MACRA Quality Payment Program Year 2 Final Rule

53568 Federal Register / Vol. 82, No.
220 / Thursday, November 16, 2017 / Rules and Regulations
DEPARTMENT OF HEALTH AND ways (please choose only one of the Benjamin Chin, (410) 7860679, for
HUMAN SERVICES ways listed): inquiries related to APMs.
1. Electronically. You may submit SUPPLEMENTARY INFORMATION:
Centers for Medicare & Medicaid electronic comments on this regulation
Services to http://www.regulations.gov. Follow Table of Contents
the Submit a comment instructions. I. Executive Summary and Background
42 CFR Part 414 2. By regular mail. You may mail A. Overview
written comments to the following B. Quality Payment Program Strategic
[CMS5522FC and IFC] address ONLY: Centers for Medicare & Objectives
Medicaid Services, Department of C. One Quality Payment Program
RIN 0938AT13 D. Summary of the Major Provisions
Health and Human Services, Attention:
CMS5522FC or CMS5522IFC (as 1. Quality Payment Program Year 2
Medicare Program; CY 2018 Updates to 2. Small Practices
the Quality Payment Program; and appropriate), P.O. Box 8016, Baltimore,
3. Summary of Major Provisions for
Quality Payment Program: Extreme MD 212448016. Advanced Alternative Payment Models
and Uncontrollable Circumstance Please allow sufficient time for mailed (Advanced APMs)
Policy for the Transition Year comments to be received before the 4. Summary of Major Provisions for the
close of the comment period. Merit-Based Incentive Payment System
AGENCY: Centers for Medicare & 3. By express or overnight mail. You (MIPS)
Medicaid Services (CMS), HHS. may send written comments to the E. Payment Adjustments
ACTION: Final rule with comment period following address ONLY: Centers for F. Benefits and Costs of the Final Rule
and interim final rule with comment Medicare & Medicaid Services, With Comment Period
Department of Health and Human G. Automatic Extreme and Uncontrollable
period. Circumstance Policy Interim Final Rule
Services, Attention: CMS5522FC or
With Comment Period
SUMMARY: The Medicare Access and CMS5522IFC (as appropriate), Mail
H. Stakeholder Input
CHIP Reauthorization Act of 2015 Stop C42605, 7500 Security II. Summary of the Provisions of the
(MACRA) established the Quality Boulevard, Baltimore, MD 212441850. Proposed Regulations, and Analysis of
Payment Program for eligible clinicians. 4. By hand or courier. Alternatively, and Responses to Public Comments
Under the Quality Payment Program, you may deliver (by hand or courier) A. Introduction
eligible clinicians can participate via your written comments ONLY to the B. Definitions
one of two tracks: Advanced Alternative following addresses prior to the close of C. MIPS Program Details
Payment Models (APMs); or the Merit- the comment period: 1. MIPS Eligible Clinicians
based Incentive Payment System a. For delivery in Washington, DC 2. Exclusions
(MIPS). We began implementing the Centers for Medicare & Medicaid 3. Group Reporting
Services, Department of Health and 4. Virtual Groups
Quality Payment Program through 5. MIPS Performance Period
rulemaking for calendar year (CY) 2017. Human Services, Room 445G, Hubert 6. MIPS Category Measures and Activities
This final rule with comment period H. Humphrey Building, 200 7. MIPS Final Score Methodology
provides updates for the second and Independence Avenue SW., 8. MIPS Payment Adjustments
future years of the Quality Payment Washington, DC 20201. 9. Review and Correction of MIPS Final
Program. (Because access to the interior of the Score
In addition, we also are issuing an Hubert H. Humphrey Building is not 10. Third Party Data Submission
interim final rule with comment period readily available to persons without 11. Public Reporting on Physician Compare
(IFC) that addresses extreme and Federal government identification, D. Overview of the APM Incentive
commenters are encouraged to leave 1. Overview
uncontrollable circumstances MIPS 2. Terms and Definitions
eligible clinicians may face as a result their comments in the CMS drop slots
3. Regulation Text Changes
of widespread catastrophic events located in the main lobby of the 4. Advanced APMs
affecting a region or locale in CY 2017, building. A stamp-in clock is available 5. Qualifying APM Participant (QP) and
such as Hurricanes Irma, Harvey and for persons wishing to retain a proof of Partial QP Determinations
Maria. filing by stamping in and retaining an 6. All-Payer Combination Option
extra copy of the comments being filed.) 7. Physician-Focused Payment Models
DATES: b. For delivery in Baltimore, MD (PFPMs)
Effective date: These provisions of Centers for Medicare & Medicaid III. Quality Payment Program: Extreme and
this final rule with comment period and Services, Department of Health and Uncontrollable Circumstances Policy for
interim final rule with comment period Human Services, 7500 Security the Transition Year Interim Final Rule
are effective on January 1, 2018. With Comment Period
Boulevard, Baltimore, MD 212441850.
Comment date: To be assured A. Background
If you intend to deliver your
consideration, comments must be B. Changes to the Extreme and
comments to the Baltimore address, call Uncontrollable Circumstances Policies
received at one of the addresses telephone number (410) 7867195 in for the MIPS Transition Year
provided below, no later than 5 p.m. on advance to schedule your arrival with C. Changes to the Final Score and Policies
January 1, 2018. one of our staff members. Comments for Redistributing the Performance
ADDRESSES: In commenting, please refer erroneously mailed to the addresses Category Weights for the Transition Year
to file code CMS5522FC when indicated as appropriate for hand or D. Changes to the APM Scoring Standard
asabaliauskas on DSKBBXCHB2PROD with RULES
commenting on issues in the final rule courier delivery may be delayed and for MIPS Eligible Clinicians in MIPS
with comment period, and CMS5522 received after the comment period. APMs for the Transition Year
IFC when commenting on issues in the For information on viewing public E. Waiver of Proposed Rulemaking for
Provisions Related to Extreme and
interim final rule with comment period. comments, see the beginning of the Uncontrollable Circumstances
Because of staff and resource SUPPLEMENTARY INFORMATION section. IV. Collection of Information Requirements
limitations, we cannot accept comments FOR FURTHER INFORMATION CONTACT: A. Wage Estimates
by facsimile (FAX) transmission. You Molly MacHarris, (410) 7864461, for B. Framework for Understanding the
may submit comments in one of four inquiries related to MIPS. Burden of MIPS Data Submission
VerDate Sep<11>2014 17:44 Nov 15, 2017 Jkt 244001 PO 00000 Frm 00002 Fmt 4701 Sfmt 4700 E:\FR\FM\16NOR2.SGM 16NOR2
Federal Register / Vol. 82, No. 220 / Thursday, November 16, 2017 / Rules and Regulations 53569
C. ICR Regarding Burden for Virtual Group CJR Comprehensive Care for Joint I. Executive Summary and Background
Election ( 414.1315) Replacement
D. ICR Regarding Burden for Election of COI Collection of Information A. Overview
Facility-Based Measurement CPR Customary, Prevailing, and Reasonable This final rule with comment period
( 414.1380(e)) CPS Composite Performance Score
E. ICRs Regarding Burden for Third-Party makes payment and policy changes to
CPT Current Procedural Terminology the Quality Payment Program. The
Reporting ( 414.1400) CQM Clinical Quality Measure
F. ICRs Regarding the Quality Performance Medicare Access and CHIP
CY Calendar Year
Category ( 414.1330 and 414.1335) Reauthorization Act of 2015 (MACRA)
eCQM Electronic Clinical Quality Measure
G. ICRs Regarding Burden Estimate for
ED Emergency Department
(Pub. L. 11410, enacted April 16, 2015)
Advancing Care Information Data amended Title XVIII of the Social
( 414.1375) EHR Electronic Health Record
EP Eligible Professional Security Act (the Act) to repeal the
H. ICR Regarding Burden for Improvement Medicare sustainable growth rate (SGR)
Activities Submission ( 414.1355) ESRD End-Stage Renal Disease
I. ICR Regarding Burden for Nomination of FFS Fee-for-Service formula, to reauthorize the Childrens
Improvement Activities ( 414.1360) FR Federal Register Health Insurance Program (CHIP), and
J. ICRs Regarding Burden for Cost FQHC Federally Qualified Health Center to strengthen Medicare access by
( 414.1350) GAO Government Accountability Office improving physician and other clinician
K. ICR Regarding Partial QP Elections HCC Hierarchical Condition Category payments and making other
( 414.1430) HIE Health Information Exchange improvements. The MACRA advances a
L. ICRs Regarding Other Payer Advanced HIPAA Health Insurance Portability and forward-looking, coordinated framework
APM Determinations: Payer-Initiated Accountability Act of 1996 for clinicians to successfully take part in
Process ( 414.1440) and Medicaid HITECH Health Information Technology for
Specific Eligible Clinician Initiated
the Quality Payment Program that
Economic and Clinical Health rewards value and outcomes in one of
Process ( 414.1445) HPSA Health Professional Shortage Area
M. ICRs Regarding Burden for Voluntary two ways:
HHS Department of Health & Human
Participants To Elect Opt Out of Services
Advanced Alternative Payment
Performance Data Display on Physician HRSA Health Resources and Services Models (Advanced APMs).
Compare ( 414.1395)
Administration Merit-based Incentive Payment
N. Summary of Annual Burden Estimates System (MIPS).
IHS Indian Health Service
O. Submission of PRA-Related Comments
IT Information Technology Our goal is to support patients and
P. Collection of Information Requirements
for the Interim Final Rule With Comment LDO Large Dialysis Organization clinicians in making their own
Period: Medicare Program; Quality MACRA Medicare Access and CHIP decisions about health care using data
Payment Program: Extreme and Reauthorization Act of 2015 driven insights, increasingly aligned
Uncontrollable Circumstances Policy for MEI Medicare Economic Index and meaningful quality measures, and
the Transition Year MIPAA Medicare Improvements for innovative technology. To implement
V. Response to Comments Patients and Providers Act of 2008 this vision, the Quality Payment
VI. Regulatory Impact Analysis MIPS Merit-based Incentive Payment Program emphasizes high-value care
A. Statement of Need System
and patient outcomes while minimizing
B. Overall Impact MLR Minimum Loss Rate
MSPB Medicare Spending per Beneficiary
burden on eligible clinicians. The
C. Changes in Medicare Payments
D. Impact on Beneficiaries MSR Minimum Savings Rate Quality Payment Program is also
E. Regulatory Review Costs MUA Medically Underserved Area designed to be flexible, transparent, and
F. Accounting Statement NPI National Provider Identifier structured to improve over time with
G. Regulatory Impact Statement for Interim OCM Oncology Care Model input from clinicians, patients, and
Final Rule With Comment Period: ONC Office of the National Coordinator for other stakeholders.
Medicare Program; Quality Payment Health Information Technology In todays health care system, we
Program: Extreme and Uncontrollable PECOS Medicare Provider Enrollment, often pay doctors and other clinicians
Circumstance Policy for the Transition Chain, and Ownership System based on the number of services they
Year PFPMs Physician-Focused Payment Models perform rather than patient health
Acronyms PFS Physician Fee Schedule outcomes. The good work that clinicians
PHI Protected Health Information
Because of the many terms to which do is not limited to conducting tests or
PHS Public Health Service
we refer by acronym in this rule, we are writing prescriptions, but also taking the
PQRS Physician Quality Reporting System
listing the acronyms used and their PTAC Physician-Focused Payment Model time to have a conversation with a
corresponding meanings in alphabetical Technical Advisory Committee patient about test results, being
order below: QCDR Qualified Clinical Data Registry available to a patient through telehealth
QP Qualifying APM Participant or expanded hours, coordinating
ABCTM Achievable Benchmark of Care medicine and treatments to avoid
QRDA Quality Reporting Document
ACO Accountable Care Organization
Architecture confusion or errors, and developing care
API Application Programming Interface
APM Alternative Payment Model QRUR Quality and Resource Use Reports plans.
APRN Advanced Practice Registered Nurse RBRVS Resource-Based Relative Value The Quality Payment Program takes a
ASC Ambulatory Surgical Center Scale comprehensive approach to payment by
ASPE HHS Office of the Assistant RFI Request for Information basing consideration of quality on a set
Secretary for Planning and Evaluation RHC Rural Health Clinic of evidenced-based measures that were
BPCI Bundled Payments for Care RIA Regulatory Impact Analysis

primarily developed by clinicians, thus
Improvement RVU Relative Value Unit
SGR Sustainable Growth Rate
encouraging improvement in clinical
CAH Critical Access Hospital practice and supporting by advances in
CAHPS Consumer Assessment of TCPI Transforming Clinical Practice
Healthcare Providers and Systems Initiative technology that allow for the easy
CBSA Core Based Statistical Area TIN Tax Identification Number exchange of information. The Quality
CEHRT Certified EHR Technology VBP Value-Based Purchasing Payment Program also offers special
CFR Code of Federal Regulations VM Value-Based Payment Modifier incentives for those participating in
CHIP Childrens Health Insurance Program VPS Volume Performance Standard certain innovative models of care that
53570 Federal Register / Vol. 82, No. 220 / Thursday, November 16, 2017 / Rules and Regulations
provide an alternative to fee-for-service (PQRS), the Physician Value-based customized communication, education,
payment. Payment Modifier (VM), and the outreach and support that meet the
We have sought and will continue to Medicare Electronic Health Record needs of the diversity of physician
seek feedback from the health care (EHR) Incentive Program for Eligible practices and patients, especially the
community through various public Professionals (EPs) and made CY 2017 unique needs of small practices; (5) to
avenues such as rulemaking, listening the transition year for clinicians under improve data and information sharing
sessions and stakeholder engagement. the Quality Payment Program. As on program performance to provide
We understand that technology, prescribed by MACRA, MIPS focuses on accurate, timely, and actionable
infrastructure, physician support the following: (1) Qualityincluding a feedback to clinicians and other
systems, and clinical practices will set of evidence-based, specialty-specific stakeholders; (6) to deliver IT systems
change over the next few years and are standards; (2) cost; (3) practice-based capabilities that meet the needs of users
committed to refine our policies for the improvement activities; and (4) use of for data submission, reporting, and
Quality Payment Program with those certified electronic health record (EHR) improvement and are seamless, efficient
factors in mind. technology (CEHRT) to support and valuable on the front and back-end;
We are aware of the diversity among interoperability and advanced quality and (7) to ensure operation excellence
clinician practices in their experience objectives in a single, cohesive program in program implementation and ongoing
with quality-based payments and expect that avoids redundancies. development; and to design the program
the Quality Payment Program to evolve This CY 2018 final rule with comment in a manner that allows smaller
over multiple years. The groundwork period continues to build and improve independent and rural practices to be
has been laid for expansion toward an upon our transition year policies, as successful. More information on these
innovative, patient-centered, health well as, address elements of MACRA objectives and the Quality Payment
system that is both outcome focused and that were not included in the first year Program can be found at qpp.cms.gov.
resource effective. A system that of the program, including virtual Stakeholder feedback is the hallmark
leverages health information technology groups, beginning with the CY 2019 of the Quality Payment Program. We
to support clinicians and patients and performance period facility-based solicited and reviewed nearly 1,300
builds collaboration across care settings. measurement, and improvement comments and had over 100,000
The Quality Payment Program: (1) scoring. This final rule with comment physicians and other stakeholders
Supports care improvement by focusing period implements policies for Quality attend our outreach sessions to help
on better outcomes for patients, and Payment Program Year 2, some of inform our policies for Quality Payment
preserving the independent clinical which will continue into subsequent Program Year 2. We have set ambitious
practice; (2) promotes the adoption of years of the Quality Payment Program. yet achievable goals for those clinicians
APMs that align incentives for high- We have also included an interim interested in APMs, as they are a vital
quality, low-cost care across healthcare final rule with comment period to part of bending the Medicare cost curve
stakeholders; and (3) advances existing establish an automatic extreme and by encouraging the delivery of high-
delivery system reform efforts, uncontrollable circumstance policy for quality, low-cost care. To allow this
including ensuring a smooth transition the 2017 MIPS performance period that program to work for all stakeholders, we
to a healthcare system that promotes recognizes recent hurricanes (Harvey, further recognize that we must provide
high-value, efficient care through Irma, and Maria) and other natural ongoing education, support, and
unification of CMS legacy programs. disasters can effectively impede a MIPS technical assistance so that clinicians
In the Merit-based Incentive Payment eligible clinicians ability to participate can understand program requirements,
System (MIPS) and Alternative Payment in MIPS. use available tools to enhance their
Model (APM) Incentive under the practices, and improve quality and
Physician Fee Schedule, and Criteria for B. Quality Payment Program Strategic
progress toward participation in APMs
Physician-Focused Payment Models Objectives
if that is the best choice for their
final rule with comment period (81 FR After extensive outreach with practice. Finally, we understand that we
77008, November 4, 2016), referred to as clinicians, patients and other must achieve excellence in program
the CY 2017 Quality Payment Program stakeholders, we created 7 strategic management, focusing on customer
final rule, we established incentives for objectives to drive continued progress needs while also promoting problem-
participation in Advanced APMs, and improvement. These objectives help solving, teamwork, and leadership to
supporting the goals of transitioning guide our final policies and future provide continuous improvements in
from fee-for-service (FFS) payments to rulemaking in order to design, the Quality Payment Program.
payments for quality and value. The CY implement, and advance a Quality
2017 Quality Payment Program final Payment Program that aims to improve C. One Quality Payment Program
rule included definitions and processes health outcomes, promote efficiency, Clinicians have told us that they do
to determine Qualifying APM minimize burden of participation, and not separate their patient care into
Participants (QPs) in Advanced APMs. provide fairness and transparency in domains, and that the Quality Payment
The CY 2017 Quality Payment Program operations. Program needs to reflect typical clinical
final rule also established the criteria for These strategic objectives are as workflows in order to achieve its goal of
use by the Physician-Focused Payment follows: (1) To improve beneficiary better patient care. Advanced APMs, the
Model Technical Advisory Committee outcomes and engage patients through focus of one pathway of the Quality
(PTAC) in making comments and patient-centered Advanced APM and Payment Program, contribute to better
recommendations to the Secretary on MIPS policies; (2) to enhance clinician care and smarter spending by allowing
proposals for physician-focused experience through flexible and physicians and other clinicians to
payment models (PFPMs). transparent program design and deliver coordinated, customized, high-
The CY 2017 Quality Payment interactions with easy-to-use program value care to their patients in a
Program final rule also established tools; (3) to increase the availability and streamlined and cost-effective manner.
policies to implement MIPS, which adoption of robust Advanced APMs; (4) Within MIPS, the second pathway of the
consolidated certain aspects of the to promote program understanding and Quality Payment Program, we believe
Physician Quality Reporting System maximize participation through that integration into typical clinical
workflows can best be accomplished by special policies for MIPS Year 2 aimed Payment Program and maximize
making connections across the four at encouraging successful participation participation, and as mandated by the
statutory pillars of the MIPS incentive in the program while reducing burden, statute, during a period of 5 years, $100
structure. Those four pillars are: (1) reducing the number of clinicians million in funding was provided for
Quality; (2) clinical practice required to participate, and preparing technical assistance to be available to
improvement activities (referred to as clinicians for the CY 2019 performance provide guidance and assistance to
improvement activities); (3) period (CY 2021 payment year). Our MIPS eligible clinicians in small
meaningful use of CEHRT (referred to as hope is for the program to evolve to the practices through contracts with
advancing care information); and (4) point where all the clinical activities regional health collaboratives, and
resource use (referred to as cost). captured in MIPS across the four others. Guidance and assistance on the
Although there are two separate performance categories reflect the MIPS performance categories or the
pathways within the Quality Payment single, unified goal of quality transition to APM participation will be
Program, Advanced APMs and MIPS improvement. available to MIPS eligible clinicians in
both contribute toward the goal of practices of 15 or fewer clinicians with
seamless integration of the Quality D. Summary of the Major Provisions
priority given to practices located in
Payment Program into clinical practice 1. Quality Payment Program Year 2 rural areas or medically underserved
workflows. Advanced APMs promote areas (MUAs), and practices with low
this seamless integration by way of We believe the second year of the
Quality Payment Program should build MIPS final scores. More information on
payment methodology and design that the technical assistance support
incentivize care coordination. The MIPS upon the foundation that has been
established which provides a trajectory available to small practices can be found
builds the capacity of eligible clinicians at https://qpp.cms.gov/docs/QPP_
across the four pillars of MIPS to for clinicians to value-based care. A
second year to ramp-up the program Support_for_Small_Practices.pdf.
prepare them for participation in APMs We have also performed an updated
in later years of the Quality Payment will continue to help build upon the
iterative learning and development of regulatory impact analysis, accounting
Program. Indeed, the bedrock of the for flexibilities, many of which are
Quality Payment Program is high-value, year 1 in preparation for a robust
program in year 3. continuing into the Quality Payment
patient-centered care, informed by Program Year 2, that have been created
useful feedback, in a continuous cycle 2. Small Practices to ease the burden for small and solo
of improvement. The principal way that practices.
MIPS measures quality of care is The support of small, independent
through a set of clinical quality practices remains an important thematic 3. Summary of Major Provisions for
measures (CQMs) from which MIPS objective for the implementation of the Advanced Alternative Payment Models
eligible clinicians can select. The CQMs Quality Payment Program and is (Advanced APMs)
are evidence-based, and the vast expected to be carried throughout future
rulemaking. Many small practices did a. Overview
majority are created or supported by
clinicians. Over time, the portfolio of not have to participate in MIPS during APMs represent an important step
quality measures will grow and develop, the transition year due to the low- forward in our efforts to move our
driving towards outcomes that are of the volume threshold, which was set for the healthcare system from volume-based to
greatest importance to patients and CY 2017 performance period at less than value-based care. Our existing APM
clinicians and away from process, or or equal to $30,000 in Medicare Part B policies provide opportunities that
check the box type measures. allowed charges or less than or equal to support state flexibility, local
Through MIPS, we have the 100 Medicare Part B patients. We have leadership, regulatory relief, and
opportunity to measure clinical and heard feedback that many small innovative approaches to improve
patient outcomes, not only through practices still face challenges in their quality, accessibility, and affordability.
evidence-based quality measures, but ability to participate in the program. We APMs that meet the criteria to be
also by accounting for activities that are implementing additional flexibilities Advanced APMs provide the pathway
clinicians and patients themselves for Year 2 including: Implementing the through which eligible clinicians, many
identify: Namely, practice-driven virtual groups provisions; increasing the of whom who would otherwise fall
quality improvement. MIPS also low-volume threshold to less than or under the MIPS, can become Qualifying
requires us to assess whether CEHRT is equal to $90,000 in Medicare Part B APM Participants (QPs), thereby earning
used in a meaningful way and based on allowed charges or less than or equal to incentives for their Advanced APM
significant feedback, this area was 200 Medicare Part B patients; adding a participation. In the CY 2017 Quality
simplified to support the exchange of significant hardship exception from the Payment Program final rule, we
patient information, engagement of advancing care information performance estimated that 70,000 to 120,000 eligible
patients in their own care through category for MIPS eligible clinicians in clinicians would be QPs for payment
technology, and the way technology small practices; providing 3 points even year 2019 based on Advanced APM
specifically supports the quality goals if small practices submit quality participation in performance year 2017
selected by the practice. And lastly, measures below data completeness (81 FR 77516). With new Advanced
MIPS requires us to measure the cost of standards; and providing bonus points APMs expected to be available for
services provided through the cost that are added to the final scores of participation in 2018, including the
performance category, which will MIPS eligible clinicians who are in Medicare ACO Track 1 Plus (1+) Model,
contribute to a MIPS eligible clinicians small practices. We believe that these and the addition of new participants for
final score beginning in the second year additional flexibilities and reduction in some current Advanced APMs, such as
of the MIPS. barriers will further enhance the ability the Next Generation ACO Model and
We realize the Quality Payment of small practices to participate Comprehensive Primary Care Plus
Program is a big change. In this final successfully in the Quality Payment (CPC+) Model, we anticipate higher
rule with comment period, we continue Program. numbers of QPs in subsequent years of
the slow ramp-up of the Quality In keeping with the objectives to the program. We currently estimate that
Payment Program by establishing provide education about the Quality approximately 185,000 to 250,000
eligible clinicians may become QPs for Eligible clinicians who participate in 8 percent of the total combined
payment year 2020 based on Advanced Advanced APMs but do not meet the QP revenues from the payer of providers
APM participation in performance year or Partial QP thresholds are subject to and suppliers in participating APM
2018. MIPS reporting requirements and Entities only for arrangements that are
payment adjustments unless they are expressly defined in terms of revenue.
b. Advanced APMs otherwise excluded from MIPS. We are also finalizing a more gradual
In the CY 2017 Quality Payment ramp-up in percentages of revenue for
d. All-Payer Combination Option
Program final rule, to be considered an the Medicaid Medical Home Model
Advanced APM, we finalized that an The All-Payer Combination Option, nominal amount standard over the next
APM must meet all three of the which uses a calculation based on an several years.
following criteria, as required under eligible clinicians participation in both We are finalizing the Payer Initiated
section 1833(z)(3)(D) of the Act: (1) The Advanced APMs and Other Payer and Eligible Clinician Other Payer
APM must require participants to use Advanced APMs to make QP Advanced APM determination
CEHRT; (2) The APM must provide for determinations, is applicable beginning processes to allow payers, APM Entities,
payment for covered professional in performance year 2019. To become a or eligible clinicians to request that we
services based on quality measures QP through the All-Payer Combination determine whether other payer
comparable to those in the quality Option, an eligible clinician must arrangements meet the Other Payer
performance category under MIPS; and participate in an Advanced APM with Advanced APM criteria. We have also
(3) The APM must either require that CMS as well as an Other Payer finalized requirements pertaining to the
participating APM Entities bear risk for Advanced APM. We determine whether submission of information.
monetary losses of a more than nominal other payer arrangements are Other We are finalizing certain
amount under the APM, or be a Medical Payer Advanced APMs based on modifications to how we calculate
Home Model expanded under section information submitted to us by eligible Threshold Scores and make QP
1115A(c) of the Act (81 FR 77408). clinicians, APM Entities, and in some determinations under the All-Payer
cases by payers, including states and Combination Option. We are retaining
We are maintaining the generally
Medicare Advantage Organizations. In the QP Performance Period for the All-
applicable revenue-based nominal
addition, the eligible clinician or the Payer Combination Option from January
amount standard at 8 percent for QP
APM Entity must submit information to 1 through August 31 of each year as
Performance Periods 2019 and 2020. We CMS so that we can determine whether finalized in the CY 2017 Quality
are exempting participants in Round 1 the eligible clinician meets the requisite Payment Program final rule.
of the CPC+ Model as of January 1, 2017 QP threshold of participation.
from the 50 eligible clinician limit as To be an Other Payer Advanced APM, e. Physician-Focused Payment Models
proposed. We are also finalizing a more as set forth in section 1833(z)(2)(B)(ii) (PFPMs)
gradual ramp-up in percentages of and (C)(ii) of the Act and implemented The PTAC is an 11-member federal
revenue for the Medical Home Model in the CY 2017 Quality Payment advisory committee that is an important
nominal amount standard over the next Program final rule, a payment avenue for the creation of innovative
several years. arrangement with a payer (for example, payment models. The PTAC is charged
c. Qualifying APM Participant (QP) and payment arrangements authorized under with reviewing stakeholders proposed
Partial QP Determinations Title XIX, Medicare Health Plan PFPMs, and making comments and
payment arrangements, and payment recommendations to the Secretary
QPs are eligible clinicians in an arrangements in CMS Multi-Payer regarding whether they meet the PFPM
Advanced APM who have met a Models) must meet all three of the criteria established by the Secretary
threshold percentage of their patients or following criteria: (1) CEHRT is used; (2) through rulemaking in the CY 2017
payments through an Advanced APM the payment arrangement must require Quality Payment Program final rule. The
or, beginning in performance year 2019, the use of quality measures comparable Secretary is required to review the
attain QP status through the All-Payer to those in the quality performance comments and recommendations
Combination Option. Eligible clinicians category under MIPS; and (3) the submitted by the PTAC and post a
who are QPs for a year are excluded payment arrangement must either detailed response to these
from the MIPS reporting requirements require the APM Entities to bear more recommendations on the CMS Web site.
and payment adjustment for the year, than nominal financial risk if actual We sought comments on broadening
and receive a 5 percent APM Incentive aggregate expenditures exceed expected the definition of PFPM to include
Payment for the year in years from 2019 aggregate expenditures, or be a payment arrangements that involve
through 2024. The statute sets Medicaid Medical Home Model that Medicaid or the Childrens Health
thresholds for the level of participation meets criteria comparable to Medical Insurance Program (CHIP) as a payer
in Advanced APMs required for an Home Models expanded under section even if Medicare is not included as a
eligible clinician to become a QP for a 1115A(c) of the Act. payer. We are maintaining the current
year. In this final rule with comment definition of a PFPM to include only
We are finalizing that for Advanced period, we are finalizing policies that payment arrangements with Medicare as
APMs that start or end during the QP provide more detail about how the All- a payer. We believe this definition
Performance Period and operate Payer Combination Option will operate. retains focus on APMs and Advanced
continuously for a minimum of 60 days We are finalizing that an other payer APMs, which would be proposals that
during the QP Performance Period for arrangement would meet the generally the Secretary has more direct authority
the year, we are making QP applicable revenue-based nominal to implement, while maintaining
determinations using payment or amount standard we proposed if, under consistency for PTACs review while
patient data only for the dates that APM the terms of the other payer they are still refining their processes. In
Entities were able to participate in the arrangement, the total amount that an addition, we sought comment on the
Advanced APM per the terms of the APM Entity potentially owes the payer Secretarys criteria and stakeholders
Advanced APM, not for the full QP or foregoes is equal to at least: For the needs in developing PFPM proposals
Performance Period. 2019 and 2020 QP Performance Periods, aimed at meeting the criteria.
4. Summary of Major Provisions for the Medicare Part B claims. While we Improvement Activities Inventory.
Merit-Based Incentive Payment System proposed to maintain a 50 percent data Specifically, as discussed in the
(MIPS) completeness threshold for the 2018 appendices (Tables F and G) of this final
For Quality Payment Program Year 2, MIPS performance period, we are not rule with comment period, we are
which is the second year of the MIPS finalizing this proposal and will be finalizing 21 new improvement
and includes the 2018 performance keeping our previously finalized data activities (some with modification) and
period and the 2020 MIPS payment completeness threshold of 60 percent changes to 27 previously adopted
year, as well as the following: for data submitted on quality measures improvement activities (some with
using QCDRs, qualified registries, EHR, modification and including 1 removal)
a. Quality or Medicare Part B claims for the 2018 for the Quality Payment Program Year 2
We previously finalized that the MIPS performance period. We also and future years (2018 MIPS
quality performance category would proposed to have the data completeness performance period and future years)
comprise 60 percent of the final score threshold for the 2021 MIPS payment Improvement Activities Inventory.
for the transition year and 50 percent of year (2019 performance period) to 60 These activities were recommended by
the final score for the 2020 MIPS percent for data submitted on quality clinicians, patients and other
payment year (81 FR 77100). While we measures using QCDRs, qualified stakeholders interested in advancing
proposed to maintain a 60 percent registries, EHR, or Medicare Part B quality improvement and innovations in
weight for the quality performance claims. We are also finalizing this healthcare. We will continue to seek
category for the 2020 MIPS payment proposal. We anticipate that as MIPS new improvement activities as the
year, we are not finalizing this proposal eligible clinicians gain experience with program evolves. Additionally, we are
and will be keeping our previously the MIPS we will propose to further finalizing several policies related to
increase these thresholds over time. submission of improvement activities.
finalized policy to weight the quality
In particular, we are formalizing the
performance category at 50 percent for b. Improvement Activities
annual call for activities process for
the 2020 MIPS payment year. We are Improvement activities are those that Quality Payment Program Year 3 and
also finalizing that for purposes of the improve clinical practice or care future years. We are finalizing with
2021 MIPS payment year, the delivery and that, when effectively modification, for the Quality Payment
performance period for the quality and executed, are likely to result in Program Year 3 and future years, that
cost performance categories is CY 2019 improved outcomes. We believe stakeholders should apply one or more
(January 1, 2019 through December 31, improvement activities support broad of the criteria when submitting
2019). We note that we had previously aims within healthcare delivery, improvement activities in response to
finalized that for the purposes of the including care coordination, beneficiary the Annual Call for Activities. In
2020 MIPS payment year the engagement, population management, addition to the criteria listed in the
performance period for the quality and and health equity. For the 2020 MIPS proposed rule for nominating new
cost performance categories is CY 2018 payment year, we previously finalized improvement activities for the Annual
(January 1, 2018 through December 31, that the improvement activities Call for Activities policy, we are
2018). We did not make proposals to performance category would comprise modifying and expanding the proposed
modify this time frame in the CY 2018 15 percent of the final score (81 FR criteria list to also include: (1)
Quality Payment Program proposed rule 77179). There are no changes in Improvement activities that focus on
and are therefore unable to modify this improvement activities scoring for meaningful actions from the person and
performance period. Quality Payment Program Year 2 (2018 familys point of view, and (2)
Quality measures are selected MIPS performance period) as discussed improvement activities that support the
annually through a call for quality in section II.C.7.a.(5) of this final rule patients family or personal caregiver. In
measures under consideration, with a with comment period. However, in this addition, we are finalizing to: (1) Accept
final list of quality measures being final rule, we are finalizing our proposal submissions for prospective
published in the Federal Register by to no longer require self-identifications improvement activities at any time
November 1 of each year. We are for non-patient facing MIPS eligible during the performance period for the
finalizing for the CAHPS for MIPS clinicians, small practices, practices Annual Call for Activities and create an
survey for the Quality Payment Program located in rural areas or geographic Improvement Activities Under Review
Year 2 and future years that the survey HPSAs, or any combination thereof, (IAUR) list; (2) only consider
administration period will, at a beginning with the 2018 MIPS prospective activities submitted by
minimum, span over 8 weeks and, at a performance period and for future years. March 1 for inclusion in the
maximum, 17 weeks and will end no We are finalizing that for Quality Improvement Activities Inventory for
later than February 28th following the Payment Program Year 2 and future the performance periods occurring in
applicable performance period. In years (2018 MIPS performance period the following calendar year; and (3) add
addition, we are finalizing for the and future years), MIPS eligible new improvement activities and
Quality Payment Program Year 2 and clinicians or groups must submit data subcategories through notice-and-
future years to remove two Summary on improvement activities in one of the comment rulemaking in future years of
Survey Modules (SSMs), specifically, following manners: Via qualified the Quality Payment Program.
Helping You to Take Medication as registries, EHR submission mechanisms, Additionally, we are finalizing that
Directed and Between Visit QCDR, CMS Web Interface, or for purposes of the 2021 MIPS payment
Communication from the CAHPS for attestation; and that for activities that year, the performance period for the
MIPS survey. are performed for at least a continuous improvement activities performance
For the 2018 MIPS performance 90 days during the performance period, category is a minimum of a continuous
period, we previously finalized that the MIPS eligible clinicians must submit a 90-day period within CY 2019, up to
data completeness threshold would yes response for activities within the and including the full CY 2019 (January
increase to 60 percent for data Improvement Activities Inventory. 1, 2019 through December 31, 2019).
submitted on quality measures using In this final rule with comment In this final rule with comment
QCDRs, qualified registries, via EHR, or period, we are finalizing updates to the period, we are also expanding our
definition of how we will recognize an category focus on the secure exchange of decertified EHR technology, and
individual MIPS eligible clinician or health information and the use of significant hardship exceptions under
group as being a certified patient- CEHRT to support patient engagement the MIPS. We are also finalizing a
centered medical home or comparable and improved healthcare quality. While significant hardship exception for MIPS
specialty practice. We are finalizing our we continue to recommend that eligible clinicians in small practices. For
proposal, with clarification, that at least physicians and clinicians migrate to the clinicians requesting a reweighting of
50 percent of the practice sites within implementation and use of EHR the advancing care information
the TIN must be recognized as a patient- technology certified to the 2015 Edition performance category, we are changing
centered medical home or comparable so they may take advantage of improved the deadline for submission of this
specialty practice to receive full credit functionalities, including care application to December 31 of the
as a certified or recognized patient- coordination and technical performance period. Lastly, we are
centered medical home or comparable advancements such as application
finalizing additional improvement
specialty practice for the 2020 MIPS programming interfaces, or APIs, we
activities that are eligible for a 10
payment year and future years. We are recognize that some practices may have
clarifying that a practice site as is the challenges in adopting new certified percent bonus under the advancing care
physical location where services are health IT. Therefore, we are finalizing information performance category if
delivered. We proposed in section that MIPS eligible clinicians may they are completed using CEHRT.
II.C.6.e.(3)(b) of the proposed rule (82 continue to use EHR technology d. Cost
FR 30054) that eligible clinicians in certified to the 2014 Edition for the
practices that have been randomized to performance period in CY 2018. We previously finalized that the cost
the control group in the CPC+ model Clinicians may also choose to use the performance category would comprise
would also receive full credit as a 2015 Edition CEHRT or a combination zero percent of the final score for the
Medical Home Model. We are not of the two. Clinicians will earn a bonus transition year and 10 percent of the
finalizing this proposal, however, for using only 2015 CEHRT in 2018. final score for the 2020 MIPS payment
because CMMI has not randomized any For the 2018 performance period, year (81 FR 77165). For the 2020 MIPS
practices into a control group in CPC+ MIPS eligible clinicians will have the payment year, we proposed to change
Round 2. option to report the Advancing Care the weight of the cost performance
We are also finalizing changes to the Information Transition Objectives and category from 10 percent to zero percent
study, including modifying the name to Measures using 2014 Edition CEHRT, (82 FR 30047). For the 2020 MIPS
the CMS Study on Burdens Associated 2015 Edition CEHRT, or a combination payment year, we are finalizing a 10
with Reporting Quality Measures, of 2014 and 2015 Edition CEHRT, as
percent weight for the cost performance
increasing the sample size for 2018, and long as the EHR technology they possess
category in the final score in order to
updating requirements. can support the objectives and measures
Furthermore, in recognition of to which they plan to attest. Similarly, ease the transition to a 30 percent
improvement activities as supporting MIPS eligible clinicians will have the weight for the cost performance category
the central mission of a unified Quality option to attest to the Advancing Care in the 2021 MIPS payment year. For the
Payment Program, we are finalizing in Information Objectives and Measures 2018 MIPS performance period, we are
section II.C.6.e.(3)(a) of this final rule using 2015 Edition CEHRT or a adopting the total per capita costs for all
with comment period to continue to combination of 2014 and 2015 Edition attributed beneficiaries measure and the
designate activities in the Improvement CEHRT, as long as their EHR technology Medicare Spending per Beneficiary
Activities Inventory that will also can support the objectives and measures (MSPB) measure that were adopted for
qualify for the advancing care to which they plan to attest. the 2017 MIPS performance period, and
information bonus score. This is We are finalizing exclusions for the e- we will not use the 10 episode-based
consistent with our desire to recognize Prescribing and Health Information measures that were adopted for the 2017
that CEHRT is often deployed to Exchange Objectives beginning with the MIPS performance period. Although
improve care in ways that our programs 2017 performance period. We are also data on the episode-based measures has
should recognize. finalizing that eligible clinicians can been made available to clinicians in the
earn 10 percentage points in their past, we are in the process of developing
c. Advancing Care Information performance score for reporting to any new episode-based measures with
For the Quality Payment Program single public health agency or clinical significant clinician input and believe it
Year 2, the advancing care information data registry to meet any of the would be more prudent to introduce
performance category is 25 percent of measures associated with the Public these new measures over time. We will
the final score. However, if a MIPS Health and Clinical Data Registry continue to offer performance feedback
eligible clinician is participating in a Reporting objective (or any of the on episode-based measures prior to
MIPS APM the advancing care measures associated with the Public
potential inclusion of these measures in
information performance category may Health Reporting Objective of the 2018
MIPS to increase clinician familiarity
be 30 percent or 75 percent of the final Advancing Care Information Transition
score depending on the availability of Objectives and Measures, for clinicians with the concept as well as specific
APM quality data for reporting. We are who choose to report on those episode-based measures. Specifically,
finalizing that for purposes of the 2021 measures) and, and will award an we are providing feedback on these new
MIPS payment year, the performance additional 5 percentage point bonus for episode-based cost measures for
period for advancing care information reporting to more than one. We are informational purposes only. We intend
performance category is a minimum of implementing several provisions of the to provide performance feedback on the
a continuous 90-day period within CY 21st Century Cures Act (Pub. L. 114 MSPB and total per capita cost measures
2019, up to and including the full CY 255, enacted on December 13, 2016) by July 1, 2018, consistent with section
2019 (January 1, 2019 through December pertaining to hospital-based MIPS 1848(q)(12) of the Act. In addition, we
31, 2019). eligible clinicians, ambulatory surgical intend to offer feedback on newly
Objectives and measures in the center-based MIPS eligible clinicians, developed episode-based cost measures
advancing care information performance MIPS eligible clinicians using in 2018 as well.
e. Submission Mechanisms practitioners or one or more groups g. MIPS APMs

We are finalizing additional flexibility consisting of 10 or fewer eligible
clinicians that elect to form a virtual MIPS eligible clinicians who
for submitting data through multiple participate in MIPS APMs are scored
submission mechanisms. Due to group for a performance period for a
year. In order for solo practitioners or using the APM scoring standard instead
operational reasons and to allow of the generally applicable MIPS scoring
additional time to communicate how such groups to be eligible to join a
virtual group, the solo practitioners and standard. For the 2018 performance
this policy intersects with our measure period, we are finalizing modifications
applicability policies, this policy will the groups would need to exceed the
low-volume threshold. A solo to the quality performance category
not be implemented for the 2018 reporting requirements and scoring for
performance period but will be practitioner or a group that does not
MIPS eligible clinicians in MIPS APMs,
implemented instead for the 2019 exceed the low-volume threshold could
and other modifications to the APM
performance period of the Quality not participate in a virtual group, and it
scoring standard. For purposes of the
Payment Program. Individual MIPS is not permissible under the statute to
APM scoring standard, we are adding a
eligible clinicians or groups will be able apply the low-volume threshold at the
fourth snapshot date that would be used
to submit measures and activities, as virtual group level. Also, we are
only to identify eligible clinicians in
available and applicable, via as many finalizing our virtual group policies to
APM Entity groups participating in
mechanisms as necessary to meet the clearly delineate those group-related
those MIPS APMs that require full TIN
requirements of the quality, policies that apply to virtual groups
participation. This snapshot date will
improvement activities, or advancing versus policies that only apply to virtual
not be used to make QP determinations.
care information performance categories groups.
Along with the other APM Entity
for the 2019 performance period. This Virtual groups are required to make groups, these APM Entity groups would
option will provide clinicians the ability an election to participate in MIPS as a be used for the purposes of reporting
to select the measures most meaningful virtual group prior to the start of an and scoring under the APM scoring
to them, regardless of the submission applicable performance period. We are standard described in the CY 2017
mechanism. also finalizing a two-stage virtual group Quality Payment Program final rule (81
Also, given stakeholder concerns election process for the applicable 2018 FR 77246).
regarding CMS multiple submissions and 2019 performance periods. The first
mechanism policy, we want to clarify stage is the optional eligibility stage, but h. Facility-Based Measurement
that under the validation process for for practices that do not choose to We solicited comments on
Year 3, MIPS eligible clinicians who participate in stage 1 of the election implementing facility-based
submit via claims or registry submission process, we will make an eligibility measurement for the 2018 MIPS
only or a combination of claims and determination during stage 2 of the performance period and future
registry submissions would not be election process. The second stage is the performance periods to add more
required to submit measures through virtual group formation stage. We are flexibility for clinicians to be assessed
other mechanisms to meet the quality also finalizing that virtual groups must in the context of the facilities at which
performance category criteria; rather, it have a formal written agreement among they work. We described facility-based
is an option available to MIPS eligible each party of a virtual group. The measures policies related to applicable
clinicians which may increase their election deadline will be December 31. measures, applicability to facility-based
quality performance category score. We measurement, group participation, and
To provide support and reduce
expect that MIPS eligible clinicians facility attribution. For clinicians whose
burden, we intend to make technical
would choose the submission primary professional responsibilities are
assistance (TA) available, to the extent
mechanism that would give them 6 in a healthcare facility we presented a
feasible and appropriate, to support
measures to report. Our intention is to method to assess performance in the
clinicians who choose to come together
offer multiple submission mechanisms quality and cost performance categories
as a virtual group for the first 2 years of
to increase flexibility for MIPS of MIPS based on the performance of
virtual group implementation applicable
individual clinicians and groups. We that facility in another value-based
to the 2018 and 2019 performance years.
are not requiring that MIPS individual purchasing program.
Clinicians already receiving technical
clinicians and groups submit via
assistance may continue to do so for After much consideration, we are
additional submission mechanisms;
virtual groups support; otherwise, the finalizing our proposal to allow
however, through this policy the option
Quality Payment Service Center is clinicians to use facility-based
would be available for those that have
available to assist and connect virtual measurement in year 3 (2019) of the
applicable measures and/or activities
groups with a technical assistance Quality Payment Program. We will use
available to them.
representative. For year 2, we believe the 2018 year to ensure that clinicians
f. Virtual Groups that we have created an election process better understand the opportunity and
Virtual groups are a new way to that is simple and straightforward. For ensure operational readiness to offer
participate in MIPS starting with the Quality Payment Program Year 3, we facility-based measurement.
2018 MIPS performance period. For the intend to provide an electronic election
process, if technically feasible. i. Scoring
2018 performance period, clinicians can
participate in MIPS as an individual, as Virtual groups are required to meet In the transition year of the Quality
a group, as an APM Entity in a MIPS the requirements for each performance Payment Program, we finalized a
APM, or as a virtual group. category and responsible for aggregating unified scoring system to determine a
For the implementation of virtual data for their measures and activities final score across the 4 performance
groups as a participation option under across the virtual group, for example, categories (81 FR 77273 through 77276).
MIPS, we are establishing the following across their TINs. In future years, we For the 2018 MIPS performance period,
policies. We are defining a virtual group intend to examine how we define we will build on the scoring
as a combination of two or more TINs group under MIPS with respect to methodology we finalized for the
assigned to one or more solo flexibility in composition and reporting. transition year, focusing on encouraging
MIPS eligible clinicians to meet data score, or be reweighted if a performance are finalizing the use of a simplified
completeness requirements. category score is not available. self-nomination process for previously
For quality performance category We are also finalizing small practice approved QCDRs and qualified
scoring, we are finalizing to extend and complex patient bonuses only for registries in good standing.
some of the transition year policies to the 2020 MIPS payment year. The small In addition, regarding information a
the 2018 MIPS performance period and practice bonus of 5 points will be QCDR specifically must provide to us at
also finalizing several modifications to applied to the final score for MIPS the time of self-nomination, we are
existing policy. Quality measures that eligible clinicians in groups, virtual making a number of clarifications,
can be scored against a benchmark that groups, or APM Entities that have 15 or finalized that the term QCDR
meet data completeness standards, and fewer clinicians and that submit data on measures will replace the existing term
meet the minimum case size at least one performance category in the of non-MIPS measures, and sought
requirements will continue to receive 2018 performance period. We will also public input on requiring full
between 3 and 10 points as measure apply a complex patient bonus capped development and testing of QCDR
achievement points. Measures that do at 5 points using the dual eligibility measures by submission. We have also
not have a benchmark or meet the case ratio and average HCC risk score. We made a few clarifications to existing
minimum requirement will continue to increased the complex patients bonus criteria as they pertain to qualified
receive 3 points. from 3 points as proposed in part to registries.
For quality data submitted via EHR, align with the small practice bonus. The We are not making any changes to the
QCDR, or qualified registry, we are final score will be compared against the health IT vendors that obtain data from
lowering the number of points available MIPS performance threshold of 15 CEHRT requirements. Regarding CMS-
for measures that do not meet the data points for the 2020 MIPS payment year, approved survey vendors, we are
completeness criteria to 1 point, except a modest increase from 3 points in the finalizing that for the Quality Payment
for a measure submitted by a small transition year. A 15-point final score Program year 2 and for future years, that
practice, which we will continue to equal to the performance threshold can the vendor application deadline be
assign 3 points. be achieved via multiple pathways and January 31st of the applicable
We are finalizing a timeline to continues the gradual transition into performance year or a later date
identify and propose to remove topped MIPS. The additional performance specified by CMS. Lastly, based on
out quality measures through future threshold for exceptional performance comments we received on the 10-year
rulemaking. We are evaluating will remain at 70 points, the same as for record retention period and our interest
additional considerations needed to the transition year. in reducing financial and time burdens
maintain measures for important aspects We are finalizing a policy of applying
under this program and having
of care, such as patient safety and high the MIPS payment adjustment to the
consistent policies across this program,
reliability, and will address this in Medicare paid amount.
we are aligning our record retention
future rulemaking. We are finalizing a j. Performance Feedback period across the program by modifying
policy of applying a scoring cap to We proposed and are finalizing the our proposal for third parties from 10
identified topped out measures with policy to provide Quality Payment years to finalize a 6-year retention
measure benchmarks that have been Program performance feedback to period. Therefore, we are finalizing that
topped out for at least 2 consecutive eligible clinicians and groups. Initially, entities must retain all data submitted to
years; however, based on feedback, we we will provide performance feedback us for purposes of MIPS for a 6 years
will award up to 7 points for topped out on an annual basis. In future years, we from the end of the MIPS performance
measures rather than the 6 points aim to provide performance feedback on period.
originally proposed. We are finalizing a more frequent basis, which is in line
the special scoring policy for the 6 l. Public Reporting
with clinician requests for timely,
measures identified for the 2018 actionable feedback that they can use to As discussed in section II.C.11. of this
performance period with a 7-point improve care. final rule with comment period, we
scoring cap. proposed and are finalizing public
We are also excluding CMS Web k. Third Party Intermediaries reporting of certain eligible clinician
Interface measures from topped out In the CY 2017 Quality Payment and group Quality Payment Program
scoring, but we will continue to monitor Program final rule (81 FR 77362), we information, including MIPS and APM
differences between CMS Web Interface finalized that qualified registries, data in an easily understandable format
and other submission options. We QCDRs, health IT vendors, and CMS- as required under the MACRA.
intend to address CAHPS through future approved survey vendors will have the m. Eligibility and Exclusion Provisions
rulemaking. ability to act as intermediaries on behalf of the MIPS Program
Beginning with the 2018 MIPS of individual MIPS eligible clinicians
performance period, we are finalizing and groups for submission of data to We are modifying the definition of a
measuring improvement scoring at the CMS across the quality, improvement non-patient facing MIPS eligible
performance category level for the activities, and advancing care clinician to apply to virtual groups. In
quality performance category, but we information performance categories. addition, we are finalizing our proposal
will monitor this approach and revisit Regarding QCDRs and qualified to specify that groups considered to be
as needed through future rule making. registries, we are finalizing our proposal non-patient facing (more than 75
We are finalizing measuring to eliminate the self-nomination percent of the NPIs billing under the
improvement scoring at the measure submission method of email and require groups TIN meet the definition of a
level for the cost performance category. that QCDRs and qualified registries non-patient facing individual MIPS
For the 2018 MIPS performance submit their self-nomination eligible clinician) during the non-
period, the quality, improvement applications via a web-based tool for patient facing determination period
activities, cost and advancing care future program years beginning with the would automatically have their
information performance category 2018 performance period. Beginning advancing care information performance
scores will be given weight in the final with the 2019 performance period, we category reweighted to zero.
Additionally, we are finalizing our on specified measures and activities expenditures include approximately
proposal to increase the low-volume within four integrated performance $675$900 million in APM incentive
threshold to less than or equal to categories. payments to QPs.
$90,000 in Medicare Part B allowed Assuming that 90 percent of MIPS
eligible clinicians of all practice sizes G. Automatic Extreme and
charges or 200 or fewer Part-B enrolled
participate in MIPS, we estimate that Uncontrollable Circumstance Policy
Medicare beneficiaries to further
MIPS payment adjustments will be Interim Final Rule With Comment
decrease burden on MIPS eligible
approximately equally distributed Period
clinicians that practice in rural areas or
are part of a small practice or are solo between negative MIPS payment In order to account for Hurricanes
practitioners. We are not finalizing our adjustments of $118 million and Harvey, Irma, and Maria and other
proposal to provide clinicians the positive MIPS payment adjustments of disasters that have occurred or might
ability to opt-in to MIPS if they meet or $118 million to MIPS eligible clinicians, occur during the 2017 MIPS
exceed one, but not all, of the low- as required by the statute to ensure performance period, we are establishing
volume threshold determinations, budget neutrality. Positive MIPS in an interim final rule with comment
including as defined by dollar amount, payment adjustments will also include period an automatic extreme and
beneficiary count or, if established, up to an additional $500 million for uncontrollable circumstance policy for
items and services. We intend to revisit exceptional performance to MIPS the quality, improvement activities, and
this policy in future rulemaking and are eligible clinicians whose final score advancing care information performance
seeking comment on methods to meets or exceeds the additional categories for the 2017 MIPS
implement this policy in a low burden performance threshold of 70 points. performance period. We believe the
manner. These MIPS payment adjustments are automatic extreme and uncontrollable
expected to drive quality improvement circumstance policy will reduce
E. Payment Adjustments in the provision of MIPS eligible clinician burden during a catastrophic
For the 2020 payment year based on clinicians care to Medicare time and will also align with Medicare
Advanced APM participation in 2018 beneficiaries and to all patients in the policies in other programs such as the
performance period, we estimated that health care system. However, the Hospital IQR Program. Under this
approximately 185,000 to 250,000 distribution will change based on the policy, we will apply the extreme and
clinicians will become QPs, and final population of MIPS eligible uncontrollable circumstance policies for
therefore, be excluded from the MIPS clinicians for CY 2020 and the the MIPS performance categories to
reporting requirements and payment distribution of scores under the individual MIPS eligible clinicians for
adjustment, and qualify for a lump sum program. We believe that starting with the 2017 MIPS performance period
APM incentive payment equal to 5 these modest initial MIPS payment without requiring a MIPS eligible
percent of their estimated aggregate adjustments is in the long-term best clinician to submit an application when
payment amounts for covered interest of maximizing participation and we determine a triggering event, such as
professional services in the preceding starting the Quality Payment Program a hurricane, has occurred and the
year. We estimate that the total lump off on the right foot, even if it limits the clinician is in an affected area. We will
sum APM incentive payments will be magnitude of MIPS positive adjustments automatically weight the quality,
between approximately $675 million during the 2018 MIPS performance improvement activities, and advancing
and $900 million for the 2020 Quality period. The increased availability of care information performance categories
Payment Program payment year. This Advanced APM opportunities, at zero percent of the final score,
expected growth in QPs between the including through Medical Home resulting in a final score equal to the
first and second year of the program is models, also provides earlier avenues to performance threshold, unless the MIPS
due in part to reopening of CPC+ and earn APM incentive payments for those eligible clinician submits MIPS data
Next Generation ACO for 2018, and the eligible clinicians who choose to which we would then score on a
Medicare ACO Track 1+ Model which is participate. performance-category-by-performance-
projected to have a large number of category-basis, like all other MIPS
participants, with a large majority F. Benefits and Costs of the Final Rule eligible clinicians. We are not making
reaching QP status. With Comment Period any changes to the APM scoring
Under the policies in this final rule We quantify several costs associated standard policies that apply in 2017 for
with comment period, and for purposes with this rule. We estimate that this participants in MIPS APMs. We are
of the Regulatory Impact Analysis, we final rule with comment period will waiving notice and comment and
estimate that approximately 622,000 result in approximately $694 million in adopting this policy on an interim final
eligible clinicians will be subject to collection of information-related basis due to the urgency of providing
MIPS reporting requirements and burden. We estimate that the relief for MIPS eligible clinicians
payment adjustments in the 2018 MIPS incremental collection of information- impacted by recent natural disasters
performance period. However, this related burden associated with this final during the 2017 MIPS performance
number may vary depending on the rule with comment period is a reduction period.
number of eligible clinicians excluded of approximately $13.9 million relative
from MIPS based on their status as QPs to the estimated burden of continuing H. Stakeholder Input
or Partial QPs. After restricting the the policies the CY 2017 Quality In developing this final rule with
population to eligible clinician types Payment Program final rule, which is comment period, we sought feedback
who are not newly enrolled, we believe $708 million. We also estimate from stakeholders and the public
the increase in the low-volume regulatory review costs of $2.2 million throughout the process, including in the
threshold is expected to exclude for this final rule with comment period. CY 2018 Quality Payment Program
540,000 clinicians who do not exceed We estimate that federal expenditures proposed rule, CY 2017 Quality
the low-volume threshold. In the 2020 will include $118 million in revenue Payment Program final rule with
MIPS payment year, MIPS payment neutral payment adjustments and $500 comment period, listening sessions,
adjustments will be applied based on million for exceptional performance webinars, and other listening venues.
MIPS eligible clinicians performance payments. Additional federal We received a high degree of interest
from a broad spectrum of stakeholders. forward to your feedback on existing or These terms and definitions are
We thank our many commenters and the need for new resources. discussed in detail in relevant sections
acknowledge their valued input of this final rule with comment period.
II. Provisions of the Proposed
throughout the rulemaking process. We C. MIPS Program Details
Regulations, and Analysis of and
summarize and respond to comments on
Responses to Comments 1. MIPS Eligible Clinicians
our proposals in the appropriate
sections of this final rule with comment The following is a summary of the a. Definition of a MIPS Eligible
period, though we are not able to proposed provisions in the Medicare Clinician
address all comments or all issues that Program; CY 2018 Updates to the
all commenters raised due to the Quality Payment Program proposed In the CY 2017 Quality Payment
volume of comments and feedback. rule (82 FR 3001030500) (hereinafter Program final rule (81 FR77040 through
Specifically, due to the volume of referred to as the CY 2018 Quality 77041), we defined at 414.1305 a MIPS
comments we have not summarized Payment Program proposed rule. In eligible clinician, as identified by a
feedback from commenters on items we this section, we also provide summaries unique billing TIN and NPI combination
solicited feedback on for future of the public comments and our used to assess performance, as any of
rulemaking purposes. However, in responses. the following (excluding those
identified at 414.1310(b)): A physician
general, commenters continue to be A. Introduction (as defined in section 1861(r) of the
supportive as we continue
The Quality Payment Program, Act), a physician assistant, nurse
implementation of the Quality Payment
authorized by the Medicare Access and practitioner, and clinical nurse
Program and maintain optimism as we
CHIP Reauthorization Act of 2015 specialist (as such terms are defined in
move from FFS Medicare payment
(MACRA) is a new approach for section 1861(aa)(5) of the Act), a
towards a payment structure focused on
reforming care across the health care certified registered nurse anesthetist (as
the quality and value of care. Public
delivery system for eligible clinicians. defined in section 1861(bb)(2) of the
support for our proposed approach and
Under the Quality Payment Program, Act), and a group that includes such
policies in the proposed rule, which
eligible clinicians can participate via clinicians. We established at
many were finalized, focused on the 414.1310(b) and (c) that the following
potential for improving the quality of one of two pathways: Advanced
Alternative Payment Models (APMs); or are excluded from this definition per the
care delivered to beneficiaries and statutory exclusions defined in section
increasing value to the publicwhile the Merit-based Incentive Payment
System (MIPS). We began implementing 1848(q)(1)(C)(ii) and (v) of the Act: (1)
rewarding eligible clinicians for their QPs; (2) Partial QPs who choose not to
efforts. Additionally we note that we the Quality Payment Program through
rulemaking for calendar year (CY) 2017. report on applicable measures and
received a number of comments from activities that are required to be
stakeholders in regards to the This rule provides updates for the
reported under MIPS for any given
application of MIPS to certain Part B second and future years of the Quality
performance period in a year; (3) low-
drugs. Additional guidance on the Payment Program.
volume threshold eligible clinicians;
applicability of MIPS to Part B drugs B. Definitions and (4) new Medicare-enrolled eligible
can be found on our Web site at clinicians. In accordance with sections
qpp.cms.gov. At 414.1305, subpart O, we define
the following terms: 1848(q)(1)(A) and (q)(1)(C)(vi) of the
We thank stakeholders again for their Act, we established at 414.1310(b)(2)
responses throughout our process, in Ambulatory Surgical Center (ASC)- that eligible clinicians (as defined at
various venues, including comments on based MIPS eligible clinician. 414.1305) who are not MIPS eligible
the Request for Information Regarding CMS Multi-Payer Model. clinicians have the option to voluntarily
Implementation of the Merit-based Facility-based MIPS eligible clinician. report measures and activities for MIPS.
Incentive Payment System, Promotion Full TIN APM. Additionally, we established at
of Alternative Payment Models, and Improvement Scoring. 414.1310(d) that in no case will a
Incentive Payments for Participation in Other MIPS APM. MIPS payment adjustment apply to the
Eligible Alternative Payment Models Solo practitioner. items and services furnished during a
(herein referred to as the MIPS and Virtual group. year by eligible clinicians who are not
APMs RFI) (80 FR 59102 through 59113) We revise the definitions of the MIPS eligible clinicians, as described in
and the CY 2017 Quality Payment following terms: 414.1310(b) and (c), including those
Program final rule (81 FR 77008 through who voluntarily report on applicable
Affiliated practitioner.
77831). We intend to continue open measures and activities specified under
APM Entity.
communication with stakeholders, MIPS.
Attributed beneficiary.
including consultation with tribes and In the CY 2017 Quality Payment
Certified Electronic Health Record
tribal officials, on an ongoing basis as Program final rule (81 FR 77340), we
Technology (CEHRT).
we develop the Quality Payment noted that the MIPS payment
Final Score.
