On Tuesday, the Centers for Medicare and Medicaid Services (CMS) released the calendar year (CY) 2018 Medicare Quality Payment Program (QPP) proposed regulation. This regulation outlines the proposed requirements for the Merit-based Incentive Payment System (MIPS), as well as for qualified or “advanced” alternative payment models (APMs) under MACRA.

CMS provided a side-by-side comparison that summarizes the proposed changes to the requirements for MIPS and APMs for calendar year 2018 compared to 2017.  You can review the QPP Year 2 Proposed Rule here.

CMS estimates that there are 10,900 MIPS-eligible GI clinicians; roughly 3.5% would receive a reimbursement cut in CY 2020.  ACG is currently reviewing the proposed rule’s impact to clinical GI.  Here is a top-line summary:


ACG is encouraged that CMS continues to ease into reporting requirements and thresholds in year 2 of MACRA, especially for smaller and rural GI practices.  For example, CMS aims to assist smaller providers by allowing them to be excluded from MACRA altogether.  For 2018, CMS proposes to increase the threshold to exclude ACG members or groups with ≤ $90,000 in Part B allowed charges or ≤ 200 Part B beneficiaries.  The current exclusion includes clinicians or groups with ≤$30,000 in Part B allowed charges OR ≤ 100 Part B beneficiaries.  Starting with the 2019 MIPS performance period, CMS proposes to let clinicians opt-in to MIPS if they exceed 1 or 2 of the low-volume threshold components.

The payment cut for the 2020 payment year is 5% for those who do not report MIPS measures in CY 2018.  This is a deeper cut from the 4% payment adjustment for not participating in MIPS in 2017, which impacts the payment for CY 2019.

Quality Payment Program Year 2 Proposals: MIPS

For the second year of the program, CMS keeps the same MIPS scoring weights that take place in 2017.  The proposed CY 2018 MIPS performance year final score includes:

CMS continues to ease into the MACRA/MIPS transition: in 2017, the minimum performance threshold for MIPS is set at 3 points, with the “exceptional performance” bonus threshold set at 70 points. This indicates that ACG members would not receive a payment cut for obtaining a score of 3 or above.  For the 2018 reporting year, CMS proposes a performance threshold of 15 points, but seeks feedback on whether or not this should be lower.  CMS also proposes the “exceptional performance” threshold to stay at 70 points for the 2018 reporting year.

Reporting requirements:
Quality and Cost: 12-month calendar year performance period.
Advancing Care Information and Improvement Activities: 90 days minimum performance period.

CMS proposes to continue re-weighting the Advancing Care Information performance category to the Quality performance category for participants who meet exclusions.

An option will also be offered for “Virtual Groups” to participate.  Virtual Groups would be composed of solo practitioners and groups of 10 or fewer eligible clinicians, eligible to participate in MIPS, who come together “virtually” with at least 1 other solo practitioner or group to participate in MIPS for a performance period of a year.

CMS proposes more flexibilities for ACG members in small practices by adding a new hardship exception for clinicians in small practices under the Advancing Care Information performance category.  CMS proposes to add bonus points to the Final Score of clinicians in small practices and continues to award small practices with 3 points for measures in the Quality performance category that don’t meet data completeness requirements (small practices are defined in the regulation as 15 or fewer clinicians).

Quality Payment Program Year 2 Proposals: APMs

MACRA does not create new alternative payment models, but rather authorizes incentives to encourage participation.  CMS and Congress view the APM as a transition away from fee-for-service and move towards reducing programmatic costs, but also as a way to improve the quality of care for the patients.  From 2019 through 2024, ACG members participating in a qualifying APM will receive a lump sum incentive payment equal to 5% of their prior year’s payments for Medicare Part B-covered professional services.  Qualifying or “advanced” APM models require the APM entity (and participants) to assume financial risk in going over any annual benchmark target, or share the rewards in going under these targets.

CMS proposes some changes and updates for APMs.  In 2017, the total potential risk under the APM must be equal to at least:

  • either 8% of the average estimated Medicare Parts A and B revenue of the participating APM Entities (the revenue-based standard), or
  • 3% of the expected expenditures for an APM Entity

In 2018, CMS proposes to extend the 8% revenue-based standard for two additional years, through performance year 2020.

The proposed rule details how an “All-Payer Combination Option” will be implemented in the 2019 performance year. CMS’ goal for this option is to allow clinicians to become Qualifying APM Participants through a combination of Medicare participation in Advanced APMs and participation in Other Payer Advanced APMs.

Stay tuned for more information on the 2018 proposed rule.  ACG hosts a wealth of educational material on the National Affairs section of the ACG website: Making $ense of MACRA.