Electronic Health Reporter

By Matthew Fusan, director of customer experience, SA Ignite.

Although the Quality Payment Program (QPP) has been in effect for a year, there continues to be a lot of change in the program as CMS continues to evolve. The new year creates an ideal time to reflect back on what changes we have experienced to date as well as look forward and examine what could happen in 2018 and beyond.

2017: A Year of Regulatory Confusion

As the QPP rolled out, confusion still reigned supreme at both the CMS and HHS levels:

• In 2017, CMS ramped up promotion and education for the QPP. Although these efforts have been more aggressive than previous programs, industry studies like the 5^th Annual Health IT Industry Outlook Survey and the KPMG-AMA Survey show that clinicians are struggling to understand the program and what they need to do to be successful. In fact, many expect their employer to provide the information and solutions to manage and are not seeking to proactively educate themselves on requirements and improvement strategies.
• While clinicians continue to experience confusion, the Department of Health and Human Services (HHS) has not done much to help clarify. CMS Administrator Seema Verma has continued to support the move away from fee-for-service and toward fee-for-value, but has also cancelled two mandatory bundled payment models – the Episode Payment Models and the Cardiac Rehabilitation Incentive Payment Model – and has also removed the mandatory requirement for the Comprehensive Care for Joint Replacement Model.
• Although some bundled payment programs have been cut/reduced, the Centers for Medicare and Medicaid Innovation (CMMI) has put out a request for information (RFI) to gather input on patient-centered care and test market-driven reforms. The intent of the initiative is to empower beneficiaries as consumers, provide price transparency, and increase choices and competition. The RFI demonstrates that all models/programs will be watched closely and are subject to change.

2018: More Focus, More Models

While some programs are being cut/reduced, there is still pressure on CMS to accelerate new Advanced Alternative Payment Models (APMs) so they are exploring options during 2018.

• The first option is to allow clinicians to use Medicare Advantage plans to meet the criteria for an Advanced APM. Even though this may require a change to the MACRA legislation, CMS has a demonstration project in the 2018 final rule to explore this option.
• Another option is the second iteration of the Bundled Payments for Care Improvement (BCPI) program, Advanced BCPI. The risk levels for other Advanced APM options may appear to be too high for physician practices so this option may have wider appeal to physician groups.
• Other models under consideration include Direct Primary Care, which is based on a non-insurance model, as well as collaborations with private payers.

While these models are all under consideration/in development, it will be interesting to see if the CMMI RFI will drive additional choice or will the changes proposed consume CMMI for 2018 and reduce the capacity to introduce new models. Either way, CMMI will look very different in 2018 and beyond.

2019: Change is Mandated

In 2019, critical components of MIPS are mandated, including:

• The weighting of the MIPS categories is re-balanced so the Cost category becomes 30 percent of the total MIPS score. While organizations have struggled with optimizing cost for years with limited results, this increase in the Cost category means that 2019 will drive organizations to look closely at cost and create a strategy for measurable improvement.
• The performance threshold that determines who receives an incentive versus a penalty will increase to the mean/or median of participants’ scores. In the 2018 final rule, CMS estimated that almost 75 percent of clinicians will earn a score greater than 70 points for 2018 so competition going into 2019 will be fierce, with healthcare organizations pitted against each other to earn high scores and financial incentives.

Every Year: Organizational Change

The start of the QPP, even with the limited implementation of MIPS, has been a wake-up call to organizations. The tipping point occurs when organizations realize that success in value-based care programs requires continual organizational changes, including operational and clinical redesign, not just adding another set of tasks for employees and clinicians. No matter what year it is, sitting on the sidelines/doing nothing is no longer an option if you want to remain competitive. Organizations who strive to understand the changes, understand the impact to their organizations, and proactively improve starting now give themselves the best chance of success.

To stay up to date on value-based care best practices, changes to the Quality Payment Program, strategies to improve performance, and more, listen to the ABCs of the QPP webinar series to learn from a rotating cast of experts.