Program in future years. adjustment applies only to the amount
Hospital-based MIPS eligible
We will continue to offer help so otherwise paid under Part B with
clinician.
clinicians can be successful in the respect to items and services furnished
Low-volume threshold.
program and make informed decisions by a MIPS eligible clinician during a
Medicaid APM.
about how to participate. You can find year, in which we will apply the MIPS
Non-patient facing MIPS eligible
out more about the help thats available payment adjustment at the TIN/NPI
clinician.
at qpp.cms.gov, which has many free level. We have received requests for
Other Payer Advanced APM.
and customized resources, or by calling additional clarifications on which
18662888292. As with the policy Rural areas. specific Part B services are subject to the
decisions, stakeholder feedback is Small practice. MIPS payment adjustment, as well as
essential to the development of We remove the following terms: which Part B services are included for
educational resources as well. We look Advanced APM Entity. eligibility determinations. We note that
when Part B items or services are permitting groups to split TINs if they occurring in 2018 and future years, we
furnished by suppliers that are also choose to participate in MIPS as a proposed that we would determine the
MIPS eligible clinicians, there may be group. Thus, we would like to clarify size of small practices as described in
circumstances in which it is not that we consider a group to be either an this section of the final rule with
operationally feasible for us to attribute entire single TIN or portion of a TIN comment period (82 FR 30020). As
those items or services to a MIPS that: (1) Is participating in MIPS noted in the CY 2017 Quality Payment
eligible clinician at an NPI level in order according to the generally applicable Program final rule, the size of a group
to include them for purposes of scoring criteria while the remaining (including a small practice) would be
applying the MIPS payment adjustment portion of the TIN is participating in a determined before exclusions are
or making eligibility determinations. MIPS APM or an Advanced APM applied (81 FR 77057). We note that
To further clarify, there are according to the MIPS APM scoring group size determinations are based on
circumstances that involve Part B standard; and (2) chooses to participate the number of NPIs associated with a
prescription drugs and durable medical in MIPS at the group level. We also TIN, which would include eligible
equipment (DME) where the supplier defined an APM Entity group at clinicians (NPIs) who may be excluded
may also be a MIPS eligible clinician. In 414.1305 as a group of eligible from MIPS participation and do not
the case of a MIPS eligible clinician who clinicians participating in an APM meet the definition of a MIPS eligible
furnishes a Part B covered item or Entity, as identified by a combination of clinician.
service, such as prescribing Part B drugs the APM identifier, APM Entity To make eligibility determinations
that are dispensed, administered, and identifier, TIN, and NPI for each regarding the size of small practices for
billed by a supplier that is a MIPS participating eligible clinician. performance periods occurring in 2018
eligible clinician, or ordering DME that and future years, we proposed that we
is administered and billed by a supplier c. Small Practices would determine the size of small
that is a MIPS eligible clinician, it is not In the CY 2017 Quality Payment practices by utilizing claims data (82 FR
operationally feasible for us at this time Program final rule (81 FR 77188), we 30020). For purposes of this section, we
to associate those billed allowed charges defined the term small practices at are coining the term small practice size
with a MIPS eligible clinician at an NPI 414.1305 as practices consisting of 15 determination period to mean a 12-
level in order to include them for or fewer clinicians and solo month assessment period, which
purposes of applying the MIPS payment practitioners. However, it has come to consists of an analysis of claims data
adjustment or making eligibility our attention that there is inconsistency that spans from the last 4 months of a
determinations. To the extent that it is between the proposed definition of a calendar year 2 years prior to the
not operationally feasible for us to do solo practitioner discussed in section performance period followed by the first
so, such items or services would not be II.C.4.b. of this final rule with comment 8 months of the next calendar year and
included for purposes of applying the period and the established definition of includes a 30-day claims run out. This
MIPS payment adjustment or making a small practice. Therefore, to resolve would allow us to inform small
eligibility determinations. However, for this inconsistency and ensure greater practices of their status near the
those billed Medicare Part B allowed consistency with established MIPS beginning of the performance period as
charges that we are able to associate terminology, we are modifying the it pertains to eligibility relating to
with a MIPS eligible clinician at an NPI definition of a small practice at technical assistance, applicable
level, such items and services would be 414.1305 to mean a practice consisting improvement activities criteria, the
included for purposes of applying the of 15 or fewer eligible clinicians. This proposed hardship exception for small
MIPS payment adjustment or making modification is not intended to practices under the advancing care
eligibility determinations. substantively change the definition of a information performance category, and
small practice. In section II.C.4.d. of this the proposed small practice bonus for
b. Groups final rule with comment period, we the final score.
As discussed in the CY 2017 Quality discuss how small practice status would Thus, for purposes of performance
Payment Program final rule (81 FR apply to virtual groups. Also, in the periods occurring in 2018 and the 2020
77088 through 77831), we indicated that final rule with comment period, we MIPS payment year, we would identify
we will assess performance either for noted that we would not make an small practices based on 12 months of
individual MIPS eligible clinicians or eligibility determination regarding the data starting from September 1, 2016 to
for groups. We defined a group at size of small practices, but indicated August 31, 2017. We would not change
414.1305 as a single Taxpayer that small practices would attest to the an eligibility determination regarding
Identification Number (TIN) with two or size of their group practice (81 FR the size of a small practice once the
more eligible clinicians (including at 77057). However, we have since determination is made for a given
least one MIPS eligible clinician), as realized that our system needs to performance period and MIPS payment
identified by their individual NPI, who account for small practice size in year. We recognize that there may be
have reassigned their Medicare billing advance of a performance period for circumstances in which the small
rights to the TIN. We recognize that operational purposes relating to practice size determinations made do
MIPS eligible clinicians participating in assessing and scoring the improvement not reflect the real-time size of such
MIPS may be part of a TIN that has one activities performance category, practices. We considered two options
portion of its NPIs participating in MIPS determining hardship exceptions for that could address such potential
according to the generally applicable small practices, calculating the small discrepancies. One option would
scoring criteria while the remaining practice bonus for the final score, and include an expansion of the proposed
portion of its NPIs is participating in a identifying small practices eligible for small practice size determination period
MIPS APM or an Advanced APM technical assistance. As a result, we to 24 months with two 12-month
according to the MIPS APM scoring believe it is critical to modify the way segments of data analysis (before and
standard. In the CY 2017 Quality in which small practice size would be during the performance period), in
Payment Program final rule (81 FR determined. To make eligibility which we would conduct a second
77058), we noted that except for groups determinations regarding the size of analysis of claims data during the
containing APM participants, we are not small practices for performance periods performance period. Such an expanded
determination period may better capture year and includes a 30-day claims run analysis of claims data that spans from
the real-time size of small practices, but out for the small practice size the last 4 months of a calendar year 2
determinations made during the determination. years prior to the performance period
performance period prevent our system Comment: Several commenters followed by the first 8 months of the
from being able to account for the supported the proposal to notify small next calendar year and includes a 30-
assessment and scoring of the practices of their status near the day claims run out for the small practice
improvement activities performance beginning of the performance period so size determination. We anticipate
category and identification of small that practices can plan accordingly. providing MIPS eligible clinicians with
practices eligible for technical Response: We are finalizing that we their small practice size determination
assistance prior to the performance will utilize a 12-month assessment by Spring 2018, for the applicable 2018
period. Specifically, our system needs to period, which consists of an analysis of performance period.
capture small practice determinations in claims data that spans from the last 4 As discussed in the CY 2018 Quality
advance of the performance period in months of a calendar year 2 years prior Payment Program proposed rule (82 FR
order for the system to reflect the to the performance period followed by 30020), there are operational barriers
applicable requirements for the the first 8 months of the next calendar with allowing groups to attest to their
improvement activities performance year and includes a 30-day claims run size. Specifically, since individual MIPS
category and when a small practice out for the small practice size eligible clinicians and groups are not
bonus would be applied. A second determination. We anticipate providing required to register to participate in
option would include an attestation MIPS eligible clinicians with their small MIPS (except for groups utilizing the
component, in which a small practice practice size determination by Spring CMS Web Interface for the Quality
that was not identified as a small 2018, for the applicable 2018 Payment Program or administering the
practice during the small practice size performance period. CAHPS for MIPS survey), requiring
determination period would be able to Comment: Several commenters small practices to attest to the size of
attest to the size of their group practice recommended that practices be allowed their group practice prior to the
prior to the performance period. to attest the size of their practice if they performance period could increase
However, this second option would are not identified during the small burden on individual MIPS eligible
require us to develop several practice size determination period. clinicians and groups. In addition,
operational improvements, such as a Specifically, a few commenters attestation would require us to develop
manual process or system that would expressed concern that utilizing claims several operational improvements, such
provide an attestation mechanism for data will result in practices learning of as a manual process or system that
small practices, and a verification their small practice status too close to would provide an attestation
process to ensure that only small the start of the performance period. A mechanism for small practices, and a
practices are identified as eligible for few commenters recommended that we verification process to ensure that only
technical assistance. Since individual should rely on attestation alone, and small practices are identified as eligible
MIPS eligible clinicians and groups are expressed concern that claims data will for technical assistance. We believe
not required to register to participate in not provide a reliable, real-time utilizing claims data will support most
MIPS (except for groups utilizing the determination of practice size. Another eligibility determinations because we
CMS Web Interface for the Quality commenter specifically recommended consider it a reliable source of how a
Payment Program or administering the that practices be required to attest 180 MIPS eligible clinician or group
CAHPS for MIPS survey), requiring days before the close of the performance interacts with Medicare.
small practices to attest to the size of period so that practices can accurately Comment: One commenter expressed
their group practice prior to the predict their status. One commenter concern that using performance period
performance period could increase recommended that we validate practice data or an attestation portal as a second
burden on individual MIPS eligible size for groups attesting as small using step in the small practice identification
clinicians and groups that are not recent claims data. One commenter process does not provide practices with
already utilizing the CMS Web Interface recommended utilizing a claims adequate advanced notice of their
for the Quality Payment Program or determination process as well as practice size determination and could
administering the CAHPS for MIPS attestation, and using whichever limit their ability to access small
survey. We solicited public comment on method yields a smaller practice size. practice support services.
the proposal regarding how we would Response: Regarding the various Response: We are finalizing that we
determine small practice size. commenters that provided different will utilize a 12-month assessment
The following is a summary of the methods for validating practice size, period, which consists of an analysis of
public comments received on the including: Attesting as small using claims data that spans from the last 4
Small Practices proposal and our recent claims data; utilizing an 180 days months of a calendar year 2 years prior
responses: attestation period; or utilizing a claims to the performance period followed by
Comment: Several commenters determination process as well as the first 8 months of the next calendar
supported using historical claims data attestation, we have considered various year and includes a 30-day claims run
to make a small practice size approaches and have determined that out for the small practice size
determination. One commenter also the most straightforward approach determination. This proposed
noted support for the definition of a which provides the lowest burden to modification of the claims run out
small practice using the number of NPIs MIPS eligible clinicians is the period from 60 days to 30 days increases
associated with a TIN. utilization of claims data. By utilizing the speed of delivery for communication
Response: We are finalizing that we claims data, we can apply the status of and creation of the file using claims
will utilize a 12-month assessment a small practice accurately without data. In addition, using the 30-day
period, which consists of an analysis of requiring clinicians to take a separate claims run out allows us to inform small
claims data that spans from the last 4 action and attest to being a small practices of their determination as soon
months of a calendar year 2 years prior practice. Therefore, we are finalizing as technically possible, as it pertains to
to the performance period followed by that we will utilize a 12-month eligibility relating to technical
the first 8 months of the next calendar assessment period, which consists of an assistance, applicable improvement
activities criteria, the proposed hardship MIPS eligible clinicians and eligible rural, using the most recent Health
exception for small practices under the clinicians, such as those in APMs. As Resources and Services Administration
advancing care information performance discussed above, we are modifying the (HRSA) Area Health Resource File data
category, and the proposed small definition of a small practice at set available.
practice bonus for the final score. As a 414.1305 to mean a practice consisting We recognize that there are cases in
result, we do not believe clinicians of 15 or fewer eligible clinicians. This which an individual MIPS eligible
ability to access small practice support modification is not intended to clinician (including a solo practitioner)
services will be limited. substantively change the definition of a or a group may have multiple practice
Comment: A few commenters small practice. In response to the sites associated with its TIN and as a
recommended that we should not allow suggestions that we assess the number result, it is critical for us to outline the
practices to attest that they are small of clinicians at a physical practice site application of rural area and HPSA
practices. Specifically, one commenter to determine small practice status, or practice designations to such practices.
expressed concern that practices may make the small practice assessment For performance periods occurring in
mistakenly expect to be identified as based on the number of full-time 2017, we consider an individual MIPS
small based on their number of MIPS equivalent employees, we acknowledge eligible clinician or a group with at least
eligible clinicians and attest incorrectly. that some practices may be structured in one practice site under its TIN in a ZIP
Response: We acknowledge and agree this manner; however, we do not code designated as a rural area or HPSA
with the commenters concern. We have currently have a reliable method of to be a rural area or HPSA practice. For
considered various approaches and have making a determination that does not performance periods occurring in 2018
determined that the most require a separate action from such and future years, we believe that a
straightforward and best representation practices, such as attestation or higher threshold than one practice
of small practice size determination is submission of supporting
the utilization of claims data. Therefore, within a TIN is necessary to designate
documentation to verify these statuses. an individual MIPS eligible clinician, a
we are finalizing that we will utilize a Rather, we believe the approach of
12-month assessment period, which group, or a virtual group as a rural or
simply counting the NPIs (clinicians) HPSA practice. We recognize that the
consists of an analysis of claims data that are associated with a TIN provides
that spans from the last 4 months of a establishment of a higher threshold
a simple method for all stakeholders to
calendar year 2 years prior to the starting in 2018 would more
understand.
performance period followed by the first appropriately identify groups and
Final Action: After consideration of
8 months of the next calendar year and the public comments, we are finalizing virtual groups with multiple practices
includes a 30-day claims run out for the that we will utilize a 12-month under a groups TIN or TINs that are
small practice size determination. assessment period, which consists of an part of a virtual group as rural or HPSA
Comment: Several commenters did analysis of claims data that spans from practice and ensure that groups and
not support the previously finalized the last 4 months of a calendar year 2 virtual groups are assessed and scored
definition of small practices as practices years prior to the performance period according to requirements that are
consisting of 15 or fewer clinicians and followed by the first 8 months of the applicable and appropriate. We note
solo practitioners. One commenter next calendar year and includes a 30- that in the CY 2017 Quality Payment
recommended that we modify the day claims run out for the small practice Program final rule (81 FR 77048 through
definition of small practices to include size determination. In addition, as 77049), we defined a non-patient facing
those that are similar in challenges and discussed above, we are modifying the MIPS eligible clinician at 414.1305 as
structure, but that may include more definition of a small practice at including a group provided that more
than 15 clinicians. The commenter 414.1305 to mean a practice consisting than 75 percent of the NPIs billing
noted that several small practices may of 15 or fewer eligible clinicians. This under the groups TIN meet the
be loosely tied together under the same modification is not intended to definition of a non-patient facing
TIN but may function as small practices substantively change the definition of a individual MIPS eligible clinician
without the benefit of shared small practice. Finally, we refer readers during the non-patient facing
organizational and administrative to section II.C.4.b. of this final rule with determination period. We refer readers
resources. The commenter comment period for a discussion of the to section II.C.1.e. of this final rule with
recommended that we assess the definition of a solo practitioner. comment period for our policy to
number of clinicians at a physical modify the definition of a non-patient
practice site to determine small practice d. Rural Area and Health Professional facing MIPS eligible clinician. We
status and ability to join a virtual group. Shortage Area Practices believe that using a similar threshold for
Several commenters believed that we In the CY 2017 Quality Payment applying the rural and HPSA
should define small practices based on Program final rule, we defined rural designation to an individual MIPS
the number of MIPS eligible clinicians, areas at 414.1305 as clinicians in ZIP eligible clinician, a group, or virtual
not eligible clinicians. A few codes designated as rural, using the group with multiple practices under its
commenters supported defining small most recent Health Resources and TIN or TINs within a virtual group will
practices based on the number of full- Services Administration (HRSA) Area add consistency for such practices
time equivalent employees, arguing that Health Resource File data set available; across the MIPS as it pertains to groups
rural and HPSAs use different staffing and Health Professional Shortage Areas and virtual groups obtaining such
arrangements to fully staff their (HPSAs) at 414.1305 as areas statuses. We also believe that
practices. designated under section 332(a)(1)(A) of establishing a 75 percent threshold

Response: Section 1848(q)(2)(B)(iii) of the Public Health Service Act. For renders an adequate representation of a
the Act defines small practices as technical accuracy purposes, we group or virtual group where a
consisting of 15 or fewer professionals. proposed to remove the language significant portion of a group or a
We previously defined small practices clinicians in as clinicians are not virtual group is identified as having
at 414.1305 as practices consisting of technically part of a ZIP code and such status. Therefore, for performance
15 or fewer clinicians and solo modify the definition of a rural areas at periods occurring in 2018 and future
practitioners in order to include both 414.1305 as ZIP codes designated as years, we proposed that an individual
MIPS eligible clinician, a group, or a appropriately identifies groups and that the 75 percent threshold provides
virtual group with multiple practices virtual groups with multiple practices adequate representation of the group,
under its TIN or TINs within a virtual under a groups TIN or TINs that are and it also aligns with our definition of
group would be designated as a rural or part of a virtual group as rural or HPSA a non-patient facing group, which
HPSA practice if more than 75 percent practices and ensure that groups and provides consistency across the
of NPIs billing under the individual virtual groups are assessed and scored program. We believe rural and HPSA
MIPS eligible clinician or groups TIN or according to requirements that are status should be assigned to groups
within a virtual group, as applicable, are applicable and appropriate. We will because we believe those clinicians that
designated in a ZIP code as a rural area take the suggestions for further analysis are in a rural or HPSA area and choose
or HPSA (82 FR 30020 through 30021). on the characteristics of practices to participate in MIPS as part of a group,
The following is a summary of the currently defined as rural or HPSA to should receive the benefit of those
public comments received on the Rural identify practices that may be statuses, regardless of their chosen
Area and Health Professional Shortage inappropriately classified into participation mechanism. In regards to
Area Practices proposals and our consideration in future rulemaking as the commenter who did not support the
responses: necessary. use of ZIP codes as a reliable indicator
Comment: Several commenters Comment: Several commenters did of rural status due to clinicians
supported the proposals to modify the not support the proposed definition of practicing at multiple sites, we disagree.
definition of rural areas as ZIP codes rural areas and did not support the We believe that utilizing ZIP codes
designated as rural and a rural group proposed group definition of rural and designated as rural is an appropriate
when more than 75 percent of NPIs HPSA practice. One commenter did not indicator of rural status. We further note
billing under the individual MIPS support the use of ZIP codes as a that if a clinician practices at multiple
eligible clinician or groups TIN or reliable indicator of rural status as some sites that have different TINs, each TIN
within a virtual group, as applicable, are clinicians have multiple sites inside and would have a separate rural analysis
designated in a ZIP code as a rural area outside of rural areas. A few applied for that particular site (TIN).
or HPSA. Another commenter commenters recommended that we not Final Action: After consideration of
recommended that we conduct further adopt the policy that a group be the public comments, we are finalizing
analysis on those clinicians who considered rural if more than 75 percent the definition of rural areas at
thought they qualified as a rural area or of NPIs billing under the TIN are 414.1305 as ZIP codes designated as
HPSA practice but did not meet the 75 designated in a ZIP code as rural or rural, using the most recent Health
percent threshold. HPSA because it would overly limit the Resources and Services Administration
Response: We are finalizing that the number of rural group practices. Of (HRSA) Area Health Resource File data
definition of a rural areas at 414.1305 these commenters, two recommended set available. In addition, we are
as ZIP codes designated as rural, using using 50 percent as a threshold, and one finalizing that for performance periods
the most recent Health Resources and commenter recommended a gradual occurring in 2018 and future years, that
Services Administration (HRSA) Area transition using the 2017 threshold for an individual MIPS eligible clinician, a
Health Resource File data set available. the 2018 MIPS performance period and group, or a virtual group with multiple
In addition, we are finalizing that for thresholds of 25 percent, 50 percent, practices under its TIN or TINs within
performance periods occurring in 2018 and 75 percent in performance periods a virtual group would be designated as
and future years, that an individual occurring in 2019, 2020, and 2021, a rural or HPSA practice if more than 75
MIPS eligible clinician, a group, or a respectively. A few commenters percent of NPIs billing under the
virtual group with multiple practices believed that expanding the number of individual MIPS eligible clinician or
under its TIN or TINs within a virtual clinicians in rural or HPSA groups groups TIN or within a virtual group, as
group would be designated as a rural or would hamper the ability of those applicable, are designated in a ZIP code
HPSA practice if more than 75 percent practices to participate fully in the as a rural area or HPSA.
of NPIs billing under the individual transition to value-based care and
MIPS eligible clinician or groups TIN or e. Non-Patient Facing MIPS Eligible
increase disparities between urban and
within a virtual group, as applicable, are Clinicians
rural care. One commenter stated that
designated in a ZIP code as a rural area the status of rural or HPSA should be Section 1848(q)(2)(C)(iv) of the Act
or HPSA. In regard to the suggestion assigned to an individual but not be requires the Secretary, in specifying
that we conduct further analysis on assigned to a group. measures and activities for a
those clinicians who thought they Response: We are finalizing that an performance category, to give
qualified as a rural area or HPSA individual MIPS eligible clinician, a consideration to the circumstances of
practice but did not meet the 75 percent group, or a virtual group with multiple professional types (or subcategories of
threshold, we would encourage those practices under its TIN or TINs within those types determined by practice
stakeholders to contact our Quality a virtual group would be designated as characteristics) who typically furnish
Payment Program Service Center which a rural or HPSA practice if more than 75 services that do not involve face-to-face
may be reached at 18662888292 percent of NPIs billing under the interaction with a patient. To the extent
(TTY 18777156222), available individual MIPS eligible clinician or feasible and appropriate, the Secretary
Monday through Friday, 8:00 a.m.8:00 groups TIN or within a virtual group, as may take those circumstances into
p.m. Eastern Time or via email at QPP@ applicable, are designated in a ZIP code account and apply alternative measures
cms.hhs.gov. as a rural area or HPSA. We do not or activities that fulfill the goals of the
Comment: One commenter believe establishing a 75 percent applicable performance category to such
recommended we further analyze the threshold would overly limit the non-patient facing MIPS eligible
characteristics of practices currently number of rural group practices, nor clinicians. In carrying out these
defined as rural or HPSA to identify hamper their ability to participate fully provisions, we are required to consult
practices that may be inappropriately in the transition to value-based care, or with non-patient facing MIPS eligible
classified. increase disparities between urban and clinicians.
Response: We believe that rural care. In response to the various In addition, section 1848(q)(5)(F) of
establishing a 75 percent threshold more threshold recommendations, we believe the Act allows the Secretary to re-weight
MIPS performance categories if there are intend to publish the list of patient- facing determination period is a 24-
not sufficient measures and activities facing encounter codes for performance month assessment period, which
applicable and available to each type of periods occurring in 2018 at includes a two-segment analysis of
MIPS eligible clinician. We assume qpp.cms.gov by the end of 2017. The list claims data regarding patient-facing
many non-patient facing MIPS eligible of patient-facing encounter codes is encounters during an initial 12-month
clinicians will not have sufficient used to determine the non-patient facing period prior to the performance period
measures and activities applicable and status of MIPS eligible clinicians. followed by another 12-month period
available to report under the The list of patient-facing encounter during the performance period. The
performance categories under MIPS. We codes includes two general categories of
initial 12-month segment of the non-
refer readers to section II.C.6.f. of this codes: Evaluation and Management
patient facing determination period
final rule with comment period for the (E&M) codes; and Surgical and
Procedural codes. E&M codes capture spans from the last 4 months of a
discussion regarding how we address
performance category weighting for clinician-patient encounters that occur calendar year 2 years prior to the
MIPS eligible clinicians for whom no in a variety of care settings, including performance period followed by the first
measures or activities are applicable and office or other outpatient settings, 8 months of the next calendar year and
available in a given performance hospital inpatient settings, emergency includes a 60-day claims run out, which
category. departments, and nursing facilities, in allows us to inform individual MIPS
In the CY 2017 Quality Payment which clinicians utilize information eligible clinicians and groups of their
Program final rule (81 FR 77048 through provided by patients regarding history, non-patient facing status during the
77049), we defined a non-patient facing present illness, and symptoms to month (December) prior to the start of
MIPS eligible clinician for MIPS at determine the type of assessments to the performance period. The second 12-
414.1305 as an individual MIPS conduct. Assessments are conducted on month segment of the non-patient facing
eligible clinician that bills 100 or fewer the affected body area(s) or organ determination period spans from the
patient-facing encounters (including system(s) for clinicians to make medical last 4 months of a calendar year 1 year
Medicare telehealth services defined in decisions that establish a diagnosis or prior to the performance period
section 1834(m) of the Act) during the select a management option(s). followed by the first 8 months of the
non-patient facing determination Surgical and Procedural codes capture performance period in the next calendar
period, and a group provided that more clinician-patient encounters that
year and includes a 60-day claims run
than 75 percent of the NPIs billing involve procedures, surgeries, and other
out, which will allow us to inform
under the groups TIN meet the medical services conducted by
clinicians to treat medical conditions. In additional individual MIPS eligible
definition of a non-patient facing
the case of many of these services, clinicians and groups of their non-
individual MIPS eligible clinician
during the non-patient facing evaluation and management work is patient status during the performance
determination period. In order to included in the payment for the single period.
account for the formation of virtual code instead of separately reported. However, based on our analysis of
groups starting in the 2018 performance Patient-facing encounter codes from data from the initial segment of the non-
year and how non-patient facing both of these categories describe direct patient facing determination period for
determinations would apply to virtual services furnished by eligible clinicians performance periods occurring in 2017
groups, we need to modify the with impact on patient safety, quality of (that is, data spanning from September
definition of a non-patient facing MIPS care, and health outcomes. 1, 2015 to August 31, 2016), we found
eligible clinician. Therefore, for For purposes of the non-patient facing that it may not be necessary to include
performance periods occurring in 2018 policies under MIPS, the utilization of
a 60-day claims run out since we could
and future years, we proposed to modify E&M codes and Surgical and Procedural
achieve a similar outcome for such
the definition of a non-patient facing codes allows for accurate identification
of patient-facing encounters, and thus, eligibility determinations by utilizing a
MIPS eligible clinician at 414.1305 to
accurate eligibility determinations 30-day claims run out. In our
mean an individual MIPS eligible
regarding non-patient facing status. As a comparison of data analysis results
clinician that bills 100 or fewer patient-
facing encounters (including Medicare result, MIPS eligible clinicians utilizing a 60-day claims run out versus
telehealth services defined in section considered non-patient facing are able a 30-day claims run out, there was a 1
1834(m) of the Act) during the non- to prepare to meet requirements percent decrease in data completeness
patient facing determination period, and applicable to non-patient facing MIPS (see Table 1 for data completeness
a group or virtual group provided that eligible clinicians. We proposed to regarding comparative analysis of a 60-
more than 75 percent of the NPIs billing continue applying these policies for day and 30-day claims run out). The
under the groups TIN or within a purposes of the 2020 MIPS payment small decrease in data completeness
virtual group, as applicable, meet the year and future years (82 FR 30021). would not negatively impact individual
definition of a non-patient facing As described in the CY 2017 Quality MIPS eligible clinicians or groups
individual MIPS eligible clinician Payment Program final rule, we regarding non-patient facing
during the non-patient facing established the non-patient facing determinations. We believe that a 30-
determination period (82 FR 30021). determination period for purposes of day claims run out would allow us to
We considered a patient-facing identifying non-patient facing MIPS complete the analysis and provide such
encounter to be an instance in which eligible clinicians in advance of the determinations in a more timely
the individual MIPS eligible clinician or performance period and during the manner.
group billed for items and services performance period using historical and
furnished such as general office visits, performance period claims data. This
outpatient visits, and procedure codes eligibility determination process allows
under the PFS. We published the list of us to begin identifying non-patient
patient-facing encounter codes for facing MIPS eligible clinicians prior to
performance periods occurring in 2017 or shortly after the start of the
at qpp.cms.gov/resources/education. We performance period. The non-patient
TABLE 1PERCENTAGES OF DATA to the performance period) to determine more than 75 percent of eligible
COMPLETENESS FOR 60-DAY AND the non-patient facing status of clinicians billing under the group meets
30-DAY CLAIMS RUN OUT individual MIPS eligible clinicians and the individual clinician definition. One
groups, and conduct another eligibility commenter appreciated the flexibility
30-Day determination analysis based on 12
60-Day we are demonstrating in considering the
Incurred year claims months of data (consisting of the last 4
claims use of telehealth. Another commenter
run out * run out *
months of the calendar year prior to the recommended we implement the same
performance period and the first 8 thresholds for rural and HPSA practices.
2015 .................. 97.1% 98.4% months of the performance period) to Response: We are finalizing for
* Note: Completion rates are estimated and determine the non-patient facing status performance periods occurring in 2018
averaged at aggregated service categories of additional individual MIPS eligible and future years that at 414.1305 non-
and may not be applicable to subsets of these clinicians and groups. We would not patient facing MIPS eligible clinician
totals. For example, completion rates can vary
by clinician due to claim processing practices, change the non-patient facing status of means an individual MIPS eligible
service mix, and post payment review activity. any individual MIPS eligible clinician clinician that bills 100 or fewer patient-
Completion rates vary from subsections of a or group identified as non-patient facing facing encounters (including Medicare
calendar year; later portions of a given cal- during the first eligibility determination telehealth services defined in section
endar year will be less complete than earlier 1834(m) of the Act) during the non-
ones. Completion rates vary due to variance in analysis based on the second eligibility
loading patterns due to technical, seasonal, determination analysis. Thus, an patient facing determination period, and
policy, and legislative factors. Completion individual MIPS eligible clinician or a group or virtual group provided that
rates are a function of the incurred date used group that is identified as non-patient more than 75 percent of the NPIs billing
to process claims, and these factors will need facing during the first eligibility under the groups TIN or within a
to be updated if claims are processed on a
claim from date or other methodology. determination analysis would continue virtual group, as applicable, meet the
to be considered non-patient facing for definition of a non-patient facing
For performance periods occurring in the duration of the performance period individual MIPS eligible clinician
2018 and future years, we proposed a and MIPS payment year regardless of during the non-patient facing
modification to the non-patient facing the results of the second eligibility determination period.
determination period, in which the determination analysis. We would Comment: Several commenters did
initial 12-month segment of the non- conduct the second eligibility not support the proposed definition of
patient facing determination period determination analysis to account for non-patient facing as an individual
would span from the last 4 months of a the identification of additional, MIPS eligible clinician that bills 100 or
calendar year 2 years prior to the previously unidentified individual fewer patient-facing encounters during
performance period followed by the first MIPS eligible clinicians and groups that the non-patient facing determination
8 months of the next calendar year and are considered non-patient facing. period, and a group provided that more
include a 30-day claims run out; and the Additionally, in the CY 2017 Quality than 75 percent of the NPIs billing
second 12-month segment of the non- Payment Program final rule (81 FR under the groups TIN meet the
patient facing determination period 77241), we established a policy definition of a non-patient facing
would span from the last 4 months of a regarding the re-weighting of the individual MIPS eligible clinician
calendar year 1 year prior to the advancing care information performance during the non-patient facing
performance period followed by the first category for non-patient facing MIPS determination period. One commenter
8 months of the performance period in eligible clinicians. Specifically, MIPS recommended that the definition of a
the next calendar year and include a 30- eligible clinicians who are considered to non-patient facing clinician be defined
day claims run out (82 FR 30022). The be non-patient facing will have their at the individual clinician level and not
proposal would only change the advancing care information performance be applied at a group level. Another
duration of the claims run out, not the category automatically reweighted to commenter did not support applying the
12-month timeframes used for the first zero (81 FR 77241). For groups that are non-patient facing definition to
and second segments of data analysis. considered to be non-patient facing (that pathologists using PECOS, but rather
For purposes of the 2020 MIPS is, more than 75 percent of the NPIs believed all pathologists should be
payment year, we would initially billing under the groups TIN meet the automatically identified as non-patient
identify individual MIPS eligible definition of a non-patient facing facing.
clinicians and groups who are individual MIPS eligible clinician) Response: We do not agree with the
considered non-patient facing MIPS during the non-patient facing commenters who did not support the
eligible clinicians based on 12 months determination period, we are finalizing proposed definition of a non-patient
of data starting from September 1, 2016, in section II.C.7.b.(3) of this final rule facing MIPS eligible clinician at the
to August 31, 2017. To account for the with comment period to automatically individual or group level. We weighed
identification of additional individual reweight their advancing care several options when considering the
MIPS eligible clinicians and groups that information performance category to appropriate definition of non-patient
may qualify as non-patient facing during zero. We proposed to continue applying facing MIPS eligible clinicians and
performance periods occurring in 2018, these policies for purposes of the 2020 believe we have established an
we would conduct another eligibility MIPS payment year and future years. appropriate threshold that provides the
determination analysis based on 12 The following is a summary of the most appropriate representation of a
months of data starting from September public comments received on the Non- non-patient facing MIPS eligible
1, 2017, to August 31, 2018. Patient Facing MIPS Eligible Clinicians clinician. The definition of a non-
Similarly, for future years, we would proposals and our responses: patient facing MIPS eligible clinician is
conduct an initial eligibility Comment: Several commenters based on a methodology that would
determination analysis based on 12 supported the policy to define non- allow us to more accurately identify
months of data (consisting of the last 4 patient facing clinicians as individual MIPS eligible clinicians who are non-
months of the calendar year 2 years eligible clinicians billing 100 or fewer patient facing by applying a threshold to
prior to the performance period and the encounters, and group or virtual groups recognize that a MIPS eligible clinician
first 8 months of the calendar year prior to be defined as non-patient facing if who furnishes almost exclusively non-
patient facing services should be treated timelines. However, we intend to non-patient facing determination
as a non-patient facing MIPS eligible publish the patient-facing codes as close period, and a group or virtual group
clinician despite furnishing a small to when the final rule with comment provided that more than 75 percent of
number of patient-facing services. This period is issued as possible and prior to the NPIs billing under the groups TIN
approach also allows us to determine if the start of the performance period. We or within a virtual group, as applicable,
an individual clinician or a group of will adopt any changes to this policy meet the definition of a non-patient
clinicians is non-patient facing. We through future rulemaking as necessary. facing individual MIPS eligible clinician
believe that having the determination of Comment: Several commenters during the non-patient facing
non-patient facing available at the supported the proposed policy on determination period. In addition, we
individual and group level provides determination periods. The commenters are finalizing that for performance
further flexibilities for MIPS eligible agreed with the proposed policy to use periods occurring in 2018 and future
clinicians on the options available to 2 determination periods. A few years that for purposes of non-patient
them for participation within the commenters recommended that we facing MIPS eligible clinicians, we will
program. Our methodology used to notify MIPS eligible clinicians and utilize E&M codes and Surgical and
identify non-patient facing MIPS groups prior to the start of the Procedural codes for accurate
eligible clinicians included a performance period by either including identification of patient-facing
quantitative, comparative analysis of such information in the MIPS eligibility encounters, and thus, accurate
claims and HCPCS code data. We refer notifications sent to eligible clinicians eligibility determinations regarding non-
commenters to CY 2017 Quality or responding to MIPS eligible clinician patient facing status. Further, we are
Payment Program Final Rule (81 FR or group requests for information. Two finalizing that a patient-facing
77041 through 77049) for a full commenters recommended that we encounter is considered to be an
discussion on the logic for which allow an appeal process or attestation by instance in which the individual MIPS
clinicians are eligible to be non-patient MIPS eligible clinicians for the non- eligible clinician or group billed for
facing MIPS eligible clinicians. We patient facing designation. items and services furnished such as
agree and intend to provide the non- Response: We agree with the general office visits, outpatient visits,
patient facing determination prior to the commenters regarding the non-patient and procedure codes under the PFS.
performance period following the non- facing determination period and that Finally, we are finalizing that for
patient facing determination period as MIPS eligible clinicians should be performance periods occurring in 2018
discussed in section II.C.1.e. of this final notified prior to the performance period and future years, that for the non-patient
rule with comment period. Regarding regarding their eligibility status. In the facing determination period, in which
the comment disagreeing with applying CY 2017 Quality Payment Program final the initial 12-month segment of the non-
the non-patient facing definition to rule (81 FR 77043 through 77048), we patient facing determination period
pathologists using PECOS, we note that established the non-patient facing would span from the last 4 months of a
we are not utilizing PECOS for the non- determination period for purposes of calendar year 2 years prior to the
patient facing determination, rather we identifying non-patient facing MIPS performance period followed by the first
utilize Part B claims data. eligible clinicians in advance of the 8 months of the next calendar year and
Comment: Two commenters performance period and during the include a 30-day claims run out; and the
recommended that we release all performance period using historical and second 12-month segment of the non-
patient-facing codes through formal performance period claims data. In patient facing determination period
notice-and-comment rulemaking rather addition, we would like to note that would span from the last 4 months of a
than subregulatory guidance. MIPS eligible clinicians may access the calendar year 1 year prior to the
Response: In the CY 2018 Quality Quality Payment Program Web site at performance period followed by the first
Payment Program proposed rule (82 FR www.qpp.cms.gov and check if they are 8 months of the performance period in
30021), we noted that we consider a required to submit data to MIPS by the next calendar year and include a 30-
patient-facing encounter to be an entering their NPI into the online tool. day claims run out.
instance in which the individual MIPS In response to the comment regarding
eligible clinician or group billed for appeals for non-patient facing status, if f. MIPS Eligible Clinicians Who Practice
items and services furnished such as a MIPS eligible clinician disagrees with in Critical Access Hospitals Billing
general office visits, outpatient visits, the non-patient facing determination, Under Method II (Method II CAHs)
and procedure codes under the PFS, and we note that clinicians can contact the In the CY 2017 Quality Payment
we described in detail two general Quality Payment Program Service Program final rule (81 FR 77049), we
categories of codes included in this list Center which may be reached at 1866 noted that MIPS eligible clinicians who
of codes, specifically, E&M codes and 2888292 (TTY 18777156222), practice in CAHs that bill under Method
Surgical and Procedural codes, and our available Monday through Friday, 8:00 I (Method I CAHs), the MIPS payment
rationale for including these codes, a.m.-8:00 p.m. Eastern Time or via email adjustment would apply to payments
which we proposed to continue at QPP@cms.hhs.gov. If an error in the made for items and services billed by
applying for purposes of the 2020 MIPS non-patient facing determination is MIPS eligible clinicians, but it would
payment year and future years. discovered, we will update the MIPS not apply to the facility payment to the
Therefore, we do not believe it is eligible clinicians status accordingly. CAH itself. For MIPS eligible clinicians
necessary to specify each individual Final Action: After consideration of who practice in Method II CAHs and
code in notice-and-comment the public comments, we are finalizing have not assigned their billing rights to
rulemaking. Moreover, we are unable to for performance periods occurring in the CAH, the MIPS payment adjustment
provide the patient-facing codes through 2018 and future years that at 414.1305 would apply in the same manner as for
the notice-and-comment rulemaking as non-patient facing MIPS eligible MIPS eligible clinicians who bill for
the final list of Current Procedural clinician means an individual MIPS items and services in Method I CAHs.
Terminology (CPT) codes used to eligible clinician that bills 100 or fewer As established in the CY 2017 Quality
determine patient facing encounters are patient-facing encounters (including Payment Program final rule (81 FR
often not available in conjunction with Medicare telehealth services defined in 77051), the MIPS payment adjustment
the proposed and final rulemaking section 1834(m) of the Act) during the will apply to Method II CAH payments
under section 1834(g)(2)(B) of the Act the ASC, HHA, Hospice, or HOPD (1) Individual Identifiers
when MIPS eligible clinicians who methodology would not be subject to As established in the CY 2017 Quality
practice in Method II CAHs have the MIPS payments adjustments (82 FR Payment Program final rule (81 FR
assigned their billing rights to the CAH. 30023). However, these eligible 77058), we define a MIPS eligible
We refer readers to the CY 2017 clinicians have the option to voluntarily clinician at 414.1305 to mean the use
Quality Payment Program final rule (81 report on applicable measures and of a combination of unique billing TIN
FR 77049 through 77051) for our activities for MIPS, in which case the and NPI combination as the identifier to
discussion of MIPS eligible clinicians data received would not be used to assess performance of an individual
who practice in Method II CAHs. assess their performance for the purpose MIPS eligible clinician. Each unique
g. MIPS Eligible Clinicians Who Practice of the MIPS payment adjustment. We TIN/NPI combination is considered a
in Rural Health Clinics (RHCs) or note that eligible clinicians who bill different MIPS eligible clinician, and
Federally Qualified Health Centers under both the PFS and one of these MIPS performance is assessed
(FQHCs) other billing methodologies (ASC, HHA, separately for each TIN under which an
Hospice, and/or HOPD) may be required individual bills.
As established in the CY 2017 Quality
Payment Program final rule (81 FR to participate in MIPS if they exceed the
low-volume threshold and are otherwise (2) Group Identifiers for Performance
77051 through 77053), services
eligible clinicians; in such case, the data As established in the CY 2017 Quality
furnished by an eligible clinician under
reported would be used to determine Payment Program final rule (81 FR
the RHC or FQHC methodology, will not
be subject to the MIPS payments their MIPS payment adjustment. 77059), we codified the definition of a
adjustments. As noted, these eligible The following is a summary of the group at 414.1305 to mean a group that
clinicians have the option to voluntarily public comments received on the MIPS consists of a single TIN with two or
report on applicable measures and Eligible Clinicians Who Practice in more eligible clinicians (including at
activities for MIPS, in which the data ASCs, HHAs, HOPDs proposal and our least one MIPS eligible clinician), as
received will not be used to assess their responses: identified by their individual NPI, who
performance for the purpose of the have reassigned their billing rights to
Comment: A few commenters agreed the TIN.
MIPS payment adjustment. with the proposal that services
We refer readers to the CY 2017 (3) APM Entity Group Identifiers for
furnished by an eligible clinician that
Quality Payment Program final rule (81 Performance
are payable under the ASC, HHA,
FR 77051 through 77053) for our
Hospice, or Outpatient payment As described in the CY 2017 Quality
discussion of MIPS eligible clinicians
methodology would not be subject to Payment Program final rule (81 FR
who practice in RHCs or FQHCs.
the MIPS payment adjustments. 77060), we established that each eligible
h. MIPS Eligible Clinicians Who Response: We appreciate the clinician who is a participant of an APM
Practice in Ambulatory Surgical Centers commenters support. We are finalizing Entity is identified by a unique APM
(ASCs), Home Health Agencies (HHAs), that services furnished by an eligible participant identifier. The unique APM
Hospice, and Hospital Outpatient clinician that are payable under the participant identifier is a combination of
Departments (HOPDs) ASC, HHA, Hospice, or HOPD four identifiers: (1) APM Identifier
Section 1848(q)(6)(E) of the Act methodology will not be subject to the (established by CMS; for example,
provides that the MIPS payment MIPS payments adjustments and that XXXXXX); (2) APM Entity identifier
adjustment is applied to the amount such data will not be utilized for MIPS (established under the APM by CMS; for
otherwise paid under Part B with eligibility purposes. example, AA00001111); (3) TIN(s) (9
respect to the items and services numeric characters; for example,
Final Action: After consideration of XXXXXXXXX); (4) EP NPI (10 numeric
furnished by a MIPS eligible clinician
the public comments, we are finalizing characters; for example, 1111111111).
during a year. Some eligible clinicians
that services furnished by an eligible We codified the definition of an APM
may not receive MIPS payment
clinician that are payable under the Entity group at 414.1305 to mean a
adjustments due to their billing
ASC, HHA, Hospice, or HOPD group of eligible clinicians participating
methodologies. If a MIPS eligible
methodology will not be subject to the in an APM Entity, as identified by a
clinician furnishes items and services in
MIPS payments adjustments and that combination of the APM identifier,
an ASC, HHA, Hospice, and/or HOPD
such data will not be utilized for MIPS APM Entity identifier, TIN, and NPI for
and the facility bills for those items and
eligibility purposes, as proposed. each participating eligible clinician.
services (including prescription drugs)
under the facilitys all-inclusive i. MIPS Eligible Clinician Identifiers 2. Exclusions
payment methodology or prospective
payment system methodology, the MIPS As described in the CY 2017 Quality a. New Medicare-Enrolled Eligible
adjustment would not apply to the Payment Program final rule (81 FR Clinician
facility payment itself. However, if a 77057), we established the use of As established in the CY 2017 Quality
MIPS eligible clinician furnishes other multiple identifiers that allow MIPS Payment Program final rule (81 FR
items and services in an ASC, HHA, eligible clinicians to be measured as an 77061 through 77062), we defined a
Hospice, and/or HOPD and bills for individual or collectively through a new Medicare-enrolled eligible clinician
those items and services separately, groups performance and that the same at 414.1305 as a professional who first
such as under the PFS, the MIPS identifier be used for all four becomes a Medicare-enrolled eligible
adjustment would apply to payments performance categories. While we have clinician within the PECOS during the
made for such items and services. Such multiple identifiers for participation performance period for a year and had
items and services would also be and performance, we established the use not previously submitted claims under
considered for purposes of applying the of a single identifier, TIN/NPI, for Medicare such as an individual, an
low-volume threshold. Therefore, we applying the MIPS payment adjustment, entity, or a part of a clinician group or
proposed that services furnished by an regardless of how the MIPS eligible under a different billing number or tax
eligible clinician that are payable under clinician is assessed. identifier. Additionally, we established
at 414.1310(c) that these eligible In the CY 2017 Quality Payment outcomes, co-morbidities, chronic
clinicians will not be treated as a MIPS Program final rule (81 FR 77069 through conditions, and other social risk factors,
eligible clinician until the subsequent 77070), we defined MIPS eligible which can result in the costs of
year and the performance period for clinicians or groups who do not exceed providing care and services being
such subsequent year. We established at the low-volume threshold at 414.1305 significantly higher compared to non-
414.1310(d) that in no case would a as an individual MIPS eligible clinician rural areas. We also have heard from
MIPS payment adjustment apply to the or group who, during the low-volume many solo practitioners and small
items and services furnished during a threshold determination period, has practices that still face challenges and
year by new Medicare-enrolled eligible Medicare Part B allowed charges less additional resource burden in
clinicians for the applicable than or equal to $30,000 or provides participating in the MIPS.
performance period. care for 100 or fewer Part B-enrolled In the CY 2017 Quality Payment
We used the term new Medicare- Medicare beneficiaries. We established Program final rule, we did not establish
enrolled eligible clinician determination at 414.1310(b) that for a year, eligible an adjustment for social risk factors in
period to refer to the 12 months of a clinicians who do not exceed the low- assessing and scoring performance. In
calendar year applicable to the volume threshold (as defined at response to the CY 2017 Quality
performance period. During the new 414.1305) are excluded from MIPS for Payment Program final rule, we received
Medicare-enrolled eligible clinician the performance period for a given public comments indicating that
determination period, we conduct calendar year. individual MIPS eligible clinicians and
eligibility determinations on a quarterly In the CY 2017 Quality Payment groups practicing in designated rural
basis to the extent that is technically Program final rule (81 FR 77069 through areas would be negatively impacted and
feasible to identify new Medicare- 77070), we defined the low-volume at a disadvantage if assessment and
enrolled eligible clinicians that would threshold determination period to mean scoring methodology did not adjust for
be excluded from the requirement to a 24-month assessment period, which social risk factors. Additionally,
participate in MIPS for the applicable includes a two-segment analysis of commenters expressed concern that
performance period. claims data during an initial 12-month such individual MIPS eligible clinicians
period prior to the performance period and groups may be disproportionately
b. Qualifying APM Participant (QP) and
followed by another 12-month period more susceptible to lower performance
Partial Qualifying APM Participant
during the performance period. The scores across all performance categories
(Partial QP)
initial 12-month segment of the low- and negative MIPS payments
In the CY 2017 Quality Payment volume threshold determination period adjustments, and as a result, such
Program final rule (81 FR 77062), we spans from the last 4 months of a outcomes may further strain already
established at 414.1305 that a QP (as calendar year 2 years prior to the limited fiscal resources and workforce
defined at 414.1305) is not a MIPS performance period followed by the first shortages, and negatively impact access
eligible clinician, and therefore, is 8 months of the next calendar year and to care (reduction and/or elimination of
excluded from MIPS. Also, we includes a 60-day claims run out, which available services).
established that a Partial QP (as defined allows us to inform eligible clinicians After the consideration of stakeholder
at 414.1305) who does not report on and groups of their low-volume status feedback, we proposed to modify the
applicable measures and activities that during the month (December) prior to low-volume threshold policy
are required to be reported under MIPS the start of the performance period. The established in the CY 2017 Quality
for any given performance period in a second 12-month segment of the low- Payment Program final rule (82 FR
year is not a MIPS eligible clinician, and volume threshold determination period 30024). We stated that we believe that
therefore, is excluded from MIPS. spans from the last 4 months of a increasing the dollar amount and
c. Low-Volume Threshold calendar year 1 year prior to the beneficiary count of the low-volume
performance period followed by the first threshold would further reduce the
Section 1848(q)(1)(C)(ii)(III) of the Act 8 months of the performance period in number of eligible clinicians that are
provides that the definition of a MIPS the next calendar year and includes a required to participate in the MIPS,
eligible clinician does not include 60-day claims run out, which allows us which would reduce the burden on
eligible clinicians who are below the to inform additional eligible clinicians individual MIPS eligible clinicians and
low-volume threshold selected by the and groups of their low-volume status groups practicing in small practices and
Secretary under section 1848(q)(1)(C)(iv) during the performance period. designated rural areas. Based on our
of the Act for a given year. Section We recognize that individual MIPS analysis of claims data, we found that
1848(q)(1)(C)(iv) of the Act requires the eligible clinicians and groups that are increasing the low-volume threshold to
Secretary to select a low-volume small practices or practicing in exclude individual eligible clinicians or
threshold to apply for the purposes of designated rural areas face unique groups that have Medicare Part B
this exclusion which may include one dynamics and challenges such as fiscal allowed charges less than or equal to
or more of the following: (1) The limitations and workforce shortages, but $90,000 or that provide care for 200 or
minimum number, as determined by the serve as a critical access point for care fewer Part B-enrolled Medicare
Secretary, of Part B-enrolled individuals and provide a safety net for vulnerable beneficiaries will exclude
who are treated by the eligible clinician populations. Claims data shows that approximately 134,000 additional
for a particular performance period; (2) approximately 15 percent of individual clinicians from MIPS from the
the minimum number, as determined by MIPS eligible clinicians (TIN/NPIs) are approximately 700,000 clinicians that
the Secretary, of items and services considered to be practicing in rural would have been eligible based on the
furnished to Part B-enrolled individuals areas after applying all exclusions. Also, low-volume threshold that was finalized
by the eligible clinician for a particular we have heard from stakeholders that in the CY 2017 Quality Payment
performance period; and (3) the MIPS eligible clinicians practicing in Program final rule. Almost half of the
minimum amount, as determined by the small practices and designated rural additionally excluded clinicians are in
Secretary, of allowed charges billed by areas tend to have a patient population small practices, and approximately 17
the eligible clinician for a particular with a higher proportion of older adults, percent are clinicians from practices in
performance period. as well as higher rates of poor health designated rural areas. Applying this
criterion decreases the percentage of the clinicians and groups who face the last 4 months of a calendar year 2
MIPS eligible clinicians that come from additional participation burden while years prior to the performance period
small practices. For example, prior to not excluding a significant portion of followed by the first 8 months of the
any exclusions, clinicians in small the clinician population. next calendar year and include a 30-day
practices represent 35 percent of all Eligible clinicians who do not exceed claims run out; and the second 12-
clinicians billing Part B services. After the low-volume threshold (as defined at month segment of the low-volume
applying the eligibility criteria for the 414.1305) are excluded from MIPS for threshold determination period would
CY 2017 Quality Payment Program final the performance period with respect to span from the last 4 months of a
rule, MIPS eligible clinicians in small a year. The low-volume threshold also calendar year 1 year prior to the
practices represent approximately 27 applies to eligible clinicians who performance period followed by the first
percent of the clinicians eligible for practice in APMs under the APM 8 months of the performance period in
MIPS; however, with the increased low- scoring standard at the APM Entity the next calendar year and include a 30-
volume threshold, approximately 22 level, in which APM Entities do not day claims run out (82 FR 30025). We
percent of the clinicians eligible for exceed the low-volume threshold. In stated that the proposal would only
MIPS are from small practices. In our such cases, the eligible clinicians change the duration of the claims run
analysis, the proposed changes to the participating in the MIPS APM Entity out, not the 12-month timeframes used
low-volume threshold showed little would be excluded from the MIPS for the first and second segments of data
impact on MIPS eligible clinicians from requirements for the applicable analysis.
practices in designated rural areas. performance period and not subject to a For purposes of the 2020 MIPS
MIPS eligible clinicians from practices MIPS payment adjustment for the payment year, we would initially
in designated rural areas account for15 applicable year. Such an exclusion identify individual eligible clinicians
to 16 percent of the total MIPS eligible would not affect an APM Entitys QP and groups that do not exceed the low-
clinician population. We note that, due determination if the APM Entity is an volume threshold based on 12 months
to data limitations, we assessed rural Advanced APM. of data starting from September 1, 2016
status based on the status of individual In the CY 2017 Quality Payment to August 31, 2017. To account for the
TIN/NPI and did not model any group Program final rule, we established the identification of additional individual
definition for practices in designated low-volume threshold determination eligible clinicians and groups that do
rural areas. period to refer to the timeframe used to not exceed the low-volume threshold
We believe that increasing the number assess claims data for making eligibility during performance periods occurring
of such individual eligible clinicians determinations for the low-volume in 2018, we would conduct another
and groups excluded from MIPS threshold exclusion (81 FR 77069 eligibility determination analysis based
participation would reduce burden and through 77070). We defined the low- on 12 months of data starting from
mitigate, to the extent feasible, the issue volume threshold determination period September 1, 2017 to August 31, 2018.
surrounding confounding variables to mean a 24-month assessment period, We would not change the low-volume
impacting performance under the MIPS. which includes a two-segment analysis status of any individual eligible
Therefore, beginning with the 2018 of claims data during an initial 12- clinician or group identified as not
MIPS performance period, we proposed month period prior to the performance exceeding the low-volume threshold
to increase the low-volume threshold. period followed by another 12-month during the first eligibility determination
Specifically, at 414.1305, we proposed period during the performance period. analysis based on the second eligibility
to define an individual MIPS eligible Based on our analysis of data from the determination analysis. Thus, an
clinician or group who does not exceed initial segment of the low-volume individual eligible clinician or group
the low-volume threshold as an threshold determination period for that is identified as not exceeding the
individual MIPS eligible clinician or performance periods occurring in 2017 low-volume threshold during the first
group who, during the low-volume (that is, data spanning from September eligibility determination analysis would
threshold determination period, has 1, 2015 to August 31, 2016), we found continue to be excluded from MIPS for
Medicare Part B allowed charges less that it may not be necessary to include the duration of the performance period
than or equal to $90,000 or provides a 60-day claims run out since we could regardless of the results of the second
care for 200 or fewer Part B-enrolled achieve a similar outcome for such eligibility determination analysis. We
Medicare beneficiaries. This would eligibility determinations by utilizing a established our policy to include two
mean that approximately 37 percent of 30-day claims run out. eligibility determination analyses in
individual eligible clinicians and groups In our comparison of data analysis order to prevent any potential confusion
would be eligible for MIPS based on the results utilizing a 60-day claims run out for an individual eligible clinician or
low-volume threshold exclusion (and versus a 30-day claims run out, there group to know whether or not
the other exclusions). However, was a 1 percent decrease in data participate in MIPS; also, such policy
approximately 65 percent of Medicare completeness. The small decrease in makes it clear from the onset as to
payments would still be captured under data completeness would not which individual eligible clinicians and
MIPS as compared to 72.2 percent of substantially impact individual MIPS groups would be required to participate
Medicare payments under the CY 2017 eligible clinicians or groups regarding in MIPS. We would conduct the second
Quality Payment Program final rule. low-volume threshold determinations. eligibility determination analysis to
We recognize that increasing the We believe that a 30-day claims run out account for the identification of
dollar amount and beneficiary count of would allow us to complete the analysis additional, previously unidentified
the low-volume threshold would and provide such determinations in a individual eligible clinicians and groups
increase the number of individual more timely manner. For performance who do not exceed the low-volume
eligible clinicians and groups excluded periods occurring in 2018 and future threshold. We note that low-volume
from MIPS. We assessed various levels years, we proposed a modification to the threshold determinations are made at
of increases and found that $90,000 as low-volume threshold determination the individual and group level, and not
the dollar amount and 200 as the period, in which the initial 12-month at the virtual group level.
beneficiary count balances the need to segment of the low-volume threshold As noted above, section
account for individual eligible determination period would span from 1848(q)(1)(C)(iv) of the Act requires the
Secretary to select a low-volume opt-in to MIPS participation if they The following is a summary of the
threshold to apply for the purposes of might otherwise be excluded under the public comments received on the Low-
this exclusion which may include one low-volume threshold, such as where Volume Threshold proposals and our
or more of the following: (1) The they only meet one of the threshold responses:
minimum number, as determined by the determinations (including a third Comment: Many commenters
Secretary, of Part B-enrolled individuals determination based on Part B items and supported raising the low-volume
who are treated by the eligible clinician services, if established). For example, if threshold to exclude an individual
for a particular performance period; (2) a clinician meets the low-volume MIPS eligible clinician or group who,
the minimum number, as determined by threshold of $90,000 in allowed charges, during the low-volume threshold
the Secretary, of items and services but does not meet the threshold of 200 determination period, has Medicare Part
furnished to Part B-enrolled individuals patients or, if established, the threshold B allowed charges less than or equal to
by the eligible clinician for a particular pertaining to Part B items and services, $90,000 or provides care for 200 or
performance period; and (3) the we believe the clinician should, to the fewer Part B-enrolled Medicare
minimum amount, as determined by the extent feasible, have the opportunity to beneficiaries. Several commenters
Secretary, of allowed charges billed by choose whether or not to participate in further suggested that we retroactively
the eligible clinician for a particular the MIPS and be subject to MIPS apply the threshold to the 2017 MIPS
performance period. We have payment adjustments. We recognize that performance period because changing
established a low-volume threshold that this choice would present additional the low-volume threshold for the 2018
accounts for the minimum number of complexity to clinicians in MIPS performance period would create
Part-B enrolled individuals who are understanding all of their available confusion, complicate operational and
treated by an eligible clinician and that options and may impose additional strategic planning for eligible clinicians,
accounts for the minimum amount of burden on clinicians by requiring them and create inefficiencies for clinicians.
allowed charges billed by an eligible to notify us of their decision. Because of One commenter noted that we has not
clinician. We did not make proposals these concerns and our desire to yet issued the required second round of
specific to a minimum number of items establish options in a way that is a low- reports notifying MIPS eligible
and service furnished to Part-B enrolled burden and user-focused experience for clinicians whether they are below the
individuals by an eligible clinician. all MIPS eligible clinicians, we would low-volume threshold, so it would be
In order to expand the ways in which not be able to offer this additional technically feasible to implement the
claims data could be analyzed for flexibility until performance periods lower threshold before the end of the CY
purposes of determining a more occurring in 2019. Therefore, as a means 2017 reporting period. A few
comprehensive assessment of the low- of expanding options for clinicians and commenters supported the proposal but
volume threshold, we have assessed the offering them the ability to participate recommended that we maintain the
option of establishing a low-volume in MIPS if they otherwise would not be current, lower low-volume threshold for
threshold for items and services included, for the purposes of the 2021 at least 2, 3, or more years to allow for
furnished to Part-B enrolled individuals MIPS payment year, we proposed to planning and investment by clinicians
by an eligible clinician. We have provide clinicians the ability to opt-in to in the program.
considered defining items and services Response: We appreciate the support
the MIPS if they meet or exceed one, but
by using the number of patient from commenters who supported raising
not all, of the low-volume threshold
encounters or procedures associated the low-volume threshold. We are
determinations, including as defined by
with a clinician. Defining items and finalizing our proposal to define at
dollar amount, beneficiary count or, if
services by patient encounters would 414.1305 an individual eligible
established, items and services (82 FR clinician or group that does not exceed
assess each patient per visit or
30026). the low-volume threshold as an
encounter with the eligible clinician.
