By Akin Demehin and Caitlin Gillooley

On Nov. 2, the Centers for Medicare & Medicaid Services released its final rule updating the Quality Payment Program required by Medicare Access & CHIP Reauthorization Act. The QPP ties Medicare payments to physicians and a handful of other types of clinicians to their performance on quality, cost and the use of electronic health records. The QPP began this year, and potential bonuses and penalties will first be applied in 2019.

While the 2018 final rule did not significantly change the overall structure of the QPP, a few major themes emerged:

1. CMS is continuing its gradual, flexible implementation approach. Following last year’s policies intended to provide clinicians with more flexibility in avoiding payment penalties and meeting QPP requirements, this year’s rule offered additional relief in two major ways.

First, CMS increased the “low-volume threshold,” which is the amount of Medicare charges or number of patients below which clinicians are excluded from the QPP. The calendar year 2018 minimum is $90,000 in Medicare Part B charges or 200 Medicare Part B patients, a substantial increase from the initial (2017) floors of $30,000 in Medicare Part B charges or 100 Medicare Part B patients. CMS estimates that this higher benchmark will exempt over 540,000 clinicians from the QPP in 2018.

Another finalized policy offers some relief from Meaningful Use reporting requirements. Clinicians will only have to report 90 days-worth of data in 2018, as finalized in last year’s rule, and this limited reporting period also will apply in 2019. In addition, clinicians will not have to upgrade to the newer, 2015 edition of certified EHRs.

2. Facility-based measurement is a go …soon. CMS will allow hospital-based clinicians to use their facility’s value-based purchasing performance in the Merit-based Incentive Program without having to report separate data. However, after hearing trepidation about the logistics of how this reporting option will work, CMS will delay the implementation of facility-based measurement until 2019 to give the agency more time to prepare.  

3. Opportunities for solo practitioners and small practices. In addition to easing the burden on clinicians with low-Medicare volumes, CMS also provides new ways for calculating a MIPS final score for small practices.

First, the QPP will offer bonus points to practices with 15 or fewer clinicians.

Second, CMS will allow solo practitioners and small practices to form virtual groups without limitations on specialty or location. These virtual groups will participate jointly in the MIPS and have access to technical assistance.

4. Flexible approach means more time to prepare, but the stakes are rising. These final policies give the field more, sorely needed, time to get ready to participate in the QPP. However, as the program progresses, so do the risks. The potential upside and downside of the MIPS begin at 4 percent in the first payment year (2019), and will ramp up to a maximum of 9 percent in 2022 and beyond. While a large number of clinicians are exempt from the program now, many will likely have to participate in the future; by the time they start working under the QPP, requirements (like EHR reporting and evaluation on cost and resource use) will be more stringent and more payment will be at risk.

5. Still limited advanced APM opportunities. CMS estimates that more providers will qualify for the advanced alternative payment model track in the second year of the program with the addition of the new Medicare Shared Savings Program Track 1+. However, there is still a short list of models that meet CMS’s APM criteria. In fact, CMS plans to keep these same criteria through the 2019 and 2020 performance years, keeping the bar for a model to be eligible for the track high.

Bottom line: MACRA is moving forward—albeit at a flexible, gradual pace. Hospitals and their clinician partners still need help understanding the requirements and opportunities in the MACRA, and we can help. Tune in Nov. 17 for an AHA webinar, at 1 p.m. ET, on the final rule. For more resources, visit


Akin Demehin, AHA director of policy, manages policy issues related to national quality reporting and pay-for-performance programs for hospitals, post-acute care providers and physicians. Caitlin Gillooley, AHA associate director of policy, focuses on issues related to quality measurement and pay-for-performance for hospitals and physicians.

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