
diagnosis
American
Academy of
OtolaryngologyHead and Neck
Surgery
Registry
Process
Registry
Etlicienc
y and
Efficiency Cost
Reductio
n
Registry
Efficicnc
y and
Efficiency Cost
Reductio
n
Registry
Outcome
Effective
Clinical
Care
Surgical Site Infection (SSI):
Percentage of patients aged 18 years and
older who had a surgical site infection
(SSI)
Process
Person
and
Caregiver
-Centered
Experien
ce and
Outcome
s
Patient-Centered Surgical Risk
Assessment and Communication:
Percentage of patients who underwent a
non-emergency surgery who had lheir
personalized risks of postoperative
American College
of Surgeons
complications assessed by their surgical
team prior to surgery using a clinical databased, patient-specific risk calculator and
who received personal discussion of those
risks with the surgeon
Registry
PO 00000
Frm 00355
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E:\FR\FM\30JNP2.SGM
30JNP2
American
Academy
of
OtolaryngologyIIead and Neck
Surgery
American
Academy of
OtolaryngologyHead and Neck
Surgery
American College
of Surgeons
EP30JN17.113
Indi~;ator
Quallty
30364
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B 12 Ot oIaryng o ogy ( con fmue d)
NQF
#
*
!
!
N/A
374
50v6
Registry,
EIIR
N/A
398
N/A
Registry
N/A
2152
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VerDate Sep<11>2014
#
CMSEData
Measure Submission
Method
lD
402
431
TBD
19:16 Jun 29, 2017
N/A
N/A
N/A
Jkt 241001
Registry
Registry
Registry
PO 00000
Measure
Type
National
Quality
Strategy
Domain
Process
Cormmmication
and Care
Coordination
Outcome
Effective
Clinical Care
Process
Community/
Population
Health
Process
Process
Frm 00356
Fmt 4701
Community/
Population
Health
Patient Safety,
Efficiency and
Cost Reduction
Sfmt 4725
Measure Title
arid Description
Closing the Referral Loop:
Receipt of Specialist Report:
Percentage of patients with
referrals, regardless of age, for
which the referring provider
receives a report from the
provider to whom the patient was
referred.
Optimal Asthma Control:
Composite measure of the
percentage of pediatric and adult
patients whose asthma is wellcontrolled as demonstrated by
one of three age appropriate
patient reported outcome tools
Tobacco Use and Help with
Quitting Among Adolescents:
The percentage of adolescents
12 to 20 years of age with a
prilnary care visit during the
measurement year for whom
tobacco use status was
documented and received help
with quitting if identified as a
tobacco user
Preventive Care and
Screening: Unhealthy Alcohol
Use: Screening & Brief
Counseling:
Percentage of patients aged 18
years and older who were
screened for unhealthy alcohol
use using a systematic screening
method at least once within the
last 24 months AND who
received brief cmmseling if
identified as an unhealthy
alcohol user.
Otitis Media with Effusion
(OME): Systemic
Antimicrobials- Avoidance of
Inappropriate Use:
Percentage of patients aged 2
months through 12 years with a
diagnosis of OME who were not
prescribed systemic
antimicrobials.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Stewttrd
Centers for
Medicare &
Medicaid
Services
Milmesota
Connnunity
Measurement
National
Cmmnittee
for Quality
Assurance
Physician
Consortium
for
Performance
Improvement
Foundation
(PCPI®)
American
Academy of
Otolaryngology
-Head and
Neck Surgery
Foundation
(AAOHNSF)
EP30JN17.114
Indicator
Quality
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30365
B13P athi ogy
o
NQF
#
Data
ClVIS,EMeasure Submission
Method
ID
Measure
Type
National
Quality,
Strategy
Domain
0391
Process
Effective
Clinical Care
100
N/A
Claims,
Registry
Process
Effective
Clinical Care
249
N/A
Claims,
Registry
Process
Effective
Clinical Care
1853
250
N/A
Claims,
Registry
Process
Effective
Clinical Care
1855
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Registry
lg54
VerDate Sep<11>2014
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0392
§
099
251
N/A
Claims,
Registry
Structure
Effective
Clinical Care
19:16 Jun 29, 2017
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PO 00000
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'
Measure Title
and Descrip,tion
Breast Cancer Resection
Pathology Reporting: pT
Category (Primary Tumor) and
pN Category (Regional Lymph
Nodes) with Histologic Grade:
Percentage of breast cancer resection
pathology reports that include the pT
category (primary tumor), the pN
category (regional lymph nodes),
and the histologic grade
Colo rectal Cancer Resection
Pathology Reporting: pT
Category (Primary Tumor) and
pN Category (Regional Lymph
Nodes) with Histologic Grade:
Percentage of colon and rectum
cancer resection pathology reports
that include the pT category
(primary tumor), the pN category
(regional lymph nodes) and the
histologic grade
Barrett's Esophagus:
Percentage of esophageal biopsy
reports that document the presence
of Barrett's mucosa that also include
a statement about dysplasia
Radical Prostatectomy Pathology
Reporting:
Percentage of radical prostatectomy
pathology reports that include the
pT category, the pN category, the
Gleason score and a statement about
margin status
Quantitative
Immunohistochemical (IHC)
Evaluation of Human Epidermal
Growth Factor Receptor 2 Testing
(HER2) for Breast Cancer
Patients:
This is a measure based on whether
quantitative evaluation of Human
Epidermal Growth Factor Receptor
2 Testing (HER2) by
immunohistochemistry (IHC) uses
the system recommended in the
current ASCO/CAP Guidelines for
Human Epidermal Growth Factor
Receptor 2 Testing in breast cancer
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
College of
American
Pathologists
College of
American
Pathologists
College of
American
Pathologists
College of
American
Pathologists
College of
American
Pathologists
EP30JN17.115
Indicator
Quality
#
30366
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B 13 P ath 00 gy ( con mue d)
I
NQF
#
#
CMSEData
Measure Submission
ID
Method
Measure
Type
National
Quality
Strategy
Domain
N/A
395
N/A
Claims,
Registry
Process
Commllllicat
ion and Care
Coordination
!
N/A
396
N/A
Claims,
Registry
Process
Commllllicat
ion and Care
Coordination
!
mstockstill on DSK30JT082PROD with PROPOSALS2
!
N/A
397
N/A
Claims,
Registry
Process
Commllllicat
ion and Care
Coordination
VerDate Sep<11>2014
19:16 Jun 29, 2017
Jkt 241001
PO 00000
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Measure Title
and Description
Lung Cancer Reporting (Biopsy/
Cytology Specimens):
Pathology reports based on biopsy
and/or cytology specimens with a
diagnosis of primary nonsmall cell
lllllg cancer classified into specific
histologic type or classified as
NSCLC-NOS with an explanation
included in the pathology report
Lung Cancer Reporting
(Resection Specimens):
Pathology reports based on resection
specimens with a diagnosis of
primary lung carcinoma that include
the pT category, pN category and for
non-small cell lung cancer,
histologic type
Melanoma Reporting:
Pathology reports for primary
malignant cutaneous melanoma that
include the pT category and a
statement on thickness and
ulceration and for pTl, mitotic rate
E:\FR\FM\30JNP2.SGM
30JNP2
·.
Measure
Steward
College of
American
Pathologists
College of
American
Pathologists
College of
American
Pathologists
EP30JN17.116
Indicator
Quality
30367
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B.14. Pediatrics
NQF
#
!!
!!
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VerDate Sep<11>2014
0069
N/A
0653
#
065
066
091
19:16 Jun 29, 2017
CMSEData
Measure Submission
ID
Method
154v6
Registry,
EHR
146v6
Registry,
EHR
N/A
Jkt 241001
Claims,
Registry
PO 00000
Measure
Type
National
Quality
Strategy
Domain
Process
Efficiency
and Cost
Reduction
Process
Efficiency
and Cost
Reduction
Process
Frm 00359
Fmt 4701
Effective
Clinical Care
Sfmt 4725
Measure Title
and Description
Appropriate Treatment for
Children with Upper Respiratory
Infection (URI):
Percentage of children 3 months
through 18 years of age who were
diagnosed with upper respiratory
infection (URI) and were not
dispensed an antibiotic prescription
on or three days after the episode.
Appropriate Testing for Children
with Pharyngitis:
Percentage of children 3-18 years of
age who were diagnosed with
pharyngitis, ordered an antibiotic
and received a group A
streptococcus (strep) test for the
episode.
Acute Otitis External (AOE):
Topical Therapy:
Percentage of patients aged 2 years
and older with a diagnosis of AOE
who were prescribed topical
preparations
E:\FR\FM\30JNP2.SGM
30JNP2
·.
Measure
Steward
National
Committee
for Quality
Assurance
National
Committee
for Quality
Assurance
American
Academy of
Otolaryngology
-Head and
Neck Surgery
EP30JN17.117
Indicator
Quality
30368
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B.14. Pediatrics (continued)
!!
*
NQF
#
0654
0041
0418
9
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§
VerDate Sep<11>2014
0405
0409
#
093
110
134
160
205
19:16 Jun 29, 2017
CMSEData
Measure Submission
ID
Method
NIA
147v7
2v7
52v6
NIA
Jkt 241001
Claims,
Registry
Claims,
Web
Interface,
Registry,
EHR
Process
National
Quality
Strategy
Domain
Measure Title
and Description
Efficiency
and Cost
Reduction
EHR
Registry
Process
Community
I Population
Health
Process
Community
I Population
Health
Process
Claims,
Web
Interface,
Registry,
EHR
PO 00000
Measure
Type
Effective
Clinical
Care
Process
Effective
Clinical
Care
Frm 00360
Fmt 4701
Sfmt 4725
Acute Otitis Extema (AOE):
Systemic Antimicrobial TherapyAvoidance of Inappropriate Use:
Percentage of patients aged 2 years
and older with a diagnosis of AOE
who were not prescribed systemic
antilnicrobial therapy
Preventive Care and Screening:
Influenza Immunization:
Percentage of patients aged 6 months
and older seen for a visit between
October 1 and March 31 who
received an influenza innnunization
OR who reported previous receipt of
an influenza immunization
Preventive Care and Screening:
Screening for Depression and
Follow-Up Plan:
Percentage of patients aged 12 years
and older screened for depression on
the date of the encounter using an age
appropriate standardized depression
screening tool AND if positive, a
follow-up plan is documented on the
date of the positive screen
IITVIAIDS: Pneumocystis Jiroveci
Pneumonia (PCP) Prophylaxis:
Percentage of patients aged 6 weeks
and older with a diagnosis of
HIVIAIDS who were prescribed
Pneumocystis Jiroveci Pneumonia
(PCP) prophylaxis
IITVIAIDS: Sexually Transmitted
Disease Screening for Chlamydia,
Gonorrhea, and Syphilis:
Percentage of patients aged 13 years
and older with a diagnosis of
HIVIAIDS for whom chlamydia,
gonorrhea and syphilis screenil1gs
were performed at least once since
the diagnosis ofHIV infection
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
American
Academy of
Otolaryngolo
gy-Headand
Neck Surgery
Physician
Consortium
for
Performance
Improvement
Foundation
(PCPI®)
Centers for
Medicare &
Medicaid
Services
National
Committee
for Quality
Assurance
National
Committee
for Quality
Assurance
EP30JN17.118
Indicator
Quality
30369
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B 14 Pediatrics (continued)
NQF
#
0024
0038
0004
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0033
VerDate Sep<11>2014
#
239
240
305
310
19:16 Jun 29, 2017
CMSEData
Measure Submission
Method
TD
155v6
117v6
137v6
EHR
EHR
EHR
153v6
EHR
Jkt 241001
PO 00000
Measure
Type
National
Quality
Strategy
Doml!in
Process
Community
I Population
Health
Process
Community
I Population
Health
Process
Effective
Clinical
Care
Process
Community
I Population
Health
Frm 00361
Fmt 4701
Sfmt 4725
Measure Title
and Description
Weight Assessment and
Counseling for Nutrition and
Physical Activity for Children and
Adolescents:
Percentage of patients 3-17 years of
age who had an outpatient visit with
a Primary Care Physician (PCP) or
Obstetrician/Gynecologist
(OBIGYN) and who had evidence of
the following dming the
measurement period. Three rates are
reported.
• Percentage of patients with height,
weight, and body mass index
(BMI) percentile documentation
• Percentage of patients with
counseling for nutrition
• Percentage of patients with
counseling for physical activity
Childhood Immunization Status:
Percentage of children 2 years of
age who had four diphtheria, tetanus
and acellular pertussis (DTaP); three
polio (IPV), one measles, mumps
and rubella (MMR); three H
influenza type B (HiB); three
hepatitis B (Hep B); one chicken
pox (VZV); four pneumococcal
conjugate (PCV); one hepatitis A
(Hep A); two or three rotavirus
(RV); and two influenza (ilu)
vaccines by their second birthday
Initiation and Engagement of
Alcohol and Other Drug
Dependence Treatment:
Percentage of patients 13 years of
age and older with a new episode of
alcohol and other drug (AOD)
dependence who received the
following. Two rates are reported.
a. Percentage of patients who
initiated treatment within 14 days of
the diagnosis.
b. Percentage of patients who
initiated treatment and who had two
or more additional services with an
AOD diagnosis within 30 days of
the initiation visit
Chlamydia Screening for Women:
Percentage of women 16-24 years of
age who were identified as sexually
active and who had at least one test
for chlamydia during the
measurement period
E:\FR\FM\30JNP2.SGM
30JNP2
·.
Measure
Steward
National
Committee
for Quality
Assurance
National
Committee
for Quality
Assurance
National
Committee
for Quality
Assurance
National
Committee
for Quality
Assurance
EP30JN17.119
Indicator
Quality
30370
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B.14. Pediatrics (continued)
NQF
#
#
0108
N/A
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VerDate Sep<11>2014
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366
379
382
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136v7
74v7
177v6
Jkt 241001
EHR
EHR
EHR
PO 00000
Measure
Type
National
Quality
Strategy
Domain
Process
Effective
Clinical
Care
Process
Effective
Clinical
Care
Process
Frm 00362
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Patient
Safety
Sfmt 4725
Measure Title
and Description
ADHD: Follow-Up Care for
Children Prescribed AttentionDeficit/Hyperactivity Disorder
(ADHD) Medication:
Percentage of children 6-12 years of
age and newly dispensed a
medication for attentiondeficit/hyperactivity disorder
(ADHD) who had appropriate followup care. Two rates are reported.
a. Percentage of children who had one
follow-up visit with a practitioner
with prescribing authority during the
30-Day Initiation Phase.
b. Percentage of children who
remained on ADHD medication for at
least 210 days and who, in addition to
the visit in the Initiation Phase, had at
least two additional follow-up visits
with a practitioner within 270 days (9
months) after the Initiation Phase
ended
Primary Caries Prevention
Intervention as Offered by Primary
Care Providers, including Dentists:
Percentage of children, age 0-20
years, who received a fluoride varnish
application during the measurement
period
Child and Adolescent Major
Depressive Disorder (MDD):
Suicide Risk Assessment:
Percentage of patient visits for those
patients aged 6 through 17 years with
a diagnosis of major depressive
disorder with an assessment for
suicide risk
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
National
Committee
for Quality
Assurance
Centers for
Medicare &
Medicaid
Services
Physician
Consortium
for
Performance
Improvement
Foundation
(PCPI®)
EP30JN17.120
Indicator
Qua}ity
Data
CMSESubmissi
Measure
on
ID
Method
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30371
B.14. Pediatrics (continued)
Qua)jty
#
#
I
!
0576
391
CMS:EData
Measure Submission
ID
Method .·
N/A
Registry
:Measure
Type
National
Quality
Strategy
Domain
Process
Commtmicat
ion/Care
Coordination
1407
!
394
N/A
Registry
Process
Community/
Population
Health
N/A
398
N/A
Registry
Outcome
Effective
Clinical Care
Process
Community/
Population
Health
Process
Efficiency
and Cost
Reduction
Process
Community/
Population
Health
N/A
§
!
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~
VerDate Sep<11>2014
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N/A
402
444
447
19:16 Jun 29, 2017
NA
Registry
N/A
Registry
N/A
Registry
Jkt 241001
PO 00000
Frm 00363
Fmt 4701
Sfmt 4725
Measure Title
and Description
Follow-up After Hospitalization
for Mental lllness (FUH):
The percentage of discharges for
patients 6 years of age and older who
were hospitalized for treatment of
selected mental illness diagnoses and
who had an outpatient visit, an
intensive outpatient encounter or
partial hospitalization with a mental
health practitioner. Two rates arc
reported:
• The percentage of discharges for
which the patient received followup within 30 days of discharge
• The percentage of discharges for
which the patient received followup within 7 days of discharge
Immunizations for Adolescents:
The percentage of adolescents 13
years of age who had the
recommended immunizations by their
13th birthday
Optimal Asthma Control:
Composite measure ofthe
percentage of pediatric and adult
patients whose asthma is wellcontrolled as demonstrated by one of
three age appropriate patient
reported outcome tools
Tobacco Use and Help with
Quitting Among Adolescents:
The percentage of adolescents 12 to
20 years of age with a primary care
visit during the measurement year
for whom tobacco use status was
documented and received help with
quitting if identified as a tobacco
user
Medication Management for
People with Asthma (MMA):
The percentage of patients 5-64
years of age during the measurement
year who were identified as having
persistent astlnna and were
dispensed appropriate medications
that they remained on for at least
75% of their treatment period.
Chlamydia Screening and Followup: The percentage of female
adolescents 16 years of age who had
a chlamydia screening test with
proper follow-up during the
measurement period
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
National
Committee
for Quality
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National
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for Quality
Assurance
MN
Community
Measurement
National
Committee
for Quality
Assurance
National
Commillee
for Quality
Assurance
National
Committee
for Quality
Assurance
EP30JN17.121
lndicato:r
NQF
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B.14. Pediatrics (continued)
Indicator
NQF
#
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#
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ID
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Submission
Method
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Type
...
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National
Quality
Strategy
Domain
Measure Title
and Description
Measure
Steward
Patient
Safely,
Efficiency
and Cost
Reduction
Otitis Media with Effusion (OME):
Systemic AntimicrobialsAvoidance of Inappropriate Use:
Percentage of patients aged 2 months
through 12 years with a diagnosis of
OME who were not prescribed
systemic antimicrobials.
American
Academy of
Otolaryngology
-Head and
Neck Surgery
Communit
y/Populati
on Health
Well-Child Visits in the Third,
Fourth, Fifth, and Sixth Years of
Life:
The percentage of children 3-6 years
of age who had one or more wellchild visits with a PCP during the
measurement year.
Communit
y/Populati
on Health
Developmental Screening in the
First Three Years of Life:
The percentage of children screened
for risk of developmental, behavioral
and social delays using a standardized
screening tool in the first three years
of life. This is a measure of screening
in the first three years of life that
includes three, age-specific indicators
assessing whether children are
screened by 12 months of age, by 24
months of age and by 36 months of
age.
Sfmt 4725
E:\FR\FM\30JNP2.SGM
30JNP2
Foundation
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National
Conunittee
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Oregon
Health&
Science
University
EP30JN17.122
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and
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Community/
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Frm 00365
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Measure title
and Description
Care Plan:
Percentage of patients aged 65 years
and older who have an advance care
plan or surrogate decision maker
documented in the medical record or
documentation in the medical record
that an advance care plan was
discussed but the patient did not
wish or was not able to name a
surrogate decision maker or provide
an advance care plan.
Osteoarthritis (OA): Function and
Pain Assessment:
Percentage of patient visits for
patients aged 21 years and older
with a diagnosis of osteoarthritis
(OA) with assessment for function
and pain
Preventive Care and Screening:
Body Mass Index (BMI) Screening
and Follow-Up Plan:
Percentage of patients aged 18 years
and older with a BMI documented
during the current encounter or
during the previous twelve months
AND with a BMI outside of normal
parameters, a follow-up plan is
documented during the encounter or
during the previous twelve months
of the current encounter.
Nonnal Parameters:
Age 18 years and older BMI => 18.5
and< 25 kg/m2
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
National
Committee
for Quality
Assurance
American
Academy of
Orthopedic
Surgeons
Centers for
Medicare &
Medicaid
Services
EP30JN17.123
Indicator
NQF
30374
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0419
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Communication
and Care
Coordination
Patient Safety
Sfmt 4725
Measure Title
and Desc.ription
Documentation of Current
Medications in the Medical
Record:
Percentage of visits for patients aged
18 years and older for which the
eligible professional attests to
documenting a list of current
medications using all immediate
resources available on the date of the
encounter. T11is list must include
ALL known prescriptions, over-thecounters, herbals, and
vitamin/mineral/dietary (nutritional)
supplements AND must contain the
medications' name, dosage,
frequency and route of
administration.
Pain Assessment and Follow-Up:
Percentage of visits for patients aged
18 years and older with
documentation of a pain assessment
using a standardized tool(s) on each
visit AND documentation of a
follow-up plan when pain is present
Falls: Risk Assessment:
Percentage of patients aged 65 years
and older with a history of falls who
had a risk assessment for falls
completed within 12 months
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
Centers
for
Medicare
&
Medicaid
Services
Centers
for
Medicare
&
Medicaid
Services
National
Committe
e for
Quality
Assurance
EP30JN17.124
lndicato:r
NQF
30375
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Measure •••
Type
Natiomll
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Communicati
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Process
Communicati
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Fmt 4701
Community/
Population
Health
Sfmt 4725
Measure Title
and Description
Falls: Plan of Care:
Percentage of patients aged 65
years and older with a history of
falls who had a plan of care for
falls documented within 12
months
Functional Outcome
Assessment:
Percentage of visits for patients
aged 18 years and older with
docmnentation of a current
functional outcome assessment
using a standardized functional
outcome assessment tool on the
date of encounter AND
docmnentation of a care plan
based on identified functional
outcome deficiencies on the date
of the identified deficiencies
Preventive Care and Screening:
Tobacco Use: Screening and
Cessation Intervention:
a. Percentage of patients aged 18
years and older who were
screened for tobacco use one or
more times within 24 months
b. Percentage of patients aged 18
years and older who were
screened for tobacco use and
identified as a tobacco user who
received tobacco cessation
intervention
c. Percentage of patients aged 18
years and older who were
screened for tobacco use one or
more times within 24 months
AND who received cessation
counseling intervention if
identified as a tobacco user.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
National
Committee
for Quality
Assurance
Centers for
Medicare
&
Medicaid
Services
Physician
Consortium
for
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EP30JN17.125
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.
.
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N/A
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N/A
Registry
Process
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Clinical Care
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•••••
'••'
Measure.
. .Steward •,
~!lld Description ·
...
.·• '
Preventive Care and Screening:
Screening for High Blood Pressure
and Follow-Up Documented:
Centers for
Percentage of patients aged 18 years
MediL:are
and older seen during the reporting
&
period who were screened for high
Medicaid
blood pressure AND a recommended
Services
follow-up plan is documented based on
the current blood pressure (BP)
reading as indicated.
Closing the Referral Loop: Receipt
Centers for
of Specialist Report:
Medicare
Percentage of patients with referrals,
&
regardless of age, for which the
referring provider receives a report
Medicaid
from the provider to whom the patient
Services
was referred.
Tobacco Usc and Help with Quitting
Among Adolescents:
The percentage of adolescents 12 to 20 National
years of age with a primary care visit
Committee
during the measurement year for
for Quality
whom tobacco use status was
Assurance
documented and received help with
quitting if identified as a tobacco user
Opioid Therapy Follow-up
Evaluation:
All patients 18 and older prescribed
American
opiates for longer than six weeks
Academy
duration who had a follow-up
of
evaluation conducted at least every
Neurology
three months during Opioid Therapy
documented in the medical record
Documentation of Signed Opioid
Treatment Agreement:
All patients 18 and older prescribed
American
opiates for longer than six weeks
Academy
duration who signed an opioid
of
treatment agreement at least once
Neurology
during Opioid Therapy documented in
the medical record
Evaluation or Interview for Risk of
Opioid Misuse:
All patients 18 and older prescribed
opiates for longer than six weeks
American
duration evaluated for risk of opioid
Academy
of
misuse using a brief validated
instrument (e.g. Opioid Risk Tool,
Neurology
SOAAP-R) or patient interview
documented at least once during
Opioid Therapy in the medical record
E:\FR\FM\30JNP2.SGM
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30JNP2
EP30JN17.126
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.
Ilulicator
..
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·..··
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· Meil'sm•e Title
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Unhealthy Alcohol Use:
Screening & Brief Counseling:
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Community
I Population
Health
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Percentage of patients aged 18
years and older who were screened
for unhealthy alcohol use using a
systematic screening method at
least once within the last 24
months AND who received brief
counseling if identified as an
unhealthy alcohol user.
E:\FR\FM\30JNP2.SGM
30JNP2
.
Measure
Steward
.
Physician
Consortium for
Performance
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Foundation
(PCPI®)
EP30JN17.127
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30378
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0239
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Registry
N/A
Claims,
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'}'ype
National
Quality
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Process
Patient
Safety
Process
Patient
Safety
Frm 00370
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Measure Title
and Description
Perioperative Care: Selection of
Prophylactic Antibiotic- First OR
Second Generation Cephalosporin:
Percentage of surgical patients aged
18 years and older undergoing
procedures with the indications for a
first OR second generation
cephalosporin prophylactic antibiotic,
who had an order for a first OR
second generation cephalosporin for
antimicrobial prophylaxis
Perioperative Care: Venom
Thromboembolism (VTE)
Prophylaxis (When Indicated in
ALL Patients):
Percentage of surgical patients aged
18 years and older undergoing
procedures for which venous
thromboembolism (VTE) prophylaxis
is indicated in all patients, who had
an order for Low Molecular Weight
Heparin (LMWH), Low-Dose
Unfractionated Heparin (LDUH),
adjusted-dose warfarin, fondaparinux
or mechanical prophylaxis to be
given within 24 hours prior lo
incision time or within 24 hours after
surgery end time
E:\FR\FM\30JNP2.SGM
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MeasU:re
Steward
American
Society of
Plastic
Surgeons
American
Society of
Plastic
Surgeons
EP30JN17.128
Indicator
NQF
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30379
B 16 PI as f IC S ur ery ( con fmue d)
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#
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#
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Process
National
Quality
Strategy
Domain
Patient
Safety
Process
Connnunity
/Population
Health
Process
Connnunity
/Population
Health
Outcome
Patient
Safety
Frm 00371
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Measure Title
and Description
Measure
Steward
..
Documentation of Current
Medications in the Medical
Record: Percentage of visits for
patients aged 18 years and older for
which the eligible clinician attests to
documenting a list of current
medications using all innnediate
resources available on the date of
the encounter. This list must include
ALL known prescriptions, over-thecounters, herbals, and
vitamin/mineral/dietary (nutritional)
supplements AND must contain the
medications' name, dosage,
frequency and route of
administration.
Preventive Care and Screening:
Tobacco Use: Screening and
Cessation Intervention:
a. Percentage of patients aged 18
years and older who were
screened for tobacco use one or
more times within 24 months
b. Percentage of patients aged 18
years and older who were
screened for tobacco use and
identified as a tobacco user who
received tobacco cessation
intervention
c. Percentage of patients aged 18
years and older who were
screened for tobacco usc one or
more times within 24 months
AND who received cessation
counseling intervention if
identified as a tobacco user.
Preventive Care and Screening:
Screening for High Blood
Pressure and Fulluw-Up
Documented:
Percentage of patients aged 18 years
and older seen during the reporting
period who were screened for high
blood pressure AND a
reconnnended follow-up plan is
documented based on the current
blood pressure (BP)
Unplanned Reoperation within
the 30 Day Postoperative Period:
Percentage of patients aged 18 years
and older who had any unplmmed
reoperation within the 30 day
postoperative period
E:\FR\FM\30JNP2.SGM
30JNP2
Centers for
Medicare &
Medicaid
Services
Physician
Consortium for
Performance
Improvement
Foundation
(PCPI®)
Centers for
Medicare &
Medicaid
Services
American
College of
Surgeons
EP30JN17.129
Indicator
30380
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B 16 PI as f IC S urgery ( con f mue d)
NQF
#
#
CMSEMeasure
ID
Data
Submission
Method
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.·
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PO 00000
National
Quality
Strategy
Domain
Measure Title
and Description
Measu.re
Steward
..
Outcome
Effective
Clinical
Care
Unplanned Hospital Readmission
within 30 Days of Principal
Procedure:
Percentage of patients aged 18 years
and older who had an unplanned
hospital readmission within 30 days
of principal procedure
Outcome
Effective
Clinical
Care
Surgical Site Infection (SSI):
Percentage of patients aged 18 years
and older who had a surgical site
infection (SSI)
American
College of
Surgeons
Person and
CaregiverCentered
Experience
and
Outcomes
Patient-Centered Surgical Risk
Assessment and Communication:
Percentage of patients who underwent
a non-emergency surgery who had
their personalized risks of
postoperative complications assessed
by their surgical team prior to surgery
using a clinical data-based, patientspecific risk calculator and who
received personal discussion of those
risks with the surgeon
American
College of
Surgeons
Process
Frm 00372
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American
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EP30JN17.130
Indi<:ator
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NQF
#
§
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N/A
Claims,
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Jkt 241001
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Type
National
Quality
Strategy
Domain
Intermediate
Outcome
Effective
Clinical
Care
Process
Commun
ication
and Care
Coordina
tion
Frm 00373
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Measure Title
and Description
Diabetes: Hemoglobin Ale
(HbAlc) Poor Control (> 9%):
Percentage of patients 18-75 years
of age with diabetes who had
hemoglobinAlc > 9.0% during the
measurement period
Communication with the
Physician or Other Clinician
Managing On-going Care PostFracture for Men and Women
Aged 50 Years and Older:
Percentage of patients aged 50 years
and older treated for a tracture with
documentation of communication,
between the physician treating the
fracture and the physician or other
clinician managing the patient's ongoing care, that a fracture occurred
and that the patient was or should be
considered for osteoporosis
treatment or testing. This measure is
reported by the physician who treats
the fracture and who therefore is
held accountable for the
communication
E:\FR\FM\30JNP2.SGM
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Quality
Assurance
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Committee for
Quality
Assurance
EP30JN17.131
Indicator
Quality
30382
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NQF
#
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Registry
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Web
Interface,
Registry,
EHR
Claims,
Web
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Registry,
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Claims,
Web
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PO 00000
Measure
Type
National
Quality
Strategy
Domain
Process
Effective
Clinical Care
Process
Communicati
on and Care
Coordination
Process
Effective
Clinical Care
Process
Person and
CaregiverCentered
Experience
and Outcomes
Measm:e Title
and Description
Screening for Osteoporosis for
Women Aged 65-85 Years of Age:
Percentage of female patients aged 6585 years of age who ever had a central
dual-energy X-ray absorptiometry
(DXA) to check for osteoporosis
Care Plan:
Percentage of patients aged 65 years
and older who have an advance care
plan or surrogate decision maker
documented in the medical record that
an advance care plan was discussed but
the patient did not wish or was not able
to name a surrogate decision maker or
provide an advance care plan.
Urinary Incontinence: Assessment of
Presence or Absence of Urinary
Incontinence in Women Aged 65
Years and Older:
Percentage of female patients aged 65
years and older who were assessed for
the presence or absence of urinary
incontinence within 12 months
Osteoarthritis (OA): Function and
Pain Assessment:
Percentage of patient visits for patients
aged 21 years and older with a
diagnosis of osteoarthritis (OA) with
assessment for function and pain
Measure
Steward
National
Committee
for Quality
Assurance
National
Committee
for Quality
Assurance
National
Committee
for Quality
Assurance
American
Academy of
Orthopedic
Surgeons
Physician
Consortium
for
Performanc
e
Improveme
nt
Foundation
(PCPI®)
Process
Community/
Population
Health
Preventive Care and Screening:
Influenza Immunization:
Percentage of patients aged 6 months
and older seen for a visit between
October 1 and March 31 who received
an influenza inununization OR who
reported previous receipt of an
inl1uenza immunization
Process
Community/
Population
Health
Pneumonia Vaccination Status fur
Older Adults:
Percentage of patients 65 years of age
and older who have ever received a
pneumococcal vaccine
National
Committee
for Quality
Assurance
Process
Effective
Clinical Care
Breast Cancer Screening:
Percentage of women 50- 74 years of
age who had a mammogram to screen
for breast cancer
National
Committee
for Quality
Assurance
Process
Effective
Clinical Care
Co1orecta1 Cancer Screening:
Percentage of patients 50-75 years of
age who had appropriate screening for
colorectal cancer.
National
Committee
for Quality
Assurance
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EP30JN17.132
Indicator
Qualily
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B.17. Preventive Medicine (continued)
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#
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116
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119
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126
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and Cost
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Measure Title
and Description
Avoidance of Antibiotic
Treatment in Adults with Acute
Bronchitis: Percentage of adults 1864 years of age with a diagnosis of
acute bronchitis who were not
dispensed an antibiotic prescription
Diabetes: Medical Attention for
Nephropathy:
The percentage of patients 18-75
years of age with diabetes who had a
nephropathy screening test or
evidence of nephropathy during the
measurement period
Diabetes Mellitus: Diabetic Foot
and Ankle Care, Peripheral
Neuropathy -Neurological
Evaluation: Percentage of patients
aged 18 years and older with a
diagnosis of diabetes mellitus who
had a neurological examination of
their lower extremities within 12
months.
Preventive Care and Screening:
Body Mass Index (BMI) Screening
and Follow-Up Plan:
Percentage of patients aged 18 years
and older with a BMI documented
during the current encounter or
during the previous twelve months
AND with a BMI outside of normal
parameters, a follow-up plan is
documented during the encounter or
during the previous twelve months
of the current encounter.
Normal Parameters:
Age 18 years and older BMI => 18.5
and< 25 kg/rn2
Documentation of Current
Medications in the Medical Record:
Percentage of visits for patients aged
18 years and older for which the
eligible professional attests to
documenting a list of current
medications using all immediate
resources available on the date of
the encounter. This list must include
ALL known prescriptions, over-thecounters, herbals, and
vitamin/mineral/dietary (nutritional)
supplements AND must contain the
medications' name, dosage,
frequency and route of
administration.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
National
Committee for
Quality
Assurance
National
Cmurnittee for
Quality
Assurance
American
Podiatric
Medical
Association
Centers for
Medicare &
Medicaid
Services
Centers for
Medicare &
Medicaid
Services
EP30JN17.133
Indicator
CMSEQualily
Measure
#
30384
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B.17. Preventive Medicine (continued)
Quality
#
.#
041R
!
!
0101
0101
134
154
155
CMSEMeasure
ID
Data
Submission
Method
2v7
Claims,
Web
Interface,
Registry,
EHR
N/A
Claims,
Registry
N/A
Claims,
Registry
Nation~}
Measure
Type
Quality
Strategy
Domain
Process
Communi
ty/
Populatio
nHealth
Process
Patient
Safety
Process
Communi
cation
and Care
Coordinat
lOll
*
§
0028
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N/A
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EHR, Web
Interface
22v6
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Process
Communi
ty/
Populatio
nHealth
Process
Commun
ity/
Populatio
nHealth
Fmt 4701
Sfmt 4725
Measure Title
and Description
Measure
Steward
..
Preventive Care and Screening:
Screening for Clinical Depression
and Follow-Up Plan:
Percentage of patients aged 12 years
and older screened for clinical
depression on the date of the encounter
using an age appropriate standardized
depression screening tool AND if
positive, a follow-up plan is
documented on the date of the positive
screen
Falls: Risk Assessment:
Percentage of patients aged 65 years
and older with a history of falls who
had a risk assessment for falls
completed within 12 months
Falls: Plan of Care:
Percentage of patients aged 65 years
and older with a history of falls who
had a plan of care for falls
documented within 12 months
Preventive Care and Screening:
Tobacco Use: Screening and
Cessation Intervention:
a. Percentage of patients aged 18
years and older who were screened
for tobacco use one or more times
within 24 months
b. Percentage of patients aged 18
years and older who were screened
for tobacco use and identified as a
tobacco user who received tobacco
cessation intervention
c. Percentage of patients aged 18
years and older who were screened
for tobacco use one or more times
within 24 months AND who
received cessation counseling
intervention if identified as a
tobacco user.
Preventive Care and Screening:
Screening for High Blood Pressure
and Follow-Up Documented:
Percentage of patients aged 18 years
and older seen during the reporting
period who were screened for high
blood pressure AND a recommended
follow-up plan is documented based
on the current blood pressure (BP)
reading as indicated.
E:\FR\FM\30JNP2.SGM
30JNP2
Centers for
Medicare &
Medicaid
Services
National
Committee for
Quality
Assurance
National
Commillee for
Quality
Assurance
Physician
Consortium for
Performance
Improvement
Foundation
(PCPI®)
Centers for
Medicare &
Medicaid
Services
EP30JN17.134
Indicator
NQF
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30385
B.17. Preventive Medicine (continued)
Quality
.#
Data
CMSEMeasure Submission
Method.
JD
Measure
Type
National
Quality
Strategy
Domain
N/A
374
50v6
EHR
Process
Cormmmication
and Care
Coordination
N/A
*
!
402
NA
Registry
Process
Community/
Population
Health
2152
*
N/A
431
438
NA
347vl
Registry,
Registry
Web
Interface,
Registry,
Process
Community/
Population
Health
Process
Effective
Clinical Care
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.Measure Title
and Description
Closing the Referral Loop:
Receipt of Specialist Report:
Percentage of patients with
referrals, regardless of age, for
which the referring provider
receives a report from the
provider to whom the patient
was referred.
Tobacco Use and Help with
Quitting Among Adolescents:
The percentage of adolescents
12 to 20 years of age with a
primary care visit during the
measurement year for whom
tobacco use status was
documented and received help
with quitting if identified as a
tobacco user
Preventive Care and
Screening: Unhealthy Alcohol
Use: Screening & Brief
Counseling:
Percentage of patients aged 18
years and older who were
screened for unhealthy alcohol
use using a systematic screening
method at least once within the
last 24 months AND who
received brief counseling if
identified as an unhealthy
alcohol user.
Statin Therapy for the
Prevention and Treatment of
Cardiovascular Disease:
Percentage of the following
patients-all considered at high
risk of cardiovascular eventswho were prescribed or were on
statin therapy during the
measurement period:
o Adults aged 2:21 years who
were previously diagnosed with
or currently have an active
diagnosis of clinical
atherosclerotic cardiovascular
disease (ASCVD); OR
o Adults aged 2:21 years who
have ever had a fasting or direct
low-density lipoprotein
cholesterol (LDL-C) level2: 190
mg/dL; OR
o Adults aged 40-75 years with a
diagnosis of diabetes with a
fasting or direct LDL-C level of
70-189 mg/dL.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
Centers for
Medicare &
Medicaid
Services
National
Committee for
Quality
Assurance
Physician
Consortium for
Performance
Improvement
Foundation
(PCPI®)
Centers for
Medicare &
Medicaid
Services
EP30JN17.135
Indicator
NQF
#
30386
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B 18 N euro ogy
#
Quality
#
.
!
CMSEM~asure
ID
0326
!
047
N/A
0419
130
68v7
Data
Submission
Method
Claims,
Registry
Claims,
Registry,
Measure
Type
Process
Process
National
Quality
Strategy
Domain
Communica
tion and
Care
Coordinatio
n
Patient
Safety
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Measure Title
.and Description
Sfmt 4725
Care Plan:
Percentage of patients aged 65 years
and older who have an advance care
plan or surrogate decision maker
documented in the medical record or
documentation in the medical record
that an advance care plan was
discussed but the patient did not wish
or was not able to name a surrogate
decision maker or provide an advance
care plan.
Documentation of Current
Medications in the Medical Record:
Percentage of visits for patients aged
18 years and older for which the
eligible professional attests to
documenting a list of current
medications using all immediate
resources available on the date of the
encounter. This list must include ALL
lmown prescriptions, over-thecounters, herbals, and
vitamin/mineral/dietary (nutritional)
supplements AND must contain the
medications' name, dosage, frequency
and route of administration.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
National
Committee for
Quality
Assurance
Centers for
Medicare &
Medicaid
Services
EP30JN17.136
Indicator
NQJi'
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B 18 Neuro ogy (continued)
CMS
NQF
#
Quality
#
EMeasur
eiD
0101
0101
*
§
0028
154
155
226
N/A
N/A
138v6
·.
J)ata
Submission
Method
Claims,
Registry
Claims,
Registry
Claims,
Web
Interface,
Registry,
Measure
·Type
..
National
Quality
Strategy
Domain
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Jkt 241001
Claims,
Registry
PO 00000
Measure
Steward
Process
Patient
Safety
Falls: Risk Assessment:
Percentage of patients aged 65 years
and older with a history of falls who
had a risk assessment for falls
completed within 12 months
National
Committee for
Quality
Assurance
Process
Collllll Lffiicat
ion and Care
Coordination
Falls: Plan of Care:
Percentage of patients aged 65 years
and older with a history of falls who
had a plan of care for falls
documented within 12 months
National
Committee for
Quality
Assurance
Process
CollllllunityI
Population
Health
Process
Effective
Clinical Care
EHR
1814
Measure Title
and Description
Frm 00379
Fmt 4701
Sfmt 4725
Preventive Care and Screening:
Tobacco Use: Screening and
Cessation Intervention:
a. Percentage of patients aged 18
years and older who were
screened for tobacco use one or
more times within 24 months
b. Percentage of patients aged 18
years and older who were
screened for tobacco use and
identified as a tobacco user who
received tobacco cessation
intervention
c. Percentage of patients aged 18
years and older who were
screened for tobacco use one or
more times within 24 months
AND who received cessation
counseling intervention if
identified as a tobacco user.
Epilepsy: Counseling for Women
of Childbearing Potential with
Epilepsy:
All female patients of childbearing
potential (12- 44 years old)
diagnosed with epilepsy who were
cmmseled or referred for counseling
for how epilepsy and its treatment
may affect contraception OR
pregnancy at least once a year
E:\FR\FM\30JNP2.SGM
30JNP2
Physician
Consortium for
Performance
Improvement
Foundation
(PCPI®)
American
Academy of
Neurology
EP30JN17.137
.
Indicator
30387
30388
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B 18Neuro ogy ( con mue d)
*
NIA
Quality
#
281
CMSEMeasure
ID
149v6
Data
Submission
Method
EHR
Measure
Type
Process
National
Quality
Strategy
Domain
Dementia: Cognitive Assessment:
Percentage of patients, regardless of
age, with a diagnosis of dementia for
whom an assessment of cognition is
perfom1ed and the results reviewed at
least once within a 12-month period
Effective
Clinical
Care
282
N/A
Registry
Process
Effective
Clinical
Care
N/A
283
N/A
Registry
Process
Effective
Clinical
Care
!
N/A
286
N/A
Registry
Process
Patient
Safety
!
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N/A
N/A
288
N/A
Registry
Process
Communi
cation and
Care
Coordinati
on
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Measure Title
and Description
Dementia: Functional Status
Assessment:
Percentage of patients, regardless of
age, with a diagnosis of dementia for
whom an assessment of functional
status is performed and the results
reviewed at least once within a 12month period
Dementia: Neuro-psychiatric
Symptom Assessment:
Percentage of patients, regardless of
age, with a diagnosis of dementia and
for whom an assessment of
neuropsychiatric symptoms is
pertom1ed and results reviewed at least
once in a 12-month period
Safety Concern Screening and
Follow-Up for Patients with
Dementia:
Percentage of patients with dementia or
their caregiver(s) for whom there was a
documented safety screening * in two
domains of risk: dangerousness to self
or others and environmental risks; and if
screening was positive in the last 12
months, there was documentation of
mitigation recommendations, including
but not limited to referral to other
resources.
Dementia: Caregiver Education and
Support:
Percentage of patients, regardless of
age, with a diagnosis of dementia whose
caregiver(s) were provided with
education on dementia disease
management and health behavior
changes AND referred lo additional
sources for support within a 12-month
period
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
Physician
Consortium
for
Pertormance
Improvement
Foundation
(PCPI®)
American
Academy of
Neurology
American
Academy of
Neurology
American
Academy of
Neurology
American
Academy of
Neurology
EP30JN17.138
Indicator
NQF
#
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30389
B 18 Neuro ogy ( con fmue d)
NQF
#
#
CMSEMeasureiD
.
Measure
Type
National
Quality· ·
Strategy
Domain
N/A
N/A
Registry
Process
Effective
Clinical Care
N/A
!
290
291
N/A
Registry
Process
Effective
Clinical Care
N/A
293
N/A
Registry
Process
Communicat
ion and Care
Coordination
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Community/
Population
Health
Sfmt 4725
Measure Title
and Description
Parkinson's Disease:
Psychiatric Symptoms
Assessment for Patients with
Parkinson's Disease:
All patients with a diagnosis of
Parkinson's disease who were
assessed for psychiatric
symptoms (e.g., psychosis,
depression, anxiety disorder,
apathy, or impulse control
disorder) in the last 12 months
Parkinson's Disease: Cognitive
Impairment or Dysfunction
Assessment:
All patients with a diagnosis of
Parkinson's disease who were
assessed for cognitive impairment
or dysfunction in the last 12
months
Parkinson's Disease:
Rehabilitative Therapy
Options:
All patients with a diagnosis of
Parkinson's disease (or
caregiver(s), as appropriate) who
had rehabilitative therapy options
(e.g., physical, occupational, or
speech therapy) discussed in the
last 12 months
Preventive Care and Screening:
Screening for High Blood
Pressure and Follow-Up
Documented:
Percentage of patients aged 18
years and older seen during the
reporting period who were
screened for high blood pressure
AND a recommended follow-up
plan is documented based on the
current blood pressure (BP)
reading as indicated.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
American
Academy of
Neurology
American
Academy of
Neurology
American
Academy of
Neurology
Centers for
Medicare &
Medicaid
Services
EP30JN17.139
Indicator
Quality
Data
Submissio
n
Method
30390
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B 18 Neuro ogy (continued)
*
#
N/A
CMSE.
Data
ID
Submission
Method
Quality Measure
#
374
50v6
Registry,
EHR
National
Measure
Type
Quality
Measure Title
Strategy
Domain
and Description
Process
Cormmmication
and Care
Coordination
386
N/A
Registry
Process
Person and
CaregiverCentered
Experience and
Outcomes
N/A
402
N/A
Registry
Process
Community/
Population
Health
N/A
408
N/A
Registry
Process
Effective
Clinical Care
N/A
412
N/A
Registry
Process
Effective
Clinical Care
N/A
414
N/A
Registry
Process
Effective
Clinical Care
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Closing the Referral Loop:
Receipt of Specialist Report:
Percentage of patients with
referrals, regardless of age, for
which the referring provider
receives a report from the provider
to whom the patient was referred.
Amyotrophic Lateral Sclerosis
(ALS) Patient Care Preferences:
Percentage of patients diagnosed
with Amyotrophic Lateral Sclerosis
(ALS) who were offered assistance
in planning for end of life issues
(e.g. advance directives, invasive
ventilation, hospice) at least once
armually
Tobacco Use and Help with
Quitting Among Adolescents:
The percentage of adolescents 12 to
20 years of age with a primary care
visit during the measurement year
for whom tobacco use status was
documented and received help with
quitting if identified as a tobacco
user
Opioid Therapy Follow-up
Evaluation:
All patients 18 and older prescribed
opiates for longer than six weeks
duration who had a follow-up
evaluation conducted at least every
three months during Opioid Therapy
documented in the medical record
Documentation of Signed Opioid
Treatment Agreement:
All patients 18 and older prescribed
opiates for longer than six weeks
duration who signed an opioid
treatment agreement at least once
during Opioid Therapy documented
in the medical record
Evaluation or Interview for Risk
of Opioid Misuse:
All patients 18 and older prescribed
opiates for longer than six weeks
duration evaluated for risk of opioid
misuse using a brief validated
instrument (e.g. Opioid Risk Tool,
SOAAP-R) or patient interview
documented at least once during
Opioid Therapy in the medical record
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
Centers for
Medicare&
Medicaid
Services
American
Academy of
Neurology
National
Committee
for Quality
Assurance
American
Academy of
Neurology
American
Academy of
Neurology
American
Academy of
Neurology
EP30JN17.140
Indicator
NQF
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30391
B 18 Neuro ogy (continued)
!!
NQ:F
Q:uality
#
#
N/A
419
Data
CMSEMeasure Submission
ID
Method
N/A
Claims,
Registry
Measure
Type
Efficienc
y
National
Quality
Strategy
Domain
Efficiency
and Cost
Reduction
N/A
Registry
Process
Population!
Community
435
N/A
Claims,
Registry
Outcome
Effective
Clinical Care
N/A
VerDate Sep<11>2014
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N/A
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TBD
N/A
Registry
Process
Patient
Safety
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Measure Title
and Description
Overuse OfNeuroimaging For
Patients With Primary Headache
And A Normal Neurological
Examination:
Percentage of patients with a
diagnosis of primary headache
disorder whom advanced brain
imaging was not ordered
Preventive Care and Screening:
Unhealthy Alcohol Use: Screening
& Brief Counseling:
Percentage of patients aged 18 years
and older who were screened for
unhealthy alcohol use using a
systematic screening method at least
once within the last 24 months AND
who received brief counseling if
identified as an unhealthy alcohol
user.
Quality Of Life Assessment For
Patients With Primary Headache
Disorders:
Percentage of patients with a
diagnosis of primary headache
disorder whose health related quality
of life (HRQoL) was assessed with a
tool( s) during at least two visits
during the 12 month measurement
period AND whose health related
quality oflife score stayed the same
or improved
Safety Concern Screening and
Follow-Up for Patients with
Dementia:
Percentage of patients with dementia
or their L:aregiver(s) for whom there
was a documented safety screening
* in two domains of risk:
dangerousness to self or others and
environmental risks; and if
screening was positive in the last 12
months, there was documentation of
mitigation recommendations,
including but not limited to referral
to other resources.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
American
Academy of
Neurology
Physician
Consortium for
Performance
Improvement
Foundation
(PCPI)
American
Academy of
Neurology
American
Academy of
Neurology
EP30JN17.141
Indicator
30392
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B.19. Mental/Behavioral Health
NQF
#
105
0104
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§
VerDate Sep<11>2014
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#
009
107
128
19:16 Jun 29, 2017
CMSEData
Measure Submission
ID
Metlwd
128v6
69v6
Claims,
Registry,
EHR, Web
Interface
Effective
Clinical Care
Process
EHR
PO 00000
National
Quality
Strategy
Domain
Process
EHR
161v6
Jkt 241001
Measure
Type
Effective
Clinical Care
Process
Community/
Population
Health
Frm 00384
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Measure Title
and Description
Anti-Depressant Medication
Management:
Percentage of patients 18 years of
age and older who were treated with
antidepressant medication, had a
diagnosis of major depression, and
who remained on antidepressant
medication treatment.
Two rates are reported:
a. Percentage of patients who
remained on an antidepressant
medication for at least 84 days (12
weeks)
b. Percentage of patients who
remained on an antidepressant
medication for at least 180 days (6
months)
Adult Major Depressive Disorder
(MDD): Suicide Risk Assessment:
Percentage of patients aged 18 years
and older with a diagnosis of major
depressive disorder (MDD) with a
suicide risk assessment completed
during the visit in which a new
diagnosis or recurrent episode was
identified.
Preventive Care and Screening:
Body Mass Index (BMI) Screening
and Follow-Up Plan:
Percentage of patients aged 18 years
and older with a BMI documented
during the current encounter or
during the previous twelve months
AND with a BMI outside of normal
parameters, a follow-up plan is
documented during the encounter or
during the previous twelve months
of the current encounter.
Normal Parameters:
Age 18 years and older BMI => 18.5
and< 25 kg/m2
E:\FR\FM\30JNP2.SGM
30JNP2
Measure.
Steward
National
Committee for
Quality
Assurance
Physician
Consortium for
Performance
Improvement
Centers for
Medicare &
Medicaid
Services
EP30JN17.142
Indicator
Quality
30393
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B.19. Mental/Behavioral Health (continued)
Indicator
NQF
#
0419
0418
!
*
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VerDate Sep<11>2014
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0028
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#
130
134
181
226
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CMSE-
Data
Measure Submission
Method
ID
68v7
Claims,
Registry,
EHR
2v7
Claims,
Web
Interface,
Registry,
EHR
NIA
Claims,
Registry
138v6
Claims,
Registry,
EHR, Web
Interface
Jkt 241001
PO 00000
Measure
Type
National
Quality
Strategy
Domafu
Measure Title
and Description
Process
Patient
Safety
Process
Community
I Population
Health
Process
Patient
Safety
Process
Frm 00385
Fmt 4701
Community
I Population
Health
Sfmt 4725
· ..
Documentation of Current
Medications in the Medical Record:
Percentage of visits for patients aged
18 years and older for which the
eligible professional allesls lo
docmnenting a list of current
medications using all immediate
resources available on the date of the
encounter. This list must include ALL
known prescriptions, over-thecounters, herbals, and
vitamin/mineral/dietary (nutritional)
supplements AND must contain the
medications' name, dosage,
frequency and route of
administration.
Preventive Care and Screening:
Screening for Clinical Depression
and Follow-Up Plan:
Percentage of patients aged 12 years
and older screened for clinical
depression on the date of the
encounter using an age appropriate
standardized depression screening
tool AND if positive, a follow-up
plan is documented on the date of the
positive screen
Elder Maltreatment Screen and
Follow-Up Plan:
Percentage of patients aged 65 years
and older with a documented elder
mal-treatment screen using an Elder
Maltreatment Screening Tool on the
date of encounter AND a docmnented
follow-up plan on the date of the
positive screen
Preventive Care and Screening:
Tobacco Use: Screening and
Cessation Intervention:
a. Percentage of patients aged 18
years and older who were screened
for tobacco use one or more times
within 24 months
b. Percentage of patients aged 18
years and older who were screened
for tobacco use and identified as a
tobacco user who received tobacco
cessation intervention
c. Percentage of patients aged 18
years and older who were screened
for tobacco use one or more times
within 24 months AND who
received cessation counseling
intervention if identified as a
tobacco user.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
Centers for
Medicare &
Medicaid
Services
Centers for
Medicare &
Medicaid
Services
Centers for
Medicare &
Medicaid
Services
Physician
Consortium for
Performance
Improvement
Foundation
(PCPI®)
EP30JN17.143
I
30394
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B.19. Mental/Behavioral Health (continued)
Indicator
NQF
#
*
N/A
281
149v6
Data
Submission
Method
EHR
Measure
Type
Process
National
Quality
Strategy
Domain
Effective
Clinical
Care
mstockstill on DSK30JT082PROD with PROPOSALS2
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282
N/A
Registry
Process
Effective
Clinical
Care
N/A
!
283
N/A
Registry
Process
Effective
Clinical
Care
N/A
286
N/A
Registry
Process
Patient
Safety
Process
Communi
cation and
Care
Coordinati
on
N/A
288
19:16 Jun 29, 2017
N/A
Jkt 241001
Registry
PO 00000
Frm 00386
Fmt 4701
Sfmt 4725
Measure
Steward
·.
Dementia: Cognitive Assessment:
Percentage of patients, regardless of
age, with a diagnosis of dementia for
whom an assessment of cognition is
performed and the results reviewed at
least once within a 12-month period
N/A
!
Measure Title
and Description
Dementia: Functional Status
Assessment:
Percentage of patients, regardless of
age, with a diagnosis of dementia for
whom an assessment of functional
status is performed and the results
reviewed at least once within a 12month period
Dementia: Neuropsychiatric
Symptom Assessment:
Percentage of patients, regardless of
age, with a diagnosis of dementia and
for whom an assessment of
neuropsychiatric symptoms is
performed and results reviewed at
least once in a 12-month period
Safety Concern Screening and
Follow-Up for Patients with
Dementia:
Percentage of patients with dementia
or their caregiver(s) for whom there
was a documented safety screening *
in two domains of risk: dangerousness
to self or others and environmental
risks; and if screening was positive in
the last 12 months, there was
documentation of mitigation
recommendations, including but not
limited to referral to other resources.
Dementia: Caregiver Education and
Support:
Percentage of patients, regardless of
age, with a diagnosis of dementia
whose caregiver(s) were provided with
education on dementia disease
management and health behavior
changes AND referred to additional
sources for support within a 12-month
period
E:\FR\FM\30JNP2.SGM
30JNP2
Physician
Consortium
for
Performance
Improvement
Foundation
(PCPI®)
American
Academy of
Neurology
American
Academy of
Neurology
American
Academy of
Neurology
American
Academy of
Neurology
EP30JN17.144
CMSE-
Quality
Measure
#
ID
30395
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B.19. Mental/Behavioral Health (continued)
NQF
#
CMSEc
Data
Measure Submission
Met}lod
ID
N/A
!
317
22v6
Claims,
Registry,
EHR
N/A
325
N/A
Registry
mstockstill on DSK30JT082PROD with PROPOSALS2
0108
VerDate Sep<11>2014
366
19:16 Jun 29, 2017
136v7
EHR
Jkt 241001
PO 00000
National
Measure
Type
Qmility
Strategy
Domain
Process
Community I
Population
Health
Process
Communication/
Care
Coordination
Process
Frm 00387
Fmt 4701
Et1ective
Clinical Care
Sfmt 4725
Measure Title
and Description
..
Measure
Steward
I
Preventive Care and Screening:
Screening for High Blood
Pressure and Follow-Up
Documented:
Percentage of patients aged 18
years and older seen during the
reporting period who were
screened for high blood pressure
AND a recommended follow-up
plan is documented based on the
current blood pressure (BP)
reading as indicated.
Adult Major Depressive
Disorder (MDD): Coordination
of Care of Patients with Specific
Comorbid Conditions:
Percentage of medical records of
patients aged 18 years and older
with a diagnosis of major
depressive disorder (MDD) and a
specific diagnosed comorbid
condition (diabetes, coronary
artery disease, ischemic stroke,
intracranial hemorrhage, chronic
kidney disease [stages 4 or 5], End
Stage Renal Disease [ESRD] or
congestive heart failure) being
treated by another clinician with
communication to the clinician
treating the comorbid condition
ADHD: Follow-Up Care for
Children Prescribed AttentionDeficit/Hyperactivity Disorder
(ADHD) Medication:
Percentage of children 6-12 years
of age and newly dispensed a
medication for attentiondeficit/hyperactivity disorder
(ADHD) who had appropriate
follow-up care. Two rates are
reported.
a. Percentage of children who had
one follow-up visit with a
practitioner with prescribing
authority during the 30-Day
Initiation Phase.
b. Percentage of children who
remained on ADHD medication
for at least 210 days and who, in
addition to the visit in the Initiation
Phase, had at least two additional
follow-up visits with a practitioner
within 270 days (9 months) after
the Initiation Phase ended.
E:\FR\FM\30JNP2.SGM
30JNP2
Centers for
Medicare &
Medicaid
Services
American
Psychiatric
Association
National
Committee
for Quality
Assurance
EP30JN17.145
Indicator
Quality
#
30396
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B.19. Mental/Behavioral Health (continued)
Quality
#
#
N/A
367
CMSE~
Data
Measure Submis$iOJt
Method
ID
*
!
EHR
Process
Et1ective
Clinical Care
Outcome
Effective
Clinical Care
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!
VerDate Sep<11>2014
0710
370
159v6
Web
Interface,
Registry,
EHR
371
160v6
EHR
50v6
Registry,
EHR
N/A
1365
374
382
19:16 Jun 29, 2017
National
Quality
Strategy
Domain
169v6
0712
§
!
Measure
type
177v5
EHR
Jkt 241001
PO 00000
Process
Process
Process
Frm 00388
Fmt 4701
Effective
Clinical Care
Communication
and Care
Coordination
Patient Safety
Sfmt 4725
Mf;lasure Title
and Description
Bipolar Disorder and Major
Depression: Appraisal for
alcohol or chemical substance
use:
Percentage of patients with
depression or bipolar disorder
with evidence of an initial
assessment that includes an
appraisal for alcohol or chemical
substance use
Depression Remission at
Twelve Months:
Patients age 18 and older with
major depression or dysthymia
and an initial Patient Health
Questionnaire (PHQ-9) score
greater than nine who
demonstrate remission at twelve
months(+/- 30 days after an
index visit) defined as a PHQ-9
score less than five. This
measure applies to both patients
with newly diagnosed and
existing depression whose
current PHQ-9 score indicates a
need for treatment.
Depression Utilization of the
PHQ-9 Tool:
Patients age 18 and older with
the diagnosis of major
depression or dysthymia who
have a Patient Health
Questionnaire (PHQ-9) tool
administered at least once during
a 4-month period in which there
was a qualifying visit
Closing the Referral Loop:
Receipt of Specialist Report:
Percentage of patients with
referrals, regardless of age, for
which the referring provider
receives a report from the
provider to whom the patient
was referred.
Child and Adolescent Major
Depressive Disorder (MDD):
Suicide Risk Assessment:
Percentage of patient visits for
those patients aged 6 through 17
years with a diagnosis of major
depressive disorder with an
assessment for suicide risk.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Stew!lrd
Center for
Quality
Assessment
and
Improvement
in Mental
Health
MN
Community
Measurement
MN
Community
Measurement
Centers for
Medicare &
Medicaid
Services
Physician
Consortium for
Performance
Improvement
Foundation
(PCPI®)
EP30JN17.146
Indicator
NQF
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30397
B.19. Mental/Behavioral Health (continued)
!
!
Quality
#
#
1879
0576
383
391
CMSEMeasqre
ID
N/A
N/A
Data
Submission
Method
Registry
Registry
Measure
Type
Intermed
iate
Outcome
Process
National
Quality
Strategy
Domain
Patient
Safety
Communi
cation/Car
e
Coordinat
lOll
N/A
mstockstill on DSK30JT082PROD with PROPOSALS2
!
VerDate Sep<11>2014
0711
402
411
19:16 Jun 29, 2017
NA
N/A
Jkt 241001
Registry
Process
Registry
Outcome
PO 00000
Frm 00389
Fmt 4701
Communi
ty/
Populatio
nHealth
Effective
Clinical
Care
Sfmt 4725
Measure Title
and Description
Adherence to Antipsychotic
Medications for Individuals with
Schizophrenia:
Percentage of individuals at least 18
years of age as ofthe beginning of the
measurement period with schizophrenia
or schizoaffective disorder who had at
least two prescriptions filled for any
antipsychotic medication and who had a
Proportion of Days Covered (PDC) of at
least 0.8 for antipsychotic medications
during the measurement period (12
consecutive months)
Follow-up After Hospitalization for
Mentallllness (FUH):
The percentage of discharges for patients
6 years of age and older who were
hospitalized for treatment of selected
mental illness diagnoses and who had an
outpatient visit, an intensive outpatient
encounter or partial hospitalization with a
mental health practitioner. Two rates are
reported:
• The percentage of discharges for which
the patient received follow-up within
30 days of discharge
• The percentage of discharges for which
the patient received follow-up within 7
days of discharge
Tobacco Use and Help with Quitting
Among Adolescents:
The percentage of adolescents 12 to 20
years of age with a primary care visit
during the measurement year for whom
tobacco use status was documented and
received help with quitting if identified as
a tobacco user
Depression Remission at Six Months:
Adult patients age 18 years and older
with major depression or dysthymia and
an initial PHQ-9 score > 9 who
demonstrate remission at six months
defined as a PHQ-9 score less than 5.
This measure applies to both patients
with newly diagnosed and existing
depression whose current PHQ-9 score
indicates a need for treatment. This
measure additionally promotes ongoing
contact between the patient and provider
as patients who do not have a follow-up
PHQ-9 score at six months (+/- 30 days)
are also included in the denominator
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
National
Committee
for Quality
Assurance
National
Committee
for Quality
Assurance
National
Committee
for Quality
Assurance
MN
Community
Measurement
EP30JN17.147
Indicator
NQF
30398
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B.19. Mental/Behavioral Health (continued)
NQF
#
Quality
#
CMSE~
Data
Measure Submission
Method
ID
Measure
Type
National
Quality
strategy
Domain
VerDate Sep<11>2014
431
N/A
Registry
Process
Community
I Population
Health
N/A
mstockstill on DSK30JT082PROD with PROPOSALS2
2152
TBD
N/A
Registry
Process
Patient
Safety
19:16 Jun 29, 2017
Jkt 241001
PO 00000
Frm 00390
Fmt 4701
Sfmt 4725
Measure Title
and .DescriptioJI
Preventive Care and Screening:
Unhealthy Alcohol Use: Screening
& Brief Counseling:
Percentage of patients aged 18 years
and older who were screened for
unhealthy alcohol use using a
systematic screening method at least
once within the last 24 months AND
who received brief counseling if
identified as an unhealthy alcohol
user.
Safety Concern Screening and
Follow~Up for Patients with
Dementia:
Percentage of patients with dementia
or their caregiver(s) for whom there
was a documented safety screening in
two domains of risk: dangerousness
to self or others and environmental
risks; and if screening was positive in
the last 12 months, there was
documentation of mitigation
recommendations, including but not
limited to referral to other resources.
E:\FR\FM\30JNP2.SGM
30JNP2
..
Measure
Steward
Physician
Consortium
for
Performance
Improvement
Foundation
(PCPI®)
American
Academy of
Neurology
EP30JN17.148
Indicator
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B20 a. n·
1agnosf IC Rd. I gy
a 100
NQF
#
.Quality
#
Data
CMSEMeasure Submission
Method
ID.
Measure
Type
National
Quality
Strategy
Domain
N/A
145
N/A
Registry
Process
Patient
Safety
!
mstockstill on DSK30JT082PROD with PROPOSALS2
!!
0508
146
N/A
Claims,
Registry
Process
Efficiency
and Cost
Reduction
VerDate Sep<11>2014
19:16 Jun 29, 2017
Jkt 241001
PO 00000
Frm 00391
Fmt 4701
Sfmt 4725
Measure Title
and Des~:ription
Radiology: Exposure Dose or
Time Reported for Procedures
Using Fluoroscopy:
Final reports for procedures using
fluoroscopy that document radiation
exposure indices, or exposure time
and number offluorographic images
(if radiation exposure indices are not
available)
Radiology: Inappropriate Use of
"Probably Benign" Assessment
Category in Mammography
Screening:
Percentage of final reports for
screening manunograms that are
classified as "probably benign"
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
American
College of
Radiology
American
College of
Radiology
EP30JN17.149
..
Indicator
30399
30400
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
Indicator
NQF
#
Quality
#
Cl\:fS E·
1\:feasure
ID
n·1a
nos f IC Rd. I ogy ( con fmue d)
a 10
D.ata
Submission
Method
1\:feasure
Type
National
Quality
Strategy
Domain
mstockstill on DSK30JT082PROD with PROPOSALS2
VerDate Sep<11>2014
147
N/A
Claims,
Registry
Process
195
N/A
Claims,
Registry
Process
Effective
Clinical Care
0509
!
N/A
0507
!
Communication
and Care
Coordination
225
N/A
Registry,
Claims
Structure
Communication
and Care
Coordination
N/A
359
N/A
Registry
Process
Communication
and Care
Coordination
19:16 Jun 29, 2017
Jkt 241001
PO 00000
Frm 00392
Fmt 4701
Sfmt 4725
Measure Title
and Description
Measure
Steward
..
Nuclear Medicine:
Correlation with Existing
Imaging Studies for All
Patients Undergoing Bone
Scintigraphy:
Percentage of final reports for
all patients, regardless of age,
undergoing bone scintigraphy
that include physician
documentation of correlation
with existing relevant imaging
studies (e.g., x-ray, MRI, CT,
etc.) that were performed
Radiology: Stenosis
Measurement in Carotid
Imaging Reports:
Percentage of final reports for
carotid imaging studies (neck
magnetic resonance
angiography [MRA], neck
computed tomography
angiography [CIA], neck
duplex ultrasound, carotid
angiogram) performed that
include direct or indirect
reference to measurements of
distal internal carotid diameter
as the denominator for stenosis
measurement
Radiology: Reminder System
for Screening Mammograms:
Percentage of patients
undergoing a screening
mammogram whose
information is entered into a
reminder system with a target
due date for the next
mammogram
Optimizing Patient Exposure
to Ionizing Radiation:
Utilization of a Standardized
Nomenclature for Computed
Tomography (CT) Imaging:
Percentage of computed
tomography (CT) imaging
reports for all patients,
regardless of age, with the
imaging study named
according to a standardized
nomenclature and the
standardized nomenclature is
used in institution's computer
systems.
E:\FR\FM\30JNP2.SGM
30JNP2
Society of
Nuclear
Medicine and
Molecular
Imaging
American
College of
Radiology
American
College of
Radiology
American
College of
Radiology
EP30JN17.150
B20a.
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
Indicator
!!
!
mstockstill on DSK30JT082PROD with PROPOSALS2
!
VerDate Sep<11>2014
NQF
#
N/A
N/A
N/A
Quality
#
360
CMSE·
Measure
ID
n·1agnosfIC Rd.10I ogy (con fmue d)
a
Data
Submission
Method
Measure.
Type
National
Quality
Strategy
Domain
N/A
Registry
Process
Patient Safety
361
N/A
Registry
Structure
Patient Safety
362
N/A
Registry
Structure
Communication
and Care
Coordination
19:16 Jun 29, 2017
Jkt 241001
PO 00000
Frm 00393
Fmt 4701
Sfmt 4725
Measure Title
and· Description
Optimizing Patient Exposure
to Ionizing Radiation: Count
of Potential High Dose
Radiation Imaging Studies:
Computed Tomography (CT)
and Cardiac Nuclear Medicine
Studies:
Percentage of computed
tomography (CT) and cardiac
nuclear medicine (myocardial
perfusion studies) imaging
reports for all patients,
regardless of age, that document
a count of known previous CT
(any type ofCT) and cardiac
nuclear medicine (myocardial
perfusion) studies that the
patient has received in the 12month period prior to the current
study.
Optimizing Patient Exposure
to Ionizing Radiation:
Reporting to a Radiation Dose
Index Registry:
Percentage of total computed
tomography (CT) studies
performed for all patients,
regardless of age, that are
reported to a radiation dose
index registry that is capable of
collecting at a minimum selected
data elements
Optimizing Patient Exposure
to Ionizing Radiation:
Computed Tomography (CT)
Images Available for Patient
Follow-up and Comparison
Purposes:
Percentage of fmal reports for
computed tomography (CT)
studies performed for all
patients, regardless of age,
which document that Digital
Imaging and Communications in
Medicine (DICOM) format
image data are available to nonaffiliated external healthcare
facilities or entities on a secure,
media free, reciprocally
searchable basis with patient
authorization for at least a 12month period after the study
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
American
College of
Radiology
American
College of
Radiology
American
College of
Radiology
EP30JN17.151
B20a.
30401
30402
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
lndh:ato:r
NQF
Quality
#
#
CMS.EMeasure
ID
n·1agnosfIC Rd.10I ogy (con fmue d)
a
Data
Submission
Method
Measure
Type
National
Quality
Strategy
Domain
N/A
363
N/A
Registry
Structure
Communicati
on and Care
Coordination
!!
N/A
364
N/A
Registry
Process
Communicati
on and Care
Coordination
N/A
mstockstill on DSK30JT082PROD with PROPOSALS2
!
405
N/A
Claims,
Registry
Process
EtTective
Clinical Care
VerDate Sep<11>2014
19:16 Jun 29, 2017
Jkt 241001
PO 00000
Frm 00394
Fmt 4701
Sfmt 4725
Measure Title
and Description
Optimizing Patient Exposure
to Ionizing Radiation: Search
for Prior Computed
Tomography (CT) Studies
Through a Secure, Authorized,
Media-Free, Shared Archive:
Percentage of fmal reports of
computed tomography (CT)
studies performed for all
patients, regardless of age,
which document that a search
for Digital Imaging and
Communications in Medicine
(DICOM) format images was
conducted for prior patient CT
imaging studies completed at
non-affiliated extemal healthcare
facilities or entities within the
past 12-months and are available
through a secure, authorized,
media free, shared archive prior
to an imaging study being
performed
Optimizing Patient Exposure
to Ionizing Radiation:
Appropriateness: Follow-up
CT Imaging for Incidentally
Detected Pulmonary Nodules
According to Recommended
Guidelines:
Percentage of fmal reports for
computed tomography (CT)
imaging studies of the thorax for
patients aged 18 years and older
with documented follow-up
recommendations for
incidentally detected puhnonary
nodules (e.g., follow-up CT
imaging studies needed or that
no follow-up is needed) based at
a minimum on nodule size AND
patient risk factors
Appropriate Follow-up
Imaging for Incidental
Abdominal Lesions:
Percentage of fmal reports for
abdominal imaging studies for
asymptomatic patients aged 18
years and older with one or more
of the following noted
incidentally with followDup
imaging recommended:
• Liver lesion :S 0.5 em
• Cystic kidney lesion< 1.0 em
• Adrenal lesion :S 1.0 em
E:\FR\FM\30JNP2.SGM
30JNP2
MeasU:re
Steward
American
College of
Radiology
American
College of
Radiology
American
College of
Radiology
EP30JN17.152
B20a.
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
Indicator
.NQJ!7
#
!!
N/A
mstockstill on DSK30JT082PROD with PROPOSALS2
N/A
VerDate Sep<11>2014
Quality
#
406
436
19:16 Jun 29, 2017
CMSEMeasure
ID
N/A
N/A
Jkt 241001
n·1a
nos f IC Rd. I ogy ( con fmue d)
a 10
Data
Submission
Method
Claims,
Registry
Clain1s,
Registry
PO 00000
Measure
Type
Process
Process
Frm 00395
Fmt 4701
National
Quality
Strategy
Domain
Effective
Clinical
Care
Effective
Clinical
Care
Sfmt 4725
Measure Title
and Description
Appropriate Follow-Up Imaging
for Incidental Thyroid Nodules
in Patients:
Percentage of final reports for
computed tomography (CT),
magnetic resonance imaging (MRI)
or magnetic resonance angiogram
(MRA) studies of the chest or neck
or ultrasound ofthe neck for
patients aged 18 years and older
with no known thyroid disease
with a thyroid nodule< 1.0 em
noted incidentally with follow-up
imaging recommended
Radiation Consideration for
Adult CT: Utilization of Dose
Lowering Techniques:
Percentage of final reports for
patients aged 18 years and older
undergoing CT with
documentation that one or more of
the following dose reduction
techniques were used:
o Automated exposure control
o Adjustment of the mA and/or kV
according to patient size
o Use of iterative reconstruction
technique
E:\FR\FM\30JNP2.SGM
30JNP2
.Measure
Steward
American
College of
Radiology
American
College of
Radiology/Arne
rican Medical
AssociationPhysician
Consortium for
Perfonnance
Improvement/
National
Committee for
Quality
Assurance
EP30JN17.153
B20a.
30403
30404
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B 20b I nt erven f wnaI R a d" I
IOOgy
mstockstill on DSK30JT082PROD with PROPOSALS2
!
VerDate Sep<11>2014
N/A
Quality
#
076
19:16 Jun 29, 2017
CMSEData
Measure Submission
·Method
ID
N/A
Jkt 241001
Claims,
Registry
PO 00000
Measure
'}'ype
Process
Frm 00396
Fmt 4701
National
Quality
Strategy
Domain
Patient
Safety
Sfmt 4725
Measure Title
and Description
Prevention of Central Venous
Catheter (CVC)-Related
Bloodstream Infections:
Percentage of patients, regardless of
age, who lmdergo central venous
catheter (eVe) insertion for whom
eve was inserted with all elements
of maximal sterile barrier technique,
hand hygiene, skin preparation and,
if ultrasound is used, sterile
ultrasound techniques followed.
E:\FR\FM\30JNP2.SGM
30JNP2
MeasU:re
Steward
American
Society of
EP30JN17.154
.Indicator
NQF
#
30405
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B 20b Interven f wnaI R a d" I ogy ( con fmue d)
10
NQF
#
N/A
*
!
N/A
N/A
N/A
#
·
..
145
374
409
413
ID
Data
Submission
Method
N/A
Claims,
Registry
50v6
Registry,
EHR
N/A
N/A
Measure
Type
Process
Patient Safety
Process
Col1llllunicati
on and Care
Coordination
Registry
Registry
National
Quality
Strategy
·. Domain
Outcome
Intermed
iate
Outcome
Effective
Clinical Care
Effective
Clinical Care
VerDate Sep<11>2014
420l
N/A
Registry
Outcome
Effective
Clinical Care
N/A
mstockstill on DSK30JT082PROD with PROPOSALS2
N/A
421
N/A
Registry
Process
Effective
Clinical Care
19:16 Jun 29, 2017
Jkt 241001
PO 00000
Frm 00397
Fmt 4701
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Measure Title
and Description
Measure
Steward
·.
Radiology: Exposure Dose or
Time Reported for Procedures
Using Fluoroscopy:
Final reports for procedures using
fluoroscopy that document
radiation exposure indices, or
exposure time and number of
fluorographic images (if radiation
exposure indices are not available)
Closing the Referral Loop:
Receipt of Specialist Report:
Percentage of patients with
referrals, regardless of age, for
which the referring provider
receives a report from the provider
to whom the patient was referred.
American
College of
Radiology
Centers for
Medicare &
Medicaid
Services
Clinical Outcome Post
Endovascular Stroke Treatment:
Percentage of patients with a mRs
score of 0 to 2 at 90 days following
endovascular stroke intervention
Society of
Interventional
Radiology
Door to Puncture Time for
Endovascular Stroke Treatment:
Percentage of patients undergoing
endovascular stroke treatment who
have a door to puncture time of
less than two hours
Society of
Interventional
Radiology
Varicose Vein Treatment with
Saphenous Ablation: Outcome
Survey: Percentage of patients
treated for varicose veins (CEAP
C2-S) who are treated with
saphenous ablation (with or
without adjunctive tributary
treatment) that report an
improvement on a disease specific
patient reported outcome survey
instrument after treatment
Appropriate Assessment of
Retrievable Inferior Vena Cava
(IV C) Filters for Removal:
Percentage of patients in whom a
retrievable IVC filter is placed
who, within 3 months postplacement, have a documented
assessment for the appropriateness
of continued filtration, device
removal or the inability to contact
the patient with at least two
attempts.
E:\FR\FM\30JNP2.SGM
30JNP2
Society of
Interventional
Radiology
Society of
Interventional
Radiology
EP30JN17.155
Indicator
CMS!.Measure
Quality
30406
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
In!Itt:at,or
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N/A
VerDate Sep<11>2014
TBD
N/A
Registry
Process
Patient
Safety
19:16 Jun 29, 2017
Jkt 241001
PO 00000
Frm 00398
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.
N11tional
Sfmt 4725
,'.,,.
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,',I
Measure Title
Mel\s~re,
and,Destript~oll
,',,
Steward
'
Rate of Surgical Conversion
from Lower Extremity
Endovascular Revascularization
Procedure:
Inpatients assigned to endovascular
treatment for obstructive arterial
disease, the percent of patients who
undergo unplanned major
amputation or surgical bypass
within 48 hours of the index
procedure,
Uterine Artery Embolization
Technique: Documentation of
Angiographic Endpoints and
Interrogation of Ovarian
Arteries:
Documentation of angiographic
endpoints of embolization AND
the documentation of embolization
strategies in the presence of
unilateral or bilateral absent uterine
arteries
E:\FR\FM\30JNP2.SGM
30JNP2
•
'
,,
,'
Society of
Interventional
Radiology
Society of
Interventional
Radiology
EP30JN17.156
,,,
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30407
B21 NeJ.hro ogy
NQF
#
§
!
mstockstill on DSK30JT082PROD with PROPOSALS2
§
!
VerDate Sep<11>2014
0059
0097
#
001
046
19:16 Jun 29, 2017
Data
CM:SEMeasure. Submission
ID
Method
122v6
N/A
Jkt 241001
Claims,
Web
Interface,
Registry,
EHR
Claims,
Web
Interface,
Registry
PO 00000
Measure
Type
National···
Quality
Strategy
Domain
Tntennedia
Effective
te
Clinical Care
Outcome
Process
Frm 00399
Fmt 4701
Communication
and Care
Coordination
Sfmt 4725
Measure Title
and Description
Diabetes: Hemoglobin Ale
(HbAlc) Poor Control
(>9%):
Percentage of patients 18-75
years of age with diabetes who
had hemoglobin Ale> 9.0%
during the measurement period.
Medication Reconciliation
Post-Discharge:
The percentage of discharges
from any inpatient facility (e.g.
hospital, skilled nursing
facility, or rehabilitation
facility) for patients 18 years
and older of age seen within 30
days following discharge in the
office by the physician,
prescribing practitioner,
registered nurse, or clinical
pharmacist providing on-going
care for whom the discharge
medication list was reconciled
with the current medication list
in the outpatient medical
record.
This measure is reported as
three rates stratified by age
group:
o Reporting Criteria 1:
18-64 years of age
o Reporting Criteria 2:
65 years and older
o Total Rate:
All patients 18 years of
age and older.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
National
Committee for
Quality
Assurance
National
Committee for
Quality
Assurance
EP30JN17.157
Indicator
Quality
30408
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B21 N ep1h roo gy con fmue d)
!
*
NQF
#
0326
0041
0043
#
047
110
111
CMSE~
Measure
1D
N/A
147v7
127v6
Data
Submission
Method
Claims,
Registry
Measure
Type .·
Process
National
Quality
Strategy
Domain
Communication
and Care
Coordination
Claims, Web
Process
Interface,
Registry, EHJ
Community/
Population
Health
Claims, Web
Interface,
Process
Registry, EHJ
Community/
Population
Health
mstockstill on DSK30JT082PROD with PROPOSALS2
VerDate Sep<11>2014
0062
119
134v6
Registry,
EHR
Process
N/A
§
122
N/A
Registry
Intermedia
Effective
te
Clinical Care
Outcome
19:16 Jun 29, 2017
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Frm 00400
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Effective
Clinical Care
Sfmt 4725
Measure Title
and Description
Care Plan:
Percentage of patients aged 65
years and older who have an
advance care plan or surrogate
decision maker documented in
the medical record or
documentation in the medical
record that an advance care
plan was discussed but the
patient did not wish or was not
able to name a surrogate
decision maker or provide an
advance care plan.
Preventive Care and
Screening: Influenza
Immunization:
Percentage of patients aged 6
months and older seen for a
visit between October 1 and
March 31 who received an
influenza immunization OR
who reported previous receipt
of an int1uenza immunization
Pneumonia Vaccination
Status fur Older Adults:
Percentage of patients 65 years
of age and older who have ever
received a pneumococcal
vaccme
Diabetes: Medical Attention
for Nephropathy:
The percentage of patients 1875 years of age with diabetes
who had a nephropathy
screening test or evidence of
nephropathy during the
measurement period
Adult Kidney Disease: Blood
Pressure Management:
Percentage of patient visits for
those patients aged 18 years
and older with a diagnosis of
chronic kidney disease (CKD)
(stage 3, 4, or 5, not receiving
Renal Replacement Therapy
[RRT]) with a blood pressure<
140/90 nmilig 0 R ~ 140/90
nm1Hg with a documented plan
of care
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
National
Committee for
Quality
Assurance
Physician
Consortium for
Performance
Improvement
Foundation
(PCPI®)
National
Committee for
Quality
Assurance
National
Committee for
Quality
Assurance
Renal
Physicians
Association
EP30JN17.158
Indicator
Quality
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30409
B21 Nep1h ro ogy con fmue d)
NQF
#
#
CMSE·
Measure
ID
Data
Submission
Method
0419
68v7
2624
182
N/A
Claims,
Registry
N/A
!
130
Claims,
Registry,
EHR,
317
22v6
Claims,
Registry,
EHR
139v6
EHR, Web
Interface
mstockstill on DSK30JT082PROD with PROPOSALS2
0101
VerDate Sep<11>2014
318
19:16 Jun 29, 2017
Jkt 241001
PO 00000
Measure
Type
National
Quality
Strate~
Measure Title
and Description
Measure
Steward
Domain
Process
Patient Safety
Process
Communication
and Care
Coordination
Process
Community I
Population
Health
Process
Frm 00401
Fmt 4701
Patient Safety
Sfmt 4725
Documentation of Current
Medications in the Medical
Record:
Percentage of visits for patients
aged 18 years and older for
which the eligible professional
attests to documenting a list of
current medications using all
immediate resources available
on the date ofthe encounter.
This list must include ALL
known prescriptions, over-thecounters, herbals, and
vitamin/mineral/dietary
(nutritional) supplements AND
must contain the medications'
name, dosage, frequency and
route of administration.
Functional Outcome
Assessment:
Percentage of visits for patients
aged 18 years and older with
documentation of a current
functional outcome assessment
using a standardized functional
outcome assessment tool on the
date of encounter AND
documentation of a care plan
based on identified functional
outcome deficiencies on the date
of the identified deficiencies
Preventive Care and
Screening: Screening for High
Blood Pressure and Follow-Up
Documented:
Percentage of patients aged 18
years and older seen during the
reporting period who were
screened for high blood pressure
AND a recommended follow-up
plan is documented based on the
current blood pressure (BP)
reading as indicated.
Falls: Screening for Future
Fall Risk:
Percentage of patients 65 years
of age and older who were
screened for future fall risk
during the measurement period.
E:\FR\FM\30JNP2.SGM
30JNP2
Centers for
Medicare &
Medicaid
Services
Centers for
Medicare &
Medicaid
Services
Centers for
Medicare &
Medicaid
Services
National
Committee for
Quality
Assurance
EP30JN17.159
Indicator
Quality
30410
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
CMSE-
Indicator
NQF
#
N/A
!
1667
Quality
Measure
#
ID
327
328
Data
Submission
Method
o~n
Measure
Type
con fmue d)
National
Quality
Strategy
Domain
N/A
Registry
Process
Effective
Clinical
Care
N/A
Registry
Intermediate
Outcome
Effective
Clinical
Care
VerDate Sep<11>2014
329
N/A
Registry
Outcome
Effective
Clinical
Care
N/A
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N/A
330
N/A
Registry
Outcome
Patient
Safety
19:16 Jun 29, 2017
Jkt 241001
PO 00000
Frm 00402
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Measure Title
and Description
Pediatric Kidney Disease:
Adequacy of Volume
Management:
Percentage of calendar months
within a 12-month period during
which patients aged 17 years and
younger with a diagnosis of End
Stage Renal Disease (ESRD)
undergoing maintenance
hemodialysis in an outpatient
dialysis facility have an assessment
of the adequacy of volume
management from a nephrologist
Pediatric Kidney Disease: ESRD
Patients Receiving Dialysis:
Hemoglobin Level< 10 g/dL:
Percentage of calendar months
within a 12-month period during
which patients aged 17 years and
younger with a diagnosis of End
Stage Renal Disease (ESRD)
receiving hemodialysis or
peritoneal dialysis have a
hemoglobin level< 10 g/dL
Adult Kidney Disease: Catheter
Use at Initiation of Hemodialysis:
Percentage of patients aged 18
years and older with a diagnosis of
End Stage Renal Disease (ESRD)
who initiate maintenance
hemodialysis during the
measurement period, whose mode
of vascular access is a catheter at
the time maintenance hemodialysis
is initiated
Adult Kidney Disease: Catheter
Use for Greater Than or Equal
to 90 Days:
Percentage of patients aged 18
years and older with a diagnosis of
End Stage Renal Disease (ESRD)
receiving maintenance
hemodialysis for greater than or
equal to 90 days whose mode of
vascular access is a catheter
E:\FR\FM\30JNP2.SGM
30JNP2
Measure.
Steward
Renal
Physicians
Association
Renal
Physicians
Association
Renal
Physicians
Association
Renal
Physicians
Association
EP30JN17.160
B21 Nep1h ro
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30411
B21 Nep1h ro ogy con fmue d)
N/A
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N/A
VerDate Sep<11>2014
CMSEQuality
Measure
#
ID
400
403
19:16 Jun 29, 2017
N/A
N/A
Jkt 241001
Data
Submission
·Method
Registry
Registry
PO 00000
Measure
'}'ype
National
Quality
Strategy
Domain
Process
Effective
Clinical Care
Process
Person and
CaregiverCentered
Experience
and Outcomes
Frm 00403
Fmt 4701
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Measure Title
a:nd Description
One-Time Screening for
Hepatitis C Virus (HCV) for
Patients at Risk:
Percentage of patients aged 18
years and older with one or more
of the following: a history of
injection drug use, receipt of a
blood transfusion prior to 1992,
receiving maintenance
hemodialysis, OR birthdate in the
years 1945-1965 who received
one-time screening for hepatitis C
virus (HCV) infection
Adult Kidney Disease: Referral
to Hospice:
Percentage of patients aged 18
years and older with a diagnosis of
ESRD who withdraw from
hemodialysis or peritoneal dialysis
who are referred to hospice care
E:\FR\FM\30JNP2.SGM
30JNP2
MeasU:re
Steward
Physician
Consortium for
Performance
Improvement
Renal
Physicians
Association
EP30JN17.161
Indicator
NQF
#
30412
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B 22 Gen era ISurgen
NQF
#
!!
mstockstill on DSK30JT082PROD with PROPOSALS2
!
VerDate Sep<11>2014
0268
0239
#
021
023
19:16 Jun 29, 2017
CMSEData
Measure Submission
ID
Method
N/A
Claims,
Registry
N/A
Claims,
Registry
Jkt 241001
PO 00000
Measure
Type
National
Quality
Strategy
Domain
Process
Patient
Safety
Process
Patient
Safety
Frm 00404
Fmt 4701
Sfmt 4725
Measure Title
and Description
Perioperative Care: Selection of
Prophylactic Antibiotic- First OR
Second Generation Cephalosporin:
Percentage of surgical patients aged
18 years and older undergoing
procedures with the indications for a
first OR second generation
cephalosporin prophylactic antibiotic,
who had an order for a first OR
second generation cephalosporin for
antimicrobial prophylaxis
Perioperative Care: Venom
Thromboembolism (VTE)
Prophylaxis (When Indicated in
ALL Patients):
Percentage of surgical patients aged
18 years and older undergoing
procedures for which venous
thromboembolism (VTE) prophylaxis
is indicated in all patients, who had
an order for Low Molecular Weight
Heparin (LMWH), Low-Dose
Unfractionated heparin (LDUH),
adjusted-dose warfarin, fondaparinux
or mechanical prophylaxis to be
given within 24 hours prior lo
incision time or within 24 hours after
surgery end time
E:\FR\FM\30JNP2.SGM
30JNP2
Measure.
Steward
American
Society of
Plastic
Surgeons
American
Society of
Plastic
Surgeons
EP30JN17.162
Indicator
Quality
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30413
B22 Gen eraIS urgery ( con fmue d)
NQF
#
#
CMSEData
Measure Submission
m
Method
!
*
mstockstill on DSK30JT082PROD with PROPOSALS2
§
VerDate Sep<11>2014
0097
046
N/A
Claims,
Web
Interface,
Registry
0326
§
047
N/A
Claims,
Registry
69v6
Claims,
Registry,
EHR, Web
Interface
0421
128
19:16 Jun 29, 2017
Jkt 241001
PO 00000
Measure
Type
National
Quality
Strategy
Domain
Process
Commllllication
and Care
Coordination
Process
Commllllication
and Care
Coordination
Process
Community /Pop
ulation Health
Frm 00405
Fmt 4701
Sfmt 4725
Measure Title
arid Description
Medication Reconciliation
Post-Discharge: The percentage
of discharges from any inpatient
facility (e.g. hospital, skilled
nursing facility, or rehabilitation
facility) for patients 18 years and
older of age seen within 30 days
following discharge in the office
by the physician, prescribing
practitioner, registered nurse, or
clinical pharmacist providing
on-going care for whom the
discharge medication list was
reconciled with the current
medication list in the outpatient
medical record.
This measure is reported as three
rates stratified by age group:
o Reporting Criteria 1: 18-64
years of age
o Reporting Criteria 2: 65 years
and older
o Total Rate: All patients 18
years of age and older.
Care Plan:
Percentage of patients aged 65
years and older who have an
advance care plan or surrogate
decision maker documented in
the medical record that an
advance care plan was discussed
but the patient did not wish or
was not able to name a surrogate
decision maker or provide an
advance care plan.
Preventive Care and
Screening: Body Mass Index
(BMI) Screening and FollowUp Plan:
Percentage of patients aged 18
years and older with a BMI
documented during the current
encounter or during the previous
twelve months AND with a BMI
outside of nonnal parameters, a
follow-up plan is documented
during the encounter or during
the previous twelve months of
the current encounter.
Normal Parameters:
Age 18 years and older BMI =>
18.5 and< 25 kg/m2
E:\FR\FM\30JNP2.SGM
30JNP2
Measure.
Steward
National
Cmmnittee for
Quality
Assurance
National
Cmmnittee for
Quality
Assurance
Centers for
Medicare &
Medicaid
Services
EP30JN17.163
Indicator
Quality
30414
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B.22. General Surgery (continued)
NQF
#
!
*
§
0419
0028
mstockstill on DSK30JT082PROD with PROPOSALS2
N/A
VerDate Sep<11>2014
Quality
#
130
226
317
19:16 Jun 29, 2017
CMSEMeasure
ID
Data
Submission
M:eth9d
68v7
Claims,
Registry,
EHR
138v6
Claims,
Registry,
EHR, Web
Interface
22v6
Claims,
Registry,
EHR
Jkt 241001
PO 00000
Measure
Type
Process
National Quality
Strategy Domain
Patient Safety
Process
Community/
Population
Health
Process
Community/
Population Health
Frm 00406
Fmt 4701
Sfmt 4725
Measure Title
and Description
Documentation of Current
Medications in the Medical
Record: Percentage of visits
for patients aged 18 years and
older for which the eligible
clinician attests to doclllllenting
a list of current medications
using all innnediate resources
available on the date of the
encounter. This list must
include ALL known
prescriptions, over-thecounters, herbals, and
vitamin/mineral/dietary
(nutritional) supplements AND
must contain the medications'
name, dosage, frequency and
route of administration.
Preventive Care and
Screening: Tobacco Use:
Screening and Cessation
Intervention:
a. Percentage of patients aged
18 years and older who were
screened for tobacco use one
or more times within 24
months
b. Percentage of patients aged
18 years and older who were
screened for tobacco use and
identified as a tobacco user
who received tobacco
cessation intervention
c. Percentage of patients aged
18 years and older who were
screened for tobacco use one
or more times within 24
months AND who received
cessation counseling
intervention if identified as a
tobacco user.
Preventive Care and
Screening: Screening for
High Blood Pressure and
Follow-Up Documented:
Percentage of patients aged 18
years and older seen during the
reporting period who were
screened for high blood
pressure AND a recommended
follow-up plan is documented
based on the current blood
pressure (BP) reading as
indicated.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
..
Centers for
Medicare &
Medicaid
Services
Physician
Consortium for
Performance
Improvement
Foundation
(PCPI®)
Centers for
Medicare &
Medicaid
Services
EP30JN17.164
Indicator
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B22 Gen eraIS urgery ( con fmue d)
NQF
#
Quality
#
Data
CMSEMeasure Submission
ID .·
Method
Measure
Type
..·
National
Quality
Strategy
Domain
Measure Title
an.d Description
!
N/A
355
N/A
Registry
Outcome
Patient
Safety
!
N/A
356
N/A
Registry
Outcome
Effective
Clinical
Care
!
N/A
357
N/A
Registry
Outcome
Effective
Clinical
Care
Process
Person and
CaregiverCentered
Experience
and
Outcomes
Process
Communica
tionand
Care
Coordinatio
n
Process
Community
I Population
Health
!
*
!
N/A
N/A
mstockstill on DSK30JT082PROD with PROPOSALS2
N/A
VerDate Sep<11>2014
358
374
402
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N/A
50v6
N/A
Jkt 241001
Registry
Registry,
EHR
Registry
PO 00000
Frm 00407
Fmt 4701
Sfmt 4725
Unplanned Reoperation within the
30 Day Postoperative Period:
Percentage of patients aged 18 years
and older who had any unplanned
reoperation within the 30 day
postoperative period
Unplanned Hospital Readmission
within 30 Days of Principal
Procedure:
Percentage of patients aged 18 years
and older who had an unplanned
hospital readmission within 30 days
of principal procedure
Surgical Site Infection (SSI):
Percentage of patients aged 18 years
and older who had a surgical site
infection (SSI)
Patient-Centered Surgical Risk
Assessment and Communication:
Percentage of patients who underwent
a non-emergency surgery who had
their personalized risks of
postoperative complications assessed
by their surgical team prior to surgery
using a clinical data-based, patientspecific risk calculator and who
received personal discussion of those
risks with the surgeon
Closing the Referral Loop:
Receipt of Specialist Report
Percentage of patients with referrals,
regardless of age, for which the
referring provider receives a report
from the provider to whom the patient
was referred
Tobacco Use and Help with
Quitting Among Adolescents:
The percentage of adolescents 12 to
20 years of age with a primary care
visit during the measurement year for
whom tobacco use status was
documented and received help with
quitting if identified as a tobacco user
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
American
College of
Surgeons
American
College of
Surgeons
American
College of
Surgeons
American
College of
Surgeons
Centers for
Medicare &
Medicaid
Services
National
Committee for
Quality
Assurance
EP30JN17.165
..
Indicator
30415
30416
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B23 Vascu ar Surgery
NQF
#
#
!!
0268
021
N/A
Claims,
Registry
!
0239
023
N/A
Claims,
Registry
0326
*
mstockstill on DSK30JT082PROD with PROPOSALS2
§
VerDate Sep<11>2014
047
N/A
Claims,
Registry
0421
128
69v6
Claims,
Registry,
EHR, Web
Interface
19:16 Jun 29, 2017
Jkt 241001
PO 00000
.
Measure
Type
National
Quality
Strategy
Domain
Process
Patient
Safety
Process
Patient
Safety
Process
Communi
cation and
Care
Coordinat
run
Process
Communi
ty/Populat
ion Health
Frm 00408
Fmt 4701
Sfmt 4725
·.
Measure Title
and Description
Perioperative Care: Selection of
Prophylactic Antibiotic- First OR Secom
Generation Cephalosporin:
Percentage of surgical patients aged 18
years and older undergoing procedures
with the indications for a first OR second
generation cephalosporin prophylactic
antibiotic, who had an order for a first OR
second generation cephalosporin for
antimicrobial prophylaxis
Perioperative Care: Venous
Thromboembolism (VTE) Prophylaxis
(When Indicated in ALL Patients):
Percentage of surgical patients aged 18
years and older undergoing procedures for
which venous thromboembolism (VIE)
prophy !axis is indicated in all patients,
who had an order for Low Molecular
Weight Heparin (LMWH), Low-Dose
Unfractionated Heparin (LDUH),
adjusted-dose warfarin, fondaparinux or
mechanical prophylaxis to be given within
24 hours prior to incision time or within 24
hours after surgery end time
Care Plan:
Percentage of patients aged 65 years and
older who have an advance care plan or
surrogate decision maker documented in
the medical record that an advance care
plan was discussed but the patient did not
wish or was nul able lu name a surrogate
decision maker or provide an advance care
plan.
Preventive Care and Screening: Body
Mass Index (BMI) Screening and
Follow-Up Plan:
Percentage of patients aged 18 years and
older with a BMI documented during the
current encounter or during the previous
twelve months AND with a BMI outside
of normal parameters, a follow-up plan is
documented during the encounter or
during the previous twelve months of the
current encounter.
Normal Parameters:
Age 18 years and older BMI => 18.5 and<
25 kg/m2
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
American
Society of
Plastic
Surgeons
American
Society of
Plastic
Surgeons
National
Committee
for Quality
Assurance
Centers for
Medicare&
Medicaid
Services
EP30JN17.166
Indicator
Quality
J)ata
CMSEMeasure Submission
Method
ID
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*
§
NQF
#
0419
0028
#
130
226
CMSEMeasure
lD
Data
Submission
Method
68v7
Claims,
Registry,
EHR
Patient
Safety
138v6
Claims,
Registry,
EHR, Web
Interface
Process
Commun
ity/Popul
ation
Health
Intermediate
Outcome
Effective
Clinical
Care
Process
Effective
Clinical
Care
165v6
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Quality.
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Domain
Process
0018
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Measure title
and DescripUon
Measure
Steward
.··
Documentation of Current
Medications in the Medical
Record:
Percentage of visits for patients
aged 18 years and older for which
the eligible clinician attests to
documenting a list of current
medications using all immediate
resources available on the date of
the encounter. This list must
include ALL known prescriptions,
over-the-counters, herbals, and
vitamin/mineral/dietary
(nutritional) supplements AND
must contain the medications'
name, dosage, frequency and route
of administration.
Preventive Care and Screening:
Tobacco Use: Screening and
Cessation Intervention:
a. Percentage of patients aged 18
years and older who were
screened for tobacco use one or
more times within 24 months
b. Percentage of patients aged 18
years and older who were
screened for tobacco use and
identified as a tobacco user who
received tobacco cessation
intervention
c. Percentage of patients aged 18
years and older who were
screened for tobacco use one or
more times within 24 months
AND who received cessation
counseling intervention if
identified as a tobacco user.
Controlling High Blood
Pressure:
Percentage of patients 18-85 years
of age who had a diagnosis of
hypertension and whose blood
pressure was adequately controlled
(<140/90 mmHg) during the
measurement period
Statin Therapy at Discharge
after Lower Extremity Bypass
(LEB):
Percentage of patients aged 18
years and older undergoing infrainguinal lower extremity bypass
who are prescribed a statin
medication at discharge
E:\FR\FM\30JNP2.SGM
30JNP2
Centers for
Medicare &
Medicaid
Services
Physician
Consortium for
Performance
Improvement
Foundation
(PCPI®)
National
Committee for
Quality
Assurance
Society for
Vascular
Surgeons
EP30JN17.167
Indicator
Quality
30418
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B23 Vascu ar surgery ( con mue d)
Quality
#
CMSE:Measu~
ID
Data
Submission
Method
Measure
Type
National
Quality
Strategy
Domain
!
N/A
258
N/A
Registry
Outcome
Patient
Safety
!
N/A
259
N/A
Registry
Outcome
Patient
Safety
I
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Outcome
Patient
Safety
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Measure Title
and Description
Rate of Open Elective Repair of
Small or Moderate Non-Ruptured
Infrarenal Abdominal Aortic
Aneurysms (AAA) without Major
Complications (Discharged to
Home by Post-Operative Day #7):
Percent of patients undergoing open
repair of small or moderate sized
non-ruptured infrarenal abdominal
aortic aneurysms who do not
experience a major complication
(discharge to home no later than
post-operative day #7)
Rate ofEndovascular Aneurysm
Repair (EVAR) of Small or
Moderate Non-Ruptured
Infrarenal Abdominal Aortic
Aneurysms (AAA) without Major
Complications (Discharged at
Home by Post-Operative Day #2):
Percent of patients undergoing
endovascular repair of small or
moderate non-ruptured infrarenal
abdominal aortic aneurysms (AAA)
that do not experience a major
complication (discharged to home
no later than post-operative day #2)
Rate of Carotid Endarterectomy
(CEA) for Asymptomatic Patients,
without Major Complications
(Discharged to Home by PostOperative Day #2):
Percent of asymptomatic patients
undergoing CEA who are
discharged to home no later than
post-operative day #2)
Preventive Care and Screening:
Screening for High Blood
Pressure and Follow-Up
Documented:
Percentage of patients aged 18 years
and older seen during the reporting
period who were screened for high
blood pressure AND a
recommended follow-up plan is
documented based on the current
blood pressure (BP) reading as
indicated.
E:\FR\FM\30JNP2.SGM
30JNP2
MeasU:re
Steward
Society for
Vascular
Surgeons
Society for
Vascular
Surgeons
Society for
Vascular
Surgeons
Centers for
Medicare &
Medicaid
Services
EP30JN17.168
Indicator
NQF
#
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
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Indicator
NQF
#
Quality
#
CMsEMeasure
ID
Data
Submission
Method
Measure
Type
National
Quality
Strategy
Domain
!
N/A
344
N/A
Registry
Outcome
N/A
345
N/A
Registry
Outcome
Rate of Carotid Artery Stenting
(CAS) for Asymptomatic Patients,
Without Major Complications
(Discharged to Home by PostOperative Day #2):
Percent of asymptomatic patients
undergoing CAS who are discharged
to home no later than post-operative
day #2
Rate of Postoperative Stroke or
Death in Asymptomatic Patients
Undergoing Carotid Artery
Stenting (CAS):
Percent of asymptomatic patients
undergoing CAS who experience
stroke or death following surgery
while in the hospital
Rate of Postoperative Stroke or
Death in Asymptomatic Patients
Undergoing Carotid
Endarterectomy (CEA):
Percent of asymptomatic patients
undergoing CEA who experience
stroke or death following surgery
while in the hospital.
Rate of Endovascular Aneurysm
Repair (EVAR of Small or
Moderate Non-Ruptured
Tnfrarenal Abdominal Aortic
Aneurysms (AAA) Who Die While
in Hospital: Percent of patients
undergoing endovascular repair of
small or moderate infrarenal
abdominal aortic aneurysms (AAA)
who die while in the hospital
Effective
Clinical
Care
!
Measure Title
and Description
Effective
Clinical
Care
Effective
Clinical
Care
Measure
Steward
Society for
Vascular
Surgeons
Society for
Vascular
Surgeons
Society for
Vascular
Surgeons
!
1540
346
N/A
Registry
Outcome
!
1534
347
N/A
Registry
Outcome
Patient
Safety
Outcome
Effective
Clinical
Care
Surgical Site Infection (SSI):
Percentage of patients aged 18 years
and older who had a surgical site
infection (SSI)
American
College of
Surgeons
Person and
CaregiverCentered
Experience
and
Outcomes
Patient-Centered Surgical Risk
Assessment and Communication:
Percentage of patients who underwent
a non-emergency surgery who had
their personalized risks of
postoperative complications assessed
by their surgical team prior to surgery
using a clinical data-based, patientspecific risk calculator and who
received personal discussion of those
risks with the surgeon
American
College of
Surgeons
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Society for
Vascular
Surgeons
30420
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B23 Vascu ar surgery ( con mue d)
*
!
Q~ality
#
#
N/A
374
CMSE-
Data
Measure
ID
S~bmisgion
50v6
Method
Registry,
EHR
Measure
.... · Type
National
Quality
Strategy
Domain
Process
Communication
and Care
Coordination
N/A
Registry
Process
417
N/A
Registry
Outcome
Patient Safety
N/A
420l
N/A
Effective
Clinical
Care
Registry
Outcome
0465
VerDate Sep<11>2014
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1523
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Community/
Population
Health
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N/A
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Claims
Process
Effective
Clinical Care
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Measure Title
ltlld Description
Closing the Referral Loop:
Receipt of Specialist Report:
Percentage of patients with
referrals, regardless of age, for
which the referring provider
receives a report from the
provider to whom the patient
was referred.
Tobacco Use and Help with
Quitting Among Adolescents:
The percentage of adolescents
12 to 20 years of age with a
primary care visit during the
measurement year for whom
tobacco use status was
documented and received help
with quilling if identified as a
tobacco user
Rate of Open Repair of Small
or Moderate Abdominal
Aortic Aneurysms (AAA)
Where Patients Are
Discharged Alive:
Percentage of patients
undergoing open repair of
small or moderate abdominal
aortic aneurysms (AAA) who
are discharged alive
Varicose Vein Treatment
with Saphenous Ablation:
Outcome Survey: Percentage
of patients treated for varicose
veins (CEAP C2-S) who are
treated with saphenous ablation
(with or without adjunctive
tributary treatment) that report
an improvement on a disease
specific patient reported
outcome survey instrument
after treatment
Perioperative Anti-platelet
Therapy for Patients
Undergoing Carotid
Endarterectomy:
Percentage of patients
undergoing carotid
endarterectomy (CEA) who are
taking an anti-platelet agent
within 48 hours prior to surgery
and are prescribed this
medication at hospital
discharge following surgery
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
Centers for
Medicare &
Medicaid
Services
National
Committee for
Quality
Assurance
Society for
Vascular
Surgeons
Society of
Interventional
Radiology
Society for
Vascular
Surgeons
EP30JN17.170
Indicator
NQF
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
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B23 Vascu ar sur gery ( con mue d)
NQF
#
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VerDate Sep<11>2014
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#
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ID
N/A
Jkt 241001
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Method
Registry
PO 00000
Frm 00413
Measure
Type
Intermed
iate
Outcome
Fmt 4701
National
Quality
Strategy
Domain
EtTective
Clinical
Care
Sfmt 4725
Measure Title
and Description
Ischemic Vascular Disease All or
None Outcome Measure
(Optimal Control): The IVD Allor-None Measure is one outcome
measure (optimal control). The
measure contains four goals. All
four goals within a measure must
be reached in order to meet that
measure. The numerator for the allor-none measure should be
collected from the organization's
total IVD denominator.
All-or-None Outcome Measure
(Optimal Control)
• Using the IVD denominator
optimal results include: Most
recent blood pressure (BP)
measurement is less than 140/90
mmHg
• And Most recent tobacco status
is Tobacco Free
• And Daily Aspirin or Other
Antiplatelet Unless
Contraindicated
• And Statin Use.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure.
Steward
Wisconsin
Collaborative
for Healthcare
Quality
(WCHQ)
EP30JN17.171
Indicator
Quality
30422
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B 24 Th oraCic Surgeq
.
.Indicator
!!
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VerDate Sep<11>2014
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#
0268
0239
Data
CMSRQuality
Measure Submission
#
ID
Method
021
023
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N/A
Claims,
Registry
N/A
Claims,
Registry
Jkt 241001
PO 00000
Measure
Type
National
Quality
Strategy
Domain
Process
Patient
Safety
Process
Patient
Safety
Frm 00414
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Meas(lre Title
and Description
Measure
Steward
'
Perioperative Care: Selection of
Prophylactic Antibiotic- First OR
Second Generation Cephalosporin:
Percentage of surgical patients aged
18 years and older undergoing
procedures with the indications for a
first OR second generation
cephalosporin prophylactic antibiotic,
who had an order for a first OR
second generation cephalosporin for
antimicrobial prophylaxis
Perioperative Care: Venous
Thromboembolism (VTE)
Prophylaxis (When Indicated in
ALL Patients):Percentage of
surgical patients aged 18 years and
older undergoing procedures for
which venous thromboembolism
(VTE) prophylaxis is indicated in all
patients, who had an order for Low
Molecular Weight Heparin (LMWH),
Low-Dose Unfractionated Heparin
(LDUH), adjusted-dose warfarin,
fondaparinux or mechanical
prophylaxis to be given within 24
hours prior to incision time or within
24 hours after surgery end time
E:\FR\FM\30JNP2.SGM
30JNP2
American
Society of
Plastic
Surgeons
American
Society of
Plastic
Surgeons
EP30JN17.172
.
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30423
.
B24 Th oraCic surgery ( con mue d)
#
0134
0326
CMSEQuality
Measure
#
ID
043
047
0419
130
!
0129
164
!
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!
0130
165
VerDate Sep<11>2014
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Data
Submission
·Method
Measure
'}'ype
National
Quality
Strategy
Domain
Process
Effective
Clinical Care
Process
Commllllication
and Care
Coordination
N/A
Registry
N/A
Claims,
Registry
68v7
Claims,
Registry,
EHR
Process
Patient Safety
Registry
Outcome
Effective
Clinical Care
Registry
Outcome
Effective
Clinical Care
N/A
N/A
Jkt 241001
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Measure Title
and Description
Coronary Artery Bypass Graft
(CABG): Use oflntemal
Mammary Artery (IMA) in
Patients with Isolated CABG
Surgery: Percentage of patients
aged 18 years and older
lllldergoing isolated CABG
surgery who received anIMA
graft.
Care Plan:
Percentage of patients aged 65
years and older who have an
advance care plan or surrogate
decision maker documented in the
medical record that an advance
care plan was discussed but the
patient did not wish or was not
able to name a surrogate decision
maker or provide an advance care
plan.
Documentation of Current
Medications in the Medical
Record: Percentage of visits for
patients aged 18 years and older
for which the eligible clinician
attests to documenting a list of
current medications using all
immediate resources available on
the date of the encounter. This list
must include ALL known
prescriptions, over-the-counters,
herbals, and
vitamin/mineral/dietary
(nutritional) supplements AND
must contain the medications'
name, dosage, frequency and route
of administration.
Coronary Artery Bypass Graft
(CABG): Prolonged Intubation:
Percentage of patients aged 18
years and older undergoing
isolated CABG surgery who
require postoperative intubation>
24 hours
Coronary Artery Bypass Graft
(CABG): Deep Sternal Wound
Infection Rate:
Percentage of patients aged 18
years and older undergoing
isolated CABG surgery who,
within 30 days postoperatively,
develop deep sternal wound
infection involving muscle, bone,
and/or mediastinUill requiring
operative intervention
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
Society of
Thoracic
Surgeons
National
Committee
for Quality
Assurance
Centers tor
Medicare &
Medicaid
Services
American
Thoracic
Society
American
Thoracic
Society
EP30JN17.173
Indicator
NQF
30424
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
.
B24 Th oraCic surgery ( con mue d)
#
CMSEQuality
Measure
#
ID
!
0131
166
!
0114
167
!
0115
168
N/A
NIA
N/A
Data
Submission
·Method
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Outcome
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Clinical
Care
Registry
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Registry,
EHR, Web
Interface
236
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Registry,
EHR, Web
Interface
19:16 Jun 29, 2017
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Quality
Strategy
Domain
Registry
0018
*
Measure
'}'ype
PO 00000
Outcome
Effective
Clinical
Care
Community/
Population
Health
Process
Intermedia Effective
e
Clinical
Outcome Care
Frm 00416
Fmt 4701
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Measure Title
and Description
Coronary Artery Bypass Graft
(CABG): Stroke:
Percentage of patients aged 18 years
and older undergoing isolated CABG
surgery who have a postoperative
stroke (i.e., any confirmed neurological
deficit of abrupt onset caused by a
disturbance in blood supply to the
brain) that did not resolve within 24
hours
Coronary Artery Bypass Graft
(CABG): Postoperative Renal
Failure:
Percentage of patients aged 18 years
and older undergoing isolated CABG
surgery (without pre-existing renal
failure) who develop postoperative
renal failure or require dialysis
Coronary Artery Bypass Graft
(CABG): Surgical Re-Exploration:
Percentage of patients aged 18 years
and older undergoing isolated CABG
surgery who require a return to the
operating room (OR) during the
current hospitalization for mediastinal
bleeding with or without tamponade,
graft occlusion, valve dysfunction, or
other cardiac reason
Preventive Care and Screening:
Tobacco Use: Screening and
Cessation Intervention:
a. Percentage of patients aged 18 years
and older who were screened for
tobacco use one or more times
within 24 months
b. Percentage of patients aged 18 years
and older who were screened for
tobacco use and identified as a
tobacco user who received tobacco
cessation intervention
c. Percentage of patients aged 18 years
and older who were screened for
tobacco use one or more times
within 24 months AND who
received cessation counseling
intervention if identified as a
tobacco user.
Controlling High Blood Pressure:
Percentage of patients 18-85 years of
age who had a diagnosis of
hypertension and whose blood pressure
was adequately controlled (<140/90
mmHg) during the measurement
period
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
American
Thoracic
Society
American
Thoracic
Society
Society of
Thoracic
Surgeons
Physician
Consortium
for
Performance
Improvement
Foundation
(PCPI
.Indicator
NQF
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30425
.
B24 Th oraCic surgery ( con mue d)
#
N/A
!
*
!
N/A
N/A
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VerDate Sep<11>2014
Quality
#
317
358
374
402
19:16 Jun 29, 2017
CMSEData
Measure Submission
·Method
ID
22v6
Claims,
Registry,
EHR
N/A
Registry
50v6
Registry,
EHR
N/A
Jkt 241001
Registry
PO 00000
Measure
'}'ype
National
Quality
Strategy
Domain
Measure Title
Description
a~d
Process
Community
/Population
Health
Process
Person and
CaregiverCentered
Experience
and
Outcomes
Process
Communica
tionand
Care
Coordinatio
n
Process
Community
I Population
Health
Frm 00417
Fmt 4701
Sfmt 4725
Preventive Care and Screening:
Screening for High Blood Pressure
and Follow-Up Documented:
Percentage of patients aged 18 years
and older seen during the reporting
period who were screened for high
blood pressure AND a recommended
follow-up plan is documented based on
the current blood pressure (BP) reading
as indicated.
Patient-Centered Surgical Risk
Assessment and Communication:
Percentage of patients who underwent a
non-emergency surgery who had their
personalized risks of postoperative
complications assessed by their surgical
team prior to surgery using a clinical
data-based, patient-specific risk
calculator and who received personal
discussion of those risks with the
surgeon
Closing the Referral Loop: Receipt of
Specialist Report:
Percentage of patients with referrals,
regardless of age, for which the
referring provider receives a report
from the provider to whom the patient
was referred.
Tobacco Use and Help with Quitting
Among Adolescents:
The percentage of adolescents 12 to 20
years of age with a primary care visit
during the measurement year for whom
tobacco use status was documented and
received help with quitting if identified
as a tobacco user
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
Centers for
Medicare &
Medicaid
Services
American
College of
Surgeons
Centers for
Medicare &
Medicaid
Services
National
Committee
for Quality
Assurance
EP30JN17.175
Indicator
NQF
30426
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
.
B24Th oraCic surgery ( con fmue d)
Indicator
NQF
#
QtJality
#
CMSE·
Measure
ID
Data
Submission
Method
.Measure
Type
National
Quality
Strategy
Domain
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441
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0119
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te
Clinical
Outcome Care
445
N/A
Registry
Outcome
19:16 Jun 29, 2017
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PO 00000
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Fmt 4701
Effective
Clinical
Care
Sfmt 4725
Measure Title
and Description
..
Measure
Steward
.··
Ischemic Vascular Disease All or
None Outcome Measure (Optimal
Control): The IVD Ali-or-None
Measure is one outcome measure
(optimal control). The measure
contains four goals. All four goals
within a measure must be reached in
order to meet that measure. The
numerator for the all-or-none measure
should be collected from the
organization's total IVD denominator.
Ali-or-None Outcome Measure
(Optimal Control)
• Using the IVD denominator optimal
results include: Most recent blood
pressure (BP) measurement is less
than 140/90 mm Hg
• And Most recent tobacco status is
Tobacco Free
• And Daily Aspirin or Other
Antiplatelet Unless Contraindicated
And Statin Use.
Risk-Adjusted Operative Mortality
for Coronary Artery Bypass Graft
(CABG):
Percent of patients aged 18 years and
older undergoing isolated CABG who
die, including both all deaths
occurring during the hospitalization
in which the CABG was performed,
even if after 30 days, and those deaths
occmring after discharge from the
hospital, but within 30 days of the
procedure
E:\FR\FM\30JNP2.SGM
30JNP2
Wisconsin
Collaborative
for Healthcare
Quality
(WCHQ)
Society of
Thoracic
Surgeons
EP30JN17.176
..
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30427
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§
VerDate Sep<11>2014
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0390
§
#
CMSEMeasure
0062
0421
102
104
119
128
19:16 Jun 29, 2017
N/A
134v6
69v6
Jkt 241001
Data
Submission
Method
Registry,
EHR
Registry
Registry,
EHR
Claims,
Registry,
EHR, Web
Interface
PO 00000
Measure
Type
National
Quality'
Strategy
Domain
Process
Efficiency
and Cost
Reduction
Process
Effective
Clinical
Care
Process
Effective
Clinical
Care
Process
Community
I
Population
Health
Frm 00419
Fmt 4701
Sfmt 4725
'
Measure Title
and Description
Prostate Cancer: Avoidance of
Overuse of Bone Scan for staging
Low Risk Prostate Cancer
Patients:
Percentage of patients, regardless of
age, with a diagnosis of prostate
cancer at low (or very low) risk of
recurrence receiving interstitial
prostate brachytherapy, OR external
beam radiotherapy to the prostate,
OR radical prostatectomy, OR
cryotherapy who did not have a
bone scan performed at any time
since diagnosis of prostate cancer
Prostate Cancer: Adjuvant
Hormonal Therapy for High Risk
or very High Risk Prostate
Cancer:
Percentage of patients, regardless of
age, with a diagnosis of prostate
cancer at high or very high risk of
recurrence receiving external beam
radiotherapy to the prostate who
were prescribed adjuvant hormonal
therapy (GnRH [gonadotropinreleasing hormone] agonist or
antagonist
Diabetes: Medical Attention tor
Nephropathy: The percentage of
patients 18-75 years of age with
diabetes who had a nephropathy
screening test or evidence of
nephropathy during the
measurement period
Preventive Care and Screening:
Body Mass Index (BMI) Screening
and Follow-Up Plan:
Percentage of patients aged 18 years
and older with a BMI documented
during the cunent encounter or
during the previous twelve months
AND with a BMI outside of normal
parameters, a follow-up plan is
documented during the encounter or
during the previous twelve months
of the current encounteL
Nonnal Parameters:
Age 18 years and older BMI => 18,5
and< 25 kg/m2
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
Physician
Consortium for
Performance
Improvement
Foundation
(PCPI®)
American
Urological
Association
Education and
Research
National
Cmmnittee for
Quality
Assurance
Centers for
Medicare &
Medicaid
Services
EP30JN17.177
Indicator
Quality
30428
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!
Quality
#
#
0239
0326
N/A
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!
VerDate Sep<11>2014
N/A
023
047
048
050
19:16 Jun 29, 2017
CMSEData
Measure Submission
·Method
ID
N/A
Claims,
Registry
N/A
Claims,
Registry
N/A
Claims,
Registry
N/A
Claims,
Registry
Jkt 241001
PO 00000
Measure
'}'ype
Process
Process
Process
Process
Frm 00420
Fmt 4701
National
Quality
Strategy
Domain
Measure T.itle
and Description
Perioperative Care: Venous
Thromboembolism (VTE)
Prophylaxis (When Indicated in
ALL Patients):
Percentage of surgical patients
aged 18 years and older
undergoing procedures for which
venous thromboembolism (VTE)
prophylaxis is indicated in all
Patient Safety
patients, who had an order for
Low Molecular Weight Heparin
(LMWH), Low-Dose
Unfractionated Heparin (LDUH),
adjusted-dose warfarin,
fondaparinux or mechanical
prophylaxis to be given within 24
hours prior to incision time or
within 24 hours after surgery end
time
Care Plan:
Percentage of patients aged 65
years and older who have an
advance care plan or surrogate
Commrmication decision maker documented in the
and Care
medical record that an advance
Coordination
care plan was discussed but the
patient did not wish or was not
able to name a surrogate decision
maker or provide an advance care
plan.
Urinary Incontinence:
Assessment of Presence or
Absence of Urinary
Incontinence in Women Aged
Effective
65 Years and Older:
Clinical Care
Percentage of female patients
aged 65 years and older who were
assessed for the presence or
absence of urinary incontinence
within 12 months
Urinary Incontinence:
Assessment of Presence or
Absence Plan of Care for
Urinary Incontinence in
Person and
Women Aged 65 Years and
CaregiverOlder:
Centered
Percentage of female patients
Experience and
aged 65 years and older with a
Outcomes
diagnosis of urinary incontinence
with a documented plan of care
for urinary incontinence at least
once within 12 months
Sfmt 4725
E:\FR\FM\30JNP2.SGM
30JNP2
MeasU:re
Steward
American
Society of
Plastic
Surgeons
National
Committee for
Quality
Assurance
National
Committee for
Quality
Assurance
National
Committee for
Quality
Assurance
EP30JN17.178
Indicator
NQF
30429
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B25 U roo~ ( con fmue d)
Indicator
NQF
Quality
#
#
0419
!
*
§
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!
VerDate Sep<11>2014
0420
130
131
CMSEData
Measure Submission
Method
ID
68v7
N/A
Claims,
Registry,
EHR
Claims,
Registry
0028
226
138v6
Claims,
Registry,
EHR, Web
Interface
N/A
265
N/A
Registry
19:16 Jun 29, 2017
Jkt 241001
PO 00000
Measure
Type
National
Quality
Strategy
Domain
Process
Patient Safety
Process
Commlmication
and Care
Coordination
Process
Community/Pop
ulation Health
Process
Communication
and Care
Coordination
Frm 00421
Fmt 4701
Sfmt 4725
Measure Title
a11d Description
Documentation of Current
Medications in the Medical
Record:
Percentage of visits for patients
aged 18 years and older for which
the eligible professional attests to
documenting a list of current
medications using all immediate
resources available on the date of
the encounter. This list must
include ALL known
prescriptions, over-the-counters,
herbals, and
vitamin/mineral/dietary
(nutritional) supplements AND
must contain the medications'
name, dosage, frequency and
route of administration.
Pain Assessment and FollowUp:
Percentage of visits for patients
aged 18 years and older with
documentation of a pain
assessment using a standardized
tool(s) on each visit AND
documentation of a follow-up
plan when pain is present
Preventive Care and Screening:
Tobacco Use: Screening and
Cessation Intervention:
a. Percentage of patients aged 18
years and older who were
screened tor tobacco use one or
more times within 24 months
b. Percentage of patients aged 18
years and older who were
screened for tobacco use and
identified as a tobacco user
who received tobacco cessation
intervention
c. Percentage of patients aged 18
years and older who were
screened for tobacco use one or
more times within 24 months
AND who received cessation
counseling intervention if
identified as a tobacco user.
Biopsy Follow-Up:
Percentage of new patients whose
biopsy results have been
reviewed and communicated to
the primary carelrefening
physician and patient by the
performing physician
E:\FR\FM\30JNP2.SGM
30JNP2
I
Mell$Ure
Steward
Centers for
Medicare &
Medicaid
Services
Centers for
Medicare &
Medicaid
Services
Physician
Consortium
tor
Performance
Improvement
Foundation
(PCPI
..
30430
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B25 U roo~ ( con fmue d)
NQF
#
N/A
!
*
I
N/A
N/A
#
·.
317
358
374
CMS!.Measure
TD
22v6
Data
Submission
Method
Claims,
Registry,
EHR
N/A
Registry
50v6
Registry,
EHR
Measure
Type
Process
Process
Process
Communica
tion and
Care
Coordinatio
n
428
N/A
Registry
Process
N/A
429
N/A
Claims,
Registry
Process
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VerDate Sep<11>2014
431
19:16 Jun 29, 2017
N/A
Jkt 241001
Registry
PO 00000
Community
/Population
Health
Person and
CaregiverCentered
Experience
and
Outcomes
N/A
2152
National
Quality
Strategy
DOIDl!in
Process
Frm 00422
Fmt 4701
Effective
Clinical
Care
Patient
Safety
Conmmnity
/Population
Health
Sfmt 4725
Measure Title
and Description
Preventive Care and Screening:
Screening for High Blood Pressure
and Follow-Up Documented:
Percentage of patients aged 18 years
and older seen during the reporting
period who were screened for high
blood pressure AND a recommended
follow-up plan is documented based
on the current blood pressure (BP)
reading as indicated.
Patient-Centered Surgical Risk
Assessment and Communication:
Percentage of patients who underwent
a non-emergency surgery who had
their personalized risks of
postoperative complications assessed
by their surgical team prior to surgery
using a clinical data-based, patientspecific risk calculator and who
received personal discussion of those
risks with the surgeon
Closing the Referral Loop: Receipt
of Specialist Report:
Percentage of patients with referrals,
regardless of age, for which the
referring provider receives a report
from the provider to whom the patient
was referred.
Pelvic Organ Prolapse: Preoperative
Assessment of Occult Stress Urinary
Incontinence:
Percentage of patients undergoing
appropriate preoperative evaluation of
stress urinary incontinence prior to
pelvic organ prolapse surgery per
ACOG/AUGS/AUA guidelines.
Pelvic Organ Prolapse: Preoperative
Screening for Uterine Malignancy:
Percentage of patients who are
screened for uterine malignancy prior
to vaginal closure or obliterative
surgery for pelvic organ prolapse.
Preventive Care and Screening:
Unhealthy Alcohol Use: Screening &
Brief Counseling:
Percentage of patients aged 18 years
and older who were screened for
unhealthy alcohol use using a
systematic screening method at least
once within the last 24 months AND
who received brief counseling if
identified as an unhealthy alcohol user
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
Centers for
Medicare &
Medicaid
Services
American
College of
Surgeons
Centers for
Medicare &
Medicaid
Services
American
Urogynecolo
gic Society
American
Urogynecolo
gic Society
Physician
Consortium
for
Performance
Improvement
EP30JN17.180
Indicator
Quality
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B25 U roo~ ( con fmue d)
NQF
#
Quality
#
CM.SEMeasure
ID
Data
Submission
Method
Measure
Type
NaJional
Qu11lity
Strategy
Domain
N/A
432
N/A
Registry
Outcome
Patient
Safety
N/A
433
N/A
Registry
Outcome
Patient
Safety
N/A
434
N/A
Registry
Outcome
Patient
Safety
mstockstill on DSK30JT082PROD with PROPOSALS2
N/A
VerDate Sep<11>2014
TBD
19:16 Jun 29, 2017
645vl
Jkt 241001
EHR
PO 00000
Process
Frm 00423
Fmt 4701
Effective
Clinical
Care
Sfmt 4725
Measute Title
and Description
Proportion of Patients Sustaining a
Bladder Injury at the Time of any
Pelvic Organ Prolapse Repair:
Percentage of patients undergoing
any surgery to repair pelvic organ
prolapse who sustains an injury to the
bladder recognized either during or
within I month after surcrery
Proportion of Patients Sustaining a
Bowel Injury at the time of any
Pelvic Organ Prolapse Repair:
Percentage of patients undergoing
surgical repair of pelvic organ
prolapse that is complicated by a
bowel injury at the time of index
surgery that is recognized
intraoperatively or within 1 month
after surgery
Proportion of Patients Sustaining a
Ureter Injury at the Time of any
Pelvic Organ Prolapse Repair:
Percentage of patients undergoing
pelvic organ prolapse repairs who
sustain an injury to the ureter
recognized either during or within 1
month atter surgery
Bone Density Evaluation for
Patients with Prostate Cancer and
Receiving Androgen Deprivation
Therapy:
Patients determined as having
prostate cancer who are currently
starting or undergoing androgen
deprivation therapy (ADT), for an
anticipated period of 12 months or
greater and who receive an initial
bone density evaluation. The bone
density evaluation must be prior to
the start of ADT or within 3 months
of the start of ADT
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
American
Urogynecologi
c Society
American
Urogynecologi
c Society
American
Urogynecologi
c Society
Oregon
Urology
Institute
EP30JN17.181
..
Indicator
30431
30432
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
Indicator
NQF
#
0326
§
!!
0389
0419
Quality
#
047
102
130
CMSEData
Measure Submission
ID 1 Method
N/A
129v7
Registry,
EHR
68v7
Claims,
Registry,
EHR
§
mstockstill on DSK30JT082PROD with PROPOSALS2
I
VerDate Sep<11>2014
0384
143
19:16 Jun 29, 2017
Claims,
Registry
157v6
Jkt 241001
Registry,
EHR
PO 00000
Measure
Type
Process
Process
ogy
National
Quality
Strategy
Domain
Conununication
and Care
Coordination
Efficiency and
Cost Reduction
Process
Patient Safety
Process
Person and
Caregiver
Centered
Experience and
Outcome
Frm 00424
Fmt 4701
Sfmt 4725
Measure Title
and Description
Care Plan:
Percentage of patients aged 65
years and older who have an
advance care plan or surrogate
decision maker documented in
the medical record that an
advance care plan was
discussed but the patient did
not wish or was not able to
name a surrogate decision
maker or provide an advance
care plan.
Prostate Cancer: Avoidance
of Overuse of Bone Scan for
Staging Low Risk Prostate
Cancer Patients:
Percentage of patients,
regardless of age, with a
diagnosis of prostate cancer at
low (or very low) risk of
recurrence receiving interstitial
prostate brachytherapy, OR
external beam radiotherapy to
the prostate, OR radical
prostatectomy, OR cryotherapy
who did not have a bone scan
performed at any time since
diagnosis of prostate cancer
Documentation of Current
Medications in the Medical
Record:
Percentage of visits for patients
aged 18 years and older for
which the eligible professional
attests to documenting a list of
current medications using all
inunediate resources available
on the date of the encounter.
This list must include ALL
known prescriptions, over-thecounters, herbals, and
vitamin/mineral/dietary
(nutritional) supplements AND
must contain the medications'
name, dosage, frequency and
route of administration.
Oncology: Medical and
Radiation -Pain Intensity
Quantified:
Percentage of patient visits,
regardless of patient age, with a
diagnosis of cancer currently
receiving chemotherapy or
radiation therapy in which pain
intensity is quantified
E:\FR\FM\30JNP2.SGM
30JNP2
MeasU:re
Steward
National
Cmmnittee for
Quality
Assurance
Physician
Consortium for
Performance
Improvement
Foundation
(PCPI®)
Centers for
Medicare &
Medicaid
Services
Physician
Consortium for
Performance
Improvement
Foundation
(PCPI®
EP30JN17.182
B26 0 nco
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30433
B26 0 nco o !!Y ( con mued)
NQF
#
!
0383
Quality
Measure
#
ID
144
..
Data
Submission
Method
§
§
*
mstockstill on DSK30JT082PROD with PROPOSALS2
!
Process
Community/
Population
Health
Process
Effective
Clinical Care
VerDate Sep<11>2014
0028
226
138v6
1853
250
N/A
Claims,
Registry
317
22v6
N/A
374
19:16 Jun 29, 2017
Person and
Caregiver
Centered
Experience
and Outcome
Registry
Claims,
Registry,
EHR, Web
Interface
50v6
Jkt 241001
Claims,
Registry,
EHR
Registry,
EHR
PO 00000
Process
National
Quality
Strategy
Domain
N/A
N/A
*
Me,. sure
Type
Process
Process
Frm 00425
Fmt 4701
Community/
Population
Health
Communicat
ion and Care
Coordination
Sfmt 4725
Measure Title
and Description
Oncology: Medical and Radiation
- Plan of Care for Pain:
Percentage of visits for patients,
regardless of age, with a diagnosis
of cancer currently receiving
chemotherapy or radiation therapy
who report having pain with a
documented plan of care to address
pam
Preventive Care and Screening:
Tobacco Use: Screening and
Cessation Intervention:
a. Percentage of patients aged 18
years and older who were
screened for tobacco use one or
more times within 24 months
b. Percentage of patients aged 18
years and older who were
screened for tobacco use and
identified as a tobacco user who
received tobacco cessation
intervention
c. Percentage of patients aged 18
years and older who were
screened for tobacco use one or
more times within 24 months
AND who received cessation
counseling intervention if
identified as a tobacco user.
Radical Prostatectomy Pathology
Reporting: Percentage of radical
prostatectomy pathology reports that
include the pT category, the pN
category, the Gleason score and a
statement about margin status.
Preventive Care and Screening:
Screening for High Blood
Pressure and Follow-Up
Documented:
Percentage of patients aged 18 years
and older seen during the reporting
period who were screened for high
blood pressure AND a
recommended follow-up plan is
documented based on the current
blood pressure (BP) reading as
indicated.
Closing the Referral Loop:
Receipt of Specialist Report:
Percentage of patients with referrals,
regardless of age, for which the
refening provider receives a report
from the provider to whom the
patient was referred.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
American
Society of
Clinical
Oncology
Physician
Consortium for
Performance
Improvement
Foundation
(PCPI®)
College of
American
Pathologists
Centers for
Medicare &
Medicaid
Services
Centers for
Medicare &
Medicaid
Services
EP30JN17.183
CMSE-
Indicator
30434
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B26 0 nco o !!Y ( con mued)
Indicator
NQF
#
N/A
CMSE•
Quality
Measure
#
ID
402
N/A
Data
Submission
Method
Measure
'{'ype
...
Registry
Process
National
Quality
Str11tegy
Domain
Communi
ty/Populat
lOn
Health
2152
§
!!
431
N/A
Registry
Process
Populatio
nl
Communi
ty
1857
449
N/A
Registry
Process
Efficiency
and Cost
Reduction
1858
450
N/A
Registry
Process
Efficiency
and Cost
Reduction
§
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§
!!
1859
451
N/A
Registry
Process
Effective
Clinical
Care
VerDate Sep<11>2014
19:16 Jun 29, 2017
Jkt 241001
PO 00000
Frm 00426
Fmt 4701
Sfmt 4725
Measure Title
and Description
Tobacco Use and Help with Quitting
Among Adolescents:
The percentage of adolescents 12 to 20
years of age with a primary care visit
during the measurement year for whom
tobacco use status was documented and
received help with quitting if identified as
a tobacco user.
Preventive Care and Screening:
Unhealthy Alcohol Use: Screening &
Brief Counseling:
Percentage of patients aged 18 years and
older who were screened tor unhealthy
alcohol use using a systematic screening
method at least once within the last 24
months AND who received brief
counseling if identified as an unhealthy
alcohol user.
HER2 Negative or Undocumented
Breast Cancer Patients Spared
Treatment with HER2-Targeted
Therapies:
Proportion of female patients (aged 18
years and older) with breast cancer who
are human epidermal growth factor
receptor 2 (HER2)/neu negative who are
not administered HER2-targeted
therapies
Trastuzumab Received By Patients
With AJCC Stage I (Tlc) -III And
HER2 Positive Breast Cancer
Receiving Adjuvant Chemotherapy:
Proportion of female patients (aged 18
years and older) with AJCC stage I (Tlc)
-III, human epidermal growth factor
receptor 2 (HER2) positive breast cancer
receiving adjuvant chemotherapy who are
also receiving trastuzumab
KRAS Gene Mutation Testing
Performed for Patients with Metastatic
Colo rectal Cancer who receive Antiepidermal Growth Factor Receptor
(EGFR) Monoclonal Antibody
Therapy::
Percentage of adult patients (aged 18 or
over) with metastatic colorectal cancer
who receive anti-epidermal growth factor
receptor monoclonal antibody therapy for
whom KRAS gene mutation testing was
pertormed.
E:\FR\FM\30JNP2.SGM
30JNP2
I
Mell$Ure
Steward
National
Committee
tor Quality
Assurance
Physician
Consortium
for
Performance
Improvement
Foundation
(PCPI)
American
Society of
Clinical
Oncology
American
Society of
Clinical
Oncology
American
Society of
Clinical
Oncology
EP30JN17.184
..
30435
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B26 0 nco 02 y ( con mued)
§
!!
§
!!
§
!!
§
!!
§
!!
NQF
#
1860
0210
0211
0213
0215
#
..
452
453
454
455
456
·. CMSEData
Measure Submission
Method
ID
N/A
N/A
N/A
N/A
N/A
Registry
Registry
Registry
Registry
Registry
Measure
Type
National
Quality
Strategy
Domain
Process
Patient
Safety
Process
Effective
Clinical
Care
Outcome
Effective
Clinical
Care
Outcome
Effective
Clinical
Care
Process
Effective
Clinical
Care
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VerDate Sep<11>2014
0216
457
N/A
Registry
Outcome
Effective
Clinical
Care
N/A
§
!!
TBD
645vl
EHR
Process
Effective
Clinical
Care
19:16 Jun 29, 2017
Jkt 241001
PO 00000
Frm 00427
Fmt 4701
Sfmt 4725
Measure Title
and Descriptioll
.··
Patients with Metastatic Colorectal
Cancer and KRAS Gene Mutation
Spared Treatment with Antiepidermal Growth Factor Receptor
(EGFR) Monoclonal: Antibodies:
Percentage of adult patients (aged 18
or over) with metastatic colorectal
cancer and KRAS gene mutation
spared treatment with anti-EGFR
monoclonal antibodies.
Proportion Receiving
Chemotherapy in the Last 14 Days
of life:
Proportion of patients who died from
cancer receiving chemotherapy in the
last 14 days of life.
Proportion of Patients who Died
from Cancer with more than One
Emergency Department Visit in the
Last 30 Days of Life:
Proportion of patients who died from
cancer with more than one emergency
room visit in the last 30 days of life.
Proportion Admitted to the
Intensive Care Unit (ICU) in the
Last 30 Days of Life:
Proportion of patients who died from
cancer admitted to the ICU in the last
30 days of life.
Proportion Not Admitted to
Hospice:
Proportion of patients who died from
cancer not admitted to hospice.
Proportion Admitted to Hospice for
less than 3 days:
Proportion of patients who died from
cancer, and admitted to hospice and
spent less than 3 days there.
Bone Density Evaluation for
Patients with Prostate Cancer and
Receiving Androgen Deprivation
Therapy:
Patients determined as having
prostate cancer who are currently
starting or undergoing androgen
deprivation therapy (ADT), for an
anticipated period of 12 months or
greater and who receive an initial
bone density evaluation. The bone
density evaluation must be prior to
the start of ADT or within 3 months
ofthe start of ADT
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
American
Society of
Clinical
Oncology
American
Society of
Clinical
Oncology
American
Society of
Clinical
Oncology
American
Society of
Clinical
Oncology
American
Society of
Clinical
Oncology
American
Society of
Clinical
Oncology
Oregon
Urology
Institute
EP30JN17.185
Indicator
Quality
30436
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B26 a. Rd. fwn 0 nco ogy
a 1a
§
!!
§
!
!
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!!
VerDate Sep<11>2014
#
0389
0384
0383
0382
Quality
#
102
143
144
156
19:16 Jun 29, 2017
CMSEData
Measure Submission
ID
·Method
129v7
l57v6
Registry,
EHR
Registry,
EHR
N/A
Registry
N/A
Claims,
Registry
Jkt 241001
PO 00000
Measure
'}'ype
National
Quality
Strategy
Domain
Measure Title
and Description
Process
Efficiency
and Cost
Reduction
Process
Person and
Caregiver
Centered
Experience
and
Outcome
Process
Person and
Caregiver
Centered
Experience
and
Outcome
Process
Patient
Safety
Frm 00428
Fmt 4701
Sfmt 4725
Prostate Cancer: Avoidance of
Overuse of Bone Scan for Staging
Low Risk Prostate Cancer Patients:
Percentage of patients, regardless of
age, with a diagnosis of prostate
cancer at low (or very low) risk of
recurrence receiving interstitial
prostate brachytherapy, OR external
beam radiotherapy to the prostate, OR
radical prostatectomy, OR
cryotherapy who did not have a bone
scan performed at any time since
diagnosis of prostate cancer
Oncology: Medical and RadiationPain Intensity Quantified:
Percentage of patient visits,
regardless of patient age, with a
diagnosis of cancer currently
receiving chemotherapy or radiation
therapy in which pain intensity is
quantified
Oncology: Medical and RadiationPlan of Care for Pain:
Percentage of visits for patients,
regardless of age, with a diagnosis of
cancer currently receiving
chemotherapy or radiation therapy
who report having pain with a
documented plan of care to address
pam
Oncology: Radiation Dose Limits to
Normal Tissues:
Percentage of patients, regardless of
age, with a diagnosis of breast, rectal,
pancreatic or lung cancer receiving
3D conformal radiation therapy who
had documentation in medical record
that radiation dose limits to normal
tissues were established prior to the
initiation of a course of 3D conformal
radiation for a minimum of two
tissues
E:\FR\FM\30JNP2.SGM
30JNP2
MeasU:re
Steward
Physician
Consortium for
Performance
Improvement
Foundation
(PCPI®)
Physician
Consortium for
Performance
Improvement
foundation
(PCPI®)
American
Society of
Clinical
Oncology
American
Society for
Radiation
Oncology
EP30JN17.186
Indicator
NQF
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30437
·t IS
B27 HOSpl ar tS
§
§
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!