We believe that defining items and We note that there may be additional individual eligible clinician or group
services by using the number of patient considerations we should address for that, during the low-volume threshold
encounters or procedures is a simple scenarios in which an individual determination period, has Medicare Part
and straightforward approach for eligible clinician or a group does not B allowed charges less than or equal to
stakeholders to understand. However, exceed the low-volume threshold and $90,000 or provides care for 200 or
we are concerned that using this unit of opts-in to participate in MIPS. We fewer Part B-enrolled Medicare
analysis could incentivize clinicians to therefore sought comment on any beneficiaries. We do not believe that we
focus on volume of services rather than additional considerations we should have the flexibility to retroactively
the value of services provided to address when establishing this opt-in apply the revised low-volume threshold
patients. Defining items and services by policy. Additionally, we note that there to the 2017 MIPS performance period
procedure would tie a specific clinical is the potential with this opt-in policy threshold. We are aware that by
procedure furnished to a patient to a for there to be an impact on our ability finalizing this policy, some MIPS
clinician. We solicited public comment to create quality benchmarks that meet eligible clinicians who were eligible to
on the methods of defining items and our sample size requirements. For participate in MIPS for Year 1 will be
services furnished by clinicians example, if particularly small practices excluded for Year 2. However, we
described in this paragraph above and or solo practitioners with low Part B would like to note that those MIPS
alternate methods of defining items and beneficiary volumes opt-in, such eligible clinicians may still participate
services (82 FR 30025 through 30026). clinicians may lack sufficient sample in Year 1. Finally, we agree with the
For the individual eligible clinicians size to be scored on many quality commenter that there are benefits of
and groups that would be excluded from measures, especially measures that do maintaining the same low-volume
MIPS participation as a result of an not apply to all of a MIPS eligible threshold for several years and will take
increased low-volume threshold, we clinicians patients. We therefore sought this into consideration in future years.
believe that in future years it would be comment on how to address any Comment: Several commenters did
beneficial to provide, to the extent potential impact on our ability to create not support the proposed low-volume
feasible, such individual eligible quality benchmarks that meet our threshold because the commenters
clinicians and groups with the option to sample size requirements (82 FR 30026). believed the low-volume threshold
should be raised further to exclude more that we are not focused on transitioning will not be required to participate in the
clinicians. Several of those commenters to value-based payment and care. A few Quality Payment Program; however, we
specifically recommended that we set commenters expressed concern that still encourage all clinicians to provide
the threshold no lower than $100,000 in raising the low-volume threshold would high-value care to their patients. The
Medicare Part B charges and to only create further disparities in quality goal of raising the low-volume threshold
apply to practices with 10 or fewer between urban and rural clinicians is to reduce burden on small practices,
eligible clinicians. based on the reduced incentives for and we do not believe it will create a
Response: We disagree with the rural clinicians to participate in value- 2-tiered system. We appreciate the
commenters regarding raising the low- based purchasing programs. One of suggestion to study the impact on the
volume threshold further. Based on our these commenters strongly rural health industry before finalizing
data analysis, applying the proposed recommended that we study the impact this policy. We do not believe a study
criterion decreases the percentage of on the rural health industry prior to is necessary prior to finalizing this
MIPS eligible clinicians that come from implementing the increased low-volume policy; rather, we believe that there is
small practices. We note that from our threshold. Many commenters noted that sufficient evidence from stakeholder
updated data models we found that the excluding more clinicians would risk feedback to reflect the value of
revised low-volume threshold will dismantling the EHR infrastructure that increasing the low-volume threshold at
exclude approximately 123,000 has developed over recent years as this time. We do not agree that this
additional clinicians from MIPS from additional practices opt-out of policy would risk dismantling the EHR
the approximately 744,000 clinicians participation in programs designed to infrastructure. We believe that the low-
that would have been eligible based on increase adoption and use of EHRs, volume threshold in Year 2 provides
the low-volume threshold that was wasting the billions of dollars we have MIPS eligible clinicians and groups,
finalized in the CY 2017 Quality invested to date in EHRs. The particularly those in smaller practices
Payment Program final rule. We believe commenters believed that reduction in and rural areas, that do not exceed the
that if we were to raise the low-volume use of EHRs will affect participating low-volume threshold with additional
threshold further, we may prevent clinicians as well by hampering time to further invest in their EHR
medium size practices that wish to connectivity and information sharing infrastructure to gain experience in
participate from the opportunity to between excluded clinicians and implementing and utilizing an EHR
receive an upward adjustment and participating clinicians. Some infrastructure to meet their needs and
would have fewer clinicians engaged in commenters also stated that decreased prepare for their potential participation
value-based care. We believe the investment in EHRs by excluded in MIPS in future years while not being
finalized low-volume threshold strikes clinicians will drive greater disparities subject to the possibility of a negative
the appropriate balance with the need to in care quality between clinicians who payment adjustment. We believe that
account for individual MIPS eligible are engaged in value-based purchasing clinicians and patients benefit from the
clinicians and groups who face and those who are not. One commenter utilization and capabilities of an EHR
additional participation burden while strongly recommended that we delay infrastructure and would continue to
not excluding a significant portion of implementation of the proposed low- utilize this technology. In addition, we
the clinician population. We are volume threshold. Another commenter do not believe we should delay
finalizing the low-volume threshold to recommended that, rather than exclude implementation of this policy as it
exclude an individual eligible clinician clinicians from MIPS, we should allow reduces the burden on individual MIPS
or group that, during the low-volume eligible clinicians and those in small
clinicians to continue the pick-your-
threshold determination period, has
pace approach and continue practices and in some rural areas. The
Medicare Part B allowed charges less
participating in MIPS. intention of the Year 1 pick-your-pace
than or equal to $90,000 or provides
Response: We acknowledge there will policies were to set the foundation for
care for 200 or fewer Part B-enrolled
be MIPS eligible clinicians who were MIPS to support long-term, high quality
Medicare beneficiaries.
Comment: Many commenters did not eligible for Year 1 of MIPS that are no patient care through feedback by
support raising the low-volume longer eligible for Year 2 of MIPS. lowering the barriers to participation.
threshold for the 2018 MIPS However, from our analyses, the MIPS Year 2 continues this transition as we
performance period because they eligible clinicians affected are mainly are providing a gradual ramp-up of the
believed it would be unfair to clinicians smaller practices and practices in rural program and of the performance
who were already participating or areas, many of which have raised thresholds. For the low-volume
planned to participate in MIPS in future concerns regarding their ability to threshold, we are finalizing our
years. The commenters noted that participate in MIPS. We want to proposal to increase the threshold,
clinicians may have already invested in encourage all clinicians to participate in which excludes more eligible clinicians
MIPS participation. Many commenters value-based care within the MIPS; from MIPS. Specifically, we are
did not support the proposed low- however, we have continued to hear finalizing our proposal to exclude an
volume threshold because they believed from practices that challenges to individual eligible clinician or group
that raising the low-volume threshold participation in the Quality Payment that, during the low-volume threshold
would reduce payment and incentives Program still exist. Therefore, we determination period, has Medicare Part
for excluded clinicians to participate in believe it is appropriate to raise the low- B allowed charges less than or equal to
value-based care, which would create volume threshold to not require these $90,000 or provides care for 200 or
additional quality and reimbursement practices to participate in the program. fewer Part B-enrolled Medicare
disparities for the beneficiaries seen by However, we will review the impacts of beneficiaries.
the excluded clinicians, creating a this policy to determine if it should Comment: Many commenters did not
2-tiered system of clinicians and related remain. We do not believe that raising support the proposed low-volume
beneficiaries that are participating in the low-volume threshold will cause threshold because it is based on the
value-based care. The commenters quality disparities between urban and amount of Medicare billings from
noted that raising the low-volume rural practices. With the increased low- clinicians or number of beneficiaries.
threshold would signal to the industry volume threshold, additional practices Instead, the commenters offered
recommendations for alternative ways Response: We note that some of the at the group level that exceeds the low-
of applying the low-volume threshold. suggestions provided are not compliant volume threshold. In the CY 2017
Many commenters recommended that with the statute, specifically, the Quality Payment Program final rule (82
we exclude all practices with 15 or suggestions on basing the low-volume FR 77071) we considered aligning how
fewer clinicians. Several commenters threshold exclusion on practice size, MIPS exclusions would be applied at
recommended redefining the low- practice location and specialty the group level. We recognized that
volume threshold so that it would characteristics. We note that section alignment would provide a uniform
mirror the policy for non-patient facing 1848(q)(1)(C)(iv) of the Act requires the application across exclusions and offer
eligible clinicians by excluding a group Secretary to select a low-volume simplicity, but we also believed that it
from MIPS if 75 percent or more of its threshold to apply for the purposes of is critical to ensure that there are
eligible clinicians individually fall this exclusion which may include one opportunities encouraging coordination,
below the low-volume threshold or if or more of the following: (1) The teamwork, and shared responsibility
the groups average Medicare allowed minimum number, as determined by the within groups. In order to encourage
charges or Medicare patient population Secretary, of Part B-enrolled individuals coordination, teamwork, and shared
falls below the threshold. The who are treated by the eligible clinician responsibility at the group level, we
for a particular performance period; (2) finalized that we would assess the low-
commenters noted that this would align
the minimum number, as determined by volume threshold so that all clinicians
status determinations across the Quality
the Secretary, of items and services within the group have the same status:
Payment Program and reduce
furnished to Part B-enrolled individuals all clinicians collectively exceed the
complexity and burden. One commenter low-volume threshold or they do not
recommended excluding: Practices with by the eligible clinician for a particular
performance period; and (3) the exceed the low-volume threshold. We
less than $100,000 per clinician in appreciate the other concerns and
Medicare charges not including Part B minimum amount, as determined by the
Secretary, of allowed charges billed by recommendations provided by the
drug costs; practices with 10 or fewer commenters. We received a range of
the eligible clinician for a particular
clinicians; and rural clinicians suggestions and considered the various
performance period. We do not believe
practicing in an area with fewer than options. We are finalizing our proposal
the statute provides discretion in
100 clinicians per 100,000 population. to exclude an individual MIPS eligible
establishing exclusions other than the
The commenter further encouraged us clinician or group that, during the low-
three exclusions specified above.
to consider excluding specialists who Additionally, for the commenters volume threshold determination period,
practice in ZIP codes or other suggestion to use a percentage of has Medicare Part B allowed charges
geographic areas with low per capita Medicare charges to total charges and a less than or equal to $90,000 or provides
numbers of clinicians in their specialty percentage of Medicare patients to total care for 200 or fewer Part B-enrolled
per population. One commenter patients as opposed to the use of a Medicare beneficiaries. In this final rule
recommended that we establish 2 minimum number of claims and with comment period, we are requesting
different low-volume thresholds for patients, we will take this suggestion additional comments regarding the
primary care and specialty care under consideration for future application of low-volume threshold at
clinicians. Another commenter rulemaking. In regards to the the group level.
recommended using a percentage of commenters suggestion to exclude all Comment: Many commenters
Medicare charges to total charges and a supported the proposed policy to
clinicians from MIPS that have non-
percentage of Medicare patients to total provide clinicians the ability to opt-in to
participation status within Medicare, we
patients as opposed to the use of claims the MIPS if they meet or exceed one, but
note that these clinicians may still fall
and patients. One commenter noted that not all, of the low-volume threshold
within the definition of a MIPS eligible
the low-volume thresholds inclusion of determinations, including as defined by
clinician at 414.1305. However, as
beneficiaries creates an incentive for dollar amount, beneficiary count, or, if
provided in 414.1310(d), in no case
clinicians to turn away Medicare established, items and services
will a MIPS payment adjustment apply
beneficiaries in order to fall below the beginning with the 2019 MIPS
to the items and services furnished
low-volume threshold. Another performance period. Other commenters
during a year by clinicians who are not
supported applying the opt-in based on
commenter recommended that we MIPS eligible clinicians. the Medicare Part B charges criterion,
exclude all clinicians who have elected We note that the low-volume but not the Medicare beneficiary
to have non-participation status for threshold is different from the other criterion. Several commenters
Medicare. As an alternative to raising exclusions in that it is not determined supported the proposal to allow opt-in
the low-volume threshold, one solely based on the individual NPI but requested that the policy be
commenter recommended that we status, it is based on both the TIN/NPI retroactively applied to the 2017 MIPS
reduce the reporting requirement for (to determine an exclusion at the performance period. A few commenters
small practices or for those practices individual level) and TIN (to determine supported the proposed opt-in option
between the previous threshold of an exclusion at the group level) status. but recommended that we establish
$30,000 and 100 beneficiaries to In regard to group-level reporting, the separate performance benchmarks for
$90,000 and 200 beneficiaries. Several group, as a whole, is assessed to excluded individuals or groups that opt-
commenters specifically did not support determine if the group (TIN) exceeds the in. Other commenters recommended
that a group could meet the low-volume low-volume threshold. Thus, eligible that we shield opt-in clinicians so that
threshold based on services provided by clinicians (TIN/NPI) who do not exceed they can avoid a negative payment
a small percentage of the clinicians in the low-volume threshold at the adjustment or other disadvantages of
the group. A few commenters individual reporting level and would participation.
recommended that we exclude otherwise be excluded from MIPS Response: We appreciate the support
individuals who do not meet the low- participation at the individual level, of the proposed policy to provide
volume threshold, even if the group would be required to participate in clinicians the ability to opt-in to the
practice otherwise met the low-volume MIPS at the group level if such eligible MIPS if they meet or exceed one, but not
threshold. clinicians are part of a group reporting all, of the low-volume threshold
determinations, including as defined by accurately evaluate clinician Medicare beneficiaries. In addition, for
dollar amount, beneficiary count, or, if performance, which may result in performance periods occurring in 2018
established, items and services unequal outcomes based on clinician and future years, we are finalizing a
beginning with the 2019 MIPS participation at the individual- or modification to the low-volume
performance period. However, we are group-level and specialty types. The threshold determination period, in
not finalizing this proposal for the 2019 commenter recommended that we fully which the initial 12-month segment of
MIPS performance period. We are evaluate the effect of the opt-in policy the low-volume threshold determination
concerned that we will not be able to prior to implementing any changes. period would span from the last 4
operationalize this policy in a low- Response: We agree with the months of a calendar year 2 years prior
burden manner to MIPS eligible commenters concerns and acknowledge to the performance period followed by
clinicians as currently proposed. that allowing an opt-in option may the first 8 months of the next calendar
Specifically, our goal is to implement a present additional complexity and year and include a 30-day claims run
process whereby a clinician can be could inadvertantly create a model out; and the second 12-month segment
made aware of their low-volume where only high-performers opt-in. of the low-volume threshold
threshold status and make an informed Therefore, we are not finalizing this determination period would span from
decision on whether they will proposal for the 2019 MIPS performance the last 4 months of a calendar year, 1
participate in MIPS or not. We believe period. Rather, we are seeking further year prior to the performance period
it is critical to implement a process that comment on the best approach to followed by the first 8 months of the
provides the least burden to clinicians implementing the low-volume opt-in performance period in the next calendar
in communicating this decision to us. policy. This additional time will give us year and include a 30-day claims run
Therefore, in this final rule with the opportunity to perform additional out. In addition, in this final rule with
comment period, we are seeking analyses. We intend to revisit this comment period, we are seeking further
additional comments on the best policy in the 2018 notice-and-comment comment on the best approach to
approach of implementing a low- rulemaking cycle. implementing a low-volume threshold
volume threshold opt-in policy. As we Comment: Several commenters opt-in policy. We welcome suggestions
plan to revisit this policy in the 2018 supported the current low-volume on ways to implement the low-volume
notice-and-comment rulemaking cycle. threshold assessment period and threshold opt-in that does not add
This additional time and additional proposal to use a 30-day claims run out. additional burden to clinicians. We also
public comments will give us the One commenter agreed with retaining are interested in receiving feedback on
opportunity to explore how best to the low-volume threshold status if ways to mitigate our concern that only
implement this policy and to perform triggered during the first 12-month high-performers will choose to opt-in.
determination period regardless of the We also are soliciting comment on
additional analyses. We do not agree
status resulting from the second 12-
that we should allow any MIPS eligible whether our current application of the
month determination period. Another
clinicians that meet the low-volume low-volume threshold to groups is still
commenter did not support the use of a
threshold exclusion from any criterion appropriate. We refer readers to the CY
determination period for low-volume
to opt-in to MIPS, as it may impact our 2017 Quality Payment Program final
threshold that is outside of the
ability to create quality performance rule (81 FR 77062 through 77070) for a
performance period and believed that
benchmarks that meet our sample size discussion on how the low-volume
only data overlapping the performance
requirements. For example, if threshold is currently applied to groups.
period should be used to determine low-
particularly small practices or solo
volume threshold status. 3. Group Reporting
practitioners with low Part B beneficiary Response: We appreciate the
volumes opt-in, such clinicians may a. Background
commenters support of the low-volume
lack sufficient sample size to be scored threshold determination period and the As discussed in the CY 2017 Quality
on many quality measures, especially proposed use of a 30-day claims run out. Payment Program final rule, we
measures that do not apply to all of a We believe that it is beneficial for MIPS established the following requirements
MIPS eligible clinicians patients. In eligible clinicians to know whether they for groups (81 FR 77072):
addition, we do not believe MIPS are excluded under the low-volume
eligible clinicians who opt-in should Individual eligible clinicians and
threshold prior to the start of the individual MIPS eligible clinicians will
have different performance benchmarks performance period. In order to identify
nor avoid a negative payment have their performance assessed as a
these MIPS eligible clinicians prior to
adjustment. If the MIPS eligible group as part of a single TIN associated
the start of the performance period, we
clinician decides to opt-in, then they are with two or more eligible clinicians
must use historical data that is outside
committing to participating in the entire (including at least one MIPS eligible
of the performance period. We refer
program, which would include being clinician), as identified by an NPI, who
commenters to the CY 2017 Quality
assessed on the same criteria as other have reassigned their Medicare billing
Payment Program final rule (82 FR
MIPS eligible clinicians. rights to the TIN (at 414.1310(e)(1)).
77069 through 77070) for a full
Comment: A few commenters discussion of this policy. A group must meet the definition of
opposed the proposed policy to provide Final Action: After consideration of a group at all times during the
clinicians the ability to opt-in to the the public comments, we are finalizing performance period for the MIPS
MIPS if they meet or exceed one, but not our proposal to define at 414.1305 an payment year in order to have its
all, of the low-volume threshold individual eligible clinician or group performance assessed as a group (at
determinations, including as defined by that does not exceed the low-volume 414.1310(e)(2)).
dollar amount, beneficiary count, or, if threshold as an individual eligible Individual eligible clinicians and
established, items and services clinician or group that, during the low- individual MIPS eligible clinicians
beginning with the 2019 MIPS volume threshold determination period, within a group must aggregate their
performance period. One commenter has Medicare Part B allowed charges performance data across the TIN to have
believed that an opt-in policy would less than or equal to $90,000 or provides their performance assessed as a group
complicate the programs ability to care for 200 or fewer Part B-enrolled (at 414.1310(e)(3)).
A group that elects to have its Entities to report using the CMS Web We received several comments on
performance assessed as a group will be Interface are not required to register for subgroup level policies and will take
assessed as a group across all four MIPS the CMS Web Interface or administer them into consideration for future
performance categories (at the CAHPS for MIPS survey separately rulemaking.
414.1310(e)(4)). from the APM.
We stated in the CY 2017 Quality When groups submit data utilizing 4. Virtual Groups
Payment Program final rule that groups third party intermediaries, such as a a. Background
attest to their group size for purpose of qualified registry, QCDR, or EHR, we are There are generally three ways to
using the CMS Web Interface or able to obtain group information from participate in MIPS: (1) Individual-level
identifying as a small practice (81 FR the third party intermediary and discern reporting; (2) group-level reporting; and
77057). In section II.C.1.c. of this final whether the data submitted represents (3) virtual group-level reporting. In the
rule with comment period, we are group submission or individual CY 2018 Quality Payment Program
finalizing our proposal to modify the submission once the data are submitted. proposed rule (82 FR 30027 through
way in which we determine small In the CY 2017 Quality Payment
30034), we proposed to establish
practice size by establishing a process Program final rule (81 FR 77072 through
requirements for MIPS participation at
under which CMS would utilize claims 77073), we discussed the
implementation of a voluntary the virtual group level.
data to make small practice size
Section 1848(q)(5)(I) of the Act
determinations. In addition, in section registration process if technically
provides for the use of voluntary virtual
II.C.4.e. of this final rule comment feasible. Since the publication of the CY
2017 Quality Payment Program final groups for certain assessment purposes,
period, we are finalizing our proposal to
rule, we have determined that it is not including the election of certain
establish a policy under which CMS
technically feasible to develop and practices to be a virtual group and the
would utilize claims data to determine
build a voluntary registration process. requirements for the election process.
group size for groups of 10 or fewer
Until further notice, we are not Section 1848(q)(5)(I)(i) of the Act
eligible clinicians seeking to form or
implementing a voluntary registration provides that MIPS eligible clinicians
join a virtual group.
As noted in the CY 2017 Quality process. electing to be a virtual group must: (1)
Payment Program final rule, group size Also, in the CY 2017 Quality Payment Have their performance assessed for the
would be determined before exclusions Program final rule (81 FR 77075), we quality and cost performance categories
are applied (81 FR 77057). We note that expressed our commitment to pursue in a manner that applies the combined
group size determinations are based on the active engagement of stakeholders performance of all the MIPS eligible
the number of NPIs associated with a throughout the process of establishing clinicians in the virtual group to each
TIN, which would include individual and implementing virtual groups. Please MIPS eligible clinician in the virtual
eligible clinicians (NPIs) who may be refer to the CY 2018 Quality Payment group for the applicable performance
excluded from MIPS participation and Program proposed rule (82 FR 30027) period; and (2) be scored for the quality
do not meet the definition of a MIPS for a full discussion of the public and cost performance categories based
eligible clinician. comments and additional stakeholder on such assessment for the applicable
feedback we received in response to the performance period. Section
b. Registration CY 2017 Quality Payment Program final 1848(q)(5)(I)(ii) of the Act requires the
As discussed in the CY 2017 Quality rule and additional stakeholder Secretary to establish and implement, in
Payment Program final rule (81 FR feedback gathered through hosting accordance with section
77072 through 77073), we established several virtual group listening sessions 1848(q)(5)(I)(iii) of the Act, a process
the following policies: and convening user groups. that allows an individual MIPS eligible
A group must adhere to an election As discussed in the CY 2018 Quality clinician or a group consisting of not
process established and required by Payment Program proposed rule (82 FR more than 10 MIPS eligible clinicians to
CMS ( 414.1310(e)(5)), which includes: 30027), one of the overarching themes elect, for a performance period, to be a
++ Groups will not be required to we have heard is that we make an virtual group with at least one other
register to have their performance option available to groups that would such individual MIPS eligible clinician
assessed as a group except for groups allow a portion of a group to report as or group. Virtual groups may be based
submitting data on performance a separate subgroup on measures and on appropriate classifications of
measures via participation in the CMS activities that are more applicable to the providers, such as by geographic areas
Web Interface or groups electing to subgroup and be assessed and scored or by provider specialties defined by
report the CAHPS for MIPS survey for accordingly based on the performance of nationally recognized specialty boards
the quality performance category. For all the subgroup. In future rulemaking, we of certification or equivalent
other data submission mechanisms, intend to explore the feasibility of certification boards.
groups must work with appropriate establishing group-related policies that Section 1848(q)(5)(I)(iii) of the Act
third party intermediaries as necessary would permit participation in MIPS at provides that the virtual group election
to ensure the data submitted clearly a subgroup level and create such process must include the following
indicates that the data represent a group functionality through a new identifier. requirements: (1) An individual MIPS
submission rather than an individual Therefore, we solicited public comment eligible clinician or group electing to be
submission. on the ways in which participation in in a virtual group must make their
++ In order for groups to elect MIPS at the subgroup level could be election prior to the start of the
participation via the CMS Web Interface established. In addition, in this final applicable performance period and
or administration of the CAHPS for rule with comment period, we are cannot change their election during the
MIPS survey, such groups must register seeking comment on additional ways to performance period; (2) an individual
by June 30 of the applicable define a group, not solely based on a MIPS eligible clinician or group may
performance period (that is, June 30, TIN. For example, redefining a group to elect to be in no more than one virtual
2018, for performance periods occurring allow for practice sites to be reflected group for a performance period, and, in
in 2018). We note that groups and/or for specialties within a TIN to the case of a group, the election applies
participating in APMs that require APM create groups. to all MIPS eligible clinicians in the
group; (3) a virtual group is a billing under such TIN) or a group with with the physician self-referral law (82
combination of TINs; (4) requirements 10 or fewer eligible clinicians (as such FR 30028).
providing for formal written agreements terms are defined at 414.1305) under We refer readers to section II.C.4.b.(3)
among individual MIPS eligible the TIN that elects to form a virtual of this final rule with comment period
clinicians and groups electing to be a group with at least one other such solo for a summary of the public comments
virtual group; and (5) such other practitioner or group for a performance we received on these proposals and our
requirements as the Secretary period for a year (82 FR 30027 through responses.
determines appropriate. 30028). (2) Application to Groups Containing
b. Definition of a Virtual Group With regard to the low-volume Participants in a MIPS APM or an
threshold, we recognized that such Advanced APM
(1) Generally determinations are made at the
individual and group level, but not at Additionally, we recognized that
As noted above, section there are circumstances in which a TIN
1848(q)(5)(I)(ii) of the Act requires the the virtual group level (82 FR 30031).
For example, if an individual MIPS may have one portion of its NPIs
Secretary to establish and implement, in participating under the generally
accordance with section eligible clinician is part of a practice
applicable MIPS scoring criteria while
1848(q)(5)(I)(iii) of the Act, a process that is participating in MIPS (that is,
the remaining portion of NPIs under the
that allows an individual MIPS eligible reporting) at the individual level, then
TIN is participating in a MIPS APM or
clinician or group consisting of not the low-volume threshold determination
an Advanced APM under the MIPS
more than 10 MIPS eligible clinicians to is made at the individual level.
APM scoring standard (82 FR 30028). To
elect, for a performance period, to be a Whereas, if an individual MIPS eligible
clarify, for all groups, including those
virtual group with at least one other clinician is part of a practice that is
containing participants in a MIPS APM
such individual MIPS eligible clinician participating in MIPS (that is, reporting)
or an Advanced APM, the groups
or group. Given that section at the group level, then the low-volume
performance assessment will be based
1848(q)(5)(I)(iii)(III) of the Act provides threshold determination is made at the on the performance of the entire TIN.
that a virtual group is a combination of group level and would be applicable to Generally, for groups other than those
TINs, we interpreted the references to such MIPS eligible clinician regardless containing participants in a MIPS APM
an individual MIPS eligible clinician of the low-volume threshold or an Advanced APM, each MIPS
in section 1848(q)(5)(I)(ii) of the Act to determination made at the individual eligible clinician under the TIN (TIN/
mean a solo practitioner, which, for level. Similarly, if a solo practitioner or NPI) receives a MIPS adjustment based
purposes of section 1848(q)(5)(I) of the a group with 10 or fewer eligible on the entire groups performance
Act, we proposed to define as a MIPS clinicians seeks to participate in MIPS assessment (entire TIN). For groups
eligible clinician (as defined at (that is, report) at the virtual group containing participants in a MIPS APM
414.1305) who bills under a TIN with level, then the low-volume threshold or an Advanced APM, only the portion
no other NPIs billing under such TIN determination made at the individual or of the TIN that is being scored for MIPS
(82 FR 30027). group level, respectively, would be according to the generally applicable
Also, we recognized that a group applicable to such solo practitioner or scoring criteria (TIN/NPI) receives a
(TIN) may include not only NPIs who group. Thus, solo practitioners or MIPS adjustment based on the entire
meet the definition of a MIPS eligible groups with 10 or fewer eligible groups performance assessment (entire
clinician, but also NPIs who do not meet clinicians that are determined not to TIN). The remaining portion of the TIN
the definition of a MIPS eligible exceed the low-volume threshold at the that is being scored according to the
clinician at 414.1305 or who are individual or group level, respectively, APM scoring standard (TIN/NPI)
excluded from the definition of a MIPS would not be eligible to participate in receives a MIPS adjustment based on
eligible clinician under 414.1310(b) or MIPS as an individual, group, or virtual that standard. We noted that such
(c). Thus, we interpreted the references group, as applicable. participants may be excluded from
to a group consisting of not more than Given that a virtual group must be a MIPS if they achieve QP or Partial QP
10 MIPS eligible clinicians in section combination of TINs, we recognized that status. For more information, we refer
1848(q)(5)(I)(ii) of the Act to mean a the composition of a virtual group could readers to the CY 2017 Quality Payment
group with 10 or fewer eligible include, for example, one solo Program final rule (81 FR 77058, 77330
clinicians (as such terms are defined at practitioner (NPI) who is practicing through 77331).
414.1305) (82 FR 30027). Under under multiple TINs (TIN A and TIN B), We proposed to apply a similar policy
414.1310(d), the MIPS payment in which the solo practitioner would be to groups, including those containing
adjustment would apply only to NPIs in able to form a virtual group with his or participants in a MIPS APM or an
the virtual group who meet the her own self based on each TIN assigned Advanced APM, that are participating in
definition of a MIPS eligible clinician at to the solo practitioner (TIN A/NPI and MIPS as part of a virtual group (82 FR
414.1305 and who are not excluded TIN B/NPI) (82 FR 30032). As discussed 30028). Specifically, for groups other
from the definition of a MIPS eligible in section II.C.4.b.(3) of this final rule than those containing participants in a
clinician under 414.1310(b) or (c). We with comment period, we did not MIPS APM or an Advanced APM, each
noted that groups must include at least propose to establish a limit on the MIPS eligible clinician under the TIN
one MIPS eligible clinician in order to number of TINs that may form a virtual (TIN/NPI) would receive a MIPS
meet the definition of a group at group at this time. adjustment based on the virtual groups
414.1305 and thus be eligible to form Lastly, we noted that qualification as combined performance assessment
or join a virtual group. a virtual group for purposes of MIPS (combination of TINs). For groups
We proposed to define a virtual group does not change the application of the containing participants in a MIPS APM
at 414.1305 as a combination of two or physician self-referral law to a financial or an Advanced APM, only the portion
more TINs composed of a solo relationship between a physician and an of the TIN that is being scored for MIPS
practitioner (that is, a MIPS eligible entity furnishing designated health according to the generally applicable
clinician (as defined at 414.1305) who services, nor does it change the need for scoring criteria (TIN/NPI) would receive
bills under a TIN with no other NPIs such a financial relationship to comply a MIPS adjustment based on the virtual
groups combined performance We solicited public comment on these groups, or allow multiple TINs within a
assessment (combination of TINs). As proposals, as well as our approach of health care delivery system to report as
discussed in section II.C.6.g. of this final not establishing appropriate a virtual group.
rule with comment period, we proposed classifications (such as by geographic Response: In the CY 2017 Quality
to use waiver authority to ensure that area or by specialty) regarding virtual Payment Program final rule (81 FR
the remaining portion of the TIN that is group composition or a limit on the 77058), we noted that except for groups
being scored according to the APM number of TINs that may form a virtual containing APM participants, we do not
scoring standard (TIN/NPI) would group at this time. permit groups to split TINs if they
receive a MIPS adjustment based on that We noted that we received public choose to participate in MIPS as a
standard. We noted that such comments in response to the CY 2017 group. As we considered the option of
participants may be excluded from Quality Payment Program final rule and permitting groups to split TINs, we
MIPS if they achieve QP or Partial QP additional stakeholder feedback by identified several issues that would
status. hosting several virtual group listening make it challenging and cumbersome to
We refer readers to section II.C.4.b.(3) sessions and convening user groups (82 implement a split TIN option such as
of this final rule with comment period FR 30028). We refer readers to the CY the administrative burden of groups
for a summary of the public comments 2018 Quality Payment Program having to monitor and track which NPIs
we received on these proposals and our proposed rule (82 FR 30027) for a are reporting under which portion of a
responses. summary of these comments and our split TIN and the identification of
response. appropriate criteria to be used for
(3) Appropriate Classifications
The following is a summary of the determining the ways in which groups
As noted above, the statute provides public comments received regarding our would be able to split TINs (for
the Secretary with discretion to proposals, as well as our approach of example, based on specialty, practice
establish appropriate classifications not establishing appropriate site, location, health IT systems, or other
regarding the composition of virtual classifications (such as by geographic factors). However, we recognize that
groups, such as by geographic area or by area or by specialty) regarding virtual there are certain advantages for allowing
specialty. We recognized that virtual group composition or a limit on the TINs to split, such as those the
groups would each have unique number of TINs that may form a virtual identified by the commenter. We intend
characteristics and varying patient group at this time. to explore the option of permitting
populations. However, we believe it is Comment: A majority of commenters groups to split TINs, and any changes
important for virtual groups to have the supported the concept of virtual groups, would be proposed in future
flexibility to determine their own as defined, as a participation option rulemaking. Thus, we consider a group
composition at this time, and, as a available under MIPS. to mean an entire single TIN that elects
result, we did not propose to establish Response: We appreciate the support to participate in MIPS at the group or
any such classifications regarding from the commenters. virtual group level. However, for
virtual group composition (82 FR Comment: Several commenters did multiple TINs that are within a health
30028). not support virtual groups being limited care delivery system, such TINs would
We further noted that the statute does to groups consisting of not more than 10 be able to form a virtual group provided
not limit the number of TINs that may eligible clinicians and requested that that each TIN has 10 or fewer eligible
form a virtual group, and we did not CMS expand virtual group participation clinicians.
propose to establish such a limit at this to groups with more than 10 eligible Comment: A significant portion of
time (82 FR 30028). We did consider clinicians. commenters expressed concern
proposing to establish such a limit, such Response: As noted above, we regarding the ineligibility of virtual
as 50 or 100 participants. In particular, interpreted the references to a group group participation for solo
we were concerned that virtual groups consisting of not more than 10 MIPS practitioners and groups that do not
of too substantial a size (for example, 10 eligible clinicians in section exceed the low-volume threshold. The
percent of all MIPS eligible clinicians in 1848(q)(5)(I)(ii) of the Act to mean a commenters noted that such solo
a given specialty or sub-specialty) may group with 10 or fewer eligible practitioners and groups would not be
make it difficult to compare clinicians (as such terms are defined at able to benefit from participating as part
performance between and among 414.1305) (82 FR 30027). We do not of a virtual group and noted that the
clinicians. We believe that limiting the have discretion to expand virtual group purpose of virtual group formation was
number of virtual group participants participation to groups with more than to provide such solo practitioners and
could eventually assist virtual groups as 10 MIPS eligible clinicians. groups, which are otherwise unable to
they aggregate their performance data Comment: One commenter participate on their own, with an
across the virtual group. However, we recommended that CMS seek a technical opportunity to join with other such
believe that as we initially implement amendment to section 1848(q)(5)(I) of entities and collectively become eligible
virtual groups, it is important for virtual the Act to replace the group eligibility to participate in MIPS as part of a
groups to have the flexibility to threshold of 10 or fewer MIPS eligible virtual group. A few commenters
determine their own size, and thus, the clinicians with a patient population recommended that the low-volume
better approach is not to place such a requirement of at least 5,000 to improve threshold be conducted at the virtual
limit on virtual group size. We will the validity of the reporting of virtual group level.
monitor the ways in which solo groups. Response: In regard to stakeholder
practitioners and groups with 10 or Response: We appreciate the feedback concerns pertaining to the low-volume
fewer eligible clinicians form virtual from the commenter and will take the threshold eligibility determinations
groups and may propose to establish commenters recommendation into made at the individual and group level
appropriate classifications regarding consideration. that would prevent certain solo
virtual group composition or a limit on Comment: A few commenters practitioners and groups from being
the number of TINs that may form a recommended that CMS allow a large, eligible to form a virtual group, we
virtual group in future rulemaking as multispecialty group under one TIN to believe there are statutory constraints
necessary. split into clinically relevant reporting that do not allow us to establish a low-
volume threshold at the virtual group account variability in patient case-mix Act; and (4) a group that includes such
level. The statute includes specific and practice needs. clinicians. The definition of a MIPS
references to MIPS eligible clinicians Response: We appreciate the feedback eligible clinician includes a group and
throughout the virtual group provisions, from the commenter and will take the we define a group at 414.1305 to mean
and we believe that such references commenters recommendation into a single TIN with two or more eligible
were intended to limit virtual group consideration. clinicians (including at least one MIPS
participation to MIPS eligible Comment: One commenter indicated eligible clinician), as identified by their
clinicians, that is, eligible clinicians that the Quality Payment Program individual NPI, who have reassigned
who meet the definition of a MIPS encourages eligible clinicians to their billing rights to the TIN. Since a
eligible clinician and are not excluded aggregate data, share financial risk, and group is included under the definition
under the low-volume threshold or any work together as virtual groups, which of a MIPS eligible clinician, which
other statutory exclusion. As a result, promotes joint accountability and would include two or more eligible
we do not believe we are able to creates delivery systems that are better clinicians (including at least one MIPS
establish a low-volume threshold at the able to improve the cost, quality, and eligible clinician), our definition of a
virtual group level because a solo experience of care. As a result, the virtual group is consistent with statute.
practitioner or group would need to be commenter recommended that CMS
In regard to determining TIN size for
considered eligible to participate in issue detailed guidance and develop
purposes of virtual group eligibility, we
MIPS to form or join a virtual group. tools, resources, technical assistance,
count each NPI associated with a TIN in
Comment: Many commenters and other materials for guidance as to
order to determine whether or not a TIN
supported the flexibility provided for how clinicians can form virtual groups.
Response: We appreciate the feedback exceeds the threshold of 10 NPIs, which
virtual group composition, such as to is an approach that we believe provides
from the commenter and note that we
not have parameters pertaining to continuity over time if the definition of
intend to publish a virtual group toolkit
geographic area, specialty, size, or other a MIPS eligible clinician is expanded in
that provides information pertaining to
factors, while other commenters had future years under section
requirements and outlines the steps a
concerns that such flexibility could 1848(q)(1)(C)(i)(II) of the Act to include
virtual group would pursue during the
circumvent bona fide clinical reasons other eligible clinicians. We considered
election process, which can be accessed
for collaboration, incentivize practice on the CMS Web site at https:// an alternative approach for determining
consolidation, and cause an increase in www.cms.gov/Medicare/Quality- TIN size, which would determine TIN
costs without improving quality and Initiatives-Patient-Assessment- size for virtual group eligibility based on
health outcomes. Instruments/Value-Based-Programs/ NPIs who are MIPS eligible clinicians.
Response: We appreciate the support MACRA-MIPS-and-APMs/MACRA- However, as we conducted a
from the commenters regarding the MIPS-and-APMs.html. comparative assessment of the
flexibility we are providing to virtual Comment: A few commenters application of such alternative approach
groups pertaining to composition. In recommended that only MIPS eligible with the current definition of a MIPS
regard to concerns from other clinicians be considered as part of a eligible clinician (as defined at
commenters regarding such flexibility, virtual group as written in the statute. 414.1305) and a potential expanded
we note that TINs vary in size, clinician The commenters indicated that CMS definition of a MIPS eligible clinician,
composition, patient population, continues to include all eligible we found that such an approach could
resources, technological capabilities, clinicians versus only MIPS eligible create confusion as to which factors
geographic area, and other clinicians in the count to determine TIN determine virtual group eligibility and
characteristics, and may join or form size and requested that CMS instead cause the pool of virtual group eligible
virtual groups for various reasons, and rely on the not more than 10 MIPS TINs to significantly be reduced once
we do not want to inhibit virtual group eligible clinicians language in the the definition of a MIPS eligible
formation due to parameters. At this statute, which would allow more groups clinician would be expanded, which
juncture of virtual group to take advantage of the virtual group may impact a larger portion of virtual
implementation, we believe that virtual reporting option and focus more directly groups that intend to participate in
groups should have the flexibility to on the number of clinicians who are MIPS as a virtual group for consecutive
determine their composition and size, participating in and contributing to performance periods. Such impact
and thus we do not want to limit the MIPS rather than clinicians who are would be the result of the current
ways in which virtual groups are excluded. definition of a MIPS eligible clinician
composed. However, we encourage TINs Response: We note that our proposed being narrower than the potential
within virtual groups to assess means definition of a virtual group reflects the expanded definition of a MIPS eligible
for promoting and enhancing the statutory premise of virtual group clinician. For example, under the
coordination of care and improving the participation pertaining to MIPS eligible recommended approach, a TIN with a
quality of care and health outcomes. We clinicians. In the CY 2017 final rule (81 total of 15 NPIs (10 MIPS eligible
will monitor the ways in which solo FR 77539), we define a MIPS eligible clinicians and 5 eligible clinicians)
practitioners and groups with 10 or clinician (identified by a unique billing would not exceed the threshold of 10
fewer eligible clinicians form virtual TIN and NPI combination used to assess MIPS eligible clinicians and would be
groups and may propose to establish performance) at 414.1305 to mean any eligible to participate in MIPS as a
appropriate classifications regarding of the following (excluding those virtual group for the 2018 performance
virtual group composition or a limit on identified at 414.1310(b)): (1) A period; however, if the definition of a
the number of TINs that may form a physician as defined in section 1861(r) MIPS eligible clinician were expanded
virtual group in future rulemaking as of the Act; (2) a physician assistant, a through rulemaking for the 2019
necessary. nurse practitioner, and clinical nurse performance period, such TIN, with no
Comment: One commenter requested specialist as such terms are defined in change in TIN size (15 NPIs), would
that CMS continue to examine the section 1861(aa)(5) of the Act; (3) a exceed the threshold of 10 MIPS eligible
formation and implementation of virtual certified registered nurse anesthetist as clinicians if 1 or more of the 5 eligible
groups, ensuring equity and taking into defined in section 1861(bb)(2) of the clinicians met the expanded definition
of a MIPS eligible clinician and no At this juncture, we are not TIN for purposes of participation in
longer eligible to participate in MIPS as establishing additional classifications MIPS, nor does any eligible clinician in
part of a virtual group. We did not (such as by geographic area or by the virtual group need to reassign their
pursue such an approach given that it specialty) regarding virtual group billing rights to a new or different TIN.
did not align with our objective of composition or a limit on the number of Comment: A few commenters
establishing virtual group eligibility TINs that may form a virtual group. indicated that EHR developers need to
policies that are simplistic in know the specifications for the virtual
c. Virtual Group Identifier for group identifier as soon as technically
understanding and provide continuity. Performance
Final Action: After consideration of feasible in order for such specifications
the public comments received, we are To ensure that we have accurately to be included in their development
finalizing with modification our captured all of the MIPS eligible efforts and implemented early in 2018.
proposal to define a solo practitioner at clinicians participating in a virtual One commenter indicated that qualified
414.1305 as a practice consisting of group, we proposed that each MIPS registries submit data at the TIN level
one eligible clinician (who is also a eligible clinician who is part of a virtual for group reporting and that individual
MIPS eligible clinician). We are also group would be identified by a unique NPI data is effectively obscured, and
finalizing with modification our virtual group participant identifier (82 requested clarification regarding the
proposal to define a virtual group at FR 30028 through 30029). The unique type of information qualified registries
414.1305 as a combination of two or virtual group participant identifier would report for virtual groups, such as
more TINs assigned to one or more solo would be a combination of three the virtual group identifier alone (VG
practitioners or one or more groups identifiers: (1) Virtual group identifier XXXXXX) or the combination of all
consisting of 10 or fewer eligible (established by CMS; for example, three identifiers (VGXXXXXX, TIN
clinicians, or both, that elect to form a XXXXXX); (2) TIN (9 numeric XXXXXXXXX, NPI11111111111).
characters; for example, XXXXXXXXX); Response: For a virtual groups that are
virtual group for a performance period
and (3) NPI (10 numeric characters; for determined to have met the virtual
for a year. We are modifying the
example, 1111111111). For example, a group formation criteria and approved
definition (i) to remove the redundant
virtual participant identifier could be to participate in MIPS as an identified
phrases with at least one other such
VGXXXXXX, TINXXXXXXXXX, NPI official virtual group, we will notify
solo practitioner or group and
11111111111. We solicited public official designated virtual group
unnecessary parenthetical cross
comment on this proposal. representatives of their official virtual
references; (ii) to accurately characterize
The following is a summary of the group status and issue a virtual group
TINs as being assigned to (rather than identifier. We intend to notify virtual
composed of) a solo practitioner or public comments received regarding our
proposal. groups of their official status as close to
group; and (iii) to clearly indicate that the start of the performance period as
Comment: A majority of commenters
a virtual group can be composed of one technically feasible. Virtual groups will
expressed support for our proposal.
or more solo practitioners or groups of Response: We appreciate the support need to provide their virtual group
10 or fewer eligible clinicians. We note from the commenters. identifiers to the third party
that we are modifying our proposed Comment: One commenter indicated intermediaries that will be submitting
definitions for greater clarity and that a virtual group identifier would their performance data, such as
consistency with established MIPS lead to administrative simplification qualified registries, QCDRs, and/or
terminology. and more accurate identification of EHRs. Qualified registries, QCDRs, and
We are also finalizing our proposal MIPS eligible clinicians caring for EHRs will include the virtual group
that for groups (TINs) that participate in Medicare beneficiaries, which could be identifier alone (VGXXXXXX) in the
MIPS as part of a virtual group and do used in recognizing and eliminating file submissions. For virtual groups that
not contain participants in a MIPS APM redundancies in the payer system. elect to participate in MIPS via the CMS
or an Advanced APM, each MIPS Response: We appreciate the support Web Interface or administer the CAHPS
eligible clinician under the TIN (each from the commenter. We believe that for MIPS survey, they will register via
TIN/NPI) will receive a MIPS payment our proposed virtual group identifier the CMS Web Interface and include the
adjustment based on the virtual groups will accurately identify each MIPS virtual group identifier alone (VG
combined performance assessment eligible clinician participating in a XXXXXX) during registration. We
(combination of TINs). For groups virtual group and be easily implemented intend to update submission
(TINs) that participate in MIPS as part by virtual groups. specifications prior to the start of the
of a virtual group and contain Comment: One commenter thanked applicable submission period.
participants in a MIPS APM or an CMS for not requiring virtual groups to Comment: One commenter expressed
Advanced APM, only the portion of the form new TINs, which would add to the concerns regarding the burden of using
TIN that is being scored for MIPS administrative burden for entities a virtual group identifier and the added
according to the generally applicable electing to become virtual groups, while administrative complexity to the claims
scoring criteria will receive a MIPS another commenter requested process of using layered identifiers and
adjustment based on the virtual groups clarification regarding whether or not modifiers. The commenter requested
combined performance assessment members of a virtual group would need that CMS simplify the reporting process
(combination of TINs). As discussed in to submit a Reassignment of Benefits for MIPS eligible clinicians, groups, and
section II.C.6.g. of this final rule with Form (CMS855R) to the MAC and virtual groups rather than increase the
comment period, the remaining portion reassign their billing rights to the administrative burden.
of the TIN that is being scored according elected virtual group. Response: We appreciate the feedback
to the APM scoring standard will Response: We note that a virtual from the commenter. We do not believe
receive a MIPS payment adjustment group is recognized as an official that the virtual group identifier would
based on that standard. We note that collective entity for reporting purposes, be burdensome for virtual groups to
such participants may be excluded from but is not a distinct legal entity for implement. We believe that our
MIPS if they achieve QP or Partial QP billing purposes. As a result, a virtual proposed virtual group identifier is the
status. group does not need to establish a new most appropriate and simple approach,
which will allow for the accurate (2) Application of Non-Patient Facing practices by utilizing claims data; for
identification of each MIPS eligible Status to Virtual Groups performance periods occurring in 2018,
clinician participating in a virtual group With regard to the applicability of the we would identify small practices based
and be easily implemented by virtual non-patient facing MIPS eligible on 12 months of data starting from
groups. clinician-related policies to virtual September 1, 2016 to August 31, 2017
Final Action: After consideration of groups, in the CY 2017 Quality Payment (82 FR 30019 through 30020). We refer
the public comments received, we are Program final rule (81 FR 77048 through readers to section II.C.1.c. of this final
finalizing our proposal that each MIPS 77049), we defined the term non-patient rule with comment period for the
eligible clinician who is part of a virtual facing MIPS eligible clinician at discussion of our proposal to identify
group will be identified by a unique small practices by utilizing claims data.
414.1305 as an individual MIPS
virtual group participant identifier, We refer readers to section II.C.4.d.(3) of
eligible clinician that bills 100 or fewer
which will be a combination of three this final rule with comment period for
patient facing encounters (including
identifiers: (1) Virtual group identifier the discussion regarding how small
Medicare telehealth services defined in
(established by CMS; for example, practice status would apply to virtual
section 1834(m) of the Act) during the
groups for scoring under MIPS.
XXXXXX); (2) TIN (9 numeric non-patient facing determination We refer readers to section II.C.4.d.(5)
characters; for example, XXXXXXXXX); period, and a group provided that more of this final rule with comment period
and (3) NPI (10 numeric characters; for than 75 percent of the NPIs billing for a summary of the public comments
example, 1111111111). For example, a under the groups TIN meet the we received on our proposal to apply
virtual group participant identifier definition of a non-patient facing small practice status to virtual groups
could be VGXXXXXX, TIN individual MIPS eligible clinician and our responses.
XXXXXXXXX, NPI11111111111. during the non-patient facing
determination period. In the CY 2018 (4) Application of Rural Area and HSPA
d. Application of Group-Related Policies Practice Status to Virtual Groups
to Virtual Groups Quality Payment Program proposed rule
(82 FR 30021, 30029), we proposed to In the CY 2018 Quality Payment
(1) Generally modify the definition of a non-patient Program proposed rule (82 FR 30020
facing MIPS eligible clinician to include through 30021), we proposed to
In the CY 2017 Quality Payment
clinicians in a virtual group, provided determine rural area and HPSA practice
Program final rule (81 FR 77070 through
that more than 75 percent of the NPIs designations at the individual, group,
77072), we finalized various
billing under the virtual groups TINs and virtual group level. Specifically, for
requirements for groups under MIPS at
meet the definition of a non-patient performance periods occurring in 2018
414.1310(e), under which groups
facing individual MIPS eligible clinician and future years, we proposed that an
electing to report at the group level are
during the non-patient facing individual MIPS eligible clinician, a
assessed and scored across the TIN for
determination period. We noted that group, or a virtual group with multiple
all four performance categories. In the
other policies previously established practices under its TIN or TINs within
CY 2018 Quality Payment Program
and proposed in the proposed rule for a virtual group would be designated as
proposed rule (82 FR 30029), we
non-patient facing groups would apply a rural area or HPSA practice if more
proposed to apply our previously
to virtual groups (82 FR 30029). For than 75 percent of NPIs billing under
finalized and proposed group-related
example, as discussed in section the individual MIPS eligible clinician or
policies to virtual groups, unless
II.C.1.e. of this final rule with comment groups TIN or within a virtual group, as
otherwise specified. We recognized that
period, virtual groups determined to be applicable, are designated in a ZIP code
there are instances in which we may
non-patient facing would have their as a rural area or HPSA. We noted that
need to clarify or modify the application
advancing care information performance other policies previously established
of certain previously finalized or
category automatically reweighted to and proposed in the proposed rule for
proposed group-related policies to
zero. rural area and HPSA groups would
virtual groups, such as the definition of We refer readers to section II.C.4.d.(5)
a non-patient facing MIPS eligible apply to virtual groups (82 FR 30029).
of this final rule with comment period We note that in section II.C.7.b.(1)(b) of
clinician; small practice, rural area and for a summary of the public comments
HPSA designations; and groups that this final rule with comment period, we
we received on these proposals and our describe our scoring proposals for
contain participants in a MIPS APM or responses.
an Advanced APM (see section II.C.4.b. practices that are in a rural area.
(3) Application of Small Practice Status We refer readers to section II.C.4.d.(5)
of this final rule with comment period).
to Virtual Groups of this final rule with comment period
More generally, such policies may
for a summary of the public comments
include, but are not limited to, those With regard to the application of we received on these proposals and our
that require a calculation of the number small practice status to virtual groups, responses.
of NPIs across a TIN (given that a virtual in the CY 2017 Quality Payment
group is a combination of TINs), the Program final rule (81 FR 77188), we (5) Applicability and Availability of
application of any virtual group defined the term small practices at Measures and Activities to Virtual
participants status or designation to the 414.1305 as practices consisting of 15 Groups
entire virtual group, and the or fewer clinicians and solo As noted above, we proposed to apply
applicability and availability of certain practitioners. In the CY 2018 Quality our previously finalized and proposed
measures and activities to any virtual Payment Program proposed rule (82 FR group-related policies to virtual groups,
group participant and to the entire 30019, 30029), we proposed that a unless otherwise specified (82 FR
virtual group. virtual group would be identified as a 30029). In particular, we recognized that
We refer readers to section II.C.4.d.(5) small practice if the virtual group does the measures and activities applicable
of this final rule with comment period not have 16 or more eligible clinicians. and available to groups would also be
for a summary of the public comments In addition, we proposed for applicable and available to virtual
we received on these proposals and our performance periods occurring in 2018 groups. Virtual groups would be
responses. and future years to identify small required to meet the reporting
requirements for each measure and virtual group would otherwise qualify TINs are in a ZIP code designated as a
activity, and the virtual group would be as a small practice and should not lose rural area or HPSA would be designated
responsible for ensuring that their the accommodations to which they as a rural area or HPSA practice at the
measure and activity data are aggregated would otherwise be entitled. The virtual group level. The commenters
across the virtual group (for example, commenters suggested that any virtual requested that CMS reduce the
across their TINs). We noted that other group, regardless of size, be considered threshold pertaining to rural area and
previously finalized and proposed a small practice. The commenters HPSA practice status for virtual groups
group-related policies pertaining to the further stated that small practices that and recommended that a virtual group
four performance categories would just slightly exceed the low-volume with more than 50 percent of the NPIs
apply to virtual groups. threshold may have the most challenges billing under a virtual groups TINs are
The following is a summary of the and difficulty succeeding in the Quality in a ZIP code designated as a rural area
public comments received regarding our Payment Program. or HPSA would be designated as a rural
proposals. Response: We note that virtual groups area or HPSA practice at the virtual
Comment: Many commenters with 15 or fewer eligible clinicians will group level.
supported our proposal to generally continue to be considered a small Response: We disagree with the
apply MIPS group-related policies to practice as a collective entity. The small recommendation from the commenters.
virtual groups, unless otherwise practice status is applied based on the In order for a virtual group to be
specified. The commenters indicated collective entity as a whole and not designated as a rural area or HPSA
that such alignment would ease undue based on the small practice status of practice, we believe that a significant
administrative and reporting burden. each TIN within a virtual group. If a portion of a virtual groups NPIs would
Response: We appreciate the support virtual group has 16 or more eligible need to be in a ZIP code designated as
from the commenters. clinicians, it would not be considered to a rural area or HPSA. Our proposal
Comment: Several commenters have a small practice status as a provides a balance between requiring
supported our proposal to modify the collective whole. We believe that our more than half of a virtual groups NPIs
definition of a non-patient facing MIPS approach is consistent with statute and to have such designations and requiring
eligible clinician to include clinicians in not unfair to small practices that are a all NPIs within a virtual group to have
a virtual group provided that more than part of virtual groups with 16 or more such designations. Also, our proposed
75 percent of the NPIs billing under the eligible clinicians. Section threshold pertaining to rural area and
virtual groups TINs meet the definition 1848(q)(2)(B)(iii) of the Act specifically HPSA practice status for virtual groups
of a non-patient facing individual MIPS refers to small practices of 15 or fewer aligns with other group-related and
eligible clinician. clinicians, and we do not believe it is virtual group policies, which creates
Response: We appreciate the support appropriate to apply such designation to continuity among policies and makes
from the commenters. a virtual group as a collective single virtual group implementation easier for
Comment: One commenter expressed entity when a virtual group has 16 or TINs forming virtual groups.
support for our proposal that a virtual more eligible clinicians. We encourage Comment: One commenter urged
group would be identified as a small small practices to weigh the benefit of CMS to eliminate the all-cause hospital
practice if the virtual group does not the special provisions specific to small readmission measure from the quality
have 16 or more eligible clinicians, practices against the benefits of virtual performance category score for virtual
while another commenter expressed group participation when considering groups with 16 or more eligible
support for our proposal that a virtual whether to form a virtual group that has clinicians. The commenter noted that
group with more than 75 percent of the 16 or more eligible clinicians. We refer virtual groups would be newly formed
NPIs billing under the virtual groups readers to section II.C.7.b.(1)(c) of this and unlikely to have the same
TINs are in a ZIP code designated as a final rule with comment for the infrastructure and care coordination
rural area or HPSA would be designated discussion regarding the scoring of functionality that established groups
as a rural area or HPSA practice at the small practices. We want to ensure that under a single TIN may have in place,
virtual group level. small practices have the ability to and that factoring the all-cause hospital
Response: We appreciate the support determine the most appropriate means readmission measure into their score
from the commenters regarding our for participating in MIPS, whether it be would be inappropriate.
proposals. as individuals, as a group or part of a Response: We recognize that small
Comment: Several commenters did virtual group. The formation of virtual practices, including solo practitioners,
not support our proposal that a virtual groups provides for a comprehensive would not be assessed on the all-cause
group would be identified as a small measurement of performance, shared hospital readmission measure as
practice if the virtual group does not responsibility, and an opportunity to individual TINs. However, we believe
have 16 or more eligible clinicians. The effectively and efficiently coordinate that the all-cause hospital readmission
commenters expressed concerns that the resources to achieve requirements under measure is an appropriate measure,
benefits of forming a virtual group could each performance category. A small when applicable, to assess performance
be outweighed by the loss of the practice may elect to join a virtual group under the quality performance category
proposed small practice bonus points in order to potentially increase their of virtual groups with 16 or more
for virtual groups with more than 15 performance under MIPS or elect to eligible clinicians that meet the case
eligible clinicians, and that the participate in MIPS as a group and take volume of 200 cases. For virtual groups
elimination of small practice bonus advantage of other flexibilities and that do not meet the minimum case
points for such virtual groups would benefits afforded to small practices. We volume of 200, the all-cause hospital
undermine the establishment of small note that if a virtual group has 16 or readmission measure would not be
practice policies afforded to such more eligible clinicians, it will not be scored. Also, we believe that our
entities in statute. The commenters considered a small practice. approach for assessing performance
indicated that the formation of virtual Comment: A few commenters did not based on the all-cause hospital
groups would involve substantial support our proposal that a virtual readmission measure for virtual groups
administrative burdens for small group with more than 75 percent of the with 16 or more eligible clinicians is
practices, and that each TIN within a NPIs billing under the virtual groups appropriate because it reflects the same
policy for groups, which was developed TINs within a virtual group would be aggregating data on the advancing care
as a requirement to reduce burden (such required to have certified EHR information performance category
measure is based on administrative technology. measures, particularly when TINs
claims data and does not require a Response: In general and unless stated within a virtual group may be using
separate submission of data) and ensure otherwise, for purposes of the advancing multiple CEHRT systems. For the 2018
that we do not unfairly penalize MIPS care information performance category, performance period, TINs within virtual
eligible clinicians or groups that did not the policies pertaining to groups will groups may be using systems which are
have adequate time to prepare apply to virtual groups. We refer readers certified to different CEHRT Editions.
adequately to succeed in the program to section II.C.6.f. of this final rule with We consider unique patients to be
while still rewarding high performers. comment period for more information individual patients treated by a TIN
Comment: One commenter supported on the generally applicable policies for within a virtual group who would
our proposal to generally apply our the advancing care information typically be counted as one patient in
group-related policies to virtual groups, performance category. the denominator of an advancing care
specifically with regard to the We note that as with virtual group information performance category
improvement activities performance reporting for the other MIPS measure. This patient may see multiple
category requirements, under which performance categories, to report as a MIPS eligible clinicians within a TIN
groups and virtual groups would receive virtual group, the virtual group will that is part of a virtual group, or may see
credit for an improvement activity as need to aggregate data for all of the MIPS eligible clinicians at multiple
long as one NPI under the groups TIN individual MIPS eligible clinicians practice sites of a TIN that is part of a
or virtual groups TINs performs an within the virtual group for which its virtual group. When aggregating
improvement activity for a continuous TINs have data in CEHRT. For solo performance on advancing care
90-day period. practitioners and groups that choose to information measures for virtual group
Response: We appreciate the support report as a virtual group, performance level reporting, we do not require that
from the commenter. on the advancing care information a virtual group determines that a patient
Comment: One commenter requested performance category objectives and seen by one MIPS eligible clinician (or
clarification regarding how the measures will be reported and evaluated at one location in the case of TINs
proposed group-related policy that at at the virtual group level. The virtual working with multiple CEHRT systems)
least 50 percent of the practice sites group will submit the data that its TINs is not also seen by another MIPS eligible
within a TIN must be certified or have utilizing CEHRT and exclude data clinician in the TIN that is part of the
recognized as a patient-centered not collected from a non-certified EHR virtual group or captured in a different
medical home or comparable specialty system. While we do not expect that CEHRT system. Virtual groups are
practice in order to receive full credit in every MIPS eligible clinician in a virtual provided with some flexibility as to the
the improvement activities performance group will have access to CEHRT, or method for counting unique patients in
category applies to virtual groups. that every measure will apply to every the denominators to accommodate such
Another commenter recommended that clinician in the virtual group, only those scenarios where aggregation may be
a virtual group receive full credit for the data contained in CEHRT should be hindered by systems capabilities across
improvement activities performance reported for the advancing care multiple CEHRT platforms. We refer
category if at least 50 percent of its information performance category. readers to section II.C.6.f.(4) of this final
eligible clinicians are certified or For example, the virtual group rule with comment for the discussion
recognized as a patient-centered calculation of the numerators and regarding certification requirements.
medical home or comparable specialty denominators for each measure must Comment: One commenter requested
practice. reflect all of the data from the that CMS require that a majority of
Response: As discussed in section individual MIPS eligible clinicians eligible clinicians within a virtual group
II.C.7.a.(5)(c) of this final rule with (unless a clinician can be excluded) that participate in activities to which the
comment period, in order for a group to have been captured in CEHRT for the virtual group attests in the improvement
receive full credit as a certified or given advancing care information activities and advancing care
recognized patient-centered medical performance category measure. If the information performance categories in
home or comparable specialty practice groups (not including solo practitioners) order for the virtual group to receive
under the improvement activities that are part of a virtual group have credit for those activities.
performance category, at least 50 CEHRT that is capable of supporting Response: We note that a virtual
percent of the practice sites within the group level reporting, the virtual group group would need to meet the group-
TIN must be recognized as a patient- would submit the aggregated data across related requirements under each
centered medical home or comparable the TINs produced by the CEHRT. If a performance category. For the
specialty practice. In order for a virtual group (TIN) that is part of a virtual improvement activities performance
group to receive full credit as a certified group does not have CEHRT that is category, a virtual group would meet the
or recognized patient-centered medical capable of supporting group level reporting requirements if at least one
home or comparable specialty practice reporting, such group would aggregate NPI within the virtual group completed
under the improvement activities the data by adding together the an improvement activity for a minimum
performance category, at least 50 numerators and denominators for each of a continuous 90-day period within
percent of the practice sites within the MIPS eligible clinician within the group CY 2018. In regard to the advancing care
TINs that are part of a virtual group for whom the group has data captured information performance category, a
must be certified or recognized as a in CEHRT. If an individual MIPS virtual group would need to fulfill the
patient-centered medical home or eligible clinician meets the criteria to required base score measures for a
comparable specialty practice. exclude a measure, their data can be minimum of 90 days in order to earn
Comment: One commenter requested excluded from the calculation of that points for the advancing care
that CMS clarify how a virtual group particular measure only. information performance category.
would be expected to meet the We recognize that it can be difficult Additionally, virtual groups are able to
advancing care information performance to identify unique patients across a submit performance score measures and
category requirements and whether all virtual group for the purposes of bonus score measures in order to
increase the number of points earned adjustment factor(s) for a performance must make their election prior to the
under the advancing care information period. In regard to an audit process, start of the applicable performance
performance category. virtual groups would be subject to the period and cannot change their election
Comment: A few commenters MIPS data validation and auditing during the performance period; and (2)
requested that virtual groups have the requirements as described in section an individual MIPS eligible clinician or
same flexibility afforded to groups II.C.9.c. of this final rule with comment group may elect to be in no more than
regarding the ability to report on period. one virtual group for a performance
different measures and utilize multiple Final Action: After consideration of period, and, in the case of a group, the
submission mechanisms under each public comments received, we are election applies to all MIPS eligible
performance category. finalizing our proposal to apply our clinicians in the group. Accordingly, we
Response: We note that virtual groups previously finalized and proposed proposed to codify at 414.1315(a) that
will have the same flexibility as groups group-related policies to virtual groups, a solo practitioner (as defined at
to report on measures and activities that unless otherwise specified. 414.1305) or group consisting of 10 or
are applicable and available to them. As We are also finalizing our proposal to fewer eligible clinicians (as such terms
discussed in section II.C.6.a.(1) of this modify the definition of a non-patient are defined at 414.1305) electing to be
final rule with comment period, the facing MIPS eligible clinician at in a virtual group must make their
submission mechanisms available to 414.1305 to include a virtual group, election prior to the start of the
groups under each performance category provided that more than 75 percent of applicable performance period and
will also be available to virtual groups. the NPIs billing under the virtual cannot change their election during the
Similarly, virtual groups will also have groups TINs meet the definition of a performance period (82 FR 30029
the same option as groups to utilize non-patient facing individual MIPS through 30030). Virtual group
multiple submission mechanisms, but eligible clinician during the non-patient participants may elect to be in no more
only one submission mechanism per facing determination period. Other than one virtual group for a performance
performance category for the 2018 previously finalized and proposed period, and, in the case of a group, the
performance period. However, starting policies related to non-patient facing election applies to all MIPS eligible
with the 2019 performance period, MIPS eligible clinicians would apply to clinicians in the group.
groups and virtual groups will be able such virtual groups. We noted that in the case of a TIN
to utilize multiple submission We are also finalizing our proposal within a virtual group being acquired or
mechanisms for each performance that a virtual group will be considered merged with another TIN, or no longer
category. a small practice if a virtual group
Comment: A few commenters operating as a TIN (for example, a group
consists of 15 or fewer eligible practice closes), during a performance
recommended that CMS establish
clinicians. Other previously finalized period, such solo practitioners or
performance feedback for virtual groups
and proposed policies related to small groups performance data would
and each TIN within a virtual group that
practices would apply to such virtual continue to be attributed to the virtual
includes complete performance data for
groups. group (82 FR 30032). The remaining
each performance category. One
We are also finalizing our proposal parties to the virtual group would
commenter requested that CMS provide
that a virtual group will be designated continue to be part of the virtual group
instructions regarding the appeal and
as a rural area or HPSA practice if more even if only one solo practitioner or
audit process for virtual groups and
than 75 percent of NPIs billing under group remains. We consider a TIN that
TINs within a virtual group.
