The Evolution of QPP and its Impact on Providers

Dr. Weinstein authored this article in his personal capacity. The views expressed are his own and do not necessarily represent the views of Falcon, LLC or DaVita, Inc.

In late June, CMS released its proposed updates for the Quality Payment Program (QPP), a.k.a. MACRA.  This proposed rule spans over 1000 pages and is more than just a list of updates.  CMS offers detailed thoughts and discussion points, including an overview of the comments they have received about the finalized rules on QPP, which were released in Fall of 2016.  To be sure, the federal register is not great literature, but there are a number of consistent themes and ideas evident throughout the proposed regulations.

CMS sees value and is attempting to include more small and rural practices in QPP.  There are a number of proposed changes focused directly at practices made up of only a few providers or located in rural communities.  One point of interest are the rules that allow for the creation of virtual groups (groups of physicians and practices made up of fewer than 10 providers who combine and report data but do not share a TIN).  In addition, CMS is proposing to award bonus points and offering enhanced scoring opportunities to small and rural practices.  Lastly, CMS is proposing that MIPS providers and practices who obtain the greatest year-over-year improvements in the quality and cost categories be given bonuses.  All of these ideas point toward efforts at easing the burdens of QPP participation, especially for providers who have less capacity to transform to the quality-reporting program.

Though the official “transition year” is 2017, CMS is extending the timeline for full participation for MIPS-eligible clinicians.  The agency has proposed allowing the continued use of 2014 CEHRT (as opposed to requiring 2015 CEHRT) in 2018, maintaining the current weighting of the Quality, Advancing Care Information, Improvement Activities, and Cost categories, and maintaining the same minimum data reporting requirements for quality measures.  In addition, ACI will continue to require only a 90-day reporting minimum, although quality and improvement activities will require a full 365 days of data for 2018.  Again, and irrespective of practice size, CMS seems to be attempting to slow the pace of implementation, thereby giving MIPS participating physicians more time to adapt to the required data collection and reporting.

CMS also intends to offer bonus points toward the final MIPS score based off specialty-specific average Hierarchical Condition Category (HCC) risk scores.  Nephrology is noted to have the highest HCC score, per CMS documentation, which means nephrologists may receive a 3-point bump in their MIPS composite score in 2018.  In addition, CMS has re-created a nephrology specific bundle of quality measures, aiding clinicians in deciding which 6 measures to gather and report data upon.  Lastly, CMS is looking for comments on aspects of the cost category of MIPS.  This provides an opportunity for the nephrology community to send CMS feedback on the Episodes of Care measure, which, as finalized in the QPP 2016 rule, could have had unintended consequences for our specialty.  Though this is a complex issue, renal docs have a strong interest in ensuring CMS’s definition of an episode of care accurately reflects appropriate patient and cost attribution.  Though in 2018 the cost category will still have no impact (0%) of the MIPS composite score, it is likely that we will be held accountable for aspects of the cost of care we are providing at a later date.  CMS is actively soliciting our feedback on this topic, which will have long term consequences under QPP-MIPS.

It is clear that CMS is marching down the path of quality-based reimbursement, but perhaps a bit more slowly than the 2016 final rule suggested.  And though these proposed rules will likely change between now and when they are finalized in the fall of 2017, the work of transformation to quality reporting cannot be avoided. Ultimately, CMS is proposing 2018 as another year for practices to further (and with minimal pain) adapt practice workflows, policies and procedures, and technology to meet the demands of collecting the data that reflects the care being delivered.

The proposed rule can be downloaded and reviewed at https://qpp.cms.gov/about/resource-library – both the full 1000+ pages of text and a smaller, more digestible summary are available.

Specific references in the full text of the proposed rule for above mentioned items:
See table 34 for a discussion of HCC risk scoring and the complex patient bonus.
See table B.21 for nephrology bundle of quality measures.
See page 137-138 for the discussion about the cost category’s episode of care measure.

About the Author:

Adam-WeinsteinAdam Weinstein, MD, is VP of medical affairs with Clinical IT Services at DaVita and a part-time clinical nephrologist in Maryland. He serves as the American Medical Association Relative Value Scale Update Committee (RUC) advisor for the Renal Physicians Association (RPA) and chairs the RPA clinical data registry workgroup.

Dr. Weinstein is a co-founder of the Kidney Health Center of Maryland. He has worked as VP of medical affairs at the University of Maryland, Shore Regional Health and has served on the Maryland Healthcare Commission and RPA board of directors. He completed his training in internal medicine and nephrology at the University of Maryland School of Medicine and University of Maryland Medical Center.