VerDate Sep<11>2014
0081
0083
0326
Quality·
#
005
008
047
19:16 Jun 29, 2017
·. CMSEData
Measure Submission
ID
Method
135v6
144v6
N/A
Jkt 241001
Registry,
EHR
Registry,
EHR
Claims,
Registry
PO 00000
Measure
Type
Process
National
Quality
Strategy
Domain
Measure Title
and Description
·.
Effective
Clinical
Care
Process
Effective
Clinical
Care
Process
Communic
ation and
Care
Coordinatio
n
Frm 00429
Fmt 4701
Sfmt 4725
Measure
Steward
Heart Failure (HF): AngiotensinConverting Enzyme (ACE)
Inhibitor or Angiotensin Receptor
Blocker (ARB) Therapy for Left
Ventricular Systolic Dysfunction
(LVSD):
Percentage of patients aged 18 years
and older with a diagnosis of heart
failure (HF) with a current or prior
left ventricular ejection fraction
(L VEF) < 40% who were prescribed
ACE inhibitor or ARB therapy either
within a 12-month period when seen
in the outpatient setting OR at each
hospital discharge
Heart Failure (HF): Beta-Blocker
Therapy for Left Ventricular
Systolic Dysfunction (LVSD):
Percentage of patients aged 18 years
and older with a diagnosis of heart
failure (HF) with a current or prior
left ventricular ejection fraction
(L VEF) < 40% who were prescribed
beta-blocker therapy either within a
12-month period when seen in the
outpatient setting OR at each hospital
discharge
Care Plan:
Percentage of patients aged 65 years
and older who have an advance care
plan or surrogate decision maker
documented in the medical record or
documentation in the medical record
that an advance care plan was
discussed but the patient did not wish
or was not able to name a surrogate
decision maker or provide an advance
care plan.
E:\FR\FM\30JNP2.SGM
30JNP2
Physician
Consortium for
Performance
Improvement
Foundation
(PCPI®)
Physician
Consortium for
Performance
Improvement
Foundation
(PCPI®)
National
Cmmnittee for
Quality
Assurance
EP30JN17.187
Indicator
NQF
#
30438
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
·t IS
B27 H OSpl ar t S (con fmue d)
NQF
Indicator
.·
!
#
N/A
Quality
#
076
CMS£.7
Measure
ID
Data
Submission
Method
N/A
Claims,
Registry
0419
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!!
VerDate Sep<11>2014
130
68v7
Claims,
Registry,
EHR
N/A
407l
N/A
Claims,
Registry
19:16 Jun 29, 2017
Jkt 241001
PO 00000
Measure
Type
National
Quality
Strategy
Domain
Process
Patient
Safety
Process
Patient
Safety
Process
Frm 00430
Fmt 4701
Effective
Clinical
Care
Sfmt 4725
Measure. Title
and Description
Prevention of Central Venous
Catheter (CVC)-Related
Bloodstream Infections:
Percentage of patients, regardless of
age, who lllldergo central venous
catheter (CVC) insertion for whom
eve was inserted with all elements
of maximal sterile barrier technique,
hand hygiene, skin preparation and, if
ultrasolllld is used, sterile ultrasound
techniques followed
Documentation of Current
Medications in the Medical Record:
Percentage of visits for patients aged
18 years and older for which the
eligible professional attests to
documenting a list of current
medications using all immediate
resources available on the date of the
encounter. This list must include ALL
known prescriptions, over-thecounters, herbals, and
vitamin/mineral/dietary (nutritional)
supplements AND must contain the
medications' name, dosage,
frequency and route of
administration.
Appropriate Treatment ofMSSA
Bacteremia:
Percentage of patients with sepsis due
to MSSA bacteremia who received
beta-lactam antibiotic (e.g. nafcillin,
oxacillin or cefazolin) as definitive
therapy.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
American
Society of
Anesthesiologis
ts
Centers for
Medicare &
Medicaid
Services
Infectious
Disease Society
of America
EP30JN17.188
..
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B28 Rh eumato ogy
!
NQF
Quality
#
#
0045
0046
0326
*
0041
mstockstill on DSK30JT082PROD with PROPOSALS2
0043
VerDate Sep<11>2014
024
039
047
110
111
19:16 Jun 29, 2017
CMSEData
Measure Submission
Method
ID
N/A
Claims,
Registry
N/A
Claims,
Registry
N/A
Claims,
Registry
147v7
127v6
Jkt 241001
Claims,
Web
Interface,
Registry,
EHR
Claims,
Web
Interface,
Registry,
EHR
PO 00000
Measure
Type
National
Quality
Strategy
Domain
Process
Communication
and Care
Coordination
Process
Effective
Clinical Care
Process
Communication
and Care
Coordination
Process
Community/
Population
Health
Process
ConmmnityI
Population
Health
Frm 00431
Fmt 4701
Sfmt 4725
Measure Title
and Description
Communication with the
Physician or Other Clinician
Managing On-going Care PostFracture for Men and Women
Aged 50 Years and Older:
Percentage of patients aged 50
years and older treated for a
fracture with documentation of
communication, between the
physician treating the fracture and
the physician or other clinician
managing the patient's on-going
care, that a fracture occurred and
that the patient was or should be
considered for osteoporosis
treatment or testing. This measure
is reported by the physician who
treats the fracture and who
therefore is held accountable for
the communication
Screening for Osteoporosis for
Women Aged 65-85 Years of
Age:
Percentage of female patients
aged 65-85 years of age who ever
had a central dual-energy X-ray
absorptiometry (DXA) to check
for osteoporosis
Care Plan:
Percentage of patients aged 65
years and older who have an
advance care plan or surrogate
decision maker documented in
the medical record that an
advance care plan was discussed
but the patient did not wish or
was not able to name a surrogate
decision maker or provide an
advance care plan.
Preventive Care and Screening:
Influenza Immunization:
Percentage of patients aged 6
months and older seen for a visit
between October 1 and March 31
who received an influenza
immunization OR who reported
previous receipt of an influenza
immunization
Pneumonia Vaccination Status
for Older Adults:
Percentage of patients 65 years of
age and older who have ever
received a pneumococcal vaccine
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
National
Committee
for Quality
Assurance
National
Committee
for Quality
Assurance
National
Committee
for Quality
Assurance
Physician
Consortium
for
Performance
Improvement
Foundation
(PCPI
.·
Indicator
30439
30440
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B28 Rh eumat oI ogy ( con fmue d)
#
ill
..
*
§
!
!
Data
Submission
Method
0421
128
69v6
Claims,
Registry,
EHR, Web
Interface
0419
130
68v7
Claims,
Registry,
EHR
0420
131
N/A
Claims,
Registry
Measure
Type
National
Quality
Strategy
Domain
Process
Communi
ty/Populat
ion Health
Process
Patient
Safety
Process
Communi
cation and
Care
Coordinat
lOll
N/A
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N/A
VerDate Sep<11>2014
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177
19:16 Jun 29, 2017
N/A
N/A
Jkt 241001
Registry
Registry
PO 00000
Process
Process
Frm 00432
Fmt 4701
Effective
Clinical
Care
Effective
Clinical
Care
Sfmt 4725
Measure Title
and Description
Measure
Steward
·.
Preventive Care and Screening: Body
Mass Index (BMI) Screening and
Follow-Up Plan:
Percentage of patients aged 18 years and
older with a BMI documented during the
current encounter or during the previous
twelve months AND with a BMI outside
of normal parameters, a follow-up plan is
documented during the encounter or
during the previous twelve months of the
current encounter.
Normal Parameters:
Age 18 years and older BMI => 18.5 and
<25 kg/m2
Documentation of Current
Medications in the Medical Record:
Percentage of visits for patients aged 18
years and older for which the eligible
clinician attests to documenting a list of
current medications using all immediate
resources available on the date of the
encounter. This list must include ALL
known prescriptions, over-the-counters,
herbals, and vitamin/mineral/dietary
(nutritional) supplements AND must
contain the medications' name, dosage,
frequency and route of administration.
Pain Assessment and Follow-Up:
Percentage of visits for patients aged 18
years and older with documentation of a
pain assessment using a standardized
tool(s) on each visit AND documentation
of a follow-up plan when pain is present
Rheumatoid Arthritis (RA):
Tuberculosis Screening:
Percentage of patients aged 18 years and
older with a diagnosis of rheumatoid
arthritis (RA) who have documentation
of a tuberculosis (TB) screening
performed and results interpreted within
6 months prior to receiving a first course
of therapy using a biologic diseasemodifying anti-rheumatic drug
(DMARD).
Rheumatoid Arthritis (RA): Periodic
Assessment of Disease Activity:
Percentage of patients aged 18 years and
older with a diagnosis of rheumatoid
arthritis (RA) who have an assessment
and classification of disease activity
within 12 months.
E:\FR\FM\30JNP2.SGM
30JNP2
Centers for
Medicare &
Medicaid
Services
Centers for
Medicare &
Medicaid
Services
Centers for
Medicare &
Medicaid
Services
American
College of
Rheumatolog
y
American
College of
Rheumatolog
y
EP30JN17.190
Indicator
CMSE~
Quality
Measure
#
NQF
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B28 Rh eumat oI ogy ( con fmue d)
NQF
Quality
#
#
CMSEData
Measure Submission
Method
ID
Measure
Type
...
N/A
178
N/A
Registry
Process
N/A
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§
VerDate Sep<11>2014
N/A
Registry
Process
N/A
*
179
180
N/A
Registry
Process
0028
226
19:16 Jun 29, 2017
138v6
Jkt 241001
Claims,
Registry,
EHR, Web
Interface
PO 00000
Process
Frm 00433
Fmt 4701
National
Quality
Strategy
Domain
Measure Title
and Description
Effective
Clinical
Care
Effective
Clinical
Care
Effective
Clinical
Care
Co11llllunity
I
Population
Health
Sfmt 4725
Rheumatoid Arthritis (RA):
Functional Status Assessment:
Percentage of patients aged 18 years
and older with a diagnosis of
rheumatoid arthritis (RA) tor whom a
functional status assessment was
performed at least once within 12
months
Rheumatoid Arthritis (RA):
Assessment and Classification of
Disease Prognosis:
Percentage of patients aged 18 years
and older with a diagnosis of
rheumatoid arthritis (RA) who have an
assessment and classification of
disease prognosis at least once within
12 months
Rheumatoid Arthritis (RA):
Glucocorticoid Management:
Percentage of patients aged 18 years
and older with a diagnosis of
rheumatoid artluitis (RA) who have
been assessed for glucocorticoid use
and, for those on prolonged doses of
prednisone 2: 10 mg daily (or
equivalent) with improvement or no
change in disease activity,
documentation of glucocorticoid
management plan within 12 months
Preventive Care and Screening:
Tobacco Use: Screening and
Cessation Intervention:
a. Percentage of patients aged 18 years
and older who were screened for
tobacco use one or more times
within 24 months
b. Percentage of patients aged 18 years
and older who were screened for
tobacco use and identified as a
tobacco user who received tobacco
cessation intervention
c. Percentage of patients aged 18 years
and older who were screened tor
tobacco use one or more times
within 24 months AND who
received cessation counseling
intervention if identified as a
tobacco user.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Stew.ard
American
College of
Rheumatology
American
College of
Rheumatology
American
College of
Rheumatology
Physician
Consortium
for
Performance
Improvement
Foundation
(PCPI®)
EP30JN17.191
..
Indicator
30441
30442
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B28 Rh eumat oI ogy ( con fmue d)
Indicator
NQF
#
§
!
0018
Quality
#
.··
236
CMSE-
. ···Measure
Data
Measure Submission
Type
ID
Method
National
Quality
Strategy
Domain
165v6
Claims,
Web
Interface,
Registry,
EHR
Process
Patient Safety
Intermediate Effective
Outcome
Clinical Care
*
!
0022
238
156v6
N/A
*
Registry,
EHR
317
22v6
Claims,
Registry,
EHR
Process
ConununityI
Population
Health
N/A
374
50v6
Registry,
EHR
Process
Communication
and Care
Coordination
Process
Community/Pop
ulation Health
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N/A
VerDate Sep<11>2014
402
19:16 Jun 29, 2017
N/A
Jkt 241001
Registry
PO 00000
Frm 00434
Fmt 4701
Sfmt 4725
Measure Title
and Description
· ..
Controlling High Blood
Pressure:
Percentage of patients 18-85
years of age who had a
diagnosis of hypertension and
whose blood pressure was
adequately controlled
(<140/90nunHg) during the
measurement period
Use of High-Risk
Medications in the Elderly:
Percentage of patients 6565
years of age and older who
were ordered high-risk
medications. Two rates are
reported.
a. Percentage of patients who
were ordered at least one
high-risk medication.
b. Percentage of patients who
were ordered at least two of
the same high-risk
medications.
Preventive Care and
Screening: Screening for
High Blood Pressure and
Follow-Up Documented:
Percentage of patients aged 18
years and older seen during
the reporting period who were
screened for high blood
pressure AND a
recommended follow-up plan
is documented based on the
current blood pressure (BP)
reading as indicated.
Closing the Referral Loop:
Receipt of Specialist Report:
Percentage of patients with
referrals, regardless of age, for
which the refening provider
receives a report from the
provider to whom the patient
was referred.
Tobacco Use and Help with
Quitting Among
Adolescents:
The percentage of adolescents
12 to 20 years of age with a
primary care visit during the
measurement year for whom
tobacco use status was
documented and received help
with quitting if identified as a
tobacco user.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
National
Cmmnittee for
Quality
Assurance
National
Cmmnittee for
Quality
Assurance
Centers for
Medicare &
Medicaid
Services
Centers for
Medicare &
Medicaid
Services
National
Cmmnittee for
Quality
Assurance
EP30JN17.192
I
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30443
B.29. Infectious Disease
NQF
Indieator
!!
!!
!!
II
*
#
0069
N/A
0653
0654
0041
0043
§
mstockstill on DSK30JT082PROD with PROPOSALS2
!!
VerDate Sep<11>2014
0058
Quality
#
065
066
091
093
110
111
116
19:16 Jun 29, 2017
.··
CMSE-
Data
Measure Submission
Method
ID
154v6
Registry,
EHR
146v6
Registry,
EHR
N/A
N/A
147v7
127v6
N/A
Jkt 241001
Claims,
Registry
Claims,
Registry
Claims,
Web
Interface,
Registry,
EHR
Claims,
Web
Interface,
Registry,
EHR
Registry
PO 00000
Measure
Type
National
Quality
Strategy
Domain
Process
Efficiency and
Cost Reduction
Process
Efficiency and
Cost Reduction
Process
Process
Effective
Clinical Care
Efficiency and
Cost Reduction
Process
Community/
Population
Health
Process
Community/
Population
Health
Process
Efficiency and
Cost Reduction
Frm 00435
Fmt 4701
Sfmt 4725
Measure Title
and Description
Appropriate Treatment for
Children with Upper
Respiratory Infection (URI):
Percentage of children 3 months-18 years of age who were
diagnosed with upper respiratory
infection (URI) and were not
dispensed an antibiotic
prescription on or three days after
the episode
Appropriate Testing for
Children with Pharyngitis:
Percentage of children 3-18 years
of age who were diagnosed with
pharyngitis, ordered an antibiotic
and received a group A
streptococcus (strep) test for the
episode.
Acute Otitis Extema (AOE):
Topical Therapy:
Percentage of patients aged 2 years
and older with a diagnosis of AOE
who were prescribed topical
preparations.
Acute Otitis Extema (AOE):
Systemic Antimicrobial Therapy
-Avoidance oflnappropriate
Use:
Percentage of patients aged 2 years
and older with a diagnosis of AOE
who were not prescribed systemic
antimicrobial therapy.
Preventive Care and Screening:
Influenza Immunization:
Percentage of patients aged 6
months and older seen for a visit
between October 1 and March 31
who received an int1uenza
immunization OR who reported
previous receipt of an int1uenza
immunization
Pneumonia Vaccination Status
for Older Adults:
Percentage of patients 65 years of
age and older who have ever
received a pneumococcal vaccine
Avoidance of Antibiotic
Treatment in Adults with Acute
Bronchitis:
Percentage of adults 18-64 years
of age with a diagnosis of acute
bronchitis who were not dispensed
an antibiotic prescription
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
National
Committee
for Quality
Assurance
National
Committee
for Quality
Assurance
American
Academy of
Otolaryngolo
gy-Headand
Neck Surgery
American
Academy of
Otolaryngolo
gy-Headand
Neck Surgery
Physician
Consortium
for
Performance
Improvement
Foundation
(PCPI
I
30444
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B.29. Infectious Disease (continued)
NQF
Indicator
*
§
#
0421
0419
Quality
#
128
130
CMSEMeasure
ID
Data
Submission
Met)lod
69v6
Claims,
Registry,
EHR, Web
Interface
68v7
Claims,
Registry,
EHR
N/A
mstockstill on DSK30JT082PROD with PROPOSALS2
§
VerDate Sep<11>2014
176
N/A
Registry
0409
205
N/A
Registry
19:16 Jun 29, 2017
Jkt 241001
PO 00000
Measure
Type
National
Quality
Strategy
Domain
Process
Communit
y/Populatio
n Health
Process
Patient
Safety
Process
Process
Frm 00436
Fmt 4701
Effective
Clinical
Care
Effective
Clinical
Care
Sfmt 4725
Measure Title
and Description
Measure
Steward
·..·
Preventive Care and Screening:
Body Mass Index (BMI) Screening
and Follow-Up Plan:
Percentage of patients aged 18 years
and older with a BMI docrunented
during the current encounter or during
the previous twelve months AND with
a BMI outside of normal parameters, a
follow-up plan is documented during
the encounter or during the previous
twelve months of the current
encounter.
Normal Parameters: Age 18 years and
older BMI => 18.5 and< 25 kg/m2
Documentation of Current
Medications in the Medical Record:
Percentage of visits for patients aged
18 years and older for which the
eligible professional attests to
documenting a list of current
medications using all immediate
resources available on the date of the
encounter. This list must include ALL
known prescriptions, over-thecounters, herbals, and
vilamin!mineralldielary (nutritional)
supplements AND must contain the
medications' name, dosage, frequency
and route of administration.
Rheumatoid Arthritis (RA):
Tuberculosis Screening:
Percentage of patients aged 18 years
and older with a diagnosis of
rheumatoid arthritis (RA) who have
documentation of a tuberculosis (TB)
screening performed and results
interpreted within 6 months prior to
receiving a first course of therapy
using a biologic disease-modifying
anti-rheumatic drug (DMARD).
HIV/AIDS: Sexually Transmitted
Disease Screening for Chlamydia,
Gonorrhea, and Syphilis:
Percentage of patients aged 13 years
and older with a diagnosis of
HIV/AIDS for whom chlamydia,
gonorrhea and syphilis screenings were
performed at least once since the
diagnosis ofHIV infection
E:\FR\FM\30JNP2.SGM
30JNP2
Centers for
Medicare &
Medicaid
Services
Centers for
Medicare &
Medicaid
Services
American
College of
Rheumatolog
y
National
Committee
for Quality
Assurance
EP30JN17.194
..
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B.29. Infectious Disease (continued)
*
§
NQF
#
0028
N/A
!!
mstockstill on DSK30JT082PROD with PROPOSALS2
!!
VerDate Sep<11>2014
N/A
N/A
CMSE•
Quality
Measure
#
ID
226
275
331
332
19:16 Jun 29, 2017
138v6
N/A
N/A
N/A
Jkt 241001
National
Measure .· Quality
Type
... Strategy
Domain
Data
Submission
Method
Claims, Web
Interface,
Registry,
EHR
Registry
Registry
Registry
PO 00000
Process
Community
I
Population
Health
Process
Effective
Clinical
Care
Process
Efficiency
and Cost
Reduction
Process
Frm 00437
Fmt 4701
Efficiency
and Cost
Reduction
Sfmt 4725
Measure Title
and Description
Preventive Care and Screening:
Tobacco Use: Screening and
Cessation Intervention:
a. Percentage of patients aged 18
years and older who were
screened for tobacco use one or
more times within 24 months
b. Percentage of patients aged 18
years and older who were
screened for tobacco use and
identified as a tobacco user who
received tobacco cessation
intervention
c. Percentage of patients aged 18
years and older who were
screened for tobacco use one or
more times within 24 months
AND who received cessation
counseling intervention if
identified as a tobacco user.
Inflammatory Bowel Disease
(IBD): Assessment of Hepatitis B
Virus (HBV) Status Before
Initiating Anti-TNF (Tumor
Necrosis Factor) Therapy:
Percentage of patients aged 18 years
and older with a diagnosis of
inflammatory bowel disease (IBD)
who had Hepatitis B Virus (HBV)
status assessed and results
interpreted within one year prior to
receiving a first course of anti-TNF
(tumor necrosis factor) therapy.
Adult Sinusitis: Antibiotic
Prescribed for Acute Sinusitis
(Overuse):
Percentage of patients, aged 18
years and older, with a diagnosis of
acute sinusitis who were prescribed
an antibiotic within 10 days after
onset of symptoms
Adult Sinusitis: Appropriate
Choice of Antibiotic: Amoxicillin
With or Without Clavulanatc
Prescribed for Patients with Acute
Bacterial Sinusitis (Appropriate
Use):
Percentage of patients aged 18 years
and older with a diagnosis of acute
bacterial sinusitis that were
prescribed amoxicillin, with or
without clavulante, as a first line
antibiotic at the time of diagnosis
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
Physician
Consortium for
Performance
Improvement
Foundation
(PCPI®)
American
Gastroenterological
Association
~merican
~cademy of
ptolaryngologyHead and Neck
Surgery
~merican
~cademy of
ptolaryngology~ead and Neck
Surgery
EP30JN17.195
..
Indicator
30445
30446
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B.29. Infectious Disease (continued)
Indicator
CMS.E~
NQF
#
Quality
Measu.re
#
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Data
Submission
Method
Registry
Measure
Type
Efficiency
National
Quality
Strategy
Domain
Efficiency
and Cost
Reduction
Registry
Efficiency
Efficiency
and Cost
Reduction
Registry
Process
Effective
Clinical
Care
Outcome
Effective
Clinical
Care
Process
Efliciency
and Cost
Reduction
Registry
Registry
Registry
PO 00000
Process
Frm 00438
Fmt 4701
Effective
Clinical
Care
Sfmt 4725
Measure Title
and Description
Adult Sinusitis: Computerized
Tomography (CT) for Acute
Sinusitis (Overuse):
Percentage of patients aged 18 years
and older with a diagnosis of acute
sinusitis who had a computerized
tomography (CT) scan of the
paranasal sinuses ordered at the time
of diagnosis or received within 28
days after date of diagnosis
Adult Sinusitis: More than One
Computerized Tomography (CT)
Scan Within 90 Days for Chronic
Sinusitis (Overuse):
Percentage of patients aged 18 years
and older with a diagnosis of chronic
sinusitis who had more than one CT
scan of the paranasal sinuses ordered
or received within 90 days after the
date of diagnosis
Tuberculosis (TB) Prevention for
Psoriasis, Psoriatic Arthritis and
Rheumatoid Arthritis Patients on a
Biological Immune Response
Modifier:
Percentage of patients whose
providers are ensuring active
tuberculosis prevention either through
yearly negative standard tuberculosis
screening tests or are reviewing the
patient's history to determine if they
have had appropriate management for
a recent or prior positive test
lllV Viral Load Suppression:
The percentage of patients, regardless
of age, with a diagnosis ofHlV with
a HlV viral load less than 200
copies/mL at last HlV viral load test
during the measurement year
lllV Medical Visit Frequency:
Percentage of patients, regardless of
age with a diagnosis ofHlV who had
at least one medical visit in each 6
month period of the 24 month
measurement period, with a minimum
of 60 days between medical visits
Annual Hepatitis C Virus (HCV)
Screening for Patients who are
Active Injection Drug Users:
Percentage of patients, regardless of
age, who are active injection drug
users who received screening for
HCV infection within the 12 month
reporting period
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
f'\merican
f'\cademy of
ptolaryngologyptolaryngology~ead and Neck
Surgery
~merican
f'\cademy of
ptolaryngologyptolaryngology~ead and Neck
Surgery
~merican
f'\cademy of
Pem1atology
Health
Resources and
Services
Administration
Health
Resources and
Services
Administration
Physician
Consortium for
Performance
Improvement
EP30JN17.196
..
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B.29. Infectious Disease (continued)
NQF
#
N/A
1407
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#
390
394
400
401
19:16 Jun 29, 2017
CMSEMeasure
ID
N/A
N/A
N/A
N/A
Jkt 241001
National
Measure .· Quality
Type
... Strategy
Domain
Data
Submis~ion
Method
Registry
Registry
Registry
Registry
PO 00000
Process
Person and
CaregiverCentered
Experience
and
Outcomes
Process
Community
/Population
Health
Process
Process
Frm 00439
Fmt 4701
Effective
Clinical
Care
Effective
Clinical
Care
Sfmt 4725
Measure Title
and Description
Hepatitis C: Discussion and
Shared Decision Making
Surrounding Treatment Options:
Percentage of patients aged 18 years
and older with a diagnosis of
hepatitis C with whom a physician
or other qualified healthcare
professional reviewed the range of
treatment options appropriate to
their genotype and demonstrated a
shared decision making approach
with the patient To meet the
measure, there must be
documentation in the patient record
of a discussion between the
physician or other qualified
healthcare professional and the
patient that includes all of the
following: treatment choices
appropriate to genotype, risks and
benefits, evidence of effectiveness,
and patient preferences toward
treatment
Immunizations for Adolescents:
The percentage of adolescents 13
years of age who had the
reconm1ended inununizations by
their 13th birthday
One-Time Screening for Hepatitis
C Virus (HCV) for Patients at
Risk:
Percentage of patients aged 18 years
and older with one or more of the
following: a history of injection
drug use, receipt of a blood
transfusion prior to 1992, receiving
maintenance hemodialysis OR
birthdate in the years 1945-1965
who received one-time screening for
hepatitis C virus (HCV) infection
Hepatitis C: Screening for
Hepatocellular Carcinoma (HCC)
in Patients with Cirrhosis:
Percentage of patients aged 18 years
and older with a diagnosis of
chronic hepatitis C cirrhosis who
underwent imaging with either
ultrasound, contrast enhanced CT or
MRI for hepatocellular carcinoma
(HCC) at least once within the 12
month reporting period
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
American
Gastroenterolo
gical
Association
National
Cmmnittee for
Quality
Assurance
Physician
Consortium for
Performance
Improvement
Foundation
(PCPI®)
American
Gastroenterological
Association/
American
Society for
Gastrointestinal
Endoscopy/
American
College of
Gastroenterology
EP30JN17.197
..
Indicator
30447
30448
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B.29. Infectious Disease (continued)
!!
§
Quality
#
#
N/A
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TRD
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CMSE:.
Measure
ro
N/A
N/A
N/A
Jkt 241001
Data
Submission
Method
Claims,
Registry
Registry
Registry
PO 00000
Measure
Type
Process
Process
Process
Frm 00440
Fmt 4701
National
Quality
Strategy
Domain
Effective
Clinical
Care
Community
I
Population
Health
Patient
Safety,
Eftlciency
and Cost
Reduction
Sfmt 4725
Measure Title
and Description
Measure
Steward
'
Appropriate Treatment of
Methicillin-Sensitive
Staphylococcus Aureus (MSSA)
Bacteremia:
Percentage of patients with sepsis due
to MSSA bacteremia who received
beta-lactam antibiotic (e.g. nafcillin,
oxacillin or cefazolin) as definitive
therapy.
Chlamydia Screening and Follow
Up: The percentage of female
adolescents 16 years of age who had a
chlamydia screening test with proper
follow-up during the measurement
period
Otitis Media with Effusion (OME):
Systemic Antimicrobials- Avoidance
oflnappropriate Use:
Percentage of patients aged 2 months
through 12 years with a diagnosis of
OME who were not prescribed
systemic antimicrobials.
E:\FR\FM\30JNP2.SGM
30JNP2
Infectious
Diseases
Society of
America
National
Committee
for Quality
Assurance
American
Academy of
Otolaryngolo
gy -Head
and Neck
Surgery
Foundation
(AAOHNSF
)
EP30JN17.198
Indicator
NQF
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B30 Neurosurg1ca
NQF
#
Quality
#
CMSEData .·.
Measure Submission
Method
ID
Measure··
Type
...
II
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0239
021
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N/A
Claims,
Registry
N/A
Claims,
Registry
Jkt 241001
PO 00000
National
Quality
Strategy
Domain
Process
Patient
Safety
Process
Patient
Safety
Frm 00441
Fmt 4701
Sfmt 4725
Measure Title
and Description
Perioperative Care: Selection of
Prophylactic Antibiotic- First OR
Second Generation Cephalosporin:
Percentage of surgical patients aged
18 years and older undergoing
procedures with the indications for a
first OR second generation
cephalosporin prophylactic antibiotic,
who had an order for a first OR
second generation cephalosporin for
antimicrobial prophylaxis
Perioperative Care: Venous
Thromboembolism (VTE)
Prophylaxis (When Indicated in
ALL Patients):
Percentage of surgical patients aged 18
years and older undergoing procedures
for which venous thromboembolism
(VTE) prophylaxis is indicated in all
patients, who had an order for Low
Molecular Weight Heparin (LMWH),
Low-Dose Unfractionated Heparin
(LDUH), adjusted-dose warfarin,
fondaparinux or mechanical prophy laxi
to be given within 24 hours prior to
incision time or within 24 hours after
surgery end time
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
American
Society of
Plastic
Surgeons
American
Society of
Plastic
Surgeons
EP30JN17.199
..
Indicator
30449
30450
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B30 N eurosur !!;ICaI (con fmue d)
Indicator
NQF
#
CMSE•
Quality
Measure
#
ID
Data
Submission
Method
...
0419
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Claims,
Registry,
EHR
N/A
*
187
N/A
Registry
138v6
Claims,
Web
Interface,
Registry,
EHR
0028
226
19:16 Jun 29, 2017
Jkt 241001
Measure
Type
PO 00000
National
Quality
Strategy
Domain
Measute Title
and Description
Process
Patient
Safety
Process
Effective
Clinical
Care
Process
Community
I
Population
Health
Frm 00442
Fmt 4701
Sfmt 4725
Documentation of Current
Medications in the Medical Record:
Percentage of visits for patients aged
18 years and older for which the
eligible professional attests to
doclllllenting a list of current
medications using all immediate
resources available on the date of the
encounter. This list must include ALL
known prescriptions, over-thecounters, herbals, and
vitamin/mineral/dietary (nutritional)
supplements AND must contain the
medications' name, dosage, frequency
and route of administration.
Stroke and Stroke Rehabilitation:
Thrombolytic Therapy:
Percentage of patients aged 18 years
and older with a diagnosis of acute
ischemic stroke who arrive at the
hospital within two hours of time last
known well and for whom IV t-PA
was initiated within three hours of
time last known well
Preventive Care and Screening:
Tobacco Use: Screening and
Cessation Intervention:
a. Percentage of patients aged 18
years and older who were screened
for tobacco use one or more times
within 24 months
h. Percentage of patients aged 18
years and older who were screened
for tobacco usc and identified as a
tobacco user who received tobacco
cessation intervention
c. Percentage of patients aged 18
years and older who were screened
for tobacco use one or more times
within 24 months AND who
received cessation counseling
intervention if identified as a
tobacco user.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
Centers for
Medicare &
Medicaid
Services
American
Heart
Association
Physician
Consortium for
Performance
Improvement
Foundation
(PCPI®)
EP30JN17.200
..
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B30 Neurosurg1caI (con fmue d)
NQF
#
CMSE•
Quality
Measure
#
ID
Data
Submission
Method
Measure
Type
!
1543
345
N/A
Registry
Outcome
!
1540
346
N/A
Registry
Outcome
N/A
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N/A
N/A
Jkt 241001
National
Quality
Strategy
Domain
Effective
Clinical
Care
Effective
Clinical
Care
Effective
Clinical
Care
Registry
Outcome
Registry
Effective
Intermedia
Clinical
te
Care
Outcome
Registry
Registry
Registry
PO 00000
Measure Title
and Description
Rate of Postoperative Stroke or
Death in Asymptomatic Patients
Undergoing Carotid Artery
Stenting (CAS):
Percent of asymptomatic patients
undergoing CAS who experience
stroke or death following surgery
while in the hospital
Rate of Postoperative Stroke or
Death in Asymptomatic Patients
Undergoing Carotid
Endarterectomy (CEA):
Percent of asymptomatic patients
undergoing CEA who experience
stroke or death following surgery
while in the hospitaL
Clinical Outcome Post
Endovascular Stroke Treatment:
Percentage of patients with a mRs
score ofO to 2 at 90 days following
endovascular stroke intervention
Door to Puncture Time for
Endovascular Stroke Treatment:
Percentage of patients undergoing
endovascular stroke treatment who
have a door to puncture time ofless
than two hours
Average Change in Back Pain
Following Lumbar Discectomy
and/or Laminotomy:
The average change (preoperative to
three months postoperative) in back
pain for patients 18 years of age or
older who had lumbar discectomy
laminotomy procedure
Measure
Steward
Society for
Vascular
Surgeons
Society for
Vascular
Surgeons
Society of
Interventional
Radiology
Society of
Interventional
Radiology
Patient
Reported
Outcome
Person
and
CaregiverCentered
Experienc
e and
Outcomes
Patient
Reported
Outcome
Person
and
CaregiverCentered
Experienc
c and
Outcomes
Average Change in Back Pain
Following Lumbar Fusion: The
average change (preoperative to one
year postoperative) in back pain for
patients 18 years of age or older who
had lumbar spine fusion surgery
Patient
Reported
Outcome
Person
and
CaregiverCentered
Experienc
e and
Outcomes
Average Change in Leg Pain
Following Lumbar Discectomy
and/or Laminotomy:
MN
The average change (preoperative to
Community
three months postoperative) in leg pain
Measurement
for patients 18 years of age or older
who had lumbar discectomy
laminotomy procedure
Frm 00443
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E:\FR\FM\30JNP2.SGM
30JNP2
MN
Community
Measurement
MN
Community
Measurement
EP30JN17.201
..
Indicator
30451
30452
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
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1a
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0101
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#
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127
128
154
155
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·. CMSEData
Measure Submission
ID
Method
N/A
N/A
Registry
Registry
69v6
Claims,
Registry,
EHR, Web
Interface
N/A
Claims,
Registry
N/A
Jkt 241001
Claims,
Registry
PO 00000
Measure
Type
National
Quality
Strategy
Domain
Measure Title
and Description
·.
Process
Effective
Clinical
Care
Process
Effective
Clinical
Care
Process
Community
/Population
Health
Process
Patient
Safety
Process
Communic
ation and
Care
Coordinatio
n
Frm 00444
Fmt 4701
Sfmt 4725
Measure
Steward
Diabetes Mellitus: Diabetic Foot
and Ankle Care, Peripheral
Neuropathy -Neurological
Evaluation: Percentage of patients
aged 18 years and older with a
diagnosis of diabetes mellitus who
had a neurological examination of
their lower extremities within 12
months.
Diabetes Mellitus: Diabetic Foot
and Ankle Care, Ulcer PreventionEvaluation of Footwear:
Percentage of patients aged 18 years
and older with a diagnosis of diabetes
mellitus who were evaluated for
proper footwear and sizing.
Preventive Care and Screening:
Body Mass Index (BMI) Screening
and Follow-Up Plan:
Percentage of patients aged 18 years
and older with a BMl documented
during the current encounter or
during the previous twelve months
AND with a BMl outside of normal
parameters, a follow-up plan is
documented during the encounter or
during the previous twelve months of
the current encounter.
Normal Parameters: Age 18 years and
older BMl => 18.5 and< 25 kg/m2
Falls: Risk Assessment:
Percentage of patients aged 65 years
and older with a history of falls who
had a risk assessment for falls
completed within 12 months
Falls: Plan of Care:
Percentage of patients aged 65 years
and older with a history of falls who
had a plan of care for falls
documented within 12 months
E:\FR\FM\30JNP2.SGM
30JNP2
American
Podiatric
Medical
Association
American
Podiatric
Medical
Association
Centers for
Medicare &
Medicaid
Services
National
Committee for
Quality
Assurance
National
Committee for
Quality
Assurance
EP30JN17.202
Indicator
NQF
#
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30453
B 31 P 0 d" t r (con fmue d)
1a
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0028
Quality
#
226
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·. CMSEMeasure
ID
138v6
Jkt 241001
Data
Submission
Method
Claims,
Registry,
EHR, Web
Interface
PO 00000
Measure
.Type
Process
Frm 00445
Fmt 4701
National
Quality
Strategy
Domain
Community
/Population
Health
Sfmt 4725
Measure 'fitle
and Description
Preventive Care and Screening:
Tobacco Use: Screening and
Cessation Intervention:
a. Percentage of patients aged 18
years and older who were
screened for tobacco use one or
more times within 24 months
b. Percentage of patients aged 18
years and older who were
screened for tobacco use and
identified as a tobacco user who
received tobacco cessation
intervention
c. Percentage of patients aged 18
years and older who were
screened for tobacco use one or
more times within 24 months
AND who received cessation
counseling intervention if
identified as a tobacco user.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
Physician
Consortium for
Performance
Improvement
Foundation
(PCPI®)
EP30JN17.203
Indicator
NQF
30454
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
B 32 Den f IS t ry
Indicator
NQF
#
Quality
#
CMSEData
Measure Submission
Method
ID
Measure
Type
...
N/A
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379
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75v6
74v7
Jkt 241001
EHR
EHR
PO 00000
National
Quality
Strategy
Domain
Measure Title
and Description
Outcome
Community
/Population
Health
Process
Effective
Clinical
Care
Frm 00446
Fmt 4701
Sfmt 4725
Children Who Have Dental Decay
or Cavities:
Percentage of children, age 0-20
years, who have had tooth decay or
cavities during the measurement
period
Primary Caries Prevention
Intervention as Offered by Primary
Care Providers, including Dentists:
Percentage of children, age 0-20
years, who received a fluoride varnish
application during the measurement
period.
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
Centers for
Medicare &
Medicaid
Services
Centers for
Medicare &
Medicaid
Services
EP30JN17.204
..
30455
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
TABLE C.l: Proposed MIPS Measures Removed Only from Specialty Sets
for the 2018 Performance Period
Note: CMS proposed removal of measures within specific specialty measure sets below based upon
review of updates made to existing quality measure specifications, the proposal of adding new measures
for inclusion in MIPS, and the feedback provided by specialty societies.
0059
N/A
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0326
001
Measure
ID
122v6
032
047
VerDate Sep<11>2014
CMSE~
N/A
N/A
19:16 Jun 29, 2017
Data
Submission
Method
Claims, Web
Interface,
Registry,
EHR
Claims,
Registry
Claims,
Registry
Jkt 241001
National
Quality
Strategy
Domain
Measure
Type
Measure Title
and Description
Intermed
iate
Outcome
Effective
Clinical
Care
Process
Effective
Clinical
Care
Process
Communica
tion and
Care
Coordinatio
n
PO 00000
Frm 00447
Fmt 4701
Measure
Steward
Diabetes: Hemoglobin Ale
(HbAlc) Poor Control
(>9%):
Percentage of patients 18-75
years of age with diabetes who
had hemoglobin Ale> 9.0%
during the measurement period
Stroke and Stroke
Rehabilitation: Discharged on
Antithrombotic Therapy:
Percentage of patients aged 18
years and older with a
diagnosis of ischemic stroke or
transient ischemic attack (TIA)
who were prescribed an
antithrombotic therapy at
discharge.
Care Plan:
Percentage of patients aged 65
years and older who have an
advance care plan or surrogate
decision maker documented in
the medical record or
documentation in the medical
record that an advance care
plan was discussed but the
patient did not wish or was not
able to name a surrogate
decision maker or provide an
advance care plan.
Sfmt 4725
E:\FR\FM\30JNP2.SGM
Specialty Set
Proposed to be
Removed From
National
Committee
for Quality
Assurance
Emergency
Medicine
American
Academy
of
Neurology
Neurosurgical
Neurology
Hospitalists
National
Committee
for Quality
Assurance
30JNP2
Emergency
Medicine
Mental/Behavioral
Health
Ophthalmology
Plastic Surgery
EP30JN17.205
NQF. Quality
#
#
30456
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
TABLE C.l: Proposed MIPS Measures Removed from Specialty Sets
for the 2018 Performance Period
Note: CMS proposed removal of measures within specific specialty measure sets below based upon
review of updates made to existing quality measure specifications, the proposal of adding new measures
for inclusion in MIPS, and the feedback provided by specialtv societies .
.
.
NQF ··QualitY
#
#.
0421
0419
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. ....
·
·
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Registry,
EHR, Web
Interface
Claims,
Registry,
Domain··
Process
Process
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VerDate Sep<11>2014
19:16 Jun 29, 2017
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PO 00000
Community
I
Population
Health
Patient
Safety
Frm 00448
Fmt 4701
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....,.··.
E:\FR\FM\30JNP2.SGM
.
Centers
for
Medicare
&
.
·.
•.
Specil;llty. Se.t ·.·.
Pp>po~ed
Steward•·
··•
Preventive Care and
Screening: Body Mass Index
(BMI) Screening and FollowUp Plan:
Percentage of patients aged 18
years and older with a BMI
doclllllented during the current
encounter or during the
previous twelve months AND
with a BMI outside of normal
parameters, a follow-up plan is
doclllllented during the
encounter or during the
previous twelve months of the
current encounter.
Normal Parameters: Age 18
years and older BMI => 18.5
and < 25 ka 1m2
Documentation of Current
Medications in the Medical
Record:
Percentage of visits for patients
aged 18 years and older for
which the eligible professional
attests to documenting a list of
current medications using all
inunediate resources available
on the date of the encounter.
This list must include ALL
known prescriptions, over-thecounters, herbals, and
vitamin/mineral/dietary
(nutritional) supplements AND
must contain the medications'
name, dosage, frequency and
route of administration.
Sfmt 4725
.}
I Mea$ure
l\1e~sure Title
a~d Descripfio,ri
. Strllt~
Type
Me~ltod •.. •
....·...·
Natirinal
Quality
t!l be
Remo-ved Frimt
I•
·•·.·
Hospitalist
Neurology
Plastic Surgery
Medicaid
Services
Centers
for
Medicare
&
Medicaid
Services
30JNP2
Anesthesiology
Emergency
Medicine
EP30JN17.206
.·
30457
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
TABLE C.l: Proposed MIPS Measures Removed from Specialty Sets
for the 2018 Performance Period
Note: CMS proposed removal of measures within specific specialty measure sets below based upon
review of updates made to existing quality measure specifications, the proposal of adding new measures
for inclusion in MIPS, and the feedback provided by specialtv societies.
"
NQF
#.
0028
Quality··
#
226
(;MSJh
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138v6
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EHR, Web
Interface
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Registry,
EHR, Web
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236
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.. .' ~\
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1·. Type
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.
.i
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259
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VerDate Sep<11>2014
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19:16 Jun 29, 2017
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:National
n'
Quality . · ....
Strategy
1\'leasure Title
ltn
.
30458
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
TABLE C.l: Proposed MIPS Measures Removed from Specialty Sets
for the 2018 Performance Period
Note: CMS proposed removal of measures within specific specialty measure sets below based upon
review of updates made to existing quality measure specifications, the proposal of adding new measures
for inclusion in MIPS, and the feedback provided by specialtv societies .
.
NQF
#
#
·.·
N/A
CMSE~
Meas11re
. m
2014
N/A
N/A
19:16 Jun 29, 2017
Registry
Registry
Jkt 241001
PO 00000
...
National
Process
Outcome
Frm 00450
M!.lasure.Titlc
1Utd DescriptiUll
.·.
.•.
••••••
Sfmt 4725
E:\FR\FM\30JNP2.SGM
•
i
;
Stew.ftrd
·.· .
Biopsy Follow-Up:
Commun Percentage of new patients whose
ication
biopsy results have been reviewed
and Care
and communicated to the primary
Coordina care/referring physician and
tion
patient by the perfonning
physician
Dementia: Management of
Neuropsychiatric Symptoms:
Percentage of patients, regardless
of age, with a diagnosis of
Effective
dementia who have one or more
Clinical
neuropsychiatric symptoms who
Care
received or were recommended to
receive an intervention for
neuropsychiatric symptoms
within a 12-month period
Parkinson's Disease:
Parkinson's Disease Medical
and Surgical Treatment
Options Reviewed:
Commun All patients with a diagnosis of
Parkinson's disease (or
ication
and Care
caregiver(s), as appropriate) who
Coordina had the Parkinson's disease
tion
treatment options (e.g., nonpharmacological treatment,
pharmacological treatment, or
surgical treatment) reviewed at
least once annually
Cataracts: Patient Satisfaction
within 90 Days Following
Cataract Surgery:
Person
Percentage of patients aged 18
Caregiver- years and older who had cataract
surgery and were satisfied with
Centered
Experienc their care within 90 days
e and
following the cataract surgery,
Outcomes based on completion of the
Consumer Assessment of
Healthcare Providers and Systems
Surgical Care Smvey
Fmt 4701
•
•·Measure ····
.......
30JNP2
Specialty Set
:Propo~cd tQ ·.·
be Rell)oved
From
American
Academy
of
Dennatolog
y
Interventional
Radiology
American
Academy
of
Nemology
Nemology
Mental/
Behavioral
Health
American
Academy
of
Nemology
American
Academy
of
Ophthalmol
ogy
Nemology
Ophthalmolog
y
EP30JN17.208
·' .··· ...
Quality
;
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
TABLE C.l: Proposed MIPS Measures Removed from Specialty Sets
for the 2018 Performance Period
Note: CMS proposed removal of measures within specific specialty measure sets below based upon
review of updates made to existing quality measure specifications, the proposal of adding new measures
for inclusion in MIPS, and the feedback provided by specialtv societies .
.
·· ....
.··.
.....·
>
.·
. ·..•..·.·
.··
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.#..· ..
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ID
312
317
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332
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22v6
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N/A
N/A
19:16 Jun 29, 2017
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Jkt 241001
type
.QuaJity .·.
Strategy
.Dotuain
PO 00000
Efficienc
y and
Cost
Reductio
n
Process
Commun
ity/
Populati
on
Health
Process
Process
Frm 00451
Efficienc
y and
Cost
Reductio
n
Efficienc
y and
Cost
Reductio
n
Fmt 4701
..
~e11~ure Title
..
..
jilld De~c,ription
·.·.
Use of Imaging Studies for Low
Back Pain:
Percentage of patients 18-50 years
of age with a diagnosis of low
back pain who did not have an
imaging study (plain X-ray, MRI,
CT scan) within 28 days of the
diagnosis
Preventive Care and Screening:
Screening for High Blood
Pressure and Follow-Up
Documented: Percentage of
patients aged 18 years and older
seen during the reporting period
who were screened for high blood
pressure AND a recommended
follow-up plan is documented
based on the current blood
pressure (BP) reading as
indicated.
Adult Sinusitis: Antibiotic
Prescribed for Acute Sinusitis
(Overuse):
Percentage of patients, aged 18
years and older, with a diagnosis
of acute sinusitis who were
prescribed an antibiotic within 10
days after onset of symptoms
Adult Sinusitis: Appropriate
Choice of Antibiotic:
Amoxicillin With or Without
Clavulanate Prescribed for
Patients with Acute Bacterial
Sinusitis (Appropriate Use):
Percentage of patients aged 18
years and older with a diagnosis
of acute bacterial sinusitis that
were prescribed amoxicillin, with
or without clavulante, as a first
line antibiotic at the time of
diagnosis
Sfmt 4725
E:\FR\FM\30JNP2.SGM
30JNP2
Measure· ·Proposed .to.··.
Steward . Jje Removed
Froin
Family
Medicine
National
Internal
Committee
Medicine
for Quality
Orthopedic
Surgery
Assurance
Physical
Medicine
Centers for
Medicare
&
Medicaid
Services
Ophthalmolog
y
Hospitalist
American
Academy
of
Otolaryngo
logyHead and
Neck
Surgery
Allergy!Immu
no logy
American
Academy
of
Otolaryngo
logyHead and
Neck
Surgery
Allergy!Immu
no logy
EP30JN17.209
NQF
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...
\
;
30459
30460
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
TABLE C.l: Proposed MIPS Measures Removed from Specialty Sets
for the 2018 Performance Period
Note: CMS proposed removal of measures within specific specialty measure sets below based upon
review of updates made to existing quality measure specifications, the proposal of adding new measures
for inclusion in MIPS, and the feedback provided by specialtv societies .
.
.·
N/A
Quality
#
....
333
CMSE:,a1eas-ure •·
m.
N/A
D.at~
Submission·
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.
···.
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N/A
334
N/A
Registry
N/A
337
N/A
Registry
N/A
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.
344
N/A
Registry
VerDate Sep<11>2014
19:16 Jun 29, 2017
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.
·.. ·· ··.
National
Quality ...·.
M~asure. title
;
Strategy
ani) DescriPtion
J)omairt
..
.··
Adult Sinusitis: Computerized
Tomography (CT) for Acute
Sinusitis (Overuse):
Percentage of patients aged 18
Efficiency years and older with a diagnosis
Efficiency and Cost
of acute sinusitis who had a
Reduction computerized tomography (CT)
scan of the paranasal sinuses
ordered at the time of diagnosis or
received within 28 days after date
of diagnosis
Adult Sinusitis: More than One
Computerized Tomography
(CT) Scan Within 90 Days for
Chronic Sinusitis (Overuse):
Efficiency
Percentage of patients aged 18
Efficiency and Cost
years and older with a diagnosis
Reduction
of chronic sinusitis who had more
than one CT scan of the paranasal
sinuses ordered or received within
90 days after the date of diagnosis
Tuberculosis (TB) Prevention
for Psoriasis, Psoriatic Arthritis
and Rheumatoid Arthritis
Patients on a Biological
Immune Response Modifier:
Percentage of patients whose
Effective
providers are ensuring active
Process
Clinical
tuberculosis prevention either
Care
through yearly negative standard
tuberculosis screening tests or are
reviewing the patient's history to
determine if they have had
appropriate management for a
recent or prior positive test
Rate of Carotid Artery Stenting
(CAS) for Asymptomatic
Patients, Without Major
Complications (Discharged to
Effective
Home by Post-Operative Day
Outcome Clinical
#2):
Care
Percent of asymptomatic patients
undergoing CAS who are
discharged to home no later than
post-operative day #2
.· ...
·.:
Measure
Type
Frm 00452
.
Fmt 4701
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E:\FR\FM\30JNP2.SGM
30JNP2
Mea~ure
Steward
·•·•
f)pecialtY Set·
Propose(lto' · •
.. be Rem~vel). >
From'
American
Academy of
Allergy!Immu
Otolaryngolo
no logy
y- Head and
Neck Surge!)
American
Academy of
Allergy!Immu
Otolaryngolo
no logy
y- Head and
Neck Surge!)
American
Academy of Rheumatology
Dermatology
Society for
Vascular
Surgeons
Interventional
Radiology
EP30JN17.210
..
.··
NQF
#
30461
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
TABLE C.l: Proposed MIPS Measures Removed from Specialty Sets
for the 2018 Performance Period
Note: CMS proposed removal of measures within specific specialty measure sets below based upon
review of updates made to existing quality measure specifications, the proposal of adding new measures
for inclusion in MIPS, and the feedback provided by specialtv societies .
.
NQF
..
1
Qtnllity'
.# .·. .·
.# ·.·.· I
.
1543
N/A
N/A
N/A
>.; ....
;
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J)ata. .·
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Measure••
.·.
\
· 1)Pe ..
···.
345
374
398
402
N/A
Registry
50v6
Registry,
EHR
Process
Registry
Outcome
N/A
N/A
Registry
Outcome
Process
Registry
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431
VerDate Sep<11>2014
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19:16 Jun 29, 2017
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Jkt 241001
PO 00000
Frm 00453
.
National I
Strategy ..
·Domain
;
·Me-asure. Title
an<{ Descnptit>n
Qulllity.
..·
.
'
....
.
..
.
Rate of Postoperative Stroke or
Death in Asymptomatic
Patients Undergoing Carotid
Effective
Artery Stenting (CAS):
Clinical
Percent of asymptomatic patients
Care
undergoing CAS who experience
stroke or death following surgery
while in the hospital
Closing the Referral Loop:
Receipt uf Specialist Report:
Communi
Percentage of patients with
cation and
referrals, regardless of age, for
Care
which the referring provider
Coordinal
receives a report from the
lOll
provider to whom the patient was
referred.
Optimal Asthma Control:
Composite measure of the
percentage of pediatric and adult
Effective
patients whose asthma is wellClinical
controlled as demonstrated by one
Care
of three age appropriate patient
reported outcome tools and not at
risk for exacerbation
Communi Tobacco Use and Help with
ty/
Quitting Among Adolescents:
Populatio The percentage of adolescents 12
to 20 years of age with a primary
n Health
care visit during the measurement
year tor whom tobacco use status
was documented and received
help with quitting if identified as
a tobacco user
Communi Preventive Care and Screening:
ty/
Unhealthy Alcohol Use:
Populatio Screening & Brief Counseling:
n Health
Percentage of patients aged 18
years and older who were
screened for unhealthy alcohol
use using a systematic screening
method at least once within the
last 24 months AND who
received brief counseling if
identified as an unhealthy alcohol
user.
Fmt 4701
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E:\FR\FM\30JNP2.SGM
30JNP2
Spedalty Se,t
MeasUt:e .·.· Pr(Jp~lsed to • ··
St¢ward [.. ~Removed
· .Ffllm
Society for
Vascular
Surgeons
Centers for
Medicare
&
Medicaid
Services
MN
Community
Measurement
National
Committee
for Quality
Assurance
Interventional
Radiology
Emergency
Medicine
Plastic
Surgery
Hospitalist
Allergy/
Immunology
Emergency
Medicine
Hospitalist
Plastic
Surgery
Urology
Physician
Emergency
Consortium Medicine
for
Hospitalist
Performance
lmprovemen
Foundation
(PCPI®)
EP30JN17.211
·•.·· ..·
30462
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
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E:\FR\FM\30JNP2.SGM
30JNP2
Committee
for Quality
Assurance
EP30JN17.212
444
1799
Medication Management for
People with Asthma:
The percentage of patients 5-64
years of age during the
Eniciency
measurement year who were
and Cost
identified as having persistent
Reduction
asthma and were dispensed
appropriate medications that they
remained on for at least 75% of
their treatment period.
30463
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
TABLE C.2: Proposed Quality Measures Removed from Merit-Based Incentive Payment System
Program for the 2018 Performance Period
Note: CMS proposed removal of measures within specific specialty measure sets based upon review of
updates made to existing quality measure specifications, the proposal of adding new measures for
inclusion in MIPS, and the feedback provided by specialty societies. Measure specific removal rationale
is provided in the table below. For example, this measure has been proposed for removal because of
outdated measure specifications based on current clinical guidelines.
NQF
#
Quality
#
CMSEMeasure
ID
Data
Submission
Method
Measure
type
National Quality
StratejO' D~nna.in
Measure Title
and Description
Measure
Steward
Rationale for
Removal
I
N/A
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Registry
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Process
PO 00000
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Effective Clinical
Care
Effective Clinical
Care
Fmt 4701
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Dementia:
Management of
Neuropsychiatric
Symptoms:
Percentage of
patients, regardless
of age, with a
diagnosis of
dementia who have
one or more
neuropsychiatric
symptoms who
received or were
recommended to
rece1ve an
intervention for
neuropsychiatric
symptoms within a
12-month period
E:\FR\FM\30JNP2.SGM
American
Academy
of
Neurology
measure stewards.
We request comment
on the removal of
this measure from the
Merit-Based
Incentive Payment
System (MIPS)
program.
CMS proposes the
removal of the
measure "Dementia:
American
Academy
of
Neurology
30JNP2
Management of
Neuropsychiatric
Symptoms" as a
quality measure from
the MIPS program,
due to the measure
steward no longer
maintaining the
measure since it was
combined with Q283
Dementia: NeuroPsychiatric Symptom
Assessment. We
request conunent on
the removal of this
measure from MIPS.
EP30JN17.213
032
Stroke and Stroke
Rehabilitation:
Discharged on
Antithrumbutic
Therapy:
Percentage of
patients aged 18
years and older with
a diagnosis of
ischemic stroke or
transient ischemic
attack (TIA) who
were prescribed an
antithrombotic
therapy at discharge.
CMS proposes the
removal of the
measure "Stroke and
Stroke
Rehabilitation:
Discharged on
Antithrombotic
Therapy" as a quality
measure from the
MIPS program. due
to the measure
steward no longer
maintaining the
measure since there
are similar existing
measures being
maintained by other
30464
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
TABLE C.2: Proposed Quality Measures Removed from Merit-Based Incentive Payment System
p rogram tor th e 2018 p er tormance p eno d
.
Quality
#
#
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N/A
VerDate Sep<11>2014
294
CMSl>
Measure
ID
N/A
19:16 Jun 29, 2017
Data
Submission
Method
Registry
Jkt 241001
PO 00000
Measure
Type
Process
Frm 00456
National Quality
Strategy Domain
Measu.re Title
l:llld Description
Measure
Steward
Rationale. for
Removal
American
Academy
of
Neurology
CMS proposes the
removal of the
Communication
and Care
Coordination
Parkinson's
Disease:
Parkinson's
Disease Medical
and Surgical
Treatment Options
Reviewed:
All patients with a
diagnosis of
Parkinson's disease
(or caregiver( s), as
appropriate) who had
the Parkinson's
disease treatment
options (e.g., nonpharmacological
treatment,
pharmacological
treatment, or surgical
treatment) reviewed a
least once annually
Fmt 4701
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E:\FR\FM\30JNP2.SGM
30JNP2
measure "Parkinson's
Disease: Parkinson's
Disease Medical and
Surgical Treatment
Options Reviewed"
as a quality measure
from the .\i!IPS
program, due to the
measure steward no
longer maintaining
the measure. We
request comment on
the removal of this
measure from the
Merit-Rased
Incentive Payment
System (MIPS)
program.
EP30JN17.214
NQF
30465
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
TABLE C.2: Proposed Quality Measures Removed from Merit-Based Incentive Payment System
p rogram tor th e 2018 p er tormance p eno d
.
.Quality
#
#
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N/A
VerDate Sep<11>2014
312
CMSl>
Measure
ID
166v7
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Data
Submission
Method
EHR
Jkt 241001
PO 00000
Measure
Type
Process
Frm 00457
National Quality
Strategy Domain
Efficiency and
Cost Reduction
Fmt 4701
Sfmt 4725
Measure Title
a11d Description
Use of Imaging
Studies for Low
Back Pain:
Percentage of patients
18-50 years of age
with a diagnosis of
low back pain who
did not have an
imaging study (plain
X-ray, MRI, CT scan)
within 28 days of the
diagnosis
E:\FR\FM\30JNP2.SGM
Measure
Steward
Rationale. for
Removal
National
Committee
for Quality
Assurance
CMS proposes the
removal of the
measure "Use of
Imaging Studies for
Low Back Pain" as a
quality measure from
the MIPS program,
due to the age cut off
as stated in the
current measure
description. The
American College of
Radiology's current
guidelines suggest
that imaging be
performed in adults
older than 50 years of
age who present with
lower back pain.
CMS had provided
the measure steward
with the opportunity
to update the age
range, in order to
retain the measure
within the program
however, no changes
have been made to
the measure
description. We
request comment on
the removal of this
measure from the
Merit-Based
Incentive Payment
System (MIPS)
program.
30JNP2
EP30JN17.215
NQF
30466
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
TABLED: 2018 Proposed Cross-Cutting Measures
Note: The table of cross-cutting measures is intended to provide clinicians with a list of measures that are
broadly applicable to all clinicians regardless of the clinician's specialty. Even though it is not required to
report on cross-cutting measures, it is provided as a reference to clinicians who are looking for additional
measures to report outside their specialty.
!
*
9
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Quality
#
#
0326
0421
0419
CMSE- Data
Measure Submission
ID
Method
N/A
Claims,
Registry
128
69v669v
6
Claims,
Web
Interface,
Registry,
EIIR
130
68v768v
7
047
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Registry,
Measure
Type
Process
Process
Process
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National
Quality
Strategy
Domain
Measure Title
and :Oescription¥
Care Plan:
Percentage of patients aged 65 years
and older who have an advance care
plan or surrogate decision maker
Connmmicat doclllllented in the medical record or
ion and Care doclllllentation in the medical record
Coordination that an advance care plan was
discussed hut the patient did not wish
or was not able to name a surrogate
decision maker or provide an advance
care plan.
Preventive Care and Screening:
Body Mass Index (BMI) Screening
and Follow-Up Plan: Percentage of
patients aged 18 years and older with
a BMI documented during the current
encounter or during the previous
Community
twelve months AND with a BMI
/Population
outside of nonnal parameters, a
Health
follow-up plan is documented during
the encounter or during the previous
twelve months of the cmrent
encounter.
Normal Parameters: Age 18 years and
older BMI => 18.5 and< 25 kg/m2
Documentation of Current
Medications in the Medical Record:
Percentage of visits for patients aged
18 years and older for which the
eligible professional attests to
docmnenti.ng a list of cmTent
medications using all immediate
Patient
resources available on the date ofthe
Safety
encounter. This list must include ALL
known prescriptions, over-thecounters, herbals, and
vitamin/mineral/dietary (nutritional)
supplements AND must contain the
medications' name, dosage, frequency
and route of administration.
Sfmt 4725
E:\FR\FM\30JNP2.SGM
30JNP2
Measure
Steward
National
Committee for
Quality
Assurance
Centers for
Medicare &
Medicaid
Services
Centers for
Medicare &
Medicaid
Services
EP30JN17.216
Indicator
30467
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
TABLED: 2018 Proposed Cross-Cutting Measures
Note: The table of cross-cutting measures is intended to provide clinicians with a list of measures that are
broadly applicable to all clinicians regardless of the clinician's specialty. Even though it is not required to
report on cross-cutting measures, it is provided as a reference to clinicians who are looking for additional
measures to report outside their specialty.
*
§
§
!
NQF
Quality
#
#
0028
0018
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N/A
VerDate Sep<11>2014
226
236
317
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CMSE- Data
Measure Submission
ID
Method
138v6
Claims,
Web
Interface,
Registry,
EHR
165v6
Claims,
Web
Interface,
Registry,
EHR
22v6
Claims,
Registry,
EHR
Jkt 241001
PO 00000
Measure
Type
National
Quality
Strategy
Domain:
'
Measure Title
and Description
Measure
.Steward
Preventive Care and Screening:
Tobacco Use: Screening and
Cessation Intervention:
a. Percentage of patients aged 18
years and older who were
screened for tobacco use one or
more times within 24 months
b. Percentage of patients aged 18
years and older who were
Community/
screened for tobacco use and
Process
Population
identified as a tobacco user who
Health
received tobacco cessation
intervention
c. Percentage of patients aged 18
years and older who were
screened for tobacco use one or
more times within 24 months
AND who received cessation
counseling intervention if
identified as a tobacco user.
Controlling High Blood Pressure:
Percentage of patients 18-85 years of
Effective
age who had a diagnosis of
ntermediat
hypertension and whose blood
Clinical
e Outcome
Care
pressure was adequately controlled
(<140/90mmHg) during the
measurement period
Preventive Care and Screening:
Screening for High Blood Pressure
and Follow-Up Documented:
Percentage of patients aged 18 years
Community
and older seen during the reporting
Process
/Population
period who were screened for high
Health
blood pressure AND a recommended
follow-up plan is documented based
on the current blood pressure (BP)
reading as indicated
Frm 00459
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E:\FR\FM\30JNP2.SGM
30JNP2
Physician
Consortium for
Performance
Improvement
Foundation
(PCPI®)
National
Committee for
Quality
Assurance
Centers for
Medicare &
Medicaid
Services
EP30JN17.217
Indicator·.
30468
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
TABLE E: Measures with Substantive Changes Proposed for MIPS Reporting in 2018
E.. CAHPS tor MIPS CrIDICian /G roup Survey
1
. .
Current Measure
Description:
Proposed Substantive
Change:
Steward:
High Priority
Measure:
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Description
0005 & 0006
321
N/A
Person and Caregiver-Centered Experience and Outcomes
CMS Approved Survey Vendor
The Consumer Assessment of Healthcare Providers and Systems (CARPS) for MIPS
Clinician/Group Survey is comprised of 12 Summary Survey Measures (SSMs) and measures
patient experience of care within a group practice.
The proposed survey would eliminate 2 SSMs (Helping You to Take Medication as Directed
and Between Visit Communication)
Agency for Healthcare Research & Quality (AHRQ)
Yes (Patient Experience)
For the Quality Payment Program Year 2 and beyond, CMS proposes to remove two SSMs,
"Helping You to Take Medication as Directed" due to low reliability and "Between Visit
Communication" as this SSM currently contains only one question. This question could also
be considered related to other SSMs entitled: "Care Coordination" or "Courteous and Helpful
Office Staff," but does not directly overlap with any of the questions under that SSM.
However, we are proposing to remove this SSM in order to maintain consistency with the
Medicare Shared Savings Program that utilizes the CARPS Survey for Accountable Care
Organizations (ACOs). The SSM entitled "Between Visit Communication" has never been a
scored measure with the Medicare Shared Savings Program CARPS Survey for A COs.
Please refer to section II.C.6.b.(3)(a)(iii) of this proposed rule for additional details on the
removal of the two SSMs.
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Category
NQF#:
Quality#:
CMS E-Measure ID:
National Quality
Strategy Domain:
Current Data
Submission Method:
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E2 P reven f 1ve
..
c are an dS creenmg: Tobacco use: screenmg an dC essaf wn I n tervenf IOn
Category
Description
NQF#:
Quality#:
CMS E-Measure ID:
National Quality
Strategy Domain:
Current Data
Submission Method:
0028
226
138v6138v6
Proposed Substantive
Change:
Steward:
High Priority
Measure:
Rationale:
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Community /Population Health
EHR, Claims, Web Interface, Qualified Registry
Percentage of patients aged 18 years and older who were screened for tobacco use one or
more times within 24 months AND who received cessation counseling intervention if
identified as a tobacco user.
We are proposing to restructure the measure more similarly to its original construct to make
it more apparent where potential gaps in care exist and how performance can be improved.
Instead ofbeing comprised of just 1 performance rate (Percentage of patients aged 18 years
and older who were screened for tobacco use one or more times within 24 months AND who
received cessation counseling intervention if identified as a tobacco user), it is now
comprised of the 3 components below:
a. Percentage of patients aged 18 years and older who were screened for tobacco use
one or more times within 24 months
b. Percentage of patients aged 18 years and older who were screened for tobacco use
and identified as a tobacco user who received tobacco cessation intervention
c. Percentage of patients aged 18 years and older who were screened for tobacco use
one or more times within 24 months AND who received cessation counseling
intervention if identified as a tobacco user.
Physician Consortium for Performance Improvement (PCPI)
No
This measure was originally developed as a two-part measure: the first part assessed
whether a patient had been screened for tobacco use within the past 24 months; the second
part assessed whether those who had been screened and identified as tobacco users in the
first part of the measure also received tobacco cessation intervention (either counseling
and/or pharmacotherapy). The two parts were eventually combined into one performance
rate. That performance rate is collective and does not show the difference in performance
with respect to how well clinicians adhere to performing tobacco use screenings and how
well clinicians follow the guidelines to provide tobacco cessation interventions. As written,
the measure has had a continuously high performance rate. The performance rate currently
does not differentiate between smokers and non-smokers with regards to counseling, thereby
demonstrating a potential inaccurately high performance rate. To address this, based on
discussions with CMS' Million Hearts program as well as the technical expert panel (TEP)
recently convened by our measure development contractor, the measure has been updated to
more accurately reflect the intended quality action. Accordingly, the measure will look to
assess tobacco use, the percentage of patients who use tobacco and were counseled to quit
and the overall percentage of patients who received counseling.
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Description:
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Description:
Proposed Substantive
Change:
Steward:
High Priority
Measure:
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Rationale:
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E3 D emen f 1a:
Description
N/A
281
149v6
c ogm"f1ve A ssessmen t
Effective Clinical Care
EHR
Percentage of patients, regardless of age, with a diagnosis of dementia for whom an
assessment of cognition is performed and the results reviewed at least once within a 12
month period
The measure currently allows for medical exceptions, including diagnosis of severe
dementia, palliative care, or other medical reasons, from numerator compliance.
Physician Consortium for Performance Improvement (PCPI)
No
The technical expert panel convened by our measure development contractor recommended
removing these exceptions as cognitive assessment is especially important for planning the
care of patients who are very sick or have advanced-stage dementia. The denominator
identifies patients with dementia. Prior to this change, patients with severe dementia,
palliative care, and medical reasons were removed from the denominator. While the
denominator seeks patients with dementia, the number of patients with severe dementia is
likely non-trivial and could impact performance rates. It is recognized that patients with
perceived severe dementia still need an objective assessment of their cognition to
appropriately care for them.
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Category
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Quality#:
CMS E-Measure ID:
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Strategy Domain:
Current Data
Submission Method:
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c are an dS creenmg: B 0 dIY Mass In dex (BMI) Screenmg an d F oII ow-UJP PI an
Current Measure
Description:
Proposed Substantive
Change:
Steward:
High Priority
Measure:
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Rationale:
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Description
0421
128
69v6
Community /Population Health
Claims, Web Interface, Registry, EHR
Percentage of patients aged 18 years and older with a BMI documented during the current
encounter or during the previous six months AND with a BMI outside of normal
parameters, a follow-up plan is documented during the encounter or during the previous six
months of the current encounter.
Normal Parameters: Age 18 years and older BMI => 18.5 and< 25 kg/m2
Change the frequency of documenting BMI from 6 to 12 months.
Centers for Medicare and Medicaid Services (CMS)
No
Based on current evidence, the expert work group for the measure recommended revising
the time frame for frequency of documenting BMI from 6 to 12 months. This proposed
change doubles the time frame for numerator compliance, providing additional
opportunities for meeting measure criteria. Extending the timeframe for numerator
compliance will decrease the burden on the clinician, and can also potentially impact the
performance rates.
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..
E4P reven f1ve
Category
NQF#:
Quality#:
CMS E-Measure ID:
National Quality
Strategy Domain:
Current Data
Submission Method:
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E5 P reven f 1ve c are an dS creenmg: I n fl uenza I mmumzaf wn
CMS E-Measure ID:
National Quality
Strategy Domain:
Current Data
Submission Method:
Current Measure
Description:
Proposed Substantive
Change:
Steward:
High Priority
Measure:
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Rationale:
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Description
0041
110
147v7
Community /Population Health
Claims, Web Interface, Registry, EHR
Percentage of patients aged 6 months and older seen for a visit between October 1 and
March 31 who received an influenza immunization OR who reported previous receipt of an
influenza immunization
Remove encounter count requirement from initial population. This change applies to the
Registry and EHR data submission methods only.
Physician Consortium for Performance Improvement (PCPI)
No
The technical expert panel (TEP) convened by our measure development contractor
recommended removing the 2-visit requirement from CMS 147. The TEP suggests the
measure should encourage clinicians to take advantage of every opportunity to administer
the flu vaccination. CMS agrees with the TEP's recommendation and believes that each
patient contact during the flu season is an opportunity to ensure that the patient received
proper vaccination. This will reduce the number of missed opportunities for vaccination. We
believe this proposed change allows clinicians to take advantage of every opportunity to
administer the flu vaccination. In light of this change, the Initial Population language and the
Initial Population logic need to be modified.
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Category
NQF#:
Quality#:
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30473
.
I
- IS
E6 U se ofH.IglhR. k M e d. f lOllS Ill th e Eld eny
ICa
..
Current Measure
Description:
Proposed Substantive
Change:
Steward:
High Priority
Measure:
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Rationale:
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Description
0022
238
156v6
Patient Safety
Registry, EHR
Percentage of patients 66 years of age and older who were ordered high-risk medications.
Two rates are reported.
a. Percentage of patients who were ordered at least one high-risk medication.
b. Percentage of patients who were ordered at least two different high-risk medications.
The change is proposed in rate b, which will be going from two different medications to two
instances of the same medication. This new change aligns with Beers criteria.
National Committee for Quality Assurance (NCQA)
Yes (Patient Safety)
The American Geriatrics Society has established the Beers criteria, inclusive of a list of
medications considered to be inappropriate for elderly patients. The Beers criteria is
important because it involves closer monitoring of drug use, application of real-time
interventions, and better patient outcomes. The parent measure requires that the patients
have two or more dispensing events (any days supply) on different dates of services during
the measurement year. The dispensing events should be for the same drug (as identified by
the drug ID in the HEDIS NDC code list).
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Category
NQF#:
Quality#:
CMS E-Measure ID:
National Quality
Strategy Domain:
Current Data
Submission Method:
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E7F uncf wna I St a t us AssessmenH or TtlKn ee R ep1acement
o a
Proposed Substantive
Change:
Steward:
High Priority
Measure:
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Rationale:
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Description
N/A
375
66v6
Person and Caregiver-Centered Experience and Outcomes
EHR
Percentage of patients 18 years of age and older with primary total knee arthroplasty (TKA)
who completed baseline and follow-up patient-reported functional status assessments
Aligning the initial population more closely with the measurement period. The overall
duration of period remains the same.
Changes to the measure description: Percentage of patients 18 years of age and older who
received an elective primary total knee arthroplasty (TKA) who completed baseline and
follow-up patient-reported and completed a functional status assessment within 90 days
prior to the surgery and in the 270-365 days after the surgery.
Centers for Medicare and Medicaid Services (CMS)
Yes (Patient Experience)
The American Association of Hip and Knee Surgeons have recommended that the
general/mental health survey be completed prior to surgery (during the preoperative visit)
and after surgery (during the post-operative visit). The guidance calls for revised aligmnent
with the measurement period.
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Category
NQF#:
Quality#:
CMS E-Measure ID:
National Quality
Strategy Domain:
Current Data
Submission Method:
Current Measure
Description:
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30475
E8 F uncf wna I St a t us AssessmenH or T ot a IH" R ep1acement
IP
Proposed Substantive
Change:
Steward:
High Priority
Measure:
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Rationale:
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Description
N/A
376
56v6
Person and Caregiver-Centered Experience and Outcomes
EHR
Percentage of patients 18 years of age and older with primary total hip arthroplasty (THA)
who completed baseline and follow-up patient-reported functional status assessments
Revise timing to identify initial population, to align more closely with the measurement
period. The overall duration of period remains the same.
Changes to the measure descriptions: Percentage of patients 18 years of age and older with
who received an elective primary total hip arthroplasty (THA) who completed baseline and
follow-up patient-reported and completed a functional status assessment within 90 days
prior to the surgery and in the 270-365 days after the surgery.
Centers for Medicare and Medicaid Services (CMS)
Yes (Patient Experience)
The American Association of Hip and Knee Surgeons have recommended that the
general/mental health survey be completed prior to surgery (during the preoperative visit)
and after surgery (during the post-operative visit). The guidance calls for revised aligmnent
with the measurement period.
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Category
NQF#:
Quality#:
CMS E-Measure ID:
National Quality
Strategy Domain:
Current Data
Submission Method:
Current Measure
Description:
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E 9 St am Th erapy t or th e p reven f wn an dT reat men t 0 fC ar d"wvascu ar n·
f
1sease
Category
Description
NQF#:
N/A
Quality#:
438
CMS E-Measure ID:
347vl
National Quality
Effective Clinical Care
Strategy Domain:
Current Data
Web Interface, Registry
Submission Method:
Percentage of the following patients-all considered at high risk of cardiovascular eventswho were prescribed or were on statin therapy during the measurement period:
• Adults aged 2: 21 years who were previously diagnosed with or currently have an active
diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR
Current Measure
• Adults aged 2:21 years who have ever had a fasting or direct low-density lipoprotein
Description:
cholesterol (LDL-C) level::=: 190 mg/dL; OR
• Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level
of 70-189 mg/dL.
Proposed Substantive
We propose to offer this measure as an eCQM for the 2018 performance period.
Change:
Centers for Medicare and Medicaid SeiVices (CMS)
Steward:
High Priority
No
Measure:
To provide eligible clinicians with an additional reporting option that can be used to report
Rationale:
for the measure.
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.
·
,peCiarIS tRepor t
E 10 Cl osmg th e R e terraIL oop: R ece1p1t o fS
Description
N/A
374
50v650v6
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Rationale:
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Communication and Care Coordination
EHR
Percentage of patients with referrals, regardless of age, for which the referring provider
receives a report from the provider to whom the patient was referred.
We propose to offer this measure as a registry measure for the 2018 performance period.
Centers for Medicare and Medicaid Services (CMS)
Yes (Care Coordination)
To provide eligible clinicians with an additional reporting option that can be used to report
for the measure.
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EP30JN17.227
Category
NQF#:
Quality#:
CMS E-Measure ID:
National Quality
Strategy Domain:
Current Data
Submission Method:
Current Measure
Description:
Proposed Substantive
Change:
Steward:
High Priority
Measure:
30478
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Ell Demen f 1a:
Category
NQF#:
Quality#:
CMS E-Measure ID:
National Quality
Strategy Domain:
Current Data
Submission Method:
Current Measure
Description:
Proposed Substantive
Change:
Steward:
High Priority
Measure:
Rationale:
t
c ounsermg Regar d"mg sa tery c oncerns
Description
N/A
286
N/A
Patient Safety
Qualified Registry
Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s)
who were counseled or referred for counseling regarding safety concerns within a 12 month
period
We propose to update the title, description and numerator of this measure to further specify
the safety screening required and documentation of mitigation recommendations, consistent
with updates from the measure steward.
American Academy of Neurology
Yes (Patient Safety)
CMS proposes to update this measure consistent with updates from the measure steward, as
it will provide a more comprehensive assessment from which the results may provide
additional insight about the patient's condition and alterations needed in the treatment plan
therefore making this a more robust measure.
s
Current Measure
Description:
Proposed Substantive
Change:
Steward:
High Priority
Measure:
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Rationale:
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E 12 D emen f 1a: N euro- p sych" t. 'ymp1t om A ssessment
1a nc
Description
N/A
283
N/A
Effective Clinical Care
Qualified Registry
Percentage of patients, regardless of age, with a diagnosis of dementia and for whom an
assessment of neuropsychiatric symptoms is performed and results reviewed at least once in
a 12-month period
The measure was updated to change 'Functional Status Assessment and Results Reviewed'
to 'Dementia Associated Behavioral and Psychiatric Symptoms Screening and
Management' Symptoms screening is for three domains 'activity disturbances', 'mood
disturbances' and 'thought and perceptual disturbances' including depression. To meet the
measure, a documented behavioral and psychiatric symptoms screen inclusive of at least one
or more symptom from each of three defined domains AND documented symptom
management recommendations if safety concerns screening is positive within the last 12
months.
American Academy of Neurology
No
The measure steward updated the measure to combine it with Q284: Dementia: Management
of Neuropsychiatric Symptoms (proposed for removal), to make the measure more robust to
include assessment of neuropsychiatric symptoms modified to include depression screening
and the management of those symptoms.
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Category
NQF#:
Quality#:
CMS E-Measure ID:
National Quality
Strategy Domain:
Current Data
Submission Method:
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30479
Appendices-Improvement Activities Table
NOTE: For previously finalized improvement activities, we refer readers to the Finalized
Improvement Activities Inventory in Table H in the Appendix of the CY 2017 Quality Payment
Program final rule (81 FR 77817). Except as otherwise proposed below, previously finalized
improvement activities would continue to apply for the Quality Payment Program year 2 and
future years.
TABLE F: Proposed New Improvement Activities
f or th e Q ual't P aymen tP rogram Y ear 2 an dF uture Y ears
uy
Activity ID:
lA AHE XX
Subcategory:
Achieving Health Equity
Activity Title:
MIPS Eligible Clinician Leadership in Clinical Trials or CBPR
Activity Description:
MIPS eligible clinician leadership in clinical trials, research alliances or
community-based participatory research (CBPR) that identify tools, research or
processes that can focuses on minimizing disparities in healthcare access, care
quality, affordabilily, or outcomes.
Medium
Weighting:
Eligible for Advancing Care
Information Bonus:
Activity ID:
No
Subcategory:
Achieving Health Equity
Activity Title:
Provide Education Opportunities for New Clinicians
Activity Description:
MIPS eligible clinicians acting as a preceptor for clinicians-in-training (such as
medical residents/fellows, medical students, physician assistants, nurse
practitioners, or clinical nurse specialists) and accepting such clinicians for
clinical rotations in community practices in small, underserved, or rural areas.
High
Weighting:
Eligible for Advancing Care
information Bonus:
Activity ID:
Subcategory:
Activity Title:
Activity Description:
Weighting:
lA AHE XX
No
lA- BMH- XX
Behavioral and Mental Health
Unhealthy Alcohol Use for Patients with Co-occurring Conditions of Mental
Health and Substance Abuse and Ambulatory Care Patients
Individual MIPS eligible clinicians or groups must regularly engage in
integrated prevention and treatment interventions, including screening and brief
counseling (for example: NQF #2152) for patients with co-occurring conditions
of mental health and substance abuse. MIPS eligible clinicians would attest that
60 percent for the 2018 performance period, and 75 percent for the Quality
Payment Program Year 2 and future years, of their ambulatory care patients are
screened for unhealthy alcohol use.
High
Care Coordination
Activity Title:
PSH Care Coordination
Activity Description:
Participation in a Perioperative Surgical Home (PSH) that provides a patientcentered, physician-led, interdisciplinary, and team-based system of coordinated
patient care, which coordinates care from pre-procedure assessment through the
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No
Subcategory:
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Eligible for Advancing Care
Information Bonus:
Activity ID:
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acute care episode, recovery, and post-acute care. This activity allows for
reporting of strategies and processes related to care coordination of patients
receiving surgical or procedural care within a PSH. The clinician must perform
one or more of the following care coordination activities:
• Coordinate with care managers/navigators in preoperative clinic to plan
and implementation comprehensive post discharge plan of care;
• Deploy perioperative clinic and care processes to reduce post-operative
visits to emergency rooms:
• Implement evidence-informed practices and standardize care across the
entire spectrum of surgical patients; or
• Implement processes to ensure effective communications and education
of patients' post-discharge instmctions.
Medium
Weighting:
Eligible for Advancing Care
Information Bonus:
Activity ID:
IA_CC_XX
Subcategory:
Care Coordination
Activity Title:
Primary Care Physician and Behavioral Healtl1 Bilateral Electronic Exchange of
Information for Shared Patients
The primary care a11d behavioral health practices use the smne electronic health
record system for shared patients or have an established bidirectional flow of
primary care and behavioral health records.
Medium
Activity Description:
Weighting:
Yes
Eligible for Advancing Care
lnfonnation Bonus:
Yes. if accomplished with CEHRT
Activity TD:
TA EPA- XX
Subcategory:
Patient Safety & Practice Assessment
Activity Tille:
Participation in User Testing of the Quality Payment Progrmn Website
(https://qpp.cms.gov/)
U scr participation in the Quality Payment Program website testing is an activity
for eligible clinicim1s who have worked with CMS to provided substantive,
timely, and responsive input to improve the CMS Quality Payment Program
website through product user-testing llmt enlmnces system a11d progrmn
accessibility, readability and responsiveness as well as providing feedback for
developing tools and guidance thereby allowing for a more user-friendly a11d
accessible clinician and practice Quality Payment Program website experience.
Medium
Activity Description:
Weighting:
Eligible for Advancing Care
Information Bonus:
Activity ID:
Subcategory:
Activity Title:
Activity Description:
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Weighting:
No
lA PM XX
Population Management
Participation in Population Health Research
Participation in federally and/or privately funded research that identifies
interventions, tools, or processes that can improve a targeted patient population.
Medium
Eligible for Advancing Care
Information Bonus:
Activity ID:
lA PM XX
Subcategory:
Population Management
Activity Title:
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Activity Description:
Weighting:
Engaging connnunity health workers to provide a comprehensive link to
community resources through family-based services focusing on success in
health, education, and self-sufficiency. Tl1is activity supports individual MIPS
eligible clinicians or groups that coordinate with primary care and other
clinicians, engage and support patients, use of health information technology,
and employ quality measurement and improvement processes. An example of
tllis conunmlity based program is the NCQA Patient-Centered Co1mected Care
(PCCC) Recognition Program or other such programs that meet these criteria.
Medium
Eligible for Advancing Care
Information Bonus:
Activity ID:
Yes, if accomplished with CEHRT
Subcategory:
Population Management
Activity Title:
Glycemic Screening Services
Activity Description:
For at-risk outpatient Medicare beneficiaries, individual MIPS eligible clinicians
and groups must attest to implementation of systematic preventive approaches
in clinical practice for at least 75 percent of electronic medical records with
documentation of screening patients for abnormal blood glucose according to
current US Preventive Services Task Force (USPSTF) and/or American
Diabetes Association (ADA) guidelines.
Medium
Weighting:
lA PM XX
Eligible for Advancing Care
Information Bonus:
Activity ID:
lA PM XX
Subcategory:
Population Management
Activity Title:
Glycemic Referring Services
Activity Description:
For at-risk outpatient Medicare beneficiaries, individual MIPS eligible clinicians
and groups must attest to implementation of systematic preventive approaches
in clinical practice for at least 75 percent of medical records with documentation
of referring eligible patients with prediabetes to a CDC-recognized diabetes
prevention program operating under the framework of the National Diabetes
Prevention Program.
Medium
Weighting:
Yes
Eligible for Advancing Care
Information Bonus:
Activity ID:
Yes
lA PM XX
Advance Care Planning
Activity Description:
Implementation of practices/processes to develop advance care planning that
includes: documenting the advance care plan or living will witllin the medical
record, educating clinicians about advance care planning motivating them to
address advance care planning needs of their patients, and how these needs can
translate into quality improvement, educating clinicians on approaches and
barriers to talking to patients about end-of-life and palliative care needs and
ways to manage its documentation, as well as informing clinicians of the
healthcare policy side of advance care planning.
Medium
Weighting:
Eligible for Advancing Care
Information Bonus:
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Subcategory:
Population Management
Activity Title:
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Activity ID:
Subcategory:
lA PSPA XX
Patient Safety and Practice Assessment
Activity Title:
CDC Training on CDC's Guideline for Prescribing Opioids for Chronic Pain
Activity Description:
Completion of all the modules of the Centers for Disease Control and
Prevention (CDC) course "Applying CDC's Guideline for Prescribing Opioids"
that reviews the 2016 "Guideline for Prescribing Opioids for Chronic Pain."
Note: This activity may be selected once every 4 years, to avoid duplicative
information given that some of the modules may change on a year by year basis
but over 4 years there would be a reasonable expectation for the set of modules
to have undergone substantive change, for the improvement activities
performance category score.
High
Weighting:
Eligible for Advancing Care
Infonnation Bonus:
Activity ID:
No
Subcategory:
Patient Safety and Practice Assessment
Activity Title:
Completion of CDC Training on Antibiotic Stewardship
Activity Description:
Completion of all modules of the Centers for Disease Control and Prevention
antibiotic stewardship course.
Note: This activity may be selected once every 4 years, to avoid duplicative
information given that some of the modules may change on a year by year basis
but over 4 years there would be a reasonable expectation for the set of modules
to have undergone substantive change, for the improvement activities
performance category score.
High
Weighting:
lA- PSPA XX
Eligible for Advancing Care
Infonnation Bonus:
Activity ID:
No
Subcategory:
Patient Safety and Practice Assessment
Activity Title:
Initiate CDC Training on Antibiotic Stewardship
Activity Description:
Completion of greater than 50 percent of the modules of the Centers for Disease
Control and Prevention antibiotic stewardship course.
Note: This activity may be selected once every 4 years, to avoid duplicative
information given that some of the modules may change on a year by year basis
but over 4 years there would be a reasonable expectation for tl1e set of modules
to have undergone substantive change, for tl1e improvement activities
performance category score.
Medium
Weighting:
lA- PSPA XX
Eligible for Advancing Care
Infonnation Bonus:
Activity ID:
No
Subcategory:
Patient Safety and Practice Assessment
lA PSPA_XX
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Activity Title:
Cost Display for Laboratory and Radiographic Orders
Activity Description:
Implementation of a cost display for laboratory and radiographic orders, such as
costs that can be obtained through tl1e Medicare clinical laboratory fee schedule.
Medium
Weighting:
Eligible for Advancing Care
Infonnation Bonus:
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No
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Activity ID:
lA- PSPA- XX
Subcategory:
Patient Safety and Practice Assessment
Activity Title:
Conmmnication of Unscheduled Visit for Adverse Drug Event and Nature of
Event
A MIPS eligible clinician providing unscheduled care (such as an emergency
room, urgent care, or other unplanned encounter) attests that, for greater than 7 5
percent of case visits that result from a clinically significant adverse drug event,
the MIPS eligible clinician provides information, including tluough the use of
health IT to the patient's primary care clinician regarding both the unscheduled
visit and the nature of the adverse drug event within 48 hours. A clinically
significant adverse event is defined as a medication-related harm or injury such
as side-effects, supratherapeutic effects, allergic reactions, laboratory
abnonnalities, or medication errors requiring urgent/emergent evaluation,
treatment, or hospitalization.
Medimn
Activity Description:
Weighting:
Eligible for Advancing Care
Information Bonus:
Activity ID:
lA PSPA XX
Subcategory:
Patient Safety and Practice Assessment
Activity Title:
Invasive Procedure or Surgery Anticoagulation Medication Management
Activity Description:
For an anticoagulated patient undergoing a planned invasive procedure for
which interruption in anticoagulation is anticipated, including patients taking
vitamin K antagonists (warfarin), target specific oral anticoagulants (such as
apixaban, dabigatran, and rivaroxaban), and heparins/low molecular weight
hcparins, documentation, including through the usc of electronic tools, that the
plan for anticoagulation management in the periprocedural period was discussed
witl1 tl1e patient and with the clinician responsible for managing the patient's
anticoagulation. Elements of the plan should include the following:
discontinuation, resumption, and, if applicable, bridging, laboratory monitoring,
and management of concomitant antithrombotic medications (such as
antiplatclcts and nonsteroidal anti-inflatmuatory drugs (NSAIDs)). An invasive
or surgical procedure is defined as a procedure in which skin or mucous
membranes and connective tissue are incised, or an instrument is introduced
tluough a natural body orifice.
Medimn
Weighting:
Yes
Eligible for Advancing Care
Information Bonus:
Activity ID:
No
lA- PSPA- XX
Completion of an Accredited Safety or Quality Improvement Program
Completion of an accredited perfonnance improvement continuing medical
education progratn tlmt addresses perfonnance or quality improvement
according to the following criteria:
• The activity must address a quality or safety gap that is supported by a
needs assessment or problem analysis, or must support the completion
of such a needs assessment as part of the activity;
• The activity must have specific, measurable aim(s) for improvement;
• The activity must include interventions intended to result in improvement;
• The activity must include data collection and analysis of performance data
to assess the impact of the interventions; and
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Patient Safety and Practice Assessment
Activity Description:
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Subcategory:
Activity Title:
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• The accredited program must define meaningful clinician participation in
their activity, describe the mechanism for identifying clinicians who
meet the requirements, and provide participant completion information.
Weighting:
Medium
Eligible for Advancing Care
Information Bonus:
No
Activity ID:
lA- PSPA- XX
Subcategory:
Patient Safety and Practice Assessment
Activity Title:
Consulting AUC Using Clinical Decision Support when Ordering Advanced
Diagnostic Imaging
Clinicians attest that they are consulting specified applicable appropriate use
criteria (AUC) through a qualified clinical decision support mechanism for all
advanced diagnostic imaging services ordered. This activity is for clinicians
that are early adopters of the Medicare AUC program (e.g., 2018 performance
year) and for clinicians that begin the Medicare AUC program in future years
will be required by §414.94 (authorized by the Protecting Access to Medicare
Act of 2014 ). Qualified mechanisms will be able to provide a report to the
ordering clinician that can be used to assess patterns of image-ordering and
improve upon those patterns to ensure that patients are receiving the most
appropriate imaging for their individual condition.
High
Activity Description:
Weighting:
Eligible for Advancing Care
Information Bonus:
Activity ID:
Yes
Subcategory:
Patient Safety and Practice Assessment
Activity Title:
PCI Bleeding Campaign
Activity Description:
Participation in the PCI Bleeding Campaign which is a national quality
improvement program that provides infrastructure for a learning network and
offers evidence-based resources and tools to reduce avoidable bleeding
associated with patients who receive a percutaneous coronary intervention
(PCI).
The program uses a patient-centered and team-based approach, leveraging
evidence-based best practices to improve care for PCI patients by implementing
quality improvement strategies:
• Radial-artery access,
• Bivalimdin, and
• Use of vascular closure devices.
Medium
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Eligible for Advancing Care
Information Bonus:
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Weighting:
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We propose to include these additional
improvement activities in the Improvement
Activities Inventory for the Quality Payment
Program Year 2 and future years based on
guidelines discussed in the CY 2017 Quality
Payment Program final rule at (81 FR 77190)
and proposed in section II.C.6.e.(7)(b) of this
proposed rule. These may include one or
more of the following criteria:
• Relevance to an existing improvement
activities subcategory (or a proposed new
subcategory);
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• Importance of an activity toward
achieving improved beneficiary health
outcome;
• Importance of an activity that could lead
to improvement in practice to reduce health
care disparities;
• Aligned with patient-centered medical
homes;
• Activities that may be considered for an
advancing care information bonus;
• Representative of activities that multiple
individual MIPS eligible clinicians or groups
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30485
could perform (for example, primary care,
specialty care);
• Feasible to implement, recognizing
importance in minimizing burden, especially
for small practices, practices in rural areas,
or in areas designated as geographic HPSAs
by HRSA;
• CMS is able to validate the activity; or
• Evidence supports that an activity has a
high probability of contributing to improved
beneficiary health outcomes.
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TABLE G: Proposed Improvement Activities with Changes for the
Quality Payment Program Year 2 and Future Years
Activity ID:
lA- AHE- 1
Subcategory:
Achieving Health Equity
Activity Title:
Engagement of New Medicaid Patients and Follow-up
Current Activity Description:
Seeing new and follow-up Medicaid patients in a timely manner, including
individuals dually eligible for Medicaid and Medicare.
High
Weighting:
Eligible for Advancing Care
Information Bonus:
Proposed Change:
No
Activity ID:
Seeing new and follow-up Medicaid patients in a timely manner, including
individuals dually eligible for Medicaid and Medicare. A timely manner is
defined as within 10 business days for this activity.
We propose to revise the wording of tlris improvement activity to clarify the
meaning of "a timely manner."
lA- AHE- 3
Subcategory:
Achieving Health Equity
Activity Title:
Leveraging a QCDR to Promote Use of PRO Tools
Current Activity Description:
Participation in a QCDR, demonstrating performance of activities that promote
implementation of shared clinical decision making capabilities.
Weighting:
Medium
Eligible for Advancing Care
Information Bonus:
Proposed Change:
No
Rationale:
Subcategory:
Beneficiary Engagement
Activity Title:
Engage Patients and Families to Guide Improvement in the System of Care
Current Activity Description:
Engage patients and families to guide improvement in the system of care.
Weighting:
High
Eligible for Advancing Care
Information Bonus:
Yes
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Rationale:
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Activity ID:
Change Activity Title to: Promote Use of Patient-Reported Outcome Tools
Change Activity Description to: Demonstrate performance of activities for
employing patient-reported outcome (PRO) tools and corresponding collection
of PRO data such as tl1e use of PQH-2 or PHQ-9, PROMIS instruments, patient
reported Wound Quality of Life (QoL), patient reported Wound Outcome, and
patient reported Nutritional Screening
Change Weight to: High
Proposed change to eligibility for advancing care information bonus: Change to
"yes" for eligible for advancing care information bonus. We believe MIPS
eligible clinicians may utilize EHR to capture this information to include
standardized data capture and incorporating patient generated health data.
We propose to revise this improvement activity to expand its application to
include employing the PRO tools and corresponding collection of PRO data.
In addition, we propose to provide additional examples of activities that may be
appropriate for this improvement activity.
lA BE 14
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
Activity ID:
Engage patients and families to guide improvement in the system of care by
leveraging digital tools for ongoing guidance and assessments outside the
encmmter, including the collection and use of patient data for return-to-work
and patient quality of life improvement. Platforms and devices that collect
patient-generated health data (PGHD) must do so with an active feedback loop,
either providing PGHD in real or near-real time to the care team, or generating
clinically endorsed real or near-real time automated feedback to the patient,
including patient reported outcomes (PROs). Examples include patient
engagement and outcomes tracking platforms, cellular or web-enabled bidirectional systems, and other devices that transmit clinically valid objective and
subjective data back to care teams.
Because many consumer-grade devices capture PGHD (for example, wellness
devices), platfonns or devices eligible for this improvement activity must be, at
a minimum, endorsed and offered clinically by care teams to patients to
automatically send ongoing guidance (one way). Platforms and devices that
additionally collect PGHD must do so with an active feedback loop, either
providing PGHD in real or near-real time to the care team, or generating
clinically endorsed real or near-real time automated feedback to the patient (e.g.
automated patient-facing instructions based on glucometer readings). Therefore,
unlike passive platforms or devices that may collect but do not transmit PGHD
in real or near-real time to clinical care teams, active devices and platforms can
inform the patient or the clinical care team in a timely manner of important
parameters regarding a patient's status, adherence, comprehension, and
indicators of clinical concern.
Proposed activity description: We believe that the usc of digital technologies
that provide either one-way or two-way data between MIPS eligible clinicians
and patients is valuable, including for the purposes of promoting patient selfmanagement, enabling remote monitoring, and detecting early indicators of
treatment failure.
Proposed weight Change to high because of increased cost and time
considerations for digital tools for ongoing guidance and assessment outside of
encounter.
Proposed change to eligibility for advancing care information bonus: Change to
"yes" for eligible for advancing care infonnation bonus. We believe MIPS
eligible clinicians will use health IT including providing patients access to
health infonnation and educational resources as well as incorporating PGHD
for tl1is activity to include standardized data capture and incorporating patient
generated healtl1 data.
lA BE 15
Subcategory:
Beneficiary Engagement
Activity Title:
Engagement of Patients, Fan1ily, and Caregivers in Developing a Plan of Care
Current Activity Description:
Engage patients, family, and caregivers in developing a plan of care and
prioritizing their goals for action, documented in the certified electronic health
record (EHR) teclmology.
Medium
Rationale:
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Weighting:
Eligible for Advancing Care
Infonnation Bonus:
Proposed Change:
Rationale:
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Yes
Engage patients, family, and caregivers in developing a plan of care and
prioritizing their goals for action, documented in the electronic health record
(EHR) technology.
We propose to remove the requirement that the EHR teclmology be certified.
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Proposed Change:
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Activity ID:
We do not believe this improvement activity should be limited to certified EHR
technology, however, when certified technology is used, eligible clinicians may
qualify for the advancing care information bonus.
lA BE- 21
Subcategory:
Beneficiary Engagement
Activity Title:
Improved Practices tl1at Disseminate Appropriate Self-Management Materials
Current Activity Description:
Provide self-management materials at an appropriate literacy level and in an
appropriate language.
Medium
Weighting:
Current Eligible for
Advancing Care Information
Bonus:
Proposed Change:
Yes
Activity ID:
We propose to correct the "eligible for advancing care information bonus" for
this improvement activity to "No."
This improvement activity contains an error and should not include an
advancing care information bonus indicator.
lA BE 22
Subcategory:
Beneficiary Engagement
Activity Title:
Improved Practices that Engage Patients Pre-Visit
Current Activity Description:
Provide a pre-visit development of a shared visit agenda with the patient.
Weighting:
Medium
Eligible for Advancing Care
Information Bonus:
Proposed Change:
No
Rationale:
Subcategory:
Behavioral and Mental Health
Activity Title:
Implementation of Integrated Patient Centered Behavioral Health Model
Current Activity Description:
Offer integrated behavioral health services to support patients with behavioral
healtl1 needs, dementia, and poorly controlled chronic conditions that could
include one or more of the following:
• Use evidence-based treatment protocols and treatment to goal where
appropriate;
• Use evidence-based screening and case finding strategies to identify
individuals at risk and in need of services;
• Ensure regular communication and coordinated workflows between
eligible clinicians in primary care and behavioral health;
• Conduct regular case reviews for at-risk or unstable patients and those
who are not responding to treatment;
• Use of a registry or health information technology functionality to support
active care management and outreach to patients in treatment; and/or
integrate behavioral health and medical care plans and facilitate
integration through co-location of services when feasible.
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Rationale:
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Activity ID:
Implementation of workflow changes that engage patients prior to the visit, such
as a pre-visit development of a shared visit agenda with the patient, or targeted
pre-visit laboratory testing that will be resulted and available to the MIPS
eligible clinician to review and discuss during the patient's appointment.
We propose to clarify the type of actions that qualify for this improvement
activity.
lA- BMH- 7
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
Weighting:
High
Eligible for Advancing Care
Information Bonus:
Proposed Change:
Yes
Activity ID:
Offer integrated behavioral health services to support patients with behavioral
health needs who also have conditions such as dementia or other poorly
controlled chronic illnesses. The services could include one or more of the
following:
• Use evidence-based treatment protocols and treatment to goal where
appropriate;
• Usc evidence-based screening and case finding strategies to identify
individuals at risk and in need of services;
• Ensure regular communication and coordinated workflows between MIPS
eligible clinicians in primary care and behavioral health;
• Conduct regular case reviews for at-risk or unstable patients and those
who are not responding to treatment;
• Use of a registry or health information technology functionality to support
active care management and outreach to patients in treatment; and/or
integrate behavioral health and medical care plans and facilitate
integration through co-location of services when feasible.
• Participate in the National Partnership to Improve Dementia Care
Initiative, which promotes a multidimensional approach that includes
public reporting, state-based coalitions, research, training, and revised
surveyor guidance.
We propose to revise the wording of this improvement activity to clarify that the
list of chronic illnesses is not limited to these examples.
lA CC 1
Subcategory:
Care Coordination
Activity Title:
Implementation of Use of Specialist Reports Back to Referring Clinician or
Group to Close Referral Loop
Perfmmance of regular practices that include providing specialist reports back
to the referring MIPS eligible clinician or group to close the referral loop or
where the referring MIPS eligible clinician or group initiates regular inquiries to
specialist for specialist reports which could be documented or noted in the
certified EHR technology.
Medium
Rationale:
Current Activity Description:
Weighting:
Eligible for Advancing Care
Information Bonus:
Proposed Change:
Yes
Subcategory:
Care Coordination
Activity Title:
TCPI Participation
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Activity ID:
Performance of regular practices that include providing specialist reports back
to the referring individual MIPS eligible clinician or group to close the referral
loop or where the referring individual MIPS eligible clinician or group initiates
regular inquiries to specialist for specialist reports which could be documented
or noted in the EHR technology.
We propose to remove the requirement that the EHR technology be
certified. We do not believe this improvement activity should be limited to
certified EHR technology, however, when certified technology is used, eligible
clinicians may qualify for the advancing care information bonus.
IA_CC_4
Rationale:
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Current Activity Description:
Participation in the CMS Transforming Clinical Practice Initiative
Weighting:
High
Eligible for Advancing Care
Information Bonus:
Proposed Change:
No
Rationale:
We propose to change the weight of this improvement activity from high to
medium for MIPS Year 2 and future years.
We designated this activity as a high-weighted activity for the transition year of
MIPS. However. we note that MIPS eligible clinicians that participate in the
CMS Transforming Clinical Practice Initiative (TCPI)-which is an APM (as
defined in section l833(z)(3)(C) of the Act)-will automatically earn a
minimum score of one-half of the highest potential score for this performance
category, as required by section l848(q)(5)(C)(ii) of the Act.
Activity ID:
In addition, we anticipate that most MIPS eligible clinicians that are fully active
TCPI participants will participate in additional practice improvement activities
and will be able to select additional improvement activities to achieve the
improvement activities highest score.
lA CC 9
Subcategory:
Care Coordination
Activity Title:
Implementation of practices/processes for developing regular individual care
plans
Implementation of practices/processes to develop regularly updated individual
care plans for at-risk patients that are shared with the beneficiary or caregiver(s).
Medium
Current Activity Description:
Weighting:
Eligible for Advancing Care
Information Bonus:
Proposed Change:
Yes
Activity ID:
Implementation of practices/processes. including a discussion on care. to
develop regularly updated individual care plans for at-risk patients that are
shared with the beneficiary or caregiver(s). Individual care plans should include
consideration of a patient's goals and priorities, as well as desired outcomes of
care.
We propose this revision because by having an open conversation on care, we
believe patients and MIPS eligible clinicians can work together to evaluate care
options and opportunities that are based on an individual patient's values and
priorities.
lA cc 13
Subcategory:
Care Coordination
Activity Title:
Practice Improvements for Bilateral Exchange of Patient Information
Current Activity Description:
Ensure that there is bilateral exchange of necessary patient information to guide
patient care tlmt could include one or more of the following:
• Participate in a Health Information Exchange if available; and/or
• Use structured referral notes.
Medium
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Weighting:
Eligible for Advancing Care
Information Bonus:
Proposed Change:
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Yes
Ensure that there is bilateral exchange of necessary patient information to guide
patient care, such as Open Notes, that could include one or more of the
following:
• Participate in a Health Information Exchange if available; and/or
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Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
30491
• Use structured referral notes.
Activity ID:
W c propose to provide additional examples of activities that would qualify for
this improvement activity.
lA CC 14
Subcategory:
Care Coordination
Activity Title:
Practice Improvements that Engage Community Resources to Support Patient
Health Goals
Develop pathways to neighborhood/community-based resources to support
patient health goals that could include one or more of the following:
• Maintain formal (referral) links to community-based chronic disease selfmanagement support programs, exercise programs and other wellness
resources with the potential for bidirectional flow of information;
and/or provide a guide to available community resources.
Medium
Rationale:
Current Activity Description:
Weighting:
Eligible for Advancing Care
Information Bonus:
Proposed Change:
Yes
Subcategory:
Expanded Practice Access
Activity Title:
Provide 2417 Access to MIPS Eligible Clinicians or Groups Who Have RealTime Access to Patient's Medical Record
• Provide 24/7 access to MIPS eligible clinicians, groups, or care teams for
advice about urgent and emergent care (e.g., MIPS eligible clinician
and care team access to medical record, cross-coverage with access to
medical record, or protocol-driven nurse line with access to medical
record) that could include one or more of the following:
• Expanded hours in evenings and weekends with access to the patient
medical record (e.g., coordinate with small practices to provide
alternate hour office visits and urgent care);
• Use of alternatives to increase access to care team by MIPS eligible
Rationale:
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Current Activity Description:
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Activity ID:
Develop pathways to neighborhood/community-based resources to support
patient health goals that could include one or more of the following:
• Maintain formal (referral) links to community-based chronic disease selfmanagement support programs, exercise programs and other wellness
resources with the potential for bidirectional flow of information;
• Including through the use of tools that facilitate electronic connnunication
between settings;
• Screen patients for health-harming legal needs;
• Screen and assess patients for social needs using tools that are preferably
health IT enabled and that include to any extent standards-based, coded
question/field for the capture of data as is feasible and available as part
of such tool; and/or
• Provide a guide to available community resources.
We propose to add screening patients for health harming legal needs to this
activity, as such screening can help MIPS eligible clinicians address the social
determinants that contribute to the most challenging problems related to
coordinating care. In addition, we propose to change the eligible for advancing
care information bonus to "yes." We believe MIPS eligible clinicians may use
EHR to communicate with community-based resources including secure
messaging, sending and receiving summary of care records, and incorporating
data from a non-clinical setting.
lA EPA- 1
30492
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clinicians and groups, such as e-visits, phone visits, group visits, home
visits and alternate locations (e.g., senior centers and assisted living
centers); and/or
• Provision of same-day or next -day access to a consistent MIPS eligible
clinician, group or care team when needed for urgent care or transition
management.
High
Weighting:
Eligible for Advancing Care
Information Bonus:
Proposed Change:
Yes
We propose to change the weight of this improvement activity from high to
medium for MIPS Year 2 and future years.
Activity ID:
In addition, we are proposing to change the language to this improvement
activity as follows:
• Provide 24/7 access to MIPS eligible clinicians, groups, or care teams for
advice about urgent and emergent care (for example, eligible clinician
and care team access to medical record, cross-coverage with access to
medical record, or protocol-driven nurse line with access to medical
record) that could include one or more of the following:
patient
• Expanded hours in evenings and weekends with access to the
medical record (for example, coordinate with small practices to
provide alternate hour office visits and urgent care);
• Use of alternatives to increase access to care team by individual MIPS
eligible clinicians and groups, such as telehealth, phone visits, group
visits, home visits and alternate locations (for example, senior centers
and assisted living centers); and/or
• Provision of same-day or next -day access to a consistent MIPS eligible
clinician, group or care team when needed for urgent care or transition
management.
We designated this activity as a high-weighted activity for the transition year of
MIPS. However, we are seeking comment on why this activity should either
maintain the current weight or why the weighting should be decreased to
medium.
lA PM 1
Subcategory:
Population Management
Activity Title:
Participation in Systematic Anticoagulation Program
Current Activity Description:
Participation in a systematic anticoagulation program (coagulation clinic, patient
self-reporting program, patient self-management program) for 60 percent of
practice patients in the transition year and 7 5 percent of practice patients in year
2 who receive anti-coagulation medications (warfarin or other coagulation
cascade inhibitors).
High
Weighting:
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Eligible for Advancing Care
Information Bonus:
Proposed Change:
Rationale:
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Participation in a systematic anticoagulation program (coagulation clinic, patient
self-reporting program, or patient self-management program) for 60 percent of
practice patients in the transition year and 7 5 percent of practice patients in
Quality Payment Program Year 2 and future years, who receive anti-coagulation
medications (warfarin or other coagulation cascade inhibitors).
We propose to clarify that the 75 percent performance target extends into future
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years.
Activity ID:
lA PM 2
Subcategory:
Population Management
Activity Title:
Anticoagulant Management Improvements
Current Activity Description:
MIPS eligible clinicians and groups who prescribe oral Vitamin K antagonist
therapy (warfarin) must attest that, in the first performance year, 60 percent or
more of their ambulatory care patients receiving warfarin are being managed by
one or more of these clinical practice improvement activities:
• Patients are being managed by an anticoagulant management service, that
involves systematic and coordinated care*, incorporating
comprehensive patient education, systematic INR testing, tracking,
follow-up, and patient communication of results and dosing decisions;
• Patients are being managed according to validated electronic decision
support and clinical management tools that involve systematic and
coordinated care, incorporating comprehensive patient education,
systematic INR testing, tracking, follow-up, and patient communication
of results and dosing decisions;
• For mral or remote patients, patients are managed using remote
monitoring or telehealth options that involve systematic and
coordinated care, incorporating comprehensive patient education,
systematic INR testing, tracking, follow-up, and patient communication
of results and dosing decisions; and/or
• For patients who demonstrate motivation, competency, and adherence,
patients are managed using either a patient self-testing (PST) or
patient-self-management (PSM) program.
MIPS eligible clinicians would attest that, 60 percent for the transition year or
75 percent for the second year, of their ambulatory care patients receiving
warfarin participated in an anticoagulation management program for at least 90
days during the performance period.
High
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Information Bonus:
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Individual MIPS eligible clinicians and groups who prescribe oral Vitamin K
antagonist therapy (warfarin) must attest that, 75 percent or more of their
ambulatory care patients receiving warfarin are being managed by one or more
of the following improvement activities:
• Patients are being managed by an anticoagulant management service, that
involves systematic and coordinated care, incorporating comprehensive
patient education, systematic prothrombin time (PT-INR) testing,
tracking, follow -up, and patient communication of results and dosing
decisions;
• Patients are being managed according to validated electronic decision
support and clinical management tools that involve systematic and
coordinated care, incorporating comprehensive patient education,
systematic PT-INR testing, tracking, follow-up, and patient
communication of results and dosing decisions;
• For mral or remote patients, patients are managed using remote
monitoring or telehealth options that involve systematic and
coordinated care, incorporating comprehensive patient education,
systematic PT-INR testing, tracking, follow-up, and patient
communication of results and dosing decisions; and/or
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Activity ID:
• For patients who demonstrate motivation, competency, and adherence,
patients are managed using either a patient self-testing (PST) or
patient-self-management (PSM) program.
We propose to clarify which actions qualify for this improvement activity for
the Quality Payment Program Year 2 and future years.
lA PM 8
Subcategory:
Population Management
Activity Title:
Participation in CMMI models such as the Million Hearts Campaign
Current Activity Description:
Participation in CMMI models such as tl1e Million Hearts Cardiovascular Risk
Reduction Model
Medium
Rationale:
Weighting:
Eligible for Advancing Care
Information Bonus:
Proposed Change:
Rationale:
No
Delete activity from tile improvement activities inventory.
Activity ID:
We do not believe participants in an APM, who have already automatically
received 50% credit in the improvement activity performance category, should
be provided additional credit for this improvement activity based solely on their
participation in a single APM.
lA PM 11
Subcategory:
Population Management
Activity Title:
Regular Review Practices in Place on Targeted Patient Population Needs
Current Activity Description:
Implementation of regular reviews of targeted patient population needs which
includes access to reports that show unique characteristics of eligible
professional's patient population, identification of vulnerable patients, and how
clinical treatment needs are being tailored, if necessary, to address unique needs
and what resources in the conmmnity have been identified as additional
resources.
Medium
Weighting:
Eligible for Advancing Care
Infonnation Bonus:
Proposed Change:
No
Subcategory:
Population Management
Activity Title:
Chronic Care and Preventative Care Management for Empaneled Patients
Current Activity Description:
Proactively manage chronic and preventive care for empaneled patients that
could include one or more of the following:
• Provide patients almually witl1 all opportunity for development alldlor
adjustment of all individualized plall of care as appropriate to age alld
health status, including health risk appraisal; gender, age and
condition-specific preventive care services; plan of care for chronic
conditions; and advance care planning;
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Activity ID:
Implementation of regular reviews of targeted patient population needs, such as
structured clinical case reviews, which includes access to reports that show
unique characteristics of eligible clinician's patient population, identification of
vulnerable patients, and how clinical treatment needs are being tailored, if
necessary, to address unique needs and what resources in tl1e community have
been identified as additional resources.
Wc propose to provide additional examples of activities that would qualify for
this improvement activity.
lA PM 13
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• Use condition-specific pathways for care of chronic conditions (e.g.,
hypertension, diabetes, depression, asthma and heart failure) with
evidence-based protocols to guide treatment to target;
• Use pre-visit planning to optimize preventive care and team management
of patients with chronic conditions;
• Use panel support tools (registry functionality) to identify services due;
• Use predictive analytical models to predict risk, onset and progression of
chronic diseases; or
• Use reminders and outreach (e.g., phone calls, emails, postcards, patient
portals and community health workers where available) to alert and
educate patients about services due; and/or Routine medication
reconciliation.
Medium
Weighting:
Eligible for Advancing Care
Information Bonus:
Proposed Change:
No
Activity ID:
Proactively manage chronic and preventive care for empaneled patients that
could include one or more of the following:
• Provide patients annually with an opportunity for development and/or
adjustment of an individualized plan of care as appropriate to age and
health status, including health risk appraisal; gender, age and
condition-specific preventive care services; and plan of care for chronic
conditions;
• Use condition-specific pathways for care of chronic conditions (e.g.,
hypertension, diabetes, depression, asthma and heart failure) with
evidence-based protocols to guide treatment to target;
• Use pre-visit planning to optimize preventive care and team management
of patients with chronic conditions;
• Use panel support tools (registry functionality) to identify services due;
• Use predictive analytical models to predict risk, onset and progression of
chronic diseases; or
• Use reminders and outreach (e.g., phone calls, emails, postcards, patient
portals and community health workers where available) to alert and
educate patients about services due; and/or routine medication
reconciliation.
We propose to remove the advance care planning portion of this improvement
activity. We are proposing to create a new improvement activity focused on
advance care planning.
lA- PSPA- 2
Subcategory:
Patient Safety & Practice Assessment
Activity Title:
Participation in MOC Part IV
Current Activity Description:
Participation in Maintenance of Certification (MOC) Part IV for improving
professional practice including participation in a local, regional or national
outcomes registry or quality assessment program. Performance of monthly
activities across practice to regularly assess performance in practice, by
reviewing outcomes addressing identified areas for improvement and evaluating
the results.
Medium
Weighting:
Eligible for Advancing Care
Information Bonus:
Proposed Change:
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Participation in Maintenance of Certification (MOC) Part IV, such as the
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Activity ID:
American Board of Internal Medicine (ABIM) Approved Quality Improvement
(AQI) Program, National Cardiovascular Data Registry (NCDR) Clinical
Quality Coach, Quality Practice Initiative Certification Program, American
Board of Medical Specialties Practice Performance Improvement Module or
ASA Simulation Education Network, for improving professional practice
including participation in a local, regional or national outcomes registry or
quality assessment program. Performance of monthly activities across practice
to regularly assess performance in practice, by reviewing outcomes addressing
identified areas for improvement and evaluating the results.
We propose to provide additional examples of activities that would qualify for
tl1is improvement activity.
lA- PSPA- 3
Subcategory:
Patient Safety & Practice Assessment
Activity Title:
Participate in llii Training/Forum Event; National Academy of Medicine,
AHRQ Team STEPPS(ll.:; or Other Similar Activity
For eligible professionals not participating in Maintenance of Certification
(MOC) Part IV, new engagement for MOC Part IV, such as llii Training/Forum
Event; National Academy of Medicine, AHRQ Team STEPPS®.
Medium
Rationale:
Current Activity Description:
Weighting:
Eligible for Advancing Care
Information Bonus:
Proposed Change:
No
Activity ID:
For MIPS eligible clinicians not participating in Maintenance of Certification
(MOC) Part IV, new engagement for MOC Part IV, such as the Institute for
Healthcare Improvement (llii) Training/Forum Event; National Academy of
Medicine, Agency for Healthcare Research and Quality (AHRQ) Team
STEPPS®, or tl1e American Board of Fan1ily Medicine (ABFM) Perfonnance in
Practice Modules.
We propose to revise this improvement activity to clarify that other MOC
programs are eligible for this improvement activity.
lA- PSPA- 4
Subcategory:
Patient Safety & Practice Assessment
Activity Title:
Administration of the AHRQ Survey of Patient Safety Culture
Current Activity Description:
Administration of the AHRQ Survey of Patient Safety Culture and subtnission
of data to the comparative database (refer to AHRQ Survey of Patient Safety
Culture website https://www.alrrq.gov/professionals/quality-patientsafety /patientsafetyculture/).
Medium
Weighting:
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Information Bonus:
Proposed Change:
Rationale:
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Administration of the AHRQ Survey of Patient Safety Culture and subtnission
of data to the comparative database (refer to AHRQ Survey of Patient Safety
Culture website https://www.alrrq.gov/professionals/quality-patientsafety /patientsafetyculture/).
Note: This activity may be selected once every 4 years, to avoid duplicative
information given that some of the modules may change on a year by year basis
but over 4 years there would be a reasonable expectation for the set of modules
to have undergone substantive change, for the improvement activities
performance category score.
We propose to revise the wording of this improvement activity to specify that it
may be selected once every 4 years to achieve the perfonnance category score.
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Activity ID:
lA- PSPA- 6
Subcategory:
Patient Safety & Practice Assessment
Activity Title:
Consultation of the Prescription Drug Monitoring Program
Current Activity Description:
Clinicians would attest that 60 percent for the first year, or 75 percent for the
second year, of consultation of prescription drug monitoring program prior to
the issuance of a Controlled Substance Schedule II (CSII) opioid prescription
that lasts for longer than 3 days.
High
Weighting:
Eligible for Advancing Care
Information Bonus:
Proposed Change:
No
Activity ID:
Clinicians would attest to reviewing the patients' history of controlled substance
prescription using state prescription drug monitoring program (PDMP) data
prior to the issuance of a Controlled Substance Schedule II (CSII) opioid
prescription lasting longer than 3 days. For the transition year, clinicians would
attest to 60 percent review of applicable patient's history. For the Quality
Payment Program Year 2 and future years, clinicians would attest to 75 percent
review of applicable patient's history performance.
We propose to clarify that in the transition year, clinicians would attest to 60
percent review of applicable patient's history. In the Quality Payment Program
Year 2 and future years, clinicians would attest to 7 5 percent review of
applicable patient's history performance.
lA- PSPA- 8
Subcategory:
Patient Safety & Practice Assessment
Activity Title:
Use ofPatient Safety Tools
Current Activity Description:
Use of tools that assist specialty practices in tracking specific measures tl1at are
meaningful to their practice, such as use of the surgical risk calculator.
Medium
Rationale:
Weighting:
Eligible for Advancing Care
Information Bonus:
Proposed Change:
No
Subcategory:
Patient Safety & Practice Assessment
Activity Title:
Participation in Bridges to Excellence or Other Similar Programs
Current Activity Description:
Participation in other quality improvement programs such as Bridges to
Excellence.
Medium
Weighting:
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Activity ID:
Use of tools that assist specialty practices in tracking specific measures that are
meaningful to their practice, such as use of a surgical risk calculator, evidence
based protocols such as Enhanced Recovery After Surgery (ERAS) protocols,
the CDC Guide for Infection Prevention for Outpatient Settings,
(https://www.cdc.gov/hai/settings/outpatient/outpatient-care-guidelines.html),
predictive algorithms, or other such tools.
We propose to include additional examples of tools that may be utilized to assist
specialty practices in tracking specific measures that are meaningful to their
practice, including evidence based protocols such as Enhanced Recovery After
Surgery (ERAS) protocols, the CDC Guide for Infection Prevention for
Outpatient Settings and the use of tools and protocols that promote appropriate
use criteria.
IA_PSPA_14
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Eligible for Advancing Care
Information Bonus:
Proposed Change:
No
Activity ID:
Proposed Activity Title: Participation in Quality Improvement Initiatives
Proposed Activity Description: Participation in other quality improvement
programs such as Bridges to Excellence or American Board of Medical
Specialties (ABMS) Multi-Specialty Portfolio Program.
We propose to revise the wording of this improvement activity to clarify that
other programs are eligible for this improvement activity.
lA- PSPA- 15
Subcategory:
Patient Safety & Practice Assessment
Activity Title:
Implementation of an ASP
Current Activity Description:
Implementation of an antibiotic stewardship program that measures the
appropriate use of antibiotics for several different conditions (URI Rx in
children, diagnosis of pharyngitis, Bronchitis Rx in adults) according to clinical
guidelines for diagnostics and therapeutics.
Medium
Rationale:
Weighting:
Eligible for Advancing Care
Information Bonus:
Proposed Change:
Subcategory:
Patient Safety & Practice Assessment
Activity Title:
Measurement and Improvement at the Practice and Panel Level
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Activity ID:
Leadership of an Antimicrobial Stewardship Program (ASP) that includes
implementation of an ASP tl1at measures the appropriate use of antibiotics for
several different conditions (such as upper respiratory infection treatment in
children, diagnosis of pharyngitis, bronchitis treatment in adults) according to
clinical guidelines for diagnostics and tl1erapeutics. Specific activities may
include:
• Develop facility-specific antibiogram and prepare report of findings with
specific action plan that aligns with overall hospital strategic plan.
• Lead the development, implementation, and monitoring of patient care
and patient safety protocols for the delivery of ASP including protocols
pertaining to the most appropriate setting for such services (i.e.,
outpatient or inpatient).
• Assist in improving ASP service line efficiency and effectiveness by
evaluating and reconunending improvements in the management
structure and workflow of ASP processes.
• Manage compliance of the ASP policies and assist with implementation
of corrective actions in accordance with hospital compliance policies
and hospital medical staff by-laws.
• Lead the education and training of professional support staff for the
purpose of maintaining an efficient and effective ASP.
• Coordinate communications between ASP management and hospital
personuel regarding activities, services, and operational/clinical
protocols to achieve overall compliance and understanding of the ASP.
• Assist, at the request of the hospital, in preparing for and responding to
third-party requests, including but not limited to payer audits,
govenm1ental inquiries, and professional inquiries tl1at pertain to tl1e
ASP service line.
We propose to provide additional examples of activities that may be appropriate
for this improvement activity.
lA- PSPA- 18
Rationale:
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No
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Current Activity Description:
Weighting:
Eligible for Advancing Care
Information Bonus:
Proposed Change:
Measure and improve quality at the practice and panel level that could include
one or more of the following:
• Regularly review measures of quality, utilization, patient satisfaction and
other measures that may be useful at the practice level and at the level
of the care team or MIPS eligible clinician or group (panel); and/or
• Use relevant data sources to create benchmarks and goals for performance
at the practice level and panel level.
Medium
No
Activity ID:
Measure and improve quality at the practice and panel level, such as the
American Board of Orthopaedic Surgery (ABOS) Physician Scorecards, that
could include one or more of the following:
• Regularly review measures of quality, utilization, patient satisfaction and
other measures that may be useful at the practice level and at the level
of the care team or MIPS eligible clinician or group (panel); and/or
• Use relevant data sources to create benchmarks and goals for performance
at the practice level and panel level.
We propose to provide additional examples of activities that may be appropriate
for this improvement activity.
lA- PSPA- 19
Subcategory:
Patient Safety & Practice Assessment
Activity Title:
Implementation of formal quality improvement methods, practice changes, or
other practice improvement processes
Adopt a formal model for quality improvement and create a culture in which all
staff actively participates in improvement activities that could include one or
more of the following:
• Train all staff in quality improvement methods;
• Integrate practice change/quality improvement into staff duties;
• Engage all staff in identifying and testing practices changes;
• Designate regular team meetings to review data and plan improvement
cycles; Promote transparency and accelerate improvement by sharing
practice level and panel level quality of care, patient experience and
utilization data with staff; and/or
• Promote transparency and engage patients and families by sharing
practice level quality of care, patient experience and utilization data
with patients and families.
Medium
Current Activity Description:
Weighting:
Eligible for Advancing Care
Information Bonus:
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BILLING CODE 4120–01–P
Agencies
[Federal Register Volume 82, Number 125 (Friday, June 30, 2017)]
[Proposed Rules]
[Pages 30010-30500]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2017-13010]
[[Page 30009]]
Vol. 82
Friday,
No. 125
June 30, 2017
Part II
Book 2 of 3 Books
Pages 30009-30500
Department of Health and Human Services
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Centers for Medicare & Medicaid Services
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42 CFR Part 414
Medicare Program; CY 2018 Updates to the Quality Payment Program;
Proposed Rule
Federal Register / Vol. 82 , No. 125 / Friday, June 30, 2017 /
Proposed Rules
[[Page 30010]]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Part 414
[CMS-5522-P]
RIN 0938-AT13
Medicare Program; CY 2018 Updates to the Quality Payment Program
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Proposed rule.
-----------------------------------------------------------------------
SUMMARY: The Medicare Access and CHIP Reauthorization Act of 2015
(MACRA) established the Quality Payment Program for eligible
clinicians. Under the Quality Payment Program, eligible clinicians can
participate via one of two tracks: Advanced Alternative Payment Models
(APMs); or the Merit-based Incentive Payment System (MIPS). We began
implementing the Quality Payment Program through rulemaking for
calendar year (CY) 2017. This rule provides proposed updates for the
second and future years of the Quality Payment Program.
DATES: To be assured consideration, comments must be received at one of
the addresses provided below, no later than 5 p.m. on August 21, 2017.
ADDRESSES: In commenting, please refer to file code CMS-5522-P. Because
of staff and resource limitations, we cannot accept comments by
facsimile (FAX) transmission. You may submit comments in one of four
ways (please choose only one of the ways listed):
1. Electronically. You may submit electronic comments on this
regulation to https://www.regulations.gov. Follow the ``Submit a
comment'' instructions.
2. By regular mail. You may mail written comments to the following
address ONLY: Centers for Medicare & Medicaid Services, Department of
Health and Human Services, Attention: CMS-5522-P, P.O. Box 8013,
Baltimore, MD 21244-8013.
Please allow sufficient time for mailed comments to be received
before the close of the comment period.
3. By express or overnight mail. You may send written comments to
the following address ONLY: Centers for Medicare & Medicaid Services,
Department of Health and Human Services, Attention: CMS-5522-P, Mail
Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
4. By hand or courier. Alternatively, you may deliver (by hand or
courier) your written comments ONLY to the following addresses prior to
the close of the comment period:
a. For delivery in Washington, DC--Centers for Medicare & Medicaid
Services, Department of Health and Human Services, Room 445-G, Hubert
H. Humphrey Building, 200 Independence Avenue SW., Washington, DC
20201.
(Because access to the interior of the Hubert H. Humphrey Building
is not readily available to persons without Federal government
identification, commenters are encouraged to leave their comments in
the CMS drop slots located in the main lobby of the building. A stamp-
in clock is available for persons wishing to retain a proof of filing
by stamping in and retaining an extra copy of the comments being
filed.)
b. For delivery in Baltimore, MD--Centers for Medicare & Medicaid
Services, Department of Health and Human Services, 7500 Security
Boulevard, Baltimore, MD 21244-1850.
If you intend to deliver your comments to the Baltimore address,
call telephone number (410) 786-7195 in advance to schedule your
arrival with one of our staff members. Comments erroneously mailed to
the addresses indicated as appropriate for hand or courier delivery may
be delayed and received after the comment period. For information on
viewing public comments, see the beginning of the SUPPLEMENTARY
INFORMATION section.
FOR FURTHER INFORMATION CONTACT:
Molly MacHarris, (410) 786-4461, for inquiries related to MIPS.
Benjamin Chin, (410) 786-0679, for inquiries related to APMs.
SUPPLEMENTARY INFORMATION:
Table of Contents
I. Executive Summary and Background
II. Provisions of the Proposed Regulations
A. Introduction
B. Definitions
C. MIPS Program Details
D. Overview of Incentives for Participation in Advanced
Alternative Payment Models
III. Collection of Information Requirements
IV. Response to Comments
V. Regulatory Impact Analysis
A. Statement of Need
B. Overall Impact
C. Changes in Medicare Payments
D. Impact on Beneficiaries
E. Regulatory Review Costs
F. Accounting Statement
Acronyms
Because of the many terms to which we refer by acronym in this
rule, we are listing the acronyms used and their corresponding meanings
in alphabetical order below:
ABCTM Achievable Benchmark of Care
ACO Accountable Care Organization
API Application Programming Interface
APM Alternative Payment Model
APRN Advanced Practice Registered Nurse
ASC Ambulatory Surgical Center
ASPE HHS' Office of the Assistant Secretary for Planning and
Evaluation
BPCI Bundled Payments for Care Improvement
CAH Critical Access Hospital
CAHPS Consumer Assessment of Healthcare Providers and Systems
CBSA Core Based Statistical Area
CEHRT Certified EHR technology
CFR Code of Federal Regulations
CHIP Children's Health Insurance Program
CJR Comprehensive Care for Joint Replacement
COI Collection of Information
CPR Customary, Prevailing, and Reasonable
CPS Composite Performance Score
CPT Current Procedural Terminology
CQM Clinical Quality Measure
CY Calendar Year
eCQM Electronic Clinician Quality Measure
ED Emergency Department
EHR Electronic Health Record
EP Eligible Professional
ESRD End-Stage Renal Disease
FFS Fee-for-Service
FR Federal Register
FQHC Federally Qualified Health Center
GAO Government Accountability Office
HIE Health Information Exchange
HIPAA Health Insurance Portability and Accountability Act of 1996
HITECH Health Information Technology for Economic and Clinical
Health
HPSA Health Professional Shortage Area
HHS Department of Health & Human Services
HRSA Health Resources and Services Administration
IHS Indian Health Service
IT Information Technology
LDO Large Dialysis Organization
MACRA Medicare Access and CHIP Reauthorization Act of 2015
MEI Medicare Economic Index
MIPAA Medicare Improvements for Patients and Providers Act of 2008
MIPS Merit-based Incentive Payment System
MLR Minimum Loss Rate
MSPB Medicare Spending per Beneficiary
MSR Minimum Savings Rate
MUA Medically Underserved Area
NPI National Provider Identifier
OCM Oncology Care Model
ONC Office of the National Coordinator for Health Information
Technology
PECOS Medicare Provider Enrollment, Chain, and Ownership System
PFPMs Physician-Focused Payment Models
PFS Physician Fee Schedule
PHI Protected Health Information
PHS Public Health Service
PQRS Physician Quality Reporting System
PTAC Physician-Focused Payment Model Technical Advisory Committee
QCDR Qualified Clinical Data Registry
QP Qualifying APM Participant
QRDA Quality Reporting Document Architecture
QRUR Quality and Resource Use Reports
RBRVS Resource-Based Relative Value Scale
[[Page 30011]]
RFI Request for Information
RHC Rural Health Clinic
RIA Regulatory Impact Analysis
RVU Relative Value Unit
SGR Sustainable Growth Rate
TCPI Transforming Clinical Practice Initiative
TIN Tax Identification Number
VBP Value-Based Purchasing
VM Value-Based Payment Modifier
VPS Volume Performance Standard
I. Executive Summary and Background
A. Overview
This proposed rule would make payment and policy changes to the
Quality Payment Program. The Medicare Access and CHIP Reauthorization
Act of 2015 (MACRA) (Pub. L. 114-10, enacted April 16, 2015) amended
title XVIII of the Social Security Act (the Act) to repeal the Medicare
sustainable growth rate (SGR), to reauthorize the Children's Health
Insurance Program, and to strengthen Medicare access by improving
physician and other clinician payments and making other improvements.
The MACRA advances a forward-looking, coordinated framework for
clinicians to successfully take part in the Quality Payment Program
that rewards value and outcomes in one of two ways:
Advanced Alternative Payment Models (Advanced APMs).
Merit-based Incentive Payment System (MIPS).
These policies are collectively referred to as the Quality Payment
Program. Recognizing that the Quality Payment Program represents a
major milestone in the way that we bring quality measurement and
improvement together with payment, we have taken efforts to review
existing policies to identify how to move the program forward in the
least burdensome manner possible. Our goal is to support patients and
clinicians in making their own decisions about health care using data
driven insights, increasingly aligned and meaningful quality measures,
and technology that allows clinicians to focus on providing high
quality healthcare for their patients. We believe our existing APMs
alongside the proposals in this proposed rule provide opportunities
that support state flexibility, local leadership, regulatory relief and
innovative approaches to improve quality accessibility and
affordability. By driving changes in how care is delivered, we believe
the Quality Payment Program supports eligible clinicians in improving
the health of their patients and increasing care efficiency. To
implement this vision, the Quality Payment Program emphasizes high-
value care and patient outcomes while minimizing burden on eligible
clinicians; the Program is also designed to be flexible, transparent,
and structured to improve over time with input from clinicians,
patients, and other stakeholders. We have sought and continue to seek
feedback from the health care community through various public avenues
such as rulemaking, listening sessions and stakeholder engagement. Last
year, when we engaged in rulemaking to establish policies for effective
implementation of the Quality Payment Program, we did so with the
explicit understanding that technology, infrastructure, physician
support systems, and clinical practices will change over the next few
years. For more information, see the Merit-based Incentive Payment
System (MIPS) and Alternative Payment Model (APM) Incentive under the
Physician Fee Schedule, and Criteria for Physician-Focused Payment
Models final rule with comment period (81 FR 77008, November 4, 2016),
hereinafter referred to as the ``CY 2017 Quality Payment Program final
rule.'' In addition, we are aware of the diversity among clinician
practices in their experience with quality-based payments. As a result
of these factors, we expect the Quality Payment Program to evolve over
multiple years in order to achieve our national goals. To date, we have
laid the groundwork for expansion toward an innovative, outcome-
focused, patient-centered, resource-effective health system that
leverages health information technology to support clinicians and
patients and builds collaboration across care settings. This proposed
rule is the next part of a staged approach to develop policies that are
reflective of system capabilities and grounded in our core strategies
to drive progress and reform efforts. We commit to continue evolving
these policies.
CMS strives to put patients first, ensuring that they can make
decisions about their own healthcare along with their clinicians. We
want to ensure innovative approaches to improve quality, accessibility
and affordability while paying particular attention to improving
clinicians and beneficiaries experience when interacting with CMS
programs. The Quality Payment Program aims to (1) support care
improvement by focusing on better outcomes for patients, decreased
clinician burden, and preservation of independent clinical practice;
(2) promote adoption of APMs that align incentives for high-quality,
low-cost care across healthcare stakeholders; and (3) advance existing
delivery system reform efforts, including ensuring a smooth transition
to a healthcare system that promotes high-value, efficient care through
unification of CMS legacy programs.
We previously finalized the transition year Quality Payment Program
policies in the CY 2017 Quality Payment Program final rule. In that
final rule, we implemented policies to improve physician and other
clinician payments by changing the way Medicare incorporates quality
measurement into payments and by developing new policies to address and
incentivize participation in APMs. The final rule established the
Quality Payment Program and its two interrelated pathways: Advanced
APMs, and the MIPS. The final rule established incentives for
participation in Advanced APMs, supporting the goals of transitioning
from fee-for-service (FFS) payments to payments for quality and value,
including approaches that focus on better care, smarter spending, and
healthier people. The final rule included definitions and processes to
identify Qualifying APM Participants (QPs) in Advanced APMs and
outlined the criteria for use by the Physician-Focused Payment Model
Technical Advisory Committee (PTAC) in making comments and
recommendations to the Secretary on proposals for physician-focused
payment models (PFPMs).
The final rule also established policies to implement MIPS, a
program for certain eligible clinicians that makes Medicare payment
adjustments based on performance on quality, cost and other measures
and activities, and that consolidates components of three precursor
programs--the Physician Quality Reporting System (PQRS), the Physician
Value-based Payment Modifier (VM), and the Medicare Electronic Health
Record (EHR) Incentive Program for eligible professionals (EPs). As
prescribed by MACRA, MIPS focuses on the following: quality--including
a set of evidence-based, specialty-specific standards; cost; practice-
based improvement activities; and use of certified electronic health
record (EHR) technology (CEHRT) to support interoperability and
advanced quality objectives in a single, cohesive program that avoids
redundancies.
In this proposed rule, we are building and improving Quality
Payment Program policies that will be familiar to stakeholders and are
designed to integrate easily across clinical practices during the
second and future years of implementation. We strive to continue our
focus on priorities that can drive improvements toward better patient
outcomes without creating undue
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burden for clinicians. In this proposed rule, we also address elements
of MACRA that were not included in the first year of the program,
including virtual groups, facility-based measurement, and improvement
scoring. We also include proposals to continue implementing elements of
MACRA that do not take effect in the first or second year of the
Quality Payment Program, including policies related to the All-Payer
Combination Option for identifying QPs and assessing eligible
clinicians' participation in Other Payer Advanced APMs. To provide
unity and consistency across the two paths of the Quality Payment
Program, MIPS and APMs, in this proposed rule we have referred to the
second year of the program as ``Quality Payment Program Year 2.''
B. Quality Payment Program Strategic Objectives
As discussed in the CY 2017 Quality Payment Program final rule (81
FR 77010), after extensive outreach with clinicians, patients and other
stakeholders, we created six strategic objectives to drive continued
progress and improvement. These objectives guided our final policies
and will guide our future rulemaking in order to design, implement, and
evolve a Quality Payment Program that aims to improve health outcomes,
promote efficiency, minimize burden of participation, and provide
fairness and transparency in operations. These strategic objectives are
as follows: (1) To improve beneficiary outcomes and engage patients
through patient-centered Advanced APM and MIPS policies; (2) to enhance
clinician experience through flexible and transparent program design
and interactions with easy-to-use program tools; (3) to increase the
availability and adoption of Advanced APMs; (4) to promote program
understanding and maximize participation through customized
communication, education, outreach and support that meet the needs of
the diversity of physician practices and patients, especially the
unique needs of small practices; (5) to improve data and information
sharing to provide accurate, timely, and actionable feedback to
clinicians and other stakeholders; and (6) to promote IT systems
capabilities that meet the needs of users and are seamless, efficient
and valuable on the front and back-end. We also believe it is important
to ensure the Quality Payment Program maintains operational excellence
as the program develops. Therefore we are adding a seventh objective,
specifically to ensure operational excellence in program implementation
and ongoing development. More information on these objectives and the
Quality Payment Program can be found at www.qpp.cms.gov.
With these objectives, we recognize that the Quality Payment
Program provides new opportunities to improve care delivery by
supporting and rewarding clinicians as they find new ways to engage
patients, families, and caregivers and to improve care coordination and
population health management. In addition, we recognize that by
developing a program that is flexible instead of one-size-fits-all,
clinicians will be able to choose to participate in a way that is best
for them, their practice, and their patients. For eligible clinicians
interested in APMs, we believe that by setting ambitious yet achievable
goals, eligible clinicians will move with greater certainty toward
these new approaches of delivering care. APMs are a vital part of
bending the Medicare cost curve by encouraging the delivery of high-
quality, low-cost care. To these ends, and to allow this program to
work for all stakeholders, we further recognize that we must provide
ongoing education, support, and technical assistance so that clinicians
can understand program requirements, use available tools to enhance
their practices, and improve quality and progress toward participation
in APMs if that is the best choice for their practice. Finally, we
understand that we must achieve excellence in program management,
focusing on customer needs, promoting problem-solving, teamwork, and
leadership to provide continuous improvements in the Quality Payment
Program.
C. One Quality Payment Program
Clinicians have told us that they do not separate their patient
care into domains, and that the Quality Payment Program needs to
reflect typical clinical workflows in order to achieve its goal of
better patient care. Advanced APMs, the focus of one pathway of the
Quality Payment Program, contribute to better care and smarter spending
by allowing physicians and other clinicians to deliver coordinated,
customized, high-value care to their patients in a streamlined and
cost-effective manner. Within MIPS, the second pathway of the Quality
Payment Program, we believe that integration into typical clinical
workflows can best be accomplished by making connections across the
four statutory pillars of the MIPS incentive structure--quality,
clinical practice improvement activities (referred to as ``improvement
activities''), meaningful use of CEHRT (referred to as ``advancing care
information''), and resource use (referred to as ``cost'')--and by
emphasizing that the Quality Payment Program is at its core about
improving the quality of patient care.