Response: We note that performance the virtual groups TINs are designated is acquired or merged with another TIN,
feedback for virtual groups will be in a ZIP code as a rural area or HPSA, or no longer operating as a TIN (for
similar to feedback reports for groups, the virtual groups TINs are designated example, a group practice closes), to
which is based on the performance of as rural areas or HPSA practices. Other mean a TIN that no longer exists or
the entire group for each performance previously finalized and proposed operates under the auspices of such TIN
category. We note that virtual groups are policies related to rural area or HPSA during a performance period.
required to aggregate their data across practices would apply to such virtual In order to provide support and
the virtual group, and will be assessed groups. reduce burden, we intend to make
and scored at the virtual group level. In response to public comments, we technical assistance (TA) available, to
Each TIN within the virtual group will are also finalizing that a virtual group the extent feasible and appropriate, to
receive feedback on their performance will be considered a certified or support clinicians who choose to come
based on participation in MIPS as a recognized patient-centered medical together as a virtual group. Clinicians
virtual group, in which each TIN under home or comparable specialty practice can access the TA infrastructure and
the virtual group will have the same under 414.1380(b)(3)(iv) if at least 50 resources that they may already be
performance feedback applicable to the percent of the practices sites within the utilizing. For Quality Payment Program
four performance categories. At this TINs are certified or recognized as a year 3, we intend to provide an
juncture, it is not technically feasible patient-centered medical home or electronic election process if technically
nor do we believe it is appropriate for comparable specialty practice. feasible. We proposed that clinicians
us to de-aggregate data at the virtual e. Virtual Group Election Process who do not elect to contact their
group level and reassess performance designated TA representative would
(1) Generally still have the option of contacting the
data at the TIN or TIN/NPI level without
requiring TINs and/or TIN/NPIs to As noted in section II.C.4.a. of this Quality Payment Program Service
submit data separately. We refer readers final rule with comment period, section Center to obtain information pertaining
to section II.C.9.a. of this final rule with 1848(q)(5)(I)(iii)(I) and (II) of the Act to virtual groups (82 FR 30030).
comment period for the discussion provides that the virtual group election We refer readers to section II.C.4.e.(3)
pertaining to performance feedback. process must include certain of this final rule with comment period
Moreover, we note that virtual groups requirements, including that: (1) An for a summary of the public comments
will have an opportunity to request a individual MIPS eligible clinician or we received on these proposals and our
targeted review of their MIPS payment group electing to be in a virtual group responses.
(2) Virtual Group Election Deadline virtual group implementation, and other otherwise, the TINs status would be
For performance periods occurring in related activities; whereas, by engaging determined at the time that the TINs
2018 future years, we proposed to directly in stage 2 as an initial step, solo virtual group election is submitted. For
establish a virtual group election period practitioners and groups might conduct example, if a group contacted their
(82 FR 30030). Specifically, we all such efforts to only have their designated TA representative on
proposed to codify at 414.1315(a) that election registration be rejected with no October 20, 2017, the claims data
a solo practitioner (as defined at recourse or remaining time to amend analysis would include the months of
414.1305) or group consisting of 10 or and resubmit. July through September of 2017, and, if
In stage 1, solo practitioners and determined not to exceed 10 eligible
fewer eligible clinicians (as such terms
groups with 10 or fewer eligible clinicians, the TINs size would be
are defined at 414.1305) electing to be
clinicians interested in forming or determined at such time, and the TINs
in a virtual group must make their
joining a virtual group would have the eligibility status would be retained for
election by December 1 of the calendar option to contact their designated TA
year preceding the applicable the duration of the election period and
representative in order to obtain the CY 2018 performance period. If
performance period. A virtual group information pertaining to virtual groups
representative would be required to another group contacted their
and/or determine whether or not they designated TA representative on
make the election, on behalf of the are eligible, as it relates to the practice
members of a virtual group, regarding November 20, 2017, the claims data
size requirement of a solo practitioner or analysis would include the months of
the formation of a virtual group for the a group of 10 or fewer eligible
applicable performance period, by the July through October of 2017, and, if
clinicians, to participate in MIPS as a determined not to exceed 10 eligible
election deadline. For example, a virtual virtual group ( 414.1315(c)(1)(i)).
group representative would need to clinicians, the TINs size would be
During stage 1 of the virtual group determined at such time, and the TINs
make an election, on behalf of the election process, we would determine
members of a virtual group, by eligibility status would be retained for
whether or not a TIN is eligible to form the duration of the election period and
December 1, 2017 for the members of or join a virtual group. In order for a
the virtual group to participate in MIPS the CY 2018 performance period.
solo practitioner to be eligible to form or We believe such a virtual group
as a virtual group during the CY 2018 join a virtual group, the solo practitioner
performance period. We intend to determination period process provides a
would need to meet the definition of a relative representation of real-time TIN
publish the beginning date of the virtual solo practitioner at 414.1305 and not
group election period applicable to size for purposes of virtual group
be excluded from MIPS under
performance periods occurring in 2018 eligibility and allows solo practitioners
414.1310(b) or (c). In order for a group
and future years in subregulatory and groups to know their real-time
to be eligible to form or join a virtual
guidance. eligibility status immediately and plan
group, a group would need to meet the
We refer readers to section II.C.4.e.(3) accordingly for virtual group
definition of a group at 414.1305, have
of this final rule with comment period implementation. It is anticipated that
a TIN size that does not exceed 10
for a summary of the public comments starting in September of each calendar
eligible clinicians, and not be excluded
we received on these proposals and our year prior to the applicable performance
from MIPS under 414.1310(b) or (c).
responses. period, solo practitioners and groups
For purposes of determining TIN size
would be able to contact their
(3) Virtual Group Eligibility for virtual group participation
eligibility, we coined the term virtual designated TA representative and
Determinations and Formation inquire about virtual group participation
group eligibility determination period
We proposed to codify at and defined it to mean an analysis of eligibility. We noted that TIN size
414.1315(c) a two-stage virtual group claims data during an assessment period determinations are based on the number
election process, stage 1 of which is of up to 5 months that would begin on of NPIs associated with a TIN, which
optional, for performance periods July 1 and end as late as November 30 would include clinicians (NPIs) who do
occurring in 2018 and 2019 (82 FR of the calendar year prior to the not meet the definition of a MIPS
30030 through 30032). Stage 1 pertains applicable performance period and eligible clinician at 414.1305 or who
to virtual group eligibility includes a 30-day claims run out. are excluded from MIPS under
determinations, and stage 2 pertains to To capture a real-time representation 414.1310(b) or (c).
virtual group formation. We noted that of TIN size, we proposed to analyze up For groups that do not choose to
activity involved in stage 1 is not to 5 months of claims data on a rolling participate in stage 1 of the election
required, but a resource available to solo basis, in which virtual group eligibility process (that is, the group does not
practitioners and groups with 10 or determinations for each TIN would be request an eligibility determination), we
fewer eligible clinicians. Solo updated and made available monthly will make an eligibility determination
practitioners and groups that engage in (82 FR 30030). We noted that an during stage 2 of the election process. If
stage 1 and are determined eligible for eligibility determination regarding TIN a group began the election process at
virtual group participation would size is based on a relative point in time stage 2 and if its TIN size is determined
proceed to stage 2; otherwise, solo within the 5-month virtual group not to exceed 10 eligible clinicians and
practitioners and groups that do not eligibility determination period, and not not excluded based on the low-volume
engage in any activity during stage 1 made at the end of such 5-month threshold exclusion at the group level,
would begin the election process at determination period. the group is determined eligible to
stage 2. Engaging in stage 1 would If at any time a TIN is determined to participate in MIPS as part of a virtual
provide solo practitioners and groups be eligible to participate in MIPS as part group, and such virtual group eligibility
with the option to confirm whether or of a virtual group, the TIN would retain determination status would be retained
not they are eligible to join or form a that status for the duration of the for the duration of the election period
virtual group before going to the lengths election period and the applicable and applicable performance period.
of executing formal written agreements, performance period. TINs could Stage 2 pertains to virtual group
submitting a formal election determine their status by contacting formation. For stage two, we proposed
registration, allocating resources for their designated TA representative; the following (82 FR 30031):
TINs comprising a virtual group each TIN participating in a virtual group provided virtual groups with an
must establish a written formal that are excluded from MIPS in order to opportunity to make an election prior to
agreement between each member of a ensure that such NPIs would not receive the publication of our final rule. On
virtual group prior to an election a MIPS payment adjustment or, when October 11, 2017, the election period
( 414.1315(c)(2)(i)). applicable and when information is began and we issued information
On behalf of a virtual group, the available, would receive a payment pertaining to the start date of the
official designated virtual group adjustment based on a MIPS APM election process via subregulatory
representative must submit an election scoring standard; calculate the low- guidance, which can be accessed on the
by December 1 of the calendar year prior volume threshold at the individual and CMS Web site at https://www.cms.gov/
to the start of the applicable group levels in order to determine Medicare/Quality-Initiatives-Patient-
performance period whether or not a solo practitioner or Assessment-Instruments/Value-Based-
( 414.1315(c)(2)(ii)). Such election will group is eligible to participate in MIPS Programs/MACRA-MIPS-and-APMs/
occur via email to the Quality Payment as part of a virtual group; and notify MACRA-MIPS-and-APMs.html. As
Program Service Center using the virtual groups as to whether or not they discussed in section II.C.4.e. of this final
following email address for the 2018 are considered official virtual groups for rule with comment period, we are
and 2019 performance periods: MIPS_ the applicable performance period. For extending the virtual group election.
VirtualGroups@cms.hhs.gov. virtual groups that are determined to
The submission of a virtual group Virtual groups would have from October
have met the virtual group formation
election must include, at a minimum, 11, 2017 to December 31, 2017 to make
criteria and identified as an official
information pertaining to each TIN and an election for the 2018 performance
virtual group participating in MIPS for
NPI associated with the virtual group an applicable performance period, we year. However, any MIPS eligible
and contact information for the virtual would contact the official designated clinicians applying to be a virtual group
group representative virtual group representative via email that does not meet all finalized virtual
( 414.1315(c)(2)(iii)). A virtual group notifying the virtual group of its official group requirements would not be
representative would submit the virtual group status and issuing a virtual permitted to participate in MIPS as a
following type of information: Each TIN group identifier for performance (as virtual group.
associated with the virtual group; each described in section II.C.4.c. of this final As previously noted, solo
NPI associated with a TIN that is part of rule with comment period) that would practitioners and groups participating in
the virtual group; name of the virtual accompany the virtual groups a virtual group would have the size of
group representative; affiliation of the submission of performance data during their TIN determined for eligibility
virtual group representative to the the submission period. purposes. We recognized that the size of
virtual group; contact information for As we engaged in various discussions a TIN may fluctuate during a
the virtual group representative; and with stakeholders during the performance period with eligible
confirmation through acknowledgment rulemaking process through listening clinicians and/or MIPS eligible
that a formal written agreement has sessions and user groups, stakeholders clinicians joining or leaving a group. For
been established between each member indicated that many solo practitioners solo practitioners and groups that are
of the virtual group (solo practitioner or and small groups have limited resources determined eligible to form or join a
group) prior to election and each and technical capacities, which may virtual group based on the one-time
eligible clinician in the virtual group is make it difficult for the entities to form determination per applicable
aware of participating in MIPS as a virtual groups without sufficient time performance period, any new eligible
virtual group for an applicable and technical assistance. Depending on clinicians or MIPS eligible clinicians
performance period. Each party to the the resources and technical capacities of that join the TIN during the
virtual group agreement must retain a the entities, stakeholders conveyed that performance period would participate
copy of the virtual groups written it may take entities 3 to 18 months to in MIPS as part of the virtual group. In
agreement. We noted that the virtual prepare to participate in MIPS as a
such cases, we recognized that a solo
group agreement is subject to the MIPS virtual group. The majority of
data validation and auditing practitioner or group may exceed 1
stakeholders indicated that virtual
requirements as described in section eligible clinician or 10 eligible
groups would need at least 6 to 12
II.C.9.c. of this final rule with comment clinicians, as applicable, associated
months prior to the start of the CY 2018
period. performance period to form virtual with its TIN during an applicable
Once an election is made, the groups, prepare health IT systems, and performance period, but such solo
virtual group representative must train staff to be ready for the practitioner or group would have been
contact their designated CMS contact to implementation of virtual group related determined eligible to form or join a
update any election information that activities by January 1, 2018. virtual group given that the TIN did not
changed during an applicable We recognized that for the first year have more than 1 eligible clinician or 10
performance period at least one time of virtual group formation and eligible clinicians, as applicable,
prior to the start of an applicable implementation prior to the start of the associated with its TIN at the time of
submission period ( 414.1315(c)(2)(iv)). CY 2018 performance period, the election. As previously noted, the
Virtual groups will use the Quality timeframe for virtual groups to make an virtual group representative would need
Payment Program Service Center as election by registering would be to contact the Quality Payment Program
their designated CMS contact; however, relatively short, particularly from the Service Center to update the virtual
we will define this further in date we issue the publication of a final groups information that was provided
subregulatory guidance. rule toward the end of the 2017 calendar during the election period if any
For stage 2 of the election process, we year. To provide solo practitioners and information changed during an
would review all submitted election groups with 10 or fewer eligible applicable performance period at least
information; confirm whether or not clinicians with additional time to one time prior to the start of an
each TIN within a virtual group is assemble and coordinate resources, and applicable submission period (for
eligible to participate in MIPS as part of form a virtual group prior to the start of example, include new NPIs who joined
a virtual group; identify the NPIs within the CY 2018 performance period, we a TIN that is part of a virtual group).
Virtual groups must re-register before performance period as technically codifying at 414.1315(b) that,
each performance period. feasible. beginning with performance periods
The following is a summary of the Comment: A few commenters occurring in 2018, a solo practitioner, or
public comments received regarding our indicated that solo practitioners and group of 10 or fewer eligible clinicians
proposed election process for virtual groups should have the option of electing to be in a virtual group must
groups. leaving a virtual group during the make their election by December 31 of
Comment: Generally, all commenters performance period or allow a virtual the calendar year preceding the
expressed support for the technical group to remove a solo practitioner or applicable performance period.
assistance infrastructure and two-stage group for non-compliance or low
performance. f. Virtual Group Agreements
election process.
Response: We appreciate the support Response: We note that the statute As noted in section II.C.4.a. of this
from commenters. specifies that a virtual group election final rule with comment period, section
cannot be changed during the 1848(q)(5)(I)(iii)(IV) of the Act provides
Comment: A majority of commenters
performance period, and such election that the virtual group election process
expressed concern regarding the
would remain for the duration of the must provide for formal written
election deadline of December 1, while
performance period. agreements among individual MIPS
several commenters recommended that
Comment: A few commenters eligible clinicians (solo practitioners)
an election deadline be established
requested that CMS allow virtual group and groups electing to be a virtual
during the performance period in order agreements to be executed during the group. We proposed that each virtual
for virtual groups to have the adequate performance period in order to provide group member (that is, each solo
and necessary time to prepare for the the virtual group parties with time to practitioner or group) would be required
implementation of virtual groups, establish goals and objectives, build to execute formal written agreements
including the establishment and relationships with each other, and with each other virtual group member to
execution of formal written agreements identify additional agreement ensure that requirements and
and coordination within virtual groups provisions that may be necessary to expectations of participation in MIPS
to address issues pertaining to include in order to meet program are clearly articulated, understood, and
interoperability, measure selection, data requirements. agreed upon (82 FR 30032 through
collection and aggregation, measure Response: We note that section 30033). We noted that a virtual group
specifications, workflows, resources, 1848(q)(5)(I)(iii)(I) and (IV) of the Act may not include a solo practitioner or
and other related items. A few provides that the virtual group election group as part of the virtual group unless
commenters recommended an election process must require an individual an authorized person of the TIN has
deadline of June 30 to align with the MIPS eligible clinician or group electing executed a formal written agreement.
election deadline for groups and virtual to be in a virtual group to make their During the election process and
groups to register to use the CMS Web election prior to the start of the submission of a virtual group election,
Interface and/or administer the CAHPS applicable performance period, and a designated virtual group
for MIPS survey. include requirements providing for representative would be required to
Response: We appreciate the feedback formal written agreements among confirm through acknowledgement that
from commenters regarding the election individual MIPS eligible clinicians and an agreement is in place between each
deadline of December 1 and note that groups electing to be a virtual group. member of the virtual group. An
section 1848(q)(5)(I)(iii)(I) of the Act Thus, we are not authorized to establish agreement would be executed for at
provides that the virtual group election an agreement deadline during the least one performance period. If an NPI
process must require an individual performance period. However, we note joins or leaves a TIN, or a change is
MIPS eligible clinician or group electing that the parties to a virtual group made to a TIN that impacts the
to be in a virtual group to make their agreement would not be precluded from agreement itself, such as a legal business
election prior to the start of the amending their agreement during the name change, during the applicable
applicable performance period. Given performance period, which enables performance period, a virtual group
that the CY performance period for the them to incorporate any additional would be required to update the
quality and cost performance categories agreement provisions that they later agreement to reflect such changes and
begins on January 1, a solo practitioner identify as necessary. A virtual group submit changes to CMS via the Quality
or group electing to be in a virtual group representative would notify CMS of the Payment Program Service Center.
would need to make their election prior implementation and execution of an We proposed, at 414.1315(c)(3), that
to January 1. As a result, we are amended virtual group agreement. a formal written agreement between
modifying our proposed election Final Action: After consideration of each member of a virtual group must
deadline by extending it to December 31 the public comments received, we are include the following elements:
of the calendar year preceding the finalizing the following policies. We are Expressly state the only parties to
applicable performance period. We note codifying at 414.1315(a) that a solo the agreement are the TINs and NPIs of
that our proposed election deadline of practitioner or a group of 10 or fewer the virtual group (at 414.1315(c)(3)(i)).
December 1 was intended to allow us to eligible clinicians must make their For example, the agreement may not be
notify virtual groups of their official election to participate in MIPS as a between a virtual group and another
status prior to the start of the virtual group prior to the start of the entity, such as an independent practice
performance period. With the applicable performance period and association (IPA) or management
modification we are finalizing for the cannot change their election during the company that in turn has an agreement
election deadline of December 31, it is performance period; and codifying at with one or more TINs within the
not operationally feasible for us to 414.1315(c) a two-stage virtual group virtual group. Similarly, virtual groups
notify virtual groups of their official election process, stage 1 of which is should not use existing contracts
virtual group status prior to the start of optional, for the applicable 2018 and between TINs that include third parties.
the performance period. However, we 2019 performance periods. We are Be executed on behalf of the TINs
intend to notify virtual groups of their finalizing a modification to our and the NPIs by individuals who are
official status as close to the start of the proposed election period deadline by authorized to bind the TINs and the
NPIs, respectively at 18, 2017. OMB approved the ICR on each such eligible clinician to be a party
414.1315(c)(3)(ii)). September 27, 2017 (OMB control to the virtual group agreement. In
Expressly require each member of number 09381343). The model formal addition, we agree that it is
the virtual group (including each NPI written agreement is not required, but unnecessarily burdensome to require
under each TIN) to agree to participate serves as a template that virtual groups each solo practitioner or group that
in MIPS as a virtual group and comply could utilize in establishing an wishes to be part of a virtual group to
with the requirements of the MIPS and agreement with each member of a have a separate agreement with every
all other applicable laws and regulations virtual group. Such agreement template other solo practitioner or group that
(including, but not limited to, federal will be made available via subregulatory wishes to be part of the same virtual
criminal law, False Claims Act, anti- guidance. Each prospective virtual group. We do not believe the statute
kickback statute, civil monetary group member should consult their own compels such a requirement; a single
penalties law, the Health Insurance legal and other appropriate counsel as agreement among all solo practitioners
Portability and Accountability Act of necessary in establishing the agreement. and groups forming a virtual group is
1996, and physician self-referral law) (at We want to ensure that all eligible sufficient to implement the statutory
414.1315(c)(3)(iii)). clinicians who bill through the TINs requirement. Accordingly, we have
Require each TIN within a virtual that are components of a virtual group revised the regulation text at
group to notify all NPIs associated with are aware of their participation in a 414.1315(c)(3) to clarify that the
the TIN of their participation in the virtual group. We want to implement an parties to a formal written virtual group
MIPS as a virtual group (at approach that considers a balance agreement must be only the groups and
414.1315(c)(3)(iv)). between the need to ensure that all solo practitioners (as identified by name
Set forth the NPIs rights and eligible clinicians in a group are aware of party, TIN, and NPI) that compose the
obligations in, and representation by, of their participation in a virtual group virtual group. We note that we are
the virtual group, including without and the minimization of administration modifying our proposals for greater
limitation, the reporting requirements burden. clarity.
and how participation in MIPS as a We solicited public comment on these We recognize that our proposals
virtual group affects the ability of the proposals and on approaches for virtual regarding virtual group agreements as
NPI to participate in the MIPS outside groups to ensure that all eligible well as other virtual group matters used
of the virtual group (at clinicians in a group are aware of their the term member of a virtual group
414.1315(c)(3)(v)). participation in a virtual group. inconsistently. In some places, we used
Describe how the opportunity to The following is a summary of the the term to refer only to the components
receive payment adjustments will public comments received regarding our of the virtual group (that is, the solo
encourage each member of the virtual proposal to require formal written practitioners and groups that can form
group (including each NPI under each agreement between each member of a a virtual group), while in other places
TIN) to adhere to quality assurance and virtual group. we used the term to mean both the
improvement (at 414.1315(c)(3)(vi)). Comment: Several commenters components of the virtual group and the
Require each member of the virtual expressed support for the proposed eligible clinicians billing through a TIN
group to update its Medicare enrollment provisions that virtual groups would that is a component of the virtual group.
information, including the addition and need to include as part of the formal We believe that some of the perceived
deletion of NPIs billing through a TIN written agreement establishing a virtual burden of the requirement for a virtual
that is part of a virtual group, on a group. group agreement was due to the
timely basis in accordance with Response: We appreciate the support ambiguous use of this terminology.
Medicare program requirements and to from commenters. Wherever possible, we modified our
notify the virtual group of any such Comment: A few commenters proposals to ensure that they
changes within 30 days after the change expressed concern regarding the burden appropriately distinguishes between the
(at 414.1315(c)(3)(vii)). associated with the agreements required components of a virtual group and the
Be for a term of at least one for virtual group implementation and eligible clinicians billing through a TIN
performance period as specified in the execution. One commenter indicated that is a component of a virtual group.
formal written agreement (at that the formal written agreement Comment: One commenter expressed
414.1315(c)(3)(viii)). process, while essential to allow for data support for the proposed agreement
Require completion of a close-out capture, poses administrative burden provision that would require the parties
process upon termination or expiration and other complexities when utilizing to a virtual group agreement to be only
of the agreement that requires the TIN multiple submission mechanisms. solo practitioners and groups (not third
(group part of the virtual group) or NPI Response: We note that section parties), while another commenter did
(solo practitioner part of the virtual 1848(q)(5)(I)(iii)(IV) of the Act provides not support such provision and
group) to furnish, in accordance with that the virtual group election process indicated that many small practices
applicable privacy and security laws, all must provide for formal written have joined IPAs to provide centralized
data necessary in order for the virtual agreements among MIPS eligible support for quality improvement
group to aggregate its data across the professionals (that is, individual MIPS training, health technology support,
virtual group (at 414.1315(c)(3)(ix)). eligible clinicians and groups) that elect reporting, and analytics needed for
On August 18, 2017, we published a to be a virtual group. As such, we do not success under payment reform programs
30-day Federal Register notice (82 FR believe that our proposal to require a such as the Quality Payment Program.
39440) announcing our formal written agreement governing the virtual The commenter also indicated that IPAs
submission of the information collection group is excessively burdensome. could serve as the administrator of a
request (ICR) for the virtual group However, although we believe the virtual group by collecting and
election process to OMB, which agreements should identify each eligible submitting data on behalf of the virtual
included a model formal written clinician billing under the TIN of a group and requested that CMS eliminate
agreement, and informing the public on practice within the virtual group, we the requirement for all members of a
its additional opportunity to review the have concluded that it would be virtual group to execute a single joint
ICR and submit comments by September unnecessarily burdensome to require agreement and expand the allowable
scope of the agreements by permitting each party to collectively meet the unaware of their participation in a
IPAs to sign a virtual group agreement program requirements under MIPS. We Medicare Shared Savings Program ACO
with each member of a virtual group. reiterate that the statute requires formal regardless of the ACOs obligation to
Response: For purposes of written agreements to between each solo notify each NPI via direct
participation in MIPS as a virtual group, practitioner and group forming the communication. We considered directly
we note that eligible clinicians within a virtual group. Individuals billing under notifying all NPIs regarding their
virtual group are collectively assessed the TIN of a party to a virtual group are participation in MIPS as part of a virtual
and scored across each performance collectively assessed and scored across group, but based on our experience
category based on applicable measures each performance category based on under the Medicare Shared Savings
and activities that pertain to the applicable measures and activities that Program, we do not believe that such
performance of all TINs and NPIs within pertain to the performance of all TINs action would be an effective way of
a virtual group. Each TIN and NPI and NPIs within a virtual group. Each ensuring that each NPI is aware of his
within a virtual group has an integral TIN and NPI within a virtual group has or her TIN being part of a virtual group.
role in improving quality of care and an integral role in improving quality of We believe that communication within
health outcomes, and increasing care care and health outcomes, and a TIN is imperative and the crux of
coordination. As such, we believe it is increasing care coordination. As such, ensuring that each NPI is aware of his
appropriate prohibit third parties from we believe it is appropriate to require
becoming parties to a virtual group or her participation in MIPS as part of
agreements to only be between solo
agreement. However, we note that a virtual group. As part of the virtual
practitioners and groups and not
virtual groups are not precluded from group election process, we will notify
include third parties. However, we note
utilizing, or executing separate that virtual groups are not precluded each virtual group representative
agreements with, third parties to from utilizing, or executing separate regarding the official status of the
provide support for virtual group agreements with, third parties to virtual group. We will also require each
implementation. provide support for virtual group TIN within a virtual group to notify all
Comment: To minimize the implementation. NPIs associated with the TIN of their
administrative burden, one commenter Comment: One commenter requested participation in the MIPS as a virtual
suggested that CMS not require all that CMS clarify the parameters group.
agreement requirements to be met in surrounding the proposed agreement Comment: One commenter expressed
freestanding agreements. The provision that requires agreements to be support for one of the proposed
commenter noted that the agreement executed on behalf of the TINs and the agreement provisions that would set
could be an addendum to existing NPIs by individuals who are authorized forth the NPIs rights and obligations in,
contracts to eliminate the need to draft to bind the TINs and the NPIs, and how and representation by, the virtual group.
an independent agreement, unless CMS would evaluate the criterion in As part of the process for establishing an
necessary. such provision when reviewing written agreement, the commenter, as well as
Response: We consider an existing agreements. other commenters, requested that CMS
contract to mean a contract that was Response: If a solo practitioner (or his allow virtual groups to discuss with all
established and executed prior to the or her professional corporation) is a participants in the virtual group the
formation of a virtual group. Depending party to a virtual group agreement, the ways in which the virtual group would
on the parties to an existing contract, solo practitioner could execute the meet the requirements for each
freestanding virtual group agreements agreement individually or on behalf of performance category, the type of
may not be necessary. For example, if an his or her professional corporation. We
submission mechanism(s) the virtual
existing contract was established recognize that groups (TINs) have
between two or more TINs prior to the group intends to utilize, the timelines
varying administrative and operational
formation of a virtual group and such for aggregating data across the TINs
infrastructures. In general, one or more
TINs formed a virtual group among within the virtual group and for data
officers, agents, or other authorized
themselves, the required provisions of a submission, and the assessment and
individuals of a group would have the
virtual group agreement could be authority to legally bind the group. The scoring of performance and application
included in the existing contract as an parties to a virtual group agreement of the MIPS payment adjustment.
addendum as long as the parties to the should ensure that the agreement is Another commenter requested that the
existing contract include each TIN executed only by appropriately agreements include other elements such
within the virtual group and all other authorized individuals. as requiring participation in
requirements are satisfied prior to the Comment: One commenter expressed improvement activities, use of EHR, and
applicable performance period. support for the proposed agreement data sharing workflows, and suggested
However, if the existing contract is with provision that would require NPIs that CMS provide guidance on specific
a third party intermediary or does not billing under a TIN in a virtual group to efficiencies and improvement goals that
include each TIN within the virtual agree to participate in MIPS as a virtual a virtual group could support and
group, the virtual group agreement group, and urged CMS to notify, by a encourage virtual groups to create a plan
could not be effectuated as an means of direct communication, each for achieving those goals as a virtual
addendum to the existing contract. NPI regarding his or her participation in group. A commenter suggested that the
We recognize that including virtual MIPS as part of a virtual group prior to model agreement include provisions
group agreement provisions as an the performance period. related to a mutual interest in quality
addendum to an existing contract may Response: We appreciate the support performance, shared responsibility in
reduce administrative burden and in from the commenter. We believe that it decision making, a meaningful way to
certain circumstances such an is critical for each eligible clinician in effectively use data to drive
addendum can be incorporated to an a virtual group to be aware of his or her performance, and a mechanism to share
existing contract. However, we do participation in MIPS as part of a virtual best practices within the virtual group.
believe it is critical that the inclusion of group. Based on our experience under Another commenter requested for CMS
such provisions as an addendum does the Medicare Shared Savings Program, to develop a checklist for interested
not limit or restrict the responsibility of we found that NPIs continued to be TINs to assist them in understanding the
requirements pertaining a virtual group performance period. Virtual groups have makes it difficult to identify specific
agreement. the flexibility to include other elements requirements pertaining to the inclusion
Response: For the successful in an agreement. Each virtual group will of administration and operationalization
implementation of virtual groups, we be unique, and as a result, we encourage of health IT components in a virtual
believe that it is critical for everyone virtual groups to establish and execute group agreement that would be
participating in a virtual group an agreement that guides how a virtual universally applicable to any virtual
(including the individuals billing under group would meet its goals and group composition, while maintaining
the TIN of a group) to understand their objectives, and program requirements. the flexibility and discretion afforded to
rights and obligations in a virtual group. Some virtual groups may elect to virtual groups in establishing additional
We believe that virtual groups should include a provision that outlines the elements for their agreements that meet
have the flexibility to identify implications of a solo practitioner or the needs of virtual groups. We
additional requirements that would group failing to meet the elements of an recognize that each TIN within a virtual
facilitate and guide a virtual group as it agreement. We will also require such group will need to coordinate within the
works to achieve its goals and meet agreements to describe how the virtual group to address issues
program requirements. We note that the opportunity to receive payment pertaining to interoperability, data
model agreement serves as a template adjustments will encourage each collection, measure specifications,
that virtual groups could utilize in member of the virtual group (and each workflows, resources, and other related
establishing a virtual group agreement, NPI under each TIN in the virtual items, and believe that a virtual group
and could include other elements that group) to adhere to quality assurance is the most appropriate entity to
would meet the needs of the virtual and improvement. determine how it will prepare,
group to ensure that each TIN and NPI Comment: One commenter implement, and execute the functions of
within a virtual group are collectively recommended that virtual group the virtual group to meet the
and collaboratively working together. agreements contain similar elements requirements for each performance
We encourage the parties to a virtual used in agreements by the private category. We believe that our proposed
group agreement to actively engage in sector, which would address factors agreement elements provide a critical
discussions with eligible clinicians to pertaining to health IT and foundation for virtual group
develop a strategic plan, identify administrative and operationalization implementation, which establishes a
resources and needs, and establish components such as: Requiring the clear responsibility and obligation of
processes, workflows, and other tools as establishment of a plan for integrating each NPI to the virtual group for the
they prepare for virtual group reporting. each virtual group components health duration of an applicable performance
To support the efforts of solo IT (for example, EHRs, patient registries, period.
practitioners and groups with 10 or and practice management systems), Comment: Many commenters
fewer eligible clinicians in virtual group including a timeline to work with health expressed concern regarding the
implementation, we intend to publish a IT vendors on such integration, if timeframe virtual groups would have to
virtual group toolkit that provides applicable; requiring component of a make an election and establish
information pertaining to requirements virtual group to serve a common patient agreements. The commenters indicated
and outlines the steps a virtual group population and provide a list of that the election period is very
would pursue during an the election hospitals and/or facilities with which restrictive and does not provide
process. they have an affiliation and a list of interested solo practitioners and groups
Comment: One commenter requested counties in which they would be active; with sufficient time to meet and execute
that the agreement be a 1-year term and and determining how a virtual group the required elements of an agreement
renewable thereafter. would be staffed and governed by and work through all of the necessary
Response: We note that an agreement identifying staff allocations to details in forming and implementing a
will need to be executed for at least one organizational leadership, clinical virtual group. The commenters also
performance period. However, with leadership, practice consultants, and IT noted that contractual agreements
virtual groups being required to be resources. between NPIs and TINs often take
assessed and scored across all four Response: We recognize that different several months, at least, to negotiate and
performance categories, and the quality sectors may have established finalize. A few commenters indicated
and cost performance categories having agreements with various elements to that interested solo practitioners and
a calendar year performance period (at facilitate and assure attainment of groups would not have adequate time to
414.1320), we clarify that a virtual program goals and objectives, which make informed decisions regarding
group agreement would need to be may serve as a useful tool to virtual virtual group participation. The
executed for least a 1-year term. Virtual groups. We encourage virtual groups to commenters noted that it would be
groups have the flexibility to establish a assess whether or not their agreement helpful to have the virtual group
new agreement or renew the execution should include other elements in agreement template available for review
of an existing agreement for the addition to our proposed agreement and comment in advance. One
preceding applicable performance provisions. Virtual groups have the commenter indicated that the lack of
period. flexibility to identify other elements that virtual group requirements at this early
Comment: One commenter requested would be critical to include in an stage of the Quality Payment Program
that the virtual group agreements clearly agreement specific to their particular causes a lack of clarity and stability for
specify the repercussions of an eligible virtual group. We believe it is essential eligible clinicians and/or groups
clinician or group within a virtual group to continue to provide virtual groups interested in forming virtual groups.
who fails to report as part of the virtual with the flexibility to establish Response: In order to provide support
group. agreements that will most appropriately and reduce burden, we intend to make
Response: We believe that the reflect the unique characteristics of a TA available, to the extent feasible and
proposed provisions of a virtual group virtual group. appropriate, to support clinicians who
agreement provide a foundation that Also, we note that different TINs, choose to come together as a virtual
sets forth the responsibilities and particularly small practices, may have group. Clinicians can access the TA
obligations of each party for a access to different resources, which infrastructure and resources that they
may already be utilizing. In section concern that while such steps are group practice (as defined for
II.C.4.e. of this final rule with comment necessary to ensure the success of purposes of the physician self-referral
period, we establish a two-stage virtual virtual groups, such steps could raise law) is a separate legal issue that is not
group election process, stage 1 of which issues regarding compliance with governed by this final rule with
is optional, for performance periods certain fraud and abuse laws, comment period. We recognize that a
occurring in 2018 and 2019 (82 FR particularly the physician self-referral virtual group may include multiple
30030 through 30032). Stage 1 pertains law (section 1877 of the Act) and the clinician practices and that the
to virtual group eligibility anti-kickback statute (section 1128B(b) clinicians in one practice may refer
determinations, and stage 2 pertains to of the Act). The commenters requested patients for services that will be
virtual group formation. During stage 1, that CMS assess the potential risks furnished by other practices in the
solo practitioners and groups have the virtual groups may have under the virtual group. However, we believe that
option to contact their designated TA physician self-referral law and whether the virtual group arrangement can be
representative in order to obtain or not a regulatory exception would be structured in a manner that both
information pertaining to virtual groups necessary to successfully implement complies with an existing physician
and/or determine whether or not they and maximize the advantages of the self-referral law exception and does not
are eligible, as it relates to the practice virtual group option. One commenter violate the anti-kickback statute. We
size requirement. Clinicians who do not noted that parties to a virtual group note that the issuance of guidance,
elect to contact their designated TA agreement may want to enter into exceptions, or safe harbors regarding the
representative would still have the financial arrangements with each other physician self-referral law or the anti-
option of contacting the Quality to maximize the benefit of the virtual kickback statute is beyond the scope of
Payment Program Service Center to group (for example, pay for one party to this rulemaking, and MACRA does not
obtain information pertaining to virtual organize and submit all measures on authorize the Secretary to waive any
groups. behalf of all the virtual group parties) fraud and abuse laws for MIPS. Finally,
We recognize that the election period, and that such an arrangement may HHS is not authorized to interpret or
including the timeframe virtual groups result in some eligible clinicians being provide guidance regarding the anti-
would have to establish and implement unable to refer patients to other trust laws.
the virtual group agreement, and the participants in the virtual group without Comment: Several commenters
timeline for establishing virtual group running afoul of the physician self- supported the development of a model
policies in this final rule with comment referral law, unless CMS established an agreement. One commenter indicated
period is short and imposes certain exception for virtual groups. A few that the model agreement lacked the
potential barriers for virtual group commenters requested that the Secretary details necessary to enable virtual
formation and limitations for the first exercise prosecutorial discretion by not groups to cover all required criteria and
year of virtual group implementation enforcing the anti-kickback statute and urged CMS to supply a template that is
that we are not able to eliminate due to the physician self-referral law for inclusive of needed detail and
statutory constraints, such as the activities involving the development instructions.
requirement for virtual groups to make and operation of a virtual group. Response: We appreciate the support
an election made prior to an applicable Many commenters expressed from commenters. In regard to the
performance period. In order to mitigate concerns regarding the lack of model agreement, we established such a
some of the challenges, we developed a information and clarity pertaining to the template in order to reduce the burden
model agreement to serve as a template interaction between virtual groups and of virtual groups having to develop an
that could be utilized by virtual groups the physician self-referral law, anti- agreement. On August 18, 2017, we
as they prepare for the implementation kickback statute, and antitrust law. The published a 30-day Federal Register
of virtual groups and are finalizing a commenters requested that CMS clarify notice (82 FR 39440) announcing our
modification to the election period the program integrity obligations of formal submission of the ICR for the
deadline by extending it to December virtual groups, issue safe harbors, and virtual group election process to OMB,
31, which can be accessed on the CMS publish guidance outlining how the which included a model formal written
Web site at https://www.cms.gov/ physician self-referral law, anti- agreement, and informing the public on
Medicare/Quality-Initiatives-Patient- kickback statute, and antitrust law apply its additional opportunity to review the
Assessment-Instruments/Value-Based- to virtual groups. The commenters information collection request and
Programs/MACRA-MIPS-and-APMs/ asserted that this was needed in order submit comments by September 18,
MACRA-MIPS-and-APMs.html. In this for solo practitioners and groups to 2017. OMB approved the ICR on
final rule with comment period, we are maintain safeguards against fraud and September 27, 2017 (OMB control
establishing virtual group policies for abuse while soliciting partners to form number 09381343). The utilization of
the 2018 and 2019 performance periods. a virtual group and working toward our model agreement is not required,
Solo practitioners and groups with 10 or common MIPS goals. but serves as a tool that can be utilized
fewer eligible clinicians that are not able Response: Nothing in this final rule by virtual groups. Each prospective
to form virtual groups for the 2018 with comment period changes the party to a virtual group agreement
performance period should have application of the physician self-referral should consult their own legal and other
sufficient time to prepare and law, anti-kickback statute, or anti-trust appropriate counsel as necessary in
implement requirements applicable to laws. We note that a group practice as establishing the agreement. We note that
virtual groups for the 2019 performance defined for purposes of the physician the received comments pertaining to the
period. self-referral law is separate and distinct content of the model agreement are out
Comment: A majority of commenters from a virtual group as defined in this of scope for this final rule with
indicated that virtual group formation final rule. A virtual group may, but is comment period.
involves preparing health IT systems, not required, to include a group Final Action: After consideration of
training staff to be ready for practice as defined for purposes of the public comments received, we are
implementation, sharing and physician self-referral law. Whether an finalizing with modification our
aggregating data, and coordinating entity that is assigned a TIN and is proposal at 414.1315(c)(3) regarding
workflows. The commenters expressed included in a virtual group should be a virtual group agreements. This final rule
with comment period requires a formal assurance and improvement (at Individual eligible clinicians and
written agreement between each solo 414.1315(c)(3)(vi)). individual MIPS eligible clinicians who
practitioner and group that composes a Requires each party to the are part of a TIN participating in MIPS
virtual group; the revised regulation text agreement to update its Medicare at the virtual group level must aggregate
makes it clear the formal written virtual enrollment information, including the their performance data across multiple
group agreement must identify, but need addition and deletion of NPIs billing TINs in order for their performance to
not include as parties to the agreement, through its TIN, on a timely basis in be assessed as a virtual group (at
all eligible clinicians who bill under the accordance with Medicare program 414.1315(d)(3)).
TINs that are components of the virtual requirements and to notify the virtual MIPS eligible clinicians that elect to
group. The requirement to execute a group of any such changes within 30 participate in MIPS at the virtual group
formal written virtual group agreement days after the change (at level would have their performance
ensures that requirements and 414.1315(c)(3)(vii)). assessed at the virtual group level across
expectations of participation in MIPS Is for a term of at least one all four MIPS performance categories (at
are clearly articulated, understood, and performance period as specified in the 414.1315(d)(4)).
agreed upon. We are finalizing our formal written agreement (at Virtual groups would need to
proposal that a virtual group agreement 414.1315(c)(3)(viii)). adhere to an election process
must be executed on behalf of a party Requires completion of a close-out established and required by CMS (at
to the agreement by an individual who process upon termination or expiration 414.1315(d)(5)).
is authorized to bind the party. For of the agreement that requires each The following is a summary of the
greater clarity, we are finalizing with party to the virtual group agreement to public comments received regarding our
modification our proposals at furnish, in accordance with applicable proposed virtual group reporting
414.1315(c)(3) that a formal written privacy and security laws, all data requirements.
agreement between each member of a necessary in order for the virtual group Comment: Many commenters
virtual group must include the to aggregate its data across the virtual generally supported our proposed
following elements: group (at 414.1315(c)(3)(ix)). reporting requirements for virtual
During the election process and groups.
Identifies the parties to the
submission of a virtual group election, Response: We appreciate the support
agreement by name of party, TIN, and
a designated virtual group from the commenters.
NPI, and includes as parties to the Comment: One commenter expressed
representative will be required to
agreement only the groups and solo support of our proposed virtual group
confirm through acknowledgement that
practitioners that compose the virtual reporting requirements and indicated
an agreement is in place between all
group (at 414.1315(c)(3)(i)). that a majority of practicing vascular
solo practitioners and groups that
Is executed on behalf of each party surgeons are part of private practices,
compose the virtual group. An
by an individual who is authorized to including groups of 10 or fewer eligible
agreement will be executed for at least
bind the party (at 414.1315(c)(3)(ii)). clinicians, and would benefit from
one performance period. If a NPI joins
Expressly requires each member of or leaves a TIN, or a change is made to participating in MIPS as part of a virtual
the virtual group (and each NPI under a TIN that impacts the agreement itself, group. The commenter noted that the
each TIN in the virtual group) to such as a legal business name change, implementation of virtual groups would
participate in MIPS as a virtual group during the applicable performance ease burdens on small practices and
and comply with the requirements of period, a virtual group will be required eligible clinicians by allowing them to
the MIPS and all other applicable laws to update the agreement to reflect such report data together for each
and regulations (including, but not changes and submit changes to CMS via performance category, and be assessed
limited to, federal criminal law, False the Quality Payment Program Service and scored as a virtual group. Another
Claims Act, anti-kickback statute, civil Center. commenter supported our proposal that
monetary penalties law, the Health allows small practices to aggregate their
Insurance Portability and g. Virtual Group Reporting data at the virtual group level, which
Accountability Act of 1996, and Requirements would allow them to have a larger
physician self-referral law) (at As discussed in section II.C.4.d. of denominator to spread risk and mitigate
414.1315(c)(3)(iii)). this final rule with comment period, we the impact of adverse outlier situations.
Identifies each NPI under each TIN believe virtual groups should generally Response: We appreciate the support
in the virtual group and requires each be treated under the MIPS as groups. from the comment regarding our
TIN within a virtual group to notify all Therefore, for MIPS eligible clinicians proposed virtual group reporting
NPIs associated with the TIN of their participating at the virtual group level, requirements.
participation in the MIPS as a virtual we proposed at 414.1315(d) the Comment: One commenter indicated
group (at 414.1315(c)(3)(iv)). following requirements (82 FR 30033): that the reporting of performance data
Sets forth the NPIs rights and Individual eligible clinicians and for all NPIs under a TIN participating in
obligations in, and representation by, individual MIPS eligible clinicians who a virtual group, particularly non-MIPS
the virtual group, including without are part of a TIN participating in MIPS eligible clinicians who are excluded
limitation, the reporting requirements at the virtual group level would have from MIPS participation, would be a
and how participation in MIPS as a their performance assessed as a virtual regulatory burden to virtual groups.
virtual group affects the ability of the group (at 414.1315(d)(1)). Response: We do not believe that
NPI to participate in the MIPS outside Individual eligible clinicians and requiring virtual groups to report on
of the virtual group (at individual MIPS eligible clinicians who data for all NPIs under a TIN
414.1315(c)(3)(v)). are part of a TIN participating in MIPS participating in a virtual group would
Describes how the opportunity to at the virtual group level would need to be burdensome to virtual groups. Based
receive payment adjustments will meet the definition of a virtual group at on previous feedback from stakeholders
encourage each member of the virtual all times during the performance period regarding group reporting under PQRS,
group (and each NPI under each TIN in for the MIPS payment year (at we believe that it would be more
the virtual group) to adhere to quality 414.1315(d)(2)). burdensome for virtual groups to
determine which clinicians are MIPS aforementioned challenges in data and CAHPS for MIPS survey differ in
eligible versus not MIPS eligible and aggregation. their application to virtual groups.
remove performance data for non-MIPS Response: We appreciate the feedback Specifically, data completeness for
eligible clinicians when reporting as a from commenters and note that statute virtual groups applies cumulatively
virtual group. While entire TINs requires virtual groups to be assessed across all TINs in a virtual group. Thus,
participate in a virtual group, including and scored, and subject to a MIPS we note that there may be a case when
each NPI under a TIN, and are assessed payment adjustment as a result of TINs a virtual group has one TIN that falls
and scored collectively as a virtual participating in a virtual group under below the 60 percent data completeness
group, we note that only NPIs that meet MIPS. The statute does not authorize us threshold, which is an acceptable case
the definition of a MIPS eligible to establish additional exclusions that as long as the virtual group
clinician would be subject to a MIPS are not otherwise identified in statute. If cumulatively exceeds such threshold. In
payment adjustment. a virtual group encounters technical regard to the CMS Web Interface and
Comment: A majority of commenters challenges regarding data aggregation CAHPS for MIPS survey, sampling
did not support our proposal to require and are not able to report on measures requirements pertain to Medicare Part B
all eligible clinicians who are part of a and activities via QCDRs, qualified patients with respect to all TINs in a
TIN participating in MIPS at the virtual registries, or EHRs, virtual groups would virtual group, where the sampling
group level to aggregate their have the option of reporting via the methodology would be conducted for
performance data across multiple TINs CMS Web Interface (for virtual groups of each TIN within the virtual group and
in order for their performance to be 25 or more eligible clinicians), a CMS- then cumulatively aggregated across the
assessed and scored as a virtual group. approved survey vendor for the CAHPS virtual group. A virtual group would
The commenters expressed concerns for MIPS survey, and administrative need to meet the beneficiary sampling
that it would be burdensome for rural claims (if applicable) for the quality and threshold cumulatively as a virtual
and small practices and prohibitive for cost performance categories, and via group.
virtual groups to perform data attestation for the improvement Comment: A few commenters urged
aggregation and requested that CMS activities and advancing care CMS to set clear expectations as to how
aggregate data for virtual groups. The information performance categories. The virtual groups should submit data across
commenters indicated that the administrative claims submission performance categories and from
requirement for virtual groups to mechanism does not require virtual multiple systems while ensuring their
aggregate data across the virtual group groups to submit data for purposes of information is aggregated and reported
could be a potential barrier for virtual the quality and cost performance correctly to maximize the virtual
group participation and would be categories but the calculation of groups final score and requested that
unlikely to occur without error. One performance data is conducted by CMS. CMS provide clarity regarding virtual
commenter requested that CMS further We note that the measure reporting group reporting. One commenter
define data aggregation and clarify requirements applicable to groups are indicated that virtual group reporting
whether or not individual reports from also generally applicable to virtual can be completed through QCDRs, in
each NPI within a virtual group could groups. However, we note that the which multiple eligible clinicians in a
simply be added together for all NPIs in requirements for calculating measures virtual group could report to one place
the virtual group or if each NPIs data and activities when reporting via on the quality of care furnished to their
could be pulled from each TINs QRDA QCDRs, qualified registries, EHRs, and respective patients. The commenter
file. attestation differ in their application to noted that the commitments from CMS
Response: We appreciate the feedback virtual groups. Specifically, these and ONC regarding interoperability and
from the commenters and recognize that requirements apply cumulatively across electronic data sharing would continue
data aggregation across multiple TINs all TINs in a virtual group. Thus, virtual to further the feasibility of virtual group
within a virtual group may pose varying groups will aggregate data for each NPI reporting through EHRs in the future.
challenges. At this juncture, it is not under each TIN within the virtual group However, a few commenters requested
technically feasible for us to aggregate by adding together the numerators and clarification regarding how data can and
the data for virtual groups, but will denominators and then cumulatively should be submitted for virtual groups,
consider such option in future years. In collate to report one measure ratio at the and whether or not QCDRs and other
order to support the implementation of virtual group level. Moreover, if each clinical outcomes data registries would
virtual groups as a participation option MIPS eligible clinician within a virtual be able to assist virtual groups by
under MIPS, we intend to issue group faces a significant hardship or has sharing in the responsibility for
subregulatory guidance pertaining to EHR technology that has been aggregating data. The commenters noted
data aggregation for virtual groups. decertified, the virtual group can apply that the aggregation of data across
Comment: A few commenters for an exception to have its advancing various TINs and health IT systems may
recommended that for the first year of care information performance category be logistically difficult and complex, as
virtual group implementation, CMS reweighted. If such exception groups and health IT systems have
hold virtual groups and registries that application is approved, the virtual different ways of collecting and storing
support virtual groups harmless from groups advancing care information data and stated that data aggregation
penalties if they encounter technical performance category is reweighted to across various systems for measures and
challenges related to data aggregation. zero percent and applied to the quality activities under each performance
The commenters noted that the performance category increasing the category may not be possible if qualified
potential penalty for technical quality performance weight from 50 registries do not have the option to
challenges in data aggregation is a percent to 75 percent. assist virtual groups.
severe 5 percent for TINs that are Additionally, the data submission Response: We appreciate the feedback
already operating on small margins and criteria applicable to groups are also from commenters and recognize that
expressed concerns that registries generally applicable to virtual groups. commenters seek clarification regarding
supporting virtual group reporting However, we note that data submission requirements for third party
would be opening themselves to completeness and sampling intermediaries such as QCDRs, qualified
potential disqualification for the requirements for the CMS Web Interface registries, and EHRs. We note that third
party intermediaries would need to Response: We note that virtual groups group. Also, the commenter indicated
meet the same requirements established are not precluded from utilizing third that it is not clear what responsibility a
at 414.1400 and form and manner per party intermediaries such as QCDRs and qualified registry would have, if any, to
submission mechanism when qualified registries to support virtual verify if a virtual group reporting
submitting data on behalf of virtual groups in meeting virtual group through a registry has all the
groups. We intend to issue reporting requirements. We intend to appropriate legal agreements in place
subregulatory guidance for virtual issue subregulatory guidance for virtual prior to their participation in the
groups and third party intermediaries groups and third party intermediaries registry.
pertaining to data aggregation and the pertaining to data aggregation and the Response: We appreciate the
collection and submission of data. collection and submission of data. commenter expressing such concern
Comment: One commenter requested Comment: A few commenters and note that we intend to issue
clarification regarding the submission of expressed concern that the submission subregulatory guidance for virtual
data for virtual groups via EHRs. The mechanisms available to virtual groups groups and third party intermediaries
commenter indicated that while groups involve multiple layers of legal and pertaining to data aggregation and the
may already be familiar with the operational complexity. The collection and submission of data. We
reporting of quality measures via EHRs, commenters indicated that certain note that the measure reporting
the addition of the improvement registries have internal data governance requirements applicable to groups are
activities and advancing care standards, including patient safety also generally applicable to virtual
information performance categories organization requirements, that they groups. However, we note that the
adds a new level of complexity. Also, must follow when contracting with requirements for calculating measures
the commenter requested clarification single TIN participants, such that legal and activities when reporting via
regarding whether or not CMS has an agreements made between solo QCDRs, qualified registries, EHRs, and
established mechanism that would practitioners and small groups within a attestation differ in their application to
accept multiple QRDA III submissions virtual group may complicate the virtual groups. Specifically, these
for a single virtual group pertaining to registries ability to comply with those requirements apply cumulatively across
the improvement activities and requirements. The commenters all TINs in a virtual group. Thus, virtual
advancing care information performance recommended that CMS provide groups will aggregate data for each NPI
categories. The commenter indicated guidance to registries on how to handle under each TIN within the virtual group
that standards do not exist to combine data sharing among virtual groups with by adding together the numerators and
files pertaining to the improvement respect to patient safety organization denominators and then cumulatively
activities and advancing care requirements. One commenter collate to report one measure ratio at the
information performance categories expressed concern regarding how virtual group level. Moreover, if each
from disparate vendors and requested registries would be able to meet virtual MIPS eligible clinician within a virtual
clarification regarding whether or not group requirements to report a sufficient group faces a significant hardship or has
combined files would be needed for number of measures given that some EHR technology that has been
virtual groups and for CMS to issue registries may have made a variety of decertified, the virtual group can apply
guidance to vendors at least 18 months measures available for individual for an exception to have its advancing
in advance regarding development and eligible clinicians to report, but may care information performance category
implementation. need to increase the available measures reweighted. If such exception
Response: We appreciate the feedback to report in order to support virtual application is approved, the virtual
from the commenter and note that we group reporting. The commenter groups advancing care information
intend to issue additional subregulatory requested that CMS provide guidance performance category is reweighted to
guidance for third party intermediaries regarding the expectations for registries zero percent and applied to the quality
pertaining to the collection and supporting virtual group reporting, performance category increasing the
submission of data for all performance particularly when considering the role quality performance weight from 50
categories. In regard to the submission of specialty registries and the quality percent to 75 percent.
of multiple QRDA III files, our system performance category. Additionally, the data submission
is not built to allow for the submission Response: We recognize that certain criteria applicable to groups are also
of multiple QRDA III files. Groups and registries may have internal governance generally applicable to virtual groups.
virtual groups are required to submit standards complicating how they would However, we note that data
one QRDA III file for each performance support virtual groups, but note that by completeness and sampling
category. Given that virtual groups are definition, a virtual group is a requirements for the CMS Web Interface
required to aggregate their data at the combination of TINs. We appreciate the and CAHPS for MIPS survey differ in
virtual level and submit one file of data feedback from commenters and note their application to virtual groups.
per performance category, there may be that we intend to issue additional Specifically, data completeness for
circumstances that would require a subregulatory guidance for third party virtual groups applies cumulatively
virtual group to combine their files in intermediaries such as qualified across all TINs in a virtual group. Thus,
order to meet the submission registries. we note that there may be a case when
requirements. However, it should be Comment: One commenter expressed a virtual group has one TIN that falls
noted that all other measures and concern regarding how quality data below the 60 percent data completeness
activities requirements would also need would be collected, aggregated and threshold, which is an acceptable case
to be met in order for virtual groups to displayed for solo practitioners and as long as the virtual group
meeting reporting and submission groups composing the virtual group. cumulatively exceeds such threshold. In
requirements. The commenter requested clarification regard to the CMS Web Interface and
Comment: One commenter requested regarding whether or not solo CAHPS for MIPS survey, sampling
that CMS allow QCDRs and other practitioners and groups composing the requirements pertain to Medicare Part B
clinical outcomes data registries to virtual group would be allowed to view patients with respect to all TINs in a
support virtual groups in aggregating the quality data of other solo virtual group, where the sampling
measures and activities for reporting. practitioners and groups in the virtual methodology would be conducted for
each TIN within the virtual group and group reporting option have a transition would increase administrative burden
then cumulatively aggregated across the year for the CY 2018 and CY 2019 for virtual groups. However, we
virtual group. A virtual group would performance periods in order for solo encourage virtual groups to actively
need to meet the beneficiary sampling practitioners and groups to become engage in discussions with its members
threshold cumulatively as a virtual familiar with implementing the virtual to develop a strategic plan, select
group. In regard to the comment group reporting option as well as the measures and activities to report,
requesting clarification on whether or election process and executing identify resources and needs, and
not solo practitioners and groups agreements. The commenter requested establish processes, workflows, and
composing a virtual group would be that virtual groups have the pick your other tools as they prepare for virtual
allowed to view quality data of other pace options that were established for group reporting. Virtual groups have the
solo practitioners and groups in the the CY 2017 performance period for the flexibility to identify other elements, in
virtual group, we note that virtual CY 2018 performance period in order to addition to our proposed agreement
groups have the flexibility to determine test the virtual group option, whereby provisions, that would be critical to
if, how, and when solo practitioners and the virtual group would only need to include in an agreement specific to their
groups in the virtual group would be report one quality measure or one particular virtual group. We believe that
able to view quality data and/or data improvement activity to avoid a virtual groups should have the
pertaining to the other three negative MIPS payment adjustment. flexibility to identify additional
performance categories, in which such Response: We note that it is not requirements that would facilitate and
permissibility could be established as a permissible for virtual groups to meet guide a virtual group as it works to
provision under the virtual group the requirements established for the achieve its goals and meet program
agreement. Moreover, the establishment 2017 performance period given that requirements.
and execution of a virtual group such requirements are not applicable to Comment: One commenter
agreement is the responsibility of the the 2018 performance period. Moreover, recommended that CMS require all
parties electing to participate in MIPS as the pick your pace options were eligible clinicians within a virtual group
part of a virtual group. Health IT based on the lower performance to report on the same measure set. The
vendors or third party intermediaries threshold established for the CY 2017 commenter indicated that unifying
are not required to verify that each performance period. As discussed in measures would allow CMS to aggregate
virtual group has established and section II.C.8.c. of this final rule with numerators and denominators more
executed a prior virtual group comment period, we are finalizing a easily when calculating performance
agreement. higher performance threshold for the CY against measures.
