The Evolving Quality Payment Program

-->November 18, 2019Billing & Compliance Alerts

    November 18, 2019

    On November 1, 2019, CMS released the 2020 Quality Payment Program (QPP) Final Rule under the MACRA (Medicare Access and CHIP Reauthorization Act of 2015) law.  This update for the 2020 reporting year is the next step in applying pressure to clinicians on public reporting of relevant quality metrics.  Thankfully, there are few surprises in the final rule (which you can read here) but we will target those changes and offer our recommendations on how to best navigate this regulatory program.

    Changes to the Penalties and Bonuses

    As the MIPS (Merit-Based Incentive Payment System) program enters its fourth year of implementation, the bonuses and penalties adjust to –9 percent to +9 percent of MIPS eligible clinicians (ECs) relative to covered professional services in the 2022 payment year.  Because of the requirement to keep the MIPS program budget neutral, CMS estimates the actual range of payment adjustments to be from -9 percent to +6.25 percent of services.  This is expected to change slightly after the 2020 reporting year concludes based on the number of penalized clinicians.


    Those who are required or choose to report through MIPS will now be required to acquire 45 MIPS points, which is an increase from 30 MIPS points in 2019.  As many will realize, 45 points can be difficult to achieve without the help of some reporting strategies in place.  For those who achieve 85 MIPS points or more, a special pool of funding is available, totaling $500 million, to be distributed based on score and volume across all of medicine.  This exceptional reporting threshold is an increase from 75 MIPS points in 2019.

    Can and Should You Report?

    Most anesthesia providers are not required to report to MIPS for 2020 as the eligibility and exemption requirements have not changed.  To be excluded from MIPS, clinicians or groups would need to meet one of the following three criteria:

    • Have ≤ $90K in Part B allowed charges for covered professional services;
    • Provide care to ≤ 200 Part B enrolled beneficiaries; OR
    • Provide ≤ 200 covered professional services under the Physician Fee Schedule (PFS).

    Most anesthesia providers are excused from reporting due to the first criteria above, which is automatically applied by CMS and reviewable on the QPP page here.  Many groups will be faced with a simple question of whether they should report despite the exemption.  This, unfortunately, is not a simple answer.

    Providers and groups do have an option to voluntarily report quality metrics to CMS for public review without risk of penalty or a reward of a bonus.  These groups are simply interested in publicly posting their performance results for general recognition purposes.  Those more ambitious individuals and practices wishing to seek a bonus will now be doing so at risk.  If a group designates that they wish to seek a bonus, CMS will now classify the individual or group as EC(s), and they must acquire 45 or more MIPS points.  However, if the individual or group fails to achieve 45 points, they will be penalized.  Once the decision is made, it cannot be adjusted, so all exempted individuals should proceed with caution with data submission for the 2019 and 2020 reporting years.

    Quality Performance Category

    As with previous years, providers participating in MIPS will be required to report cases for all 12 months of the reporting year.  Additionally, the reporting threshold has increased to 70% of all eligible cases.  This is an increase from 60 percent in 2019.  One subtle change over previous years was that all measures reported received a score of at least one MIPS point.  Measures that don’t meet the 70% reporting threshold will now receive zero points in the 2020 reporting year, making it even more important to closely monitor all cases that are eligible for quality reporting.

    CMS has also expanded the Anesthesia Specialty Set to include the following measures:

    • MIPS 44 – Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery
    • MIPS 76 – Prevention of Central Venous Catheter (CVC) – Related Bloodstream Infections
    • MIPS 404 – Anesthesiology Smoking Abstinence
    • MIPS 424 – Perioperative Temperature Management
    • MIPS 430 – Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy
    • MIPS 463 – Prevention of Post-Operative Vomiting (POV) – Combination Therapy (Pediatrics)
    • MIPS 477 – Multimodal Pain Management (NEW for 2020)

    MIPS 477 was added and was known as AQI 59 in 2019 within the QCDR measure set.  This specialty set will be very important for reporting reasons in the 2020 reporting year.

    QCDR vs. QR

    Anesthesia Business Consultants (ABC) has operated its Qualified Clinical Data Registry (QCDR) since the program started in 2016.  It has become one of the tools that practices have used to comply with and defend against the QPP, earn bonuses, and avoid penalties using the least invasive data collection mechanisms available.  By all metrics, it has been a very successful program and beneficial to our clients.

    CMS has since implemented rules to block organizations like ABC from continuing as a QCDR.  However, with continued examination and data modeling, a new pathway has emerged for our clients that is even less burdensome and offers an even higher upside: the Qualified Registry (QR).  The difference between a QCDR and a QR is that a QR is only required to report MIPS measures such as the Anesthesia Specialty Set listed above.  Initially, this was interpreted as a restrictive path; but, upon further examination, it can be a huge asset to the anesthesia specialty.

    CMS implemented rules for QRs under the Eligible Measure Applicability (EMA) process that effectively require anesthesia providers to only report the measures that are applicable to their particular practice.  This immediately makes the reporting process much easier for all practices.  For example:

    • Many groups don’t perform enough CABG cases to require MIPS 44 reporting.
    • Many groups don’t insert enough central lines to require MIPS 76 reporting.
    • Many groups don’t cover pre-surgical testing prior to the DOS and therefore don’t require MIPS 404 reporting.
    • Many groups don’t cover enough pediatric cases to require MIPS 463 reporting.

    This leaves only measures MIPS 424, MIPS 430, and MIPS 477 as eligible measures for most practices.   While no benchmark currently exists for MIPS 477, based on historical ABC reporting, most groups that fit into this limited-measure category would achieve approximately 81 MIPS Points.  This is possible because the EMA process will rebalance the value of the remaining applicable measures reported.  Again, if you are reporting all six measures, it is likely even higher scores would be achieved.  Based on published historical benchmarking data and aggregated ABC data collected since 2016, the following is the expectation of 2020 reporting for ABC and Medac clients:


    The first column lists the number of measures reported which, when calculated with the historical benchmarks and the ABC data, would yield the Base Score in column two.  The Promoting Interoperability performance category excludes anesthesia reporting and its MIPS points are assigned to the Quality category yielding the adjusted total in column three.  The Improvement Activities and Cost categories are assumed to be fully reported, yielding the Total value in the last column.

    Using the data above and comparing your 2018 MIPS score, it becomes clear the new model will allow for a higher reporting yield with less burden.  Additionally, if your practice requires reporting of custom metrics to meet contract obligations to your facilities or insurance payers, ABC and Medac will continue to collect, aggregate, and report that data for you.  These custom metrics will not be made available to CMS but will be made available to you for your own purposes, providing the exact balance desired between governmental reporting and practice quality initiatives.

    Conclusions and Next Steps

    The new models for quality reporting under a QR offer practices a streamlined process of reporting to the QPP.  Accordingly, in 2020, ABC and Medac will jettison QCDR reporting in favor of this better approach. We believe this change will protect your time, effort, and interests.

    When you are ready to setup your 2020 Quality reporting, let your account manager know to schedule time with the Quality Department at ABC and Medac to get started and feel free to email us at if you have any questions at all.

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