Although there are two separate pathways within the Quality Payment
Program, the Advanced APM and MIPS tracks both contribute toward the
goal of seamless integration of the Quality Payment Program into
clinical practice workflows. Advanced APMs promote this seamless
integration by way of payment methodology and design that incentivize
care coordination, and the MIPS builds the capacity of eligible
clinicians across the four pillars of MIPS to prepare them for
participation in MIPS APMs and Advanced APMs in later years of the
Quality Payment Program. Indeed, the bedrock of the Quality Payment
Program is high-value, patient-centered care, informed by useful
feedback, in a continuous cycle of improvement. The principal way that
MIPS measures quality of care is through a set of clinical quality
measures (CQMs) from which MIPS eligible clinicians can select. The
CQMs are evidence-based, and the vast majority are created or supported
by clinicians. Over time, the portfolio of quality measures will grow
and develop, driving towards outcomes that are of the greatest
importance to patients and clinicians and away from process, or ``check
the box'' type measures.
Through MIPS, we have the opportunity to measure quality, not only
through evidence-based quality measures, but also by accounting for
activities that clinicians themselves identify: namely, practice-driven
quality improvement. MIPS also requires us to assess whether CEHRT is
used meaningfully. Based on significant feedback, this area was
simplified to support the exchange of patient information, engagement
of patients in their own care through technology, and the way
technology specifically supports the quality goals selected by the
practice. The cost performance category was simplified and weighted at
zero percent of the final score for the transition year of CY 2017 to
allow clinicians an opportunity to ease into the Quality Payment
Program. We further note the cost performance category requires no
separate submissions for participation which minimizes burden on
clinicians. The assessment of cost is a vital part of ensuring that
clinicians are providing Medicare beneficiaries with high-value care.
Given the primary focus on value, we indicated in the CY 2017 Quality
[[Page 30013]]
Payment Program final rule our intention to align cost measures with
quality measures over time in the scoring system (81 FR 77010). That
is, we established special policies for the first year of the Quality
Payment Program, which enabled a ramp-up and gradual transition with
less financial risk for clinicians in the transition year. We called
this approach ``pick your pace'' and allowed clinicians and groups to
participate in MIPS through flexible means while avoiding a negative
payment adjustment. In this proposed rule, we continue the slow ramp-up
of the Quality Payment Program by establishing special policies for
Program Year 2 aimed at encouraging successful participation in the
program while reducing burden, reducing the number of clinicians
required to participate, and preparing clinicians for the CY 2019
performance period (CY 2021 payment year).
D. Summary of the Major Provisions
1. Quality Payment Program Year 2
We believe the second year of the Quality Payment Program should
build upon the foundation that has been established which provides a
trajectory for clinicians to value-based care. This trajectory provides
to clinicians the ability to participate in the program through two
pathways: MIPS and Advanced APMs. As we indicated in the CY 2017
Quality Payment Program final rule (81 FR 77011), we believed that a
second transition period would be necessary to build upon the iterative
learning and development period as we build towards a steady state. We
continue to believe this to be true and have therefore crafted our
policies to extend flexibilities into Quality Payment Program Year 2.
2. Small Practices
The support of small, independent practices remains an important
thematic objective for the implementation of the Quality Payment
Program and is expected to be carried throughout future rulemaking. For
MIPS performance periods occurring in 2017, many small practices are
excluded from new requirements due to the low-volume threshold, which
was set at less than or equal to $30,000 in Medicare Part B allowed
charges or less than or equal to 100 Medicare Part B patients. We have
heard feedback, however, from many small practices that challenges
still exist in their ability to participate in the program. We are
proposing additional flexibilities including: Implementing the virtual
groups provisions; increasing the low-volume threshold to less than or
equal to $90,000 in Medicare Part B allowed charges or less than or
equal to 200 Medicare Part B patients; adding a significant hardship
exception from the advancing care information performance category for
MIPS eligible clinicians in small practices; and providing bonus points
that are added to the final scores of MIPS eligible clinicians who are
in small practices. We believe that these additional flexibilities and
reduction in barriers will further enhance the ability of small
practices to participate successfully in the Quality Payment Program.
In keeping with the objectives to provide education about the
Quality Payment Program and maximize participation, and as mandated by
the statute, during a period of 5 years, $100 million in funding was
provided for technical assistance to be available to provide guidance
and assistance to MIPS eligible clinicians in small practices through
contracts with regional health collaboratives, and others. Guidance and
assistance on the MIPS performance categories or the transition to APM
participation will be available to MIPS eligible clinicians in
practices of 15 or fewer clinicians with priority given to practices
located in rural areas or medically underserved areas (MUAs), and
practices with low MIPS final scores. More information on the technical
assistance support available to small practices can be found at https://qpp.cms.gov/docs/QPP_Support_for_Small_Practices.pdf.
As discussed in section V.C. of this proposed rule, we have also
performed an updated regulatory impact analysis, accounting for
flexibilities, many of which are continuing into the Quality Payment
Program Year 2, that have been created to ease the burden for small and
solo practices. We estimate that at least 80 percent of clinicians in
small practices with 1-15 clinicians will receive a positive or neutral
MIPS payment adjustment. We refer readers to section V.C. of this
proposed rule for details on how this estimate was developed.
3. Summary of Major Provisions for Advanced Alternative Payment Models
(Advanced APMs)
a. Overview
APMs represent an important step forward in our efforts to move our
healthcare system from volume-based to value-based care. APMs that meet
the criteria to be Advanced APMs provide the pathway through which
eligible clinicians, who would otherwise fall under the MIPS, can
become Qualifying APM Participants (QPs), thereby earning incentive
payments for their Advanced APM participation. In the CY 2017 Quality
Payment Program final rule (81 FR 77516), we estimated that 70,000 to
120,000 eligible clinicians would be QPs for payment year 2019 based on
Advanced APM participation in performance year 2017. With new Advanced
APMs expected to be available for participation in 2018, including the
Medicare ACO Track 1 Plus (1+) Model, and the reopening of the
application process to new participants for some current Advanced APMs,
such as the Next Generation ACO Model and Comprehensive Primary Care
Plus Model, we anticipate higher numbers of QPs in subsequent years of
the program. We currently estimate that approximately 180,000 to
245,000 eligible clinicians may become QPs for payment year 2020 based
on Advanced APM participation in performance year 2018.
b. Advanced APMs
In the CY 2017 Quality Payment Program final rule (81 FR 77408), to
be considered an Advanced APM, we finalized that an APM must meet all
three of the following criteria, as required under section
1833(z)(3)(D) of the Act: (1) The APM must require participants to use
CEHRT; (2) The APM must provide for payment for covered professional
services based on quality measures comparable to those in the quality
performance category under MIPS and; (3) The APM must either require
that participating APM Entities bear risk for monetary losses of a more
than nominal amount under the APM, or be a Medical Home Model expanded
under section 1115A(c) of the Act.
We are proposing to maintain the generally applicable revenue-based
nominal amount standard at 8 percent of the estimated average total
Parts A and B revenue of eligible clinicians in participating APM
Entities for QP Performance Periods 2019 and 2020.
c. Qualifying APM Participant (QP) and Partial QP Determination
QPs are eligible clinicians in an Advanced APM who have met a
threshold for a certain percentage of their patients or payments
through an Advanced APM. QPs are excluded from MIPS for the year, and
receive a 5 percent APM Incentive Payment for each year they are QPs
beginning in 2019 through 2024. The statute sets thresholds for the
level of participation in Advanced APMs required for an eligible
clinician to become a QP for a year. For Advanced APMs that start or
end during the Medicare QP Performance Period and operate
[[Page 30014]]
continuously for a minimum of 60 days during the Medicare QP
Performance Period for the year, we are proposing to make QP
determinations using payment or patient data only for the dates that
APM Entities were able to participate in the Advanced APM per the terms
of the Advanced APM, not for the full Medicare QP Performance Period.
Eligible clinicians who participate in Advanced APMs but do not meet
the QP or Partial QP thresholds are subject to MIPS reporting
requirements and payment adjustments.
d. All-Payer Combination Option
The All-Payer Combination Option, which uses a calculation based on
both the Medicare Option and the eligible clinician's participation in
Other Payer Advanced APMs to conduct QP determinations, is applicable
beginning in performance year 2019. To become a QP through the All-
Payer Combination Option, an eligible clinician must participate in an
Advanced APM with CMS, as well as an Other Payer Advanced APM. We
identify Other Payer Advanced APMs based on information submitted to us
by eligible clinicians, APM Entities, and in some cases by payers,
including states and Medicare Advantage Organizations. In addition, the
eligible clinician or the APM Entity must submit information to CMS so
that we can determine whether other payer arrangements are Other Payer
Advanced APMs and whether the eligible clinician meets the requisite QP
threshold of participation. To be an Other Payer Advanced APM, as set
forth in section 1833(z)(2)(B)(ii) and (C)(ii) of the Act and
implemented in the CY 2017 Quality Payment Program final rule, a
payment arrangement with a payer (for example, payment arrangements
authorized under Title XIX, Medicare Health Plan payment arrangements,
and payment arrangements in CMS Multi-Payer Models) must meet all three
of the following criteria: (1) CEHRT is used; (2) the payment
arrangement must require the use of quality measures comparable to
those in the quality performance category under MIPS and; (3) the
payment arrangement must either require the APM Entities to bear more
than nominal financial risk if actual aggregate expenditures exceed
expected aggregate expenditures, or be a Medicaid Medical Home Model
that meets criteria comparable to Medical Home Models expanded under
section 1115A(c) of the Act.
We are proposing modifications pertaining to the third criterion
that the payment arrangement must either require the APM Entities to
bear more than nominal financial risk if actual aggregate expenditures
exceed expected aggregate expenditures; or be a Medicaid Medical Home
Model that meets criteria comparable to Medical Home Models expanded
under section 1115A(c) of the Act. Specifically, we are proposing to
add a revenue-based nominal amount standard in addition to the
benchmark-based nominal amount standard that would be applicable only
to payment arrangements in which risk is expressly defined in terms of
revenue.
We are proposing modifications to our methodologies to determine
whether eligible clinicians will meet the QP thresholds using the All-
Payer Combination Option. Specifically, we are proposing to conduct all
QP determinations under the All-Payer Combination Option at the
individual eligible clinician level and are seeking comment on any
possible exceptions to this proposed policy that would be warranted,
such as a determination based on APM Entity group performance under the
All-Payer Combination Option for eligible clinicians participating in
CMS Multi-Payer Models. We are also proposing to establish an All-Payer
QP Performance Period to assess participation in Other Payer Advanced
APMs under the All-Payer Combination Option, and to rename the QP
Performance Period we established in rulemaking last year as the
Medicare QP Performance Period.
We are proposing to modify the information submission requirements
for the All-Payer Combination Option. Specifically, we are proposing
modifications to the information we require to make APM Entity or
eligible clinician initiated determinations of Other Payer Advanced
APMs after the All-Payer QP Performance Period, as well as the
information we require to perform QP determinations under the All-Payer
Combination Option. We are also proposing policies on the handling of
information submitted for purposes of assessment under the All-Payer
Combination Option.
We are proposing a Payer Initiated Other Payer Advanced APM
Determination Process, which would allow certain other payers,
including payment arrangements authorized under Title XIX, Medicare
Health Plans, and payers with payment arrangements in CMS Multi-Payer
Models, to request that we determine whether their other payer
arrangements are Other Payer Advanced APMs starting prior to the 2019
All-Payer QP Performance Period and each year thereafter.
e. Physician-Focused Payment Models (PFPMs)
The PTAC is an 11-member federal advisory committee that is an
important avenue for the creation of innovative payment models. The
PTAC is charged with reviewing stakeholders' proposed PFPMs, and making
comments and recommendations to the Secretary regarding whether they
meet the PFPM criteria established by the Secretary through rulemaking
in the CY 2017 Quality Payment Program final rule. PTAC comments and
recommendations will be reviewed by the CMS Innovation Center and the
Secretary, and we will post a detailed response to them on the CMS Web
site. We are seeking comments on broadening the definition of PFPM to
include payment arrangements that involve Medicaid or the Children's
Health Insurance Program (CHIP) as a payer even if Medicare is not
included as a payer. This broadened definition might be more inclusive
of potential PFPMs that could focus on areas not generally applicable
to the Medicare population, and could engage more stakeholders in
designing PFPMs. In addition, as we gain experience with public
submission of PFPM proposals to the PTAC, we are seeking comments on
the Secretary's criteria and stakeholders' needs in developing PFPM
proposals aimed at meeting the criteria.
4. Summary of Major Provisions for the Merit-Based Incentive Payment
System (MIPS)
For Quality Payment Program Year 2 which is the second year of the
MIPS and includes the performance periods in 2018 and the 2020 MIPS
payment year, we are proposing the following policies:
a. Quality
We previously finalized that the quality performance category would
comprise 60 percent of the final score for the transition year and 50
percent of the final score for the 2020 MIPS payment year (81 FR
77100). For the 2020 MIPS payment year, now we are proposing to
maintain a 60 percent weight for the quality performance category
contingent upon our proposal to reweight the cost performance category
to zero for the 2020 MIPS payment year as discussed in section
II.C.6.b.(2) in this proposed rule. Quality measures are selected
annually through a call for quality measures, and a final list of
quality measures will be published in the Federal Register by November
1 of each year. Except as discussed in section II.C.6.b.(3)(a)(iii) of
this proposed rule with regard to the
[[Page 30015]]
CAHPS for MIPS survey, we are not proposing any changes to the
submission criteria for quality measures in this proposed rule. We are
proposing for the CAHPS for MIPS survey for the Quality Payment Program
Year 2 and future years that the survey administration period would, at
a minimum, span over 8 weeks and would end no later than February 28th
following the applicable performance period. In addition, we are
proposing for the Quality Payment Program Year 2 and future years to
remove two Summary Survey Modules (SSM), specifically, ``Helping You to
Take Medication as Directed'' and ``Between Visit Communication'' from
the CAHPS for MIPS survey.
For the 2018 MIPS performance period, we previously finalized that
the data completeness threshold would increase to 60 percent for data
submitted on quality measures using QCDRs, qualified registries, via
EHR, or Medicare Part B claims. We noted that these thresholds for data
submitted on quality measures using QCDRs, qualified registries, via
EHR, or Medicare Part B claims would increase for performance periods
occurring in 2019 and future years. However, as discussed in section
II.C.6.b. of this proposed rule, we are proposing for the 2018 MIPS
performance period to maintain the transition year data completeness
threshold of 50 percent for data submitted on quality measures using
QCDRs, qualified registries, EHR, or Medicare Part B claims to provide
an additional year for individual MIPS eligible clinicians and groups
to gain experience with the MIPS before increasing the data
completeness threshold. However, we are proposing to increase the data
completeness threshold for the 2021 MIPS payment year to 60 percent for
data submitted on quality measures using QCDRs, qualified registries,
EHR, or Medicare Part B claims. We anticipate that for performance
periods going forward, as MIPS eligible clinicians gain experience with
the MIPS, we would further increase these thresholds over time.
b. Improvement Activities
Improvement activities are those that support broad aims within
healthcare delivery, including care coordination, beneficiary
engagement, population management, and health equity. In response to
comments from experts and stakeholders across the healthcare system,
improvement activities were given relative weights of high and medium.
For the 2020 MIPS payment year, we previously finalized that the
improvement activities performance category would comprise 15 percent
of the final score (81 FR 77179). For performance periods occurring in
2018, we are not proposing any changes in improvement activities
scoring as discussed in the CY 2017 Quality Payment Program final rule
(81 FR 77312).
As discussed in the appendices of this proposed rule, we are
proposing new improvement activities (Table F) and improvement
activities with changes (Table G) for the 2018 MIPS performance period
and future years for inclusion in the Improvement Activities Inventory.
Activities proposed in this section would apply for the 2018 MIPS
performance period and future performance periods unless further
modified via notice and comment rulemaking. We refer readers to Table H
of the CY 2017 Quality Payment Program final rule for a list of all the
previously finalized improvement activities (81 FR 77817 through
77831).
As discussed in section II.C.6.e.3.(c) of this proposed rule, we
are proposing to expand our definition of how we will recognize an
individual MIPS eligible clinician or group as being a certified
patient-centered medical home or comparable specialty practice. We
finalized at Sec. 414.1380(b)(3)(iv) in the CY 2017 Quality Payment
Program final rule that a certified patient-centered medical home
includes practice sites with current certification from a national
program, regional or state program, private payer or other body that
administers patient-centered medical home accreditation. We are
proposing in section II.C.6.e.(3)(b) of this proposed rule that
eligible clinicians in practices that have been randomized to the
control group in the CPC+ model would also receive full credit as a
Medical Home Model. In addition, for group reporters, for the 2018 MIPS
performance period and future performance periods, we are proposing to
require that at least 50 percent of the practice sites within a TIN
must be recognized as a certified or recognized patient-centered
medical home or comparable specialty practice to receive full credit in
the improvement activities performance category.
As discussed in section II.C.6.f.(2)(d) of this proposed rule, in
recognition of improvement activities as supporting the central mission
of a unified Quality Payment Program, we propose to continue to
designate activities in the Improvement Activities Inventory that will
also qualify for the advancing care information bonus score. This is
consistent with our desire to recognize that CEHRT is often deployed to
improve care in ways that our programs should recognize.
c. Advancing Care Information
For the Quality Payment Program Year 2, the advancing care
information performance category comprises 25 percent of the final
score. However, if a MIPS eligible clinician is participating in a MIPS
APM the advancing care information performance category may comprise 30
percent or 75 percent of the final score depending on the availability
of APM quality data for reporting. Objectives and measures in the
advancing care information performance category focus on the secure
exchange of health information and the use CEHRT to support patient
engagement and improved healthcare quality. While we continue to
recommend that physicians and clinicians migrate to the implementation
and use of EHR technology certified to the 2015 Edition so they may
take advantage of improved functionalities, including care coordination
and technical advancements such as application programming interfaces,
or APIs, we recognize that some practices may have challenges in
adopting new certified health IT. Therefore we are proposing that MIPS
eligible clinicians may continue to use EHR technology certified to the
2014 Edition for the performance period in CY 2018. We are proposing
minor modifications to the advancing care information objectives and
measures and the 2017 advancing care information transition objectives
and measures. We are also proposing to add an exclusion for the e-
Prescribing and Health Information Exchange Objectives. We are
proposing to modify our scoring policy for the Public Health and
Clinical Data Registry Reporting Objectives and Measures for the
performance score and the bonus score.
We are also proposing to implement several provisions of the 21st
Century Cures Act (Pub. L. 114-255, enacted on December 13, 2016)
pertaining to hospital-based MIPS eligible clinicians, ambulatory
surgical center-based MIPS eligible clinicians, MIPS eligible
clinicians using decertified EHR technology, and significant hardship
exceptions under the MIPS. We are also proposing to add a significant
hardship exception for MIPS eligible clinicians in small practices.
d. Cost
In this proposed rule, we are proposing to weight the cost
performance category at zero percent of the final score for the 2020
MIPS payment year in order to improve clinician understanding of the
measures
[[Page 30016]]
and continue development of episode-based measures that will be used in
this performance category.
For the 2018 MIPS performance period, we are proposing to adopt for
the cost performance category the total per capita costs for all
attributed beneficiaries measure and the Medicare Spending per
Beneficiary (MSPB) measure that were adopted for the 2017 MIPS
performance period. For the 2018 MIPS performance period, we are not
proposing to use the 10 episode-based measures that were adopted for
the 2017 MIPS performance period. Although data on the episode-based
measures has been made available to clinicians in the past, we are in
the process of developing new episode-based measures with significant
clinician input and believe it would be more prudent to introduce these
new measures over time. We will continue to offer performance feedback
on episode-based measures prior to potential inclusion of these
measures in MIPS to increase clinician familiarity with the concept as
well as specific episode-based measures.
Specifically, we intend to provide feedback on these new episode-
based cost measures in the fall of this year for informational purposes
only. We intend to provide performance feedback on the MSPB and total
per capita cost measures by July 1, 2018, consistent with section
1848(q)(12) of the Act. In addition, we intend to offer feedback on
another set of newly developed episode-based cost measures in 2018 as
well. Therefore, clinicians would have received feedback on cost
measures at several points prior to the cost performance category
counting as part of the final score.
e. Submission Mechanisms
As discussed in section II.6.a. of this proposed rule, we are
proposing additional flexibility for submitting data. Individual MIPS
eligible clinicians or groups would be able to submit measures and
activities, as available and applicable, via as many mechanisms as
necessary to meet the requirements of the quality, improvement
activities, or advancing care information performance categories. We
expect that this option will provide clinicians the ability to select
the measures most meaningful to them, regardless of the submission
mechanism.
f. Virtual Groups
There are generally three ways to participate in MIPS: (1) As an
individual; (2) as a group; and (3) as a virtual group. In this
proposed rule, we are proposing to establish requirements for MIPS
participation at the virtual group level. We propose to define a
virtual group as a combination of two or more TINs composed of a solo
practitioner (a MIPS eligible clinician (as defined at Sec. 414.1305)
who bills under a TIN with no other NPIs billing under such TIN) or a
group (as defined at Sec. 414.1305) with 10 or fewer eligible
clinicians under the TIN that elects to form a virtual group with at
least one other such solo practitioner or group for a performance
period for a year.
To provide support and reduce burden, we intend to make technical
assistance (TA) available, to the extent feasible and appropriate, to
support clinicians who choose to come together as a virtual group for
the first 2 years of virtual group implementation applicable to the
2018 and 2019 performance years. Clinicians can access the TA
infrastructure that they may be already utilizing. For Quality Payment
Program Year 3, we intend to provide an electronic election process if
technically feasible. Clinicians who do not elect to contact their
designated TA representative would still have the option of contacting
the Quality Payment Program Service Center. We believe that our
proposal will create an election process that is simple and
straightforward.
g. MIPS APMs
In the CY 2017 Quality Payment Program final rule (81 FR 77246), we
finalized that MIPS eligible clinicians who participate in MIPS APMs
will be scored using the APM scoring standard instead of the generally
applicable MIPS scoring standard. For the 2018 performance period, we
are proposing modifications to the quality performance category
reporting requirements and scoring for MIPS eligible clinicians in most
MIPS APMs, and other modifications to the APM scoring standard. For
purposes of the APM scoring standard, we are proposing to add a fourth
snapshot date that would be used only to identify APM Entity groups
participating in those MIPS APMs that require full TIN participation.
Along with the other APM Entity groups, these APM Entity groups would
be used for the purposes of reporting and scoring under the APM scoring
standard described the CY 2017 Quality Payment Program final rule (81
FR 77246).
h. Facility-Based Measurement
For the transition year of MIPS, we considered an option for
facility-based MIPS eligible clinicians to elect to use their
institution's performance rates as a proxy for the MIPS eligible
clinician's performance in the quality and cost performance categories.
However, we did not propose an option for the transition year of MIPS
because there were several operational considerations that needed to be
addressed before this option could be implemented. After consideration
of comments received on the CY 2017 Quality Payment Program proposed
rule (81 FR 28192) and other comments received, we have decided to
implement facility-based measures for the 2018 MIPS performance period
and future performance periods to add more flexibility for clinicians
to be assessed in the context of the facilities at which they work. As
discussed in section II.C.7.b. of this proposed rule, we are proposing
facility-based measures policies related to applicable measures,
applicability to facility-based measurement, group participation, and
facility attribution.
For clinicians whose primary professional responsibilities are in a
healthcare facility we present a method to assess performance in the
quality and cost performance categories of MIPS based on the
performance of that facility in another value-based purchasing program.
While we propose to limit that opportunity to clinicians who practice
primarily in the hospital, we seek to expand the program to other
value-based payment programs as appropriate in the future. We discuss
that new method of scoring in section II.C.7.b.(4) of this proposed
rule.
i. Scoring
In the CY 2017 Quality Payment Program final rule, we finalized a
unified scoring system to determine a final score across the 4
performance categories (81 FR 77273 through 77276). For the 2018 MIPS
performance period, we propose to build on the scoring methodology we
finalized for the transition year, focusing on encouraging MIPS
eligible clinicians to meet data completeness requirements.
For quality performance category scoring, we are proposing to
extend some of the transition year policies to the 2018 MIPS
performance period and are also proposing several modifications to
existing policy. For the 2018 MIPS performance period, we are proposing
to maintain the 3 point floor for measures that can be reliably scored
against a benchmark. We are also proposing, to maintain the policy to
assign 3 points to measures that are submitted but do not have a
benchmark or do not meet the case minimum, which does not apply to the
CMS Web Interface measures and administrative claims based measures.
For the 2018 MIPS performance period, we are also proposing to lower
the number of points available for measures that do not meet the data
completeness
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criteria, except for a measure submitted by a small practice, which we
propose to continue to assign 3 points if the measure does not meet
data completeness. This does not apply to CMS Web Interface measures or
administrative claims based measures.
Beginning with the 2018 MIPS performance period, we are proposing
to add performance standards for scoring improvement for the quality
and cost performance categories. We are also proposing a systematic
approach to address topped out quality measures.
For the 2018 MIPS performance period, we are proposing that 3
performance category scores (quality, improvement activities, and
advancing care information) would be given weight in the final score,
or be reweighted if a performance category score is not available. We
are also proposing to add final score bonuses for small practices and
for MIPS eligible clinicians that care for complex patients.
We are also proposing that the final score will be compared against
a MIPS performance threshold of 15 points, which can be achieved via
multiple pathways and continues the gradual transition into MIPS.
j. Performance Feedback
We are proposing to provide Quality Payment Program performance
feedback to eligible clinicians and groups. Initially, we would provide
performance feedback on an annual basis. In future years, we aim to
provide performance feedback on a more frequent basis, which is in line
with clinician requests for timely, actionable feedback that they can
use to improve care.
k. Targeted Review Process
In the CY 2017 Quality Payment Program final rule (81 FR 77353), we
finalized a targeted review process under MIPS wherein a MIPS eligible
clinician or group may request that we review the calculation of the
MIPS payment adjustment factor and, as applicable, the calculation of
the additional MIPS payment adjustment factor applicable to such MIPS
eligible clinician or group for a year. We are not proposing any
changes to this process for the second year of the MIPS.
l. Third Party Intermediaries
We believe that third party intermediaries that collect or submit
data on behalf of individual eligible clinicians and groups
participating in MIPS and allowing for flexible reporting options, will
provide individual MIPS eligible clinicians and groups with options to
accommodate different practices and make measurement meaningful. In the
CY 2017 Quality Payment Program final rule (81 FR 77362), we finalized
that qualified registries, QCDRs, health IT vendors, and CMS-approved
survey vendors will have the ability to act as intermediaries on behalf
of individual MIPS eligible clinicians and groups for submission of
data to CMS across the quality, improvement activities, and advancing
care information performance categories. As discussed in section
II.C.10.a.(3) of this proposed rule, we propose to eliminate the self-
nomination submission method of email and require that QCDRs and
qualified registries submit their self-nomination applications via a
web-based tool for future program years beginning with performance
periods occurring in 2018. We are proposing, beginning with the 2019
performance period, a simplified process in which existing QCDRs or
qualified registries in good standing may continue their participation
in MIPS by attesting that their approved data validation plan, cost,
approved QCDR measures (applicable to QCDRs only), MIPS quality
measures, activities, services, and performance categories offered in
the previous year's performance period of MIPS have no changes. QCDRs
and qualified registries in good standing, may also make substantive or
minimal changes to their approved self-nomination application from the
previous year of MIPS that would be submitted during the self-
nomination period for CMS review and approval. By attesting that
certain aspects of their application will remain the same, as approved
from the previous year, existing QCDRs in good standing and qualified
registries will be spending less time completing the self-nomination
application, as was previously required. This process will be conducted
on an annual basis.
In addition, we are proposing that the term ``QCDR measures''
replace the term ``non-MIPS measures,'' without proposing any changes
to the definition, criteria, or requirements that were finalized in the
CY 2017 Quality Payment Program final rule (81 FR 77375). We are not
proposing any changes to the health IT vendors that obtain data from
CEHRT requirements.
Lastly, we are proposing for future program years, beginning with
performance periods occurring in 2018 that we remove the April 30th
survey vendor application deadline. We are proposing for the Quality
Payment Program Year 2 and future years that the vendor application
deadline be January 31st of the applicable performance year or a later
date specified by CMS. We will notify vendors of the application
deadline, to become a CMS-approved survey vendor through additional
communications and postings.
m. Public Reporting
As discussed in section II.C.11. of this proposed rule, we are
proposing public reporting of certain eligible clinician and group
Quality Payment Program information, including MIPS and APM data in an
easily understandable format as required under the MACRA.
n. Eligibility and Exclusion Provisions of the MIPS Program
In section II.C.1.f. of this proposed rule, we are proposing to
modify the definition of a non-patient facing MIPS eligible clinician
to apply to virtual groups. We are also proposing to specify that
groups considered to be non-patient facing (more than 75 percent of the
NPIs billing under the group's TIN meet the definition of a non-patient
facing individual MIPS eligible clinician) during the non-patient
facing determination period would automatically have their advancing
care information performance category reweighted to zero. Additionally,
in section II.C.3.c. of this proposed rule, we are proposing to modify
the low-volume threshold policy established in the CY 2017 Quality
Payment Program final rule. As discussed in section II.C.3.c of this
proposed rule, we believe that increasing the low-volume threshold to
less than or equal to $90,000 in Medicare Part B charges or 200 or
fewer Part-B enrolled Medicare beneficiaries would further decrease
burden on MIPS eligible clinicians that practice in rural areas or are
part of a small practice or are solo practitioners.
E. Payment Adjustments
As discussed in section V.C. of this proposed rule, for the 2020
payment year based on Advanced APM participation in 2018 performance
period, we estimate that approximately 180,000 to 245,000 clinicians
will become QPs, and therefore be exempt from MIPS and qualify for lump
sum incentive payments based on 5 percent of their Part B allowable
charges for covered professional services. We estimate that the total
lump sum incentive payments will be between approximately $590 and $800
million for the 2020 Quality Payment Program payment year. This
expected growth in QPs between the first and second year of the program
is due in part to reopening of CPC+ and Next Generation ACO for 2018,
and the ACO Track 1+ which is projected to have a large number of
participants, with a large majority reaching QP status.
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Under the policies in this proposed rule, we estimate that
approximately 572,000 eligible clinicians would be required to
participate in MIPS in the 2018 MIPS performance period, although this
number may vary depending on the number of eligible clinicians excluded
from MIPS based on their status as QPs or Partial QPs. After
restricting the population to eligible clinician types who are not
newly enrolled, the proposed increase in the low-volume threshold is
expected to exclude 585,560 clinicians who do not exceed the low-volume
threshold. In the 2020 MIPS payment year, MIPS payment adjustments will
be applied based on MIPS eligible clinicians' performance on specified
measures and activities within three integrated performance categories;
the fourth category of cost, as previously outlined, would be weighted
to zero in the 2020 MIPS payment year. Assuming that 90 percent of
eligible clinicians of all practice sizes participate in MIPS, we
estimate that MIPS payment adjustments will be approximately equally
distributed between negative MIPS payment adjustments ($173 million)
and positive MIPS payment adjustments ($173 million) to MIPS eligible
clinicians, as required by the statute to ensure budget neutrality.
Positive MIPS payment adjustments will also include up to an additional
$500 million for exceptional performance to MIPS eligible clinicians
whose final score meets or exceeds the additional performance threshold
of 70 points. These MIPS payment adjustments are expected to drive
quality improvement in the provision of MIPS eligible clinicians' care
to Medicare beneficiaries and to all patients in the health care
system. However, the distribution will change based on the final
population of MIPS eligible clinicians for CY 2020 and the distribution
of scores under the program. We believe that starting with these modest
initial MIPS payment adjustments is in the long-term best interest of
maximizing participation and starting the Quality Payment Program off
on the right foot, even if it limits the magnitude of MIPS positive
adjustments during the 2018 MIPS performance period. The increased
availability of Advanced APM opportunities, including through Medical
Home models, also provides earlier avenues to earn APM incentive
payments for those eligible clinicians who choose to participate.
F. Benefits and Costs of Proposed Rule
The Quality Payment Program may result in quality improvements and
improvements to the patients' experience of care as MIPS eligible
clinicians respond to the incentives for high-quality care provided by
MIPS and implement care quality improvements in their clinical
practices.
We also quantify several costs associated with this rule. We
estimate that this proposed rule will result in approximately $857
million in collection of information-related burden. We estimate that
the incremental collection of information-related burden associated
with this proposed rule is approximately $12.4 million relative to the
estimated burden of continuing the policies the CY 2017 Quality Payment
Program final rule, which is $869 million. We also estimate regulatory
review costs of $4.8 million for this proposed rule, comparable to the
regulatory review costs of the CY 2017 Quality Payment Program proposed
rule. We estimate that federal expenditures will include $173 million
in revenue neutral payment adjustments and $500 million for exceptional
performance payments. Additional federal expenditures include
approximately $590-$800 million in APM incentive payments to QPs.
G. Stakeholder Input
In developing this proposed rule, we sought feedback from
stakeholders and the public throughout the process, including in the CY
2017 Quality Payment Program final rule with comment period, listening
sessions, webinars, and other listening venues. We received a high
degree of interest from a broad spectrum of stakeholders. We thank our
many commenters and acknowledge their valued input throughout the
rulemaking process. We discuss the substance of relevant comments in
the appropriate sections of this proposed rule, though we were not able
to address all comments or all issues that all commenters brought forth
due to the volume of comments and feedback. In general, commenters
continue to support establishment of the Quality Payment Program and
maintain optimism as we move from pure FFS Medicare payment towards an
enhanced focus on the quality and value of care. Public support for our
proposed approach and policies in the proposed rule focused on the
potential for improving the quality of care delivered to beneficiaries
and increasing value to the public--while rewarding eligible clinicians
for their efforts.
We thank stakeholders again for their considered responses
throughout our process, in various venues, including comments on the
Request for Information Regarding Implementation of the Merit-based
Incentive Payment System, Promotion of Alternative Payment Models, and
Incentive Payments for Participation in Eligible Alternative Payment
Models (herein referred to as the MIPS and APMs RFI) (80 FR 59102
through 59113) and the CY 2017 Quality Payment Program final rule (81
FR 77008 through 77831). We intend to continue open communication with
stakeholders, including consultation with tribes and tribal officials,
on an ongoing basis as we develop the Quality Payment Program in future
years.
II. Provisions of the Proposed Regulations and Analysis of and
Responses to Comments
A. Introduction
The Quality Payment Program, authorized by the Medicare Access and
CHIP Reauthorization Act of 2015 (MACRA) is a new approach for
reforming care across the health care delivery system for eligible
clinicians. Under the Quality Payment Program, eligible clinicians can
participate via one of two pathways: Advanced Alternative Payment
Models (APMs); or the Merit-based Incentive Payment System (MIPS). We
began implementing the Quality Payment Program through rulemaking for
calendar year (CY) 2017. This rule provides proposed updates for the
second and future years of the Quality Payment Program.
B. Definitions
At Sec. 414.1305, subpart O, we propose to define the following
terms:
All-Payer QP Performance Period.
Ambulatory Surgical Center (ASC)-based MIPS eligible
clinician.
CMS Multi-Payer Model.
Full TIN APM.
Improvement Scoring.
Medicare QP Performance Period.
Other MIPS APM.
Virtual group.
We propose to revise the definitions of the following terms:
Affiliated practitioner.
APM Entity.
Attributed beneficiary.
Certified Electronic Health Record Technology (CEHRT).
Final Score.
Hospital-based MIPS eligible clinician.
Low-volume threshold.
Medicaid APM.
Non-patient facing MIPS eligible clinician.
Other Payer Advanced APM.
Rural areas.
We propose to remove the following terms:
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Advanced APM Entity.
QP Performance Period.
These terms and definitions are discussed in detail in relevant
sections of this proposed rule.
C. MIPS Program Details
1. MIPS Eligible Clinicians
a. Definition of a MIPS Eligible Clinician
In the CY 2017 Quality Payment Program final rule (81 FR77040
through 77041), we defined at Sec. 414.1305 a MIPS eligible clinician,
as identified by a unique billing TIN and NPI combination used to
assess performance, as any of the following (excluding those identified
at Sec. 414.1310(b)): A physician (as defined in section 1861(r) of
the Act), a physician assistant, nurse practitioner, and clinical nurse
specialist (as such terms are defined in section 1861(aa)(5) of the
Act), a certified registered nurse anesthetist (as defined in section
1861(bb)(2) of the Act), and a group that includes such clinicians. We
established at Sec. 414.1310(b) and (c) that the following are
excluded from this definition per the statutory exclusions defined in
section 1848(q)(1)(C)(ii) and (v) of the Act: (1) QPs; (2) Partial QPs
who choose not to report on applicable measures and activities that are
required to be reported under MIPS for any given performance period in
a year; (3) low-volume threshold eligible clinicians; and (4) new
Medicare-enrolled eligible clinicians. In accordance with sections
1848(q)(1)(A) and (q)(1)(C)(vi) of the Act, we established at Sec.
414.1310(b)(2) that eligible clinicians (as defined at Sec. 414.1305)
who are not MIPS eligible clinicians have the option to voluntarily
report measures and activities for MIPS. Additionally, we established
at Sec. 414.1310(d) that in no case will a MIPS payment adjustment
apply to the items and services furnished during a year by eligible
clinicians who are not MIPS eligible clinicians, as described in Sec.
414.1310(b) and (c), including those who voluntarily report on
applicable measures and activities specified under MIPS.
In the CY 2017 Quality Payment Program final rule (81 FR 77340), we
noted that the MIPS payment adjustment applies only to the amount
otherwise paid under Part B with respect to items and services
furnished by a MIPS eligible clinician during a year, in which we will
apply the MIPS payment adjustment at the TIN/NPI level. We have
received requests for additional clarifications on which specific Part
B services are subject to the MIPS payment adjustment, as well as which
Part B services are included for eligibility determinations. We note
that when Part B items or services are rendered by suppliers that are
also MIPS eligible clinicians, there may be circumstances in which it
is not operationally feasible for us to attribute those items or
services to a MIPS eligible clinician at an NPI level in order to
include them for purposes of applying the MIPS payment adjustment or
making eligibility determinations.
To further clarify, there are circumstances that involve Part B
prescription drugs and durable medical equipment where the supplier may
also be a MIPS eligible clinician. In circumstances in which a MIPS
eligible clinician furnishes a Part B covered item or service such as
prescribing Part B drugs that are dispensed, administered, and billed
by a supplier that is a MIPS eligible clinician, or ordering durable
medical equipment that is administered and billed by a supplier that is
a MIPS eligible clinician, it is not operationally feasible for us at
this time to associate those billed allowable charges with a MIPS
eligible clinician at an NPI level in order to include them for
purposes of applying the MIPS payment adjustment or making eligibility
determinations. For Part B items and services furnished by a MIPS
eligible clinician such as purchasing and administering Part B drugs
that are billed by the MIPS eligible clinician, such items and services
may be subject to MIPS adjustment based on the MIPS eligible
clinician's performance during the applicable performance period or
included for eligibility determinations. For those billed Medicare Part
B allowable charges relating to the purchasing and administration of
Part B drugs that we are able to associate with a MIPS eligible
clinician at an NPI level, such items and services furnished by the
MIPS eligible clinician would be included for purposes of applying the
MIPS payment adjustment or making eligibility determinations.
b. Group Practice (Group)
As discussed in the CY 2017 Quality Payment Program final rule (81
FR 77088 through 77831), we indicated that we will assess performance
either for individual MIPS eligible clinicians or for groups. We
defined a group at Sec. 414.1305 as a single Taxpayer Identification
Number (TIN) with two or more eligible clinicians (including at least
one MIPS eligible clinician), as identified by their individual NPI,
who have reassigned their Medicare billing rights to the TIN. We
recognize that MIPS eligible clinicians participating in MIPS may be
part of a TIN that has one portion of its NPIs participating in MIPS
according to the generally applicable scoring criteria while the
remaining portion of its NPIs is participating in a MIPS APM or an
Advanced APM according to the MIPS APM scoring standard. In the CY 2017
Quality Payment Program final rule (81 FR 77058), we noted that except
for groups containing APM participants, we are not permitting groups to
``split'' TINs if they choose to participate in MIPS as a group. Thus,
we would like to clarify that we consider a group to be either an
entire single TIN or portion of a TIN that: (1) Is participating in
MIPS according to the generally applicable scoring criteria while the
remaining portion of the TIN is participating in a MIPS APM or an
Advanced APM according to the MIPS APM scoring standard; and (2)
chooses to participate in MIPS at the group level. Also, we defined an
APM Entity group at Sec. 414.1305 as a group of eligible clinicians
participating in an APM Entity, as identified by a combination of the
APM identifier, APM Entity identifier, TIN, and NPI for each
participating eligible clinician.
c. Small Practices
In the CY 2017 Quality Payment Program final rule (81 FR 77188), we
defined the term small practices at Sec. 414.1305 as practices
consisting of 15 or fewer clinicians and solo practitioners. In section
II.C.4.d. of this proposed rule, we discuss how small practice status
would apply to virtual groups. Also, in the final rule, we noted that
we would not make an eligibility determination regarding the size of
small practices, but indicated that small practices would attest to the
size of their group practice (81 FR 77057). However, we have since
realized that our system needs to account for small practice size in
advance of a performance period for operational purposes relating to
assessing and scoring the improvement activities performance category,
determining hardship exceptions for small practices as proposed in this
proposed rule, calculating the small practice bonus for the final score
as proposed in this proposed rule, and identifying small practices
eligible for technical assistance. As a result, we believe it is
critical to modify the way in which small practice size would be
determined. To make eligibility determinations regarding the size of
small practices for performance periods occurring in 2018 and future
years, we propose that CMS would determine the size of small practices
as described in this section of the proposed rule. As noted in the CY
2017 Quality Payment
[[Page 30020]]
Program final rule, the size of a group (including a small practice)
would be determined before exclusions are applied (81 FR 77057). We
note that group size determinations are based on the number of NPIs
associated with a TIN, which would include clinicians (NPIs) who may be
excluded from MIPS participation and do not meet the definition of a
MIPS eligible clinician.
To make eligibility determinations regarding the size of small
practices for performance periods occurring in 2018 and future years,
we propose that CMS would determine the size of small practices by
utilizing claims data. For purposes of this section, we are coining the
term ``small practice size determination period'' to mean a 12-month
assessment period, which consists of an analysis of claims data that
spans from the last 4 months of a calendar year 2 years prior to the
performance period followed by the first 8 months of the next calendar
year and includes a 30-day claims run out. This would allow us to
inform small practices of their status near the beginning of the
performance period as it pertains to eligibility relating to technical
assistance, applicable improvement activities criteria, the proposed
hardship exception for small practices under the advancing care
information performance category, and the proposed small practice bonus
for the final score.
Thus, for purposes of performance periods occurring in 2018 and the
2020 MIPS payment year, we would identify small practices based on 12
months of data starting from September 1, 2016 to August 31, 2017. We
would not change an eligibility determination regarding the size of a
small practice once the determination is made for a given performance
period and MIPS payment year. We recognize that there may be
circumstances in which the small practice size determinations made by
CMS do not reflect the real-time size of such practices. We considered
two options that could address such potential discrepancies. One option
would include an expansion of the proposed small practice size
determination period to 24 months with two 12-month segments of data
analysis (before and during the performance period), in which CMS would
conduct a second analysis of claims data during the performance period.
Such an expanded determination period may better capture the real-time
size of small practices, but determinations made during the performance
period prevent our system from being able to account for the assessment
and scoring of the improvement activities performance category and
identification of small practices eligible for technical assistance
prior to the performance period. Specifically, our system needs to
capture small practice determinations in advance of the performance
period in order for the system to reflect the applicable requirements
for the improvement activities performance category and when a small
practice bonus would be applied. A second option would include an
attestation component, in which a small practice that was not
identified as a small practice during the proposed small practice size
determination period would be able to attest to the size of their group
practice prior to the performance period. However, this second option
would require us to develop several operational improvements, such as a
manual process or system that would provide an attestation mechanism
for small practices, and a verification process to ensure that only
small practices are identified as eligible for technical assistance.
Since individual MIPS eligible clinicians and groups are not required
to register to participate in MIPS (except for groups utilizing the CMS
Web Interface for the Quality Payment Program or administering the
CAHPS for MIPS survey), requiring small practices to attest to the size
of their group practice prior to the performance period could increase
burden on individual MIPS eligible clinicians and groups that are not
already utilizing the CMS Web Interface for the Quality Payment Program
or administering the CAHPS for MIPS survey. We solicit public comment
on the proposal regarding how CMS would determine small practice size.
d. Rural Area and Health Professional Shortage Area Practices
In the CY 2017 Quality Payment Program final rule (81 FR 77188), we
finalized at Sec. 414.1380 that for individual MIPS eligible
clinicians and groups that are located in rural areas or geographic
HPSAs, to achieve full credit under the improvement activities
performance category, one high-weighted or two medium-weighted
improvement activities are required. In addition, we defined rural
areas at Sec. 414.1305 as clinicians in ZIP codes designated as rural,
using the most recent Health Resources and Services Administration
(HRSA) Area Health Resource File data set available; and Health
Professional Shortage Areas (HPSAs) at Sec. 414.1305 as areas
designated under section 332(a)(1)(A) of the Public Health Service Act.
For technical accuracy purposes, we are proposing to modify the
definition of a rural areas at Sec. 414.1305 as ZIP codes designated
as rural, using the most recent Health Resources and Services
Administration (HRSA) Area Health Resource File data set available. We
recognize that there are cases in which an individual MIPS eligible
clinician (including a solo practitioner) or a group may have multiple
practice sites associated with its TIN and as a result, it is critical
for us to outline the application of rural area and HPSA practice
designations to such practices. For performance periods occurring in
2017, we consider an individual MIPS eligible clinician or a group with
at least one practice site under its TIN in a ZIP code designated as a
rural area or HPSA to be a rural area or HPSA practice. For performance
periods occurring in 2018 and future years, we believe that a higher
threshold than one practice within a TIN is necessary to designate an
individual MIPS eligible clinician, a group, or a virtual group as a
rural or HPSA practice. We recognize that the establishment of a higher
threshold starting in 2018 would more appropriately identify groups and
virtual groups with multiple practices under a group's TIN or TINs that
are part of a virtual group as rural or HPSA practices and ensure that
groups and virtual groups are assessed and scored according to
requirements that are applicable and appropriate. We note that in the
CY 2017 Quality Payment Program final rule (81 FR 77048 through 77049),
we defined a non-patient facing MIPS eligible clinician at Sec.
414.1305 as including a group provided that more than 75 percent of the
NPIs billing under the group's TIN meet the definition of a non-patient
facing individual MIPS eligible clinician during the non-patient facing
determination period. We refer readers to section II.C.1.e. of this
proposed rule for our proposal to modify the definition of a non-
patient facing MIPS eligible clinician. We believe that using a similar
threshold for applying the rural and HPSA designation to an individual
MIPS eligible clinician, a group, or virtual group with multiple
practices under its TIN or TINs within a virtual group will add
consistency for such practices across the MIPS as it pertains to groups
and virtual groups obtaining such statuses. Also, we believe that
establishing a 75 percent threshold renders an adequate representation
of a group or virtual group where a significant portion of a group or a
virtual group is identified as having such status. Therefore, for
performance periods occurring in 2018 and future
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years, we propose that an individual MIPS eligible clinician, a group,
or a virtual with multiple practices under its TIN or TINs within a
virtual group would be designated as a rural or HPSA practice if more
than 75 percent of NPIs billing under the individual MIPS eligible
clinician or group's TIN or within a virtual group, as applicable, are
designated in a ZIP code as a rural area or HPSA. We solicit public
comment on these proposals.
e. Non-Patient Facing MIPS Eligible Clinicians
Section 1848(q)(2)(C)(iv) of the Act requires the Secretary, in
specifying measures and activities for a performance category, to give
consideration to the circumstances of professional types (or
subcategories of those types determined by practice characteristics)
who typically furnish services that do not involve face-to-face
interaction with a patient. To the extent feasible and appropriate, the
Secretary may take those circumstances into account and apply
alternative measures or activities that fulfill the goals of the
applicable performance category to such non-patient facing MIPS
eligible clinicians. In carrying out these provisions, we are required
to consult with non-patient facing MIPS eligible clinicians.
In addition, section 1848(q)(5)(F) of the Act allows the Secretary
to re-weight MIPS performance categories if there are not sufficient
measures and activities applicable and available to each type of MIPS
eligible clinician. We assume many non-patient facing MIPS eligible
clinicians will not have sufficient measures and activities applicable
and available to report under the performance categories under MIPS. We
refer readers to section II.C.6.f.(7) of this proposed rule for the
discussion regarding how we address performance category weighting for
MIPS eligible clinicians for whom no measures or activities are
applicable and available in a given category.
In the CY 2017 Quality Payment Program final rule (81 FR 77048
through 77049), we defined a non-patient facing MIPS eligible clinician
for MIPS at Sec. 414.1305 as an individual MIPS eligible clinician
that bills 100 or fewer patient-facing encounters (including Medicare
telehealth services defined in section 1834(m) of the Act) during the
non-patient facing determination period, and a group provided that more
than 75 percent of the NPIs billing under the group's TIN meet the
definition of a non-patient facing individual MIPS eligible clinician
during the non-patient facing determination period. In order to account
for the formation of virtual groups starting in the 2018 performance
year and how non-patient facing determinations would apply to virtual
groups, we need to modify the definition of a non-patient facing MIPS
eligible clinician. Therefore, for performance periods occurring in
2018 and future years, we propose to modify the definition of a non-
patient facing MIPS eligible clinician at Sec. 414.1305 to mean an
individual MIPS eligible clinician that bills 100 or fewer patient-
facing encounters (including Medicare telehealth services defined in
section 1834(m) of the Act) during the non-patient facing determination
period, and a group or virtual group provided that more than 75 percent
of the NPIs billing under the group's TIN or within a virtual group, as
applicable, meet the definition of a non-patient facing individual MIPS
eligible clinician during the non-patient facing determination period.
We considered a patient-facing encounter to be an instance in which
the individual MIPS eligible clinician or group billed for items and
services furnished such as general office visits, outpatient visits,
and procedure codes under the PFS. We published the list of patient-
facing encounter codes for performance periods occurring in 2017 at
qpp.cms.gov/resources/education. We intend to publish the list of
patient-facing encounter codes for performance periods occurring in
2018 at qpp.cms.gov by the end of 2017. The list of patient-facing
encounter codes is used to determine the non-patient facing status of
MIPS eligible clinicians.
The list of patient-facing encounter codes include two general
categories of codes: Evaluation and Management (E&M) codes; and
Surgical and Procedural codes. E&M codes capture clinician-patient
encounters that occur in a variety of care settings, including office
or other outpatient settings, hospital inpatient settings, emergency
departments, and nursing facilities, in which clinicians utilize
information provided by patients regarding history, present illness,
and symptoms to determine the type of assessments to conduct.
Assessments are conducted on the affected body area(s) or organ
system(s) for clinicians to make medical decisions that establish a
diagnosis or select a management option(s).
Surgical and Procedural codes capture clinician-patient encounters
that involve procedures, surgeries, and other medical services
conducted by clinicians to treat medical conditions. In the case of
many of these services, evaluation and management work is included in
the payment for the single code instead of separately reported.
Patient-facing encounter codes from both of these categories describe
direct services furnished by eligible clinicians with impact on patient
safety, quality of care, and health outcomes.
For purposes of the non-patient facing policies under MIPS, the
utilization of E&M codes and Surgical and Procedural codes allows for
accurate identification of patient-facing encounters, and thus accurate
eligibility determinations regarding non-patient facing status. As a
result, MIPS eligible clinicians considered non-patient facing are able
to prepare to meet requirements applicable to non-patient facing MIPS
eligible clinicians. We propose to continue applying these policies for
purposes of the 2020 MIPS payment year and future years.
As described in the CY 2017 Quality Payment Program final rule, we
established the non-patient facing determination period for purposes of
identifying non-patient facing MIPS eligible clinicians in advance of
the performance period and during the performance period using
historical and performance period claims data. This eligibility
determination process allows us to begin identifying non-patient facing
MIPS eligible clinicians prior to or shortly after the start of the
performance period. The non-patient facing determination period is a
24-month assessment period, which includes a two-segment analysis of
claims data regarding patient-facing encounters during an initial 12-
month period prior to the performance period followed by another 12-
month period during the performance period. The initial 12-month
segment of the non-patient facing determination period spans from the
last 4 months of a calendar year 2 years prior to the performance
period followed by the first 8 months of the next calendar year and
includes a 60-day claims run out, which allows us to inform individual
MIPS eligible clinicians and groups of their non-patient facing status
during the month (December) prior to the start of the performance
period. The second 12-month segment of the non-patient facing
determination period spans from the last 4 months of a calendar year 1
year prior to the performance period followed by the first 8 months of
the performance period in the next calendar year and includes a 60-day
claims run out, which will allow us to inform additional individual
MIPS eligible clinicians and groups of their non-patient status during
the performance period.
[[Page 30022]]
However, based on our analysis of data from the initial segment of
the non-patient facing determination period for performance periods
occurring in 2017 (that is, data spanning from September 1, 2015 to
August 31, 2016), we found that it may not be necessary to include a
60-day claims run out since we could achieve a similar outcome for such
eligibility determinations by utilizing a 30-day claims run out. In our
comparison of data analysis results utilizing a 60-day claims run out
versus a 30-day claims run out, there was a 1 percent decrease in data
completeness (see Table 1 for data completeness regarding comparative
analysis of a 60-day and 30-day claims run out). The small decrease in
data completeness would not negatively impact individual MIPS eligible
clinicians or groups regarding non-patient facing determinations. We
believe that a 30-day claims run out would allow us to complete the
analysis and provide such determinations in a more timely manner.
Table 1--Percentages of Data Completeness for 60-Day and 30-Day Claims
Run Out
------------------------------------------------------------------------
30-day claims 60-day claims
Incurred year run out * run out *
------------------------------------------------------------------------
2015.................................. 97.1% 98.4%
------------------------------------------------------------------------
* Note: Completion rates are estimated and averaged at aggregated
service categories and may not be applicable to subsets of these
totals. For example, completion rates can vary by provider due to
claim processing practices, service mix, and post payment review
activity. Completion rates vary from subsections of a calendar year;
later portions of a given calendar year will be less complete than
earlier ones. Completion rates vary due to variance in loading
patterns due to technical, seasonal, policy, and legislative factors.
Completion rates are a function of the incurred date used to process
claims, and these factors will need to be updated if claims are
processed on a claim from date or other methodology.
For performance periods occurring in 2018 and future years, we
propose a modification to the non-patient facing determination period,
in which the initial 12-month segment of the non-patient facing
determination period would span from the last 4 months of a calendar
year 2 years prior to the performance period followed by the first 8
months of the next calendar year and include a 30-day claims run out;
and the second 12-month segment of the non-patient facing determination
period would span from the last 4 months of a calendar year 1 year
prior to the performance period followed by the first 8 months of the
performance period in the next calendar year and include a 30-day
claims run out. This proposal would only change the duration of the
claims run out, not the 12-month timeframes used for the first and
second segments of data analysis.
For purposes of the 2020 MIPS payment year, we would initially
identify individual MIPS eligible clinicians and groups who are
considered non-patient facing MIPS eligible clinicians based on 12
months of data starting from September 1, 2016, to August 31, 2017. To
account for the identification of additional individual MIPS eligible
clinicians and groups that may qualify as non-patient facing during
performance periods occurring in 2018, we would conduct another
eligibility determination analysis based on 12 months of data starting
from September 1, 2017, to August 31, 2018.
Similarly, for future years, we would conduct an initial
eligibility determination analysis based on 12 months of data
(consisting of the last 4 months of the calendar year 2 years prior to
the performance period and the first 8 months of the calendar year
prior to the performance period) to determine the non-patient facing
status of individual MIPS eligible clinicians and groups, and conduct
another eligibility determination analysis based on 12 months of data
(consisting of the last 4 months of the calendar year prior to the
performance period and the first 8 months of the performance period) to
determine the non-patient facing status of additional individual MIPS
eligible clinicians and groups. We would not change the non-patient
facing status of any individual MIPS eligible clinician or group
identified as non-patient facing during the first eligibility
determination analysis based on the second eligibility determination
analysis. Thus, an individual MIPS eligible clinician or group that is
identified as non-patient facing during the first eligibility
determination analysis would continue to be considered non-patient
facing for the duration of the performance period and MIPS payment year
regardless of the results of the second eligibility determination
analysis. We would conduct the second eligibility determination
analysis to account for the identification of additional, previously
unidentified individual MIPS eligible clinicians and groups that are
considered non-patient facing.
Additionally, in the CY 2017 Quality Payment Program final rule (81
FR 77241), we established a policy regarding the re-weighting of the
advancing care information performance category for non-patient facing
MIPS eligible clinicians. Specifically, MIPS eligible clinicians who
are considered to be non-patient facing will have their advancing care
information performance category automatically reweighted to zero (81
FR 77241). For groups that are considered to be non-patient facing
(that is, more than 75 percent of the NPIs billing under the group's
TIN meet the definition of a non-patient facing individual MIPS
eligible clinician) during the non-patient facing determination period,
we are proposing in section II.C.7.b.(3) of this proposed rule to
automatically reweight their advancing care information performance
category to zero.
We propose to continue applying these policies for purposes of the
2020 MIPS payment year and future years. We solicit public comment on
these proposals.
f. MIPS Eligible Clinicians Who Practice in Critical Access Hospitals
Billing Under Method II (Method II CAHs)
In the CY 2017 Quality Payment Program final rule (81 FR 77049), we
noted that MIPS eligible clinicians who practice in CAHs that bill
under Method I (Method I CAHs), the MIPS payment adjustment would apply
to payments made for items and services billed by MIPS eligible
clinicians, but it would not apply to the facility payment to the CAH
itself. For MIPS eligible clinicians who practice in Method II CAHs and
have not assigned their billing rights to the CAH, the MIPS payment
adjustment would apply in the same manner as for MIPS eligible
clinicians who bill for items and services in Method I CAHs. As
established in the CY 2017 Quality Payment Program final rule (81 FR
77051), the MIPS payment adjustment will apply to Method II CAH
payments under section 1834(g)(2)(B) of the Act when MIPS eligible
clinicians who practice in Method II CAHs have assigned their billing
rights to the CAH.
We refer readers to the CY 2017 Quality Payment Program final rule
(81 FR 77049 through 77051) for our discussion of MIPS eligible
clinicians who practice in Method II CAHs.
g. MIPS Eligible Clinicians Who Practice in Rural Health Clinics (RHCs)
or Federally Qualified Health Centers (FQHCs)
As established in the CY 2017 Quality Payment Program final rule
(81 FR 77051 through 77053), services rendered by an eligible clinician
under the RHC or FQHC methodology, will not be subject to the MIPS
payments adjustments. As noted, these eligible clinicians have the
option to voluntarily report on applicable measures and activities for
MIPS, in which the data received will not be used to assess their
[[Page 30023]]
performance for the purpose of the MIPS payment adjustment.
We refer readers to the CY 2017 Quality Payment Program final rule
(81 FR 77051 through 77053) for our discussion of MIPS eligible
clinicians who practice in RHCs or FQHCs.
h. MIPS Eligible Clinicians Who Practice in Ambulatory Surgical Centers
(ASCs), Home Health Agencies (HHAs), Hospice, and Hospital Outpatient
Departments (HOPDs)
Section 1848(q)(6)(E) of the Act provides that the MIPS payment
adjustment is applied to the amount otherwise paid under Part B with
respect to the items and services furnished by a MIPS eligible
clinician during a year. Some eligible clinicians may not receive MIPS
payment adjustments due to their billing methodologies. If a MIPS
eligible clinician furnishes items and services in an ASC, HHA,
Hospice, and/or HOPD and the facility bills for those items and
services (including prescription drugs) under the facility's all-
inclusive payment methodology or prospective payment system
methodology, the MIPS adjustment would not apply to the facility
payment itself. However, if a MIPS eligible clinician furnishes other
items and services in an ASC, HHA, Hospice, and/or HOPD and bills for
those items and services separately, such as under the PFS, the MIPS
adjustment would apply to payments made for such items and services.
Such items and services would also be considered for purposes of
applying the low-volume threshold. Therefore, we propose that services
rendered by an eligible clinician that are payable under the ASC, HHA,
Hospice, or HOPD methodology would not be subject to the MIPS payments
adjustments. However, these eligible clinicians have the option to
voluntarily report on applicable measures and activities for MIPS, in
which the data received would not be used to assess their performance
for the purpose of the MIPS payment adjustment. We note that eligible
clinicians who bill under both the PFS and one of these other billing
methodologies (ASC, HHA, Hospice, and/or HOPD) may be required to
participate in MIPS if they exceed the low-volume threshold and are
otherwise eligible clinicians; in such case, data reported would be
used to determine their MIPS payment adjustment. We solicit public
comments on this proposal.
i. MIPS Eligible Clinician Identifier
As described in the CY 2017 Quality Payment Program final rule (81
FR 77057), we established that the use of multiple identifiers that
allow MIPS eligible clinicians to be measured as an individual or
collectively through a group's performance and that the same identifier
be used for all four performance categories. While we have multiple
identifiers for participation and performance, we established the use
of a single identifier, TIN/NPI, for applying the MIPS payment
adjustment, regardless of how the MIPS eligible clinician is assessed.
(1) Individual Identifiers
As established in the CY 2017 Quality Payment Program final rule
(81 FR 77058), we define a MIPS eligible clinician at Sec. 414.1305 to
mean the use of a combination of unique billing TIN and NPI combination
as the identifier to assess performance of an individual MIPS eligible
clinician. Each unique TIN/NPI combination is considered a different
MIPS eligible clinician, and MIPS performance is assessed separately
for each TIN under which an individual bills.
(2) Group Identifiers for Performance
As established in the CY 2017 Quality Payment Program final rule
(81 FR 77059), we codified the definition of a group at Sec. 414.1305
to mean a group that consists of a single TIN with two or more eligible
clinicians (including at least one MIPS eligible clinician), as
identified by their individual NPI, who have reassigned their billing
rights to the TIN.
(3) APM Entity Group Identifier for Performance
As described in the CY 2017 Quality Payment Program final rule (81
FR 77060), we established that each eligible clinician who is a
participant of an APM Entity is identified by a unique APM participant
identifier. The unique APM participant identifier is a combination of
four identifiers: (1) APM Identifier (established by CMS; for example,
XXXXXX); (2) APM Entity identifier (established under the APM by CMS;
for example, AA00001111); (3) TIN(s) (9 numeric characters; for
example, XXXXXXXXX); (4) EP NPI (10 numeric characters; for example,
1111111111). We codified the definition of an APM Entity group at Sec.
414.1305 to mean a group of eligible clinicians participating in an APM
Entity, as identified by a combination of the APM identifier, APM
Entity identifier, TIN, and NPI for each participating eligible
clinician.
2. Exclusions
a. New Medicare-Enrolled Eligible Clinician
As established in the CY 2017 Quality Payment Program final rule
(81 FR 77061 through 77062), we defined a new Medicare-enrolled
eligible clinician at Sec. 414.1305 as a professional who first
becomes a Medicare-enrolled eligible clinician within the PECOS during
the performance period for a year and had not previously submitted
claims under Medicare such as an individual, an entity, or a part of a
physician group or under a different billing number or tax identifier.
Additionally, we established at Sec. 414.1310(c) that these eligible
clinicians will not be treated as a MIPS eligible clinician until the
subsequent year and the performance period for such subsequent year. We
established at Sec. 414.1310(d) that in no case would a MIPS payment
adjustment apply to the items and services furnished during a year by
new Medicare-enrolled eligible clinicians for the applicable
performance period.
We used the term ``new Medicare-enrolled eligible clinician
determination period'' to refer to the 12 months of a calendar year
applicable to the performance period. During the new Medicare-enrolled
eligible clinician determination period, we conduct eligibility
determinations on a quarterly basis to the extent that is technically
feasible to identify new Medicare-enrolled eligible clinicians that
would be excluded from the requirement to participate in MIPS for the
applicable performance period.
b. Qualifying APM Participant (QP) and Partial Qualifying APM
Participant (Partial QP)
In the CY 2017 Quality Payment Program final rule (81 FR 77062), we
established at Sec. 414.1305 that a QP (as defined at Sec. 414.1305)
is not a MIPS eligible clinician, and is therefore excluded from MIPS.
Also, we established that a Partial QP (as defined, at Sec. 414.1305)
who does not report on applicable measures and activities that are
required to be reported under MIPS for any given performance period in
a year is not a MIPS eligible clinician.
c. Low-Volume Threshold
Section 1848(q)(1)(C)(ii)(III) of the Act provides that the
definition of a MIPS eligible clinician does not include MIPS eligible
clinicians who are below the low-volume threshold selected by the
Secretary under section 1848(q)(1)(C)(iv) of the Act for a given year.
Section 1848(q)(1)(C)(iv) of the Act requires the Secretary to select a
low-volume
[[Page 30024]]
threshold to apply for the purposes of this exclusion which may include
one or more of the following: (1) The minimum number, as determined by
the Secretary, of Part B-enrolled individuals who are treated by the
MIPS eligible clinician for a particular performance period; (2) the
minimum number, as determined by the Secretary, of items and services
furnished to Part B-enrolled individuals by the MIPS eligible clinician
for a particular performance period; and (3) the minimum amount, as
determined by the Secretary, of allowed charges billed by the MIPS
eligible clinician for a particular performance period.
In the CY 2017 Quality Payment Program final rule (81 FR 77069
through 77070), we defined individual MIPS eligible clinicians or
groups who do not exceed the low-volume threshold at Sec. 414.1305 as
an individual MIPS eligible clinician or group who, during the low-
volume threshold determination period, has Medicare Part B allowed
charges less than or equal to $30,000 or provides care for 100 or fewer
Part B-enrolled Medicare beneficiaries. We established at Sec.
414.1310(b) that for a year, MIPS eligible clinicians who do not exceed
the low-volume threshold (as defined at Sec. 414.1305) are excluded
from MIPS for the performance period for a given calendar year.
In the CY 2017 Quality Payment Program final rule (81 FR 77069
through 77070), we defined the low-volume threshold determination
period to mean a 24-month assessment period, which includes a two-
segment analysis of claims data during an initial 12-month period prior
to the performance period followed by another 12-month period during
the performance period. The initial 12-month segment of the low-volume
threshold determination period spans from the last 4 months of a
calendar year 2 years prior to the performance period followed by the
first 8 months of the next calendar year and includes a 60-day claims
run out, which allows us to inform eligible clinicians and groups of
their low-volume status during the month (December) prior to the start
of the performance period. The second 12-month segment of the low-
volume threshold determination period spans from the last 4 months of a
calendar year 1 year prior to the performance period followed by the
first 8 months of the performance period in the next calendar year and
includes a 60-day claims run out, which allows us to inform additional
eligible clinicians and groups of their low-volume status during the
performance period.
We recognize that individual MIPS eligible clinicians and groups
that are small practices or practicing in designated rural areas face
unique dynamics and challenges such as fiscal limitations and workforce
shortages, but serve as a critical access point for care and provide a
safety net for vulnerable populations. Claims data shows that
approximately 15 percent of individual MIPS eligible clinicians (TIN/
NPIs) are considered to be practicing in rural areas after applying all
exclusions. Also, we have heard from stakeholders that MIPS eligible
clinicians practicing in small practices and designated rural areas
tend to have a patient population with a higher proportion of older
adults, as well as higher rates of poor health outcomes, co-
morbidities, chronic conditions, and other social risk factors, which
can result in the costs of providing care and services being
significantly higher compared to non-rural areas. We also have heard
from many solo practitioners and small practices who still face
challenges and additional resource burden in participating in the MIPS.
In the CY 2017 Quality Payment Program final rule, we did not
establish an adjustment for social risk factors in assessing and
scoring performance. In response to the CY 2017 Quality Payment Program
final rule, we received public comments indicating that individual MIPS
eligible clinicians and groups practicing in designated rural areas
would be negatively impacted and at a disadvantage if assessment and
scoring methodology did not adjust for social risk factors.
Additionally, commenters expressed concern that such individual MIPS
eligible clinicians and groups may be disproportionately more
susceptible to lower performance scores across all performance
categories and negative MIPS payments adjustments, and as a result,
such outcomes may further strain already limited fiscal resources and
workforce shortages, and negatively impact access to care (reduction
and/or elimination of available services).
After the consideration of stakeholder feedback provided during
informal listening sessions since the publication of the CY 2017
Quality Payment Program final rule, we are proposing to modify the low-
volume threshold policy established in the CY 2017 Quality Payment
Program final rule. We believe that increasing the dollar amount and
beneficiary count of the low-volume threshold would further reduce the
number of eligible clinicians that are required to participate in the
MIPS, which would reduce the burden on individual MIPS eligible
clinicians and groups practicing in small practices and designated
rural areas. Based on our analysis of claims data, we found that
increasing the low-volume threshold to to exclude individual eligible
clinicians or groups that have Medicare Part B allowed charges less
than or equal to $90,000 or that provide care for 200 or fewer Part B-
enrolled Medicare beneficiaries will exclude approximately 134,000
additional clinicians from MIPS from the approximately 700,000
clinicians that would have been eligible based on the low-volume
threshold that was finalized in the CY 2017 Quality Payment Program
final rule. Almost half of the additionally excluded clinicians are in
small practices and approximately 17 percent are clinicians from
practices in designated rural areas. Applying this criterion decreases
the percent of the MIPS eligible clinicians that come from small
practices. For example, prior to any exclusions, clinicians in small
practices represent 35 percent of all clinicians billing Part B
services. After applying the eligibility criteria for the CY 2017
Quality Payment Program final rule, MIPS eligible clinicians in small
practices represent approximately 27 percent of the clinicians eligible
for MIPS; however, with the increased low-volume threshold,
approximately 22 percent of the clinicians eligible for MIPS are from
small practices. In our analysis, the proposed changes to the low-
volume threshold showed little impact on MIPS eligible clinicians from
practices in designated rural areas. MIPS eligible clinicians from
practices in designated rural areas account for 15 to 16 percent of the
total MIPS eligible population. We note that, due to data limitations,
we assessed rural status based on the status of individual TIN/NPI and
did not model any group definition for practices in designated rural
areas.
We believe that increasing the number of such individual eligible
clinicians and groups excluded from MIPS participation would reduce
burden and mitigate, to the extent feasible, the issue surrounding
confounding variables impacting performance under the MIPS. Therefore,
beginning with the 2018 MIPS performance period, we are proposing to
increase the low-volume threshold. Specifically, at Sec. 414.1305, we
are proposing to define an individual MIPS eligible clinician or group
who does not exceed the low-volume threshold as an individual MIPS
eligible clinician or group who, during the low-volume threshold
determination period, has Medicare Part B allowed charges less than or
equal to $90,000 or provides care for 200 or fewer Part B-enrolled
Medicare beneficiaries. This
[[Page 30025]]
would mean that 37 percent of individual MIPS eligible clinicians and
groups would be in MIPS based on the low-volume threshold exclusion
(and the other exclusions). However, 65 percent of Medicare payments
would still be captured under MIPS compared to 72.2 percent of Medicare
payments under the CY 2017 Quality Payment Program final rule.
We recognize that increasing the dollar amount and beneficiary
count of the low-volume threshold would increase the number of
individual MIPS eligible clinicians and groups excluded from MIPS. We
assessed various levels of increases and found that $90,000 as the
dollar amount and 200 as the beneficiary count balances the need to
account for individual MIPS eligible clinicians and groups who face
additional participation burden while not excluding a significant
portion of the clinician population.
MIPS eligible clinicians who do not exceed the low-volume threshold
(as defined at Sec. 414.1305) are excluded from MIPS for the
performance period with respect to a year. The low-volume threshold
also applies to MIPS eligible clinicians who practice in APMs under the
APM scoring standard at the APM Entity level, in which APM Entities do
not exceed the low-volume threshold. In such cases, the MIPS eligible
clinicians participating in the MIPS APM Entity would be excluded from
the MIPS requirements for the applicable performance period and not
subject to a MIPS payment adjustment for the applicable year. Such an
exclusion would not affect an APM Entity's QP determination if the APM
Entity is an Advanced APM.
In the CY 2017 Quality Payment Program final rule, we established
the low-volume threshold determination period to refer to the timeframe
used to assess claims data for making eligibility determinations for
the low-volume threshold exclusion (81 FR 77069 through 77070). We
defined the low-volume threshold determination period to mean a 24-
month assessment period, which includes a two-segment analysis of
claims data during an initial 12-month period prior to the performance
period followed by another 12-month period during the performance
period. Based on our analysis of data from the initial segment of the
low-volume threshold determination period for performance periods
occurring in 2017 (that is, data spanning from September 1, 2015 to
August 31, 2016), we found that it may not be necessary to include a
60-day claims run out since we could achieve a similar outcome for such
eligibility determinations by utilizing a 30-day claims run out.
In our comparison of data analysis results utilizing a 60-day
claims run out versus a 30-day claims run out, there was a 1 percent
decrease in data completeness. The small decrease in data completeness
would not substantially impact individual MIPS eligible clinicians or
groups regarding low-volume threshold determinations. We believe that a
30-day claims run out would allow us to complete the analysis and
provide such determinations in a more timely manner. For performance
periods occurring in 2018 and future years, we propose a modification
to the low-volume threshold determination period, in which the initial
12-month segment of the low-volume threshold determination period would
span from the last 4 months of a calendar year 2 years prior to the
performance period followed by the first 8 months of the next calendar
year and include a 30-day claims run out; and the second 12-month
segment of the low-volume threshold determination period would span
from the last 4 months of a calendar year 1 year prior to the
performance period followed by the first 8 months of the performance
period in the next calendar year and include a 30-day claims run out.
This proposal would only change the duration of the claims run out, not
the 12-month timeframes used for the first and second segments of data
analysis.
For purposes of the 2020 MIPS payment year, we would initially
identify individual eligible clinicians and groups that do not exceed
the low-volume threshold based on 12 months of data starting from
September 1, 2016 to August 31, 2017. To account for the identification
of additional individual eligible clinicians and groups that do not
exceed the low-volume threshold during performance periods occurring in
2018, we would conduct another eligibility determination analysis based
on 12 months of data starting from September 1, 2017 to August 31,
2018. We would not change the low-volume status of any individual
eligible clinician or group identified as not exceeding the low-volume
threshold during the first eligibility determination analysis based on
the second eligibility determination analysis. Thus, an individual
eligible clinician or group that is identified as not exceeding the
low-volume threshold during the first eligibility determination
analysis would continue to be excluded from MIPS for the duration of
the performance period regardless of the results of the second
eligibility determination analysis. We established our policy to
include two eligibility determination analyses in order to prevent any
potential confusion for an individual eligible clinician or group to
know whether or not participate in MIPS; also, such policy makes it
clear from the onset as to which individual eligible clinicians and
groups would be required to participate in MIPS. We would conduct the
second eligibility determination analysis to account for the
identification of additional, previously unidentified individual
eligible clinicians and groups who do not exceed the low-volume
threshold. We note that low-volume threshold determinations are made at
the individual and group level, and not at the virtual group level.
We note that section 1848(q)(1)(C)(iv) of the Act requires the
Secretary to select a low-volume threshold to apply for the purposes of
this exclusion which may include one or more of the following: (1) The
minimum number, as determined by the Secretary, of Part B-enrolled
individuals who are treated by the MIPS eligible clinician for a
particular performance period; (2) the minimum number, as determined by
the Secretary, of items and services furnished to Part B-enrolled
individuals by the MIPS eligible clinician for a particular performance
period; and (3) the minimum amount, as determined by the Secretary, of
allowed charges billed by the MIPS eligible clinician for a particular
performance period. We have established a low-volume threshold that
accounts for the minimum number of Part-B enrolled individuals who are
treated by a MIPS eligible clinician and that accounts for the minimum
amount of allowed charges billed by a MIPS eligible clinician. We have
not made proposals specific to a minimum number of items and service
furnished to Part-B enrolled individuals by a MIPS eligible clinician.
In order to expand the ways in which claims data could be analyzed
for purposes of determining a more comprehensive assessment of the low-
volume threshold, we have assessed the option of establishing a low-
volume threshold for items and services furnished to Part-B enrolled
individuals by a MIPS eligible clinician. We have considered defining
items and services by using the number of patient encounters or
procedures associated with a clinician. Defining items and services by
patient encounters would assess each patient per visit or encounter
with the MIPS eligible clinician. We believe that defining items and
services by using the number of patient encounters or procedures is a
simple and straightforward approach for stakeholders to understand.
However,
[[Page 30026]]
we are concerned that using this unit of analysis could incentivize
clinicians to focus on volume of services rather than the value of
services provided to patients. Defining items and services by procedure
would tie a specific clinical procedure rendered to a patient to a
clinician. We solicit public comment on the methods of defining items
and services furnished by clinicians described above and alternate
methods of defining items and services.
For the individual MIPS eligible clinicians and groups that would
be excluded from MIPS participation as a result of an increased low-
volume threshold, we believe that in future years it would be
beneficial to provide, to the extent feasible, such individual MIPS
eligible clinicians and groups with the option to opt-in to MIPS
participation if they might otherwise be excluded under the low-volume
threshold such as where they only meet one of the threshold
determinations (including a third determination based on Part B items
and services, if established). For example, if a clinician meets the
low-volume threshold of $90,000 in allowed charges, but does not meet
the threshold of 200 patients or, if established, the threshold
pertaining to Part B items and services, we believe the clinician
should, to the extent feasible, have the opportunity to choose whether
or not to participate in the MIPS and be subject to MIPS payment
adjustments. We recognize that this choice would present additional
complexity to clinicians in understanding all of their available
options and may impose additional burden on clinicians by requiring
them to notify CMS of their decision. Because of these concerns and our
desire to establish options in a way that is a low-burden and user-
focused experience for all MIPS eligible clinicians, we would not be
able to offer this additional flexibility until performance periods
occurring in 2019. Therefore, as a means of expanding options for
clinicians and offering them the ability to participate in MIPS if they
otherwise would not be included, for the purposes of the 2021 MIPS
payment year, we propose to provide clinicians the ability to opt-in to
the MIPS if they meet or exceed one, but not all, of the low-volume
threshold determinations, including as defined by dollar amount,
beneficiary count or, if established, items and services. We request
public comment on this proposal.
We note that there may be additional considerations we should
address for scenarios in which an individual eligible clinician or a
group does not exceed the low-volume threshold and opts-in to
participate in MIPS. We therefore seek comment on any additional
considerations we should address when establishing this opt-in policy.
Such as, should we establish parameters for individual clinicians or
groups who elect to opt-in to participate in MIPS such as required
length of participation? Additionally, we note that there is the
potential with this opt-in policy for there to be an impact on our
ability to create quality benchmarks that meet our sample size
requirements. For example, if particularly small practices or solo
practitioners with low Part B beneficiary volumes opt-in, such
clinician's may lack sufficient sample size to be scored on many
quality measures, especially measures that do not apply to all of a
MIPS eligible clinician's patients. We therefore seek comment on how to
address any potential impact on our ability to create quality
benchmarks that meet our sample size requirements.
We solicit public comments on these proposals.
3. Group Reporting
a. Background
As described in the CY 2017 Quality Payment Program final rule, we
established the following requirements for groups (81 FR 77072):
Individual eligible clinicians and individual MIPS
eligible clinicians will have their performance assessed as a group as
part of a single TIN associated with two or more eligible clinicians
(including at least one MIPS eligible clinician), as identified by a
NPI, who have reassigned their Medicare billing rights to the TIN (at
Sec. 414.1310(e)(1)).
A group must meet the definition of a group at all times
during the performance period for the MIPS payment year in order to
have its performance assessed as a group (at Sec. 414.1310(e)(2)).
Individual eligible clinicians and individual MIPS
eligible clinicians within a group must aggregate their performance
data across the TIN to have their performance assessed as a group (at
Sec. 414.1310(e)(3)).
A group that elects to have its performance assessed as a
group will be assessed as a group across all four MIPS performance
categories (at Sec. 414.1310(e)(4)).
As noted in the CY 2017 Quality Payment Program final rule, we
would not make an eligibility determination regarding group size, but
indicated that groups would attest to their group size for purpose of
using the CMS Web Interface or a group identifying as a small practice
(81 FR 77057). In section II.C.1.d. of this proposed rule, we are
proposing to modify the way in which size would be determined for small
practices by establishing a process under which CMS would utilize
claims data to make small practice size determinations. Also, in
section II.C.4.e. of this proposed rule, we are proposing to establish
a policy under which CMS would utilize claims data to determine group
size for groups of 10 or fewer eligible clinicians seeking to form or
join a virtual group.
As noted in the CY 2017 Quality Payment Program final rule, a group
size would be determined before exclusions are applied (81 FR 77057).
We note that group size determinations are based on the number of NPIs
associated with a TIN, which would include clinicians (NPIs) who may be
excluded from MIPS participation and do not meet the definition of a
MIPS eligible clinician.
b. Registration
As described in the CY 2017 Quality Payment Program final rule (81
FR 77072 through 77073), we established, the following policies:
A group must adhere to an election process established and
required by CMS (Sec. 414.1310(e)(5)), which includes:
++ Groups will not be required to register to have their
performance assessed as a group except for groups submitting data on
performance measures via participation in the CMS Web Interface or
groups electing to report the CAHPS for MIPS survey for the quality
performance category. For all other data submission mechanisms, groups
must work with appropriate third party intermediaries as necessary to
ensure the data submitted clearly indicates that the data represent a
group submission rather than an individual submission.
++ In order for groups to elect participation via the CMS Web
Interface or administration of the CAHPS for MIPS survey, such groups
must register by June 30 of the applicable performance period (that is,
June 30, 2018, for performance periods occurring in 2018). We note that
groups participating in APMs that require APM Entities to report using
the CMS Web Interface are not required to register for the CMS Web
Interface or administer the CAHPS for MIPS survey separate from the
APM.
When groups submit data utilizing third party intermediaries, such
as a qualified registry, QCDR, or EHR, we are able to obtain group
information from the third party intermediary and discern whether the
data submitted represents group submission or individual submission
once the data are submitted.
[[Page 30027]]
In the CY 2017 Quality Payment Program final rule (81 FR 77072
through 77073), we discussed the implementation of a voluntary
registration process if technically feasible. Since the publication of
the CY 2017 Quality Payment Program final rule, we have determined that
it is not technically feasible to develop and build a voluntary
registration process. Until further notice, we are not implementing a
voluntary registration process.
Also, in the CY 2017 Quality Payment Program final rule (81 FR
77075), we expressed our commitment to pursue the active engagement of
stakeholders throughout the process of establishing and implementing
virtual groups. We received public comments in response to the CY 2017
Quality Payment Program final rule and additional stakeholder feedback
by hosting several virtual group listening sessions and convening user
groups. Many stakeholders requested that CMS provide an option that
would permit a portion of a group to participate in MIPS outside the
group by reporting as a separate subgroup or forming a virtual group.
Stakeholders indicated that the option would measure performance more
effectively, enable groups to identify areas for improvement at a
granular level that would further improve quality of care and health
outcomes, and increase coordination of care.
We recognize that groups, including multi-specialty groups, have
requested over the years that we make an option available to them that
would allow a portion of a group to report as a separate subgroup on
measures and activities that are more applicable to the subgroup and be
assessed and scored accordingly based on the performance of the
subgroup. In future rulemaking, we intend to explore the feasibility of
establishing group-related policies that would permit participation in
MIPS at a subgroup level and create such functionality through a new
identifier. We solicit public comment on the ways in which
participation in MIPS at the subgroup level could be established.
4. Virtual Groups
a. Background
There are generally three ways to participate in MIPS: (1)
Individual-level reporting; (2) group-level reporting; and (3) virtual
group-level reporting. We refer readers to sections II.C.1., II.C.3.,
and II.C.5. of this proposed rule for a discussion of the previously
established requirements for individual- and group-level participation
and our proposed policies for performance periods occurring in 2018 and
future years. In this rule, we are proposing to establish requirements
for MIPS participation at the virtual group level.
Section 1848(q)(5)(I) of the Act provides for the use of voluntary
virtual groups for certain assessment purposes, including the election
of practices to be a virtual group and the requirements for the
election process. Section 1848(q)(5)(I)(i) of the Act provides that
MIPS eligible clinicians electing to be a virtual group must: (1) Have
their performance assessed for the quality and cost performance
categories in a manner that applies the combined performance of all the
MIPS eligible clinicians in the virtual group to each MIPS eligible
clinician in the virtual group for the applicable performance period;
and (2) be scored for the quality and cost performance categories based
on such assessment. Section 1848(q)(5)(I)(ii) of the Act requires, in
accordance with section 1848(q)(5)(I)(iii) of the Act, the
establishment and implementation of a process that allows an individual
MIPS eligible clinician or a group consisting of not more than 10 MIPS
eligible clinicians to elect, for a given performance period, to be a
virtual group with at least one other such individual MIPS eligible
clinician or group. The virtual group may be based on appropriate
classifications of providers, such as by geographic areas or by
provider specialties defined by nationally recognized specialty boards
of certification or equivalent certification boards.
Section 1848(q)(5)(I)(iii) of the Act provides that the virtual
group election process must include the following requirements: (1) An
individual MIPS eligible clinician or group electing to be in a virtual
group must make their election prior to the start of the applicable
performance period and cannot change their election during the
performance period; (2) an individual MIPS eligible clinician or group
may elect to be in no more than one virtual group for a performance
period, and, in the case of a group, the election applies to all MIPS
eligible clinicians in the group; (3) a virtual group is a combination
of TINs; (4) the requirements must provide for formal written
agreements among individual MIPS eligible clinicians and groups
electing to be a virtual group; and (5) such other requirements as the
Secretary determines appropriate.
b. Definition of a Virtual Group
As noted above, section 1848(q)(5)(I)(ii) of the Act requires, in
accordance with section 1848(q)(5)(I)(iii) of the Act, the
establishment and implementation of a process that allows an individual
MIPS eligible clinician or group consisting of not more than 10 MIPS
eligible clinicians to elect, for a given performance period, to be a
virtual group with at least one other such individual MIPS eligible
clinician or group. Given that section 1848(q)(5)(I)(iii)(V) of the Act
provides that a virtual group is a combination of TINs, we interpret
the references to an ``individual'' MIPS eligible clinician in section
1848(q)(5)(I)(ii) of the Act to mean a solo practitioner, which, for
purposes of section 1848(q)(5)(I) of the Act, we propose to define as a
MIPS eligible clinician (as defined at Sec. 414.1305) who bills under
a TIN with no other NPIs billing under such TIN.
Also, we recognize that a group (TIN) may include not only NPIs who
meet the definition of a MIPS eligible clinician, but also NPIs who do
not meet the definition of a MIPS eligible clinician at Sec. 414.1305
and who are excluded from MIPS under Sec. 414.1310(b) or (c) based on
one of four exclusions (new Medicare-enrolled eligible clinician; QP;
Partial QP who chooses not to report on measures and activities under
MIPS; and eligible clinicians that do not exceed the low-volume
threshold). Thus, we interpret the references to a group ``consisting
of not more than 10'' MIPS eligible clinicians in section
1848(q)(5)(I)(ii) of the Act to mean that a group with 10 or fewer
eligible clinicians (as defined at Sec. 414.1305) would be eligible to
form or join a virtual group. For purposes of the MIPS payment
adjustment, the adjustment would apply only to NPIs in the virtual
group who meet the definition of a MIPS eligible clinician at Sec.
414.1305 and who are not excluded from MIPS under Sec. 414.1310(b) or
(c). We note that such groups, as defined at Sec. 414.1305, would need
to include at least one MIPS eligible clinician in order to be eligible
to join or form a virtual group. We refer readers to section II.C.4.g.
of this proposed rule for discussion regarding the assessment and
scoring of groups participating in MIPS as a virtual group.
We propose to define a virtual group at Sec. 414.1305 as a
combination of two or more TINs composed of a solo practitioner (a MIPS
eligible clinician (as defined at Sec. 414.1305) who bills under a TIN
with no other NPIs billing under such TIN), or a group (as defined at
Sec. 414.1305) with 10 or fewer eligible clinicians under the TIN that
elects to form a virtual group with at least one
[[Page 30028]]
other such solo practitioner or group for a performance period for a
year.
Lastly, we note that qualifications as a virtual group for purposes
of MIPS do not change the application of the physician self-referral
law to a financial relationship between a physician and an entity
furnishing designated health services, nor does it change the need for
such a financial relationship to comply with the physician self-
referral law.
We note that while entire TINs participate in a virtual group,
including each NPI under a TIN, and are assessed and scored
collectively as a virtual group, only NPIs that meet the definition of
a MIPS eligible clinician would be subject to a MIPS payment
adjustment. However, we note that, as discussed in section II.C.4.h. of
this proposed rule, any MIPS eligible clinician who is part of a TIN
participating in a virtual group and participating in a MIPS APM or
Advanced APM under the MIPS APM scoring standard would not receive a
MIPS payment adjustment based on the virtual group's final score, but
would receive a payment adjustment based on the MIPS APM scoring
standard.
Additionally, we recognize that there are circumstances in which a
TIN may have one portion of its NPIs participating under the generally
applicable MIPS scoring criteria while the remaining portion of NPIs
under the TIN is participating in a MIPS APM or an Advanced APM under
the MIPS APM scoring standard. In the CY 2017 Quality Payment Program
final rule (81 FR 77058), we noted that except for groups containing
APM participants, we are not permitting groups to ``split'' TINs if
they choose to participate in MIPS as a group (81 FR 77058). Thus, we
consider a group to mean an entire single TIN that elects to
participate in MIPS at the group or virtual group level, including
groups that have a portion of its NPIs participating in a MIPS APM or
an Advanced APM. We note that such groups would participate in MIPS
similar to other groups.
To clarify, for all groups, including groups containing
participants in a MIPS APM or an Advanced APM, the group's performance
assessment consists of the entire TIN regardless of whether the group
participates in MIPS as part of a virtual group. Generally, for groups
other than groups containing participants in a MIPS APM or an Advanced
APM, each MIPS eligible clinician under the TIN (TIN/NPI) receives a
MIPS adjustment based on the entire group's performance assessment
(entire TIN). For groups containing participants in a MIPS APM or an
Advanced APM, only the portion of the TIN that is being scored for MIPS
according to the generally applicable scoring criteria (TIN/NPI)
receives a MIPS adjustment based on the entire group's performance
assessment (entire TIN). The remaining portion of the TIN that is being
scored according to the APM scoring standard (TIN/NPI) receives a MIPS
adjustment based on that standard, or may be exempt from MIPS if they
achieve QP or Partial QP status.
We propose to apply a similar policy to groups, including groups
containing participants in a MIPS APM or an Advanced APM, that are
participating in MIPS as part of a virtual group. Specifically, for
groups other than groups containing participants in a MIPS APM or an
Advanced APM, each MIPS eligible clinician (TIN/NPI) would receive a
MIPS adjustment based on the virtual group's combined performance
assessment (combination of TINs). For groups containing participants in
a MIPS APM or an Advanced APM, only the portion of the TIN that is
being scored for MIPS according to the generally applicable scoring
criteria (TIN/NPI) would receive a MIPS adjustment based on the virtual
group's combined performance assessment (combination of TINs). As
discussed in section II.C.4.h. of this proposed rule, we are proposing
to use waiver authority to ensure that any participants in the group
who are participating in a MIPS APM receive their payment adjustment
based on their score under the APM scoring standard (TIN/NPI). Such
participants may be exempt from MIPS if they achieve QP or Partial QP
status.
We refer readers to section II.C.4.e. of this proposed rule for a
discussion of the proposed virtual group election process and section
II.C.4.g. of this proposed rule for discussion of our proposals
regarding the assessment and scoring of virtual groups.
We recognize that virtual groups would each have unique
characteristics and varying patient populations. As noted in section
II.C.4.a. of this proposed rule, the statute provides the Secretary
with discretion to establish appropriate classifications regarding the
composition of virtual groups such as by geographic area or specialty.
However, we believe it is important for virtual groups to have the
flexibility to determine their own composition at this time, and, as a
result, we are not proposing to establish any such classifications
regarding virtual group composition. We further note that the statute
does not limit the number of TINs that may form a virtual group, and we
are not proposing to establish such a limit at this time. We did
consider however proposing to establish such a limit, such as 50 or 100
participants. In particular, we are concerned that virtual groups of
too substantial a size (for example, 10 percent of all MIPS eligible
clinicians in a given specialty or sub-specialty) may make it difficult
to compare performance between and among clinicians. We believe that
limiting the number of virtual group participants could eventually
assist virtual groups as they aggregate their performance data across
the virtual group. However, we believe that as we initially implement
virtual groups, it is important for virtual groups to have the
flexibility to determine their own size, and thus, a better approach is
to not place such a limit on virtual group size. We will, however,
monitor the ways in which solo practitioners and groups with 10 or
fewer eligible clinicians form virtual groups and may propose to
establish appropriate classifications regarding virtual group
composition or a limit on the number of TINs that may form a virtual
group in future rulemaking as necessary. We solicit public comment on
these proposals, as well as our approach of not establishing
appropriate classifications (such as classification by geographic area
or specialty) regarding virtual group composition or a limit on the
number of TINs that may form a virtual group at this time.
In the CY 2017 Quality Payment Program final rule (81 FR 77073
through 77077), we expressed our commitment to pursue the active
engagement of stakeholders throughout the process of establishing and
implementing virtual groups. We received public comments in response to
the CY 2017 Quality Payment Program final rule and additional
stakeholder feedback by hosting several virtual group listening
sessions and convening user groups. Many stakeholders requested that
CMS provide an option that would permit a portion of a group to
participate in MIPS outside the group by reporting separately or
forming a virtual group. We refer readers to section II.C.b.3. of this
proposed rule for discussion regarding a potential option for
addressing such issue.
c. MIPS Virtual Group Identifier for Performance
To ensure that we have accurately captured all of the MIPS eligible
clinicians participating in a virtual group, we propose that each MIPS
eligible clinician who is part of a virtual group would be identified
by a unique virtual group participant identifier. The unique virtual
group participant
[[Page 30029]]
identifier would be a combination of three identifiers: (1) Virtual
group identifier (established by CMS; for example, XXXXXX); (2) TIN (9
numeric characters; for example, XXXXXXXXX); and (3) NPI (10 numeric
characters; for example, 1111111111). For example, a virtual
participant identifier could be VG-XXXXXX, TIN-XXXXXXXXX, NPI-
11111111111. We solicit public comment on this proposal.
d. Application of MIPS Group Policies to Virtual Groups
In the CY 2017 Quality Payment Program final rule (81 FR 77070
through 77072), we finalized various requirements for groups under MIPS
at Sec. 414.1310(e), under which groups electing to report at the
group level are assessed and scored across the TIN for all four
performance categories. We propose to apply our previously finalized
and proposed group policies to virtual groups, unless otherwise
specified. We recognize that there are instances in which we may need
to clarify or modify the application of certain previously finalized or
proposed group-related policies to virtual groups, such as the
definition of a non-patient facing MIPS eligible clinician; small
practice, rural area and HPSA designations; and groups that have a
portion of its NPIs participating in a MIPS APM or an Advanced APM (see
section II.C.4.b. of this proposed rule). More generally, such policies
may include those that require a calculation of the number of NPIs
across a TIN (given that a virtual group is a combination of TINs), the
application of any virtual group participant's status or designation to
the entire virtual group, and the applicability and availability of
certain measures and activities to any virtual group participant and to
the entire virtual group.
With regard to the applicability of the non-patient facing policies
to virtual groups, in the CY 2017 Quality Payment Program final rule
(81 FR 77048 through 77049), we defined the term non-patient facing
MIPS eligible clinician at Sec. 414.1305 as an individual MIPS
eligible clinician that bills 100 or fewer patient facing encounters
(including Medicare telehealth services defined in section 1834(m) of
the Act) during the non-patient facing determination period, and a
group provided that more than 75 percent of the NPIs billing under the
group's TIN meet the definition of a non-patient facing individual MIPS
eligible clinician during the non-patient facing determination period.
We are proposing to modify the definition of a non-patient facing MIPS
eligible clinician to include clinicians in a virtual group provided
that more than 75 percent of the NPIs billing under the virtual group's
TINs meet the definition of a non-patient facing individual MIPS
eligible clinician during the non-patient facing determination period.
We refer readers to section II.C.4.f. of this rule for the proposed
modification. We note that other policies previously established and
proposed in this proposed rule for non-patient facing groups would
apply to virtual groups. For example, as discussed in section II.C.1.e.
of this proposed rule, virtual groups determined to be non-patient
facing would have their advancing care information performance category
automatically reweighted to zero.
In regard to the application of small practice status to virtual
groups, we are proposing that a virtual group would be identified as
having a small practice status if the virtual group does not have 16 or
more members of a virtual group (NPIs). We refer readers to section
II.C.4.d. of this proposed rule for discussion regarding how small
practice status would apply to virtual groups for scoring under MIPS.
In the CY 2017 Quality Payment Program final rule (81 FR 77188), we
defined the term small practices at Sec. 414.1305 as practices
consisting of 15 or fewer clinicians and solo practitioners. In section
II.C.1.c. of this proposed rule, we are proposing for performance
periods occurring in 2018 and future years to identify small practices
by utilizing claims data. For performance periods occurring in 2018, we
would identify small practices based on 12 months of data starting from
September 1, 2016 to August 31, 2017.
In section II.C.1.e. of this rule, we propose to determine rural
area and HPSA practice designations for groups participating in MIPS at
the group level. We note that in section II.C.7.b we describe our
scoring proposals for practices that are in a rural area or HPSA
practice. For performance periods occurring in 2018 and future years,
we are proposing that a group with 75 percent or more of the TIN's
practice sites designated as rural areas or HPSA practices would be
designated as a rural area or HPSA at the group level. We are proposing
that a virtual group with 75 percent or more of the virtual group's
TINs designated as rural areas or HPSA practices would be designated as
a rural area or HPSA practice at the virtual group level. We note that
other policies previously established and proposed in this proposed
rule for rural area and HPSA groups would apply to virtual groups.
We recognize that the measures and activities available to groups
would also be available to virtual groups. Virtual groups would be
required to meet the reporting requirements for each measure and
activity, and the virtual group would be responsible for ensuring that
their measures and activities are aggregated across the virtual group
(for example, across their TINs). We note that other previously
established group-related policies and proposed policies in this
proposed rule pertaining to the four performance categories would apply
to virtual groups.
Therefore, we propose to apply MIPS group policies to virtual
groups except as otherwise specified. We solicit public comment on this
proposal. We are also interested on receiving feedback on how such
group-related policies previously established and proposed in this
proposed rule either would or would not apply to virtual groups. In
addition, we request public comment on any other policies that may need
to be clarified or modified with respect to virtual groups, such as
those that require a calculation of the number of NPIs across a TIN
(given that a virtual group is a combination of TINs), the application
of any virtual group participant's status or designation to the entire
virtual group, the application of the group reporting requirements for
the individual performance categories to virtual groups, and the
applicability and availability of certain measures and activities to
any virtual group participant and to the entire virtual group.
e. Election Process
As noted above, section 1848(q)(5)(I)(iii)(I) and (II) of the Act
provides that the virtual group election process must include certain
requirements, including that: (1) An individual MIPS eligible clinician
or group electing to be in a virtual group must make their election
prior to the start of the applicable performance period and cannot
change their election during the performance period; and (2) an
individual MIPS eligible clinician or group may elect to be in no more
than one virtual group for a performance period, and, in the case of a
group, the election applies to all MIPS eligible clinicians in the
group. We propose to codify at Sec. 414.1315(a) that a solo
practitioner or a group of 10 or fewer eligible clinicians must make
their election prior to the start of the applicable performance period
and cannot change their election during the performance period. Virtual
group participants may elect to be in no more than one virtual group
for a performance period and, in the case of a group, the election
applies to all MIPS eligible
[[Page 30030]]
clinicians in the group. For the 2018 performance year and future
years, we are proposing to establish an election period.
We propose to codify at Sec. 414.1315(b) that, beginning with
performance periods occurring in 2018, a solo practitioner, or group of
10 or fewer eligible clinicians electing to be in a virtual group must
make their election by December 1 of the calendar year preceding the
applicable performance period. For example, a solo practitioner or
group would need to make their election by December 1, 2017 to
participate in MIPS as a virtual group during the 2018 performance
period. Prior to the election deadline, a virtual group representative
would have the opportunity to make an election, on behalf of the
members of a virtual group, regarding the formation of a virtual group
for an applicable performance period. We intend to publish the
beginning date of the virtual group election period applicable to the
2018 performance period and future years in subregulatory guidance.
In order to provide support and reduce burden, we intend to make
technical assistance (TA) available, to the extent feasible and
appropriate, to support clinicians who choose to come together as a
virtual group. Clinicians can access TA infrastructure and resources
that they may already be utilizing). For Quality Payment Program year
3, we intend to provide an electronic election process if technically
feasible. We propose that clinicians who do not elect to contact their
designated TA representative would still have the option of contacting
the Quality Payment Program Service Center.
We propose to codify at Sec. 414.1315(c) a two-stage virtual group
election process, stage 1 of which is optional, for the applicable 2018
and 2019 performance periods. Stage 1 pertains to virtual group
eligibility determinations. In stage 1, solo practitioners and groups
with 10 or fewer eligible clinicians interested in forming or joining a
virtual group would have the option to contact their designated TA
representative or the Quality Payment Program Service Center in order
to obtain information pertaining to virtual groups and/or determine
whether or not they are eligible, as it relates to the practice size
requirement of a solo practitioner or a group of 10 or fewer eligible
clinicians, to participate in MIPS as a virtual group (Sec.
414.1315(a)(1)(i)). We note that activity involved in stage 1 is not
required, but a resource available to solo practitioners and groups
with 10 or fewer eligible clinicians; otherwise, solo practitioners or
groups with 10 or fewer eligible clinicians that do not engage in any
activity during stage 1, they would begin the election process at stage
2. For solo practitioners and groups who engage in stage 1 and were
determined eligible for virtual group participation, they would proceed
to stage 2. Engaging in stage 1 would provide solo practitioners and
groups with the option to confirm whether or not they are eligible to
join or form a virtual group before going to the lengths of executing
formal written agreements, submitting a formal election registration,
allocating resources for virtual group implementation, and other
related activities; whereas, engaging directly in stage 2 as an initial
step, solo practitioners and groups may have conducted all such efforts
to only have their election registration be rejected with no recourse
or remaining time to amend and resubmit.
During stage 1 of the virtual group election process, we would
determine whether or not a TIN is eligible to form or join a virtual
group. In order for a solo practitioner to be eligible to form or join
a virtual group, the solo practitioner would need to be considered a
MIPS eligible clinician (defined at Sec. 414.1305) who bills under a
TIN with no other NPIs billing under such TIN, and not excluded from
MIPS under Sec. 414.1310(b) and (c). In order for a group to be
eligible to form or join a virtual group, a group would need to have a
TIN size that does not exceed 10 eligible clinicians and not excluded
from MIPS based on the low-volume threshold exclusion at the group
level. For purposes of determining TIN size for virtual group
participation eligibility, we coin the term ``virtual group eligibility
determination period'' and define it to mean an analysis of claims data
during an assessment period of up to five months that would begin on
July 1 and end as late as November 30 of a calendar year prior to the
performance year and includes a 30-day claims run out.
To capture a real-time representation of TIN size, we propose to
analyze up to five months of claims data on a rolling basis, in which
virtual group eligibility determinations for each TIN would be updated
and made available monthly. We note that an eligibility determination
regarding TIN size is based on a relative point in time within the
five-month virtual group eligibility determination period, and not an
eligibility determination made at the end of such five-month
determination period. If at any time a TIN is determined to be eligible
to participate in MIPS as part of a virtual group, the TIN would retain
that status for the duration of the election period and the applicable
performance period. TINs could determine their status by contacting
their designated TA representative or the Quality Payment Program
Service Center; otherwise, the TIN's status would be determined at the
time that the TIN's virtual group election is submitted. For example,
if a group contacted their designated TA representative or the Quality
Payment Program Service Center on October 20, 2017, the claims data
analysis would include the months of July through September of 2017,
and if determined not to exceed 10 eligible clinicians, such TIN's size
status would be identified at such time and would be retained for the
duration of the election period and the 2018 performance period. If
another group contacted their designated TA representative or the
Quality Payment Program Service Center on November 20, 2017, the claims
data analysis would include the months of July through October of 2017,
and if determined not to exceed 10 eligible clinicians, such TIN's size
status would be identified at such time and would be retained for the
duration of the election period and the 2018 performance period.
We believe such a virtual group determination period process
provides a relative representation of real-time group size for purposes
of virtual group eligibility and allows groups to know their real-time
size status immediately and plan accordingly for virtual group
implementation. It is anticipated that starting in September of each
calendar year prior to the applicable performance year beginning in
2018, groups would be able to contact their designated TA
representative or the Quality Payment Program Service Center and
inquire about virtual group participation eligibility. We note that TIN
size determinations are based on the number of NPIs associated with a
TIN, which would include clinicians (NPIs) excluded from MIPS
participation and who do not meet the definition of a MIPS eligible
clinician.
For groups that do not choose to participate in stage 1 of the
election process (that is, the group does not request an eligibility
determination), we will make an eligibility determination during stage
2 of the election process. If a group began the election process at
stage 2 and if its TIN size is determined not to exceed 10 eligible
clinicians and not excluded based on the low-volume threshold exclusion
at the group level, the group is determined eligible to participate in
MIPS as part of a virtual group, and such virtual group eligibility
determination status would be retained
[[Page 30031]]
for the duration of the election period and applicable performance
period.
Stage 2 pertains to virtual group formation. For stage two, we
propose the following:
TINs comprising a virtual group must establish a written
formal agreement between each member of a virtual group prior to an
election (Sec. 414.1315(c)(2)(i)).
On behalf of a virtual group, the official designated
virtual group representative must submit an election by December 1 of
the calendar year prior to the start of the applicable performance
period. (Sec. 414.1315(c)(2)(ii)). We anticipate this election will
occur via email to the Quality Payment Program Service Center using the
following email address: MIPS_VirtualGroups@cms.hhs.gov.
The submission of a virtual group election must include,
at a minimum, information pertaining to each TIN and NPI associated
with the virtual group and contact information for the virtual group
representative (Sec. 414.1315(c)(2)(iii). A virtual group
representative would submit the following type of information: each TIN
associated with the virtual group; each NPI associated with a TIN that
is part of the virtual group; name of the virtual group representative;
affiliation of the virtual group representative to the virtual group;
contact information for the virtual group representative; and confirm
through acknowledgment that a written formal agreement has been
established between each member of the virtual group prior to election
and each member of the virtual group is aware of participating in MIPS
as a virtual group for an applicable performance period. Each member of
the virtual group must retain a copy of the virtual group's written
agreement. We note that the virtual group agreement is subject to the
MIPS data validation and auditing requirements as described in section
II.C.9.c. of this rule.
Once an election is made, the virtual group representative
must contact their designated CMS contact to update any election
information that changed during an applicable performance period one
time prior to the start of an applicable submission period (Sec.
414.1315(c)(2)(iv)). We anticipate that virtual groups will use the
Quality Payment Program Service Center as their designated CMS contact;
however, we will define this further in subregulatory guidance.
For stage 2 of the election process, we would review all submitted
election information; confirm whether or not each TIN within a virtual
group is eligible to participate in MIPS as part of a virtual group;
identify the NPIs within each TIN participating in a virtual group that
are excluded from MIPS in order to ensure that such NPIs would not
receive a MIPS payment adjustment or, when applicable and when
information is available, would receive a payment adjustment based on a
MIPS APM scoring standard; calculate the low-volume threshold at the
individual and group levels in order to determine whether or not a solo
practitioner or group is eligible to participate in MIPS as part of a
virtual group; and notify virtual groups as to whether or not they are
considered official virtual groups for the applicable performance
period. For virtual groups that are determined to have met the virtual
group formation criteria and identified as an official virtual group
participating in MIPS for an applicable performance period, we would
contact the official designated virtual group representative via email
notifying the virtual group of its official virtual group status and
issuing a virtual group identifier for performance (as described in
section II.C.4.c. of this proposed rule) that would accompany the
virtual group's submission of performance data during the submission
period.
In regard to virtual group determinations pertaining to the low-
volume threshold, we recognize that such determinations are made at the
individual and group level, but not at the virtual group level. The
low-volume threshold determinations are applicable to the way in which
individual eligible clinicians and groups participate in MIPS as
individual MIPS eligible clinicians (solo practitioners) or groups. For
example, if an individual MIPS eligible clinician is part of a practice
that is participating in MIPS at the individual level (reporting at the
individual level), then the low-volume threshold determination is made
at the individual level. Whereas, if an individual MIPS eligible
clinician is part of a practice that is participating in MIPS at the
group level (reporting at the group level), then the low-volume
threshold determination at the group level would be applicable to such
MIPS eligible clinician regardless of the low-volume threshold
determination made at the individual level because such individual MIPS
eligible clinician is part of a group reporting at the group level and
the low-volume threshold determinations for groups applies to the group
as a whole. Similarly, if a solo practitioner or a group with 10 or
fewer eligible clinicians seeks to participate in MIPS at the virtual
group level (reporting at the virtual group level), then the low-volume
threshold determination at the individual or group level would be
applicable to such solo practitioner or group with 10 or fewer eligible
clinicians. Thus, solo practitioners (individual MIPS eligible
clinicians) or groups with 10 or fewer eligible clinicians that are
determined not to exceed the low-volume threshold at the individual or
group level would not be eligible to participate in MIPS as an
individual, group, or virtual group.
As we engaged in various discussions with stakeholders during the
rulemaking process through listening sessions and user groups,
stakeholders indicated that many solo practitioners and small groups
have limited resources and technical capacities, which may make it
difficult for the entities to form virtual groups without sufficient
time and technical assistance. Depending on the resources and technical
capacities of the entities, stakeholders conveyed that it may take
entities 3 to 18 months to prepare to participate in MIPS as a virtual
group. The majority of stakeholders indicated that virtual groups would
need at least 6 to 12 months prior to the start of the 2018 performance
period to form virtual groups, prepare health IT systems, and train
staff to be ready for the implementation of virtual group related
activities by January 1, 2018.
We recognize that for the first year of virtual group formation and
implementation prior to the start of the 2018 performance period, the
timeframe for virtual groups to make an election by registering would
be relatively short, particularly from the date we issue the
publication of a final rule toward the end of the 2017 calendar year.
To provide solo practitioners and groups with 10 or fewer eligible
clinicians with additional time to assemble and coordinate resources,
and form a virtual group prior to the start of the 2018 performance
period, we are providing virtual groups with an opportunity to make an
election prior to the publication of our final rule. We intend for the
virtual group election process to be available as early as mid-
September of 2017; we will publicize the specific opening date via
subregulatory guidance. Virtual groups would have from mid-September to
December 1, 2017 to make an election for the 2018 performance year. In
regard to our proposed policies pertaining to virtual group
implementation (for example, definition of a virtual group and election
process requirements), we intend to closely align with the statutory
requirements in order to establish clear expectations for solo
practitioners and
[[Page 30032]]
small groups, and have an opportunity to begin the preparation of
forming virtual groups in advance of the publication of our final rule.
However, any MIPS eligible clinicians applying to be a virtual group
that does not meet all finalized virtual group requirements would not
be permitted to participate in MIPS as a virtual group.
As previously noted, groups participating in a virtual group would
have the size of their TIN determined for eligibility purposes. The
virtual group size would be determined one time for each performance
period. We recognize that the size of a group may fluctuate during a
performance period with eligible clinicians and/or MIPS eligible
clinicians joining or leaving a group. For groups within a virtual
group that are determined to have a group size of 10 eligible
clinicians or less based on the one time determination per applicable
performance year, any new eligible clinicians or MIPS eligible
clinicians that join the group during the performance period would
participate in MIPS as part of the virtual group. In such cases, we
recognize that a group may exceed 10 eligible clinicians associated
with its TIN during an applicable performance period, but at the time
of election, such group would have been determined eligible to form or
join a virtual group given that the TIN did not have more than 10
eligible clinicians associated with its TIN. As previously noted, the
virtual group representative would need to contact the Quality Payment
Program Service Center to update the virtual group's information that
was provided during the election period if any information changed
during an applicable performance period one time prior to the start of
an applicable submission period (for example, include new NPIs who
joined a TIN that is part of a virtual group). Virtual groups must re-
register before each performance period.
The statute provides that a solo practitioner (TIN/NPI) and a group
with 10 or fewer eligible clinicians may elect to be in no more than
one virtual group for a performance period. We note that such a solo
practitioner or a group that is part of a virtual group may not elect
to be in more than one virtual group for a performance period. Also,
the statute determines that a virtual group election by the group for
an applicable performance period applies to all MIPS eligible
clinicians in the group. In the case of a TIN within a virtual group
being acquired or merged with another TIN, or no longer operating as a
TIN (for example, a group practice closes) during a performance period,
such solo practitioner or group's performance data would continue to be
attributed to the virtual group. The remaining members of a virtual
group would continue to be part of the virtual group even if only one
solo practitioner or group remains. We consider a TIN that is acquired
or merged with another TIN, or no longer operating as a TIN (e.g., a
group practice closes) to mean a TIN that no longer exists or operates
under the auspices of such TIN during a performance year.
As outlined in section 1848(q)(5)(I)(iii) of the Act and previously
noted, a virtual group is a combination of TINs, which would include at
least two separate TINs associated with a solo practitioner (TIN/NPI),
or a group with 10 or fewer eligible clinicians and another such solo
practitioner, or group. However, given that a virtual group must be a
combination of TINs, we recognize that the composition of a virtual
group could include, for example, one solo practitioner (NPI) who is
practicing under multiple TINs, in which the solo practitioner would be
able to form a virtual group with his or her own self based on each TIN
assigned to the solo practitioner. For the number of TINs able to form
a virtual group, we note that there is not a limit to the number of
TINs able to comprise a virtual group.
f. Virtual Group Agreements
The statute provides for formal written agreements among the MIPS
eligible clinicians electing to form a virtual group. We propose that
each virtual group member would be required to execute formal written
agreements with each other virtual group member to ensure that
requirements and expectations of participation in MIPS are clearly
articulated, understood, and agreed upon. We note that a virtual group
may not include a solo practitioner or group as part of the virtual
group unless an authorized person of the TIN has executed a formal
written agreement. During the election process and submission of a
virtual group election, a designated virtual group representative would
be required to confirm through acknowledgement that an agreement is in
place between each member of the virtual group. An agreement would be
executed for at least one performance period. If a NPI joins or leaves
a TIN, or a change is made to a TIN that impacts the agreement itself,
such as a legal business name change, during the applicable performance
year, a virtual group would be required to update the agreement to
reflect such changes and submit changes to CMS via the Quality Payment
Program Service Center.
We propose, at Sec. 414.1315(c)(3), that a formal written
agreement between each member of a virtual group must include the
following elements:
Expressly state the only parties to the agreement are the
TINs and NPIs of the virtual group (at Sec. 414.1315(c)(3)(i)). For
example, the agreement may not be between a virtual group and another
entity, such as an independent practice association (IPA) or management
company that in turn has an agreement with one or more TINs within the
virtual group. Similarly, virtual groups should not use existing
contracts between TINs that include third parties.
Be executed on behalf of the TINs and the NPIs by
individuals who are authorized to bind the TINs and the NPIs,
respectively at Sec. 414.1315(c)(3)(ii)).
Expressly require each member of the virtual group
(including each NPI under each TIN) to agree to participate in MIPS as
a virtual group and comply with the requirements of the MIPS and all
other applicable laws and regulations (including, but not limited to,
federal criminal law, False Claims Act, anti-kickback statute, civil
monetary penalties law, Health Insurance Portability and Accountability
Act, and physician self-referral law) at Sec. 414.1315(c)(3)(iii)).
Require each TIN within a virtual group to notify all NPIs
associated with the TIN of their participation in the MIPS as a virtual
group at Sec. 414.1315(c)(3)(iv)).
Set forth the NPI's rights and obligations in, and
representation by, the virtual group, including without limitation, the
reporting requirements and how participation in MIPS as a virtual group
affects the ability of the NPI to participate in the MIPS outside of
the virtual group at Sec. 414.1315(c)(3)(v)).
Describe how the opportunity to receive payment
adjustments will encourage each member of the virtual group (including
each NPI under each TIN) to adhere to quality assurance and improvement
at Sec. 414.1315(c)(3)(vi)).
Require each member of the virtual group to update its
Medicare enrollment information, including the addition and deletion of
NPIs billing through a TIN that is part of a virtual group, on a timely
basis in accordance with Medicare program requirements and to notify
the virtual group of any such changes within 30 days after the change
at Sec. 414.1315(c)(3)(vii)).
Be for a term of at least one performance period as
specified in the formal written agreement at Sec.
414.1315(c)(3)(viii)).
[[Page 30033]]
Require completion of a close-out process upon termination
or expiration of the agreement that requires the TIN (group part of the
virtual group) or NPI (solo practitioner part of the virtual group) to
furnish all data necessary in order for the virtual group to aggregate
its data across the virtual group at Sec. 414.1315(c)(3)(ix)).
As part of the virtual group election ICR, we filed a 60-day notice
on June 14, 2017 (82 FR 27257), which includes an agreement template
that could be used by virtual groups and will be made available via
subregulatory guidance. The agreement template is not required, but
serves as a model agreement that could be utilized by virtual groups.
The agreement template includes all necessary elements required for
such an agreement.
We solicit public comment on these proposals.
Through the formal written agreements, we want to ensure that all
members of a virtual group are aware of their participation in a
virtual group. As noted above, formal written agreements must include a
provision that requires each TIN within a virtual group to notify all
NPIs associated with the TIN regarding their participation in the MIPS
as a virtual group in order to ensure that each member of a virtual
group is aware of their participation in the MIPS as a virtual group.
We want to implement an approach that considers a balance between the
need to ensure that all members of a virtual group are aware of their
participation in a virtual group and the minimization of administration
burden. We solicit public comment on approaches for virtual groups to
ensure that all members of a virtual group are aware of their
participation in the virtual group.
g. Reporting Requirements
As we noted in this proposed rule, we believe virtual groups should
generally be treated under the MIPS as groups. Therefore, for MIPS
eligible clinicians participating at the virtual group level, we
propose the following requirements:
Individual eligible clinicians and individual MIPS
eligible clinicians who are part of a TIN participating in MIPS at the
virtual group level would have their performance assessed as a virtual
group at Sec. 414.1315(d)(1).
Individual eligible clinicians and individual MIPS
eligible clinicians who are part of a TIN participating in MIPS at the
virtual group level would need to meet the definition of a virtual
group at all times during the performance period for the MIPS payment
year (at Sec. 414. 1315(d)(2)).
Individual eligible clinicians and individual MIPS
eligible clinicians who are part of a TIN participating in MIPS at the
virtual group level must aggregate their performance data across
multiple TINs in order for their performance to be assessed as a
virtual group (at Sec. 414.1315(d)(3)).
MIPS eligible clinicians that elect to participate in MIPS
at the virtual group level would have their performance assessed at the
virtual group level across all four MIPS performance categories (at
Sec. 414.1315(d)(4)).
Virtual groups would need to adhere to an election process
established and required by CMS (at Sec. 414.1315(d)(5)).
We solicit public comment on these proposals.
h. Assessment and Scoring for the MIPS Performance Categories
As noted above, section 1848(q)(5)(I)(i) of the Act provides that
eligible clinicians electing to be a virtual group will: (1) Have their
performance assessed for the quality and cost performance categories in
a manner that applies the combined performance of all eligible
clinicians in the virtual group to each MIPS eligible clinician (except
for those participating in a MIPS APM or an Advanced APM under the MIPS
APM scoring standard) in the virtual group for a performance period of
a year; and (2) be scored based on the assessment of the combined
performance described above regarding the quality and cost performance
categories for a performance period. We believe it is critical for
virtual groups to be assessed and scored at the virtual group level for
all performance categories; it eliminates the burden of virtual group
members having to report as a virtual group and separately outside of a
virtual group. Additionally, we believe that the assessment and scoring
at the virtual group level provides for a comprehensive measurement of
performance, shared responsibility, and an opportunity to effectively
and efficiently coordinate resources to also achieve performance under
the improvement activities and the advancing care information
performance categories. We propose at Sec. 414.1315 that virtual
groups would be assessed and scored across all four MIPS performance
categories at the virtual group level for a performance period of a
year.
In the CY 2017 Quality Payment Program final rule (81 FR 77319
through 77329), we established the MIPS final score methodology, which
will apply to virtual groups. We refer readers to sections II.C.7.b.
and II.C.8. of this proposed rule for scoring policies that would apply
to virtual groups.
As previously noted, we propose to allow solo practitioners and
groups with 10 or fewer eligible clinicians that have elected to be
part of a virtual group to have their performance measured and
aggregated at the virtual group level across all four performance
categories; however, we would apply payment adjustments at the
individual TIN/NPI level. Each TIN/NPI would receive a final score
based on the virtual group performance, but the payment adjustment
would still be applied at the TIN/NPI level. We would assign the
virtual group score to all TIN/NPIs billing under a TIN in the virtual
group during the performance period.
During the performance year, we recognize that NPIs in a TIN that
has joined a virtual group may also be participants in an APM. The TIN,
as part of the virtual group, must submit performance data for all
eligible clinicians associated with the TIN, including those
participating in APMs, to ensure that all eligible clinicians
associated with the TIN are being measured under MIPS.
For participants in MIPS APMs, we propose to use our authority
under section 1115A(d)(1) for MIPS APM authorized under section 1115A
of the Act, and under section 1899(f) for the Shared Savings Program,
to waive the requirement under section 1848 (q)(2)(5)(I)(i)(II) of the
Act that requires performance category scores from virtual group
reporting must be used to generate the composite score upon which the
MIPS payment adjustment is based for all TIN/NPIs in the virtual group.
Instead, we would use the score assigned to the MIPS eligible clinician
based on the applicable APM Entity score to determine MIPS payment
adjustments for all MIPS eligible clinicians that are part of an APM
Entity participating in a MIPS APM, in accordance with Sec. 414.1370,
instead of determining MIPS payment adjustments for these MIPS eligible
clinicians using the composite score of their virtual group.
APMs seek to deliver better care at lower cost and to test new ways
of paying for care and measuring and assessing performance. In the CY
2017 Quality Payment Program final rule, we established policies to the
address concerns we have expressed in regard to the application of
certain MIPS policies to MIPS eligible clinicians in MIPS APMs (81 FR
77246 through 77269). In section II.C.6.g. of this proposed rule, we
reiterate those concerns and propose additional policies for the APM
scoring standard. We believe it is important to
[[Page 30034]]
consistently apply the APM scoring standard under MIPS for eligible
clinicians participating in MIPS APMs in order to avoid potential
misalignments between the evaluation of performance under the terms of
the MIPS APM and evaluation of performance on measures and activities
under MIPS, and to preserve the integrity of the initiatives we are
testing. Therefore, we believe it is necessary to waive the requirement
to only use the virtual group scores under section 1848(q)(5)(I)(i)(II)
of the Act, and instead to apply the score under the APM scoring
standard for eligible clinicians in virtual groups who are also in an
APM Entity participating in an APM.
We note that MIPS eligible clinicians who are participants in both
a virtual group and a MIPS APM would be assessed under MIPS as part of
the virtual group and under the APM scoring standard as part of an APM
Entity group, but would receive their payment adjustment based only on
the APM Entity score. In the case of an eligible clinician
participating in both a virtual group and an Advanced APM who has
achieved QP status, the clinician would be assessed under MIPS as part
of the virtual group, but would still be excluded from the MIPS payment
adjustment as a result of his or her QP status. We refer readers to
section II.C.6.g.(2) of this proposed rule for further discussion
regarding the waiver and the CY 2017 Quality Payment Program final rule
(81 FR 77013) for discussion regarding the timeframe used for
determining QP status.
5. MIPS Performance Period
In the CY 2017 Quality Payment Program final rule (81 FR 77085), we
finalized at Sec. 414.1320(b)(1) that for purposes of the MIPS payment
year 2020, the performance period for the quality and cost performance
categories is CY 2018 (January 1, 2018 through December 31, 2018). For
the improvement activities and advancing care information performance
categories, we finalized at Sec. 414.1320(b)(2) that for purposes of
the MIPS payment year 2020, the performance period for the improvement
activities and advancing care information performance categories is a
minimum of a continuous 90-day period within CY 2018, up to and
including the full CY 2018 (January 1, 2018, through December 31,
2018). We are not proposing any changes to these policies.
We also finalized at Sec. 414.1325(f)(2) to use claims with dates
of service during the performance period that must be processed no
later than 60 days following the close of the performance period for
purposes of assessing performance and computing the MIPS payment
adjustment. Lastly, we finalized that individual MIPS eligible
clinicians or groups who report less than 12 months of data (due to
family leave, etc.) would be required to report all performance data
available from the applicable performance period (for example, CY 2018
or a minimum of a continuous 90-day period within CY 2018).
We are proposing at Sec. 414.1320(c) and (c)(1) that for purposes
of the MIPS payment year 2021 and future years, for the quality and
cost performance categories, the performance period under MIPS would be
the full calendar year (January 1 through December 31) that occurs 2
years prior to the applicable payment year. For example, for the MIPS
payment year 2021, the performance period would be CY 2019 (January 1,
2019 through December 31, 2019), and for the MIPS payment year 2022 the
performance period would be CY 2020 (January 1, 2020 through December
31, 2020).
We are proposing at Sec. 414.1320(d) and (d)(1) that for purposes
of the MIPS payment year 2021, the performance period for the
improvement activities and advancing care information performance
categories would be a minimum of a continuous 90-day period within the
calendar year that occurs 2 years prior to the applicable payment year,
up to and including the full CY 2019 (January 1, 2019 through December
31, 2019).
We request comments on our proposals for the performance period for
MIPS payment year 2021 and future years.
6. MIPS Performance Category Measures and Activities
a. Performance Category Measures and Reporting
(1) Submission Mechanisms
We finalized in the CY 2017 Quality Payment Program final rule (81
FR 77094) at Sec. 414.1325(a) that individual MIPS eligible clinicians
and groups must submit measures and activities, as applicable, for the
quality, improvement activities, and advancing care information
performance categories. For the cost performance category, we finalized
that each individual MIPS eligible clinician's and group's cost
performance would be calculated using administrative claims data. As a
result, individual MIPS eligible clinicians and groups are not required
to submit any additional information for the cost performance category.
For individual eligible clinicians and groups that are not MIPS
eligible clinicians, such as physical therapists, but elect to report
to MIPS, we will calculate administrative claims-based cost measures
and quality measures, if data are available. We finalized in the CY
2017 Quality Payment Program final rule (81 FR 77094 through 77095)
multiple data submission mechanisms for MIPS, which provide individual
MIPS eligible clinicians and groups with the flexibility to submit
their MIPS measures and activities in a manner that best accommodates
the characteristics of their practice, as indicated in Tables 2 and 3.
Table 2 summarizes the data submission mechanisms for individual MIPS
eligible clinicians that we finalized at Sec. 414.1325(b) and (e).
Table 3 summarizes the data submission mechanisms for groups that are
not reporting through an APM that we finalized at Sec. 414.1325(c) and
(e).
Table 2--Data Submission Mechanisms for MIPS Eligible Clinicians
Reporting Individually
[TIN/NPI]
------------------------------------------------------------------------
Performance category/submission Individual reporting data submission
combinations accepted mechanisms
------------------------------------------------------------------------
Quality........................... Claims.
QCDR.
Qualified registry.
EHR.
Cost.............................. Administrative claims.\1\
[[Page 30035]]
Advancing Care Information........ Attestation.
QCDR.
Qualified registry.
EHR.
Improvement Activities............ Attestation.
QCDR.
Qualified registry.
EHR.
------------------------------------------------------------------------
Table 3--Data Submission Mechanisms for MIPS Eligible Clinicians
Reporting as Groups (TIN)
------------------------------------------------------------------------
Performance category/submission Group reporting data submission
combinations accepted mechanisms
------------------------------------------------------------------------
Quality........................... QCDR.
Qualified registry.
EHR.
CMS Web Interface (groups of 25 or
more).
CMS-approved survey vendor for CAHPS
for MIPS (must be reported in
conjunction with another data
submission mechanism).
and
Administrative claims (for all-cause
hospital readmission measure; no
submission required).
Cost.............................. Administrative claims.\1\
Advancing Care Information........ Attestation.
QCDR.
Qualified registry.
EHR.
CMS Web Interface (groups of 25 or
more).
Improvement Activities............ Attestation.
QCDR.
Qualified registry.
EHR.
CMS Web Interface (groups of 25 or
more).
------------------------------------------------------------------------
We finalized at Sec. 414.1325(d) that individual MIPS eligible
clinicians and groups may elect to submit information via multiple
mechanisms; however, they must use the same identifier for all
performance categories, and they may only use one submission mechanism
per performance category. In response to the CY 2017 Quality Payment
Program final rule (81 FR 77089), we received comments supportive of
the use of multiple submission mechanisms for a single performance
category due to the flexibility it would provide clinicians. Another
commenter supported such an approach because they believed that the
scoring of only one submission mechanism per performance category may
influence which quality measures a MIPS eligible clinician chooses to
report given that the commenter believed only a limited number of
measures relevant to one's practice might be available through a
particular submission mechanism. The commenter also believed that such
flexibility would encourage continued participation in MIPS.
---------------------------------------------------------------------------
\1\ Requires no separate data submission to CMS: Measures are
calculated based on data available from MIPS eligible clinicians'
billings on Medicare Part B claims. Note: Claims differ from
administrative claims as they require MIPS eligible clinicians to
append certain billing codes to denominator eligible claims to
indicate the required quality action or exclusion occurred.
---------------------------------------------------------------------------
We are proposing to revise Sec. 414.1325(d) for purposes of the
2020 MIPS payment year and future years, beginning with performance
periods occurring in 2018, to allow individual MIPS eligible clinicians
and groups to submit data on measures and activities, as applicable,
via multiple data submission mechanisms for a single performance
category (specifically, the quality, improvement activities, or
advancing care information performance category). Under this proposal,
individual MIPS eligible clinicians and groups that have fewer than the
required number of measures and activities applicable and available
under one submission mechanism could be required to submit data on
additional measures and activities via one or more additional
submission mechanisms, as necessary, provided that such measures and
activities are applicable and available to them to receive the maximum
number of points under a performance category. We considered an
approach that would require MIPS eligible clinicians to first submit
data on as many required measures and activities as possible via one
submission mechanism before submitting data via an additional
submission mechanism, but we believe that such an approach would limit
flexibility.
If an individual MIPS eligible clinician or group submits the same
measure through two different mechanisms, each submission would be
calculated and scored separately. We do not have the ability to
aggregate data on the same measure across submission mechanisms. We
would only count the submission that gives the clinician the higher
score, thereby avoiding the double count. We refer readers to section
II.C.7. of this proposed rule, which further outlines how we propose to
score measures and activities regardless of submission mechanism.
We believe that this flexible approach would help individual MIPS
eligible clinicians and groups with reporting, as it provides more
options for the submission of data for the applicable
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performance categories. For example, an individual MIPS eligible
clinician or group submitting data on four applicable and available
quality measures via EHR may not be able to receive the maximum number
of points available under the quality performance category. However,
with this proposed modification, the MIPS eligible clinician could meet
the requirement to report six quality measures by submitting data on
two additional quality measure via another submission mechanism, such
as claims or qualified registry. This would enable the MIPS eligible
clinician to receive the maximum number of points available under the
quality performance category. We believe that by providing this
flexibility, we would be allowing MIPS eligible clinicians the
flexibility to choose the measures and activities that are most
meaningful to them, regardless of the submission mechanism. We are
aware that this proposal for increased flexibility in data submission
mechanisms may increase complexity and in some instances additional
costs for clinicians, as they may need to establish relationships with
additional data submission mechanism vendors in order to report
additional measures and/or activities for any given performance
category. We would like to clarify that the requirements for the
performance categories remain the same, regardless of the number of
submission mechanisms used. It is also important to note for the
improvement activities and advancing care information performance
categories, that using multiple data submission mechanisms (for
example, attestation and the qualified registry) may limit our ability
to provide real-time feedback. While we strive to provide flexibility
to individual MIPS eligible clinicians and groups, we would like to
note that our goal within the MIPS program is to minimize complexity
and administrative burden to individual MIPS eligible clinicians and
groups. We request comments on this proposal.
As discussed in section II.C.4. of this proposed rule, we are
proposing to generally apply our previously finalized and proposed
group policies to virtual groups. With respect to data submission
mechanisms, we are proposing that virtual groups would be able to use a
different submission mechanism for each performance category, and would
be able to utilize multiple submission mechanisms for the quality
performance category, beginning with performance periods occurring in
2018. However, virtual groups would be required to utilize the same
submission mechanism for the improvement activities and the advancing
care information performance categories.
For those MIPS eligible clinicians participating in a MIPS APM, who
are on an APM Participant List on at least one of the three snapshot
dates as finalized in the CY 2017 Quality Payment Program Final Rule
(81 FR 77444 through 77445), or for MIPS eligible clinicians
participating in a full TIN MIPS APM, who are on an APM Participant
List on at least one of the four snapshot dates as discussed in section
II.C.6.g.(2) of this proposed rule, the APM scoring standard applies.
We refer readers to Sec. 414.1370 and the CY 2017 Quality Payment
Program final rule (81 FR 77246), which describes how MIPS eligible
clinicians participating in APM entities submit data to MIPS in the
form and manner required, including separate approaches to the quality
and cost performance categories applicable to MIPS APMs. We are not
proposing any changes to how APM entities in MIPS APMs and their
participating MIPS eligible clinicians submit data to MIPS.
(2) Submission Deadlines
In the CY 2017 Quality Payment Program final rule (81 FR 77097), we
finalized submission deadlines by which all associated data for all
performance categories must be submitted for the submission mechanisms
described in this rule.
As specified at Sec. 414.1325(f)(1), the data submission deadline
for the qualified registry, QCDR, EHR, and attestation submission
mechanisms is March 31 following the close of the performance period.
The submission period will begin prior to January 2 following the close
of the performance period, if technically feasible. For example, for
performance periods occurring in 2018, the data submission period will
occur prior to January 2, 2019, if technically feasible, through March
31, 2019. If it is not technically feasible to allow the submission
period to begin prior to January 2 following the close of the
performance period, the submission period will occur from January 2
through March 31 following the close of the performance period. In any
case, the final deadline will remain March 31, 2019.
At Sec. 414.1325(f)(2), we specified that for the Medicare Part B
claims submission mechanism, data must be submitted on claims with
dates of service during the performance period that must be processed
no later than 60 days following the close of the performance period.
Lastly, for the CMS Web Interface submission mechanism, at Sec.
414.1325(f)(3), we specified that the data must be submitted during an
8-week period following the close of the performance period that will
begin no earlier than January 2, and end no later than March 31. For
example, the CMS Web Interface submission period could span an 8-week
timeframe beginning January 16 and ending March 13. The specific
deadline during this timeframe will be published on the CMS Web site.
We are not proposing any changes to the submission deadlines in this
proposed rule.
b. Quality Performance Criteria
(1) Background
Sections 1848(q)(1)(A)(i) and (ii) of the Act require the Secretary
to develop a methodology for assessing the total performance of each
MIPS eligible clinician according to performance standards and, using
that methodology, to provide for a final score for each MIPS eligible
clinician. Section 1848(q)(2)(A)(i) of the Act requires us to use the
quality performance category in determining each MIPS eligible
clinician's final score, and section 1848(q)(2)(B)(i) of the Act
describes the measures and activities that must be specified under the
quality performance category.
The statute does not specify the number of quality measures on
which a MIPS eligible clinician must report, nor does it specify the
amount or type of information that a MIPS eligible clinician must
report on each quality measure. However, section 1848(q)(2)(C)(i) of
the Act requires the Secretary, as feasible, to emphasize the
application of outcomes-based measures.
Sections 1848(q)(1)(E) of the Act requires the Secretary to
encourage the use of QCDRs, and section 1848(q)(5)(B)(ii)(I) of the Act
requires the Secretary to encourage the use of CEHRT and QCDRs for
reporting measures under the quality performance category under the
final score methodology, but the statute does not limit the Secretary's
discretion to establish other reporting mechanisms.
Section 1848(q)(2)(C)(iv) of the Act generally requires the
Secretary to give consideration to the circumstances of non-patient
facing MIPS eligible clinicians and allows the Secretary, to the extent
feasible and appropriate, to apply alternative measures or activities
to such clinicians.
As discussed in the CY 2017 Quality Payment Program final rule (81
FR 77098 through 77099), we finalized MIPS quality criteria that focus
on measures that are important to beneficiaries and maintain some of
the
[[Page 30037]]
flexibility from PQRS, while addressing several of the comments we
received in response to the CY 2017 Quality Payment Program proposed
rule and the MIPS and APMs RFI.
To encourage meaningful measurement, we finalized allowing
individual MIPS eligible clinicians and groups the flexibility to
determine the most meaningful measures and data submission mechanisms
for their practice.
To simplify the reporting criteria, we aligned the
submission criteria for several of the data submission mechanisms.
To reduce administrative burden and focus on measures that
matter, we lowered the required number of the measures for several of
the data submission mechanisms, yet still required that certain types
of measures, particularly outcome measures, be reported.
To create alignment with other payers and reduce burden on
MIPS eligible clinicians, we incorporated measures that align with
other national payers.
To create a more comprehensive picture of a practice's
performance, we also finalized the use of all-payer data where
possible.
As beneficiary health is always our top priority, we finalized
criteria to continue encouraging the reporting of certain measures such
as outcome, appropriate use, patient safety, efficiency, care
coordination, or patient experience measures. However, as discussed in
the CY 2017 Quality Payment Program final rule (81 FR 77098), we
removed the requirement for measures to span across multiple domains of
the NQS. We continue to believe the NQS domains are extremely
important, and we encourage MIPS eligible clinicians to continue to
strive to provide care that focuses on: Effective clinical care,
communication and care coordination, efficiency and cost reduction,
person and caregiver-centered experience and outcomes, community and
population health, and patient safety. While we do not require that
MIPS eligible clinicians select measures across multiple domains, we
encourage them to do so. In addition, we believe the MIPS program
overall, with the focus on the quality, cost, improvement activities,
and advancing care information performance categories, will naturally
cover many elements in the NQS.
(2) Contribution to Final Score
For MIPS payment year 2019, the quality performance category will
account for 60 percent of the final score, subject to the Secretary's
authority to assign different scoring weights under section
1848(q)(5)(F) of the Act. Section 1848(q)(2)(E)(i)(I)(aa) of the Act
states that the quality performance category will account for 30
percent of the final score for MIPS. However, section
1848(q)(2)(E)(i)(I)(bb) of the Act stipulates that for the first and
second years for which MIPS applies to payments, the percentage of the
final score applicable for the quality performance category will be
increased so that the total percentage points of the increase equals
the total number of percentage points by which the percentage applied
for the cost performance category is less than 30 percent. Section
1848(q)(2)(E)(i)(II)(bb) of the Act requires that, for the transition
year for which MIPS applies to payments, not more than 10 percent of
the final score shall be based on the cost performance category.
Furthermore, section 1848(q)(2)(E)(i)(II)(bb) of the Act states that,
for the second year for which MIPS applies to payments, not more than
15 percent of the final score shall be based on the cost performance
category.
In the CY 2017 Quality Payment Program final rule (81 FR 77100), we
finalized at Sec. 414.1330(b) that, for MIPS payment years 2019 and
2020, 60 percent and 50 percent, respectively, of the MIPS final score
will be based on the quality performance category. For the third and
future years, 30 percent of the MIPS final score will be based on the
quality performance category.
As discussed in section II.C.6.d. of this proposed rule, we are
proposing to weight the cost performance category at zero percent for
the second MIPS payment year (2020). In accordance with section
1848(q)(5)(E)(i)(I)(bb) of the Act, for the first 2 years, the
percentage of the MIPS final score that would otherwise be based on the
quality performance category (that is, 30 percent) must be increased by
the same number of percentage points by which the percentage based on
the cost performance category is less than 30 percent. Therefore, if
our proposal to reweight the cost performance category for MIPS payment
year 2020 is finalized, we would need to inversely reweight the quality
performance category for the same year. Accordingly, we are proposing
to modify Sec. 414.1330(b)(2) to reweight the percentage of the MIPS
final score based on the quality performance category for MIPS payment
year 2020 as may be necessary to account for any reweighting of the
cost performance category, if finalized. For example, if our proposal
to reweight the cost performance category to zero percent for MIPS
payment year 2020 is finalized, then we would modify Sec.
414.1330(b)(2) to provide that performance in the quality performance
category will comprise 60 percent of a MIPS eligible clinician's final
score for MIPS payment year 2020. We refer readers to section II.C.6.d.
for more information on the cost performance category.
As also discussed in section II.C.6.d. of this proposed rule, we
note that by reweighting the cost performance category to zero percent
in performance period 2018, there will be a sharp increase in the cost
performance category to a 30 percent weight in performance period 2019.
In order to assist MIPS eligible clinicians and groups in obtaining
additional comfort with measurement based on the cost performance
category, we considered maintaining our previously-finalized cost
performance category weight of 10 percent for the 2018 performance
period. However, in our discussions with some MIPS eligible clinicians
and clinician societies, eligible clinicians expressed their desire to
down-weight the cost performance category to zero percent for an
additional year with full knowledge that the cost performance category
weight is set at 30 percent under the statute for the 2021 MIPS payment
year. The clinicians we spoke with preferred our proposed approach and
noted that they are actively preparing for full cost performance
category implementation and would be prepared for the 30 percent
statutory weight for the cost performance category for the 2021 MIPS
payment year.
We intend to provide an initial opportunity for clinicians to
review their performance based on the new episode-based measures at
some point in the fall of 2017, as the measures are developed and as
the information is available. We note that this feedback will be
specific to the new episode-based measures that are developed under the
process described above and may be presented in a different format than
MIPS eligible clinicians' performance feedback as described in section
II.C.9.a. of this proposed rule. However, our intention is to align the
feedback as much as possible to ensure clinicians receive opportunities
to review their performance on potential new episode-based measures for
the cost performance category prior to the proposed 2019 MIPS
performance period. We are unable to offer a list of new episode-based
measures on which we will provide feedback because that will be
determined in our ongoing development work described above. We are
concerned that continuing to
[[Page 30038]]
provide feedback on the older episode-based measures along with
feedback on new episode-based measures will be confusing and a poor use
of resources. Because we are focusing on development of new episode-
based measures, our feedback on episode-based measures that were
previously developed will discontinue after 2017 as these measures
would no longer be maintained or reflect changes in diagnostic and
procedural coding. As described in section II.C.9.a. of this proposed
rule, we intend to provide feedback on these new measures as they
become available in a new format around summer 2018, in addition to the
fall 2017 feedback discussed previously. We note that the feedback
provided in the summer of 2018 will go to those MIPS eligible
clinicians for whom we are able to calculate the episode-based
measures, which means it would be possible that a clinical may not
receive feedback on episode-based measures in both the fall of 2017 and
the summer of 2018. We believe that receiving feedback on the new
episode-based measures, along with the previously-finalized total per
capita cost and MSPB measures, will support clinicians in their
readiness for the proposed 2019 MIPS performance period.
