More MIPS exemptions ‘relief’ to some, counterproductive to others

More than 1,100 organizations and individuals offered comments on proposed changes for the second year of the Medicare Access and CHIP Reauthorization Act’s (MACRA) Quality Payment Program (QPP), and some questioned the reasoning behind exempting more clinicians from the new payment tracks.

The Merit-based Incentive Payment System (MIPS) had been criticized as too challenging for many providers, particularly small and rural ones, though the first year of the program exempted 65 percent of clinicians and offered “pick your pace” participation options. For 2018, the new administration at HHS and CMS proposed raising the low-volume exemption thresholds to receiving under $90,000 in Part B charges (up from $30,000 in 2017) or treating fewer than 200 patients (up from 100).

The American Hospital Association (AHA) was one of many groups to praise the higher thresholds, saying it “would provide needed relief and additional time to transition into MIPS.” It encouraged CMS to go further and apply the proposed 2018 exemptions to the rest of the 2017 reporting period. In the future, however, it also said the agency will need to lower the exemption threshold to protect the program’s incentives.

“The higher thresholds make the pool of participating clinicians much smaller than it would be otherwise. In the context of a budget-neutral program, this means the potential upside of the MIPS will be quite limited until more clinicians are included,” the AHA wrote. “CMS should monitor the progress of the field in adopting more value-oriented payment approaches, and consider lowering the threshold as the field gains experience with these payment models.”

The American College of Physicians (ACP) also supported the higher exemption thresholds in general, calling it a better “safety net” for clinicians. It did, however, advocate for allowing practices to “opt in” to MIPS and receive bonuses based on their performance.

“We would also like to note our concern that this proposal poses a risk of stalling these exempted practices in making progress toward value based payment, which is contrary to the Congressional intent of MACRA and the overarching movement toward value in the healthcare system,” wrote Jacqueline Fincher, MD, chair of ACP’s Medical Practice and Quality Committee.

The ACP supported the opt-in provision in a joint letter with the American Academy of Family Physicians (AAFP) and the American Osteopathic Association. In its own letter, however, AAFP had some stronger concerns about the exemptions, saying it could it undercut preparations practices made for MIPS in 2017, only to find they’re exempted in 2018. It also argued it would “entirely thwart impacted practices from participating in virtual groups.”

“By raising the low-volume threshold and not offering an opt-in ability, CMS is further and needlessly delaying practices from payment based on value over volume, as well as the intent behind the establishment of virtual groups,” AAFP wrote. “Bluntly, and as discussed further in this comment letter, the virtual group option should already be in place, yet CMS was unwilling or unable to implement it for the 2017 MIPS performance period.”

Some of the strongest criticisms about the low-volume threshold changes came from the American Medical Group Association (AMGA). Much like its comments in an initial interview with HealthExec, AMGA said greater exemptions would send the wrong message on value-based care, making it a “check-the-box exercise” for clinicians required to participate. It called on CMS to head in the other direction, and exempt fewer clinicians from the program.

“If MACRA is ever to be a catalyst for change, the proposal to increase the exclusion thresholds is neither right nor effective,” AMGA said.

Other parts of the proposed rule were more broadly supported, such as the 90-day reporting periods for the MIPS’ version of meaningful use, Advancing Care Information. Still others drew a more mixed reaction, such as allowing use of 2014-edition certified EHR technology (CEHRT) in 2018. This was supported by groups like the American Medical Informatics Association, with the caveat that it wants to see 2015 CEHRT standards required for 2019.

“With the sunset of Meaningful Use for Medicare, we view MIPS and APM requirements as a primary mechanism to incentivize continued investment and use of certified EHR technology among ambulatory providers. It is important that CMS continue to view CEHRT as a means to encourage adoption and maintenance of modern information and communication technology in care delivery, and focus on making the use of such systems easier for clinicians,” AMIA wrote.