Comment: One commenter indicated 2018 performance period, and the Response: For virtual groups that
that there would be added technical statute requires the establishment of one report via the CMS Web Interface, they
challenges for a virtual group performance threshold for a would report on all measures within the
representative when submitting on performance period, which is the same CMS Web Interface. For virtual groups
behalf of their virtual group given that for all MIPS eligible clinicians that report via other submission
he or she may face errors or warnings regardless of how or when they mechanisms, they would report on the
during submission and, due to the participate in MIPS. Year 2 same 6 measures for the quality
possibility that individual files could requirements for virtual groups are performance category. We encourage
come from various EHR vendors, that defined throughout this final rule with virtual groups to assess the types of
representative would not have authority comment period. measures and measure sets to report to
or the ability to work directly with Comment: One commenter requested ensure that they would meet the
another TINs vendor. that CMS require virtual groups to reporting requirements for the
Response: We note that virtual groups report a plan prior to the start of the applicable performance categories.
have the flexibility to determine how performance period regarding how Comment: One commenter
they would complete reporting under members of the virtual group (solo recommended that CMS develop a web-
MIPS. We believe that virtual groups practitioners and groups) would share based portal that would streamline
would need to address operational data internally, including how they reporting requirements for virtual
elements to ensure that it would meet would identify the measures that the groups. For example, CMS could model,
the reporting requirements for each virtual group would report, and share to the extent possible and appropriate,
performance category. Virtual groups NPI-level performance data on those a virtual group web-based portal on the
are able to utilize the same multiple measures with each other during the CMS Web Interface. The availability of
submission mechanisms that are performance period to facilitate a web-based portal would relieve a
available to groups. For the 2018 performance improvement. substantial burden for solo practitioners
performance period, groups and virtual Response: We appreciate the and small groups who do not have the
groups can utilize multiple submission commenter recommending requirements same level of resources as larger groups
mechanism, but only use one for virtual groups, but disagree with the to purchase and maintain the
submission mechanism per performance recommendation that would require infrastructure necessary for MIPS
category. Starting with the 2019 virtual groups to submit a report to us reporting. Moreover, the commenter
performance period, groups and virtual prior to the start of the performance indicated that a single reporting portal
groups will be able to utilize multiple period outlining how the virtual group would ease data collection burden on
submission mechanisms for each would share data internally, how the CMS, enabling the Agency to collect and
performance category. virtual group would identify the pull data from a single source under a
Comment: One commenter measures and activities to report, and single submission mechanism rather
recommended that the virtual group share NPI-level performance data on than engaging in a more cumbersome
infrastructure be defined and tested those measures with each other during process that could require multiple data
prior to implementation and noted that the performance period to facilitate collection and submission mechanisms.
virtual group implementation does not performance improvement. We believe Response: We have developed a web-
appear to be ready for CY 2018. Another that the submission of such report prior based portal submission system that
commenter suggested that the virtual to the start of the performance period streamlines and simplifies the
submission of data at the individual, execution of virtual groups. Also, we application is approved, the virtual
group, and virtual group level, recognize that certain solo practitioners groups advancing care information
including the utilization of multiple and groups may not be ready to form performance category is reweighted to
submission mechanisms (one virtual groups for the 2018 performance zero percent and applied to the quality
submission mechanism per performance period. performance category increasing the
category), for each performance Comment: One commenter expressed quality performance weight from 50
category. We will be issuing guidance at concern regarding how a health IT percent to 75 percent.
qpp.cms.gov pertaining to the utilization vendor would support a virtual group Additionally, the data submission
and functionality of such portal. regardless of submission mechanism, criteria applicable to groups are also
Comment: Several commenters CEHRT, registry, and/or billing claims. generally applicable to virtual groups.
requested that CMS clarify whether or The commenter indicated that having However, we note that data
not data should be de-duplicated for multiple health IT vendors and products completeness and sampling
virtual group reporting. The to support within a single virtual group requirements for the CMS Web Interface
commenters indicated that TINs already would complicate the ability to and CAHPS for MIPS survey differ in
have an issue of not being able to de- aggregate data for a final score, affect the their application to virtual groups.
duplicate patient data across different productivity of the health IT vendor in Specifically, data completeness for
health IT systems/multiple EHRs. The its effort to support the virtual groups, virtual groups applies cumulatively
commenters indicated that virtual and increase coding and billing errors. across all TINs in a virtual group. Thus,
groups need clear guidelines regarding Response: We note that virtual groups we note that there may be a case when
how to achieve accurate reporting and may elect to utilize health IT vendors a virtual group has one TIN that falls
suggested that CMS may want to and/or third party intermediaries for the below the 60 percent data completeness
consider delaying implementation of the collection and submission of data on threshold, which is an acceptable case
virtual group reporting option until all behalf of virtual groups. As discussed in as long as the virtual group
related logistics issues and solutions are section II.C.6.a.(1) of this final rule with cumulatively exceeds such threshold. In
identified. comment period, the submission regard to the CMS Web Interface and
Response: We interpret the mechanisms available to groups under CAHPS for MIPS survey, sampling
commenters reference to de- each performance category will also be requirements pertain to Medicare Part B
duplicate to mean the identification of available to virtual groups. Similarly, patients with respect to all TINs in a
unique patients across a virtual group. virtual groups will also have the same
virtual group, where the sampling
We recognize that it may be difficult to option as groups to utilize multiple
methodology would be conducted for
identify unique patients across a virtual submission mechanisms, but only one
each TIN within the virtual group and
group for the purposes of aggregating submission mechanism per performance
then cumulatively aggregated across the
performance on the advancing care category for the 2018 performance
virtual group. A virtual group would
information measures, particularly period. However, starting with the 2019
need to meet the beneficiary sampling
when a virtual group is using multiple performance period, groups and virtual
threshold cumulatively as a virtual
CEHRT systems. For 2018, virtual groups will be able to utilize multiple
group.
groups may be using systems which are submission mechanisms for each
certified to different CEHRT editions performance category. We believe that Final Action: After consideration of
further adding to this challenge. We our policies pertaining to the the public comments received, we are
consider unique patients to be availability and utilization of multiple finalizing the following virtual group
individual patients treated by a TIN submission mechanisms increases reporting requirements:
within a virtual group who would flexibility and reduces burden. Individual eligible clinicians and
typically be counted as one patient in However, we recognize that data individual MIPS eligible clinicians who
the denominator of an advancing care aggregation across at the virtual group are part of a TIN participating in MIPS
information measure. This patient may level may pose varying challenges. at the virtual group level will have their
see multiple MIPS eligible clinicians We note that the measure reporting performance assessed as a virtual group
within a TIN that is part of a virtual requirements applicable to groups are at 414.1315(d)(1).
group, or may see MIPS eligible also generally applicable to virtual Individual eligible clinicians and
clinicians at multiple practice sites of a groups. However, we note that the individual MIPS eligible clinicians who
TIN that is part of a virtual group. When requirements for calculating measures are part of a TIN participating in MIPS
aggregating performance on advancing and activities when reporting via at the virtual group level will need to
care information measures for virtual QCDRs, qualified registries, EHRs, and meet the definition of a virtual group at
group level reporting, we do not require attestation differ in their application to all times during the performance period
that a virtual group determine that a virtual groups. Specifically, these for the MIPS payment year (at
patient seen by one MIPS eligible requirements apply cumulatively across 414.1315(d)(2)).
clinician (or at one location in the case all TINs in a virtual group. Thus, virtual Individual eligible clinicians and
of TINs working with multiple CEHRT groups will aggregate data for each NPI individual MIPS eligible clinicians who
systems) is not also seen by another under each TIN within the virtual group are part of a TIN participating in MIPS
MIPS eligible clinician in the TIN that by adding together the numerators and at the virtual group level must aggregate
is part of the virtual group or captured denominators and then cumulatively their performance data across multiple
in a different CEHRT system. collate to report one measure ratio at the TINs in order for their performance to
In regard to the suggestion provided virtual group level. Moreover, if each be assessed as a virtual group (at
by the commenter regarding the delay of MIPS eligible clinician within a virtual 414.1315(d)(3)).
the implementation of virtual groups, group faces a significant hardship or has MIPS eligible clinicians that elect to
we are not able to further postpone the EHR technology that has been participate in MIPS at the virtual group
implementation of virtual groups. We decertified, the virtual group can apply level will have their performance
recognize that there are various for an exception to have its advancing assessed at the virtual group level across
elements and factors that virtual groups care information performance category all four MIPS performance categories (at
would need to address prior to the reweighted. If such exception 414.1315(d)(4)).
Virtual groups will need to adhere assign the virtual group score to all TIN/ determining MIPS payment adjustments
to an election process established and NPIs billing under a TIN in the virtual for these MIPS eligible clinicians using
required by CMS (at 414.1315(d)(5)). group during the performance period. the final score of their virtual group.
During the performance period, we We noted that MIPS eligible clinicians
h. Virtual Group Assessment and recognized that NPIs in a TIN that has
Scoring who are participants in both a virtual
joined a virtual group may also be group and a MIPS APM would be
As noted in section II.C.4.a. of this participants in an APM. The TIN, as assessed under MIPS as part of the
final rule with comment period, section part of the virtual group, would be virtual group and under the APM
1848(q)(5)(I)(i) of the Act provides that required to submit performance data for scoring standard as part of an APM
MIPS eligible clinicians electing to be a all eligible clinicians associated with Entity group, but would receive their
virtual group must: (1) Have their the TIN, including those participating in payment adjustment based only on the
performance assessed for the quality APMs, to ensure that all eligible APM Entity score. In the case of an
and cost performance categories in a clinicians associated with the TIN are eligible clinician participating in both a
manner that applies the combined being measured under MIPS. virtual group and an Advanced APM
performance of all the MIPS eligible APMs seek to deliver better care at who has achieved QP status, the
clinicians in the virtual group to each lower cost and to test new ways of clinician would be assessed under MIPS
MIPS eligible clinician in the virtual paying for care and measuring and as part of the virtual group, but would
group for the applicable performance assessing performance. In the CY 2017 still be excluded from the MIPS
period; and (2) be scored for the quality Quality Payment Program final rule, we payment adjustment as a result of his or
and cost performance categories based established policies to the address her QP status. We refer readers to
on such assessment for the applicable concerns we have expressed in regard to section II.C.6.g. of this final rule with
performance period. We believe it is the application of certain MIPS policies comment period for further discussion
critical for virtual groups to be assessed to MIPS eligible clinicians in MIPS regarding the waiver.
and scored at the virtual group level for APMs (81 FR 77246 through 77269). In The following is a summary of the
all performance categories, as it the CY 2018 Quality Payment Program public comments received regarding our
eliminates the burden of virtual group proposed rule, we reiterated those proposals.
components having to report as a virtual concerns and proposed additional
Comment: Many commenters
group and separately outside of a virtual policies for the APM scoring standard
supported our proposals regarding the
group. Additionally, we believe that the (82 FR 30080 through 30091). We
assessment and scoring of virtual group
assessment and scoring at the virtual believe it is important to consistently
group level provides for a performance and the application of the
apply the APM scoring standard under
comprehensive measurement of MIPS payment adjustment to MIPS
MIPS for eligible clinicians participating
performance, shared responsibility, and eligible clinicians based on the virtual
in MIPS APMs in order to avoid
an opportunity to effectively and potential misalignments between the groups final score.
efficiently coordinate resources to also evaluation of performance under the Response: We appreciate the support
achieve performance under the terms of the MIPS APM and evaluation from the commenters.
improvement activities and the of performance on measures and Comment: One commenter supported
advancing care information performance activities under MIPS, and to preserve our proposal to assess and score virtual
categories. Therefore, we proposed at the integrity of the initiatives we are groups at the virtual group level and
414.1315(d)(4) that virtual groups testing. Therefore, we believe it is indicated that such an approach would
would be assessed and scored across all necessary to waive the requirement to provide comprehensive measurement,
four MIPS performance categories at the only use the virtual group scores under shared responsibility and coordination
virtual group level for a performance section 1848(q)(5)(I)(i)(II) of the Act, and of resources, and reduce burden.
period for a year (82 FR 30033 through instead to apply the score under the Another commenter expressed support
30034). APM scoring standard for eligible for requiring the aggregation of data
In the CY 2017 Quality Payment clinicians in virtual groups who are also across the TINs within a virtual group,
Program final rule (81 FR 77319 through in an APM Entity participating in an including the performance data of APM
77329), we established the MIPS final APM. participants, to assess the performance
score methodology at 414.1380, which Specifically, for participants in MIPS of a virtual group given that it would be
would apply to virtual groups. We refer APMs, we proposed to use our authority difficult for TINs to separate and
readers to sections II.C.4.h. and II.C.6.g. under section 1115A(d)(1) of the Act for exclude data for some NPIs. One
of this final rule with comment period MIPS APMs authorized under section commenter supported our proposal to
for scoring policies that would apply to 1115A of the Act, and under section utilize waiver authority, which allows
virtual groups. 1899(f) of the Act for the Shared Savings MIPS eligible clinicians within a virtual
As noted in section II.C.4.g. of this Program, to waive the requirement group to receive their MIPS payment
final rule with comment period, we under section 1848(q)(2)(5)(I)(i)(II) of the adjustment based on the virtual group
proposed to allow solo practitioners and Act that requires performance category score while allowing APM participants
groups with 10 or fewer eligible scores from virtual group reporting to be who are also a part of a virtual group to
clinicians that have elected to be part of used to generate the final score upon receive their MIPS payment adjustment
a virtual group to have their which the MIPS payment adjustment is based on their APM Entity score under
performance measured and aggregated based for all TIN/NPIs in the virtual the APM scoring standard.
at the virtual group level across all four group. Instead, we would use the score Response: We appreciate the support
performance categories; however, we assigned to the MIPS eligible clinician from the commenters regarding our
would apply payment adjustments at based on the applicable APM Entity proposals.
the individual TIN/NPI level. Each TIN/ score to determine MIPS payment Comment: One commenter requested
NPI would receive a final score based on adjustments for all MIPS eligible clarification regarding whether or not
the virtual group performance, but the clinicians that are part of an APM Entity the MIPS payment adjustment would
payment adjustment would still be participating in a MIPS APM, in only apply to MIPS eligible clinicians
applied at the TIN/NPI level. We would accordance with 414.1370, instead of within a virtual group.
Response: We note that each eligible attesting to only one to two performance categories at the virtual
clinician in a virtual group will receive improvement activities) in order to group level.
a virtual group score that is reflective of account for the short timeframe (a few Comment: One commenter suggested
the combined performance of a virtual months) TINs have to form and that CMS explore the development of a
group; however, only MIPS eligible implement virtual groups in preparation test to determine, in advance, if a virtual
clinicians will receive a MIPS payment for the CY 2018 performance period. group would have sufficient numbers
adjustment based on the virtual group Response: We appreciate the for valid measurement.
final score. In the case of an eligible recommendations from commenters. We Response: We interpret the
clinician participating in both a virtual believe that the ability for solo commenters reference to sufficient
group and an Advanced APM who has practitioners and groups to form and/or numbers for valid measurement to
achieved QP status, such eligible join virtual groups is an advantage and mean sufficient numerator and
clinician will be assessed under MIPS as provides flexibility. We note that virtual denominator data to enable the data to
part of the virtual group, but will still groups are generally able to take accurately reflect the virtual groups
be excluded from the MIPS payment advantage and benefit from all scoring performance on specific measures and
adjustment as a result of his or her QP incentives and bonuses that are activities. As virtual groups are
status. Conversely, in the case of an currently provided under MIPS. We will implemented, we will take this
eligible clinician participating in both a take into consideration the development recommendation into consideration.
virtual group and an Advanced APM of additional incentives, and any Comment: One commenter expressed
who has achieved Partial QP status, it is changes would be proposed in future concern that virtual groups would have
recognized that such eligible clinician rulemaking. the ability to skew benchmark scoring
would be excluded from the MIPS Comment: One commenter requested standards to the disadvantage of MIPS
payment adjustment unless such that CMS consider scoring virtual eligible clinicians who choose not to
eligible clinician elects to report under groups by weighting each individual participate in MIPS as part of a virtual
MIPS. We note that affirmatively group category score by the number of group.
clinicians. The commenter indicated Response: We disagree with the
agreeing to participate in MIPS as part
that the requirement to consolidate commenter and do not believe that
of a virtual group prior to the start of the
scoring for each performance category virtual groups would skew benchmark
applicable performance period would scoring standards to the disadvantage of
constitute an explicit election to report would limit the ability of TINs to take
advantage of the virtual group option, MIPS eligible clinicians participating in
under MIPS. Thus, eligible clinicians MIPS at the individual or group level as
who participate in a virtual group and particularly with regard to the
advancing care information performance a result of how benchmarks are
achieve Partial QP status would remain calculated, which is based on the
category, where the use of different EHR
subject to the MIPS payment adjustment composite of available data for all MIPS
vendors may make finding viable
due to their election to report under eligible clinicians. MIPS eligible
partners difficult and preclude easy
MIPS. New Medicare-enrolled eligible clinicians that are participating in MIPS
reporting. Another commenter indicated
clinicians and clinician types not as part of a virtual group would already
that our proposal to require virtual
included in the definition of a MIPS be eligible and able to participate in
groups to be scored across all
eligible clinician who are associated MIPS at the individual or group level;
performance categories may cause
with a TIN that is part of a virtual group therefore, the benchmark scoring
unintended consequences, such as
would receive a virtual group score, but standards would not be skewed
virtual groups being dissuaded from
would not receive a MIPS payment regardless of such MIPS eligible
admitting TINs that do have EHR
adjustment. MIPS eligible clinicians technology certified to the 2014 Edition clinicians participating in MIPS at the
who are participants in both a virtual in order for virtual groups advancing individual, group, or virtual group level.
group and a MIPS APM will be assessed care information performance category Also, we believe that solo practitioners
under MIPS as part of the virtual group scores not to be impacted. and groups with 10 or fewer eligible
and under the APM scoring standard as Response: We believe it is important clinicians that form virtual groups
part of an APM Entity group, but will for TINs participating in MIPS as part of would increase their performance by
receive their payment adjustment based a virtual group to be assessed and joining together.
only on the APM Entity score. scored at the virtual group level across Comment: One commenter urged
Comment: In order to increase virtual each performance category. We believe CMS to address risk adjustment
group participation and incentivize solo it provides continuity in assessment and mechanisms for virtual groups and
practitioners and groups (including allows virtual groups to share and develop methodologies to account for
rural and small practices) to form virtual coordinate resources pertaining to each the unique nature of virtual groups and
groups and move toward joint performance category. We recognize that noted that appropriate risk adjustment
accountability, many commenters there may be challenges pertaining to is critical for virtual groups because of
recommended that CMS provide bonus aligning EHR technology and the ways the heterogeneous make-up of virtual
points to TINs that elect to form virtual in which EHR technology captures data, groups (for example, geographic and
groups given that virtual groups would but believe that virtual groups have the specialty diversity).
face administrative and operational opportunity to coordinate and identify Response: We appreciate the
challenges, such as identifying reliable means to align elements of EHR recommendation from the commenter.
partners, aggregating and sharing data, technology that would benefit the Under the Improving Medicare Post-
and coordinating workflow across virtual group. In order for virtual groups Acute Transformation (IMPACT) Act of
multiple TINs and NPIs. One to accurately have their performance 2014, the Office of the Assistant
commenter recommended that CMS assessed and scored as a collective Secretary for Planning and Evaluation
consider granting virtual groups (of any entity and identify areas to improve care (ASPE) has been conducting studies on
size) special reporting and/or scoring coordination, quality of care, and health the issue of risk adjustment for
accommodations similar to the outcomes, we believe that each eligible sociodemographic factors on quality
previously finalized and proposed clinician in a virtual group should be measures and cost, as well as other
policies for small practices (for example, assessed and scored across all four strategies for including social
determinants of health status evaluation measures denominator criteria, then cumulatively aggregated across the
in CMS programs. We will closely regardless of payer for the performance virtual group. A virtual group would
examine the ASPE studies when they period. We expect to receive quality need to meet the beneficiary sampling
are available and incorporate findings as data for both Medicare and non- threshold cumulatively as a virtual
feasible and appropriate through future Medicare patients under these group.
rulemaking. Also, we will monitor submission mechanisms. Virtual groups In regard to performance under the
outcomes of beneficiaries with social submitting quality measures data using improvement activities performance
risk factors, as well as the performance the CMS Web Interface or a CMS- category, we clarified in the CY 2017
of the MIPS eligible clinicians who care approved survey vendor to report the Quality Payment Program final rule (81
for them to assess for potential CAHPS for MIPS survey must meet the FR 77181) that if one MIPS eligible
unintended consequences such as data submission requirements on the clinician (NPI) in a group completed an
penalties for factors outside the control sample of the Medicare Part B patients improvement activity, the entire group
of clinicians. CMS provides. We note that the (TIN) would receive credit for that
Comment: One commenter requested measure reporting requirements activity. In addition, we specified that
clarification regarding how compliance applicable to groups are also generally all MIPS eligible clinicians reporting as
would be implemented for the quality applicable to virtual groups. However, a group would receive the same score
and improvement activities performance we note that the requirements for for the improvement activities
categories at the virtual group level and calculating measures and activities performance category if at least one
whether or not a virtual group would be when reporting via QCDRs, qualified clinician within the group is performing
able to achieve the highest possible registries, EHRs, and attestation differ in the activity for a continuous 90 days in
score for the improvement activities their application to virtual groups. the performance period. As discussed in
performance category if only one NPI Specifically, these requirements apply section II.C.4.d. of this final rule with
within the virtual group meets the cumulatively across all TINs in a virtual comment period, we are finalizing our
requirements regardless of the total group. Thus, virtual groups will proposal to generally apply our
number of NPIs participating in the aggregate data for each NPI under each previously finalized and proposed
virtual group. Also, the commenter TIN within the virtual group by adding group policies to virtual groups, unless
requested clarification regarding together the numerators and otherwise specified. Thus, if one MIPS
whether or not a virtual group would denominators and then cumulatively eligible clinician (NPI) in a virtual group
meet the requirements under the quality collate to report one measure ratio at the completed an improvement activity, the
performance category if the virtual virtual group level. Moreover, if each entire virtual group would receive credit
group included a TIN that reported a MIPS eligible clinician within a virtual for that activity and receive the same
specialty measures set that is not group faces a significant hardship or has score for the improvement activities
applicable to other eligible clinicians in EHR technology that has been performance category if at least one
the virtual group. decertified, the virtual group can apply
Response: As discussed in section clinician within the virtual group is
for an exception to have its advancing performing the activity for a minimum
II.C.4.d. of this final rule with comment
care information performance category of a continuous 90-day period in CY
period, we are generally applying our
reweighted. If such exception 2018. In order for virtual groups to
previously finalized and proposed
application is approved, the virtual achieve full credit under the
group policies to virtual groups, unless
groups advancing care information improvement activities performance
specified. Thus, in order for virtual
performance category is reweighted to category for the 2018 performance
groups to meet the requirements for the
zero percent and applied to the quality period, they would need to submit four
quality and improvement activities
performance categories, they would performance category increasing the medium-weighted or two high-weighted
need to meet the same requirements quality performance weight from 50 activities that were for a minimum of a
established for groups and meet virtual percent to 75 percent. continuous 90-day period in CY 2018.
group reporting requirements. Virtual Additionally, the data submission Virtual groups that are considered to be
groups will have their performance criteria applicable to groups are also non-patient facing or small practices, or
assessed and scored for the quality and generally applicable to virtual groups. designated as rural or HPSA practices
improvement activities performance However, we note that data will receive full credit by submitting
categories based submitting the completeness and sampling one high-weighted improvement
minimum number of measures and requirements for the CMS Web Interface activity or two medium-weighted
activities. Generally, virtual groups and CAHPS for MIPS survey differ in improvement activities that were
reporting quality measures are required their application to virtual groups. conducted for a minimum of a
to select at least 6 measures, one of Specifically, data completeness for continuous 90-day period in CY 2018.
which must be an outcome measure, or virtual groups applies cumulatively In regard to compliance with quality
if an outcome measure is not available across all TINs in a virtual group. Thus, and improvement activities performance
a high priority measure to collectively we note that there may be a case when category requirements, virtual groups
report for the performance period of CY a virtual group has one TIN that falls would meet the same performance
2018. Virtual groups are encouraged to below the 60 percent data completeness category requirements applicable to
select the quality measures that are most threshold, which is an acceptable case groups. In section II.C.4.g. of this final
appropriate to the TINs and NPIs within as long as the virtual group rule with comment period, we outline
their virtual group and patient cumulatively exceeds such threshold. In virtual group reporting requirements.
population. regard to the CMS Web Interface and Virtual groups are required to adhere to
For the 2018 performance period, CAHPS for MIPS survey, sampling the requirements established for each
virtual groups submitting data on requirements pertain to Medicare Part B performance category. Performance data
quality measures using QCDRs, patients with respect to all TINs in a submitted to CMS on behalf of virtual
qualified registries, or via EHR must virtual group, where the sampling groups must be meet form and manner
report on at least 60 percent of the methodology would be conducted for requirements for each submission
virtual groups patients that meet the each TIN within the virtual group and mechanism.
Final Action: After consideration of performance period. In this final rule CMS allowing clinicians to choose the
the public comments received, we are with comment period, we are finalizing length of their performance period. One
finalizing the following proposals. Solo three policies (small practice size commenter recommended that CMS
practitioners and groups with 10 or determination, non-patient facing provide bonus points to clinicians who
fewer eligible clinicians that have determination, and low-volume report for a performance period that is
elected to be part of a virtual group will threshold determination) that utilize a longer than 90 days. A few commenters
have their performance measured and 30-day claims run out. We refer readers recommended that CMS analyze the
aggregated at the virtual group level to sections II.C.l.c., II.C.l.e., and II.C.2.c. quality and cost performance data to
across all four performance categories. of this final rule with comment period determine the appropriate length of the
We will apply payment adjustments at for details on these three policies. performance period, taking into
the individual TIN/NPI level. Each TIN/ Lastly, we finalized that individual consideration whether there are any
NPI will receive a final score based on MIPS eligible clinicians or groups who unintended consequences for practices
the virtual group performance, but the report less than 12 months of data (due of a particular size or specialty. One
payment adjustment would still be to family leave, etc.) are required to commenter suggested that CMS work
applied at the TIN/NPI level. We will report all performance data available with physicians to develop options and
assign the virtual group score to all TIN/ from the applicable performance period a specific plan to provide
NPIs billing under a TIN in the virtual (for example, CY 2018 or a minimum of accommodations where possible, such
group during the performance period. a continuous 90-day period within CY as providing clinicians multiple
For participants in MIPS APMs, we 2018). different performance periods to choose
will use our authority under section We proposed at 414.1320(c)(1) that from. A few commenters noted that a
1115A(d)(1) for MIPS APM authorized for purposes of the 2021 MIPS payment 90-day performance period may
under section 1115A of the Act, and year and future years, the performance eliminate issues for clinicians that
under section 1899(f) for the Shared period for the quality and cost either switch or update their EHR
Savings Program, to waive the performance categories would be the system during the performance period.
requirement under section 1848 full calendar year (January 1 through Furthermore, a few commenters noted
(q)(2)(5)(I)(i)(II) of the Act that requires December 31) that occurs 2 years prior that since the QCDR self-nominations
performance category scores from to the applicable payment year. For are not due until November 1, 2017,
virtual group reporting to be used to example, for the 2021 MIPS payment CMS would need to review and approve
generate the final score upon which the year, the performance period would be QCDR measures within less than 2
MIPS payment adjustment is based for CY 2019 (January 1, 2019 through months, for clinicians to have QCDR
all TIN/NPIs in the virtual group. We December 31, 2019), and for the 2022 measures to report at the start of the CY
will use the score assigned to the MIPS MIPS payment year, the performance 2018 performance period. One
eligible clinician based on the period would be CY 2020 (January 1, commenter noted that a 90-day
applicable APM Entity score to 2020 through December 31, 2020). performance period is preferable as
determine MIPS payment adjustments We proposed at 414.1320(d)(1) that
clinicians will need time to update their
for all MIPS eligible clinicians that are for purposes of the 2021 MIPS payment
systems and train staff after QCDR
part of an APM Entity participating in year, the performance period for the
measures have been approved.
a MIPS APM, in accordance with improvement activities and advancing
414.1370, instead of determining MIPS care information performance categories Response: We understand the
payment adjustments for these MIPS would be a minimum of a continuous commenters concerns. However, we
eligible clinicians using the final score 90-day period within CY 2019, up to believe that it would not be in the best
of their virtual group. and including the full CY 2019 (January interest of MIPS eligible clinicians to
1, 2019 through December 31, 2019). have less than a full calendar year
5. MIPS Performance Period The following is a summary of the performance period for the quality and
In the CY 2017 Quality Payment public comments received on the MIPS cost performance categories beginning
Program final rule (81 FR 77085), we Performance Period proposals and our with the 2021 MIPS payment year, as
finalized at 414.1320(b)(1) that for responses: we previously finalized at
purposes of the 2020 MIPS payment Comment: Many commenters did not 414.1320(b)(1) a full calendar year
year, the performance period for the support our proposal that beginning performance period for the quality and
quality and cost performance categories with the 2021 MIPS payment year, the cost performance categories for the 2020
is CY 2018 (January 1, 2018 through performance period for the quality and MIPS payment year, which will occur
December 31, 2018). We finalized at cost performance categories would be during CY 2018. By finalizing a full
414.1320(b)(2) that for purposes of the the full calendar year that occurs 2 years calendar year performance period for
2020 MIPS payment year, the prior to the applicable payment year. the quality and cost performance
performance period for the The commenters believed that MIPS categories for the 2021 MIPS payment
improvement activities and advancing eligible clinicians are not prepared to year, we are maintaining consistency
care information performance categories move from pick your pace flexibility with the performance period for the
is a minimum of a continuous 90-day to a full calendar year performance 2020 MIPS payment year. We believe
period within CY 2018, up to and period and that the proposal would this will be less burdensome and
including the full CY 2018 (January 1, create significant administrative burden confusing for MIPS eligible clinicians.
2018, through December 31, 2018). We and confusion for MIPS eligible We also would like to note that a longer
did not propose any changes to these clinicians. A few commenters noted that performance period for the quality and
policies. a full calendar year of data does not cost performance categories will likely
We also finalized at 414.1325(f)(2) necessarily improve the validity of the include more patient encounters, which
that for Medicare Part B claims, data data. Many commenters recommended will increase the denominator of the
must be submitted on claims with dates that CMS continue pick your pace quality and cost measures. Statistically,
of service during the performance flexibility with respect to the larger sample sizes provide more
period that must be processed no later performance period, while several accurate and actionable information.
than 60 days following the close of the commenters expressed an interest in Additionally, the longer performance
period (a year) is consistent with how payment year. The commenters noted Response: We understand the
many of the measures used in our that MIPS eligible clinicians are not commenters concerns that the proposed
program were designed to be reported prepared to move from pick your pace performance periods for quality and cost
and performed, such as Quality #303 flexibility to a full calendar year would not be consistent with the
(Cataracts: Improvement in Patients performance period and that this policy improvement activities and advancing
Visual Function within 90 Days will create significant administrative care information performance
Following Cataract Surgery) and Quality burden and confusion for MIPS eligible categories. For the improvement
#304 (Cataracts: Patient Satisfaction clinicians. activities performance category, a
within 90 Days Following Cataract Response: We understand the minimum of a continuous 90-day
Surgery). Finally, some of the measures commenters concerns in regards to the performance period provides MIPS
do not allow for a 90-day performance full calendar year MIPS performance eligible clinicians more flexibility as
period (such as those looking at period for the quality performance some improvement activities may be
complications after certain surgeries or category for the 2020 MIPS payment ongoing, while others may be episodic.
improvement in certain conditions after year. We would like to note that the For the advancing care information
treatment). In regards to the MIPS performance period for the 2020 performance category, a minimum of a
recommendation of providing bonus MIPS payment year was finalized in the continuous 90-day period performance
points to MIPS eligible clinicians that CY 2017 Quality Payment Program final period provides MIPS eligible clinicians
report for a performance period longer rule, and we made no new proposals for more flexibility and time to adopt and
than 90 days, we believe a more the MIPS performance period for the implement 2015 Edition CEHRT. As for
appropriate incentive is for MIPS 2020 MIPS payment year. Therefore, we the quality and cost performance
eligible clinicians to perform on a full are unable to modify the MIPS categories, we believe that a full
year so that they have the ability to performance period for the quality calendar year performance period is
improve their performance due to performance category for the 2020 MIPS most appropriate. Additionally,
having a larger sample size, etc. We also payment year. submitting only 90 days of performance
understand the commenters preference Comment: Several commenters data may create challenges for specific
of a 90-day performance period, so that supported the proposal to increase the measures. Finally, with respect to the
there is adequate time to update systems performance period for the 2021 MIPS cost performance category, we would
and train staff. We agree that adequate payment year and future payment years like to note that no data submission is
time is needed to update systems, to 12 months occurring 2 years prior required, as this performance category is
workflows and train staff. However, we because the longer performance period calculated utilizing Part B claim data.
note that the quality measures are provides a more accurate picture of Comment: Many commenters
eligible clinicians performance. A few supported the proposed 90-day
finalized as part of this final rule, and
commenters noted that their support performance period for the
the specifications are published on our
was contingent on CMS approving 2018 improvement activities and advancing
Web site by no later than December 31
QCDR measure specifications by care information performance
prior to the performance period. While
December 1, 2017. One commenter categories. A few commenters requested
we strongly encourage all clinicians to
noted that a 90-day performance period that CMS adopt a 90-day performance
review the current performance periods
is insufficient to thoroughly assess period for the improvement activities
measure specifications, we note that the
performance. One commenter noted that and advancing care information
overwhelming majority of MIPS quality
the full year will ensure continuity in performance categories for the 2022
measures are maintained year over year
the quality of care delivered to MIPS payment year and future years.
with only minor code set updates. beneficiaries. One commenter noted that Response: We thank the commenters
Further, for quality, we have a 60 a TIN participating in Track 1 of the for their support and will consider the
percent data completeness threshold, Shared Savings Program is commenters recommendation for future
which provides a buffer for clinicians if automatically required to report for the rulemaking.
they are not able to implement their full year, so requiring all MIPS eligible Comment: A few commenters did not
selected measures immediately at the clinicians to participate for a full year support the length of time between the
start of the performance period. Finally, would be fairer now that scores are proposed performance period and the
we would like to clarify that many reflected on Physician Compare. applicable payment year because the
registries, QCDRs, and EHRs have the Response: We thank the commenters commenters believed it would not allow
ability to accept historical data so that for their support. We would also like to practices time to make necessary
once the EHR system is switched or note that in the CY 2017 Quality adjustments before the next
updated, the MIPS eligible clinician can Payment Program final rule (81 FR performance period begins. One
report their information. With regard to 77158), we stated that we would post commenter recommended that, as the
the suggestion that we work with the approved QCDR measures through program matures, one consideration for
physicians to develop options and a the qualified posting by no later than shortening this timeframe could be a
specific plan to provide January 1, 2018. quarterly rolling annual performance
accommodations where possible, such Comment: A few commenters did not period with a three- to 6-month
as providing clinicians multiple support the proposed performance validation period prior to any payment
different performance periods to choose periods because the quality and cost adjustment. Another commenter
from, we will consider this suggestion performance categories would not be recommended that we consider
for future rulemaking as necessary. aligned with the improvement activities staggered performance periods; for
Comment: While we did not propose and advancing care information example payment adjustments for 2021,
any changes to the previously finalized performance categories. The would ideally be based on a
performance periods for the 2020 MIPS commenters believed it would be performance period running from July 1,
payment year, many commenters did confusing to clinicians. One commenter 2019 through June 30, 2020.
not support a full calendar year recommended that all performance Response: We understand the
performance period for the quality categories have a 12-month performance commenters concerns regarding the
performance category for the 2020 MIPS period. length of time between the proposed
performance period and the applicable Comment: One commenter 6. MIPS Performance Category Measures
payment year and appreciate the encouraged CMS to implement the and Activities
commenters suggestions for shortening MIPS program as soon as possible. This a. Performance Category Measures and
this timeframe. While a shortened commenter noted that a transition Reporting
timeframe between performance period period could discourage eligible
and payment year may be desirable, clinicians from participating in the (1) Submission Mechanisms
there are operational challenges with program. We finalized in the CY 2017 Quality
this approach that we do not anticipate Payment Program final rule (81 FR
can be resolved in the near future. Response: We appreciate the
commenters recommendation to 77094) at 414.1325(a) that individual
Specifically, we need to allow time for MIPS eligible clinicians and groups
the post submission processes of implement the MIPS program as soon as
must submit measures and activities, as
calculating MIPS eligible clinicians possible; however, we disagree that a
applicable, for the quality, improvement
final scores, establishing budget transition period will discourage
activities, and advancing care
neutrality, issuing the payment participation. We believe that a information performance categories. For
adjustment factors, and allowing for a transition period will reduce barriers the cost performance category, we
targeted review period to occur prior to from participation that existed in the finalized that each individual MIPS
the application of the MIPS payment legacy programs. eligible clinicians and groups cost
adjustment to MIPS eligible clinicians Final Action: After consideration of performance would be calculated using
claims. However, we are continuing to the public comments, we are finalizing administrative claims data. As a result,
look for opportunities to shorten the at 414.1320(c)(1) that for purposes of individual MIPS eligible clinicians and
timeframe between the end of the the 2021 MIPS payment year, the groups are not required to submit any
performance period and when payment performance period for the quality and additional information for the cost
adjustments are applied. cost performance categories is CY 2019 performance category. We finalized in
Comment: One commenter (January 1, 2019 through December 31, the CY 2017 Quality Payment Program
recommended a 2-year performance 2019). We are not finalizing the final rule (81 FR 77094 through 77095)
period for clinicians who have patient proposed performance period for the multiple data submission mechanisms
volume insufficient for statistical for MIPS, which provide individual
quality and cost performance categories
analysis so that the clinician has a MIPS eligible clinicians and groups
for purposes of the 2022 MIPS payment
sufficient sample size to analyze. with the flexibility to submit their MIPS
year and future years. We are also
Response: We thank the commenter measures and activities in a manner that
redesignating proposed 414.1320(d)(1)
for their suggestion and will consider it best accommodates the characteristics of
and finalizing at 414.1320(c)(2) that for
for future rulemaking. We would like to their practice, as indicated in Tables 2
note that in this final rule with purposes of the 2021 MIPS payment and 3. Table 2 summarizes the data
comment period, we are only finalizing year, the performance period for the submission mechanisms for individual
the performance period for the 2021 advancing care information and MIPS eligible clinicians that we
MIPS payment year, not future years, so improvement activities performance finalized at 414.1325(b) and (e). Table
that we can continue to monitor and categories is a minimum of a continuous 3 summarizes the data submission
assess whether changes to the 90-day period within CY 2019, up to mechanisms for groups that are not
performance period through future and including the full CY 2019 (January reporting through an APM that we
rulemaking would be beneficial. 1, 2019 through December 31, 2019). finalized at 414.1325(c) and (e).
TABLE 2DATA SUBMISSION MECHANISMS FOR MIPS ELIGIBLE CLINICIANS REPORTING INDIVIDUALLY
[TIN/NPI]
Performance category/submission Individual reporting data submission mechanisms

combinations accepted
Quality ................................................................. Claims.

QCDR.
Qualified registry.
EHR.
Cost ..................................................................... Administrative claims.1
Advancing Care Information ................................ Attestation.
QCDR.
Qualified registry.
EHR.
Improvement Activities ........................................ Attestation.
QCDR.
Qualified registry.
EHR.
TABLE 3DATA SUBMISSION MECHANISMS FOR MIPS ELIGIBLE CLINICIANS REPORTING AS GROUPS
[TIN]
Performance category/submission Group reporting data submission mechanisms

Quality ................................................................. QCDR.

Qualified registry.
EHR.
TABLE 3DATA SUBMISSION MECHANISMS FOR MIPS ELIGIBLE CLINICIANS REPORTING AS GROUPSContinued
[TIN]
Performance category/submission Group reporting data submission mechanisms

CMS Web Interface (groups of 25 or more).

CMS-approved survey vendor for CAHPS for MIPS (must be reported in conjunction with an-
other data submission mechanism).
and
Administrative claims (for all-cause hospital readmission measure; no submission required).
Cost ..................................................................... Administrative claims.1
Advancing Care Information ................................ Attestation.
QCDR.
Qualified registry.
EHR.
Improvement Activities ........................................ Attestation.
QCDR.
Qualified registry.
EHR.
We finalized at 414.1325(d) that mechanisms. We would only count the As discussed in section II.C.4 of this
individual MIPS eligible clinicians and submission that gives the clinician the final rule with comment period, we
groups may elect to submit information higher score, thereby avoiding the proposed to generally apply our
via multiple mechanisms; however, they double count. We refer readers to previously finalized and proposed
must use the same identifier for all section II.C.7.a.(2) of this final rule with group policies to virtual groups. With
performance categories, and they may comment period, which further outlines respect to data submission mechanisms,
only use one submission mechanism per how we proposed to score measures and we proposed that virtual groups would
performance category. activities regardless of submission be able to use a different submission
We proposed to revise 414.1325(d) mechanism. mechanism for each performance
for purposes of the 2020 MIPS payment We believe that this flexible approach category, and would be able to utilize
year and future years, beginning with would help individual MIPS eligible multiple submission mechanisms for
performance periods occurring in 2018, clinicians and groups with reporting, as the quality performance category,
to allow individual MIPS eligible it provides more options for the beginning with performance periods
clinicians and groups to submit data on submission of data for the applicable occurring in 2018 (82 FR 30036).
measures and activities, as applicable performance categories. We believe that However, virtual groups would be
and available, via multiple data by providing this flexibility, we would required to utilize the same submission
submission mechanisms for a single be allowing MIPS eligible clinicians to mechanism for the improvement
performance category (specifically, the choose the measures and activities that activities and the advancing care
quality, improvement activities, or are most meaningful to them, regardless information performance categories.
advancing care information performance of the submission mechanism. We are
aware that this proposal for increased For those MIPS eligible clinicians
category) (82 FR 30035). Under this
flexibility in data submission participating in a MIPS APM, who are
proposal, individual MIPS eligible
mechanisms may increase complexity on an APM Participant List on at least
clinicians and groups that have fewer
and in some instances necessitate one of the three snapshot dates as
than the required number of measures
additional costs for clinicians, as they finalized in the CY 2017 Quality
and activities applicable and available
may need to establish relationships with Payment Program Final Rule (81 FR
under one submission mechanism could
submit data on additional measures and additional data submission mechanism 77444 through 77445), or for MIPS
activities via one or more additional vendors in order to report additional eligible clinicians participating in a full
submission mechanisms, as necessary, measures and/or activities for any given TIN MIPS APM, who are on an APM
to receive a potential maximum number performance category. We clarified that Participant List on at least one of the
of points under a performance category. the requirements for the performance four snapshot dates as discussed in
If an individual MIPS eligible categories remain the same, regardless section II.C.6.g.(2) of this final rule with
clinician or group submits the same of the number of submission comment period, the APM scoring
measure through two different mechanisms used. It is also important to standard applies. We refer readers to
mechanisms, each submission would be note that for the improvement activities 414.1370 and the CY 2017 Quality
calculated and scored separately. We do and advancing care information Payment Program final rule (81 FR
not have the ability to aggregate data on performance categories, that using 77246), which describes how MIPS
the same measure across submission multiple data submission mechanisms eligible clinicians participating in APM
may limit our ability to provide real- entities submit data to MIPS in the form
1 Requires no separate data submission to CMS: time feedback. While we strive to and manner required, including
Measures are calculated based on data available provide flexibility to individual MIPS separate approaches to the quality and
from MIPS eligible clinicians billings on Medicare eligible clinicians and groups, we noted cost performance categories applicable
Part B claims. Note: Claims differ from that our goal within the MIPS program to MIPS APMs. We did not propose any
administrative claims as they require MIPS eligible
clinicians to append certain billing codes to
is to minimize complexity and changes to how APM entities in MIPS
denominator eligible claims to indicate the required administrative burden to individual APMs and their participating MIPS
quality action or exclusion occurred. MIPS eligible clinicians and groups. eligible clinicians submit data to MIPS.
The following is a summary of the performance period, we will apply our performance periods beginning in 2019,
public comments received on the validation process to determine if other if a MIPS eligible clinician or group
Performance Category Measures and measures are available and applicable reports for the quality performance
Reporting: Submission Mechanisms only with respect to the data submission category by using multiple instances of
proposal and our responses: mechanism(s) that a MIPS eligible the same data submission mechanism
Comment: Many commenters clinician utilizes for the quality (for example, multiple EHRs) then all
supported the proposal to allow MIPS performance category for a performance the submissions would be scored, and
eligible clinicians and groups to submit period. With regard to a specialty the 6 quality measures with the highest
measures and activities via multiple measure set, specialists who report on a performance (that is, the greatest
submission mechanisms. Several speciality measure set are only required number of measure achievement points)
commenters noted it will help ease to report on the measures within that would be utilized for the quality
reporting and administrative burden. set, even if it is less than the required performance category score. As noted
Several commenters also noted it will 6 measures. If the specialty set includes above, if an individual MIPS eligible
provide greater flexibility, including measures that are available through clinician or group submits the same
increasing the number of measures multiple submission mechanisms, then measure through two different
available. Several commenters stated it through this policy, beginning with the mechanisms, each submission would be
will allow clinicians to report the 2019 performance period, the option to calculated and scored separately. We do
measures that are most meaningful and report additional measures would be not have the ability to aggregate data on
applicable to them. Several commenters available for those that have applicable the same measure across multiple
also stated it will help MIPS eligible measures and/or activities available to submission mechanisms. We would
clinicians and groups successfully them, which may potentially increase only count the submission that gives the
report required measures and meet their score, but they are not required to clinician the higher score, thereby
MIPS reporting requirements. A few utilize multiple submission methods to avoiding the double count. For example,
commenters specifically supported the meet the 6 measure requirement. In if a MIPS eligible clinician submits
policy to allow reporting of quality addition, for MIPS eligible clinicians performance data for Quality Measure
measures across multiple data reporting on a specialty measure set via 236, Controlling High Blood Pressure,
submission mechanisms because 6 claims or registry, we will apply our using a registry and also through an
clinically-applicable quality measures validation process to determine if other EHR, these two submissions would be
may not always be available using one measures are available and applicable scored separately, and we would apply
submission mechanism; it will provide within the specialty measure set only the submission with the higher score
clinicians who belong to multi-specialty with respect to the data submission towards the quality performance score.
groups more ease in reporting quality mechanism(s) that a MIPS eligible We would not aggregate the score of the
measures they may be already reporting clinician utilizes for the quality registry and EHR submission of the
to qualified vendors, versus forcing performance category for a performance same measure. This approach decreases
different specialties to find a common period. the likelihood of cumulative
reporting platform that causes much Comment: A few commenters stated overcounting in the event that the
more administrative, and often financial this proposal will allow MIPS eligible submissions may have time or patient
burden; it will allow greater flexibility clinicians to determine which method is overlaps that may not be readily
in measure selection and will most appropriate for the different MIPS identifiable.
particularly benefit specialists who may categories. Several commenters noted it Comment: One commenter supported
want to report one or 2 eCQMs but will will encourage MIPS participation. that virtual groups would be able to use
need to use a registry to report the rest Many commenters stated it will multiple submission mechanisms for
of their measure set; and it is especially encourage the reporting of measures quality reporting but would have to use
helpful for those who want to report via through new submission methods such the same submission mechanism for the
EHR to the extent possible even though as QCDRs and EHRs. A few commenters improvement activities and advancing
not all measures can be submitted via stated it will reduce burden on care information performance
that mechanism. One commenter asked clinicians and EHR vendors by allowing categories. A few commenters suggested
if specialists who would have used a large groups that report under different that both groups and virtual groups have
specialty measure set would be required EHRs to report using multiple EHRs. the same submission requirements.
to use multiple submission methods to Response: In the CY 2017 Quality Another commenter suggested that we
meet the 6-measure requirement. Payment Program final rule, we reconsider multiple submission
Response: We appreciate the finalized that for the quality mechanisms due to the complexity it
commenters support for our proposal. performance category, an individual will place on clinicians.
Due to operational feasibility concerns, MIPS eligible clinician or group that Response: We are not finalizing our
we are not finalizing this proposal submits data on quality measures via proposal that virtual groups would be
beginning with the CY 2018 EHR, QCDR, qualified registry, claims, required to utilize the same submission
performance period as proposed, but or a CMS-approved survey vendor for mechanism for the improvement
instead beginning with the CY 2019 the CAHPS for MIPS survey will be activities and the advancing care
performance period. Moreover, we are assigned measure achievement points information performance categories
not requiring that MIPS individual for 6 measures (1 outcome, or if an because we believe that virtual groups
clinicians and groups submit via outcome measure is not available, should have the same reporting
additional submission mechanisms; another high priority measure and the capabilities as groups. Thus, groups and
however, through this proposal the next 5 highest scoring measures) as virtual groups have the same
option would be available for those that available and applicable, and we will submission requirements, which for the
have applicable measures and/or receive applicable measure bonus points CY 2018 performance period, includes
activities available to them. As for all measures submitted that meet the the utilization of multiple submission
discussed in section II.C.7.a.(2)(e) of this bonus criteria (81 FR 77282 through mechanisms with the caveat that only
final rule with comment period, 77301). Consistent with this policy, we one submission mechanism must be
beginning with the CY 2019 would like to clarify that for used per performance category. Starting
with the CY 2019 performance period, burdens with requiring clinicians to use That CMS eventually require a MIPS
groups and virtual groups will be able multiple submission mechanisms, if eligible clinician or group to submit all
to utilize multiple submission they have fewer than the required data on measures and activities across a
mechanisms for each performance number of measures and activities single data submission mechanism of
category. As noted above, due to applicable and available under one their choosing to ensure that reliable,
operational feasibility concerns, we are submission mechanism, as the trustworthy, comparative data can be
not finalizing this proposal beginning requirements for the performance extracted from the MIPS eligible
with the CY 2018 performance period as categories remain the same regardless of clinician and/or groups MIPS
proposed, but instead beginning with the number of submission mechanisms performance information and to
the CY 2019 performance period. used. A commenter expressed concern alleviate the resource intensity
Comment: A few commenters stated with making multiple submissions part associated with retaining all data across
this proposal would help clinicians and of the measure validation process for the the multiple submission mechanisms
groups receive the maximum number of review of whether 6 measures are for auditing purposes; and that claims-
points available. One commenter noted available for reporting. only reporting for the quality
it will ease the path for small and rural Response: We appreciate the performance category be phased-out due
practice clinicians to participate in commenters support for our proposal. to difficulty with clinically abstracting
MIPS. One commenter stated it will Due to operational feasibility concerns, meaningful quality data.
support reporting the highest quality we are not finalizing this proposal Response: We thank the commenter
data available. One commenter noted it beginning with the CY 2018 for their recommendations regarding
may allow clinicians to complete more performance period as proposed, but using a single data submission
activities. One commenter noted it will instead beginning with the CY 2019 mechanism and phasing out claims-only
provide EHR and registry vendors performance period. Moreover, we are reporting for the quality performance
flexibility in submitting data on behalf not requiring that MIPS individual category, and will take their
of their customers. One commenter clinicians and groups submit via recommendations into consideration for
stated that while it may add some additional submission mechanisms; future rulemaking. We refer readers to
burdens to reporting quality measures however, through this proposal the section II.C.9.c of this final rule with
because MIPS eligible clinicians will be option would be available for those that comment period for a discussion of our
required to report on 6 quality measures have applicable measures and/or data validation and auditing policies.
instead of only the number available via activities available to them. As Comment: Commenters requested that
a given submission mechanism, they discussed in section II.C.7.a.(2)(e) of this CMS continue to look for ways to
stated that they believe it will ultimately final rule with comment period, increase flexibility in the Quality
drive adoption of more robust measures beginning with the CY 2019 Payment Program and believed the best
based on clinical data and outcomes. performance period, we will apply our way to ensure participating clinicians
Response: We note that under this validation process to determine if other can meet the requirements of each
policy, individual MIPS eligible measures are available and applicable performance category is to increase the
clinicians and groups are not required only with respect to the data submission number of meaningful measures
to, but may use multiple data mechanism(s) that a MIPS eligible available. For clinicians who do not
submission mechanisms to report on six clinician utilizes for the quality want to manage multiple submission
quality measures in order to potentially performance category for a performance mechanisms an alternative solution
achieve the maximum score for the period. With regard to a specialty would be for each specialty within a
quality performance category beginning measure set, specialists who report on a group to create their own TINs and
with the 2019 performance period. speciality measure set are only required report as subgroups, because the
Individual MIPS eligible clinicians and to report on the measures within that commenter stated that allowing all
groups could report on additional set, even if it is less than the required MIPS eligible groups to report unique
measures and/or activities using 6 measures. If the specialty set includes sets of measures via a single mechanism
multiple data submission mechanisms measures that are available through or multiple mechanisms promotes the
for the Quality, Advancing Care multiple submission mechanisms, then ability for all clinicians to have a
Information, and Improvement through this policy, beginning with the meaningful impact on overall MIPS
Activities performance categories 2019 performance period, the option to performance, although the commenter
should applicable measures and/or report additional measures would be recognized that this subgroup approach
activities be available to them. We agree available for those that have applicable could create challenges with the current
that this policy provides small and rural measures and/or activities available to MIPS group scoring methodology.
practice clinicians with additional them, which may potentially increase Response: We agree that reporting on
flexibility to participate in MIPS by not their score, but they are not required to quality measures should be meaningful
limiting them to the use of one utilize multiple submission methods to for clinicians, and note that measures
submission mechanism per performance meet the 6 measure requirement. In are taken into consideration on an
category. We believe that MIPS eligible addition, for MIPS eligible clinicians annual basis prior to rule-making and
clinicians and groups should select and reporting on a specialty measure set via we encourage stakeholders to
report on measures that provide claims or registry, we will apply our communicate their concerns regarding
meaningful measurement within the validation process to determine if other gaps in measure development to
scope of their practice that should measures are available and applicable measure stewards. We thank
include a focus on more outcomes-based within the specialty measure set only commenters for their suggestions
measurement. with respect to the data submission regarding an alternative approach to
Comment: One commenter who mechanism(s) that a MIPS eligible submission mechanisms. We would like
supported the proposal expressed clinician utilizes for the quality to clarify that each newly created TIN
concern that the flexibility may create performance category for a performance would be considered a new group, and
more complexity and confusion, as well period. as discussed in the CY 2018 Quality
as burden on CMS. Another commenter Comment: A few commenters offered Payment Program proposed rule (82 FR
stated that while there could be some additional recommendations including: 30027), we intend to explore the
feasibility of establishing group-related track measures. One commenter asked the CY 2019 performance period, we
policies that would permit participation for clarification to distinguish between will apply our validation process to
in MIPS at a subgroup level through the scenarios where a clinician is determine if other measures are
future rulemaking. We refer readers required to submit under both EHR and available and applicable only with
section II.C.3. of this final rule with registry because their EHR is not respect to the data submission
comment period for additional certified for enough measures and when mechanism(s) that a MIPS eligible
information regarding group reporting. a clinician is required to submit under clinician utilizes for the quality
Comment: Commenters suggested that both EHR and registry because CMS has performance category for a performance
CMS ensure that entire specialty not created enough electronic measures period. With regard to a specialty
specific measure sets can be reported for the clinicians specialty. measure set, specialists who report on a
through a single submission mechanism Response: We appreciate the speciality measure set are only required
of their choice, specifically expressing suggestions, and will take them into to report on the measures within that
concern for the measures within the consideration for future rulemaking. As set, even if it is less than the required
radiation oncology subspecialty indicated in the CY 2017 Quality 6 measures. If the specialty set includes
measure set. Payment Program final rule (81 FR measures that are available through
Response: We would like to note that multiple submission mechanisms, then
77090), we intend to reduce the number
a majority of the measures in the through this policy, beginning with the
of claims-based measures in the future
specialty measure sets are available 2019 performance period, the option to
as more measures are available through
through registry reporting, and that report additional measures would be
health IT mechanisms that produce
specifically to the commenters concern, available for those that have applicable
valid measurement such as registries,
that all the measures within the measures and/or activities available to
QCDRs, and health IT vendors. We plan
radiation oncology subspecialty them, which may potentially increase
measure set are available through to continuously work with MIPS eligible
clinicians and other stakeholders to their score, but they are not required to
registry reporting. A majority of the utilize multiple submission methods to
quality measures in the MIPS program continue to improve the submission
mechanisms available for MIPS. We meet the 6 measure requirement. In
are not owned by CMS, but rather are addition, for MIPS eligible clinicians
developed and maintained by third agree that there is value to EHR based
reporting; however, we recognize that reporting on a specialty measure set via
party measure stewards. As a part of claims or registry, we will apply our
measure development and maintenance, there are relatively fewer measures
available via EHR reporting and we validation process to determine if other
measure stewards conduct feasibility measures are available and applicable
testing of adding a new submission generally want to retain solutions that
are low burden unless and until we within the specialty measure set only
mechanism as a reporting option for with respect to the data submission
their measure. We will share this identify viable alternatives. As indicated
in the quality measures appendices in mechanism(s) that a MIPS eligible
recommendation with the measure
this final rule with comment period, we clinician utilizes for the quality
stewards for future consideration.
are finalizing 54 out of the 275 quality performance category for a performance
Comment: One commenter suggested
that CMS retroactively provide similar measures available through EHR period.
flexibility for the CY 2017 MIPS reporting for the CY 2018 performance Comment: Several commenters
performance period. period. MIPS eligible clinicians should recommended that CMS make multiple
Response: For operational and evaluate the options available to them submission mechanisms optional only.
feasibility reasons, we believe that it and choose which available submission A few commenters expressed concern
would not be possible to retroactively mechanism and measures they believe that a requirement to report via multiple
allow MIPS individual eligible will provide meaningful measurement mechanisms to meet the required 6
clinicians and groups to submit data for their scope of practice. We intend to measures in the quality performance
through multiple submission provide stakeholders with additional category would increase burden on
mechanisms for the CY 2017 MIPS education with regards to the use of MIPS eligible clinicians and groups that
performance period. multiple submission mechanisms by the are unable to meet the minimum
Comment: Some commenters implementation of this policy for the CY requirement using one submission
suggested that CMS not overly rely on 2019 performance period. We plan to mechanism. A few commenters stated
claims-based measures to drive quality continuously work with MIPS eligible that MIPS eligible clinicians and groups
improvement and scoring in future clinicians and other stakeholders to should not be required to contract with
program years, that CMS develop a continue to improve the submission vendors and pay to report data on
transition plan toward only accepting mechanisms available for MIPS. It is not additional quality measures that are not
data from electronic systems that have our intent to provide larger practices an reportable through their preferred
demonstrated abilities to produce valid advantage over smaller practices, rather method or be penalized for failing to
measurement, such as those EHRs that our intention is to provide all MIPS report additional measures via a second
have achieved NCQA eMeasure eligible clinicians and groups the submission mechanism and that CMS
Certification; and that CMS create opportunity to submit data on measures should only review the measures
educational programs to help clinicians that are available and applicable to their available to a clinician or group given
and groups understand the multiple scope of practice. We are not requiring their chosen submission mechanism
submission option. A few commenters that MIPS individual clinicians and claims, registry, EHR or QCDRto
recommended making more quality groups submit via additional determine if they could have reported
measures available under each of the submission mechanisms; however, on additional measures. A few
submission mechanisms so MIPS through this proposal the option would commenters recommended that CMS
eligible clinicians have sufficient be available for those that have only offer multiple submission
measures within a single submission applicable measures and/or activities mechanisms as an option that could
mechanism. One commenter stated it available to them. As discussed in earn a clinician bonus points to
would inadvertently advantage large section II.C.7.a.(2)(e) of this final rule recognize investment in an additional
practices that may be better equipped to with comment period, beginning with submission mechanism. One commenter
recommended that reporting using more burden and complexity around the use clinician to use multiple submission
than one submission mechanism be of multiple submission mechanisms. we mechanisms would penalize them for
required for a given performance period are not requiring that MIPS individual something out of their control,
only if the MIPS eligible clinician or clinicians and groups submit via specifically development of specialty-
group already has an additional additional submission mechanisms; specific eCQMs, noting that even with
submission mechanism in place that however, through this proposal the software certified to all 64 eCQMs,
could be utilized to submit additional option would be available for those that fewer than 6 have a positive
measures. have applicable measures and/or denominator. A few commenters
Response: We are not requiring that activities available to them. As expressed concern with how this
MIPS individual clinicians and groups discussed in section II.C.7.a.(2)(e) of this proposal would interact with the
submit via additional submission final rule with comment period, measure validation process to determine
mechanisms; however, through this beginning with the CY 2019 whether a clinician could have reported
proposal the option would be available performance period, we will apply our additional measures, specifically
for those that have applicable measures validation process to determine if other expressing concern that it would require
and/or activities available to them. As measures are available and applicable eligible clinicians to look across
discussed in section II.C.7.a.(2)(e) of this only with respect to the data submission multiple mechanisms to fulfill the 6-
final rule with comment period, mechanism(s) that a MIPS eligible measure requirement and that MIPS
beginning with the CY 2019 clinician utilizes for the quality
performance period, we will apply our eligible clinicians should not be held
performance category for a performance accountable to meet more measures or
validation process to determine if other period. With regard to a specialty
measures are available and applicable look across submission mechanisms,
measure set, specialists who report on a and potentially invest in multiple
only with respect to the data submission speciality measure set are only required
mechanism(s) that a MIPS eligible mechanisms, because CMS is making
to report on the measures within that additional submission mechanisms
clinician utilizes for the quality set, even if it is less than the required
performance category for a performance available.