Section 1848(q)(5)(B)(i) of the Act requires the Secretary to treat
any MIPS eligible clinician who fails to report on a required measure
or activity as achieving the lowest potential score applicable to the
measure or activity. Specifically, under our finalized scoring
policies, an individual MIPS eligible clinician or group that reports
on all required measures and activities could potentially obtain the
highest score possible within the performance category, assuming they
perform well on the measures and activities they report. An individual
MIPS eligible clinician or group who does not submit data on a required
measure or activity would receive a zero score for the unreported items
in the performance category (in accordance with section
1848(q)(5)(B)(i) of the Act). The individual MIPS eligible clinician or
group could still obtain a relatively good score by performing very
well on the remaining items, but a zero score would prevent the
individual MIPS eligible clinician or group from obtaining the highest
possible score within the performance category.
(3) Quality Data Submission Criteria
(a) Submission Criteria
(i) Submission Criteria for Quality Measures Excluding Groups Reporting
via the CMS Web Interface and the CAHPS for MIPS Survey
In the CY 2017 Quality Payment Program final rule (81 FR 77114), we
finalized at Sec. 414.1335(a)(1) that individual MIPS eligible
clinicians submitting data via claims and individual MIPS eligible
clinicians and groups submitting data via all mechanisms (excluding the
CMS Web Interface and the CAHPS for MIPS survey) are required to meet
the following submission criteria. For the applicable period during the
performance period, the individual MIPS eligible clinician or group
will report at least six measures, including at least one outcome
measure. If an applicable outcome measure is not available, the
individual MIPS eligible clinician or group will be required to report
one other high priority measure (appropriate use, patient safety,
efficiency, patient experience, and care coordination measures) in lieu
of an outcome measure. If fewer than six measures apply to the
individual MIPS eligible clinician or group, then the individual MIPS
eligible clinician or group would be required to report on each measure
that is applicable. We defined ``applicable'' to mean measures relevant
to a particular MIPS eligible clinician's services or care rendered. As
discussed in section II.C.7.a.(2)(e)., we will only make determinations
as to whether a sufficient number of measures are applicable for
claims-based and registry submission mechanisms; we will not make this
determination for EHR and QCDR submission mechanisms, for example.
Alternatively, the individual MIPS eligible clinician or group will
report one specialty measure set, or the measure set defined at the
subspecialty level, if applicable. If the measure set contains fewer
than six measures, MIPS eligible clinicians will be required to report
all available measures within the set. If the measure set contains six
or more measures, MIPS eligible clinicians will be required to report
at least six measures within the set. Regardless of the number of
measures that are contained in the measure set, MIPS eligible
clinicians reporting on a measure set will be required to report at
least one outcome measure or, if no outcome measures are available in
the measure set, the MIPS eligible clinician will report another high
priority measure (appropriate use, patient safety, efficiency, patient
experience, and care coordination measures) within the measure set in
lieu of an outcome measure. MIPS eligible clinicians may choose to
report measures in addition to those contained in the specialty measure
set and will not be penalized for doing so, provided that such MIPS
eligible clinicians follow all requirements discussed here.
In accordance with Sec. 414.1335(a)(1)(ii), individual MIPS
eligible clinicians and groups will select their measures from either
the set of all MIPS measures listed or referenced in Table A of the
Appendix in this proposed rule or one of the specialty measure sets
listed in Table B of the Appendix in this proposed rule. We note that
some specialty measure sets include measures grouped by subspecialty;
in these cases, the measure set is defined at the subspecialty level.
Previously finalized quality measures may be found in the CY 2017
Quality Payment Program final rule (81 FR 77558 through 77816).
We also finalized the definition of a high priority measure at
Sec. 414.1305 to mean an outcome, appropriate use, patient safety,
efficiency, patient experience, or care coordination quality measure.
Except as discussed in section II.C.6.b.(3)(a) of this proposed rule
with regard to the CMS Web Interface and the CAHPS for MIPS survey, we
are not proposing any changes to the submission criteria or definitions
established for measures in this proposed rule.
In the CY 2017 Quality Payment Program final rule (81 FR 77114), we
solicited comments regarding adding a requirement to our finalized
policy that patient-facing MIPS eligible clinicians would be required
to report at least one cross-cutting measure in addition to the high
priority measure requirement for further consideration for the Quality
Payment Program Year 2 and future years. For clarification, we consider
a cross-cutting measure to be any measure that is broadly applicable
across multiple clinical settings and individual MIPS eligible
clinicians or groups within a variety of specialties. We specifically
requested feedback on how we could construct a cross-cutting measure
requirement that would be most meaningful to MIPS eligible clinicians
from different specialties and that would have the greatest impact on
improving the health of populations. We received conflicting feedback
on adding a future requirement for MIPS eligible clinicians to report
at least one cross-cutting measure in the Quality Payment Program Year
2 and future years.
[[Page 30039]]
Many commenters agreed that cross-cutting measures are applicable
across multiple clinical settings and that MIPS eligible clinicians
within a variety of specialties should report at least one cross-
cutting measure. Some stated that cross-cutting measures promote shared
accountability and improve the health of populations. Others
recommended we continue to work with stakeholders and specialists,
including solo and small practices, to develop cross-cutting measures
for all settings, whether they be patient-facing or non-patient facing
practices that are patient-centric (that is, following the patient and
not the site of care) and recommended the term ``patient-centered
measures'' rather than ``cross-cutting measures.'' In addition, some
commenters stated we should consider measures that are
multidisciplinary, foster cross-collaboration within virtual groups,
improve patient outcomes, target high-cost areas, target areas with
gaps in care, and include individual patient preferences in shared
decision-making. A few commenters provided specific measures that they
recommended utilizing as cross-cutting measures, such as: Screening for
Hepatitis C; Controlling High Blood Pressure; Tobacco Use Cessation
Counseling and Treatment; Advance Care Planning; or Medication
Reconciliation. One commenter recommended we utilize shared
accountability measures around surgical goals of care, shared decision
making relying on some form of risk estimation such as a risk
calculator, medication reconciliation, and a shared plan of care across
clinicians. Another commenter suggested that instead of having a cross-
cutting measure requirement, we could use health IT as a cross-cutting
requirement. Specifically, the commenter noted we could require that at
least one measure using end-to-end electronic reporting, or that at
least one measure be tied to an improvement activity the clinician is
performing. Other commenters suggested that we provide bonus points to
practices that elect to submit data on cross-cutting measures and hold
harmless from any future cross-cutting measure requirements MIPS
eligible clinicians who have less than 15 instances in the measure
denominator during the performance period, allow MIPS eligible
clinicians to use high-priority measures in the place of a cross-
cutting measure if necessary, and apply the guiding principles listed
in NQF's ``Attribution: Principles and Approaches'' final report which
may be found at https://www.qualityforum.org/ProjectDescription.aspx?projectID=80808.
Other commenters appreciated our decision not to finalize the
requirement to report a cross-cutting measure in the transition year
and requested that we not require cross-cutting measures in the future,
as they believed it is administratively burdensome for clinicians and
QCDRs and removes focus and resources from quality measures that are
more relevant to MIPS eligible clinicians' scope of practice and
important to their patients' treatment and outcomes. They stated that
PQRS demonstrated the challenge of identifying cross-cutting measures
that are truly meaningful across different specialties and that truly
have an impact on improving the health of populations. Some stated we
should focus on high-priority measures over cross-cutting measures. A
few commenters did not agree that cross-cutting measures were relevant
and stated they should not be a requirement in MIPS until all MIPS
eligible clinicians can successfully meet the current requirements.
Others did not agree that QCDRs should be required to submit cross-
cutting measures because they believed that Congress did not intend for
QCDRs to submit clinical process measures, that implementation may be
complicated by practices that upgrade their health IT, and vendors have
indicated it would take 12 to 18 months to implement system changes to
support capture of cross-cutting measures. They also questioned the
value of investing additional time and resources in this effort,
especially if these cross-cutting measures are ultimately found to be
topped out or removed. Others believed we should delay implementation
until the Quality Payment Program Year 3 in order to allow MIPS
eligible clinicians to focus on implementing new CEHRT requirements and
modifying their processes to address lessons learned from reporting in
the first 2 years.
Except as discussed in section II.C.6.b.(3)(a)(iii). of this
proposed rule with regard to the CAHPS for MIPS survey, we are not
proposing any changes to the submission criteria for quality measures
in this proposed rule. We thank the commenters for their feedback and
will take the comments into consideration in future rulemaking. We
welcome additional feedback on meaningful ways to incorporate cross-
cutting measurement into MIPS and the Quality Payment Program
generally.
(ii) Submission Criteria for Quality Measures for Groups Reporting via
the CMS Web Interface
In the CY 2017 Quality Payment Program final rule (81 FR 77116), we
finalized at Sec. 414.1335(a)(2) the following criteria for the
submission of data on quality measures by registered groups of 25 or
more eligible clinicians who want to report via the CMS Web Interface.
For the applicable 12-month performance period, the group would be
required to report on all measures included in the CMS Web Interface
completely, accurately, and timely by populating data fields for the
first 248 consecutively ranked and assigned Medicare beneficiaries in
the order in which they appear in the group's sample for each module or
measure. If the sample of eligible assigned beneficiaries is less than
248, then the group would report on 100 percent of assigned
beneficiaries. A group would be required to report on at least one
measure for which there is Medicare patient data. Groups reporting via
the CMS Web Interface are required to report on all of the measures in
the set. Any measures not reported would be considered zero performance
for that measure in our scoring algorithm. In addition, we are
proposing to clarify that these criteria apply to groups of 25 or more
eligible clinicians. Specifically, we propose to revise Sec.
414.1335(a)(2)(i) to provide criteria applicable to groups of 25 or
more eligible clinicians, report on all measures included in the CMS
Web Interface. The group must report on the first 248 consecutively
ranked beneficiaries in the sample for each measure or module.
In the CY 2017 Quality Payment Program final rule (81 FR 77116), we
finalized to continue to align the 2019 CMS Web Interface beneficiary
assignment methodology with the attribution methodology for two of the
measures that were formerly in the VM: The population quality measure
discussed in the CY 2017 Quality Payment Program proposed rule (81 FR
28188) and total per capita cost for all attributed beneficiaries
discussed in the CY 2017 Quality Payment Program proposed rule (81 FR
28196). When establishing MIPS, we also finalized a modified
attribution process to update the definition of primary care services
and to adapt the attribution to different identifiers used in MIPS.
These changes are discussed in the CY 2017 Quality Payment Program
proposed rule (81 FR 28196). We note that groups reporting via the CMS
Web Interface may also report the CAHPS for MIPS survey and receive
bonus points for submitting that
[[Page 30040]]
measure. We are not proposing any changes to the submission criteria
for quality measures for groups reporting via the CMS Web Interface in
this proposed rule.
(iii) Performance Criteria for Quality Measures for Groups Electing To
Report Consumer Assessment of Healthcare Providers and Systems (CAHPS)
for MIPS Survey
In the CY 2017 Quality Payment Program final rule (81 FR 77100), we
finalized at Sec. 414.1335(a)(3) the following criteria for the
submission of data on the CAHPS for MIPS survey by registered groups
via CMS-approved survey vendor: For the applicable 12-month performance
period, a group that wishes to voluntarily elect to participate in the
CAHPS for MIPS survey measure must use a survey vendor that is approved
by CMS for a particular performance period to transmit survey measures
data to CMS. The CAHPS for MIPS survey counts for one measure towards
the MIPS quality performance category and, as a patient experience
measure, also fulfills the requirement to report at least one high
priority measure in the absence of an applicable outcome measure. In
addition, groups that elect this data submission mechanism must select
an additional group data submission mechanism (that is, qualified
registries, QCDRs, EHR, etc.) in order to meet the data submission
criteria for the MIPS quality performance category. The CAHPS for MIPS
survey will count as one patient experience measure, and the group will
be required to submit at least five other measures through one other
data submission mechanism. A group may report any five measures within
MIPS plus the CAHPS for MIPS survey to achieve the six measures
threshold. We are not proposing any changes to the performance criteria
for quality measures for groups electing to report the CAHPS for MIPS
survey in this proposed rule.
In the CY 2017 Quality Payment Program final rule (see 81 FR
77120), we finalized retaining the CAHPS for MIPS survey administration
period that was utilized for PQRS of November to February. However,
this survey administration period has become operationally problematic
for the administration of MIPS. In order to compute scoring, we must
have the CAHPS for MIPS survey data earlier than the current survey
administration period deadline allows. Therefore, we are proposing for
the Quality Payment Program Year 2 and future years that the survey
administration period would, at a minimum, span over 8 weeks and would
end no later than February 28th following the applicable performance
period. In addition, we propose to further specify the start and end
timeframes of the survey administration period through our normal
communication channels.
In addition, as discussed in the CY 2017 Quality Payment Program
final rule (81 FR 77116), we anticipated exploring the possibility of
updating the CAHPS for MIPS survey under MIPS, specifically not
finalizing all of the proposed Summary Survey Measures (SSMs). The
CAHPS for MIPS survey currently consists of the core CAHPS Clinician &
Group (CG-CAHPS) Survey developed by the Agency for Healthcare Research
and Quality (AHRQ), plus additional survey questions to meet CMS's
program needs. We are proposing for the Quality Payment Program Year 2
and future years to remove two SSMs, specifically, ``Helping You to
Take Medication as Directed'' and ``Between Visit Communication'' from
the CAHPS for MIPS survey. We are proposing to remove the SSM entitled
``Helping You to Take Medication as Directed'' due to low reliability.
In 2014 and 2015, the majority of groups had very low reliability on
this SSM. Furthermore, based on analyses conducted of SSMs in an
attempt to improve their reliability, removing questions from this SSM
did not result in any improvements in reliability. The SSM, ``Helping
You to Take Medication as Directed,'' has also never been a scored
measure with the Medicare Shared Savings Program CAHPS for Accountable
Care Organizations (ACOs) Survey. We refer readers to the CY 2014
Physician Fee Schedule final rule for a discussion on the CAHPS for ACO
survey scoring (79 FR 67909 through 67910) and measure tables (79 FR
67916 through 67917). The SSM entitled ``Between Visit Communication''
currently contains only one question. This question could also be
considered related to other SSMs entitled: ``Care Coordination'' or
``Courteous and Helpful Office Staff,'' but does not directly overlap
with any of the questions under that SSM. However, we are proposing to
remove this SSM in order to maintain consistency with the Medicare
Shared Savings Program which, utilizes the CAHPS for Accountable Care
Organizations (ACOs) Survey. The SSM entitled ``Between Visit
Communication'' has never been a scored measure with the Medicare
Shared Savings Program CAHPS for ACOs Survey.
In addition to public comments we receive, we will also take into
consideration analysis we will be conducting before finalizing this
proposal. Specifically, we will review the findings of the CAHPS for
ACO survey pilot, which was administered from November 2016 through
February 2017. The CAHPS for ACO survey pilot utilized a survey
instrument which did not contain the two SSMs we are proposing for
removal from the CAHPS for MIPS survey. For more information on the
other SSMs within the CAHPS for MIPS survey, please see the explanation
of the CAHPS for PQRS survey in the CY 2016 PFS final rule with comment
period (80 FR 71142 through 71143).
Table 4--Proposed Summary Survey Measures (SSMs) Included in the CAHPS
for MIPS Survey
------------------------------------------------------------------------
Summary survey measures (SSMs)
-------------------------------------------------------------------------
Getting Timely Care, Appointments, and Information.
How Well Providers Communicate.
Patient's Rating of Provider.
Access to Specialists.
Health Promotion and Education.
Shared Decision-Making.
Health Status and Functional Status.
Courteous and Helpful Office Staff.
Care Coordination.
Stewardship of Patient Resources.
------------------------------------------------------------------------
We are seeking comment on expanding the patient experience data
available for the CAHPS for MIPS survey. Currently, the CAHPS for MIPS
survey is available for groups to report under the MIPS. The patient
experience survey data that is available on Physician Compare is highly
valued by patients and their caregivers as they evaluate their health
care options. However, in user testing with patients and caregivers in
regard to the Physician Compare Web site, the users regularly ask for
more information from patients like them in their own words. Patients
regularly request that we include narrative reviews of individual
clinicians and groups on the Web site. AHRQ is fielding a beta version
of the CAHPS Patient Narrative Elicitation Protocol (https://www.ahrq.gov/cahps/surveys-guidance/item-sets/elicitation/).
This includes five open-ended questions designed to be added to the CG
CAHPS survey, after which the CAHPS for MIPS survey is modeled. These
five questions have been developed and tested in order to capture
patient narratives in a scientifically grounded and rigorous way,
setting it apart from other patient narratives collected by various
health systems and patient rating sites. More scientifically rigorous
patient narrative data would not only greatly benefit patients in their
[[Page 30041]]
decision for healthcare, but it would also greatly aid individual MIPS
eligible clinicians and groups as they assess how their patients
experience care. We are seeking comment on adding these five open-ended
questions to the CAHPS for MIPS survey in future rulemaking. Beta
testing is an ongoing process, and we anticipate reviewing the results
of that testing in collaboration with AHRQ before proposing changes to
the CAHPS for MIPS survey.
We are requiring, where possible, all-payer data for all reporting
mechanisms, yet certain reporting mechanisms are limited to Medicare
Part B data. Specifically, the CAHPS for MIPS survey currently relies
on sampling protocols based on Medicare Part B billing; therefore, only
Medicare Part B beneficiaries are sampled through that methodology. In
the CY 2017 Quality Payment Program proposed rule (81 FR 28189), we
requested comments on ways to modify the methodology to assign and
sample patients for these mechanisms using data from other payers. We
received mixed feedback on the use of all-payer data overall. The full
discussion of the comments and the responses can be found in the CY
2017 Quality Payment Program final rule (81 FR 77123 through 77125). We
are requesting additional comments on ways to modify the methodology to
assign and sample patients using data from other payers for reporting
mechanisms that are currently limited to Medicare Part B data. In
particular, we are seeking comment on the ability of groups to provide
information on the patients to whom they provide care during a calendar
year, whether it would be possible to identify a list of patients seen
by individual clinicians in the group, and what type of patient contact
information groups would be able to provide. Further, we would like to
seek comment on the challenges groups may anticipate in trying to
provide this type of information, especially for vulnerable beneficiary
populations, such as those lacking stable housing. We are also seeking
comment on EHR vendors' ability to provide information on the patients
who receive care from their client groups.
(b) Data Completeness Criteria
In the CY 2017 Quality Payment Program final rule (81 FR 77125), we
finalized data completeness criteria for the transition year and MIPS
payment year 2020. We finalized at Sec. 414.1340 the data completeness
criteria below for performance periods occurring in 2017.
Individual MIPS eligible clinicians or groups submitting
data on quality measures using QCDRs, qualified registries, or via EHR
must report on at least 50 percent of the individual MIPS eligible
clinician or group's patients that meet the measure's denominator
criteria, regardless of payer for the performance period. In other
words, for these submission mechanisms, we expect to receive quality
data for both Medicare and non-Medicare patients. For the transition
year, MIPS eligible clinicians whose measures fall below the data
completeness threshold of 50 percent would receive 3 points for
submitting the measure.
Individual MIPS eligible clinicians submitting data on
quality measures data using Medicare Part B claims, would report on at
least 50 percent of the Medicare Part B patients seen during the
performance period to which the measure applies. For the transition
year, MIPS eligible clinicians whose measures fall below the data
completeness threshold of 50 percent would receive 3 points for
submitting the measure.
Groups submitting quality measures data using the CMS Web
Interface or a CMS-approved survey vendor to report the CAHPS for MIPS
survey must meet the data submission requirements on the sample of the
Medicare Part B patients CMS provides.
In addition, we finalized an increased data completeness threshold
of 60 percent for MIPS for performance periods occurring in 2018 for
data submitted on quality measures using QCDRs, qualified registries,
via EHR, or Medicare Part B claims. We noted that these thresholds for
data submitted on quality measures using QCDRs, qualified registries,
via EHR, or Medicare Part B claims would increase for performance
periods occurring in 2019 and onward.
We are proposing to modify the previously established data
completeness criteria for MIPS payment year 2020. Specifically, we
would like to provide an additional year for individual MIPS eligible
clinicians and groups to gain experience with MIPS before increasing
the data completeness thresholds for data submitted on quality measures
using QCDRs, qualified registries, via EHR, or Medicare Part B claims.
We are concerned about the unintended consequences of accelerating the
data completeness threshold so quickly, which may jeopardize MIPS
eligible clinicians' ability to participate and perform well under the
MIPS, particularly those clinicians who are least experienced with MIPS
quality measure data submission. We want to ensure that an appropriate
yet achievable level of data completeness is applied to all MIPS
eligible clinicians. We continue to believe it is important to
incorporate higher data completeness thresholds in future years to
ensure a more accurate assessment of a MIPS eligible clinician's
performance on quality measures and to avoid any selection bias.
Therefore, we propose, below, a 60 percent data completeness threshold
for MIPS payment year 2021. We strongly encourage all MIPS eligible
clinicians to perform the quality actions associated with the quality
measures on their patients. The data submitted for each measure is
expected to be representative of the individual MIPS eligible
clinician's or group's overall performance for that measure. The data
completeness threshold of less than 100 percent is intended to reduce
burden and accommodate operational issues that may arise during data
collection during the initial years of the program. We are providing
this notice to MIPS eligible clinicians so that they can take the
necessary steps to prepare for higher data completeness thresholds in
future years.
Therefore, we propose to revise the data completeness criteria for
the quality performance category at Sec. 414.1340(a)(2) to provide
that MIPS eligible clinicians and groups submitting quality measures
data using the QCDR, qualified registry, or EHR submission mechanism
must submit data on at least 50 percent of the individual MIPS eligible
clinician's or group's patients that meet the measure's denominator
criteria, regardless of payer, for MIPS payment year 2020. We also
propose to revise the data completeness criteria for the quality
performance category at Sec. 414.1340(b)(2) to provide that MIPS
eligible clinicians and groups submitting quality measures data using
Medicare Part B claims, must submit data on at least 50 percent of the
applicable Medicare Part B patients seen during the performance period
to which the measure applies for MIPS payment year 2020. We further
propose at Sec. 414.1340(a)(3), that MIPS eligible clinicians and
groups submitting quality measures data using the QCDR, qualified
registry, or EHR submission mechanism must submit data on at least 60
percent of the individual MIPS eligible clinician or group's patients
that meet the measure's denominator criteria, regardless of payer for
MIPS payment year 2021. We also propose at Sec. 414.1340(b)(3), that
MIPS eligible clinicians and groups submitting quality measures data
using Medicare Part B claims, must submit data on at least 60 percent
of the applicable Medicare Part
[[Page 30042]]
B patients seen during the performance period to which the measure
applies for MIPS payment year 2021. We would like to note that we
anticipate for future MIPS payment years we will propose to increase
the data completeness threshold for data submitted using QCDRs,
qualified registries, EHR submission mechanisms, or Medicare Part B
claims. As MIPS eligible clinicians gain experience with the MIPS, we
would propose to steadily increase these thresholds for future years
through rulemaking. In addition, we are seeking comment on what data
completeness threshold should be established for future years.
In the CY 2017 Quality Payment Program final rule (81 FR 77125
through 77126), we finalized our approach of including all-payer data
for the QCDR, qualified registry, and EHR submission mechanisms because
we believed this approach provides a more complete picture of each MIPS
eligible clinician's scope of practice and provides more access to data
about specialties and subspecialties not currently captured in PQRS. In
addition, those clinicians who utilize a QCDR, qualified registry, or
EHR submission must contain a minimum of one quality measure for at
least one Medicare patient. We are not proposing any changes to these
policies in this proposed rule. As noted in the CY 2017 Quality Payment
Program final rule, those MIPS eligible clinicians who fall below the
data completeness thresholds will receive 3 points for the specific
measures that fall below the data completeness threshold in the
transition year of MIPS only. For the Quality Payment Program Year 2,
we are proposing that MIPS eligible clinicians would receive 1 point
for measures that fall below the data completeness threshold, with an
exception for small practices of 15 or fewer who would still receive 3
points for measures that fail data completeness. We refer readers to
section II.C.6.b.(3)(b) of this proposed rule for our proposed policies
on instances when MIPS eligible clinicians' measures fall below the
data completeness threshold.
(c) Summary of Data Submission Criteria
Table 5 reflects our proposed quality data submission criteria for
MIPS payment year 2020 via Medicare Part B claims, QCDR, qualified
registry, EHR, CMS Web Interface, and the CAHPS for MIPS survey. It is
important to note that while we finalized at Sec. 414.1325(d) in the
CY 2017 Quality Payment Program final rule that individual MIPS
eligible clinicians and groups may only use one submission mechanism
per performance category, in section II.C.6.a.(1) of this rule, we are
proposing to revise Sec. 414.1325(d) for purposes of the 2020 MIPS
payment year and future years to allow individual MIPS eligible
clinicians and groups to submit measures and activities, as applicable,
via as many submission mechanisms as necessary to meet the requirements
of the quality, improvement activities, or advancing care information
performance categories. We refer readers to section II.C.6.a.(1) of
this proposed rule for further discussion of this proposal.
Table 5--Summary of Proposed Quality Data Submission Criteria for MIPS Payment Year 2020 via Part B Claims,
QCDR, Qualified Registry, EHR, CMS Web Interface, and the CAHPS for MIPS Survey
----------------------------------------------------------------------------------------------------------------
Submission Submission
Performance period Clinician type mechanism criteria Data completeness
----------------------------------------------------------------------------------------------------------------
Jan 1-Dec 31.................... Individual MIPS Part B Claims..... Report at least 50 percent of
eligible six measures individual MIPS
clinicians. including one eligible
outcome measure, clinician's
or if an outcome Medicare Part B
measure is not patients for the
available report performance
another high period.
priority measure;
if less than six
measures apply
then report on
each measure that
is applicable.
Individual MIPS
eligible
clinicians would
have to select
their measures
from either the
set of all MIPS
measures listed
or referenced in
Table A or one of
the specialty
measure sets
listed in Table B
of the Appendix
in this proposed
rule.
Jan 1-Dec 31.................... Individual MIPS QCDR, Qualified Report at least 50 percent of
eligible Registry, & EHR. six measures individual MIPS
clinicians, including one eligible
groups or virtual outcome measure, clinician's,
groups. or if an outcome group's, or
measure is not virtual group's
available report patients across
another high all payers for
priority measure; the performance
if less than six period.
measures apply
then report on
each measure that
is applicable.
Individual MIPS
eligible
clinicians,
groups, or
virtual groups
would have to
select their
measures from
either the set of
all MIPS measures
listed or
referenced in
Table A or one of
the specialty
measure sets
listed in Table B
of the Appendix
in this proposed
rule.
Jan 1-Dec 31.................... Groups or virtual CMS Web Interface. Report on all Sampling
groups. measures included requirements for
in the CMS Web the group's or
Interface; AND virtual group's
populate data Medicare Part B
fields for the patients.
first 248
consecutively
ranked and
assigned Medicare
beneficiaries in
the order in
which they appear
in the group's or
virtual group's
sample for each
module/measure.
If the pool of
eligible assigned
beneficiaries is
less than 248,
then the group or
virtual group
would report on
100 percent of
assigned
beneficiaries.
[[Page 30043]]
Jan 1-Dec 31.................... Groups or virtual CAHPS for MIPS CMS-approved Sampling
groups. Survey. survey vendor requirements for
would need to be the group's or
paired with virtual group's
another reporting Medicare Part B
mechanism to patients.
ensure the
minimum number of
measures is
reported. CAHPS
for MIPS survey
would fulfill the
requirement for
one patient
experience
measure towards
the MIPS quality
data submission
criteria. CAHPS
for MIPS survey
would only count
for one measure
under the quality
performance
category.
----------------------------------------------------------------------------------------------------------------
As discussed in section II.C.4.d. of this proposed rule, we are
proposing to generally apply our previously finalized and proposed
group policies to virtual groups.
(4) Application of Quality Measures to Non-Patient Facing MIPS Eligible
Clinicians
In the CY 2017 Quality Payment Program final rule (81 FR 77127), we
finalized at Sec. 414.1335 that non-patient facing MIPS eligible
clinicians would be required to meet the applicable submission criteria
that apply for all MIPS eligible clinicians for the quality performance
category. We are not proposing any changes to this policy in this
proposed rule.
(5) Application of Facility-Based Measures
Section 1848(q)(2)(C)(ii) of the Act provides that the Secretary
may use measures used for payment systems other than for physicians,
such as measures used for inpatient hospitals, for purposes of the
quality and cost performance categories. However, the Secretary may not
use measures for hospital outpatient departments, except in the case of
items and services furnished by emergency physicians, radiologists, and
anesthesiologists. We refer readers to section II.C.7.a.(4) of this
proposed rule for a full discussion of our proposals regarding the
application of facility-based measures.
(6) Global and Population-Based Measures
In the CY 2017 Quality Payment Program final rule (81 FR 77136), we
did not finalize all of our proposals on global and population-based
measures as part of the quality score. Specifically, we did not
finalize our proposal to use the acute and chronic composite measures
of the AHRQ Prevention Quality Indicators (PQIs). We agreed with
commenters that additional enhancements, including the addition of risk
adjustment, needed to be made to these measures prior to inclusion in
MIPS. We did, however, calculate these measures at the TIN level,
through the QRURs released in September 2016, and this data can be used
by MIPS eligible clinicians for informational purposes.
We did finalize the all-cause hospital readmissions (ACR) measure
from the VM Program as part of the quality measure domain for the MIPS
total performance score. We finalized this measure with the following
modifications. We did not apply the ACR measure to solo practices or
small groups (groups of 15 or less). We did apply the ACR measure to
groups of 16 or more who meet the case volume of 200 cases. A group was
scored on the ACR measure even if it did not submit any quality
measures, if it submitted in other performance categories. Otherwise,
the group was not scored on the readmission measure if it did not
submit data in any of the performance categories. In our transition
year policies, the readmission measure alone would not produce a
neutral to positive MIPS payment adjustment since in order to achieve a
neutral to positive MIPS payment adjustment, an individual MIPS
eligible clinician or group must submit information on one of the three
performance categories as discussed in the CY 2017 Quality Payment
Program final rule (81 FR 77329). In addition, the ACR measure in the
MIPS transition year CY 2017 was based on the performance period
(January 1, 2017 through December 31, 2017). However, for MIPS eligible
clinicians who did not meet the minimum case requirements, the ACR
measure was not applicable. We are not proposing any changes for the
global and population-based measures in this proposed rule. As
discussed in section II.C.4.d. of this rule, we are proposing to
generally apply our previously finalized and proposed group policies to
virtual groups.
c. Selection of MIPS Quality Measures for Individual MIPS Eligible
Clinicians and Groups Under the Annual List of Quality Measures
Available for MIPS Assessment
(1) Background and Policies for the Call for Measures and Measure
Selection Process
Under section 1848(q)(2)(D)(i) of the Act, the Secretary, through
notice and comment rulemaking, must establish an annual list of MIPS
quality measures from which MIPS eligible clinicians may choose for
purposes of assessment for a performance period. The annual list of
MIPS quality measures must be published in the Federal Register no
later than November 1 of the year prior to the first day of a
performance period. Updates to the annual list of MIPS quality measures
must be published in the Federal Register no later than November 1 of
the year prior to the first day of each subsequent performance period.
Updates may include the addition of new MIPS quality measures,
substantive changes to MIPS quality measures, and removal of MIPS
quality measures. MIPS eligible clinicians reporting on the quality
performance category are required to use the most recent version of the
clinical quality measure (CQM) electronic specifications as indicated
in the CY 2017 Quality Payment Program final rule (81 FR 77291). For
purposes of the 2018 MIPS performance period, the spring 2017 version
of the eCQM annual update to the measure specifications and any
applicable addenda are available on the electronic clinical quality
improvement (eCQI) Resource Center Web site at https://ecqi.healthit.gov. The CMS Quality Measure Development Plan (MDP)
serves as a strategic framework for the future of the clinician quality
measure development to support MIPS and APMs. The MDP is available on
the CMS Web site and highlights known measurement gaps and recommends
[[Page 30044]]
approaches to close those gaps through development, use, and refinement
of quality measures that address significant variation in performance
gaps. We encourage stakeholders to develop additional quality measures
for MIPS that would address the gaps.
Under section 1848(q)(2)(D)(ii) of the Act, the Secretary must
solicit a ``Call for Quality Measures'' each year. Specifically, the
Secretary must request that eligible clinician organizations and other
relevant stakeholders identify and submit quality measures to be
considered for selection in the annual list of MIPS quality measures,
as well as updates to the measures. Under section 1848(q)(2)(D)(ii) of
the Act, eligible clinician organizations are professional
organizations as defined by nationally recognized specialty boards of
certification or equivalent certification boards. However, we do not
believe there needs to be any special restrictions on the type or make-
up of the organizations that submit measures for consideration through
the call for measures. Any such restriction would limit the type of
quality measures and the scope and utility of the quality measures that
may be considered for inclusion under the MIPS.
As we described previously in the CY 2017 Quality Payment Program
final rule (81 FR 77137), we will accept quality measures submissions
at any time, but only measures submitted during the timeframe provided
by us through the pre-rulemaking process of each year will be
considered for inclusion in the annual list of MIPS quality measures
for the performance period beginning 2 years after the measure is
submitted. This process is consistent with the pre-rulemaking process
and the annual call for measures, which are further described at
(https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Pre-Rule-Making.html).
Submission of potential quality measures, regardless of whether
they were previously published in a proposed rule or endorsed by an
entity with a contract under section 1890(a) of the Act, which is
currently the National Quality Forum, is encouraged. The annual Call
for Measures process allows eligible clinician organizations and other
relevant stakeholder organizations to identify and submit quality
measures for consideration. Presumably, stakeholders would not submit
measures for consideration unless they believe that the measure is
applicable to clinicians and can be reliably and validly measured at
the individual clinician level. The NQF-convened Measure Application
Partnership (MAP) provides an additional opportunity for stakeholders
to provide input on whether or not they believe the measures are
applicable to clinicians as well as feasible, scientifically
acceptable, and reliable and valid at the clinician level. Furthermore,
we must go through notice and comment rulemaking to establish the
annual list of quality measures, which gives stakeholders an additional
opportunity to review the measures and provide input on whether or not
they believe the measures are applicable to clinicians, as well as
feasible, scientifically acceptable, and reliable and valid at the
clinician level. Additionally, we are required by statute to submit new
measures to an applicable specialty-appropriate, peer-reviewed journal.
As previously noted, we encourage the submission of potential
quality measures regardless of whether such measures were previously
published in a proposed rule or endorsed by an entity with a contract
under section 1890(a) of the Act. However, we propose to request that
stakeholders apply the following considerations when submitting quality
measures for possible inclusion in MIPS:
Measures that are not duplicative of an existing or
proposed measure.
Measures that are beyond the measure concept phase of
development and have started testing, at a minimum, with strong
encouragement and preference for measures that complete or are near
completion of reliability and validity testing.
Measures that include a data submission method beyond
claims-based data submission.
Measures that are outcome-based rather than clinical
process measures.
Measures that address patient safety and adverse events.
Measures that identify appropriate use of diagnosis and
therapeutics.
Measures that address the domain for care coordination.
Measures that address the domain for patient and caregiver
experience.
Measures that address efficiency, cost, and resource use.
Measures that address significant variation in
performance.
We will apply these considerations when considering quality
measures for possible inclusion in MIPS.
In addition, we note that we are likely to reject measures that do
not provide substantial evidence of variation in performance; for
example, if a measure developer submits data showing a small variation
in performance among a group already composed of high performers, such
evidence would not be substantial enough to assure us that sufficient
variation in performance exists. We also note that we are likely to
reject measures that are not outcome-based measures, unless (1) there
is substantial documented and peer reviewed evidence that the clinical
process measured varies directly with the outcome of interest and (2)
it is not possible to measure the outcome of interest in a reasonable
timeframe.
We also note that retired measures that were in one of CMS's
previous quality programs, such as the Physician Quality Reporting
System (PQRS) program, will likely be rejected if proposed for
inclusion. This includes measures that were retired due to being topped
out, as defined below. For example, measures may be retired due to
attaining topped out status because of high performance, or measures
that are retired due to a change in the evidence supporting their use.
In the CY 2017 Quality Payment Program final rule (81 FR 77153), we
established that we will categorize measures into the six NQS domains
(patient safety, person- and caregiver-centered experience and
outcomes, communication and care coordination, effective clinical care,
community/population health, and efficiency and cost reduction). We
intend to submit future MIPS quality measures to the NQF-convened
Measure Application Partnership's (MAP), as appropriate, and we intend
to consider the MAP's recommendations as part of the comprehensive
assessment of each measure considered for inclusion under MIPS.
In the CY 2017 Quality Payment Program final rule (81 FR 77155), we
established that we use the Call for Quality Measures process as a
forum to gather the information necessary to draft the journal articles
for submission from measure developers, measure owners and measure
stewards since we do not always develop measures for the quality
programs. The submission of this information does not preclude us from
conducting our own research using Medicare claims data, Medicare survey
results, and other data sources that we possess. We submit new measures
for publication in applicable specialty-appropriate, peer-reviewed
journals before including such measures in the final annual list of
quality measures.
In the CY 2017 Quality Payment Program final rule (81 FR 77158), we
established at Sec. 414.1330(a)(2) that for purposes of assessing
performance of MIPS eligible clinicians on the quality performance
category, we use quality measures developed by QCDRs. In the
circumstances where a QCDR wants to
[[Page 30045]]
use a QCDR measure for inclusion in the MIPS program for reporting,
those measures go through a CMS approval process during the QCDR self-
nomination period. We also established that we post the quality
measures for use by QCDRs by no later than January 1 for performance
periods occurring in 2018 and future years.
Previously finalized MIPS quality measures can be found in the CY
2017 Quality Payment Program final rule (81 FR 77558 through 77675).
Updates may include the proposal to add new MIPS quality measures,
including measures selected 2 years ago during the Call for Measures
process. The new MIPS quality measures proposed for inclusion in MIPS
for the 2018 performance period and future years are found in Table A.
The proposed new and modified MIPS specialty sets for the 2018
performance period and future years are listed in Table B, and include
existing measures that are proposed with modifications, new measures,
and measures finalized in the CY 2017 Quality Payment Program final
rule. We note that the modifications made to the specialty sets may
include the removal of certain quality measures that were previously
finalized. The specialty measure sets should be used as a guide for
eligible clinicians to choose measures applicable to their specialty.
To clarify, some of the MIPS specialty sets have further defined
subspecialty sets, each of which is effectively a separate specialty
set. In instances where an individual MIPS eligible clinician or group
reports on a specialty or subspecialty set, if the set has less than
six measures, that is all the clinician is required to report. MIPS
eligible clinicians are not required to report on the specialty measure
sets, but they are suggested measures for specific specialties.
Throughout measure utilization, measure maintenance should be a
continuous process done by the measure owners, to include environmental
scans of scientific literature about the measure. New information
gathered during this ongoing review may trigger an ad hoc review. The
specialty measure sets in Table B of the Appendix, include existing
measures that are proposed with modifications, new measures, and
measures that were previously finalized in the CY 2017 Quality Payment
Program final rule. Please note that these specialty specific measure
sets are not all inclusive of every specialty or subspecialty. On
January 25, 2017, we announced that we would be accepting
recommendations for potential new specialty measure sets for year 2 of
MIPS under the Quality Payment Program. These recommendations were
based on the MIPS quality measures finalized in the CY 2017 Quality
Payment Program final rule, and include recommendations to add or
remove the current MIPS quality measures from the specialty measure
sets. The current specialty measure sets can be found on the Quality
Payment Program Web site at https://qpp.cms.gov/measures/quality. All
specialty measure sets submitted for consideration were assessed to
ensure that they met the needs of the Quality Payment Program.
As a result, we propose to add new quality measures to MIPS (Table
A), revise the specialty measure sets in MIPS (Table B), remove
specific MIPS quality measures only from specialty sets (Table C.1),
and propose to remove specific MIPS quality measures from the MIPS
program for the 2018 performance period (Table C.2). The aforementioned
measure tables can be found in the Appendix of this proposed rule. In
addition, we are proposing to also remove cross cutting measures from
most of the specialty sets. Specialty groups and societies reported
that cross cutting measures may or may not be relevant to their
practices, contingent on the eligible clinicians or groups. CMS chose
to retain the cross cutting measures in Family Practice, Internal
Medicine and Pediatrics specialty sets because they are frequently used
in these practices. The proposed 2017 cross cutting measures, (81 FR
28447 through 28449), were compiled and placed in a separate table for
eligible clinicians to elect to use or not, for reporting. To clarify,
the cross-cutting measures are intended to provide clinicians with a
list of measures that are broadly applicable to all clinicians
regardless of the clinician's specialty. Even though it is not required
to report on cross-cutting measures, it is provided as a reference to
clinicians who are looking for additional measures to report outside
their specialty. We continue to consider cross-cutting measures to be
an important part of our quality measure programs, and seek comment on
ways to incorporate cross-cutting measures into MIPS in the future. The
proposed Table of Cross-Cutting Measures can be found in Table D of the
Appendix.
For MIPS quality measures that are undergoing substantive changes,
we propose to identify measures including, but not limited to measures
that have had measure specification, measure title, and domain changes.
MIPS quality measures with proposed substantive changes can be found at
Table E of the Appendix.
The measures that would be used for the APM scoring standard and
our authority for waiving certain measure requirements are described in
section II.C.6.g.(3)(b)(ii) and the measures that would be used to
calculate a quality score for the APM scoring standard are proposed in
Tables 14, 15, and 16.
We also seek comment for this rule, on whether there are any MIPS
quality measures that commenters believe should be classified in a
different NQS domain than what is being proposed, or that should be
classified as a different measure type (for example, process vs.
outcome) than what is being proposed in this rule.
(2) Topped Out Measures
As defined in the CY 2017 Quality Payment Program final rule at (81
FR 77136), a measure may be considered topped out if measure
performance is so high and unvarying that meaningful distinctions and
improvement in performance can no longer be made. Topped out measures
could have a disproportionate impact on the scores for certain MIPS
eligible clinicians, and provide little room for improvement for the
majority of MIPS eligible clinicians. We refer readers to section
II.C.7.a.(2)(c) of this proposed rule for additional information
regarding the scoring of topped out measures.
We noted in the CY 2017 Quality Payment Program final rule that we
anticipate removing topped out measures over time and sought comment on
what point in time we should remove topped out measures from MIPS (81
FR 77286). We received the following comments.
Many commenters recommended that we retain topped out quality
measures for 2 or more years because commenters believed they serve to
motivate continued high-quality care; more clinicians may participate
in MIPS compared to prior programs such as PQRS, and thus there may be
more performance variation in MIPS showing that the measure is not
actually topped out; declines in performance will not be captured if a
measure is eliminated; it will help provide stability and encourage
reporting in the early years of the MIPS program; removing topped out
measures could further limit the number of measures available to
specialists; and providing eligible clinicians and the public with
information about high performance is as important as informing them
about deficits.
A few commenters recommended that we publish information about
topped out and potentially topped out measures prior to the performance
period to allow clinicians time to adjust their reporting
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strategies, with one commenter noting that improvement may be rewarded
in addition to achievement. One commenter recommended pushing back the
baseline performance period for the purpose of identifying topped out
measures to 2018 because in the transition year it is unclear how many
eligible clinicians will be reporting at different times and for what
time period they will report.
Finally, a few commenters recommended that we consider specialty,
case mix, and rural location before determining that a measure is
topped out, specifically whether there is still room for improvement
among certain specialist groups and to ensure that rural provider
improvement is recognized. One commenter recommended that we determine
topped out measures based on reporting in the Quality Payment Program
rather than PQRS or value modifier reporting because the commenter
believed using historical performance disadvantages small groups. A few
commenters requested that the process for identifying and determining
the removal of topped out measures be transparent, evidence-based,
patient-centered, and include feedback from all appropriate
stakeholders, including the medical community and measures owner. A few
commenters specifically recommended that determining whether to remove
a topped out measure be part of a rulemaking process while another
commenter suggested that we seek out stakeholder input from the Measure
Applications Partnership (MAP) on whether a measure should be removed,
awarded lower points, or remain with benchmarks as a flat percentage.
We propose a 3-year timeline for identifying and proposing to
remove topped out measures. After a measure has been identified as
topped out for three consecutive years, we may propose to remove the
measure through comment and rulemaking for the 4th year. Therefore, in
the 4th year, if finalized through rulemaking, the measure would be
removed and would no longer be available for reporting during the
performance period. This proposal provides a path toward removing
topped out measures over time, and will apply to the MIPS quality
measures. QCDR measures that consistently are identified as topped out
according to the same timeline as proposed below, would not be approved
for use in year 4 during the QCDR self-nomination review process, and
would not go through the comment and rulemaking process described
below.
We propose to phase in this policy starting with a select set of
six highly topped out measures identified in section II.C.7.a.(2)(c) of
this proposed rule. In section II.C.7.a.(2)(c) of this proposed rule,
we are also proposing to phase in special scoring for measures
identified as topped out in the published benchmarks for two
consecutive performance periods, starting with the select set of highly
topped out measures for the 2018 MIPS performance period. An example
illustrating the proposed timeline for the removal and special scoring
of topped out measures, as it would be applied to the select set of
highly topped out measures identified in section II.C.7.a.(2)(c), is as
follows:
Year 1: The measures are identified as topped out in the
benchmarks published for the 2017 MIPS performance Period. The 2017
benchmarks are posted on the Quality Payment Program Web site: https://qpp.cms.gov/resources/education.
Year 2: Measures are identified as topped out in the
benchmarks published for the 2018 MIPS performance period. We refer
readers to section II.C.7.a.(2)(c) of this proposed rule for additional
information regarding the scoring of topped out measures.
Year 3: Measures are identified as topped out in the
benchmarks published for the 2019 MIPS performance period. The measures
identified as topped out in the benchmarks published for the 2019 MIPS
performance period and the previous two consecutive performance periods
would continue to have special scoring applied for the 2019 MIPS
performance period and would be considered, through notice-and-comment
rulemaking, for removal for the 2020 MIPS performance period.
Year 4: Topped out measures that are finalized for removal
are no longer available for reporting. For example, the measures in the
set of highly topped out measures identified as topped out for the
2017, 2018 and 2019 MIPS performance periods, and if subsequently
finalized for removal will not be available on the list of measures for
the 2020 MIPS performance period and future years.
For all other measures, the timeline would apply starting with the
benchmarks for the 2018 MIPS performance period. Thus, the first year
any other topped out measure could be proposed for removal would be in
rulemaking for the 2021 MIPS performance period, based on the
benchmarks being topped out in the 2018, 2019, and 2020 MIPS
performance periods. If the measure benchmark is not topped out during
one of the three MIPS performance periods, then the lifecycle would
stop and start again at year 1 the next time the measure benchmark is
topped out.
We seek comment on the above proposed timeline, specifically
regarding the number of years before a topped out measure is identified
and considered for removal, and under what circumstances we should
remove topped out measures once they reach that point. For example,
should we automatically remove topped out measures after they are
identified for the proposed number of years or should we review
measures identified for removal and consider certain criteria before
removing the measure? If so what criteria should be considered? We
would like to note that if for some reason a measure benchmark is
topped out for only one submission mechanism benchmark, then we would
remove that measure from the submission mechanism, but not remove the
measure from other submission mechanisms available for submitting that
measure.
We also seek comment on whether topped out Summary Survey Measures
(SSMs), if topped out, should be considered for removal from the
Consumer Assessment of Healthcare Providers and Systems (CAHPS) for
MIPS Clinician or Group Survey measure due to high, unvarying
performance within the SSM, or whether there is another alternative
policy that could be applied for topped out SSMs within the CAHPS for
MIPS Clinician or Group Survey measure.
In the CY 2017 Quality Payment Program final rule, we state that we
do not believe it would be appropriate to remove topped out measures
from the CMS Web Interface for the Quality Payment Program because the
CMS Web Interface measures are used in MIPS and in APMs, such as the
Shared Savings Program. Removing topped out measures from the CMS Web
Interface would not be appropriate because we have aligned policies
where possible, with the Shared Savings Program, such as using the
Shared Savings Program benchmarks for the CMS Web Interface measures
(81 FR 77285). In the CY 2017 Quality Payment Program final rule, we
also finalized that MIPS eligible clinicians reporting via the CMS Web
Interface must report all measures included in the CMS Web Interface
(81 FR 77116). Thus, if a CMS Web Interface measure is topped out, the
CMS Web Interface reporter cannot select other measures. We refer
readers to section II.C.7.a.(2) of this proposed rule for information
on scoring policies with regards to topped out measures from the CMS
Web Interface for the Quality Payment Program. We are not proposing to
include CMS Web Interface measures
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in our proposal on removing topped out measures.
(3) Non-Outcome Measures
In the CY 2017 Quality Payment Program final rule, we sought
comment on whether we should remove non-outcomes measures for which
performance cannot reliably be scored against a benchmark (for example,
measures that do not have 20 reporters with 20 cases that meet the data
completeness standard) for 3 years in a row (81 FR 77288).
A few commenters recommended that measures that cannot be scored
against a benchmark should be removed from the MIPS score. One
commenter recommended that non-outcome measures that are unscorable
should be given a weight of zero or re-weighted in the performance
category. One commenter supported removing non-outcomes measures for
which performance cannot reliably be scored against a benchmark for 3
years in a row. One commenter believed it would also be appropriate to
remove outcomes measures under a separate more protracted timeline
because the commenter believed the reporting of outcome measures is
more difficult and expected to increase at a slower pace, while
maintaining outcome measures would encourage the testing and
availability of such measures.
Based on the need for CMS to further assess this issue, we are not
proposing to remove non-outcome measures in this proposed rule.
However, we seek comment on what the best timeline for removing both
non-outcome and outcome measures that cannot be reliably scored against
a benchmark for 3 years. We intend to revisit this issue and make
proposals in future rulemaking.
(4) Quality Measures Determined To Be Outcome Measures
Under the MIPS, individual MIPS eligible clinicians are generally
required to submit at least one outcome measure, or, if no outcome
measure is available, one high priority measure. As such, our
determinations as to whether a measure is an outcome measure is of
importance to stakeholders. We utilize the following as a basis to
determine if a measure is considered an outcome measure:
Measure Steward and National Quality Forum (NQF)
designation--For most measures, we will utilize the designation as
determined by the measure steward and the measure's NQF designation to
determine if it is an outcome measure or not. If this is not clear, we
will consider the following step.
Utilization of the CMS Blueprint definitions for outcome
measures: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/Blueprint-130.pdf. An outcome of
care is a health state of a patient resulting from health care. Outcome
measures are supported by evidence that the measure has been used to
detect the impact of one or more clinical interventions. Clinical
analysts are utilized to evaluate the measure.
We also note that patient-reported outcome measures are considered
outcome measures, as they measure the health of the patient directly
resulting from the health care provided. Efficiency measures are not
considered outcome measures, as they are measuring the cost of care
associated with a specific level of care, but we do note that
efficiency is considered a high priority measure.
After a MIPS quality measure is established in the program, it is
generally only reviewed again if there are significant changes to a
measure for the next program year that might warrant a change to the
designation of outcome or not. In most cases, these updates are
significant enough that they are usually presented as a new measure
from the measure owner. New measures to the program will follow the
criteria outlined above. QCDR measures however, are reviewed on a
yearly basis (during the fall) regardless if there is a significant
change or not. We refer readers to section II.C.10.a. for additional
information on the QCDR self-nomination and measures review and
approval process.
We seek comment on the criteria and process outlined above on how
we designate outcome measures. Specifically are there additional
criteria we should take into consideration when we determine if a
measure meets the criteria of an outcome measure? Should we use
different criteria for MIPS measures versus QCDR measures?
d. Cost Performance Category
(1) Background
(a) General Overview
Measuring cost is an integral part of measuring value as part of
MIPS. In implementing the cost performance category for the transition
year (2017 MIPS performance period/2019 MIPS payment year), we started
with measures that had been used in previous programs but noted our
intent to move towards episode-based measurement as soon as possible,
consistent with the statute and the feedback from the clinician
community. Specifically, we adopted 2 measures that had been used in
the VM: The total per capita costs for all attributed beneficiaries
measure (referred to as the total per capita cost measure) and the MSPB
measure (81 FR 77166 through 77168). We also adopted 10 episode-based
measures that had previously been included in the Supplemental Quality
and Resource Use Reports (sQRURs) (81 FR 77171 through 77174).
At Sec. 414.1325(e), we finalized that all measures used under the
cost performance category would be derived from Medicare administrative
claims data and, thus, participation would not require additional data
submission. We finalized a reliability threshold of 0.4 for measures in
the cost performance category (81 FR 77170). We also finalized a case
minimum of 35 for the MSPB measure (81 FR 77171) and 20 for the total
per capita cost measure (81 FR 77170) and each of the 10 episode-based
measures (81 FR 77175) in the cost performance category to ensure the
reliability threshold is met.
For the transition year, we finalized a policy to weight the cost
performance category at zero percent in the final score in order to
give clinicians more opportunity to understand the attribution and the
scoring methodology and gain more familiarity with the measures through
performance feedback (81 FR 77165 through 77166) so that clinicians may
be able to act to improve their performance. In the CY 2017 Quality
Payment Program final rule, we finalized a cost performance category
weight of 10 percent for the 2020 MIPS payment year (81 FR 77165). For
the 2021 MIPS payment year and beyond, the cost performance category
will have a weight of 30 percent of the final score as required by
section 1848(q)(5)(E)(i)(II)(aa) of the Act.
For descriptions of the statutory basis and our existing policies
for the cost performance category, we refer readers to the CY 2017
Quality Payment Program final rule (81 FR 77162 through 77177).
As finalized at Sec. 414.1370(g)(2), the cost performance category
is weighted at zero percent for MIPS eligible clinicians scored under
the MIPS APM scoring standard because many MIPS APM models incorporate
cost measurement in other ways. For more on the APM scoring standard,
see II.C.6.E. of this proposed rule.
(2) Weighting in the Final Score
We are proposing at Sec. 414.1350(b)(2) to change the weight of
the cost performance category from 10 percent to zero percent for the
2020 MIPS payment year. We continue to have concerns
[[Page 30048]]
about the level of familiarity and understanding of cost measures among
clinicians. We will use this additional year in which the score in the
cost performance category does not count towards the final score for
outreach to increase understanding of the measures so that clinicians
will be more comfortable with their role in reducing costs for their
patients. In addition, we will use this additional year to develop more
episode-based measures, which are cost measures that are focused on a
clinical conditions or procedures. We intend to propose in future
rulemaking to adopt episode-based measures currently in development.
Although we believe reducing this weight is appropriate given the
level of understanding of the measures and the scoring standards, we
note that section 1848(q)(5)(E)(i)(II)(aa) of the Act requires the cost
performance category be assigned a weight of 30 percent of the MIPS
final score beginning in the 2021 MIPS payment year. We recognize that
assigning a zero percent weight to the cost performance category for
the 2020 MIPS payment year may not provide a smooth enough transition
for integrating cost measures into MIPS and may not provide enough
encouragement to clinicians to review their performance on cost
measures. This policy could reduce understanding of the measures when
we reach the 2021 MIPS payment year and the cost performance category
will be used to determine 30 percent of the final score for MIPS
eligible clinicians, when in the two previous years it was weighted at
zero. Therefore, we also seek comment on keeping the weight of the cost
performance category at 10 percent for the 2020 MIPS payment year.
In our discussions with clinicians and clinician societies,
clinicians expressed their desire to down-weight the cost performance
category to zero percent for an additional year with full knowledge
that the cost performance category weight is set at 30 percent under
the statute for the 2021 MIPS payment year. The clinicians we spoke
with preferred a low weighting and noted that they are actively
preparing for cost performance category implementation and would be
prepared for the 30 percent statutory weight for the cost performance
category for the 2021 MIPS payment year. We intend to continue to
provide education to clinicians to help them prepare for the upcoming
30 percent weight.
We invite public comments on this proposal of a zero percent
weighting for the cost performance category and the alternative option
of 10 percent weighting for the cost performance category for the 2020
MIPS payment year.
(3) Cost Criteria
(a) Measures Proposed for the MIPS Cost Performance Category
(i) Background
Under Sec. 414.1350(a), we specify cost measures for a performance
period to assess the performance of MIPS eligible clinicians on the
cost performance category. For the 2017 MIPS performance period, we
will utilize 12 cost measures that are derived from Medicare
administrative claims data. Two of these measures, the MSPB measure and
total per capita cost measure, have been used in the VM (81 FR 77166
through 77168), and the remaining 10 are episode-based measures that
were included in the sQRURs in 2014 and 2015 (81 FR 77171 through
77174).
Section 1848(r) of the Act specifies a series of steps and
activities for the Secretary to undertake to involve the physician,
practitioner, and other stakeholder communities in enhancing the
infrastructure for cost measurement, including for purposes of MIPS.
Section 1848(r)(2) of the Act requires the development of care episode
and patient condition groups, and classification codes for such groups,
and provides for care episode and patient condition groups to account
for a target of an estimated one-half of expenditures under Parts A and
B (with this target increasing over time as appropriate). Section
1848(r) of the Act requires us to consider several factors when
establishing these groups. For care episode groups, we must consider
the patient's clinical problems at the time items and services are
furnished during an episode of care, such as clinical conditions or
diagnoses, whether inpatient hospitalization occurs, the principal
procedures or services furnished, and other factors determined
appropriate by the Secretary. For patient condition groups, we must
consider the patient's clinical history at the time of a medical visit,
such as the patient's combination of chronic conditions, current health
status, and recent significant history (such as hospitalization and
major surgery during a previous period), and other factors determined
appropriate.
Section 1848(r)(2) of the Act requires us to post on the CMS Web
site a draft list of care episode and patient condition groups and
codes for solicitation of input from stakeholders, and subsequently,
post on the CMS Web site an operational list of such groups and codes.
In December 2016, we published the Episode-Based Cost Measure
Development for the Quality Program (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Episode-Based-Cost-Measure-Development-for-the-Quality-Payment-Program.pdf) and requested input on a draft
list of care episode and patient condition groups and codes as required
by section 1848(r)(2)(E) and (F) of the Act. We additionally requested
feedback on our overall approach to cost measure development, including
several pages of specific questions on the proposed approach for
clinicians and stakeholders to provide feedback on. This feedback will
be used to modify our cost measure development and ensure that our
approach is continually informed by stakeholder feedback. We are
currently reviewing the feedback that was recently received on that
posting and will share plans to work with clinicians and others on the
further developments of these episodes in the future.
We will be posting the operational list of care episode and patient
condition groups in December 2017, as required by section 1848(r)(2)(G)
of the Act. Section 1848(r)(2)(H) of the Act also requires that not
later than November 1 of each year (beginning with 2018), the Secretary
shall, through rulemaking, revise the operational list as the Secretary
determines may be appropriate.
(ii) Total Per Capita Cost and MSPB Measures
For the 2018 MIPS performance period and future performance
periods, we are proposing to include in the cost performance category
the total per capita cost measure and the MSPB measure as finalized for
the 2017 MIPS performance period. We refer readers to the description
of these measures in the CY 2017 Quality Payment Program final rule (81
FR 77164 through 77171). We are proposing to include the total per
capita cost measure because it is a global measure of all Medicare Part
A and Part B costs during the performance period. MIPS eligible
clinicians are familiar with the total per capita cost measure because
the measure has been used in the VM since the 2015 payment adjustment
period and performance feedback has been provided through the annual
QRUR since 2013 (for a subset of groups that had 20 or more eligible
professionals, based on 2014 performance) and to all groups in the
annual QRUR since 2014 (based on 2013 performance) and mid-year QRUR
since 2015. We are proposing to use the MSPB measure because many MIPS
eligible
[[Page 30049]]
clinicians will be familiar with the measure from the VM, where it has
been included since the 2016 payment adjustment period and in annual
QRUR since 2014 (based on 2013 performance) and the mid-year QRUR since
2015, or its hospital-specified version, which has been a part of the
Hospital VBP Program since 2015, based on 2013 performance. In addition
to familiarity, these two measures cover a large number of patients and
provide an important measurement of clinician contribution to the
overall population that a clinician encounters.
We are not proposing any changes to the methodologies for payment
standardization, risk adjustment, and specialty adjustment for these
measures and refer readers to the CY 2017 Quality Payment Program final
rule (81 FR 77164 through 77171) for more information about these
methodologies.
We will continue to evaluate cost measures that are included in
MIPS on a regular basis and anticipate that measures could be added or
removed, subject to rulemaking under applicable law, as measure
development continues. We will also maintain the measures that are used
in the cost performance category by updating specifications, risk
adjustment, and attribution as appropriate. We anticipate including a
list of cost measures for a given performance period in annual
rulemaking.
We invite public comments on these proposals.
(iii) Episode-Based Measures
Episode-based measures differ from the total per capita cost
measure and MSPB measure because their specifications only include
services that are related to the episode of care for a clinical
condition or procedure (as defined by procedure and diagnosis codes),
as opposed to including all services that are provided to a patient
over a given period of time. For the 2018 MIPS performance period, we
are not proposing to include in the cost performance category the 10
episode-based measures that we adopted for the 2017 MIPS performance
period in the CY 2017 Quality Payment Program final rule (81 FR 77171
through 77174). We instead will work to develop new episode-based
measures, with significant clinician input, for future performance
periods.
We received extensive comments on our proposal to include 41 of
these episode-based measures for the 2017 MIPS performance period,
which we responded to in the CY 2017 Quality Payment Program final rule
(81 FR 77171 through 77174). We also received additional comments after
publication of that final rule with comment period about the decision
to include 10 episode-based measures for the 2017 MIPS performance
period. Although comments were generally in favor of the inclusion of
episode-based measures in the future, there was also overwhelming
stakeholder interest in more clinician involvement in the development
of these episode-based measures as required by section 1848(r)(2) of
the Act. Although there was an opportunity for clinician involvement in
the development of some of the episode-based measures included for the
2017 MIPS performance period, it was not as extensive as the process we
are currently using to develop episode-based measures. We believe that
the new episode-based measures, which we intend to propose in future
rulemaking to include in the cost performance category for the 2019
MIPS performance period, will be substantially improved by more
extensive stakeholder feedback and involvement in the process.
Thus far, stakeholder feedback has been sought in several ways.
First, stakeholder feedback has been sought through various public
postings. In October 2015 and April 2016, pursuant to section
1848(r)(2)(B) and (C) of the Act, we gathered input from stakeholders
on the episode groups previously developed under section 1848(n)(9)(A)
of the Act that has been used to inform the process of constructing the
new episode-based cost measures. This feedback emphasized several key
aspects of cost measure development such as attribution, risk
adjustment, and alignment with quality measurement and patient
outcomes. Stakeholders have also emphasized that feedback related to
cost measures should be actionable and timely. In addition, a draft
list of care episode and patient condition groups, along with trigger
codes, was posted for comment in December 2016 (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Episode-Based-Cost-Measure-Development-for-the-Quality-Payment-Program.pdf) as required by section
1848(r)(2)(E) of the Act and comments were accepted as required by
section 1848(r)(2)(F) of the Act.
This draft list of care episode and patient condition groups and
trigger codes was informed by engagement with clinicians from over 50
clinician specialty societies through a Clinical Committee formed to
participate in cost measure development. The Clinical Committee work
has provided input from a diverse array of clinicians on identifying
conditions and procedures for episode groups. Moving forward, the
Clinical Committee will recommend which services or claims would be
counted in episode costs. This will ensure that cost measures in
development are directly informed by a substantial number of clinicians
and members of specialty societies.
In addition, a technical expert panel has met 3 times to provide
oversight and guidance for our development of episode-based cost
measures. The technical expert panel has offered recommendations for
defining an episode group, assigning costs to the group, and
attributing episode groups to clinicians. This expert feedback has been
built into the current cost measure development process.
As this process continues, we are continuing to seek input from
clinicians. Earlier this year, we opened an opportunity to submit the
names of clinicians to participate in this process. This process
remains open to additional individuals. We believe that episode-based
measures will benefit from this comprehensive approach to development.
In addition, because it is possible that the new episode-based measures
under development could address similar conditions as those in the
episode-based measures finalized for the 2017 MIPS performance period,
we believe that it would be better to focus attention on the new
episode-based measures, so that clinicians would not receive feedback
or scores from two measures for the same patient condition or
procedure. Recognizing that under section 1848(q)(5)(E)(i)(II)(aa) of
the Act, we must assign a weight of 30 percent to the cost performance
category for the 2021 MIPS payment year, we will endeavor to have as
many episode-based measures available as possible for the proposed 2019
MIPS performance period.
We plan to include episode-based measures in the cost performance
category in future years as they are developed and would propose new
measures in future rulemaking.
Although we are not proposing to include any episode-based measures
in calculating the cost performance category score for the 2020 MIPS
payment year, we do plan to continue to provide confidential
performance feedback to clinicians on their performance on episode-
based measures developed under the processes required by section
1848(r)(2) of the Act as appropriate in order to increase familiarity
with the concept of episode-based measurement as well as the specific
episodes that could be included
[[Page 30050]]
in determining the cost performance category score in the future.
Because these measures will be generated based on claims data like
other cost measures, we will not collect any additional data from
clinicians. As we develop new episode-based measures, we believe it is
likely that they would cover similar clinical topics to those that are
in the previously developed episode-based measures because of our
intent to address common clinical conditions with episode-based
measures. We aim to provide an initial opportunity for clinicians to
review their performance based on the new episode-based measures at
some point in the fall of 2017, as the measures are developed and as
the information is available. We note that this feedback will be
specific to the new episode-based measures that are developed under the
process described above and may be presented in a different format than
MIPS eligible clinicians' performance feedback as described in section
II.C.9.a. of this proposed rule. However, our intention is to align the
feedback as much as possible to ensure clinicians receive opportunities
to review their performance on potential new episode-based measures for
the cost performance category prior to the proposed 2019 MIPS
performance period. We are unable to offer a list of new episode-based
measures on which we will provide feedback because that will be
determined in our ongoing development work described above. We are
concerned that continuing to provide feedback on the older episode-
based measures along with feedback on new episode-based measures will
be confusing and a poor use of resources. Because we are focusing on
development of new episode-based measures, our feedback on episode-
based measures that were previously developed will discontinue after
2017 as these measures would no longer be maintained or reflect changes
in diagnostic and procedural coding. As described in section II.C.9.a.
of this proposed rule, we intend to provide feedback on these new
measures as they become available in a new format around summer 2018.
We note that the feedback provided in the summer of 2018 will go to
those MIPS eligible clinicians for whom we are able to calculate the
episode-based measures, which means it would be possible a clinician
may not receive feedback on episode-based measures in both the fall of
2017 and the summer of 2018. We believe that receiving feedback on the
new episode-based measures, along with the previously-finalized total
per capita cost and MSPB measures, will support clinicians in their
readiness for the proposed 2019 MIPS performance period.
As previously finalized in the CY 2017 Quality Payment Program
final rule (81 FR 77173), the episode-based measures that we are not
proposing for the 2018 MIPS performance period will be used for
determining the cost performance category score for the 2019 MIPS
payment year, although the cost performance category score will be
weighted at zero percent in that year.
We invite public comments on this proposal.
(iv) Attribution
In the CY 2017 Quality Payment Program final rule, we changed the
list of primary care services that had been used to determine
attribution for the total per capita cost measure by adding
transitional care management (CPT codes 99495 and 99496) codes and a
chronic care management code (CPT code 99490) (81 FR 77169). In the CY
2017 Physician Fee Schedule final rule, we changed the payment status
for two existing CPT codes (CPT codes 99487 and 99489) that could be
used to describe care management from B (bundled) to A (active) meaning
that the services would be paid under the Physician Fee Schedule (81 FR
80349). The services described by these codes are substantially similar
to those described by the chronic care management code that we added to
the list of primary care services beginning with the 2017 performance
period. We therefore propose to add CPT codes 99487 and 99489, both
describing complex chronic care management, to the list of primary care
services used to attribute patients under the total per capita cost
measure.
We are not proposing any changes to the attribution methods for the
MSPB measure and refer readers to the CY 2017 Quality Payment Program
final rule (81 FR 77168 through 77169) for more information.
We invite public comment on our proposals.
(v) Reliability
In the CY 2017 Quality Payment Program final rule (81 FR 77169
through 77170), we finalized a reliability threshold of 0.4 for
measures in the cost performance category. Reliability is an important
evaluation for cost measures to ensure that differences in performance
are not the result of random variation. Statistically, reliability
depends on performance variation for a measure across clinicians
(``signal''), the random variation in performance for a measure within
a clinician's attributed beneficiaries (``noise''), and the number of
beneficiaries attributed to the clinician. High reliability for a
measure suggests that comparisons of relative performance among
clinicians are likely to be stable over different performance periods
and that the performance of one clinician on the measure can be
confidently distinguished from another. As an example of the
statistical concept of reliability, a test in which the same individual
received very different scores depending on how the included questions
are framed would not be reliable. Potential reliability values range
from 0.00 to 1.00, where 1.00 (highest possible reliability) signifies
that all variation in the measure's rates is the result of variation in
differences in performance across clinicians, whereas 0.0 (lowest
possible reliability) signifies that all variation could be a result of
measurement error. The 0.4 reliability threshold that we adopted for
the cost performance category measures in MIPS means that the majority
of MIPS eligible clinicians and groups who meet the case minimum
required for scoring under a measure have measure reliability scores
that exceed 0.4. We generally consider reliability levels between 0.4
and 0.7 to indicate ``moderate'' reliability and levels above 0.7 to
indicate ``high'' reliability.
We addressed comments we received on the CY 2017 Quality Payment
Program proposed rule (81 FR 77169 through 77171), that expressed
concern that our 0.4 reliability threshold was too low. Many commenters
recommended that cost measures be included only when they could meet
the standard of ``high'' reliability (0.7 or above). Many commenters on
the CY 2017 Quality Payment Program final rule made similar comments.
Commenters emphasized the importance of reliability; however, we have
also seen commenters incorrectly refer to measures as being 40 percent
reliable. Reliability is not a percentage but is instead a coefficient
so a measure with 0.4 reliability does not reflect that it is only
correct for 40 percent of those measured. We encourage a review of our
analysis of reliability for the total per capita cost measure (80 FR
71282) and MSPB (81 FR 77169 through 77171).
Reliability is an important evaluation tool for an individual
measure, but it is only one element of evaluation. Reliability
generally increases as we increase the case size but a high reliability
may also reflect low variation. A measure in which all clinicians
perform at nearly the same rate would be reliable but not valuable in a
program
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that attempts to recognize and reward differential performance. A
measure in which there is very little variation provides little value
in a program like MIPS given the devotion of resources to developing
and maintaining that measure over other potential measures. Reliability
must also be considered in the context of a measurement system like
MIPS which incorporates other elements of measurement. We understand
and appreciate the concerns that have been expressed about reliability
of measures. Medicine, however, always has a certain amount of
variability which may affect the reliability score. We want strong
reliability, but not at the expense of losing valuable information
about clinicians. We are concerned that placing too much of an emphasis
on reliability calculations could limit the applicability of cost
measures to large group practices who, by nature of their size, have
larger patient populations, thus depriving solo clinicians and
individual reporters from being rewarded for efforts to better manage
patients. Therefore, we are not proposing any adjustments to our
reliability policies, but we will continue to evaluate reliability as
we develop new measures and to ensure that our measures meet an
appropriate standard.
(b) Attribution for Individuals and Groups
We are not proposing any changes for how we attribute cost measures
to individual and group reporters. We refer readers to the CY 2017
Quality Payment Program final rule for more information (81 FR 77175
through 77176).
(c) Incorporation of Cost Measures With SES or Risk Adjustment
Both measures proposed for inclusion in the cost performance
category for the 2018 MIPS performance period are risk adjusted at the
measure level. Although the risk adjustment of the 2 measures is not
identical, in both cases it is used to recognize the higher risk
associated with demographic factors (such as age) or certain clinical
conditions. We recognize that the risks accounted for with this
adjustment are not the only potential attributes that could lead to a
higher cost patient. Stakeholders have pointed to many other factors
such as income level, race, and geography that they believe contribute
to increased costs. These issues and our plans for attempting to
address them are discussed in length in section II.C.7.b.(1)(a) of this
rule.
(d) Incorporation of Cost Measures With ICD-10 Impacts
In section II.C.7.a.(1)(c) of this proposed rule, we discuss our
proposal to assess performance on any measures impacted by ICD-10
updates based only on the first 9 months of the 12-month performance
period. Because the total per capita cost and MSPB measures include
costs from all Medicare Part A and B services, regardless of the
specific ICD-10 codes that are used on claims, and do not assign
patients based on ICD-10, we do not anticipate that any measures for
the cost performance category would be affected by this ICD-10 issue
during the 2018 MIPS performance period. However, as we continue our
plans to expand cost measures to incorporate episode-based measures,
ICD-10 changes could become important. Episode-based measures may be
opened (triggered) by and may assign services based on ICD-10 codes.
Therefore, a change to ICD-10 coding could have a significant effect on
an episode-based measure. Changes to ICD-10 codes will be incorporated
into the measure specifications on a regular basis through the measure
maintenance process.
(e) Application of Measures to Non-Patient Facing MIPS Eligible
Clinicians
We are not proposing changes to the policy we finalized in the CY
2017 Quality Payment Program final rule (81 FR 77176) that we will
attribute cost measures to non-patient facing MIPS eligible clinicians
who have sufficient case volume, in accordance with the attribution
methodology.
Section 1848(q)(2)(C)(iv) of the Act requires the Secretary to
consider the circumstances of professional types who typically furnish
services without patient facing interaction (non-patient facing) when
determining the application of measures and activities. In addition,
this section allows the Secretary to apply alternative measures or
activities to non-patient facing MIPS eligible clinicians that fulfill
the goals of a performance category. Section 1848(q)(5)(F) of the Act
allows the Secretary to re-weight MIPS performance categories if there
are not sufficient measures and activities applicable and available to
each type of MIPS eligible clinician involved.
We believe that non-patient facing clinicians are an integral part
of the care team and that their services do contributed to the overall
costs but at this time we believe it better to focus on the development
of a comprehensive system of episode-based measures which focus on the
role of patient-facing clinicians. Accordingly, for the 2018 MIPS
performance period, we are not proposing alternative cost measures for
non-patient facing MIPS eligible clinicians or groups. This means that
non-patient facing MIPS eligible clinicians or groups are unlikely to
be attributed any cost measures that are generally attributed to
clinicians who have patient-facing encounters with patients. Therefore,
we anticipate that, similar to MIPS eligible clinicians or groups that
do not meet the required case minimums for any cost measures, many non-
patient facing MIPS eligible clinicians may not have sufficient cost
measures applicable and available to them and would not be scored on
the cost performance category under MIPS. We continue to consider
opportunities to develop alternative cost measures for non-patient
facing clinicians and solicit comment on this topic to inform our
future rulemaking.
(f) Facility-Based Measurement as it Relates to the Cost Performance
Category
In section II.C.7.a.(4) of this proposed rule, we discuss our
proposal to implement section 1848(q)(2)(C)(ii) of the Act by assessing
clinicians who meet certain requirements and elect participation based
on the performance of their associated hospital in the Hospital VBP
Program. We refer readers to that section for full details on our
proposals related to facility-based measurement, including the measures
and how the measures are scored, for the cost performance category.
e. Improvement Activity Criteria
(1) Background
Section 1848(q)(2)(C)(v)(III) of the Act defines an improvement
activity as an activity that relevant eligible clinician organizations
and other relevant stakeholders identify as improving clinical practice
or care delivery, and that the Secretary determines, when effectively
executed, is likely to result in improved outcomes. Section
1848(q)(2)(B)(iii) of the Act requires the Secretary to specify
improvement activities under subcategories for the performance period,
which must include at least the subcategories specified in section
1848(q)(2)(B)(iii)(I) through (VI) of the Act, and in doing so to give
consideration to the circumstances of small practices, and practices
located in rural areas and geographic health professional shortage
areas (HPSAs).
Section 1848(q)(2)(C)(iv) of the Act generally requires the
Secretary to give consideration to the circumstances of
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non-patient facing individual MIPS eligible clinicians or groups and
allows the Secretary, to the extent feasible and appropriate, to apply
alternative measures and activities to such individual MIPS eligible
clinicians and groups.
Section 1848(q)(2)(C)(v) of the Act required the Secretary to use a
request for information (RFI) to solicit recommendations from
stakeholders to identify improvement activities and specify criteria
for such improvement activities, and provides that the Secretary may
contract with entities to assist in identifying activities, specifying
criteria for the activities, and determining whether individual MIPS
eligible clinicians or groups meet the criteria set. For a detailed
discussion of the feedback received from the MIPS and APMs RFI, see the
CY 2017 Quality Payment Program 2017 final rule (81 FR 77177).
We defined improvement activities at Sec. 414.1305 as an activity
that relevant MIPS eligible clinicians, organizations and other
relevant stakeholders identify as improving clinical practice or care
delivery and that the Secretary determines, when effectively executed,
is likely to result in improved outcomes.
In the CY 2017 Quality Payment Program final rule (81 FR 77199), we
solicited comments on activities that would advance the usage of health
IT to support improvement activities. We received several comments in
support of the concept to include emerging certified health IT
capabilities as part of the activities in the Improvement Activities
Inventory and several commenters supported our assessment that using
CEHRT can aid in improving clinical practices and help healthcare
organizations achieve success on numerous improvement activities, as
well as the continued integration of improvement activities and
advancing clinical information. However, several commenters expressed
concern about health IT-associated burdens and costs and recommended
that we also continue to offer diverse activities that do not rely on
emerging capabilities of certified health IT, as they are not
universally available or may only be offered as high cost add-on
capabilities. Some commenters also requested that we be less
prescriptive in our requirements for the use of health IT.
In response to the comments, we will continue to focus on
incentivizing the use of health IT, telehealth, and connection of
patients to community-based services. The use of health IT is an
important aspect of care delivery processes described in many of the
proposed new improvement activities in Table F in the Appendix of this
proposed rule, and in Table H: Finalized Improvement Activities
Inventory that we finalized in the CY 2017 Quality Payment Program
final rule (81 FR 77817 through 77831). In that same final rule, we
also finalized a policy to allow MIPS eligible clinicians to achieve a
bonus in the advancing care information performance category when they
use functions included in CEHRT to complete eligible activities from
the Improvement Activities Inventory. Please refer to section
II.C.6.f.(2)(d) of this proposed rule for details on how improvement
activities using CEHRT relate to the objectives and measures of the
advancing care information and improvement activities performance
categories. We are not proposing any changes to these policies for
incentivizing the use of health IT in this proposed rule; however, we
will continue to consider including emerging certified health IT
capabilities as part of activities within the Improvement Activities
Inventory in future years.
In addition, as noted previously, we believe a key goal of the
Quality Payment Program is to establish a program that allows for close
alignment of the four performance categories. Although we are not
proposing any specific new policies, we seek comment on how we might
provide flexibility for MIPS eligible clinicians to effectively
demonstrate improvement through health IT usage while also measuring
such improvement. We welcome public comment on these considerations.
(2) Contribution to the Final Score
In the CY 2017 Quality Payment Program final rule (81 FR 77179
through 77180), we finalized at Sec. 414.1355 that the improvement
activities performance category would account for 15 percent of the
final score. We also finalized at Sec. 414.1380(b)(3)(iv) criteria for
recognition as a certified-patient centered medical home or comparable
specialty practice. We are proposing to clarify the term ``certified''
patient-centered medical home finalized at Sec. 414.1380(b)(3)(iv). It
has come to our attention that the common terminology utilized in the
general medical community for ``certified'' patient-centered medical
home is ``recognized'' patient-centered medical home. Therefore, in
order to provide clarity we are proposing that the term ``recognized''
be accepted as equivalent to the term ``certified'' when referring to
the requirements for a patient-centered medical home to receive full
credit for the improvement activities performance category for MIPS.
Specifically, we propose to revise Sec. 414.1380(b)(3)(iv) to provide
that a MIPS eligible clinician or group in a practice that is certified
or recognized as a patient-centered medical home or comparable
specialty practice, as determined by the Secretary, receives full
credit for performance on the improvement activities performance
category. For purposes of Sec. 414.1380 (b)(3)(iv), ``full credit''
means that the MIPS eligible clinician or group has met the highest
potential category score of 40 points. A practice is certified or
recognized as a patient-centered medical home if it meets any of the
criteria specified under Sec. 414.1380(b)(3)(iv).
In the CY 2017 Quality Payment Program final rule (81 FR 77198), we
requested commenters' specific suggestions for additional activities or
activities that may merit additional points beyond the ``high'' level.
Several commenters urged us to increase the overall number of high-
weighted activities in this performance category. Some commenters
recommended additional criteria for designating high-weighted
activities, such as an improvement activity's impact on population
health, medication adherence, and shared decision-making tools, and
encouraged us to be more transparent in our weighting decisions.
Several commenters recommended that we weight registry-related
activities as high, and suggested that we award individual MIPS
eligible clinicians and groups in APMs full credit in this performance
category. The commenters also offered many recommendations for changing
current medium-weighted activities to high and offered many specific
suggestions for new high-weighted improvement activities.
In response to the comments, we are proposing new, high-weighted
activities in Table F in the Appendix of this proposed rule. As
explained in the CY 2017 Quality Payment Program final rule (81 FR
77194), we believe that high weighting should be used for activities
that directly address areas with the greatest impact on beneficiary
care, safety, health, and well-being. We are not proposing changes to
this approach in this proposed rule; however, we will take these
suggested additional criteria into consideration for designating high-
weighted activities in future rulemaking. For MIPS eligible clinicians
participating in MIPS APMs, we finalized a policy to reduce reporting
burden through the APM scoring standard for this category to recognize
improvement activities work performed through participation in MIPS
APMs. This policy is codified at Sec. 414.1370(g)(3), and we refer
readers to the CY 2017 Quality Payment Program
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final rule for further details on reporting and scoring this category
under the APM Scoring Standard (81 FR 77259 through 77260).
(3) Improvement Activities Data Submission Criteria
(a) Submission Mechanisms
In the CY 2017 Quality Payment Program final rule (81 FR 77180), we
discussed that for the transition year of MIPS we would allow for
submission of data for the improvement activities performance category
using the qualified registry, EHR, QCDR, CMS Web Interface, and
attestation data submission mechanisms through attestation.
Specifically, we finalized a policy that regardless of the data
submission method, with the exception of MIPS eligible clinicians in
MIPS APMs, all individual MIPS eligible clinicians or groups must
select activities from the Improvement Activities Inventory. In
addition, we finalized at Sec. 414.1360 that for the transition year
of MIPS, all individual MIPS eligible clinicians or groups, or third
party intermediaries such as health IT vendors, QCDRs and qualified
registries that submit on behalf of an individual MIPS eligible
clinician or group, must designate a ``yes'' response for activities on
the Improvement Activities Inventory. In the case where an individual
MIPS eligible clinician or group is using a health IT vendor, QCDR, or
qualified registry for their data submission, the individual MIPS
eligible clinician or group will certify all improvement activities
were performed and the health IT vendor, QCDR, or qualified registry
would submit on their behalf. We would like to maintain stability in
the Quality Payment Program and continue this policy into future years.
Therefore, we are proposing at Sec. 414.1360 that for purposes of the
transition year of MIPS and future years all individual MIPS eligible
clinicians or groups, or third party intermediaries such as health IT
vendors, QCDRs and qualified registries that submit on behalf of an
individual MIPS eligible clinician or group, must designate a ``yes''
response for activities on the Improvement Activities Inventory. In the
case where an individual MIPS eligible clinician or group is using a
health IT vendor, QCDR, or qualified registry for their data
submission, the MIPS eligible clinician or group will certify all
improvement activities were performed and the health IT vendor, QCDR,
or qualified registry would submit on their behalf. In addition, as
discussed in section II.C.4.d. of this proposed rule, we are proposing
to generally apply our previously finalized and proposed group policies
to virtual groups.
We would like to note that while we finalized at Sec. 414.1325(d)
in the CY 2017 Quality Payment Program final rule that individual MIPS
eligible clinicians and groups may only use one submission mechanism
per performance category, in section II.C.6.a.(1) of this proposed
rule, we are proposing to revise Sec. 414.1325(d) for purposes of the
2020 MIPS payment year and future years to allow individual MIPS
eligible clinicians and groups to submit measures and activities, as
applicable, via as many submission mechanisms as necessary to meet the
requirements of the quality, improvement activities, or advancing care
information performance categories. We refer readers to section
II.C.6.a.(1) of this proposed rule for further discussion of this
proposal.
We also included a designation column in the Improvement Activities
Inventory at Table H in the Appendix of the CY 2017 Quality Payment
Program final rule (81 FR 77817) that indicated which activities
qualified for the advancing care information bonus finalized at Sec.
414.1380. In future updates to the Improvement Activities Inventory we
intend to continue to indicate which activities qualify for the
advancing care information performance category bonus.
In the CY 2017 Quality Payment Program final rule (81 FR 77181), we
clarified that if one MIPS eligible clinician (NPI) in a group
completed an improvement activity, the entire group (TIN) would receive
credit for that activity. In addition, we specified that all MIPS
eligible clinicians reporting as a group would receive the same score
for the improvement activities performance category if at least one
clinician within the group is performing the activity for a continuous
90 days in the performance period. As discussed in section II.C.4.d. of
this proposed rule, we are proposing to generally apply our previously
finalized and proposed group policies to virtual groups. We are not
proposing any changes to this policy in this proposed rule. However, we
are requesting comment on whether we should establish a minimum
threshold (for example, 50 percent) of the clinicians (NPIs) that must
complete an improvement activity in order for the entire group (TIN) to
receive credit in the improvement activities performance category in
future years. In addition, we are requesting comments on recommended
minimum threshold percentages and whether we should establish different
thresholds based on the size of the group. For example, in considering
different thresholds we could attribute recognition as a certified or
recognized patient-centered medical home or comparable specialty
practice at the individual TIN/NPI level, and attribute this
designation to the group under which they bill if they are
participating in MIPS as a group or as part of a virtual group. A group
or virtual group consisting of 100 NPIs could have a reporting
threshold of 50 percent while a group consisting of 10 NPIs could have
a lower reporting threshold of 10 percent. We are concerned that while
establishing any specific threshold for the percentage of NPIs in a TIN
that must participate in an improvement activity for credit will
incentivize some groups to move closer to the threshold, it may have
the unintended consequence of incentivizing groups who are exceeding
the threshold to gravitate back toward the threshold. Therefore, we are
requesting comments on how to set this threshold while maintaining the
goal of promoting greater participation in an improvement activity.
Additionally, we noted in the CY 2017 Quality Payment Program final
rule (81 FR 77197) that we intended, in future years, to score the
improvement activities performance category based on performance and
improvement, rather than simple attestation. We seek comment on how we
could measure performance and improvement; we are especially interested
in ways to measure performance without imposing additional burden on
eligible clinicians, such as by using data captured in eligible
clinicians' daily work.
(b) Submission Criteria
In the CY 2017 Quality Payment Program final rule (81 FR 77185), we
finalized at Sec. 414.1380 to set the improvement activities
submission criteria under MIPS, to achieve the highest potential score,
at two high-weighted improvement activities or four medium-weighted
improvement activities, or some combination of high and medium-weighted
improvement activities. While the minimum reporting period for one
improvement activity is 90 days, the maximum frequency with which an
improvement activity may be reported would be once during the 12-month
performance period. In addition, as discussed in section II.C.4.d. of
this proposed rule, we are proposing to generally apply our previously
finalized and proposed group policies to virtual groups.
We established exceptions to the above for: small practices;
practices located in rural areas; practices located in geographic
HPSAs; non-patient facing
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individual MIPS eligible clinicians or groups; and individual MIPS
eligible clinicians and groups that participate in a MIPS APM or a
patient-centered medical home submitting in MIPS. Specifically, for
individual MIPS eligible clinicians and groups that are small
practices, practices located in rural areas or geographic HPSAs, or
non-patient facing individual MIPS eligible clinicians or groups, to
achieve the highest score, one high-weighted or two medium-weighted
improvement activities are required. For these individual MIPS eligible
clinicians and groups, in order to achieve one-half of the highest
score, one medium-weighted improvement activity is required.
Under the APM scoring standard, all clinicians identified on the
Participation List of an APM receive at least one-half of the highest
score applicable to the MIPS APM. To develop the improvement activities
score assigned to each MIPS APM, we compare the requirements of the
specific MIPS APM with the list of activities in the Improvement
Activities Inventory and score those activities in the same manner that
they are otherwise scored for MIPS eligible clinicians. If by our
assessment the MIPS APM does not receive the maximum improvement
activities performance category score then the APM entity can submit
additional improvement activities. All other individual MIPS eligible
clinicians or groups that we identify as participating in APMs that are
not MIPS APMs will need to select additional improvement activities to
achieve the improvement activities highest score. We refer readers to
section II.C.6.g. of this proposed rule for further discussion of the
APM scoring standard.
We also provided full credit for the improvement activities
performance category, as required by law, for an individual MIPS
eligible clinician or group that has received certification or
accreditation as a patient-centered medical home or comparable
specialty practice from a national program or from a regional or state
program, private payer or other body that administers patient-centered
medical home accreditation and certifies 500 or more practices for
patient-centered medical home accreditation or comparable specialty
practice certification, or for an individual MIPS eligible clinician or
group that is a participant in a medical home model.
We also noted in the CY 2017 Quality Payment Program final rule
that practices may receive this designation at a practice level and
that TINs may be comprised of both undesignated practices and
designated practices (81 FR 77178). We finalized at Sec.
414.1380(b)(3)(viii) that to receive full credit as a certified
patient-centered medical home or comparable specialty practice, a TIN
that is reporting must include at least one practice that is a
certified patient-centered medical home or comparable specialty
practice. We also indicated that we would continue to have more
stringent requirements in future years, and would lay the groundwork
for expansion towards continuous improvement over time (81 FR 77189).
We received many comments on the CY 2017 Quality Payment Program final
rule regarding our transition year policy that only one practice site
within a TIN needs to be certified as a patient-centered medical home
for the entire TIN to receive full credit in the improvement activities
performance category. While several commenters supported our transition
year policy, others disagreed and suggested to move to a more stringent
requirement in future years while still offering some flexibility.
Accordingly, we propose to revise Sec. 414.1380(b)(3)(x) to provide
that for the 2020 MIPS payment year and future years, to receive full
credit as a certified or recognized patient-centered medical home or
comparable specialty practice, at least 50 percent of the practice
sites within the TIN must be recognized as a patient-centered medical
home or comparable specialty practice. This is an increase to the
requirement that only one practice site within a TIN needs to be
certified as a patient-centered medical home, but does not require
every site be certified, which could be overly restrictive given that
some sites within a TIN may be in the process of being certified as
patient-centered medical homes. In addition, we believe a 50 percent
threshold is achievable which is supported by a study of physician-
owned primary care groups in a recent Annals of Family Medicine article
(Casalino, et al., 2016) https://www.annfammed.org/content/14/1/16.full.
For nearly all groups in this study (sampled with variation in size and
geographic area) at least 50 percent of the practice sites within the
group had a medical home designation. If the group is unable to meet
the 50 percent threshold then the individual MIPS eligible clinician
may choose to receive full credit as a certified patient-centered
medical home or comparable specialty practice by reporting as an
individual for all performance categories. In addition, as discussed in
section II.C.4.d. of this proposed rule, we are proposing to generally
apply our previously finalized and proposed group policies to virtual
groups. Further, we welcome suggestions on an appropriate threshold for
the number of NPIs within the TIN that must be recognized as a
certified patient-centered medical home or comparable specialty
practice to receive full credit in the improvement activities
performance category.
We have determined that the Comprehensive Primary Care Plus (CPC+)
APM design satisfies the requirements to be designated as a medical
home model, as defined in Sec. 414.1305, and is therefore a certified
or recognized patient-centered medical home for purposes of the
improvement activities performance category. The CPC+ model meets the
criteria to be an Advanced APM. CPC+ eligibility criteria for practices
include, but are not limited to, the use of CEHRT and care delivery
activities such as: Assigning patients to clinician panels; providing
24/7 clinician access; and supporting quality improvement activities.
Control groups in CPC+ are required to meet the same eligibility
criteria as those selected to be active participants in the model. For
Round 2 of CPC+, CMS is randomly assigning accepted practices into the
intervention group or a control group. Practices accepted into CPC+ and
randomized into the control group have satisfied the requirements for
participation in CPC+, a medical home model, and we believe that the
MIPS eligible clinicians in the control group should therefore receive
full credit for the improvement activities performance category. In
addition, the practices randomized to the CPC+ control group must sign
a Participation Agreement with us; the agreement will require practices
in a control group to maintain a Practitioner Roster of all MIPS
eligible clinicians in the practice.
Accordingly, we are proposing that MIPS eligible clinicians in
practices that have been randomized to the control group in the CPC+
APM would receive full credit as a medical home model, and therefore a
certified patient-centered medical home, for the improvement activities
performance category. MIPS eligible clinicians who attest that they are
in practices that have been randomized to the control group in the CPC+
APM would receive full credit for the improvement activities
performance category for each performance period in which they are on
the Practitioner Roster, the official list of eligible clinicians
participating in a practice in the CPC+ control group. The inclusion of
MIPS eligible clinicians in practices that have been randomized into
the CPC+ control group recognizes that they have met the
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requirements to receive full credit for performance in the improvement
activities performance category as a medical home model, and will help
ensure more equitable treatment of the CPC+ control group by allowing
clinicians in the control group that have met the criteria for
participation in the CPC+ APM to receive the same recognition as those
actively participating in the CPC+ intervention group.
We request comments on these proposals.
(c) Required Period of Time for Performing an Activity
In the CY 2017 Quality Payment Program final rule (81 FR 77186), we
specified at Sec. 414.1360 that MIPS eligible clinicians or groups
must perform improvement activities for at least 90 consecutive days
during the performance period for improvement activities performance
category credit. Activities, where applicable, may be continuing (that
is, could have started prior to the performance period and are
continuing) or be adopted in the performance period as long as an
activity is being performed for at least 90 days during the performance
period. In addition, as discussed in section II.C.4.d. of this proposed
rule, we are proposing to generally apply our previously finalized and
proposed group policies to virtual groups. We are not proposing any
changes to the required period of time for performing an activity for
the improvement activities performance category in this proposed rule.
(4) Application of Improvement Activities to Non-Patient Facing
Individual MIPS Eligible Clinicians and Groups
In the CY 2017 Quality Payment Program final rule (81 FR 77187), we
specified at Sec. 414.1380(b)(3)(vii) that for non-patient facing
individual MIPS eligible clinicians or groups, to achieve the highest
score one high-weighted or two medium-weighted improvement activities
are required. For these individual MIPS eligible clinicians and groups,
in order to achieve one-half of the highest score, one medium-weighted
improvement activity is required. We are not proposing any changes to
the application of improvement activities to non-patient facing
individual MIPS eligible clinicians and groups for the improvement
activities performance category in this proposed rule.
(5) Special Consideration for Small, Rural, or Health Professional
Shortage Areas Practices
In the CY 2017 Quality Payment Program final rule (81 FR 77188), we
finalized at Sec. 414.1380(b)(3)(vii) that one high-weighted or two
medium-weighted improvement activities are required for individual MIPS
eligible clinicians and groups that are small practices or located in
rural areas, or geographic HPSAs, to achieve full credit. In addition,
we specified at Sec. 414.1305 that a rural area means ZIP codes
designated as rural, using the most recent HRSA Area Health Resource
File data set available. Lastly, we finalized the following definitions
at Sec. 414.1305: (1) Small practices is defined to mean practices
consisting of 15 or fewer clinicians and solo practitioners; and (2)
Health Professional Shortage Areas (HPSA) refers to areas as designated
under section 332(a)(1)(A) of the Public Health Service Act. We are not
proposing any changes to the special consideration for small, rural, or
health professional shortage areas practices for the improvement
activities performance category in this proposed rule.
(6) Improvement Activities Subcategories
In the CY 2017 Quality Payment Program final rule (81 FR 77190), we
finalized at Sec. 414.1365 that the improvement activities performance
category will include the subcategories of activities provided at
section 1848(q)(2)(B)(iii) of the Act. In addition, we finalized at
Sec. 414.1365 the following additional subcategories: Achieving Health
Equity; Integrated Behavioral and Mental Health; and Emergency
Preparedness and Response. We are not proposing any changes to the
improvement activities subcategories for the improvement activities
performance category in this proposed rule.
(7) Improvement Activities Inventory
(a) Proposed Approach on the Annual Call for Activities Process for
Adding New Activities
In Table H in the Appendix of the CY 2017 Quality Payment Program
final rule (81 FR 77817), we finalized the Improvement Activities
Inventory for MIPS. In addition, through subregulatory guidance we
provided an informal process for submitting new improvement activities
for potential inclusion in the comprehensive Improvement Activities
Inventory for the Quality Payment Program Year 2. During this
transition period we received input from various MIPS eligible
clinicians and organizations suggesting possible new activities via a
nomination form that was posted on the CMS Web site at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/CallForMeasures.html. We are proposing new activities
and changes to the Improvement Activities Inventory in Tables F and G
of the Appendix of this proposed rule.
For the Quality Payment Program Year 3 and future years, we are
proposing to formalize an Annual Call for Activities process for adding
possible new activities to the Improvement Activities Inventory. We
believe this is a way to engage eligible clinician organizations and
other relevant stakeholders, including beneficiaries, in the
identification and submission of improvement activities for
consideration. We propose that individual MIPS eligible clinicians or
groups and other relevant stakeholders may recommend activities for
potential inclusion in the Improvement Activities Inventory via a
similar nomination form utilized in the transition year of MIPS found
on the Quality Payment Program Web site at www.qpp.cms.gov. As part of
the process, individual MIPS eligible clinicians, groups, and other
relevant stakeholders would be able to nominate additional improvement
activities that we may consider adding to the Improvement Activities
Inventory. Individual MIPS eligible clinicians and groups and relevant
stakeholders would be able to provide an explanation via the nomination
form of how the improvement activity meets all the criteria we have
identified in section II.C.6.e.(7)(b) of this proposed rule. The 2018
proposed new improvement activities and the 2018 proposed improvement
activities with changes can be found in Tables F and G of the Appendix
of this proposed rule and will be available on the CMS Web site.
We request comments on this proposed annual Call for Activities
process.
(b) Criteria for Nominating New Improvement Activities for the Annual
Call for Activities
We propose for the Quality Payment Program Year 2 and future years
that stakeholders would apply one or more of the following criteria
when submitting improvement activities in response to the Annual Call
for Activities:
Relevance to an existing improvement activities
subcategory (or a proposed new subcategory);
Importance of an activity toward achieving improved
beneficiary health outcome;
[[Page 30056]]
Importance of an activity that could lead to improvement
in practice to reduce health care disparities;
Aligned with patient-centered medical homes;
Activities that may be considered for an advancing care
information bonus;
Representative of activities that multiple individual MIPS
eligible clinicians or groups could perform (for example, primary care,
specialty care);
Feasible to implement, recognizing importance in
minimizing burden, especially for small practices, practices in rural
areas, or in areas designated as geographic HPSAs by HRSA;
Evidence supports that an activity has a high probability
of contributing to improved beneficiary health outcomes; or
CMS is able to validate the activity.
We note that in future rulemaking, activities that overlap with
other performance categories may be included if such activities support
the key goals of the program.
We request comments on this proposal.
(c) Submission Timeline for Nominating New Improvement Activities for
the Annual Call for Activities
It is our intention that the nomination and acceptance process
will, to the best extent possible, parallel the Annual Call for
Measures process already conducted for MIPS quality measures. Aligned
with this approach, we propose to accept submissions for prospective
improvement activities at any time during the performance period for
the Annual Call for Activities and create an Improvement Activities
under Review (IAUR) list. This list will be considered by us and may
include federal partners in collaboration with stakeholders. The IAUR
list will be analyzed with consideration of the proposed criteria for
inclusion of improvement activities in the Improvement Activities
Inventory. In addition, we propose that for the Annual Call for
Activities, only activities submitted by March 1 would be considered
for inclusion in the Improvement Activities Inventory for the
performance periods occurring in the following calendar year. This
proposal is slightly different than the Call for Measures timeline. The
Annual Call for Measures requires a 2-year implementation timeline
because the measures being considered for inclusion in MIPS undergo the
pre-rulemaking process with review by the Measures Application
Partnership (MAP). We are not proposing that improvement activities
undergo MAP review. Therefore, our intention is to close the Annual
Call for Activities submissions by March 1 before the applicable
performance period, which will enable us to propose the new improvement
activities for adoption in the same year's rulemaking cycle for
implementation in the following year. For example, an improvement
activity submitted prior to March 1, 2018, would be considered for
performance periods occurring in 2019. In addition, we propose that we
will add new improvement activities to the inventory through notice-
and-comment rulemaking. In future years we anticipate developing a
process and establishing criteria for identifying activities for
removal from the Improvement Activities Inventory through the Annual
Call for Activities process. We are requesting comments on what
criteria should be used to identify improvement activities for removal
from the Improvement Activities Inventory.
(8) Approach for Adding New Subcategories
In the CY 2017 Quality Payment Program final rule (81 FR 77197), we
finalized the following criteria for adding a new subcategory to the
improvement activities performance category:
The new subcategory represents an area that could
highlight improved beneficiary health outcomes, patient engagement and
safety based on evidence.
The new subcategory has a designated number of activities
that meet the criteria for an improvement activity and cannot be
classified under the existing subcategories.
Newly identified subcategories would contribute to
improvement in patient care practices or improvement in performance on
quality measures and cost performance categories.
We are not proposing any changes to the approach for adding new
subcategories for the improvement activities performance category in
this proposed rule. However, we are proposing that in future years of
the Quality Payment Program we will add new improvement activities
subcategories through notice-and-comment rulemaking. In addition, we
are seeking comments on new improvement activities subcategories.
A number of stakeholders have suggested that a separate subcategory
for improvement activities specifically related to health IT would make
it easier for MIPS eligible clinicians and vendors to understand and
earn points toward their final score through the use of health IT. Such
a health IT subcategory could include only improvement activities that
are specifically related to the advancing care information performance
category measures and allow MIPS eligible clinicians to earn credit in
the improvement activities performance category, while receiving a
bonus in the advancing care information performance category as well.
We are seeking suggestions on how a health IT subcategory within the
improvement activities performance category could be structured to
afford MIPS eligible clinicians with flexible opportunities to gain
experience in using CEHRT and other health IT to improve their
practice. Should the current policies where improvement activities earn
bonus points within the advancing care information performance category
be enhanced? Are there additional policies that should be explored in
future rulemaking? We welcome public comment on this potential health
IT subcategory.
(9) CMS Study on Burdens Associated With Reporting Quality Measures
In the CY 2017 Quality Payment Program final rule (81 FR 77195), we
finalized specifics regarding the CMS Study on Improvement Activities
and Measurement including the study purpose, study participation credit
and requirements, and the study procedure. We are modifying the name of
the study in this proposed rule to the ``CMS study on burdens
associated with reporting quality measures'' to more accurately reflect
the purpose of the study. The study assesses clinician burden and data
submission errors associated with the collection and submission of
clinician quality measures for MIPS, enrolling groups of different
sizes and individuals in both rural and non-rural settings and also
different specialties. We also noted that study participants would
receive full credit in the improvement activities performance category
after successfully electing, participating, and submitting data to the
study coordinators at CMS for the full calendar year (81 FR 77196). We
requested comment on the study, and received generally supportive
feedback for the study.
We are not proposing any changes to the study purpose. We are
proposing changes to the study participation credit and requirements
sample size, how the study sample is categorized into groups, and the
frequency of quality data submission, focus groups, and surveys. In
addition to performing descriptive statistics to compare the trends in
errors and burden between study years 2017 and 2018, we would like to
perform a more rigorous statistical analysis with the 2018 data, which
will require a larger sample size. We propose this increase in the
sample size for 2018 to
[[Page 30057]]
provide the minimum sample needed to get a significant result with
adequate power for the following investigation.
Specifically, we are interested in whether there are any
significant differences in quality measurement data submission errors
and/or clinician burdens between rural clinicians submitting either
individually or as a group, and urban clinicians submitting as an
individual or as a group. A statistical power analysis was performed
and a total sample size of 118 will be adequate for the main objective
of the study. However, allowance will be made to account for attrition
and other additional (or secondary) analysis.
This analysis would be compared at different sizes of practices (<3
eligible clinicians, between 3-8 eligible clinicians, etc.). This
assessment is important since it facilitates tracing the root causes of
measurement burdens and data submission errors that may be associated
with any sub-group of clinician practice. This comparison may further
break the sample down into more than four categories and a much larger
sample size is a requisite for significant results with adequate
probability of certainty.
The sample size for performance periods occurring in 2017 consisted
of 42 MIPS groups as stated by MIPS criteria from the following seven
categories:
10 urban individual or groups of <3 eligible clinicians.
10 rural individual or groups of <3 eligible clinicians.
10 groups of 3-8 eligible clinicians.
5 groups of 8-20 eligible clinicians.
3 groups of 20-100 eligible clinicians.
2 groups of 100 or greater eligible clinicians.
2 specialty groups.
We are proposing to increase the sample size for the performance
periods occurring in 2018 to a minimum of:
20 urban individual or groups of <3 eligible clinicians--
(broken down into 10 individuals & 10 groups).
20 rural individual or groups of <3 eligible clinicians--
(broken down into 10 individuals & 10 groups).
10 groups of 3-8 eligible clinicians.
10 groups of 8-20 eligible clinicians.
10 groups of 20-100 eligible clinicians.
10 groups of 100 or greater eligible clinicians.
6 groups of >20 eligible clinicians reporting as
individuals--(broken down into 3 urban & 3 rural).
6 specialty groups--(broken down into 3 reporting
individually & 3 reporting as a group).
Up to 10 non-MIPS eligible clinicians reporting as a group
or individual (any number of individuals and any group size).
In addition, we are proposing changes to the study procedures. In
the transition year of MIPS, study participants were required to attend
a monthly focus group to share lessons learned in submitting quality
data along with providing survey feedback to monitor effectiveness.
However, an individual MIPS eligible clinician or group who chooses to
report all 6 measures within a period of 90 days may not need to be a
part of all of the focus groups and survey sessions after their first
focus group and survey following the measurement data submission. This
is because they may have nothing new to contribute in terms of
discussion of errors or clinician burdens. This also applies to MIPS
eligible clinicians that submit only three MIPS measures within the
performance period, if they submitted all three measures within the 90-
day period or at one submission. All study participants would
participate in surveys and focus group meetings at least once after
each measures data submission. For those who elect to report data for a
90-day period, we would make further engagement optional. Therefore, we
are proposing that for Quality Payment Program Year 2 and future years
that study participants would be required to attend as frequently as
four monthly surveys and focus group sessions throughout the year, but
certain study participants would be able to attend less frequently.
Further, the CY 2017 study requires study measurement data to be
collected at baseline and at every 3 months (quarterly basis)
afterwards for the duration of the calendar year. It also calls for a
minimum requirement of three MIPS quality measures four times within
the year. We believe this is inconsistent with clinicians reporting a
full year's data as we believe some study participants may choose to
submit data for all measures at one time, or alternatively, may choose
to submit data up to six times during the 1-year period. We are
proposing for the Quality Payment Program Year 2 and future years to
offer study participants flexibility in their submissions so that they
could submit once, as can occur in the MIPS program, and participate in
study surveys and focus groups while still earning improvement
activities credit.
It must be noted that although the aforementioned activities
constitute an information collection request as defined in the
implementing regulations of the Paperwork Reduction Act of 1995 (5 CFR
1320), the associated burden is exempt from application of the
Paperwork Reduction Act. Specifically, section 1848(s)(7) of the Act,
as added by section 102 of the MACRA (Pub. L. 114-10) states that
Chapter 35 of title 44, United States Code, shall not apply to the
collection of information for the development of quality measures. Our
goals for new measures are to develop new high quality, low cost
measures that are meaningful, easily understandable and operable, and
also, reliably and validly measure what they purport. This study shall
inform us (and our contractors) on the root causes of clinicians'
performance measure data collection and data submission burdens and
challenges that hinders accurate and timely quality measurement
activities. In addition, this study will inform us on the
characteristic attributes that our new measures must possess to be able
to accurately capture and measure the priorities and gaps MACRA aims
for, as described in the Quality Measures Development Plan.\2\ This
study, therefore, serves as the initial stage of developing new
measures and also adapting existing measures. We believe that
understanding clinician's challenges and skepticisms, and especially,
understanding the factors that undermine the optimal functioning and
effectiveness of quality measures are requisites of developing measures
that are not only measuring what it purports but also that are user
friendly and understandable for frontline clinicians--our main
stakeholders in measure development. This will lead to the creation of
practice-derived, tested measures that reduces burden and create a
culture of continuous improvement in measure development.
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\2\ https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Final-MDP.pdf (assessed: 06/02/2017).
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We request comments on our study on burdens associated with
reporting quality measures proposals regarding sample size for the
performance periods occurring in 2018, study procedures for the
performance periods occurring in 2018 and future years, and data
submissions for the performance periods occurring in 2018 and future
years.
f. Advancing Care Information Performance Category
(1) Background
Section 1848(q)(2)(A) of the Act includes the meaningful use of
CEHRT as a performance category under the MIPS. We refer to this
performance
[[Page 30058]]
category as the advancing care information performance category, and it
is reported by MIPS eligible clinicians as part of the overall MIPS
program. As required by sections 1848(q)(2) and (5) of the Act, the
four performance categories of the MIPS shall be used in determining
the MIPS final score for each MIPS eligible clinician. In general, MIPS
eligible clinicians will be evaluated under all four of the MIPS
performance categories, including the advancing care information
performance category.
(2) Scoring
Section 1848(q)(5)(E)(i)(IV) of the Act states that 25 percent of
the MIPS final score shall be based on performance for the advancing
care information performance category. We established at Sec.
414.1380(b)(4) that the score for the advancing care information
performance category would be comprised of a base score, performance
score, and potential bonus points for reporting on certain measures and
activities. For further explanation of our scoring policies for the
advancing care information performance category, we refer readers to 81
FR 77216-77227.
(a) Base Score
For the CY 2018 performance period, we are not proposing any
changes to the base score methodology as established in the CY 2017
Quality Payment Program final rule (81 FR 77217-77223). We established
the policy that MIPS eligible clinicians must report a numerator of at
least one for the numerator/denominator measures, or a ``yes'' response
for the yes/no measure in order to earn the 50 percentage points in the
base score. In addition, if the base score requirements are not met, a
MIPS eligible clinician would receive a score of zero for the ACI
performance category.
(b) Performance Score
In the CY 2017 Quality Payment Program final rule (81 FR 77223
through 77226), we finalized that MIPS eligible clinicians can earn 10
percentage points in the performance score for meeting the Immunization
Registry Reporting Measure. We believe we should modify this policy
because we have learned that there are areas of the country where
immunization registries are not available, and we did not intend to
disadvantage MIPS eligible clinicians practicing in those areas. Thus,
we are proposing to modify the scoring of the Public Health and
Clinical Data Registry Reporting objective beginning with the
performance period in CY 2018. We propose if a MIPS eligible clinician
fulfills the Immunization Registry Reporting Measure, the MIPS eligible
clinician would earn 10 percentage points in the performance score. If
a MIPS eligible clinician cannot fulfill the Immunization Registry
Reporting Measure, we are proposing that the MIPS eligible clinician
could earn 5 percentage points in the performance score for each public
health agency or clinical data registry to which the clinician reports
for the following measures, up to a maximum of 10 percentage points:
Syndromic Surveillance Reporting; Electronic Case Reporting; Public
Health Registry Reporting; and Clinical Data Registry Reporting. A MIPS
eligible clinician who chooses to report to more than one public health
agency or clinical data registry may receive credit in the performance
score for the submission to more than one agency or registry; however,
the MIPS eligible clinician would not earn more than a total of 10
percentage points for such reporting.
We further propose similar flexibility for MIPS eligible clinicians
who choose to report the measures specified for the Public Health
Reporting Objective of the 2018 Advancing Care Information Transition
Objective and Measure set. (In section II.C.6.f.(6)(b) of this proposed
rule, we are proposing to allow MIPS eligible clinicians to report
using the 2018 Advancing Care Information Transition Objectives and
Measures in 2018.) We propose if a MIPS eligible clinician fulfills the
Immunization Registry Reporting Measure, the MIPS eligible clinician
would earn 10 percentage points in the performance score. If a MIPS
eligible clinician cannot fulfill the Immunization Registry Reporting
Measure, we are proposing that the MIPS eligible clinician could earn 5
percentage points in the performance score for each public health
agency or specialized registry to which the clinician reports for the
following measures, up to a maximum of 10 percentage points: Syndromic
Surveillance Reporting; Specialized Registry Reporting. A MIPS eligible
clinician who chooses to report to more than one specialized registry
or public health agency to submit syndromic surveillance data may earn
5 percentage points in the performance score for reporting to each one,
up to a maximum of 10 percentage points.
By proposing to expand the options for fulfilling the Public Health
and Clinical Data Registry Reporting and the Public Health Reporting
objectives, we believe that we are adding flexibility so that
additional MIPS eligible clinicians can successfully fulfill this
objective and earn 10 percentage points in the performance score. We
are not proposing to change the maximum performance score that a MIPS
eligible clinician can earn; it remains at 90 percent.
We are inviting public comment on these proposals.
(c) Bonus Score
In the CY 2017 Quality Payment Program final rule (81 FR 77220
through 77226), for the Public Health and Clinical Data Registry
Reporting objective and the Public Health Reporting objective, we
finalized that MIPS eligible clinicians who report to one or more
public health agencies or clinical data registries beyond the
Immunization Registry Reporting Measure will earn a bonus score of 5
percentage points in the advancing care information performance
category. (In section II.C.6.f.(6)(b) of this proposed rule, we are
proposing to allow MIPS eligible clinicians to report using the 2018
Advancing Care Information Transition Objectives and Measures in 2018.)
Based on our proposals above to allow MIPS eligible clinicians who
cannot fulfill the Immunization Registry Reporting Measure to earn
additional points in the performance score, we believe we should modify
this policy so that MIPS eligible clinicians cannot earn points in both
the performance score and bonus score for reporting to the same public
health agency or clinical data registry. We are proposing to modify our
policy beginning with the performance period in CY 2018. We are
proposing that a MIPS eligible clinician may only earn the bonus score
of 5 percentage points for reporting to at least one additional public
health agency or clinical data registry that is different from the
agency/agencies or registry/or registries to which the MIPS eligible
clinician reports to earn a performance score. For example, if a MIPS
eligible clinician reports to a public health agency and a clinical
data registry for the performance score, they could earn the bonus
score of 5 percentage points by reporting to a different agency or
registry that the clinician did not identify for purposes of the
performance score. A MIPS eligible clinician would not receive credit
under both the performance score and bonus score for reporting to the
same agency or registry.
We are proposing that for the Advancing Care Information Objectives
and Measures, a bonus of 5 percentage points would be awarded if the
MIPS eligible clinician reports ``yes'' for any one of the following
measures associated with the Public Health and Clinical Data Registry
Reporting
[[Page 30059]]
objective: Syndromic Surveillance Reporting; Electronic Case Reporting;
Public Health Registry Reporting; or Clinical Data Registry Reporting.
We are proposing that for the 2018 Advancing Care Information
Transition Objectives and Measures, a bonus of 5 percent would be
awarded if the MIPS eligible clinician reports ``yes'' for any one of
the following measures associated with the Public Health Reporting
objective: Syndromic Surveillance Reporting or Specialized Registry
Reporting. We are proposing that to earn the bonus score, the MIPS
eligible clinician must be in active engagement with one or more
additional public health agencies or clinical data registries that is/
are different from the agency or registry that they identified to earn
a performance score.
We are inviting public comment on this proposal.
(d) Improvement Activities Bonus Score Under the Advancing Care
Information Performance Category
In the CY 2017 Quality Payment Program final rule (81 FR 77202), we
discussed our approach to the measurement of the use of health IT to
allow MIPS eligible clinicians and groups the flexibility to implement
health IT in a way that supports their clinical needs. In addition, we
discussed the need to move toward measurement of health IT use with
respect to its contribution to effective care coordination and
improving outcomes for patients. We stated that this approach would
allow us to more directly link health IT adoption and use to patient
outcomes, moving MIPS beyond the measurement of EHR adoption and
process measurement and into a more patient-focused health IT program.
Toward that end, we adopted a policy to award a bonus score to MIPS
eligible clinicians who use CEHRT to complete certain activities in the
improvement activities performance category based on our belief that
the use of CEHRT in carrying out these activities could further the
outcomes of clinical practice improvement.
We adopted a final policy to award a 10 percent bonus for the
advancing care information performance category if a MIPS eligible
clinician attests to completing at least one of the improvement
activities we have specified using CEHRT (81 FR 77209). We refer
readers to Table 8 in the CY 2017 Quality Payment Program final rule
(81 FR 77202-77209) for a list of the improvement activities eligible
for the advancing care information performance category bonus. In this
proposed rule, we are proposing to expand this policy beginning with
the CY 2018 performance period by identifying additional improvement
activities in Table 6 that would be eligible for the advancing care
information performance category bonus score if they are completed
using CEHRT functionality. The activities eligible for the bonus score
would include those listed in Table 6, as well as those listed in Table
8 in last year's final rule. We refer readers to the Improvement
Activities section of this proposed rule (section II.C.6.e. of this
proposed rule) for a discussion of the proposed new improvement
activities and proposed changes to the improvement activities for 2018.
Ten percentage points is the maximum bonus a MIPS eligible
clinician would receive if they attest to using CEHRT for one or more
of the activities we have identified as eligible for the bonus. This
bonus is intended to support progression toward holistic health IT use
and measurement; attesting to even one improvement activity
demonstrates that the MIPS eligible clinician is working toward this
holistic approach to the use of their CEHRT. The weight of the
improvement activity for the improvement activities performance
category has no effect on the bonus awarded in the advancing care
information performance category.
We invite comment on this proposal.
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(3) Performance Periods for the Advancing Care Information Performance
Category
In the CY 2017 Quality Payment Program final rule (81 FR 77210
through 77211), we established a performance period for the advancing
care information performance category to align with the overall MIPS
performance period of one full year to ensure all four performance
categories are measured and scored based on the same period of time. We
believe this will lower reporting burden, focus clinician quality
improvement efforts and align administrative actions so that MIPS
eligible clinicians can use common systems and reporting pathways. We
stated for the first and second performance periods of MIPS (CYs 2017
and 2018), we will accept a minimum of 90 consecutive days of data and
encourage MIPS eligible clinicians to report data for the full year
performance period. We are maintaining this policy as finalized for the
performance period in CY 2018, and will accept a minimum of 90
consecutive days of data in CY 2018. We are proposing the same policy
for the advancing care information performance category for the
performance period in CY 2019, Quality Payment Program Year 3, and
would accept a minimum of 90 consecutive days of data in CY 2019. We
refer readers to section II.C.5. in this proposed rule for additional
information on the MIPS performance period.
(4) Certification Requirements
In the CY 2017 Quality Payment Program final rule (81 FR 77211
through 77213), we outlined the requirements for MIPS eligible
clinicians using CEHRT during the CY 2017 performance period for the
advancing care information performance category as it relates to the
objectives and measures they select to report, and also outlined
requirements for the CY 2018 performance period. We additionally
adopted a definition of CEHRT at Sec. 414.1305 for MIPS eligible
clinicians that is based on the definition that applies in the EHR
Incentive Programs under Sec. 495.4.
For the CY 2017 performance period, we adopted a policy by which
MIPS eligible clinicians may use EHR
[[Page 30064]]
technology certified to either the 2014 or 2015 Edition certification
criteria, or a combination of the two. For the CY 2018 performance
period, we previously stated that MIPS eligible clinicians must use EHR
technology certified to the 2015 Edition to meet the objectives and
measures specified for the advancing care information performance
category.
We received significant comments and feedback from stakeholders
requesting that we extend the use of 2014 Edition CEHRT beyond CY 2017
into CY 2018 and even CY 2019. Many commenters noted the lack of
products certified to the 2015 Edition. Others stated that switching
from the 2014 Edition to the 2015 Edition requires a large amount of
time and planning and if it is rushed there is a potential risk to
patient health. Some commenters noted the significant burden of
combining outputs from multiple CEHRTs. A few mentioned that the cost
to switch to the 2015 Edition is prohibitive for smaller practices.
Our experience with the transition from EHR technology certified to
the 2011 Edition to EHR technology certified to the 2014 Edition did
make us aware of the many issues associated with the adoption of EHR
technology certified to a new Edition. These include the time that will
be necessary to effectively deploy EHR technology certified to the 2015
Edition standards and certification criteria and to make the necessary
patient safety, staff training, and workflow investments to be prepared
to report for the advancing care information performance category for
2018. We understand and appreciate these concerns, and are working in
collaboration with our federal partners at the Office of the National
Coordinator for Health Information Technology (ONC) to monitor progress
on the 2015 Edition upgrade.
As noted in the FY 2018 Inpatient Prospective Payment Systems for
Acute Care Hospitals and the Long-Term Care Hospital Prospective
Payment System proposed rule (referred to as the FY 2018 IPPS/LTCH PPS
proposed rule) (82 FR 20136), ONC is working with health IT developers
to analyze and monitor the status of developer readiness for 2015
Edition technology. As part of these analyses, ONC also reviewed health
IT being certified to 2015 Edition by health IT developers who have
products that were certified for the 2014 Edition and were used by EHR
Incentive Program participants to attest. This analysis compared the
pace of 2014 Edition certification with the pace of 2015 Edition
certification to date. As of the beginning of the second quarter of CY
2017, ONC confirmed that at least 53 percent of eligible clinicians and
80 percent of eligible hospitals have 2015 Edition certified EHR
technology available based on previous EHR Incentive Programs
attestation data. Based on these data, and as compared to the
transition from 2011 Edition to 2014 Edition, it appears that the
transition from the 2014 Edition to the 2015 Edition is on schedule for
the CY 2018 performance period.
However, the analysis also considered market trends such as
consolidation and the number of large and small developers covering
various groups of participants and the potential impact on readiness.
The eligible hospital market is fairly concentrated, with nearly 98
percent of eligible hospital EHR Incentive Program participants using
health IT from the top ten developers (ranked by market share) with a
significant majority of that coverage by the top five developers. For
hospitals, some developers representing a smaller market share also
have certified health IT already available and are not expected to have
a release schedule much different from their larger competitors.
Considering market factors and using previous EHR Incentive Programs
attestation data, ONC estimates that at least 85 percent of eligible
hospitals would have EHR technology certified to the 2015 Edition
available for use by the end of CY 2017 for program participation in
2018. In the FY 2018 IPPS/LTCH PPS proposed rule (82 FR 20136), we
proposed to shorten the EHR reporting period to a minimum of any
continuous 90-day period within CY 2018 for eligible hospitals and
CAHs, as well as EPs who attest for a state's Medicaid EHR Incentive
Program, to allow additional time for successful implementation of EHR
technology certified to the 2015 Edition in CY 2018.
For MIPS eligible clinicians, the concern of potential impact on
participation readiness when reviewing these market factors may be more
significant. As noted in the FY 2018 IPPS/LTCH PPS proposed rule (82 FR
20136), historical data indicates eligible professionals were more
likely to use a wider range of certified health IT, including those
which individually make up a smaller segment of the overall market.
Therefore, when market factors are taken into account, there exists a
larger proportion of readiness that is unknown due to the wider range
of certified health IT which may be used by MIPS eligible clinicians.
This necessitated a more conservative approach for MIPS eligible
clinician readiness. That estimate is that 74 percent of MIPS eligible
clinicians will be ready to participate in MIPS using 2015 Edition
certified EHR technologies by January 1, 2018.
However, subsequent to the preliminary analysis, ONC has continued
to monitor readiness and to receive feedback from stakeholders on
factors influencing variations in the development and implementation
timelines for developers supporting different segments of the market,
as well as the relationship between the developer readiness timeline
and participant readiness. This continuing analysis supports a
potential need for a longer implementation timeline for MIPS eligible
clinicians. Stakeholder feedback suggests that while the estimate for
known readiness remains the same, readiness among the remaining MIPS
eligible clinicians may not be on the same timeline. About one quarter
of eligible professional EHR Incentive Program participants in prior
years used certified health IT from small developers that each has an
historical market share of 1 percent or less. Therefore, MIPS eligible
clinicians will need a significant number of smaller developers to
reach the same readiness on the same timeline as larger companies in
order to support program participants seeking to upgrade to the 2015
Edition. However, small developers generally offer a limited number or
type of products, and may have more limited resources to dedicate to
upgrade development, testing and certification, and implementation,
which may affect availability and timing. In addition, the same factors
may impact the capacity of some developers to support participants
during the process and therefore the timeline for participant readiness
would also potentially be longer. This is supported by historical
analysis as a smaller percentage of eligible professionals used 2014
Edition certified EHR technology for participation in the EHR Incentive
Programs during the 2014 calendar year than eligible hospitals and CAHs
for the same year. For this reason, we believe additional flexibility
for MIPS eligible clinicians is essential to support successful
participation in the advancing care information performance category.
We continue to believe that there are many benefits for switching
to EHR technology certified to the 2015 Edition. As noted in the FY
2018 IPPS/LTCH PPS proposed rule (82 FR 20136), the 2015 Edition health
IT certification criteria enables health information exchange through
new and enhanced certification criteria standards, and through
implementation specifications
[[Page 30065]]
for interoperability. The 2015 Edition also incorporates changes that
are designed to spur innovation and provide more choices to health care
providers and patients for the exchange of electronic health
information, including new Application Programming Interface (API)
certification criteria. APIs are required for patient engagement
measures within the advancing care information category; however, they
may also be enabled by a health care provider or organization for their
own use of third party applications with their CEHRT, such as for
quality improvement. An API can also be enabled by a health care
provider to give patients access to their health information through a
third-party application with more flexibility than is often found in
many current patient portals. From the MIPS eligible clinician
perspective, an API could complement a patient portal or could also
potentially make one unnecessary if patients are able to use software
applications designed to interact with an API that could support their
ability to view, download, and transmit their health information to a
third party. In addition, the 2015 Edition health IT transitions of
care certification criterion rigorously assesses a product's ability to
create and receive a Consolidated-Clinical Document Architecture (C-
CDA) formatted documents. The ONC also adopted certification criteria
that both support interoperability in other settings and use cases,
such as the Common Clinical Data Set summary record, data segmentation
for privacy, and care plan certification criteria (80 FR 62603).
However, in light of the conservative readiness estimates for MIPS
eligible clinicians, and in line with our commitment to supporting
small practices, solo practitioners and specialties which may be more
likely to use certified health IT offered by small developers, we are
proposing that MIPS eligible clinicians may use EHR technology
certified to either the 2014 or 2015 Edition certification criteria, or
a combination of the two for the CY 2018 performance period. We propose
to amend Sec. 414.1305 to reflect this change. We further note, that
to encourage new participants to adopt certified health IT and to
incentivize participants to upgrade their technology to 2015 Edition
products which better support interoperability across the care
continuum, we are proposing to offer a bonus of 10 percentage points
under the advancing care information performance category for MIPS
eligible clinicians who report the Advancing Care Information
Objectives and Measures for the performance period in CY 2018 using
only 2015 Edition CEHRT. We are proposing to amend Sec.
414.1380(b)(4)C)(3) to reflect this change. We are proposing this one-
time bonus for CY 2018 to support and recognize MIPS eligible
clinicians and groups that invest in implementing certified EHR
technology in their practice. Specifically, we intend this bonus to
support new participants that may be adopting health IT for the first
time in CY 2018 and do not have 2014 Edition technology available to
use or that may have no prior experience with meaningful use objectives
and measures. We believe this bonus will help recognize their
investment to adopt health IT and support their participation in the
advancing care information performance category in MIPS. In addition,
we believe this bonus will help to incentivize participants to continue
the process of upgrading from 2014 Edition to 2015 Edition, especially
small practices where the investment in updated workflows and
implementation may present unique challenges. We intend this bonus to
support and recognize their efforts to engage with the advancing care
information measures using technology certified to the 2015 Edition,
which include more robust measures using updated standards and
functions which support interoperability. We seek comment on this
proposed bonus. Specifically, we seek comment on if the percentage of
the bonus is appropriate, or whether it should be limited to new
participants in MIPS and small practices.
This bonus is not available to MIPS eligible clinicians who use a
combination of the 2014 and 2015 Editions. We note that with the
addition of the 2015 Edition CEHRT bonus of 10 percentage points, MIPS
eligible clinicians would be able to earn a bonus score of up to 25
percentage points in CY 2018 under the advancing care information
performance category, an increase from the 15 percentage point bonus
score available in CY 2017.
To facilitate readers in identifying the requirements of CEHRT for
the Advancing Care Information Objectives and Measures, we are
including Table 8 in section II.C.6.f.(6)(a) which lists the 2015
Edition and 2014 Edition certification criteria required to meet the
objectives and measures.
We invite comments on these proposals.
(5) Scoring Methodology Considerations
Section 1848(q)(5)(E)(i)(IV) of the Act states that 25 percent of
the MIPS final score shall be based on performance for the advancing
care information performance category. Further, section
1848(q)(5)(E)(ii) of the Act, provides that in any year in which the
Secretary estimates that the proportion of eligible professionals (as
defined in section 1848(o)(5) of the Act) who are meaningful EHR users
(as determined under section 1848(o)(2) of the Act) is 75 percent or
greater, the Secretary may reduce the applicable percentage weight of
the advancing care information performance category in the MIPS final
score, but not below 15 percent, and increase the weightings of the
other performance categories such that the total percentage points of
the increase equals the total percentage points of the reduction. We
note that section 1848(o)(5) of the Act defines an eligible
professional as a physician, as defined in section 1861(r) of the Act.
In CY 2017 Quality Payment Program final rule (81 FR 77226-77227),
we established a final policy, for purposes of applying section
1848(q)(5)(E)(ii) of the Act, to estimate the proportion of physicians
as defined in section 1861(r) of the Act who are meaningful EHR users
as those physician MIPS eligible clinicians who earn an advancing care
information performance category score of at least 75 percent for a
performance period. We established that we will base this estimation on
data from the relevant performance period, if we have sufficient data
available from that period. For example, if feasible, we would consider
whether to reduce the applicable percentage weight of the advancing
care information performance category in the MIPS final score for the
2019 MIPS payment year based on an estimation using the data from the
2017 performance period. We stated that we will not include in the
estimation physicians for whom the advancing care information
performance category is weighted at zero percent under section
1848(q)(5)(F) of the Act, which we relied on in the CY 2017 Quality
Payment Program final rule (81 FR 77226 through 77227) to establish
policies under which we would weigh the advancing care information
performance category at zero percent of the final score. In addition,
we are proposing not to include in the estimation physicians for whom
the advancing care information performance category would be weighted
at zero percent under our proposal in section II.C.6.f.(7) of this
proposed rule to implement certain provisions of the 21st Century Cures
Act (that is, physicians who are determined hospital-based or
ambulatory surgical center-based, or who are granted an exception based
on
[[Page 30066]]
significant hardship or decertified EHR technology.
We are considering modifications to the policy we established in
last year's rulemaking to base our estimation of physicians who are
meaningful EHR users for a MIPS payment year (for example, 2019) on
data from the relevant performance period (for example, 2017). We are
concerned that if in future rulemaking we decide to propose to change
the weight of the advancing care information performance category based
on our estimation, such a change may cause confusion to MIPS eligible
clinicians who are adjusting to the MIPS program and believe this
performance category will make up 25 percent of the final score for the
2019 MIPS payment year. The earliest we would be able to make our
estimation based on 2017 data and propose in future rulemaking to
change the weight of the advancing care information performance
category for the 2019 MIPS payment year would be in mid-2018, as the
deadline for data submission is March 31, 2018. We are requesting
public comments on whether this timeframe is sufficient, or whether a
more extended timeframe would be preferable. We are proposing to modify
our existing policy such that we would base our estimation of
physicians who are meaningful EHR users for a MIPS payment year on data
from the performance period that occurs four years before the MIPS
payment year. For example, we would use data from the 2017 performance
period to estimate the proportion of physicians who are meaningful EHR
users for purposes of reweighting the advancing care information
performance category for the 2021 MIPS payment year.
We invite comments on this proposal.
(6) Objectives and Measures
(a) Advancing Care Information Objectives and Measures Specifications
We are proposing to maintain for the CY 2018 performance period the
Advancing Care Information Objectives and Measures as finalized in the
CY 2017 Quality Payment Program final rule (81 FR 77227 through 77229)
with the modifications proposed below. As we noted (81 FR 77227), these
objectives and measures were adapted from the Stage 3 objectives and
measures finalized in the 2015 EHR Incentive Programs final rule (80 FR
62829 through 62871), however, we did not maintain the previously
established thresholds for MIPS. For a more detailed discussion of the
Stage 3 objectives and measures, including explanatory material and
defined terms, we refer readers to the 2015 EHR Incentive Programs
final rule (80 FR 62829 through 62871).
[[Page 30067]]
[GRAPHIC] [TIFF OMITTED] TP30JN17.004
[[Page 30068]]
Objective: Protect Patient Health Information.
Objective: Protect electronic protected health information (ePHI)
created or maintained by the CEHRT through the implementation of
appropriate technical, administrative, and physical safeguards.
Security Risk Analysis Measure: Conduct or review a security risk
analysis in accordance with the requirements in 45 CFR 164.308(a)(1),
including addressing the security (to include encryption) of ePHI data
created or maintained by CEHRT in accordance with requirements in 45
CFR 164.312(a)(2)(iv) and 164.306(d)(3), implement security updates as
necessary, and correct identified security deficiencies as part of the
MIPS eligible clinician's risk management process.
Objective: Electronic Prescribing.
Objective: Generate and transmit permissible prescriptions
electronically.
E-Prescribing Measure: At least one permissible prescription
written by the MIPS eligible clinician is queried for a drug formulary
and transmitted electronically using CEHRT.
Denominator: Number of prescriptions written for drugs
requiring a prescription to be dispensed other than controlled
substances during the performance period; or number of prescriptions
written for drugs requiring a prescription to be dispensed during the
performance period.
Numerator: The number of prescriptions in the denominator
generated, queried for a drug formulary, and transmitted electronically
using CEHRT.
Objective: Patient Electronic Access.
Objective: The MIPS eligible clinician provides patients (or
patient-authorized representative) with timely electronic access to
their health information and patient-specific education.
Provide Patient Access Measure: For at least one unique patient
seen by the MIPS eligible clinician: (1) The patient (or the patient-
authorized representative) is provided timely access to view online,
download, and transmit his or her health information; and (2) The MIPS
eligible clinician ensures the patient's health information is
available for the patient (or patient-authorized representative) to
access using any application of their choice that is configured to meet
the technical specifications of the Application Programing Interface
(API) in the MIPS eligible clinician's CEHRT.
Denominator: The number of unique patients seen by the
MIPS eligible clinician during the performance period.
Numerator: The number of patients in the denominator (or
patient authorized representative) who are provided timely access to
health information to view online, download, and transmit to a third
party and to access using an application of their choice that is
configured meet the technical specifications of the API in the MIPS
eligible clinician's CEHRT.
Definition of timely--Beginning with the 2018 performance period,
we are proposing to define ``timely'' as within 4 business days of the
information being available to the MIPS eligible clinician. This
definition of timely is the same as we adopted under the EHR Incentive
Programs (80 FR 62815).
Patient-Specific Education Measure: The MIPS eligible clinician
must use clinically relevant information from CEHRT to identify
patient-specific educational resources and provide electronic access to
those materials to at least one unique patient seen by the MIPS
eligible clinician.
Denominator: The number of unique patients seen by the
MIPS eligible clinician during the performance period.
Numerator: The number of patients in the denominator who
were provided electronic access to patient-specific educational
resources using clinically relevant information identified from CEHRT
during the performance period.
Objective: Coordination of Care Through Patient Engagement.
Objective: Use CEHRT to engage with patients or their authorized
representatives about the patient's care.
View, Download, Transmit (VDT) Measure: During the performance
period, at least one unique patient (or patient-authorized
representatives) seen by the MIPS eligible clinician actively engages
with the EHR made accessible by the MIPS eligible clinician. A MIPS
eligible clinician may meet the measure by either (1) view, download or
transmit to a third party their health information; or (2) access their
health information through the use of an API that can be used by
applications chosen by the patient and configured to the API in the
MIPS eligible clinician's CEHRT; or (3) a combination of (1) and (2).
Proposed change to the View, Download, Transmit (VDT) Measure:
During the performance period, at least one unique patient (or patient-
authorized representatives) seen by the MIPS eligible clinician
actively engages with the EHR made accessible by the MIPS eligible
clinician by either (1) viewing, downloading or transmitting to a third
party their health information; or (2) accessing their health
information through the use of an API that can be used by applications
chosen by the patient and configured to the API in the MIPS eligible
clinician's CEHRT; or (3) a combination of (1) and (2). We are
proposing this change because we erroneously described the actions in
the measure (viewing, downloading or transmitting; or accessing through
an API) as being taken by the MIPS eligible clinician rather than the
patient or the patient-authorized representatives. This change would
align the measure description with the requirements of the numerator
and denominator. We propose this change would apply beginning with the
performance period in 2017.
Denominator: Number of unique patients seen by the MIPS
eligible clinician during the performance period.
Numerator: The number of unique patients (or their
authorized representatives) in the denominator who have viewed online,
downloaded, or transmitted to a third party the patient's health
information during the performance period and the number of unique
patients (or their authorized representatives) in the denominator who
have accessed their health information through the use of an API during
the performance period.
Secure Messaging Measure: For at least one unique patient seen by
the MIPS eligible clinician during the performance period, a secure
message was sent using the electronic messaging function of CEHRT to
the patient (or the patient-authorized representative), or in response
to a secure message sent by the patient (or the patient-authorized
representative).
Denominator: Number of unique patients seen by the MIPS
eligible clinician during the performance period.
Numerator: The number of patients in the denominator for
whom a secure electronic message is sent to the patient (or patient-
authorized representative) or in response to a secure message sent by
the patient (or patient-authorized representative), during the
performance period.
Patient-Generated Health Data Measure: Patient-generated health
data or data from a non-clinical setting is incorporated into the CEHRT
for at least one unique patient seen by the MIPS eligible clinician
during the performance period.
Denominator: Number of unique patients seen by the MIPS
eligible clinician during the performance period.
Numerator: The number of patients in the denominator for
whom data from non-clinical settings, which may
[[Page 30069]]
include patient-generated health data, is captured through the CEHRT
into the patient record during the performance period.
Objective: Health Information Exchange
Objective: The MIPS eligible clinician provides a summary of care
record when transitioning or referring their patient to another setting
of care, receives or retrieves a summary of care record upon the
receipt of a transition or referral or upon the first patient encounter
with a new patient, and incorporates summary of care information from
other health care clinician into their EHR using the functions of
CEHRT.
Proposed Change to the Objective: The MIPS eligible clinician
provides a summary of care record when transitioning or referring their
patient to another setting of care, receives or retrieves a summary of
care record upon the receipt of a transition or referral or upon the
first patient encounter with a new patient, and incorporates summary of
care information from other health care providers into their EHR using
the functions of CEHRT.
We inadvertently used the term ``health care clinician'' and are
proposing to replace it with the more appropriate term ``health care
provider''. We are proposing this change would apply beginning with the
performance period in 2017.
Send a Summary of Care Measure: For at least one transition of care
or referral, the MIPS eligible clinician that transitions or refers
their patient to another setting of care or health care clinician (1)
creates a summary of care record using CEHRT; and (2) electronically
exchanges the summary of care record.
Proposed Change to the Send a Summary of Care Measure: For at least
one transition of care or referral, the MIPS eligible clinician that
transitions or refers their patient to another setting of care or
health care provider (1) creates a summary of care record using CEHRT;
and (2) electronically exchanges the summary of care record.
We inadvertently used the term ``health care clinician'' and are
proposing to replace it with the more appropriate term ``health care
provider''. We are proposing this change would apply beginning with the
2017 performance period.
Denominator: Number of transitions of care and referrals
during the performance period for which the MIPS eligible clinician was
the transferring or referring clinician.
Numerator: The number of transitions of care and referrals
in the denominator where a summary of care record was created using
CEHRT and exchanged electronically.
Request/Accept Summary of Care Measure: For at least one transition
of care or referral received or patient encounter in which the MIPS
eligible clinician has never before encountered the patient, the MIPS
eligible clinician receives or retrieves and incorporates into the
patient's record an electronic summary of care document.
Denominator: Number of patient encounters during the
performance period for which a MIPS eligible clinician was the
receiving party of a transition or referral or has never before
encountered the patient and for which an electronic summary of care
record is available.
Numerator: Number of patient encounters in the denominator
where an electronic summary of care record received is incorporated by
the clinician into the CEHRT.
Clinical Information Reconciliation Measure: For at least one
transition of care or referral received or patient encounter in which
the MIPS eligible clinician has never before encountered the patient,
the MIPS eligible clinician performs clinical information
reconciliation. The MIPS eligible clinician must implement clinical
information reconciliation for the following three clinical information
sets: (1) Medication. Review of the patient's medication, including the
name, dosage, frequency, and route of each medication; (2) Medication
allergy. Review of the patient's known medication allergies; (3)
Current Problem list. Review of the patient's current and active
diagnoses.
Denominator: Number of transitions of care or referrals
during the performance period for which the MIPS eligible clinician was
the recipient of the transition or referral or has never before
encountered the patient.
Numerator: The number of transitions of care or referrals
in the denominator where the following three clinical information
reconciliations were performed: Medication list; medication allergy
list; and current problem list.
Objective: Public Health and Clinical Data Registry Reporting.
Objective: The MIPS eligible clinician is in active engagement with
a public health agency or clinical data registry to submit electronic
public health data in a meaningful way using CEHRT, except where
prohibited, and in accordance with applicable law and practice.
Immunization Registry Reporting Measure: The MIPS eligible
clinician is in active engagement with a public health agency to submit
immunization data and receive immunization forecasts and histories from
the public health immunization registry/immunization information system
(IIS).
We note that the functionality to be bi-directional is part of EHR
technology certified to the 2015 Edition (80 FR 62554). It means that
in addition to sending the immunization record to the immunization
registry, the CEHRT must be able to receive and display a consolidated
immunization history and forecast.
