The Centers for Medicare and Medicaid Services (CMS) released a proposed rule on Tuesday for implementing Medicare’s new physician payment program.  Congress passed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which creates two avenues for physicians to be paid under the Medicare program – MIPS (Merit-based Incentive Payment System) and APMs (Alternative Payment Models).  MIPS and APMs make up the Quality Payment Program (QPP).

Physicians participating in the “advanced” APMs are not subject to MIPS.  However, the AMP models must include performance measures similar to MIPS.

Orthopaedic surgeons are unlikely to be eligible for more than a handful of APM opportunities.  However, we are watching for a potential rule this summer that would create new physician-led BPCI bundles for 2018 that could qualify for APMs.

CMS expects all physicians in advanced APMs to receive the 5 percent payment bonus in the first year.

The proposed rule released on Tuesday states: “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 to participate, and preparing clinicians for the CY 2019 performance period (CY 2021 payment year).”

2017 Performance for 2019 Payments

This is the first year that physicians must report to the QPP.  2017 performance will apply to 2019 payments.  CMS’s recent proposal would apply to 2018, which would serve as the performance period for 2020 payments.

$90,000 Threshold

CMS already exempted MIPS physicians who bill Medicare no more than $30,000 and see fewer than 100 Medicare beneficiaries per year.  The proposed rule would increase the threshold to $90,000 and 200 Medicare beneficiaries.

Small Practices and Virtual Groups

The proposal would help small group physicians perform well in MIPS by helping them form virtual groups, which can lead to a larger pool for performance measurements.  The proposal would define a virtual group as a combination of at least two provider tax identification numbers, and it would include at least one solo practitioner.  Practices in the virtual groups may have no more than 10 clinicians.

Additional Small Practice Support

The proposed rule would provide bonus points to small practices that do not seek exclusions from MIPS.

Electronic Health Records

Small practices may be able to seek exemptions from the EHR requirements.  In addition, the proposed rule includes a provision that would delay a requirement to upgrade EHRs for practices of all sizes.  The proposal would include bonus points on performance scores for those practices that upgrade to 2015 certified EHR technology.

Cost Performance Measures Delay

The proposed rule states: “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 clinical understanding of the measures and continue development of episode-based measures that will be used in this performance category.”

AAOS Reaction

Click here to view the American Academy of Orthopaedic Surgeons’ reaction to the proposal.

2018 vs. 2017

McDermott + Consulting created an outstanding chart that compares the 2018 proposal to the final rule for 2017.  Click here to view it.