CMS Releases 2020 MIPS Proposed Rule

• Quality: 45%
• Cost: 15%
• Promoting Interoperability: 25%
• Improvement Activities: 15%

• Quality: 40%
• Cost: 20%
• Promoting Interoperability: 25%
• Improvement Activities: 15%

• Medicare Part B Claims measures: 60% of Medicare Part B patients for the performance period
• QCDR measures, MIPS CQMs, and eCQMs: 60% of clinician’s or group’s patients across all payers for the performance period

• Applicable
• Feasible
• Reliable
• Valid at the individual clinician level
• Different from existing measures

• A quality measure may be considered for removal if the measure is no longer meaningful, such as measures that are topped out
• A measure would be considered for removal if a measure steward is no longer able to maintain the quality measure

• QCDR measures must be beyond the measure concept phase of development
• CMS will show a preference for QCDR measures that are outcome-based rather than clinical process measures
• Measures should address significant variation in performance
• QCDR measures are approved for use in MIPS for a single performance period

• Medicare Part B claims measures: 70% sample of Medicare Part B patients for the performance period
• QCDR measures, MIPS CQMs, and eCQMs: 70% sample of clinician’s or group’s patients across all payers for the performance period
• Note: If quality data is submitted selectively such that the data are unrepresentative of a MIPS eligible clinician or group’s performance, any such adat would not be true, accurate, or complete

• Measures submitted in response to Call for Measures would be required to demonstrate a link to existing and related cost measures and improvement activities as appropriate and feasible

• MIPS quality measures that do not meet case minimum and reporting volumes required for benchmarking for 2 consecutive years would be removed
• We may consider a MIPS quality measure for removal if we determine it is not available for MIPS Quality reporting by or on behalf of all MIPS eligible clinicians (including via third party intermediaries)

QCDR Measure Rejections
CMS is proposing the following guidelines to help QCDRs understand when a QCDR measure would likely be rejected during the annual self-nomination process:

• QCDR measures that are duplicative of an existing measure or one that has been removed from MIPS or legacy programs
• Existing QCDR measures that are “topped out” (though these may be resubmitted in future years)
• QCDR measures that are process-based (consideration given to the impact on the number of measures available for a specific specialty) or have no actionable quality action
• Considerations and evaluation of the measure’s performance data, to determine whether performance variance exists
• QCDR measures that have the potential for unintended consequences
• QCDR measures that split a single clinical practice/action into several measures or that focus on rare events
• QCDR measures that are “check-box” with no actionable quality action
• Existing QCDR measures that have been in MIPS for two years and have failed to reach benchmarking thresholds due to low adoption (unless a plan to improve adoption is submitted and approved)
• Whether the existing approved QCDR measure is no longer considered robust, in instances where new QCDR measures are considered to have a more vigorous quality action, where CMS preference is to include the new QCDR measure rather than requesting QCDR measure harmonization
• QCDR measures with clinician attribution issues, where the quality action is not under the direct control of the reporting clinician. (that is, the quality aspect being measured cannot be attributed to the clinician or is not under the direct control of the reporting clinician)
• QCDR measures that focus on rare events or “never events” in the measurement period

Patient-Centered Medical Home Criteria
To be eligible for Patient-Centered Medical Home designation, the practice must meet one of the following criteria:

• The practice has received accreditation from one of four accreditation organizations that are nationally recognized:
• The Accreditation Association for Ambulatory Healthcare
• The National Committee for Quality Assurance (NCQA)
• The Joint Commission
• The Utilization Review Accreditation Commission (URAC); OR
• The practice is participating in a Medicaid Medical Home Model or Medical Home Model; OR
• The practice is a comparable specialty practice that has received the NCQA Patient Centered Specialty Recognition

• Added 1 new criterion, “Include a public health emergency as determined by the Secretary”
• Removed “Activities that may be considered for a Promoting Interoperability bonus”

Removal of Improvement Activities
No formal policy but invited public comments on what criteria should be used to identify improvement activities for removal from the inventory.

Requirement for Improvement Activity Credit for Groups
Group or virtual group can attest to an improvement activity if at least one clinician in the TIN participates.

Patient-Centered Medical Home Criteria
To be eligible for Patient-Centered Medical Home designation, the practice would need to meet one of the following criteria:

• The practice has received accreditation from an accreditation organization that is nationally recognized
• The practice is participating in a Medicaid Medical Home Model or Medical Home Model
• The practice is a comparable specialty practice that has received recognition through a specialty recognition program offered through a nationally recognized accreditation organization; OR 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

• Addition of 2 new Improvement Activities
• Modification of 7 existing Improvement Activities
• Removal of 15 existing Improvement Activities

Please review Appendix 2 in the CY 2020 NPRM for a comprehensive look at the changes proposed to the inventory.