Syndromic Surveillance Reporting Measure: The MIPS eligible
clinician is in active engagement with a public health agency to submit
syndromic surveillance data from a non-urgent care ambulatory setting
where the jurisdiction accepts syndromic data from such settings and
the standards are clearly defined.
Proposed Change to the Syndromic Surveillance Reporting Measure:
The MIPS eligible clinician is in active engagement with a public
health agency to submit syndromic surveillance data. We are proposing
this change because we inadvertently finalized the measure description
that we had proposed for Stage 3 of the EHR Incentive Program (80 FR
82866) and not the measure description that we finalized (80 FR 82970).
The proposed change aligns with the measure description finalized for
Stage 3.
Electronic Case Reporting Measure: The MIPS eligible clinician is
in active engagement with a public health agency to electronically
submit case reporting of reportable conditions.
Public Health Registry Reporting Measure: The MIPS eligible
clinician is in active engagement with a public health agency to submit
data to public health registries.
Clinical Data Registry Reporting Measure: The MIPS eligible
clinician is in active engagement to submit data to a clinical data
registry.
We note that we have split the Specialized Registry Reporting
Measure that we adopted under the 2017 Advancing Care Information
Transition Objectives and Measures into two separate measures, Public
Health Registry and Clinical Data Registry Reporting to better define
the registries available for reporting. We want to continue to
encourage those MIPS eligible clinicians who have already started down
the path of reporting to a specialized registry to continue to engage
in public health and clinical data registry reporting. Therefore, we
propose to allow MIPS eligible clinicians and groups to continue to
count active engagement in electronic
[[Page 30070]]
public health reporting with specialized registries. We propose to
allow these registries to be counted for purposes of reporting the
Public Health Registry Reporting Measure or the Clinical Data Registry
Reporting Measure beginning with the 2018 performance period. A MIPS
eligible clinician may count a specialized registry if the MIPS
eligible clinician achieved the phase of active engagement as described
under ``active engagement option 3: production'' in the 2015 EHR
Incentive Programs final rule with comment period (80 FR 62862 through
62865), meaning the clinician has completed testing and validation of
the electronic submission and is electronically submitting production
data to the public health agency or clinical data registry.
As noted previously, to facilitate readers in identifying the
requirements of CEHRT for the Advancing Care Information Objectives and
Measures, we are including the following Table 8, which includes the
2015 Edition and 2014 Edition certification criteria required to meet
the objectives and measures.
Table 8--Advancing Care Information Objectives and Measures and Certification Criteria for 2014 and 2015
Editions
----------------------------------------------------------------------------------------------------------------
Objective Measure 2015 Edition 2014 Edition
----------------------------------------------------------------------------------------------------------------
Protect Patient Health Information Security Risk The requirements are a The requirements are
Analysis. part of CEHRT specific to included in the Base EHR
each certification Definition.
criterion.
Electronic Prescribing............ e-Prescribing........ Sec. 170.315(b)(3) Sec. 170.314(b)(3)
(Electronic Prescribing). (Electronic
Sec. 170.315(a)(10) Prescribing). Sec.
(Drug-Formulary and 170.314(a)(10) (Drug-
Preferred Drug List Formulary and Preferred
checks. Drug List checks.
Patient Electronic Access......... Provide Patient Sec. 170.315(e)(1) Sec. 170.314(e)(1)
Access. (View, Download, and (View, Download, and
Transmit to 3rd Party). Transmit to 3rd Party).
Sec. 170.315(g)(7)
(Application Access--
Patient Selection). Sec.
170.315(g)(8)
(Application Access--Data
Category Request). Sec.
170.315(g)(9)
(Application Access--All
Data Request) The three
criteria combined are the
``API'' certification
criteria.
Patient Electronic Access......... Patient Specific Sec. 170.315(a)(13) Sec. 170.314(a)(13)
Education. (Patient-specific (Patient-specific
Education Resources). Education Resources).
Coordination of Care Through View, Download, or Sec. 170.315(e)(1) Sec. 170.314(e)(1)
Patient Engagement. Transmit (VDT). (View, Download, and (View, Download, and
Transmit to 3rd Party). Transmit to 3rd Party).
Sec. 170.315(g)(7)
(Application Access--
Patient Selection). Sec.
170.315(g)(8)
(Application Access--Data
Category Request). Sec.
170.315(g)(9)
(Application Access--All
Data Request) The three
criteria combined are the
``API'' certification
criteria.
Coordination of Care Through Secure Messaging..... Sec. 170.315(e)(2) Sec. 170.314(e)(3)
Patient Engagement. (Secure Messaging). (Secure Messaging).
Coordination of Care Through Patient-Generated Sec. 170.315(e)(3) N/A.
Patient Engagement. Health Data. (Patient Health
Information Capture)
Supports meeting the
measure, but is NOT
required to be used to
meet the measure. The
certification criterion
is part of the CEHRT
definition beginning in
2018.
Health Information Exchange....... Send a Summary of Sec. 170.315(b)(1) Sec. 170.314(b)(2)
Care. (Transitions of Care). (Transitions of Care-
Create and Transmit
Transition of Care/
Referral Summaries or
Sec. 170.314(b)(8)
(Optional--Transitions
of Care).
Health Information Exchange....... Request/Accept Sec. 170.315(b)(1) Sec. 170.314(b)(1)
Summary of Care. (Transitions of Care). (Transitions of Care-
Receive, Display and
Incorporate Transition
of Care/Referral
Summaries or Sec.
170.314(b)(8) (Optional-
Transitions of Care).
Health Information Exchange....... Clinical Information Sec. 170.315(b)(2) Sec. 170.314(b)(4)
Reconciliation. (Clinical Information (Clinical Information
Reconciliation and Reconciliation or Sec.
Incorporation). 170.314(b)(9) (Optional--
Clinical Information
Reconciliation and
Incorporation).
Public Health and Clinical Data Immunization Registry Sec. 170.315(f)(1) N/A.
Registry Reporting. Reporting. (Transmission to
Immunization Registries).
Public Health and Clinical Data Syndromic Sec. 170.315(f)(2) Sec. 170.314(f)(3)
Registry Reporting. Surveillance (Transmission to Public (Transmission to Public
Reporting. Health Agencies-- Health Agencies--
Syndromic Surveillance) Syndromic Surveillance)
Urgent Care Setting Only. or Sec. 170.314(f)(7)
(Optional-Ambulatory
Setting Only-
Transmission to Public
Health Agencies--
Syndromic Surveillance).
Public Health and Clinical Data Electronic Case Sec. 170.315(f)(5) N/A.
Registry Reporting. Reporting. (Transmission to Public
Health Agencies--
Electronic Case
Reporting).
[[Page 30071]]
Public Health and Clinical Data Public Health EPs may choose one or more Sec. 170.314(f)(5)
Registry Reporting. Registry Reporting. of the following: Sec. (Optional--Ambulatory
170.315(f)(4) Setting Only--Cancer
(Transmission to Cancer Case Information and
Registries). Sec. 170.314(f)(6)
Sec. 170.315(f)(7) (Optional--Ambulatory
(Transmission to Public Setting Only--
Health Agencies--Health Transmission to Cancer
Care Surveys). Registries).
Public Health and Clinical Data Clinical Data No 2015 Edition health IT N/A.
Registry Reporting. Registry Reporting. certification criteria at
this time.
----------------------------------------------------------------------------------------------------------------
We are inviting public comment on these proposals.
(b) 2017 and 2018 Advancing Care Information Transition Objectives and
Measures Specifications
Table 9--Advancing Care Information Performance Category Scoring Methodology for 2018 Advancing Care Information
Transition Objectives and Measures
----------------------------------------------------------------------------------------------------------------
2018 Advancing Care 2018 Advancing Care Required/ not
Information Transition Information required for base Performance Score Reporting
Objective Transition Measure score (50%) (up to 90%) requirement
----------------------------------------------------------------------------------------------------------------
Protect Patient Health Security Risk Required........... 0.................. Yes/No
Information. Analysis. Statement.
Electronic Prescribing....... E-Prescribing........ Required........... 0.................. Numerator/
Denominator.
Patient Electronic Access.... Provide Patient Required........... Up to 20........... Numerator/
Access. Denominator.
View, Download, or Not Required....... Up to 10........... Numerator/
Transmit (VDT). Denominator.
Patient-Specific Education... Patient-Specific Not Required....... Up to 10........... Numerator/
Education. Denominator.
Secure Messaging............. Secure Messaging..... Not Required....... Up to 10........... Numerator/
Denominator.
Health Information Exchange.. Health Information Required........... Up to 20........... Numerator/
Exchange. Denominator.
Medication Reconciliation.... Medication Not Required....... Up to 10........... Numerator/
Reconciliation. Denominator.
Public Health Reporting...... Immunization Registry Not Required....... 0 or 10............ Yes/No
Reporting. Statement.
Syndromic Not Required....... 0 or 5 *........... Yes/No
Surveillance Statement.
Reporting.
Specialized Registry Not Required....... 0 or 5 *........... Yes/No
Reporting. Statement.
----------------------------------------------------------------------------------------------------------------
Bonus up to 15%
----------------------------------------------------------------------------------------------------------------
Report to one or more additional public health agencies or clinical data 5 bonus............ Yes/No
registries beyond those identified for the performance score. Statement.
Report improvement activities using CEHRT................................ 10 bonus........... Yes/No
Statement.
----------------------------------------------------------------------------------------------------------------
* A MIPS eligible clinician who cannot fulfill the Immunization Registry Reporting measure may earn 5% for each
public health agency or clinical data registry to which the clinician reports, up to a maximum of 10% under
the performance score.
In the CY 2017 Quality Payment Program final rule (81 FR 77229
through 77237), we finalized the 2017 Advancing Care Information
Transition Objectives and Measures for MIPS eligible clinicians using
EHR technology certified to the 2014 Edition. We noted (81 FR 77229
that these objectives and measures have been adapted from the Modified
Stage 2 objectives and measures finalized in the 2015 EHR Incentive
Programs final rule (80 FR 62793 through 62825); however, we did not
maintain the previously established thresholds for MIPS. For a more
detailed discussion of the Modified Stage 2 Objectives and Measures,
including explanatory material and defined terms, we refer readers to
the 2015 EHR Incentive Programs final rule (80 FR 62793 through 62825).
We are proposing to make several modifications identified and described
below to the 2017 Advancing Care Information Transition Objectives and
Measures for the advancing care information performance category of
MIPS for the 2017 and 2018 performance periods. These modifications
would not require changes to EHR technology that has been certified to
the 2014 Edition.
We finalized the 2017 Advancing Care Information Transition
Objectives and Measures only for the 2017 performance period because
these objectives and measures are for MIPS eligible clinicians using
EHR technology certified to the 2014 Edition. Because we are proposing
in section II.C.6.f.(4) to continue to allow the use of EHR technology
certified to the 2014 Edition in the 2018 performance period, we are
also proposing to allow MIPS eligible clinicians to report the
Advancing Care Information Transition Objectives and Measures in 2018.
Objective: Protect Patient Health Information.
Objective: Protect electronic protected health information (ePHI)
created or maintained by the CEHRT through the
[[Page 30072]]
implementation of appropriate technical, administrative, and physical
safeguards.
Security Risk Analysis Measure: Conduct or review a security risk
analysis in accordance with the requirements in 45 CFR 164.308(a)(1),
including addressing the security (to include encryption) of ePHI data
created or maintained by CEHRT in accordance with requirements in 45
CFR 164.312(a)(2)(iv) and 164.306(d)(3), and implement security updates
as necessary and correct identified security deficiencies as part of
the MIPS eligible clinician's risk management process.
Objective: Electronic Prescribing.
Objective: MIPS eligible clinicians must generate and transmit
permissible prescriptions electronically.
E-Prescribing Measure: At least one permissible prescription
written by the MIPS eligible clinician is queried for a drug formulary
and transmitted electronically using CEHRT.
Denominator: Number of prescriptions written for drugs
requiring a prescription to be dispensed other than controlled
substances during the performance period; or number of prescriptions
written for drugs requiring a prescription to be dispensed during the
performance period.
Numerator: The number of prescriptions in the denominator
generated, queried for a drug formulary, and transmitted electronically
using CEHRT.
Objective: Patient Electronic Access.
Objective: The MIPS eligible clinician provides patients (or
patient-authorized representative) with timely electronic access to
their health information and patient-specific education.
Proposed Modification to the Objective: We are proposing to modify
this objective beginning with the 2017 performance period by removing
the word ``electronic'' from the description of timely access as it was
erroneously included in the final rule (81 FR 77228). It was our
intention to align the objective with the objectives for Patient
Specific Education and Patient Electronic Access adopted under modified
Stage 2 in the 2015 EHR Incentive Programs final rule (80 FR 62809 and
80 FR 62815), which do not include the word ``electronic''. The word
``electronic'' was also not included in the certification
specifications for the 2014 Edition, Sec. 170.314(a)(15) (Patient-
specific education resources) and Sec. 170.314(e)(1) (View, download,
and transmit to third party).
Provide Patient Access Measure: At least one patient seen by the
MIPS eligible clinician during the performance period is provided
timely access to view online, download, and transmit to a third party
their health information subject to the MIPS eligible clinician's
discretion to withhold certain information.
Denominator: The number of unique patients seen by the
MIPS eligible clinician during the performance period.
Numerator: The number of patients in the denominator (or
patient authorized representative) who are provided timely access to
health information to view online, download, and transmit to a third
party.
View, Download, Transmit (VDT) Measure: At least one patient seen
by the MIPS eligible clinician during the performance period (or
patient-authorized representative) views, downloads or transmits their
health information to a third party during the performance period.
Denominator: Number of unique patients seen by the MIPS
eligible clinician during the performance period.
Numerator: The number of unique patients (or their
authorized representatives) in the denominator who have viewed online,
downloaded, or transmitted to a third party the patient's health
information during the performance period.
Objective: Patient-Specific Education.
Objective: The MIPS eligible clinician provides patients (or
patient authorized representative) with timely electronic access to
their health information and patient-specific education.
Proposed Change to the Objective: The MIPS eligible clinician uses
clinically relevant information from CEHRT to identify patient-specific
educational resources and provide those resources to the patient. We
inadvertently finalized the description of the Patient Electronic
Access objective for the Patient-Specific Education Objective, so that
the Patient-Specific Education Objective had the wrong description. We
are proposing to correct this error by adopting the description of the
Patient-Specific Education Objective adopted under modified Stage 2 in
the 2015 EHR Incentive Programs final rule (80 FR 62809 and 80 FR
62815). We are proposing this change would apply beginning with the
performance period in 2017.
Patient-Specific Education Measure: The MIPS eligible clinician
must use clinically relevant information from CEHRT to identify
patient-specific educational resources and provide access to those
materials to at least one unique patient seen by the MIPS eligible
clinician.
Denominator: The number of unique patients seen by the
MIPS eligible clinician during the performance period.
Numerator: The number of patients in the denominator who
were provided access to patient-specific educational resources using
clinically relevant information identified from CEHRT during the
performance period.
Objective: Secure Messaging.
Objective: Use CEHRT to engage with patients or their authorized
representatives about the patient's care.
Secure Messaging Measure: For at least one patient seen by the MIPS
eligible clinician during the performance period, a secure message was
sent using the electronic messaging function of CEHRT to the patient
(or the patient-authorized representative), or in response to a secure
message sent by the patient (or the patient authorized representative)
during the performance period.
Denominator: Number of unique patients seen by the MIPS
eligible clinician during the performance period.
Numerator: The number of patients in the denominator for
whom a secure electronic message is sent to the patient (or patient-
authorized representative) or in response to a secure message sent by
the patient (or patient-authorized representative), during the
performance period.
Objective: Health Information Exchange.
Objective: The MIPS eligible clinician provides a summary of care
record when transitioning or referring their patient to another setting
of care, receives or retrieves a summary of care record upon the
receipt of a transition or referral or upon the first patient encounter
with a new patient, and incorporates summary of care information from
other health care clinicians into their EHR using the functions of
CEHRT.
Proposed Change to the Objective: The MIPS eligible clinician
provides a summary of care record when transitioning or referring their
patient to another setting of care, receives or retrieves a summary of
care record upon the receipt of a transition or referral or upon the
first patient encounter with a new patient, and incorporates summary of
care information from other health care providers into their EHR using
the functions of CEHRT.
We inadvertently used the term ``health care clinician'' and are
proposing to replace it with the more appropriate term ``health care
provider''. We are proposing this change would
[[Page 30073]]
apply beginning with the performance period in 2017.
Health Information Exchange Measure: The MIPS eligible clinician
that transitions or refers their patient to another setting of care or
health care clinician (1) uses CEHRT to create a summary of care
record; and (2) electronically transmits such summary to a receiving
health care clinician for at least one transition of care or referral.
Proposed Change to the Measure: The MIPS eligible clinician that
transitions or refers their patient to another setting of care or
health care provider (1) uses CEHRT to create a summary of care record;
and (2) electronically transmits such summary to a receiving health
care provider for at least one transition of care or referral.
This change reflects the change proposed to the Health Information
Exchange objective replacing ``health care clinician'' with ``health
care provider''. We are proposing this change would apply beginning
with the performance period in 2017.
Denominator: Number of transitions of care and referrals
during the performance period for which the EP was the transferring or
referring health care clinician.
Proposed Change to the Denominator: Number of transitions of care
and referrals during the performance period for which the MIPS eligible
clinician was the transferring or referring health care provider. This
change reflects the change proposed to the Health Information Exchange
Measure replacing ``health care clinician'' with ``health care
provider''. We also inadvertently referred to the EP in the description
and are replacing ``EP'' with ``MIPS eligible clinician''. We are
proposing this change would apply beginning with the performance period
in 2017.
Numerator: The number of transitions of care and referrals
in the denominator where a summary of care record was created using
CEHRT and exchanged electronically.
Medication Reconciliation
Objective: Medication Reconciliation.
Proposed Objective: We are proposing to add a description of the
Medication Reconciliation Objective beginning with the CY 2017
performance period, which we inadvertently omitted from the CY 2017
Quality Payment Program proposed and final rules, as follows:
Proposed Objective: The MIPS eligible clinician who receives a
patient from another setting of care or provider of care or believes an
encounter is relevant performs medication reconciliation. This
description aligns with the objective adopted for Modified Stage 2 at
80 FR 62811.
Medication Reconciliation Measure: The MIPS eligible clinician
performs medication reconciliation for at least one transition of care
in which the patient is transitioned into the care of the MIPS eligible
clinician.
Denominator: Number of transitions of care or referrals
during the performance period for which the MIPS eligible clinician was
the recipient of the transition or referral or has never before
encountered the patient.
Numerator: The number of transitions of care or referrals
in the denominator where the following three clinical information
reconciliations were performed: Medication list, Medication allergy
list, and current problem list.
Proposed Modification to the Numerator
Proposed Numerator: The number of transitions of care or referrals
in the denominator where medication reconciliation was performed.
We are proposing to modify the numerator by removing medication
list, medication allergy list, and current problem list. These three
criteria were adopted for Stage 3 (80 FR 62862) but not for Modified
Stage 2 (80 FR 62811). We are proposing this change would apply
beginning with the performance period in 2017.
Objective: Public Health Reporting.
Objective: The MIPS eligible clinician is in active engagement with
a public health agency or clinical data registry to submit electronic
public health data in a meaningful way using CEHRT, except where
prohibited, and in accordance with applicable law and practice.
Immunization Registry Reporting Measure: The MIPS eligible
clinician is in active engagement with a public health agency to submit
immunization data.
Syndromic Surveillance Reporting Measure: The MIPS eligible
clinician is in active engagement with a public health agency to submit
syndromic surveillance data.
Specialized Registry Reporting Measure: The MIPS eligible clinician
is in active engagement to submit data to a specialized registry.
We invite public comments on these proposals.
(c) Exclusions
We are proposing to add exclusions to the measures associated with
the Health Information Exchange and Electronic Prescribing objectives
required for the base score. We propose these exclusions would apply
beginning with the CY 2017 performance period. In the CY 2017 Quality
Payment Program final rule (81 FR 77237 through 77238), we did not
finalize any exclusions for the measures specified for the advancing
care information performance category as we believe that the MIPS
exclusion criteria and that the advancing care information performance
category scoring methodology together accomplish the same end as the
previously established exclusions for the majority of the advancing
care information performance category measures. We further noted that
it was not necessary to finalize the proposed exclusion for the
Immunization Registry Reporting Measure because MIPS eligible
clinicians have the flexibility to choose whether to report the measure
because it is part of the performance score of the advancing care
information performance category. However, we understand that many MIPS
eligible clinicians may not achieve a base score because they cannot
fulfill the measures associated with the Health Information Exchange
objective in the base score because they seldom refer or transition
patients, and we believe that the implementation burden of the
objective is too high to require of those with only a small number of
referrals or transitions. Similarly, we understand that many MIPS
eligible clinicians do not often write prescriptions in their practice
or lack prescribing authority, and thus could not meet the E-
prescribing Measure and would also fail to earn a base score. As this
was not our intention, we are proposing to establish exclusions for
these measures, as described below.
Proposed Exclusion for the E-Prescribing Objective and Measure: In
the CY 2017 Quality Payment Program final rule (81 FR 28237 through
28238), we established a policy that MIPS eligible clinicians who write
fewer than 100 permissible prescriptions in a performance period may
elect to report their numerator and denominator (if they have at least
one permissible prescription for the numerator), or they may report a
null value. This policy has confused MIPS eligible clinicians as a null
value would appear to indicate a MIPS eligible clinician has failed the
measure and thus not would not achieve a base score. We are proposing
to change this policy beginning with the CY 2017 performance period and
propose to establish an exclusion for the e-Prescribing Measure. MIPS
eligible clinicians who wish to claim this exclusion would select
``yes'' to the exclusion and submit a null value for the measure,
thereby fulfilling the requirement to report this measure as
[[Page 30074]]
part of the base score. It is important that a MIPS eligible clinician
actually claims the exclusion if they wish to exclude the measure. If a
MIPS eligible clinician does not claim the exclusion, they would fail
the measure and not earn a base score or any score in the advancing
care information performance category.
Advancing Care Information Objective and Measure.
Objective: Electronic Prescribing.
Objective: Generate and transmit permissible prescriptions
electronically.
E-Prescribing Measure: At least one permissible prescription
written by the MIPS eligible clinician is queried for a drug formulary
and transmitted electronically using CEHRT.
Denominator: Number of prescriptions written for drugs
requiring a prescription to be dispensed other than controlled
substances during the performance period; or number of prescriptions
written for drugs requiring a prescription to be dispensed during the
performance period.
Numerator: The number of prescriptions in the denominator
generated, queried for a drug formulary, and transmitted electronically
using CEHRT.
Proposed Exclusion: Any MIPS eligible clinician who writes fewer
than 100 permissible prescriptions during the performance period.
2017 and 2018 Advancing Care Information Transition Objective and
Measure
Objective: Electronic Prescribing.
Objective: MIPS eligible clinicians must generate and transmit
permissible prescriptions electronically.
E-Prescribing Measure: At least one permissible prescription
written by the MIPS eligible clinician is queried for a drug formulary
and transmitted electronically using CEHRT.
Denominator: Number of prescriptions written for drugs
requiring a prescription to be dispensed other than controlled
substances during the performance period; or number of prescriptions
written for drugs requiring a prescription to be dispensed during the
performance period.
Numerator: The number of prescriptions in the denominator
generated, queried for a drug formulary, and transmitted electronically
using CEHRT.
Proposed Exclusion: Any MIPS eligible clinician who writes fewer
than 100 permissible prescriptions during the performance period.
Proposed Exclusion for the Health Information Exchange Objective
and Measures: We are proposing to add exclusions for the measures
associated with the Health Information Exchange Objective. Stakeholders
have expressed concern through public comments on the CY 2017 Quality
Payment Program proposed rule and other inquiries to us that some MIPS
eligible clinicians are unable to meet the measures associated with the
Health Information Exchange Objective, which are required for the base
score, because they do not regularly refer or transition patients in
the normal course of their practice. As we did not intend to
disadvantage those MIPS eligible clinicians and prevent them from
earning a base score, we are proposing the exclusions.
Advancing Care Information Objective and Measures
Objective: Health Information Exchange.
Objective: The MIPS eligible clinician provides a summary of care
record when transitioning or referring their patient to another setting
of care, receives or retrieves a summary of care record upon the
receipt of a transition or referral or upon the first patient encounter
with a new patient, and incorporates summary of care information from
other health care clinician into their EHR using the functions of
CEHRT.
We note that we proposed above to replace ``health care clinician''
with ``health care provider''.
Send a Summary of Care Measure: For at least one transition of care
or referral, the MIPS eligible clinician that transitions or refers
their patient to another setting of care or health care clinician (1)
creates a summary of care record using CEHRT; and (2) electronically
exchanges the summary of care record.
We note that we proposed above to replace ``health care clinician''
with ``health care provider''.
Denominator: Number of transitions of care and referrals
during the performance period for which the MIPS eligible clinician was
the transferring or referring clinician.
Numerator: The number of transitions of care and referrals
in the denominator where a summary of care record was created using
CEHRT and exchanged electronically.
Proposed Exclusion: Any MIPS eligible clinician who transfers a
patient to another setting or refers a patient fewer than 100 times
during the performance period.
Request/Accept Summary of Care Measure: For at least one transition
of care or referral received or patient encounter in which the MIPS
eligible clinician has never before encountered the patient, the MIPS
eligible clinician receives or retrieves and incorporates into the
patient's record an electronic summary of care document.
Denominator: Number of patient encounters during the
performance period for which a MIPS eligible clinician was the
receiving party of a transition or referral or has never before
encountered the patient and for which an electronic summary of care
record is available.
Numerator: Number of patient encounters in the denominator
where an electronic summary of care record received is incorporated by
the clinician into the CEHRT.
Proposed Exclusion: Any MIPS eligible clinician who receives
transitions of care or referrals or has patient encounters in which the
MIPS eligible clinician has never before encountered the patient fewer
than 100 times during the performance period.
2017 and 2018 Advancing Care Information Transition Objective and
Measures
Objective: Health Information Exchange.
Objective: The MIPS eligible clinician provides a summary of care
record when transitioning or referring their patient to another setting
of care, receives or retrieves a summary of care record upon the
receipt of a transition or referral or upon the first patient encounter
with a new patient, and incorporates summary of care information from
other health care clinicians into their EHR using the functions of
CEHRT.
We note that we are proposing above to replace ``health care
clinician'' with ``health care provider''.
Health Information Exchange Measure: The MIPS eligible clinician
that transitions or refers their patient to another setting of care or
health care clinician (1) uses CEHRT to create a summary of care
record; and (2) electronically transmits such summary to a receiving
health care clinician for at least one transition of care or referral.
We note that we are proposing above to replace ``health care
clinician'' with ``health care provider''.
Denominator: Number of transitions of care and referrals
during the performance period for which the EP was the transferring or
referring health care clinician.
We note that we are proposing above to replace ``health care
clinician'' with ``health care provider''.
Numerator: The number of transitions of care and referrals
in the denominator where a summary of care
[[Page 30075]]
record was created using CEHRT and exchanged electronically.
Proposed Exclusion: Any MIPS eligible clinician who transfers a
patient to another setting or refers a patient fewer than 100 times
during the performance period.
We are inviting public comment on these proposals.
(7) Additional Considerations
(a) 21st Century Cures Act
As we noted in the CY 2017 Quality Payment Program final rule (81
FR 77238), section 101(b)(1)(A) of the MACRA amended section
1848(a)(7)(A) of the Act to sunset the meaningful use payment
adjustment at the end of CY 2018. Section 1848(a)(7) of the Act
includes certain statutory exceptions to the meaningful use payment
adjustment under section 1848(a)(7)(A) of the Act. Specifically,
section 1848(a)(7)(D) of the Act exempts hospital-based EPs from the
application of the payment adjustment under section 1848(a)(7)(A) of
the Act. In addition, section 1848(a)(7)(B) of the Act provides that
the Secretary may, on a case-by-case basis, exempt an EP from the
application of the payment adjustment under section 1848(a)(7)(A) of
the Act if the Secretary determines, subject to annual renewal, that
compliance with the requirement for being a meaningful EHR user would
result in a significant hardship, such as in the case of an EP who
practices in a rural area without sufficient internet access. The last
sentence of section 1848(a)(7)(B) of the Act also provides that in no
case may an exemption be granted under subparagraph (B) for more than 5
years. The MACRA did not maintain these statutory exceptions for the
advancing care information performance category of the MIPS. Thus, we
had previously stated that the provisions under sections 1848(a)(7)(B)
and (D) of the Act are limited to the meaningful use payment adjustment
under section 1848(a)(7)(A) of the Act and do not apply in the context
of the MIPS.
Following the publication of the CY 2017 Quality Payment Program
final rule, the 21st Century Cures Act (Pub. L. 114-255) was enacted on
December 13, 2016. Section 4002(b)(1)(B) of the 21st Century Cures Act
amended section 1848(o)(2)(D) of the Act to state that the provisions
of sections 1848(a)(7)(B) and (D) of the Act shall apply to assessments
of MIPS eligible clinicians under section 1848(q) of the Act with
respect to the performance category described in subsection
(q)(2)(A)(iv) (the advancing care information performance category) in
an appropriate manner which may be similar to the manner in which such
provisions apply with respect to the meaningful use payment adjustment
made under section 1848(a)(7)(A) of the Act. As a result of this
legislative change, we believe that the general exceptions described
under sections 1848(a)(7)(B) and (D) of the Act are applicable under
the MIPS program. We include below proposals to implement these
provisions as applied to assessments of MIPS eligible clinicians under
section 1848(q) of the Act with respect to the advancing care
information performance category.
(i) MIPS Eligible Clinicians Facing a Significant Hardship
In the CY 2017 Quality Payment Program final rule (81 FR 77240
through 77243), we recognized that there may not be sufficient measures
applicable and available under the advancing care information
performance category to MIPS eligible clinicians facing a significant
hardship, such as those who lack sufficient internet connectivity, face
extreme and uncontrollable circumstances, lack control over the
availability of CEHRT, or do not have face-to-face interactions with
patients. We relied on section 1848(q)(5)(F) of the Act to establish a
final policy to assign a zero percent weighting to the advancing care
information performance category in the final score if there are not
sufficient measures and activities applicable and available to MIPS
eligible clinicians within the categories of significant hardship noted
above (81 FR 77243). Additionally, under the final policy (81 FR
77243), we did not impose a limitation on the total number of MIPS
payment years for which the advancing care information performance
category could be weighted at zero percent, in contrast with the 5-year
limitation on significant hardship exceptions under the Medicare EHR
Incentive Program as required by section 1848(a)(7)(B) of the Act.
We are not proposing substantive changes to this policy; however,
as a result of the changes in the law made by the 21st Century Cures
Act discussed above, we will not rely on section 1848(q)(5)(F) of the
Act and instead are proposing to use the authority in the last sentence
of section 1848(o)(2)(D) of the Act for significant hardship exceptions
under the advancing care information performance category under MIPS.
Section 1848(o)(2)(D) of the Act, as amended by section 4002(b)(1)(B)
of the 21st Century Cures Act, states in part that the provisions of
section 1848(a)(7)(B) of the Act shall apply to assessments of MIPS
eligible clinicians with respect to the advancing care information
performance category in an appropriate manner which may be similar to
the manner in which such provisions apply with respect to the payment
adjustment made under section 1848(a)(7)(A) of the Act. We would assign
a zero percent weighting to the advancing care information performance
category in the MIPS final score for a MIPS payment year for MIPS
eligible clinicians who successfully demonstrate a significant hardship
through the application process. We would use the same categories of
significant hardship and application process as established in the CY
2017 Quality Payment Program final rule (81 FR 77240-77243). We would
automatically reweight the advancing care information performance
category to zero percent for a MIPS eligible clinician who lacks face-
to-face patient interaction and is classified as a non-patient facing
MIPS eligible clinician without requiring an application. If a MIPS
eligible clinician submits an application for a significant hardship
exception or is classified as a non-patient facing MIPS eligible
clinician, but also reports on the measures specified for the advancing
care information performance category, they would be scored on the
advancing care information performance category like all other MIPS
eligible clinicians, and the category would be given the weighting
prescribed by section 1848(q)(5)(E) of the Act regardless of the MIPS
eligible clinician's score.
We believe this policy would be an appropriate application of the
provisions of section 1848(a)(7)(B) of the Act to MIPS eligible
clinicians and is similar to the manner in which those provisions apply
with respect to the payment adjustment made under section 1848(a)(7)(A)
of the Act. Under the Medicare EHR Incentive Program an approved
hardship exception exempted an EP from the payment adjustment. We
believe that weighting the advancing care information performance
category to zero percent is similar in effect to an exemption from the
requirements of that performance category.
As required under section 1848(a)(7)(B) of the Act, eligible
professionals were not granted significant hardship exceptions for the
payment adjustments under the Medicare EHR Incentive Program for more
than 5 years. We propose not to apply the 5-year limitation under
section 1848(a)(7)(B) of the Act to significant hardship exceptions for
the advancing care information performance category under MIPS. We
believe this proposal is an appropriate application of the provisions
of section 1848(a)(7)(B)
[[Page 30076]]
of the Act to MIPS eligible clinicians due to our desire to reduce
clinician burden, promote the greatest level of participation in the
MIPS program, and maintain consistency with the policies established in
last year's final rule (81 FR 77243). In the Medicare EHR Incentive
Program, we received many applications for significant hardship
exceptions and approved most of them, which we believe indicates many
eligible professionals were unable to or would have struggled to
satisfy the requirements of meaningful use. We believe that there will
be a continued need for significant hardship exceptions in order to
provide clinicians with the necessary flexibility to participate in the
MIPS program that best matches their available resources and
circumstances, which may not change during a 5-year time period. For
example, a clinician in an area without internet connectivity may
continue to lack connectivity for more than 5 years. In addition, in
the CY 2017 Quality Payment Program final rule (81 FR 77242 through
77243), we noted that we had received comments expressing appreciation
that CMS moved away from the 5-year limitation to significant hardship
exceptions.
We solicit comments on the proposed use of the authority provided
in the 21st Century Cures Act in section 1848(o)(2)(D) of the Act as it
relates to application of significant hardship exceptions under MIPS
and the proposal not to apply a 5-year limit to such exceptions.
(ii) Significant Hardship Exception for MIPS Eligible Clinicians in
Small Practices
Section 1848(q)(2)(B)(iii) of the Act requires the Secretary to
give consideration to the circumstances of small practices (consisting
of 15 or fewer professionals) and practices located in rural areas and
geographic HPSAs in establishing improvement activities under MIPS. In
the CY 2017 Quality Payment Program final rule (81 FR 77187 through
77188), we finalized that for MIPS eligible clinicians and groups that
are in small practices or located in rural areas, or geographic health
professional shortage areas (HPSAs), to achieve full credit under the
improvement activities category, one high-weighted or two medium-
weighted improvement activities are required.
While there is no corresponding statutory provision for the
advancing care information performance category, we believe that
special consideration should also be available for MIPS eligible
clinicians located in small practices. Through comments received on the
CY 2017 Quality Payment Program proposed rule (81 FR 28161-28586), we
heard many concerns about the impact of MIPS on eligible clinicians in
small practices. Some commenters stated that there was not a meaningful
exclusion for small practices that cannot afford the upfront
investments (including investments in EHR technology) (81 FR 77066).
Many noted there are still many small practices that have not adopted
EHRs due to the administrative and financial burden. Some expressed
concern that small group and solo practices would be driven out of
business because of the potential negative payment adjustments under
MIPS (81 FR 77055). A few commenters were concerned about the impact of
MACRA on small practices and asked CMS to remain sensitive to this
concern and offer special opportunities for MIPS eligible clinicians in
areas threatened by access problems (81 FR 77055).
Based on these concerns, we are proposing a significant hardship
exception for the advancing care information performance category for
MIPS eligible clinicians who are in small practices, under the
authority in section 1848(o)(2)(D) of the Act, as amended by section
4002(b)(1)(B) of the 21st Century Cures Act (see discussion of the
statutory authority for significant hardship exceptions in section
II.C.6.f.(7)(ii). We are proposing that this hardship exception would
be available to MIPS eligible clinicians in small practices as defined
under Sec. 414.1305 (15 or fewer clinicians and solo practitioners).
We are proposing in section II.C.1.e. of this proposed rule, that CMS
would make eligibility determinations regarding the size of small
practices for performance periods occurring in 2018 and future years.
We are proposing to reweight the advancing care information performance
category to zero percent of the MIPS final score for MIPS eligible
clinicians who qualify for this hardship exception. We are proposing
this exception would be available beginning with the 2018 performance
period and 2020 MIPS payment year. We are proposing a MIPS eligible
clinician seeking to qualify for this exception would submit an
application in the form and manner specified by us by December 31st of
the performance period or a later date specified by us. We are also
proposing MIPS eligible clinicians seeking this exception must
demonstrate in the application that there are overwhelming barriers
that prevent the MIPS eligible clinician from complying with the
requirements for the advancing care information performance category.
In accordance with section 1848(a)(7)(B) of the Act, the exception
would be subject to annual renewal. Under our proposal in section
II.C.6.f.(7)(a), the 5-year limitation under section 1848(a)(7)(B) of
the Act would not apply to this significant hardship exception for MIPS
eligible clinicians in small practices.
We believe that applying the significant hardship exception in this
way would be appropriate given the challenges small practices face as
described by the commenters. In addition, we believe this application
would be similar to the manner in which the exception applies with
respect to the payment adjustment made under section 1848(a)(7)(A) of
the Act because weighting the advancing care information performance
category to zero percent is similar in effect to an exemption from the
requirements of that performance category.
While we would be making this significant hardship exception
available to small practices in particular, we are considering whether
other categories or types of clinicians might similarly require an
exception. We solicit comment on what those categories or types are,
why such an exception is required, and any data available to support
the necessity of the exception. We note that supporting data would be
particularly helpful to our consideration of whether any additional
exceptions would be appropriate.
We are seeking comments on these proposals.
(iii) Hospital-Based MIPS Eligible Clinicians
In the CY 2017 Quality Payment Program final rule (81 FR 77238
through 77240), we defined a hospital-based MIPS eligible clinician
under Sec. 414.1305 as a MIPS eligible clinician who furnishes 75
percent or more of his or her covered professional services in sites of
service identified by the Place of Service (POS) codes used in the
HIPAA standard transaction as an inpatient hospital (POS 21), on-campus
outpatient hospital (POS 22), or emergency room (POS 23) setting, based
on claims for a period prior to the performance period as specified by
CMS. We intend to use claims with dates of service between September 1
of the calendar year 2 years preceding the performance period through
August 31 of the calendar year preceding the performance period, but in
the event it is not operationally feasible to use claims from this time
period, we will use a 12-month period as close as practicable to this
time period. We discussed our assumption that MIPS eligible clinicians
who are determined hospital-based do not have
[[Page 30077]]
sufficient advancing care information measures applicable to them, and
we established a policy to reweight the advancing care information
performance category to zero percent of the MIPS final score for the
MIPS payment year in accordance with section 1848(q)(5)(F) of the Act
(81 FR 77240).
We are not proposing substantive changes to this policy; however,
as a result of the changes in the law made by the 21st Century Cures
Act discussed above, we will not rely on section 1848(q)(5)(F) of the
Act and instead are proposing to use the authority in the last sentence
of section 1848(o)(2)(D) of the Act for exceptions for hospital-based
MIPS eligible clinicians under the advancing care information
performance category. Section 1848(o)(2)(D) of the Act, as amended by
section 4002(b)(1)(B) of the 21st Century Cures Act, states in part
that the provisions of section 1848(a)(7)(D) of the Act shall apply to
assessments of MIPS eligible clinicians with respect to the advancing
care information performance category in an appropriate manner which
may be similar to the manner in which such provisions apply with
respect to the payment adjustment made under section 1848(a)(7)(A) of
the Act. We would assign a zero percent weighting to the advancing care
information performance category in the MIPS final score for a MIPS
payment year for hospital-based MIPS eligible clinicians as previously
defined. A hospital-based MIPS eligible clinician would have the option
to report the advancing care information measures for the performance
period for the MIPS payment year for which they are determined
hospital-based. However, if a MIPS eligible clinician who is determined
hospital-based chooses to report on the advancing care information
measures, they would be scored on the advancing care information
performance category like all other MIPS eligible clinicians, and the
category would be given the weighting prescribed by section
1848(q)(5)(E) of the Act regardless of their score.
We believe this policy would be an appropriate application of the
provisions of section 1848(a)(7)(D) of the Act to MIPS eligible
clinicians and is similar to the manner in which those provisions apply
with respect to the payment adjustment made under section 1848(a)(7)(A)
of the Act. Under the Medicare EHR Incentive Program an approved
hardship exception exempted an EP from the payment adjustment. We
believe that weighting the advancing care information performance
category to zero percent is similar in effect to an exemption from the
requirements of that performance category.
We propose to amend Sec. 414.1380(c)(1) and (2) of the regulation
text to reflect this proposal.
We request comments on the proposed use of the authority provided
in the 21st Century Cures Act in section 1848(o)(2)(D) of the Act as it
relates to hospital-based MIPS eligible clinicians.
(iv) Ambulatory Surgical Center (ASC)--Based MIPS Eligible Clinicians
Section 16003 of the 21st Century Cures Act amended section
1848(a)(7)(D) of the Act to provide that no payment adjustment may be
made under section 1848(a)(7)(A) of the Act for 2017 and 2018 in the
case of an eligible professional who furnishes substantially all of his
or her covered professional services in an ambulatory surgical center
(ASC). Section 1848(a)(7)(D)(iii) of the Act provides that
determinations of whether an eligible professional is ASC-based may be
made based on the site of service as defined by the Secretary or an
attestation, but shall be made without regard to any employment or
billing arrangement between the eligible professional and any other
supplier or provider of services. Section 1848(a)(7)(D)(iv) of the Act
provides that the ASC-based exception shall no longer apply as of the
first year that begins more than 3 years after the date on which the
Secretary determines, through notice and comment rulemaking, that CEHRT
applicable to the ASC setting is available.
Under section 1848(o)(2)(D) of the Act, as amended by section
4002(b)(1)(B) of the 21st Century Cures Act, the ASC-based provisions
of section 1848(a)(7)(D) of the Act shall apply to assessments of MIPS
eligible clinicians under section 1848(q) of the Act with respect to
the advancing care information performance category in an appropriate
manner which may be similar to the manner in which such provisions
apply with respect to the payment adjustment made under section
1848(a)(7)(A) of the Act. We believe our proposals set forth below for
ASC-based MIPS eligible clinicians are an appropriate application of
the provisions of section 1848(a)(7)(D) of the Act to MIPS eligible
clinicians. Under the Medicare EHR Incentive Program an approved
hardship exception exempted an EP from the payment adjustment. We
believe that weighting the advancing care information performance
category to zero percent is similar in effect to an exemption from the
requirements of that performance category.
To align with our hospital-based MIPS eligible clinician policy, we
are proposing to define at Sec. 414.1305 an ASC-based MIPS eligible
clinician as a MIPS eligible clinician who furnishes 75 percent or more
of his or her covered professional services in sites of service
identified by the Place of Service (POS) code 24 used in the HIPAA
standard transaction based on claims for a period prior to the
performance period as specified by us. We request comments on this
proposal and solicit comments as to whether other POS codes should be
used to identify a MIPS eligible clinician's ASC-based status or if an
alternative methodology should be used. We note that the ASC-based
determination will be made independent of the hospital-based
determination.
To determine a MIPS eligible clinician's ASC-based status, we are
proposing to use claims with dates of service between September 1 of
the calendar year 2 years preceding the performance period through
August 31 of the calendar year preceding the performance period, but in
the event it is not operationally feasible to use claims from this time
period, we would use a 12-month period as close as practicable to this
time period. For example, for the 2018 performance period (2020 MIPS
payment year), we would use the data available at the end of October
2017 for Medicare claims with dates of service between September 1,
2016 through August 31, 2017, to determine whether a MIPS eligible
clinician is considered ASC-based under our proposed definition. We are
proposing this timeline to allow us to notify MIPS eligible clinicians
of their ASC-based status prior to the start of the performance period
and to align with the hospital-based MIPS eligible clinician
determination period. For the 2019 MIPS payment year, we would not be
able to notify MIPS eligible clinicians of their ASC-based status until
after the final rule is published, which we anticipate would be later
in 2017. We expect that we would provide this notification through
QPP.cms.gov.
For MIPS eligible clinicians who we determine are ASC-based, we
propose to assign a zero percent weighting to the advancing care
information performance category in the MIPS final score for the MIPS
payment year. However, if a MIPS eligible clinician who is determined
ASC-based chooses to report on the advancing care information measures
for the performance period for the MIPS payment year for which they are
determined ASC-based, we propose they would be scored on the advancing
care information performance category like
[[Page 30078]]
all other MIPS eligible clinicians, and the performance category would
be given the weighting prescribed by section 1848(q)(5)(E) of the Act
regardless of their advancing care information performance category
score.
We are proposing these ASC-based policies would apply beginning
with the 2017 performance period/2019 MIPS payment year.
We propose to amend Sec. 414.1380(c)(1) and (2) of the regulation
text to reflect these proposals.
We request comments on these proposals.
(v) Exception for MIPS Eligible Clinicians Using Decertified EHR
Technology
Section 4002(b)(1)(A) of the 21st Century Cures Act amended section
1848(a)(7)(B) of the Act to provide that the Secretary shall exempt an
eligible professional from the application of the payment adjustment
under section 1848(a)(7)(A) of the Act with respect to a year, subject
to annual renewal, if the Secretary determines that compliance with the
requirement for being a meaningful EHR user is not possible because the
CEHRT used by such professional has been decertified under ONC's Health
IT Certification Program. Section 1848(o)(2)(D) of the Act, as amended
by section 4002(b)(1)(B) of the 21st Century Cures Act, states in part
that the provisions of section 1848(a)(7)(B) of the Act shall apply to
assessments of MIPS eligible clinicians with respect to the advancing
care information performance category in an appropriate manner which
may be similar to the manner in which such provisions apply with
respect to the payment adjustment made under section 1848(a)(7)(A) of
the Act.
We are proposing that a MIPS eligible clinician may demonstrate
through an application process that reporting on the measures specified
for the advancing care information performance category is not possible
because the CEHRT used by the MIPS eligible clinician has been
decertified under ONC's Health IT Certification Program. We are
proposing that if the MIPS eligible clinician's demonstration is
successful and an exception is granted, we would assign a zero percent
weighting to the advancing care information performance category in the
MIPS final score for the MIPS payment year. In accordance with section
1848(a)(7)(B) of the Act, the exception would be subject to annual
renewal, and in no case may a MIPS eligible clinician be granted an
exception for more than 5 years. We are proposing this exception would
be available beginning with the CY 2018 performance period and the 2020
MIPS payment year.
We are proposing that a MIPS eligible clinician may qualify for
this exception if their CEHRT was decertified either during the
performance period for the MIPS payment year or during the calendar
year preceding the performance period for the MIPS payment year. We
believe that this timeframe is appropriate because the loss of
certification may prevent a MIPS eligible clinician from reporting for
the advancing care information performance category because it will
require that the MIPS eligible clinician switch to an alternate CEHRT,
a process that we believe may take up to 2 years. For example, for the
2020 MIPS payment year, if the MIPS eligible clinician's EHR technology
was decertified during the CY 2018 performance period or during CY
2017, the MIPS eligible clinician may qualify for this exception. In
addition, we are proposing that the MIPS eligible clinician must
demonstrate in their application and through supporting documentation
if available that the MIPS eligible clinician made a good faith effort
to adopt and implement another CEHRT in advance of the performance
period. We are proposing a MIPS eligible clinician seeking to qualify
for this exception would submit an application in the form and manner
specified by us by December 31st of the performance period, or a later
date specified by us.
We believe that applying the exception in this way is an
appropriate application of the provisions of section 1848(a)(7)(B) of
the Act to MIPS eligible clinicians given that weighting the advancing
care information performance category to zero percent is similar in
effect to an exemption from the requirements of that performance
category. Under the Medicare EHR Incentive Program an approved hardship
exception exempted an EP from the payment adjustment. We believe that
weighting the advancing care information performance category to zero
percent is similar in effect to an exemption from the requirements of
that performance category.
The ONC Health IT Certification Program: Enhanced Oversight and
Accountability final rule (``EOA final rule'') (81 FR 72404), effective
December 19, 2016, created a regulatory framework for the ONC's direct
review of health information technology (health IT) certified under the
ONC Health IT Certification Program, including, when necessary,
requiring the correction of non-conformities found in health IT
certified under the Program and/or terminating certifications issued to
certified health IT. Prior to the EOA final rule, ONC-Authorized
Certification Bodies (ONC-ACBs) had the only authority to terminate or
revoke certification of health IT under the program, which they used on
previous occasions. On September 23, 2015, we posted an FAQ discussing
the requirements for using a decertified CEHRT.\3\
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\3\ https://questions.cms.gov/faq.php?isDept=0&search=decertify&searchType=keyword&submitSearch=1&id=5005.
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Once all administrative processes, if any, are complete, then
notice of a ``termination of certification'' is listed on the of the
Certified Health IT Product List (CPHL) Web page.\4\ As appropriate,
ONC will also publicize the termination of certification of health IT
through other communication channels (for example, ONC list serv(s)).
Further, when ONC terminates the certification of a health IT product,
the health IT developer is required to notify all potentially affected
customers in a timely manner.
---------------------------------------------------------------------------
\4\ The list is available at https://chpl.healthit.gov/#/decertifications/products.
---------------------------------------------------------------------------
We further note that in comparison to termination actions taken by
ONC and ONC-ACBs, a health IT developer may voluntarily withdraw a
certification that is in good standing under the ONC Health IT
Certification Program. A voluntary withdrawal may be the result of the
health IT developer going out of business, the developer no longer
supporting the product, or for other reasons that are not in response
to ONC-ACB surveillance, ONC direct review, or a finding of non-
conformity by ONC or an ONC-ACB.\5\ In such instances, ONC will list
these products on the ``Inactive Certificates'' \6\ Web page of the
CHPL.
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\5\ For further descriptions of certification statuses, please
consult the CHPL Public User Guide.
\6\ The ``Inactive Certificates'' Web page is available at
https://chpl.healthit.gov/#/decertifications/inactive.
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We propose to amend Sec. 414.1380(c)(1) and (2) of the regulation
text to reflect these proposals. We are seeking comments on these
proposals.
(b) Hospital-Based MIPS Eligible Clinicians
In the CY 2017 Quality Payment Program final rule (81 FR 77238
through 77240, we defined a hospital-based MIPS eligible clinician as a
MIPS eligible clinician who furnishes 75 percent or more of his or her
covered professional services in sites of services identified by the
Place of Service (POS) codes used in the HIPAA standard transaction as
an inpatient hospital (POS 21), on campus outpatient hospital
[[Page 30079]]
(POS 22) or emergency room (POS 23) setting, based on claims for a
period prior to the performance period as specified by CMS.
We are proposing to modify our policy to include covered
professional services furnished by MIPS eligible clinicians in an off-
campus-outpatient hospital (POS 19) in the definition of hospital-based
MIPS eligible clinician. POS 19 was developed in 2015 in order to
capture the numerous physicians that are paid for a portion of their
services in an ``off campus-outpatient hospital'' versus an on campus-
outpatient hospital, (POS 22). We also believe that these MIPS eligible
clinicians would not typically have control of the development and
maintenance of their EHR systems, just like those who bill using POS
22. We propose to add POS 19 to our existing definition of a hospital-
based MIPS eligible clinician beginning with the performance period in
2018.
We invite comment on this proposal.
(c) Nurse Practitioners, Physician Assistants, Clinical Nurse
Specialists, and Certified Registered Nurse Anesthetists
In the CY 2017 Quality Payment Program final rule (81 FR 77243-
77244), we discussed our belief that certain types of MIPS eligible
clinicians (NPs, PAs, CNSs, and CRNAs) may lack experience with the
adoption and use of CEHRT. Because many of these non-physician
clinicians are not eligible to participate in the Medicare or Medicaid
EHR Incentive Program, we stated that we have little evidence as to
whether there are sufficient measures applicable and available to these
types of MIPS eligible clinicians under the advancing care information
performance category. We established a policy under section
1848(q)(5)(F) of the Act to assign a weight of zero to the advancing
care information performance category in the MIPS final score if there
are not sufficient measures applicable and available to NPs, PAs,
CRNAs, and CNSs. We will assign a weight of zero only in the event that
an NP, PA, CRNA, or CNS does not submit any data for any of the
measures specified for the advancing care information performance
category. We encouraged all NPs, PAs, CRNAs, and CNSs to report on
these measures to the extent they are applicable and available,
however, we understand that some NPs, PAs, CRNAs, and CNSs may choose
to accept a weight of zero for this performance category if they are
unable to fully report the advancing care information measures. These
MIPS eligible clinicians may choose to submit advancing care
information measures should they determine that these measures are
applicable and available to them; however, we noted that if they choose
to report, they will be scored on the advancing care information
performance category like all other MIPS eligible clinicians and the
performance category will be given the weighting prescribed by section
1848(q)(5)(E) of the Act regardless of their advancing care information
performance category score.
We stated that this approach is appropriate for the first MIPS
performance period based on the payment consequences associated with
reporting, the fact that many of these types of MIPS eligible
clinicians may lack experience with EHR use, and our current
uncertainty as to whether we have adopted sufficient measures that are
applicable and available to these types of MIPS eligible clinicians. We
noted that we would use the first MIPS performance period to further
evaluate the participation of these MIPS eligible clinicians in the
advancing care information performance category and would consider for
subsequent years whether the measures specified for this category are
applicable and available to these MIPS eligible clinicians. At this
time we have no additional information because the first MIPS
performance period is currently underway, and thus we propose the same
policy for NPs, PAs, CRNAs, and CNSs for the 2018 performance period as
well. We still intend to evaluate the participation of these MIPS
eligible clinicians in the advancing care information performance
category for 2017 and expect to adopt measures applicable and available
to them in subsequent years.
We are seeking comment on how the advancing care information
performance category could be applied to NPs, PAs, CRNAs, and CNSs in
future years of MIPS, and the types of measures that would be
applicable and available to these types of MIPS eligible clinicians. In
addition, through the Call for Measures Process we are seeking new
measures that may be more broadly applicable to these additional types
of MIPS eligible clinicians in future program years. For more
information on the Call for Measures, see https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/CallForMeasures.html.
We are inviting public comment on these proposals.
(d) Scoring for MIPS Eligible Clinicians in Group Practices
In any of the situations described in the sections above, we would
assign a zero percent weighting to the advancing care information
performance category in the MIPS final score for the MIPS payment year
if the MIPS eligible clinician meets certain specified requirements for
this weighting. We noted that these MIPS eligible clinicians may choose
to submit advancing care information measures; however, if they choose
to report, they will be scored on the advancing care information
performance category like all other MIPS eligible clinicians and the
performance category will be given the weighting prescribed by section
1848(q)(5)(E) of the Act regardless of their advancing care information
performance category score. This policy includes MIPS eligible
clinicians choosing to report as part of a group practice or part of a
virtual group.
Group practices as defined at Sec. 414.1310(e)(1) are required to
aggregate their performance data across the TIN in order for their
performance to be assessed as a group (81 FR 77058). Additionally,
groups that elect to have their performance assessed as a group will be
assessed as a group across all four MIPS performance categories. By
reporting as part of a group practice, MIPS eligible clinicians are
subscribing to the data reporting and scoring requirements of the group
practice. We note that the data submission criteria for groups
reporting advancing care information performance category described in
the CY 2017 Quality Payment Program final rule (81 FR 77215) state that
group data should be aggregated for all MIPS eligible clinicians within
the group practice. This includes those MIPS eligible clinicians who
may qualify for a zero percent weighting of the advancing care
information performance category due to the circumstances as described
above, such as a significant hardship or other type of exception,
hospital-based or ASC-based status, or certain types of non-physician
practitioners (NPs, PAs, CNSs, and CRNAs). If these MIPS eligible
clinicians report as part of a group practice or virtual group, they
will be scored on the advancing care information performance category
like all other MIPS eligible clinicians and the performance category
will be given the weighting prescribed by section 1848(q)(5)(E) of the
Act regardless of the group practice's advancing care information
performance category score.
[[Page 30080]]
(e) Timeline for Submission of Reweighting Applications
In the CY 2017 Quality Payment Program final rule (81 FR77240-
77243), we established the timeline for the submission of applications
to reweight the advancing care information performance category in the
MIPS final score to align with the data submission timeline for MIPS.
We established that all applications for reweighting the advancing care
information performance category be submitted by the MIPS eligible
clinician or designated group representative in the form and manner
specified by us. All applications may be submitted on a rolling basis,
but must be received by us no later than the close of the submission
period for the relevant performance period, or a later date specified
by us. An application would need to be submitted annually to be
considered for reweighting each year.
The Quality Payment Program Exception Application will be used to
apply for the following exceptions: Insufficient Internet Connectivity;
Extreme and Uncontrollable Circumstances; Lack of Control over the
Availability of CEHRT; Decertification of CEHRT; and Small Practice.
We are proposing to change the submission deadline for the
application as we believe that aligning the data submission deadline
with the reweighting application deadline could disadvantages MIPS
eligible clinicians. We are proposing to change the submission deadline
for the CY 2017 performance period to December 31, 2017, or a later
date specified by us. We believe this change would help MIPS eligible
clinicians by allowing them to learn whether their application is
approved prior to the data submission deadline for the CY 2017
performance period, March 31, 2018. We plan to have the application
available in mid-2017. We encourage MIPS eligible clinicians to apply
early as we expect to process the applications on a rolling basis. We
note that if a MIPS eligible clinician submits data for the advancing
care information category after an application has been submitted, the
data would be scored, the application would be considered voided and
the advancing care information performance category would not be
reweighted.
We further propose that the submission deadline for the 2018
performance period will be December 31, 2018, or a later date as
specified by us. We believe this would help MIPS eligible clinicians by
allowing them to learn whether their application is approved prior to
the data submission deadline for the CY 2018 performance period, March
31, 2019.
We request comments on these proposals.
g. APM Scoring Standard for MIPS Eligible Clinicians in MIPS APMs
(1) Overview
Under section 1848(q)(1)(C)(ii)(1) of the Act, Qualifying APM
Participants (QPs) are not MIPS eligible clinicians and are thus
excluded from MIPS reporting requirements and payment adjustments.
Similarly, under section 1848(q)(1)(c)(ii)(II) of the Act, Partial
Qualifying APM Participants (Partial QPs) are also not MIPS eligible
clinicians unless they opt to report and be scored under MIPS. All
other eligible clinicians, including those participating in MIPS APMs,
are MIPS eligible clinicians and subject to MIPS reporting requirements
and payment adjustments unless they are excluded on another basis such
as being newly enrolled in Medicare or not exceeding the low volume
threshold.
In the CY 2017 Quality Payment Program final rule (81 FR 77246-
77269, 77543), we finalized the APM scoring standard, which is designed
to reduce reporting burden for participants in certain APMs by
minimizing the need for them to make duplicative data submissions for
both MIPS and their respective APMs. We also sought to ensure that
eligible clinicians in APM Entities that participate in certain types
of APMs that assess their participants on quality and cost are assessed
as consistently as possible across MIPS and their respective APMs.
Given that many APMs already assess their participants on cost and
quality of care and require engagement in certain improvement
activities, we believe that without the APM scoring standard,
misalignments could be quite common between the evaluation of
performance under the terms of the APM and evaluation of performance on
measures and activities under MIPS.
In the CY 2017 Quality Payment Program final rule (81 FR 77249), we
identified the types of APMs for which the APM scoring standard would
apply as MIPS APMs. We finalized that to be a MIPS APM, an APM must
satisfy the following criteria: (1) APM Entities participate in the APM
under an agreement with CMS or by law or regulation; (2) the APM
requires that APM Entities include at least one MIPS eligible clinician
on a Participation List; and (3) the APM bases payment incentives on
performance (either at the APM Entity or eligible clinician level) on
cost/utilization and quality measures. We specified that we will post
the list of MIPS APMs prior to the first day of the MIPS performance
year for each year (81 FR 77250). We finalized in the regulation at
Sec. 414.1370(b) that for a new APM to be a MIPS APM, its first
performance year must start on or before the first day of the MIPS
performance year. A list of MIPS APMs is available at www.qpp.cms.gov.
We established in the regulation at Sec. 414.1370(c) that the MIPS
performance year under Sec. 414.1320 of the regulations applies for
the APM scoring standard.
We finalized that under section Sec. 414.1370(f) of our
regulations on the APM scoring standard, MIPS eligible clinicians will
be scored at the APM Entity group level and each eligible clinician
will receive the APM Entity group's final score. The MIPS payment
adjustment is applied at the TIN/NPI level for each of the MIPS
eligible clinicians in the APM Entity. The MIPS final score is
comprised of the four MIPS performance category scores, as described in
our regulation at Sec. 414.1370(g): quality, cost, improvement
activities, and advancing care information. Both the Medicare Shared
Savings Program and Next Generation ACO Model are MIPS APMs for the CY
2017 performance year. For these two MIPS APMs, in accordance with our
regulation at Sec. 414.1370(h), the MIPS performance category scores
are weighted as follows: Quality at 50 percent; cost at zero percent;
improvement activities at 20 percent; and advancing care information at
30 percent of the final score. For all other MIPS APMs for the CY 2017
performance year, quality and cost are each weighted at zero percent,
improvement activities at 25 percent, and advancing care information at
75 percent of the final score.
As explained in the following sections, we propose to: Add an APM
participant assessment date for full TIN APMs; add the CAHPS for ACOs
survey to the Shared Savings Program and Next Generation ACO quality
measures included for scoring under the MIPS APM quality performance
category; define Other MIPS APMs; and add scoring for quality
improvement to the MIPS APM quality performance category for MIPS APMs
beginning in 2018. We also propose a Quality Payment Program 2018
performance year quality scoring methodology for Other MIPS APMs, and
describe the scoring methodology for quality improvement for Other MIPS
APMs as applicable.
In reviewing these proposals, we remind readers that the APM
scoring
[[Page 30081]]
standard is built upon the generally applicable MIPS scoring standard,
but provides for special policies to address the unique circumstances
of MIPS eligible clinicians who are in APM Entities participating in
MIPS APMs. For the cost, improvement activities, and advancing care
information performance categories, unless a separate policy has been
established or is being proposed for the APM scoring standard, the
generally applicable MIPS policies would be applicable. Additionally,
unless we include a proposal to adopt a unique policy for the APM
scoring standard, we propose to adopt the same generally applicable
MIPS policies proposed elsewhere in this proposed rule, and would treat
the APM Entity group as the group for purposes of MIPS. For the quality
performance category, however, the APM scoring standard we propose is
presented as a separate, unique standard, and therefore generally
applicable MIPS policies would not be applied to the quality
performance category under the APM scoring standard unless specifically
stated. We seek comment on whether there may be potential conflicts or
inconsistencies between the generally applicable MIPS policies and
those under the APM scoring standard, particularly where these could
impact our goals to reduce duplicative and potentially incongruous
reporting requirements and performance evaluations that could undermine
our ability to test or evaluate MIPS APMs, or whether certain generally
applicable MIPS policies should be made explicitly applicable to the
APM scoring standard.
(2) Assessment Dates for Inclusion of MIPS Eligible Clinicians in APM
Entity Groups Under the APM Scoring Standard
In the CY 2017 Quality Payment Program final rule, we specified in
the regulation at Sec. 414.1370(e) that the APM Entity group for
purposes of scoring under the APM scoring standard is determined in the
manner prescribed at Sec. 414.1425(b)(1), which provides that eligible
clinicians who are on a Participation List on at least one of three
dates (March 31, June 30, and August 31) would be considered part of
the APM Entity group. Under these regulations, MIPS eligible clinicians
who are not on a Participation List on one of these three assessment
dates are not scored under the APM scoring standard. Instead, they
would need to submit data to MIPS through one of the MIPS data
submission mechanisms and their performance would be assessed either as
individual MIPS eligible clinicians or as a group according to the
generally applicable MIPS reporting and scoring criteria.
We will continue to use the three assessment dates of March 31,
June 30, and August 31 to identify MIPS eligible clinicians who are on
an APM Entity's Participation List and determine the APM Entity group
that is used for purposes of the APM scoring standard. Beginning in the
2018 performance year, we propose to add a fourth assessment date of
December 31 to identify those MIPS eligible clinicians who participate
in a full TIN APM. We propose to define full TIN APM at Sec. 414.1305
to mean an APM where participation is determined at the TIN level, and
all eligible clinicians who have assigned their billing rights to a
participating TIN are therefore participating in the APM. An example of
a full TIN APM is the Shared Savings Program which requires all
individuals and entities that have reassigned their right to receive
Medicare payment to the TIN of an ACO participant to participate in the
ACO and comply with the requirements of the Shared Savings Program.
If an eligible clinician elects to reassign their billing rights to
a TIN participating in a full TIN APM, the eligible clinician is
necessarily participating in the full TIN APM. We propose to add this
fourth date of December 31 only for eligible clinicians in a full TIN
APM, and only for purposes of applying the APM scoring standard. We are
not proposing to use this additional assessment date of December 31 for
purposes of QP determinations. Therefore, we propose to amend Sec.
414.1370(e) to identify the four assessment dates that would be used to
identify the APM Entity group for purposes of the APM scoring standard,
and to specify that the December 31 date would be used only to identify
eligible clinicians on the APM Entity's Participation List for a MIPS
APM that is a full TIN APM in order to add them to the APM Entity group
that is scored under the APM scoring standard.
We propose to use this fourth assessment date of December 31 to
extend the APM scoring standard to only those MIPS eligible clinicians
participating in MIPS APMs that are full TIN APMs, ensuring that an
eligible clinician who joins the full TIN APM late in the performance
year would be scored under the APM scoring standard. We considered
proposing to use the fourth assessment date more broadly for all MIPS
APMs. However, we believe that this approach would have allowed MIPS
eligible clinicians to inappropriately leverage the fourth assessment
date to avoid reporting and scoring under the generally applicable MIPS
scoring standard when they were part of the MIPS APM for only a very
limited portion of the performance year. That is, for MIPS APMs that
allow split TIN participation, it would be possible for eligible
clinicians to briefly join a MIPS APM principally in order to benefit
from the APM scoring standard, despite having limited opportunity to
contribute to the APM Entity's performance in the MIPS APM. In
contrast, we believe MIPS eligible clinicians would be less likely to
join a full TIN APM principally to avail themselves of the APM scoring
standard, since doing so would require either that the entire TIN join
the MIPS APM or the administratively burdensome act of the eligible
clinician reassigning their billing rights to the TIN of an entity
participating in the full TIN APM.
We will continue to use only the three dates of March 31, June 30,
and August 31 to determine, based on Participation Lists, the MIPS
eligible clinicians who participate in MIPS APMs that are not full TIN
APMs. We seek comment on the proposed addition of the fourth date of
December 31 to assess Participation Lists to identify MIPS eligible
clinicians who participate in MIPS APMs that are full TIN APMs for
purposes of the APM scoring standard.
(3) Calculating MIPS APM Performance Category Scores
In the CY 2017 Quality Payment Program final rule, we established a
scoring standard for MIPS eligible clinicians participating in MIPS
APMs to reduce participant reporting burden by reducing the need for
eligible clinicians participating in these types of APMs to make
duplicative data submissions for both MIPS and their respective APMs
(81 FR 77246 through 77271). In accordance with section
1848(q)(1)(D)(i) of the Act, we proposed to assess the performance of a
group of MIPS eligible clinicians in an APM Entity that participates in
one or more MIPS APMs based on their collective performance as an APM
Entity group, as defined at Sec. 414.1305.
In addition to reducing reporting burden, we sought to ensure that
eligible clinicians in MIPS APMs are not assessed in multiple ways on
the same performance activities. Depending on the terms of the
particular MIPS APM, we believe that misalignments could be common
between the evaluation of performance on quality and cost under MIPS
versus under the terms of the APM. We believe requiring eligible
clinicians in MIPS APMs to submit data, be scored on measures, and be
subject
[[Page 30082]]
to payment adjustments that are not aligned between MIPS and an APM
could potentially undermine the validity of testing or performance
evaluation under the APM. We also believe imposition of MIPS reporting
requirements would result in reporting activity that provides little or
no added value to the assessment of eligible clinicians, and could
confuse eligible clinicians as to which CMS incentives should take
priority over others in designing and implementing care improvement
activities.
(a) Cost Performance Category
In the CY 2017 Quality Payment Program final rule, for MIPS
eligible clinicians participating in MIPS APMs, we used our authority
to waive requirements under the Medicare statute to reduce the scoring
weight for the cost performance category to zero (81 FR 77258, 77262,
and 77266). We did this for MIPS APMs authorized under section 1115A of
the Act using our authority under section 1115A(d)(1) of the Act to
waive the requirement under section 1848(q)(5)(E)(i)(II) of the Act
that specifies the scoring weight for the cost performance category.
Having reduced the cost performance category weight to zero, we further
used our authority under section 1115A(d)(1) of the Act to waive the
requirements under sections 1848(q)(2)(B)(ii) and 1848(q)(2)(A)(ii) of
the Act to specify and use, respectively, cost measures in calculating
the MIPS final score for MIPS eligible clinicians participating in
Other MIPS APMs (81 FR 77261 through 77262 and 77265 through 77266).
Similarly, for MIPS eligible clinicians participating in the Medicare
Shared Savings Program, we used our authority under section 1899(f) of
the Act to waive the same requirements of section 1848 of the Act for
the MIPS cost performance category (81 FR 77257 through 77258). We
finalized this policy because: (1) APM Entity groups are already
subject to cost and utilization performance assessment under the MIPS
APMs; (2) MIPS APMs usually measure cost in terms of total cost of
care, which is a broader accountability standard that inherently
encompasses the purpose of the claims-based measures that have
relatively narrow clinical scopes, and MIPS APMs that do not measure
cost in terms of total cost of care may depart entirely from MIPS
measures; and (3) the beneficiary attribution methodologies differ for
measuring cost under APMs and MIPS, leading to an unpredictable degree
of overlap (for eligible clinicians and for CMS) between the sets of
beneficiaries for which eligible clinicians would be responsible that
would vary based on the unique APM Entity characteristics such as which
and how many eligible clinicians comprise an APM Entity group. We
believe that with an APM Entity's finite resources for engaging in
efforts to improve quality and lower costs for a specified beneficiary
population, measurement of the population identified through the APM
must take priority in order to ensure that the goals and the model
evaluation associated with the APM are as clear and free of confounding
factors as possible. The potential for different, conflicting results
across APMs and MIPS assessments may create uncertainty for MIPS
eligible clinicians who are attempting to strategically transform their
respective practices and succeed under the terms of the APM. We are not
proposing changes to these policies.
We welcome comment on our proposal to continue to waive the
weighting of the cost performance category for the 2020 payment year
forward.
(i) Measuring Improvement in the Cost Performance Category
In setting performance standards with respect to measures and
activities in each MIPS performance category, section 1848(q)(3)(B) of
the Act requires us to consider, historical performance standards,
improvement, and the opportunity for continued improvement. Section
1848(q)(5)(D)(i)(I) requires us to introduce the measurement of
improvement into performance scores in the cost performance category
for MIPS eligible clinicians for the 2020 MIPS Payment Year if data
sufficient to measure improvement are available. Section
1848(q)(5)(D)(i)(II) permits us to take into account improvement in the
case of performance scores in other performance categories. Given that
we have in effect waivers of the scoring weight for the cost
performance category, and of the requirement to specify and use cost
measures in calculating the MIPS final score for MIPS eligible
clinicians participating in MIPS APMs, and for the same reasons that we
initially waived those requirements, we propose to use our authority
under section 1115A(d)(1) of the Act for MIPS APMs authorized under
section 1115A of the Act and under section 1899(f) of the Act for MIPS
APMs under the Medicare Shared Savings Program, to waive the
requirement under section 1848(q)(5)(D)(i)(I) of the Act to take
improvement into account for performance scores in the cost performance
category beginning with the 2018 MIPS performance year.
We seek comment on this proposal.
(b) Quality Performance Category
(i) Web Interface Reporters: Shared Savings Program and Next Generation
ACO Model
(A) Quality Measures
We finalized in the CY 2017 Quality Payment Program final rule that
under the APM scoring standard, participants in the Shared Savings
Program and Next Generation ACO Model would be assessed for the
purposes of generating a MIPS APM quality performance category score
based exclusively on quality measures submitted using the CMS Web
Interface (81 FR 77256 and 77261). In the CY 2017 Quality Payment
Program final rule, we recognized that ACOs in both the Shared Savings
Program and Next Generation ACO Model use the CMS Web Interface to
submit data on quality measures, and that the measures they would
report were also MIPS measures for 2017. For the Shared Savings Program
and the Next Generation ACO Model, we finalized a policy to use quality
measures and data submitted by the participant ACOs to the CMS Web
Interface (as required under the rules for these initiatives) and MIPS
benchmarks for these measures to score quality for MIPS eligible
clinicians in these MIPS APMs at the APM Entity level (81 FR 77256,
77261). For these MIPS APMs, which we refer to as Web Interface
reporters going forward, we established that quality performance data
that are not submitted to the CMS Web Interface, for example the CAHPS
for ACOs survey and claims-based measures, will not be included in the
MIPS APM quality performance category score for 2017.
(aa) Addition of New Measures
For the Shared Savings Program and Next Generation ACO Model, we
propose to score the CAHPS for ACOs survey, in addition to the CMS Web
Interface measures that are used to calculate the MIPS APM quality
performance category score for the Shared Savings Program and Next
Generation ACO Model, beginning in the 2018 performance year. The CAHPS
for ACOs survey is already required in the Shared Savings Program and
Next Generation ACO Model, and including the CAHPS for ACOs survey
would better align the measures on which participants in these MIPS
APMs are assessed under the APM scoring standard with the measures used
to
[[Page 30083]]
assess participants' quality performance under the APM.
We did not initially propose to include the CAHPS for ACOs survey
as part of the MIPS APM quality performance category scoring for the
Shared Savings Program and Next Generation ACO Model because we
believed that the CAHPS for ACOs survey would not be collected and
scored in time to produce a MIPS quality performance category score.
However, operational efficiencies have recently been introduced that
have made it possible to score the CAHPS for ACOs survey on the same
timeline as the CAHPS for MIPS survey. Under our proposal, the CAHPS
for ACOs survey would be added to the total number of quality
performance category measures available for scoring in these MIPS APMs.
While the CAHPS for ACOs survey is new to MIPS APM scoring, the CG-
CAHPS survey upon which it is based is also the basis for the CAHPS for
MIPS survey, which was included on the MIPS final list for the 2017
performance year. For a further discussion of the CAHPS for ACOs
survey, and the way it will be scored, we refer readers to
II.C.6.b.(3)(a)(ii) of this proposed rule, which describes the
identical CAHPS for MIPS survey and its scoring method that will be
used for MIPS in the 2018 performance year. We note that although each
question in the CAHPS for ACOs survey can also be found in the CAHPS
for MIPS survey, the CAHPS for ACOs survey will have one fewer survey
question the SSM entitled ``Between Visit Communication'', which has
never been a scored measure with the Medicare Shared Savings Program
CAHPS for ACOs Survey and which we believe to be inappropriate for use
by ACOs.
Table 10--Web Interface Reporters: Shared Savings Program and Next Generation ACO Model New Measure
----------------------------------------------------------------------------------------------------------------
NQF/quality National
Measure name number (if quality Measure description Primary measure
applicable) strategy domain steward
----------------------------------------------------------------------------------------------------------------
CAHPS for ACOs............... N/A............ Patient/ Consumer Assessment of Agency for
Caregiver Healthcare Providers and Healthcare
Experience. Systems (CAHPS) surveys for Research and
Accountable Care Quality (AHRQ)
Organizations (ACOs) in the
Medicare Shared Savings
Program (SSP) and Next
Generation ACOs ask consumers
about their experiences with
health care. The CAHPS for
ACOs Survey is collected from
a sample of beneficiaries who
get the majority of their
care from an ACO, and the
questions address care
received from a named
clinician within the ACO.
Survey measures include:
--Getting Timely Care,
Appointments, and
Information.
--How Well Your Providers
Communicate.
--Patients' Rating of
Providers.
--Access to Specialists....
--Health Promotion and
Education.
--Shared Decision Making...
--Health Status/Functional
Status.
--Stewardship of Patient
Resources.
----------------------------------------------------------------------------------------------------------------
(B) Calculating Quality Scores
We refer readers to section II.C.7.a.(1)(h)(ii) of this proposed
rule for our summary of finalized policies and proposed changes related
to calculating the MIPS quality performance category percent score for
MIPS eligible clinicians, including APM Entity groups reporting through
the CMS Web Interface. Those policies and proposed changes in section
II.C.7.a.(1)(h)(ii) of this proposed rule would apply in the same
manner under the APM scoring standard except as otherwise noted in this
section of the proposed rule. However, we propose not to subject MIPS
APM Web Interface reporters to a 3 point floor because we do not
believe it is necessary to apply this transition year policy to
eligible clinicians participating in previously established MIPS APMs.
(C) Incentives to Report High Priority Measures
In the CY 2017 Quality Payment Program final rule, we finalized
that for CMS Web Interface reporters, we will apply bonus points based
on the finalized set of measures reportable through the CMS Web
Interface. (81 FR 77291 through 77294). We will assign two bonus points
for reporting two or more outcome or patient experience measures and
one bonus point for reporting any other high priority measure, beyond
the first high priority measure. We note that in addition to the
measures required by the APM to be submitted through the CMS Web
Interface, APM Entities in the Shared Savings Program and Next
Generation ACO Models must also report the CAHPS for ACOs survey and we
propose that beginning for the 2020 payment year forward they may
receive bonus points under the APM scoring standard for submitting that
measure. Participants in MIPS APMs, like all MIPS eligible clinicians,
are also subject to the 10 percent cap on bonus points for reporting
high priority measures. APM Entities reporting through the CMS Web
Interface will only receive bonus points if they submit a high priority
measure with a performance rate that is greater than zero, provided
that the measure meets the case minimum requirements.
(D) Scoring Quality Improvement
Beginning in the CY 2018 performance year, section
1848(q)(5)(D)(i)(I) of the Act requires us to score improvement for the
MIPS quality performance category for MIPS eligible clinicians,
including those participating in MIPS APMs, if data sufficient to
measure quality improvement are available. We propose to calculate the
quality improvement score using the methodology described in section
II.C.7.a.(1)(i) for scoring quality improvement for eligible clinicians
submitting quality measures via the CMS Web Interface. We believe
aligning the scoring methodology used for all CMS Web Interface
submissions will minimize confusion among MIPS eligible clinicians
receiving a MIPS score, including those participating in MIPS APMs.
(E) Total Quality Performance Category Score for CMS Web Interface
Reporters
We propose to calculate the total quality percent score for MIPS
eligible clinicians using the CMS Web Interface according to the
methodology described
[[Page 30084]]
in section II.C.7.a.(1)(h)(2) of this proposed rule.
We seek comment on our proposed quality performance category
scoring methodology for CMS Web Interface reporters.
(ii) Other MIPS APMs
We propose to define the term Other MIPS APM at Sec. 414.1305 as a
MIPS APM that does not require reporting through the CMS Web Interface.
We propose to add this definition as we believe it will be useful in
discussing our policies for the APM scoring standard. In the 2018 MIPS
performance period, Other MIPS APMs will include the Comprehensive ESRD
Care Model, the Comprehensive Primary Care Plus Model (CPC+), and the
Oncology Care Model.
(A) Quality Measures
In the CY 2017 Quality Payment Program final rule, we explained
that current MIPS APMs have requirements regarding the number of
quality measures, measure specifications, as well as the measure
reporting method(s) and frequency of reporting, and have an established
mechanism for submission of these measures to us within the structure
of the specific MIPS APM. We explained that operational considerations
and constraints interfered with our ability to use the quality measure
data from some MIPS APMs for the purpose of satisfying MIPS data
submission requirements for the quality performance category for the
first performance year. We concluded that there was insufficient time
to adequately implement changes to the current MIPS APM quality measure
data collection timelines and infrastructure in the first performance
year to conduct a smooth hand-off to the MIPS system that would enable
use of APM quality measure data to satisfy the MIPS quality performance
category requirements in the first MIPS performance year (81 FR 77264).
Out of concern that subjecting MIPS eligible clinicians who participate
in MIPS APMs to multiple, potentially duplicative or inconsistent
performance assessments could undermine the validity of testing or
performance evaluation under the MIPS APMs; and that there was
insufficient time to make adjustments in operationally complex systems
and processes related to the alignment, submission and collection of
APM quality measures for purposes of MIPS, we used our authority under
section 1115A(d)(1) to waive certain requirements of section 1848(q).
We finalized that for the first MIPS performance year only, for
MIPS eligible clinicians participating in APM Entities in Other MIPS
APMs, the weight for the quality performance category is zero (81 FR
77268). To avoid risking adverse operational or program evaluation
consequences for MIPS APMs while we worked toward incorporating MIPS
APM quality measures into scoring for future performance years, we used
the authority provided by section 1115A(d)(1) of the Act to waive the
quality performance category weight required under section
1848(q)(5)(E)(i)(I) of the Act, and we indicated that with the
reduction of the quality performance category weight to zero, it was
unnecessary to establish for MIPS APMs a final list of quality measures
as required under section 1848(q)(2)(D) of the Act or to specify and
use quality measures in determining the MIPS final score for these MIPS
eligible clinicians. As such, we further waived the requirements under
sections 1848(q)(2)(D), 1848(q)(2)(B)(i) and 1848(q)(2)(A)(i) of the
Act to establish a final list of quality measures (using certain
criteria and processes); and to specify and use, respectively, quality
measures in calculating the MIPS final score for the first MIPS
performance year.
In the CY 2017 Quality Payment Program final rule, we anticipated
that beginning with the second MIPS performance year, the APM quality
measure data submitted to us during the MIPS performance year would be
used to derive a MIPS quality performance score for APM Entities in all
MIPS APMs.
We also anticipated that it may be necessary to propose policies
and waivers of requirements of the statute, such as section
1848(q)(2)(D) of the Act, to enable the use of non-MIPS quality
measures in the quality performance category score. We anticipated that
by the second performance year we would have had sufficient time to
resolve operational constraints related to use of separate quality
measure systems and to adjust quality measure data submission
timelines. Accordingly, we stated our intention to, in future
rulemaking, use our section 1115A(d)(1) waiver authority to establish
that the quality measures and data that are used to evaluate
performance for APM Entities in MIPS APMs would be used to calculate a
MIPS quality performance score under the APM scoring standard.
We have since designed the means to overcome the operational
constraints that prevented us from scoring quality under the APM
scoring standard in the first performance year, and we propose to adopt
quality measures for use under the APM scoring standard, and begin
collecting MIPS APM quality measure performance data in order to
generate a MIPS quality performance category score for APM Entities
participating in MIPS APMs beginning with the 2018 performance year.
(aa) APM Measures for MIPS
In the CY 2017 Quality Payment Program final rule, we explained the
concerns that led us to express our intent to use the quality measures
and data that apply in the MIPS APM for purposes of the APM scoring
standard, including concerns about the application of multiple,
potentially duplicative or inconsistent performance assessments that
could negatively impact our ability to evaluate MIPS APMs (81 FR
77246). Additionally, the quality and cost/utilization measures that
are used to calculate performance-based payments in MIPS APMs may vary
from one MIPS APM to another. Factors such as the type and quantity of
measures required, the MIPS APM's particular measure specifications,
how frequently the measures must be reported, and the mechanisms used
to collect or submit the measures all add to the diversity in the
quality and cost/utilization measures used to evaluate performance
among MIPS APMs. Given these concerns and the differences between and
among the quality measures used to evaluate performance within MIPS
APMs as opposed to those used more generally under MIPS, we propose to
use our authority under section 1115A(d)(1) of the Act to waive
requirements under section 1848(q)(2)(D) of the Act, which requires the
Secretary to use certain criteria and processes to establish an annual
MIPS final list of quality measures from which all MIPS eligible
clinicians may choose measures for purposes of assessment, and instead
to establish a MIPS APM quality measure list for purposes of the APM
scoring standard. The MIPS APM quality measure list would be adopted as
the final list of MIPS quality measures under the APM scoring standard,
and would reflect the quality measures that are used to evaluate
performance on quality within each MIPS APM.
The MIPS APM quality measure list we propose in Table 13, would
define distinct measure sets for participants in each MIPS APM for
purposes of the APM scoring standard, based on the measures that are
used by the APM, and for which data will be collected by the close of
the MIPS submission period. The measure sets on the MIPS APM measure
list would represent all possible measures which may contribute to an
APM Entity's MIPS score for the MIPS quality performance
[[Page 30085]]
category, and may include measures that are the same as or similar to
those used by MIPS. However, measures may ultimately not be used for
scoring if a measure's data becomes inappropriate or unavailable for
scoring; for example, if a measure's clinical guidelines are changed or
the measure is otherwise modified by the APM during the performance
year, the data collected during that performance year would not be
uniform, and as such may be rendered unusable for purposes of the APM
scoring standard (See Tables 14, 15, and 16).
(B) Measure Requirements for Other MIPS APMs
Because the quality measure sets for each Other MIPS APM are
unique, we propose to calculate the MIPS quality performance category
score using APM-specific quality measures. For purposes of the APM
scoring standard, we will score only measures that: (1) Are tied to
payment as described under the terms of the APM, (2) are available for
scoring near the close of the MIPS submission period, (3) have a
minimum of 20 cases available for reporting, and (4) have an available
benchmark. We discuss each of these requirements for Other MIPS APM
quality measures below.
(aa) Tied to Payment
For purposes of the APM scoring standard, we will consider a
measure to be tied to payment if an APM Entity group will receive a
payment adjustment or other incentive payment under the terms of the
APM, based on the APM Entity's performance on the measure.
(bb) Available for Scoring
Some MIPS APM quality measure results are not available until late
in the calendar year subsequent to the MIPS performance year, which
would prevent us from including them in the MIPS APM quality
performance category score due to the larger programmatic timelines for
providing MIPS eligible clinician performance feedback by July and
issuing budget-neutral MIPS payment adjustments. Consequently, we
propose to only use the MIPS APM quality measure data that are
submitted by the close of the MIPS submission period and are available
for scoring in time for inclusion to calculate a MIPS quality
performance category score. Measures are to be submitted according to
requirements under the terms of the APM; the measure data will then be
aggregated and prepared for submission to MIPS for the purpose of
creating a MIPS quality performance category score.
We believe using the Other MIPS APMs' quality measure data that
have been submitted no later than the close of the MIPS submission
period and have been processed and made available to MIPS for scoring
in time to calculate a MIPS quality performance category score is
consistent with our intent to decrease duplicative reporting for MIPS
eligible clinicians who would otherwise need to report quality measures
to both MIPS and their APM. Going forward, these are the measures to
which we are referring when we limit scoring to measures that are
available near the close of the MIPS submission period.
(cc) 20 Case Minimum
We also believe that a 20 case minimum, in alignment with the one
finalized generally under MIPS in the CY 2017 Quality Payment Program
final rule (81 FR 77288), is necessary to ensure the reliability of the
measure data submitted, as explained the CY 2017 Quality Payment
Program final rule.
As under the general policy for MIPS, when an APM Entity reports a
quality measure that includes less than 20 cases, that measure would
receive a null score for that measure's achievement points, and the
measure would be removed from both the numerator and the denominator of
the MIPS quality performance category percentage. We propose to apply
this policy under the APM scoring standard.
(dd) Available Benchmark
An APM Entity's score on each quality measure would be calculated
in part by comparing the APM Entity's performance on the measure with a
benchmark performance score. Therefore, we would need all scored
measures to have a benchmark available by the time that the MIPS
quality performance category score is calculated, in order to make that
comparison.
We propose that, for the APM scoring standard, the benchmark score
used for a quality measure would be the benchmark used in the MIPS APM
for calculation of the performance based payments, where such a
benchmark is available. If the APM does not produce a benchmark score
for a reportable measure that is included on the APM measures list, we
would use the benchmark score for the measure that is used for the MIPS
quality performance category generally (outside of the APM scoring
standard) for that performance year, provided the measure
specifications for the measure are the same under both the MIPS final
list and the APM measures list. If neither the APM nor MIPS has a
benchmark available for a reported measure, the APM Entity that
reported that measure would receive a null score for that measure's
achievement points, and the measure would be removed from both the
numerator and the denominator of the quality performance category
percentage.
(C) Calculating the Quality Performance Category Percent Score
Eligible clinicians who participate in Other MIPS APMs are subject
to specific quality measure reporting requirements within these APMs.
To best align with APM design and objectives, we propose that the
minimum number of required measures to be reported for the APM scoring
standard would be the minimum number of quality measures that are
required by the MIPS APM and are collected and available in time to be
included in the calculation for the APM Entity score under the APM
scoring standard. For example, if an Other MIPS APM requires
participating APM Entities to report nine of 14 quality measures by a
specific date and the APM Entity misses the MIPS submission deadline,
then for the purposes of calculating an APM Entity quality performance
category score, the APM Entity would receive a zero for those measures.
An APM Entity that does not submit any APM quality measures by the MIPS
submission deadline would receive a zero for its MIPS APM quality
performance category percent score for the performance year.
We propose that if an APM Entity submits some, but not all of the
measures required by the MIPS APM by the close of the MIPS submission
period, the APM Entity would receive points for the measures that were
submitted, but would receive a score of zero for each remaining measure
between the number of measures reported and the number of measures
required by the APM that were available for scoring.
For example, if an APM Entity in the above hypothetical MIPS APM
submits quality performance data on three of the APM's measures,
instead of the required nine, the APM Entity would receive quality
points in the APM scoring standard quality performance category percent
score for the three measures it submitted, but would receive zero
points for each of the six remaining measures that were required under
the terms of the MIPS APM. On the other hand, if an APM Entity reports
on more than the minimum number of measures required to be reported
under the MIPS APM and the measures meet the other
[[Page 30086]]
criteria for scoring, only the measures with the highest scores, up to
the number of measures required to be reported under the MIPS APM,
would be counted; however, any bonus points earned by reporting on
measures beyond the minimum number of required measures would be
awarded.
If a measure is reported but fails to meet the 20 case minimum or
does not have a benchmark available, there would be a null score for
that measure, and it would be removed from both the numerator and the
denominator, so as not to negatively affect the APM Entity's quality
performance category score.
We propose to assign bonus points for reporting high priority
measures or measures with end-to-end CEHRT reporting as described for
general MIPS scoring in the CY 2017 Quality Payment Program final rule
(81 FR 77297 through 77299).
(aa) Quality Measure Benchmarks
An APM Entity's MIPS quality measure score will be calculated by
comparing the APM Entity's performance on a given measure with a
benchmark performance score. We propose that the benchmark score used
for a quality measure would be the benchmark used by the MIPS APM for
calculation of the performance based payments within the APM, if
possible, in order to best align the measure performance outcomes
between the APM and MIPS programs. If the MIPS APM does not produce a
benchmark score for a reportable measure that will be available at the
close of the MIPS submission period, the benchmark score for the
measure that is used for the MIPS quality performance category
generally for that performance year would be used, provided the measure
specifications are the same for both. If neither the APM nor MIPS has a
benchmark available for a reported measure, the APM Entity that
reported that measure will receive a null score for that measure's
achievement points, and the measure will be removed from both the
numerator and the denominator of the quality performance category
percentage.
We are proposing that for measures that are pay for reporting or
which do not measure performance on a continuum of performance, we will
consider these measures to be lacking a benchmark and they will be
treated as such. For example, if a model only requires that an APM
Entity must surpass a threshold and does not measure APM Entities on
performance beyond surpassing a threshold, we would not consider such a
measure to measure performance on a continuum.
We propose to score quality measure performance under the APM
scoring standard using a percentile distribution, separated by decile
categories, as described in the finalized MIPS quality scoring
methodology (81 FR 77282 through 77284). For each benchmark, we will
calculate the decile breaks for measure performance and assign points
based on the benchmark decile range into which the APM Entity's measure
performance falls.
We propose to use a graduated points-assignment approach, where a
measure is assigned a continuum of points out to one decimal place,
based on its place in the decile. For example, a raw score of 55
percent would fall within the sixth decile of 41.0 percent to 61.9
percent and would receive between 6.0 and 6.9 points.
We seek comment on this proposed method.
Table 11--Benchmark Decile Distribution
------------------------------------------------------------------------
Graduated
Sample benchmark decile Sample quality points (with
measure (%) no floor)
------------------------------------------------------------------------
Example Benchmark Decile 1.............. 0-9.9 1.0-1.9
Example Benchmark Decile 2.............. 10.0-17.9 2.0-2.9
Example Benchmark Decile 3.............. 18.0-22.9 3.0-3.9
Example Benchmark Decile 4.............. 23.0-35.9 4.0-4.9
Example Benchmark Decile 5.............. 36.0-40.9 5.0-5.9
Example Benchmark Decile 6.............. 41.0-61.9 6.0-6.9
Example Benchmark Decile 7.............. 62.0-68.9 7.0-7.9
Example Benchmark Decile 8.............. 69.0-78.9 8.0-8.9
Example Benchmark Decile 9.............. 79.0-84.9 9.0-9.9
Example Benchmark Decile 10............. 85.0-100 10.0
------------------------------------------------------------------------
(bb) Assigning Quality Measure Points Based on Achievement
For the APM scoring standard quality performance category, we
propose that each APM Entity that reports on quality measures would
receive between 1 and 10 achievement points for each measure reported
that can be reliably scored against a benchmark, up to the number of
measures that are required to be reported by the APM. Because measures
that lack benchmarks or 20 reported cases are removed from the
numerator and denominator of the quality performance category
percentage, it is unnecessary to include a point-floor for scoring of
Other MIPS APMs. Similarly, because the quality measures reported by
the MIPS APM for MIPS eligible clinicians under the APM scoring
standard are required to be submitted to the APM under the terms of
participation in the APM, and the MIPS eligible clinicians do not
select their APM measures, there will be no cap on topped out measures
for MIPS APM participants being scored under the APM scoring standard,
which differs from the policy for other MIPS eligible clinicians
proposed at section II.C.7.a.(2)(c) of this proposed rule.
Beginning in the 2018 MIPS performance year, we propose that APM
Entities in MIPS APMs, like other MIPS eligible clinicians, would be
eligible to receive bonus points for the MIPS quality performance
category for reporting on high priority measures or measures submitted
via CEHRT (for example, end-to-end submission) according to the
criteria described in section II.C.7.a.(1) of this proposed rule. For
each Other MIPS APM, we propose to identify whether any of their
available measures meets the criteria to receive a bonus, and add the
bonus points to the quality achievement points. Further, we propose
that the total number of awarded bonus points may not exceed 10 percent
of the APM Entity's total available achievement points for the MIPS
quality performance category score.
To generate the APM Entity's quality performance category
percentage, achievement points would be added to any applicable bonus
points, and then divided by the total number of available achievement
points, with a cap of 100
[[Page 30087]]
percent. For more detail on the MIPS quality performance category
percentage score calculation, we refer readers to section II.C.7.a.(1)
of this proposed rule.
Under the APM scoring standard for Other MIPS APMs, the number of
available achievement points would be the number of measures required
under the terms of the APM and available for scoring multiplied by ten.
If, however, an APM Entity reports on a required measure that fails the
20 case minimum requirement, or which has no available benchmark for
that performance year, the measure would receive a null score and all
points from that measure would be removed from both the numerator and
the denominator.
For example, if an APM Entity reports on four out of four measures
required to be reported by the MIPS APM, and receives an achievement
score of five on each and no bonus points, the APM Entity's quality
performance category percentage would be [(5 points x 4 measures) + 0
bonus points]/(4 measures x 10 max available points), or 50 percent.
If, however, one of those measures failed the 20 case minimum
requirement or had no benchmark available, that measure would have a
null value and would be removed from both the numerator and denominator
to create a quality performance category percentage of [(5 points x 3
measures) + 0 bonus points]/(3measures x 10 max available points), or
50 percent.
If an APM Entity fails to meet the 20 case minimum on all available
APM measures, that APM Entity would have its quality performance
category score reweighted to zero, as described below.
We request comment on the above proposals for calculating the
quality category percent score.
(D) Quality Improvement Scoring
Beginning in the 2018 performance year, we propose to score
improvement as well as achievement in the quality performance category.
For the APM scoring standard, we propose that the quality
improvement percentage points would be awarded based on the following
formula:
Quality Improvement Score = (Absolute Improvement/Previous Year Quality
Performance Category Percent Score Prior to Bonus Points)/10
For a more detailed discussion of improvement scoring for the
quality performance category under the APM scoring standard, we refer
readers to the discussion on calculating improvement at the quality
performance category level for MIPS at section II.C.7.a.(1)(i) of this
proposed rule.
(E) Calculating Total Quality Performance Category Score
We propose that the APM Entity's total quality performance category
score would be equal to [(achievement points + bonus points)/total
available achievement points] + quality improvement score. The APM
Entity's total quality performance category score may not exceed 100
percent. We request comment on the above proposed quality scoring
methodology.
We seek comment on the proposed quality performance category
scoring methodology for APM Entities participating in Other MIPS APMs.
(c) Improvement Activities Performance Category
As finalized in the CY 2017 Quality Payment Program final rule, for
all MIPS APMs we will assign the same improvement activities score to
each APM Entity based on the activities involved in participation in a
MIPS APM. APM Entities will receive a minimum of one half of the total
possible points. This policy is in accordance with section
1848(q)(5)(C)(ii) of the Act. In the event that the assigned score does
not represent the maximum improvement activities score, the APM Entity
group will have the opportunity to report additional improvement
activities to add points to the APM Entity level score.
(d) Advancing Care Information Performance Category
In the CY 2017 Quality Payment Program final rule, we finalized our
policy to attribute one score to each MIPS eligible clinician in an APM
Entity group by looking for both individual and group TIN level data
submitted for a MIPS eligible clinician, and using the highest
available score (81 FR 77268). We will then use these scores to create
an APM Entity's score based on the average of the highest scores
available for all MIPS eligible clinicians in the APM Entity group. If
an individual or TIN did not report on the advancing care information
performance category, they will contribute a zero to the APM Entity's
aggregate score. Each MIPS eligible clinician in an APM Entity group
will receive one score, weighted equally with the scores of every other
MIPS eligible clinician in the APM Entity group, and we will use these
to calculate a single APM Entity-level advancing care information
performance category score.
We refer readers to section II.C.6.f.(6) of this proposed rule for
our summary of proposed changes related to scoring the advancing care
information performance category.
(i) Special Circumstances
As described in the CY 2017 Quality Payment Program final rule (81
FR 77238-77245), under the generally applicable MIPS scoring standard,
we will assign a weight of zero percent to the advancing care
information performance category in the final score for MIPS eligible
clinicians who meet specific criteria: hospital-based MIPS eligible
clinicians, MIPS eligible clinicians who are facing a significant
hardship, and certain types of non-physician practitioners (NPs, PAs,
CRNAs, CNSs) who are MIPS eligible clinicians. In section II.C.7.a.(6)
of this proposed rule, we are also proposing to include in this
weighting policy ASC-based MIPS eligible clinicians and MIPS eligible
clinicians who are using decertified EHR technology.
Under the APM scoring standard, we propose that if a MIPS eligible
clinician who qualifies for a zero percent weighting of the advancing
care information performance category in the final score is part of a
TIN that includes one or more MIPS eligible clinicians who do not
qualify for a zero percent weighting, we would not apply the zero
percent weighting to the qualifying MIPS eligible clinician, and the
TIN would still be required to report on behalf of the group, although
the TIN would not need to report data for the qualifying MIPS eligible
clinician. All MIPS eligible clinicians in the TIN would count towards
the TIN's weight when calculating an aggregated APM Entity score for
the advancing care information performance category.
If, however, the MIPS eligible clinician is a solo practitioner and
qualifies for a zero percent weighting, or if all MIPS eligible
clinicians in a TIN qualify for the zero percent weighting, the TIN
would not be required to report on the advancing care information
performance category, and if the TIN chooses not to report that TIN
would be assigned a weight of 0 when calculating the APM Entity's
advancing care information performance category score.
If advancing care information data are reported by one or more TINs
in an APM Entity, an advancing care information performance category
score will be calculated for, and will be applicable to, all MIPS
eligible clinicians in the APM Entity group. If all MIPS eligible
clinicians in all TINs in an APM Entity group qualify for a zero
percent weighting of have the advancing care information performance
category, or in the case of a solo practitioner who comprises an entire
[[Page 30088]]
APM Entity and qualifies for zero percent weighting, the advancing care
information performance category would be weighted at zero percent of
the final score, and the advancing care information performance
category's weight would be redistributed to the quality performance
category.
(4) Calculating Total APM Entity Score
(a) Performance Category Weighting
As discussed in section II.C.6.g.(3)(a) of this proposed rule, we
propose to continue to use our authority to waive sections
1848(q)(2)(B)(ii) and 1848(q)(2)(A)(ii) of the Act to specify and use,
respectively, cost measures; and to maintain the cost performance
category weight of zero under the APM scoring standard for the 2018
performance period and subsequent MIPS performance periods. Because the
cost performance category would be reweighted to zero that weight would
need to be redistributed to other performance categories. We propose to
use our authority under section 1115A(d)(1) to waive requirements under
sections 1848(q)(5)(E)(i)(I)(bb), 1848(q)(5)(E)(i)(III) and
1848(q)(5)(E)(i)(IV) of the Act that prescribe the weights,
respectively, for the quality, improvement activities, and ACI
performance categories. We propose to weight the quality performance
category score to 50 percent, the improvement activities performance
category to 20 percent, and the advancing care information performance
category to 30 percent of the final score for all APM Entities in Other
MIPS APMs. We propose these weights to align the Other MIPS APM
performance category weights with those assigned to the Web Interface
reporters, which we adopted as explained in the CY 2017 Quality Payment
Program final rule at 81 FR 77262 through 77263. We believe it is
appropriate to align the performance category weights for APM Entities
in MIPS APMs that require reporting through the Web Interface with
those in Other MIPS APMs. By aligning the performance category weights
among all MIPS APMs, we would create greater scoring parity among the
MIPS eligible clinicians in MIPS APMs who are being scored under the
APM scoring standard. These proposals are summarized in Table 12.
Table 12--APM Scoring Standard Performance Category Weights--Beginning for the 2018 Performance Period
----------------------------------------------------------------------------------------------------------------
Performance
MIPS performance category APM entity submission Performance category score category
requirement weight (%)
----------------------------------------------------------------------------------------------------------------
Quality............................. The APM Entity will be CMS will assign the same 50
required to submit quality quality category
measures to CMS as required performance score to each
by the MIPS APM. Measures TIN/NPI in an APM Entity
available at the close of group based on the APM
the MIPS submission period Entity's total quality
will be used to calculate score, derived from
the MIPS quality available APM quality
performance category score. measures.
If the APM Entity does not
submit any APM required
measures by the MIPS
submission deadline, the
APM Entity will be assigned
a zero.
Cost................................ The APM Entity group will N/A......................... 0
not be assessed on cost
under MIPS.
Improvement Activities.............. MIPS eligible clinicians do CMS will assign the same 20
not need to report improvement activities
improvement activities score to each APM Entity
data; if the CMS-assigned based on the activities
improvement activities involved in participation
score is below the maximum in the MIPS APM. APM
improvement activities Entities will receive a
score APM Entities will minimum of one half of the
have the opportunity to total possible points. In
submit additional the event that the assigned
improvement activities to score does not represent
raise the APM Entity the maximum improvement
improvement activity score. activities score, the APM
Entity will have the
opportunity to report
additional improvement
activities to add points to
the APM Entity level score.
Advancing Care Information.......... Each MIPS eligible clinician We will attribute the same 30
in the APM Entity group is score to each MIPS eligible
required to report clinician in the APM Entity
advancing care information group. This score will be
to MIPS through either the highest score
group TIN or individual attributable to the TIN/NPI
reporting. combination of each MIPS
eligible clinician, which
may be derived from either
group or individual
reporting. The scores
attributed to each MIPS
eligible clinicians will be
averaged for a single APM
Entity score.
----------------------------------------------------------------------------------------------------------------
It is possible that there could be instances where an Other MIPS
APM has no measures available to score for the quality performance
category for a MIPS performance period; for example, it is possible
that none of the Other MIPS APM's measures would be available for
calculating a quality performance category score by or shortly after
the close of the MIPS submission period because the measures were
removed due to changes in clinical practice guidelines. In addition, as
explained in section II.C.6.g.(3)(d)(i) of this proposed rule, the MIPS
eligible clinicians in an APM Entity may qualify for a zero percent
weighting for the advancing care information performance category. In
such instances, under the APM scoring standard, we propose to reweight
the affected performance category to zero, in accordance with section
1848(q)(5)(F) of the Act.
If the quality performance category is reweighted to zero, we
propose to reweight the improvement activities and advancing care
information performance categories to 25 and 75 percent, respectively.
If the advancing care information performance category is reweighted to
zero, the quality performance category weight would be
[[Page 30089]]
increased to 80 percent. These proposals are summarized in Table 13.
Table 13--APM Scoring Standard Performance Category Weights for Other MIPS APMs With Performance Categories
Weighted to 0--Beginning for the 2018 Performance Period
----------------------------------------------------------------------------------------------------------------
Performance
Performance category
APM entity submission Performance category category weight (no
MIPS performance category requirement score weight (no advancing care
quality) (%) information)
(%)
----------------------------------------------------------------------------------------------------------------
Quality........................ The APM Entity would CMS will assign the 0 80
not be assessed on same quality category
quality under MIPS if performance score to
no quality data are each TIN/NPI in an
available at the close APM Entity group
of the MIPS submission based on the APM
period. The APM Entity Entity's total
will submit quality quality score,
measures to CMS as derived from
required by the MIPS available APM quality
APM. measures.
Cost........................... The APM Entity group N/A................... 0 0
will not be assessed
on cost under MIPS.
Improvement Activities......... MIPS eligible CMS will assign the 25 20
clinicians do not need same improvement
to report improvement activities score to
activities data unless each APM Entity group
the CMS-assigned based on the
improvement activities activities involved
scores is below the in participation in
maximum improvement the MIPS APM.
activities score. APM Entities will
receive a minimum of
one half of the total
possible points. In
the event that the
assigned score does
not represent the
maximum improvement
activities score, the
APM Entity will have
the opportunity to
report additional
improvement
activities to add
points to the APM
Entity level score.
Advancing Care Information..... Each MIPS eligible We will attribute the 75 0
clinician in the APM same score to each
Entity group reports MIPS eligible
advancing care clinician in the APM
information to MIPS Entity group. This
through either group score will be the
TIN or individual highest score
reporting. attributable to the
TIN/NPI combination
of each MIPS eligible
clinician, which may
be derived from
either group or
individual reporting.
The scores attributed
to each MIPS eligible
clinicians will be
averaged for a single
APM Entity score.
----------------------------------------------------------------------------------------------------------------
We seek comment on the proposed reweighting for APM Entities
participating in MIPS APMs.
(b) Risk Factor Score
Section 1848(q)(1)(G) of the Act requires us to consider risk
factors in our scoring methodology. Specifically, that section provides
that the Secretary, on an ongoing basis, shall, as the Secretary
determines appropriate and based on individuals' health status and
other risk factors, assess appropriate adjustments to quality measures,
cost measures, and other measures used under MIPS and assess and
implement appropriate adjustments to payment adjustments, final scores,
scores for performance categories, or scores for measures or activities
under the MIPS.
We refer readers to II.C.7.b.(1) of this proposed rule for a
description of the risk factor adjustment and its application to APM
Entities.
(c) Small Practice Bonus
We believe an adjustment for eligible clinicians in small practices
(referred to herein as the small practice bonus) is appropriate to
recognize barriers faced by small practices, such as unique challenges
related to financial and other resources, environmental factors, and
access to health information technology, and to incentivize eligible
clinicians in small practices to participate in the Quality Payment
Program and to overcome any performance discrepancy due to practice
size.
We refer readers to section II.C.7.b.(2) of this proposed rule for
a discussion of the small practice adjustment and its application to
APM Entities.
(d) Final Score Methodology
In the CY 2017 Quality Payment Program final rule, we finalized the
methodology for calculating a final score of 0-100 based on the four
performance categories (81 FR 77320). We refer readers to section
II.C.7.c. of this proposed rule for a discussion of the changes we are
proposing for the final score methodology.
(5) MIPS APM Performance Feedback
In the CY 2017 Quality Payment Program final rule (81 FR 77270), we
finalized that all MIPS eligible clinicians scored under the APM
scoring standard will receive performance feedback as specified under
section 1848(q)(12) of the Act on the quality and cost performance
categories to the extent applicable, based on data collected in the
September 2016 QRUR, unless they did not have data included in the
September 2016 QRUR. Those eligible clinicians without data included in
the September 2016 QRUR will not receive any performance feedback until
performance data is available for feedback.
Beginning with the 2018 performance year, we propose that MIPS
eligible clinicians whose MIPS payment adjustment is based on their
score under the APM scoring standard will receive performance feedback
as specified
[[Page 30090]]
under section 1848(q)(12) of the Act for the quality, advancing care
information, and improvement activities performance categories to the
extent data are available for the MIPS performance year. Further, we
propose that in cases where performance data are not available for a
MIPS APM performance category because the MIPS APM performance category
has been weighted to zero for that performance year, we would not
provide performance feedback on that MIPS performance category.
We believe that with an APM Entity's finite resources for engaging
in efforts to improve quality and lower costs for a specified
beneficiary population, the incentives of the APM must take priority
over those offered by MIPS in order to ensure that the goals and
evaluation associated with the APM are as clear and free of confounding
factors as possible. The potential for different, conflicting messages
in performance feedback provided by the APMs and that provided by MIPS
may create uncertainty for MIPS eligible clinicians who are attempting
to strategically transform their respective practices and succeed under
the terms of the APM. Accordingly, under section 1115A(d)(1) and
section 1899(f), for all performance years we propose to waive--for
MIPS eligible clinicians participating in MIPS APMs--the requirement
under section 1848(q)(12)(A)(i)(I) of the Act to provide performance
feedback for the cost performance category.
We request comment on these proposals to waive requirements for
performance feedback on the cost performance category indefinitely, and
for the other performance categories in years for which the weight for
those categories has been reweighted to zero.
(6) Summary of Proposals
In summary, we have proposed the following in this section:
We propose to amend the regulation at Sec. 414.1370(e) to
identify the four assessment dates that would be used to identify the
APM Entity group for purposes of the APM scoring standard, and to
specify that the December 31 date will be used only to identify
eligible clinicians on the APM Entity's Participation List for a MIPS
APM that is a full TIN APM in order to add them to the APM Entity group
that is scored under the APM scoring standard. We propose to use this
fourth assessment date of December 31 to extend the APM scoring
standard to only those MIPS eligible clinicians participating in MIPS
APMs that are full TIN APMs, ensuring that an eligible clinician who
joins the full TIN APM late in the performance year would be scored
under the APM scoring standard.
We propose to continue to weight the cost performance
category under the APM scoring standard for Web Interface reporters at
zero percent for the 2020 payment year forward.
Aligned with our proposal to weight the cost performance
category at zero percent, we propose not to take improvement into
account for performance scores in the cost performance category for Web
Interface reporters beginning with the 2020 MIPS Payment Year.
We propose to score the CAHPS for ACOs survey, in addition
to the CMS Web Interface measures that are used to calculate the MIPS
APM quality performance category score for Web Interface reporters
including the Shared Savings Program and Next Generation ACO Model),
beginning in the 2018 performance year.
We propose that, beginning for the 2018 performance year,
eligible clinicians in MIPS APMs that are Web Interface reporters may
receive bonus points under the APM scoring standard for submitting the
CAHPS for ACOs survey.
We propose to calculate the quality improvement score for
MIPS eligible clinicians submitting quality measures via the CMS Web
Interface using the methodology described in section II.C.7.a.(1)(i).
We propose to calculate the total quality percent score
for MIPS eligible clinicians using the CMS Web Interface according to
the methodology described in section II.C.7.a.(1)(h)(2) of this
proposed rule.
We propose to establish a separate MIPS final list of
quality measures for each Other MIPS APM that would be the quality
measure list used for purposes of the APM scoring standard.
We propose to calculate the MIPS quality performance
category score for Other MIPS APMs using MIPS APM-specific quality
measures. For purposes of the APM scoring standard, we would score only
measures that: (1) Are tied to payment as described under the terms of
the APM, (2) are available for scoring near the close of the MIPS
submission period, (3) have a minimum of 20 cases available for
reporting, and (4) have an available benchmark.
We propose to only use the MIPS APM quality measure data
that are submitted by the close of the MIPS submission period and are
available for scoring in time for inclusion to calculate a MIPS quality
performance category score.
We propose that, for the APM scoring standard, the
benchmark score used for a quality measure would be the benchmark used
in the MIPS APM for calculation of the performance based payments,
where such a benchmark is available. If the APM does not produce a
benchmark score for a reportable measure that is included on the APM
measures list, we would use the benchmark score for the measure that is
used for the MIPS quality performance category generally (outside of
the APM scoring standard) for that performance year, provided the
measure specifications for the measure are the same under both the MIPS
final list and the APM measures list.
We propose that the minimum number of quality measures
required to be reported for the APM scoring standard would be the
minimum number of quality measures that are required within the MIPS
APM and are collected and available in time to be included in the
calculation for the APM Entity score under the APM scoring standard. We
propose that if an APM Entity submits some, but not all of the measures
required by the MIPS APM by the close of the MIPS submission period,
the APM Entity would receive points for the measures that were
submitted, but would receive a score of zero for each remaining measure
between the number of measures reported and the number of measures
required by the APM that were available for scoring.
We propose that the benchmark score used for a quality
measure would be the benchmark used by the MIPS APM for calculation of
the performance based payments within the APM, if possible, in order to
best align the measure performance outcomes between the two programs.
We are proposing that for measures that are pay for reporting or which
do not measure performance on a continuum of performance, we will
consider these measures to be lacking a benchmark and they will be
treated as such.
We propose to score quality measure performance under the
APM scoring standard using a percentile distribution, separated by
decile categories, as described in the finalized MIPS quality scoring
methodology. We propose to use a graduated points-assignment approach,
where a measure is assigned a continuum of points out to one decimal
place, based on its place in the decile.
We propose that each APM Entity that reports on quality
measures would receive between 1 and 10 achievement points for each
measure reported that can be reliably scored against a benchmark, up to
the number of
[[Page 30091]]
measures that are required to be reported by the APM.
We propose that APM Entities in MIPS APMs, like other MIPS
eligible clinicians, would be eligible to receive bonus points for the
MIPS quality performance category for reporting on high priority
measures or measures submitted via CEHRT. For each Other MIPS APM, we
propose to identify whether any of their available measures meets the
criteria to receive a bonus, and add the bonus points to the quality
achievement points.
Beginning in the 2018 performance year, we propose to
score improvement as well as achievement in the quality performance
category. For the APM scoring standard, we propose that the improvement
percentage points would be awarded based on the following formula:
Quality Improvement Score = (Absolute Improvement/Previous Year Quality
Performance Category Percent Score Prior to Bonus Points)/10.
We propose that the APM Entity's total quality performance
category score would be equal to [(achievement points + bonus points)/
total available achievement points] + quality improvement score.
Under the APM scoring standard, we propose that if a MIPS
eligible clinician who qualifies for a zero percent weighting of the
advancing care information performance category in the final score is
part of a TIN that includes one or more MIPS eligible clinicians who do
not qualify for a zero percent weighting, we would not apply the zero
percent weighting to the qualifying MIPS eligible clinician, and the
TIN would still be required to report on behalf of the group, although
the TIN would not need to report data for the qualifying MIPS eligible
clinician.
We propose to maintain the cost performance category
weight of zero for Other MIPS APMs under the APM scoring standard for
the 2020 MIPS payment year and subsequent MIPS payment years. Because
the cost performance category would be reweighted to zero that weight
would need to be redistributed to other performance categories. We
propose to align the Other MIPS APM performance category weights with
those proposed for Web Interface reporters and weight the quality
performance category to 50 percent, the improvement activities
performance category to 20 percent, and the advancing care information
performance category to 30 percent of the APM Entity final score.
It is possible that none of the Other MIPS APM's measures
would be available for calculating a quality performance category score
by or shortly after the close of the MIPS submission period, for
example, due to changes in clinical practice guidelines. In addition,
the MIPS eligible clinicians in an APM Entity may qualify for a zero
percent weighting for the advancing care information performance
category. In such instances, under the APM scoring standard, we propose
to reweight the affected performance category to zero.
Beginning with the 2018 performance year, we propose that
MIPS eligible clinicians whose MIPS payment adjustment is based on
their score under the APM scoring standard will receive performance
feedback as specified under section 1848(q)(12) of the Act for the
quality, advancing care information, and improvement activities
performance categories to the extent data are available for the MIPS
performance year. Further, we propose that in cases where the MIPS APM
performance category has been weighted to zero for that performance
year, we would not provide performance feedback on that MIPS
performance category.
The following tables represent the measures being introduced for
notice and comment, and would serve as the measure set used by
participants in the identified MIPS APMs in order to create a MIPS
score under the APM scoring standard, as described in section
II.C.6.g.(3)(b)(ii)(A) of this proposed rule. Once this list is
finalized, no measures may be added to this list.
Table 14--MIPS APM Measures List--Oncology Care Model
----------------------------------------------------------------------------------------------------------------
NQF/Quality
Measure name number (if National quality Measure description Primary measure
applicable) strategy domain steward
----------------------------------------------------------------------------------------------------------------
Risk-adjusted proportion of NA............... Effective Percentage of OCM- NA
patients with all-cause Clinical Care. attributed FFS
hospital admissions within the beneficiaries who
6-month episode. were had an acute-
care hospital stay
during the
measurement period.
Risk-adjusted proportion of NA............... Effective Percentage of OCM- .................
patients with all-cause ED Clinical Care. attributed FFS
visits or observation stays beneficiaries who had
that did not result in a an ER visit that did
hospital admission within the not result in a
6-month episode. hospital stay during
the measurement
period.
Proportion of patients who died NA............... Effective Percentage of OCM- NA
who were admitted to hospice Clinical Care. attributed FFS
for 3 days or more. beneficiaries who
died and spent at
least 3 days in
hospice during the
measurement time
period.
Oncology: Medical and 0384/143......... Person and Percentage of patient Physician
Radiation--Pain Intensity Caregiver visits, regardless of Consortium for
Quantified. Centered patient age, with a Performance
Experience. diagnosis of cancer Improvement
currently receiving Foundations
chemotherapy or (PCPI).
radiation therapy in
which pain intensity
is quantified.
Oncology: Medical and 0383/144......... Person and Percentage of visits American Society
Radiation--Plan of Care for Caregiver for patients, of Clinical
Pain. Centered regardless of age, Oncology.
Experience. with a diagnosis of
cancer currently
receiving
chemotherapy or
radiation therapy who
report having pain
with a documented
plan of care to
address pain.
Preventive Care and Screening: 0418/134......... Community/ Percentage of patients Centers for
Screening for Depression and Population aged 12 and older Medicare &
Follow-Up Plan. Health. screened for Medicaid
depression on the Services.
date of the encounter
using an age
appropriate
standardized
depression screening
tool AND if positive,
a follow-up plan is
documented on the
date of the positive
screen.
[[Page 30092]]
Patient-Reported Experience of NA............... Person and Summary/Survey NA
Care. Caregiver Measures may include:
Centered --Overall measure of
Experience. patient experience.
--Exchanging
Information with
Patients.
--Access..............
--Shared Decision
Making.
--Enabling Self-
Management.
--Affective
Communication.
Prostate Cancer: Adjuvant 0390/104......... Effective Percentage of American
Hormonal Therapy for High or Clinical Care. patients, regardless Urological
Very High Risk Prostate Cancer. of age, with a Association
diagnosis of prostate Education and
cancer at high or Research.
very high risk of
recurrence receiving
external beam and
radiotherapy to the
prostate who were
prescribed adjuvant
hormonal therapy
(GnRH [gonadotropin
releasing hormone]
agonist or
antagonist).
Adjuvant chemotherapy is 0223............. Communication and Percentage of patients Commission on
recommended or administered Care under the age of 80 Cancer, American
within 4 months (120 days) of Coordination. with AJCC III (lymph College of
diagnosis to patients under node positive) colon Surgeons.
the age of 80 with AJCC III cancer for whom
(lymph node positive) colon adjuvant chemotherapy
cancer. is recommended and
not received or
administered within 4
months (120 days) of
diagnosis.
Combination chemotherapy is 0559............. Communication and Percentage of female Commission on
recommended or administered Care patients, age >18 at Cancer, American
within 4 months (120 days) of Coordination. diagnosis, who have College of
diagnosis for women under 70 their first diagnosis Surgeons.
with AJCC T1cN0M0, or Stage of breast cancer
IB--III hormone receptor (epithelial
negative breast cancer. malignancy), at AJCC
stage T1cN0M0 (tumor
greater than 1 cm),
or Stage IB--III,
whose primary tumor
is progesterone and
estrogen receptor
negative recommended
for multiagent
chemotherapy
(recommended or
administered) within
4 months (120 days)
of diagnosis.
Trastuzumab administered to 1858/450......... Efficiency and Proportion of female American Society
patients with AJCC stage I Cost Reduction. patients (aged 18 of Clinical
(T1c)--III and human epidermal years and older) with Oncology.
growth factor receptor 2 AJCC stage I (Tlc)--
(HER2) positive breast cancer Ill, human epidermal
who receive adjuvant growth factor
chemotherapy. receptor 2 (HER2)
positive breast
cancer receiving
adjuvant chemotherapy.
Breast Cancer: Hormonal Therapy 0387............. Communication and Percentage of female AMA-convened
for Stage I (T1b)--IIIC Care patients aged 18 Physician
Estrogen Receptor/Progesterone Coordination. years and older with Consortium for
Receptor (ER/PR) Positive Stage I (T1b) through Performance
Breast Cancer. IIIC, ER or PR Improvement.
positive breast
cancer who were
prescribed tamoxifen
or aromatase
inhibitor (AI) during
the 12-month
reporting period.
Documentation of Current 0419/130......... Patient Safety... Percentage of visits Centers for
Medications in the Medical for patients aged 18 Medicare &
Record. years and older for Medicaid
which the eligible Services.
clinician attests to
documenting a list of
current medications
using all immediate
resources available
on the date of the
encounter. This list
must include ALL
known prescriptions,
over-the counters,
herbals, and vitamin/
mineral/dietary AND
must contain the
medications' name,
dosage, frequency and
route of
administration.
----------------------------------------------------------------------------------------------------------------
Table 15--MIPS APM Measures List--Comprehensive ESRD Care
----------------------------------------------------------------------------------------------------------------
NQF/Quality
Measure name number (if National quality Measure description Primary measure
applicable) strategy domain steward
----------------------------------------------------------------------------------------------------------------
ESCO Standardized Mortality 0101/154......... Patient Safety... Falls: Risk National
Ratio. Assessment: Committee for
Percentage of Quality
patients aged 65 Assurance.
years and older with
a history of falIs
who had a risk
assessment for falls
completed within for
Quality 12 months.
Falls: Screening, Risk 0101/154......... Communication and Falls: Risk National
Assessment and Plan of Care to Coordination. Assessment: Committee for
Prevent Future Falls. Percentage of Quality
patients aged 65 Assurance.
years and older with
a history of falIs
who had a risk
assessment for falls
completed within for
Quality 12 months.
Advance Care Plan.............. 0326/47.......... Patient Safety... Percentage of patients National
aged 65 years and Committee for
older who have an Quality
advance care plan or Assurance.
surrogate decision
maker documented in
the medical record or
documentation in the
medical record that
an advance care plan
was discussed but the
patient did not wish
or was not able to
name a surrogate
decision maker or
provide an advance
care plan.
[[Page 30093]]
ICH-CAHPS: Nephrologists' 0258............. Person and Summary/Survey Agency for
Communication and Caring. Caregiver Measures may include: Healthcare
Centered --Getting timely care, Research and
Experience and appointments, and Quality.
Outcome. information.
--How well providers
communicate.
--Patients' rating of
provider.
--Access to
specialists.
--Health promotion and
education.
--Shared decision-
making.
--Health status and
functional status.
--Courteous and
helpful office staff.
--Care coordination...
--Between visit
communication.
--Helping you to take
medications as
directed, and.
--Stewardship of
patient resources.
ICH-CAHPS: ICH-CAHPS: Rating of 0258............. Person and Comparison of services Agency for
Dialysis Center. Caregiver and quality of care Healthcare
Centered that dialysis Research and
Experience and facilities provide Quality.
Outcome. from the perspective
of ESRD patients
receiving in-center
hemodialysis care.
Patients will assess
their dialysis
providers, including
nephrologists and
medical and non-
medical staff, the
quality of dialysis
care they receive,
and information
sharing about their
disease.
ICH-CAHPS: Quality of Dialysis 0258............. ................. Comparison of services Agency for
Center Care and Operations. and quality of care Healthcare
that dialysis Research and
facilities provide Quality.
from the perspective
of ESRD patients
receiving in-center
hemodialysis care.
Patients will assess
their dialysis
providers, including
nephrologists and
medical and non-
medical staff, the
quality of dialysis
care they receive,
and information
sharing about their
disease.
ICH-CAHPS: Providing 0258............. ................. Comparison of services Agency for
Information to Patients. and quality of care Healthcare
that dialysis Research and
facilities provide Quality.
from the perspective
of ESRD patients
receiving in-center
hemodialysis care.
Patients will assess
their dialysis
providers, including
nephrologists and
medical and non-
medical staff, the
quality of dialysis
care they receive,
and information
sharing about their
disease.
ICH-CAHPS: Rating of Kidney 0258............. ................. Comparison of services Agency for
Doctors. and quality of care Healthcare
that dialysis Research and
facilities provide Quality.
from the perspective
of ESRD patients
receiving in-center
hemodialysis care.
Patients will assess
their dialysis
providers, including
nephrologists and
medical and non-
medical staff, the
quality of dialysis
care they receive,
and information
sharing about their
disease.
ICH-CAHPS: Rating of Dialysis 0258............. ................. Comparison of services Agency for
Center Staff. and quality of care Healthcare
ICH-CAHPS: Rating of Dialysis that dialysis Research and
Center. facilities provide Quality.
from the perspective
of ESRD patients
receiving in-center
hemodialysis care.
Patients will assess
their dialysis
providers, including
nephrologists and
medical and non-
medical staff, the
quality of dialysis
care they receive,
and information
sharing about their
disease.
Medication Reconciliation Post 0554............. Communication and The percentage of National
Discharge. Care discharges from any Committee for
Coordination. inpatient facility Quality
(e.g. hospital, Assurance.
skilled nursing
facility, or
rehabilitation
facility) for
patients 18 years of
age and older seen
within 30 days
following the
discharge in the
office by the
physicians,
prescribing
practitioner,
registered nurse, or
clinical pharmacist
providing on-going
care for whom the
discharge medication
list was reconciled
with the current
medication list in
the outpatient
medical record. This
measure is reported
as three rates
stratified by age
group:
Reporting
Criteria 1: 18-64
years of age.
Reporting
Criteria 2: 65
years and older.
Total
Rate: All patients
18 years of age
and Older.
Diabetes Care: Eye Exam........ 0055/117......... Effective Percentage of patients National
Clinical Care. 18-75 years of age Committee for
with diabetes who had Quality
a retinal or dilated Assurance.
eye exam by an eye
care professional
during the
measurement period or
a negative retinal
exam (no evidence of
retinopathy) in the
12 months prior to
the measurement
period.
Diabetes Care: Foot Exam....... 0056/163......... Effective Percentage of patients National
Clinical Care. 18-75 years of age Committee for
with diabetes (type 1 Quality
and type 2) who Assurance.
received a foot exam
(visual inspection
and sensory exam with
mono filament and a
pulse exam) during
the previous
measurement year.
Influenza Immunization for the 0041/110, 0226... Community/ Percentage of patients Kidney Care
ESRD Population. Population aged 6 months and Quality Alliance
Health. older seen for a (KCQA).
visit between October
1 and March 31 who
received an influenza
immunization OR who
reported previous
receipt of an
influenza
immunization.
Pneumococcal Vaccination Status 0043/111......... Community/ Percentage of patients National
Population 65 years of age and Committee for
Health. older who have ever Quality
received a Assurance.
pneumococcal vaccine.
[[Page 30094]]
Screening for Clinical 0418/134......... Community/ Percentage of patients Centers for
Depression and Follow-Up Plan. Population aged 12 and older Medicare and
Health. screened for Medicaid
depression on the Services.
date of the encounter
and using an age
appropriate
standardized
depression screening
tool AND if positive,
a follow-up plan is
documented on the
date of the positive
screen.
Tobacco Use: Screening and 0028/226......... Community/ Percentage of patients Physician
Cessation Intervention. Population aged 18 years and Consortium for
Health. older who were Performance
screened for tobacco Improvement
use one or more times Foundations
within 24 months AND (PCPI).
who received
cessation counseling
intervention if
identified as a
tobacco user.
----------------------------------------------------------------------------------------------------------------
Table 16--MIPS APM Measures List--Comprehensive Primary Care Plus (CPC+)
----------------------------------------------------------------------------------------------------------------
NQF/Quality
Measure name number (if National quality Measure description Primary measure
applicable) strategy domain steward
----------------------------------------------------------------------------------------------------------------
Depression Remission at Twelve 0710/370......... Effective Patients age 18 and Minnesota
Months. Clinical Care. older with major Community
depression or Measurement
dysthymia and an
initial Patient
Health Questionnaire
(PHQ-9) score greater
than nine who
demonstrate remission
at twelve months (+/-
30 days after an
index visit) defined
as a PHQ-9 score less
than five. This
measure applies to
both patients with
newly diagnosed and
existing depression
whose current PHQ-9
score indicates a
need for treatment.
Controlling High Blood Pressure 0018/236......... Effective Percentage of patients National
Clinical Care. 18-85 years of age Committee for
who had a diagnosis Quality
of hypertension and Assurance
whose blood pressure
was adequately
controlled (<140/90
mmHg) during the
measurement period.
Diabetes: Eye Exam............. 0055/117......... Effective Percentage of patients National
Clinical Care. 18-75 years of age Committee for
with diabetes who had Quality
a retinal or dilated Assurance
eye exam by an eye
care professional
during the
measurement period or
a negative retinal
exam (no evidence of
retinopathy) in the
12 months prior to
the measurement
period.
Diabetes: Hemoglobin A1c 0059/001......... Effective Percentage of patients National
(HbA1c) Poor Control (>9%). Clinical Care. 18-75 years of age Committee for
with diabetes who had Quality
hemoglobin A1c >9.0% Assurance
during the
measurement period.
Use of High-Risk Medications in 0022/238......... Patient Safety... Percentage of patients National
the Elderly. 66 years of age and Committee for
older who were Quality
ordered high-risk Assurance
medications. Two
rates are reported.
a. Percentage of
patients who were
ordered at least
one high-risk
medication.
b. Percentage of
patients who were
ordered at least
two different high-
risk medications.
Dementia: Cognitive Assessment. NA/281........... Effective Percentage of Physician
Clinical Care. patients, regardless Consortium for
of age, with a Performance
diagnosis of dementia Improvement
for whom an Foundation
assessment of (PCPI)
cognition is
performed and the
results reviewed at
least once within a
12-month period.
Falls: Screening for Future 0101/318......... Patient Safety... Percentage of patients National
Fall Risk. 65 years of age and Committee for
older who were Quality
screened for future Assurance
fall risk at least
once during the
measurement period.
Initiation and Engagement of 0004/305......... Effective Percentage of patients National
Alcohol and Other Drug Clinical Care. 13 years of age and Committee for
Dependence Treatment. older with a new Quality
episode of alcohol Assurance
and other drug (AOD)
dependence who
received the
following. Two rates
are reported.
a. Percentage of
patients who
initiated treatment
within 14 days of the
diagnosis.
b. Percentage of
patients who
initiated
treatment and who
had two or more
additional
services with an
AOD diagnosis
within 30 days of
the initiation
visit.
Closing the Referral Loop: NA/374........... Communication and Percentage of Patients Centers for
Receipt of Specialist Report. Care with referrals, Medicare and
Coordination. regardless of age, Medicaid
for which the Services
referring provider
receives a report
from the provider to
whom the patient was
referred.
Cervical Cancer Screening...... 0032/309......... Effective Percentage of women 21- National
Clinical Care. 64 years of age, who Committee for
were screened for Quality
cervical cancer using Assurance
either of the
following criteria.
Women age
21-64 who had
cervical cytology
performed every 3
years.
Women age
30-64 who had
cervical cytology/
human
papillomavirus
(HPV) co-testing
performed every 5
years.
Colorectal Cancer Screening.... 0034/113......... Effective Percentage of National
Clinical Care. patients, 50-75 years Committee for
of age who had Quality
appropriate screening Assurance
for colorectal cancer.
Preventive Care and Screening: 0028/226......... Community/ Percentage of patients Physician
Tobacco Use: Screening and Population aged 18 years and Consortium for
Cessation Intervention. Health. older who were Performance
screened for tobacco Improvement
use one or more times Foundations
within 24 months AND (PCPI)
who received
cessation counseling
intervention if
identified as a
tobacco user.
[[Page 30095]]
Breast Cancer Screening........ 2372/112......... Effective Percentage of women 50- National
Clinical Care. 74 years of age who Committee for
had a mammogram to Quality
screen for breast Assurance
cancer.
Preventive Care and Screening: 0041/110......... Community/ Percentage of patients PCPI(R)
Influenza Immunization. Population aged 6 months and Foundation
Health. older seen for a (PCPI[R])
visit between October
1 and March 31 who
received an influenza
immunization OR who
reported previous
receipt of an
influenza
immunization.
Pneumonia Vaccination Status 0043/111......... Community/ Percentage of patients National
for Older Adults. Population 65 years of age and Committee for
Health. older who have ever Quality
received a Assurance
pneumococcal vaccine.
Diabetes: Medical Attention for 0062/119......... Effective The percentage of National
Nephropathy. Clinical Care. patients 18-75 years Committee for
of age with diabetes Quality
who had a nephropathy Assurance
screening test or
evidence of
nephropathy during
the measurement
period.
Ischemic Vascular Disease 0068/204......... Effective Percentage of patients National
(IVD): Use of Aspirin or Clinical Care. 18 years of age and Committee
Another. older who were Quality
diagnosed with acute Assurance
myocardial infarction
(AMI), coronary
artery bypass graft
(CABG) or
percutaneous coronary
interventions (PCI)
in the 12 months
prior to the
measurement period,
or who had an active
diagnosis of ischemic
vascular disease
(IVD) during the
measurement period,
and who had
documentation of use
of aspirin or another
antiplatelet during
the measurement
period.
Hypertension: Improvement in NA/373........... Effective Percentage of patients Centers for
Blood Pressure. Clinical Care. aged 18-85 years of Medicare &
age with a diagnosis Medicaid
of hypertension whose Services (CMS)
blood pressure
improved during the
measurement period.
Preventive Care and Screening: 0418/134......... Community/ Percentage of patients Centers for
Screening for Depression and Population aged 12 years and Medicare &
Follow-Up Plan. Health. older screened for Medicaid
depression on the Services (CMS)
date of the encounter
using an age
appropriate
standardized
depression screening
tool AND if positive,
a follow-up plan is
documented on the
date of the positive
screen.
Diabetes: Foot Exam............ 0056/163......... Effective The percentage of National
Clinical Care. patients 18-75 years Committee for
of age with diabetes Quality
(type 1 and type 2) Assurance
who received a foot
exam (visual
inspection and
sensory exam with
mono filament and a
pulse exam) during
the measurement year.
Statin Therapy for the NA/438........... Not provided in Percentage of the Quality Insights
Prevention and Treatment of the measure. following patients--
Cardiovascular Disease. all considered at
high risk of
cardiovascular
events--who were
prescribed or were on
statin therapy during
the measurement
period:
* Adults aged >=21
years who were
previously diagnosed
with or currently
have an active
diagnosis of clinical
atherosclerotic
cardiovascular
disease (ASCVD); OR.
* Adults aged >=21
years who have ever
had a fasting or
direct low-density
lipoprotein
cholesterol (LDL-C)
level >=190 mg/dL or
were previously
diagnosed with or
currently have an
active diagnosis of
familial or pure
hypercholesterolemia;
OR
* Adults aged 40-75
years with a
diagnosis of
diabetes with a
fasting or direct
LDL-C level of 70-
189 mg/dL.
Inpatient Hospital Utilization NA............... ................. For members 18 years National
(IHU). of age and older, the Committee for
risk-adjusted ratio Quality
of observed to Assurance
expected acute
inpatient discharges
during the
measurement year
reported by Surgery,
Medicine, and Total.
Emergency Department NA............... ................. For members 18 years National
Utilization (EDU). of age and older, the Committee for
risk-adjusted ratio Quality
of observed to Assurance
expected emergency
department (ED)
visits during the
measurement year.
Preventive Care and Screening: 0421............. Community/ Percentage of patients Centers for
Body Mass Index (BMI) Population aged 18 years and Medicare &
Screening and Follow-Up Plan. Health. older with a BMI Medicaid
documented during the Services (CMS)
current encounter or
during the previous
six months AND with a
BMI outside of normal
parameters, a follow-
up plan is documented
during the encounter
or during the
previous six months
of the current
encounter. Normal
Parameters: Age 18
years and older BMI
[gteqt]18.5 and <25
kg/m2.
CAHPS.......................... CPC+ specific; ................. CG-CAHPS Survey 3.0... AHRQ
different than
CAHPS for MIPS.
----------------------------------------------------------------------------------------------------------------
7. MIPS Final Score Methodology
For the 2020 MIPS payment year, we intend to build on the scoring
methodology we finalized for the transition year, which allows for
accountability and alignment across the performance categories and
minimizes burden on MIPS eligible clinicians, while continuing to
prepare MIPS eligible clinicians for the performance threshold required
for the 2021 MIPS payment year. Our rationale for our scoring
methodology continues to be grounded in the understanding that the MIPS
scoring system has many components and numerous moving parts.
As we continue to move forward in implementing the MIPS program, we
strive to balance the statutory requirements and programmatic goals
[[Page 30096]]
with the ease of use, stability, and meaningfulness for MIPS eligible
clinicians, while also emphasizing simplicity and scoring that is
understandable for MIPS eligible clinicians. In this section, we
propose refinements to the performance standards, the methodology for
determining a score for each of the four performance categories (the
``performance category score''), and the methodology for determining a
final score based on the performance category scores.
We intend to continue the transition of MIPS by proposing the
following policies:
Continuation of many transition year scoring policies in
the quality performance category, with an adjustment to the number of
achievement points available for measures that fail to meet the data
completeness criteria, to encourage MIPS eligible clinician to meet
data completeness while providing an exception for small practices;
An improvement scoring methodology that rewards MIPS
eligible clinicians who improve their performance in the quality and
cost performance categories;
A new scoring option for the quality and cost performance
categories that allows facility-based MIPS eligible clinicians to be
scored based on their facility's performance;
Special considerations for MIPS eligible clinicians in
small practices or those who care for complex patients; and
Policies that allow multiple pathways for MIPS eligible
clinicians to receive a neutral to positive MIPS payment adjustment.
We believe these sets of proposed policies will help clinicians
smoothly transition from the transition year to the 2021 MIPS payment
year, for which the performance threshold (which represents the final
score that would earn a neutral MIPS adjustment) will be either the
mean or median (as selected by the Secretary) of the MIPS final scores
for all MIPS eligible clinicians from a previous period specified by
the Secretary.
Unless otherwise noted, for purposes of this section II.C.7. on
scoring, the term ``MIPS eligible clinician'' will refer to MIPS
eligible clinicians that submit data and are scored at either the
individual- or group-level, including virtual groups, but will not
refer to MIPS eligible clinicians who elect facility-based scoring. The
scoring rules for facility-based measurement are discussed in section
II.C.7.a.(4). of this proposed rule. We also note that the APM scoring
standard applies to APM Entities in MIPS APMs, and those policies take
precedence where applicable; however, where those policies do not
apply, scoring for MIPS eligible clinicians as described in this
section II.C.7. on scoring will apply. We refer readers to section
II.C.6.g. of this proposed rule for additional information about the
APM scoring standard.
a. Converting Measures and Activities Into Performance Category Scores
(1) Policies That Apply Across Multiple Performance Categories
The detailed policies and proposals for scoring the four
performance categories are described in detail in section II.C.7.a. of
this proposed rule. However, as the four performance categories
collectively create a single MIPS final score, there are several
policies that apply across categories, which we discuss in section
II.C.7.a.(1) of this proposed rule.
(a) Performance Standards
In accordance with section 1848(q)(3) of the Act, in the CY 2017
Quality Payment Program final rule, we finalized performance standards
for the four performance categories. We refer readers to the CY 2017
Quality Payment Program final rule for a description of the performance
standards against which measures and activities in the four performance
categories are scored (81 FR 77271 through 77272).
As discussed in section II.C.7.a.(1)(b)(i) of this proposed rule,
we are proposing to add an improvement scoring standard to the quality
and cost performance categories starting for the 2020 MIPS payment
year.
(b) Policies Related to Scoring Improvement
(i) Background
In accordance with section 1848(q)(5)(D)(i) of the Act, beginning
with the 2020 MIPS payment year, if data sufficient to measure
improvement are available, the final score methodology shall take into
account improvement of the MIPS eligible clinician in calculating the
performance score for the quality and cost performance categories and
may take into account improvement for the improvement activities and
advancing care information performance categories. In addition, section
1848(q)(3)(B) of the Act provides that the Secretary, in establishing
performance standards for measures and activities for the MIPS
performance categories, shall consider: Historical performance
standards; improvement; and the opportunity for continued improvement.
Section 1848(q)(5)(D)(ii) of the Act also provides that achievement may
be weighted higher than improvement.
In the CY 2017 Quality Payment Program final rule, we summarized
public comments received on the proposed rule regarding potential ways
to incorporate improvement into the scoring methodology moving forward,
including approaches based on methodologies used in the Hospital VBP
Program, the Shared Savings Program, and Medicare Advantage 5-star
Ratings Program (81 FR 77306 through 77308). We did not finalize a
policy at that time on this topic and indicated we would take comments
into account in developing a proposal for future rulemaking.
When considering the applicability of these programs to MIPS, we
looked at the approach that was used to measure improvement for each of
the programs and how improvement was incorporated into the overall
scoring system. An approach that focuses on measure-level comparison
enables a more granular assessment of improvement because performance
on a specific measure can be considered and compared from year to year.