6 measures. If the specialty set includes
period. With regard to a specialty measures that are available through Response: We are not requiring that
measure set, specialists who report on a multiple submission mechanisms, then MIPS individual clinicians and groups
speciality measure set are only required through this policy, beginning with the submit via additional submission
to report on the measures within that 2019 performance period, the option to mechanisms; however, through this
set, even if it is less than the required report additional measures would be proposal the option would be available
6 measures. If the specialty set includes available for those that have applicable for those that have applicable measures
measures that are available through measures and/or activities available to and/or activities available to them. As
multiple submission mechanisms, then them, which may potentially increase discussed in section II.C.7.a.(2)(e) of this
through this policy, beginning with the their score, but they are not required to final rule with comment period,
2019 performance period, the option to utilize multiple submission methods to beginning with the CY 2019
report additional measures would be meet the 6 measure requirement. In performance period, we will apply our
available for those that have applicable addition, for MIPS eligible clinicians validation process to determine if other
measures and/or activities available to reporting on a specialty measure set via measures are available and applicable
them, which may potentially increase claims or registry, we will apply our only with respect to the data submission
their score, but they are not required to mechanism(s) that a MIPS eligible
validation process to determine if other
utilize multiple submission methods to clinician utilizes for the quality
measures are available and applicable
meet the 6 measure requirement. In performance category for a performance
within the specialty measure set only
addition, for MIPS eligible clinicians period. With regard to a specialty
with respect to the data submission
reporting on a specialty measure set via measure set, specialists who report on a
mechanism(s) that a MIPS eligible
claims or registry, we will apply our
clinician utilizes for the quality speciality measure set are only required
validation process to determine if other
performance category for a performance to report on the measures within that
measures are available and applicable
period. set, even if it is less than the required
within the specialty measure set only
Comment: A few commenters 6 measures. If the specialty set includes
with respect to the data submission
expressed concern that this policy could measures that are available through
mechanism(s) that a MIPS eligible
clinician utilizes for the quality substantially increase costs and burden multiple submission mechanisms, then
performance category for a performance for MIPS eligible clinicians, as it may through this policy, beginning with the
period. require a MIPS eligible clinician or 2019 performance period, the option to
Comment: Many commenters did not group practice to purchase an additional report additional measures would be
support our proposal to allow data submission mechanism in order to available for those that have applicable
submission of measures via multiple report 6 measures, and another measures and/or activities available to
submission mechanisms or expressed commenter expressed concern for them, which may potentially increase
concerns with the proposal. Several financial impact on small and solo their score, but they are not required to
commenters expressed concern that it practices. A few commenters stated that utilize multiple submission methods to
would add burden, confusion, and it would increase costs to vendors, meet the 6 measure requirement. In
complexity for MIPS eligible clinicians which would be passed on to customers addition, for MIPS eligible clinicians
and groups, as well as vendors, possibly and patients. One commenter expressed reporting on a specialty measure set via
requiring them to track measures across concern regarding decreased claims or registry, we will apply our
mechanisms based on varying productivity, and increased opportunity validation process to determine if other
benchmarks and to review measures and for coding errors. A few commenters measures are available and applicable
tools to determine if there are additional expressed concern that they may be within the specialty measure set only
applicable measures. required to report on measures that are with respect to the data submission
Response: We understand the potentially not clinically relevant. One mechanism(s) that a MIPS eligible
commenters concerns with regards to commenter noted that requiring the clinician utilizes for the quality
performance category for a performance measure and associated submission EHR, these two submissions would be
period. mechanism. scored separately, and we would apply
Comment: One commenter Comment: One commenter requested the submission with the higher score
recommended that CMS withhold the clarification on how the data towards the quality performance score;
option for submission through multiple completeness will be determined if we would not aggregated the score of
mechanisms in the quality category for reporting the same quality measures via the registry and EHR submission of the
future implementation, or until CMS multiple submission mechanisms, for same measure. This approach decreases
has become comfortable with the data example, if a clinician utilized two the likelihood of cumulative
received in year 1 of the program. submission mechanisms to report the overcounting in the event that the
Response: We agree with the same measure, would 50 percent data submissions may have time or patient
commenter and due to operational completeness need to be achieved for overlaps that may not be readily
feasibility concerns, we have each submission mechanism or for the identifiable.
determined that this proposal will be combined data submitted. Another Final Action: After consideration of
implemented beginning with the CY commenter asked how CMS will take the public comments received, we are
2019 performance period. By the time into consideration data that is submitted finalizing our proposal at 414.1325(d)
this proposal is implemented for the CY using the same submission mechanism, with modification. Specifically, due to
2019 performance period, we will have but using two different products or operational reasons, and to allow for
greater familiarity with which the way services, specifically data submitted additional time to communicate how
data is submitted to CMS based off from two different certified EHRs in a this policy intersects with out measure
submissions from the CY 2017 single performance period when applicability policies, we are not
performance period. clinicians switch EHRs mid- finalizing this policy for the CY 2019
Comment: One commenter asked that performance year. performance period. For the CY 2018
Response: In the CY 2017 Quality performance period, we intend to
CMS confirm that a MIPS eligible
Payment Program final rule, we continue implementing the submission
clinician would be allowed to submit
finalized that for the quality mechanisms policies as finalized in the
data using multiple QCDRs under the
performance category, an individual CY 2017 Quality Payment Program final
same TIN/NPI or TIN because allowing MIPS eligible clinician or group that rule (81 FR 77094) that individual MIPS
submission via multiple QCDRs in submits data on quality measures via eligible clinicians and groups may elect
single TIN could serve as a pathway EHR, QCDR, qualified registry, claims, to submit information via multiple
forward for greater specialist or a CMS-approved survey vendor for submission mechanisms; however, they
participation within multispecialty the CAHPS for MIPS survey will be must use one submission mechanism
groups. assigned measure achievement points per performance category. We are,
Response: A MIPS individual eligible for 6 measures (1 outcome, or if an however, finalizing our proposal
clinician or group would be able to outcome measure is not available, beginning with the CY 2019
submit data using multiple QCDRs if another high priority measure and the performance period. Thus, for purposes
they are able to find measures supported next 5 highest scoring measures) as of the 2021 MIPS payment year and
by other QCDRs that would provide available and applicable, and we will future years, beginning with
meaningful measurement for the receive applicable measure bonus points performance periods occurring in 2019,
clinicians, and those measures are for all measures submitted that meet the individual MIPS eligible clinicians,
applicable. Consistent with the policy bonus criteria (81 FR 77282 through groups, and virtual groups may submit
finalized in the CY 2017 Quality 77301). Consistent with this policy, we data on measures and activities, as
Payment Program final rule (81 FR would like to clarify that for applicable, via multiple data submission
77282 through 77301), we would like to performance periods beginning in 2019, mechanisms for a single performance
clarify that beginning with the CY 2019 if a MIPS eligible clinician or group category (specifically, the quality,
performance period, if a MIPS eligible reports for the quality performance improvement activities, or advancing
clinician or group reports for the quality category by using multiple instances of care information performance category).
performance category by using multiple the same data submission mechanism Individual MIPS eligible clinicians and
instances of the same submission (for example, multiple EHRs) then all groups that have fewer than the required
mechanism (for example, multiple the submissions would be scored, and number of measures and activities
QCDRs), then all the submissions would the 6 quality measures with the highest applicable and available under one
be scored, and the 6 quality measures performance (that is, the greatest submission mechanism may submit data
with the highest performance (that is, number of measure achievement points) on additional measures and activities
the greatest number of measure would be utilized for the quality via one or more additional submission
achievement points) would be utilized performance category score. As noted mechanisms, as necessary, provided
for the quality performance category above, if an individual MIPS eligible that such measures and activities are
score. As noted above, if an individual clinician or group submits the same applicable and available to them.
MIPS eligible clinician or group submits measure through two different We are finalizing our proposal with
the same measure through two different mechanisms, each submission would be modification. Specifically, we are not
submission mechanisms, each calculated and scored separately. We do finalizing our proposal for the CY 2018
submission would be calculated and not have the ability to aggregate data on performance period, and our previously
scored separately. We do not have the the same measure across multiple finalized policies continue to apply for
ability to aggregate data on the same submission mechanisms. We would the CY 2018 performance period. Thus,
measure across submission only count the submission that gives the for the CY 2018 performance period,
mechanisms. Similarly, data clinician the higher score, thereby virtual groups may elect to submit
completeness cannot be combined for avoiding the double count. For example, information via multiple submission
the same measure that is reported if a MIPS eligible clinician submits mechanisms; however, they must use
through multiple submission performance data for Quality Measure the same identifier for all practice
mechanisms, but data completeness 236, Controlling High Blood Pressure, categories, and they may only use one
would need to be achieved for each using a registry and also through an submission mechanism per performance
category. We are, however, finalizing a methodology for assessing the total measures for several of the data
our proposal beginning with the CY performance of each MIPS eligible submission mechanisms, yet still
2019 performance period. Thus, clinician according to performance required that certain types of measures,
beginning with the CY 2019 standards and, using that methodology, particularly outcome measures, be
performance period, virtual groups will to provide for a final score for each reported.
be able to use multiple submission MIPS eligible clinician. Section To create alignment with other
mechanisms for each performance 1848(q)(2)(A)(i) of the Act requires us to payers and reduce burden on MIPS
category. use the quality performance category in eligible clinicians, we incorporated
determining each MIPS eligible measures that align with other national
(2) Submission Deadlines clinicians final score, and section payers.
In the CY 2017 Quality Payment 1848(q)(2)(B)(i) of the Act describes the To create a more comprehensive
Program final rule (81 FR 77097), we measures and activities that must be picture of a practices performance, we
finalized submission deadlines by specified under the quality performance also finalized the use of all-payer data
which all associated data for all category. where possible.
performance categories must be The statute does not specify the As beneficiary health is always our
submitted for the submission number of quality measures on which a top priority, we finalized criteria to
mechanisms described in this rule. MIPS eligible clinician must report, nor continue encouraging the reporting of
As specified at 414.1325(f)(1), the does it specify the amount or type of certain measures such as outcome,
data submission deadline for the information that a MIPS eligible appropriate use, patient safety,
qualified registry, QCDR, EHR, and clinician must report on each quality efficiency, care coordination, or patient
attestation submission mechanisms is measure. However, section experience measures. However, as
March 31 following the close of the 1848(q)(2)(C)(i) of the Act requires the discussed in the CY 2017 Quality
performance period. The submission Secretary, as feasible, to emphasize the Payment Program final rule (81 FR
period will begin prior to January 2 application of outcomes-based 77098), we removed the requirement for
following the close of the performance measures. measures to span across multiple
period, if technically feasible. For Sections 1848(q)(1)(E) of the Act domains of the NQS. While we do not
example, for performance periods requires the Secretary to encourage the require that MIPS eligible clinicians
occurring in 2018, the data submission use of QCDRs, and section select measures across multiple
period will occur prior to January 2, 1848(q)(5)(B)(ii)(I) of the Act requires domains, we encourage them to do so.
2019, if technically feasible, through the Secretary to encourage the use of (2) Contribution to Final Score
March 31, 2019. If it is not technically CEHRT and QCDRs for reporting
measures under the quality performance For MIPS payment year 2019, the
feasible to allow the submission period quality performance category will
to begin prior to January 2 following the category under the final score
methodology, but the statute does not account for 60 percent of the final score,
close of the performance period, the subject to the Secretarys authority to
submission period will occur from limit the Secretarys discretion to
establish other reporting mechanisms. assign different scoring weights under
January 2 through March 31 following section 1848(q)(5)(F) of the Act. Section
the close of the performance period. In Section 1848(q)(2)(C)(iv) of the Act
generally requires the Secretary to give 1848(q)(2)(E)(i)(I)(aa) of the Act states
any case, the final deadline will remain that the quality performance category
March 31, 2019. consideration to the circumstances of
non-patient facing MIPS eligible will account for 30 percent of the final
At 414.1325(f)(2), we specified that score for MIPS. However, section
for the Medicare Part B claims clinicians and allows the Secretary, to
the extent feasible and appropriate, to 1848(q)(2)(E)(i)(I)(bb) of the Act
submission mechanism, data must be stipulates that for the first and second
submitted on claims with dates of apply alternative measures or activities
to such clinicians. years for which MIPS applies to
service during the performance period payments, the percentage of the final
As discussed in the CY 2017 Quality
that must be processed no later than 60 score applicable for the quality
days following the close of the performance category will be increased
77098 through 77099), we finalized
performance period. Lastly, for the CMS so that the total percentage points of the
MIPS quality criteria that focus on
Web Interface submission mechanism, increase equals the total number of
measures that are important to
at 414.1325(f)(3), we specified that the percentage points by which the
beneficiaries and maintain some of the
data must be submitted during an 8- percentage applied for the cost
flexibility from PQRS, while addressing
week period following the close of the performance category is less than 30
several of the comments we received in
performance period that will begin no percent. Section 1848(q)(2)(E)(i)(II)(bb)
response to the CY 2017 Quality
earlier than January 2, and end no later of the Act requires that, for the
Payment Program proposed rule and the
than March 31. For example, the CMS transition year for which MIPS applies
MIPS and APMs RFI.
Web Interface submission period could
To encourage meaningful to payments, not more than 10 percent
span an 8-week timeframe beginning of the final score shall be based on the
measurement, we finalized allowing
January 16 and ending March 13. The cost performance category. Furthermore,
individual MIPS eligible clinicians and
specific deadline during this timeframe section 1848(q)(2)(E)(i)(II)(bb) of the Act
groups the flexibility to determine the
will be published on the CMS Web site. states that, for the second year for which
most meaningful measures and data
We did not propose any changes to the MIPS applies to payments, not more
submission mechanisms for their
submission deadlines in the CY 2018 than 15 percent of the final score shall
practice.
Quality Payment Program proposed To simplify the reporting criteria, be based on the cost performance
rule. we aligned the submission criteria for category.
b. Quality Performance Criteria several of the data submission In the CY 2017 Quality Payment
mechanisms. Program final rule (81 FR 77100), we
(1) Background To reduce administrative burden finalized at 414.1330(b) that, for MIPS
Sections 1848(q)(1)(A)(i) and (ii) of and focus on measures that matter, we payment years 2019 and 2020, 60
the Act require the Secretary to develop lowered the required number of the percent and 50 percent, respectively, of
the MIPS final score will be based on eligible clinician or group could still refer readers to section II.C.6.d. of this
the quality performance category. For obtain a relatively good score by final rule with comment period for more
the third and future years, 30 percent of performing very well on the remaining information on the cost performance
the MIPS final score will be based on items, but a zero score would prevent category.
the quality performance category. the individual MIPS eligible clinician or Comment: One commenter requested
As discussed in section II.C.6.d. of group from obtaining the highest clarification on the policy to weight the
this final rule with comment period, we possible score within the performance quality performance category at 60
are not finalizing our proposal to weight category. percent of the final score for the 2020
the cost performance category at zero The following is a summary of the MIPS payment year instead of 50
percent for the second MIPS payment public comments received on the percent. The commenter requested
year (2020) and are instead retaining the Contribution to Final Score proposal clarification as to which performance
previously finalized cost performance and our responses: category the 10 percent difference
category weight of 10 percent for that Comment: Many commenters would apply if the quality performance
year. In accordance with section supported the policy to weight the category was weighted at 50 percent in
1848(q)(5)(E)(i)(I)(bb) of the Act, for the quality performance category at 60 the 2020 MIPS payment year.
first 2 years, the percentage of the MIPS percent of the final score for the 2020 Response: As previously noted in this
final score that would otherwise be MIPS payment year. One commenter final rule with comment period, for the
based on the quality performance expressed appreciation for the proposal 2020 MIPS payment year, the quality
category (that is, 30 percent) must be because it maintains consistency within performance category will be weighted
increased by the same number of the program, which facilitates easier at 50 percent. The 10 percent difference
percentage points by which the implementation for upcoming years. will be applied to the cost performance
percentage based on the cost Response: We appreciate the category.
performance category is less than 30 commenters support. However, as Comment: A few commenters urged
percent. We proposed to modify noted above, we are not finalizing our CMS to reconsider the proposal to
414.1330(b)(2) to reweight the proposal at 414.1330(b)(2) to provide weight the quality performance category
percentage of the MIPS final score based that performance in the quality at 60 percent of the final score for the
on the quality performance category for performance category will comprise 60 2020 MIPS payment year for non-patient
MIPS payment year 2020 as may be percent of a MIPS eligible clinicians facing MIPS eligible clinicians. One
necessary to account for any final score for MIPS payment year 2020. commenter noted that the quality
reweighting of the cost performance We believe that by keeping our current performance category accounts for 85
category, if finalized (82 FR 30037). policy to weight the quality percent of the total score for
Thus, since we are not finalizing our performance period at 50 percent and pathologists, and placing this much
proposal to reweight the cost the cost performance category at 10 weight on the quality performance
performance category to zero percent for percent will help ease the transition so category puts pathologists at an unfair
MIPS payment year 2020, we are not that MIPS eligible clinicians can disadvantage given the lack of
finalizing our proposal to modify understand how they will be scored in reportable measures. The commenter
414.1330(b)(2), as the performance in future years under MIPS generally and recommended that the improvement
the quality performance category the cost performance category in activity performance category be
currently comprises 50 percent of a particular, as the cost performance weighted more heavily at a 50 percent
MIPS eligible clinicians final score for category will be weighted at 30 percent weight and that the quality performance
MIPS payment year 2020, and no beginning with MIPS payment year category receive a 50 percent weight.
reweighting is necessary to account for 2021. Another commenter indicated that it
the previously finalized cost Comment: One commenter did not was not possible for non-patient facing
performance category weight. We refer support the policy to weight the quality MIPS eligible clinicians to achieve a
readers to section II.C.6.d. of this final performance category at 60 percent of score higher than 40 percent, in the
rule with comment period for more the final score for the 2020 MIPS quality performance category, given a
information on the cost performance payment year. Instead, the commenter lack of measures and given that those
category. recommended that CMS retain the measures that are applicable are only
Section 1848(q)(5)(B)(i) of the Act previously finalized weighting for the worth 3 points. While this score allows
requires the Secretary to treat any MIPS quality performance category of 50 them to avoid a penalty, the commenter
eligible clinician who fails to report on percent for the 2020 MIPS payment noted it precludes them from achieving
a required measure or activity as year. The commenter explained that a bonus. Thus, the commenter
achieving the lowest potential score since the 2021 MIPS payment year will recommended that CMS reweight the
applicable to the measure or activity. require a cost performance category quality performance category for non-
Specifically, under our finalized scoring weighting of 30 percent, they patient facing MIPS eligible clinicians
policies, an individual MIPS eligible recommended that CMS not retreat from so that they can receive a score of 70
clinician or group that reports on all progressing toward that amount in the percent or higher. This would give non-
required measures and activities could intervening year. patient facing MIPS eligible clinicians
potentially obtain the highest score Response: We appreciate the motivation for improvement as well as
possible within the performance commenters recommendation and note encourage them to continue to
category, assuming they perform well on that we are not finalizing the cost participate in the Quality Payment
the measures and activities they report. performance category weighting at zero Program should it become voluntary.
An individual MIPS eligible clinician or percent toward the final score for the Response: As previously noted in this
group who does not submit data on a 2020 MIPS payment year. Further, the final rule with comment period, we are
required measure or activity would percentage of the MIPS final score based not finalizing our proposal to reweight
receive a zero score for the unreported on the quality performance category for the quality performance to 60 percent of
items in the performance category (in MIPS payment year 2020 will be 50 the final score or the cost performance
accordance with section 1848(q)(5)(B)(i) percent in accordance with section category to zero percent of the final
of the Act). The individual MIPS 1848(q)(5)(E)(i)(I)(bb) of the Act. We score for the 2020 MIPS payment year.
Therefore, we are keeping our available, the individual MIPS eligible quality measures may be found in the
previously finalized policy to weight the clinician or group will be required to CY 2017 Quality Payment Program final
quality performance category at 50 report one other high priority measure rule (81 FR 77558 through 77816).
percent and the cost performance (appropriate use, patient safety, We also finalized the definition of a
category at 10 percent for the 2020 MIPS efficiency, patient experience, and care high priority measure at 414.1305 to
payment year. It is important to note coordination measures) in lieu of an mean an outcome, appropriate use,
that for the 2021 MIPS payment year outcome measure. If fewer than six patient safety, efficiency, patient
that the quality performance category measures apply to the individual MIPS experience, or care coordination quality
will be 30 percent of the final score, and eligible clinician or group, then the measure. Except as discussed in section
the cost performance category will be 30 individual MIPS eligible clinician or II.C.6.b.(3)(a) of this final rule with
percent of the final score as required by group would be required to report on comment period with regard to the CMS
statute. We cannot weight the each measure that is applicable. We Web Interface and the CAHPS for MIPS
improvement activities performance defined applicable to mean measures survey, we did not propose any changes
category more heavily as suggested relevant to a particular MIPS eligible to the submission criteria or definitions
because section 1848(q)(5)(E)(i)(III) of clinicians services or care rendered. As established for measures in the
the Act specifies that the improvement discussed in section II.C.7.a.(2) of this proposed rule.
activities performance category will final rule with comment period, we will In the CY 2017 Quality Payment
account for 15 percent of the final score only make determinations as to whether Program final rule (81 FR 77114), we
and was codified as such at 414.1355. a sufficient number of measures are solicited comments regarding adding a
Regarding the comment on applicable applicable for claims-based and registry requirement to our finalized policy that
measures being worth less points, we submission mechanisms; we will not patient-facing MIPS eligible clinicians
note that non-patient facing MIPS make this determination for EHR and would be required to report at least one
eligible clinicians may report on a QCDR submission mechanisms, for cross-cutting measure in addition to the
specialty-specific measure set (which example. high priority measure requirement for
may have fewer than the required six Alternatively, the individual MIPS further consideration for the Quality
measures) or may report through a eligible clinician or group will report Payment Program Year 2 and future
QCDR that can report QCDR measures one specialty measure set, or the years. For clarification, we consider a
in order to earn the full points in the measure set defined at the subspecialty cross-cutting measure to be any measure
quality performance category. level, if applicable. If the measure set that is broadly applicable across
Final Action: After consideration of contains fewer than six measures, MIPS multiple clinical settings and individual
the public comments, we are not eligible clinicians will be required to MIPS eligible clinicians or groups
finalizing our proposal at report all available measures within the within a variety of specialties. We
414.1330(b)(2) to provide that set. If the measure set contains six or specifically requested feedback on how
performance in the quality performance more measures, MIPS eligible clinicians we could construct a cross-cutting
category will comprise 60 percent of a will be required to report at least six measure requirement that would be
MIPS eligible clinicians final score for measures within the set. Regardless of most meaningful to MIPS eligible
MIPS payment year 2020. Rather we the number of measures that are clinicians from different specialties and
will be maintaining our previously contained in the measure set, MIPS that would have the greatest impact on
finalized policy at 414.1330(b)(2) to eligible clinicians reporting on a improving the health of populations. We
provide that the performance in the measure set will be required to report at refer readers to the CY 2018 Quality
quality performance category will least one outcome measure or, if no Payment Program proposed rule (82 FR
comprise 50 percent of a MIPS eligible outcome measures are available in the 30038 through 30039) for a full
clinicians final score for MIPS payment measure set, the MIPS eligible clinician discussion of the comments received
year 2020. will report another high priority and responses provided.
measure (appropriate use, patient safety, Except as discussed in section
(3) Quality Data Submission Criteria efficiency, patient experience, and care II.C.6.b.(3)(a)(iii) of this final rule with
(a) Submission Criteria coordination measures) within the comment period with regard to the
measure set in lieu of an outcome CAHPS for MIPS survey, we did not
(i) Submission Criteria for Quality
measure. MIPS eligible clinicians may propose any changes to the submission
Measures Excluding Groups Reporting
choose to report measures in addition to criteria for quality measures. We
via the CMS Web Interface and the
those contained in the specialty solicited additional feedback on
CAHPS for MIPS Survey
measure set and will not be penalized meaningful ways to incorporate cross-
In the CY 2017 Quality Payment for doing so, provided that such MIPS cutting measurement into MIPS and the
Program final rule (81 FR 77114), we eligible clinicians follow all Quality Payment Program generally. We
finalized at 414.1335(a)(1) that requirements discussed here. received several comments regarding
individual MIPS eligible clinicians In accordance with incorporating cross-cutting
submitting data via claims and 414.1335(a)(1)(ii), individual MIPS measurements into the Quality Payment
individual MIPS eligible clinicians and eligible clinicians and groups will select Program and will take them into
groups submitting data via all their measures from either the set of all consideration in future rulemaking.
mechanisms (excluding the CMS Web MIPS measures listed or referenced in
Interface and the CAHPS for MIPS Table A of the Appendix in this final (ii) Submission Criteria for Quality
survey) are required to meet the rule with comment period or one of the Measures for Groups Reporting via the
following submission criteria. For the specialty measure sets listed in Table B CMS Web Interface
applicable period during the of the Appendix in this final rule with In the CY 2017 Quality Payment
performance period, the individual comment period. We note that some Program final rule (81 FR 77116), we
MIPS eligible clinician or group will specialty measure sets include measures finalized at 414.1335(a)(2) the
report at least six measures, including at grouped by subspecialty; in these cases, following criteria for the submission of
least one outcome measure. If an the measure set is defined at the data on quality measures by registered
applicable outcome measure is not subspecialty level. Previously finalized groups of 25 or more eligible clinicians
who want to report via the CMS Web period in which performance is comment period for more information
Interface. For the applicable 12-month assessed. The process attributes a on submission mechanisms.
performance period, the group would be beneficiary to a TIN that bills the Final Action: After consideration of
required to report on all measures plurality of primary care services for the public comments, we are finalizing
included in the CMS Web Interface that beneficiary. In order to conduct our proposal at 414.1335(a)(2) to
completely, accurately, and timely by attribution for the CMS Web Interface, clarify that the CMS Web Interface
populating data fields for the first 248 we utilize retrospective assignment to criteria applies only to group of 25 or
consecutively ranked and assigned identify beneficiaries eligible for more eligible clinicians. As previously
Medicare beneficiaries in the order in sampling and identify the beneficiary finalized at 414.1335(a)(2)(i), the group
which they appear in the groups claims that will be utilized for the must report on the first 248
sample for each module or measure. If calculations of cost. Beneficiary consecutively ranked beneficiaries in
the sample of eligible assigned assignment for groups is based on a 10- the sample for each measure or module.
beneficiaries is less than 248, then the month period (between January and (iii) Performance Criteria for Quality
group would report on 100 percent of October) and determined retrospectively Measures for Groups Electing To Report
assigned beneficiaries. A group would after the month of October for the Consumer Assessment of Healthcare
be required to report on at least one applicable performance period. We note Providers and Systems (CAHPS) for
measure for which there is Medicare that it is not operationally feasible for us MIPS Survey
patient data. Groups reporting via the to utilize a period longer than 10
CMS Web Interface are required to months, to assess claims data for In the CY 2017 Quality Payment
report on all of the measures in the set. beneficiary assignment for a Program final rule (81 FR 77100), we
Any measures not reported would be performance period. finalized at 414.1335(a)(3) the
considered zero performance for that following criteria for the submission of
Lastly, we note that groups reporting
measure in our scoring algorithm. data on the CAHPS for MIPS survey by
via the CMS Web Interface may also
Specifically, we proposed to revise registered groups via CMS-approved
report the CAHPS for MIPS survey and
414.1335(a)(2) to clarify that the CMS survey vendor: For the applicable 12-
receive bonus points for submitting that
Web Interface criteria applies only to month performance period, a group that
measure. We did not propose any wishes to voluntarily elect to participate
groups of 25 or more eligible clinicians changes to the submission criteria for
(82 FR 30039). As previously finalized in the CAHPS for MIPS survey measure
quality measures for groups reporting must use a survey vendor that is
at 414.1335(a)(2)(i), groups using the via the CMS Web Interface in the
CMS Web Interface must report on all approved by CMS for a particular
proposed rule. performance period to transmit survey
measures included in the CMS Web The following is a summary of the
Interface and report on the first 248 measures data to CMS. The CAHPS for
public comments received on the MIPS survey counts for one measure
consecutively ranked beneficiaries in Submission Criteria for Quality
the sample for each measure or module. towards the MIPS quality performance
Measures for Groups Reporting via the category and, as a patient experience
CMS Web Interface proposal and our measure, also fulfills the requirement to
Program final rule (81 FR 77116), we
responses: report at least one high priority measure
finalized to continue to align the 2019
CMS Web Interface beneficiary Comment: One commenter suggested in the absence of an applicable outcome
assignment methodology with the that CMS allow groups with fewer than measure. In addition, groups that elect
attribution methodology for two of the 25 eligible clinicians (such as 2 or more this data submission mechanism must
measures that were formerly in the VM: eligible clinicians in a group) to use select an additional group data
the acute and chronic composite CMS Web Interface reporting. The submission mechanism (that is,
measures of Agency for Healthcare commenter was concerned that the qualified registries, QCDRs, EHR, etc.)
Research and Quality (AHRQ) Quality Payment Program is more in order to meet the data submission
Prevention Quality Indicators (PQIs) limiting than PQRS with regard to criteria for the MIPS quality
discussed in the CY 2017 Quality available submission mechanisms. performance category. The CAHPS for
Payment Program proposed rule (81 FR Response: The CMS Web Interface has MIPS survey will count as one patient
28192) and total per capita cost for all been limited to groups of 25 or more experience measure, and the group will
attributed beneficiaries discussed in the eligible clinicians because smaller be required to submit at least five other
CY 2017 Quality Payment Program groups have not been able to meet the measures through one other data
proposed rule (81 FR 28196). When data submission requirements on the submission mechanism. A group may
establishing MIPS, we also finalized a sample of the Medicare Part B patients report any five measures within MIPS
modified attribution process to update we provide. We would like to clarify plus the CAHPS for MIPS survey to
the definition of primary care services that we have made available the same achieve the six measures threshold. We
and to adapt the attribution to different submission mechanisms for the Quality did not propose any changes to the
identifiers used in MIPS. These changes Payment Program that were available for performance criteria for quality
are discussed in the CY 2017 Quality PQRS. In addition, we are finalizing our measures for groups electing to report
Payment Program proposed rule (81 FR proposal to revise 414.1325(d) for the CAHPS for MIPS survey in the
28196). purposes of the 2021 MIPS payment proposed rule.
We clarify that the attribution year and future years to allow In the CY 2017 Quality Payment
methodology for the CMS Web Interface individual MIPS eligible clinicians and Program final rule (see 81 FR 77120), we
implemented under MIPS is similar to groups to submit measures and finalized retaining the CAHPS for MIPS
the attribution methodology activities, as applicable, via as many survey administration period that was
implemented under the Physician submission mechanisms as necessary to utilized for PQRS of November to
Quality Reporting System (PQRS) Group meet the requirements of the quality, February. However, this survey
Practice Reporting Option (GPRO) Web improvement activities, or advancing administration period has become
Interface, which utilizes a two-step care information performance operationally problematic for the
attribution process to associate categories. We refer readers to section administration of MIPS. In order to
beneficiaries with TINs during the II.C.6.a.(1) of this final rule with compute scoring, we must have the
CAHPS for MIPS survey data earlier Visit Communication has never been a developed and tested in order to capture
than the current survey administration scored measure with the Medicare patient narratives in a scientifically
period deadline allows. Therefore, we Shared Savings Program CAHPS for grounded and rigorous way, setting it
proposed for the Quality Payment ACOs Survey. We refer readers to apart from other patient narratives
Program Year 2 and future years that the section II.C.6.g. for the discussion of the collected by various health systems and
survey administration period would, at CAHPS for ACOs survey. patient rating sites. More scientifically
a minimum, span over 8 weeks and In addition to public comments we rigorous patient narrative data would
would end no later than February 28th received, we also took into not only greatly benefit patients in their
following the applicable performance consideration analysis we conducted decision for healthcare, but it would
period (82 FR 30040). In addition, we before finalizing this provision. also greatly aid individual MIPS eligible
proposed to further specify the start and Specifically, we reviewed the findings clinicians and groups as they assess
end timeframes of the survey of the CAHPS for ACOs survey pilot, how their patients experience care. We
administration period through our which was administered from sought comment on adding these five
normal communication channels. November 2016 through February 2017. open-ended questions to the CAHPS for
In addition, as discussed in the CY The CAHPS for ACOs survey pilot MIPS survey in future rulemaking. Beta
2017 Quality Payment Program final utilized a survey instrument which did testing is an ongoing process, and we
rule (81 FR 77116), we anticipated not contain the two SSMs that we anticipate reviewing the results of that
exploring the possibility of updating the proposed for removal from the CAHPS testing in collaboration with AHRQ
CAHPS for MIPS survey under MIPS, for MIPS survey. For more information before proposing changes to the CAHPS
specifically not finalizing all of the on the other SSMs within the CAHPS for MIPS survey.
for MIPS survey, please see the We are requiring, where possible, all-
proposed Summary Survey Measures
explanation of the CAHPS for PQRS payer data for all reporting mechanisms,
(SSMs). The CAHPS for MIPS survey
survey in the CY 2016 PFS final rule yet certain reporting mechanisms are
currently consists of the core CAHPS
with comment period (80 FR 71142 limited to Medicare Part B data.
Clinician & Group (CGCAHPS) Survey
through 71143). Specifically, the CAHPS for MIPS
developed by the Agency for Healthcare
survey currently relies on sampling
Research and Quality (AHRQ), plus
TABLE 4SUMMARY SURVEY MEAS- protocols based on Medicare Part B
additional survey questions to meet
billing; therefore, only Medicare Part B
CMSs program needs. We proposed for URES (SSMS) INCLUDED IN THE
beneficiaries are sampled through that
the Quality Payment Program Year 2 CAHPS FOR MIPS SURVEY methodology. We requested comments
and future years to remove two SSMs, on ways to modify the methodology to
specifically, Helping You to Take Getting Timely Care, Appointments, and In-
assign and sample patients using data
Medication as Directed and Between formation.
How Well Providers Communicate. from other payers for reporting
Visit Communication from the CAHPS mechanisms that are currently limited
for MIPS survey (82 FR 30040). We Patients Rating of Provider.
Access to Specialists. to Medicare Part B data (82 FR 30041).
proposed to remove the SSM entitled In particular, we sought comment on the
Health Promotion and Education.
Helping You to Take Medication as Shared Decision-Making. ability of groups to provide information
Directed due to low reliability. In 2014 Health Status and Functional Status. on the patients to whom they provide
and 2015, the majority of groups had Courteous and Helpful Office Staff. care during a calendar year, whether it
very low reliability on this SSM. Care Coordination. would be possible to identify a list of
Furthermore, based on analyses Stewardship of Patient Resources. patients seen by individual clinicians in
conducted of SSMs in an attempt to the group, and what type of patient
improve their reliability, removing We sought comment on expanding the contact information groups would be
questions from this SSM did not result patient experience data available for the able to provide. Further, we sought
in any improvements in reliability. The CAHPS for MIPS survey (82 FR 30040 comment on the challenges groups may
SSM, Helping You to Take Medication through 30401). Currently, the CAHPS anticipate in trying to provide this type
as Directed, has also never been a for MIPS survey is available for groups of information, especially for vulnerable
scored measure with the Medicare to report under the MIPS. The patient beneficiary populations, such as those
Shared Savings Program CAHPS for experience survey data that is available lacking stable housing. We also sought
Accountable Care Organizations (ACOs) on Physician Compare is highly valued comment on EHR vendors ability to
Survey. We refer readers to the CY 2014 by patients and their caregivers as they provide information on the patients who
Physician Fee Schedule final rule for a evaluate their health care options. receive care from their client groups.
discussion on the CAHPS for ACOs However, in user testing with patients The following is a summary of the
survey scoring (79 FR 67909 through and caregivers in regard to the Physician public comments received on the
67910) and measure tables (79 FR 67916 Compare Web site, the users regularly Performance Criteria for Quality
through 67917). The SSM entitled request more information from patients Measures for Groups Electing to Report
Between Visit Communication like them in their own words. Patients the CAHPS for MIPS Survey proposals
currently contains only one question. regularly request that we include and our responses:
This question could also be considered narrative reviews of individual Comment: A few commenters
related to other SSMs entitled: Care clinicians and groups on the Web site. supported removing the 2 SSMs,
Coordination or Courteous and AHRQ is fielding a beta version of the Helping You to Take Medication as
Helpful Office Staff, but does not CAHPS Patient Narrative Elicitation Directed and Between Visit
directly overlap with any of the Protocol (https://www.ahrq.gov/cahps/ Communication from CAHPS for MIPS
questions under that SSM. However, we surveys-guidance/item-sets/elicitation/ for the 2018 MIPS performance period
proposed to remove this SSM in order index.html). This includes five open- and future MIPS performance periods.
to maintain consistency with the ended questions designed to be added to The commenters recommended that
Medicare Shared Savings Program the CG CAHPS survey, after which the CMS communicate all changes made to
which, utilizes the CAHPS for ACOs CAHPS for MIPS survey is modeled. the CAHPS for MIPS survey well in
Survey. The SSM entitled Between These five questions have been advance of the annual registration
deadline. While supportive of CMS Response: We acknowledge the its administration, which is often well
proposal to remove these 2 SSMs, one commenters concerns with respect to after the patients visit.
commenter urged CMS to replace the removing the Between Visit Response: We plan to consider
Helping You to Take Medication as Communication and Helping You to additional ways to improve the survey
Directed module with a reliable way to Take Medication as Directed SSMs. We in regards to the timeframe for
measure patient experience for patients would like to note that the Shared administering the survey, frequency of
as part of understanding their Savings Program piloted tested a revised the results, as well as the survey
medications. Finally, one commenter CAHPS survey that did not include instrument and its administration. We
urged CMS to make the survey even these two SSMs, and we have reviewed are finalizing that for the Quality
shorter, stating that it is still the results of that survey. Results from Payment Program Year 2 and future
significantly too long to gain a large the pilot study suggest that years the survey administration period
enough adoption rate among patients administration of the shortened version would span over a minimum of 8 weeks
and needs to be reduced further to of the survey (that is, the pilot survey) to a maximum of 17 weeks and would
increase completion rates. is likely to result in improvements in end no later than February 28th
Response: We thank the commenters overall response rates. Findings show following the applicable performance
for their support and will make every that the response rate to the pilot survey period. In addition, we are finalizing to
effort to continue to communicate was 3.4 percentage points higher than further specify the start and end
changes to the CAHPS for MIPS survey. the response rate to the Reporting Year timeframes of the survey administration
We also appreciate the commenters (RY) 2016 CAHPS for ACOs survey period through our normal
suggestion to replace the Helping You among ACOs participating in the pilot communication channels.
to Take Medication as Directed SSM study. Increases in response rates Comment: A few commenters did not
with a reliable way to measure patients tended to be larger among ACOs that support the proposal to change the
understanding of their medications, as had lower response rates in the prior minimum fielding period for CAHPS for
well as the suggestion to reduce the year. In addition, after accounting for MIPS, expressing concern that 2 months
number of questions in the CAHPS for survey questions that were removed of data is inadequate for a meaningful
MIPS survey, and will consider these from the pilot survey, the average assessment of the patient experience.
suggestions for future years of the survey responses for ACOs who One commenter expressed concern that
CAHPS for MIPS survey. We are participated in the pilot study were the cost to engage a survey vendor for
finalizing for the Quality Payment mostly similar across the two survey a relatively short period and for
Program Year 2 and future years to versions (pilot and RY 2016). Based on potentially low returns may limit the
remove two SSMs, specifically, results of the piloted CAHPS survey, we value of participation, especially if the
Helping You to Take Medication as cost is in addition to costs for the
recommend the removal of the two
Directed and Between Visit mechanisms to support the other 5
SSMs Between Visit Communication
Communication from the CAHPS for quality measures. Commenters
and Helping You to Take Medications
MIPS survey. encouraged CMS to field the CAHPS for
as Directed. Further, the SSM,
Comment: Several commenters did MIPS survey for at least 10 to 14
Between Visit Communication,
not support the proposal to remove the weeksor to select 12 weeks in
currently contains only one question.
2 SSMs without alternative domains or alignment with existing CAHPS
This question could also be considered
better patient experience or patient- guidelinesin order to improve the
related to other SSMs entitled: Care
reported outcomes measures to replace patient response rate and avoid
Coordination or Courteous and
them and urged us to leave these SSMs unintentionally excluding patients who
Helpful Office Staff, but does not have a more difficult time responding
in the survey at this time. Commenters
noted that although the Between Visit directly overlap with any of the within the shortened response period.
Communication measure is related to 2 questions under that SSM. As for the Response: We appreciate the
other SSMs (Care Coordination and SSM, Helping You to Take Medication commenters concern that 2 months of
Courteous and Helpful Office Staff), as Directed, this SSM has had low data is inadequate for a meaningful
these measures do not entirely overlap, reliability. However, we will continue to assessment of patient experience and
and poor communication between visits look at ways to further improve the the recommendation to field the CAHPS
can have serious consequences. The CAHPS for MIPS survey including for MIPS survey for at least 10 to 14
commenters also expressed concern that exploring new questions and domains of weeks. We would like to clarify that the
the Helping You to Take Medication as patient experience. We are finalizing for proposal was for the survey
Directed SSM is needed to continue to the Quality Payment Program Year 2 administration, at a minimum, to span
capture safe and appropriate medication and future years to remove two SSMs, over 8 weeks. We believe that an 8 week
use as a domain of the CAHPS for MIPS specifically, Helping You to Take minimum is adequate for the
survey. One commenter expressed Medication as Directed and Between meaningful assessment of the patient
concern that removal of the SSM is Visit Communication from the CAHPS experience because it provides
premature and encouraged us to for MIPS survey. sufficient time for the beneficiaries to
improve this SSM instead of removing Comment: A few commenters respond to the survey. With respect to
it entirely, urging us to retain the SSM supported the proposal to reduce the the 2018 CAHPS for MIPS survey, we
and capture this information within minimum fielding period for CAHPS for anticipate that the survey
both the CAHPS for MIPS and the MIPS from 4 months to 2 months in the administration period will be longer
CAHPS for ACOs surveys if necessary. 2018 MIPS performance period to allow than the minimum 8 weeks and note
Another commenter recommended that CMS to have adequate time to collect that we will specify the start and end
CMS keep the current CAHPS format the data needed to administer the MIPS timeframes of the survey administration
which they noted provides important program. One commenter urged CMS to period through our normal
feedback on key areas such as timely explore additional ways to improve the communication channels. Further, this
appointments, easy access to survey in terms of the survey policy will allow us the flexibility to
information, and good communication administration time frame, frequency of adjust the survey administration period
with healthcare providers. results, and the length of the survey and to meet future operational needs, as well
as any newly identified adjustments to measures fall below the data during the initial years of the program.
the survey administration period that completeness threshold of 50 percent We provided this notice to MIPS eligible
would result in improvements, such as would receive 3 points for submitting clinicians so that they can take the
response rates. We are finalizing that for the measure. necessary steps to prepare for higher
the Quality Payment Program Year 2 Groups submitting quality measures data completeness thresholds in future
and future years the survey data using the CMS Web Interface or a years.
administration period would, span over CMS-approved survey vendor to report Therefore, we proposed to revise the
a minimum of 8 weeks to a maximum the CAHPS for MIPS survey must meet data completeness criteria for the
of 17 weeks and end no later than the data submission requirements on the quality performance category at
February 28th following the applicable sample of the Medicare Part B patients 414.1340(a)(2) to provide that MIPS
performance period. We refer readers to that CMS provides. eligible clinicians and groups
section II.C.6.a. of this final rule with In addition, we finalized an increased submitting quality measures data using
comment period for more information data completeness threshold of 60 the QCDR, qualified registry, or EHR
on submission mechanisms. percent for MIPS for performance submission mechanism must submit
Final Action: After consideration of periods occurring in 2018 for data data on at least 50 percent of the
the public comments, we are finalizing submitted on quality measures using individual MIPS eligible clinicians or
that for the Quality Payment Program QCDRs, qualified registries, via EHR, or groups patients that meet the measures
Year 2 and future years the survey Medicare Part B claims. We noted that denominator criteria, regardless of
administration period would span over we anticipate we will propose to payer, for MIPS payment year 2020. We
a minimum of 8 weeks to a maximum increase these thresholds for data also proposed to revise the data
of 17 weeks and would end no later submitted on quality measures using completeness criteria for the quality
than February 28th following the QCDRs, qualified registries, via EHR, or performance category at 414.1340(b)(2)
applicable performance period. In Medicare Part B claims for performance to provide that MIPS eligible clinicians
addition, we are finalizing to further periods occurring in 2019 and onward. and groups submitting quality measures
specify the start and end timeframes of We proposed to modify the previously data using Medicare Part B claims, must
the survey administration period established data completeness criteria submit data on at least 50 percent of the
through our normal communication for MIPS payment year 2020 (82 FR applicable Medicare Part B patients seen
channels. Further, we are finalizing for 30041 through 30042). Specifically, we during the performance period to which
the Quality Payment Program Year 2 proposed to provide an additional year the measure applies for MIPS payment
and future years to remove two SSMs, for individual MIPS eligible clinicians year 2020. We further proposed at
specifically, Helping You to Take and groups to gain experience with 414.1340(a)(3), that MIPS eligible
Medication as Directed and Between MIPS before increasing the data clinicians and groups submitting quality
Visit Communication from the CAHPS completeness thresholds for data measures data using the QCDR,
for MIPS survey. submitted on quality measures using qualified registry, or EHR submission
QCDRs, qualified registries, via EHR, or mechanism must submit data on at least
(b) Data Completeness Criteria Medicare Part B claims. We noted 60 percent of the individual MIPS
In the CY 2017 Quality Payment concerns about the unintended eligible clinician or groups patients that
Program final rule (81 FR 77125), we consequences of accelerating the data meet the measures denominator
finalized data completeness criteria for completeness threshold so quickly, criteria, regardless of payer, for MIPS
the transition year and MIPS payment which may jeopardize MIPS eligible payment year 2021. We also proposed at
year 2020. We finalized at 414.1340 clinicians ability to participate and 414.1340(b)(3), that MIPS eligible
the data completeness criteria that perform well under the MIPS, clinicians and groups submitting quality
follows for performance periods particularly those clinicians who are measures data using Medicare Part B
occurring in 2017. least experienced with MIPS quality claims, must submit data on at least 60
Individual MIPS eligible clinicians measure data submission. We wanted to percent of the applicable Medicare Part
or groups submitting data on quality ensure that an appropriate yet B patients seen during the performance
measures using QCDRs, qualified achievable level of data completeness is period to which the measure applies for
registries, or via EHR must report on at applied to all MIPS eligible clinicians. MIPS payment year 2021. We noted that
least 50 percent of the individual MIPS We continue to believe it is important we anticipate for future MIPS payment
eligible clinician or groups patients that to incorporate higher data completeness years we will propose to increase the
meet the measures denominator thresholds in future years to ensure a data completeness threshold for data
criteria, regardless of payer, for the more accurate assessment of a MIPS submitted using QCDRs, qualified
performance period. In other words, for eligible clinicians performance on registries, EHR submission mechanisms,
these submission mechanisms, we quality measures and to avoid any or Medicare Part B claims. As MIPS
expect to receive quality data for both selection bias. Therefore, we proposed a eligible clinicians gain experience with
Medicare and non-Medicare patients. 60 percent data completeness threshold the MIPS, we would propose to steadily
For the transition year, MIPS eligible for MIPS payment year 2021. We increase these thresholds for future
clinicians whose measures fall below strongly encouraged all MIPS eligible years through rulemaking. In addition,
the data completeness threshold of 50 clinicians to perform the quality actions we sought comment on what data
percent would receive 3 points for associated with the quality measures on completeness threshold should be
submitting the measure. their patients. The data submitted for established for future years.
Individual MIPS eligible clinicians each measure is expected to be In the CY 2017 Quality Payment
submitting data on quality measures representative of the individual MIPS Program final rule (81 FR 77125 through
data using Medicare Part B claims, eligible clinicians or groups overall 77126), we finalized our approach of
would report on at least 50 percent of performance for that measure. The data including all-payer data for the QCDR,
the Medicare Part B patients seen during completeness threshold of less than 100 qualified registry, and EHR submission
the performance period to which the percent is intended to reduce burden mechanisms because we believed this
measure applies. For the transition year, and accommodate operational issues approach provides a more complete
MIPS eligible clinicians whose that may arise during data collection picture of each MIPS eligible clinicians
scope of practice and provides more for the 2020 MIPS payment year and are benchmarking for quality improvement.
access to data about specialties and instead retaining the previously One commenter noted that a delay
subspecialties not currently captured in finalized data completeness threshold of would continue to create a
PQRS. In addition, those clinicians who 60 percent that year. In addition, we are misalignment between the MIPS and
utilize the QCDR, qualified registry, or finalizing our proposal to increase the Advanced APM tracks. One commenter
EHR data submission methods must data completeness threshold to 60 disagreed with the 50 percent threshold
contain a minimum of one quality percent for MIPS payment year 2021. itself, expressing concern that this
measure for at least one Medicare Comment: Many commenters standard may motivate MIPS eligible
patient. We did not propose any supported the proposal to apply the data clinicians and groups to cherry pick
changes to these policies. As noted in completeness criteria that was the cases that make up the denominator
the CY 2017 Quality Payment Program previously finalized for the CY 2017 for reporting. This commenter suggested
final rule, those MIPS eligible clinicians performance period to the CY 2018 that for any reporting mechanism for
who fall below the data completeness performance period because they which a MIPS eligible clinician could
thresholds will receive 3 points for the believed that it would help create attest to a formal, auditable
specific measures that fall below the stability within the quality performance representative sampling, we should
data completeness threshold in the category, would enable MIPS eligible exempt the MIPS eligible clinician from
transition year of MIPS only. For the clinicians and groups to gain additional the data completeness standard.
Quality Payment Program Year 2, we experience reporting on quality Response: We agree that a larger
proposed that MIPS eligible clinicians measures and make improvements, and sample reduces the likelihood of
would receive 1 point for measures that would enhance the ability of MIPS selection bias and provides a more
fall below the data completeness eligible clinicians and groups to perform reliable and valid representation of true
threshold, with an exception for small well in the program. Several performance. As a result, we are not
practices, which would still receive 3 commenters noted that taking a slower finalizing our proposal to decrease the
points for measures that fail data approach to increasing the data data completeness threshold to 50
completeness. We refer readers to completeness criteria is the best way to percent for the 2020 MIPS payment year
section II.C.6.b.(3) of this final rule with ensure reliable and accurate data is and are instead retaining the previously
comment period for our finalized submitted so that CMS has a complete finalized data completeness threshold of
policies on instances when MIPS and accurate reflection of MIPS eligible 60 percent for that year. In addition, we
eligible clinicians measures fall below clinician performance. are finalizing our proposal to increase
the data completeness threshold. Response: While we understand the the data completeness threshold to 60
The following is a summary of the commenters desire to take a more percent for MIPS payment year 2021.
public comments received on the Data gradual approach, we must balance this Final Action: After consideration of
Completeness Criteria proposals and with need to ensure that we have a the public comments, we are not
our responses: complete an accurate reflection of MIPS finalizing our proposal regarding the
Comment: Several commenters eligible clinician performance. As such, data completeness criteria for MIPS
expressed support for our proposal to we are not finalizing our proposal to payment year 2020. Instead, we are
increase the data completeness decrease the data completeness retaining our previously finalized
threshold to 60 percent for the 2021 threshold to 50 percent for the 2020 requirements at:
MIPS payment year. MIPS payment year and are instead 414.1340(a)(2) that MIPS eligible
Response: We appreciate the retaining the previously finalized data clinicians and groups submitting quality
commenters support and are finalizing completeness threshold of 60 percent measures data using the QCDR,
this proposal. for that year. In addition, we are qualified registry, or EHR submission
Comment: Several commenters urged finalizing our proposal to increase the mechanism must submit data on at least
CMS to not finalize an increase in the data completeness threshold to 60 60 percent of the MIPS eligible clinician
data completeness threshold for the percent for MIPS payment year 2021. or groups patients that meet the
2021 MIPS payment year or future Comment: A few commenters did not measures denominator criteria,
payment years. Commenters noted that support our proposal to delay moving to regardless of payer for MIPS payment
constant changing in reporting a higher data completeness threshold year 2020; and
requirements creates administrative until the 2019 MIPS performance period 414.1340(b)(2) that MIPS eligible
challenges for eligible clinicians and and 2021 MIPS payment year, clinicians submitting quality measures
their staff. Other commenters observed expressing concern that a delay would data using Medicare Part B claims, must
that a higher threshold of data encourage MIPS eligible clinicians and submit data on at least 60 percent of the
completeness requires a significant groups to avoid the selection of applicable Medicare Part B patients seen
amount of technical and administrative population-based measures that would during the performance period to which
coordination which can take several more easily meet any higher the measure applies for MIPS payment
months to properly validate, both for completeness requirements that we years 2020.
MIPS eligible clinicians in larger might set; would negatively impact the We are, however, finalizing our
practices and those in small and rural ability of high performers to receive a proposal regarding the data
practices. substantial payment increase in the completeness criteria for MIPS payment
Response: We understand the 2020 MIPS payment year; and would year 2021. Specifically, we are finalizing
commenters concerns but believe it is not prepare MIPS eligible clinicians and at:
important to incorporate higher groups for a more rigorous program in 414.1340(a)(2) that MIPS eligible
thresholds to ensure a more accurate future years. A few commenters clinicians and groups submitting quality
assessment of a MIPS eligible clinicians suggested that 50 percent of available measures data using the QCDR,
performance on the quality measures data is insufficient and that a larger qualified registry, or EHR submission
and to avoid any selection bias. patient sample provides a more reliable mechanism must submit data on at least
Therefore, we are not finalizing our and valid representation of true 60 percent of the MIPS eligible clinician
proposal to decrease the data performance and will better support or groups patients that meet the
completeness threshold to 50 percent clinician groups in internal measures denominator criteria,
regardless of payer for MIPS payment years 2020 and 2021 via Medicare Part individual MIPS eligible clinicians and
year 2021; and B claims, QCDR, qualified registry, EHR, groups to submit measures and
414.1340(b)(2) that MIPS eligible CMS Web Interface, and the CAHPS for activities, as applicable, via as many
clinicians submitting quality measures MIPS survey. It is important to note that submission mechanisms as necessary to
data using Medicare Part B claims, must while we finalized at 414.1325(d) in meet the requirements of the quality,
submit data on at least 60 percent of the the CY 2017 Quality Payment Program improvement activities, or advancing
applicable Medicare Part B patients seen final rule that individual MIPS eligible care information performance
during the performance period to which clinicians and groups may only use one categories. We refer readers to section
the measure applies for MIPS payment
submission mechanism per performance II.C.6.a.(1) of this final rule with
years 2021.
category, in section II.C.6.a.(1) of this comment period for further discussion
(c) Summary of Data Submission final rule with comment period, we are of this policy.
Criteria finalizing to revise 414.1325(d) for
Table 5 reflects our final quality data purposes of the 2021 MIPS payment
submission criteria for MIPS payment year and future years to allow
TABLE 5SUMMARY OF FINAL QUALITY DATA SUBMISSION CRITERIA FOR MIPS PAYMENT YEAR 2020 AND 2021 VIA
PART B CLAIMS, QCDR, QUALIFIED REGISTRY, EHR, CMS WEB INTERFACE, AND THE CAHPS FOR MIPS SURVEY
Performance Clinician type Submission mechanism Submission criteria Data completeness
period
Jan 1Dec 31 .... Individual MIPS eligible cli- Part B Claims ..................... Report at least six measures including one outcome 60 percent of individual
nicians. measure, or if an outcome measure is not available MIPS eligible clinicians
report another high priority measure; if less than six Medicare Part B patients
measures apply then report on each measure that is for the performance pe-
applicable. Individual MIPS eligible clinicians would riod.
have to select their measures from either the set of
all MIPS measures listed or referenced, or one of the
specialty measure sets listed in, the applicable final
rule.
Jan 1Dec 31 .... Individual MIPS eligible cli- QCDR, Qualified Registry, Report at least six measures including one outcome 60 percent of individual
nicians, groups. & EHR. measure, or if an outcome measure is not available MIPS eligible clinicians,
report another high priority measure; if less than six or groups patients
measures apply then report on each measure that is across all payers for the
applicable. Individual MIPS eligible clinicians, or performance period.
groups would have to select their measures from ei-
ther the set of all MIPS measures listed or ref-
erenced, or one of the specialty measure sets listed
in, the applicable final rule.
Jan 1Dec 31 .... Groups ............................... CMS Web Interface ........... Report on all measures included in the CMS Web Sampling requirements for
Interface; AND populate data fields for the first 248 the groups Medicare
consecutively ranked and assigned Medicare bene- Part B patients.
ficiaries in the order in which they appear in the
groups sample for each module/measure. If the pool
of eligible assigned beneficiaries is less than 248,
then the group would report on 100 percent of as-
signed beneficiaries.
Jan 1Dec 31 .... Groups ............................... CAHPS for MIPS Survey ... CMS-approved survey vendor would need to be paired Sampling requirements for
with another reporting mechanism to ensure the min- the groups Medicare
imum number of measures is reported. CAHPS for Part B patients.
MIPS survey would fulfill the requirement for one pa-
tient experience measure towards the MIPS quality
data submission criteria. CAHPS for MIPS survey
would only count for one measure under the quality
performance category.
We note that the measure reporting group faces a significant hardship or has requirements for the CMS Web Interface
requirements applicable to groups are EHR technology that has been and CAHPS for MIPS survey differ in
also generally applicable to virtual decertified, the virtual group can apply their application to virtual groups.
groups. However, we note that the for an exception to have its advancing Specifically, data completeness for
requirements for calculating measures care information performance category virtual groups applies cumulatively
and activities when reporting via reweighted. If such exception across all TINs in a virtual group. Thus,
QCDRs, qualified registries, EHRs, and application is approved, the virtual we note that there may be a case when
attestation differ in their application to groups advancing care information a virtual group has one TIN that falls
virtual groups. Specifically, these performance category is reweighted to below the 60 percent data completeness
requirements apply cumulatively across zero percent and applied to the quality threshold, which is an acceptable case
all TINs in a virtual group. Thus, virtual performance category increasing the as long as the virtual group
groups will aggregate data for each NPI quality performance weight from 50 cumulatively exceeds such threshold. In
under each TIN within the virtual group percent to 75 percent. regard to the CMS Web Interface and
by adding together the numerators and Additionally, the data submission CAHPS for MIPS survey, sampling
denominators and then cumulatively criteria applicable to groups are also requirements pertain to Medicare Part B
collate to report one measure ratio at the generally applicable to virtual groups. patients with respect to all TINs in a
virtual group level. Moreover, if each However, we note that data virtual group, where the sampling
MIPS eligible clinician within a virtual completeness and sampling methodology would be conducted for
each TIN within the virtual group and ACR measure to solo practices or small 2018 Quality Payment Program
then cumulatively aggregated across the groups (groups of 15 or less). We did proposed rule (82 FR 30043 and 30044)
virtual group. A virtual group would apply the ACR measure to groups of 16 for additional information regarding
need to meet the beneficiary sampling or more who meet the case volume of eCQM reporting and the Measure
threshold cumulatively as a virtual 200 cases. A group will be scored on the Development Plan that serves as a
group. ACR measure even if it did not submit strategic framework for the future of the
any quality measures, if it submitted in clinician quality measure development
(4) Application of Quality Measures to
other performance categories. to support MIPS and APMs. We
Non-Patient Facing MIPS Eligible
Otherwise, the group will not be scored encourage stakeholders to develop
Clinicians
on the readmission measure if it did not additional quality measures for MIPS
In the CY 2017 Quality Payment submit data in any of the performance that would address the gaps.
Program final rule (81 FR 77127), we categories. In our transition year Under section 1848(q)(2)(D)(ii) of the
finalized at 414.1335 that non-patient policies, the readmission measure alone Act, the Secretary must solicit a Call
facing MIPS eligible clinicians would be would not produce a neutral to positive for Quality Measures Under
required to meet the applicable MIPS payment adjustment since in Consideration each year. Specifically,
submission criteria that apply for all order to achieve a neutral to positive the Secretary must request that eligible
MIPS eligible clinicians for the quality MIPS payment adjustment, an clinician organizations and other
performance category. We did not individual MIPS eligible clinician or relevant stakeholders identify and
propose any changes to this policy in group must submit information in one submit quality measures to be
the proposed rule. of the three performance categories as considered for selection in the annual
(5) Application of Facility-Based discussed in the CY 2017 Quality list of MIPS quality measures, as well as
Payment Program final rule (81 FR updates to the measures. Under section
Measures
77329). However, for MIPS eligible 1848(q)(2)(D)(ii) of the Act, eligible
Section 1848(q)(2)(C)(ii) of the Act clinician organizations are professional
clinicians who did not meet the
provides that the Secretary may use organizations as defined by nationally
minimum case requirements, the ACR
measures used for payment systems recognized specialty boards of
measure was not applicable. In the CY
other than for physicians, such as certification or equivalent certification
2018 Quality Payment Program
measures used for inpatient hospitals, boards. However, we do not believe
proposed rule, we did not propose to
for purposes of the quality and cost there needs to be any special restrictions
remove this measure from the list of
performance categories. However, the on the type or make-up of the
quality measures for the MIPS quality
Secretary may not use measures for organizations that submit measures for
performance category. Nor did we
hospital outpatient departments, except consideration through the call for
propose any changes for the ACR
in the case of items and services measures. Any such restriction would
measure in the proposed rule. As
furnished by emergency physicians, limit the type of quality measures and
discussed in section II.C.4.d. of this
radiologists, and anesthesiologists. We the scope and utility of the quality
final rule with comment period, we are
refer readers to section II.C.7.a.(4) of this measures that may be considered for
finalizing our proposal to generally
final rule with comment period for a full inclusion under the MIPS.
apply our finalized group policies to
discussion of the finalized policies As we described previously in the CY
virtual groups.
regarding the application of facility- 2017 Quality Payment Program final
based measures. c. Selection of MIPS Quality Measures rule (81 FR 77137), we will accept
for Individual MIPS Eligible Clinicians quality measures submissions at any
(6) Global and Population-Based
and Groups Under the Annual List of time, but only measures submitted
Measures
Quality Measures Available for MIPS during the timeframe provided by us
In the CY 2017 Quality Payment Assessment through the pre-rulemaking process of
Program final rule (81 FR 77136), we each year will be considered for
did not finalize all of our proposals on (1) Background and Policies for the Call
inclusion in the annual list of MIPS
global and population-based measures for Measures and Measure Selection
quality measures for the performance
as part of the quality score. Specifically, Process
period beginning 2 years after the
we did not finalize our proposal to use Under section 1848(q)(2)(D)(i) of the measure is submitted. This process is
the acute and chronic composite Act, the Secretary, through notice and consistent with the pre-rulemaking
measures of the AHRQ Prevention comment rulemaking, must establish an process and the annual call for
Quality Indicators (PQIs). We agreed annual list of MIPS quality measures measures, which are further described at
with commenters that additional from which MIPS eligible clinicians (https://www.cms.gov/Medicare/
enhancements, including the addition of may choose for purposes of assessment Quality-Initiatives-Patient-Assessment-
risk adjustment, needed to be made to for a performance period. The annual Instruments/QualityMeasures/Pre-Rule-
these measures prior to inclusion in list of MIPS quality measures must be Making.html).