Removal of Improvement Activities
Establish factors to consider for removal of improvement activities from the Inventory. An activity would be considered for removal if:

• It is duplicative of another activity
• An alternative activity exists with stronger relationship to quality care or improvements in clinical practice
• The activity does not align with current clinical guidelines or practice
• The activity does not align with at least one meaningful measures area
• The activity does not align with Quality, Cost, or Promoting Interoperability performance categories
• There have been no attestations of the activity for 3 consecutive years
• The activity is obsolete

• Group or virtual group would be able to attest to an improvement activity when at least 50% of MIPS eligible clinicians (in the group or virtual group) participate in or perform the activity
• At least 50% of a group’s NPIs must perform the same activity for the same continuous 90 days in the performance period

A group is identified as hospital-based and eligible for reweighting when 100% of the MIPS eligible clinicians in the group meet the definition of a hospital-based MIPS eligible clinician.

A group would be identified as hospital-based and eligible for reweighting if more than 75% of the NPIs in the group meet the definition of a hospital-based individual MIPS eligible clinician.

For non-patient facing groups (more than 75% of the MIPS-eligible clinicians in the group are classified as non-patient facing) we would automatically reweight the Promoting Interoperability performance category.

No change to definition of an individual hospital-based MIPS eligible clinician.

• One set of objectives and measures based on the 2015 Edition CEHRT
• Four objectives: ePrescribing, Health Information Exchange, Provider to Patient Exchange, and Public Health and Clinical Data Exchange
• Clinicians are required to report certain measures from each of the four objectives, unless an exclusion is claimed
• PTwo new measures for the e-Prescribing objective: Query of Prescription Drug Monitoring Program (PDMP) and Verify Opioid Treatment Agreement as optional with bonus points available

• CMS would require a yes/no response for the Query of PDMP measure
• CMS would redistribute the points for the Support Electronic Referral Loops by Sending Health Information measure to the Provide Patients Access to Their Health Information measure if an exclusion is claimed

• Total Per Capita Cost (TPCC)
• Medicare Spending Per Beneficiary (MSPB)
• 8 episode-based measures

• 10 for procedural episodes
• 20 for acute inpatient medical condition episodes

• All measures are attributed at the TIN/NPI level for both individuals and groups
• Plurality of primary care services rendered by the clinician to determine attribution for the total per capita cost measure
• Plurality of Part B services billed during the index admission to determine attribution for the MSPB measure
• For procedural episodes, we attribute episodes to each MIPS eligible clinician who renders a trigger service (identified by HCPCS/CPT procedure codes)
• For acute inpatient medical condition episodes, we attribute episodes to each MIPS eligible clinician who bills inpatient evaluation and management (E&M) claim lines during a trigger inpatient hospitalization under a TIN that renders at least 30% of the inpatient E&M claim lines in that hospitalization

• TPCC measure (Revised)
• MSPB-C (MSPB Clinician) measure (Name and specification Revised)
• 8 existing episode-based measures
• 10 new episode-based measures

• Measure attribution would be different for individuals and groups and would be defined in the measure specifications
• TPCC attribution would require E&M services to have an associated primary care service or a follow up E&M service from the same clinician group
• TPCC attribution would exclude certain clinicians who primarily deliver certain non-primary care services (e.g. general surgery)
• MSPB clinician attribution changes would have a different methodology for surgical and medical patients
• No changes proposed for attribution in episode-based measures (existing and new)

• No policy to account for data integrity concerns
• Several scenarios for reweighting have previously been finalized, including extreme and uncontrollable events (all performance categories) and hardship exemptions specific to the Promoting Interoperability performance category

• We would reweight performance categories in rare events due to compromised data outside the control of the MIPS eligible clinician. MIPS eligible clinicians or third party intermediaries can inform CMS that they believe they are impacted by a relevant event by providing information on the event (CMS may also independently learn of qualifying events)
• If we determine that reweighting for compromised data is appropriate, we would generally redistribute to the Promoting Interoperability performance category as well as the Quality performance category
• In rare cases, we would redistribute to the Cost performance category

• Performance Threshold is set at 30 points
• Additional performance threshold set at 75 points for exceptional performance
• As required by statute, the maximum negative payment adjustment is – 7%
• Positive payment adjustments can be up to 7% (not including additional positive payment adjustments for exceptional performance) but are multiplied by a scaling factor to achieve budget neutrality, which could result in an adjustment above or below 7%

• Performance Threshold would be set at 45 points
• Additional performance threshold would be set at 80 points for exceptional performance
• As required by statute, the maximum negative payment adjustment is -9%
• Positive payment adjustments can be up to 9% (not including additional positive adjustments for exceptional performance) but are multiplied by a scaling factor to achieve budget neutrality, which could result in an adjustment above or below 9%

MIPS eligible clinicians and groups may submit a targeted review request by September 30 following the release of the MIPS payment adjustment factor(s) with performance feedback.

All requests for targeted review would be required to be submitted within 60 days of the release of the MIPS payment adjustment factor(s) with performance feedback.