All options that we considered last year use a standard set of measures
that do not provide for choice of measures to assess performance;
therefore, they are better structured to compare changes in performance
based on the same measure from year to year. The aforementioned
programs do not use a category-level approach; however, we believe that
a category-level approach would provide a broader perspective,
particularly in the absence of a standard set of measures, because it
would allow for a more flexible approach that enables MIPS eligible
clinicians to select measures and data submission mechanisms that can
change from year to year and be more appropriate to their practice in a
given year.
We believe that both approaches are viable options for measuring
improvement. Accordingly, we believe that an appropriate approach for
measuring improvement for the quality performance category and the cost
performance category should consider the unique characteristics of each
performance category rather than necessarily applying a uniform
approach across both performance categories. For the quality
performance category, clinicians are offered a variety of different
measures which can be submitted by different mechanisms, rather than a
standard set of measures or a single data submission mechanism.
[[Page 30097]]
For the cost performance category, however, clinicians are scored on
the same set of cost measures to the extent each measure is applicable
and available to them; clinicians cannot choose which cost measures
they will be scored on. In addition, all of the cost measures are
derived from administrative claims data with no additional submission
required by the clinician.
When considering the applicability of these programs to MIPS, we
also considered how scoring improvement is incorporated into the
overall scoring system, including when only achievement or improvement
is incorporated into a final score or when improvement and achievement
are both incorporated into a final score.
We considered whether we could adapt the Hospital VBP Program's
general approach for assessing improvement to MIPS and note that many
commenters, in response to the CY 2017 Quality Payment Program proposed
rule, recommended this methodology for MIPS because it is familiar to
the health care community. However, we decided that the Hospital VBP
Program's improvement scoring methodology, which compares changes in
performance based on the same measure from year to year, is not fully
translatable to MIPS for the quality performance category and the cost
performance category. The scoring methodology used to assess
achievement in the Hospital VBP Program, as required by section
1886(o)(5)(B)(ii) of the Act, does not reward points for achievement in
the same method as MIPS, because hospitals that fall below the
achievement threshold (the median performance during the benchmark
period) are not awarded achievement points. We refer readers to the
Hospital Inpatient VBP Program Final Rule (76 FR 26516 through 26525)
for additional discussion of the Hospital VBP Program's scoring
methodology. In addition, the Hospital VBP Program requires the use of
either the achievement score or the improvement points, but not both,
for the Program's performance scoring calculation. Adopting the
Hospital VBP Program method for MIPS would require significant changes
to the scoring methodology used for the quality and cost performance
categories. For the quality performance category, there are a wide
variety of measures available in MIPS, and clinicians have flexibility
in selecting measures and submission mechanisms, with the potential for
clinicians to select different measures from year to year, which would
affect our ability to capture performance changes at the measure level.
We continue to believe that flexibility for clinicians to select
meaningful measures is appropriate for MIPS, especially for the quality
performance category. The Hospital VBP Program methodology, which
relies on consistent measures from year to year in order to track
improvement, would limit our ability to measure improvement in MIPS.
We also considered adopting the Shared Savings Program's approach
for assessing improvement, where participants can receive bonus points
for improving on quality measures over time. The Shared Savings Program
methodology could be adopted without an underlying change to the
scoring of achievement in the quality and cost performance categories
with an approach that considers both achievement and improvement in its
overall scoring calculation and would align MIPS and the Shared Savings
Program. However, we believe that the Shared Savings Program's
improvement methodology would not be appropriate for the MIPS quality
performance category because we are again concerned about the wide
variety of quality measures available in MIPS and the flexibility
clinicians have in selecting measures and submission mechanisms that
could affect our ability to capture performance changes at the measure
level. We seek to balance a system that allows for meaningful
measurement to clinicians and accommodates the various practice types
by allowing for a choice of measures and submission mechanisms that may
differ from year to year for the quality performance category. However,
as we discuss in section II.C.7.a.(3)(a) of this proposed rule, we do
believe the Shared Savings Program measure level methodology could be
translated for cost measures in the cost performance category.
Finally, we also considered adopting the Medicare Advantage
Program's 5-Star Rating approach for assessing improvement, where
Medicare Advantage contracts are rated on quality and performance
measures. Under this approach, we would identify an overall
``improvement measure score'' by comparing the underlying numeric data
for measures from the prior year with the data from measures for the
performance period. To obtain an ``improvement measure score'' MIPS
eligible clinicians would need to have data for both years in at least
half of the required measures for the quality performance category (81
FR 77307). We are again concerned that the wide variety of measures
available in MIPS and the flexibility clinicians have in selecting
different measures and submission mechanisms from year to year could
affect our ability to capture performance changes at the measure level,
particularly for the quality performance category. Accordingly, we do
not believe this is an appropriate approach for the quality performance
category. Although this approach could be considered for the cost
performance category, we believe that the Shared Savings Program is
more analogous to MIPS and that the improvement methodology used in
that program is one with which more stakeholders in MIPS would be
familiar.
After taking all of this into consideration, we are proposing two
different approaches for scoring improvement from year to year. As
described in section II.C.7.a.(2)(i)(i) of this proposed rule, we are
proposing to measure improvement at the performance category level for
the quality performance category score. Because clinicians can elect
the submission mechanisms and quality measures that are most meaningful
to their practice, and these choices can change from year to year, we
want a flexible methodology that allows for improvement scoring even
when the quality measures change. This is particularly important as we
encourage MIPS eligible clinicians to move away from topped out
measures and toward more outcome measures. We do not want the
flexibility that is offered to MIPS eligible clinicians in the quality
performance category to limit clinicians' ability to move towards
outcome measures, or limit our ability to measure improvement. Our
proposal for taking improvement into account as part of the quality
performance category score is addressed in detail in sections
II.C.7.a.(2)(i) through II.C.7.a.(2)(j) of this proposed rule.
We believe that there is reason to adopt a different methodology
for scoring improvement for the cost performance category from that
used for the quality performance category. In contrast to the quality
performance category, for the cost performance category, MIPS eligible
clinicians do not have a choice in measures or submission mechanisms;
rather, all MIPS eligible clinicians are assessed on all measures based
on the availability and applicability of the measure to their practice,
and all measures are derived from administrative claims data.
Therefore, for the cost performance category, we propose in section
II.C.7.a.(3)(a)(i) of this proposed rule to measure improvement at the
measure
[[Page 30098]]
level. We also note, that while we are statutorily required to measure
improvement for the cost performance category beginning with the second
MIPS payment year if data sufficient to measure improvement is
available, we are also proposing at II.C.6.d.(2) of this proposed rule
to weight the cost performance category at zero percent for the 2018
MIPS performance period/2020 MIPS payment year. Therefore, the
improvement score for the cost performance category would not affect
the MIPS final score for the 2018 MIPS performance period/2020 MIPS
payment year and would be for informational purposes only.
We are not proposing to score improvement in the improvement
activities performance category or the advancing care information
performance category at this time, though we may address improvement
scoring for these performance categories in future rulemaking.
We propose to amend Sec. 414.1380(a)(1)(i) to add that improvement
scoring is available for performance in the quality performance
category and for the cost performance category at Sec.
414.1380(a)(1)(ii) beginning with the 2020 MIPS payment year.
We invite public comment on our proposals to score improvement for
the quality and cost performance categories starting with the 2020 MIPS
payment year.
(ii) Data Sufficiency Standard To Measure Improvement
Section 1848(q)(5)(D)(i) of the Act requires us to measure
improvement for the quality and cost performance categories of MIPS if
data sufficient to measure improvement are available, which we
interpret to mean that we would measure improvement when we can
identify data from a current performance period that can be compared to
data from a prior performance period or data that compares performance
from year to year. In section II.C.7.a.(2)(i)(ii) of this proposed
rule, we propose for the quality performance category that we would
measure improvement when data are available because there is a
performance category score for the prior performance period. In section
II.C.7.a.(3)(a)(i) of this proposed rule, we propose for the cost
performance category that we would measure improvement when data are
available which is when there is sufficient case volume to provide
measurable data on measures in subsequent years with the same
identifier. We refer readers to the noted sections for details on these
proposals.
(c) Scoring Flexibility for ICD-10 Measure Specification Changes During
the Performance Period
The quality and cost performance categories rely on measures that
use detailed measure specifications that include ICD-10-CM/PCS (``ICD-
10'') code sets. We annually issue new ICD-10 coding updates, which are
effective from October 1, through September 30 (https://www.cms.gov/Medicare/Coding/ICD10/ICD10OmbudsmanandICD10CoordinationCenterICC.html). As part of this
update, codes are added as well as removed from the ICD-10 code set.
To provide scoring flexibility for MIPS eligible clinicians and
groups for measures impacted by ICD-10 coding changes in the final
quarter of the Quality Payment Program performance period--which may
render the measures no longer comparable to the historical benchmark--
we propose at Sec. 414.1380(b)(1)(xviii) and Sec. 414.1320(c)(2) to
provide that we will assess performance on measures considered
significantly impacted by ICD-10 updates based only on the first 9
months of the 12-month performance period (for example, January 1, 2018
through September 30, 2018, for the 2018 MIPS performance period). We
believe it would be appropriate to assess performance for significantly
impacted measures based on the first 9 months of the performance
period, rather than the full 12 months, because the indicated
performance for the last quarter could be affected by the coding
changes rather than actual differences in performance. Performance on
measures that are not significantly impacted by changes to ICD-10 codes
would continue to be assessed on the full 12-month performance period
(January 1 through December 31).
Any measure that relies on an ICD-10 code which is added, modified,
or removed, such as in the measure numerator, denominator, exclusions,
or exceptions, could have an impact on the indicated performance on the
measure, although the impact may not always be significant. We propose
an annual review process to analyze the measures that have a code
impact and assess the subset of measures significantly impacted by ICD-
10 coding changes during the performance period. Depending on the data
available, we anticipate that our determination as to whether a measure
is significantly impacted by ICD-10 coding changes would include these
factors: A more than 10 percent change in codes in the measure
numerator, denominator, exclusions, and exceptions; guideline changes
or new products or procedures reflected in ICD-10 code changes; and
feedback on a measure received from measure developers and stewards. We
considered an approach where we would consider any change in ICD-10
coding to impact performance on a measure and thus only rely on the
first 9 months of the 12-month performance period for such measures.
However, we believe such an approach would be too broad and truncate
measurement for too many measures where performance may not be
significantly affected. We believe that our proposed approach ensures
the measures on which individual MIPS eligible clinicians and groups
will have their performance assessed are accurate for the performance
period and are consistent with the benchmark set for the performance
period.
We propose to publish on the CMS Web site which measures are
significantly impacted by ICD-10 coding changes and would require the
9-month assessment. We propose to publish this information by October
1st of the performance period if technically feasible, but by no later
than the beginning of the data submission period, which is January 1,
2019 for the 2018 performance period.
We request comment on the proposal to address ICD-10 measures
specification changes during the performance period by relying on the
first 9 months of the 12-month performance period. We also request
comment on potential alternate approaches to address measures that are
significantly impacted due to ICD-10 changes during the performance
period, including the factors we might use to determine whether a
measure is significantly impacted.
(2) Scoring the Quality Performance Category for Data Submission via
Claims, Data Submissions via EHR, Third Party Data Submission Options,
CMS Web Interface, and Administrative Claims
Many comments submitted in response to the CY 2017 Quality Payment
Program final rule requested additional clarification on our finalized
scoring methodology for the 2019 MIPS payment year. To provide further
clarity to MIPS eligible clinicians about the transition year scoring
policies, before describing our proposed scoring policies for the 2020
MIPS payment year, we provide a summary of the scoring policies
finalized in the CY 2017 Quality Payment Program final rule along with
examples of how they apply under several scenarios.
In the CY 2017 Quality Payment Program final rule (81 FR 77286
through
[[Page 30099]]
77287), we finalized that the quality performance category would be
scored by assigning achievement points to each submitted measure, which
we refer to in this section of the proposed rule as ``measure
achievement points'' and we propose to amend various paragraphs in
Sec. 414.1380(b)(1) to use this term in place of ``achievement
points''. MIPS eligible clinicians can also earn bonus points for
certain measures (81 FR 77293 through 77294; 81 FR 77297 through
77299), which we refer to as ``measure bonus points'', and we propose
to amend Sec. 414.1380(b)(1)(xiii) (which we propose to redesignate as
Sec. 414.1380(b)(1)(xiv) in this proposed rule),\7\ Sec.
414.1380(b)(1)(xiv) (which we propose to redesignate as Sec.
414.1380(b)(1)(xv) in this proposed rule), and Sec. 414.1380(b)(1)(xv)
(which we propose to redesignate as Sec. 414.1380(b)(1)(xvii) in this
proposed rule) to use this term in place of ``bonus points''. The
measure achievement points assigned to each measure would be added with
any measure bonus points and then divided by the total possible points
(Sec. 414.1380(b)(1)(xv) (which we propose to redesignate as Sec.
414.1380(b)(1)(xvii)). In this section of the proposed rule we refer to
the total possible points as ``total available measure achievement
points'', and we propose to amend Sec. 414.1380(b)(1)(xv) to use this
term in place of ``total possible points''. We also propose to amend
these terms in Sec. 414.1380(b)(1)(xiii)(D) (which we propose to
redesignate as Sec. 414.1380(b)(1)(xiv)(D) in this proposed rule), and
Sec. 414.1380(b)(1)(xiv) (which we propose to redesignate as Sec.
414.1380(b)(1)(xv) in this proposed rule).
---------------------------------------------------------------------------
\7\ In section II.C.7.a.(2)(c) of this proposed rule, we propose
a new provision to be codified at Sec. 414.1380(b)(1)(xiii), and in
section II.C.7.a.(2)(i) of this proposed rule, we propose a new
provision to be codified at Sec. 414.1380(b)(1)(xvi). As a result,
we propose as well that the remaining paragraphs be redesignated in
order following the new provisions.
---------------------------------------------------------------------------
This resulting quality performance category score is a fraction
from zero to 1, which can be formatted as a percent; therefore, for
this section, we will present the quality performance category score as
a percent and refer to it as ``quality performance category percent
score.'' We also propose to amend Sec. 414.1380(b)(1)(xv) (which we
propose to redesignate as Sec. 414.1380(b)(1)(xvii) in this proposed
rule) to use this term in place of ``quality performance category
score''. Thus, the formula for the quality performance category percent
score that we will use in this section is as follows:
(total measure achievement points + total measure bonus points)/total
available measure achievement points = quality performance category
percent score.
In the CY 2017 Quality Payment Program final rule, we finalized
that for the quality performance category, an individual MIPS eligible
clinician or group that submits data on quality measures via EHR, QCDR,
qualified registry, claims, or a CMS-approved survey vendor for the
CAHPS for MIPS survey will be assigned measure achievement points for 6
measures (1 outcome or, if an outcome measure is not available, other
high priority measure and the next 5 highest scoring measures) as
available and applicable, and will receive applicable measure bonus
points for all measures submitted that meet the bonus criteria (81 FR
77282 through 77301).
In addition, for groups of 16 or more clinicians who meet the case
minimum of 200, we will also automatically score the administrative
claims-based all-cause hospital readmission measure as a seventh
measure (81 FR 77287). For individual MIPS eligible clinicians and
groups for whom the readmission measure does not apply, the denominator
is generally 60 (10 available measure achievement points multiplied by
6 available measures). For groups for whom the readmission measure
applies, the denominator is generally 70 points.
If we determined that a MIPS eligible clinician has fewer than 6
measures available and applicable, we will score only the number of
measures that are available and adjust the denominator accordingly to
the total available measure achievement points (81 FR 77291). We refer
readers to section II.C.7.a.(2)(e) of this proposed rule, for a
description of the validation process to determine measure
availability.
For the 2019 MIPS payment year, a MIPS eligible clinician that
submits quality measure data via claims, EHR, or third party data
submission options (that is, QCDR, qualified registry, EHR, or CMS-
approved survey vendor for the CAHPS for MIPS survey), can earn between
3 and 10 measure achievement points for quality measures submitted for
the performance period of greater than or equal to 90 continuous days
during CY 2017. A MIPS eligible clinician can earn measure bonus points
(subject to a cap) if they submit additional high priority measures
with a performance rate that is greater than zero, and that meet the
case minimum and data completeness requirements, or submit a measure
using an end-to-end electronic pathway. An individual MIPS eligible
clinician that has 6 or more quality measures available and applicable
will have 60 total available measure achievement points. For example,
as shown in Table 17, if an individual MIPS eligible clinician submits
7 measures, including one required outcome measure and 2 additional
high priority measures, the MIPS eligible clinician will be assigned
points based on achievement for the required outcome measure and the
next 5 measures with the highest number of measure achievement points.
In this example, the second high priority measure has the lowest number
of measure achievement points and therefore is not included in the
total measure achievement points calculated (81 FR 77300), but the MIPS
eligible clinician will still receive a bonus point for submitting a
high priority measure (81 FR 77291 through 77294). We note that in the
CY 2017 Quality Payment Program proposed rule, we proposed that bonus
points would be available for high priority measures that are not
scored (not included in the top 6 measures for the quality performance
category score) as long as the measure has the required case minimum,
data completeness, and has a performance rate greater than zero,
because we believed these qualities would allow us to include the
measure in future benchmark development (81 FR 28255). Although we
received public comments on this policy, responded to those comments,
and reiterated this proposal in the CY 2017 Quality Payment Program
final rule (81 FR 77292), we would like to clarify that our policy to
assign measure bonus points for high priority measures, even if the
measure's achievement points are not included in the total measure
achievement points for calculating the quality performance category
percent score, as long as the measure has the required case minimum,
data completeness, and has a performance rate greater than zero,
applies beginning with the transition year. We propose to amend Sec.
414.1380(b)(1)(xiii)(A) (which we propose to redesignate as Sec.
414.1380(b)(1)(xiv)(A)) to state that measure bonus points may be
included in the calculation of the quality performance category percent
score regardless of whether the measure is included in the calculation
of the total measure achievement points. We also propose a technical
correction to the second sentence of that paragraph to state that to
qualify for measure bonus points, each measure must be reported with
sufficient case volume to meet the required case minimum, meet the
required data completeness criteria, and
[[Page 30100]]
not have a zero percent performance rate.
Table 17--Example Calculation of the Quality Performance Category Percent Score for an Individual for the
Transition Year
----------------------------------------------------------------------------------------------------------------
Total
available
Measure achievement Measure bonus measure Performance category
points points * achievement percent score
points
----------------------------------------------------------------------------------------------------------------
Measure 1 (Outcome--required).... 3.................. n/a 10 (measure achievement
Measure 2........................ 6.................. n/a 10 points from 6 measures
+ measure bonus points)/
total available measure
achievement points.
Measure 3........................ 6.................. n/a 10
Measure 4........................ 6.................. n/a 10
Measure 5........................ 6.................. n/a 10
Measure 6 (High priority)........ 4.................. 1 10
Measure 7 (High priority)........ 3 (not included for 1 n/a ........................
achievement).
------------------------------------------------------------------------------
Total........................ 31................. 2 60 (31+2)/60 = 55%
----------------------------------------------------------------------------------------------------------------
* Assumes the measures meet the required case minimum, data completeness, and has performance greater than zero.
Assumes no bonus points for end-to-end electronic submission. This example does not apply to CMS Web Interface
Reporters because individuals are not able to submit data via that mechanism.
A group of 16 or more clinicians will also be automatically scored
on the hospital readmission measure if they meet the case minimum.
Table 18 illustrates an example of a group that submitted the 6
required quality measures, including an additional high priority
measure, and received 3 measure achievement points for each submitted
measure and the all-cause readmission measure.
Table 18--Example Calculation of the Quality Performance Category Percent Score for a Group of 16 or More
Clinicians, Non-CMS Web Interface Reporter for the Transition Year
----------------------------------------------------------------------------------------------------------------
Total
Measure available
achievement Measure bonus measure Performance category
points points * achievement percent score
points
----------------------------------------------------------------------------------------------------------------
Measure 1 (Outcome--required)...... 3 n/a 10 (measure achievement points
from 7 measures + measure
bonus points)/total
available measure
achievement points.
Measure 2 (High priority).......... 3 1 10
Measure 3.......................... 3 n/a 10
Measure 4.......................... 3 n/a 10
Measure 5.......................... 3 n/a 10
Measure 6.......................... 3 n/a 10
Measure 7--(readmission measure 3 n/a 10
with 200+ cases).
----------------------------------------------------------------------------
Total.......................... 21 1 70 (21+1)/70 = 31.4%
----------------------------------------------------------------------------------------------------------------
* Assumes the measures meet the required case minimum, data completeness, and has performance greater than zero.
Assumes no bonus points for end-to-end electronic submission.
In the CY 2017 Quality Payment Program final rule, we also
finalized scoring policies specific to groups of 25 or more that submit
their quality performance measures using the CMS Web Interface (81 FR
77278 through 77306).
Although we are not proposing to change the basic scoring system
that we finalized in the CY 2017 Quality Payment Program final rule for
the 2020 MIPS payment year, we are proposing several modifications to
scoring the quality performance category, including adjusting scoring
for measures that do not meet the data completeness criteria, adding a
method for scoring measures submitted via multiple mechanisms, adding a
method for scoring selected topped out measures, and adding a method
for scoring improvement. We also note that in section II.C.7.a.(4) of
this proposed rule, we are also proposing an additional option for
facility-based scoring for the quality performance category.
(a) Quality Measure Benchmarks
We are not proposing to change the policies on benchmarking
finalized in the CY 2017 Quality Payment Program final rule and
codified at paragraphs (b)(1)(i) through (iii) of Sec. 414.1380;
however, we are proposing a technical correction to paragraphs (i) and
(ii) to clarify that measure benchmark data are separated into decile
categories based on percentile distribution, and that, other than using
performance period data, performance period benchmarks are created in
the same manner as historical benchmarks using decile categories based
on a percentile distribution and that each benchmark must have a
minimum of 20 individual clinicians or groups who reported on the
measure meeting the data completeness requirement and case minimum case
size criteria and performance greater than zero. We refer
[[Page 30101]]
readers to the discussion at 81 FR 77282 for more details on that
policy.
We note that in section II.C.2.c. of this proposed rule, we are
proposing to increase the low-volume threshold which, because we
include MIPS eligible clinicians and comparable APMs that meet our
benchmark criteria in our measure benchmarks, could have an impact on
our MIPS benchmarks, specifically by reducing the number of individual
eligible clinicians and groups that meet the definition of a MIPS
eligible clinician and contribute to our benchmarks. Therefore, we seek
feedback on whether we should broaden the criteria for creating our
MIPS benchmarks to include PQRS and any data from MIPS, including
voluntary reporters, that meet our benchmark performance, case minimum
and data completeness criteria when creating our benchmarks.
In the CY 2017 Quality Payment Program final rule, we did not
stratify benchmarks by practice characteristics, such as practice size,
because we did not believe there was a compelling rationale for such an
approach, and we believed that stratifying could have unintended
negative consequences for the stability of the benchmarks, equity
across practices, and quality of care for beneficiaries (81 FR 77282).
However, we sought comment on any rationales for or against stratifying
by practice size we may not have considered. We note that we do create
separate benchmarks for each of the following submission mechanisms:
EHR submission options; QCDR and qualified registry submission options;
claims submission options; CMS Web Interface submission options; CMS-
approved survey vendor for CAHPS for MIPS submission options; and
administrative claims submission options (for measures derived from
claims data, such as the all-cause hospital readmission measure) (81 FR
77282).
Several commenters who responded to our solicitation of comment in
the final rule supported stratifying measure benchmarks by practice
size because the commenters believed it would help small practices,
which have limited resources compared to larger practices, and because
quality measures may have characteristics that are less favorable to
small groups. One commenter recommended that we stratify by practice
size during the 5 years in which technical assistance is available. One
commenter recommended that we develop criteria for determining when a
benchmark should be stratified by group size, and another commenter
recommended if we do not stratify benchmarks by practice size, we
adjust MIPS payment adjustments for practice size. Several commenters
recommended that we stratify benchmarks beyond practice size and
include adjustments for disease severity and socioeconomic status of
patients, specialty or sub-specialty, geographic region, and/or site of
service. One commenter specifically suggested that we use peer
comparison groups when establishing measure benchmarks.
After consideration of the comments we received, we are not
proposing to change our policies related to stratifying benchmarks by
practice size for the 2020 MIPS payment year. For many measures, the
benchmarks may not need stratification as they are only meaningful to
certain specialties and only expected to be submitted by those certain
specialists. We would like to further clarify that in the majority of
instances our current benchmarking approach only compares like
clinicians to like clinicians. We continue to believe that stratifying
by practice size could have unintended negative consequences for the
stability of the benchmarks, equity across practices, and quality of
care for beneficiaries. However, we seek comment on methods by which we
could stratify benchmarks, while maintaining reliability and stability
of the benchmarks, to use in developing future rulemaking for future
performance and payment years. Specifically, we seek comment on methods
for stratifying benchmarks by specialty or by place of service. We also
request comment on specific criteria to consider for stratifying
measures, such as how we should stratify submissions by multi-specialty
practices or by practices that operate in multiple places of service.
(b) Assigning Points Based on Achievement
In the CY 2017 Quality Payment Program final rule, we finalized at
Sec. 414.1380(b)(1) that a MIPS quality measure must have a measure
benchmark to be scored based on performance. MIPS quality measures that
do not have a benchmark (for example, because fewer than 20 MIPS
eligible clinicians or groups submitted data that met our criteria to
create a reliable benchmark) will not be scored based on performance
(81 FR 77286). We are not proposing any changes to this policy, but we
are proposing a technical correction to the regulatory text at Sec.
414.1380(b)(1) to delete the term ``MIPS'' before ``quality measure''
in third sentence of that paragraph and to delete the term MIPS before
``quality measures'' in the fourth sentence of that paragraph because
this policy applies to all quality measures, including the measures
finalized for the MIPS program and the quality measures submitted
through a QCDR that have been approved for MIPS.
We are also not proposing to change the policies to score quality
measure performance using a percentile distribution, separated by
decile categories and assign partial points based on the percentile
distribution finalized in the CY 2017 Quality Payment Program final
rule and codified at paragraphs (b)(1)(ix), (x), and (xi) of Sec.
414.1380; however, we propose a technical correction to paragraph (ix)
to clarify that measures are scored against measure benchmarks. We
refer readers to the discussion at 81 FR 77286 for more details on
those policies.
For illustration, Table 19 provides an example of assigning points
for performance based on benchmarks using a percentile distribution,
separated by decile categories. The example is of the benchmarks for
Measure 130 Documentation of Current Medications in the Medical Record,
which is based on our 2015 benchmark file for the 2017 MIPS performance
period.
Table 19--Example of Assigning Points for Performance Based on a Benchmark, Separated by Deciles
----------------------------------------------------------------------------------------------------------------
Measure ID #130 (documentation of current medications
in the medical record) *
--------------------------------------------------------
Submission mechanism Claims
performance EHR performance Registry/QCDR
benchmark benchmark benchmark
----------------------------------------------------------------------------------------------------------------
Decile 1 or 2 (3 points)............................... <96.11 <76.59 <61.27
Decile 3 (3.0-3.9 points).............................. 96.11-98.73 76.59-87.88 61.27-82.11
Decile 4 (4.0-4.9 points).............................. 98.74-99.64 87.89-92.73 82.12-91.71
Decile 5 (5.0-5.9 points).............................. 99.65-99.99 92.74-95.35 91.72-96.86
[[Page 30102]]
Decile 6 (6.0-6.9 points).............................. -- 95.36 -97.08 96.87-99.30
Decile 7 (7.0-7.9 points).............................. -- 97.09-98.27 99.31 -99.99
Decile 8 (8.0-8.9 points).............................. -- 98.28-99.12 --
Decile 9 (9.0-9.9 points).............................. -- 99.13-99.75 --
Decile 10 (10 points).................................. 100 >= 99.76 100
----------------------------------------------------------------------------------------------------------------
* Based on our historical benchmark file for the 2017 MIPS performance period.
In Table 19, the cells with ``--'' represent where there is a
cluster at the top of benchmark distribution. For example, for the
claims benchmark, over 50 percent of the MIPS eligible clinicians
submitting that measure had a performance rate of 100 percent based on
2015 PQRS data. Because of the cluster, clinicians who are at the 6, 7,
8, and 9th decile all would have performance rates of 100 percent and
would all receive a score of 10 points, indicated by dashes for those
deciles. Based on this clustered distribution, those clinicians with
performance of 99.99 percent fall into decile 5 and receive points in
the range from 5.0 to 5.9 points. For this measure, the benchmark for
each submission mechanism is topped out.
We note that for quality measures for which baseline period data is
available, we will publish the numerical baseline period benchmarks
with deciles prior to the start of the performance period (or as soon
as possible thereafter) (81 FR 77282). For quality measures for which
there is no comparable data from the baseline period, we will publish
the numerical performance period benchmarks after the end of the
performance period (81 FR 77282). We will also publish further
explanation of how we calculate partial points at qpp.cms.gov.
(i) Floor for Scored Quality Measures
For the 2017 MIPS performance period, we also finalized at Sec.
414.1380(b)(1) a global 3-point floor for each scored quality measure,
as well as for the hospital readmission measure (if applicable), such
that MIPS eligible clinicians would receive between 3 and 10 measure
achievement points for each submitted measure that can be reliably
scored against a benchmark, which requires meeting the case minimum and
data completeness requirements (81 FR 77286 through 77287). Likewise,
for measures without a benchmark based on the baseline period, we
stated that we would continue to assign between 3 and 10 measure
achievement points for performance years after the first transition
year because it would help to ensure that the MIPS eligible clinicians
are protected from a poor performance score that they would not be able
to anticipate (81 FR 77282; 81 FR 77287). For measures with benchmarks
based on the baseline period, we stated the 3-point floor was for the
transition year and that we would revisit the 3-point floor in future
years (81 FR 77286 through 77287).
For the 2018 MIPS performance period, we propose to again apply a
3-point floor for each measure that can be reliably scored against a
benchmark based on the baseline period, and to amend Sec.
414.1380(b)(1) accordingly. We refer readers to section
II.C.7.a.(2)(h)(ii) of this rule, for our proposal to score measures in
the CMS Web Interface for the Quality Payment Program for which
performance is below the 30th percentile. We will revisit the 3-point
floor for such measures again in future rulemaking.
We invite public comment on this proposal to again apply this 3-
point floor for quality measures that can be reliably scored against a
baseline benchmark in the 2018 MIPS performance period.
(ii) Additional Policies for the CAHPS for MIPS Measure Score
In the CY 2017 Quality Payment Program final rule, we finalized a
policy for the CAHPS for MIPS measure, such that each Summary Survey
Measure (SSM) will have an individual benchmark, that we will score
each SSM individually and compare it against the benchmark to establish
the number of points, and the CAHPS score will be the average number of
points across SSMs (81 FR 77284).
As described in section II.C.6.b.(3)(a)(iii) of this proposed rule,
we are proposing to remove two SSMs from the CAHPS for MIPS survey,
which would result in the collection of 10 SSMs in the CAHPS for MIPS
survey. Eight of those 10 SSMs have had high reliability for scoring in
prior years, or reliability is expected to improve for the revised
version of the measure, and they also represent elements of patient
experience for which we can measure the effect one practice has
compared to other practices participating in MIPS. The ``Health Status
and Functional Status'' SSM, however, assesses underlying
characteristics of a group's patient population characteristics and is
less of a reflection of patient experience of care with the group.
Moreover, to the extent that health and functional status reflects
experience with the practice, case-mix adjustment is not sufficient to
separate how much of the score is due to patient experience versus due
to aspects of the underlying health of patients. The ``Access to
Specialists'' SSM has low reliability; historically it has had small
sample sizes, and therefore, the majority of groups do not achieve
adequate reliability, which means there is limited ability to
distinguish between practices' performance.
For these reasons, we propose not to score the ``Health Status and
Functional Status'' SSM and the ``Access to Specialists'' SSM beginning
with the 2018 MIPS performance period. Despite not being suitable for
scoring, both SSMs provide important information about patient care.
Qualitative work suggests that ``Access to Specialists'' is a critical
issue for Medicare FFS beneficiaries. The survey is also a useful tool
for assessing beneficiaries' self-reported health status and functional
status, even if this measure is not used for scoring practices' care
experiences. Therefore, we believe that continued collection of the
data for these two SSMs is appropriate even though we do not propose to
score them.
Other than these two SSMs, we propose to score the remaining 8 SSMs
because they have had high reliability for scoring in prior years, or
reliability is expected to improve for the revised version of the
measure, and they also
[[Page 30103]]
represent elements of patient experience for which we can measure the
effect one practice has compared to other practices participating in
MIPS. Table 20 summarizes the proposed SSMs included in the CAHPS for
MIPS survey and illustrates application of our proposal to score only 8
measures.
Table 20--Proposed SSM for CAHPS for MIPS Scoring
----------------------------------------------------------------------------------------------------------------
Proposed for inclusion in Proposed for inclusion in
Summary survey measure the CAHPS for MIPS survey? CAHPS for MIPS scoring?
----------------------------------------------------------------------------------------------------------------
Getting Timely Care, Appointments, and Information... Yes......................... Yes.
How Well Providers Communicate....................... Yes......................... Yes.
Patient's Rating of Provider......................... Yes......................... Yes.
Health Promotion & Education......................... Yes......................... Yes.
Shared Decision Making............................... Yes......................... Yes.
Stewardship of Patient Resources..................... Yes......................... Yes.
Courteous and Helpful Office Staff................... Yes......................... Yes.
Care Coordination.................................... Yes......................... Yes.
Health Status and Functional Status.................. Yes......................... No.
Access to Specialists................................ Yes......................... No.
----------------------------------------------------------------------------------------------------------------
We invite comment on our proposal not to score the ``Health Status
and Functional Status'' and ``Access to Specialists'' SSMs beginning
with the 2018 MIPS performance period.
We note that in section II.C.6.g.(3)(b)(i)(A) of this proposed
rule, we are proposing to add the CAHPS for ACOs survey as an available
measure for calculating the MIPS APM score for the Shared Savings
Program and Next Generation ACO Model. We refer readers participating
in ACOs to section II.C.6.g.(3)(b) of this proposed rule for the CAHPS
for ACOs scoring methodology.
(c) Identifying and Assigning Measure Achievement Points for Topped Out
Measures
Section 1848(q)(3)(B) of the Act requires that, in establishing
performance standards with respect to measures and activities, we
consider, among other things, the opportunity for continued
improvement. We finalized in the CY 2017 Quality Payment Program final
rule that we would identify topped out process measures as those with a
median performance rate of 95 percent or higher (81 FR 77286). For non-
process measures we finalized a topped out definition similar to the
definition used in the Hospital VBP Program: Truncated Coefficient of
Variation is less than 0.10 and the 75th and 90th percentiles are
within 2 standard errors (81 FR 77286). When a measure is topped out, a
large majority of clinicians submitting the measure performs at or very
near the top of the distribution; therefore, there is little or no room
for the majority of MIPS eligible clinicians who submit the measure to
improve. We understand that every measure we have identified as topped
out may offer room for improvement for some MIPS eligible clinicians;
however, we believe asking clinicians to submit measures that we have
identified as topped out and measures for which they already excel is
an unnecessary burden that does not add value or improve beneficiary
outcomes.
Based on 2015 historic benchmark data,\8\ approximately 45 percent
of the quality measure benchmarks currently meet the definition of
topped out, with some submission mechanisms having a higher percent of
topped out measures than others. Approximately 70 percent of claims
measures are topped out, 10 percent of EHR measures are topped out, and
45 percent of registry/QCDR measures are topped out.
---------------------------------------------------------------------------
\8\ The topped out determination is calculated on historic
performance data and the percentage of topped out measures may
change when evaluated for the most applicable annual period.
---------------------------------------------------------------------------
In the CY 2017 Quality Payment Program final rule, we finalized
that for the 2019 MIPS payment year, we would score topped out quality
measures in the same manner as other measures (81 FR 77286). We
finalized that we would not modify the benchmark methodology for topped
out measures for the first year that the measure has been identified as
topped out, but that we would modify the benchmark methodology for
topped out measures beginning with the 2020 MIPS payment year, provided
that it is the second year the measure has been identified as topped
out. As described in detail later in this section, we are proposing a
phased in approach to apply special scoring to topped out measures,
beginning with the 2018 MIPS performance period (2020 MIPS payment
year), rather than modifying the benchmark methodology for topped out
measures as indicated in the CY 2017 Quality Payment Program final
rule.
In the CY 2017 Quality Payment Program final rule, we sought
comment on how topped out measures should be scored provided that it is
the second year the measure has been identified as topped out (81 FR
77286). We suggested three possible options: (1) Score the measures
using a mid-cluster approach; (2) remove topped out measures; or (3)
apply a flat percentage in building the benchmarks for topped out
measures. Flat percentages assign points based directly on the
percentage of performance rather than by a percentile distribution by
decile. Flat-rate would provide high scores to virtually all clinicians
submitting the measure because performance rates tend to be high.
Cluster-based benchmarks for topped out measures are based on a
percentile distribution, but because many submitters are clustered at
the top of performance, there can be large drops in points assigned for
relatively small differences in performance. The current top of the
cluster approach can result in many clinicians receiving 10 points. A
mid-cluster approach would limit the maximum number of points a topped
out measure can achieve based on how clustered the score are, and could
still result in large drops, although less than with the top of the
cluster approach, in points assigned for relatively small differences
in performance. We also noted in the CY 2017 Quality Payment Program
final rule that we anticipate removing topped out measures over time
and sought comment on what point in time we should remove topped out
measures from MIPS (81 FR 77286). The comments and our proposed policy
for removing topped out measures are described in section II.C.6.c.(2)
of this proposed rule.
In response to our request for comment in the CY 2017 Quality
Payment Program final rule, a few
[[Page 30104]]
commenters believed that we should not score topped out measures
differently from other measures because commenters believed changing
the scoring could reduce quality, add complexity to the program, and
reduce incentives to participate in MIPS. Several commenters
recommended that if we do score topped out measures differently, we use
flat percentages rather than cluster-based benchmarks, with a few
commenters noting that using flat percentages could help ensure those
with high performance on a measure are not penalized as low performers
and another noting that allowing high scorers to earn maximum or near
maximum points is similar to the approach in the Shared Savings
Program. A few commenters recommended that we publish information about
topped out and potentially topped out measures prior to the performance
period to allow clinicians time to adjust their reporting strategies,
with one commenter noting that improvement may be rewarded in addition
to achievement. One commenter recommended pushing back the baseline
performance period for identifying topped out measures to the 2018 MIPS
performance period because in the transition year it is unclear how
many eligible clinicians will be reporting at different times and for
what period they will report.
As described in section II.C.6.c.(2) of this proposed rule, we are
proposing a lifecycle for topped out measures by which, after a measure
benchmark is identified as topped out in the published benchmark for 2
years, in the third consecutive year it is identified as topped out it
will be considered for removal through notice-and-comment rulemaking or
the QCDR approval process and may be removed from the benchmark list in
the fourth year, subject to the phased in approach described in section
II.C.6.c.(2) of this proposed rule.
As part of the lifecycle for topped out measures, we also propose
in this section II.C.7.a.(2)(c) of this proposed rule, a method to
phase in special scoring for topped out measure benchmarks starting
with the 2018 MIPS performance period, provided that is the second
consecutive year the measure benchmark is identified as topped out in
the benchmarks published for the performance period. This special
scoring would not apply to measures in the CMS Web Interface, as
explained later in this section. The phased-in approach described in
this section represents our first step in methodically implementing
special scoring for topped out measures.
We are not proposing to remove topped out measures for the 2018
MIPS performance period because we recognize that there are currently a
large number of topped out measures and removing them may impact the
ability of some MIPS eligible clinicians to submit 6 measures and may
impact some specialties more than others. We note, however, that as
described in section II.C.6.c.(2) of this proposed rule, we are
proposing a timeline for removing topped out measures in future years.
We believe this provides MIPS eligible clinicians the ability to
anticipate and plan for the removal of specific topped out measures,
while providing measure developers time to develop new measures.
We note that because we create a separate benchmark for each
submission mechanism available for a measure, a benchmark for one
submission mechanism for the measure may be identified as topped out
while another submission mechanism's benchmark may not be topped out.
The topped out designation and special scoring apply only to the
specific benchmark that is topped out, not necessarily every benchmark
for a measure. For example, the benchmark for the claims submission
mechanism may be topped out for a measure, but the benchmark for the
EHR submission mechanisms for that same measure may not be topped out.
In this case, the topped out scoring would only apply to measures
submitted via the claims submission mechanism, which has the topped out
benchmark. We also describe in section II.C.6.c.(2) of this proposed
rule that, similarly, only the submission mechanism that is topped out
for the measure would be removed.
We propose to cap the score of topped out measures at 6 measure
achievement points. We are proposing a 6-point cap for multiple
reasons. First, we believe applying a cap to the current method of
scoring a measure against a benchmark is a simple approach that can
easily be predicted by clinicians. Second, the cap will create
incentives for clinicians to submit other measures for which they can
improve and earn future improvement points. Third, considering our
proposed topped out measure lifecycle, we believe this cap would only
be used for a few years and the simplicity of a cap on the current
benchmarks would outweigh the cluster-based options or applying a cap
on benchmarks based on flat-percentage, which are more complicated. The
rationale for a 6-point cap is that 6 points is the median score for
any measure as it represents the start of the 6th decile for
performance and represents the spot between the bottom 5 deciles and
start of the top 5 deciles.
We believe this proposed capped scoring methodology will
incentivize MIPS eligible clinicians to begin submitting non-topped out
measures without performing below the median score. This methodology
also would not impact scoring for those MIPS eligible clinicians that
do not perform near the top of the measure and therefore have
significant room to improve on the measure. We may also consider
lowering the cap below 6 points in future years, especially if we
remove the 3-point floor for performance in future years.
We note that although we are proposing a new methodology for
assigning measure achievement points for topped out measures, we are
not changing the policy for awarding measure bonus points for topped
out measures. Topped out measures will still be eligible for measure
bonus points if they meet the required criteria. We refer readers to
sections II.C.7.a.(2)(f) and II.C.7.a.(2)(g) of this proposed rule for
more information about measure bonus points.
We request comments on our proposal to score topped out measures
differently by applying a 6-point cap, provided it is the second
consecutive year the measure is identified as topped out. Specifically,
we seek feedback on whether 6 points is the appropriate cap or whether
we should consider another value. We also seek comment on other
possible options for scoring topped out measures that would meet our
policy goals to encourage clinicians to begin to submit measures that
are not topped out while also providing stability for MIPS eligible
clinicians.
While we believe it is important to score topped out measures
differently because they could have a disproportionate impact on the
scores for certain MIPS eligible clinicians and topped out measures
provide little room for improvement for the majority of MIPS eligible
clinicians who submit them, we also recognize that numerous measure
benchmarks are currently identified as topped out and special scoring
for topped out measures could impact some specialties more than others.
Therefore, we considered ways to phase in special scoring for topped
out measures in a way that will begin to apply special scoring, but
would not overwhelm any one specialty and would also provide additional
time to evaluate the impact of topped out measures before implementing
it for all topped out measures, while also beginning to encourage
submission of measures that are not topped out.
[[Page 30105]]
We believe the best way to accomplish this is by applying special
topped out scoring to a select number of measures for the 2018
performance period and to then apply the special topped out scoring to
all topped out measures for the 2019 performance period, provided it is
the second consecutive year the measure is topped out. We believe this
approach allows us time to further evaluate the impact of topped out
measures and allows for a methodical way to phase in topped out
scoring.
We identified measures we believe should be scored with the special
topped out scoring for the 2018 performance period by using the
following set criteria, which are only intended as a way to phase in
our topped-out measure policy for selected measures and are not
intended to be criteria for use in future policies:
Measure is topped out and there is no difference in
performance between decile 3 through decile 10. We applied this
limitation because, based on historical data, there is no room for
improvement for over 80 percent of MIPS eligible clinicians that
reported on these measures.
Process measures only because we want to continue to
encourage reporting on high priority outcome measures, and the small
subset of structure measures was confined to only three specialties.
MIPS measures only (which does not include measures that
can only be reported through a QCDR) given that QCDR measures go
through a separate process for approval and because we want to
encourage use of QCDRs required by section 1848(q)(1)(E) of the Act.
Measure is topped out for all mechanisms by which the
measure can be submitted. Because we create a separate benchmark for
each submission mechanism available for a measure, a benchmark for one
submission mechanism for the measure may be identified as topped out
while another submission mechanism's benchmark may not be topped out.
For example, the benchmark for the claims submission mechanism may be
topped out for a measure, but the benchmark for the EHR submission
mechanisms for that same measure may not be topped out. We decided to
limit our criteria to only measures that were topped out for all
measures for simplicity and to avoid confusion about what scoring is
applied to a measure.
Measure is in a specialty set with at least 10 measures,
because 2 measures in the pathology specialty set, which only has 8
measures total would have been included.
Applying these criteria results in the 6 measures as listed in
Table 21.
Table 21--Topped Out Measures Proposed for Special Scoring for the 2018 MIPS Performance Period
----------------------------------------------------------------------------------------------------------------
Topped out for all
Measure name Measure ID Measure type submission Specialty set
mechanisms
----------------------------------------------------------------------------------------------------------------
Perioperative Care: Selection 21 Process............. Yes................ General Surgery,
of Prophylactic Antibiotic-- Orthopedic Surgery,
First OR Second Generation Otolaryngology,
Cephalosporin. Thoracic Surgery,
Plastic Surgery.
Melanoma: Overutilization of 224 Process............. Yes................ Dermatology.
Imaging Studies in Melanoma.
Perioperative Care: Venous 23 Process............. Yes................ General Surgery,
Thromboembolism (VTE) Orthopedic Surgery,
Prophylaxis (When Indicated Otolaryngology,
in ALL Patients). Thoracic Surgery,
Plastic Surgery.
Image Confirmation of 262 Process............. Yes................ n/a.
Successful Excision of Image--
Localized Breast Lesion.
Optimizing Patient Exposure to 359 Process............. Yes................ Diagnostic Radiology.
Ionizing Radiation:
Utilization of a Standardized
Nomenclature for Computerized
Tomography (CT) Imaging
Description.
Chronic Obstructive Pulmonary 52 Process............. Yes................ n/a.
Disease (COPD): Inhaled
Bronchodilator Therapy.
----------------------------------------------------------------------------------------------------------------
We propose to apply the special topped out scoring method that we
finalize for the 2018 performance period to only the 6 measures in
Table 21 for the 2018 performance period, provided they are again
identified as topped out in the benchmarks for the 2018 performance
period. If these measures are not identified as topped out in the
benchmarks published for the 2018 performance period, they will not be
scored differently because they would not be topped out for a second
consecutive year.
We seek comment on our proposal to apply special topped out scoring
only to the 6 measures identified in Table 21 for the 2018 performance
period.
Starting with the 2019 performance period, we propose to apply the
special topped out scoring method to all topped out measures, provided
it is the second (or more) consecutive year the measure is identified
as topped out. We seek comment on our proposal to apply special topped
out scoring to all topped out measures, provided it is the second (or
more) consecutive year the measure is identified as topped out.
We illustrate the lifecycle for scoring and removing topped out
measures based on our proposals as follows:
Year 1: Measure benchmarks are identified as topped out,
which in this example would be in the benchmarks published for the 2017
MIPS performance period.
Year 2: Measure benchmarks are identified as topped out,
which in this example would be in the benchmarks published for the 2018
MIPS performance period. Measures identified in Table 21 have special
scoring applied, provided they are identified as topped out for the
2018 MIPS performance period, meaning it is the second consecutive year
they are identified as topped out.
Year 3: Measure benchmarks are identified as topped out in
the benchmarks published for the 2019 MIPS performance period. All
measure benchmarks identified as topped out for the second (or more)
consecutive year have special scoring applied for the 2019 MIPS
performance period. In Year 3 we would also consider removal of the
select set of topped out measures identified in Table 21, through
notice and comment rulemaking, provided they are identified as topped
out during the previous two (or more) consecutive
[[Page 30106]]
years. In our example, Year 3 would be the 2019 performance period.
Year 4: Measure benchmarks are identified as topped out in
the benchmarks published for the 2020 MIPS performance period. Measure
benchmarks identified as topped out for a second (or more) consecutive
year continue to have special scoring applied. Topped out measures
finalized for removal for the 2020 MIPS performance period are no
longer available for reporting.
An example of applying the proposed scoring cap compared to scoring
applied for the 2017 MIPS performance period is provided in Table 22.
Table 22--Proposed Scoring for Topped Out Measures* Starting in the CY 2018 MIPS Performance Period Compared to the Transition Year Scoring
--------------------------------------------------------------------------------------------------------------------------------------------------------
Quality Cate-
Scoring policy Measure 1 Measure 2 Measure 3 Measure 4 Measure 5 (not Measure 6 (not gory Percent
(topped out) (topped out) (topped out) (topped out) topped out) topped out) Score *
--------------------------------------------------------------------------------------------------------------------------------------------------------
2017 MIPS performance period 10 measure 10 measure 10 measure 4 measure 10 measure 5 measure 49/60 = 81.67%.
Scoring. achievement achievement achievement achievement achievement achievement
points. points. points. points (did not points. points.
get max score).
Proposed Capped Scoring 6 measure 6 measure 6 measure 4 measure 10 measure 5 measure 37/60 = 61.67%.
applied. achievement achievement achievement achievement achievement achievement
points. points. points. points. points. points.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Notes........................ Topped out measures scored with 6-point measure achievement point cap.
Cap does not impact score if the MIPS eligible clinician's score is
below the cap.
Still possible to earn maximum
measure achievement points on the
non-topped out measures.
--------------------------------------------------------------------------------------------------------------------------------------------------------
* This example would only apply to the 6 measures identified in Table 21 for the CY 2018 MIPS Performance Period. This example also excludes bonus
points and improvement scoring proposed in section II.C.7.a.(2)(i) of this proposed rule.
Together the proposed policies for phasing in capped scoring and
removing topped out measures are intended to provide an incentive for
MIPS eligible clinicians to begin to submit measures that are not
topped out while also providing stability by allowing MIPS eligible
clinicians who have few alternative measures to continue to receive
standard scoring for most topped out measures for an additional year,
and not perform below the median score for those 6 measures that
receive special scoring. It also provides MIPS eligible clinicians the
ability to anticipate and plan for the removal of specific topped out
measures, while providing measure developers time to develop new
measures.
We propose to add a new paragraph at Sec. 414.1380(b)(1)(xiii) to
codify our proposal for the lifecycle for removing topped out measures.
We also propose to add at Sec. 414.1380(b)(1)(xiii)(A) that for
the 2018 MIPS performance period, the 6 measures identified in Table 21
will receive a maximum of 6 measure achievement points, provided that
the measure benchmarks are identified as topped out again in the
benchmarks published for the 2018 MIPS performance period. We also
propose to add at Sec. 414.1380(b)(1)(xiii)(B) that beginning with the
2019 MIPS performance period, measure benchmarks, except for measures
in the CMS Web Interface, that are identified as topped out for two 2
or more consecutive years will receive a maximum of 6 measure
achievement points in the second consecutive year it is identified as
topped out, and beyond. We specifically seek comment on whether the
proposed policy to cap the score of topped out measures beginning with
the 2019 performance period should apply to SSMs in the CAHPS for MIPS
survey measure or whether there is another alternative policy that
could be applied for the CAHPS for MIPS survey measure due to high,
unvarying performance within the SSM. We note that we would like to
encourage groups to report the CAHPS for MIPS survey as it incorporates
beneficiary feedback.
We stated in the CY 2017 Quality Payment Program final rule that we
do not believe it would be appropriate to remove topped out measures
from the CMS Web Interface for the Quality Payment Program because the
CMS Web Interface measures are used in MIPS and in APMs such as the
Shared Savings Program and because we have aligned policies, where
possible, with the Shared Savings Program, such as using the Shared
Savings Program benchmarks for the CMS Web Interface measures (81 FR
77285). In the CY 2017 Quality Payment Program final rule, we also
finalized that MIPS eligible clinicians submitting via the CMS Web
Interface must submit all measures included in the CMS Web Interface
(81 FR 77116). Thus, if a CMS Web Interface measure is topped out, the
CMS Web Interface submitter cannot select other measures. Because of
the lack of ability to select measures, we are not proposing to apply a
special scoring adjustment to topped out measures for CMS Web Interface
for the Quality Payment Program.
Additionally, because the Shared Savings Program incorporates a
methodology for measures with high performance into the benchmark, we
do not believe capping benchmarks from the CMS Web Interface for the
Quality Payment Program is appropriate. We finalized in the CY 2017
Quality Payment Program final rule at Sec. 414.1380(b)(1)(ii)(A) to
use benchmarks from the corresponding reporting year of the Shared
Savings Program. The Shared Savings Program adjusts some benchmarks to
a flat percentage when the 60th percentile is equal to or greater than
80.00 percent for individual measures (78 FR 74759 through 74763), and,
for other measures, benchmarks are set using flat percentages when the
90th percentile for a measure are equal to or greater than 95.00
percent (79 FR 67925). Thus, we are not proposing to apply the topped
out measure cap to measures in the CMS Web Interface for the Quality
Payment Program.
We seek comment on this proposal not to apply the topped out
measure cap to measures in the CMS Web Interface for the Quality
Payment Program.
(d) Case Minimum Requirements and Measure Reliability and Validity
To help ensure reliable measurement, in the CY 2017 Quality Payment
Program final rule (81 FR 77288), we finalized a 20-case minimum for
all quality measures except the all-cause hospital readmission measure.
For the all-cause hospital readmission measure, we finalized in the CY
2017 Quality Payment Program final rule a 200-case minimum and
finalized to apply the all-cause hospital readmission measure only to
groups of 16 or more clinicians that meet the 200-case minimum
requirement (81 FR 77288).
[[Page 30107]]
We are not proposing any changes to these policies.
For the 2019 MIPS payment year, we finalized in the CY 2017 Quality
Payment Program final rule that if the measure is submitted but is
unable to be scored because it does not meet the required case minimum,
does not have a benchmark, or does not meet the data completeness
requirement, the measure would receive a score of 3 points (81 FR 77288
through 77289). We identified two classes of measures for the
transition year. Class \9\ 1 measures are measures that can be scored
based on performance because they have a benchmark, meet the case
minimum requirement, and meet the data completeness standard. We
finalized that Class 1 measures would receive 3 to 10 points based on
performance compared to the benchmark (81 FR 77289). Class 2 measures
are measures that cannot be scored based on performance because they do
not have a benchmark, do not have at least 20 cases, or the submitted
measure does not meet data completeness criteria. We finalized that
Class 2 measures, which do not include measures submitted with the CMS
Web Interface or administrative claims-based measures, receive 3 points
(81 FR 77289).
---------------------------------------------------------------------------
\9\ References to ``Classes'' of measures in this section
II.C.7.a.(2)(d) are intended only to characterize the measures for
ease of discussion.
---------------------------------------------------------------------------
We propose to maintain the policy to assign 3 points for measures
that are submitted but do not meet the required case minimum or does
not have a benchmark for the 2020 MIPS payment year and amend Sec.
414.1380(b)(1)(vii) accordingly.
We also propose a change to the policy for scoring measures that do
not meet the data completeness requirement for the 2020 MIPS payment
year.
To encourage complete reporting, we are proposing that in the 2020
MIPS payment year, measures that do not meet data completeness
standards will receive 1 point instead of the 3 points that were
awarded in the 2019 MIPS payment year. We propose lowering the point
floor to 1 for measures that do not meet data completeness standards
for several reasons. First, we want to encourage complete reporting
because data completeness is needed to reliably measure quality.
Second, unlike case minimum and availability of a benchmark, data
completeness is within the direct control of the MIPS eligible
clinician. In the future, we intend that measures that do not meet the
completeness criteria will receive zero points; however, we believe
that during the second year of transitioning to MIPS, clinicians should
continue to receive at least 1 measure achievement point for any
submitted measure, even if the measure does not meet the data
completeness standards.
We are concerned, however, that data completeness may be harder to
achieve for small practices. For example, small practices tend to have
small case volume and missing one or two cases could cause the MIPS
eligible clinician to miss the data completeness standard as each case
may represent multiple percentage points for data completeness. For
example, for a small practice with only 20 cases for a measure, each
case is worth 5 percentage points, and if they miss reporting just 11
or more cases, they would fail to meet the data completeness threshold,
whereas for a practice with 200 cases, each case is worth 0.5
percentage points towards data completeness and the practice would have
to miss more than 100 cases to fail to meet the data completeness
criteria. Applying 1 point for missing data completeness based on
missing a relatively small number of cases could disadvantage these
clinicians, who may have additional burdens for reporting in MIPS,
although we also recognize that failing to report on 10 or more
patients is undesirable. In addition, we know that many small practices
may have less experience with submitting quality performance category
data and may not yet have systems in place to ensure they can meet the
data completeness criteria. Thus, we are also proposing an exception to
the proposed policy for measures submitted by small practices, as
defined in Sec. 414.1305. We propose that these clinicians would
continue to receive 3 points for measures that do not meet data
completeness.
Therefore, we propose to revise Class 2 measures to include only
measures that cannot be scored based on performance because they do not
have a benchmark or do not have at least 20 cases. We also propose to
create Class 3 measures, which are measures that do not meet the data
completeness requirement. We propose that the revised Class 2 measure
would continue to receive 3 points. The proposed Class 3 measures would
receive 1 point, except if the measure is submitted by a small practice
in which case the Class 3 measure would receive 3 points. However,
consistent with the policy finalized in the CY 2017 Quality Payment
Program final rule, these policies for Class 2 and Class 3 measures
would not apply to measures submitted with the CMS Web Interface or
administrative claims-based measures. A summary of the proposals is
provided in Table 23.
Table 23--Quality Performance Category: Scoring Measures Based on Performance
----------------------------------------------------------------------------------------------------------------
Scoring rules in 2017 Description proposed Proposed for 2018
Measure type Description in MIPS performance for 2018 MIPS MIPS performance
transition year period performance period period
----------------------------------------------------------------------------------------------------------------
Class 1.............. Measures that can be 3 to 10 points based Same as transition Same as transition
scored based on on performance year. year.
performance. compared to the 3 to 10 points based
Measures that were benchmark. on performance
submitted or compared to the
calculated that met benchmark.
the following
criteria:
(1) The measure
has a benchmark;.
(2) Has at least
20 cases; and.
(3) Meets the data
completeness
standard
(generally 50
percent.).
[[Page 30108]]
Class 2.............. Measures that cannot 3 points............. Measures that were 3 points
be scored based on * This Class 2 submitted and meet *This Class 2
performance. measure policy does data completeness, measure policy
Measures that were not apply to CMS Web but does not have would not apply to
submitted, but fail Interface measures one or both of the CMS Web Interface
to meet one of the and administrative following: measures and
Class 1 criteria. claims based (1) a benchmark...... administrative
The measure either measures. (2) at least 20 cases claims based
measures.
(1) does not have
a benchmark,.
(2) does not have
at least 20
cases, or.
(3) does not meet
data completeness
criteria..
Class 3.............. n/a.................. n/a.................. Measures that were 1 point except for
submitted, but do small practices,
not meet data which would receive
completeness 3 points.
criteria, regardless *This Class 3
of whether they have measure policy
a benchmark or meet would not apply to
the case minimum. CMS Web Interface
measures and
administrative
claims based
measures.
----------------------------------------------------------------------------------------------------------------
We propose to amend Sec. 414.1380(b)(1)(vii) to assign 3 points
for measures that do not meet the case minimum or do not have a
benchmark in the 2020 MIPS payment year, and to assign 1 point for
measures that do not meet data completeness requirements, unless the
measure is submitted by a small practice, in which case it would
receive 3 points.
We invite comment on our proposal to assign 1 point to measures
that do not meet data completeness criteria, with an exception for
measures submitted by small practices.
We are not proposing to change the methodology we use to score
measures submitted via the CMS Web Interface that do not meet the case
minimum, do not have a benchmark, or do not meet the data completeness
requirement finalized in the CY 2017 Quality Payment Program final rule
and codified at paragraph (b)(1)(viii) of Sec. 414.1380. However, we
note that as described in section II.C.7.a.(2)(h)(ii) of this proposed
rule, we are proposing to add that CMS Web Interface measures with a
benchmark that are redesignated from pay for performance to pay for
reporting by the Shared Savings Program will not be scored. We refer
readers to the discussion at 81 FR 77288 for more details on our
previously finalized policy.
We are also not proposing any changes to the policy to not include
administrative claims measures in the quality performance category
percent score if the case minimum is not met or if the measure does not
have a benchmark finalized in the CY 2017 Quality Payment Program final
rule and codified at paragraph (b)(1)(viii) of Sec. 414.1380. We refer
readers to the discussion at 81 FR 77288 for more details on that
policy.
To clarify the exclusion of measures submitted via the CMS Web
Interface and based on administrative claims from the policy changes
proposed to be codified at paragraph (b)(1)(vii) previously, we are
amending paragraph (b)(1)(vii) to make it subject to paragraph
(b)(1)(viii), which codifies the exclusion.
(e) Scoring for MIPS Eligible Clinician That Do Not Meet Quality
Performance Category Criteria
In the CY 2017 Quality Payment Program final rule, we finalized
that MIPS eligible clinicians who fail to submit a measure that is
required to satisfy the quality performance category submission
criteria would receive zero points for that measure (81 FR 77291). For
each required measure that is not submitted, a MIPS eligible clinician
would receive zero points out of 10. For example, if a MIPS eligible
clinician had 6 measures available and applicable but submitted only 4
measures, the MIPS eligible clinician would be assigned zero out of 10
measure achievement points for the 2 missing measures, which would be
calculated into their performance category percent score.
We are not proposing any changes to the policy to assign zero
points for failing to submit a measure that is required in this
proposed rule.
In the CY 2017 Quality Payment Program final rule, we also
finalized implementation of a validation process for claims and
registry submissions to validate whether MIPS eligible clinicians have
6 applicable and available measures, whether an outcome measure is
available or whether another high priority measure is available if an
outcome measure is not available (81 FR 77290 through 77291).
We are not proposing any changes to apply a process to validate
whether MIPS eligible clinicians that submit measures via claims and
registry submissions have measures available and applicable. As stated
in the CY 2017 Quality Payment Program final rule (81 FR 77290), we did
not intend to establish a validation process for QCDRs because we
expect that MIPS eligible clinicians that enroll in QCDRs will have
sufficient meaningful measures to meet the quality performance category
criteria (81 FR 77290 through 77291). We do not propose any changes to
this policy.
We also stated that if a MIPS eligible clinician did not have 6
measures relevant within their EHR to meet the full specialty set
requirements or meet the requirement to submit 6 measures, the MIPS
eligible clinician should select a different submission mechanism to
meet the quality performance category requirements and should work with
their EHR vendors to incorporate applicable measures as feasible (81 FR
77290 through 77291). Under our proposals in section II.C.6.a.(1) of
this proposed rule to allow measures to be submitted and scored via
multiple mechanisms within a performance category, we anticipate that
MIPS
[[Page 30109]]
eligible clinicians that submit fewer than 6 measures via EHR will have
sufficient additional measures available via a combination of
submission mechanisms to submit the measures required to meet the
quality performance category criteria. For example, the MIPS eligible
clinician could submit 2 measures via EHR and supplement that with 4
measures via QCDR or registry.
Therefore, given our proposal to score multiple mechanisms, if a
MIPS eligible clinician submits any quality measures via EHR or QCDR,
we would not conduct a validation process because we expect these MIPS
eligible clinicians to have sufficient measures available to meet the
quality performance category requirements.
Given our proposal in section II.C.7.a.(2)(h) of this proposed rule
to score measures submitted via multiple mechanisms, we propose to
validate the availability and applicability of measures only if a MIPS
eligible clinician submits via claims submission options only, registry
submission options only, or a combination of claims and registry
submission options. In these cases, we propose that we will apply the
validation process to determine if other measures are available and
applicable broadly across claims and registry submission options. We
will not check if there are measures available via EHR or QCDR
submission options for these reporters. We note that groups cannot
report via claims and therefore groups and virtual groups will only
have validation applied across registries. We would validate the
availability and applicability of a measure through a clinically
related measure analysis based on patient type, procedure, or clinical
action associated with the measure specifications. For us to recognize
fewer than 6 measures, an individual MIPS eligible clinician must
submit exclusively using claims or qualified registries or a
combination of the two, and a group or virtual group must submit
exclusively using qualified registries. Given our proposal in section
II.C.7.a.(2)(h) of this proposed rule to score measures submitted via
multiple mechanisms, validation will be conducted first by applying the
clinically related measure analysis for the individual measure and
then, to the extent technically feasible, validation will be applied to
check for available measures available via both claims and registries.
We recognize that in extremely rare instances there may be a MIPS
eligible clinician who may not have available and applicable quality
measures. For example, a subspecialist who focuses on a very targeted
clinical area may not have any measures available. However, in many
cases, the clinician may be part of a broader group or would have the
ability to select some of the cross-cutting measures that are
available. Given the wide array of submission options, including QCDRs
which have the flexibility to develop additional measures, we believe
this scenario should be extremely rare. If we are not able to score the
quality performance category, we may reweight their score according to
the reweighting policies described in section II.C.7.b.(3)(b) and
II.C.7.b.(3)(d) of this proposed rule. We note that we anticipate this
will be a rare circumstance given our proposals to allow measures to be
submitted and scored via multiple mechanisms within a performance
category and to allow facility-based measurement for the quality
performance category.
(f) Incentives To Report High Priority Measures
In the CY 2017 Quality Payment Program final rule, we finalized
that we would award 2 bonus points for each outcome or patient
experience measure and 1 bonus point for each additional high priority
measure that is reported in addition to the 1 high priority measure
that is already required to be reported under the quality performance
category submission criteria, provided the measure has a performance
rate greater than zero, and the measure meets the case minimum and data
completeness requirements (81 FR 77293). High priority measures were
defined as outcome, appropriate use, patient safety, efficiency,
patient experience and care coordination measures, as identified in
Tables A and E in the Appendix of the CY 2017 Quality Payment Program
final rule (81 FR 77558 and 77686). We also finalized that we will
apply measure bonus points for the CMS Web Interface for the Quality
Payment Program based on the finalized set of measures reportable
through that submission mechanism (81 FR 77293). We note that in
addition to the 14 required measures, CMS Web Interface reporters may
also report the CAHPS for MIPS survey and receive measure bonus points
for submitting that measure.
We are not proposing any changes to these policies for awarding
measure bonus points for reporting high priority measures in this
proposed rule.
In the CY 2017 Quality Payment Program final rule, we finalized a
cap on high priority measure bonus points at 10 percent of the
denominator (total possible measure achievement points the MIPS
eligible clinician could receive in the quality performance category)
of the quality performance category for the first 2 years of MIPS (81
FR 77294). Groups that submit via the CMS Web Interface for the Quality
Payment Program are also subject to the 10 percent cap on high priority
measure bonus points. We are not proposing any changes to the cap on
measure bonus points for reporting high priority measures, which is
codified at Sec. 414.1380(b)(1)(xiv)(D) \10\, in this proposed rule.
---------------------------------------------------------------------------
\10\ Redesignated from Sec. 414.1380(b)(1)(xiii)(D).
---------------------------------------------------------------------------
(g) Incentives to Use CEHRT To Support Quality Performance Category
Submissions
Section 1848(q)(5)(B)(ii) of the Act outlines specific scoring
rules to encourage the use of CEHRT under the quality performance
category. For more of the statutory background and description of the
proposed and finalized policies, we refer readers to the CY 2017
Quality Payment Program final rule (81 FR 77294 through 77299).
In the CY 2017 Quality Payment Program final rule at Sec.
414.1380(b)(1)(xiv), we codified that 1 bonus point is available for
each quality measure submitted with end-to-end electronic reporting,
under certain criteria described below (81 FR 77297). We also finalized
a policy capping the number of bonus points available for electronic
end-to-end reporting at 10 percent of the denominator of the quality
performance category percent score, for the first 2 years of the
program (81 FR 77297). For example, when the denominator is 60, the
number of measure bonus points will be capped at 6 points. We also
finalized that the CEHRT bonus would be available to all submission
mechanisms except claims submissions. Specifically, MIPS eligible
clinicians who report via qualified registries, QCDRs, EHR submission
mechanisms, or the CMS Web Interface for the Quality Payment Program,
in a manner that meets the end-to-end reporting requirements, may
receive 1 bonus point for each reported measure with a cap as described
(81 FR 77297).
We are not proposing changes to these policies related to bonus
points for using CEHRT for end-to-end reporting in this proposed rule.
However, we are seeking comment on the use of health IT in quality
measurement and how HHS can encourage the use of certified EHR
technology in quality measurement as established in the statute. What
other incentives within this category for reporting in an end-to-end
manner could be leveraged to incentivize more clinicians to report
electronically? What format should these incentives take? For
[[Page 30110]]
example, should clinicians who report all of their quality performance
category data in an end-to-end manner receive additional bonus points
than those who report only partial electronic data? Are there other
ways that HHS should incentivize providers to report electronic quality
data beyond what is currently employed? We welcome public comment on
these questions.
(h) Calculating Total Measure Achievement and Measure Bonus Points
In section II.C.7.a.(2)(i) of this proposed rule, we are proposing
a new methodology to reward improvement based on achievement, from 1
year to another, which requires modifying the calculation of the
quality performance category percent score. In this section
II.C.7.a.(2)(h) of the proposed rule, we are summarizing the policies
for calculating the total measure achievement points and total measure
bonus points, prior to scoring improvement and the final quality
performance category percent score. We note that we will refer to
policies finalized in the CY 2017 Quality Payment Program final rule
that apply to the quality performance category score, which is referred
to as the quality performance category percent score in this proposed
rule, in this section. We are also proposing some refinements to
address the ability for MIPS eligible clinicians to submit quality data
via multiple submission mechanisms.
(i) Calculating Total Measure Achievement and Measure Bonus Points for
Non-CMS Web Interface Reporters
In the CY 2017 Quality Payment Program final rule (81 FR 77300), we
finalized that if a MIPS eligible clinician elects to report more than
the minimum number of measures to meet the MIPS quality performance
category criteria, then we will only include the scores for the
measures with the highest number of assigned points, once the first
outcome measure is scored, or if an outcome measure is not available,
once another high priority measure is scored. We are not proposing any
changes to the policy to score the measures with the highest number of
assigned points in this proposed rule; however, we are proposing
refinements to account for measures being submitted across multiple
submission mechanisms.
In the CY 2017 Quality Payment Program final rule, we sought
comment on whether to score measures submitted across multiple
submission mechanisms (81 FR 77275). As described in section
II.C.6.a.(1) of this proposed rule, we are proposing that MIPS eligible
clinicians be able to submit measures within a performance category via
multiple submission mechanisms. In the CY 2017 Quality Payment Program
final rule, we also sought comment on what approach we should use to
combine the scores for quality measures from multiple submission
mechanisms into a single aggregate score for the quality performance
category (81 FR 77275). Examples of possible scoring options were a
weighted average score on quality measures submitted through two or
more different mechanisms or taking the highest scores for any
submitted measure regardless of how the measure is submitted. A few
comments received in response to the CY 2017 Quality Payment Program
final rule did not support developing different weights for different
submission methods. One commenter recommended that we take the highest
score for any submitted measure, regardless of submission mechanisms,
or alternatively, calculate independent scores that would each
contribute equally to the final score.
After consideration of the comments we received, we are proposing,
beginning with the 2018 MIPS performance period, a method to score
quality measures if a MIPS eligible clinician submits measures via more
than one of the following submission mechanisms: Claims, qualified
registry, EHR or QCDR submission options. We believe that allowing MIPS
eligible clinicians to be scored across these data submission
mechanisms in the quality performance category will provide additional
options for MIPS eligible clinicians to report the measures required to
meet the quality performance category criteria, and encourage MIPS
eligible clinicians to begin using electronic submission mechanisms,
even if they may not have 6 measures to report via a single electronic
submission mechanism alone. We note that we also continue to score the
CMS-approved survey vendor for CAHPS for MIPS submission options in
conjunction with other submission mechanisms (81 FR 77275) as noted in
Table 24.
We propose to score measures across multiple mechanisms using the
following rules:
As with the rest of MIPS, we will only score measures
within a single identifier. For example, as codified in Sec.
414.1310(e), eligible clinicians and MIPS eligible clinicians within a
group aggregate their performance data across the TIN in order for
their performance to be assessed as a group. Therefore, measures can
only be scored across multiple mechanisms if reported by the same
individual MIPS eligible clinician, group, virtual group or APM Entity,
as described in Table 24.
We do not propose to aggregate measure results across
different submitters to create a single score for an individual measure
(for example, we are not going to aggregate scores from different TINs
within a virtual group TIN to create a single virtual group score for
the measures; rather, virtual groups must perform that aggregation
across TINs prior to data submission to CMS). Virtual groups are
treated like other groups and must report all of their measures at the
virtual group level, for the measures to be scored. Data completeness
and all the other criteria will be evaluated at the virtual group
level. Then the same rules apply for selecting which measures are used
for scoring. In other words, if a virtual group representative submits
some measures via a qualified registry and other measures via EHR, but
an individual TIN within the virtual group also submits measures, we
will only use the scores from the measures that were submitted at the
virtual group level, because the TIN submission does not use the
virtual group identifier. This is consistent with our other scoring
principles, where, for virtual groups, all quality measures are scored
at the virtual group level.
Separately, as also described in Table 24, because CMS Web
Interface and facility-based measurement each have a comprehensive set
of measures that meet the proposed MIPS submission requirements, we do
not propose to combine CMS Web Interface measures or facility-based
measurement with other group submission mechanisms (other than CAHPS
for MIPS, which can be submitted in conjunction with the CMS Web
Interface). We refer readers to section II.C.7.a.(2)(h)(ii) of this
proposed rule for discussion of calculating the total measure
achievement and measure bonus points for CMS Web Interface reporters
and to section II.C.7.a.(4) of this proposed rule for a description of
our proposed policies on facility-based measurement. We list these
submission mechanisms in Table 24, to illustrate that CMS Web Interface
submissions and facility-based measurement cannot be combined with
other submission options, except that the CAHPS for MIPS survey can be
combined with CMS Web Interface, as described in section
II.C.7.a.(2)(h)(ii) of this proposed rule.
[[Page 30111]]
Table 24--Scoring Allowed Across Multiple Mechanisms by Submission
Mechanism
[Determined by MIPS identifier and submission mechanism]
------------------------------------------------------------------------
When can quality measures be
MIPS identifier and submission scored across multiple
mechanisms mechanisms?
------------------------------------------------------------------------
Individual eligible clinician reporting Can combine claims, EHR, QCDR,
via claims, EHR, QCDR, and registry and registry.
submission options.
Group reporting via EHR, QCDR, Can combine EHR, QCDR,
registry, and the CAHPS for MIPS registry, and CAHPS for MIPS
survey. survey.
Virtual group reporting via EHR, QCDR, Can combine EHR, QCDR,
registry, and the CAHPS for MIPS registry, and CAHPS for MIPS
survey. survey.
Group reporting via CMS Web Interface.. Cannot be combined with other
submission mechanisms, except
for the CAHPS for MIPS survey.
Virtual group reporting via CMS Web Cannot be combined with other
Interface. submission mechanisms, except
for the CAHPS for MIPS survey.
Individual or group reporting facility- Cannot be combined with other
based measures. submission mechanisms.
MIPS APMs reporting Web Interface or MIPS APMs are subject to
other quality measures. separate scoring standards and
cannot be combined with other
submission mechanisms.
------------------------------------------------------------------------
If a MIPS eligible clinician submits the same measure via
2 different submission mechanisms, we will score each mechanism by
which the measure is submitted for achievement and take the highest
measure achievement points of the 2 mechanisms.
Measure bonus points for high priority measures would be
added for all measures submitted via all the different submission
mechanisms available, even if more than 6 measures are submitted, but
high priority measure bonus points are only available once for each
unique measure (as noted by the measure number) that meets the criteria
for earning the bonus point. For example, if a MIPS eligible clinician
submits 8 measures--6 process and 2 outcome--and both outcome measures
meet the criteria for a high priority bonus (meeting the required data
completeness, case minimum, and has a performance rate greater than
zero), the outcome measure with the highest measure achievement points
would be scored as the required outcome measure and then the measures
with the next 5 highest measure achievement points will contribute to
the final quality score. This could include the second outcome measure
but does not have to. Even if the measure achievement points for the
second outcome measure are not part of the quality performance category
percent score, measure bonus points would still be available for
submitting a second outcome measure and meeting the requirement for the
high priority measure bonus points. The rationale for providing measure
bonus points for measures that do not contribute measure achievement
points to the quality performance category percent score is that it
would help create better benchmarks for outcome and other high priority
measures by encouraging clinicians to report them even if they may not
have high performance on the measure. We also want to encourage MIPS
eligible clinicians to submit to us all of their available MIPS data,
not only the data that they or their intermediary deem to be their best
data. We believe it will be in the best interest of all MIPS eligible
clinicians that we determine which measures will result in the
clinician receiving the highest MIPS score. If the same measure is
submitted through multiple submission mechanisms, we would apply the
bonus points only once to the measure. We propose to amend Sec.
414.1380(b)(1)(xiv) (as redesignated from Sec. 414.1380(b)(1)(xiii))
to add paragraph (b)(1)(xiv)(E) that if the same high priority measure
is submitted via two or more submission mechanisms, as determined using
the measure ID, the measure will receive high priority measure bonus
points only once for the measure. The total measure bonus points for
high-priority measures would still be capped at 10 percent of the total
possible measure achievement points.
Measure bonus points that are available for the use of
end-to-end electronic reporting would be calculated for all submitted
measures across all submission mechanisms, including measures that
cannot be reliably scored against a benchmark. If the same measure is
submitted through multiple submission mechanisms, then we would apply
the bonus points only once to the measure. For example, if the same
measure is submitted using end-to-end reporting via both a QCDR and EHR
reporting mechanism, the measure would only get a measure bonus point
one time. We propose to amend Sec. 414.1380(b)(1)(xv) (as
redesignated) to add that if the same measure is submitted via two or
more submission mechanisms, as determined using the measure ID, the
measure will receive measure bonus points only once for the measure.
The total measure bonus points for end-to-end electronic reporting
would still be capped at 10 percent of the total available measure
achievement points.
Although we provide a policy to account for scoring in those
circumstances when the same measure is submitted via multiple
mechanisms, we anticipate that this will be a rare circumstance and do
not encourage clinicians to submit the same measure via multiple
mechanisms. Table 25 illustrates how we would assign total measure
achievement points and total measure bonus points across multiple
submission mechanisms under our proposal. In this example, a MIPS
eligible clinician elects to submit quality data via 3 submission
mechanisms: 3 Measures via registry, 4 measures via claims, and 5
measures via EHR. The 3 registry measures are also submitted via claims
(as noted by the same measure letter in this example). The EHR measures
do not overlap with either the registry or claims measures. In this
example, we assign measure achievement and bonus points for each
measure. If the same measure (as determined by measure ID) is
submitted, then we use the highest achievement points for that measure.
For the bonus points, we assess which of the outcome measures meets the
outcome measure requirement and then we identify any other unique
measures that qualify for the high priority bonus. We also identify the
unique measures that qualify for end-to-end electronic reporting bonus.
[[Page 30112]]
Table 25--Example of Assigning Total Measure Achievement and Bonus Points for an Individual MIPS Eligible
Clinician That Submits Measures Across Multiple Submission Mechanisms
----------------------------------------------------------------------------------------------------------------
High priority Incentive for
Measure achievement 6 Scored measures measure bonus CEHRT measure
points points bonus points
----------------------------------------------------------------------------------------------------------------
Registry
----------------------------------------------------------------------------------------------------------------
Measure A (Outcome)............ 7.1................... 7.1 (Outcome (required outcome
measure with measure does not
highest receive bonus
achievement points).
points).
Measure B...................... 6.2 (points not
considered because it
is lower than the 8.2
points for the same
claims measure).
Measure C (high priority 5.1 (points not ................. 1
patient safety measure that considered because it
meets requirements for is lower than the 6.0
additional bonus points). points for the same
claims measure).
----------------------------------------------------------------------------------------------------------------
Claims
----------------------------------------------------------------------------------------------------------------
Measure A (Outcome)............ 4.1 (points not ................. No bonus points
considered because it because the
is lower than the 7.1 registry
points for the same submission of
measure submitted via the same measure
a registry). satisfies
requirement for
outcome measure.
Measure B...................... 8.2................... 8.2
Measure C (High priority 6.0................... 6.0.............. No bonus (Bonus
patient safety measure that applied to the
meets requirements for registry
additional bonus points). measure).
Measure D (outcome measure <50% 1.0................... 1.0.............. (no high priority
of data submitted). bonus points
because below
data
completeness).
----------------------------------------------------------------------------------------------------------------
EHR (using end-to-end) Reporting that
meets CEHRT
bonus point
criteria
----------------------------------------------------------------------------------------------------------------
Measure E...................... 5.1................... 5.1.............. ................. 1
Measure F...................... 5.0................... 5.0.............. ................. 1
Measure G...................... 4.1................... ................. ................. 1
Measure H...................... 4.2................... 4.2.............. ................. 1
Measure I (high priority 3.0................... ................. (no high priority 1
patient safety measure that is bonus points
below case minimum). because below
case minimum).
35.6.................. 1 (below 10% 5 (below 10% cap)
cap\1\).
--------------------------------------------------------
Quality Performance Category ...................... (35.6 + 1 + 5)/60 = 69.33%
Percent Score Prior to
Improvement Scoring.
----------------------------------------------------------------------------------------------------------------
\1\ In this example the cap would be 6 points, which is 10 percent of the total available measure achievement
points of 60.
We propose to amend Sec. 414.1380(b)(1)(xii) to add paragraph (A)
to state that if a MIPS eligible clinician submits measures via claims,
qualified registry, EHR, or QCDR submission options, and submits more
than the required number of measures, they are scored on the required
measures with the highest assigned measure achievement points. MIPS
eligible clinicians that report a measure via more than 1 submission
mechanism can be scored on only 1 submission mechanism, which will be
the submission mechanism with the highest measure achievement points.
Groups that submit via these submission mechanisms may also submit and
be scored on CMS-approved survey vendor for CAHPS for MIPS submission
mechanisms.
We invite comments on our proposal to calculate the total measure
achievement points by using the measures with the 6 highest measure
achievement points across multiple submission mechanisms. We invite
comments on our proposal that if the same measure is submitted via 2 or
more mechanisms, we will only take the one with the highest measure
achievement points. We invite comments on our proposal to assign high
priority measure bonus points to all measures, with performance greater
than zero, that meet case minimums, and that meet data completeness
requirements, regardless of submission mechanism and to assign measure
[[Page 30113]]
bonus points for each unique measure submitted using end-to-end
electronic reporting. We invite comments on our proposal that if the
same measure is submitted using 2 different mechanisms, the measure
will receive measure bonus points once.
We are not proposing any changes to our policy that if a MIPS
eligible clinician does not have any scored measures, then a quality
performance category percent score will not be calculated as finalized
in the CY 2017 Quality Payment Program final rule at 81 FR 77300. We
refer readers to the discussion at 81 FR 77299 through 77300 for more
details on that policy. As stated in section II.C.7.a.(2)(e) of this
proposed rule, we anticipate that it will be only in rare case that a
MIPS eligible clinician does not have any scored measures and a quality
performance category percent score cannot be calculated.
(ii) Calculating Total Measure Achievement and Measure Bonus Points for
CMS Web Interface Reporters
In the CY 2017 Quality Payment Program final rule, we finalized
that CMS Web Interface reporters are required to report 14 measures, 13
individual measures, and a 2-component measure for diabetes (81 FR
77302 through 77305). We note that for the transition year, 3 measures
did not have a benchmark in the Shared Savings Program. Therefore, for
the transition year, CMS Web Interface reporters are scored on 11 of
the total 14 required measures, provided that they report all 14
required measures.
In the CY 2017 Quality Payment Program final rule, we finalized a
global floor of 3 points for all CMS Web Interface measures submitted
in the transition year, even with measures at zero percent performance
rate, provided that these measures have met the data completeness
criteria, have a benchmark and meet the case minimum requirements (82
FR 77305). Therefore, measures with performance below the 30th
percentile will be assigned a value of 3 points during the transition
year to be consistent with the floor established for other measures and
because the Shared Savings Program does not publish benchmarks below
the 30th percentile (82 FR 77305). We stated that we will reassess
scoring for measures below the 30th percentile in future years.
We propose to continue to assign 3 points for measures with
performance below the 30th percentile, provided the measure meets data
completeness, has a benchmark, and meets the case minimum requirements
for the 2018 MIPS performance year; we make this proposal in order to
continue to align with the 3-point floor for other measures and because
the Shared Savings Program does not publish benchmarks with values
below the 30th percentile. We will reassess this policy again next year
through rulemaking.
We are not proposing any changes to our previously finalized policy
to exclude from scoring CMS Web Interface measures that are submitted
but that do not meet the case minimum requirement or that lack a
benchmark, or to our policy that measures that are not submitted and
measures submitted below the data completeness requirements will
receive a zero score (82 FR 77305). However, to further increase
alignment with the Shared Savings Program, we propose to also exclude
CMS Web Interface measures from scoring if the measure is redesignated
from pay for performance to pay for reporting for all Shared Savings
Program ACOs, although we will recognize the measure was submitted.
While the Shared Savings Program designates measures that are pay for
performance in advance of the reporting year, the Shared Savings
Program may redesignate a measure as pay for reporting under certain
circumstances (see 42 CFR 425.502(a)(5)). Therefore, we propose to
amend Sec. 414.1380(b)(1)(viii) to add that CMS Web Interface measures
that have a measure benchmark but are redesignated as pay for reporting
for all Shared Savings Program ACOs by the Shared Savings Program will
not be scored, as long as the data completeness requirement is met.
We invite comment on our proposal to not score CMS Web Interface
measures redesignated as pay for reporting by the Shared Savings
Program.
We also note that, while we did not state explicitly in the CY 2017
Quality Payment Program final rule, groups that choose to report
quality measures via the CMS Web Interface may, in addition to the 14
required measures, also submit the CAHPS for MIPS survey in the quality
performance category (81 FR 77094 through 77095; 81 FR 77292). If they
do so, they can receive bonus points for submitting this high priority
measure and will be scored on it as an additional measure. Therefore,
we propose to amend Sec. 414.1380(b)(1)(xii) to add paragraph (B) to
state that groups that submit measures via the CMS Web Interface may
also submit and be scored on CMS-approved survey vendor for CAHPS for
MIPS submission options.
In addition, groups of 16 or more eligible clinicians that meet the
case minimum for administrative claims measures will automatically be
scored on the all-cause hospital readmission measure and have that
measure score included in their quality category performance percent
score.
We are not proposing any changes to calculating the total measure
achievement points and measure bonus points for CMS Web Interface
measures in this proposed rule, although we are proposing to add
improvement to the quality performance category percent score for such
submissions (as well as other submission mechanisms) in section
II.C.7.a.(2)(j) of this proposed rule.
(i) Scoring Improvement for the MIPS Quality Performance Category
Percent Score
(i) Calculating Improvement at the Quality Performance Category Level
In the CY 2017 Quality Payment Program final rule, we noted that we
consider achievement to mean how a MIPS eligible clinician performs
relative to performance standards, and improvement to mean how a MIPS
eligible clinician performs compared to the MIPS eligible clinician's
own previous performance on measures and activities in the performance
category (81 FR 77274). We also solicited public comments in the CY
2017 Quality Payment Program proposed rule on potential ways to
incorporate improvement in the scoring methodology. In section
II.C.7.a.(1)(b)(i) of this proposed rule, we explain why we believe
that the options set forth in the CY 2017 Quality Payment Program
proposed rule, including the Hospital VBP Program, the Shared Savings
Program, and Medicare Advantage 5-star Ratings Program, were not fully
translatable to MIPS. Beginning with the 2018 MIPS performance period,
we propose here to score improvement as well as achievement in the
quality performance category level when data is sufficient. We believe
that scoring improvement at the performance category level, rather than
measuring improvement at the measure level, for the quality performance
category would allow improvement to be available to the broadest number
of MIPS eligible clinicians because we are connecting performance to
previous MIPS quality performance as a whole rather than changes in
performance for individual measures. Just as we believe it is important
for a MIPS eligible clinician to have the flexibility to choose
measures that are meaningful to their practice, we want them to be able
to adopt new measures without concern
[[Page 30114]]
about losing the ability to be measured on improvement. In addition, we
are encouraging MIPS eligible clinicians to select more outcome
measures and to move away from topped out measures. We do not want to
remove the opportunity to score improvement from those who select
different measures between performance periods for the quality
performance category; therefore, we are proposing to measure
improvement at the category level which can be calculated with
different measures.
We propose at Sec. 414.1380(b)(1)(xvi)(E) to define an improvement
percent score to mean the score that represents improvement for the
purposes of calculating the quality performance category percent score.
We also propose at Sec. 414.1380(b)(1)(xvi)(C) that an improvement
percent score would be assessed at the quality performance category
level and included in the calculation of the quality performance
category percent score. When we evaluated different improvement scoring
options, we saw two general methods for incorporating improvement. One
method measures both achievement and improvement and takes the higher
of the two scores for each measure that is compared. The Hospital VBP
Program incorporates such a methodology. The second method is to
calculate an achievement score and then add an improvement score if
improvement is measured. The Shared Savings Program utilizes a similar
methodology for measuring improvement. For the quality performance
category, we are proposing to calculate improvement at the category
level and believe adding improvement to an existing achievement percent
score would be the most straight-forward and simple way to incorporate
improvement. For the purpose of improvement scoring methodology, the
term ``quality performance category achievement percent score'' means
the total measure achievement points divided by the total possible
available measure achievement points, without consideration of bonus
points or improvement adjustments and is discussed in section
II.C.7.a.(2)(i)(iv) of this proposed rule.
Consistent with bonuses available in the quality performance
category, we propose at Sec. 414.1380(b)(1)(xvi)(B) that the
improvement percent score may not total more than 10 percentage points.
We invite public comments on these proposals.
(ii) Data Sufficiency Standard To Measure Improvement for Quality
Performance Category
Section 1848(q)(5)(D)(i) of the Act stipulates that beginning with
the second year to which the MIPS applies, if data sufficient to
measure improvement is available then we shall measure improvement for
the quality performance category. Measuring improvement requires a
direct comparison of data from one Quality Payment Program year to
another. Starting with the 2020 MIPS payment year, we propose that a
MIPS eligible clinician's data would be sufficient to score improvement
in the quality performance category if the MIPS eligible clinician had
a comparable quality performance category achievement percent score for
the MIPS performance period immediately prior to the current MIPS
performance period; we explain our proposal to identify how we will
identify ``comparable'' quality performance category achievement
percent scores below. We believe that this approach would allow
improvement to be broadly available to MIPS eligible clinicians and
encourage continued participation in the MIPS program. Moreover, this
approach would encourage MIPS eligible clinicians to focus on efforts
to improve the quality of care delivered. We note that, by measuring
improvement based only on the overall quality performance category
achievement percent score, some MIPS eligible clinicians and groups may
generate an improvement score simply by switching to measures on which
they perform more highly, rather than actually improving at the same
measures. We will monitor how frequently improvement is due to actual
improvement versus potentially perceived improvement by switching
measures and will address through future rulemaking, as needed. We also
solicit comment on whether we should require some level of year to year
consistency when scoring improvement.
We propose that ``comparability'' of quality performance category
achievement percent scores would be established by looking first at the
submitter of the data. As discussed in more detail in section
II.C.7.a.(2)(i)(i) of this proposed rule, we are comparing results at
the category, rather than the performance measure level because we
believe that the performance category score from 1 year is comparable
to the performance category score from the prior year, even if the
measures in the performance category have changed from year to year.
We propose to compare results from an identifier when we receive
submissions with that same identifier (either TIN/NPI for individual,
or TIN for group, APM entity, or virtual group identifier) for two
consecutive performance periods. However, if we do not have the same
identifier for two consecutive performance periods, we propose a
methodology to create a comparable performance category score that can
be used for improvement measurement. Just as we do not want to remove
the opportunity to earn an improvement score from those who elect new
measures between performance periods for the quality performance
category, we also do not want to restrict improvement for those MIPS
eligible clinicians who elect to participate in MIPS using a different
identifier.
There are times when submissions from a particular individual
clinician or group of clinicians use different identifiers between 2
years. For example, a group of 20 MIPS eligible clinicians could choose
to submit as a group (using their TIN identifier) for the current
performance period. If the group also submitted as a group for the
previous year's performance period, we would simply compare the group
scores associated with the previous performance period to the current
performance period (following the methodology explained in section
II.C.7.a.(2)(i)(iv) of this proposed rule). However, if the group
members had previously elected to submit to MIPS as individual
clinicians, we would not have a group score at the TIN level from the
previous performance period to which to compare the current performance
period.
In circumstances where we do not have the same identifier for two
consecutive performance periods, we propose to identify a comparable
score for individual submissions or calculate a comparable score for
group, virtual group, and APM entity submissions. For individual
submissions, if we do not have a quality performance category
achievement percent score for the same individual identifier in the
immediately prior period, then we propose to apply the hierarchy logic
that is described in section II.C.8.a.(2) of this proposed rule to
identify the quality performance category achievement score associated
with the final score that would be applied to the TIN/NPI for payment
purposes. For example, if there is no historical score for the TIN/NPI,
but there is a TIN score (because in the previous period the TIN
submitted as a group), then we would use the quality performance
category achievement
[[Page 30115]]
percent score associated with the TIN's prior performance. If the NPI
had changed TINs and there was no historical score for the same TIN/
NPI, then we would take the highest prior score associated with the
NPI.
When we do not have a comparable TIN group, virtual group, or APM
Entity score, we propose to calculate a score based on the individual
TIN/NPIs in the practice for the current performance period. For
example, in a group of 20 clinicians that previously participated in
MIPS as individuals, but now want to participate as a group, we would
not have a comparable TIN score to use for scoring improvement. We
believe however it is still important to provide to the MIPS eligible
clinicians the improvement points they have earned. Similarly, in cases
where a group of clinicians previously participated in MIPS as
individuals, but now participates as a new TIN, or a new virtual group,
or a new APM Entity submitting data in the performance period, we would
not have a comparable TIN, virtual group, or APM Entity score to use
for scoring improvement. Therefore, we propose to calculate a score by
taking the average of the individual quality performance category
achievement scores for the MIPS eligible clinicians that were in the
group for the current performance period. If we have more than one
quality performance category achievement percent score for the same
individual identifier in the immediately prior period, then we propose
to apply the hierarchy logic that is described in section II.C.8.a.(2)
of this proposed rule to identify the quality performance category
score associated with the final score that would be applied to the TIN/
NPI for payment purposes. We would exclude any TIN/NPI's that did not
have a final score because they were not eligible for MIPS. We would
include quality performance category achievement percent scores of zero
in the average.
There are instances where we would not be able to measure
improvement due to lack of sufficient data. For example, if the MIPS
eligible clinicians did not participate in MIPS in the previous
performance period because they were not eligible for MIPS, we could
not calculate improvement because we would not have a previous quality
performance category achievement percent score.
Table 26 summarizes the different cases when a group or individual
would be eligible for improvement scoring under this proposal.
Table 26--Eligibility for Improvement Scoring Examples
----------------------------------------------------------------------------------------------------------------
Prior MIPS
performance
Current MIPS period identifier Eligible for
Scenario performance (with score improvement Data comparability
period identifier greater than scoring
zero)
----------------------------------------------------------------------------------------------------------------
No change in identifier........ Individual (TIN A/ Individual (TIN A/ Yes.............. Current individual
NPI 1). NPI 1). score is compared to
individual score from
prior performance
period.
No change in identifier........ Group (TIN A).... Group (TIN A).... Yes.............. Current group score is
compared to group
score from prior
performance period.
Individual is with same group, Individual (TIN A/ Group (TIN A).... Yes.............. Current individual
but selects to submit as an NPI 1). score is compared to
individual whereas previously the group score
the group submitted as a group. associated with the
TIN/NPI from the
prior performance
period.
Individual changes practices, Individual (TIN B/ Individual (TIN A/ Yes.............. Current individual
but submitted to MIPS NPI). NPI). score is compared to
previously as an individual. the individual score
from the prior
performance period.
Individual changes practices Individual (TIN C/ Group (TIN A/ Yes.............. Current individual
and has multiple scores in NPI). NPI); Individual score is compared to
prior performance period. (TIN B/NPI). highest score from
the prior performance
period.
Group does not have a previous Group (TIN A).... Individual scores Yes.............. The current group
group score from prior (TIN A/NPI 1, score is compared to
performance period. TIN A/NPI 2, TIN the average of the
A/NPI 3, etc.). scores from the prior
performance period of
individuals who
comprise the current
group.
Virtual group does not have Virtual Group Individuals (TIN Yes.............. The current group
previous group score from (Virtual Group A/NPI 1, TIN A/ score is compared to
prior performance period. Identifier A) NPI 2, TIN B/NPI the average of the
(Assume virtual 1, TIN B/NPI 2). scores from the prior
group has 2 TINs performance period of
with 2 individuals who
clinicians.). comprise the current
group.
Individual does not have a Individual (TIN A/ Individual was No............... The individual quality
quality performance category NPI 1). not eligible for performance category
achievement score for the MIPS and did not score is missing for
prior performance period. voluntarily the prior performance
submit any period and not
quality measures eligible for
to MIPS. improvement scoring.
----------------------------------------------------------------------------------------------------------------
We propose at Sec. 414.1380(b)(1)(xvi)(A) to state that
improvement scoring is available when the data sufficiency standard is
met, which means when data are available and a MIPS eligible clinician
or group has a quality performance category achievement percent score
for the previous performance period. We also propose at Sec.
414.1380(b)(1)(xvi)(A)(1) that data must be comparable to meet the
requirement of data sufficiency,
[[Page 30116]]
which means that the quality performance category achievement percent
score is available for the current performance period and the previous
performance period and, therefore, quality performance category
achievement percent scores can be compared. We also propose at Sec.
414.1380(b)(1)(xvi)(A)(2) that quality performance category achievement
percent scores are comparable when submissions are received from the
same identifier for two consecutive performance periods. We also
propose an exception at Sec. 414.1380(b)(1)(xvi)(A)(3) that if the
identifier is not the same for 2 consecutive performance periods, then
for individual submissions, the comparable quality performance category
achievement percent score is the quality performance category
achievement percent score associated with the final score from the
prior performance period that will be used for payment. For group,
virtual group, and APM entity submissions, the comparable quality
performance category achievement percent score is the average of the
quality performance category achievement percent score associated with
the final score from the prior performance period that will be used for
payment for each of the individuals in the group. As noted above, these
proposals are designed to offer improvement scoring to all MIPS
eligible clinicians with sufficient data in the prior MIPS performance
period. We invite public comments on our proposals as they relate to
data sufficiency for improvement scoring.
We also seek comment on an alternative to this proposal: Whether we
should restrict improvement to those who submit quality performance
data using the same identifier for two consecutive MIPS performance
periods. We believe this option would be simpler to apply, communicate
and understand than our proposal is, but this alternative could have
the unintended consequence of not allowing improvement scoring for
certain MIPS eligible clinicians, groups, virtual groups and APM
entities.
(iii) Additional Requirement for Full Participation To Measure
Improvement for Quality Performance Category
To receive a quality performance category improvement percent score
greater than zero, we are also proposing that MIPS eligible clinicians
must fully participate, which we propose in Sec.
414.1380(b)(1)(xvi)(F) to mean compliance with Sec. 414.1330 and Sec.
414.1340, in the current performance year. Compliance with those
referenced regulations entails the submission of all required measures,
including meeting data completeness, for the quality performance
category for the current performance period. For example, for MIPS
eligible clinicians submitting via QCDR, full participation would
generally mean submitting 6 measures including 1 outcome measure if an
outcome measure is available or 1 high priority measure if an outcome
measure is not available, and meeting the 50 percent data completeness
criteria for each of the 6 measures.
We believe that improvement is most meaningful and valid when we
have a full set of quality measures. A comparison of data resulting
from full participation of a MIPS eligible clinician from 1 year to
another enables a more accurate assessment of improvement because the
performance being compared is based on the applicable and available
measures for the performance periods and not from changes in
participation. While we are not requiring full participation for both
performance periods, requiring full participation for the current
performance period means that any future improvement scores for a
clinician or group would be derived solely from changes in performance
and not because the clinician or group submitted more measures. We
propose at Sec. 414.1380(b)(1)(xvi)(C)(5) that the quality improvement
percent score is zero if the clinician did not fully participate in the
quality performance category for the current performance period.
Because we want to award improvement for net increases in
performance and not just improved participation in MIPS, we want to
measure improvement above a floor for the 2018 MIPS performance period,
to account for our transition year policies. We considered that MIPS
eligible clinicians who chose the ``test'' option of the ``pick your
pace'' approach for the transition year may not have submitted all the
required measures and, as a result, may have a relatively low quality
performance category achievement score for the 2017 MIPS performance
period. Due to the transition year policy to award at least 3 measure
achievement points for any submitted measure via claims, EHR, QCDR,
qualified registry, and CMS-approved survey vendor for CAHPS for MIPS,
and the 3-point floor for the all-cause readmission measure (if the
measure applies), a MIPS eligible clinician that submitted some data
via these mechanisms on the required number of measures would
automatically have a quality performance category achievement score of
at least 30 percent because they would receive at least 3 of 10
possible measure achievement points for each required measure. For
example, if a solo practitioner submitted 6 measures and received 3
points for each measure, then the solo practitioner would have 18
measure achievement points out of a possible 60 total possible measure
achievement points (3 measure achievement points x 6 measures). The
quality performance category achievement percent score is 18/60 which
equals 30 percent. For groups with 16 or more clinicians that submitted
6 measures and receive 3 measure achievement points for each submitted
measure as well as the all-cause hospital readmission measure, then the
group would have 21 measure achievement points out of 70 total possible
measure achievement points or a quality performance category
achievement percent score of 21/70 which equals 30 percent (3 measure
achievement points x 7 measures). For the CMS Web Interface submission
option, MIPS eligible clinicians that fully participate by submitting
and meeting data completeness for all measures, would also be able to
achieve a quality performance category achievement percent score of at
least 30 percent, as each scored measure would receive 3 measure
achievement points out of 10 possible measure achievement points.
Therefore, we propose at Sec. 414.1380(b)(1)(xvi)(C)(4) that if a
MIPS eligible clinician has a previous year quality performance
category score less than or equal to 30 percent, we would compare 2018
performance to an assumed 2017 quality performance category achievement
percent score of 30 percent. In effect, for the MIPS 2018 performance
period, improvement would be measured only if the clinician's 2018
quality performance category achievement percent score for the quality
performance category exceeds 30 percent. We believe this approach
appropriately recognizes the participation of MIPS eligible clinicians
who participated in the transition year and accounts for MIPS eligible
clinicians who participated minimally and may otherwise be awarded for
an increase in participation rather than an increase in achievement
performance.
We invite public comment on these proposals.
(iv) Measuring Improvement Based on Changes in Achievement
To calculate improvement with a focus on quality performance, we
are proposing to focus on improvement based on achievement performance
and would not consider measure bonus
[[Page 30117]]
points in our improvement algorithm. Bonus points may be awarded for
reasons not directly related to performance such as the use of end-to-
end electronic reporting. We believe that improvement points should be
awarded based on improvement related to achievement. Accordingly, we
are proposing to use an individual MIPS eligible clinician's or group's
total measure achievement points from the prior MIPS performance period
without the bonus points the individual MIPS eligible clinician or
group may have received, to calculate improvement. Therefore, to
measure improvement at the quality performance category level, we will
use the quality performance category achievement percent score
excluding measure bonus points (and any improvement score) for the
applicable years. We propose at Sec. 414.1380(b)(1)(xvi)(D) to call
this score, which is based on achievement only, the ``quality
performance category achievement percent score'' which is calculated
using the following formula:
Quality performance category achievement percent score = total measure
achievement points/total available measure achievement points.
Table 27 illustrates how the quality performance category
achievement percent score is calculated. For simplicity, we assume the
MIPS eligible clinician received 6 measure achievement points for each
of the submitted 6 required measures in the current performance period,
which equals 36 total measure achievement points. This is compared to
the previous performance period when the MIPS eligible clinician
received only 5 measure achievement points per measure, for 30 total
measure achievement points. The quality performance category
achievement percent score is represented in line 2. For improvement,
performance in the current 2018 MIPS performance period (60 percent) is
compared to the performance category achievement percent score in the
2017 MIPS performance period (50 percent).
Table 27--Comparison of Quality Performance Category Achievement Percent
Scores
------------------------------------------------------------------------
Current MIPS Previous MIPS
performance period performance period
------------------------------------------------------------------------
(1) Total Measure 6 measure 5 measure
Achievement Points. achievement points achievement points
x 6 measures = 36 x 6 measures = 30
total measure total measure
achievement points. achievement points.
(2) Quality Performance 36/60 = 60 percent.. 30/60 = 50 percent.
Category Achievement
Percent Score (measure
achievement points/60 for
this example).
------------------------------------------------------------------------
The current MIPS performance period quality performance category
achievement percent score is compared to the previous performance
period quality performance category achievement percent score. If the
current score is higher, the MIPS eligible clinician may qualify for an
improvement percent score to be added into the quality performance
category percent score for the current performance year.
We propose to amend the regulatory text at Sec.
414.1380(b)(1)(xvi) to state that improvement scoring is available to
MIPS eligible clinicians and groups that demonstrate improvement in
performance in the current MIPS performance period compared to the
performance in the previous MIPS performance period, based on
achievement. Bonus points or improvement percent score adjustments made
to the category score in the prior or current performance period are
not taken into account when determining whether an improvement has
occurred or the size of any improvement percent score.
We invite public comment on our proposal to award improvement based
on changes in the quality performance category achievement percent
score.
(v) Improvement Scoring Methodology for the Quality Performance
Category
We believe the improvement scoring methodology that we are
proposing for the quality performance category recognizes the rate of
increase in quality performance category scores of MIPS eligible
clinicians from one performance period to another performance period so
that a higher rate of improvement results in a higher improvement
percent score. We believe this is particularly true for those
clinicians with lower performance who will be incentivized to begin
improving with the opportunity to increase their improvement
significantly and achieve a higher improvement percent score.
We propose to award an ``improvement percent score'' based on the
following formula:
Improvement percent score = (increase in quality performance category
achievement percent score from prior performance period to current
performance period/prior year quality performance category achievement
percent score) * 10 percent.
Using the example from Table 27, the quality performance category
achievement percent score for the current performance period is 60
percent, and the previous performance period achievement percent score
is 50 percent. The increase in achievement is 10 percentage points (60
percent--50 percent). Therefore, the improvement percent score is 10
percent (increase in achievement)/50 percent (previous performance
period achievement percent score) * 10 percent = 2 percentage points.
Another way to explain the logic is a 20 percent rate of improvement
for achievement (for example increasing the achievement percent score
10 percentage points which is 20 percent higher than the original 50
percent achievement percent score) is worth a 2 percentage point
increase to the quality performance category achievement percent score.
We believe that this improvement scoring methodology provides an
easily explained and applied approach that is consistent for all MIPS
eligible clinicians. Additionally, it provides additional incentives
for MIPS eligible clinicians who are lower performers to improve
performance. We believe that providing larger incentives for MIPS
eligible clinicians with lower quality performance category scores to
improve will not only increase the quality performance category scores
but also will have the greatest impact on improving quality for
beneficiaries.
We also propose that the improvement percent score cannot be
negative (that is, lower than zero percentage points). The improvement
percent score would be zero for those who do not have sufficient data
or who are not eligible under our proposal for improvement points. For
example, as noted in section II.C.7.a.(2)(i)(ii) of this proposed rule,
a MIPS eligible clinician would not be eligible for improvement if the
clinician was not eligible for MIPS
[[Page 30118]]
in the prior performance period and did not have a quality performance
category achievement percent score. We are also proposing to cap the
size of the improvement award at 10 percentage points, which we believe
appropriately rewards improvement and does not outweigh percentage
points available through achievement. In effect, 10 percentage points
under our proposed formula would represent 100 percent improvement--or
doubling of achievement measure points--over the immediately preceding
period. For the reasons stated, we anticipate that this amount will
encourage participation by individual MIPS eligible clinicians and
groups and will provide an appropriate recognition and award for the
largest increases in performance improvement.
Table 28 illustrates examples of the proposed improvement percent
scoring methodology, which is based on rate of increase in quality
performance category achievement percent scores.
Table 28--Improvement Scoring Examples Based on Rate of Increase in Quality Performance Category Achievement
Percent Scores
----------------------------------------------------------------------------------------------------------------
Year 1 quality Year 2 quality
performance performance
category category Increase in Rate of Improvement
achievement achievement achievement improvement percent score
percent score percent score
----------------------------------------------------------------------------------------------------------------
Individual Eligible 5% (Will 50 20% Because the 20%/30%= 0.67.. 0.67*10% = 6.7%
Clinician #1 (Pick your substitute 30% year 1 score No cap needed.
Pace Test Option). which is the is below 30%,
lowest score a we measure
clinician can improvement
achieve with above 30%.
complete
reporting in
year 1.).
Individual Eligible 60%............ 66 6%............. 6%/60%= 0.10... 0.10*10% = 1.0%
Clinician #2. No cap needed.
Individual Eligible 90%............ 93 3%............. 3%/90%= 0.033.. 0.033*10% =
Clinician #3. 0.3% No cap
needed.
Individual Eligible 30%............ 70 40%............ 40%/30%=1.33... 1.33*10%=13.3%
Clinician #4. Apply cap at
10%.
----------------------------------------------------------------------------------------------------------------
We also considered an alternative to measuring the rate of
improvement. The alternative would use band levels to determine the
improvement points for MIPS eligible clinicians who qualify for
improvement points. Under the band level methodology, a MIPS eligible
clinician's improvement points would be determined by an improvement in
the quality performance category achievement percent score from 1 year
to the next year to determine improvement in the same manner as set
forth in the rate of improvement methodology. However, for the band
level methodology, an improvement percent score would then be assigned
by taking into account a portion (50, 75 or 100 percent) of the
improvement in achievement, based on the clinician's performance
category achievement percent score for the prior year. Bands would be
set for category achievement percent scores, with increases from lower
category achievement scores earning a larger portion (percentage) of
the improvement points. Under this alternative, simple improvement
percentage points for improvement are awarded to MIPS eligible
clinicians whose category scores improved across years according to the
band level, up to a maximum of 10 percent of the total score.
In Table 29, we illustrate the band levels we considered as part of
this alternative proposal. The chart depicts the band level and the
improvement points allotted for the increases in improvement scores
that fall within the transition year score range.
Table 29--Band Level and Improvement Points Allotted for Determining
Improvement Percent Scores
------------------------------------------------------------------------
% Credit for each percent
Transition year score range increase in achievement
------------------------------------------------------------------------
1-50................................... 100% of increase in
achievement.
51-75.................................. 75% of increase in achievement.
75-100................................. 50% of increase in achievement.
------------------------------------------------------------------------
Table 30 illustrates examples of the improvement scoring
methodology based on band levels. Generally, this methodology would
generate a higher improvement percent score for clinicians; however, we
believe the policy we proposed would provide a score that better
represents true improvement at the performance category level, rather
than comparing simple increases in performance category scores.
[[Page 30119]]
Table 30--Examples of Improvement Scoring Methodology Based on Band Levels
----------------------------------------------------------------------------------------------------------------
Year 1 quality Year 2 quality
performance performance Band for Improvement
category category Increase in improvement percent score
achievement achievement achievement adjustment (after applying
percent score percent score the cap)
----------------------------------------------------------------------------------------------------------------
Individual Eligible Clinician 5% (Will 50% 20% Because the 100% 20%*100%= 20%
#1 (Pick your Pace Test substitute 30% year 1 score which is
Option). which is the is below 30%, capped at 10%.
lowest score a we measure
clinician can improvement
achieve with above 30%.
complete
reporting in
year 1.)
Individual Eligible Clinician 60%............ 66% 6%............. 75% 6%*75%= 4.5% No
#2. cap needed
Individual Eligible Clinician 90%............ 93% 3%............. 50% 3%*50%= 1.5% No
#3. cap needed
----------------------------------------------------------------------------------------------------------------
In addition, we considered another alternative that would adopt the
improvement scoring methodology of the Shared Savings Program\11\ for
CMS Web Interface submissions in the quality performance category, but
decided to not adopt this approach. Under the Shared Savings Program
approach, eligible clinicians and groups that submit through the CMS
Web Interface would have been required to submit on the same set of
quality measures, and we would have awarded improvement for all
eligible clinicians or groups who submitted complete data in the prior
year. As Shared Savings Program and Next Generation ACOs report using
the CMS Web Interface, using the same improvement score approach would
align MIPS with these other programs. We believed it could be
beneficial to align improvement between the programs because it would
align incentives for those who participate in the Shared Savings
Program or ACOs. The Shared Savings Program approach would test each
measure for statistically significant improvement or statistically
significant decline. We would sum the number of measures with a
statistically significant improvement and subtract the number of
measures with a statistically significant decline to determine the Net
Improvement. We would next divide the Net Improvement in each domain by
the number of eligible measures in the domain to calculate the
Improvement Score. We would cap the number of possible improvement
percentage points at 10.
---------------------------------------------------------------------------
\11\ For additional information on the Shared Savings Program's
scoring methodology, we refer readers to the Quality Measurement
Methodology and Resources, September 2016, Version 1 and the
Medicare Shared Savings Program Quality Measure Benchmarks for the
2016 and 2017 Reporting Years (available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/MSSP-QM-Benchmarks-2016.pdf.)
---------------------------------------------------------------------------
We considered the Shared Savings Program methodology because it
would promote alignment with ACOs. We ultimately decided not to adopt
this scoring methodology because we believe having a single performance
category level approach for all quality performance category scores
encourages a uniformity in our approach to improvement scoring and
simplifies the scoring rules for MIPS eligible clinicians. It also
allows us greater flexibility to compare performance scores across the
diverse submission mechanisms, which makes improvement scoring more
broadly available to eligible clinicians and groups that elect
different ways of participating in MIPS.
We propose to add regulatory text at Sec.
414.1380(b)(1)(xvi)(C)(3) to state that an improvement percent score
cannot be negative (that is, lower than zero percentage points). We
also propose to add regulatory text at Sec. 414.1380(b)(1)(xvi)(C)(1)
to state that improvement scoring is awarded based on the rate of
increase in the quality performance category achievement percent score
of individual MIPS eligible clinicians or groups from the current MIPS
performance period compared to the score in the year immediately prior
to the current MIPS performance period. We also propose to add
regulatory text at Sec. 414.1380(b)(1)(xvi)(C)(2) to state that an
improvement percent score is calculated by dividing the increase in the
quality performance category achievement percent score of an individual
MIPS eligible clinician or group, which is calculated by comparing the
quality performance category achievement percent score the current MIPS
performance period to the quality performance category achievement
percent score from the MIPS performance period in the year immediately
prior to the current MIPS performance period, by the prior year quality
performance category achievement percent score, and multiplying by 10
percent.
We invite public comments on our proposal to calculate improvement
scoring using a methodology that awards improvement points based on the
rate of improvement and, alternatively, on rewarding improvement at the
band level or using the Shared Saving Program approach for CMS Web
Interface submissions.
(j) Calculating the Quality Performance Category Percent Score
Including Improvement
In the CY 2017 Quality Payment Program final rule, we finalized at
Sec. 414.1380(b)(1)(xv) that the quality performance category score is
the sum of all points assigned for the measures required for the
quality performance category criteria plus bonus points, divided by the
sum of total possible points (81 FR 77300). Using the terminology
proposed in section II.C.7.a.(2) of this proposed rule, this formula
can be represented as:
Quality performance category percent score = (total measure achievement
points + measure bonus points)/total available measure achievement
points.
We propose to incorporate the improvement percent score, which is
proposed in section II.C.7.a.(2)(i)(i) of this proposed rule, into the
quality performance category percent score. We propose to amend Sec.
414.1380(b)(1)(xv) (redesignated as Sec. 414.1380(b)(1)(xvii)) to add
the improvement percent score (as calculated pursuant to proposed
paragraph (b)(1)(xvi)(A) through (F)) to the quality performance score.
We also propose to amend Sec. 414.1380(b)(1)(xv) (redesignated as
Sec. 414.1380(b)(1)(xvii)) to amend the text that states the quality
performance category percent score cannot exceed the total possible
points for the quality performance category to clarify that the total
possible points for
[[Page 30120]]
the quality performance category cannot exceed 100 percentage points.
Thus, the calculation for the proposed quality performance category
percent score including improvement, can be summarized in the following
formula:
Quality performance category percent score = ([total measure
achievement points + measure bonus points]/total available measure
achievement points) + improvement percent score, not to exceed 100
percent.
This same formula and logic will be applied for both CMS Web
Interface and Non-CMS Web Interface reporters.
Table 31 illustrates an example of calculating the quality
performance category percent score including improvement for a non-CMS
Web Interface reporter. In this example, an individual MIPS eligible
clinician received measure achievement points for their 6 required
measures, and received 6 measure bonus points. Because this is an
individual clinician and the administrative claims based measure is not
applicable, the total available measure achievement points for this
clinician is 60. The improvement percent score would be calculated
based on the proposal in section II.C.7.a.(2)(i) of this proposed rule;
Table 31 does not illustrate the underlying calculations for the
improvement percent score. To calculate the quality performance
category percent score, the total measures achievement points would be
summed with the total measure bonus points and then divided by the
total available measure achievement points. The improvement percent
score would be added to that calculation. The resulting quality
performance category percent score cannot exceed 100 percentage points.
Table 31--Example of Scoring the Quality Performance Category Percent Score Including Improvement
--------------------------------------------------------------------------------------------------------------------------------------------------------
Total
Total measure available Improvement
achievement Total measure measure Calculation prior to percent score Quality performance
points bonus points achievement improvement (%) category percent score
points
--------------------------------------------------------------------------------------------------------------------------------------------------------
Individual Eligible Clinician... 35.6 6 60 (35.6 + 6)/60 = 69.33%.... 1.9 69.33% + 1.9% = 71.23%
Individual Eligible Clinician 35.6 6 60 (35.6 + 6)/60 = 69.33%.... 0 69.33% + 0% = 69.33%
(did not submit in Year 1).
Individual Eligible Clinician 50 6 60 (50 + 6)/60 = 93.33%...... 10 93.33% + 10% = 103.33%,
(with maximum improvement). which is capped at 100%
--------------------------------------------------------------------------------------------------------------------------------------------------------
We note that the quality performance category percent score is then
multiplied by the performance category weight for calculating the final
score.
We invite public comment on this overall methodology and formula
for calculating the quality performance category percent score.
(3) Scoring the Cost Performance Category
We score the cost performance category using a methodology that is
generally consistent with the methodology used for the quality
performance category. In the CY 2017 Quality Payment Program final rule
(81 FR 77309), we codified at Sec. 414.1380(b)(2) that a MIPS eligible
clinician receives 1 to 10 achievement points for each cost measure
attributed to the MIPS eligible clinician based on the MIPS eligible
clinician's performance compared to the measure benchmark. We establish
a single benchmark for each cost measure and base those benchmarks on
the performance period (81 FR 77309). Because we base the benchmarks on
the performance period, we will not be able to publish the actual
numerical benchmarks in advance of the performance period (81 FR
77309). We develop a benchmark for a cost measure only if at least 20
groups (for those MIPS eligible clinicians participating in MIPS as a
group practice) or TIN/NPI combinations (for those MIPS eligible
clinicians participating in MIPS as an individual) can be attributed
the case minimum for the measure (81 FR 77309). If a benchmark is not
developed, the cost measure is not scored or included in the
performance category (81 FR 77309). For each set of benchmarks, we
calculate the decile breaks based on cost measure performance during
the performance period and assign 1 to 10 achievement points for each
measure based on which benchmark decile range the MIPS eligible
clinician's performance on the measure is between (81 FR 77309 through
77310). We also codified at Sec. 414.1380(b)(2)(iii) that a MIPS
eligible clinician's cost performance category score is the equally-
weighted average of all scored cost measures (81 FR 77311).
In the CY 2017 Quality Payment Program final rule (81 FR 77311), we
adopted a final policy to not calculate a cost performance category
score if a MIPS eligible clinician or group is not attributed any cost
measures because the MIPS eligible clinician or group has not met the
case minimum requirements for any of the cost measures or a benchmark
has not been created for any of the cost measures that would otherwise
be attributed to the clinician or group. We inadvertently failed to
include this policy in the regulation text and are proposing to codify
it under Sec. 414.1380(b)(2)(v).
For more of the statutory background and descriptions of our
current policies for the cost performance category, we refer readers to
the CY 2017 Quality Payment Program final rule (81 FR 77308 through
77311).
In section II.C.7.a.(3)(a) of this proposed rule, we propose to add
improvement scoring to the cost performance category scoring
methodology starting with the 2020 MIPS payment year. We do not propose
any changes to the methodology for scoring achievement in the cost
performance category for the 2020 MIPS payment year other than the
method used for facility-based measurement described in II.C.7.a.(4) of
this proposed rule. We are proposing a change in terminology to refer
to the ``cost performance category percent score in order to be
consistent with the terminology used in the quality performance
category. In section II.C.7.a.(2) of this proposed rule, we propose to
calculate a ``quality performance category percent score'' which is
reflective of performance in the quality performance category based on
dividing the sum of total measure achievement points and bonus points
by the total available measure achievement points. We propose to revise
Sec. 414.1380(b)(2)(iii) to provide that a
[[Page 30121]]
MIPS eligible clinician's cost performance category percent score is
the sum of the following, not to exceed 100 percent: The total number
of achievement points earned by the MIPS eligible clinician divided by
the total number of available achievement points (which can be
expressed as a percentage); and the cost improvement score. This
terminology change to refer to the score as a percentage is consistent
with the change in section II.C.7.a.(2) for the quality performance
category. We discuss our proposals for improvement scoring in the cost
performance category in section II.C.7.b.3.(a) of this proposed rule.
(a) Measuring Improvement
(i) Calculating Improvement at the Cost Measure Level
In section II.C.7.a.(1)(b) of this proposed rule, we propose to
make available to MIPS eligible clinicians and groups a method of
measuring improvement in the quality and cost performance categories.
In section II.C.7.a.(2)(i) of this proposed rule, for the quality
performance category, we propose to assess improvement on the basis of
the score at the performance category level. For the cost performance
category, similar to the quality performance category, we propose at
Sec. 414.1380(b)(2)(iv) that improvement scoring is available to MIPS
eligible clinicians and groups that demonstrate improvement in
performance in the current MIPS performance period compared to their
performance in the immediately preceding MIPS performance period (for
example, demonstrating improvement in the 2018 MIPS performance period
over the 2017 MIPS performance period).
In section II.C.7.a.(2)(i) of this proposed rule, we note the
various challenges associated with attempting to measure improvement in
the quality performance category at the measure level, given the many
opportunities available to clinicians to select which measures to
report. The cost performance category is not subject to this same issue
of measure selection. Cost measures are calculated based on Medicare
administrative claims data maintained by CMS, without any additional
data input from or reporting by clinicians, and MIPS eligible
clinicians are not given the opportunity to select which cost measures
apply to them. We believe that there are advantages to measuring cost
improvement at the measure level. Principally, MIPS eligible clinicians
could see their performance on each cost measure and better understand
how practice improvement changes can drive changes for each specific
cost measure. Additionally, as discussed in section II.C.7.a.(1)(b)(i)
of this proposed rule, other Medicare value-based purchasing programs
generally assess performance improvement at the measure level.
Therefore, we propose at section Sec. 414.1380(b)(2)(iv)(A) to measure
cost improvement at the measure level for the cost performance
category.
As described in section II.C.7.a.(1)(b)(ii) of this proposed rule,
we believe that we would have data sufficient to measure improvement
when we can measure performance in the current performance period
compared to the prior performance period. Due to the differences in our
proposals for measuring improvement for the quality and cost
performance categories, such as measuring improvement at the measure
level versus the performance category level, we are proposing a
different data sufficiency standard for the cost performance category
than for the quality performance category, which is proposed in section
II.C.7.a.(2)(i)(ii) of this proposed rule. First, for data sufficient
to measure improvement to be available for the cost performance
category, the same cost measure(s) would need to be specified for the
cost performance category for 2 consecutive performance periods. For
the 2020 MIPS payment year, only 2 cost measures, the MSPB measure and
the total per capita cost measure, would be eligible for improvement
scoring. For a measure to be scored in either performance period, a
MIPS eligible clinician would need to have a sufficient number of
attributed cases to meet or exceed the case minimum for the measure.
In addition, a clinician would have to report for MIPS using the
same identifier (TIN/NPI combination for individuals, TIN for groups,
or virtual group identifiers for virtual groups) and be scored on the
same measure(s) for 2 consecutive performance periods. We wish to
encourage action on the part of clinicians in reviewing and
understanding their contribution to patient costs. For example, a
clinician who is shown to have lower performance on the MSPB measure
could focus on the efficient use of post-acute care and be able to see
that improvement reflected in the cost improvement score in future
years. This review could highlight opportunities for better stewardship
of healthcare costs such as better recognition of unnecessary costs
related to common ordering practices. For these reasons, we believe
that improvement should be evaluated only when there is a consistent
identifier.
Therefore, for the cost performance category, we are proposing at
Sec. 414.1380(b)(2)(iv)(B) that we would calculate a cost improvement
score only when data sufficient to measure improvement is available. We
are proposing that sufficient data would be available when a MIPS
eligible clinician participates in MIPS using the same identifier in 2
consecutive performance periods and is scored on the same cost
measure(s) for 2 consecutive performance periods (for example, in the
2017 MIPS performance period and the 2018 MIPS performance period). If
the cost improvement score cannot be calculated because sufficient data
is not available, we are proposing to assign a cost improvement score
of zero percentage points. While the total available cost improvement
score would be limited at first because only 2 cost measures would be
included in both the first and second performance periods of the
program (total per capita cost and MSPB), more opportunities for
improvement scoring would be available in the future as additional cost
measures, including episode-based measures, are added in future
rulemaking. MIPS eligible clinicians would be able to review their
performance feedback and make improvements compared to the score in
their previous feedback.
We invite public comments on these proposals.
(ii) Improvement Scoring Methodology
In section II.C.7.a.(1)(b)(i) of this proposed rule, we discuss a
number of different programs and how they measure improvement at the
category or measure level as part of their scoring systems. For
example, the Hospital Value-Based Purchasing (VBP) Program awards
either measure improvement or measure achievement, but not both. In the
proposed method for the quality performance category, we compare the
overall rate of achievement on all the underlying measures in the
quality performance category and measure a rate of overall improvement
to calculate an improvement percent score. We then add the improvement
percent score after taking into account measure achievement points and
measure bonus points as described in proposed Sec.
414.1380(b)(1)(xvii). In reviewing the methodologies that are specified
in section II.C.7.a.(1)(b)(i) of this proposed rule that include
consideration of improvement at the measure level, we noted that the
methodology used in the Shared Savings Program would best reward
achievement and improvement
[[Page 30122]]
for the cost performance category because this program includes
measures for clinicians, the methodology is straightforward, and it
only recognizes significant improvement. We propose to quantify
improvement in the cost performance category by comparing the number of
cost measures with significant improvement in performance and the
number of cost measures with significant declines in performance. We
propose at Sec. 414.1380(b)(2)(iv)(C) to determine the cost
improvement score by subtracting the number of cost measures with
significant declines from the number of cost measures with significant
improvement, and then dividing the result by the number of cost
measures for which the MIPS eligible clinician or group was scored in
both performance periods, and then multiplying the result by the
maximum cost improvement score. For the 2020 MIPS payment year,
improvement scoring would be possible for the total per capita cost
measure and the MSPB measure as those 2 measures would be available for
2 consecutive performance periods under our proposals in section
II.C.6.d.(3)(a). As in our proposed quality improvement methodology, we
propose at Sec. 414.1380(b)(2)(iv)(D) that the cost improvement score
could not be lower than zero, and therefore, could only be positive.
We propose to determine whether there was a significant improvement
or decline in performance between the 2 performance periods by applying
a common standard statistical test, a t-test, as is used in the Shared
Savings Program (79 FR 67930 through 67931). The t-test's statistical
significance and the t-test's effect size are the 2 primary outputs of
the t-test. Statistical significance indicates whether the difference
between sample averages is likely to represent an actual difference
between populations and the effect size indicates whether that
difference is large enough to be practically meaningful. Statistical
significance testing in this case assesses how unlikely it is that
differences as large as those observed would be due to chance when the
performance is actually the same. The test recognizes and appropriately
adjusts measures at both high and low levels of performance for
statistically significant levels of change. However, as an alternative,
we welcome public comments on whether we should consider instead
adopting an improvement scoring methodology that measures improvement
in the cost performance category the same way we propose to do in the
quality performance category; that is, using the rate of improvement
and without requiring statistical significance. We refer readers to
section II.C.7.a.(2)(i) of this proposed rule for our proposal related
to measuring improvement in the quality performance category.
Section 1848(q)(5)(D)(ii) of the Act specifies that the Secretary
may assign a higher scoring weight under subparagraph (F) with respect
to the achievement of a MIPS eligible clinician than with respect to
any improvement of such clinician with respect to a measure, activity,
or category described in paragraph (2). We believe that there are many
opportunities for clinicians to actively work on improving their
performance on cost measures, through more active care management or
reductions in certain services. However, we recognize that most
clinicians are still learning about their opportunities in cost
measurement. We aim to continue to educate clinicians about
opportunities in cost measurement and continue to develop opportunities
for robust feedback and measures that better recognize the role of
clinicians. Since MIPS is still in its beginning years and we
understand that clinicians are working hard to understand how we
measure costs for purposes of the cost performance category, as well as
how we score their performance in all other aspects of the program, we
believe improvement scoring in the cost performance category should be
limited to avoid creating additional confusion. Based on these
considerations, we propose in section II.C.6.d.(2) of this proposed
rule to weight the cost performance category at zero percent for the
2020 MIPS payment year/2018 MIPS performance period. With the entire
cost performance category proposed to be weighted at zero percent, we
believe that the focus of clinicians should be on achievement as
opposed to improvement, and therefore we propose at Sec.
414.1380(b)(2)(iv)(E) that although improvement would be measured
according to the method described above, the maximum cost improvement
score for the 2020 MIPS payment year would be zero percentage points.
Section 1848(q)(5)(D)(ii) of the Act provides discretion for the
Secretary to assign a higher scoring weight under subparagraph (F),
which refers to section 1848(q)(5)(F) of the Act, with respect to
achievement than with respect to improvement. Section 1848(q)(5)(F) of
the Act provides if there are not sufficient measures and activities
applicable and available to each type of MIPS eligible clinician, the
Secretary shall assign different scoring weights (including a weight of
zero) for measures, activities, and/or performance categories. When
read together, we interpret sections 1848(q)(5)(D)(ii) and
1848(q)(5)(F) of the Act to provide discretion to the Secretary to
assign a scoring weight of zero for improvement on the measures
specified for the cost performance category. Under the improvement
scoring methodology we have proposed, we believe a maximum cost
improvement score of zero would be effectively the same as a scoring
weight of zero. As a result of our proposal, the cost improvement score
would not contribute to the cost performance category percent score
calculated for the 2020 MIPS payment year. In other words, we would
calculate a cost improvement score, but the cost improvement score
would not contribute any points to the cost performance category
percent score for the 2020 MIPS payment year.
In section II.C.6.d.(2) of this proposed rule, we consider an
alternative to make no changes to the previously finalized weight of 10
percent for the cost performance category for the 2020 MIPS payment
year. If we finalize this alternative, we believe that improvement
should be given weight towards the cost performance category percent
score, but it should still be limited. Therefore, we propose that if we
maintain a weight of 10 percent for the cost performance category for
the 2020 MIPS payment year, the maximum cost improvement score
available in the cost performance category would be 1 percentage point
out of 100 percentage points available for the cost performance
category percent score. If a clinician were measured on only one
measure consistently from one performance period to the next and met
the requirements for improvement, the clinician would receive one
improvement percentage point in the cost performance category percent
score. If a clinician were measured on 2 measures consistently,
improved significantly on one, and did not show significant improvement
on the other (as measured by the t-test method described above), the
clinician would receive 0.5 improvement percentage points.
We invite comments on these proposals as well as alternative ways
to measure changes in statistical significance for the cost measure.
(b) Calculating the Cost Performance Category Percent Score With
Achievement and Improvement
In section II.C.7.a.(1)(b) of this proposed rule, we evaluated
different improvement scoring options used in other CMS programs. In
those programs, we saw 2 general methods for
[[Page 30123]]
incorporating improvement. One method measures both achievement and
improvement and takes the higher of the 2 scores for each measure that
is compared. The Hospital VBP Program incorporates such a methodology.
The second method is to calculate an achievement score and then add an
improvement score if improvement is measured. The Shared Savings
Program utilizes a similar methodology for measuring improvement. For
the cost performance category, we are proposing to evaluate improvement
at the measure level, unlike the quality performance category where we
are proposing to evaluate improvement at the performance category
level. For both the quality performance category and the cost
performance category, we are proposing to add improvement to an
existing category percent score. We believe this is the most straight-
forward and simple way to incorporate improvement. It is also
consistent with other Medicare programs that reward improvement.
As noted in section II.7.b.(3) of this proposed rule, we have
proposed a change in terminology to express the cost performance
category percent score as a percentage. We propose to revise Sec.
414.1380(b)(2)(iii) to provide that a MIPS eligible clinician's cost
performance category percent score is the sum of the following, not to
exceed 100 percent: The total number of achievement points earned by
the MIPS eligible clinician divided by the total number of available
achievement points (which can be expressed as a percentage); and the
cost improvement score. With these two proposed changes, the formula
would be (Cost Achievement Points/Available Cost Achievement Points) +
(Cost Improvement Score) = (Cost Performance Category Percent Score).
We invite public comments on these proposals.
In Table 32, we provide an example of cost performance category
percent scores along with the determination of improvement or decline.
For illustrative purposes, we are using the alternative proposal of a
maximum cost improvement score of 1. This example is for group
reporting where the group is measured on both the total per capita cost
measure and the MSPB measure for 2 consecutive performance periods.
Table 32--Example of Assessing Achievement and Improvement in the Cost Performance Category
----------------------------------------------------------------------------------------------------------------
Significant Significant
Measure Total possible improvement decline from
Measure achievement measure from prior prior
points earned achievement performance performance
by the group points period period
----------------------------------------------------------------------------------------------------------------
Total per Capita Cost Measure................... 8.2 10 Yes No
MSPB Measure.................................... 6.4 10 No No
----------------------------------------------------------------------------------------------------------------
In this example, there are 20 total possible measure achievement
points and 14.6 measure achievement points earned by the group, and the
group improved on one measure but not the other, with both measures
being scored in each performance period. The cost improvement score
would be determined as follows: ((1 measure with significant
improvement-zero measures with significant decline)/2 measures) * 1
percentage point = 0.5 percentage points. Under the proposed revised
formula, the cost performance category percent score would be (14.6/20)
+ 0.5% = 73.5%.
As discussed in section II.C.7.b.(2) of this proposed rule, in
determining the MIPS final score, the cost performance category percent
score is multiplied by the cost performance category weight. For the
2020 MIPS payment year, if we finalize the cost performance category
weight of zero percent, then the cost performance category percent
score will not contribute to the final score.
(4) Facility-Based Measures Scoring Option for the 2020 MIPS Payment
Year for the Quality and Cost Performance Categories
(a) Background
Section 1848(q)(2)(C)(ii) of the Act provides that the Secretary
may use measures used for payment systems other than for physicians,
such as measures for inpatient hospitals, for purposes of the quality
and cost performance categories. However, the Secretary may not use
measures for hospital outpatient departments, except in the case of
items and services furnished by emergency physicians, radiologists, and
anesthesiologists. In the MIPS and APMs RFI (80 FR 59108), we sought
comment on how we could best use this authority. We refer readers to
the CY 2017 Quality Payment Program final rule (81 FR 77127) for a
summary of these comments.
As noted in the CY 2017 Quality Payment Program proposed rule (81
FR 28192), we considered an option for facility-based MIPS eligible
clinicians to elect to use their institution's performance rates as a
proxy for the MIPS eligible clinician's quality score. However, we did
not propose an option for the transition year of MIPS because there
were several operational considerations that we believed needed to be
addressed before this option could be implemented. We requested
comments on the following issues: (1) Whether we should attribute a
facility's performance to a MIPS eligible clinician for purposes of the
quality and cost performance categories and under what conditions such
attribution would be appropriate and representative of the MIPS
eligible clinician's performance; (2) possible criteria for attributing
a facility's performance to a MIPS eligible clinician for purposes of
the quality and cost performance categories; (3) the specific measures
and settings for which we can use the facility's quality and cost data
as a proxy for the MIPS eligible clinician's quality and cost
performance categories; and (4) if attribution should be automatic or
if an individual MIPS eligible clinician or group should elect for it
to be done and choose the facilities through a registration process.
As noted in the CY 2017 Quality Payment Program final rule (81 FR
77127 through 77130), the majority of the comments we received
supported attributing a facility's performance to a MIPS eligible
clinician for purposes of the quality and cost performance categories.
Some commenters opposed using a facility's quality and cost performance
as a proxy for MIPS eligible clinicians. Many of these commenters
expressed the view that facility scores do not represent the individual
MIPS eligible clinician's performance. In addition, we received
suggestions on how we should attribute a facility's performance to a
MIPS eligible clinician, as well as comments suggesting that
attribution should be voluntary and that the facility's measures should
be relevant to the MIPS eligible clinician. A full discussion of the
comments we received
[[Page 30124]]
and our responses can be found in the CY 2017 Quality Payment Program
final rule (81 FR 77127 through 77130).
In addition, we have received ongoing feedback from various
stakeholder associations and individuals regarding facility-based
measurement for MIPS eligible clinicians, which included: Support for
MIPS eligible clinicians being able to choose to be assessed in this
manner; several groups' preference that value-based purchasing and
quality reporting program measure data be used for facility-based
scoring; support for a ``hybrid'' approach where MIPS eligible
clinicians could select both clinician-based measures and facility-
based measures for purposes of MIPS scoring; and a suggested 2-year
pilot program before expanding facility-based scoring more broadly with
an emphasis on no negative impact on those who are measured in this
fashion. We took this feedback, as well as the comments discussed in
the CY 2017 Quality Payment Program final rule, into consideration when
developing proposals for the application of facility-based measures.
(b) Facility-Based Measurement
We believe that facility-based measurement is intended to reduce
reporting burden on facility-based MIPS eligible clinicians by
leveraging existing quality data sources and value-based purchasing
experiences and aligning incentives between facilities and the MIPS
eligible clinicians who provide services there. In addition, we believe
that facility-based MIPS eligible clinicians contribute substantively
to their respective facilities' performance on facility-based measures
of quality and cost, and that their performance may be better reflected
by their facilities' performance on such measures.
Medicare operates both pay-for-reporting programs and pay-for-
performance programs. Pay-for-reporting programs incentivize the act of
reporting data on quality and/or other measures and activities,
typically by applying a downward payment adjustment to facilities or
clinicians, as applicable, that fail to submit data as required by the
Secretary. This type of program does not adjust payments based on
performance. In contrast, pay-for-performance programs, such as VBP
programs, score facilities or clinicians, as applicable, on their
performance on specified quality and/or other measures and activities
and adjust payments based on that performance. Pay-for-performance
programs, such as VBP programs, are more analogous to MIPS given its
focus on performance and not just reporting. For this reason, we
believe that facility-based measurement under MIPS should be based on
pay-for-performance programs rather than pay-for-reporting programs.
Many Medicare payment systems include a pay-for-performance
program, such as the Hospital VBP Program, the Skilled Nursing Facility
VBP Program (SNF VBP), the End Stage Renal Disease Quality Incentive
Program (ESRD QIP), and the Home Health Value-Based Purchasing Program
(HHVBP). We believe that clinicians play a role in contributing to
quality performance in all of these programs. However, we believe that
a larger and more diverse group of clinicians contributes to quality in
the inpatient hospital setting than in other settings in which we might
begin to implement this measurement option. In addition, the inpatient
hospital setting has a mature value-based purchasing program, first
established to adjust payment for hospitals in FY 2013 (76 FR 26489).
Therefore, we believe it is appropriate to implement this scoring
option in a limited fashion in the first year of incorporating
additional facility-based measures under MIPS by focusing on inpatient
hospital measures that are used for certain pay-for-performance
programs as facility-based measures.
The inpatient hospital setting includes three distinct pay-for-
performance programs: The Hospital VBP Program, the Hospital
Readmissions Reduction Program (HRRP), and the Hospital-Acquired
Condition Reduction Program (HACRP). We believe that the Hospital VBP
Program is most analogous to the MIPS program at this time because the
Hospital VBP Program compares facilities on a series of different
measures that intend to capture the breadth of care provided in a
facility. In contrast, the HACRP and HRRP each focus on a single type
of outcome for patients treated in a hospital (safety and readmissions,
respectively), though we note that these outcomes are critically
important to health care improvement. The payment adjustments
associated with those 2 programs are intended to provide negative
adjustments for poor performance but do not similarly reward high
performance. In contrast, the Hospital VBP Program compares performance
among hospitals and rewards high performers and provides negative
adjustments to poor performers.
We also considered program timing when determining what Hospital
VBP Program year to use for facility-based measurement for the 2020
MIPS payment year. Quality measurement for the FY 2019 Hospital VBP
Program's performance period will be concluded by December 31, 2017 (we
refer readers to the finalized FY 2019 performance periods in the FY
2017 Inpatient Prospective Payment System/Long-Term Care Hospital
Prospective Payment System Final Rule, 81 FR 57002), and the Hospital
VBP Program scoring reports (referred to as the Percentage Payment
Summary Reports) will be provided to participating hospitals not later
than 60 days prior to the beginning of FY 2019, pursuant to the
Hospital VBP Program's statutory requirement at section 1886(o)(8) of
the Act. We further note that hospitals must meet case and measure
minimums during the performance period to receive a Total Performance
Score under that Program. We discuss eligibility for facility-based
measurement in section II.C.7.b.(4)(c) of this proposed rule, and we
note that the determination of the applicable hospital will be made on
the basis of a period that overlaps with the applicable Hospital VBP
Program performance period. Although Hospital VBP Program measures have
different measurement periods, the FY 2019 measures all overlap from
January to June in 2017, which also overlaps with our first 12-month
period to determine MIPS eligibility.