MIPS. We did, however, calculate these published in the Federal Register no Submission of potential quality
measures at the TIN level, and provided later than November 1 of the year prior measures, regardless of whether they
the measure data through the QRURs to the first day of a performance period. were previously published in a
released in September 2016, and this Updates to the annual list of MIPS proposed rule or endorsed by an entity
data can be used by MIPS eligible quality measures must be published in with a contract under section 1890(a) of
clinicians for informational purposes. the Federal Register no later than the Act, which is currently the National
We did finalize the all-cause hospital November 1 of the year prior to the first Quality Forum, is encouraged. The
readmissions (ACR) measure from the day of each subsequent performance annual Call for Measures process allows
VM Program as part of the annual list of period. Updates may include the eligible clinician organizations and
quality measures for the MIPS quality addition of new MIPS quality measures, other relevant stakeholder organizations
performance category. We finalized this substantive changes to MIPS quality to identify and submit quality measures
measure with the following measures, and removal of MIPS quality for consideration. Presumably,
modifications. We did not apply the measures. We refer readers to the CY stakeholders would not submit
measures for consideration unless they performance; for example, if a measure performance category, we use quality
believe that the measure is applicable to developer submits data showing a small measures developed by QCDRs. In the
clinicians and can be reliably and variation in performance among a group circumstances where a QCDR wants to
validly measured at the individual already composed of high performers, use a QCDR measure for inclusion in the
clinician level. The NQF-convened such evidence would not be substantial MIPS program for reporting, those
Measure Application Partnership (MAP) enough to assure us that sufficient measures go through a CMS approval
provides an additional opportunity for variation in performance exists. We also process during the QCDR self-
stakeholders to provide input on noted that we are likely to reject nomination period. We also established
whether or not they believe the measures that are not outcome-based that we post the quality measures for
measures are applicable to clinicians as measures, unless: (1) There is use by QCDRs by no later than January
well as feasible, scientifically substantial documented and peer 1 for performance periods occurring in
acceptable, and reliable and valid at the reviewed evidence that the clinical 2018 and future years.
clinician level. Furthermore, we must go process measured varies directly with Previously finalized MIPS quality
through notice and comment the outcome of interest; and (2) it is not measures can be found in the CY 2017
rulemaking to establish the annual list possible to measure the outcome of Quality Payment Program final rule (81
of quality measures, which gives interest in a reasonable timeframe. FR 77558 through 77675). Updates may
stakeholders an additional opportunity We also noted that retired measures include the addition of proposed new
to review the measures and provide that were in one of CMSs previous MIPS quality measures, including
input on whether or not they believe the quality programs, such as the Physician measures selected 2 years ago during the
measures are applicable to clinicians, as Quality Reporting System (PQRS)
Call for Measures process. The new
well as feasible, scientifically program, will likely be rejected if
MIPS quality measures proposed for
acceptable, and reliable and valid at the proposed for inclusion. This includes
inclusion in MIPS for the 2018
clinician level. Additionally, we are measures that were retired due to being
performance period and future years
required by statute to submit new topped out, as defined below. For
were found in Table A of the CY 2018
measures to an applicable specialty- example, measures may be retired due
Quality Payment Program proposed rule
appropriate, peer-reviewed journal. to attaining topped out status because of
(82 FR 30261 through 30270). The
As previously noted, we encourage high performance, or measures that are
proposed new and modified MIPS
the submission of potential quality retired due to a change in the evidence
specialty sets for the 2018 performance
measures regardless of whether such supporting their use.
In the CY 2017 Quality Payment period and future years were listed in
measures were previously published in Table B of the CY 2018 Quality Payment
a proposed rule or endorsed by an entity Program final rule (81 FR 77153), we
established that we will categorize Program proposed rule (82 FR 30271
with a contract under section 1890(a) of through 30454), and included existing
the Act. However, we proposed to measures into the six NQS domains
(patient safety, person- and caregiver- measures that were proposed with
request that stakeholders apply the modifications, new measures, and
following considerations when centered experience and outcomes,
communication and care coordination, measures finalized in the CY 2017
submitting quality measures for possible Quality Payment Program final rule. We
inclusion in MIPS: effective clinical care, community/
population health, and efficiency and noted that the modifications made to the
Measures that are not duplicative of specialty sets may include the removal
an existing or proposed measure. cost reduction). We intend to submit
future MIPS quality measures to the of certain quality measures that were
Measures that are beyond the previously finalized. The specialty
measure concept phase of development NQF-convened Measure Application
Partnerships (MAP), as appropriate, measure sets should be used as a guide
and have started testing, at a minimum, for eligible clinicians to choose
with strong encouragement and and we intend to consider the MAPs
recommendations as part of the measures applicable to their specialty.
preference for measures that have To clarify, some of the MIPS specialty
completed or are near completion of comprehensive assessment of each
measure considered for inclusion under sets have further defined subspecialty
reliability and validity testing. sets, each of which is effectively a
Measures that include a data MIPS.
In the CY 2017 Quality Payment separate specialty set. In instances
submission method beyond claims- where an individual MIPS eligible
based data submission. Program final rule (81 FR 77155), we
established that we use the Call for clinician or group reports on a specialty
Measures that are outcome-based
Quality Measures process as a forum to or subspecialty set, if the set has less
rather than clinical process measures.
Measures that address patient safety gather the information necessary to draft than six measures, that is all the
and adverse events. the journal articles for submission from clinician is required to report. MIPS
Measures that identify appropriate measure developers, measure owners eligible clinicians are not required to
use of diagnosis and therapeutics. and measure stewards. The submission report on the specialty measure sets, but
Measures that address the domain of this information does not preclude us they are suggested measures for specific
for care coordination. from conducting our own research using specialties. Throughout measure
Measures that address the domain Medicare claims data, Medicare survey utilization, measure maintenance
for patient and caregiver experience. results, and other data sources that we should be a continuous process done by
Measures that address efficiency, possess. We submit new measures for the measure owners, to include
cost, and resource use. publication in applicable specialty- environmental scans of scientific
Measures that address significant appropriate, peer-reviewed journals literature about the measure. New
variation in performance. before including such measures in the information gathered during this
We will apply these considerations final annual list of quality measures. ongoing review may trigger an ad hoc
when considering quality measures for In the CY 2017 Quality Payment review. Please note that these specialty
possible inclusion in MIPS. Program final rule (81 FR 77158), we specific measure sets are not all
In addition, we note that we are likely established at 414.1330(a)(2) that for inclusive of every specialty or
to reject measures that do not provide purposes of assessing performance of subspecialty. On January 25, 2017, we
substantial evidence of variation in MIPS eligible clinicians in the quality announced that we would be accepting
recommendations for potential new proposed to identify measures clinicians with a list of measures that
specialty measure sets for year 2 of including, but not limited to measures are broadly applicable to all clinicians
MIPS under the Quality Payment that have had measure specification, regardless of the clinicians specialty.
Program. These recommendations were measure title, and domain changes. Even though MIPS eligible clinicians are
based on the MIPS quality measures MIPS quality measures with proposed not required to report on cross-cutting
finalized in the CY 2017 Quality substantive changes can be found at measures, they are provided as a
Payment Program final rule, and include Table E of the Appendix in the CY 2018 reference to clinicians who are looking
recommendations to add or remove the Quality Payment Program proposed rule for additional measures to report
current MIPS quality measures from the (82 FR 30468 through 30478). outside their specialty.
specialty measure sets. The current The measures that would be used for Final Action: After consideration of
specialty measure sets can be found on the APM scoring standard and our the public comments received, we refer
the Quality Payment Program Web site authority for waiving certain measure readers to the appendix of this final rule
at https://qpp.cms.gov/measures/ requirements are described in section with comment period for the finalized
quality. All specialty measure sets II.C.6.g.(3)(b)(ii) of this final rule with list of new quality measures available
submitted for consideration were comment period, and the measures that for reporting in MIPS for the 2018
assessed to ensure that they met the would be used to calculate a quality performance period and future years
needs of the Quality Payment Program. score for the APM scoring standard are (Table A); the finalized specialty
As a result, we proposed (82 FR proposed in Tables 14, 15, and 16 of the measure sets available for reporting in
30045) to add new quality measures to CY 2018 Quality Payment Program MIPS for the 2018 performance period
MIPS (Table A in the proposed rule (82 proposed rule (82 FR 30091 through and future years (Table B); the MIPS
FR 30261 through 30270)), revise the 30095). quality measures removed only from
specialty measure sets in MIPS (Table B We also sought comment on whether specialty sets for the 2018 performance
in the proposed rule (82 FR 30271 there are any MIPS quality measures period and future years (Table C.1); the
through 30454)), remove specific MIPS that commenters believe should be MIPS quality measures removed from
quality measures only from specialty classified in a different NQS domain the MIPS program for the 2018
sets (Table C.1 in the proposed rule (82 than what is being proposed, or that performance period and future years
FR 30455 through 30462)), and should be classified as a different (Table C.2); the cross-cutting measures
proposed to remove specific MIPS measure type (for example, process vs. available for the 2018 MIPS
quality measures from the MIPS outcome) than what we proposed (82 FR performance period and future years
program for the 2018 performance 30045). We did not receive any public (Table D); and the MIPS quality
period (Table C.2 in the proposed rule comments in response to this measures finalized with substantive
(82 FR 30463 through 30465)). In solicitation. changes for the 2018 performance
addition, we proposed to also remove The following is a summary of the period and future years (Table E).
cross cutting measures from most of the public comments received on the
Background and Policies for the Call (2) Topped Out Measures
specialty sets. Specialty groups and
societies reported that cross cutting for Measures and Measure Selection As defined in the CY 2017 Quality
measures may or may not be relevant to Process proposals and our responses: Payment Program final rule at (81 FR
their practices, contingent on the Comment: A few commenters 77136), a measure may be considered
eligible clinicians or groups. We chose supported the proposal to remove cross- topped out if measure performance is so
to retain the cross cutting measures in cutting measures from most specialty high and unvarying that meaningful
Family Practice, Internal Medicine, and sets. One commenter agreed that cross- distinctions and improvement in
Pediatrics specialty sets because they cutting measures may or may not be performance can no longer be made.
are frequently used in these practices. relevant to certain practices. Topped out measures could have a
The proposed 2017 cross cutting Response: We appreciate the disproportionate impact on the scores
measures (81 FR 28447 through 28449) commenters support. for certain MIPS eligible clinicians, and
were compiled and placed in a separate Comment: One commenter provide little room for improvement for
table for eligible clinicians to elect to recommended that CMS retain cross- the majority of MIPS eligible clinicians.
use or not, for reporting. To clarify, the cutting measures in specialty sets with We refer readers to section II.C.7.a.(2)(c)
cross-cutting measures are intended to fewer than six measures because the of this final rule with comment period
provide clinicians with a list of commenter believed it would allow for additional information regarding the
measures that are broadly applicable to parity in quality measure reporting scoring of topped out measures.
all clinicians regardless of the across all clinicians and provide Although we proposed a 3-year
clinicians specialty. Even though it is incentives for all specialties to develop timeline to identify and propose to
not required to report on cross-cutting quality measures. remove (through future rulemaking)
measures, it is provided as a reference Response: We did not retain the cross- topped out measures (82 FR 30046). We
to clinicians who are looking for cutting measures in all the specialty would like to clarify that the proposed
additional measures to report outside sets, including those sets with less than timeline is more accurately described as
their specialty. We continue to consider six measures, because we believe that a 4-year timeline. After a measure has
cross-cutting measures to be an cross-cutting measures are not been identified as topped out for 3
important part of our quality measure necessarily reflective of all specialty consecutive years, we may propose to
programs, and seek comment on ways to groups scope of their practice. One goal remove the measure through notice-and-
incorporate cross-cutting measures into of the MIPS program is to ensure that comment rulemaking for the 4th year.
MIPS in the future. The Table of Cross- meaningful measurement occurs, and Therefore, in the 4th year, if finalized
Cutting Measures can be found in Table CMS chose to retain the cross cutting through rulemaking, the measure would
D of the Appendix in the CY 2018 measures in Family Practice, Internal be removed and would no longer be
Quality Payment Program proposed rule Medicine, and Pediatrics specialty sets available for reporting during the
(82 FR 30466 through 30467). because they are frequently used in performance period. This proposal
For MIPS quality measures that are these practices. The cross-cutting would provide a path toward removing
undergoing substantive changes, we measures are intended to provide topped out measures over time, and will
apply to the MIPS quality measures. performance period. Thus, the first year included in the CMS Web Interface (81
QCDR measures that consistently are any other topped out measure could be FR 77116). Thus, if a CMS Web Interface
identified as topped out according to the proposed for removal would be in measure is topped out, the CMS Web
same timeline as proposed below, rulemaking for the 2021 MIPS Interface reporter cannot select other
would not be approved for use in year performance period, based on the measures. We refer readers to section
4 during the QCDR self-nomination benchmarks being topped out in the II.C.7.a.(2) of this final rule with
review process. These identified QCDR 2018, 2019, and 2020 MIPS performance comment period for information on
measures would not be removed periods. If the measure benchmark is scoring policies with regards to topped
through the notice-and-comment and not topped out during one of the 3 MIPS out measures from the CMS Web
rulemaking process described below. performance periods, then the lifecycle Interface for the Quality Payment
We proposed to phase in this policy would stop and start again at year 1 the Program. We did not propose to include
starting with a select set of six highly next time the measure benchmark is CMS Web Interface measures in our
topped out measures identified in topped out. proposal on removing topped out
section II.C.7.a.(2)(c) of this final rule We sought comment on the proposed measures.
with comment period. We also proposed timeline; specifically, regarding the The following is a summary of the
to phase in special scoring for measures number of years before a topped out public comments received on the
identified as topped out in the measure is identified and considered for Topped Out Measures proposals and
published benchmarks for 2 consecutive removal, and under what circumstances our responses:
performance periods, starting with the we should remove topped out measures Comment: Many commenters
select set of highly topped out measures once they reach that point (82 FR supported the proposed timeline for
for the 2018 MIPS performance period. 30046). We also noted that if for some identification and removal of topped out
An example illustrating the proposed reason a measure benchmark is topped measures because the process relies on
timeline for the removal and special out for only one submission mechanism multiple years of data and the lifecycle
scoring of topped out measures, as it benchmark, then we would remove that permits enough time to avoid
would be applied to the select set of measure from the submission disadvantaging certain clinicians who
highly topped out measures identified mechanism, but not remove the measure may report these measures. The
in section II.C.7.a.(2)(c) of this final rule from other submission mechanisms commenters supported the lifecycle
with comment period, is as follows: available for submitting that measure. over multiple years to find a trend in
Year 1: Measures are identified as The comments we received and our high performance, providing time for
topped out in the benchmarks published responses are discussed further below. consideration of replacement measures
for the 2017 MIPS performance Period. We also sought comment on whether to sustain the focus on clinical areas
The 2017 benchmarks are posted on the topped out Summary Survey Measures where improvement opportunities exist.
Quality Payment Program Web site: (SSMs), if topped out, should be A few commenters supported the
https://qpp.cms.gov/resources/ considered for removal from the timeline and encouraged CMS to
education. Consumer Assessment of Healthcare develop a more comprehensive
Year 2: Measures are identified as Providers and Systems (CAHPS) for approach to identifying topped out
topped out in the benchmarks published MIPS Clinician or Group Survey measures, to ensure that voluntary
for the 2018 MIPS performance period. measure due to high, unvarying reporting on a menu of quality measures
We refer readers to section II.C.7.a.(2)(c) performance within the SSM, or does not allow eligible clinicians to
of this final rule with comment period whether there is another alternative cherry pick measures. One commenter
for additional information regarding the policy that could be applied for topped supported not applying the topped out
scoring of topped out measures. out SSMs within the CAHPS for MIPS measure policies to measures in the
Year 3: Measures are identified as Clinician or Group Survey measure (82 CMS Web Interface to align with
topped out in the benchmarks published FR 30046). We received a comment on measures used in APMs such as the
for the 2019 MIPS performance period. this item and appreciate the input Shared Savings Program for the CMS
The measures identified as topped out received. As this was a request for Web Interface submission mechanism
in the benchmarks published for the comment only, we will take the for the Quality Payment Program.
2019 MIPS performance period and the feedback provided into consideration Response: We agree that by
previous two consecutive performance for future rulemaking. identifying and removing topped out
periods would continue to have special In the CY 2017 Quality Payment measures, we may greatly reduce
scoring applied for the 2019 MIPS Program final rule, we stated that we do eligible clinicians ability to cherry
performance period and would be not believe it would be appropriate to pick measures. We believe that the
considered, through notice-and- remove topped out measures from the benchmarks will help us identify those
comment rulemaking, for removal for CMS Web Interface for the Quality measures that meet our definition of
the 2020 MIPS performance period. Payment Program because the CMS Web topped out measures.
Year 4: Topped out measures that Interface measures are used in MIPS and Comment: Many commenters did not
are finalized for removal are no longer in APMs, such as the Shared Savings support removal of the measures,
available for reporting. For example, the Program. Removing topped out because they noted: Benchmarks
measures in the set of highly topped out measures from the CMS Web Interface published for the 2017 performance
measures identified as topped out for would not be appropriate because we period were not derived from MIPS
the 2017, 2018 and 2019 MIPS have aligned policies where possible, reported data; criteria to identify topped
performance periods, and if with the Shared Savings Program, such out measures did not include
subsequently finalized for removal will as using the Shared Savings Program consideration of important clinical
not be available on the list of measures benchmarks for the CMS Web Interface considerations including patient safety
for the 2020 MIPS performance period measures (81 FR 77285). In the CY 2017 and the ability to accurately measure
and future years. Quality Payment Program final rule, we and motivate high quality care; and
For all other measures, the timeline also finalized that MIPS eligible removal of measures may
would apply starting with the clinicians reporting via the CMS Web disproportionately impact one
benchmarks for the 2018 MIPS Interface must report all measures submission mechanism or clinicians
based on medical specialty, practice size the availability of other relevant EHR measures used by QCDRs are less
or regional variation. Several specialty measures prior to deciding likely to be topped out because QCDRs
commenters indicated that whether or not to remove the measure led by specialty societies have
identification of topped out measures is from the program. Through the Call for significant expertise in quality measure
challenging because measures are Measures process and annual approval development, measurement, and
voluntarily selected with limited of QCDR measures, we anticipate that implementation, and are uniquely
reporting on each measure, and thus MIPS eligible clinicians and groups will poised to develop and test meaningful
benchmarks may appear to be topped have measures that provide meaningful measures. The commenter indicated
out when in fact there is still the room measurement and are reflective of their that specialty registries can continue to
for improvement. A few commenters current scope of practice. We believe monitor vital topped out measures, even
cautioned against removing measures that through the annual Call for if the measures are removed from MIPS
because this may lead to back sliding Measures and QCDR self-nomination reporting. A few commenters noted that
due to a shift in resources from support processes additional quality measures many topped out process measures are
of current practices yielding high will be developed and implemented in important to monitor and to provide
performance to new practices to support the program, that will provide eligible feedback to clinicians because less than
a new measure. Several commenters clinicians and groups with a very high performance is concerning
indicated that the criteria for selection continuously growing selection of and should be flagged.
of topped out measures should be measures to choose from that will allow Response: We disagree that the
expanded to consider the clinical for meaningful measurement. We removal of topped out QCDR measures
importance of measures, and a few recognize that there are certain types of would reduce the ability of specialists to
commenters recommended the high value measures such as patient develop and strengthen new measures.
identification of measures that are safety and patient experience, but we Rather, we believe that QCDRs can
essential for high quality care such as disagree that such measures should be develop QCDR measures that would
patient safety, public health or patient designated as never to be removed from address areas in which there is a known
experience that should never be the list of available quality measures. performance gap and in which there is
removed from the list of measures. We thank the commenters for their need for improvement. We also disagree
Many commenters voiced concern over suggestion to remove topped out that the removal of QCDR measures
the potential number of measures that measures if there are adequate should occur through the notice-and-
may be topped out which they believed replacement measures added to the comment rulemaking process, as QCDR
would leave eligible clinicians, measures list, and we will take this into measures are not approved for use in the
particularly specialists with few consideration, while encouraging program through rulemaking. We refer
relevant measures to submit. Many measure stewards to submit measures to readers to section 1848(q)(2)(D)(vi) of
commenters recommended only us through the Call for Measures the Act, which expressly provides that
removing topped out measures if there process. We would like to note that this QCDR measures are not subject to the
are adequate replacement measures policy creates a standard timeline for us notice-and-comment rulemaking
added to the measures list. A few to consider which measures are topped requirements described in section
commenters indicated that topped out out and may need to be removed. Each 1848(q)(2)(D)(i) of the Act that apply to
measures could be incorporated into removal would need to be proposed and other MIPS measures, and that the
composite measures reflecting multiple, finalized through rulemaking, and we Secretary is only required to publish the
important aspects of care. A few would have the discretion to retain any list of QCDR measures on the CMS Web
commenters recommended that prior to particular measure that, after site. We appreciate the QCDRs expertise
the removal of a measure, CMS evaluate consideration of public comments and in given areas of specialty, but as
the topped out measure across other factors, may be determined to be previously indicated, we will utilize
submission mechanisms to determine if inappropriate for removal. benchmarks for all submission
the measure is harmonized across Comment: Several commenters did mechanisms to appropriately identify
submission mechanisms. not support the removal of topped out measures as topped out, and will
Response: The benchmarks for the measures from QCDR submissions consider performance in all submission
2017 performance period are derived because commenters believed this mechanisms before indicating that a
from the measures historical would reduce the ability of specialists to given measure is topped out. QCDR
performance data which helps us trend develop and strengthen new measures. measures should also be removed from
the measures anticipated performance A few commenters believed that not MIPS through a similar timeline when
in the future. Topped out measures are including QCDR measures in the topped QCDR measures meet the definition of
considered topped out if the measure out measure policy would ensure that a topped out measure. We understand
performance is so high and unvarying eligible clinicians, including anesthesia the importance of monitoring high
that meaningful differences and clinicians, have measures of merit performance among clinicians, but we
improvement in performance can no during the transition to full also believe that topped out QCDR
longer be seen. Retaining topped out implementation of MIPS. One measures may inadvertently penalize
measures could have a disproportionate commenter urged CMS not to remove clinicians who are considered high
impact on the scores for certain MIPS QCDR topped out measures but rather performers when they are compared to
eligible clinicians. We note that topped allow topped out measures as controls other high performer clinicians, as
out measures must be consecutively for new and developing measures by described in the CY 2017 Quality
identified for 3 years (in MIPS) as which true statistical validity and Payment Program final rule (81 FR
topped out before it is proposed for reliability can be assessed. One 77286). For example, a clinician who
removal in the 4th year through commenter voiced concern over performs at the 90th percentile, when
rulemaking and comment period. As a potential removal of QCDR topped out compared to another high performing
part of the topped out measure timeline, measures without going through the clinician who scored in the 98th
we will take into consideration other notice-and-comment rulemaking percentile, could potentially receive a
factors such as clinical relevance and process. One commenter indicated that lower score based on the cohort in
which they are compared. QCDR scored for 2 years after the measure is variances in the benchmarks, and
measures, their performance data, and identified as topped out. The provide sufficient timing to request
clinical relevance are reviewed commenters indicated this will support public comment on the proposed
extensively as QCDRs self-nominate and MIPS eligible clinicians in incorporating removal of topped out measures. There
submit their QCDR measures for appropriate measures into EHR systems are a variety of quality and QCDR
consideration on an annual basis. We and updating clinical practice. Several measures to choose from in the MIPS
agree that specialty registries can commenters recommended a delay in program, and we encourage MIPS
continue to monitor their data the start of the lifecycle to allow individual eligible clinicians and groups
submission of topped out measures for benchmarks to be developed from MIPS to select measures that provide
purposes of monitoring performance data and a more representative sample, meaningful measurement for them.
and improvement, even after the while giving time for MIPS eligible Final Action: After consideration of
measures are removed from MIPS. clinicians to experience the program. the public comments received and since
Additional data provided by QCDRs or One commenter requested a delay in the topped out measures may provide little
discussions about their QCDR measures initiation of the lifecycle for measures room for improvement for the majority
is taken into consideration during the without a benchmark to allow of MIPS eligible clinicians, and a
review process. additional submissions in future years disproportionate impact on the scores
Comment: A few commenters which may lead to the development of for certain MIPS eligible clinicians, we
encouraged CMS to have a transparent benchmarks. are finalizing our proposed 4-year
process using multiple communication Response: We note that the topped timeline to identify topped out
processes to indicate which measures out measure lifecycle has built in a 4- measures, after which we may propose
are topped out and which measures will year timeline, which would be triggered to remove the measures through future
have the scoring cap to ensure MIPS when topped out measures are rule making topped out measures. After
eligible clinicians have the necessary identified through the benchmarks as a measure has been identified as topped
time to alter their reporting under the topped out. We believe the 4-year out for 3 consecutive years, we may
quality performance category before timeline would provide MIPS eligible propose to remove the measure through
topped-out measures are finalized for clinicians, groups, and third-party notice and comment rulemaking for the
removal. Some commenters intermediaries with a sufficient amount 4th year. Therefore, in the 4th year, if
recommended that CMS provide of time to adjust to the removal of finalized through rulemaking, the
detailed information on the measures identified topped out measures. Topped measure would be removed and would
considered to be topped-out, including out measures are identified through the
no longer be available for reporting
the number and type of clinicians or benchmarks, and cannot be identified as
during the performance period. This
groups reporting the measure each year, topped out until the benchmark is
policy provides a path toward removing
the number and type of clinicians or established. We would like to note that
topped out MIPS quality measures over
groups consistently reporting the this policy creates a standard timeline
time. QCDR measures that consistently
measure, the range of performance for us to consider which measures are
are identified as topped out according to
scores and any statistical testing topped out and may need to be
the same timeline would not be
information. Other commenters removed. Each removal would need to
approved for use in year 4 during the
suggested that CMS announce the status be proposed and finalized through
QCDR self-nomination review process.
of a topped out measure in a draft rulemaking, and we would have the
proposed rule with at least a 45-day discretion to retain any particular Removal of these QCDR measures
comment period. One commenter urged measure that, after consideration of would not go through the comment and
CMS to announce topped out measures public comments and other factors may rulemaking process as MIPS quality
at a consistent time each year. be determined to be inappropriate for measures would.
Response: We intend to indicate removal. We believe that the 4-year (3) Non-Outcome Measures
which measures are topped out through timeline will provide MIPS eligible
the benchmarks that will be published clinicians with sufficient time to In the CY 2017 Quality Payment
on the Quality Payment Program Web incorporate measures into their EHR Program final rule, we sought comment
site annually, as feasible prior to the systems and to update their clinical on whether we should remove non-
beginning of each performance period. practice. outcomes measures for which
We intend to consider, and as Comment: A few commenters did not performance cannot reliably be scored
appropriate, propose removal of topped support the proposed topped out against a benchmark (for example,
out measures in future notice-and- measure removal timeline, noting that measures that do not have 20 reporters
comment rulemaking in accordance the proposal would delay the retirement with 20 cases that meet the data
with the proposed timeline. We thank of topped out measures and selection completeness standard) for 3 years in a
commenters for their suggestions as to and use of different quality measures. row (81 FR 77288).
what information should be available on One commenter believed that allowing Based on the need for CMS to further
measures considered topped out and performance to be supported by the assess this issue, we did not propose to
will provide additional data elements, selection of topped out measures will remove non-outcome measures.
as technically feasible and appropriate. not provide sufficient incentive for However, we sought comment on what
Comment: A few commenters did not eligible clinicians to select the more the best timeline for removing both non-
support the proposed lifecycle and challenging and difficult measures outcome and outcome measures that
made suggestions regarding the delay of available. cannot be reliably scored against a
the initiation of the lifecycle or Response: We believe that the topped benchmark for 3 years (82 FR 30047).
extension to the timeline, to allow more out measure timeline reflects a We received a number of comments on
time to adjust and continue to sufficient amount of time in which we this item and appreciate the input
demonstrate improvement over time are able to clearly distinguish topped received. As this was a request for
within MIPS. A few commenters out measures through their performance comment only, we will take the
recommended lengthening the lifecycle in the benchmarks. The timing will feedback provided into consideration
by 1 year, allowing the measure to be allow us to take into consideration any for future rulemaking.
(4) Quality Measures Determined To Be performance category to ensure the percent of the MIPS final score
Outcome Measures reliability threshold is met. beginning in the 2021 MIPS payment
Under the MIPS, individual MIPS For the transition year, we finalized a year. We recognized that assigning a
eligible clinicians are generally required policy to weight the cost performance zero percent weight to the cost
to submit at least one outcome measure, category at zero percent of the final performance category for the 2020 MIPS
or, if no outcome measure is available, score in order to give clinicians more payment year may not provide a smooth
one high priority measure. As such, our opportunity to understand the enough transition for integrating cost
determinations as to whether a measure attribution and scoring methodologies measures into MIPS and may not
is an outcome measure is of importance and gain more familiarity with the provide enough encouragement to
to stakeholders. We did not make any measures through performance feedback clinicians to review their performance
proposals on how quality measures are so that clinicians may take action to on cost measures. Therefore, we sought
determined to be outcome measures, improve their performance (81 FR 77165 comment on keeping the weight of the
and refer readers to the CY 2018 Quality through 77166). In the CY 2017 Quality cost performance category at 10 percent
Payment Program proposed rule (82 FR Payment Program final rule, we for the 2020 MIPS payment year (82 FR
30047) for the criteria utilized in finalized a cost performance category 30048).
determining if a measure is considered weight of 10 percent for the 2020 MIPS We invited public comments on this
an outcome measure. We sought payment year (81 FR 77165). For the proposal of a zero percent weighting for
comment on the criteria and process 2021 MIPS payment year and beyond, the cost performance category and the
outlined in the proposed rule on how the cost performance category will have alternative option of a 10 percent
we designate outcome measures (82 FR a weight of 30 percent of the final score weighting for the cost performance
30047). We received a number of as required by section category for the 2020 MIPS payment
comments on this item and appreciate 1848(q)(5)(E)(i)(II)(aa) of the Act. year (82 FR 30048).
For descriptions of the statutory basis The following is a summary of the
the input received. As this was a request
and our existing policies for the cost public comments received on these
for comment only, we will take the
performance category, we refer readers proposals and our responses:
feedback provided into consideration Comment: Many commenters
to the CY 2017 Quality Payment
for future rulemaking. supported our alternative option to keep
d. Cost Performance Category 77177). the weight of the cost performance
(1) Background As finalized at 414.1370(g)(2), the category at 10 percent for the 2020 MIPS
cost performance category is weighted at payment year, as we previously
(a) General Overview zero percent for MIPS eligible clinicians finalized in the CY 2017 Quality
Measuring cost is an integral part of scored under the MIPS APM scoring Payment Program final rule. The
measuring value as part of MIPS. In standard because many MIPS APMs commenters expressed concern that the
implementing the cost performance incorporate cost measurement in other statutorily mandated 30 percent weight
category for the transition year (2017 ways. For more on the APM scoring of the cost performance category in the
MIPS performance period/2019 MIPS standard, see II.C.6.g. of this final rule 2021 MIPS payment year would be too
payment year), we started with with comment period. steep an increase from zero percent, and
measures that had been used in MIPS eligible clinicians would be
(2) Weighting in the Final Score unprepared. Some commenters
previous programs (mainly the VM) but
noted our intent to move towards We proposed at 414.1350(b)(2) to indicated that they believed that cost
episode-based measurement as soon as change the weight of the cost measures are intrinsic measures of value
possible, consistent with the statute and performance category from 10 percent to and that clinicians can demonstrate
the feedback from the clinician zero percent for the 2020 MIPS payment value through lower costs. One
community. Specifically, we adopted 2 year. We noted that we continue to have commenter recommended that the cost
measures that had been used in the VM: concerns about the level of familiarity performance category be weighted at 15
The total per capita costs for all with and understanding of cost percent for the 2020 MIPS payment
attributed beneficiaries measure measures among clinicians. We noted year.
(referred to as the total per capita cost that we could use the additional year Response: We share the commenters
measure); and the MSPB measure (81 FR where the cost performance category concerns about the increase in the
77166 through 77168). We also adopted would not affect the final score to weight of the cost performance category
10 episode-based measures that had increase understanding of the measures from zero percent in the 2020 MIPS
previously been included in the so that clinicians would be more payment year to 30 percent in the 2021
Supplemental Quality and Resource Use comfortable with their role in reducing MIPS payment year, which is statutorily
Reports (sQRURs) (81 FR 77171 through costs for their patients. In addition, we required. We agree with the commenters
77174). could use this additional year to that cost measures are an important
At 414.1325(e), we finalized that all develop and refine episode-based cost component of value, and that weighting
measures used under the cost measures, which are cost measures that the cost category at 10 percent will help
performance category would be derived are focused on clinical conditions or to provide a smoother transition for
from Medicare administrative claims procedures. We intend to propose in clinicians by giving them more time to
data and, thus, participation would not future rulemaking policies to adopt experience cost measurement with the
require additional data submission. We episode-based measures currently in cost category having a lower relative
finalized a reliability threshold of 0.4 for development. weight of 10 percent. Furthermore,

measures in the cost performance Although we believed that reducing moving forward with a lower relative
category (81 FR 77170). We also this weight could be appropriate given weight in anticipation of the
finalized a case minimum of 35 for the the level of understanding of the requirement to go to 30 percent in the
MSPB measure (81 FR 77171) and 20 for measures and the scoring standards, we 2021 MIPS payment year will allow
the total per capita cost measure (81 FR noted that section 1848(q)(5)(E)(i)(II)(aa) more time for the development of
77170) and each of the 10 episode-based of the Act requires the cost performance episode-based cost measures, which are
measures (81 FR 77175) in the cost category to be assigned a weight of 30 being developed with substantial
clinician input. We are therefore 30 percent of the final score beginning feedback, including on cost measures.
adopting our alternative option to in the third MIPS payment year. We do As noted there, we will also be
maintain the 10 percent weight for the not believe the statute affords us providing information on newly
cost performance category for the 2020 flexibility to adjust this prescribed developed episode-based measures
MIPS payment year, as we finalized in weight, unless we determine there are which may become a part of the MIPS
the CY 2017 Quality Payment Program not sufficient cost measures applicable cost performance category in future
final rule (81 FR 77165). and available to MIPS eligible clinicians years.
Comment: Many commenters under section 1848(q)(5)(F) of the Act. Comment: A few commenters
supported our proposal to weight the We believe that a clinicians influence recommended that the cost performance
cost performance category at zero on the costs borne by both patients and category be weighted at zero percent for
percent of the final score for the 2020 the Medicare program is an important certain specialties or types of clinicians
MIPS payment year. The commenters component of measuring value as for an indefinite period of time because
stated that MIPS eligible clinicians are envisioned by the creation of the MIPS not enough measures are available for
still gaining familiarity with the scoring program. In addition, because of our them. One commenter suggested that if
methodology and the cost measures and concerns about the dramatic transition at least one episode-based measure
would appreciate additional time to between the cost performance category cannot be calculated for a clinician or
review feedback reports. Some being weighed at zero percent for a year group that they not be scored in the cost
commenters supported the proposal and 30 percent for the next year, we are performance category.
because episode-based measures were adopting our alternative to maintain the Response: We recognize that not every
not yet included and therefore many 10 percent weight for the cost clinician will have cost measures
clinicians would not be measured in the performance category for the 2020 MIPS attributed to them in the initial years of
cost performance category. Some payment year. We continue to work MIPS and therefore may not receive a
commenters suggested that CMS use the with clinicians to better understand the cost performance category score.
additional time to continue to improve cost measures as they prepare for the However, we do not believe that it is
risk adjustment, attribution, and other category to be weighted at 30 percent of appropriate to exclude certain clinicians
components of cost measures. the final score. We are seeking extensive from cost measurement on the basis of
Response: We will continue to work input from clinicians on the their specialty if they are attributed a
to make clinicians more familiar with development of episode-based measures sufficient number of cases to meet the
the measures and continue to refine the and technical updates to existing case minimum for the cost measure. We
measures. However, we are concerned measures in addition to providing did not propose any episode-based
that not assigning any weight to the cost feedback reports so that clinicians can measures for the 2018 MIPS
performance category when the weight better understand the measures. performance period. We address MIPS
is required to be at 30 percent in the Comment: Several commenters cost performance category scoring
third MIPS payment year will result in recommended that the cost performance policies in section II.C.7.a.(3) of this
too dramatic a transition in a single category be weighted at 10 percent in final rule with comment period, but we
year. We also agree with commenters the 2020 MIPS payment year only for did not propose any changes related to
that new episode-based cost measures those clinicians who volunteer to be the minimum number of measures
will be an important part of the cost measured on cost. Other commenters required to receive a cost performance
category, and intend to make future expressed their support for a zero category score. A MIPS eligible clinician
proposals about implementing episode- percent weighting but requested that must be attributed a sufficient number
based measures as soon as they are clinicians be given information on how of cases for at least one cost measure,
developed. they would have scored under cost and that cost measure must have a
Comment: Several commenters stated measurement. benchmark, in order for the clinician to
that although the statute requires the Response: We do not have the receive a cost performance category
cost performance category to be statutory authority to score cost score (81 FR 77322 through 77323).
weighted at 30 percent of the final score measures on a voluntary basis under Comment: One commenter
in the third MIPS payment year, we MIPS. Because the MIPS cost measures recommended that small practices
should use flexibility in the statute to are calculated based on Medicare claims (defined as 15 or fewer clinicians) not
weight the cost performance category at data and do not require additional have the cost performance category
zero percent or a percentage lower than reporting by clinicians, we are able to contribute to the weight of their final
30 percent for the third MIPS payment provide outreach and model scoring score, at least until more valid and
year and for additional years in the scenarios without clinicians reliable measures are developed.
future either by determining that there volunteering to complete any actions. Response: While we have a strong
are no applicable measures in the cost We are planning to provide feedback on commitment to ensuring that small
performance category or using broader both individual measures as well as the practices are able to participate in MIPS,
flexibility to reweight the performance cost performance category to increase we do not have the statutory authority
categories. These commenters supported understanding and familiarity going into to exempt small practices from the cost
the zero percent weight for the 2020 future years. performance category. We have offered
MIPS payment year but believed that Comment: Many commenters additional flexibility for small practices
the cost performance category should requested that CMS provide extensive in a number of areas, including a small
not count towards the final score until feedback on cost measures and the cost practice bonus that will be added to the
clinicians have gained more experience performance category score to ensure final score for the 2020 MIPS payment
with this category, episode-based that clinicians are best positioned for year (see section II.C.7.b.(1)(c) of this
measures are more developed, and risk the cost performance category to be final rule with comment period). Many
adjustment models are more robust. weighted at 30 percent of the final score of these policies are intended to
Response: While we understand the for the 2021 MIPS payment year. recognize the different level of
concerns of commenters, section Response: We discuss in section administrative or other support a small
1848(q)(5)(E) of the Act requires the cost II.C.9.a of this final rule with comment practice might have in comparison to a
performance category to be weighted at period our plans to provide performance larger entity. Because the MIPS cost
measures do not require reporting of that clinicians can influence the cost of with the total per capita cost measure
data by clinicians other than the usual services that they do not personally because the measure has been used in
submission of claims, there is no perform by improving care management the VM since the 2015 payment
additional administrative burden with other clinicians and avoiding adjustment period and performance
associated with being a small practice in unnecessary services. feedback has been provided through the
the cost performance category. Final Action: After consideration of annual QRUR since 2013 for a subset of
Furthermore, it is possible that some the public comments, we are not groups that had 20 or more eligible
small practices will not have any cost finalizing our proposal to weight the professionals) and to all groups in the
measures applicable and available to cost performance category at zero annual QRUR since 2014 and mid-year
them because they may not meet the percent of the final score for the 2020 QRUR since 2015. We proposed to use
case minimums for any of the cost MIPS payment year. We are instead the MSPB measure because many MIPS
measures. Other small practices may adopting our alternative option to eligible clinicians will be familiar with
have a considerable volume of patients maintain the weight of the cost the measure from the VM, where it has
and wish to be rewarded for their performance category at 10 percent of been included since the 2016 payment
commitment to reducing the cost of the final score for the 2020 MIPS adjustment period and in annual QRUR
care. payment year as we finalized in the CY since 2014 and the mid-year QRUR
Comment: A few commenters 2017 Quality Payment Program final since 2015, or its hospital-specified
recommended that the cost performance rule (81 FR 77165). version, which has been a part of the
category be weighted at a percentage Hospital VBP Program since 2015. In
higher than zero percent but lower than (3) Cost Criteria addition to familiarity, these two
10 percent so that the cost performance (a) Measures Proposed for the MIPS Cost measures cover a large number of
category would have a limited Performance Category patients and provide an important
contribution to the final score. (i) Background measurement of clinician contribution
Response: We are adopting our to the overall population that a clinician
alternative of maintaining the cost Under 414.1350(a), we specify cost encounters.
performance category weight at 10 measures for a performance period to We did not propose any changes to
percent of the final score for the 2020 assess the performance of MIPS eligible the methodologies for payment
MIPS payment year. We are doing so clinicians on the cost performance standardization, risk adjustment, and
because we are concerned about the category. For the 2017 MIPS specialty adjustment for these measures
dramatic transition between a zero performance period, we will utilize 12 and refer readers to the CY 2017 Quality
percent weight and the 30 percent cost measures that are derived from Payment Program final rule (81 FR
weight mandated for the 2021 MIPS Medicare administrative claims data. 77164 through 77171) for more
payment year. We did receive many Two of these measures, the MSPB information about these methodologies.
comments in favor of the 10 percent measure and total per capita cost We noted that we will continue to
weight and do not believe that a weight measure, have been used in the VM (81 evaluate cost measures that are included
below 10 percent will provide an easier FR 77166 through 77168), and the in MIPS on a regular basis and
transition to the 30 percent weight for remaining 10 are episode-based anticipate that measures could be added
the 2021 MIPS payment year. measures that were included in the or removed, subject to rulemaking under
Comment: Some commenters sQRURs in 2014 and 2015 (81 FR 77171 applicable law, as measure development
expressed general concern about our through 77174). continues. We will also maintain the
approach to measuring the cost Section 1848(r) of the Act specifies a measures that are used in the cost
performance category. Some suggested series of steps and activities for the performance category by updating
that cost measures should not be Secretary to undertake to involve the specifications, risk adjustment, and
included if there are not quality physician, practitioner, and other attribution as appropriate. We anticipate
measures for the same group of patients. stakeholder communities in enhancing including a list of cost measures for a
A few commenters suggested that cost the infrastructure for cost measurement, given performance period in annual
measures should only consider services including for purposes of MIPS, which rulemaking.
that were personally provided or we summarized in detail in the CY 2018 The following is a summary of the
ordered by a clinician. Quality Payment Program proposed rule public comments received on these
Response: We have designed the (82 FR 30048). proposals and our responses:
Quality Payment Program to be flexible Comment: Many commenters opposed
and allow clinicians to select quality (ii) Total Per Capita Cost and MSPB the inclusion of the total per capita cost
measures that reflect their practice. We Measures measure and the MSPB measure as cost
expect that most clinicians and groups For the 2018 MIPS performance measures for the 2018 MIPS
will select measures based on the types period and future performance periods, performance period and future
of patients they typically see. Because we proposed to include in the cost performance periods. Commenters
the measures for the cost performance performance category the total per expressed concern that these measures
category are calculated based on capita cost measure and the MSPB did not differentiate between services or
Medicare claims submitted, we believe measure as finalized for the 2017 MIPS circumstances that clinicians could
they will also reflect a clinicians performance period (82 FR 30048 control from those that they could not.
practice. While we are finalizing cost through 30049). We referred readers to The commenters stated that the MSPB
measures that do not directly the description of these measures in the measure had been developed for the
correspond to quality measures, we note CY 2017 Quality Payment Program final hospital setting and had not been
that each performance category is rule (81 FR 77164 through 77171). We endorsed for use for clinician
weighted and combined to determine proposed to include the total per capita accountability by the NQF. The
the final score. In that sense, we believe cost measure because it is a global commenters stated that the total per
that we are measuring value by measure of all Medicare Part A and Part capita cost measure had not been
rewarding performance in quality while B costs during the performance period. endorsed by the NQF. Some
keeping down costs. We also believe MIPS eligible clinicians are familiar commenters recommended that these
measures be eliminated when episode- applicable, to account for the cost of A draft list of care episodes and
based measures are made part of the drugs under Medicare Part D as part of patient condition groups that could
program because episode-based cost measurement under MIPS, and we become episode-based measures used in
measures are more focused on certain will continue to explore the addition of the Quality Payment Program, along
conditions. this data in cost measures. with trigger codes that would indicate
Response: Both the total per capita Final Action: After consideration of the beginning of the episode, was posted
cost and MSPB measures were included the public comments, we are finalizing for comment in December 2016 (https://
in the QRURs and used in the VM for our proposal to include the total per www.cms.gov/Medicare/Quality-
many years before the implementation capita cost and MSPB measures in the Initiatives-Patient-Assessment-
of MIPS. These two measures cover a cost performance category for the 2018 Instruments/Value-Based-Programs/
large number of patients and provide an MIPS performance period and future MACRA-MIPS-and-APMs/Episode-
important measurement of clinician performance periods. Based-Cost-Measure-Development-for-
contribution to the overall population the-Quality-Payment-Program.pdf). This
(iii) Episode-Based Measures
that a clinician encounters. Like all of material was informed by engagement
the cost measures that we have Episode-based measures differ from with clinicians from over 50 clinician
developed, we continue to refine these the total per capita cost measure and specialty societies through a Clinical
measures for improvement. If we find MSPB measure because their Committee formed to participate in cost
that episode-based measures would be specifications only include services that measure development. Subsequently,
an appropriate replacement for both of are related to the episode of care for a Clinical Subcomittees have been formed
these measures, we would address that clinical condition or procedure (as to provide input from a diverse array of
issue in future rulemaking. At this time, defined by procedure and diagnosis clinicians on identifying conditions and
we believe that the total per capita and codes), as opposed to including all procedures for episode groups. For the
MSPB measures are tested and reliable services that are provided to a patient first set of episode-based cost measures
for Medicare populations and are over a given period of time. For the 2018 being developed, the Clinical
therefore the best measures available for MIPS performance period, we did not Subcommittees have nearly 150
the cost performance category. We are propose to include in the cost clinicians affiliated with nearly 100
concurrently developing new episode- performance category the 10 episode- national specialty societies,
based cost measures with substantial based measures that we adopted for the recommending which services or claims
clinician input, that we will consider for 2017 MIPS performance period in the would be counted in episode costs. This
proposals in future rulemaking. CY 2017 Quality Payment Program final will ensure that cost measures in
Comment: Several commenters rule (81 FR 77171 through 77174). We development are directly informed by a
supported our proposal to include the instead will work to develop new substantial number of clinicians and
total per capita cost measure and MSPB episode-based measures, with members of specialty societies.
measure as cost measures for the 2018 significant clinician input, for future In addition, a technical expert panel
MIPS performance period. These performance periods. has met to provide oversight and
commenters stated that these measures We received extensive comments on guidance for our development of
had been used in the legacy VM and our proposal to include 41 of these episode-based cost measures. The
would be applicable to many clinicians. episode-based measures for the 2017 technical expert panel has offered
Response: We appreciate the MIPS performance period, which we recommendations for defining an
commenters for their support. responded to in the CY 2017 Quality episode group, assigning costs to the
Comment: A few commenters Payment Program final rule (81 FR group, attributing episode groups to
recommended that Part B drugs be 77171 through 77174). We also received clinicians, risk adjusting episodes, and
excluded from the cost measures additional comments after publication aligning cost and quality. This expert
because Part D drugs are excluded. They of that final rule with comment period feedback has been built into the current
suggested that including Part B drugs is about the decision to include 10 cost measure development process.
unfair because it would penalize episode-based measures for the 2017 As this process continues, we are
clinicians for prescribing or providing MIPS performance period. Although continuing to seek input from
appropriate care. comments were generally in favor of the clinicians. We believe that episode-
Response: We believe that clinicians inclusion of episode-based measures in based measures will benefit from this
play a key role in prescribing drugs for the future, there was also overwhelming comprehensive approach to
their patients and that the costs stakeholder interest in more clinician development. In addition, because it is
associated with drugs can be a involvement in the development of possible that the new episode-based
significant contributor to the overall these episode-based measures as measures under development could
cost of caring for a patient. We do not required by section 1848(r)(2) of the Act. address similar conditions as those in
believe it would be appropriate to Although there was an opportunity for the episode-based measures finalized for
remove the cost of Medicare Part B clinician involvement in the the 2017 MIPS performance period, we
drugs from the cost measures, when development of some of the episode- believe that it would be better to focus
other services that are ordered but not based measures included for the 2017 attention on the new episode-based
performed by clinicians, such as MIPS performance period, it was not as measures, so that clinicians would not
laboratory tests or diagnostic imaging, extensive as the process we are receive feedback or scores from two
are included. Clinicians play a similar currently using to develop episode- measures for the same patient condition
role in prescribing Part D drugs, and based measures. We believe that the or procedure. We will endeavor to have
Part D drugs can also be a significant new episode-based measures, which we as many episode-based measures
contributor to the overall cost of care. intend to propose in future rulemaking available as possible for the 2019 MIPS
However, there are technical challenges to include in the cost performance performance period but will continue to
that would need to be addressed to category for the 2019 MIPS performance develop measures for potential
integrate Part D drug costs. Section period, will be substantially improved consideration in the more distant future.
1848(q)(2)(B)(ii) of the Act requires by more extensive stakeholder feedback Although we did not propose to
CMS, to the extent feasible and and involvement in the process. include any episode-based measures in
calculating the cost performance be used for determining the cost and we would discuss the assessment
category score for the 2020 MIPS performance category score for the 2019 and testing of the measures at the time
payment year, we noted that we do plan MIPS payment year in conjunction with of their proposal. Although CMS is
to continue to provide confidential the MSPB measure and the total per conducting a rigorous process to ensure
performance feedback to clinicians on capita cost measure, although the cost that any new measure is rigorously
their performance on episode-based performance category score will be reviewed before implementation, we
measures developed under the weighted at zero percent in that year. believe it is in the interest of MIPS
processes required by section 1848(r)(2) The following is a summary of the participants, particularly certain
of the Act as appropriate in order to public comments received and our specialists, to have access to new
increase familiarity with the concept of responses: episode based measures. We will
episode-based measurement as well as Comment: Many commenters consider the opportunity to submit
the specific episodes that could be supported our decision not to propose measures that have been or may be
included in determining the cost for the 2018 MIPS performance period adopted for the cost performance
performance category score in the the 10 episode-based measures that will category for NQF endorsement and to
future. We recently provided an initial be used for the 2017 MIPS performance the MAP review process in the future.
opportunity for clinicians to review period. These commenters stated that Comment: A few commenters
their performance based on the new they supported the focus on the recommended specific clinical topics
episode-based measures, as the development of new episode-based for episode-based measures, including
measures are developed and as the measures that are currently being oncology care, chronic care, care of the
information is available. We note that developed under section 1848(r)(2) of frail elderly, and rare disease. One
this feedback will be specific to the new the Act and agreed that there would be commenter recommended that CMS
episode-based measures that are confusion if multiple versions of consider a measure that focuses on
developed under the process described episode-based measures existed. adherence to clinical pathways, rather
above and may be presented in a Response: We appreciate the than using costs of care, because clinical
commenters for their support. pathways would differentiate care that
different format than MIPS eligible
Comment: Many commenters is appropriate from care that is not.
clinicians performance feedback as
expressed support for episode-based Response: We appreciate the
described in section II.C.9.a. of this final measurement but concern about our
rule with comment period. However, suggestions for future development of
stated plan to introduce new episode- episode-based measures and other
our intention is to align the feedback as based measures to be used in the cost
much as possible to ensure clinicians measures. We will continue to endeavor
performance category beginning in next to develop measures that capture the
receive opportunities to review their years proposed rule. Many commenters cost of care for as many different types
performance on potential new episode- expressed support for the process that of patients and clinicians as possible.
based measures for the cost performance had prioritized clinician involvement We would also review potential
category prior to the 2019 MIPS but were concerned that the measures different methodologies as appropriate.
performance period. We are concerned would not be able to be tested or Comment: Several commenters
that continuing to provide feedback on understood by clinicians prior to their recommended that episode-based
the older episode-based measures along introduction in the MIPS program. measures be developed so that all drugs
with feedback on new episode-based Some commenters recommended that costs are considered in the same
measures will be confusing and a poor episode-based measures be made manner, rather than Medicare Part B
use of resources. Because we are available for feedback for at least a year drugs being included and Medicare Part
focusing on development of new before contributing to the cost D drugs being excluded. These
episode-based measures, our feedback performance category percent score. commenters suggested the clinical
on episode-based measures that were Some commenters recommended that interchangeability of these types of
previously developed will discontinue cost measures not be included unless drugs and expressed concern that they
after 2017, as these measures would no they were endorsed by the NQF or would be considered differently in
longer be maintained or reflect changes recommended by the MAP. determining cost measures.
in diagnostic and procedural coding. We Response: As part of our episode- Response: Section 1848(q)(2)(B)(ii) of
intend to provide feedback on newly based measure development, we are the Act requires CMS, to the extent
developed episode-based measures as completing an extensive outreach feasible and applicable, to account for
they become available in a new format initiative in the fall of 2017 to share the cost of drugs under Medicare Part D
around summer 2018. We noted that the performance information with many as part of cost measurement under
feedback provided in the summer of clinicians on the newly developed MIPS. As stated in the CY 2017 Quality
2018 will go to those MIPS eligible episode-based measures as part of field Payment Program final rule, we will
clinicians for whom we are able to testing, a part of measure development. continue to explore methods to add Part
calculate the episode-based measures, We believe these efforts go beyond the D drug costs into cost measures in the
which means it would be possible a typical testing associated with many future. We believe that Part D drugs are
clinician may not receive feedback on performance measures and should a significant contributor to costs for both
episode-based measures in both the fall reveal issues that were not clear during patients and the Medicare program and
of 2017 and the summer of 2018. We the development, which also included should be measured when technically
believe that receiving feedback on the many clinician experts. We did not feasible. Episode-based measures may
new episode-based measures will make any specific proposals related to include Part B drug costs if clinically
support clinicians in their readiness for the inclusion of episode-based measures appropriate as we believe these are an
the 2019 MIPS performance period. in future years, but this development important component of health
As previously finalized in the in the work is intended to develop measures spending.
CY 2017 Quality Payment Program final that could be used in the MIPS cost Comment: One commenter requested
rule (81 FR 77173), the 10 episode-based performance category. All measures that that CMS develop a process to allow
measures (which we did not propose for will be included in the program would stakeholders to develop their own cost
the 2018 MIPS performance period) will be included in a future proposed rule, measures, rather than only relying on
the CMS episode-based measure 2017, and may propose to include them applicable practitioner with a patient at
development. This commenter in MIPS as appropriate in future the time of furnishing an item or
suggested that this would allow for rulemaking. service. In the CY 2018 Physician Fee
more leadership from relevant Schedule proposed rule (82 FR 34129),
(iv) Attribution
specialties of medicine. we proposed to use certain HCPCS
Response: Although we continue to In the CY 2017 Quality Payment modifiers as the patient relationship
develop episode-based measures, we are Program final rule, we changed the list codes. Section 1848(r)(4) of the Act
open to considering other types of of primary care services that had been requires claims submitted for items and
measures for use in the cost used to determine attribution for the services furnished by a physician or
performance category. If an episode- total per capita cost measure by adding applicable practitioner on or after
based measure or cost measure were to transitional care management (CPT January 1, 2018, shall, as determined
be created by an external stakeholder, codes 99495 and 99496) codes and a appropriate by the Secretary, include
we may consider it for inclusion in the chronic care management code (CPT the applicable patient relationship code,
program along the same criteria that we code 99490) (81 FR 77169). In the CY in addition to other information. We
have used to develop and refine other 2017 Physician Fee Schedule final rule, proposed (82 FR 34129) that for at least
cost measures. we changed the payment status for two an initial period while clinicians gain
Comment: A few commenters existing CPT codes (CPT codes 99487 familiarity, reporting the HCPCS
opposed the decision to not propose the and 99489) that could be used to modifiers on claims would be voluntary,
inclusion of the 10 episode-based describe care management from B and the use and selection of the
measures as cost performance category (bundled) to A (active) meaning that the modifiers would not be a condition of
measures for the 2018 MIPS services would be paid under the payment. The statute requires us to
performance period and for future Physician Fee Schedule (81 FR 80349). include the cost performance category
performance periods. These commenters The services described by these codes in the MIPS program, and thus, we
suggested that clinicians would benefit are substantially similar to those cannot delay the use of cost measures in
from having these measures as part of described by the chronic care MIPS until after the patient relationship
their score even as new episode-based management code that we added to the codes have been implemented, as
measures are developed. list of primary care services beginning recommended by the commenters.
Response: Many of the 10 episode- with the 2017 performance period. We However, we may consider future
based measures that are included for the therefore proposed to add CPT codes changes to our attribution methods for
2019 MIPS payment year have similar 99487 and 99489, both describing cost measures based on the patient
topics to those in the new list of complex chronic care management, to relationship codes that will be reported
episode-based measures we are the list of primary care services used to on claims.
currently developing. We believe that attribute patients under the total per Comment: One commenter
continuing to use these measures would capita cost measure (82 FR 30050). recommended that services provided in
create confusion. Furthermore, we want We did not propose any changes to a nursing facility (POS 32) not be
to potentially include episode-based the attribution methods for the MSPB included for purposes of attribution
cost measures that have significant measure and referred readers to the CY under the total per capita cost measure.
clinician input, which is a cornerstone 2017 Quality Payment Program final One commenter recommended that
of the new episode-based cost measures rule (81 FR 77168 through 77169) for services provided in a skilled nursing
currently being developed. more information. home facility (POS 31) continue to be
Comment: A few commenters The following is a summary of the excluded for purposes of attribution
recommended that, in addition to public comments received on these under the total per capita cost measure.
episode-based measures, we include proposals and our responses: Response: Patients in a skilled
condition-specific total per capita cost Comment: Some commenters nursing home facility (SNF) (POS 31)
measures that were used in the VM. supported the proposal to add CPT require more frequent practitioner
Response: We are currently focusing codes 99487 and 99489 to the list of visitsoften from 1 to 3 times a week.
on the development of episode-based primary care services used to attribute In contrast, patients in nursing facilities
measures. We continue to believe that patients under the total per capita cost (NFs) (POS 32) are almost always
the total per capita cost measure we measure, noting the similarity of these permanent residents and generally
have adopted is inclusive of the four codes to other codes defined as primary receive their primary care services in
condition-specific total per capita cost care services for this purpose. the facility for the duration of their life.
measures that have been used under the Response: We appreciate the On the other hand, patients in an NF
VM (chronic obstructive pulmonary commenters for their support. (POS 32) are usually seen every 30 to 60
disease, congestive heart failure, Comment: Some commenters days unless medical necessity dictates
coronary artery disease, and diabetes expressed concern that cost measures otherwise. We believe this distinction is
mellitus). were being attributed to clinicians important enough to treat these sites of
Final Action: After consideration of before patient relationship codes were service differently in terms of
the public comments, for the 2018 MIPS being reported by clinicians. Some attribution for the total per capita cost
performance period, we will not include commenters recommended that cost measure. Services provided in POS 31
in the cost performance category the 10 measures not be used before the patient are not included in the definition of
episode-based measures that we relationship codes are implemented and primary care services used for the total
adopted for the 2017 performance studied. per capita cost measure, but services
period, and we do not anticipate Response: To facilitate the attribution provided in POS 32 are. We will
proposing to include these measures in of patients and episodes to one or more continue to evaluate attribution
future performance periods. We will clinicians, section 1848(r)(3) of the Act methods as part of measure
continue to work on development and requires the development of patient development and maintenance.
outreach for new episode-based relationship categories and codes that Comment: One commenter opposed
measures, such as those that are define and distinguish the relationship the addition of complex chronic care
undergoing field testing in October and responsibility of a physician or management codes because palliative
care physicians often bill for the policies, we did receive a number of include costs from all Medicare Part A
services, but serve in a consulting role comments on issues related to reliability and B services, regardless of the specific
as opposed to serving as a primary care which we will consider as part of future ICD10 codes that are used on claims,
clinician. rulemaking. We will continue to and do not assign patients based on
Response: We believe that the evaluate reliability as we develop new ICD10, we do not anticipate that any
attribution model that assigns patients measures and to ensure that our measures for the cost performance
on the basis of a plurality of services measures meet an appropriate standard. category would be affected by this ICD
would not assign patients for the 10 issue during the 2018 MIPS
purposes of the total per capita cost (b) Attribution for Individuals and
performance period. However, as we
measure on the basis of a single visit, Groups
continue our plans to expand cost
unless that patient had also not seen a We did not propose any changes for measures to incorporate episode-based
primary care clinician during the year. how we attribute cost measures to measures, ICD10 changes could
We believe these codes are consistent individual and group reporters. We refer become important. Episode-based
with other services typically provided readers to the CY 2017 Quality Payment measures may be opened (triggered) by
by primary care clinicians. Program final rule for more information and may assign services based on ICD
Comment: Many commenters (81 FR 77175 through 77176). Although 10 codes. Therefore, a change to ICD10
expressed general concerns about we did not propose any adjustments to coding could have a significant effect on
attribution methods, stating that they our attribution policies, we did receive an episode-based measure. Changes to
were not well understood, were not a number of comments on issues related ICD10 codes will be incorporated into
properly tested, and were unfair. These to attribution which we will consider as the measure specifications on a regular
commenters encouraged CMS to part of future rulemaking. basis through the measure maintenance
improve or perfect attribution methods. process. Please refer to section
(c) Incorporation of Cost Measures With
Response: We will continue to work II.C.7.a.(1)(c) of this final rule with
SES or Risk Adjustment
to improve attribution methods as we comment period for a summary of the
develop the measures and methods that Both measures proposed for inclusion comments and our response on this
are part of the cost performance in the cost performance category for the issue.
category. We do not use a single 2018 MIPS performance period are risk
attribution methodinstead the adjusted at the measure level. Although (e) Application of Measures to Non-
attribution method is linked to a the risk adjustment of the 2 measures is Patient Facing MIPS Eligible Clinicians
measure and attempts to best identify not identical, in both cases it is used to We did not propose changes to the
the clinician who may have influenced recognize the higher risk associated policy we finalized in the CY 2017
the spending for a patient, whether it be with demographic factors (such as age) Quality Payment Program final rule (81
all spending in a year or a more narrow or certain clinical conditions. We FR 77176) that we will attribute cost
set of spending in a defined period. As recognize that the risks accounted for measures to non-patient facing MIPS
we continue our work to develop with this adjustment are not the only eligible clinicians who have sufficient
episode-based measures and refine the potential attributes that could lead to a case volume, in accordance with the
two cost measures included for the 2018 higher cost patient. Stakeholders have attribution methodology. Although we
MIPS performance period, we will work pointed to many other factors such as did not propose any adjustments to our
to explain the methodology for income level, race, and geography that attribution of cost measures to non-
attribution and how it works in relation they believe contribute to increased patient facing MIPS eligible clinicians
to the measure and the scoring costs. These issues and our plans for with sufficient case volume policies, we
methodology. attempting to address them are did receive a few comments which we
Final Action: After consideration of discussed in length in section will consider as part of future
the public comments, we are finalizing II.C.7.b.(1)(a) of this final rule with rulemaking.
our proposal to add CPT codes 99487 comment period. While we did not Section 1848(q)(2)(C)(iv) of the Act
and 99489 to the list of primary care propose any changes to address risk requires the Secretary to consider the
services used to attribute patients under adjustment for cost measures in this circumstances of professional types who
the total per capita cost measure. rule, we continue to believe that this is typically furnish services without
an important issue and it will be patient facing interaction (non-patient
(v) Reliability facing) when determining the
considered carefully in the development
In the CY 2017 Quality Payment of future cost measures and for the application of measures and activities.