We believe that MIPS eligible clinicians electing the facility-
based measurement option under MIPS should be able to consider as much
information as possible when making that decision, including how their
attributed hospital performed in the Hospital VBP Program because an
individual clinician is a part of the clinical team in the hospital,
rather than the sole clinician responsible for care as tracked by
quality measures. Therefore, we concluded that we should be as
transparent as possible with MIPS eligible clinicians about their
potential facility-based scores before they begin data submission for
the MIPS performance period since this policy option is intended to
minimize reporting burdens on clinicians that are already participating
in quality improvement efforts through other CMS programs. We expect
that MIPS eligible clinicians that would consider facility-based
scoring would generally be aware of their hospital's performance on its
quality measures, but believe that providing this information directly
to clinicians ensures that such clinicians are fully aware of the
implications of their scoring elections under MIPS. However, we note
that this policy could conceivably place non-facility-based MIPS
eligible clinicians at a competitive
[[Page 30125]]
disadvantage since they would not have any means by which to ascertain
their MIPS measure scores in advance. We view that compromise as a
necessity to maximize transparency, and we request comment on whether
this notification in advance of the conclusion of the MIPS performance
period is appropriate, or if we should consider notifying facility-
based clinicians later in the MIPS performance period or even after its
conclusion. Notification after the MIPS performance period would
prevent facility-based clinicians from being able to compare their
expected MIPS performance category scores under the facility-based
measurement option with their expected scores under the options
available to all MIPS eligible clinicians and pick the higher of the
two. Since higher performance category scores may result in a higher
final score and a higher MIPS payment adjustment, there is a
substantial incentive for a clinician to undertake this comparison, a
comparison unavailable to non-facility-based peers.
The performance periods proposed in section II.C.5. of this
proposed rule for the 2020 MIPS payment year occur in 2018, with data
submission for most mechanisms starting in January 2019. To provide
potential facility-based scores to clinicians by the time the data
submission period for the 2018 MIPS performance period begins assuming
that timeframe is operationally feasible), we believe that the FY 2019
program year of the Hospital VBP Program, as well as the corresponding
performance periods, is the most appropriate program year to use for
purposes of facility-based measurement under the quality and cost
performance categories for the 2020 MIPS payment year. However, we note
also that Hospital VBP performance periods can run for periods as long
as 36 months, and for some FY 2019 Hospital VBP Program measures, the
performance period begins in 2014. We request comment on whether this
lengthy performance period duration should override our desire to
include all Hospital VBP Program measures as discussed further below.
We propose at Sec. 414.1380(e)(6)(iii) that the performance period for
facility-based measurement is the performance period for the measures
for the measures adopted under the value-based purchasing program of
the facility of the year specified.
We considered whether we should include the entire set of Hospital
VBP Program measures for purposes of facility-based measurement under
MIPS or attempt to differentiate those which may be more influenced by
clinicians' contribution to quality performance than others. However,
we believe that clinicians have a broad and important role as part of
the healthcare team at a hospital and that attempting to differentiate
certain measures undermines the team-based approach of facility-based
measurement. We propose at Sec. 414.1380(e)(6)(i) that the quality and
cost measures are those adopted under the value-based purchasing
program of the facility program for the year specified.
Therefore, we propose for the 2020 MIPS payment year to include all
the measures adopted for the FY 2019 Hospital VBP Program on the MIPS
list of quality measures and cost measures. Under this proposal, we
consider the FY 2019 Hospital VBP Program measures to meet the
definition of additional system-based measures provided in section
1848(q)(2)(C)(ii) of the Act, and we propose at Sec. 414.1380(e)(1)(i)
that facility-based measures available for the 2018 MIPS performance
period are the measures adopted for the FY 2019 Hospital VBP Program
year authorized by section 1886(o) of the Act and codified in our
regulations at Sec. Sec. 412.160 through 412.167. Measures in the FY
2019 Hospital VBP Program have different performance periods as noted
in Table 33.
We request comments on these proposals. We also request comments on
what other programs, if any, we should consider including for purposes
of facility-based measurement under MIPS in future program years.
(c) Facility-Based Measurement Applicability
(i) General
The percentage of professional time a clinician spends working in a
hospital varies considerably. Some clinicians may provide services in
the hospital regularly, but also treat patients extensively in an
outpatient office or another environment. Other clinicians may practice
exclusively within a hospital. Recognizing the various levels of
presence of different clinicians within a hospital environment, we seek
to limit the potential applicability of facility-based measurement to
those MIPS eligible clinicians with a significant presence in the
hospital.
In the CY 2017 Quality Payment Program final rule (81 FR 77238
through 77240), we adopted a definition of ``hospital-based MIPS
eligible clinician'' under Sec. 414.1305 for purposes of the advancing
care information performance category. Section 414.1305 defines a
hospital-based MIPS eligible clinician as a MIPS eligible clinician who
furnishes 75 percent or more of his or her covered professional
services in sites of service identified by the POS codes used in the
HIPAA standard transaction as an inpatient hospital, on-campus
outpatient hospital, or emergency room setting, based on claims for a
period prior to the performance period as specified by CMS. We
considered whether we should simply use this definition to determine
eligibility for facility-based measurement under MIPS. However, we are
concerned that this definition could include many clinicians that have
limited or no presence in the inpatient hospital setting. We have noted
that hospital-based clinicians may not have control over important
aspects of the certified EHR technology that is available in the
hospital setting (81 FR 77238). In that regard, there is little
difference between outpatient and inpatient hospital settings. But we
are proposing to determine a MIPS eligible clinician's quality
performance category score and cost performance category score based on
a hospital's Hospital VBP performance, which is based on inpatient
services. Section 1848(q)(2)(C)(ii) of the Act limits our ability to
incorporate measures used for hospital outpatient departments. Our
proposal at section II.C.6.f.(7)(a)(i) of this proposed rule to expand
the definition of a hospital-based MIPS eligible clinician for the
advancing care information performance category to include clinicians
who practice primarily in off-campus outpatient hospitals could include
clinicians that practice many miles away from the hospital in practices
which are owned by the hospital, but do not substantially contribute to
the hospital's Hospital VBP Program performance. As we discuss further
in this section, the measures used in the Hospital VBP Program are
focused on care provided in the inpatient setting. We do not believe it
is appropriate for a MIPS eligible clinician to use a hospital's
Hospital VBP Program performance for MIPS scoring if they did not
provide services in that setting.
Therefore, we believe establishing a different definition for
purposes of facility-based measurement is necessary to implement this
option. We also note that, since we are seeking comments above on other
programs to consider including for purposes of facility-based
measurement in future years, we believe establishing a separate
definition that could be expanded as needed for this purpose is
appropriate. We propose at Sec. 414.1380(e)(2) that a MIPS eligible
clinician is eligible for facility-based
[[Page 30126]]
measurement under MIPS if they are determined facility-based as an
individual. We propose at Sec. 414.1380(e)(2)(i) that a MIPS eligible
clinician is considered facility-based as an individual if the MIPS
eligible clinician furnishes 75 percent or more of their covered
professional services (as defined in section 1848(k)(3)(A) of the Act)
in sites of service identified by the POS codes used in the HIPAA
standard transaction as an inpatient hospital, as identified by POS
code 21, or an emergency room, as identified by POS code 23, based on
claims for a period prior to the performance period as specified by
CMS. We understand that the services of some clinicians who practice
solely in the hospital are billed using place of service codes such as
code 22, reflecting an on-campus outpatient hospital for patients who
are in observation status. Because there are limits on the length of
time a Medicare patient may be seen under observation status, we
believe that these clinicians would still furnish 75 percent or more of
their covered professional services using POS code 21, but seek comment
on whether a lower or higher threshold of inpatient services would be
appropriate. We do not propose to include POS code 22 in determining
whether a clinician is facility-based because many clinicians who bill
for services using this POS code may work on a hospital campus but in a
capacity that has little to do with the inpatient care in the hospital.
In contrast, we believe those who provide services in the emergency
room or the inpatient hospital clearly contribute to patient care that
is captured as part of the Hospital VBP Program because many patients
who are admitted are admitted through the emergency room. We seek
comments on whether POS 22 should be included in determining if a
clinician is facility-based and how we might distinguish those
clinicians who contribute to inpatient care from those who do not. We
note that the inclusion of any POS code in our definition is pending
technical feasibility to link a clinician to a facility under the
method described in section II.C.7.b.(4)(d) of this proposed rule.
We note that this more limited definition would mean that a
clinician who is determined to be facility-based likely would also be
determined to be hospital-based for purposes of the advancing care
information performance category, because this proposed definition of
facility-based is narrower than the hospital-based definition
established for that purpose. Clinicians would be determined to be
facility-based through an evaluation of covered professional services
between September 1 of the calendar year 2 years preceding the
performance period through August 31 of the calendar year preceding the
performance period with a 30-day claims run out. For example, for the
2020 MIPS payment year, where we have adopted a performance period of
CY 2018 for the quality and cost performance categories, we would use
the data available at the end of October 2017 to determine whether a
MIPS eligible clinician is considered facility-based by our definition.
At that time, those data would include Medicare claims with dates of
service between September 1, 2016 and August 31, 2017. In the event
that it is not operationally feasible to use claims from this exact
time period, we would use a 12-month period as close as practicable to
September 1 of the calendar year 2 years preceding the performance
period and August 31 of the calendar year preceding the performance
period. This determination would allow clinicians to be made aware of
their eligibility for facility-based measurement near the beginning of
the MIPS performance period. We believe that this definition allows us
to identify MIPS eligible clinicians who are significant contributors
to facilities' care for Medicare beneficiaries and other patients for
purposes of facility-based measurement.
We also recognize that in addition to the variation in the
percentage of time a clinician is present in the hospital, there is
also great variability in the types of services that clinicians
perform. Some may be responsible for overall management of patients
throughout their stay, others may perform a procedure, and others may
serve a role in supporting diagnostics. We considered whether certain
clinicians should be identified as eligible for this facility-based
measurement option based on characteristics in addition to their
percentage of covered professional services furnished in the inpatient
hospital or emergency room setting, such as by requiring a certain
specialty such as hospital medicine or by limiting eligibility to those
who served in patient-facing roles. However, we believe that all MIPS
eligible clinicians with a significant presence in the facility play a
role in the overall performance of a facility, and therefore, are not
proposing at this time to further limit this option based on
characteristics other than the percentage of covered professional
services furnished in an inpatient hospital or emergency room setting.
Additionally, we believe that allowing facility-based MIPS eligible
clinicians the most flexibility possible, while still being able to
accurately measure the value of care those clinicians provide, as we
continue implementation of the Quality Payment Program is paramount in
ensuring that clinicians understand the program and its effects on the
care they provide.
We request comments on this proposal.
(ii) Facility-Based Measurement Group Participation
We are also proposing at Sec. 414.1380(e)(2) that a MIPS eligible
clinician is eligible for facility-based measurement under MIPS if they
are determined facility-based as part of a group. We are proposing at
Sec. 414.1380(e)(2)(ii) that a facility-based group is a group in
which 75 percent or more of the MIPS eligible clinician NPIs billing
under the group's TIN are eligible for facility-based measurement as
individuals as defined in Sec. 414.1380(e)(2)(i). We also considered
an alternative proposal in which a facility-based group would be a
group where the TIN overall furnishes 75 percent or more of its covered
professional services (as defined in section 1848(k)(3)(A) of the Act)
in sites of service identified by the POS codes used in the HIPAA
standard transaction as an inpatient hospital, as identified by POS
code 21, or the emergency room, as identified by POS code 23, based on
claims for a period prior to the performance period as specified by
CMS. Groups would be determined to be facility-based through an
evaluation of covered professional services between September 1 of the
calendar year 2 years preceding the performance period through August
31 of the calendar year preceding the performance period with a 30 day
claims run out period (or if not operationally feasible to use claims
from this exact time period, a 12-month period as close as practicable
to September 1 of the calendar year 2 years preceding the performance
period and August 31 of the calendar year preceding the performance
period).
We request comments on our proposal and alternative proposal.
(d) Facility Attribution for Facility-Based Measurement
Many MIPS eligible clinicians provide services at more than one
hospital, so we must develop a method to identify which hospital's
scores should be associated with that MIPS eligible clinician under
this facility-based measurement option. We considered
[[Page 30127]]
whether a clinician should be required to identify for us the hospital
with which they were affiliated, but felt that such a requirement would
add unnecessary administrative burden in a process that we believe was
intended to reduce burden. We also considered whether we could combine
scores from multiple hospitals, but believe that such a combination
would reduce the alignment between a single hospital and a clinician or
group and could be confusing for participants. We believe we must
establish a reasonable threshold for a MIPS eligible clinician's
participation in clinical care at a given facility to allow that MIPS
eligible clinician to be scored using that facility's measures. We do
not believe it to be appropriate to allow MIPS eligible clinicians to
claim credit for facilities' measures if the MIPS eligible clinician
does not participate meaningfully in the care provided at a given
facility.
Therefore, we propose at Sec. 414.1380(e)(5) that MIPS eligible
clinicians who elect facility-based measurement would receive scores
derived from the value-based purchasing score (using the methodology
described in section II.B.7.b.4 of this proposed rule) for the facility
at which they provided services for the most Medicare beneficiaries
during the period of September 1 of the calendar year 2 years preceding
the performance period through August 31 of the calendar year preceding
the performance period with a 30 day claims run out. This mirrors our
period of determining if a clinician is eligible for facility-based
measurement and also overlaps with parts of the performance period for
the applicable Hospital VBP program measures. For the first year, the
value-based purchasing score for the facility is the FY 2019 Hospital
VBP Program's Total Performance Score. In cases in which there was an
equal number of Medicare beneficiaries treated at more than one
facility, we propose to use the value-based purchasing score from the
facility with the highest score.
(e) Election of Facility-Based Measurement
Stakeholders have expressed a strong preference that facility-based
measurement be a voluntary process, and we agree with this preference
considering our general goal in making MIPS as flexible as possible.
Therefore, we propose at Sec. 414.1380(e)(3) that individual MIPS
eligible clinicians or groups who wish to have their quality and cost
performance category scores determined based on a facility's
performance must elect to do so. We propose that those clinicians or
groups who are eligible for and wish to elect facility-based
measurement would be required to submit their election during the data
submission period as determined at Sec. 414.1325(f) through the
attestation submission mechanism established for the improvement
activities and advancing care information performance categories. If
technically feasible, we would let the MIPS eligible clinician know
that they were eligible for facility-based measurement prior to the
submission period, so that MIPS eligible clinicians would be informed
if this option is available to them.
We also considered an alternative approach of not requiring an
election process but instead automatically applying facility-based
measurement to MIPS eligible clinicians and groups who are eligible for
facility-based measurement, if technically feasible. Under this
approach, we would calculate a MIPS eligible clinician's facility-based
measurement score based on the hospital's (as identified using the
process described in section II.C.6.b. of this proposed rule)
performance using the methodology described in section II.C.7.a.2.b. of
this proposed rule, and automatically use that facility-based
measurement score for the quality and cost performance category scores
if the facility-based measurement score is higher than the quality and
cost performance category scores as determined based on data submitted
by the MIPS eligible clinician through any available reporting
mechanism. This facility-based measurement score would be calculated
even if an individual MIPS eligible clinician or group did not submit
any data for the quality performance category. This option would reduce
burden for MIPS eligible clinicians by not requiring them to elect
facility-based measurement, but is contrary to stakeholders' request
for a voluntary policy. Additionally, under this option, our
considerations about Hospital VBP Program timing would be less
applicable. That is, we explained our rationale for specifying the FY
2019 Hospital VBP Program above, in part to ensure that MIPS eligible
clinicians are informed about their potential facility-based scores
prior to the conclusion of the MIPS performance period. However, under
an automatic process, we could consider automatically using other
Hospital VBP Program years' scores. For example, we could apply FY 2020
Hospital VBP Program scores instead of FY 2019. We intend in general to
align Hospital VBP and MIPS performance periods when feasible, and the
timing considerations we described above led us to conclude that FY
2019 was the most appropriate Hospital VBP Program year for the first
year of the facility-based measurement option under MIPS, and selecting
other years would result in further divergence between the MIPS
performance period and the Hospital VBP Program's performance periods.
We are also concerned that a method that does not require active
selection may result in MIPS eligible clinicians being scored on
measures at a facility and being unaware that such scoring is taking
place. We are also concerned that such a method could provide an
advantage to those facility-based clinicians who do not submit quality
measures in comparison to those who work in other environments. We also
note that this option may not be technically feasible for us to
implement for the 2018 MIPS performance period.
We invite comments on this proposal and alternate proposal.
(e) Facility-Based Measures
For the FY 2019 program year, the Hospital VBP Program has adopted
13 quality and efficiency measures. The Hospital VBP Program currently
includes 4 domains: Person and community engagement, clinical care,
safety, and efficiency and cost reduction. These domains align with
many MIPS high priority measures (outcome, appropriate use, patient
safety, efficiency, patient experience, and care coordination measures)
in the quality performance category and the efficiency and cost
reduction domain closely aligns with our cost performance category. We
believe this set of measures covering 4 domains and composed primarily
of measures that would be considered high priority under the MIPS
quality performance category capture a broad picture of hospital-based
care. For example, the HCAHPS survey under the Hospital VBP Program is
a patient experience measure, which would make it a high-priority
measure under MIPS. Additionally, the Hospital VBP Program has adopted
several measures of clinical outcomes in the form of 30-day mortality
measures, and clinical outcomes are a high-priority topic for MIPS. The
Hospital VBP Program includes several measures in a Safety domain,
which meets our definition of patient safety measures as high-priority.
Therefore, we propose that facility-based individual MIPS eligible
clinicians or groups that are attributed to a hospital would be scored
on all the measures on which the hospital is scored for the Hospital
VBP Program via the Hospital VBP Program's Total
[[Page 30128]]
Performance Score (TPS) scoring methodology.
The Hospital VBP Program's FY 2019 measures, and their associated
performance periods, have been reproduced in Table 33 (see 81 FR 56985
and 57002).
Table 33--FY 2019 Hospital VBP Program Measures
----------------------------------------------------------------------------------------------------------------
Short name Domain/measure name NQF No. Performance period
----------------------------------------------------------------------------------------------------------------
Person and Community Engagement Domain
----------------------------------------------------------------------------------------------------------------
HCAHPS.............................. Hospital Consumer Assessment 0166 (0228) CY 2017
of Healthcare Providers and
Systems (HCAHPS) (including
Care Transition Measure).
----------------------------------------------------------------------------------------------------------------
Clinical Care Domain
----------------------------------------------------------------------------------------------------------------
MORT-30-AMI......................... Hospital 30-Day, All-Cause, 0230 July 1, 2014--June 30,
Risk-Standardized Mortality 2017
Rate (RSMR) Following Acute
Myocardial Infarction (AMI)
Hospitalization.
MORT-30-HF.......................... Hospital 30-Day, All-Cause, 0229 July 1, 2014--June 30,
Risk-Standardized Mortality 2017
Rate (RSMR) Following Heart
Failure (HF) Hospitalization.
MORT-30-PN.......................... Hospital 30-Day, All-Cause, 0468 July 1, 2014--June 30,
Risk-Standardized Mortality 2017
Rate (RSMR) Following
Pneumonia Hospitalization.
THA/TKA............................. Hospital-Level Risk- 1550 January 1, 2015--June
Standardized Complication 30, 2017
Rate (RSCR) Following
Elective Primary Total Hip
Arthroplasty (THA) and/or
Total Knee Arthroplasty
(TKA).
----------------------------------------------------------------------------------------------------------------
Safety Domain
----------------------------------------------------------------------------------------------------------------
CAUTI............................... National Healthcare Safety 0138 CY 2017
Network (NHSN) Catheter-
Associated Urinary Tract
Infection (CAUTI) Outcome
Measure.
CLABSI.............................. National Healthcare Safety 0139 CY 2017
Network (NHSN) Central Line-
Associated Bloodstream
Infection (CLABSI) Outcome
Measure.
Colon and Abdominal Hysterectomy SSI American College of Surgeons-- 0753 CY 2017
Centers for Disease Control
and Prevention (ACS-CDC)
Harmonized Procedure
Specific Surgical Site
Infection (SSI) Outcome
Measure.
MRSA Bacteremia..................... National Healthcare Safety 1716 CY 2017
Network (NHSN) Facility-wide
Inpatient Hospital-onset
Methicillin-resistant
Staphylococcus aureus (MRSA)
Bacteremia Outcome Measure.
CDI................................. National Healthcare Safety 1717 CY 2017
Network (NHSN) Facility-wide
Inpatient Hospital-onset
Clostridium difficile
Infection (CDI) Outcome
Measure.
PSI-90*............................. Patient Safety for Selected 0531 July 1, 2015--June 30
Indicators (Composite 2017
Measure).
PC-01............................... Elective Delivery............ 0469 CY 2017
----------------------------------------------------------------------------------------------------------------
Efficiency and Cost Reduction Domain
----------------------------------------------------------------------------------------------------------------
MSPB................................ Payment-Standardized Medicare 2158 CY 2017
Spending Per Beneficiary
(MSPB).
----------------------------------------------------------------------------------------------------------------
* PSI-90 has been proposed in the FY 2018 IPPS/LTCH PPS proposed rule for removal beginning with the FY 2019
program year.
We note that the Patient Safety Composite Measure (PSI-90) was
proposed for removal beginning with the FY 2019 measure set in the FY
2018 IPPS/LTCH proposed rule (82 FR 19970) due to issues with
calculating the measure score. If the proposal to remove that measure
from the hospital measure set is finalized, we would remove the measure
from the list of those adopted for facility-based measurement in the
MIPS program.
We propose at Sec. 414.1380(e)(4) that there are no data
submission requirements for the facility-based measures used to assess
performance in the quality and cost performance categories, other than
electing the option through attestation as proposed in section
II.C.7.a.(4)(e). We also refer readers to section II.C.7. of this
proposed rule for further details on how we will incorporate scoring
for facility-based measurements into MIPS.
(f) Scoring Facility-Based Measurement
(i) Hospital VBP Program Scoring
As we discuss above in subsection (b), we believe that the Hospital
VBP Program represents the most appropriate value-based purchasing
program with which to begin implementation of the facility-based
measurement option under MIPS.
Section 1886(o) of the Act, as added by section 3001(a)(1) of the
Affordable Care Act, requires the Secretary to establish a hospital
value-based purchasing program (the Hospital VBP Program) under which
value-based incentive payments are made in a fiscal year to hospitals
that meet performance standards established for a performance period
for such fiscal year. These value-based incentive payments are funded
through a reduction to participating hospitals' base-operating DRG
payment amounts, with the amount of the reduction specified by statute.
For the FY 2019 program year, that reduction will be equal to 2
percent. Participating hospitals then receive value-based incentive
payments depending on their performance on measures adopted
[[Page 30129]]
under the Program. For more detail on the statutory background and
history of the Hospital VBP Program's implementation, we refer readers
to 81 FR 56979.
As noted previously, the FY 2019 Hospital VBP Program will score
participating hospitals on 13 measures covering 4 domains of care,
although as discussed in the FY 2018 IPPS/LTCH proposed rule (82 FR
19970), we have proposed to remove the PSI 90 Patient Safety Composite
measure from the FY 2019 measure set. For each of the measures,
performance standards are established for the applicable fiscal year
that include levels of achievement and improvement. For the FY 2019
program year, the achievement threshold and benchmark are calculated
using baseline period data with respect to that fiscal year, with the
achievement threshold for each of these measures being the median of
hospital performance on the measure during the baseline period and the
benchmark for each of these measures being the arithmetic mean of the
top decile of hospital performance during the baseline period. The
achievement threshold and benchmark for the MSPB measure are calculated
using the same methodology, except that we use performance period data
instead of baseline period data in our calculations. We then calculate
hospital performance on each measure during the performance period for
which they have sufficient data and calculate a measure score based on
that performance as compared with the performance standards that apply
to the measure. For achievement scoring, those hospitals that perform
below (or above in the case of measures for which a lower rate is
better) the level of the achievement threshold are not awarded any
achievement points. Those that perform between the level of the
achievement threshold and the benchmark are awarded points based on the
relative performance of the hospital, according to formulas specified
by the Hospital VBP Program (see the Hospital Inpatient VBP Program
final rule, 76 FR 26518 through 26519). Those hospitals whose
performance meets or exceeds the benchmark are awarded 10 achievement
points for the measure. Hospitals are also provided the opportunity to
receive improvement points based on their improvement between the
baseline period for the measure and the performance period. A hospital
is awarded between 0 and 10 points for achievement and 0 and 9 points
for improvement, and is awarded the higher of the 2 scores for each
individual measure. There are no floors established for scoring and no
bonus points are available in this scoring system.
Points awarded for measures within each domain are summed to reach
the unweighted domain score. We note for the person and community
engagement domain only, the domain score consists of a base score and a
consistency score. The base score is based on the greater of
improvement or achievement points for each of the 8 HCAHPS survey
dimensions. Consistency points are awarded based on a hospital's lowest
HCAHPS dimension score during the performance period relative to
national hospital scores on that dimension during the baseline period.
The domain scores are then weighted according to domain weights
specified each Program year, then summed to reach the Total Performance
Score, which is converted to a value-based incentive payment percentage
that is used to adjust payments to each hospital for inpatient services
furnished during the applicable program year. For the FY 2019 program
year, all 4 domains will be weighted equally. We refer readers to 81 FR
57005 and 81 FR 79857 through 79858 for additional information on the
Hospital VBP Program's performance standards, as well as the QualityNet
Web site for certain technical updates to the performance standards.
(ii) Applying Hospital VBP Program Scoring to the MIPS Quality and Cost
Performance Categories
We considered several methods to incorporate facility-based
measures into scoring for the 2020 MIPS payment year, including
selecting hospitals' measure scores, domain scores, and the Hospital
VBP Program Total Performance Scores to form the basis for the cost and
quality performance category scores for individual MIPS eligible
clinicians and groups that are eligible to participate in facility-
based measurement. Although each of these approaches may have merit, we
have proposed the option that we believe provides the fairest
comparison between performance in the 2 programs and will best allow us
to expand the opportunity to other programs in the future.
Unlike MIPS, the Hospital VBP Program does not have performance
categories. There are instead four domains of measures. We considered
whether we should try to identify certain domains or measures that were
more closely aligned with those identified in the quality performance
category or the cost performance category. We also considered whether
we should limit the application of facility-based measurement to the
quality performance category and calculate the cost performance
category score as we do for other clinicians. However, we believe that
value-based purchasing programs are generally constructed to assess an
overall picture of the care provided by the facility, taking into
account both the costs and the quality of care provided. Given our
focus on alignment between quality and cost, we also do not believe it
is appropriate to measure quality on one unit (a hospital) and cost on
another (such as an individual clinician or TIN). Therefore, we propose
at Sec. 414.1380(e) that facility-based scoring is available for the
quality and cost performance categories and that the facility-based
measurement scoring standard is the MIPS scoring methodology applicable
for those who meet facility-based eligibility requirements and who
elect facility-based measurement.
(iii) Benchmarking Facility-Based Measures
Measures in the MIPS quality performance category are benchmarked
to historical performance on the basis of performance during the 12-
month calendar year that is 2 years prior to the performance period for
the MIPS payment year. If a historical benchmark cannot be established,
a benchmark is calculated during the performance period. In the cost
performance category, benchmarks are established during the performance
period because changes in payment policies year to year can make it
challenging to compare performance on cost measure year to year.
Although we propose a different performance period for MIPS eligible
clinicians in facility-based measurement, the baseline period used for
creating MIPS benchmarks is generally consistent with this approach. We
note that the Hospital VBP Program uses measures for the same fiscal
year even if those measures do not have the same performance period
length, but the baseline period closes well before the performance
period. The MSPB is benchmarked in a manner that is similar to measures
in the MIPS cost performance category. The MSPB only uses a historical
baseline period for improvement scoring and bases its achievement
threshold and benchmark solely on the performance period (81 FR 57002).
We propose at Sec. 414.1380(e)(6)(ii) that the benchmarks for
facility-based measurement are those that are adopted under the value-
based purchasing program of the facility for the year specified.
[[Page 30130]]
(iv) Assigning MIPS Performance Category Scores Based on Hospital VBP
Performance
Performance measurement in the Hospital VBP Program and MIPS is
quite different in part due to the design and the maturity of the
programs. As noted above, the Hospital VBP Program only assigns
achievement points to a hospital for its performance on a measure if
the hospital's performance during the performance period meets or
exceeds the median of hospital performance on that measure during the
applicable baseline period, whereas MIPS assigns achievement points to
all measures that meet the required data completeness and case
minimums. In addition, the Hospital VBP Program has removed many
process measures and topped out measures since its first program year
(FY 2013), while both process and topped out measures are available in
MIPS. With respect to the FY 2017 program year, for example, the median
Total Performance Score for a hospital in Hospital VBP was 33.88 out of
100 possible points. If we were to simply assign the Hospital VBP Total
Performance Score for a hospital to a clinician, the performance of
those MIPS eligible clinicians electing facility-based measurement
would likely be lower than most who participated in the MIPS program,
particularly in the quality performance category.
We believe that we should recognize relative performance in the
facility programs that reflects their different designs. Therefore, we
propose at Sec. 414.1380(e)(6)(iv) that the quality performance
category score for facility-based measurement is reached by determining
the percentile performance of the facility determined in the value-
based purchasing program for the specified year as described under
Sec. 414.1380(e)(5) and awarding a score associated with that same
percentile performance in the MIPS quality performance category score
for those clinicians who are not scored using facility-based
measurement. We also propose at Sec. 414.1380(e)(6)(v) that the cost
performance category score for facility-based measurement is
established by determining the percentile performance of the facility
determined in the value-based purchasing program for the specified year
as described in Sec. 414.1380(e)(5) and awarding the number of points
associated with that same percentile performance in the MIPS cost
performance category score for those clinicians who are not scored
using facility-based measurement. For example, if the median Hospital
VBP Program Total Performance Score was 35 out of 100 possible points
and the median quality performance category percent score in MIPS was
75 percent and the median cost performance category score was 50
percent, then a clinician or group that is evaluated based on a
hospital that received an Hospital VBP Program Total Performance Score
of 35 points would receive a score of 75 percent for the quality
performance category and 50 percent for the cost performance category.
The percentile distribution for both the Hospital VBP Program and MIPS
would be based on the distribution during the applicable performance
periods for each of the programs and not on a previous benchmark year.
We believe this proposal offers a fairer comparison of the
performance among participants in MIPS and the Hospital VBP Program
compared to other options we considered and provides an objective means
to normalize differences in measured performance between the programs.
In addition, we believe this method will make it simpler to apply the
concept of facility-based measurement to additional programs in the
future.
We welcome public comments on this proposal.
(v) Scoring Improvement for Facility-Based Measurement
The Hospital VBP Program includes a methodology for recognizing
improvement on individual measures which is then incorporated into the
total performance score for each participating hospital. A hospital's
performance on a measure is compared to a national benchmark as well as
its own performance from a corresponding baseline period.
In this proposed rule, we have proposed to consider improvement in
the quality and cost performance categories. In section II.C.7.a.(2)(i)
of this proposed rule, we propose to measure improvement in the quality
performance category based on improved achievement for the performance
category percent score and award improvement even if, under certain
circumstances, a clinician moves from one identifier to another from 1
year to the next. For those who may be measured under facility-based
measurement, improvement is already captured in the scoring method used
by the Hospital VBP Program, so we do not believe it is appropriate to
separately measure improvement using the proposed MIPS methodology.
Although the improvement methodology is not identical, a hospital that
demonstrated improvement in the individual measures would in turn
receive a higher score through the Hospital VBP Program methodology, so
that improvement is reflected in the underlying Hospital VBP Program
measurement. In addition, improvement is already captured in the
distribution of MIPS performance scores that is used to translate
Hospital VBP Total Performance Score into a MIPS quality performance
category score. Therefore, we are not proposing any additional
improvement scoring for facility-based measurement for either the
quality or cost performance category.
Because we intend to allow clinicians the flexibility to elect
facility-based measurement on an annual basis, some clinicians may be
measured through facility-based measurement in 1 year and through
another MIPS method in the next. Because the first MIPS performance
period in which a clinician could switch from facility-based
measurement to another MIPS method would be in 2019, we seek comment on
how to assess improvement for those that switch from facility-based
scoring to another MIPS method. We request comment on whether it is
appropriate to include measurement of improvement in the MIPS quality
performance category for facility-based measured clinicians and groups
given that the Hospital VBP Program already takes improvement into
account in its scoring methodology.
In section II.C.7.a.(3)(a) of this proposed rule, we discuss our
proposal to measure improvement in the cost performance category at the
measure level. We propose that clinicians under facility-based
measurement would not be eligible for a cost improvement score in the
cost performance category. As in the quality performance category, we
believe that a clinician participating in facility-based measurement in
subsequent years would already have improvement recognized as part of
the Hospital VBP Program methodology and should therefore not be given
additional credit. In addition, because we propose to limit measurement
of improvement to those MIPS eligible clinicians that participate in
MIPS using the same identifier and are scored on the same cost
measure(s) in 2 consecutive performance periods, those MIPS eligible
clinicians who elect facility-based measurement would not be eligible
for a cost improvement score in the cost performance category under our
proposed methodology because they would not be scored on the same cost
measure(s) for 2 consecutive performance periods.
[[Page 30131]]
We invite comments on these proposals.
(vi) Bonus Points for Facility-Based Measurement
MIPS eligible clinicians that report on quality measures are
eligible for bonus points for the reporting of additional outcome and
high priority measures beyond the one that is required. 2 bonus points
are awarded for each additional outcome or patient experience measure,
and one bonus point is awarded for each additional other high priority
measure. These bonus points are intended to encourage the use of
measures that are more impactful on patients and better reflect the
overall goals of the MIPS program. Many of the measures in the Hospital
VBP Program meet the criteria that we have adopted for high-priority
measures. We support measurement that takes clinicians' focus away from
clinical process measures; however, our proposed scoring method
described above is based on a percentile distribution of scores within
the quality and cost performance categories that already accounts for
bonus points. For this reason, we are not proposing to calculate
additional high priority bonus points for facility-based measurement.
We note that clinicians have an additional opportunity to receive
bonus points in the quality performance category score for using end-
to-end electronic submission of quality measures. The Hospital VBP
Program does not capture whether or not measures are reported using
end-to-end electronic reporting. In addition, our proposed facility-
based scoring method described above is based on a percentile
distribution of scores within the quality and cost performance
categories that already accounts for bonus points. For this reason, we
are not proposing to calculate additional end-to-end electronic
reporting bonus points for facility-based measurement.
We welcome public comments on our approach.
(vii) Special Rules for Facility-Based Measurement
Some hospitals do not receive a Total Performance Score in a given
year in the Hospital VBP Program, whether due to insufficient quality
measure data, failure to meet requirements under the Hospital Inpatient
Quality Reporting Program, or other reasons. In these cases, we would
be unable to calculate a facility-based score based on the hospital's
performance, and facility-based clinicians would be required to
participate in MIPS via another method. Most hospitals which do not
receive a Total Performance Score in the Hospital VBP Program are
routinely excluded, such as hospitals in Maryland. In such cases,
facility-based clinicians would know well in advance that the hospital
would not receive a Total Performance Score, and that they would need
to participate in MIPS through another method. However, we are
concerned that some facility-based clinicians may provide services in
hospitals which they expect will receive a Total Performance Score but
do not due to various rare circumstances such as natural disasters. In
section II.C.7.b.(3)(c) of this proposed rule, we propose a process for
requesting a reweighting assessment for the quality, cost and
improvement activities performance categories due to extreme and
uncontrollable circumstances, such as natural disasters. We propose
that MIPS eligible clinicians who are facility-based and affected by
extreme and uncontrollable circumstances, such as natural disasters,
may apply for reweighting.
In addition, we note that hospitals may submit correction requests
to their Total Performance Scores calculated under the Hospital VBP
Program, and may also appeal the calculations of their Total
Performance Scores, subject to Hospital VBP Program requirements
established in prior rulemaking. We intend to use the final Hospital
VBP Total Performance Score for the facility-based measurement option
under MIPS. In the event that a hospital obtains a successful
correction or appeal of its Total Performance Score, we would update
MIPS eligible clinicians' quality and cost performance category scores
accordingly, as long as the update could be made prior to the
application of the MIPS payment adjustment for the relevant MIPS
payment year. We welcome public comments on whether a different
deadline should be considered.
Additionally, although we wish to tie the hospital and clinician
performance as closely together as possible for purposes of the
facility-based scoring policy, we do not wish to disadvantage those
clinicians and groups that select this measurement method. In section
II.C.7.a.(2) of this proposed rule, we propose to retain a policy
equivalent to the 3-point floor for all measures with complete data in
the quality performance category scored against a benchmark in the 2020
MIPS payment year. However, the Hospital VBP Program does not have a
corresponding scoring floor. Therefore, we propose to adopt a floor on
the Hospital VBP Program Total Performance Score for purposes of
facility-based measurement under MIPS so that any score in the quality
performance category, once translated into the percentile distribution
described above, that would result in a score of below 30 percent would
be reset to a score of 30 percent in the quality performance category.
We believe that this adjustment is important to maintain consistency
with our other policies. There is no similar floor established for
measures in the cost performance category under MIPS, so we do not
propose any floor for the cost performance category for facility-based
measurement.
Some MIPS eligible clinicians who select facility-based measurement
could have sufficient numbers of attributed patients to meet the case
minimums for the cost measures established under MIPS. Although there
is no additional data reporting for cost measures, we believe that, to
facilitate the relationship between cost and quality measures, they
should be evaluated covering the same population as opposed to
comparing a hospital population and a population attributed to an
individual clinician or group. In addition, we believe that including
additional cost measures in the cost performance category score for
MIPS eligible clinicians who elect facility-based measurement would
reduce the alignment of incentives between the hospital and the
clinician. Thus, we are proposing at Sec. 414.1380(e)(6)(v)(A) that
MIPS eligible clinicians who elect facility-based measurement would not
be scored on other cost measures specified for the cost performance
category, even if they meet the case minimum for a cost measure.
If a clinician or a group elects facility-based measurement but
also submits quality data through another MIPS mechanism, we propose to
use the higher of the two scores for the quality performance category
and base the score of the cost performance category on the same method
(that is, if the facility-based quality performance category score is
higher, facility-based measurement is used for quality and cost). Since
this policy may result in a higher final score, it may provide
facility-based clinicians with a substantial incentive to elect
facility-based measurement, whether or not the clinician believes such
measures are the most accurate or useful measures of that clinician's
performance. Therefore, this policy may create an unfair advantage for
facility-based clinicians over non-facility-based clinicians, since
non-facility-based clinicians would not have the opportunity to use the
higher of two scores. Therefore, we seek comment on whether this
proposal to use the higher score is the best approach to score the
performance of facility-based clinicians
[[Page 30132]]
in comparison to their non-facility-based peers.
(5) Scoring the Improvement Activities Performance Category
Section 1848(q)(5)(C) of the Act specifies scoring rules for the
improvement activities performance category. For more of the statutory
background and description of the proposed and finalized policies, we
refer readers to the CY 2017 Quality Payment Program final rule (81 FR
77311 through 77319). We have also codified certain requirements for
the improvement activities performance category at Sec.
414.1380(b)(3). Based on these criteria, we finalized at Sec.
414.1380(b)(3) in the CY 2017 Quality Payment Program final rule the
scoring methodology for this category, which assigns points based on
certified patient-centered medical home participation or comparable
specialty practice participation, APM participation, and the
improvement activities reported by the MIPS eligible clinician (81 FR
77312). A MIPS eligible clinician's performance will be evaluated by
comparing the reported improvement activities to the highest possible
score (40 points). We are not proposing any changes to the scoring of
the improvement activities performance category in this proposed rule.
(a) Assigning Points to Reported Improvement Activities
We will assign points for each reported improvement activity within
2 categories: Medium-weighted and high-weighted activities. Each
medium-weighted activity is worth 10 points toward the total category
score of 40 points, and each high-weighted activity is worth 20 points
toward the total category score of 40 points. These points are doubled
for small practices, practices in rural areas, or practices located in
geographic HPSAs, and non-patient facing MIPS eligible clinicians. We
refer readers to Sec. 414.1380(b)(3) and the CY 2017 Quality Payment
Program final rule (81 FR 78312) for further detail on improvement
activities scoring.
Activities will be weighted as high based on the extent to which
they align with activities that support the certified patient-centered
medical home, since that is consistent with the standard under section
1848(q)(5)(C)(i) of the Act for achieving the highest potential score
for the improvement activities performance category, as well as with
our priorities for transforming clinical practice (81 FR 77311).
Additionally, activities that require performance of multiple actions,
such as participation in the Transforming Clinical Practice Initiative
(TCPI), participation in a MIPS eligible clinician's state Medicaid
program, or an activity identified as a public health priority (such as
emphasis on anticoagulation management or utilization of prescription
drug monitoring programs) are justifiably weighted as high (81 FR 77311
through 77312).
We refer readers to Table 26 of the CY 2017 Quality Payment Program
final rule for a summary of the previously finalized improvement
activities that are weighted as high (81 FR 77312 through 77313), and
we refer readers to Table H of the same final rule, for a list of all
the previously finalized improvement activities, both medium- and high-
weighted (81 FR 77817 through 77831). Please refer to Table F and Table
G in the appendices of this proposed rule for proposed additions and
changes to the Improvement Activities Inventory for the 2020 MIPS
payment year and future years. Activities included in these proposed
tables would apply for the 2020 MIPS payment year and future years
unless further modified via notice and comment rulemaking. Consistent
with our unified scoring system principles, we finalized in the CY 2017
Quality Payment Program final rule that MIPS eligible clinicians will
know in advance how many potential points they could receive for each
improvement activity (81 FR 77311 through 77319).
(b) Improvement Activities Performance Category Highest Potential Score
At Sec. 414.1380(b)(3), we finalized that we will require a total
of 40 points to receive the highest score for the improvement
activities performance category (81 FR 77315). For more of the
statutory background and description of the proposed and finalized
policies, we refer readers to the CY 2017 Quality Payment Program final
rule (81 FR 77314 through 77315).
For small practices, practices in rural areas and geographic HPSA
practices and non-patient facing MIPS eligible clinicians, the weight
for any activity selected is doubled so that these practices and
eligible clinicians only need to select one high- or two medium-
weighted activities to achieve the highest score of 40 points (81 FR
77312).
In accordance with section 1848(q)(5)(C)(ii) of the Act, we
codified at Sec. 414.1380(b)(3)(ix) that individual MIPS eligible
clinicians or groups who are participating in an APM (as defined in
section 1833(z)(3)(C) of the Act) for a performance period will
automatically earn at least one half of the highest potential score for
the improvement activities performance category for the performance
period. In addition, MIPS eligible clinicians that are participating in
MIPS APMs will be assigned an improvement activity score, which may be
higher than one half of the highest potential score. This assignment is
based on the extent to which the requirements of the specific model
meet the list of activities in the Improvement Activities Inventory.
For a further description of improvement activities and the APM scoring
standard for MIPS, we refer readers to the CY 2017 Quality Payment
Program final rule (81 FR 77246). For all other individual MIPS
eligible clinicians or groups, we refer readers to the scoring
requirements for individual MIPS eligible clinicians and groups in the
CY 2017 Quality Payment Program final rule (81 FR 77270). An individual
MIPS eligible clinician or group is not required to perform activities
in each improvement activities subcategory or participate in an APM to
achieve the highest potential score in accordance with section
1848(q)(5)(C)(iii) of the Act (81 FR 77178).
In the CY 2017 Quality Payment Program final rule, we also
finalized that individual MIPS eligible clinicians and groups that
successfully participate and submit data to fulfill the requirements
for the CMS Study on Improvement Activities and Measurement will
receive the highest score for the improvement activities performance
category (81 FR 77315). We refer readers to section II.C.6.e.(7) of
this proposed rule for further detail on this study.
(c) Points for Certified Patient-Centered Medical Home or Comparable
Specialty Practice
Section 1848(q)(5)(C)(i) of the Act specifies that a MIPS eligible
clinician who is in a practice that is certified as a patient-centered
medical home or comparable specialty practice for a performance period,
as determined by the Secretary, must be given the highest potential
score for the improvement activities performance category for the
performance period. Accordingly, at Sec. 414.1380(b)(3)(iv), we
specify that a MIPS eligible clinician who is in a practice that is
certified as a patient-centered medical home, including a Medicaid
Medical Home, Medical Home Model, or comparable specialty practice,
will receive the highest potential score for the improvement activities
performance category (81 FR 77196 through 77180).
We are not proposing any changes to the scoring of the patient-
centered medical home or comparable specialty
[[Page 30133]]
practice; although we are proposing a change to how groups qualify for
this activity. We refer readers to section II.C.6.e. of this proposed
rule for a discussion of the requirements for certified patient-
centered medical home practices or comparable specialty practices.
(d) Calculating the Improvement Activities Performance Category Score
In the CY 2017 Quality Payment Program final rule (81 FR 77318), we
finalized that individual MIPS eligible clinicians and groups must earn
a total of 40 points to receive the highest score for the improvement
activities performance category. To determine the improvement
activities performance category score, we sum the points for all of a
MIPS eligible clinician's reported activities and divide by the
improvement activities performance category highest potential score of
40. A perfect score will be 40 points divided by 40 possible points,
which equals 100 percent. If MIPS eligible clinicians have more than 40
improvement activities points we will cap the resulting improvement
activities performance category score at 100 percent.
Section 1848(q)(2)(B)(iii) of the Act requires the Secretary to
give consideration to the circumstances of small practices and
practices located in rural areas and in geographic HPSAs (as designated
under section 332(a)(1)(A) of the PHS Act) in defining activities.
Section 1848(q)(2)(C)(iv) of the Act also requires the Secretary to
give consideration to non-patient facing MIPS eligible clinicians.
Further, section 1848(q)(5)(F) of the Act allows the Secretary to
assign different scoring weights for measures, activities, and
performance categories, if there are not sufficient measures and
activities applicable and available to each type of eligible clinician.
Accordingly, we finalized that the following scoring applies to
MIPS eligible clinicians who are a non-patient facing MIPS eligible
clinician, a small practice (consisting of 15 or fewer professionals),
a practice located in a rural area, or practice in a geographic HPSA or
any combination thereof:
Reporting of one medium-weighted activity will result in
20 points or one-half of the highest score.
Reporting of two medium-weighted activities will result in
40 points or the highest score.
Reporting of one high-weighted activity will result in 40
points or the highest score.
The following scoring applies to MIPS eligible clinicians who are
not a non-patient facing clinician, a small practice, a practice
located in a rural area, or a practice in a geographic HPSA:
Reporting of one medium-weighted activity will result in
10 points which is one-fourth of the highest score.
Reporting of two medium-weighted activities will result in
20 points which is one-half of the highest score.
Reporting of three medium-weighted activities will result
in 30 points which is three-fourths of the highest score.
Reporting of four medium-weighted activities will result
in 40 points which is the highest score.
Reporting of one high-weighted activity will result in 20
points which is one-half of the highest score.
Reporting of two high-weighted activities will result in
40 points which is the highest score.
Reporting of a combination of medium-weighted and high-
weighted activities where the total number of points achieved are
calculated based on the number of activities selected and the weighting
assigned to that activity (number of medium-weighted activities
selected x 10 points + number of high-weighted activities selected x 20
points) (81 FR 78318).
We also finalized in the CY 2017 Quality Payment Program final rule
that certain activities in the improvement activities performance
category will also qualify for a bonus under the advancing care
information performance category (81 FR 78318). This bonus will be
calculated under the advancing care information performance category
and not under the improvement activities performance category. We refer
readers to section II.C.6.f.5.(d) of this proposed rule for further
details. For more information about our finalized improvement
activities scoring policies and for several sample scoring charts, we
refer readers to the CY 2017 Quality Payment Program final rule (81 FR
78319). Finally, in that same final rule, we codified at Sec.
414.1380(b)(3)(ix) that MIPS eligible clinicians participating in APMs
that are not certified patient-centered medical homes will
automatically earn a minimum score of one-half of the highest potential
score for the performance category, as required by section
1848(q)(5)(C)(ii) of the Act. For any other MIPS eligible clinician who
does not report at least one activity, including a MIPS eligible
clinician who does not identify to us that they are participating in a
certified patient-centered medical home or comparable specialty
practice, we will calculate a score of zero points (81 FR 77319).
(e) Self-Identification Policy for MIPS Eligible Clinicians
We also noted in the CY 2017 Quality Payment Program final rule (81
FR 77319), that individual MIPS eligible clinicians or groups
participating in APMs would not be required to self-identify as
participating in an APM, but that all MIPS eligible clinicians would be
required to self-identify if they were part of a certified patient-
centered medical home or comparable specialty practice, a non-patient
facing MIPS eligible clinician, a small practice, a practice located in
a rural area, or a practice in a geographic HPSA or any combination
thereof, and that we would validate these self-identifications as
appropriate. However, beginning with the 2018 MIPS performance period,
we are proposing to no longer require these self-identifications for a
non-patient facing MIPS eligible clinician, a small practice, a
practice located in a rural area, or a practice in a geographic HPSA or
any combination thereof because it is technically feasible for us to
identify these MIPS eligible clinicians during attestation to the
performance of improvement activities following the performance period.
We define these MIPS eligible clinicians in the CY 2017 Quality Payment
Program final rule (81 FR 77540), and they are discussed in this
proposed rule in section II.C.1. of this proposed rule. However, MIPS
eligible clinicians that are part of a certified patient-centered
medical home or comparable specialty practice are still required to
self-identify for the 2018 MIPS performance period, and we will
validate these self-identifications as appropriate. We refer readers to
section II.C.6.e.3.(c) of this proposed rule for the criteria for
recognition as a certified patient-centered medical home or comparable
specialty practice.
(6) Scoring the Advancing Care Information Performance Category
We refer readers to section II.C.6.f. of this proposed rule with
comment period, where we discuss scoring the advancing care information
performance category.
b. Calculating the Final Score
For a description of the statutory basis and our policies for
calculating the final score for MIPS eligible clinicians, we refer
readers to the discussion in the CY 2017 Quality Payment Program final
rule (81 FR 77319 through 77329) and Sec. 414.1380. In this proposed
rule, we propose to add a complex patient scoring bonus and add a small
practice bonus to the final score. In addition, we review the final
score calculation for the
[[Page 30134]]
2020 MIPS payment year and propose refinements to the reweighting
policies.
(1) Accounting for Risk Factors
Section 1848(q)(1)(G) of the Act requires us to consider risk
factors in our scoring methodology. Specifically, that section provides
that the Secretary, on an ongoing basis, shall, as the Secretary
determines appropriate and based on individuals' health status and
other risk factors, assess appropriate adjustments to quality measures,
cost measures, and other measures used under MIPS and assess and
implement appropriate adjustments to payment adjustments, final scores,
scores for performance categories, or scores for measures or activities
under the MIPS. In doing this, the Secretary is required to take into
account the relevant studies conducted under section 2(d) of the
Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014
and, as appropriate, other information, including information collected
before completion of such studies and recommendations. We refer readers
to our discussion of risk factors for the transition year of MIPS (81
FR 77320 through 77321).
In this section, we summarize our efforts related to social risk
and the relevant studies conducted under section 2(d) of the IMPACT Act
of 2014. We also propose some short-term adjustments to address patient
complexity.
(a) Considerations for Social Risk
We understand that social risk factors such as income, education,
race and ethnicity, employment, disability, community resources, and
social support (certain factors of which are also sometimes referred to
as socioeconomic status (SES) factors or socio-demographic status (SDS)
factors) play a major role in health. One of our core objectives is to
improve beneficiary outcomes, including reducing health disparities,
and we want to ensure that all beneficiaries, including those with
social risk factors, receive high quality care. In addition, we seek to
ensure that the quality of care furnished by providers and suppliers is
assessed as fairly as possible under our programs while ensuring that
beneficiaries have adequate access to excellent care.
We have been reviewing reports prepared by the Office of the
Assistant Secretary for Planning and Evaluation (ASPE) and the National
Academies of Sciences, Engineering, and Medicine on the issue of
accounting for social risk factors in CMS' value-based purchasing and
quality reporting programs, and considering options on how to address
the issue in these programs. On December 21, 2016, ASPE submitted the
first of several Reports to Congress on a study it was required to
conduct under section 2(d) of the IMPACT Act of 2014. The first study
analyzed the effects of certain social risk factors in Medicare
beneficiaries on quality measures and measures of resource use used in
one or more of nine Medicare value-based purchasing programs.\12\ The
report also included considerations for strategies to account for
social risk factors in these programs. A second report due October 2019
will expand on these initial analyses, supplemented with non-Medicare
datasets to measure social risk factors. In a January 10, 2017 report
released by the National Academies of Sciences, Engineering, and
Medicine, that body provided various potential methods for accounting
for social risk factors, including stratified public reporting.\13\
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\12\ Office of the Assistant Secretary for Planning and
Evaluation. 2016. Report to Congress: Social Risk Factors and
Performance Under Medicare's Value-Based Purchasing Programs.
Available at https://aspe.hhs.gov/pdf-report/report-congress-social-risk-factors-and-performance-under-medicares-value-based-purchasing-programs.
\13\ National Academies of Sciences, Engineering, and Medicine.
2017. Accounting for social risk factors in Medicare payment.
Washington, DC: The National Academies Press.
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As noted in the FY 2017 IPPS/LTCH PPS final rule (81 FR 56974), the
NQF has undertaken a 2-year trial period in which certain new measures
and measures undergoing maintenance, and measures endorsed with the
condition that they enter the trial period can be assessed to determine
whether risk adjustment for selected social risk factors is appropriate
for these measures. This trial entails temporarily allowing inclusion
of social risk factors in the risk-adjustment approach for these
measures. At the conclusion of the trial, NQF will issue
recommendations on the future inclusion of social risk factors in risk
adjustment for these quality measures, and we will closely review its
findings.
As we continue to consider the analyses and recommendations from
these and any future reports, and await the results of the NQF trial on
risk adjustment for quality measures, we are continuing in this
proposed rule to work with stakeholders in this process. As we have
previously communicated, we are concerned about holding providers to
different standards for the outcomes of their patients with social risk
factors because we do not want to mask potential disparities or
minimize incentives to improve the outcomes for disadvantaged
populations. Keeping this concern in mind, while we sought input on
this topic previously, we continue to seek public comment on whether we
should account for social risk factors in the MIPS, and if so, what
method or combination of methods would be most appropriate for
accounting for social risk factors in the MIPS. Examples of methods
include: Adjustment of MIPS eligible clinician scores (for example,
stratifying the scores of MIPS eligible clinicians based on the
proportion of their patients who are dual eligible); confidential
reporting of stratified measure rates to MIPS eligible clinicians;
public reporting of stratified measure results; risk adjustment of a
particular measure as appropriate based on data and evidence; and
redesigning payment incentives (for instance, rewarding improvement for
clinicians caring for patients with social risk factors or
incentivizing clinicians to achieve health equity). We are seeking
comments on whether any of these methods should be considered, and if
so, which of these methods or combination of methods would best account
for social risk factors in MIPS, if any.
In addition, we are seeking public comment on which social risk
factors might be most appropriate for stratifying measure scores and/or
potential risk adjustment of a particular measure. Examples of social
risk factors include, but are not limited to the following: Dual
eligibility/low-income subsidy; race and ethnicity; and geographic area
of residence. We are seeking comment on which of these factors,
including current data sources where this information would be
available, could be used alone or in combination, and whether other
data should be collected to better capture the effects of social risk.
We will take commenters' input into consideration as we continue to
assess the appropriateness and feasibility of accounting for social
risk factors in MIPS. We note that any such changes would be proposed
through future notice and comment rulemaking.
We look forward to working with stakeholders as we consider the
issue of accounting for social risk factors and reducing health
disparities in CMS programs. Of note, implementing any of the above
methods would be taken into consideration in the context of how this
and other CMS programs operate (for example, data submission methods,
availability of data, statistical considerations relating to
reliability of data calculations, among others), we also welcome
comment on operational considerations. CMS is committed to ensuring
that its beneficiaries have access to and receive excellent care, and
that the quality of care furnished by
[[Page 30135]]
providers and suppliers is assessed fairly in CMS programs.
(b) Complex Patient Bonus
While we work with stakeholders on these issues as we have
described, we are proposing, under the authority within section
1848(q)(1)(G) of the Act, which allows us to assess and implement
appropriate adjustments to payment adjustments, MIPS final scores,
scores for performance categories, or scores for measures or activities
under MIPS, to implement a short-term strategy for the Quality Payment
Program to address the impact patient complexity may have on final
scores. The overall goal when considering a bonus for complex patients
is two-fold: (1) To protect access to care for complex patients and
provide them with excellent care; and (2) to avoid placing MIPS
eligible clinicians who care for complex patients at a potential
disadvantage while we review the completed studies and research to
address the underlying issues. We used the term ``patient complexity''
to take into account a multitude of factors that describe and have an
impact on patient health outcomes; such factors include the health
status and medical conditions of patients, as well as social risk
factors. We believe that as the number and intensity of these factors
increase for a single patient, the patient may require more services,
more clinician focus, and more resources in order to achieve health
outcomes that are similar to those who have fewer factors. In
developing the policy for the complex patient bonus, we assessed
whether there was a MIPS performance discrepancy by patient complexity
using two well-established indicators in the Medicare program. Our
proposal is intended to address any discrepancy, without masking
performance. Because this bonus is intended to be a short-term
strategy, we are proposing the bonus only for the 2018 MIPS performance
period (2020 MIPS payment year) and will assess on an annual basis
whether to continue the bonus and how the bonus should be structured.
When considering approaches for a complex patient bonus, we
reviewed evidence to identify how indicators of patient complexity have
an impact on performance under MIPS as well as availability of data to
implement the bonus. Specifically, we identified two potential
indicators for complexity: Medical complexity as measured through
Hierarchical Condition Category (HCC) risk scores, and social risk as
measured through the proportion of patients with dual eligible status.
We identified these indicators because they are common indicators of
patient complexity in the Medicare program and the data is readily
available. As discussed below, both of these indicators have been used
in Medicare programs to account for risk and both data elements are
already publicly available for individual NPIs in the Medicare
Physician and Other Supplier Public Use File (referred to as the
Physician and Other Supplier PUF) (https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/medicare-provider-charge-data/physician-and-other-supplier.html). While we
recognize that these indicators are interrelated (as dual eligible
status is one of the factors included in calculation of HCC risk
scores), we intend for the sake of simplicity to implement one of these
indicators for the 2020 MIPS payment year.
We believe that average HCC risk scores are a valid proxy for
medical complexity that have been used by other CMS programs. The HCC
model was developed by CMS as a risk-adjustment model that uses
hierarchical condition categories to assign risk scores to Medicare
beneficiaries. Those scores estimate how Medicare beneficiaries' FFS
spending will compare to the overall average for the entire Medicare
population. According to the Physician and Other Supplier PUF
methodological overview, published in January of 2017,\14\ the average
risk score is set at 1.08; beneficiaries with scores greater than that
are expected to have above-average spending, and vice versa. Risk
scores are based on a beneficiary's age and sex; whether the
beneficiary is eligible for Medicaid, first qualified for Medicare on
the basis of disability, or lives in an institution (usually a nursing
home); and the beneficiary's diagnoses from the previous year. The HCC
model was designed for risk adjustment on larger populations, such as
the enrollees in an MA plan, and generates more accurate results when
used to compare groups of beneficiaries rather than individuals. For
more information on the HCC risk score, see: https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors.html.
---------------------------------------------------------------------------
\14\ https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Downloads/Medicare-Physician-and-Other-Supplier-PUF-Methodology.pdf.
---------------------------------------------------------------------------
HCC risk scores have been used in the VM to apply an additional
upward payment adjustment of +1.0x for clinicians whose attributed
patient population has an average risk score that is in the top 25
percent of all beneficiary risk scores (77 FR 69325 through 69326). CMS
proposes and announces changes to the HCC risk adjustment model as part
of the announcement of payment policies for Medicare Advantage plans
under section 1853 of the Act; the proposals and announcements are
posted at https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Announcements-and-Documents.html.
A mean HCC risk score for a MIPS eligible clinician can be
calculated by averaging the HCC risk scores for the beneficiaries cared
for by the clinician. In considering options for a complex patient
bonus, we explored the use of average HCC risk scores while recognizing
that ``complexity'' is one of several drivers of that metric. We
believe that using the HCC risk score as a proxy for patient complexity
is a helpful starting point, and will explore methods for further
distinguishing complexity from other reasons a clinician could receive
a high average HCC risk score.
In addition to medical complexity, patient complexity includes
social risk factors, and we considered identifying patients dually
eligible for Medicare and Medicaid, which we believe is a proxy for
social risk factors. A ratio of beneficiaries seen by a MIPS eligible
clinician who are dual eligible can be calculated using claims data
based on the proportion of unique patients who are dually eligible for
Medicare and full- and partial-benefit Medicaid (referred to herein as
``dual eligible status'') seen by the MIPS eligible clinician during
the performance year among all unique Medicare beneficiaries seen
during the performance year. Dual eligible Medicare beneficiaries are
qualified to receive Medicare and Medicaid benefits. In the Physician
and Other Supplier PUF, beneficiaries are classified as Medicare and
Medicaid entitlement if in any month in the given calendar year they
were receiving full or partial Medicaid benefits.\15\ Dual eligibility
has been used in the Medicare Advantage 5-star methodology \16\ and
stratification by proportion of dual eligibility status is proposed for
the Hospital Readmissions Reduction Program (82 FR 19959 through
19961).
---------------------------------------------------------------------------
\15\ https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Downloads/Medicare-Physician-and-Other-Supplier-PUF-Methodology.pdf.
\16\ Centers for Medicare & Medicaid Services. Medicare 2017
Part C & D Star Rating Technical Notes. Available at https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/Downloads/2017-Part-C-and-D-Medicare-Star-Ratings-Data-v04-04-2017-.zip.
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[[Page 30136]]
We evaluated both indicators (average HCC risk score and proportion
dual eligible status) using the 2015 Physician and Other Supplier PUF.
We incorporated these factors into our scoring model that uses
historical PQRS data to simulate scores for MIPS eligible clinicians
including estimates for the quality, advancing care information, and
improvement activities performance categories, and the small practice
bonus that is proposed in section II.C.7.b.(1)(c) of this proposed
rule. The scoring model is described in more detail in the regulatory
impact analysis in section V.C. of this proposed rule. For HCC, we
merged the average HCC risk score by NPI with each TIN/NPI in our
population. We calculated a dual eligible ratio by taking a proportion
of dual eligible beneficiaries and divided by total beneficiaries for
each NPI. We created group level scores by taking an average of NPI
scores weighted by the number of beneficiaries. We divided clinicians
and groups into quartiles based on average HCC risk score and percent
of duals. To assess whether there was a difference in MIPS simulated
scores by these two variables, we analyzed the effect of average HCC
risk score and dual eligible ratio separately for groups and
individuals. When looking at individuals, we focused on individuals
that reported 6 or more measures (removing individuals who reported no
measures or who reported less than 6 measures). We restricted our
analysis to individuals who reported 6 or more measures because we
wanted to look at differences in performance for those who reported the
required 6 measures, rather than differences in scores due to
incomplete reporting.
We observed modest correlation between these two indicators. Using
the Physician and Other Supplier PUF (after restricting to those
clinicians that we estimate to be MIPS eligible in our scoring model
described in section V.C of this proposed rule), the correlation
coefficient for these two factors is 0.487 (some correlation is
expected due to the inclusion of dual eligible status in the HCC risk
model). The correlation between average HCC risk scores and proportion
of patients with dual eligible status indicates that while there is
overlap between these two indicators, they cannot be used
interchangeably.
We also assessed the correlation of these indicators with MIPS
final scores based on performance and the small practice bonus for MIPS
eligible clinicians, as well as variations by practice size, submission
mechanism, and specialty. Average MIPS simulated scores (prior to any
complex patient bonus) varied from 82.73 (fourth HCC quartile, highest
risk) to 87.14 (first HCC quartile, lowest risk) for group reporters,
and from 82.36 (fourth HCC quartile, highest risk) to 86.39 (first HCC
quartile, lowest risk) for individual reporters who reported 6 or more
measures (see Table 34). When reviewing average HCC risk scores by
practice size, we found that MIPS eligible clinicians in larger
practices had slightly higher risk scores than those in small practices
(average HCC risk score of 1.82 for practices with 100 or more
clinicians, compared with 1.61 for practices with 1-15 clinicians) (see
Table 35) and that the average HCC risk score varied by specialty, with
nephrology having the highest average HCC risk score (3.05) and
dermatology having the lowest (1.24). The average HCC risk score for
family medicine was 1.58 (see Table 36).
We also ranked MIPS eligible clinicians by proportion of patients
with dual eligibility (see Table 34). Performance for MIPS eligible
clinicians ranged from 82.35 in the fourth dual quartile (highest
proportion dual eligible patients) to 89.49 in the second dual quartile
(second lowest proportion dual eligible patients) for group reporters.
Performance for MIPS eligible clinicians reporting individually who
reported 6 or more measures ranged from 83.08 in the fourth dual
quartile (highest proportion dual eligible patients) to 86.80 in the
first dual quartile (lowest proportion dual eligible patients).
Table 34--MIPS Simulated Score * by HCC Risk Quartile and Dual Eligible
Ratio Quartile
------------------------------------------------------------------------
Individuals
with 6+ Group
measures **
------------------------------------------------------------------------
HCC Quartile
Quartile 1--Lowest Average HCC Risk 86.39 87.14
Score..............................
Quartile 2.......................... 84.89 88.41
Quartile 3.......................... 83.31 86.76
Quartile 4--Highest Average HCC Risk 82.36 82.73
Score..............................
Dual Eligible Ratio
Quartile 1--Lowest Proportion of 86.80 88.03
Dual Status........................
Quartile 2.......................... 83.76 89.49
Quartile 3.......................... 82.63 85.39
Quartile 4--Highest Proportion of 83.08 82.35
Dual Status........................
------------------------------------------------------------------------
* The simulated score includes estimated quality, advancing care
information, and improvement activities performance categories without
complex patient bonus. Simulated score does include small practice
bonus proposed in II.C.7.b.(1)(c) of this proposed rule.
** We restricted this column to individuals who reported 6 or more
measures to assess differences in performance for those who reported
the required 6 measures and to not consider changes due to incomplete
reporting.
Table 35--Average HCC Risk Score and Dual Eligible Ratio by Practice
Size
------------------------------------------------------------------------
Average HCC Dual eligible
Practice size risk score ratio (%)
------------------------------------------------------------------------
1-15 clinicians......................... 1.61 24.90
16-24 clinicians........................ 1.70 26.20
25-99 clinicians........................ 1.72 27.50
100 or more clinicians.................. 1.82 26.90
Total............................... 1.75 26.60
------------------------------------------------------------------------
[[Page 30137]]
Table 36--Average HCC Risk Score and Dual Eligible Ratio by Specialty
------------------------------------------------------------------------
Average HCC Dual eligible
Specialty * risk score ratio (%)
------------------------------------------------------------------------
Total................................... 1.75 26.60
Addiction Medicine...................... 1.77 37.00
Allergy/Immunology...................... 1.38 19.70
Anesthesiology.......................... 1.78 26.00
Anesthesiology Assistant................ 1.94 26.50
Cardiac Electrophysiology............... 1.85 23.20
Cardiac Surgery......................... 1.93 25.10
Cardiovascular Disease (Cardiology)..... 1.85 25.30
Certified Clinical Nurse Specialist..... 1.78 31.20
Certified Registered Nurse Anesthetist 1.77 25.50
(CRNA).................................
Chiropractic............................ 1.27 19.10
Clinic or Group Practice................ 1.57 30.60
Colorectal Surgery (Proctology)......... 1.70 22.10
Critical Care (Intensivists)............ 2.06 28.50
Dermatology............................. 1.24 11.90
Diagnostic Radiology.................... 1.78 26.50
Emergency Medicine...................... 1.94 34.10
Endocrinology........................... 1.78 24.70
Family Medicine *....................... 1.58 25.80
Gastroenterology........................ 1.70 24.20
General Practice........................ 1.60 35.80
General Surgery......................... 1.83 27.10
Geriatric Medicine...................... 1.93 29.60
Geriatric Psychiatry.................... 1.92 39.30
Gynecological Oncology.................. 1.76 24.20
Hand Surgery............................ 1.39 17.80
Hematology.............................. 1.95 25.80
Hematology-Oncology..................... 1.92 24.90
Hospice and Palliative Care............. 1.93 26.90
Infectious Disease...................... 2.35 31.60
Internal Medicine....................... 1.84 28.10
Interventional Cardiology............... 1.79 22.90
Interventional Pain Management.......... 1.50 26.90
Interventional Radiology................ 2.18 28.80
Maxillofacial Surgery................... 1.90 30.20
Medical Oncology........................ 1.94 23.50
Nephrology.............................. 3.05 33.00
Neurology............................... 1.79 27.40
Neuropsychiatry......................... 1.76 30.30
Neurosurgery............................ 1.68 24.70
Nuclear Medicine........................ 1.91 26.10
Nurse Practitioner...................... 1.78 28.60
Obstetrics & Gynecology................. 1.63 26.20
Ophthalmology........................... 1.37 18.70
Optometry............................... 1.33 24.80
Oral Surgery (Dentist only)............. 1.82 29.20
Orthopedic Surgery...................... 1.44 20.50
Osteopathic Manipulative Medicine....... 1.62 29.70
Otolaryngology.......................... 1.50 21.10
Pain Management......................... 1.57 29.50
Pathology............................... 1.71 23.70
Pediatric Medicine...................... 1.95 31.10
Peripheral Vascular Disease............. 1.83 23.10
Physical Medicine and Rehabilitation.... 1.76 27.00
Physician Assistant..................... 1.69 26.40
Physician, Sleep Medicine............... 1.70 23.20
Plastic and Reconstructive Surgery...... 1.74 23.60
Podiatry................................ 1.72 27.70
Preventive Medicine..................... 1.80 27.60
Psychiatry.............................. 1.80 39.50
Pulmonary Disease....................... 2.00 27.20
Radiation Oncology...................... 1.79 22.20
Rheumatology............................ 1.65 23.40
Sports Medicine......................... 1.54 22.70
Surgical Oncology....................... 1.92 25.10
Thoracic Surgery........................ 1.94 26.30
Urology................................. 1.56 20.30
Vascular Surgery........................ 2.22 26.80
------------------------------------------------------------------------
* Specialty descriptions as self-reported on Part B claims. Note that
all categories are mutually exclusive, including General Practice and
Family Practice. `Family Medicine' is used here for physicians listed
as `Family Practice' in Part B claims.
[[Page 30138]]
Based on our assessment of these two indicators, we generally see
high average simulated scores \17\ that are above 80 points for each
quartile based on average HCC risk score or proportion of dual status
patients (see Table 34). As discussed in II.C.8.d. of this proposed
rule, 70 points is the proposed additional performance threshold at
which MIPS eligible clinicians can receive the additional adjustment
factor for exceptional performance. However, even though the simulated
scores are high, we also generally see a very modest decrease in
simulated scores of 4.0 points (for individuals who report 6 or more
measures) and 4.4 points (for groups) from the top quartile to the
bottom quartile for the average patient HCC risk score and from 3.7
(for individuals who report 6 or more measures) and 5.7 points (for
groups) from the top quartile to the bottom quartile for dual eligible
ratio. While we are transitioning into MIPS and evolving our scoring
policies, we want to ensure safeguards and access for these vulnerable
patients; therefore, we are proposing to apply a small complex patient
bonus to final scores used for the 2020 MIPS payment year. As we stated
earlier, we intend to start with one dimension of patient complexity
for simplicity. For the 2020 MIPS payment year, we are proposing a
complex patient bonus based on the average HCC risk score because this
is the indicator that clinicians are familiar with from the VM.
---------------------------------------------------------------------------
\17\ Scores are simulated prior to any complex patient bonus.
---------------------------------------------------------------------------
We propose at Sec. 414.1380(c)(3) to add a complex patient bonus
to the final score for the 2020 MIPS payment year for MIPS eligible
clinicians that submit data (as explained below) for at least one
performance category. We propose at Sec. 414.1380(c)(3)(i) to
calculate an average HCC risk score, using the model adopted under
section 1853 of the Act for Medicare Advantage risk adjustment
purposes, for each MIPS eligible clinician or group, and to use that
average HCC risk score as the complex patient bonus. We would calculate
the average HCC risk score for a MIPS eligible clinician or group by
averaging HCC risk scores for beneficiaries cared for by the MIPS
eligible clinician or clinicians in the group during the second 12-
month segment of the eligibility period, which spans from the last 4
months of a calendar year 1 year prior to the performance period
followed by the first 8 months of the performance period in the next
calendar year (September 1, 2017 to August 31, 2018 for the 2018 MIPS
performance period) as described in section II.C.3.c. of this proposed
rule. We propose the second 12-month segment of the eligibility period
to align with other MIPS policies and to ensure we have sufficient time
to determine the necessary calculations. The second period 12-month
segment overlaps 8-months with the MIPS performance period which means
that many of the patients in our complex patient bonus would have been
cared for by the clinician, group, virtual group or APM Entity during
the MIPS performance period.
HCC risk scores for beneficiaries would be calculated based on the
calendar year immediately prior to the performance period. For the 2018
MIPS performance period, the HCC risk scores would be calculated based
on beneficiary services from the 2017 calendar year. We chose this
approach because CMS uses prior year diagnoses to set Medicare
Advantage rates prospectively every year and has employed this approach
in the VM (77 FR 69317-8). Additionally, this approach mitigates the
risk of ``upcoding'' to get higher expected costs, which could happen
if concurrent risk adjustments were incorporated. We realize using the
2017 calendar year to assess beneficiary HCC risk scores overlaps by 4-
months with the 12-month data period to identify beneficiaries (which
is September 1, 2017 to August 31, 2018 for the 2018 MIPS performance
period); however, we annually calculate the beneficiary HCC risk score
and use it for multiple purposes (like the Physician and Other Supplier
PUF).
For MIPS APMs and virtual groups, we propose at Sec.
414.1380(c)(3)(ii) to use the beneficiary weighted average HCC risk
score for all MIPS eligible clinicians, and if technically feasible,
TINs for models and virtual groups which rely on complete TIN
participation, within the APM Entity or virtual group, respectively, as
the complex patient bonus. We would calculate the weighted average by
taking the sum of the individual clinician's (or TIN's as appropriate)
average HCC risk score multiplied by the number of unique beneficiaries
cared for by the clinician and then divide by the sum of the
beneficiaries cared for by each individual clinician (or TIN as
appropriate) in the APM Entity or virtual group.
We propose at Sec. 414.1380(c)(3)(iii) that the complex patient
bonus cannot exceed 3 points. This value was selected because the
differences in performance we observed between simulated scores between
the first and fourth quartiles of average HCC risk scores was
approximately 4 points for individuals and approximately 5 points for
groups. We considered whether we should apply a set number of points to
those in a specific quartile (for example, for the highest risk
quartile only), but did not want to restrict the bonus to only certain
MIPS eligible clinicians. Rather than assign points based on quartile,
we believed that adding the average HCC risk score directly to the
final score would achieve our goal of accounting for patient complexity
without masking low performance and does provide a modest effect on the
final score. The 95th percentile of HCC values for individual
clinicians was 2.91 which we rounded to 3 for simplicity. We believe
applying this bonus to the final score is appropriate because caring
for complex and vulnerable patients can affect all aspects of a
practice and not just specific performance categories. It may also
create a small incentive to provide access to complex patients.
Finally, we propose that the MIPS eligible clinician, group,
virtual group or APM Entity must submit data on at least one measure or
activity in a performance category during the performance period to
receive the complex patient bonus. Under this proposal, MIPS eligible
clinicians would not need to meet submissions requirements for the
quality performance category in order to receive the bonus (they could
instead submit improvement activities or advancing care information
measures only or submit fewer than the required number of measures for
the quality performance category).
Based on our data analysis, we estimate that this bonus on average
would range from 1.16 points in the first quartile based on HCC risk
scores to 2.49 points in the fourth quartile for individual reporters
submitting 6 or more measures, and 1.26 points in the first quartile to
2.23 points in the fourth quartile for group reporters. For example, a
MIPS eligible clinician with a final score of 55.11 with an average HCC
risk score of 2.01 would receive a final score of 57.12. We propose in
section II.C.7.b.(2) of this proposed rule that if the result of the
calculation is greater than 100 points, then the final score would be
capped at 100 points.
We also seek comment on an alternative complex patient bonus
methodology, similarly for the 2020 MIPS payment year only. Under the
alternative, we would apply a complex patient bonus based on a ratio of
patients who are dual eligible, because we believe that dual eligible
status is a common indicator of social risk for
[[Page 30139]]
which we currently have data available. We believe the advantage of
this option is its relative simplicity and that it creates a direct
incentive to care for dual eligible patients, who are often medically
complex and have concurrent social risk factors. In addition, whereas
the HCC risk scores rely on the diagnoses a beneficiary receives which
could be impacted by variations in coding practices among clinicians,
the dual eligibility ratio is not impacted by variations in coding
practices. For this alternative option, we would calculate a dual
eligible ratio (including both full and partial Medicaid beneficiaries)
for each MIPS eligible clinician based on the proportion of unique
patients who have dual eligible status seen by the MIPS eligible
clinician among all unique patients seen during the second 12-month
segment of the eligibility period, which spans from the last 4 months
of a calendar year 1 year prior to the performance period followed by
the first 8 months of the performance period.
For MIPS APMs and virtual groups, we would use the average dual
eligible patient ratio for all MIPS eligible clinicians, and if
technically feasible, TINs for models and virtual groups which rely on
complete TIN participation, within the APM entity or virtual group,
respectively.
Under this alternative option, we would identify dual eligible
status (numerator of the ratio) using data on dual-eligibility status
sourced from the state Medicare Modernization Act (MMA) files, which
are files each state submits to CMS with monthly Medicaid eligibility
information. We would use dual-eligibility status data from the state
MMA files because it is the best available data for identifying dual
eligible beneficiaries. Under this alternative option, an individual
would be counted as a full-benefit or partial-benefit dual patient if
the beneficiary was identified as a full-benefit or partial-benefit
dual in the state MMA files at the conclusion of the second 12-month
segment of the eligibility determination period.
We would define the proportion of full benefit or partial dual
eligible beneficiaries as the proportion of dual eligible patients
among all unique Medicare patients seen by the MIPS eligible clinician
or group during the second 12-month segment of the eligibility period
which spans from the last 4 months of a calendar year prior to the
performance period followed by the first 8 months of the performance
period in the next calendar year (September 1, 2017 to August 31, 2018
for the 2018 MIPS performance period) as described in section II.C.3.c.
of this proposed rule, to identify MIPS eligible clinicians for
calculation of the complex patient bonus. This date range aligns with
the second low-volume threshold determination and also represents care
provided during the performance period.
We would propose to multiply the dual eligible ratio by 5 points to
calculate a complex patient bonus for each MIPS eligible clinician. For
example, a MIPS eligible clinician who sees 400 patients with dual
eligible status out of 1000 total Medicare patients seen during the
second 12-month segment of the eligibility period would have a complex
patient ratio of 0.4, which would be multiplied by 5 points for a
complex patient bonus of 2 points toward the final score. We believe
this approach is simple to explain and would be available to all
clinicians who care for dual eligible beneficiaries. We also believe a
complex patient bonus ranging from 1 to 5 points (with most MIPS
eligible clinicians receiving a bonus between 1 and 3 points) is
appropriate because, in our analysis, we estimated differences in
performance between the 1st and 4th quartiles of dual eligible ratios
to be approximately 3 points for individuals and approximately 6 points
for groups. A bonus of less than 5 points would help to mitigate the
impact of caring for patients with social risk factors while not
masking poor performance. Using this approach, we estimate that the
bonus would range from 0.45 (first dual quartile) to 2.42 (fourth dual
quartile) for individual reporters, and from 0.63 (first dual quartile)
to 2.19 (fourth dual quartile) for group reporters. Under this
alternative option, we would also include the complex patient bonus in
the calculation of the final score. Again, we propose in section
II.C.7.b.(2) of this proposed rule that if the result of the
calculation is greater than 100 points, then the final score would be
capped at 100 points. We seek comments on our proposed bonus for
complex patients based on average HCC risk scores, and our alternative
option using a ratio of dual eligible patients in lieu of average HCC
risk scores. We reiterate that the complex patient bonus is intended to
be a short-term solution, which we plan to revisit on an annual basis,
to incentivize clinicians to care for patients with medical complexity.
We may consider alternate adjustments in future years after methods
that more fully account for patient complexity in MIPS have been
developed. We also seek comments on alternative methods to construct a
complex patient bonus.
(c) Small Practice Bonus for the 2020 MIPS Payment Year
Eligible clinicians and groups who work in small practices are a
crucial part of the health care system. The Quality Payment Program
provides options designed to make it easier for these MIPS eligible
clinicians and groups to report on performance and quality and
participate in advanced alternative payment models for incentives. We
have heard directly from clinicians in small practices that they face
unique challenges related to financial and other resources,
environmental factors, and access to health information technology. We
heard from many commenters that the Quality Payment Program advantages
large organizations because such organizations have more resources
invested in the infrastructure required to track and report measures to
MIPS. Based on our scoring model, which is described in the regulatory
impact analysis in section V.C. of this proposed rule, practices with
more than 100 clinicians may perform better in the Quality Payment
Program, on average compared to smaller practices. We believe this
trend is due primarily to two factors: Participation rates and
submission mechanism. Based on the most recent PQRS data available,
practices with 100 or more MIPS eligible clinicians have participated
in the PQRS at a higher rate than small practices (99.4 percent
compared to 69.7 percent, respectively). As we indicate in our
regulatory impact analysis in section V.C. of this proposed rule, we
believe participation rates based only on historic 2015 quality data
submitted under PQRS significantly underestimate the expected
participation in MIPS particularly for small practices. Therefore, we
have modeled the regulatory impact analysis using minimum participation
assumptions of 80 percent and 90 percent participation for each
practice size category (1-15 clinicians, 16-24 clinicians, 25-99
clinicians, and 100 or more clinicians). However, even with these
enhanced participation assumptions, MIPS eligible clinicians in small
practices would have lower participation than MIPS eligible clinicians
in larger practices as 80 or 90 percent participation is still much
lower than the 99.4 percent participation for MIPS eligible clinicians
in practices with 100 or more clinicians.
In addition, practices with 100 or more MIPS eligible clinicians
are more likely to report as a group, rather than individually, which
reduces burden to individuals within those practices due
[[Page 30140]]
to the unified nature of group reporting. Specifically, 63.1 percent of
practices with 100 or more MIPS eligible clinicians are reporting via
CMS Web Interface (either through the Shared Savings Program or as a
group practice) compared to 20.5 percent of small practices (the CMS
Web Interface reporting mechanism is only available to small practices
participating in the Shared Saving Program or Next Generation ACO
Model.) \18\
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\18\ Groups must have at least 25 clinicians to participate in
Web Interface.
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These two factors have financial implications based on the MIPS
scoring model described in section V.C. of this proposed rule. Looking
at the combined impact performance, we see consistent trends for small
practices in various scenarios. A combined impact of performance
measurement looks at the aggregate net percent change (the combined
impact of MIPS negative and positive adjustments in the final score).
In analyzing the combined impact performance, we see MIPS eligible
clinicians in small practices consistently have a lower combined impact
performance than larger practices based on actual historical data and
after we apply the 80 and 90 percent participation assumptions.
Due to these challenges, we believe an adjustment to the final
score for MIPS eligible clinicians in small practices (referred to
herein as the ``small practice bonus'') is appropriate to recognize
these barriers and to incentivize MIPS eligible clinicians in small
practices to participate in the Quality Payment Program and to overcome
any performance discrepancy due to practice size. To receive the small
practice bonus, we propose that the MIPS eligible clinician must
participate in the program by submitting data on at least one
performance category in the 2018 MIPS performance period. Therefore,
MIPS eligible clinicians would not need to meet submission requirements
for the quality performance category in order to receive the bonus
(they could instead submit improvement activities or advancing care
information measures only or submit fewer than the required number of
measures for the quality performance category). Additionally, we
propose that group practices, virtual groups, or APM Entities that
consist of a total of 15 or fewer clinicians may receive the small
practice bonus.
We propose at Sec. 414.1380(c)(4) to add a small practice bonus of
five points to the final score for MIPS eligible clinicians who
participate in MIPS for the 2018 MIPS performance period and are in
small practices or virtual groups or APM entities with 15 or fewer
clinicians (the entire virtual group or APM entity combined must
include 15 or fewer clinicians to qualify for the bonus). We believe a
bonus of 5 points is appropriate to acknowledge the challenges small
practices face in participating in MIPS, and to help them achieve the
performance threshold proposed at section II.C.8.c. of this proposed
rule at 15 points for the 2020 MIPS payment year, as this bonus
represents one-third of the total points needed to meet or exceed the
performance threshold and receive a neutral to positive payment
adjustment. With a small practice bonus of 5 points, small practices
could achieve this performance threshold by reporting 2 quality
measures or 1 quality measure and 1 improvement activity.\19\ We
believe that a higher bonus (for example, a bonus that would meet or
exceed the performance threshold) is not ideal because it might
discourage small practices from actively participating in MIPS or could
mask poor performance. We propose in section II.C.7.b.(2) of this
proposed rule that if the result of the calculation is greater than 100
points, then the final score would be capped at 100 points.
---------------------------------------------------------------------------
\19\ Assuming the small practice did not submit advancing care
information and applied for the hardship exception and had the
advancing care information performance category weight redistributed
to quality, the small practice would have a final score with 85
percent weight from the quality performance category score and 15
percent from improvement activities. With the proposed scoring for
small practices, submitting one measure one time would provide at
least 3 measure achievement points out of 60 total available measure
points. With 85 percent quality performance category weight, each
quality measure would be worth at least 4.25 point towards the final
score. ((3/60) x 85% x 100= 4.25 points). For improvement
activities, each medium weighted activity is worth 20 out of 40
possible points which translates to 7.5 points to the file score.
(20/40) x 15% x 100 = 7.5 points).
---------------------------------------------------------------------------
This bonus is intended to be a short-term strategy to help small
practices transition to MIPS, therefore, we are proposing the bonus
only for the 2018 MIPS performance period (2020 MIPS payment year) and
will assess on an annual basis whether to continue the bonus and how
the bonus should be structured.
We are inviting public comment on our proposal to apply a small
practice bonus for the 2020 MIPS payment year.
We also considered applying a bonus for MIPS eligible clinicians
that practice in either a small practice or a rural area. However, on
average, we saw less than a one point difference between scores for
MIPS eligible clinicians who practice in rural areas and those who do
not. Therefore, we are not proposing to extend the final score bonus to
those who practice in a rural area, but plan to continue to monitor the
Quality Payment Program's impacts on the performance of those who
practice in rural areas. We also seek comment on the application of a
rural bonus in the future, including available evidence demonstrating
differences in clinician performance based on rural status. If we
implement a bonus for practices located in rural areas, we would use
the definition for rural specified in section II.C.1. of this proposed
rule for individuals and groups (including virtual groups).
(2) Final Score Calculation
With the proposed addition of the complex patient and small
practice bonuses, we propose to use the formula at Sec. 414.1380(c) to
calculate the final score for all MIPS eligible clinicians, groups,
virtual groups, and MIPS APMs starting with the 2020 MIPS payment year.
We propose to revise the final score calculation at Sec.
414.1380(c) to reflect this updated formula. We also propose to revise
the policy finalized in the CY 2017 Quality Payment Program final rule
to assign MIPS eligible clinicians with only 1 scored performance
category a final score that is equal to the performance threshold (81
FR 77326 through 77328) (we note that we inadvertently failed to codify
this policy in Sec. 414.1380(c)). We are proposing this revision to
the policy to account for our proposal in section II.C.7.b.(3)(c) of
this proposed rule for extreme and uncontrollable circumstances which,
if finalized, could result in a scenario where a MIPS eligible
clinician is not scored on any performance categories. To reflect this
proposal, we propose to add to Sec. 414.1380(c) that a MIPS eligible
clinician with fewer than 2 performance category scores would receive a
final score equal to the performance threshold.
With the proposed addition of the complex patient and small
practice bonuses, we also propose to strike the following phrase from
the final score definition at Sec. 414.1305: ``The final score is the
sum of each of the products of each performance category score and each
performance category's assigned weight, multiplied by 100.'' We believe
this portion of the definition would be incorrect and redundant of the
proposed revised regulation at Sec. 414.1380(c).
We invite public comment on the proposed final score methodology
and associated revisions to regulation text.
[[Page 30141]]
(3) Final Score Performance Category Weights
(a) General Weights
Section 1848(q)(5)(E)(i) of the Act specifies weights for the
performance categories included in the MIPS final score: In general, 30
percent for the quality performance category, 30 percent for the cost
performance category, 25 percent for the advancing care information
performance category, and 15 percent for the improvement activities
performance category. However, that section also specifies different
weightings for the quality and cost performance categories for the
first and second years for which the MIPS applies to payments. Section
1848(q)(5)(E)(i)(II)(bb) of the Act specifies that for the transition
year, not more than 10 percent of the final score will be based on the
cost performance category, and for the 2020 MIPS payment year, not more
than 15 percent will be based on the cost performance category. Under
section 1848(q)(5)(E)(i)(I)(bb) of the Act, the weight of the quality
performance category for each of the first 2 years will increase by the
difference of 30 percent minus the weight specified for the cost
performance category for the year.
In the CY 2017 Quality Payment Program final rule, we established
the weights of the cost performance category as 10 percent of the final
score (81 FR 77166) and the quality performance category as 50 percent
of the final score (81 FR 77100) for the 2020 MIPS payment year.
However, we are proposing in section II.C.6.d. of this proposed rule to
change the weight of the cost performance category to zero percent and
in section II.C.6.b. of this proposed rule to change the weight of the
quality performance category to 60 percent for the 2020 MIPS payment
year. We refer readers to sections II.C.6.b. and II.C.6.d. of this
proposed rule for further information on the policies related to the
weight of the quality and cost performance categories, including our
rationale for our proposed weighting for each category.
As specified in section 1848(q)(5)(E)(i) of the Act, the weights
for the other performance categories are 25 percent for the advancing
care information performance category and 15 percent for the
improvement activities performance category. Section 1848(q)(5)(E)(ii)
of the Act provides that in any year in which the Secretary estimates
that the proportion of eligible professionals (as defined in section
1848(o)(5) of the Act) who are meaningful EHR users (as determined in
section 1848(o)(2) of the Act) is 75 percent or greater, the Secretary
may reduce the applicable percentage weight of the advancing care
information performance category in the final score, but not below 15
percent. For more on our policies concerning section 1848(q)(5)(E)(ii)
of the Act and a review of our proposal for reweighting the advancing
care information performance category in the event that the proportion
of MIPS eligible clinicians who are meaningful EHR users is 75 percent
or greater starting with the 2019 MIPS performance period, we refer
readers to section II.C.6.f.(5) of this proposed rule.
Table 37 summarizes the weights specified for each performance
category under section 1848(q)(5)(E)(i) of the Act and in accordance
with our policies in the CY 2017 Quality Payment Program final rule as
codified at Sec. Sec. 414.1380(c)(1), 414.1330(b), 414.1350(b),
414.1355(b), and 414.1375(a), and with our proposals in section II.C.6.
of this proposed rule.
Table 37--Finalized and Proposed Weights by MIPS Performance Category *
----------------------------------------------------------------------------------------------------------------
2020 MIPS payment 2021 MIPS payment
Performance category Transition year year (proposed) year and beyond
(final) (%) (%) (final) (%)
----------------------------------------------------------------------------------------------------------------
Quality............................................. 60 60 30
Cost................................................ 0 0 30
Improvement Activities.............................. 15 15 15
Advancing Care Information**........................ 25 25 25
----------------------------------------------------------------------------------------------------------------
* In sections II.C.6.b. and II.C.6.c., we propose to maintain the same weights from the transition year for the
2020 MIPS payment year for quality and cost (60 percent and zero percent, respectively).
**[hairsp]As described in section II.C.6.f. of this proposed rule, the weight for advancing care information
could decrease (not below 15 percent) starting with the 2021 MIPS payment year if the Secretary estimates that
the proportion of physicians who are meaningful EHR users is 75 percent or greater.
(b) Flexibility for Weighting Performance Categories
Under section 1848(q)(5)(F) of the Act, if there are not sufficient
measures and activities applicable and available to each type of MIPS
eligible clinician involved, the Secretary shall assign different
scoring weights (including a weight of zero) for each performance
category based on the extent to which the category is applicable and
for each measure and activity based on the extent to which the measure
or activity is applicable and available to the type of MIPS eligible
clinician involved. For the 2020 MIPS payment year, we propose to
assign a scoring weight of zero percent to a performance category and
redistribute its weight to the other performance categories in the
following scenarios.
For the quality performance category, we propose that having
sufficient measures applicable and available means that we can
calculate a quality performance category percent score for the MIPS
eligible clinician because at least one quality measure is applicable
and available to the MIPS eligible clinician. Based on the volume of
measures available to MIPS eligible clinicians via the multiple
submission mechanisms, we generally believe there will be at least one
quality measure applicable and available to every MIPS eligible
clinician. Given that we generally believe there will be at least one
quality measure applicable and available to every MIPS eligible
clinician, if we receive no quality performance category submission
from a MIPS eligible clinician, the MIPS eligible clinician generally
will receive a performance category score of zero (or slightly above
zero if the all-cause hospital readmission measure applies because the
clinician submits data for a performance category other than the
quality performance category).\20\
[[Page 30142]]
However, as described in section II.C.7.a.(2)(e) of this proposed rule,
there may be rare instances that we believe could affect only a very
limited subset of MIPS eligible clinicians (as well as groups and
virtual groups) that may have no quality measures available and
applicable and for whom we receive no quality performance category
submission (and for whom the all-cause hospital readmission measure
does not apply). In those instances, we would not be able to calculate
a quality performance category percent score.
---------------------------------------------------------------------------
\20\ As discussed in the CY 2017 Quality Payment Program final
rule (81 FR 77300), groups of 16 or more eligible clinicians that
meet the applicable case minimum requirement are automatically
scored on the all-cause readmission measure, even if they do not
submit any other data under the quality performance category,
provided that they submit data under one of the other performance
categories. If such groups do not submit data under any performance
category, the readmission measure is not scored.
---------------------------------------------------------------------------
The proposed quality performance category scoring policies for the
2020 MIPS payment year continue many of the special scoring policies
from the transition year which would enable us to determine a quality
performance category percent score whenever a MIPS eligible clinician
has submitted at least 1 quality measure. In addition, MIPS eligible
clinicians that do not submit quality measures when they have them
available and applicable would receive a quality performance category
percent score of zero percent. It is only in the rare scenarios when we
determine that a MIPS eligible clinician does not have any relevant
quality measures available to report or the MIPS eligible clinician is
approved for reweighting the quality performance category based on
extreme and uncontrollable circumstances as proposed in section
II.C.7.b.(3)(c) of this proposed rule, that we would reweight the
quality performance category. Therefore, we continue to believe that we
will not be able to calculate a score for the quality performance
category only in the rare scenarios when a MIPS eligible clinician does
not have any relevant quality measures available to report.
For the cost performance category, we continue to believe that
having sufficient measures applicable and available means that we can
reliably calculate a score for the cost measures that adequately
captures and reflects the performance of a MIPS eligible clinician, and
that MIPS eligible clinicians who are not attributed enough cases to be
reliably measured should not be scored for the cost performance
category (81 FR 77322 through 77323). We established a policy that if a
MIPS eligible clinician is not attributed a sufficient number of cases
for a measure (in other words, has not met the required case minimum
for the measure), or if a measure does not have a benchmark, then the
measure will not be scored for that clinician (81 FR 77323). If we do
not score any cost measures for a MIPS eligible clinician in accordance
with this policy, then the clinician would not receive a cost
performance category percent score. Because we have proposed in section
II.C.6.d. of this proposed rule to set the weight of the cost
performance category to zero percent of the final score for the 2020
MIPS payment year, we are not proposing to redistribute the weight of
the cost performance category to any other performance categories for
the 2020 MIPS payment year. In the event we do not finalize this
proposal, we are proposing to redistribute the weight of the cost
performance category as described in section II.C.7.b.(3)(d) of this
proposed rule.
For the improvement activities performance category, we believe
that all MIPS eligible clinicians will have sufficient activities
applicable and available; however, as discussed in section
II.C.7.b.(3)(c) of this proposed rule, we believe there are limited
extreme and uncontrollable circumstances, such as natural disasters,
where a clinician is unable to report improvement activities. Barring
these circumstances, we are not proposing any changes that would affect
our ability to calculate an improvement activities performance category
score.
We refer readers to section II.C.6.f. of this proposed rule for a
detailed discussion of our proposals and policies under which we would
not score the advancing care information performance category and would
assign a weight of zero percent to that category for a MIPS eligible
clinician.
We invite public comment on our interpretation of sufficient
measures available and applicable in the performance categories.
(c) Extreme and Uncontrollable Circumstances
In the CY 2017 Quality Payment Program final rule (81 FR 77241
through 77243), we discussed our belief that extreme and uncontrollable
circumstances, such as a natural disaster in which an EHR or practice
location is destroyed, can happen at any time and are outside a MIPS
eligible clinician's control. We stated that if a MIPS eligible
clinician's CEHRT is unavailable as a result of such circumstances,
then the measures specified for the advancing care information
performance category may not be available for the MIPS eligible
clinician to report. We established a policy allowing a MIPS eligible
clinician affected by extreme and uncontrollable circumstances to
submit an application to us to be considered for reweighting of the
advancing care information performance category under section
1848(q)(5)(F) of the Act. Although we are proposing in section
II.C.6.f. of this proposed rule to use the authority in the last
sentence of section 1848(o)(2)(D) of the Act, as amended by section
4002(b)(1)(B) of the 21st Century Cures Act, as the authority for this
policy, rather than section 1848(q)(5)(F) of the Act, we continue to
believe that extreme and uncontrollable circumstances could affect the
availability of a MIPS eligible clinician's CEHRT and the measures
specified for the advancing care information performance category.
While we did not propose or finalize a similar reweighting policy
for other performance categories in the transition year, we believe a
similar reweighting policy may be appropriate for the quality, cost,
and improvement activities performance categories beginning with the
2020 MIPS payment year. For these performance categories, we propose to
define ``extreme and uncontrollable circumstances'' as rare (that is,
highly unlikely to occur in a given year) events entirely outside the
control of the clinician and of the facility in which the clinician
practices that cause the MIPS eligible clinician to not be able to
collect information that the clinician would submit for a performance
category or to submit information that would be used to score a
performance category for an extended period of time (for example, 3
months could be considered an extended period of time with regard to
information a clinician would collect for the quality performance
category). For example, a tornado or fire destroying the only facility
in which a clinician practices likely would be considered an ``extreme
and uncontrollable circumstance;'' however, neither the inability to
renew a lease--even a long or extended lease--nor a facility being
found not compliant with federal, state, or local building codes or
other requirements would be considered ``extreme and uncontrollable
circumstances.'' We propose that we would review both the circumstances
and the timing independently to assess the availability and
applicability of measures and activities independently for each
performance category. For example, in 2018 the performance period for
improvement activities is only 90 days, whereas it is 12 months for the
quality performance category, so an issue lasting 3 months may have
more impact on the availability of measures for the quality performance
category than for the improvement activities performance category,
because
[[Page 30143]]
the MIPS eligible clinician, conceivably, could participate in
improvement activities for a different 90-day period.
We believe that extreme and uncontrollable circumstances, such as
natural disasters, may affect a clinician's ability to access or submit
quality measures via all submission mechanisms (effectively rendering
the measures unavailable to the clinician) as well as the availability
of numerous improvement activities. In addition, damage to a facility
where care is provided due to a natural disaster, such as a hurricane,
could result in practice management and clinical systems that are used
for the collection or submission of data to be down, thus impacting a
clinician's ability to submit necessary information via Qualified
Registry, QCDR, CMS Web Interface, or claims. This policy would not
include issues that third party intermediaries, such as EHRs, Qualified
Registries, or QCDRs, might have submitting information to MIPS on
behalf of a MIPS eligible clinician. Instead, this policy is geared
towards events, such as natural disasters, that affect the MIPS
eligible clinician's ability to submit data to the third party
intermediary, which in turn, could affect the ability of the clinician
(or the third party intermediary acting on their behalf) to
successfully submit measures and activities to MIPS.
We also propose to use this policy for measures which we derive
from claims data, such as the all-cause hospital readmission measure
and the cost measures. Other programs, such as the Hospital VBP
Program, allow hospitals to submit exception applications when ``a
hospital is able to continue to report data on measures . . . but can
demonstrate that its Hospital VBP Program measure rates are negatively
impacted as a result of a natural disaster or other extraordinary
circumstance and, as a result, the hospital receives a lower value-
based incentive payment'' (78 FR 50705). For the Hospital VBP Program,
we ``interpret[ed] the minimum numbers of cases and measures
requirement in the Act to enable us to not score . . . all applicable
quality measure data from a performance period and, thus, exclude the
hospital from the Hospital VBP Program for a fiscal year during which
the hospital has experienced a disaster or other extraordinary
circumstance'' (78 FR 50705). Hospitals that request and are granted an
exception are exempted from the Program entirely for the applicable
year.
For the 2020 MIPS payment year, we would score quality measures and
assign points even for those clinicians who do not meet the case
minimums for the quality measures they submit. However, we established
a policy not to score a cost measure unless a MIPS eligible clinician
has met the required case minimum for the measure (81 FR 77323), and
not to score administrative claims measures, such as the all-cause
hospital readmission measure, if they cannot be reliably scored against
a benchmark (81 FR 77288 through 77289). Even if the required case
minimums have been met and we are able to reliably calculate scores for
the measures that are derived from claims, we believe a MIPS eligible
clinician's performance on those measures could be adversely impacted
by a natural disaster or other extraordinary circumstance, similar to
the issues we identified for the Hospital VBP Program. For example, the
claims data used to calculate the cost measures or the all-cause
hospital readmission measure could be significantly affected if a
natural disaster caused wide-spread injury or health problems for the
community, which could not have been prevented by high-value
healthcare. In such cases, we believe that the measures are available
to the clinician, but are likely not applicable, because the extreme
and uncontrollable circumstance has disrupted practice and measurement
processes. Therefore, we believe an approach similar to Hospital VBP
Program is warranted under MIPS, and we are proposing that we would
exempt a MIPS eligible clinician from all quality and cost measures
calculated from administrative claims data if the clinician is granted
an exception for the respective performance categories based on extreme
and uncontrollable circumstances.
Beginning with the 2020 MIPS payment year, we propose that we would
reweight the quality, cost, and/or improvement activities performance
categories if a MIPS eligible clinician, group, or virtual group's
request for a reweighting assessment based on extreme and
uncontrollable circumstances is granted. We propose that MIPS eligible
clinicians could request a reweighting assessment if they believe
extreme and uncontrollable circumstances affect the availability and
applicability of measures for the quality, cost, and improvement
activities performance categories. To the extent possible, we would
seek to align the requirements for submitting a reweighting assessment
for extreme and uncontrollable circumstances with the requirements for
requesting a significant hardship exception for the advancing care
information performance category. For example, we propose to adopt the
same deadline (December 31, 2018 for the 2018 MIPS performance period)
for submission of a reweighting assessment (see section II.C.6.f. of
this proposed rule), and we would encourage the requests to be
submitted on a rolling basis. We propose the reweighting assessment
must include the nature of the extreme and uncontrollable circumstance,
including the type of event, date of the event, and length of time over
which the event took place, performance categories impacted, and other
pertinent details that impacted the ability to report on measures or
activities to be considered for reweighting of the quality, cost, or
improvement activities performance categories (for example, information
detailing how exactly the event impacted availability and applicability
of measures). If we finalize the policy to allow reweighting based on
extreme and uncontrollable circumstances beginning with the 2020 MIPS
payment year, we would specify the form and manner in which these
reweighting applications must be submitted outside of the rulemaking
process after the final rule is published.
For virtual groups, we propose to ask the virtual group to submit a
reweighting assessment for extreme and uncontrollable circumstances
similar to groups, and we would evaluate whether sufficient measures
and activities are applicable and available to the majority of TINs in
the virtual group. We are proposing that a majority of TINs in the
virtual group would need to be impacted before we grant an exception.
We still find it important to measure the performance of virtual group
members unaffected by an extreme and uncontrollable circumstance even
if some of the virtual group's TINs are affected.
We also seek comment on what additional factors we should consider
for virtual groups. This reweighting assessment due to extreme and
uncontrollable circumstances for the quality, cost, and improvement
activities would not be available to APM Entities in the APM scoring
standard for the following reasons. First, all MIPS eligible clinicians
scored under the APM scoring standard will automatically receive an
improvement activities category score based on the terms of their
participation in a MIPS APM and need not report anything for this
performance category. Second, the cost performance category has no
weight under the APM scoring standard. Finally, for the quality
performance category, each MIPS APM has its own rules related to
quality measures and we believe any decisions related to
[[Page 30144]]
availability and applicability of measures should reside within the
model. As noted in II.C.6.g.(2)(d) of this proposed rule, MIPS APM
entities would be able to request reweighting of the advancing care
information performance category.
If we finalize these proposals for reweighting the quality, cost,
and improvement activities performance categories based on extreme and
uncontrollable circumstances, then it would be possible that one or
more of these performance categories would not be scored and would be
weighted at zero percent of the final score for a MIPS eligible
clinician. We propose to assign a final score equal to the performance
threshold if fewer than two performance categories are scored for a
MIPS eligible clinician. This is consistent with our policy finalized
in the CY 2017 Quality Payment Program final rule that because the
final score is a composite score, we believe the intention of section
1848(q)(5) of the Act is for MIPS eligible clinicians to be scored
based on multiple performance categories (81 FR 77326 through 77328).
We request comment on our extreme and uncontrollable circumstances
proposals. We also seek comment on the types of the extreme and
uncontrollable circumstances we should consider for this policy given
the general parameters we describe in this section.
(d) Redistributing Performance Category Weights
In the CY 2017 Quality Payment Program final rule, we codified at
Sec. 414.1380(c)(2) that we will assign different scoring weights for
the performance categories if we determine there are not sufficient
measures and activities applicable and available to MIPS eligible
clinicians (81 FR 77327). We also finalized a policy to assign MIPS
eligible clinicians with only one scored performance category a final
score that is equal to the performance threshold, which means the
clinician would receive a MIPS payment adjustment factor of zero
percent for the year (81 FR 77326 through 77328). We are proposing in
section II.C.7.b.(2) of this proposed rule to refine this policy such
that a MIPS eligible clinician with fewer than 2 performance category
scores would receive a final score equal to the performance threshold.
This refinement is to account for our proposal in section
II.C.7.b.(3)(c) of this proposed rule for extreme and uncontrollable
circumstances which, if finalized, could result in a scenario where a
MIPS eligible clinician is not scored on any performance categories. We
refer readers to the CY 2017 Quality Payment Program final rule for a
description of our policies for redistributing the weights of the
performance categories (81 FR 77325 through 77329). For the 2020 MIPS
payment year, we propose to redistribute the weights of the performance
categories in a manner that is similar to the transition year. However,
we are also proposing new scoring policies to incorporate our proposals
for extreme and uncontrollable circumstances.
In section II.C.6.f. of this proposed rule, we are proposing to use
the authority in the last sentence of section 1848(o)(2)(D) of the Act,
as amended by section 4002(b)(1)(B) of the 21st Century Cures Act, as
the authority for certain policies under which we would assign a
scoring weight of zero percent for the advancing care information
performance category, and to amend Sec. 414.1380(c)(2) to reflect our
proposals. We are not, however, proposing substantive changes to the
policy established in the CY 2017 Quality Payment Program final rule to
redistribute the weight of the advancing care information performance
category to the other performance categories for the transition year
(81 FR 77325 through 77329).
For the 2020 MIPS payment year, if we assign a weight of zero
percent for the advancing care information performance category for a
MIPS eligible clinician, we propose to continue our policy from the
transition year and redistribute the weight of the advancing care
information performance category to the quality performance category
(assuming the quality performance category does not qualify for
reweighting). We believe redistributing the weight of the advancing
care information performance category to the quality performance
category (rather than redistributing to both the quality and
improvement activities performance categories) is appropriate because
MIPS eligible clinicians have more experience reporting quality
measures through the PQRS program, and measurement in this performance
category is more mature.
If we do not finalize our proposal at section II.C.6.d. of this
proposed rule to weight the cost performance category at zero percent
(which means the weight of the cost performance category is greater
than zero percent), then we propose to not redistribute the weight of
any other performance categories to the cost performance category. We
believe this is consistent with our policy of introducing cost
measurement in a deliberate fashion and recognition that clinicians are
more familiar with other elements of MIPS. In the rare and unlikely
scenario where a MIPS eligible clinician qualifies for reweighting of
the quality performance category percent score (because there are not
sufficient quality measures applicable and available to the clinician
or the clinician is facing extreme and uncontrollable circumstances)
and the MIPS eligible clinician is eligible to have the advancing care
information performance category reweighted to zero and the MIPS
eligible clinician has sufficient cost measures applicable and
available to have a cost performance category percent score that is not
reweighted, then we would redistribute the weight of the quality and
advancing care information performance categories to the improvement
activities performance category and would not redistribute the weight
to the cost performance category. If we finalize the cost performance
category weight at zero percent for the 2020 MIPS payment year, then we
would set the final score at the performance threshold because the
final score would be based on improvement activities which would not be
a composite of two or more performance category scores.
For the 2020 MIPS payment year, if we do not finalize the proposal
to set the cost performance category a zero percent weight, and if a
MIPS eligible clinician does not receive a cost performance category
percent score because there are not sufficient cost measures applicable
and available to the clinician or the clinician is facing extreme and
uncontrollable circumstances, we propose to redistribute the weight of
the cost performance category to the quality performance category. In
the rare scenarios where a MIPS eligible clinician does not receive a
quality performance category percent score because there are not
sufficient quality measures applicable and available to the clinician
or the clinician is facing extreme and uncontrollable circumstances, we
propose to redistribute the weight of the cost performance category
equally to the remaining performance categories that are not
reweighted.
In the rare event a MIPS eligible clinician is not scored on at
least one measure in the quality performance category because there are
not sufficient measures applicable and available or the clinician is
facing extreme and uncontrollable circumstances, we propose for the
2020 MIPS payment year to continue our policy from the transition year
and redistribute the 60 percent weight of the quality performance
category so that the performance category weights are 50
[[Page 30145]]
percent for the advancing care information performance category and 50
percent for the improvement activities performance category (assuming
these performance categories do not qualify for reweighting). While
clinicians have more experience reporting advancing care information
measures, we believe equal weighting to both the improvement activities
and advancing care information is appropriate for simplicity.
Additionally, in the absence of quality measures, we believe increasing
the relative weight of the improvement activities performance category
is appropriate because both improvement activities and advancing care
information have elements of quality and care improvement which are
important to emphasize. Should the cost performance category have
available and applicable measures and the cost performance category
weight is not zero, but either the improvement activities or advancing
care information performance category is reweighted to zero percent,
then we would redistribute the weight of the quality performance
category to the remaining performance category that is not weighted at
zero percent. We would not redistribute the weight to the cost
performance category.
We believe that all MIPS eligible clinicians will have sufficient
improvement activities applicable and available. It is possible that a
MIPS eligible clinician might face extreme and uncontrollable
circumstances that render the improvement activities not applicable or
available to the clinician; however, in that scenario, we believe it is
likely that the measures specified for the other performance categories
also would not be applicable or available to the clinician based on the
circumstances. In the rare event that the improvement activities
performance category would qualify for reweighting based on extreme and
uncontrollable circumstances, and the other performance categories
would not also qualify for reweighting, we propose to redistribute the
improvement activities performance category weight to the quality
performance category consistent with the redistribution policies for
the cost and advancing care information performance categories. Should
the cost performance category have available and applicable measures
and the cost performance category weight is not finalized at zero
percent, and the quality performance category is reweighted to zero
percent, then we would redistribute the weight of the improvement
activities performance category to the advancing care information
performance category.
Table 38 summarizes the potential reweighting scenarios based on
our proposals for the 2020 MIPS payment year should the cost
performance category be weighted at zero percent.
Table 38--Proposed Performance Category Redistribution Policies for the 2020 MIPS Payment Year if the Cost
Performance Category Weight Is Zero Percent
----------------------------------------------------------------------------------------------------------------
Reweight Reweight
scenario if no Reweight scenario if no
Weighting for advancing care scenario if no improvement
Performance category the 2020 MIPS information quality activities
payment year performance performance performance
(%) category score category category score
(%) percent score (%)
----------------------------------------------------------------------------------------------------------------
Quality......................................... 60 85 0 75
Cost............................................ 0 0 0 0
Improvement Activities.......................... 15 15 50 0
Advancing Care Information...................... 25 0 50 25
----------------------------------------------------------------------------------------------------------------
In response to our final policy to redistribute the advancing care
information performance category weight solely to the quality
performance category in the CY 2017 Quality Payment Program final rule
(81 FR 77327), we received some comments expressing concern that this
would place undue emphasis on the quality performance category.
Commenters expressed the belief that this policy would particularly
affect non-patient facing MIPS eligible clinicians who have limited
available measures, and would limit the ability to fairly compare
different specialties that are reweighted differently. One reason for
the discrepancy is that MIPS eligible clinicians that submit data to
the advancing care information performance category can readily achieve
a base score of 50 percent if they meet the requirements for the base
score measures, whereas the quality performance category does not start
at the same base. Commenters also expressed the belief that specialties
with few quality measures available to them will be unfairly impacted
by this reweighting policy, by putting a disproportionate weight on
just a few quality measures. Commenters suggested we redistribute the
weight of the advancing care information performance category to the
improvement activities performance category because the improvement
activities performance category allows for the most flexibility. One
commenter recommended redistributing the weight of the advancing care
information performance category to both the quality and improvement
activities performance categories.
We continue to have concerns about increasing the weight of the
improvement activities performance category, given that this
performance category is based on attestation only and is not connected
to a predecessor CMS program like the other MIPS performance
categories. However, based on the comments we received, we considered
an alternative approach for the 2020 MIPS payment year to redistribute
the weight of the advancing care information performance category to
the quality and improvement activities performance categories, to
minimize the impact of the quality performance category on the final
score. For this approach, we would redistribute 15 percent to the
quality performance category (60 percent + 15 percent = 75 percent) and
10 percent to the improvement activities performance category (15
percent + 10 percent = 25 percent). We considered redistributing the
weight of the advancing care information performance category equally
to the quality and improvement activities performance categories.
However, for simplicity, we wanted to redistribute the weights in
increments of 5 points. Because MIPS eligible clinicians have more
experience reporting quality measures and because these measures are
more mature, under
[[Page 30146]]
this alternative option, we would redistribute slightly more to the
quality performance category (15 percent vs. 10 percent). Should the
cost performance category have available and applicable measures and
the cost performance category weight is not finalized at zero percent
and the quality performance category is reweighted to zero percent,
then we would redistribute the weight of the advancing care information
performance category to the improvement activities performance
category. This alternative approach, assuming the cost performance
category weight is zero percent is detailed in Table 39.
Table 39--Alternative Option for Reweighting the Advancing Care
Information Performance Category for the 2020 MIPS Payment Year if the
Cost Performance Category Weight Is Zero Percent
------------------------------------------------------------------------
Reweight
scenario if no
Weighting for advancing care
Performance category the 2020 MIPS information
payment year performance
(%) category score
(%)
------------------------------------------------------------------------
Quality............................... 60 75
Cost.................................. 0 0
Improvement Activities................ 15 25
Advancing Care Information............ 25 0
------------------------------------------------------------------------
We invite comments on our proposal for weighting the performance
categories for the 2020 MIPS payment year and our alternative option
for reweighting the advancing care information performance category.
8. MIPS Payment Adjustments
a. Payment Adjustment Identifier and Final Score Used in Payment
Adjustment Calculation
(1) Payment Adjustment Identifier
For purposes of applying the MIPS payment adjustment under section
1848(q)(6)(E) of the Act, we finalized a policy in the CY 2017 Quality
Payment Program final rule to use a single identifier, TIN/NPI, for all
MIPS eligible clinicians, regardless of whether the TIN/NPI was
measured as an individual, group or APM Entity group (81 FR 77329
through 77330). In other words, a TIN/NPI may receive a final score
based on individual, group, or APM Entity group performance, but the
MIPS payment adjustment would be applied at the TIN/NPI level.
We are not proposing any changes to the MIPS payment adjustment
identifier.
(2) Final Score Used in Payment Adjustment Calculation
In CY 2017 Quality Payment Program final rule (81 FR 77330 through
77332), we finalized a policy to use a TIN/NPI's historical performance
from the performance period associated with the MIPS payment
adjustment. We also proposed the following policies, and, although we
received public comments on them and responded to those comments, we
inadvertently failed to state that we were finalizing these policies,
although it was our intention to do so. Thus, we clarify that the
following final policies apply beginning with the transition year. For
groups submitting data using the TIN identifier, we will apply the
group final score to all the TIN/NPI combinations that bill under that
TIN during the performance period. For individual MIPS eligible
clinicians submitting data using TIN/NPI, we will use the final score
associated with the TIN/NPI that is used during the performance period.
For eligible clinicians in MIPS APMs, we will assign the APM Entity
group's final score to all the APM Entity Participant Identifiers that
are associated with the APM Entity. For eligible clinicians that
participate in APMs for which the APM scoring standard does not apply,
we will assign a final score using either the individual or group data
submission assignments.
In the case where a MIPS eligible clinician starts working in a new
practice or otherwise establishes a new TIN that did not exist during
the performance period, there would be no corresponding historical
performance information or final score for the new TIN/NPI. In cases
where there is no final score associated with a TIN/NPI from the
performance period, we will use the NPI's performance for the TIN(s)
the NPI was billing under during the performance period. If the MIPS
eligible clinician has only one final score associated with the NPI
from the performance period, then we will use that final score. In the
event that an NPI bills under multiple TINs in the performance period
and bills under a new TIN in the MIPS payment year, we finalized a
policy of taking the highest final score associated with that NPI in
the performance period (81 FR 77332).
In some cases, a TIN/NPI could have more than one final score
associated with it from the performance period, if the MIPS eligible
clinician submitted duplicative data sets. In this situation, the MIPS
eligible clinician has not changed practices; rather, for example, a
MIPS eligible clinician has a final score for an APM Entity and a final
score for a group TIN. If a MIPS eligible clinician has multiple final
scores, the following hierarchy will apply. If a MIPS eligible
clinician is a participant in MIPS APM, then the APM Entity final score
would be used instead of any other final score. If a MIPS eligible
clinician has more than one APM Entity final score, we will apply the
highest APM Entity final score to the MIPS eligible clinician. If a
MIPS eligible clinician reports as a group and as an individual and not
as an APM Entity, we will calculate a final score for the group and
individual identifier and use the highest final score for the TIN/NPI
(81 FR 77332).
For a further description of our policies, we refer readers to the
CY 2017 Quality Payment Program final rule (81 FR 77330 through 77332).
In addition to the above policies from the CY 2017 Quality Payment
Program final rule, beginning with the 2020 MIPS payment year, we are
proposing to modify the policies to address the addition of virtual
groups. Section 1848(q)(5)(I)(i) of the Act provides that MIPS eligible
clinicians electing to be a virtual group must: (1) Have their
performance assessed for the quality and cost performance categories in
a manner that applies the combined performance of all the MIPS eligible
clinicians in the virtual group to each MIPS eligible clinician in the
virtual group for the applicable performance period; and (2) be scored
for the quality
[[Page 30147]]
and cost performance categories based on such assessment. Therefore,
when identifying a final score for payment adjustments, we must
prioritize a virtual group final score over other final scores such as
individual and group scores. Because we also wish to encourage movement
towards APMs, we will prioritize using the APM Entity final score over
any other score for a TIN/NPI, including a TIN/NPI that is in a virtual
group. If a TIN/NPI is in both a virtual group and a MIPS APM, we
propose to use the waiver authority for Innovation Center models under
section 1115A(d)(1) of the Act and the Shared Savings Program waiver
authority under section 1899(f) of the Act to waive section
1848(q)(5)(I)(i)(I) and (II) of the Act. As discussed in section
II.C.4.h. of this proposed rule, the use of waiver authority is to
avoid creating competing incentives between MIPS and the APM. We want
MIPS eligible clinicians to focus on the requirements of the APM to
ensure that the models produce valid results that are not confounded by
the incentives created by MIPS.
We also propose to modify our hierarchy to state that if a MIPS
eligible clinician is not in an APM Entity and is in a virtual group,
the MIPS eligible clinician would receive the virtual group final score
over any other final score. Our policies remain unchanged for TIN/NPIs
who are not in an APM Entity or virtual group.
We invite public comment on our proposals.
Table 40 illustrates the previously finalized and newly proposed
policies for determining which final score to use when more than one
final score is associated with a TIN/NPI.
Table 40--Hierarchy for Final Score When More Than One Final Score Is
Associated With a TIN/NPI
------------------------------------------------------------------------
Final score used to determine
Example payment adjustments
------------------------------------------------------------------------
TIN/NPI has more than one APM Entity The highest of the APM Entity
final score. final scores.
TIN/NPI has an APM Entity final score APM Entity final score.
that is not a virtual group score and
also has a group final score.
TIN/NPI has an APM Entity final score APM Entity final score.
and also has a virtual group score.
TIN/NPI has a virtual group score and Virtual group score.
an individual final score.
TIN/NPI has a group final score and an The highest of the group or
individual final score, but no APM individual final score.
Entity final score and is not in a
virtual group.
------------------------------------------------------------------------
Table 41 illustrates the previously finalized policies that apply
if there is no final score associated with a TIN/NPI from the
performance period, such as when a MIPS eligible clinician starts
working in a new practice or otherwise establishes a new TIN.
Table 41--No Final Score Associated With a TIN/NPI
------------------------------------------------------------------------
Final score
Performance TIN/NPI billing used to
MIPS eligible period final in MIPS payment determine
clinician (NPI 1) score year (yes/no) payment
adjustments
------------------------------------------------------------------------
TIN A/NPI 1.......... 90............. Yes (NPI 1 is 90 (Final score
still billing for TIN A/NPI
under TIN A in 1 from the
the MIPS performance
payment year). period).
TIN B/NPI 1.......... 70............. No (NPI 1 has n/a (no claims
left TIN B and are billed
no longer under TIN B/
bills under NPI 1).
TIN B in the
MIPS payment
year).
TIN C/NPI 1.......... n/a (NPI 1 was Yes (NPI 1 has 90 (No final
not part of joined TIN C score for TIN
TIN C during and is billing C/NPI 1, so
the under TIN C in use the
performance the MIPS highest final
period). payment year). score
associated
with NPI 1
from the
performance
period).
------------------------------------------------------------------------
b. MIPS Payment Adjustment Factors
For a description of the statutory background and further
description of our policies, we refer readers to the CY 2017 Quality
Payment Program final rule (81 FR 77332 through 77333).
We are not proposing any changes to these policies.
c. Establishing the Performance Threshold
Under section 1848(q)(6)(D)(i) of the Act, for each year of the
MIPS, the Secretary shall compute a performance threshold with respect
to which the final scores of MIPS eligible clinicians are compared for
purposes of determining the MIPS payment adjustment factors under
section 1848(q)(6)(A) of the Act for a year. The performance threshold
for a year must be either the mean or median (as selected by the
Secretary, and which may be reassessed every 3 years) of the final
scores for all MIPS eligible clinicians for a prior period specified by
the Secretary. Section 1848(q)(6)(D)(iii) of the Act outlines a special
rule for the initial 2 years of MIPS, which requires the Secretary,
prior to the performance period for such years, to establish a
performance threshold for purposes of determining the MIPS payment
adjustment factors under section 1848(q)(6)(A) of the Act and an
additional performance threshold for purposes of determining the
additional MIPS payment adjustment factors under section 1848(q)(6)(C)
of the Act, each of which shall be based on a period prior to the
performance period and take into account data available for performance
on measures and activities that may be used under the performance
categories and other factors determined appropriate by the Secretary.
We codified the term performance threshold at Sec. 414.1305 as the
numerical threshold for a MIPS payment year against which the final
scores of MIPS eligible clinicians are compared to determine the MIPS
payment adjustment factors. We codified at Sec. 414.1405(b) that a
performance threshold will be specified for each MIPS payment year. We
refer readers to the CY 2017 Quality Payment Program final rule for
further discussion
[[Page 30148]]
of the performance threshold (81 FR 77333 through 77338). In accordance
with the special rule set forth in section 1848(q)(6)(D)(iii) of the
Act, we finalized a performance threshold of 3 points for the
transition year (81 FR 77334 through 77338).
Our goal was to encourage participation and provide an opportunity
for MIPS eligible clinicians to become familiar with the MIPS Program.
We determined that it would have been inappropriate to set a
performance threshold that would result in downward adjustments to
payments for many clinicians who may not have had time to prepare
adequately to succeed under MIPS. By providing a pathway for many
clinicians to succeed under MIPS, we believed that we would encourage
early participation in the program, which may enable more robust and
thorough engagement with the program over time. We set the performance
threshold at a low number to provide MIPS eligible clinicians an
opportunity to achieve a minimum level of success under the program,
while gaining experience with reporting on the measures and activities
and becoming familiar with other program policies and requirements. We
believed if we set the threshold too high, using a new formula that is
unfamiliar and confusing to clinicians, many could be discouraged from
participating in the first year of the program, which may lead to lower
participation rates in future years. Additionally, we believed this
flexibility is particularly important to reduce the burden for MIPS
eligible clinicians in small or solo practices. We believed that active
participation of MIPS eligible clinicians in MIPS will improve the
overall quality, cost, and care coordination of services provided to
Medicare beneficiaries. In accordance with section 1848(q)(6)(D)(iii)
of the Act, we took into account available data regarding performance
on measures and activities, as well as other factors we determined
appropriate. We refer readers to 81 FR 77333 through 77338 for details
on our analysis. We also stated our intent to increase the performance
threshold in the 2020 MIPS payment year, and that, beginning in the
2021 MIPS payment year, we will use the mean or median final score from
a prior period as required by section 1848(q)(6)(D)(i) of the Act (81
FR 77338).
For the 2020 MIPS payment year, we again want to use the
flexibility provided in section 1848(q)(6)(D)(iii) to help transition
MIPS eligible clinicians to the 2021 MIPS payment year, when the
performance threshold will be the mean or median of the final scores
for all MIPS eligible clinicians from a prior period. We want to
encourage continued participation and the collection of meaningful data
by MIPS eligible clinicians. A higher performance threshold would help
MIPS eligible clinicians strive to achieve more complete reporting and
better performance and prepare MIPS eligible clinicians for the 2021
MIPS payment year. However, a performance threshold set too high could
also create a performance barrier, particularly for MIPS eligible
clinicians who did not previously participate in PQRS or the EHR
Incentive Programs. We have heard from stakeholders requesting that we
continue a low performance threshold and from stakeholders requesting
that we ramp up the performance threshold to help MIPS eligible
clinicians prepare for the 2021 MIPS payment year and to meaningfully
incentivize higher performance. Given our desire to provide a
meaningful ramp between the transition year's 3-point performance
threshold and the 2021 MIPS payment year performance threshold using
the mean or median of the final scores for all MIPS eligible clinicians
for a prior period, we are proposing to set the performance threshold
at 15 points for the 2020 MIPS payment year.
We propose a performance threshold of 15 points because it
represents a meaningful increase in performance threshold, compared to
3 points in the transition year, while maintaining flexibility for MIPS
eligible clinicians in the pathways available to achieve this
performance threshold. For example, submitting the maximum number of
improvement activities could qualify for a score for 15 points (40 out
40 possible points for the improvement activity which is worth 15
percent of the final score). The performance threshold could also be
met by full participation in the quality performance category: By
submitting all required measures with the necessary data completeness,
MIPS eligible clinicians would earn at least a quality performance
category percent score of 30 percent (which is 3 measure achievement
points out of 10 measure points for each required measure).
If the quality performance category is weighted at 60 percent, then
the quality performance category would be 30 percent x 60 percent x 100
which equals 18 points toward the final score and exceeds the
performance threshold. Finally, a MIPS eligible clinician could achieve
a final score of 15 points through an advancing care information
performance category score of 60 percent or higher (60 percent
advancing care information performance category score x 25 percent for
the advancing care information performance category weight x 100 equals
15 points towards the final score). We refer readers to section
II.C.8.g.(2) of this proposed rule for complete examples of how MIPS
eligible clinician could exceed the performance threshold. We believe
the proposed performance threshold would mitigate concerns from MIPS
eligible clinicians about participating in the program for the second
year. However, we remain concerned that moving from a performance
threshold of 15 points for the 2020 MIPS payment year to a performance
threshold of the mean or median of the final scores for all MIPS
eligible clinicians for a prior period for the 2021 MIPS payment year
may be a steep jump.
By the 2021 MIPS payment year, MIPS eligible clinicians would
likely need to submit most of the required information and perform well
on the measures and activities to receive a positive MIPS payment
adjustment. Therefore, we also seek comment on setting the performance
threshold either lower or higher than the proposed 15 points for the
2020 MIPS payment year. A performance threshold lower than the proposed
15 points for the 2020 MIPS payment year presents the potential for a
significant increase in the final score a MIPS eligible clinician must
earn to meet the performance threshold in the 2021 MIPS payment year,
as well as providing for a potentially smaller total amount of negative
MIPS payment adjustments upon which the total amount of the positive
MIPS payment adjustments would depend due to the budget neutrality
requirement under section 1848(q)(6)(F)(ii) of the Act. A performance
threshold higher than the proposed 15 points would increase the final
score required to receive a neutral MIPS payment adjustment, which may
be particularly challenging for small practices, even with the proposed
addition of the small practice bonus. A higher performance threshold
would also allow for potentially higher positive MIPS payment
adjustments for those who exceed the performance threshold.
We considered an alternative of setting a performance threshold of
6 points, which could be met by submitting two quality measures with
required data completeness or one high-weighted improvement activity.
While this lower performance threshold may provide a sharp increase to
the required performance threshold in MIPS payment year 2021 (the mean
or median of the final scores for all MIPS eligible clinicians for a
prior period), it would continue to reward clinicians for participation
in MIPS as they transition into the program.
[[Page 30149]]
We also considered an alternative of setting the performance
threshold at 33 points, which would require full participation both in
improvement activities and in the quality performance category (either
for a small group or for a large group that meets data completeness
standards) to meet the performance threshold. Such a threshold would
make the step to the required mean or median performance threshold in
MIPS payment year 2021 less steep, but could present further challenges
to clinicians who have not previously participated in legacy quality
reporting programs.
As required by section 1848(q)(6)(D)(iii) of the Act, for the
purposes of determining the performance threshold, we considered data
available for performance on measures and activities that may be used
under the MIPS performance categories. Specifically, we updated our
scoring model using 2019 MIPS payment year eligibility data from the
initial 12-month period to identify potential MIPS eligible clinicians
who are physicians (doctors of medicine, doctors of osteopathy,
chiropractors, dentists, optometrists, and podiatrists), nurse
practitioners, physician assistants, certified registered nurse
anesthetists, and clinical nurse specialists, and who exceeded the low-
volume threshold. We estimated newly enrolled Medicare clinicians who
would be excluded from MIPS by using clinicians (identified by NPI)
that have Part B charges in the eligibility file, but no Part B charges
in 2015. To exclude QPs from our scoring model, we used a preliminary
version of the file used for the predictive qualifying Alternative
Payment Model participants analysis made available on qpp.cms.gov on
June 2, 2017 and prepared using claims for services between January 1,
2016 through August 31, 2016. We assumed that all partial QPs would
participate in MIPS and included them in our scoring model.
We used 2014 and 2015 PQRS and 2015 VM data to estimate scores for
the quality performance category, using the published benchmarks for
the 2017 MIPS performance period. We used 2015 and 2016 Medicare and
Medicaid EHR Incentive files to estimate advancing care information
performance category scores. We also modeled an improvement activities
performance category score using assumptions based on prior PQRS and
EHR Incentive Program participation. We did not model any cost measures
as we proposed in section II.C.6.d.(2) of this proposed rule to weight
the cost performance category at zero percent. We refer readers to the
regulatory impact analysis in section V.C. of this proposed rule for a
detailed description of our scoring model and data sources.
Using 2015 PQRS data, we determined which of these MIPS eligible
clinicians participated in PQRS and estimated participation rates for
the MIPS quality performance category based on PQRS participation,
which is the performance category that accounts for the largest share
(a minimum of 60 percent) of the 2020 MIPS payment year final score. We
noted that 92.4 percent of the estimated MIPS eligible clinicians
submitted data to PQRS, but the participation rate was lower for MIPS
eligible clinicians in small practices at 69.7 percent. While we
believe many of the policies in this proposed rule and the technical
assistance for small practices would help increase participation, we
believe it is important to keep the performance threshold low so that
these small practices can learn to participate and perform well in MIPS
for future years without excessive financial risk.
We invite public comments on the proposal to set the performance
threshold at 15 points, and also seek comment on setting the
performance threshold at the alternative of 6 points or at 33 points
for the 2020 MIPS payment year.
We also seek public comments on principles and considerations for
setting the performance threshold beginning with the 2021 MIPS payment
year, which will be the mean or median of the final scores for all MIPS
eligible clinicians from a prior period.
d. Additional Performance Threshold for Exceptional Performance
Section 1848(q)(6)(D)(ii) of the Act requires the Secretary to
compute, for each year of the MIPS, an additional performance threshold
for purposes of determining the additional MIPS payment adjustment
factors for exceptional performance under paragraph (C). For each such
year, the Secretary shall apply either of the following methods for
computing the additional performance threshold: (1) The threshold shall
be the score that is equal to the 25th percentile of the range of
possible final scores above the performance threshold determined under
section 1848(q)(6)(D)(i) of the Act; or (2) the threshold shall be the
score that is equal to the 25th percentile of the actual final scores
for MIPS eligible clinicians with final scores at or above the
performance threshold for the prior period described in section
1848(q)(6)(D)(i) of the Act.
We codified at Sec. 414.1305 the definition of additional
performance threshold as the numerical threshold for a MIPS payment
year against which the final scores of MIPS eligible clinicians are
compared to determine the additional MIPS payment adjustment factors
for exceptional performance. We also codified at Sec. 414.1405(d) that
an additional performance threshold will be specified for each of the
MIPS payment years 2019 through 2024. We refer readers to the CY 2017
Quality Payment Program final rule for further discussion of the
additional performance threshold (81 FR 77338 through 77339).
Based on the special rule for the initial 2 years of MIPS in
section 1848(q)(6)(D)(iii) of the Act, for the transition year, we
decoupled the additional performance threshold from the performance
threshold and established the additional performance threshold at 70
points. We selected a 70-point numerical value for the additional
performance threshold, in part, because it would require a MIPS
eligible clinician to submit data for and perform well on more than one
performance category (except in the event the advancing care
information performance category is reweighted to zero percent and the
weight is redistributed to the quality performance category making the
quality performance category worth 85 percent of the final score).
Under section 1848(q)(6)(C) of the Act, a MIPS eligible clinician with
a final score at or above the additional performance threshold will
receive an additional MIPS payment adjustment factor and may share in
the $500,000,000 available for the year under section 1848(q)(6)(F)(iv)
of the Act. We believed these additional incentives should only be
available to those clinicians with very high performance on the MIPS
measures and activities. We took into account the data available and
the modeling described in section II.E.7.c.(1) of the CY 2017 Quality
Payment Program final rule in selecting the additional performance
threshold for the transition year (81 FR 77338 through 77339).
As we discussed in section II.C.8.c. of this proposed rule, we are
relying on the special rule under section 1848(q)(6)(D)(iii) of the Act
to establish the performance threshold at 15 points for 2020 MIPS
payment year. We are proposing to again decouple the additional
performance threshold from the performance threshold. Because we do not
have actual MIPS final scores for a prior performance period, if we do
not decouple the additional performance threshold from the performance
threshold, then we would have to set the additional performance
threshold at
[[Page 30150]]
the 25th percentile of possible final scores above the performance
threshold. With a performance threshold set at 15 points, the range of
total possible points above the performance threshold is 16 to 100
points. The 25th percentile of that range is 36.25 points, which is
barely more than one third of the possible 100 points in the MIPS final
score. We do not believe it would be appropriate to lower the
additional performance threshold to 36.25 points, as we do not believe
a final score of 36.25 points demonstrates exceptional performance by a
MIPS eligible clinician. We believe these additional incentives should
only be available to those clinicians with very high performance on the
MIPS measures and activities. Therefore, we are relying on the special
rule under section 1848(q)(6)(D)(iii) of the Act to set the additional
performance threshold at 70 points for the 2020 MIPS payment year,
which is higher than the 25th percentile of the range of the possible
final scores above the performance threshold.
We took into account the data available and the modeling described
in section II.C.8.c. of this proposed rule to estimate final scores for
the 2020 MIPS payment year. We believe 70 points is appropriate because
it requires a MIPS eligible clinician to submit data for and perform
well on more than one performance category (except in the event the
advancing care information measures are not applicable and available to
a MIPS eligible clinician). Generally, a MIPS eligible clinician could
receive a maximum score of 60 points for the quality performance
category, which is below the 70-point additional performance threshold.
In addition, 70 points is at a high enough level that MIPS eligible
clinicians must submit data for the quality performance category to
achieve this target. For example, if a MIPS eligible clinician gets a
perfect score for the improvement activities and advancing care
information performance categories, but does not submit quality
measures data, then the MIPS eligible clinician would only receive 40
points (0 points for quality + 15 points for improvement activities +
25 points for advancing care information), which is below the
additional performance threshold. We believe the additional performance
threshold at 70 points maintains the incentive for excellent
performance while keeping the focus on quality performance. Finally, we
believe keeping the additional performance threshold at 70 points
maintains consistency with the 2019 MIPS payment year which helps to
simplify the overall MIPS framework.
We invite public comment on these proposals. We also seek feedback
on whether we should raise the additional performance threshold to a
higher number which would in many instances require the use of an EHR
for those to whom the advancing care information performance category
requirements would apply. In addition, a higher additional performance
threshold would incentivize better performance and would also allow
MIPS eligible clinicians to receive a higher additional MIPS payment
adjustment.
We also seek public comment on which method we should use to
compute the additional performance threshold beginning with the 2021
MIPS payment year. Section 1848(q)(6)(D)(ii) of the Act requires the
additional performance threshold to be the score that is equal to the
25th percentile of the range of possible final scores above the
performance threshold for the year, or the score that is equal to the
25th percentile of the actual final scores for MIPS eligible clinicians
with final scores at or above the performance threshold for the prior
period described in section 1848(q)(6)(D)(i) of the Act. For example,
should we use the lower of the two options, which would result in more
MIPS eligible clinicians receiving an additional MIPS payment
adjustment for exceptional performance? Or should we use the higher of
the options, which would restrict the additional MIPS payment
adjustment for exceptional performance to those with the higher final
scores? Since a fixed amount is available for a year under section
1848(q)(6)(F)(iv) of the Act to fund the additional MIPS payment
adjustments, the more clinicians that receive an additional MIPS
payment adjustment, the lower the average clinician's additional MIPS
payment adjustment will be.
e. Scaling/Budget Neutrality
We codified at Sec. 414.1405(b)(3) that a scaling factor not to
exceed 3.0 may be applied to positive MIPS payment adjustment factors
to ensure budget neutrality such that the estimated increase in
aggregate allowed charges resulting from the application of the
positive MIPS payment adjustment factors for the MIPS payment year
equals the estimated decrease in aggregate allowed charges resulting
from the application of negative MIPS payment adjustment factors for
the MIPS payment year. We refer readers to the CY 2017 Quality Payment
Program final rule for further discussion of budget neutrality (81 FR
77339).
We are not proposing any changes to the scaling and budget
neutrality requirements as they are applied to MIPS payment adjustment
factors in this proposed rule.
f. Additional Adjustment Factors
We refer readers to the CY 2017 Quality Payment Program final rule
for further discussion of the additional MIPS payment adjustment factor
(81 FR 77339 through 77340). We are not proposing any changes to
determine the additional MIPS payment adjustment factors.
g. Application of the MIPS Payment Adjustment Factors
(1) Application to the Medicare Paid Amount
Section 1848(q)(6)(E) of the Act provides that for items and
services furnished by a MIPS eligible clinician during a year
(beginning with 2019), the amount otherwise paid under Part B for such
items and services and MIPS eligible clinician for such year, shall be
multiplied by 1 plus the sum of the MIPS payment adjustment factor
determined under section 1848(q)(6)(A) of the Act divided by 100, and
as applicable, the additional MIPS payment adjustment factor determined
under section 1848(q)(6)(C) of the Act divided by 100.
We codified at Sec. 414.1405(e) the application of the MIPS
payment adjustment factors. For each MIPS payment year, the MIPS
payment adjustment factor, and if applicable the additional MIPS
payment adjustment factor, are applied to Medicare Part B payments for
items and services furnished by the MIPS eligible clinician during the
year.
We are proposing to apply the MIPS payment adjustment factor, and
if applicable, the additional MIPS payment adjustment factor, to the
Medicare paid amount for items and services paid under Part B and
furnished by the MIPS eligible clinician during the year. This proposal
is consistent with the approach taken for the value-based payment
modifier (77 FR 69308 through 69310) and would mean that beneficiary
cost-sharing and coinsurance amounts would not be affected by the
application of the MIPS payment adjustment factor and the additional
MIPS payment adjustment factor. The MIPS payment adjustment applies
only to the amount otherwise paid under Part B for items and services
furnished by a MIPS eligible clinician during a year. Please refer to
the CY 2017 Quality Payment Program final rule at 81 FR 77340 and
section II.C.3.c.
[[Page 30151]]
of this proposed rule for further discussion and our proposals
regarding which Part B covered items and services would be subject to
the MIPS payment adjustment.
(2) Example of Adjustment Factors
Figure A provides an example of how various final scores would be
converted to an adjustment factor, and potentially an additional
adjustment factor, using the statutory formula and based on proposed
policies. In Figure A, the performance threshold is 15 points. The
applicable percentage is 5 percent for 2020. The adjustment factor is
determined on a linear sliding scale from zero to 100, with zero being
the lowest negative applicable percentage (negative 5 percent for the
2020 MIPS payment year), and 100 being the highest positive applicable
percentage. However, there are two modifications to this linear sliding
scale. First, there is an exception for a final score between zero and
one-fourth of the performance threshold (zero and 3.75 points based on
the proposed performance threshold for the 2020 MIPS payment year). All
MIPS eligible clinicians with a final score in this range would receive
the lowest negative applicable percentage (negative 5 percent for the
2020 MIPS payment year). Second, the linear sliding scale line for the
positive MIPS adjustment factor is adjusted by the scaling factor (as
discussed in section II.C.8.e. of this proposed rule). If the scaling
factor is greater than zero and less than or equal to 1.0, then the
adjustment factor for a final score of 100 would be less than or equal
to 5 percent. If the scaling factor is above 1.0, but less than or
equal to 3.0, then the adjustment factor for a final score of 100 would
be higher than 5 percent. Only those MIPS eligible clinicians with a
final score equal to 15 points (which is the performance threshold in
this example) would receive a neutral MIPS payment adjustment. Because
our proposed policies have set the performance threshold at 15 points,
we anticipate that the scaling factor would be less than 1.0 and the
payment adjustment for MIPS eligible clinicians with a final score of
100 points would be less than 5 percent.
Figure A of this proposed rule illustrates an example slope. In
this example, the scaling factor for the adjustment factor is 0.22,
which is much lower than 1.0. In this example, MIPS eligible clinicians
with a final score equal to 100 would have an adjustment factor of 1.10
percent (5 percent x 0.22).
The additional performance threshold is 70 points. An additional
adjustment factor of 0.5 percent starts at the additional performance
threshold and increases on a linear sliding scale up to 10 percent
times a scaling factor that is greater than zero and less than or equal
to 1.0. The scaling factor will be determined so that the estimated
aggregate increase in payments associated with the application of the
additional adjustment factors is equal to $500,000,000. In Figure A of
this proposed rule, the example scaling factor for the additional
adjustment factor is 0.183. Therefore, MIPS eligible clinicians with a
final score of 100 would have an additional adjustment factor of 1.83
percent (10 percent x 0.183). The total adjustment for a MIPS eligible
clinician with a final score equal to 100 would be 1 + 0.0110 + 0.0183
= 1.0293, for a total positive MIPS payment adjustment of 2.93 percent.
[[Page 30152]]
[GRAPHIC] [TIFF OMITTED] TP30JN17.005
The final MIPS payment adjustments would be determined by the
distribution of final scores across MIPS eligible clinicians and the
performance threshold. More MIPS eligible clinicians above the
performance threshold means the scaling factors would decrease because
more MIPS eligible clinicians receive a positive MIPS payment
adjustment. More MIPS eligible clinicians below the performance
threshold means the scaling factors would increase because more MIPS
eligible clinicians would have negative MIPS payment adjustments and
relatively fewer MIPS eligible clinicians receive positive MIPS payment
adjustments.
Table 42 illustrates the changes in payment adjustments from the
transition year to the 2020 MIPS payment year based on the proposals in
this proposed rule as well as the statutorily-required increase in the
applicable percent as required by section 1848(q)(6)(B) of the Act.
Table 42--Illustration of Point System and Associated Adjustments
Comparison Between Transition Year and the 2020 MIPS Payment Year
------------------------------------------------------------------------
Transition year 2020 MIPS payment year
------------------------------------------------------------------------
Final score
Final score points MIPS adjustment points MIPS adjustment
------------------------------------------------------------------------
0.0-0.75.............. Negative 4 0.0-3.75 Negative 5
percent. percent.
0.76-2.99............. Negative MIPS 3.76-14.99 Negative MIPS
payment payment
adjustment adjustment
greater than greater than
negative 4 negative 5
percent and percent and
less than 0 less than 0
percent on a percent on a
linear sliding linear sliding
scale. scale.
3.00.................. 0 percent 15.00 0 percent
adjustment. adjustment.
3.01-69.99............ Positive MIPS 15.01-69.99 Positive MIPS
payment payment
adjustment adjustment
greater than 0 greater than 0
percent on a percent on a
linear sliding linear sliding
scale scale
multiplied by multiplied by
a scaling a scaling
factor to factor to
preserve preserve
budget budget
neutrality. neutrality.
The linear .............. The linear
sliding scale sliding scale
ranges from ranges from
greater than 0 greater than 0
to 4 percent to 5 percent
for scores for scores
from 3.01 to from 15.01 to
100.00. 100.00.
[[Page 30153]]
70.00-100............. Positive MIPS 70.00-100 Positive MIPS
payment payment
adjustment on adjustment on
a linear a linear
sliding scale sliding scale
multiplied by multiplied by
a scaling a scaling
factor to factor to
preserve preserve
budget budget
neutrality AND neutrality AND
additional additional
MIPS payment MIPS payment
adjustment for adjustment for
exceptional exceptional
performance. performance.
(Additional (Additional
MIPS payment MIPS payment
adjustment adjustment
starting at starting at
0.5 percent 0.5 percent
and increasing and increasing
on a linear on a linear
sliding scale sliding scale
to 10 percent to 10 percent
multiplied by multiplied by
a scaling a scaling
factor.) factor.)
The linear .............. The linear
sliding scale sliding scale
ranges from ranges from
greater than 0 greater than 0
to 4 percent to 5 percent
for scores for scores
from 3.01 to from 15.01 to
100.00. 100.00.
------------------------------------------------------------------------
We have provided the following examples for the 2020 MIPS payment
year to demonstrate scenarios in which MIPS eligible clinicians can
achieve a final score at or above the performance threshold of 15
points.
Example 1: MIPS Eligible Clinician in Small Practice Submits 1 Quality
Measure and 1 Improvement Activity
In the example illustrated in Table 43, a MIPS eligible clinician
in a small practice reporting individually meets the performance
threshold by reporting one measure one time via claims and one medium-
weight improvement activity. The practice does not submit data for the
advancing care information performance category, but does submit a
significant hardship exception application which is approved;
therefore, the weight for the advancing care information performance
category is reweighted to the quality performance category due to
proposed reweighting policies discussed in section II.C.7.b,(3) of this
proposed rule. We also assume the small practice has a cost performance
category percent score of 50 percent, although the cost performance
category percent score will not contribute to the final score. Finally,
we assume the average HCC score for the beneficiaries seen by the MIPS
eligible clinician is 1.5.
There are several special scoring rules which affect MIPS eligible
clinicians in a small practice:
3 measure achievement points for each quality measure even
if the measure does not meet data completeness standards. We refer
readers to section II.C.7.a.(2)(d) of this proposed rule for discussion
of this policy. Therefore, a quality measure submitted one time would
receive 3 points. Because the measure is submitted via claims, it does
not qualify for the end-to-end electronic reporting bonus, nor would it
qualify for the high-priority bonus because it is the only measure
submitted. However, because the MIPS eligible clinician does not meet
full participation requirements, the MIPS eligible clinician does not
qualify for improvement scoring. We refer you to section
II.C.7.a.(2)(i)(iii) of this proposed rule for a discussion on full
participation requirements. Therefore, the quality performance category
is (3 measure achievement points + zero measure bonus points)/60 total
available measure points + zero improvement percent score which is 5
percent.
The advancing care information performance category weight
is redistributed to quality so that the quality performance category
percent score is worth 85 percent of the final score. We refer you to
section II.C.7.b.(3)(d) of this proposed rule for a discussion of this
proposed policy.
MIPS eligible clinicians in small practices qualify for
special scoring for improvement activities so a medium weighted
activity is worth 20 points out of a total 40 possible points for the
improvement activities performance category. We refer you to section
II.C.6.e.(5) of this proposed rule for a discussion of this proposed
policy.
MIPS eligible clinicians in small practices qualify for
the 5 point small practice bonus which is applied to the final score.
We refer you to section II.C.7.b.(1)(c) of this proposed rule for a
discussion of this proposed policy.
This MIPS eligible clinician exceeds the performance threshold of
15 points (but does not exceed the additional performance threshold).
This score is summarized in Table 43.
Table 43--Scoring Example 1, MIPS Eligible Clinician in a Small Practice
----------------------------------------------------------------------------------------------------------------
Earned points
Performance category Performance score Category weight ([B]*[C]*100)
----------------------------------------------------------------------------------------------------------------
[A] [B]............................ [C]............................ [D]
----------------------------------------------------------------------------------------------------------------
Quality....................... 5%............................. 85%............................ 4.25
Cost.......................... 50%............................ 0%............................. 0
Improvement Activities........ 20 out of 40 points--50%....... 15%............................ 7.5
Advancing Care Information.... Missing........................ 0% (reweighted to quality)..... 0
---------------------------------------------------------------------------------
Subtotal (Before Bonuses). ............................... ............................... 11.75
----------------------------------------------------------------------------------------------------------------
Complex Patient Bonus......... ............................... ............................... 1.5
Small Practice Bonus.......... ............................... ............................... 5
---------------------------------------------------------------------------------
Final Score (not to exceed ............................... ............................... 18.25
100).
----------------------------------------------------------------------------------------------------------------
[[Page 30154]]
Example 2: Group Submission Not in a Small Group
In the example illustrated in Table 44, a MIPS eligible clinician
in a medium size practice participating in MIPS as a group meets 75
percent of the quality score and 100 percent for the advancing care
information and improvement activities performance categories. There
are many paths for a practice to receive a 75 percent score in the
quality performance category, so for simplicity we are assuming the
score has been calculated. Both the performance threshold and the
additional performance threshold are exceeded. Again, for simplicity,
we assume the average HCC score for the group is 1.5. In this example,
the group practice does not qualify for any special scoring, yet is
able to exceed the additional performance threshold and achieve the
additional adjustment factor.
Table 44--Scoring Example 2, MIPS Eligible Clinician in a Medium Practice
----------------------------------------------------------------------------------------------------------------
Category Earned points
Performance category Performance score weight ([B]*[C]*100)
----------------------------------------------------------------------------------------------------------------
[A] [B]..................................... [C] [D]
----------------------------------------------------------------------------------------------------------------
Quality............................... 75%..................................... 60% 45
Cost.................................. 50%..................................... 0% 0
Improvement Activities................ 40 out of 40 points--100%............... 15% 15
Advancing Care Information............ 100%.................................... 25% 25
-------------------------------------------------------------------------
Subtotal (Before Bonuses)......... ........................................ .............. 85
----------------------------------------------------------------------------------------------------------------
Complex Patient Bonus................. ........................................ .............. 1.5
Small Practice Bonus.................. ........................................ .............. 0
-------------------------------------------------------------------------
Final Score (not to exceed 100)... ........................................ .............. 86.5
----------------------------------------------------------------------------------------------------------------
Example 3: Non-Patient Facing MIPS Eligible Clinician
In the example illustrated in Table 45, an individual MIPS eligible
clinician that is non-patient facing and not in a small practice meets
50 percent of the quality score and 50 percent for 1 medium-weighted
for improvement activity. Again, there are many paths for a practice to
receive a 50 percent score in the quality performance category, so for
simplicity we are assuming the score has been calculated. Because the
MIPS eligible clinician is non-patient facing, they qualify for special
scoring for improvement activities, they receive 20 points (out of 40
possible points) for the medium weighted activity. Also, this
individual did not submit advancing care information measures and
qualifies for the automatic reweighting of the advancing care
information performance category to quality. The non-patient facing
MIPS eligible clinician has an average HCC score of 1.5, but as the
MIPS eligible clinician is not in a small practice, the MIPS eligible
clinician does not qualify for the small practice bonus.
In this example, the performance threshold is exceeded while the
additional performance threshold is not.
Table 45--Scoring Example 2, Non-Patient Facing MIPS Eligible Clinician
----------------------------------------------------------------------------------------------------------------
Category Earned points
Performance category Performance score weight ([B]*[C]*100)
----------------------------------------------------------------------------------------------------------------
[A] [B]..................................... [C] [D]
----------------------------------------------------------------------------------------------------------------
Quality............................... 50%..................................... 60% 30
Cost.................................. 50%..................................... 0% 0
Improvement Activities................ 20 out of 40 points for 1 medium weight 15% 7.5
activity--50%.
Advancing Care Information............ 0%...................................... 25% 0
-------------------------------------------------------------------------
Subtotal (Before Bonuses)......... ........................................ .............. 37.5
----------------------------------------------------------------------------------------------------------------
Complex Patient Bonus................. ........................................ .............. 1.5
Small Practice Bonus.................. ........................................ .............. 0
-------------------------------------------------------------------------
Final Score (not to exceed 100)... ........................................ .............. 39
----------------------------------------------------------------------------------------------------------------
We note that these examples are not intended to be exhaustive of
the types of participants nor the opportunities for reaching and
exceeding the performance threshold.
9. Review and Correction of MIPS Final Score
a. Feedback and Information To Improve Performance
(1) Performance Feedback
As we have stated previously in the CY 2017 Quality Payment Program
final rule (81 FR 77345), we will continue to engage in user research
with front-line clinicians to ensure we are providing the performance
feedback data in a user-friendly format, and that we are including the
data most relevant to clinicians. Any suggestions from user research
would be considered as we
[[Page 30155]]
develop the systems needed for performance feedback, which would occur
outside of the rulemaking process.
Over the past year, we have conducted numerous user research
sessions to determine what the community most needs in performance
feedback. In summary we have found the users want the following:
(1) To know as soon as possible how I am performing based on my
submitted data so that I have confidence that I performed the way I
thought I would.
(2) To be able to quickly understand how and why my payments will
be adjusted so that I can understand how my business will be impacted.
(3) To be able to quickly understand how I can improve my
performance so that I can increase my payment in future program years.
(4) To know how I am performing over time so I can improve the care
I am providing patients in my practice.
(5) To know how my performance compares to my peers.
Based on that research, we have already begun development of real-
time feedback on data submission and scoring where technically feasible
(some scoring requires all clinician data be submitted, and therefore,
cannot occur until the end of the submission period). By ``real-time''
feedback, we mean instantaneous feedback; for example, when a clinician
submits their data via our Web site or a third party submits data via
our Application Program Interface (API), they will know immediately if
their submission was successful.
We will continue to provide information for stakeholders who wish
to participate in user research via our education and communication
channels. Suggestions can also be sent via the ``Contact Us''
information on qpp.cms.gov. However, we note that suggestions provided
through this channel will not be considered comments on this proposed
rule. To submit comments on this proposed rule, please see the
explanation of how to submit such comments and relevant deadlines
explained at the beginning of this proposed rule.
(a) MIPS Eligible Clinicians
Under section 1848(q)(12)(A)(i) of the Act, we are at a minimum
required to provide MIPS eligible clinicians with timely (such as
quarterly) confidential feedback on their performance under the quality
and cost performance categories beginning July 1, 2017, and we have
discretion to provide such feedback regarding the improvement
activities and advancing care information performance categories.
Beginning July 1, 2018, we are proposing to provide performance
feedback to MIPS eligible clinicians and groups for the quality and
cost performance categories for the 2017 performance period, and if
technically feasible, for the improvement activities and advancing care
information performance categories. We propose to provide this
performance feedback at least annually, and as, technically feasible,
we would provide it more frequently, such as quarterly. If we are able
to provide it more frequently, we would communicate the expected
frequency to our stakeholders via our education and outreach
communication channels.
Based on public comments summarized and responded to in the CY 2017
Quality Payment Program final rule (81 FR 77347), we also propose that
the measures and activities specified for the CY 2017 performance
period (for all four MIPS performance categories), along with the final
score, would be included in the performance feedback provided on or
about July 1, 2018. We request comment on these proposals.
For cost measures, since we can measure performance using any 12-
month period of prior claims data, we request comment on whether it
would be helpful to provide more frequent feedback on the cost
performance category using rolling 12-month periods or quarterly
snapshots of the most recent 12-month period; how frequent that
feedback should be; and the format in which we should make it available
to clinicians and groups. In addition, as described in sections
II.C.6.b. and II.C.6.d. of this proposed rule, we intend to provide
cost performance feedback in the fall of 2017 and the summer of 2018 on
new episode-based cost measures that are currently under development by
CMS. With regard to the format of feedback on cost measures, we are
considering utilizing the parts of the Quality and Resource Use Reports
(QRURs) that user testing has revealed beneficial while making the
overall look and feel usable to clinicians. We request comment whether
that format is appropriate or if other formats or revisions to that
format should be used to provide performance feedback on cost measures.
(b) MIPS APMs
We are proposing that MIPS eligible clinicians who participate in
MIPS APMs would receive performance feedback in 2018 and future years
of the Quality Payment Program, as technically feasible. Please refer
to section II.C.6.g.(5) of this proposed rule for additional
information related to this proposal.
(c) Voluntary Clinician and Group Reporting
As noted in the CY 2017 Quality Payment Program final rule (81 FR
77071), eligible clinicians who are not included in the definition of a
MIPS eligible clinician during the first 2 years of MIPS (or any
subsequent year) may voluntarily report on measures and activities
under MIPS, but will not be subject to the payment adjustment. In the
final rule (81 FR 77346), we summarized public comments requesting that
eligible clinicians who are not required, but who voluntarily report on
measures and activities under MIPS, should receive the same access to
performance feedback as MIPS eligible clinicians, and indicated that we
would take the comments into consideration in the future development of
performance feedback. We propose to furnish performance feedback to
eligible clinicians and groups that do not meet the definition of a
MIPS eligible clinician but voluntarily report on measures and
activities under MIPS. We propose that this would begin with data
collected in performance period 2017, and would be available beginning
July 1, 2018. Based on user and market research, we believe that making
this information available would provide value in numerous ways. First,
it would help clinicians who are excluded from MIPS in the 2017
performance period, but who may be considered MIPS eligible clinicians
in future years, to prepare for participation in the Quality Payment
Program when there are payment consequences associated with
participation. Second, it would give all clinicians equal access to the
CMS claims and benchmarking data available in performance feedback. And
third, it would allow clinicians who may be interested in participating
in an APM to make a more informed decision.
We request comments on this proposal.
(2) Mechanisms
Under section 1848(q)(12)(A)(ii) of the Act, the Secretary may use
one or more mechanisms to make performance feedback available, which
may include use of a web-based portal or other mechanisms determined
appropriate by the Secretary. For the quality performance category,
described in section 1848(q)(2)(A)(i) of the Act, the feedback shall,
to the extent an eligible clinician chooses to participate in a data
registry for purposes of MIPS (including registries under sections
1848(k) and (m) of the Act), be provided based on
[[Page 30156]]
performance on quality measures reported through the use of such
registries. For any other performance category (that is, cost,
improvement activities, or advancing care information), the Secretary
shall encourage provision of feedback through qualified clinical data
registries (QCDRs) as described in section 1848(m)(3)(E) of the Act.
As previously stated in the CY 2017 Quality Payment Program final
rule (81 FR 77347 through 77349), we will use a CMS-designated system
as the mechanism for making performance feedback available, which we
expect will be a web-based application. We expect to use a new and
improved format for the next performance feedback, anticipated to be
released around July 1, 2018. It will be provided via the Quality
Payment Program Web site (qpp.cms.gov), and we intend to leverage
additional mechanisms, such as health IT vendors, registries, and QCDRs
to help disseminate data and information contained in the performance
feedback to eligible clinicians, where applicable.
We are also seeking comment on how health IT, either in the form of
an EHR or as a supplemental module, could better support the feedback
related to participation in the Quality Payment Program and quality
improvement in general. Specifically--
Are there specific health IT functionalities that could
contribute significantly to quality improvement?
Are there specific health IT functionalities that could be
part of a certified EHR technology or made available as optional health
IT modules in order to support the feedback loop related to Quality
Payment Program participation or participation in other HHS reporting
programs?
In what other ways can health IT support clinicians
seeking to leverage quality data reports to inform clinical improvement
efforts? For example, are there existing or emerging tools or resources
that could leverage an API to provide timely feedback on quality
improvement activities?
Are there opportunities to expand existing tracking and
reporting for use by clinicians, for example expanding the feedback
loop for patient engagement tools to support remote monitoring of
patient status and access to education materials?
We welcome public comment on these questions.
We intend to continue to leverage third party intermediaries as a
mechanism to provider performance feedback. In the CY 2017 Quality
Payment Program final rule (81 FR 77367 through 77386) we finalized
that at least 4 times per year, qualified registries and QCDRs will
provide feedback on all of the MIPS performance categories that the
qualified registry or QCDR reports to us (improvement activities,
advancing care information, and/or quality performance category). The
feedback should be given to the individual MIPS eligible clinician or
group (if participating as a group) at the individual participant level
or group level, as applicable, for which the qualified registry or QCDR
reports. The qualified registry or QCDR is only required to provide
feedback based on the MIPS eligible clinician's data that is available
at the time the performance feedback is generated. In regard to third
party intermediaries, we also noted we would look to propose ``real
time'' feedback as soon as it is technically feasible.
Per the policies finalized in the CY 2017 Quality Payment Program
final rule (81 FR 77367 through 77386), we continue to require
qualified registries and QCDRs, as well as encourage other third party
intermediaries (such as health IT vendors that submit data to us on
behalf of a MIPS eligible clinician or group), to provide performance
feedback to individual MIPS eligible clinicians and groups via the
third party intermediary with which they are already working. We also
understand that performance feedback is valuable to individual
clinicians and groups, and seek feedback from third party
intermediaries on when ``real-time'' feedback could be provided.
Additionally, we plan to continue to work with third party
intermediaries as we continue to develop the mechanisms for performance
feedback, to see where we may be able to develop and implement
efficiencies for the Quality Payment Program. We are exploring options
with an API, which could allow authenticated third party intermediaries
to access the same data that we use to provide confidential feedback to
the individual clinicians and groups on whose behalf the third party
intermediary reports for purposes of MIPS, in accordance with
applicable law, including, but not limited to, the HIPAA Privacy and
Security Rules. Our goal is to enable individual clinicians and groups
to more easily access their feedback via the mechanisms and
relationships they already have established. We are seeking comments on
this approach as we continue to develop performance feedback
mechanisms. We refer readers to section II.C.10. of this proposed rule
for additional information on Third Party Data Submission.
(3) Receipt of Information
Section 1848(q)(12)(A)(v) of the Act, states that the Secretary may
use the mechanisms established under section 1848(q)(12)(A)(ii) of the
Act to receive information from professionals. This allows for expanded
use of the feedback mechanism to not only provide feedback on
performance to MIPS eligible clinicians, but to also receive
information from professionals.
In the CY 2017 Quality Payment Program final rule (81 FR 77350), we
discussed that we intended to explore the possibility of adding this
feature to the CMS-designated system, such as a portal, in future years
under MIPS. Although we are not making any specific proposals at this
time, we are again seeking comment on the features that could be
developed for the expanded use of the feedback mechanism. This could be
a feature where eligible clinicians and groups can send their feedback
(for example, if they are experiencing issues accessing their data,
technical questions about their data, etc.) to us through the Quality
Payment Program Service Center or the Quality Payment Program Web site.
We appreciate that eligible clinicians and groups may have questions
regarding the Quality Payment Program information contained in their
performance feedback. To assist eligible clinicians and groups, we
intend to utilize existing resources, such as a helpdesk or offer
technical assistance, to help address questions with the goal of
linking these resource features to the Quality Payment Program Web site
and Service Center.
(4) Additional Information--Type of Information
Section 1848(q)(12)(B)(i) of the Act states that beginning July 1,
2018, the Secretary shall make available to MIPS eligible clinicians
information about the items and services for which payment is made
under Title 18 that are furnished to individuals who are patients of
MIPS eligible clinicians by other suppliers and providers of services.
This information may be made available through mechanisms determined
appropriate by the Secretary, such as the CMS-designated system that
would also provide performance feedback. Section 1848(q)(12)(B)(ii) of
the Act specifies that the type of information provided may include the
name of such providers, the types of items and services furnished, and
the dates that items and services were furnished. Historical data
regarding the total, and components of, allowed charges (and
[[Page 30157]]
other figures as determined appropriate by the Secretary) may also be
provided.
We propose, beginning with the performance feedback provided around
July 1, 2018, to make available to MIPS eligible clinicians and
eligible clinicians information about the items and services for which
payment is made under Title 18 that are furnished to individuals who
are patients of MIPS eligible clinicians and eligible clinicians by
other suppliers and providers of services. We propose to include as
much of the following data elements as technically feasible: The name
of such suppliers and providers of services; the types of items and
services furnished and received; the dollar amount of services provided
and received; and the dates that items and services were furnished. We
propose that the additional information would include historical data
regarding the total, and components of, allowed charges (and other
figures as determined appropriate). We propose that this information be
provided on the aggregate level; with the exception of data on items
and services, as we could consider providing this data at the patient
level, if clinicians find that level of data to be useful, although we
note it may contain personally identifiable information and protected
health information. We propose the date range for making this
information available would be based on what is most helpful to
clinicians, such as the most recent data we have available, which as
technically feasible would be provided from a 3 to 12-month period. We
propose to make this information available via the Quality Payment
Program Web site, and as technically feasible, as part of the
performance feedback. Finally, because data on items and services
furnished is generally kept confidential, we propose that access would
be provided only after secure credentials are obtained. We request
comment on these proposals.
(5) Performance Feedback Template
As we have previously indicated (81 FR 77352), we intend to do as
much as we can of the development of the template for performance
feedback by working with the stakeholder community in a transparent
manner. We believe this will encourage stakeholder commentary and make
sure the result is the best possible format(s) for feedback.
To continue with our collaborative goal of working with the
stakeholder community, we seek comment on the structure, format,
content (for example, detailed goals, data fields, and elements) that
would be useful for MIPS eligible clinicians and groups to include in
performance feedback, including the data on items and services
furnished, as discussed above. Additionally, we understand the term
``performance feedback'' may not be meaningful to clinicians or groups
to clearly denote what this data might imply. Therefore, we seek
comment on what to term ``performance feedback.'' User testing to date
has provided some considerations for a name in the Quality Payment
Program, such as Progress Notes, Reports, Feedback, Performance
Feedback, or Performance Reports.
Any suggestions on the template to be used for performance feedback
or what to call ``performance feedback'' can be submitted to the
Quality Payment Program Web site at qpp.cms.gov.
b. Targeted Review
In the CY 2017 Quality Payment Program final rule (81 FR 77546), we
finalized at Sec. 414.1385 that MIPS eligible clinicians or groups may
request a targeted review of the calculation of the MIPS payment
adjustment factor under section 1848(q)(6)(A) of the Act and, as
applicable, the calculation of the additional MIPS payment adjustment
factor under section 1848(q)(6)(C) of the Act applicable to such MIPS
eligible clinician or group for a year. We note MIPS eligible
clinicians who are scored under the APM scoring standard described in
section II.C.6.g. of this proposed rule may request this targeted
review. Although we are not proposing any changes to the targeted
review process, we are providing information on the process that was
finalized in the CY 2017 Quality Payment Program final rule (81 FR
77353 through 77358).
(1) MIPS eligible clinicians and groups have a 60-day period to
submit a request for targeted review, which begins on the day we make
available the MIPS payment adjustment factor, and if applicable the
additional MIPS payment adjustment factor, for the MIPS payment year
and ends on September 30 of the year prior to the MIPS payment year or
a later date specified by us.
(2) We will respond to each request for targeted review timely
submitted and determine whether a targeted review is warranted.
Examples under which a MIPS eligible clinician or group may wish to
request a targeted review include, but are not limited to:
The MIPS eligible clinician or group believes that
measures or activities submitted to us during the submission period and
used in the calculations of the final score and determination of the
adjustment factors have calculation errors or data quality issues.
These submissions could be with or without the assistance of a third
party intermediary; or
The MIPS eligible clinician or group believes that there
are certain errors made by us, such as performance category scores were
wrongly assigned to the MIPS eligible clinician or group (for example,
the MIPS eligible clinician or group should have been subject to the
low-volume threshold exclusion and should not have received a
performance category score).
(3) The MIPS eligible clinician or group may include additional
information in support of their request for targeted review at the time
the request is submitted. If we request additional information from the
MIPS eligible clinician or group, it must be provided and received by
us within 30 days of the request. Non-responsiveness to the request for
additional information may result in the closure of the targeted review
request, although the MIPS eligible clinician or group may submit
another request for targeted review before the deadline.
(4) Decisions based on the targeted review are final, and there is
no further review or appeal.
c. Data Validation and Auditing
In the CY 2017 Quality Payment Program final rule (81 FR 77546
through 77547), we finalized at Sec. 414.1390(a) that we will
selectively audit MIPS eligible clinicians and groups on a yearly
basis. If a MIPS eligible clinician or group is selected for audit, the
MIPS eligible clinician or group will be required to do the following
in accordance with applicable law and timelines we establish:
(1) Comply with data sharing requests, providing all data as
requested by us or our designated entity. All data must be shared with
us or our designated entity within 45 days of the data sharing request,
or an alternate timeframe that is agreed to by us and the MIPS eligible
clinician or group. Data will be submitted via email, facsimile, or an
electronic method via a secure Web site maintained by us.
(2) Provide substantive, primary source documents as requested.
These documents may include: Copies of claims, medical records for
applicable patients, or other resources used in the data calculations
for MIPS measures, objectives, and activities. Primary source
documentation also may include verification of records for Medicare and
non-Medicare beneficiaries where applicable. We are not proposing any
changes to the requirements in section Sec. 414.1390(a).
We indicated in the CY 2017 Quality Payment Program final rule that
all
[[Page 30158]]
MIPS eligible clinicians and groups that submit data to us
electronically must attest to the best of their knowledge that the data
submitted to us is accurate and complete (81 FR 77362). We also
indicated in the final rule that attestation requirements would be part
of the submission process (81 FR 77360). We neglected to codify this
requirement in regulation text of the CY 2017 Quality Payment Program
final rule. Additionally, after further consideration since the final
rule, the requirement is more in the nature of a certification, rather
than an attestation. Thus, we are proposing to revise Sec. 414.1390 to
add a new paragraph (b) that requires all MIPS eligible clinicians and
groups that submit data and information to CMS for purposes of MIPS to
certify to the best of their knowledge that the data submitted to CMS
is true, accurate, and complete. We also propose that the certification
by the MIPS eligible clinician or group must accompany the submission.
We also indicated in the CY 2017 Quality Payment Program final rule
that if a MIPS eligible clinician or group is found to have submitted
inaccurate data for MIPS, we would reopen and revise the determination
in accordance with the rules set forth at Sec. Sec. 405.980 through
405.984 (81 FR 77362). We neglected to codify this policy in regulation
text of the CY 2017 Quality Payment Program final rule and further, we
did not include Sec. 405.986, which is also an applicable rule in our
reopening policy. We also finalized our approach to recoup incorrect
payments from the MIPS eligible clinician by the amount of any debts
owed to us by the MIPS eligible clinician and likewise, we would recoup
any payments from the group by the amount of any debts owed to us by
the group. Thus, we are proposing to revise Sec. 414.1390 to add a new
paragraph (c) that states we may reopen and revise a MIPS payment
determination in accordance with the rules set forth at Sec. Sec.
405.980 through 405.986.
In the CY 2017 Quality Payment Program, we also indicated that MIPS
eligible clinicians and groups should retain copies of medical records,
charts, reports and any electronic data utilized for reporting under
MIPS for up to 10 years after the conclusion of the performance period
(81 FR 77360). We neglected to codify this policy in regulation text of
the CY 2017 Quality Payment Program final rule. Thus, we are proposing
to revise Sec. 414.1390 to add a new paragraph (d) that states that
all MIPS eligible clinicians or groups that submit data and information
to CMS for purposes of MIPS must retain such data and information for a
period of 10 years from the end the MIPS Performance Period.
Finally, we indicated in the CY 2017 Quality Payment Program final
rule, that, in addition to recouping any incorrect payments, we intend
to use data validation and audits as an educational opportunity for
MIPS eligible clinicians and groups and we note that this process will
continue to include education and support for MIPS eligible clinicians
and groups selected for an audit.
10. Third Party Data Submission
In developing MIPS, our goal is to develop a program that is
meaningful, understandable, and flexible for participating MIPS
eligible clinicians. Flexible reporting options will provide eligible
clinicians with options to accommodate different practices and make
measurement meaningful. We believe that allowing eligible clinicians to
participate in MIPS through the use of third party intermediaries that
will collect or submit data on their behalf, will help us accomplish
our goal of implementing a flexible program. We strongly encourage all
third party intermediaries to work with their MIPS eligible clinicians
to ensure the data submitted are representative of the individual MIPS
eligible clinician's or group's overall performance for that measure or
activity.
For purposes of this section, we use the term third party to refer
to a qualified registry, QCDR, a health IT vendor or other third party
that obtains data from a MIPS eligible clinician's Certified Electronic
Health Record Technology, or a CMS approved survey vendor. In the CY
2017 Quality Payment Program final rule (81 FR 77363), we finalized at
Sec. 414.1400(a)(1) that MIPS data may be submitted by third party
intermediaries on behalf of a MIPS eligible clinician or group by: (1)
A qualified registry; (2) a QCDR; (3) a health IT vendor; or (4) a CMS
approved survey vendor. Additionally, we finalized at Sec.
414.1400(a)(3) that third party intermediaries must meet all the
criteria designated by us as a condition of their qualification or
approval to participate in MIPS as a third party intermediary. Lastly,
as finalized at Sec. 414.1400(a)(3)(ii), all submitted data must be
submitted in the form and manner specified by us.
We are proposing to revise Sec. 414.1400(a)(1) to state that MIPS
data may be submitted by third party intermediaries on behalf of an
individual MIPS eligible clinician, group, or virtual group. See
section II.C.4. of this rule for more information related to virtual
groups.
Additionally, we believe it is important that the MIPS data
submitted by third party intermediaries is true, accurate, and
complete. To that end, we are proposing to add a requirement at Sec.
414.1400(a)(5) stating that all data submitted to CMS by a third party
intermediary on behalf of a MIPS eligible clinician, group or virtual
group must be certified by the third party intermediary to the best of
its knowledge as true, accurate, and complete. We also propose that
this certification occur at the time of the submission and accompany
the submission. We solicit comments on this proposal.
As more clinicians participate in value based payment arrangements
with multiple payers, we believe third-party intermediaries will play
an important role in calculating quality measures, reporting once to
all payers, and sharing actionable feedback to clinicians. A robust
ecosystem of third-party intermediaries would more reliably calculate
measures using data across clinical practices caring for the same
patients and reduce burden by streamlining reporting to all payers and
offering timely feedback to clinicians that is easier to act on in
addressing gaps in care. Third-party intermediaries can also take the
burden off clinical practices by integrating various types of health
care data, including administrative data from payers, other utilization
data, cost data, and clinical data derived from health IT systems, to
provide front-line clinicians and others with a comprehensive view of
the cost and quality of the care they are delivering.
We are continuing to explore how we can further encourage those
third-party intermediaries that provide comprehensive data services to
support eligible clinicians participating in both MIPS and APMs. For
instance, should we consider implementing additional incentives for
eligible clinicians to use a third-party intermediary which has
demonstrated substantial participation from additional payers and/or
other clinical data sources across practices caring for a cohort of
Medicare beneficiaries within a given geographic area? Should these
incentives also include expectations that structured, standardized data
be shared with third party intermediaries? Should there be additional
refinements to the approach to qualifying third party intermediaries
which evaluate the degree to which these intermediaries can deliver
longitudinal information on a patient to participating clinicians, for
example, a
[[Page 30159]]
virtual care team of primary and specialty physicians? Should there be
a special designation for registries that would convey the availability
of longitudinal clinical data for robust measurement and feedback? We
seek comment on these and other ideas which can further advance the
role of intermediaries and reduce clinician burden by enabling a
streamlined reporting and feedback system.
a. Qualified Clinical Data Registries (QCDRs)
In the CY 2017 Quality Payment Program final rule (81 FR 77364), we
finalized the definition and capabilities of a QCDR. We are not
proposing any changes to the definition or the capabilities of a QCDR
in this proposed rule, and refer readers to the CY 2017 Quality Payment
Program final rule for a detailed discussion of the definition and
capabilities of a QCDR.
(1) Establishment of an Entity Seeking To Qualify as a QCDR
In the CY 2017 Quality Payment Program final rule (81 FR 77365), we
finalized the criteria to establish an entity seeking to qualify as a
QCDR. We are not proposing any changes to the criteria in this proposed
rule, and refer readers to the CY 2017 Quality Payment Program final
rule for the criteria to qualify as a QCDR.
(2) Self-Nomination Period
In the CY 2017 Quality Payment Program final rule (81 FR 77365
through 77366), we finalized the self-nomination period for the 2018
performance period and for future years of the program to be from
September 1 of the year prior to the applicable performance period
until November 1 of the same year. As an example, the self-nomination
period for the 2018 performance period will begin on September 1, 2017,
and will end on November 1, 2017. Entities that desire to qualify as a
QCDR for the purposes of MIPS for a given performance period will need
to self-nominate for that year and provide all information requested by
us at the time of self-nomination. Having qualified as a QCDR in a
prior year does not automatically qualify the entity to participate in
MIPS as a QCDR in subsequent performance periods. Furthermore, prior
performance of the QCDR (when applicable) will be taken into
consideration in approval of their self-nomination. For example, a QCDR
may choose not to continue participation in the program in future
years, or the QCDR may be precluded from participation in a future year
due to multiple data or submission errors as noted below. Finally,
QCDRs may want to update or change the measures or services or
performance categories they intend to provide. We believe an annual
self-nomination process is the best process to ensure accurate
information is conveyed to MIPS eligible clinicians and accurate data
is submitted to MIPS.
However, we do understand that some QCDRs have no changes to the
measure and/or activity inventory they offer to their clients and
intend to participate in the MIPS for many years. Because of this, we
are proposing, beginning with the 2019 performance period, a simplified
process in which existing QCDRs in good standing may continue their
participation in MIPS, by attesting that the QCDR's approved data
validation plan, cost, measures, activities, services, and performance
categories offered in the previous year's performance period of MIPS
have minimal or no changes and will be used for the upcoming
performance period. Specifically, existing QCDRs in good standing may
attest during the self-nomination period that they have no changes to
their approved self-nomination application from the previous year of
MIPS. In addition, the existing QCDRs may decide to make minimal
changes to their approved self-nomination application from the previous
year, which would be submitted by the QCDR for CMS review and approval
by the close of the self-nomination period. Minimal changes may include
limited changes to their performance categories, adding or removing
MIPS quality measures, and adding or updating existing services and/or
cost information. Existing QCDRs in good standing, may also submit for
CMS review and approval, substantive changes to measure specifications
for existing QCDR measures that were approved the previous year, or
submit new QCDR measures for CMS review and approval without having to
complete the entire self-nomination application process, which is
required to be completed by a new QCDR. By attesting that certain
aspects of their approved application from the previous year have not
changed, existing QCDRs in good standing would be spending less time
completing the entire self-nomination form, as was previously required
on a yearly basis. We are proposing such a simplified process to reduce
the burden of self-nomination for those existing QCDRs who have
previously participated in MIPS, and are in good standing (not on
probation or disqualified, as described below) and to allow for
sufficient time for us to review data submissions and to make
determinations on the standing of the QCDRs. We note that substantive
changes to existing QCDR measure specifications or any new QCDR
measures would have to be submitted for CMS review and approval by the
close of the self-nomination period. This proposed process will allow
existing QCDRs in good standing to avoid completing the entire
application annually, as is required in the existing process, and in
alignment with the existing timeline. We request comments on this
proposal. In the development of this proposal, we had reviewed the
possibility of offering a multi-year approval, where QCDRs would be
approved for a 2-year increment of time. We are concerned that
utilizing a multi-year approval process in which QCDRs would be
approved for 2 continuous years using the same fixed services they had
for the first year, would not provide the QCDR with the flexibility to
add or remove services and/or measures or activities based on their
QCDR capabilities for the upcoming program year. Furthermore, another
concern with a multi-year approval process is the concern for those
QCDRs who perform poorly during the first year, and who should be
placed on probation or disqualified (as described below). We request
comments on this alternative.
We finalized to require other information (described below) of
QCDRs at the time of self-nomination. If an entity becomes qualified as
a QCDR, they will need to sign a statement confirming this information
is correct prior to listing it on their Web site. Once we post the QCDR
on our Web site, including the services offered by the QCDR, we will
require the QCDR to support these services or measures for its clients
as a condition of the entity's qualification as a QCDR for purposes of
MIPS. Failure to do so will preclude the QCDR from participation in
MIPS in the subsequent year.
For future years, beginning with the 2018 performance period, we
are proposing that self-nomination information must be submitted via a
web-based tool, and to eliminate the submission method of email. We
will provide further information on the web-based tool at
www.qpp.cms.gov. We request comments on this proposal.
(3) Information Required at the Time of Self-Nomination
In the CY 2017 Quality Payment Program final rule (81 FR 77366
through 77367), we finalized the information a QCDR must provide to us
at the time of self-nomination. We are proposing to replace the term
non-MIPS measures
[[Page 30160]]
with QCDR measures for future program years, beginning with the 2018
performance period. We note that although we are proposing a change in
the term referring to such measures, we are not proposing any other
changes to the information a QCDR must provide to us at the time of
self-nomination finalized in the CY 2017 Quality Payment Program final
rule. We refer readers to the CY 2017 Quality Payment Program final
rule for specific information requirements.
(4) QCDR Criteria for Data Submission
In the CY 2017 Quality Payment Program final rule (81 FR 77367
through 77374), we finalized that a QCDR must perform specific
functions to meet the criteria for data submission. While we are not
proposing any changes to the criteria for data submission in this
proposed rule, we would like to note the following as clarifications to
existing criteria. Specifically, a QCDR--
Must have in place mechanisms for the transparency of data
elements and specifications, risk models, and measures. That is, we
expect that the QCDR measures, and their data elements (that is,
specifications) comprising these measures be listed on the QCDR's Web
site unless the measure is a MIPS measure, in which case the
specifications will be posted by us. QCDR measure specifications should
be provided at a level of detail that is comparable to what is posted
by us on the CMS Web site for MIPS quality measures specifications.
Approved QCDRs may post the MIPS quality measure
specifications on their Web site, if they so choose. If the MIPS
quality measure specifications are posted by the QCDRs, they must
replicate exactly the same as the MIPS quality measure specifications
posted on the CMS Web site.
Enter into and maintain with its participating MIPS
eligible clinicians an appropriate Business Associate agreement that
complies with the HIPAA Privacy and Security Rules. Ensure that the
Business Associate agreement provides for the QCDR's receipt of
patient-specific data from an individual MIPS eligible clinician or
group, as well as the QCDR's disclosure of quality measure results and
numerator and denominator data or patient specific data on Medicare and
non-Medicare beneficiaries on behalf of MIPS eligible clinicians and
groups.
Must provide timely feedback at least 4 times a year, on
all of the MIPS performance categories that the QCDR will report to us.
We refer readers to section II.C.9.a. of this proposed rule for
additional information on third party intermediaries and performance
feedback.
For purposes of distributing performance feedback to MIPS
eligible clinicians, we encourage QCDRs to assist MIPS eligible
clinicians in the update of their email addresses in CMS systems--
including PECOS and the Identity and Access System--so that they have
access to feedback as it becomes available on www.qpp.cms.gov and have
documentation from the MIPS eligible clinician authorizing the release
of his or her email address.
As noted in the CY 2017 Quality Payment Program final rule (81 FR
77370), we will on a case-by-case basis allow QCDRs and qualified
registries to request review and approval for additional MIPS measures
throughout the performance period. We would like to explain that this
flexibility would only apply for MIPS measures; QCDRs will not be able
to request additions of any new QCDR measures throughout the
performance period. QCDRs will not be able to retire any measures they
are approved for during the performance period. Should a QCDR encounter
an issue regarding the safety or change in evidence for a measure
during the performance period, they must inform CMS of said issue and
indicate whether they will or will not be reporting on the measure, and
we will review measure issues on a case-by-case basis. Any measures
QCDRs wish to retire would need to be retained until the next annual
self-nomination process and applicable performance period.
(5) QCDR Measure Specifications Criteria
In the CY 2017 Quality Payment Program final rule (81 FR 77374
through 77375), we specified at Sec. 414.1400(f) that the QCDR must
provide specific QCDR measures specifications criteria. We generally
intend to apply a process similar to the one used for MIPS measures to
QCDR measures that have been identified as topped out. We are not
proposing any changes to the QCDR measure specifications criteria as
finalized in the CY2017 Quality Payment Program final rule. We would
like to note that for QCDR quality measures, we encourage alignment
with our measures development plan, but will consider all QCDR measures
submitted by the QCDR. For MIPS measures, we would also like to note
that CMS expects that a QCDR reporting on MIPS measures retain and use
the MIPS specifications as they exist for the performance period.
We would like to clarify that we will likely not approve retired
measures that were previously in one of CMS's quality programs, such as
the Physician Quality Reporting System (PQRS) program, if proposed as
QCDR measures. This includes measures that were retired due to being
topped out (as defined in section II.C.6.c.(2) of this proposed rule)
due to high-performance or measures retired due to a change in the
evidence supporting the use of the measure.
We seek comment for future rulemaking, on requiring QCDRs that
develop and report on QCDR measures, must fully develop and test (that
is, conduct reliability and validity testing) their QCDR measures, by
the time of submission of the new measure during the self-nomination
process.
Beginning with the 2018 performance period and for future program
years, we propose that QCDR vendors may seek permission from another
QCDR to use an existing measure that is owned by the other QCDR. If a
QCDR would like report on an existing QCDR measure that is owned by
another QCDR, they must have permission from the QCDR that owns the
measure that they can use the measure for the performance period.
Permission must be granted at the time of self-nomination, so that the
QCDR that is using the measure can include the proof of permission for
CMS review and approval for the measure to be used in the performance
period. The QCDR measure owner (QCDR vendor) would still own and
maintain the QCDR measure, but would allow other approved QCDRs to
utilize their QCDR measure with proper notification. This proposal will
help to harmonize clinically similar measures and limit the use of
measures that only slightly differ from another. We invite comments on
this proposal.
We would like to clarify from the CY 2017 Quality Payment Program
final rule (81 FR 77375) that the QCDR must publicly post the measure
specifications no later than 15 calendar days following our approval of
these measures specifications for each QCDR measure it intends to
submit for MIPS.
We refer readers to the CY 2017 Quality Payment Program final rule
for the QCDR measure specifications criteria.
(6) Identifying QCDR Quality Measures
In the CY 2017 Quality Payment Program final rule (81 FR 77375
through 77377), we finalized the definition and types of QCDR quality
measures for purposes of QCDRs submitting data for the MIPS quality
performance category. We are not proposing any changes to the criteria
on how to identify QCDR quality measures in this proposed rule. We
would like to clarify that QCDRs are not limited to reporting on QCDR
measures,
[[Page 30161]]
and may also report on MIPS measures as indicated above in the QCDR
data submission criteria section.
(7) Collaboration of Entities To Become a QCDR
In the CY 2017 Quality Payment Program final rule (81 FR 77377), we
finalized policy on the collaboration of entities to become a QCDR. We
are not proposing any changes to this policy in this proposed rule, and
would refer readers to the CY 2017 Quality Payment Program final rule
for the criteria.
In response to the CY 2017 Quality Payment Program final rule,
commenters recommended that we work with QCDRs to determine a more
reasonable cycle for self-nomination, measure selection, and reporting
because the current process is burdensome. Commenters also recommended
that we not disqualify QCDRs that do not have the capability to allow
MIPS eligible clinicians to report across all performance categories
using only one submission mechanism, and noted that the ability for
QCDRs to report their own measures allows MIPS eligible clinicians the
ability to implement measures that are more clinically meaningful and
up-to-date than those measures that may be available in the MIPS
measure set. We would like to note that we are proposing above, a
simplified self-nomination and measure selection process available to
existing QCDRs that are in good standing, beginning in the third year
of the Quality Payment Program. We would also like to explain that
QCDRs are not required to report on all performance categories across
the MIPS program, and would not be disqualified for not being able to
report data across on performance categories only using one mechanism.
We thank the commenters for their support with regards to allowing
QCDRs to nominate and report on QCDR measures that may be specialty
related. We thank the commenters for their feedback and will take their
comments into consideration in future rule making.
b. Health IT Vendors That Obtain Data From MIPS Eligible Clinicians'
Certified EHR Technology (CEHRT)
In the CY 2017 Quality Payment Program final rule 81 FR 77382, we
finalized definitions and criteria around health IT vendors that obtain
data from MIPS eligible clinicians CEHRT. We note that, for this
proposed rule, a health IT vendor that serves as a third party
intermediary to collect or submit data on behalf MIPS eligible
clinicians may or may not also be a ``health IT developer.'' Under the
ONC Health IT Certification Program (Program), (80 FR 62604), a health
IT developer constitutes a vendor, self-developer, or other entity that
presents health IT for certification or has health IT certified under
the Program. The use of ``health IT developer'' is consistent with the
use of the term ``health IT'' in place of ``EHR'' or ``EHR technology''
under the Program (see 80 FR 62604; and section II.C.6.f. of this
proposed rule). Throughout this proposed rule, we use the term ``health
IT vendor'' to refer to entities that support the health IT
requirements of a clinician participating in the Quality Payment
Program.
We are not proposing any changes to this policy in this proposed
rule, and would refer readers to the CY 2017 Quality Payment Program
final rule for the criteria. However we seek comment for future
rulemaking regarding the potential shift to seeking alternatives which
might fully replace the QRDA III format in the Quality Payment Program
in future program years.
c. Qualified Registries
In the CY 2017 Quality Payment Program final rule (81 FR 77382
through 77386), we finalized the definition and capability of qualified
registries. We are not proposing any changes to the definition or the
capabilities of qualified registries in this final rule, and refer
readers to the CY 2017 Quality Payment Program final rule for the
detailed definition and capabilities of a qualified registry.
(1) Establishment of an Entity Seeking To Qualify as a Registry
In the CY 2017 Quality Payment Program final rule (81 FR 77383), we
finalized the requirements for the establishment of an entity seeking
to qualify as a registry. We are not proposing any changes to the
criteria regarding the establishment of an entity seeking to qualify as
a registry criteria in this proposed rule, and refer readers to the
final rule for the criteria for establishing an entity seeking to
qualify as a registry.
(2) Self-Nomination Period
For the 2018 performance period, and for future years of the
program, we finalized at Sec. 414.1400(g) a self-nomination period
from September 1 of the year prior to the applicable performance
period, until November 1 of the same year. For example, for the 2018
performance period, the self-nomination period would begin on September
1, 2017, and end on November 1, 2017. Entities that desire to qualify
as a qualified registry for purposes of MIPS for a given performance
period will need to provide all requested information to us at the time
of self-nomination and would need to self-nominate for that performance
period. Having previously qualified as a qualified registry does not
automatically qualify the entity to participate in subsequent MIPS
performance periods. Furthermore, prior performance of the qualified
registry (when applicable) will be taken into consideration in approval
of their self-nomination. For example, a qualified registry may choose
not to continue participation in the program in future years, or the
qualified registry may be precluded from participation in a future
year, due to multiple data or submission errors as noted below. As
such, we believe an annual self-nomination process is the best process
to ensure accurate information is conveyed to MIPS eligible clinicians
and accurate data is submitted to MIPS.
However, we do understand that some qualified registries have no
changes to the measures and/or activity inventory they offer to their
clients and intend to participate in MIPS for many years. Because of
this, we are proposing, beginning with the 2019 performance period, a
simplified process in which existing qualified registries in good
standing may continue their participation in MIPS by attesting that the
qualified registry's approved data validation plan, cost, approved MIPS
quality measures, services, and performance categories offered in the
previous year's performance period of MIPS have minimal or no changes
and will be used for the upcoming performance period. Specifically,
existing qualified registries in good standing may attest during the
self-nomination period that they have no changes to their approved
self-nomination application from the previous year of MIPS. In
addition, the existing qualified registry may decide to make minimal
changes to their self-nomination application from the previous year,
which would be submitted by the qualified registry for CMS review and
approval by the close of the self-nomination period. Minimal changes
may include limited changes to their performance categories, adding or
removing MIPS quality measures, and adding or updating existing
services and/or cost information. By attesting that certain aspects of
their approved application from the previous year have not changed,
existing qualified registries will be spending less time completing the
entire self-nomination form, as was previously required on a yearly
basis. We are proposing such a simplified process to reduce the burden
of self-
[[Page 30162]]
nomination for those existing qualified registries who have previously
participated in MIPS, and are in good standing (not on probation or
disqualified, as described below) and to allow for sufficient time for
us to review data submissions and to make determinations on the
standing of qualified registries. This proposed process will allow
existing qualified registries in good standing to avoid completing the
entire application annually, as is required in the existing process,
and in alignment with the existing timeline. We request comments on
this proposal. In the development of this proposal, we had reviewed the
possibility of offering a multi-year approval, where qualified
registries would be approved for a 2-year increment of time. We are
concerned that utilizing a multi-year approval process in which
qualified registries would be approved for 2 continuous program years
using the same fixed services they had for the first year, would not
provide the qualified registry with the flexibility to add or remove
services and or measures based on their capabilities for the upcoming
program year. Furthermore, another concern with a multi-year approval
process is the concern for those qualified registries who perform
poorly during the first year, who should be placed on probation or
disqualified (as described below). We are proposing that this process
be conducted on a yearly basis, from September 1 of the year prior to
the applicable performance period until November 1 of the same year,
starting in 2018, aligning with the annual self-nomination period in
order to ensure that only those qualified registries who are in good
standing utilize this process. We believe that this annual process will
provide qualified registries with the flexibility to make minor changes
to their services should they wish to do so. We request comments on
this proposal. We also seek comment to potentially allow for qualified
registries to utilize a multi-year approval process, in which they
would be approved for a continuous 2-year increment since qualified
registries can only make minor changes (for example, including a
performance category, or a MIPS quality measure, all of which are
already considered a part of the MIPS program).
We finalized to require further information of qualified registries
at the time of self-nomination. If an entity becomes qualified as a
qualified registry, they would need to sign a statement confirming this
information is correct prior to us listing their qualifications on
their Web site. Once we post the qualified registry on our Web site,
including the services offered by the qualified registry, we would
require the qualified registry to support these services/measures for
its clients as a condition of the entity's qualification as a qualified
registry for purposes of MIPS. Failure to do so will preclude the
qualified registry from participation in MIPS in the subsequent
performance year.
For the 2018 performance period and beyond, we are proposing that
self-nomination information must be submitted via a web-based tool, and
to eliminate the submission method of email. We will provide further
information on the web-based tool at www.qpp.cms.gov. We request
comments on this proposal.
(3) Information Required at the Time of Self-Nomination
We finalized in the CY 2017 Quality Payment Program final rule (81
FR 77384) that a qualified registry must provide specific information
to us at the time of self-nomination. We are not proposing any changes
to the information required at the time of self-nomination in this
proposed rule, and refer readers to the final rule for specific
information requirements.
(4) Qualified Registry Criteria for Data Submission
In the CY 2017 Quality Payment Program final rule (81 FR 77386), we
finalized the criteria for qualified registry data submission. We are
not proposing any changes to the data submission criteria in this
proposed rule, and refer readers to the final rule for specific
criteria regarding qualified registry data submission. We would like to
note two clarifications to the existing criteria:
Enter into and maintain with its participating MIPS
eligible clinicians an appropriate Business Associate agreement that
complies with the HIPAA Privacy and Security Rules. Ensure that the
Business Associate agreement provides for the Qualified Registry's
receipt of patient-specific data from an individual MIPS eligible
clinician or group, as well as the Qualified Registry's disclosure of
quality measure results and numerator and denominator data or patient
specific data on Medicare and non-Medicare beneficiaries on behalf of
individual MIPS eligible clinicians and groups.
We had finalized that timely feedback be provided at least
four times a year, on all of the MIPS performance categories that the
qualified registry will report to us. We refer readers to section
II.C.9.a. of this proposed rule for additional information on third
party intermediaries and performance feedback.
We had received comments in response to the CY 2017 Quality Payment
Program final rule from commenters who expressed concern that the 3
percent acceptable error rate for qualified registries is too low.
Commenters recommended we analyze reporting for the transition year and
increase the error rate to 5 percent at the minimum because qualified
registries may make a small number of errors given that 2017 is the
first year of MIPS and that removing qualified registries due to a low
error threshold could hurt clinicians. We thank the commenters for
their feedback and will take the comments into consideration in future
rulemaking.
As indicated in the CY 2017 Quality Payment Program final rule (81
FR 77370), we will on a case-by-case basis allow qualified registries
to request review and approval for additional MIPS measures throughout
the performance period. Any new measures that are approved by us will
be added to the information related to the qualified registry on the
CMS Web site, as technically feasible. We anticipate only being able to
update this information on the Web site on a quarterly basis, as
technically feasible.
d. CMS-Approved Survey Vendors
In the CY 2017 Quality Payment Program final rule (81 FR 77386), we
finalized the definition, criteria, required forms, and vendor business
requirements needed to participate in MIPS as a survey vendor. We refer
readers to the CY 2017 Quality Payment Program final rule for specific
details on requirements. We have heard from some groups that it would
be useful to have a final list of CMS-approved survey vendors to inform
their decision on whether or not to participate in the CAHPS for MIPS
survey. Therefore, beginning with the 2018 performance period and for
future program years, we propose to remove the April 30th survey vendor
application deadline because this deadline is within the timeframe of
when groups can elect to participate in the CAHPS for MIPS survey. In
order to provide a final list of CMS-approved survey vendors earlier in
the timeframe during which groups can elect to participate in the CAHPS
for MIPS survey, an earlier vendor application deadline would be
necessary. This could be accomplished by having a rolling application
period, where vendors would be able to submit an application by the end
of the first quarter. However, in addition to
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submitting a vendor application, vendors must also complete vendor
training and submit a Quality Assurance Plan and we need to allow
sufficient time for these requirements as well. Therefore, we propose
for the Quality Payment Program Year 2 and future years that the vendor
application deadline would be January 31st of the applicable
performance year or a later date specified by CMS. This proposal would
allow us to adjust the application deadline beyond January 31st on a
year to year basis, based on program needs. We will notify vendors of
the application deadline to become a CMS-approved survey vendor through
additional communications and postings. We request comments on this
proposal and other alternatives that would allow us to provide a final
list of CMS-approved survey vendors early in the timeframe during which
groups can elect to participate in the CAHPS for MIPS survey.
e. Probation and Disqualification of a Third Party Intermediary
At Sec. 414.1400(k), we finalized the process for placing third
party intermediaries on probation and for disqualifying such entities
for failure to meet certain standards established by us (81 FR 77386).
Specifically, we proposed that if at any time we determine that a third
party intermediary (that is, a QCDR, health IT vendor, qualified
registry, or CMS-approved survey vendor) has not met all of the
applicable criteria for qualification, we may place the third party
intermediary on probation for the current performance period or the
following performance period, as applicable.
In addition, we finalized that we require a corrective action plan
from the third party intermediary to address any deficiencies or issues
and prevent them from recurring. We finalized that the corrective
action plan must be received and accepted by us within 14 days of the
CMS notification to the third party intermediary of the deficiencies or
probation. Failure to comply with these corrective action plan
requirements would lead to disqualification from MIPS for the
subsequent performance period.
We finalized for probation to mean that, for the applicable
performance period, the third party intermediary must meet all
applicable criteria for qualification and approval and also must submit
a corrective action plan for remediation or correction of any
deficiencies identified by CMS that resulted in the probation (81 FR
77548).
In addition, we finalized that if the third party intermediary has
data inaccuracies including (but not limited to) TIN/NPI mismatches,
formatting issues, calculation errors, data audit discrepancies
affecting in excess of 3 percent (but less than 5 percent) of the total
number of MIPS eligible clinicians or groups submitted by the third
party intermediary, we would annotate the listing of qualified third
party intermediaries on the CMS Web site, noting that the third party
intermediary furnished data of poor quality and would place the entity
on probation for the subsequent performance period.
Further, we finalized if the third party intermediary does not
reduce their data error rate below 3 percent for the subsequent
performance period, the third party intermediary would continue to be
on probation and have their listing on the CMS Web site continue to
note the poor quality of the data they are submitting for MIPS for one
additional performance period. After 2 years on probation, the third
party intermediary would be disqualified for the subsequent performance
period. Data errors affecting in excess of 5 percent of the MIPS
eligible clinicians or groups submitted by the third party intermediary
may lead to the disqualification of the third party intermediary from
participation for the following performance period. In placing the
third party intermediary on probation; we would notify the third party
intermediary of the identified issues, at the time of discovery of such
issues.
In addition, we finalized that if the third party intermediary does
not submit an acceptable corrective action plan within 14 days of
notification of the deficiencies and correct the deficiencies within 30
days or before the submission deadline--whichever is sooner, we may
disqualify the third party intermediary from participating in MIPS for
the current performance period or the following performance period, as
applicable.
We note that MIPS eligible clinicians are ultimately responsible
for the data that are submitted by their third party intermediaries and
expect that MIPS eligible clinicians and groups should ultimately hold
their third party intermediaries accountable for accurate reporting. We
will consider cases of vendors leaving the marketplace during the
performance period on a case by case basis, but would note that we will
not consider cases prior to the performance period. We would however,
need proof that the MIPS eligible clinician had an agreement in place
with the vendor at the time of their withdrawal from the marketplace.
We are not proposing any changes to the process of probation and
disqualification of a third party intermediary in this proposed rule.
Commenters on the final rule requested that we provide
opportunities for MIPS eligible clinicians and groups that discover an
issue with their third party intermediary to change reporting methods
and/or third party intermediaries without restriction on the eligible
clinicians. We thank the commenters for their feedback and will take
the comments into consideration in future rulemaking.
f. Auditing of Third Party Intermediaries Submitting MIPS Data
In the CY 2017 Quality Payment Program final rule (81 FR 77389), we
finalized at Sec. 414.1400(j) that any third party intermediary (that
is, a QCDR, health IT vendor, qualified registry, or CMS-approved
survey vendor) must comply with the following procedures as a condition
of their qualification and approval to participate in MIPS as a third
party intermediary:
(1) The entity must make available to us the contact information of
each MIPS eligible clinician or group on behalf of whom it submits
data. The contact information will include, at a minimum, the MIPS
eligible clinician or group's practice phone number, address, and if
available, email;
(2) The entity must retain all data submitted to us for MIPS for a
minimum of 10 years; and
(3) For the purposes of auditing, we may request any records or
data retained for the purposes of MIPS for up to 6 years and 3 months.
We are proposing to change Sec. 414.1400(j)(2) to clarify that the
entity must retain all data submitted to us for purposes of MIPS for a
minimum of 10 years from the end of the MIPS performance period.
11. Public Reporting on Physician Compare
This section contains the approach for public reporting on
Physician Compare for the CY 2018 Quality Payment Program final rule,
including MIPS, APMs, and other information as required by the MACRA
and building on the MACRA public reporting policies previously
finalized (81 FR 77390 through 77399).
Physician Compare draws its operating authority from section
10331(a)(1) of the Affordable Care Act. As required by section
10331(a)(1) of the Affordable Care Act, by January 1, 2011, we
developed a Physician Compare
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Internet Web site with information on physicians enrolled in the
Medicare program under section 1866(j) of the Act, as well as
information on other EPs who participate in the PQRS under section 1848
of the Act. More information about Physician Compare can be accessed on
the Physician Compare Initiative Web site at https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/physician-compare-initiative/.
The first phase of Physician Compare was launched on December 30,
2010 (https://www.medicare.gov/physiciancompare). Since the initial
launch, Physician Compare has been continually improved and more
information has been added. In December 2016, the site underwent a
complete user-informed, evidenced-based redesign to further enhance
usability and functionality on both desktop computers and mobile
devices and to begin to prepare the site for the inclusion of more data
as required by the MACRA.
Currently, Web site users can view information about approved
Medicare clinicians, such as: Name; Medicare primary and secondary
specialties; practice locations; group affiliations; hospital
affiliations that link to the hospital's profile on Hospital Compare as
available; Medicare assignment status; education; residency; and,
American Board of Medical Specialties (ABMS), American Osteopathic
Association (AOA), and American Board of Optometry (ABO) board
certification information. For groups, users can view group names,
specialties, practice locations, Medicare assignment status, and
affiliated clinicians. In December 2016, we also added indicators on
the results page to show those clinicians and groups that had
performance scores available to view. We also included an indicator on
profile pages to show those Medicare clinicians and groups that
satisfactorily or successfully participated in a CMS quality program to
indicate their commitment to quality.
Consistent with section 10331(a)(2) of the Affordable Care Act,
Physician Compare phased in public reporting of performance scores that
provide comparable information on quality and patient experience
measures for reporting periods beginning January 1, 2012. To the extent
that scientifically sound measures are developed and are available,
Physician Compare is required to include, to the extent practicable,
the following types of measures for public reporting: Measures
collected under PQRS and an assessment of efficiency, patient health
outcomes, and patient experience, as specified. The first set of
quality measures were publicly reported on Physician Compare in
February 2014. Currently, Physician Compare publicly reports 91 group-
level measures collected through either the Web Interface or registry
for groups participating in 2015 under the PQRS, 19 quality measures
for ACOs participating in the 2015 Shared Savings Program or Pioneer
ACO program, and 90 individual clinician-level measures collected
either through claims or registry for individual EPs participating in
2015 under the PQRS. In addition, 31 total individual clinician-level
Qualified Clinical Data Registry (QCDR) non-PQRS measures are publicly
available either through Physician Compare profile pages or 2015 QCDR
Web sites. A complete history of public reporting on Physician Compare
is detailed in the CY 2016 PFS final rule (80 FR 71117 through 71122).
As finalized in the CY 2015 and CY 2016 PFS final rules (79 FR
67547 and 80 FR 70885, respectively), Physician Compare will continue
to expand public reporting. This expansion includes publicly reporting
both individual eligible professional (now referred to as eligible
clinician) and group-level QCDR measures starting with 2016 data
available for public reporting in late 2017, as well as the inclusion
of a benchmark and 5-star rating in late 2017 based on 2016 data (80 FR
71125 and 71129), among other additions.
This expansion will continue under the MACRA. Sections
1848(q)(9)(A) and (D) of the Act facilitate the continuation of our
phased approach to public reporting by requiring the Secretary to make
available on the Physician Compare Web site, in an easily
understandable format, individual MIPS eligible clinician and group
performance information, including:
The MIPS eligible clinician's final score;
The MIPS eligible clinician's performance under each MIPS
performance category (quality, cost, improvement activities, and
advancing care information);
Names of eligible clinicians in Advanced APMs and, to the
extent feasible, the names of such Advanced APMs and the performance of
such models; and,
Aggregate information on the MIPS, posted periodically,
including the range of final scores for all MIPS eligible clinicians
and the range of the performance of all MIPS eligible clinicians for
each performance category.
Initial plans to publicly report this performance information on
Physician Compare were finalized in the CY 2017 Quality Payment Program
final rule (81 FR 77390). The proposals related to each of these
requirements for year 2 of the Quality Payment Program are addressed
below in this section.
Section 1848(q)(9)(B) of the Act also requires that this
information indicate, where appropriate, that publicized information
may not be representative of the eligible clinician's entire patient
population, the variety of services furnished by the eligible
clinician, or the health conditions of individuals treated. The
information mandated for Physician Compare under section 1848(q)(9) of
the Act will generally be publicly reported consistent with sections
10331(a)(2) and 10331(b) of the Affordable Care Act, and like all
measure data included on Physician Compare, will be comparable. In
addition, section 10331(b) of the Affordable Care Act requires that we
include, to the extent practicable, processes to ensure that data made
public are statistically valid, reliable, and accurate, including risk
adjustment mechanisms used by the Secretary. In addition to the public
reporting standards identified in the Affordable Care Act--
statistically valid and reliable data that are accurate and
comparable--we have established a policy that, as determined through
user testing, the data we disclose generally should resonate with and
be accurately interpreted by Web site users to be included on Physician
Compare profile pages. Together, we refer to these conditions as the
Physician Compare public reporting standards (80 FR 71118 through
71120). Section 10331(d) of the Affordable Care Act also requires us to
consider input from multi-stakeholder groups, consistent with sections
1890(b)(7) and 1890A of the Act. We continue to receive general input
from stakeholders on Physician Compare through a variety of means,
including rulemaking and different forms of stakeholder outreach (for
example, Town Hall meetings, Open Door Forums, webinars, education and
outreach, Technical Expert Panels, etc.).
In addition, section 1848(q)(9)(C) of the Act requires the
Secretary to provide an opportunity for MIPS eligible clinicians to
review the information that will be publicly reported prior to such
information being made public. This is generally consistent with
section 10331(a)(2) of the Affordable Care Act, under which we have
established a 30-day preview period for all measurement performance
data that allows physicians and other eligible clinicians to view
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their data as it will appear on the Web site in advance of publication
on Physician Compare (80 FR 77392). Section 1848(q)(9)(C) of the Act
also requires that MIPS eligible clinicians be able to submit
corrections for the information to be made public. We finalized a
policy to extend the current Physician Compare 30-day preview period
for MIPS eligible clinicians starting with data from the 2017 MIPS
performance period, which is available for public reporting in late
2018. Therefore, we finalized a 30-day preview period in advance of the
publication of data on Physician Compare (81 FR 77392).
We will coordinate data review and any relevant data resubmission
or correction between Physician Compare and the four performance
categories of MIPS. All data available for public reporting--measure
rates, scores, and attestations, etc.--are available for review and
correction during the targeted review process, which will begin at
least 30 days in advance of the publication of new data. Data under
review is not publicly reported until the review is complete. All
corrected measure rates, scores, and attestations submitted as part of
this process are available for public reporting. The technical details
of the process are communicated directly to affected MIPS eligible
clinicians and groups and detailed outside of rulemaking with specifics
made public on the Physician Compare Initiative page on www.cms.gov and
communicated through Physician Compare and other CMS listservs (81 FR
77391).
In addition, section 1848(q)(9)(D) of the Act requires that
aggregate information on the MIPS be periodically posted on the
Physician Compare Web site, including the range of final scores for all
MIPS eligible clinicians and the range of performance for all MIPS
eligible clinicians for each performance category.
Lastly, section 104(e) of the MACRA requires the Secretary to make
publicly available, on an annual basis, in an easily understandable
format, information for physicians and, as appropriate, other eligible
clinicians related to items and services furnished to people with
Medicare, and to include, at a minimum:
Information on the number of services furnished under Part
B, which may include information on the most frequent services
furnished or groupings of services;
Information on submitted charges and payments for Part B
services; and,
A unique identifier for the physician or other eligible
clinician that is available to the public, such as an NPI.
The information is further required to be made searchable by at
least specialty or type of physician or other eligible clinician;
characteristics of the services furnished (such as, volume or groupings
of services); and the location of the physician or other eligible
clinician.
In accordance with section 104(e) of the MACRA, we finalized a
policy in the CY 2016 PFS final rule (80 FR 71130) to add utilization
data to the Physician Compare downloadable database. Utilization data
is currently available at https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Physician-and-Other-Supplier.html. This information is integrated
on the Physician Compare Web site via the downloadable database each
year using the most current data, starting with the 2016 data, targeted
for initial release in late 2017 (80 FR 71130). Not all available data
will be included. The specific HCPCS codes included are to be
determined based on analysis of the available data, focusing on the
most used codes. Additional details about the specific HCPCS codes that
are included in the downloadable database will be provided to
stakeholders in advance of data publication. All data available for
public reporting--on the public-facing Web site pages or in the
downloadable database--are available for review during the 30-day
preview period.
We propose to revise the public reporting regulation at Sec.
414.1395(a), to more completely and accurately reference the data
available for public reporting on Physician Compare. We propose to
modify Sec. 414.1395(a) to remove from the heading and text references
to ``MIPS'' and ``public Web site'' and instead reference ``Quality
Payment Program'' and ``Physician Compare''. Specifically, proposed
Sec. 414.1395(a) reads as follows: ``Public reporting of eligible
clinician and group Quality Payment Program information. For each
program year, CMS posts on Physician Compare, in an easily
understandable format, information regarding the performance of
eligible clinicians or groups under the Quality Payment Program.'' We
also propose to add paragraphs (b), (c), and (d) at Sec. 414.1395, to
capture previously established policies for Physician Compare relating
to the public reporting standards, first year measures, and the 30-day
preview period. Specifically, at proposed Sec. 414.1395(b), we propose
that, with the exception of data that must be mandatorily reported on
Physician Compare, for each program year, we rely on the established
public reporting standards to guide the information available for
inclusion on Physician Compare. The public reporting standards require
data included on Physician Compare to be statistically valid, reliable,
and accurate; be comparable across reporting mechanisms; and, meet the
reliability threshold. And, to be included on the public facing profile
pages, the data must also resonate with Web site users, as determined
by CMS. At proposed Sec. 414.1395(c), we propose to codify our policy
regarding first year measures: ``For each program year, CMS does not
publicly report any first year measure, meaning any measure in its
first year of use in the quality and cost performance categories. After
the first year, CMS reevaluates measures to determine when and if they
are suitable for public reporting.'' At proposed Sec. 414.1395(d), we
propose to specify the 30-day preview period rule: ``For each program
year, CMS provides a 30-day preview period for any clinician or group
with Quality Payment Program data before the data are publicly reported
on Physician Compare.''
We believe section 10331 of the Affordable Care Act supports the
overarching goals of the MACRA by providing the public with quality
information that will help them make informed decisions about their
health care, while encouraging clinicians to improve the quality of
care they provide to their patients. In accordance with section 10331
of the Affordable Care Act, section 1848(q)(9) of the Act, and section
104(e) of the MACRA, we plan to continue to publicly report performance
information on Physician Compare. As such, we propose the inclusion of
the following information on Physician Compare.
a. Final Score, Performance Categories, and Aggregate Information
Sections 1848(q)(9)(A) and (D) of the Act require that we publicly
report on Physician Compare the final score for each MIPS eligible
clinician, performance of each MIPS eligible clinician for each
performance category, and periodically post aggregate information on
the MIPS, including the range of final scores for all MIPS eligible
clinicians and the range of performance of all the MIPS eligible
clinicians for each performance category. We finalized such data for
public reporting on Physician Compare for the transition year (81 FR
77393), and we are now proposing to add these data each year to
Physician Compare for each MIPS eligible clinician or group, either on
the profile pages or in the downloadable
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database, as technically feasible. Statistical testing and user
testing, as well as consultation of the Physician Compare Technical
Expert Panel, will determine how and where these data are best reported
on Physician Compare. As the MACRA requires that this information be
available for public reporting on Physician Compare, we are proposing
to include it each year moving forward, as technically feasible. We
request comment on this proposal to publicly report on Physician
Compare the final score for each MIPS eligible clinician or group,
performance of each MIPS eligible clinician or group for each
performance category, and periodically post aggregate information on
the MIPS, including the range of final scores for and the range of
performance of all the MIPS eligible clinicians or groups for each
performance category, as technically feasible.
A detailed discussion of proposals related to each performance
category of MIPS data follows.
b. Quality
As detailed in the CY 2017 Quality Payment Program final rule (81
FR 77395), and consistent with the existing policy that makes all
current PQRS measures available for public reporting, we finalized a
decision to make all measures under the MIPS quality performance
category available for public reporting on Physician Compare in the
transition year of the Quality Payment Program, as technically
feasible. This included all available measures reported via all
available submission methods, and applied to both MIPS eligible
clinicians and groups.
Also consistent with current policy, although all measures will be
available for public reporting, not all measures will be made available
on the public-facing Web site profile pages. As explained in the CY
2017 Quality Payment Program final rule (81 FR 77394), providing too
much information can overwhelm Web site users and lead to poor decision
making. Therefore, consistent with section 1848(q)(9)(A)(i)(II) of the
Act, all measures in the quality performance category that meet the
statistical public reporting standards will be included in the
downloadable database, as technically feasible. We also finalized a
policy that a subset of these measures will be publicly reported on the
Web site's profile pages, as technically feasible, based on Web site
user testing. Statistical testing and user testing will determine how
and where measures are reported on Physician Compare. In addition, we
adopted our existing policy of not publicly reporting first year
measures, meaning new measures that have been in use for less than 1
year, regardless of submission method used, for this MIPS quality
performance category. After a measure's first year in use, we will
evaluate the measure to see if and when the measure is suitable for
public reporting (81 FR 77395).
Currently, there is a minimum sample size requirement of 20
patients for performance data to be included on Physician Compare. We
previously sought comment on moving away from this requirement and
moving to a reliability threshold for public reporting. In general,
commenters supported a minimum reliability threshold. As a result, we
finalized instituting a minimum reliability threshold for public
reporting data on Physician Compare starting with 2017 data available
for public report in late 2018 and each year moving forward (81 FR
77395).
The reliability of a measure refers to the extent to which the
variation in the performance rate is due to variation in quality of
care as opposed to random variation due to sampling. Statistically,
reliability depends on performance variation for a measure across
entities, the random variation in performance for a measure within an
entity's panel of attributed patients, and the number of patients
attributed to the entity. High reliability for a measure suggests that
comparisons of relative performance across entities, such as eligible
clinicians or groups, are likely to be stable and consistent, and that
the performance of one entity on the quality measure can confidently be
distinguished from another. We will conduct analyses to determine the
reliability of the data collected and use this to calculate the minimum
reliability threshold for the data. Once an appropriate minimum
reliability threshold is determined, we will only publicly report those
performance rates for any given measure that meet the minimum
reliability threshold. We note that reliability standards for public
reporting and reliability for scoring need not align; reliability for
public reporting is unique because, for example, public reporting
requires ensuring additional protections to maintain confidentiality.
In addition, because publicly reported measures can be compared across
clinicians and across groups, it is particularly important for the most
stringent reliability standards to be in place to ensure differences in
performance scores reflect true differences in quality of care to
promote accurate comparisons by the public. For further information on
reliability as it relates to scoring of cost measures see section
II.C.7.a.(3) of this proposed rule.
In the CY 2017 Quality Payment Program final rule, we established
that we will include the total number of patients reported on each
measure in the downloadable database to facilitate transparency and
more accurate understanding and use of the data (81 FR 77395). We will
begin publishing the total number of patients reported on each measure
in the downloadable database with 2017 data available for public
reporting in late 2018 and for each year moving forward.
Understanding that we will continue our policies to not publicly
report first year quality measures, that we will only report those
measures that meet the reliability threshold and meet the public
reporting standards, and include the total number of patients reported
on for each measure in the downloadable database, we are again
proposing to make all measures under the MIPS quality performance
category available for public reporting on Physician Compare, as
technically feasible. This would include all available measures
reported via all available submission methods for both MIPS eligible
clinicians and groups, for 2018 data available for public reporting in
late 2019, and for each year moving forward, these data are required by
the MACRA to be available for public reporting on Physician Compare,
continuing to publicly report these data ensures continued transparency
and provides people with Medicare and their caregivers valuable
information they can use to make informed health care decisions. We
request comment on this proposal.
In addition, we seek comment on expanding the patient experience
data available for public reporting on Physician Compare. Currently,
the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for
MIPS survey is available for groups to report under the MIPS. This
patient experience survey data is highly valued by patients and their
caregivers as they evaluate their health care options. However, in
testing with patient and caregivers, they regularly ask for more
information from patients like them in their own words. Patients
regularly request we include narrative reviews of clinicians and groups
on the Web site. The Agency for Healthcare Research and Quality (AHRQ)
is fielding a beta version of the CAHPS Patient Narrative Elicitation
Protocol (https://www.ahrq.gov/cahps/surveys-guidance/item-sets/elicitation/). This includes five open-ended questions
designed to be added to the Clinician &
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Groups CAHPS survey, which CAHPS for MIPS is molded after. These five
questions have been developed and tested to work to capture patient
narratives in a scientifically grounded and rigorous way, setting it
apart from other patient narratives collected by various health systems
and patient rating sites. More scientifically rigorous patient
narrative data would not only greatly benefit patients, but it would
also greatly aid clinicians and groups as they work to assess how their
patients experience care. We are seeking comment on potentially public
reporting these five open-ended questions for the CAHPS for MIPS survey
on Physician Compare as a consideration in future rulemaking. We direct
readers to the Quality Performance Criteria in section II.C.6.b.(3)(a)
of this proposed rule for additional information related to seeking
comment on adding these questions to the CAHPS for MIPS survey.
c. Cost
Consistent with section 1848(q)(9)(A)(i)(II) of the Act, we
finalized in the CY 2017 Quality Payment Program final rule a decision
to make all measures under the MIPS cost performance category available
for public reporting on Physician Compare (81 FR 77396). This included
all available measures reported via all available submission methods,
and applied to both MIPS eligible clinicians and groups. However, as
noted in the final rule, we may not have data available for public
reporting in the transition year of the Quality Payment Program for the
cost performance category (2017 data available for public reporting in
late 2018).
As discussed in the final rule (81 FR 77395), cost data are
difficult for patients to understand and, as a result, publicly
reporting these measures could lead to significant misinterpretation
and misunderstanding. For this reason, we are again proposing to
include on Physician Compare a sub-set of cost measures that meet the
public reporting standards, either on profile pages or in the
downloadable database, if technically feasible, for 2018 data available
for public reporting in late 2019, and for each year moving forward.
These data are required by the MACRA to be available for public
reporting on Physician Compare, but we want to ensure we only share
those cost measures that can help patients and caregivers make informed
health care decisions on profile pages. For transparency purposes, the
cost measures that meet all other public reporting standards would be
included in the downloadable database. Statistical testing and Web site
user testing would determine how and where measures are reported on
Physician Compare to minimize passing the complexity of these measures
on to patients and to ensure those measures included are accurately
understood and correctly interpreted. Under this proposal, we note that
the policies we previously mentioned regarding first year measures, the
minimum reliability threshold, and all public reporting standards would
apply. This proposal applies to all available measures reported via all
available submission methods, and applies to both MIPS eligible
clinicians and groups. We request comment on this proposal.
d. Improvement Activities
Consistent with section 1848(q)(9)(A)(i)(II) of the Act, we
finalized a decision to make all activities under the MIPS improvement
activities performance category available for public reporting on
Physician Compare (81 FR 77396). This included all available
improvement activities reported via all available submission methods,
and applied to both MIPS eligible clinicians and groups.
Consistent with the policy finalized for the transition year, we
are again proposing to include a subset of improvement activities data
on Physician Compare that meet the public reporting standards, either
on the profile pages or in the downloadable database, if technically
feasible, for 2018 data available for public reporting in late 2019,
and for each year moving forward. This again includes all available
activities reported via all available submission methods, and applies
to both MIPS eligible clinicians and groups. For those eligible
clinicians or groups that successfully meet the improvement activities
performance category requirements this information may be posted on
Physician Compare as an indicator. This information is required by the
MACRA to be available for public reporting on Physician Compare, but
the improvement activities performance category is a new field of data
for Physician Compare so concept and Web site user testing is still
needed to ensure these data are understood by stakeholders. Therefore,
we again propose that statistical testing and user testing would
determine how and where improvement activities are reported on
Physician Compare.
For the transition year, we proposed to exclude first year
activities from public reporting. First year activities are any
improvement activities in their first year of use. Starting with year 2
(2018 data available for public reporting in late 2019), we propose
publicly reporting first year activities if all other reporting
criteria are satisfied. This evolution in our Quality Payment Program
public reporting plan provides an opportunity to make more valuable
information public given that completion of or participation in
activities the first year they are available is different from
reporting first year quality or cost measures. Clinicians and groups
can learn from the first year of quality and cost data, understand why
their performance rate is what it is, and take time to improve. A
waiting period for indicating completion or participation in an
improvement activity is unlikely to produce the same benefit. We
request comments on these proposals.
e. Advancing Care Information
Since the beginning of the EHR Incentive Programs in 2011,
participant performance data has been publicly available in the form of
public use files on the CMS Web site. In the 2015 EHR Incentive
Programs final rule (80 FR 62901), we addressed comments requesting
that we not only continue this practice but also include a wider range
of information on participation and performance. In that rule, we
stated our intent to publish the performance and participation data on
Stage 3 objectives and measures of meaningful use in alignment with
quality programs which utilize publicly available performance data such
as Physician Compare. At this time there is only an indicator on
Physician Compare profile pages to show that an eligible clinician
successfully participated in the current Medicare EHR Incentive
Program.
As MIPS will include advancing care information as one of the four
MIPS performance categories, we decided, consistent with section
1848(q)(9)(i)(II) of the Act, to include more information on an
eligible clinician's or group's performance on the objectives and
measures of meaningful use on Physician Compare for the transition year
(81 FR 77387). An important consideration was that to meet the public
reporting standards, the data added to Physician Compare must resonate
with Medicare patients and their caregivers. Testing to date has shown
that people with Medicare value the use of certified EHR technology and
see EHR use as something that if used well can improve the quality of
their care. In addition, we believe the inclusion of indicators for
clinicians and groups who achieve high
[[Page 30168]]
performance in key care coordination and patient engagement activities
provide significant value for patients and their caregivers as they
make health care decisions.
Consistent with our transition year final policy, and understanding
the value of this information to Web site users, we are again proposing
to include an indicator on Physician Compare for any eligible clinician
or group who successfully meets the advancing care information
performance category, as technically feasible. Also, as technically
feasible, we propose to include additional indicators, including but
not limited to, objectives, activities, or measures specified in
section II.C.6.f. of this proposed rule, such as, identifying if the
eligible clinician or group scores high performance in patient access,
care coordination and patient engagement, or health information
exchange. These proposals would apply to 2018 data available for public
reporting in late 2019, and for each year moving forward, as this
information is required by the MACRA to be available for public
reporting on Physician Compare. We also propose that any advancing care
information objectives, activities, or measures would need to meet the
public reporting standards applicable to data posted on Physician
Compare, either on the profile pages or in the downloadable database.
This would include all available objectives, activities, or measures
reported via all available submission methods, and would apply to both
MIPS eligible clinicians and groups. Statistical testing and Web site
user testing would determine how and where objectives and measures are
reported on Physician Compare. As with improvement activities, we are
also proposing to allow first year advancing care information
objectives, activities, and measures to be available for public
reporting starting in year 2 (2018 data available for public reporting
in late 2019). Again, especially if we are including an indicator over
a performance rate, the benefits of waiting 1 year are not the same and
thus, we believe it is more important to make more information
available for public reporting as the Quality Payment Program matures.
We request comment on these proposals.
f. Achievable Benchmark of Care (ABCTM)
Benchmarks are important to ensuring that the quality data
published on Physician Compare are accurately understood. A benchmark
allows Web site users to more easily evaluate the information published
by providing a point of comparison between groups and between
clinicians. In an effort to find the best possible methodology for
Physician Compare, we embarked on a year-long information gathering and
stakeholder outreach effort in advance of the CY 2016 PFS rule process.
We reached out to stakeholders, including specialty societies, consumer
advocacy groups, physicians and other clinicians, measure experts, and
quality measure specialists, as well as other CMS Quality Programs.
Based on this outreach and the recommendation of our Technical Expert
Panel, we proposed and ultimately finalized (80 FR 71129) a decision to
publicly report on Physician Compare an item, or measure-level,
benchmark using the Achievable Benchmark of Care (ABCTM)
\21\ methodology annually based on the PQRS performance rates most
recently available by reporting mechanism. As a result, in late 2017,
we expect to publicly report a benchmark based on the 2016 PQRS
performance rates for each measure by each available reporting
mechanism. The specific measures the benchmark will be calculated for
will be determined once the data are available and analyzed. As with
all data, the benchmark will only be applied to those measures deemed
to meet the established public reporting standards.
---------------------------------------------------------------------------
\21\ Kiefe CI, Weissman NW., Allison JJ, Farmer R, Weaver M,
Williams OD. Identifying achievable benchmarks of care: concepts and
methodology. International Journal of Quality Health Care. 1998 Oct;
10(5):443-7.
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We believe ABCTM is a well-tested, data-driven
methodology that allows us to account for all of the data collected for
a quality measure, evaluate who the top performers are, and then use
that to set a point of comparison for all of those groups or clinicians
who report the measure.
ABCTM starts with the pared-mean, which is the mean of
the best performers on a given measure for at least 10 percent of the
patient population--not the population of reporters. To find the pared-
mean, we will rank order physicians or groups (as appropriate per the
measure being evaluated) in order from highest to lowest performance
score. We will then subset the list by taking the best performers
moving down from best to worst until we have selected enough reporters
to represent 10 percent of all patients in the denominator across all
reporters for that measure.
We finalized that the benchmark would be derived by calculating the
total number of patients in the highest scoring subset receiving the
intervention or the desired level of care, or achieving the desired
outcome, and dividing this number by the total number of patients that
were measured by the top performing doctors. This would produce a
benchmark that represents the best care provided to the top 10 percent
of patients by measure, by reporting mechanism.
An Example: A clinician reports on how many patients with diabetes
she has given foot exams. There are four steps to establishing the
benchmark for this measure.
(1) We look at the total number of patients with diabetes for all
clinicians who reported this diabetes measure.
(2) We rank clinicians that reported this diabetes measure from
highest performance score to lowest performance score to identify the
set of top clinicians who treated at least 10 percent of the total
number of patients with diabetes.
(3) We count how many of the patients with diabetes who were
treated by the top clinicians also got a foot exam.
(4) This number is divided by the total number of patients with
diabetes who were treated by the top clinicians, producing the
ABCTM benchmark.
To account for low denominators, ABCTM suggests the
calculation of an adjusted performance fraction (AFP) using a Bayesian
Estimator or use of another statistical methodology. After analysis, we
have determined that the use of a beta binomial model adjustment is
most appropriate for the type of data we are working with. The beta
binomial method moves extreme values toward the average for a given
measure, while the Bayesian Estimator moves extreme values toward 50
percent. Using the beta binomial method is a more methodologically
sophisticated approach to address the issue of extreme values based on
small sample sizes. This ensures that all clinicians are accounted for
and appropriately figured in to the benchmark.
The benchmarks for Physician Compare developed using the
ABCTM methodology will be based on the current year's data,
so the benchmark will be appropriate regardless of the unique
circumstances of data collection or the measures available in a given
reporting year. We also finalized (80 FR 71129) a decision to use the
ABCTM methodology to generate a benchmark which will be used
to systematically assign stars for the Physician Compare 5-star rating.
The details of how the benchmark will be specifically used to determine
the 5-star categories for all applicable measures is being determined
in close collaboration with stakeholders, CMS programs, measure
experts, and the Physician Compare
[[Page 30169]]
Technical Expert Panel. We expect to publicly report the benchmark and
5-star rating for the first time on Physician Compare in late 2017
using the 2016 PQRS performance scores for both clinicians and groups.
As a result of stakeholder feedback asking that we consider one
consistent approach for benchmarking and parsing the data based on the
benchmark across the Quality Payment Program, we did consider an
alternative approach. We reviewed the benchmark and decile breaks being
used to assign points and determine payment under MIPS (see
II.C.7.a.(2)(b) of this proposed rule). This approach was not
considered ideal for public reporting for several reasons. A primary
concern was that the decile approach when used for public reporting
would force a star rating distribution inconsistent with the raw
distribution of scores on a given measure. If applied to star ratings,
there would need to be an equal distribution of clinicians in each of
the star rating categories.
Using the ABCTM methodology for the benchmark sets the
5-star rating at the performance rate that is the best achievable rate
in the current clinical climate based on the current set of measures
and the current universe of reporters. The star ratings are then
derived from there consistent with the raw score distribution. In this
way, if the majority of clinicians performed well on a measure, the
majority would receive a high star rating. If we used the decile
approach some clinicians would be reported as having a ``low'' star
rating despite their relative performance on the measure.
It is not always ideal to use the same methodology across the
program as scoring for payment purposes may be designed in a somewhat
different way that may incorporate factors that are not necessarily as
applicable for public reporting, while the key consideration for public
reporting is that the methodology used best helps patients and
caregivers easily interpret the data accurately. Testing with Web site
users has shown that the star rating based on the ABCTM
benchmark helps patients and caregivers interpret the data accurately.
ABCTM has been historically well received by the
clinicians and entities it is measuring because the benchmark
represents quality while being both realistic and achievable; it
encourages continuous quality improvement; and, it is shown to lead to
improved quality of care.22 23 24 Appreciating this and the
support this methodology received in previous rulemaking and throughout
our outreach process to date, we are again proposing to use the
ABCTM methodology to determine a benchmark for the quality,
cost, improvement activities, and advancing care information data, as
feasible and appropriate, by measure and by reporting mechanism for
each year of the Quality Payment Program, starting with the transition
year data (2017 data available for public reporting in late 2018). We
are also proposing to use this benchmark to determine a 5-star rating
for each MIPS measure, as feasible and appropriate. As previously
finalized, only those measures that meet the public reporting standards
would be considered and the benchmark would be based on the most
recently available data. The details of how the benchmark will
translate to the 5-star rating will be determined in consultation with
stakeholders.
---------------------------------------------------------------------------
\22\ Kiefe CI, Weissman NW., Allison JJ, Farmer R, Weaver M,
Williams OD. Identifying achievable benchmarks of care: concepts and
methodology. International Journal of Quality Health Care. 1998 Oct;
10(5):443-7.
\23\ Kiefe CI, Allison JJ, Williams O, Person SD, Weaver MT,
Weissman NW. Improving Quality Improvement Using Achievable
Benchmarks For Physician Feedback: A Randomized Controlled Trial.
JAMA. 2001;285(22):2871-2879.
\24\ Wessell AM, Liszka HA, Nietert PJ, Jenkins RG, Nemeth LS,
Ornstein S. Achievable benchmarks of care for primary care quality
indicators in a practice-based research network. American Journal of
Medical Quality 2008 Jan-Feb;23(1):39-46.
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We believe that displaying the appropriate and relevant MIPS data
in this user-friendly format provides more opportunities to present
these data to people with Medicare in a way that is most likely to be
accurately understood and interpreted. We request comment on these
proposals.
g. Voluntary Reporting
In CY 2017 Quality Payment Program proposed rule (81 FR 28291), we
solicited comment on the advisability and technical feasibility of
including on Physician Compare data voluntarily reported by eligible
clinicians and groups that are not subject to MIPS payment adjustments,
such as exempt clinician types and those clinicians practicing through
Rural Health Centers (RHCs), Federally Qualified Health Centers
(FQHCs), etc., to be addressed through separate notice-and-comment
rulemaking.
Overall, comments received were favorable. Stakeholders generally
support clinicians and groups being permitted to have data available
for public reporting when submitting these data voluntarily under MIPS.
As a result, we are now proposing that starting with year 2 of the
Quality Payment Program (2018 data available for public reporting in
2019) and for each year moving forward, to make available for public
reporting all data submitted voluntarily across all MIPS performance
categories, regardless of submission method, by clinician and groups
not subject to the MIPS payment adjustments, as technically feasible.
If a clinician or group chooses to submit quality, cost,
improvement activity, or advancing care information, these data would
become available for public reporting. However, because these data
would be submitted voluntarily, we propose that during the 30-day
preview period these clinicians and groups would have the option to opt
out of having their data publicly reported on Physician Compare. If
clinicians and groups do not actively opt out at this time, their data
would be available for inclusion on Physician Compare if the data meet
all previously stated public reporting standards and the minimum
reliability threshold. As clinicians and groups not required to report
under MIPS, particularly in the first years of the Quality Payment
Program, are taking additional steps to show their commitment to
quality care, we want to ensure they have the opportunity to report
their data and have it included on Physician Compare. We request
comment on this proposal.
h. APM Data
Section 1848(q)(9)(A)(ii) of the Act requires us to publicly report
names of eligible clinicians in Advanced APMs and, to the extent
feasible, the names and performance of Advanced APMs. We see this as an
opportunity to continue to build on the ACO reporting we are now doing
on Physician Compare. At this time, if a clinician or group submitted
quality data as part of an ACO, there is an indicator on the
clinician's or group's profile page indicating this. In this way, it is
known which clinicians and groups took part in an ACO. Also, currently,
all ACOs have a dedicated page on the Physician Compare Web site to
showcase their data. For the transition year of the Quality Payment
Program, we decided to use this model as a guide as we add APM data to
Physician Compare. Specifically, we finalized a policy to indicate on
eligible clinician and group profile pages of Physician Compare when
the eligible clinician or group is participating in an APM (81 FR
77398). We also finalized a decision to link eligible clinicians and
groups to their APM's data, as technically feasible, through Physician
Compare. The finalized policy provides the opportunity to publicly
report data for
[[Page 30170]]
both Advanced APMs and APMs that are not considered Advanced APMs for
the transition year, as technically feasible.
At the outset, APMs will be very new concepts for Medicare patients
and their caregivers. In these early years, indicating who participated
in APMs and testing language to accurately explain that to Web site
users provides useful and valuable information as we continue to evolve
Physician Compare. As we come to understand how to best explain this
concept to patients and their caregivers, we can continue to assess how
to most fully integrate these data on the Web site. Understanding this
and understanding the value of adding APM data to Physician Compare, we
are again proposing to publicly report names of eligible clinicians in
Advanced APMs and the names and performance of Advanced APMs and APMs
that are not considered Advanced APMs related to the Quality Payment
Program starting with year 2 (2018 data available for public reporting
in late 2019), and for each year moving forward, as technically
feasible. In addition, we again propose to continue to find ways to
more clearly link clinicians and groups and the APMs they participate
in on Physician Compare, as technically feasible. We request comment on
these proposals.
i. Stratification by Social Risk Factors
We understand that social risk factors such as income, education,
race and ethnicity, employment, disability, community resources, and
social support play a major role in health. One of our core objectives
is to improve the outcomes of people with Medicare, and we want to
ensure that complex patients, as well as those with social risk factors
receive excellent care. In addition, we seek to ensure that all
clinicians are treated as fairly as possible within all CMS programs.
In the CY 2017 Quality Payment Program final rule (81 FR 77395), we
noted that we would review the first of several reports by the Office
of the Assistant Secretary for Planning and Evaluation (ASPE).\25\ In
addition, we have been reviewing the report of the National Academies
of Sciences, Engineering, and Medicine on the issue of accounting for
social risk factors in CMS programs. ASPE's first report, as required
by the Improving Medicare Post-Acute Care Treatment (IMPACT) Act, was
released on December 21, 2016, and analyzed the effects of social risk
factors of people with Medicare on clinician performance under nine
Medicare value-based purchasing programs. A second report due October
2019 will expand on these initial analyses, supplemented with non-
Medicare datasets to measure social risk factors. The National
Academies of Sciences, Engineers, and Medicine released its fifth and
final report on January 10, 2017, and provided various potential
methods for accounting for social risk factors, including stratified
public reporting, as well as recommended next steps.\26\
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\25\ ASPE, ``Report to Congress: Social Risk Factors and
Performance Under Medicare's Value-Based Purchasing Programs.'' 21
Dec 2016. Available at https://aspe.hhs.gov/pdf-report/report-congress-social-risk-factors-and-performance-under-medicares-value-based-purchasing-programs.
\26\ National Academies of Sciences, Engineering, and Medicine.
2017. Accounting for social risk factors in Medicare payment.
Washington, DC: The National Academies Press.
---------------------------------------------------------------------------
As we continue to consider the analyses and recommendations from
these and any future reports, we look forward to working with
stakeholders in this process. Therefore, we seek comment only on
accounting for social risk factors through public reporting on
Physician Compare. Specifically, we seek comment on stratified public
reporting by risk factors and ask for feedback on which social risk
factors or indicators should be used and from what sources. Examples of
social risk factor indicators include but are not limited to dual
eligibility/low-income subsidy, race and ethnicity, social support, and
geographic area of residence. We also seek comment on the process for
accessing or receiving the necessary data to facilitate stratified
reporting. Finally, we seek comment on whether strategies such as
confidential reporting of stratified rates using social risk factor
indicators should be considered in the initial years of the Quality
Payment Program in lieu of publicly reporting stratified performance
rates for quality and cost measures under the MIPS on Physician
Compare. We seek comment only on these items for possible consideration
in future rulemaking.
j. Board Certification
Finally, we propose adding additional Board Certification
information to the Physician Compare Web site. Board Certification is
the process of reviewing and certifying the qualifications of a
physician or clinician by a board of specialists in the relevant field.
We currently include ABMS, AOA, and ABO data as part of clinician
profiles on Physician Compare. We appreciate that there are additional,
well respected boards that are not included in the ABMS, AOA, and ABO
data currently available on Physician Compare that represent clinicians
and specialties represented on the Web site. Such board certification
information is of interest to users as it provides additional
information to use to evaluate and distinguish between clinicians on
the Web site, which can help in making an informed health care
decision. The more data of immediate interest that is included on
Physician Compare, the more users will come to the Web site and find
quality data that can help them make informed decisions. Please note we
are not endorsing any particular boards.
Another board, the American Board of Wound Medicine and Surgery
(ABWMS), has shown interest in being added to Physician Compare and
have demonstrated that they have the data to facilitate inclusion of
this information on the Web site. We believe this board fills a gap for
a specialty that is not currently covered by the ABMS, so we propose to
add ABWMS Board Certification information to Physician Compare.
Additionally, for all years moving forward, for any board that
would like to be considered to be added to the Physician Compare Web
site, we propose to establish a process for reviewing interest from
these boards as it is brought to our attention on a case-by-case basis,
and selecting boards as possible sources of additional board
certification information for Physician Compare. We further propose
that, for purposes of CMS's selection, the board would need to
demonstrate that it: Fills a gap in currently available board
certification information listed on Physician Compare, can make the
necessary data available, and if appropriate, can make arrangements and
enter into agreements to share the needed information for inclusion on
Physician Compare. We propose that boards contact the Physician Compare
support team at PhysicianCompare@Westat.com to indicate interest and
initiate the review and discussion process. Once decisions are made,
they will be communicated via the CMS.gov Physician Compare initiative
Web page and via the Physician Compare listserv. We request comments on
these proposals.
D. Overview of the APM Incentive
1. Overview
Section 1833(z) of the Act requires that an incentive payment be
made to QPs for participation in Advanced APMs. In the CY 2017 Quality
Payment Program final rule (81 FR 77399 through 77491), we finalized
policies relating to the following topics:
[[Page 30171]]
Beginning in 2019, if an eligible clinician participated
sufficiently in an Advanced APM during the QP Performance Period, that
eligible clinician may become a QP for the year. Eligible clinicians
who are QPs are excluded from the MIPS reporting requirements in the
performance year and payment adjustment for the payment year.
For years from 2019 through 2024, QPs receive a lump sum
incentive payment equal to 5 percent of their prior year's payments for
Part B covered professional services. Beginning in 2026, QPs receive a
higher update under the PFS for the year than non-QPs.
For 2019 and 2020, eligible clinicians may become QPs only
through participation in Advanced APMs.
For 2021 and later, eligible clinicians may become QPs
through a combination of participation in Advanced APMs and Other Payer
Advanced APMs (which we refer to as the All-Payer Combination Option).
In this proposed rule, we discuss proposals for clarifications and
modifications to some of the policies that we previously finalized, and
provide additional details and proposals regarding the All-Payer
Combination Option.
2. Terms and Definitions
As we continue to develop the Quality Payment Program, we have
identified the need to propose additions, deletions, and changes to
some of the previously finalized definitions. A list of these
definitions is available in the CY 2017 Quality Payment Program final
rule (81 FR 77537 through 77540).
As we discuss in section II.D.6.d.(2)(a) of this proposed rule, we
propose to change the timeframe of the QP Performance Period under the
All-Payer Combination Option so that it would begin on January 1 and
end on June 30 of the calendar year that is 2 years prior to the
payment year. We propose to add the definition of All-Payer QP
Performance Period using this timeframe. We also propose to add the
definition of Medicare QP Performance Period, which would begin on
January 1 and end on August 31 of the calendar year that is 2 years
prior to the payment year. We would replace the definition we
established in the CY 2017 Quality Payment Program final rule for QP
Performance Period with the definitions of All-Payer QP Performance
Period and Medicare QP Performance Period. To update the regulation to
incorporate this proposal, we also propose to remove ``QP Performance
Period'' each time it occurs in our regulations and replace it with
either ``All-Payer QP Performance Period'' or ``Medicare QP Performance
Period'' as relevant. As we discuss in section II.D.6.d.(3)(a) of this
proposed rule, we propose to make QP determinations under the All-Payer
Combination Option at the eligible clincian level only. In connection
with our proposals to calculate Threshold Scores for QP determinations
under the All-Payer Combination Option, we do not anticipate having or
receiving information about attributed beneficiaries as we do under the
Medicare Option. This is because, under the All-Payer Combination
Option, APM Entities or eligible clinicians would only submit aggregate
payment and patient data. We would not have anything similar to a
Participation List or an Affiliated Practitioner List for Other Payer
Advanced APMs. Therefore, we are proposing to change the definition of
attributed beneficiary so that it only applies to Advanced APMs, not to
Other Payer Advanced APMs. We seek comment on these proposals.
We seek comment on these terms, including how we have defined the
terms, the relationship between terms, any additional terms that we
should formally define to clarify the explanation and implementation of
this program, and potential conflicts with other terms we use in
similar contexts. We also seek comment on the naming of the terms and
whether there are ways to name or describe their relationships to one
another that make the definitions more distinct and easier to
understand. For instance, we would consider options for a framework of
definitions that might more intuitively distinguish between APMs and
Other Payer Advanced APMs and between APMs and Advanced APMs.
3. Regulation Text Changes
a. Clarifications and Corrections
We propose to revise the definition of APM Entity in the regulation
at Sec. 414.1305 to clarify that a ``payment arrangement with a non-
Medicare payer'' is an other payer arrangement as defined in Sec.
414.1305. We propose to make technical changes to the definition of
Medicaid APM in Sec. 414.1305 to clarify that these arrangements must
meet the Other Payer Advanced APM criteria set forth in Sec. 414.1420,
and not just the criteria under Sec. 414.1420(a) as provided under the
current definition.
To consolidate our regulations and avoid unnecessarily defining a
term, we propose to remove the defined term for Advanced APM Entity in
Sec. 414.1305 and to replace ``Advanced APM Entity'' where it appears
throughout the regulations with ``APM Entity.'' We also propose to make
this substitution in the definitions of Affiliated Practitioner and
Attributed Beneficiary in Sec. 414.1305. Similarly, we propose to
replace ``Advanced APM Entity group'' with ``APM Entity group'' where
it appears throughout our regulations. We note that these proposed
changes are technical, and would not have a substantive effect on our
policies.
We propose technical changes to correct the references in the first
sentence of the regulation at Sec. 414.1415 to refer to the financial
risk standard under paragraph (c)(1) or (2) and the nominal amount
standard under paragraph (c)(3) or (4). Due to typographical errors,
the current regulation refers to paragraphs (d)(1) through (4), and
there is no paragraph (d) in this section. We also propose to correct
typographical errors in Sec. 414.1420(a)(3)(i), (ii), (d) and (d)(1).
In Sec. 414.1420(d), we propose to correct the reference to the
``nominal risk standard'' to instead refer to the ``nominal amount
standard.'' We propose technical, non-substantive clarifications in
Sec. Sec. 414.1425(a)(1) through (3), 414.1425(b)(2), and 414.1435(d).
We also propose to correct a typographical error in Sec. 414.1460(b)
to refer to participation ``during a Medicare QP Performance Period''
instead of ``during the QP Performance Periods.''
b. Changes to Sec. 414.1460
We propose to reorganize and revise the monitoring and program
integrity provisions at Sec. 414.1460. We propose changes to
paragraphs (a), (b), and (d) in this section of the proposed rule as
these policies apply to both the Medicare Option and the All-Payer
Combination Option. We discuss proposed changes to paragraph (c) of
Sec. 414.1460 in sections II.D.6.c.(7) and II.D.6.d.(4) of this
proposed rule, and changes to paragraph (e) of Sec. 414.1460 in
sections II.D.6.c.(7)(b) and II.D.6.d.(4)(c), as the policies in these
paragraphs only apply to the All-Payer Combination Option.
We finalized in the CY 2017 Quality Payment Program final rule at
Sec. 414.1460(d) that for any QPs who are terminated from an Advanced
APM or found to be in violation of any federal, state, or tribal
statute, regulation, or binding guidance during the QP Performance
Period or Incentive Payment Base Period or terminated after these
periods as a result of a violation occurring during either period we
may rescind such eligible clinician's QP determinations and, if
necessary, recoup
[[Page 30172]]
part or all of any such eligible clinician's APM Incentive Payment or
deduct such amount from future payments to such individuals. We also
finalized that we may reopen and recoup any payments that were made in
error (81 FR 77555). We recognize that rescinding QP determinations and
reopening and recouping APM Incentive Payments are separate policies
and for this reason, we propose to reorganize Sec. 414.1460 so that
paragraph (b) sets forth our policy on rescinding QP determinations and
paragraph (d) sets forth our policy on reopening and recouping APM
Incentive Payments. We propose to revise Sec. 414.1460(b) to provide
when we may rescind a QP determination. In addition, we propose to
remove the last sentence of Sec. 414.1460(d), which provides that an
APM Incentive Payment will be recouped if an audit reveals a lack of
support for attested statements provided by eligible clinicians and APM
Entitles. We believe that this provision is duplicative of the
immediately preceding sentence, which permits us to reopen and recoup
any erroneous payments in accordance with existing procedures set forth
at Sec. Sec. 405.980 through 405.986 and 405.370 through 405.379. We
propose to codify our recoupment policy at Sec. 414.1460(d)(2), which
provides that we may reopen, revise, and recoup an APM Incentive
Payment that was made in error in accordance with procedures similar to
those set forth at Sec. Sec. 405.980 through 405.986 and 405.370
through 405.379 or as established under the relevant APM.
In the CY 2017 Quality Payment Program final rule, we indicated at
Sec. 414.1460(b) that CMS may reduce or deny an APM Incentive Payment
to eligible clinicians who are terminated by APMs or whose APM Entities
are terminated by APMs for non-compliance with all Medicare conditions
of participation or the terms of the relevant Advanced APMs in which
they participate during the QP Performance Period. We also finalized at
Sec. 414.1460(a) that for QPs who CMS determines are not in compliance
with all Medicare conditions of participation and the terms of the
relevant Advanced APMs in which they participate during the QP
Performance Period, there may be a reduction or denial of the APM
Incentive Payment. We propose to consolidate our policy on reducing and
denying APM Incentive Payments and redesignate it to Sec.
414.1460(d)(1). Thus, we propose to remove provisions regarding
reducing and denying APM Incentive Payments from paragraphs (a) and (b)
of Sec. 414.1460, and revise paragraph (d) to discuss when CMS may
reduce or deny an APM Incentive Payment to an eligible clinician. We
solicit comment on these proposals.
4. Advanced APMs
a. Overview
In the CY 2017 Quality Payment Program final rule (81 FR 77408), we
finalized the criteria that define an Advanced APM based on the
requirements set forth in sections 1833(z)(3)(C) and (D) of the Act. An
Advanced APM is an APM that:
Requires its participants to use certified EHR technology
(CEHRT) (See 81 FR 77409-44414);
Provides for payment for covered professional services
based on quality measures comparable to measures under the quality
performance category under MIPS (See 81 FR 77414-77418); and
Either requires its participating APM Entities to bear
financial risk for monetary losses that are in excess of a nominal
amount, or the APM is a Medical Home Model expanded under section
1115A(c) of the Act (See 81 FR 77418-77431).
APMs may offer multiple options or tracks with variations in CEHRT
use requirements, quality-based payments, and the level of financial
risk; or multiple tracks designed for different types of participant
organizations, and we finalized in the CY 2017 Quality Payment Program
final rule (81 FR 77406) that we will consider different tracks or
options within an APM separately for purposes of making Advanced APM
determinations.
b. Bearing Financial Risk for Monetary Losses
In the CY 2017 Quality Payment Program final rule (81 FR 77418), we
divided the discussion of this criterion into two main elements: (1)
What it means for an APM Entity to bear financial risk for monetary
losses under an APM); and (2) what levels of risk we would consider to
be in excess of a nominal amount. For each of these elements, we
established a generally applicable standard and a Medical Home Model
standard.
As we discussed in the CY 2017 Quality Payment Program final rule,
we believe that it is important to maintain the distinction between
Medical Home Models and other APMs because we believe that Medical Home
Models are categorically different than other types of APMs, as
supported by specific provisions in the statute enabling unique
treatment of Medical Home Models. Also, Medical Home Model participants
tend to be smaller in size and have lower Medicare revenues relative to
total Medicare spending than other APM Entities, which affects their
ability to bear substantial risk, especially in relation to total cost
of care. We believe that the meaning of nominal financial risk varies
according to context, and that smaller practices participating in
Medical Home Models, as a category, experience risk differently than
much larger, multispecialty focused organizations do. Historically,
Medical Home Model participants have not been required to bear
financial risk, which means the assumption of any new financial risk
presents a new challenge for these entities (81 FR 77420-77421). For
these reasons, we finalized special standards for Medical Home Models
that are exceptions to the generally applicable financial risk and
nominal amount standards.
(1) Medical Home Model Eligible Clinician Limit
In the CY 2017 Quality Payment Program final rule, we finalized
that beginning in the 2018 Medicare QP Performance Period, the Medical
Home Model financial risk standard would only apply to APM Entities
that participate in Medical Home Models and that have fewer than 50
eligible clinicians in the organization through which the APM Entity is
owned and operated (81 FR 77430). Under this policy, in a Medical Home
Model that otherwise meets the criteria to be an Advanced APM, the
Medical Home Model financial risk standard would be applicable only for
those APM Entities owned and operated by organizations with fewer than
50 eligible clinicians. We note this policy does not apply to Medical
Home Models expanded under section 1115A of the Act.
We are proposing to exempt from this requirement any APM Entities
enrolled in Round 1 of the Comprehensive Primary Care Plus Model
(CPC+).
We finalized the Medical Home Model eligible clinician limit after
practices applied and signed agreements with CMS to participate in CPC+
Round 1. As such, practices applying to participate in CPC+ Round 1
were not necessarily aware of the eligible clinician limit policy and
will have already participated in CPC+ for one year without this
requirement applying to them by the beginning of CY 2018. Thus, to
permit continued and uninterrupted testing of CPC+ in existing regions,
we believe it is necessary to exempt practices participating in CPC+
Round 1 from this requirement. Additionally, since in future all APM
Entities would know about this requirement prior to their
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enrollment and in order to ensure that large APM entities that are able
to bear more risk enroll in such higher risk models, we are also
proposing that CPC+ participants who enroll in the future (for example,
in CPC+ Round 2) will not be exempt from this requirement. While this
creates a small difference between the incentives for large APM
Entities in different cohorts to participate in CPC+, we believe an APM
Entity should seek to enroll in an APM, including an Advanced APM,
primarily based on the framework of that APM itself, rather than the
possibility of other associated payments such as the Advanced APM
incentive payment. Additionally, we note that any eligible clinicians
in APM Entities participating in CPC+ that do not achieve QP status for
the year would be scored under MIPS using the APM scoring standard,
meaning minimal additional burden would be required for such MIPS
eligible clinicians.
We seek comment on these proposals.
(2) Nominal Amount of Risk
We finalized in the CY 2017 Quality Payment Program final rule (81
FR 77427) that an APM would meet the generally applicable nominal
amount standard if, under the terms of the APM, the total annual amount
that an APM Entity potentially owes us or foregoes is equal to at
least:
For QP Performance Periods in 2017 and 2018, 8 percent of
the average estimated total Medicare Parts A and B revenue of
participating APM Entities (the revenue-based standard); or
For all QP Performance Periods, 3 percent of the expected
expenditures for which an APM Entity is responsible under the APM (the
benchmark-based standard).
We also finalized in the CY 2017 Quality Payment Program final rule
(81 FR 77428) that to be an Advanced APM, a Medical Home Model must
require that the total annual amount that an Advanced APM potentially
owes us or foregoes under the Medical Home Model be at least the
following amounts in a given performance year:
In 2017, 2.5 percent of the APM Entity's total Medicare
Parts A and B revenue.
In 2018, 3 percent of the APM Entity's total Medicare
Parts A and B revenue.
In 2019, 4 percent of APM Entity's total Medicare Parts A
and B revenue.
In 2020 and later, 5 percent of the APM Entity's total
Medicare Parts A and B revenue.
Both the generally applicable and Medical Home Model revenue-based
nominal amount standards state the standard in terms of average
estimated total Medicare Parts A and B revenue of participating APM
Entities. We recognize that this language may be ambiguous as to
whether it is intended to include payments to all providers and
suppliers in an APM Entity or only payments directly to the APM Entity
itself. To eliminate this potential ambiguity, we propose to amend
Sec. Sec. 414.1415(c)(3)(i)(A) and (c)(4)(i)(A) through (D) to more
clearly define the generally applicable revenue-based nominal amount
standard and the Medical Home Model revenue-based nominal amount
standard as a percentage of the average estimated total Medicare Parts
A and B revenue of providers and suppliers in participating APM
Entities. Under this proposed policy, when assessing whether an APM
meets the generally applicable revenue-based nominal amount standard,
where total risk under the model is not expressly defined in terms of
revenue, we would calculate the estimated total Medicare Parts A and B
revenue of providers and suppliers at risk for each APM Entity. We
would then calculate an average of all the estimated total Medicare
Parts A and B revenue of providers and suppliers at risk for each APM
Entity, and if that average estimated total Medicare Parts A and B
revenue at risk for all APM Entities was equal to or greater than 8
percent, the APM would satisfy the generally applicable revenue-based
nominal amount standard.
We request comment on this proposal.
(a) Generally Applicable Revenue-Based Nominal Amount Standard
In the CY 2017 Quality Payment Program final rule we finalized the
amount of the generally applicable revenue-based nominal amount
standard for the first two QP Performance Periods only, and we sought
comment on what the revenue-based nominal amount standard should be for
the third and subsequent QP Performance Periods. Specifically, we
sought comment on: (1) Setting the revenue-based standard for 2019 and
later at up to 15 percent of revenue; or (2) setting the revenue-based
standard at 10 percent so long as risk is at least equal to 1.5 percent
of expected expenditures for which an APM Entity is responsible under
an APM (81 FR 77427).
Many commenters requested that we not raise the revenue-based
nominal amount standard for 2019 and beyond. Some commenters stated
that maintaining the 8 percent revenue-based nominal amount standard
for 2019 would allow for stability and predictability for eligible
clinicians participating in certain APMs. Other commenters noted that
increasing the revenue-based nominal amount standard may reduce or
discourage eligible clinicians from participating in Advanced APMs and
that the added complexity of requiring that a 10 percent revenue-based
standard also be equivalent to at least 1.5 percent of expected
expenditures would be confusing for participants and other
stakeholders. A few commenters suggested that we only consider
increasing the revenue-based nominal amount standard after we review
how the finalized standard affects participation in Advanced APMs.
We agree that maintaining the revenue-based nominal amount standard
at 8 percent of the average estimated total Medicare Parts A and B
revenue of providers and suppliers in participating APM Entities would
provide stability and clarity for eligible clinicians and APM Entities.
We also continue to believe that 8 percent of the average estimated
total Medicare Parts A and B revenue of providers and suppliers in
participating APM Entities represents a reasonable standard to
determine what constitutes a more than nominal amount of financial
risk. We believe that the continued testing and evaluation of APMs with
two-sided risk will yield critical information about the best way to
structure financial incentives and financial risk, and this information
may have bearing on what constitutes a more than nominal amount of
risk. Therefore, we will continue to evaluate the revenue-based nominal
amount standard in light of participation in Advanced APMs before
considering any increase in later years.
After considering public comments submitted on the potential
options for increasing the revenue-based nominal amount standard for
Medicare QP Performance Periods 2019 and later, we propose to maintain
the current revenue-based nominal amount standard at 8 percent of the
average estimated total Medicare Parts A and B revenue of all providers
and suppliers in participating APM Entities for the 2019 and 2020
Medicare QP Performance Periods, and to address the standard for
Medicare QP Performance Periods after 2020 through subsequent
rulemaking. We seek comment on whether we should consider either a
lower or higher revenue-based nominal amount standard for the 2019 and
2020 Medicare QP Performance Periods, and on the amount and structure
of the revenue-based nominal amount standard for Medicare QP
Performance Periods 2021 and later.
[[Page 30174]]
We also seek comment on whether we should consider a different,
potentially lower, revenue-based nominal amount standard only for small
practices and those in rural areas that are not participating in a
Medical Home Model for the 2019 and 2020 Medicare QP Performance
Periods. For the purposes of the Quality Payment Program, we use the
definition of small practices and rural areas in Sec. 414.1305.
Specifically, we seek comment on whether such a standard should apply
only to small and, or rural practices that are participants in an APM,
or also small and, or rural practices that join larger APM Entities in
order to participate in APMs. We also seek comment on how we should
decide where a practice is located in order to determine whether it is
operating in a rural area as rural area is defined in Sec. 414.1305 of
our regulations. We believe that a different, potentially lower,
revenue-based nominal amount standard for the 2019 and 2020 Medicare QP
Performance Periods specifically for small practices and those in rural
areas that are not participating in a Medical Home Model may allow for
their increased participation in Advanced APMs, which may help increase
the quality and coordination of care beneficiaries receive as a result.
We believe such a standard should not apply to small and, or rural
practices participating in a Medical Home Model because participants in
Medical Home Models with fewer than 50 eligible clinicians in their
parent organization benefit from the lower Medical Home Model nominal
amount standard. We also note that such a standard may have certain
disadvantages, including reducing the likelihood that potential
Advanced APMs will ultimately result in reductions in the growth of
Medicare expenditures and increasing the complexity of the generally
applicable nominal amount standard.
(b) Medical Home Model Nominal Amount Standard
In the CY 2017 Quality Payment Program final rule, we finalized
that if the financial risk arrangement under the Medical Home Model is
not based on revenue (for example, it is based on total cost of care or
a per beneficiary per month dollar amount), we will make a
determination for the APM based on the risk under the Medical Home
Model compared to the average estimated total Parts A and B revenue of
its participating APM Entities using the most recently available data
(81 FR 77428).
We received comments suggesting that few APM Entities in Medical
Home Models have had experience with financial risk, and that many
would be financially challenged to provide sufficient care or even
remain a viable business if they were faced with the kinds of
substantial disruptions in revenue that can accompany financial risk
arrangements. Some commenters indicated that taking on the level of
risk required under our finalized policy would still represent an
increase in total risk that is too great in magnitude and premature for
the many APM Entities in Medical Home Models that have little
experience with financial risk.
We recognize these concerns, however, we still believe that a final
Medical Home Model nominal amount standard of 5 percent is the
appropriate target for the standard, and that ultimately setting the
standard at 5 percent of Parts A and B revenue of providers and
suppliers in participating APM Entities would strike the appropriate
balance to reflect the meaning of ``nominal'' in the Medical Home Model
context. We continue to believe that the meaning of the term
``nominal'' depends on the situation in which it is applied, so it is
appropriate to consider the characteristics of Medical Home Models and
their participating APM Entities in setting the nominal amount standard
for Medical Home Models.
We have reconsidered the incremental annual increases in the
nominal amount standard that we finalized to occur over several years
from 2.5 percent to 5 percent. We recognize that establishing an even
more gradual increase in risk for Medical Home Models with a lower risk
floor for the 2018 Medicare QP Performance Period may be better suited
to the circumstances of many APM Entities in Medical Home Models that
have little experience with risk. We also reiterate, as we note for the
generally applicable nominal amount standard, that the terms and
conditions in the particular APM govern the actual risk that
participants experience; the nominal amount standard merely sets a
floor on the level of risk required for the APM to be considered an
Advanced APM. To that end, we believe a small reduction of risk in the
Medical Home Model nominal amount standard beginning in the 2018
Medicare QP Performance Period, along with a more gradual progression
toward the 5 percent nominal amount standard, would allow for greater
flexibility at the APM level in setting financial risk thresholds that
would encourage more participation in Medical Home Models and be more
sustainable for the type of APM Entities that would potentially
participate in Medical Home Models.
Therefore, we are proposing that to be an Advanced APM, a Medical
Home Model must require that the total annual amount that an APM Entity
potentially owes us or foregoes under the Medical Home Model be at
least the following:
For Medicare QP Performance Period 2018, 2 percent of the
average estimated total Medicare Parts A and B revenue of all providers
and suppliers in participating APM Entities.
For Medicare QP Performance Period 2019, 3 percent of the
average estimated total Medicare Parts A and B revenue of all providers
and suppliers in participating APM Entities.
For Medicare QP Performance Period 2020, 4 percent of the
average estimated total Medicare Parts A and B revenue of all providers
and suppliers in participating APM Entities.
For Medicare QP Performance Periods 2021 and later, 5
percent of the average estimated total Medicare Parts A and B revenue
of all providers and suppliers in participating APM Entities.
We seek comment on this proposal.
c. Summary of Proposals
In summary, we are making the following proposals in this section:
We are proposing to amend our regulation at Sec.
414.1415(c)(3)(i)(A) and (c)(4)(i)(A) through (D) to more clearly
define the generally applicable revenue-based nominal amount standard
and the Medical Home Model revenue-based nominal amount standard as a
percentage of the average estimated total Medicare Parts A and B
revenue of all providers and suppliers in participating APM Entities.
We are proposing to amend our regulation at Sec.
414.1415(c)(2) to any APM Entities enrolled in an Advanced APM
qualifying under the Medical Home Model standard as of January 1, 2017,
to exempt Round 1 of the CPC+ Model from the requirement that beginning
in the 2018 Medicare QP Performance Period, the Medical Home Model
financial risk standard applies only to an APM Entity that is
participating in a Medical Home Model if it has fewer than 50 eligible
clinicians in its parent organization.
We are proposing to amend our regulation at Sec.
414.1415(c)(3)(i)(A) to provide that the generally applicable revenue-
based nominal amount standard remain at 8 percent of the average
estimated total Medicare Parts A and B revenue of providers and
suppliers in participating APM Entities for the 2019 and 2020 Medicare
QP Performance Periods, and to address the standard for Medicare QP
Performance Periods after 2020 through subsequent rulemaking.
[[Page 30175]]
We are proposing to amend our regulation at Sec.
414.1415(c)(4)(i)(A) through (D) to provide that, to be an Advanced
APM, a Medical Home Model must require that the total annual amount
that an APM Entity potentially owes us or foregoes under the Medical
Home Model be at least the following amounts:
++ For Medicare QP Performance Period 2018, 2 percent of the
average estimated total Medicare Parts A and B revenue of all providers
and suppliers in participating APM Entities.
++ For Medicare QP Performance Period 2019, 3 percent of the
average estimated total Medicare Parts A and B revenue of all providers
and suppliers in participating APM Entities.
++ For Medicare QP Performance Period 2020, 4 percent of the
average estimated total Medicare Parts A and B revenue of all providers
and suppliers in participating APM Entities.
++ For Medicare QP Performance Periods 2021 and later, 5 percent of
the average estimated total Medicare Parts A and B revenue of all
providers and suppliers in participating APM Entities.
5. Qualifying APM Participant (QP) and Partial QP Determination
We finalized policies relating to QP and Partial QP determinations
in the CY 2017 Quality Payment Program final rule (See 81 FR 77433
through 77450).
We finalized that the QP Performance Period will run from January 1
through August 31 of the calendar year that is 2 years prior to the
payment year (81 FR 77446). As we discuss in section II.D.6.(d)(2)(a)of
this proposed rule, we propose to refer to this time period for the
Medicare Option as the Medicare QP Performance Period.
a. Advanced APMs Starting or Ending During a Medicare QP Performance
Period
We acknowledge that there may be Advanced APMs that start after
January 1 of the Medicare QP Performance Period for a year. There may
also be Advanced APMs that end prior to the August 31 end of the
Medicare QP Performance Period for a year. By ``start'' and ``end,'' in
this context, we mean that the period of active testing of the model
starts or ends such that there is no opportunity for any APM Entity to
participate in the Advanced APM before it starts, or to participate in
it after it ends. We consider the active testing period to mean the
dates within the performance period specific to the model, which is
also the time period for which we consider payment amounts or patient
counts through the Advanced APM when we make QP determinations. An
Advanced APM is in active testing if APM Entities are furnishing
services to beneficiaries and those services will count toward the APM
Entity's performance in the Advanced APM. Active testing does not
include, for example, the period of time after an APM Entity has
stopped furnishing services to beneficiaries under the terms of the
Advanced APM but is waiting for calculation or receipt of a
performance-based payment. We note that we tie this policy to the
timeframe during which APM Entities, rather than eligible clinicians,
participate in an Advanced APM. To the extent the participation of APM
Entities and eligible clinicians is not the same, we believe it is more
appropriate and consistent with other policies relating to the APM
incentive, and to APMs in general, to base the active testing period
for an APM on the activities of the APM Entities because they are the
participants directly subject to the terms of the Advanced APM,
including the specified performance period for the Advanced APM. For
example, in a model like CJR, where we identify eligible clinicians for
QP determinations based on the Affiliated Practitioner List, it would
be possible for APM Entities to be participating in active testing of
the Advanced APM without any Affiliated Practitioners for a period of
time. In that case, we would consider the dates the APM Entities were
able to be in active testing for CJR, as opposed to the dates when
eligible clinicians began participating as Affiliated Practitioners. If
a specific APM Entity joins an Advanced APM after the January 1 start
and before the August 31 end of a Medicare QP Performance Period, but
other APM Entities participate during the entire Medicare QP
Performance Period (from January 1 through August 31), then we would
consider the Advanced APM to be in active testing for the entire
Medicare QP Performance Period.
For example, the performance period for an Advanced APM may start
on May 1, which is after the first QP determination date (March 31) and
before the second QP determination date (June 30) during the Medicare
QP Performance Period. If we were to calculate Threshold Scores in such
an Advanced APM using data in the denominator for all attribution-
eligible beneficiaries from January through June 30, which would
include data for the period before the Advanced APM is actively tested,
the APM Entities, or, as applicable, individual eligible clinicians in
that Advanced APM, are less likely to achieve a QP threshold on either
the June 30 or the final August 31 determination date for the year.
This outcome would be a direct result of our operational decisions to
begin the performance period for the Advanced APM on May 1, which is
outside of the control of both the participating APM Entities and
eligible clinicians. As such, participants in Advanced APMs that start
or end during the Medicare QP Performance Period for the year could be
disadvantaged for purposes of QP determinations. This is because the
numerator of the Threshold Score calculation would include payment
amounts or patient counts from only the period before the QP
determination date during which the Advanced APM was actively tested,
while the denominator would include payment amounts or patient counts
for the entire Medicare QP performance period up to the QP
determination date.
We propose to modify our policies regarding the timeframe(s) for
which payment amount and patient count data are included in the QP
payment amount and patient count threshold calculations for Advanced
APMs that start after January 1 or end before August 31 in a given
Medicare QP Performance Period. In these situations, we would calculate
QP Threshold Scores using only data in the numerator and denominator
for the dates that APM Entities were able to participate in active
testing of the Advanced APM, per the terms of the Advanced APM, so long
as APM Entities were able to participate in the Advanced APM for 60 or
more continuous days during the Medicare QP Performance Period. We
propose to add this policy at Sec. 414.1425(c)(6) of our regulations.
The QP Threshold Score would be calculated at the APM Entity level or
the Affiliated Practitioner level as set forth in Sec. 414.1425(b);
this change would not affect our established policy as to which list of
eligible clinicians, the Participation List or Affiliated Practitioner
List, would be used.
This proposed change would not affect how we make QP and Partial QP
determinations for eligible clinicians who participate in multiple
Advanced APMs as set forth by Sec. Sec. 414.1425(c)(4) and
414.1425(d)(2). We propose to make those calculations using the full
Medicare QP Performance Period even if the eligible clinician
participates in one or more Advanced APMs that start or end during the
Medicare QP Performance Period. We believe that this policy
appropriately reflects the participation of the individual eligible
clinician in multiple Advanced APMs and is consistent with our general
framework for making QP determinations. For these QP determinations, we
would include
[[Page 30176]]
patients or payments through all Advanced APMs the eligible clinician
participates in for a Medicare QP Performance Period, including any
Advanced APMs that are in active testing for less than 60 continuous
days. This policy accounts for the eligible clinician's flexibility in
participating in Advanced APMs while combining that participation to
potentially meet the QP threshold.
With the exception of QP determinations for individual eligible
clinicians who participate in multiple Advanced APMs, we believe it is
appropriate to require that an Advanced APM must be actively tested for
a minimum of 60 continuous days during the Medicare QP Performance
Period in order for the payment amount or patient count data to be
considered for purposes of QP determinations for the year because it is
important that the QP determination be based on a measure of meaningful
participation in an Advanced APM. For example, if an Advanced APM
started on August 30, we do not believe a QP determination made based
on only 2 days of payment amount or patient count data in the numerator
and denominator would reflect a meaningful assessment of participation
in an Advanced APM. We have chosen a minimum of 60 continuous days
because it is the shortest amount of time between two snapshot dates:
June 30 and August 31. We believe this amount of time is sufficient for
purposes of measuring participation in an Advanced APM. We seek comment
on whether it would be more appropriate to require that the Advanced
APM be in active testing for at least 90 days, since 90 days is the
shortest possible length of time we would use to make a QP
determination (if the QP determination is based on January 1 through
March 31).
Under this proposal, we would make QP determinations for all QP
determination snapshot dates that fall after the Advanced APM meets the
minimum time requirement of 60 continuous days, whether the Advanced
APM starts or ends during the Medicare QP Performance Period. We would
not make a QP or Partial QP determination for participants in Advanced
APMs that are not actively tested for a period of at least 60
continuous days during the Medicare QP Performance Period. For example,
for an Advanced APM that starts its performance period on June 1, we
would not make any QP Threshold Score calculations for the June 30
snapshot date because the Advanced APM would not yet have been actively
tested for 60 consecutive days. We would wait until the August 31
snapshot date because this would be the first snapshot where the
Advanced APM was active for 60 or more continuous days. The QP
determination would be made based on payment amounts or patient counts
from the June 1 start date to August 31 in both the numerator and the
denominator. For an Advanced APM that starts on or before January 1 and
ends active testing on June 1, we would make QP determinations on each
snapshot date, but those determinations would be made based only on
payment amounts or patient counts from January 1 to June 1. Although
the Advanced APM would not be actively tested between June 30 and
August 31, we would still make another QP Threshold Score calculation
for APM Entities or eligible clinicians who had not met the QP
Threshold in case the additional time for claims run out would give us
more accurate information. For an Advanced APM that started on August
30 of a year, we would not make a QP determination for that year
because the APM would not be actively tested for 60 continuous days
during the Medicare QP Performance Period.
We believe that this proposal allows us to properly measure
performance in Advanced APMs without penalizing APM Entities or
eligible clinicians for start or end dates that are wholly outside of
their control. We believe this policy is needed to match the data used
to assess Advanced APM participation for purposes of the APM incentive
payment with the timeframe during which the Advanced APM is actively
tested and to accurately reflect the participation of APM Entities and
eligible clinicians. This proposed policy would not apply to Other
Payer Advanced APMs because eligible clinicians have more control over
the start and end dates of payment arrangements with Other Payers, such
as through contract negotiations, than they do over our start and end
dates, which we exclusively determine.
This proposed policy would not apply to APM Entities that had the
opportunity to participate in the Advanced APM track of an APM during
the entire Medicare QP Performance Period, but did not do so until
partway through the Medicare QP Performance Period. For example,
Oncology Care Model (OCM), has two risk tracks: One-sided and two-sided
risk. Only the two-sided risk track is an Advanced APM. APM Entities
participating in OCM now have the opportunity to change their risk
track from one-sided to two-sided risk, to take effect on either
January 1 or July 1 of the applicable calendar year. Applying this
proposed policy to OCM, an APM Entity participating in OCM that
requests two-sided risk to take effect beginning on July 1, 2018, would
be considered a participant in and Advanced APM as of July 1, but would
be subject to a QP determination based on payment and patient count
data for the full Medicare QP Performance Period because that APM
Entity had the opportunity to elect two-sided risk beginning on January
1, 2018. In this scenario, the APM Entity has control over its
participation in an Advanced APM, and could choose to be in the
Advanced APM for the full Medicare QP Performance Period.
We clarify that this proposed policy for Advanced APMs that start
or end during the Medicare QP Performance Period does not apply to the
CEHRT Track (Track 1) of the Comprehensive Care for Joint Replacement
Model (CJR) because we have determined that Track 1 of CJR is an
Advanced APM for the 2017 QP Performance Period. Therefore, we will
include episodes ending on or after January 1, 2017 in QP
determinations as set forth in our regulations at Sec. 414.1425.
b. Participation in Multiple Advanced APMs
We propose to edit Sec. 414.1425(c)(4) and (d)(4) to better
reflect our intended policy for QP determinations and Partial QP
determinations for eligible clinicians who are included in more than
one APM Entity group and none of the APM Entity groups in which the
eligible clinician is included meets the corresponding QP or Partial QP
threshold, or who are Affiliated Practitioners. As we explained in the
CY 2017 Quality Payment Program final rule (81 FR 77446-7), eligible
clinicians may become QPs through any of the assessments conducted for
the three snapshot dates: March 31, June 30, and August 31. If the APM
Entity group meets the QP threshold under this first assessment, then
all eligible clinicians in the APM Entity group will be QPs unless the
APM Entity's participation in the Advanced APM is voluntarily or
involuntarily terminated before the end of the Medicare QP Performance
Period, or in the event of eligible clinician or APM Entity program
integrity violation. We stated these same procedures apply to the QP
determination made for individual eligible clinicians on an APM
Entity's Affiliated Practitioner List or individual eligible clinicians
in multiple Advanced APMs whose APM Entity groups did not meet the QP
threshold.
We propose to amend our regulation to make clear that under Sec.
414.1425(c)(4), if an eligible clinician is a determined to be a QP
based on
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participation in multiple Advanced APMs, but any of the APM Entities in
which the eligible clinician participates voluntarily or involuntarily
terminates from the Advanced APM before the end of the Medicare QP
Performance Period, the eligible clinician is not a QP. We propose to
make the same clarification for Partial QP determinations under Sec.
414.1425(d)(4). These clarifying edits specify that this policy applies
within the context of QP and Partial QP determinations based on
participation in multiple Advanced APMs, not all QP determinations.
Accordingly, for example, if an eligible clinician is a QP through
participation in both of two Advanced APMs under Sec. 414.1425(b)(1),
and one APM Entity voluntarily or involuntarily terminates from one of
those Advanced APMs, the eligible clinician is still a QP. However, if
the eligible clinician is a QP through participation in multiple
Advanced APMs under Sec. 414.1425(c)(4), and any APM Entity that
eligible clinician participates in that counts towards the QP
determination voluntarily or involuntarily terminates, the eligible
clinician is no longer a QP. We seek comment on these proposals.
c. Summary of Proposals
In summary, we are making the following proposals in this section:
We propose to calculate QP Threshold Scores for Advanced
APMs that are actively tested continuously for a minimum of 60 days
during the Medicare QP Performance Period and start or end during the
Medicare QP Performance Period using only the dates that APM Entities
were able to participate in the Advanced APM per the terms of the
Advanced APM, not the full Medicare QP Performance Period.
We propose to make QP determinations under Sec.
414.1425(c)(4), for eligible clinicians participating in multiple
Advanced APMs using the full Medicare QP Performance Period even if the
eligible clinician participates in one or more Advanced APMs that start
or end during the Medicare QP Performance Period.
We propose to amend our regulation to make clear that
under Sec. 414.1425(c)(4), if an eligible clinician is determined to
be a QP based on participation in multiple Advanced APMs, but any of
the APM Entities in which the eligible clinician participates
voluntarily or involuntarily terminates from the Advanced APM before
the end of the Medicare QP Performance Period, the eligible clinician
is not a QP.
6. All-Payer Combination Option
a. Overview
Section 1833(z)(2)(B)(ii) of the Act requires that beginning in
payment year 2021, in addition to the Medicare Option, eligible
clinicians may become QPs through the Combination All-Payer and
Medicare Payment Threshold Option, which we refer to as the All-Payer
Combination Option. In the CY 2017 Quality Payment Program final rule
(81 FR 77459), we finalized our overall approach to the All-Payer
Combination Option. The Medicare Option focuses on participation in
Advanced APMs, and we make determinations under this option based on
Medicare Part B covered professional services attributable to services
furnished through an APM Entity. The All-Payer Combination Option does
not replace or supersede the Medicare Option; instead, it would allow
eligible clinicians to become QPs by meeting the QP thresholds through
a pair of calculations that assess Medicare Part B covered professional
services furnished through Advanced APMs, and a combination of both
Medicare Part B covered professional services furnished through
Advanced APMs and services furnished through Other Payer Advanced APMs.
We finalized that beginning in payment year 2021, we will conduct QP
determinations sequentially so that the Medicare Option is applied
before the All-Payer Combination Option (81 FR 77438). An eligible
clinician only needs to be a QP under either the Medicare Option or the
All-Payer Combination Option to be a QP for the payment year. The All-
Payer Combination Option encourages eligible clinicians to participate
in payment arrangements with payers other than Medicare that have
payment designs that satisfy the Other Payer Advanced APM criteria. It
also encourages sustained participation in Advanced APMs across
multiple payers.
We finalized that the QP determinations under the All-Payer
Combination Option are based on payment amounts or patient counts as
illustrated in Tables 46, 47, and Figures K1 and K2 (See 81 FR 77460
through 77461). We also finalized that, in making QP determinations, we
will use the Threshold Score that is most advantageous to the eligible
clinician toward achieving QP status for the year, or if QP status is
not achieved, Partial QP status for the year (81 FR 77475).
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Unlike the Medicare Option, where we have access to all of the
information necessary to determine whether an APM meets the criteria to
be an Advanced APM, we cannot identify whether an other payer
arrangement meets the criteria to be an Other Payer Advanced APM
without receiving the required information from an external source.
Similarly, we do not have the necessary payment amount and patient
count information to determine under the All-Payer Combination Option
whether an eligible clinician meets the payment amount or patient count
threshold to be a QP without receiving the required information from an
external source.
We finalized the process that eligible clinicians can use to seek a
QP determination under the All-Payer Combination Option (81 FR 77478
through 77480):
The eligible clinician submits to CMS sufficient
information on all relevant payment arrangements with other payers;
Based upon that information CMS determines that at least
one of those payment arrangements is an Other Payer Advanced APM; and
The eligible clinician meets the relevant QP thresholds by
having sufficient payments or patients attributed to a combination of
participation in Other Payer Advanced APMs and Advanced APMs.
We address the following topics in this section of the proposed
rule: (1) Other Payer Advanced APM Criteria; (2) Determination of Other
Payer Advanced APMs; and (3) Calculation of All-Payer Combination
Option Threshold Scores and QP Determinations.
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b. Other Payer Advanced APM Criteria
(1) In General
Our goal is to align the Advanced APM criteria under the Medicare
Option and the Other Payer Advanced APM criteria under the All-Payer
Combination Option as permitted by statute and as feasible and
appropriate. We believe this alignment will help simplify the Quality
Payment Program and encourage participation in Other Payer Advanced
APMs.
In the CY 2017 Quality Payment Program final rule, we finalized
that, in general, an other payer arrangement with any payer other than
traditional Medicare, including Medicare Health Plans, which include
Medicare Advantage, Medicaid-Medicaid Plans, 1876 and 1833 Cost Plans,
and Programs of All Inclusive Care for the Elderly (PACE) plans, will
be an Other Payer Advanced APM if it meets all three of the following
criteria:
The other payer arrangement requires at least 50 percent
of participating eligible clinicians in each APM Entity (or each
hospital if hospitals are the APM participants) to use Certified EHR
Technology (CEHRT) to document and communicate clinical care (81 FR
77464 through 77465);
The other payer arrangement requires that quality measures
comparable to measures under the MIPS quality performance category
apply, which means measures that are evidence-based, reliable and
valid; and, if available, at least one measure must be an outcome
measure (81 FR 77466); and