Program final rule (81 FR 77169 through overall cost performance category. In addition, this section allows the
77170), we finalized a reliability Although we did not propose any Secretary to apply alternative measures
threshold of 0.4 for measures in the cost adjustments to our policies on or activities to non-patient facing MIPS
performance category. Reliability is an incorporating cost measures with SES or eligible clinicians that fulfill the goals of
important evaluation for cost measures risk adjustment, we did receive a a performance category. Section
to ensure that differences in number of comments which we will 1848(q)(5)(F) of the Act allows the
performance are not the result of consider as part of future rulemaking. Secretary to re-weight MIPS
random variation. In the proposed rule, performance categories if there are not
we provided a summary of the (d) Incorporation of Cost Measures With sufficient measures and activities
importance of reliability in ICD10 Impacts applicable and available to each type of
measurement and how high reliability In the CY 2018 Quality Payment MIPS eligible clinician involved.
must be balanced with other goals, such Program proposed rule (82 FR 30098), We believe that non-patient facing
as measuring where there is significant we discussed our proposal to assess clinicians are an integral part of the care
variation and ensuring that cost performance on any measures impacted team and that their services do
measurement is not limited to large by ICD10 updates based only on the contribute to the overall costs but at this
groups with large case volume (82 FR first 9 months of the 12-month time we believe it better to focus on the
30050). Although we did not propose performance period. Because the total development of a comprehensive system
any adjustments to our reliability per capita cost and MSPB measures of episode-based measures which focus
on the role of patient-facing clinicians. Section 1848(q)(2)(C)(iv) of the Act the improvement activities performance
Accordingly, for the 2018 MIPS generally requires the Secretary to give category would account for 15 percent
performance period, we did not propose consideration to the circumstances of of the final score. We also finalized at
alternative cost measures for non- non-patient facing individual MIPS 414.1380(b)(3)(iv) criteria for
patient facing MIPS eligible clinicians eligible clinicians or groups and allows recognition as a certified patient-
or groups. This means that non-patient the Secretary, to the extent feasible and centered medical home or comparable
facing MIPS eligible clinicians or groups appropriate, to apply alternative specialty practice. Since then, it has
are unlikely to be attributed any cost measures and activities to such come to our attention that the common
measures that are generally attributed to individual MIPS eligible clinicians and terminology utilized in the general
clinicians who have patient-facing groups. medical community for certified
encounters with patients. Therefore, we Section 1848(q)(2)(C)(v) of the Act patient-centered medical home is
anticipate that, similar to MIPS eligible required the Secretary to use a request recognized patient-centered medical
clinicians or groups that do not meet the for information (RFI) to solicit home.
required case minimums for any cost recommendations from stakeholders to Therefore, in order to provide clarity,
measures, many non-patient facing identify improvement activities and in the CY 2018 Quality Payment
MIPS eligible clinicians may not have specify criteria for such improvement Program proposed rule (82 FR 30052),
sufficient cost measures applicable and activities, and provides that the we proposed that the term recognized
available to them and would not be Secretary may contract with entities to be accepted as equivalent to the term
scored on the cost performance category assist in identifying activities, certified when referring to the
under MIPS. specifying criteria for the activities, and requirements for a patient-centered
determining whether individual MIPS medical home to receive full credit for
We will continue to explore methods the improvement activities performance
to incorporate non-patient facing eligible clinicians or groups meet the
criteria set. For a detailed discussion of category for MIPS. Specifically, we
clinicians into the cost performance proposed to revise 414.1380(b)(3)(iv)
category in the future. the feedback received from the MIPS
and APMs RFI, see the CY 2017 Quality to provide that a MIPS eligible clinician
(f) Facility-Based Measurement as It Payment Program 2017 final rule (81 FR or group in a practice that is certified or
Relates to the Cost Performance 77177). recognized as a patient-centered
Category In the CY 2017 Quality Payment medical home or comparable specialty
Program final rule (81 FR 77178), we practice, as determined by the Secretary,
In the CY 2018 Quality Payment defined improvement activities at receives full credit for performance on
Program proposed rule (82 FR 30123), 414.1305 as an activity that relevant the improvement activities performance
we discussed our proposal to implement MIPS eligible clinicians, organizations category. A practice is certified or
section 1848(q)(2)(C)(ii) of the Act by and other relevant stakeholders identify recognized as a patient-centered
assessing clinicians who meet certain as improving clinical practice or care medical home if it meets any of the
requirements and elect participation delivery and that the Secretary criteria specified under
based on the performance of their determines, when effectively executed, 414.1380(b)(3)(iv).
associated hospital in the Hospital VBP is likely to result in improved outcomes. We invited public comment on this
Program. We refer readers to section In the CY 2017 Quality Payment proposal.
II.C.7.a.(4) of this final rule with Comment: A few commenters
Program final rule (81 FR 77199), we
comment period for full details on the supported the proposed expansion of
solicited comments on activities that
final policies related to facility-based the patient-centered medical home
would advance the usage of health IT to
measurement, including the measures definition, to include both medical
support improvement activities for
and how the measures are scored, for homes that are certified and those
future consideration. Please refer to the
the cost performance category. that are recognized. These
CY 2018 Quality Payment Program
commenters noted that inclusion of both
e. Improvement Activity Criteria proposed rule (82 FR 30052) for a full
terms aligns with the terminology used
discussion of the public comments we
(1) Background by various organizations and states that
received in response to the CY 2017
have patient-centered medical home
Section 1848(q)(2)(C)(v)(III) of the Act Quality Payment Program final rule and
programs that may be eligible for full
defines an improvement activity as an our responses provided on activities
credit in the improvement activities
activity that relevant eligible clinician that would advance the usage of health
organizations and other relevant IT to support improvement activities. Response: We thank the commenters
stakeholders identify as improving In the CY 2018 Quality Payment for their support.
clinical practice or care delivery, and Program proposed rule (82 FR 30052), Comment: One commenter stated that
that the Secretary determines, when we sought comment on how we might in the CY 2017 Quality Payment
effectively executed, is likely to result in provide flexibility for MIPS eligible Program final rule, the documented
improved outcomes. Section clinicians to effectively demonstrate recognition as a patient-centered
1848(q)(2)(B)(iii) of the Act requires the improvement through health IT usage medical home from an accredited body
Secretary to specify improvement while also measuring such improvement combined with continual improvements
activities under subcategories for the for future consideration. We received was listed as already receiving credit in
performance period, which must many comments on this topic and will the improvement activity performance
include at least the subcategories take them into consideration for future category.
specified in section 1848(q)(2)(B)(iii)(I) rulemaking. Response: We believe the commenter
through (VI) of the Act, and in doing so (2) Contribution to the Final Score is referring to our discussion in the CY
to give consideration to the 2017 Quality Payment Program final
circumstances of small practices, and (i) Patient-Centered Medical Home rule (81 FR 77179 through 77180),
practices located in rural areas and In the CY 2017 Quality Payment where we finalized at 414.1380 an
geographic health professional shortage Program final rule (81 FR 77179 through expanded definition of what is
areas (HPSAs). 77180), we finalized at 414.1355 that acceptable for recognition as a certified-
patient centered medical home or December 31st of a given performance acceptable for recognition as a certified
comparable specialty practice. We year, since NCQA requires that practices patient-centered medical home or
recognized a MIPS eligible clinician or seeking patient-centered medical home comparable specialty practice that we
group as being a certified patient- and patient-centered specialty practice finalized in the CY 2017 Quality
centered medical home or comparable (PCSP) recognition perform the Payment Program final rule (81 FR
specialty practice if they have achieved appropriate activities for a minimum of 77180) and codified under
certification or accreditation as such 90 days. Further, these commenters 414.1380(b)(3)(iv). Without more
from a national program, or they have recommended that this policy should information, we cannot provide
achieved certification or accreditation as extend to any other approved patient- information as to whether the suggested
such from a regional or state program, centered medical home programs that entities fall within our previously
private payer or other body that certifies use a 90-day look-back period. established definition above.
at least 500 or more practices for Response: We acknowledge the Furthermore, while we are not
patient-centered medical home commenters suggestions that we considering any changes to this
accreditation or comparable specialty consider additional models as patient- definition and criteria for the CY 2018
practice certification. In the CY 2018 centered medical homes for full credit performance period, we may consider
Quality Payment Program proposed in this performance category. In the CY commenters suggestions as we craft
rule, we did not propose any 2017 Quality Payment Program final policy for future rulemaking. Moreover,
substantive changes to that definition. rule (81 FR 77180), we previously stated we would like to make clear that credit
However, for the sake of clarity we that we recognize a MIPS eligible is not automatically granted; MIPS
proposed that we will accept the clinician or group as being a certified eligible clinicians and groups must
designation of recognized as patient-centered medical home or attest in order to receive the credit (81
equivalent to the designation of comparable specialty practice if they FR 77181) which is codified at
certified when referring to the have achieved certification or 414.1360.
requirements for a patient-centered Final Action: After consideration of
accreditation as such from a national
medical home or comparable specialty the public comments received, we are
program, or they have achieved
practice to receive full credit for the finalizing, as proposed, our proposals:
certification or accreditation as such
improvement activities performance (1) That the term recognized be
from a regional or state program, private
category for MIPS and also to update accepted as equivalent to the term
payer or other body that certifies at least certified when referring to the
414.1380(b)(3)(iv) to reflect this. Our 500 or more practices for patient-
intention behind this proposal was to requirements for a patient-centered
centered medical home accreditation or medical home to receive full credit for
reflect common terminology utilized in comparable specialty practice
the general medical communitythat the improvement activities performance
certification. We went on to state that category for MIPS; and (2) to update
certified patient-centered medical examples of nationally recognized
home is equivalent to recognized 414.1380(b)(3)(iv) to reflect this
accredited patient-centered medical change.
patient-centered medical home. A homes are: (1) The Accreditation
practice is certified or recognized as a Association for Ambulatory Health Care; (ii) Weighting of Improvement Activities
patient-centered medical home if it (2) the National Committee for Quality As previously explained in the CY
meets any of the criteria specified under Assurance (NCQA) Patient-Centered 2017 Quality Payment Program final
414.1380(b)(3)(iv). Medical Home; (3) The Joint rule (81 FR 77194), we believe that high
Comment: Several commenters Commission Designation; or (4) the weighting should be used for activities
provided comments that were not Utilization Review Accreditation that directly address areas with the
related to our proposal to accept the Commission (URAC) (81 FR 77180). We greatest impact on beneficiary care,
designation of recognized as finalized that the criteria for being a safety, health, and well-being. In the CY
equivalent to the designation of nationally recognized accredited 2017 Quality Payment Program final
certified when referring to the patient-centered medical home are that rule (81 FR 77198), we requested
requirements for a patient-centered it must be national in scope and must commenters specific suggestions for
medical home or comparable specialty have evidence of being used by a large additional activities or activities that
practice to receive full credit for the number of medical organizations as the may merit additional points beyond the
improvement activities performance model for their patient-centered medical high level for future consideration.
category for MIPS. They are summarized home (81 FR 77180). We also stated that Comment: Several commenters urged
here. Some commenters recommended we will also provide full credit for the CMS to increase the overall number of
that CMS consider other models as improvement activities performance high-weighted activities in this
patient-centered medical homes for full category for a MIPS eligible clinician or performance category. Some
credit in this performance category. group that has received certification or commenters recommended additional
These commenters suggested that CMS accreditation as a patient-centered criteria for designating high-weighted
consider full credit to those MIPS medical home or comparable specialty activities, such as an improvement
eligible clinicians and groups practice from a national program or activitys impact on population health,
participating in models such as a Patient from a regional or state program, private medication adherence, and shared
Centered Medical Neighborhood payer, or other body that administers decision-making tools, and encouraged
(PCMN), participation in a Certified patient-centered medical home CMS to be more transparent in our
Community Behavioral Health Clinic accreditation and certifies 500 or more weighting decisions. Several
(CCBHC) or a Medicaid Section 2703 practices for patient-centered medical commenters recommended that CMS
Health Home, or Blue Distinction Total home accreditation or comparable weight registry-related activities as high,
Care. Other commenters suggested that specialty practice certification (81 FR and suggested that we award individual
CMS establish a policy to offer full auto- 77180). We note, however, that in the MIPS eligible clinicians and groups in
credit to any practice that achieves CY 2018 Quality Payment Program APMs full credit in this performance
National Committee for Quality proposed rule we did not propose any category. The commenters also offered
Assurance (NCQA) recognition by changes to the definition of what is many recommendations for changing
current medium-weighted activities to individual MIPS eligible clinicians or groups may only use one submission
high and offered many specific groups must select activities from the mechanism per performance category,
suggestions for new high-weighted Improvement Activities Inventory. In (81 FR 77275), in section II.C.6.a.(1) of
improvement activities. addition, we codified at 414.1360, that this final rule with comment period, we
Response: After review and for the transition year of MIPS, all are finalizing our proposal, with
consideration of comments in the CY individual MIPS eligible clinicians or modification, to revise 414.1325(d) for
2017 Quality Payment Program final groups, or third party intermediaries purposes of the 2021 MIPS payment
rule, while we did not propose changes such as health IT vendors, QCDRs and year and future years to allow
to our approach for weighting qualified registries that submit on behalf individual MIPS eligible clinicians and
improvement activities in the CY 2018 of an individual MIPS eligible clinician groups to submit measures and
Quality Payment Program proposed rule or group, must designate a yes activities, as applicable, via as many
(82 FR 30052), we will take the response for activities on the submission mechanisms as necessary to
additional criteria suggested by Improvement Activities Inventory. We meet the requirements of the quality,
commenters for designating high- also codified at 414.1360 that in the improvement activities, or advancing
weighted activities into consideration in case where an individual MIPS eligible care information performance
future rulemaking. We did however, clinician or group is using a health IT categories. We refer readers to section
propose new, high-weighted as well as vendor, QCDR, or qualified registry for II.C.6.a.(1) of this final rule with
new medium weighted activities, in their data submission, the individual comment period for discussion of this
Table F in the Appendix of the MIPS eligible clinician or group will proposal as finalized.
proposed rule. We refer readers to Table validate the improvement activities that We also included a designation
F in the Appendix of this final rule with were performed, and the health IT column in the Improvement Activities
comment period where we are finalizing vendor, QCDR, or qualified registry Inventory at Table H in the Appendix of
new activites, and Table G in the same would submit on their behalf. the CY 2017 Quality Payment Program
Appendix where we are finalizing We would like to maintain stability in final rule (81 FR 77817) that indicated
changes to existing improvement the Quality Payment Program and which activities qualified for the
activities. continue these policies into future advancing care information bonus
For MIPS eligible clinicians years. In the CY 2018 Quality Payment codified at 414.1380. In future updates
participating in MIPS APMs, in the CY proposed rule (82 FR 30053), we to the Improvement Activities
2017 Quality Payment Program final proposed to update 414.1360 for the Inventory, we intend to continue to
rule (81 FR 77185) we finalized a policy transition year of MIPS and future years, indicate which activities qualify for the
to reduce reporting burden through the to reflect that all individual MIPS advancing care information performance
APM scoring standard for this eligible clinicians or groups, or third category bonus.
performance category to recognize party intermediaries such as health IT We invited public comment on our
improvement activities work performed vendors, QCDRs and qualified registries proposals.
through participation in MIPS APMs. that submit on behalf of an individual Comment: A few commenters
This policy is codified at MIPS eligible clinician or group, must expressed support for our proposal that
414.1370(g)(3), and we refer readers to designate a yes response for activities for the transition year of MIPS and
the CY 2017 Quality Payment Program on the Improvement Activities future years, all individual MIPS
final rule for further details on reporting Inventory. We note that these are the eligible clinicians or groups, or third
and scoring this performance category same requirements as previously party intermediaries such as health IT
under the APM Scoring Standard (81 FR codified for the transition year; vendors, QCDRs, and qualified registries
77259 through 77260). In the CY 2018 requirements for the transition year that submit on behalf of an individual
Quality Payment Program proposed remain unchanged. We merely proposed MIPS eligible clinician or group, must
rule, we did not propose any changes to to extend the same policies for future designate a yes response for activities
these policies. years. on the Improvement Activities
We received many comments on this In addition, in the case where an Inventory, and that where an individual
topic and will take them into individual MIPS eligible clinician or MIPS eligible clinician or group is using
consideration for future rulemaking. group is using a health IT vendor, a health IT vendor, QCDR, or qualified
QCDR, or qualified registry for their data registry for their data submission, the
(3) Improvement Activities Data submission, we proposed that the MIPS MIPS eligible clinician or group must
Submission Criteria eligible clinician or group will certify all certify all improvement activities were
(a) Submission Mechanisms improvement activities were performed performed and the health IT vendor,
and the health IT vendor, QCDR, or QCDR, or qualified registry would
(i) Generally qualified registry would submit on their submit on their behalf.
In the CY 2017 Quality Payment behalf (82 FR 30053). In summary, we Response: We thank the commenters
Program final rule (81 FR 77180), we proposed to continue our previously for their support. We realize the way the
discussed that for the transition year of established policies for future years and proposal was worded may have caused
MIPS, we would allow for submission of to generally apply our group policies to some potential confusion. Therefore, we
data for the improvement activities virtual groups. Furthermore, we refer are clarifying here that our proposal
performance category using the readers to the CY 2018 Quality Payment merely extends the same requirements,
qualified registry, EHR, QCDR, CMS Program proposed rule at (82 FR 30029) as previously codified for the transition
Web Interface, and attestation data and section II.C.4.d. of this final rule, year, to future years; requirements for
submission mechanisms through where we are finalizing to generally the transition year remain unchanged.
attestation. Specifically, in the CY 2017 apply our group policies to virtual Comment: One commenter urged
Quality Payment Program final rule (81 groups. CMS to refer to registries more broadly,
FR 77180), we finalized a policy that While we previously codified at rather than using the term QCDR,
regardless of the data submission 414.1325(d) in the CY 2017 Quality noting that many qualified registries are
method, with the exception of MIPS Payment Program final rule that in use by clinicians, even though these
eligible clinicians in MIPS APMs, all individual MIPS eligible clinicians and may not have received official QCDR
status for one reason or another. all MIPS eligible clinicians reporting as (b) Submission Criteria
Another commenter requested that CMS a group would receive the same score (i) Background
consider allowing other third parties for the improvement activities
that may be collecting information that performance category if at least one In the CY 2017 Quality Payment
is indicative of completion of an Program final rule (81 FR 77185), we
clinician within the group is performing
improvement activity to submit data to finalized at 414.1380 to set the
the activity for a continuous 90 days in
CMS, suggesting that for example, an improvement activities submission
the performance period. We refer
organization that awards continuing criteria under MIPS, to achieve the
readers to section II.C.4.d. of this final highest potential score, at two high-
medical education (CME) credits that rule with comment period, where we
qualify as improvement activities could weighted improvement activities or four
are finalizing to generally apply our medium-weighted improvement
submit a list of MIPS eligible clinicians group policies to virtual groups. We did
who received qualifying CME credit activities, or some combination of high
not propose any changes to our group and medium-weighted improvement
directly to CMS.
Response: We note that the terms reporting policies in the proposed rule. activities. While the minimum reporting
qualified registry and QCDR are However, in the CY 2017 Quality period for one improvement activity is
defined terms for the purposes of MIPS, Payment Program proposed rule (82 FR 90 days, the maximum frequency with
as codified at 414.1400. We refer 30053), we requested comment for which an improvement activity may be
readers to section II.C.10. of this final future consideration on whether we reported would be once during the 12-
rule with comment period for a detailed should establish a minimum threshold month performance period (81 FR
discussion of third party intermediaries. (for example, 50 percent) of the 77185). In addition, we refer readers to
While we recognize that there are other clinicians (NPIs) that must complete an section II.C.4.d. of this final rule with
registries that are not considered MIPS improvement activity in order for the comment period, where we are
qualified registry or QCDRs, those entire group (TIN) to receive credit in finalizing to generally apply group
registries have the option to become a the improvement activities performance policies to virtual groups.
MIPS QCDR using the process finalized category in future years. In addition, we In the CY 2017 Quality Payment
in the CY 2017 Quality Payment requested comments for future Program final rule (81 FR 77185), we
Program final rule (81 FR 77365), or consideration on recommended established exceptions to the above for:
qualify as a MIPS registry using the minimum threshold percentages and Small practices; practices located in
process finalized at 81 FR 77383 in that whether we should establish different rural areas; practices located in
same final rule. If an organization geographic HPSAs; non-patient facing
thresholds based on the size of the
becomes a MIPS qualified registry or individual MIPS eligible clinicians or
group. In the proposed rule, (82 FR
QCDR then they could submit MIPS groups; and individual MIPS eligible
30053), we noted that we are concerned clinicians and groups that participate in
data to us. that while establishing any specific
Final Action: After consideration of a MIPS APM or a patient-centered
threshold for the percentage of NPIs in medical home submitting in MIPS.
the public comments we received, we a TIN that must participate in an
are finalizing our proposals, with Specifically, for individual MIPS
improvement activity for credit will eligible clinicians and groups that are
clarification, to continue our previously
incentivize some groups to move closer small practices, practices located in
established policies for future years.
to the threshold, it may have the rural areas or geographic HPSAs, or
Specifically: (1) For purposes of MIPS
Year 2 and future years, MIPS eligible unintended consequence of non-patient facing individual MIPS
clinicians or groups must submit data incentivizing groups who are exceeding eligible clinicians or groups, to achieve
on MIPS improvement activities in one the threshold to gravitate back toward the highest score, one high-weighted or
of the following manners: Via qualified the threshold. Therefore, we requested two medium-weighted improvement
registries; EHR submission mechanisms; comments for future consideration on activities are required (81 FR 77185).
QCDR, CMS Web Interface; or how to set this threshold while For these individual MIPS eligible
attestation. Our proposal language may maintaining the goal of promoting clinicians and groups, in order to
have potentially caused some confusion, greater participation in an improvement achieve one-half of the highest score,
because it included the transition year; activity. one medium-weighted improvement
however, we are clarifying here that Additionally, we noted in the CY activity is required (81 FR 77185).
policies were previously established for 2017 Quality Payment Program final In the CY 2017 Quality Payment
that year and remain unchanged. We are rule (81 FR 77197) that we intended, in Program final rule (81 FR 77185), we
also finalizing, as proposed: (2) For future years, to score the improvement finalized that under the APM scoring
activities that are performed for at least activities performance category based on standard, all clinicians identified on the
a continuous 90 days during the performance and improvement, rather Participation List of an APM receive at
performance period, MIPS eligible than simple attestation. In the CY 2018 least one-half of the highest score
clinicians must submit a yes response applicable to the MIPS APM. To
Quality Payment Program proposed rule
for activities within the Improvement develop the improvement activities
(82 FR 30053), we sought comment on
Activities Inventory; and (3) that score assigned to each MIPS APM, we
how we could measure performance and
414.1360 will be updated to reflect compare the requirements of the
improvement for future consideration;
these changes. specific MIPS APM with the list of
we were especially interested in ways to
activities in the Improvement Activities
(ii) Group Reporting measure performance without imposing Inventory and score those activities in
In the CY 2017 Quality Payment additional burden on eligible clinicians, the same manner that they are otherwise
Program final rule (81 FR 77181), we such as by using data captured in scored for MIPS eligible clinicians (81
clarified that if one MIPS eligible eligible clinicians daily work. FR 77185). If by our assessment the
clinician (NPI) in a group completed an We received many comments on these MIPS APM does not receive the
improvement activity, the entire group topics and will take them into maximum improvement activities
(TIN) would receive credit for that consideration as we craft for future performance category score then the
activity. In addition, we specified that policies. APM entity can submit additional
improvement activities (81 FR 77185). to a more stringent requirement in In the CY 2018 QPP proposed rule (82
All other individual MIPS eligible future years while still offering some FR 30054 through 55) we invited public
clinicians or groups that we identify as flexibility. We refer readers to the CY comments on our proposals to revise
participating in APMs that are not MIPS 2017 Quality Payment Program final 414.1380(b)(3)(x) to provide that for
APMs will need to select additional rule (81 FR 77180 through 77182) for the 2020 MIPS payment year and future
improvement activities to achieve the the details of those comments and our years, to receive full credit as a certified
improvement activities highest score (81 responses. In response to these or recognized patient-centered medical
FR 77185). We did not propose any comments, in the CY 2018 Quality home or comparable specialty practice,
changes to these policies; we refer Payment Program proposed rule (82 FR at least 50 percent of the practice sites
readers to section II.C.6.g. of this final 30054), we proposed to revise within the TIN must be recognized as a
rule with comment period for further 414.1380(b)(3)(x) to provide that for patient-centered medical home or
discussion of the APM scoring standard. the 2020 MIPS payment year and future comparable specialty practice. However,
We received many comments on this years, to receive full credit as a certified we are correcting here that we intended
topic and will take them into or recognized patient-centered medical to add 414.1380(b)(3)(x) as a new
consideration for future rulemaking. home or comparable specialty practice, provision, not revise it. This was an
(ii) Patient-Centered Medical Homes or at least 50 percent of the practice sites inadvertent typographical error. The
Comparable Specialty Practices within the TIN must be recognized as a following is a summary of the public
patient-centered medical home or comments received and our responses.
In the CY 2017 Quality Payment Comment: Several commenters
Program final rule (81 FR 77185), we comparable specialty practice. This is
supported CMSs proposal to raise the
finalized at 414.1380(b)(3)(iv) to an increase to the previously established
threshold to 50 percent for the number
provide full credit for the improvement requirement codified at 414.1380(b)(3) of practice sites that must be recognized
activities performance category, as in the CY 2017 Quality Payment within a TIN to receive full credit in this
required by law, for an individual MIPS Program final rule (81 FR 77178) that performance category as a patient-
eligible clinician or group that has only one practice site within a TIN centered medical home or comparable
received certification or accreditation as needs to be certified as a patient- specialty. These commenters noted that
a patient-centered medical home or centered medical home. We chose not to the proposal strikes an appropriate
comparable specialty practice from a propose to require that every site be balance between requiring a TIN to
national program or from a regional or certified, because that could potentially show substantial accomplishment
state program, private payer or other be overly restrictive given that some before receiving full credit in this
body that administers patient-centered sites within a TIN may be in the process performance category and
medical home accreditation and of being certified as patient-centered acknowledging that it may be infeasible
certifies 500 or more practices for medical homes. We believe a 50 percent for every practice site within a TIN to
patient-centered medical home threshold is achievable, and is achieve this recognition. One
accreditation or comparable specialty supported by a study of physician- commenter urged CMS to accept data
practice certification, or for an owned primary care groups in a recent feeds from accrediting bodies so that we
individual MIPS eligible clinician or Annals of Family Medicine article can move to requiring 100 percent of
group that is a participant in a medical (Casalino, et al., 2016) http:// practice sites within a TIN to achieve
home model. We noted in the CY 2017 www.annfammed.org/content/14/1/ recognition in order to receive full
Quality Payment Program final rule (81 16.full. For nearly all groups in this credit in this performance category.
FR 77178) that practices may receive study (sampled with variation in size Response: We appreciate the support
this designation at a practice level and and geographic area), at least 50 percent and agree that establishing a 50 percent
that TINs may be comprised of both of the practice sites within the group threshold strikes an appropriate
undesignated practices and designated had a medical home designation.2 If the balance. In addition, we appreciate the
practices. We finalized at group is unable to meet the 50 percent comment regarding accepting data feeds
414.1380(b)(3)(viii) that to receive full threshold, then the individual MIPS from accrediting bodies and will explore
credit as a certified patient-centered eligible clinician may choose to receive this idea, including whether it is
medical home or comparable specialty full credit as a certified patient-centered technically feasible, as we craft future
practice, a TIN that is reporting must medical home or comparable specialty policy.
include at least one practice site which practice by reporting as an individual Comment: Another commenter
is a certified patient-centered medical for all performance categories. In supported the proposal, but suggested
home or comparable specialty practice addition, we refer readers to section that it would be most logical to define
(81 FR 77178). We also indicated that II.C.4.d. of this final rule with comment the threshold as 50 percent of the
we would continue to have more period, where we are finalizing to primary care sites for TINs with both
stringent requirements in future years, generally apply our group policies to specialty and primary care, and for
and would lay the groundwork for virtual groups. Further, in the proposed groups with both primary care and
expansion towards continuous rule, we welcomed suggestions on an specialty only sites, the denominator for
improvement over time (81 FR 77189). appropriate threshold for the number of the threshold should be the number of
We received many comments on the NPIs within the TIN that must be primary care.
CY 2017 Quality Payment Program final Response: It is important to note that
recognized as a certified patient-
rule regarding our transition year policy our criteria for patient-centered medical
centered medical home or comparable
that only one practice site within a TIN homes include specialty sites as well,
specialty practice to receive full credit
needs to be certified as a patient- not just primary care. We do not believe
in the improvement activities
centered medical home for the entire it is appropriate to restrict patient-
TIN to receive full credit in the centered medical home designation to
improvement activities performance 2 Casalino LP, Chen MA, Staub CT, Press MJ,
primary care sites only. Based on a
category. While several commenters Mendelsohn JL, Lynch JT, Miranda Y. Large
survey of patient-centered medical
supported our transition year policy, independent primary care medical groups. Ann homes accrediting organizations, named
others disagreed and suggested to move Fam Med. 2016;14(1):1625. in the Annals of Family Medicine article
2017 (Casalino, et al., 2016) cited above would need to demonstrate other threshold to encourage TINs to increase
in our proposal, only one specifically improvement activities. Although MIPS their number of patient-centered
requires that practices be primary care, eligible clinicians may choose to receive medical homes. We do not believe that
and another offers specialty-specific full credit by reporting as an individual only one MIPS eligible clinician should
patient-centered medical homes clinician, one commenter noted that this represent the entire group going
recognition. Therefore, it is reasonable is not a reasonable alternative due to the forward; and accordingly, do not believe
to assume that specialty practices could complexity and burden required to do one MIPS eligible clinicians patient-
attain patient-centered medical homes so as part of a large multi-specialty centered medical home status should
recognition through multiple group. This commenter suggested that qualify the entire group to receive the
accrediting organizations along with before proceeding with this policy, CMS maximum improvement activity
their primary care sites if they choose should determine an alternative that performance category score (15 points)
to. Overall, we believe that setting the allows a portion of a group under one toward their final score beyond the
patient-centered medical home group TIN to report as a separate subgroup on transition year. In addition, as discussed
threshold at 50 percent of the group is measures and activities that are more in our proposal above, we determined
achievable and it is our goal to applicable to that subgroup. This that a 50 percent threshold would be
encourage TINs to have more practice commenter suggested that alternatively, appropriate, because we believe it is an
sites undergo transformation. CMS could incorporate thresholds into achievable goal and it is supported by
Comment: Several commenters improvement activities, consider a a study of physician-owned primary
opposed CMSs proposal to raise the variety of thresholds (for example, care groups in a recent Annals of Family
threshold to 50 percent for the number clinicians participating, target Medicine article, in which nearly all
of practice sites that must be recognized population included, entire practice groups of varying sizes in this study
within a TIN to receive full credit in this included, etc.) and adjust the thresholds (sampled with variation in size and
performance category as a patient- based on the type of improvement geographic area) have 50 percent or
centered medical home or comparable activity. Another commenter suggested more of the practice sites within a group
specialty, expressing concern that it is a that CMS equate this threshold with the being an NCQA patient-centered
significant change from the first year of credit received, giving the example that medical home.
the program, and urging CMS to if 70 percent of NPIs within a TIN are In response to the commenters who
continue to provide flexibility in this performing an improvement activity, believed that the proposed threshold
area or gradually increase the threshold then that group should get 70 percent may interfere with their ability to report
in future years. credit toward that improvement activity
Several commenters expressed participation in an improvement
score. Commenters suggested that this activity that may be unique to their
concern that the proposed threshold is addresses the possibility of a decline in
premature and may interfere with their specialty group, if those specialty
further improvement once the set groups decided to use patient-centered
ability to report participation in an
threshold is achieved. medical home recognition as their credit
improvement activity that may be
unique to their specialty group or Response: We disagree with the for the improvement activities
discourage participation by some commenters who oppose increasing the performance category, those specialty
clinicians in the medical home models threshold to 50 percent of the group groups would not be able to report on
altogether. practice sites to receive patient-centered improvement activities unique to their
Other commenters expressed concern medical home designation. Currently, specialties. We refer commenters to our
that CMSs proposed policy fails to only one practice site in a TIN with proposal above where we state that if
account for the effort and investment multiple practice sites is required for the group is unable to meet the 50
required to achieve this designation, full credit as a patient-centered medical percent threshold, then the individual
and fails to account for how the work home. We recognized that the transition MIPS eligible clinicians may choose to
of those sites that do achieve such year was the first time MIPS eligible receive full credit as a recognized or
recognition impacts specialty clinics clinicians or groups would be measured certified patient-centered medical home,
within a TIN by ensuring coordinated on the quality improvement work on a or comparable specialty practice, as an
primary care for patients as those national scale. Therefore, we individual for all performance
practice sites refer patients needing approached the improvement activities categories (82 FR 30054). To emphasize
specialized care who cannot be performance category with these this point, specialty clinicians could
managed by primary care. Some principles in mind along with the either be recognized as a comparable
commenters recommended that CMS overarching principle for the MIPS specialty practice under the patient-
consider alternatives to our proposal. A program that we are building a process centered medical home designation,
few commenters recommended a that will have increasingly more which would reflect the specialty care
threshold of 2 or more practice sites, or stringent requirements over time. We they provide, or they could report on
beginning with a lower threshold, such noted in the CY 2017 Quality Payment improvement activities that may be
as 33 percent. One commenter suggested Program final rule (81 FR 77188 through unique to their specialty group as
that CMS instead consider awarding 77189) that the baseline requirements individual reporters. Therefore, we do
prorated credit for the entire TIN that is that would continue to have more not believe that setting the patient-
in proportion to the percentage of the stringent requirements in future years, centered medical home threshold at 50
TIN that is a patient-centered medical and that we were laying the groundwork percent would interfere with a groups
home or comparable specialty. For for expansion towards continuous ability to report other specialty specific
example, for one practice site that is a improvement over time. We recognized improvement activities. We believe that
patient-centered medical home out of that quality improvement is a critical the suggestion that we use a threshold
five sites under the same TIN, this aspect of improving the health of of 2 or more practice sites, instead of 50
practice would receive 20 percent of the individuals and the health care delivery percent might discourage large medical
100 percent credit for the performance system overall. We have provided great groups from investing in patient-
category score, and eligible clinicians in flexibility during the transition year and centered medical home transformation
the other four sites within the TIN believe it is time to increase this more broadly, because many large
medical groups may have ten practice would mean a very different investment with the commenter that defining this
sites, and having only 2 sites recognized for a practice with 3 sites than it would term will reduce ambiguity. In response,
as patient-centered medical homes for a practice with 30 sites. we are clarifying in this final rule that
would mean a very different investment Comment: Another commenter a practice site is the physical location
for a practice with 3 sites than it would suggested that CMS use the CMS Study where services are delivered. We are
for a practice with 30 sites. We also on Burden Associated with Quality operationalizing this definition by using
disagree that a threshold of 33 percent Reporting that is discussed in section the practice address field within the
is appropriate, because the literature II.C.6.e.(9) of this final rule with Provider Enrollment, Chain and
(Casalino, et al., 2016), as cited in our comment period to solicit input from Ownership System (PECOS). We believe
proposal, demonstrated that a 50 stakeholders about how to assess this definition is generally acceptable in
percent target is achievable and we have thresholds of participation, score the medical community as a whole,
seen a subset of large, multi-specialty practices on performance, and assess because physical practice locations are
medical groups from across the country improvement. a common way for primary care to be
that have already surpassed this target. Response: As discussed in the CY organized.
We also believe that finalizing a 2017 Quality Payment Program final Comment: One commenter stated that
proportion lower than 50 percent of rule (81 FR 77195) the CMS Study on the intent of MACRA was to give all
practice sites would unfairly discredit Burden Associated with Quality practices recognized as a patient-
practices that have greater integration Reporting goals are to see whether there centered medical home or comparable
and required a significant investment. In will be improved outcomes, reduced specialty full credit in the improvement
addition, using a pro-rated approach as burden in reporting, and enhancements activities performance category and that
suggested by a commenter brings in clinical care by selected MIPS eligible the proposed threshold is not consistent
significant added complexity and clinicians desiring: with the intent of Congress.
burden, for which we do not believe A more data driven approach to Response: We disagree with the
outweighs the benefits. quality measurement. commenter that our proposal is contrary
Comment: Several commenters Measure selection unconstrained by to the intent of Congress. Section
indicated that large multispecialty a CEHRT program or system. 1848(q)(5)(C)(i) of the Act specifies that
practices, such as academic medical Improving data quality submitted to a MIPS eligible clinician or group that
centers, have a large number of CMS. is certified or recognized as a patient-
specialists; therefore, it is unlikely that Enabling CMS get data more centered medical home or comparable
50 percent of the practice sites under frequently and provide feedback more specialty practice, as determined by the
their TIN would be recognized as often. Secretary, must be given the highest
medical homes. Commenters cautioned We do not believe the CMS Study on potential score for the improvement
that excluding these medical homes Burden Associated with Quality activities performance category for the
from getting credit while other practices Reporting is the appropriate vehicle to performance period. We believe the
get full credit is likely to discourage assess thresholds of participation, score statute gives the Secretary discretion to
practice locations from seeking this practices on performance, and assess determine what qualifies as a certified
designation. improvement. We will, however, take or recognized patient-centered medical
Response: Regarding commenters who these comments into consideration as home or comparable specialty practice.
suggested that large multispecialty we craft future policies. We have provided the utmost flexibility
practices, such as academic medical Comment: One commenter requested by allowing any undesignated practices
centers with a large number of that CMS more clearly define the term to receive full credit simply by virtue of
specialists would be unlikely to have 50 practice used in the CY 2018 Quality being in a TIN with one designated
percent of the practice sites under their Payment proposed rule (82 FR 30054) practice. As discussed in the CY 2017
TIN recognized as medical homes, we and clarify, for example, whether Quality Payment Program final rule (81
want to raise the threshold to encourage practice means a physical location FR 30054) for the transition year, that
greater transition such that there a where services are delivered or the practices may receive a patient-centered
meaningful investment in transforming administrative address, among other medical home designation at a practice
their practice sites. Having 50 percent of things, and urged CMS to define this level, and that individual TINs may be
their sites being recognized as patient- term in a way that includes as many composed of both undesignated
centered medical homes represents a individual MIPS eligible clinicians as practices and practices that have
significant investment toward practice possible. received a designation as a patient-
transformation that is achievable and Response: In the CY 2018 Quality centered medical home (for example,
supported by the literature. As cited in Payment Program proposed rule (82 FR only one practice site has received
our proposal (Casalino, et al., 2016), 30054), we proposed to revise patient-centered medical home
studies have demonstrated that a 50 414.1380(b)(3)(x) to provide that for designation in a TIN that includes five
percent target is achievable and we have the 2020 MIPS payment year and future practice sites). In addition, we finalized
seen a subset of large, multi-specialty years, to receive full credit as a certified an expanded definition of what is
medical groups from across the country or recognized patient-centered medical acceptable for recognition as a certified
that have already surpassed this target. home or comparable specialty practice, patient-centered medical home or
In addition, if an academic medical at least 50 percent of the practice sites comparable specialty practice (81 FR
center has numerous sites, and only one within the TIN must be recognized as a 77180). We refer readers to
is a patient-centered medical home, we patient-centered medical home or 414.1380(3)(iv) for details. We

do not believe that represent the same comparable specialty practice. However, recognized a MIPS eligible clinician or
degree of investment in practice we note again that we intended to add group as being a certified patient-
transformation as a TIN with 50 percent 414.1380(b)(3)(x) as a new provision, centered medical home or comparable
or more of the practice sites being not revise it. This was an inadvertent specialty practice if they have achieved
recognized medical homes, because typographical error. We interpret certification or accreditation as such
because having only 2 sites recognized commenter to be referring to our use of from a national program, or they have
as patient-centered medical homes the term practice sites and we agree achieved certification or accreditation as
such from a regional or state program, delivered. We are also finalizing to add Accordingly, in the CY 2018 Quality
private payer or other body that certifies 414.1380(b)(3)(x) to reflect these Payment Program proposed rule (82 FR
at least 500 or more practices for changes. 30054 through 30055), we proposed that
patient-centered medical home MIPS eligible clinicians in practices
(A) CPC+
accreditation or comparable specialty randomized to the control group in the
practice certification (81 FR 77180). In the CY 2018 Quality Payment CPC+ APM would receive full credit as
Examples of nationally recognized Program proposed rule (82 FR 30054) a medical home model, and therefore, a
accredited patient-centered medical we stated that we have determined that certified patient-centered medical home,
homes are: (1) The Accreditation the Comprehensive Primary Care Plus for the improvement activities
Association for Ambulatory Health Care; (CPC+) APM design satisfies the performance category. In other words,
(2) the National Committee for Quality requirements to be designated as a MIPS eligible clinicians who attest that
Assurance (NCQA) Patient-Centered medical home model, as defined in they are in practices that have been
Medical Home; (3) The Joint 414.1305; and therefore, as defined at randomized to the control group in the
Commission Designation; or (4) the 81 FR 77178 that states that patient- CPC+ APM would receive full credit for
Utilization Review Accreditation centered medical homes will be the improvement activities performance
Commission (URAC) (81 FR 77180). We recognized if it is a nationally category for each performance period in
finalized that the criteria for being a recognized accredited patient-centered which they are on the Practitioner
nationally recognized accredited medical home, a Medicaid Medical Roster, the official list of eligible
patient-centered medical home are that Home Model, or a Medical Home clinicians participating in a practice in
it must be national in scope and must Model, CPC+ APM is also a certified or the CPC+ control group (82 FR 30054
have evidence of being used by a large recognized patient-centered medical through 30055).
number of medical organizations as the home for purposes of the improvement We invited public comment on our
model for their patient-centered medical activities performance category. We proposal. The following is a summary of
home (81 FR 77180). We also provided have also determined that the CPC+ public comments received on this
full credit for the improvement APM meets the criteria to be an proposal and our response.
activities performance category for a Advanced APM. We refer readers to Comment: Several commenters stated
MIPS eligible clinician or group that has that they support recognizing CPC+
https://qpp.cms.gov/docs/QPP_
received certification or accreditation as control group participants as
Advanced_APMs_in_2017.pdf for more
a patient-centered medical home or participating in a medical home model
information. Participating CPC+
comparable specialty practice from a and receiving full credit for the
practices in the Model must adopt, at a
improvement activities performance
national program or from a regional or minimum, the certified health IT
category. The commenters noted that
state program, private payer or other needed to meet the certified EHR
the focus of these practices should be on
body that administers patient-centered technology (CEHRT) definition at
developing a balance in primary care
medical home accreditation and 414.1305. In addition, participating
and specialty care focused high-weight
certifies 500 or more practices for CPC+ practices receive payments for
improvement activities. One commenter
patient-centered medical home covered professional services based on
stated that the requirements of CPC+ are
accreditation or comparable specialty quality measures comparable to those
such that there would be a guarantee
practice certification (81 FR 77180). used in the quality performance
that participants are carrying out true
Once a MIPS eligible clinician or group category of MIPS, and they bear more
practice improvement activities focused
is certified or recognized as a patient- than a nominal amount of financial risk
on patient-centered care.
centered medical home or comparable for monetary losses as described at Response: We thank commenters for
specialty practice, those clinicians or 414.1415. their support. As an update, CMS has
groups are given the full improvement We recognized the possibility that not randomized any practices that will
activities score (for example, 40 points) certain practices that applied to begin participation in CPC+ in 2018 into
(81 FR 77180). This policy specifically participate in Round 2 of the CPC+ a control group. Because we have not
applies to MIPS eligible groups; APM, but were not chosen to participate randomized any practices into a control
individual MIPS eligible clinicians may in the model, could potentially be group in CPC+ Round 2, we are not
still attest that their practice is part of randomized into a CPC+ control group. finalizing our proposal.
a patient-centered medical home or The control group practices would meet Final Action: After consideration of
comparable specialty practice as all of the same eligibility requirements the public comments we received and
established for the transition year in the as the CPC+ participating practices (also developments in the CPC+ Model, we
CY 2017 Quality Payment Program final known as the intervention group) but are not finalizing our proposal as
rule (81 FR 77189). the control group would not discussed above.
Final Action: After consideration of participate in the APM (for example,
the public comments received, we are undertake the CPC+ care delivery (c) Required Period of Time for
finalizing our proposals with activities such as providing 24/7 Performing an Activity
clarification. Specifically, we are clinician access, or empanel attributed In the CY 2017 Quality Payment
finalizing that for the 2020 MIPS Medicare beneficiaries) or receive any of Program final rule (81 FR 77186), we
payment year and future years, to the CPC+ payments. In the CY 2018 specified at 414.1360 that MIPS
receive full credit as a certified or Quality Payment Program proposed rule eligible clinicians or groups must
recognized patient-centered medical (82 FR 30015), we discussed that we perform improvement activities for at
home or comparable specialty practice, believe MIPS eligible clinicians, who least 90 consecutive days during the
at least 50 percent of the practice sites are participating in the CPC+ APM, performance period for improvement
within the TIN must be recognized as a whether actively in the intervention activities performance category credit.
patient-centered medical home or group or as part of the control group, Activities, where applicable, may be
comparable specialty practice. We are should therefore receive full credit for continuing (that is, could have started
clarifying that a practice site as is the the improvement activities performance prior to the performance period and are
physical location where services are category. continuing) or be adopted in the
performance period as long as an Professional Shortage Areas (HPSA) research. We interviewed high
activity is being performed for at least refers to areas as designated under performing organizations of all sizes,
90 days during the performance period. section 332(a)(1)(A) of the Public Health conducted an environmental scan to
In the CY 2018 Quality Payment Service Act. In the CY 2018 Quality identify existing models, activities, or
Program proposed rule (82 FR 30055), Payment Program proposed rule (82 FR measures that met all or part of the
we did not propose any changes to the 30055), we did not propose any changes improvement activities performance
required period of time for performing to the special consideration for small, category requirements, including the
an activity for the improvement rural, or health professional shortage patient-centered medical homes, the
activities performance category in the areas practices for the improvement Transforming Clinical Practice Initiative
proposed rule. We also refer readers to activities performance category in the (TCPI), CAHPS surveys, and AHRQs
section II.C.4.d. of this final rule with proposed rule. Patient Safety Organizations (81 FR
comment period, where we are We received many comments on this 77190). In addition, we reviewed
finalizing to generally apply our group topic and will take them into comments from the CY 2016 PFS final
policies to virtual groups. consideration for future rulemaking. rule with comment period (80 FR
We received many comments on this 70886), and those received in response
(6) Improvement Activities
topic and will take them into to the MIPS and APMs RFI published in
Subcategories
consideration for future rulemaking. the October 1, 2015 Federal Register (80
In the CY 2017 Quality Payment FR 59102, 59106 through 59107)
(4) Application of Improvement Program final rule (81 FR 77190), we
Activities to Non-Patient Facing regarding the improvement activities
finalized at 414.1365 that the performance category. The Improvement
Individual MIPS Eligible Clinicians and improvement activities performance
Groups Activities Inventory finalized in the CY
category will include the subcategories 2017 Quality Payment Program final
In the CY 2017 Quality Payment of activities provided at section rule (81 FR 77817 through 77831) in
Program final rule (81 FR 77187), we 1848(q)(2)(B)(iii) of the Act. In addition, Table H of the Appendix, for the
specified at 414.1380(b)(3)(vii) that for we finalized (81 FR 77190) at 414.1365 transition year and future years, was
non-patient facing individual MIPS the following additional subcategories: compiled as a result of the stakeholder
eligible clinicians or groups, to achieve Achieving Health Equity; Integrated input, an environmental scan, the MIPS
the highest score one high-weighted or Behavioral and Mental Health; and and APMs RFI comments, and
two medium-weighted improvement Emergency Preparedness and Response. subsequent working sessions with
activities are required. For these In the CY 2018 Quality Payment AHRQ and ONC and additional
individual MIPS eligible clinicians and Program proposed rule (82 FR 30055), communications with CDC, SAMHSA,
groups, in order to achieve one-half of we did not propose any changes to the and HRSA.
the highest score, one medium-weighted improvement activities subcategories for
improvement activity is required (81 FR the improvement activities performance (ii) Year 2
77187). In the CY 2018 Quality Payment category in the proposed rule. For the Quality Payment Program
Program proposed rule (82 FR 30055), We received a few comments on this Year 2, we provided an informal process
we did not propose any changes to the topic and will take them into for submitting new improvement
application of improvement activities to consideration for future rulemaking. activities for potential inclusion in the
non-patient facing individual MIPS (7) Improvement Activities Inventory comprehensive Improvement Activities
eligible clinicians and groups for the Inventory for the Quality Payment
improvement activities performance We refer readers to Table H in the Program Year 2 and future years through
category. Appendix of the CY 2017 Quality subregulatory guidance (https://
We received a few comments on this Payment Program final rule (81 FR www.cms.gov/Medicare/Quality-
topic and will take them into 77817) for our previously finalized Initiatives-Patient-Assessment-
consideration for future rulemaking. Improvement Activities Inventory for Instruments/MMS/Downloads/Annual-
the transition year of MIPS and future Call-for-Measures-and-Activities-for-
(5) Special Consideration for Small, years. In this final rule with comment MIPS_Overview-Factsheet.pdf). As part
Rural, or Health Professional Shortage period, we are finalizing updates to the of this informal process, we solicited
Areas Practices Improvement Activities Inventory, and received input from various MIPS
In the CY 2017 Quality Payment formalizing the process for adding new eligible clinicians and organizations
Program final rule (81 FR 77188), we improvement activities to the suggesting possible new activities via a
finalized at 414.1380(b)(3)(vii) that one Improvement Activities Inventory, and nomination form that was posted on the
high-weighted or two medium-weighted finalizing the criteria for nominating CMS Web site at https://www.cms.gov/
improvement activities are required for new improvement activities. These are Medicare/Quality-Initiatives-Patient-
individual MIPS eligible clinicians and discussed in detail below. Assessment-Instruments/MMS/
groups that are small practices or (a) Annual Call for Activities Process for Downloads/CallForMeasures.html.
located in rural areas, or geographic Adding New Activities These nominations were vetted by an
HPSAs, to achieve full credit. In internal CMS review panel that
addition, we specified at 414.1305 that (i) Transition Year conferred with other federal partners.
a rural area means ZIP codes designated As discussed in the CY 2017 Quality New activities or modifications to
as rural, using the most recent HRSA Payment Program final rule (81 FR existing activities were proposed in the
Area Health Resource File data set 77190), for the transition year of MIPS, CY 2018 Quality Payment Program
available (81 FR 77012). Lastly, in the we implemented the initial proposed rule (82 FR 30479 through
CY 2017 Quality Payment Program final Improvement Activities Inventory and 30500) Improvement Activities
rule (81 FR 77539 through 77540), we took several steps to ensure it was Inventory in Tables F and G of the
codified the following definitions at inclusive of activities in line with Appendix for Year 2 of the MIPS
414.1305: (1) Small practices is statutory and program requirements. program. We refer readers to the CY
defined to mean practices consisting of Prior to selecting the improvement 2017 Quality Payment Program final
15 or eligible clinicians; and (2) Health activities, we conducted background rule (81 FR 77817 through 77831) in
Table H of the Appendix, for the for improvement activities that continue that are also eligible for the advancing
transition year and future years and to follow the priorities of the National care information performance category
Tables F and G of the Appendix of this Quality Strategy. In addition, other in the Improvement Activities
final rule with comment period for our commenters noted that the addition of Inventory. We encourage stakeholders to
finalized Improvement Activities new improvement activities creates submit new improvement activities and
Inventory for Year 2 and future years of more opportunity for clinicians to select modifications to existing improvement
MIPS. a suite of activities that further a activities that help to align performance
particular improvement goal, rather categories through the Annual Call for
(iii) Year 3 and Future Years
than choosing several discrete activities, Activities.
For the Quality Payment Program which together may not move the Comment: Commenters also
Year 3 and future years, in the CY 2018 practice toward transformation. Several encouraged CMS to ensure that the
Quality Payment Program proposed rule commenters supported the inclusion of process is transparent, urged CMS to
(82 FR 30055), we proposed to formalize improvement activities that demonstrate continue to be flexible and include as
an Annual Call for Activities process for the delivery of patient and family many proposed improvement activities
adding possible new activities or centered care. on the final list as possible, and urged
providing modifications to the current Response: We thank the commenters CMS to create more explicit inclusion
activities in the Improvement Activities for their support. criteria, which would further streamline
Inventory. We believe this is a way to Comment: One commenter suggested the process of hospitals identifying the
engage eligible clinician organizations that quality and practice transformation broader activity to which the discrete
and other relevant stakeholders, standards such as the National activity belongs. A few commenters
including beneficiaries, in the Committee for Quality Assurance expressed concern that improvement
identification and submission of (NCQA) patient-centered medical home activities that were submitted were not
improvement activities for recognition should be the basis for accepted and urged CMS to be more
consideration. Specifically, we reporting and validating improvement transparent in the manner in which they
proposed that individual MIPS eligible activities. make decisions about: (1) Which
clinicians or groups and other relevant Response: We are considering the
improvement activities are included and
stakeholders may recommend activities standards for reporting and validation,
not included in the inventory, and (2)
for potential inclusion in the given that each national accrediting
the weighting of improvement activities.
Improvement Activities Inventory via a organization has different reporting
In addition, they urged CMS to provide
similar nomination form that was requirements and utilizes different
standards to evaluate their respective additional rationale to submitters when
utilized in the Year 2 of MIPS informal
patient-centered medical home their recommended improvement
Annual Call for Activities found on the
recognition programs. Although the activities are not accepted and engage
Quality Payment Program Web site at
AHRQ patient-centered medical home specialists and non-specialists equally
www.qpp.cms.gov, as discussed above.
As part of this formalized process, definition (https://pcmh.ahrq.gov/page/ to select improvement activities for
individual MIPS eligible clinicians, defining-pcmh) identified national inclusion in the Inventory.
groups, and other relevant stakeholders accrediting organizations patient- Response: As we have developed the
would be able to nominate new centered medical home models which Improvement Activity Inventory, we
improvement activities that we may align around recognized functions, their have strived to be flexible and have
consider adding to the Improvement standards and activities for evaluation accepted as many improvement
Activities Inventory. Individual MIPS of each element may be different. activities as possible that are
eligible clinicians and groups and Likewise, the data collected and appropriate. As we work to further
relevant stakeholders would be required maintained by each accrediting develop the Annual Call for Activities
to provide an explanation, via the organization may be updated during process, we intend to be as transparent
nomination form, of how the different time frames and assess or as feasible. In the CY 2017 Quality
improvement activity meets all the evaluate performance elements using Payment final rule (81 FR 77190), we
relevant criteria proposed in the CY different methodologies, presenting discussed some guidelines by which
2018 Quality Payment Program challenges to standardizing validation improvement activities are selected
proposed rule (82 FR 30055 through that would need to be addressed based on a set of criteria. We note that
30056) and finalized below in section through further research. We are the Annual Call for Activities that was
II.C.6.e.(7)(b) of this final rule with evaluating the technical feasibility of held in Year 2 for improvement
comment period. having an external entity report and activities that will be applicable for the
We refer readers to the Improvement potentially validate improvement 2018 performance period, was an
Activities Inventory in Tables F and G activities in the future. We refer readers informal process. We formally proposed
of the Appendix of this final rule with to the Quality Payment Program Web criteria in the CY 2018 QPP proposed
comment period where we are finalizing site Resource Library at https:// rule (82 FR 30055 through 30056) and
new activities and changes to existing qpp.cms.gov/ (MIPS Data Validation are finalizing them in section
activities, some with modification. We Criteria), which provides the current II.C.6.e.(7)(b) of this final rule with
invited public comment on our proposal expected data validation information. comment period. We refer readers to
to formalize the Annual Call for Comment: Some commenters also section II.C.6.e.(7)(b) of this final rule
Activities process for the Quality encouraged CMS to ensure that accepted with comment period.
Payment Program Year 3 and future improvement activities are aligned with We will take the commenters
years. measures for the other performance feedback into consideration as we work
Comment: Several commenters categories. to refine the Annual Call for Activities
supported the proposal to formalize an Response: We agree that it is process for future years.
Annual Call for Activities process to important to create a program in which Comment: Another commenter
facilitate the solicitation of new the performance categories are aligned recommended that CMS prioritize
improvement activities. The as much as possible. We will continue additional modifications to existing
commenters supported CMSs criteria to identify those improvement activities improvement activities and adopt new
improvement activities on a more added that would support a practices note that in addition to those functions
gradual basis. capacity to analyze its own quality data included under the CEHRT definition,
Response: We do not disagree that we and be prepared to share downside risk we advised in the CY 2017 Quality
should prioritize modifications to the in order to participate in an APM. The Payment Program final rule (81 FR
current improvement activities over commenters encouraged CMS to align 77199) that we may consider including
new improvement activities as we the thresholds and reporting additional ONC certified health IT
believe they are both valuable. We must requirements across performance capabilities as part of activities within
balance burden with including a categories for any of these overlapping the improvement activities inventory in
sufficient number and variety of activities, in order to reduce burden. future years. However, we are not
improvement activities in the Inventory Response: Section 1848(q)(2)(B)(iii) of making any changes to our current
so that all MIPS eligible clinician and the Act specified subcategories approach for allowing MIPS eligible
groups have relevant activities to select. improvement activities. However, we clinicians to achieve a bonus in the
However, we are mindful of adopting are working to ensure that improvement advancing care performance category in
new activities gradually; the activities align across the performance this final rule with comment period.
Improvement Activities Inventory has categories and must balance burden Comment: Some commenters
not grown by more than 20 percent for with including a sufficient number and encouraged CMS to consider the role of
the 2018 performance period. variety of improvement activities in the digital technologies in improving care
Comment: Several commenters Inventory so that all MIPS eligible and including related activities as part
supported the addition of improvement clinician and groups have relevant of continual improvement activities for
activities for hospitals, but activities to select, and in particular for future consideration. Some commenters
recommended that CMS work with clinicians who do not participate in supported the inclusion of telehealth-
partners, clinicians, researchers, and APMs as we do not want to the related improvement activities in the
other stakeholders to develop a broad Inventory to be exclusive to any one Inventory and suggested that these be
set of activities to fill existing gaps in group. We encourage stakeholders to high-weighted activities. A few
the program. Some commenters submit new improvement activities and commenters recommended that
expressed concern that the Inventory is modifications to existing improvement improvement activities that are registry-
too heavily focused on primary care and activities through the Annual Call for focused be assigned a high-weight, or
urged us to work closely with specialty Activities. alternatively, that CMS allow eligible
societies to solicit and develop Comment: One commenter clinicians who participate in a registry
additional improvement activities. encouraged CMS to specify and meet certain basic requirements to
Response: We consistently engage a improvement activities for which a receive the maximum score in this
variety of groups within different participant can use application performance category.
specialties via webinars and listening programming interfaces (APIs) to Response: We acknowledge
sessions to get improvement activity receive another advancing care commenters suggestions for considering
feedback. We do not agree that the information bonus point. The digital technologies and telehealth in
Improvement Activities Inventory is commenter noted that doing so would improvement activities and their
primary care focused as there are many further incentivize clinicians to utilize weighting in the Improvement Activities
activities specialists may perform. As the API functionality for health Inventory. We note that we have
discussed in the CY 2017 Quality information sharing with beneficiaries reserved high weighting for activities
Payment Program final rule (82 FR as part of patient engagement and care that directly address areas with the
77190), we wanted to create a broad list coordination activities. greatest impact on beneficiary care,
of activities that can be used by multiple Response: We will take the safety, health, and well-being, as
practice types to demonstrate commenters suggestions for specifying explained in the CY 2017 Quality
improvement activities and activities improvement activities that are eligible Payment Program final rule (81 FR
that may lend themselves to being for a bonus in the advancing care 77194). We are not making any changes
measured for improvement in future information performance category into to this approach in this final rule with
years. We took several steps to ensure consideration in future rulemaking. We comment period; however, we will take
the initial improvement activities note that in the CY 2017 Quality these commenters suggestions into
inventory is inclusive of activities in Payment Program final rule (81 FR consideration for future rulemaking. We
line with the statutory language. We had 77182), we finalized a policy to allow also encourage stakeholders to submit
numerous interviews with highly MIPS eligible clinicians to achieve a activities for consideration during our
performing organizations of all sizes, bonus in the advancing care information formal Annual Call for Activities
conducted an environmental scan to performance category when they use finalized in this final rule with
identify existing models, activities, or functions included in CEHRT to comment period, as suggestions
measures that met all or part of the complete eligible activities from the regarding improvement activity type,
improvement activities performance improvement activities inventory, and and content will be taken into
category. We also encourage specialties codified at 414.1380 that we would consideration as part of that process.
to submit new improvement activities provide a designation indicating which Finally, we do not agree that clinicians
and modifications to existing activities qualify for the advancing care who participate in a registry and meet
improvement activities through the information bonus finalized. In certain basic requirements should
Annual Call for Activities. addition, we refer readers to section receive the maximum improvement
Comment: Several commenters noted II.E.5.g. of this final rule with comment activities score at this time, as we do not
that it would make more sense to period for details on how improvement have sufficient data to determine what
reorganize and augment the activities using CEHRT relate to the basic requirements might be sufficient
Improvement Activities Inventory to objectives and measures of the to merit full credit, or what impact such
align explicitly with the requirements in advancing care information and an approach would have across MIPS
MIPS, and for APMs. Several improvement activities performance eligible clinicians and groups.
commenters believed that improvement categories. We acknowledge the Comment: One commenter noted that
activities should be developed and commenters additional suggestions and some of the proposed activities exclude
clinicians who are not physicians from improvement activities for MIPS Year 2 We invited public comment on our
participation, and advised us to be is now closed, we encourage proposal. The following is a summary of
mindful of this going forward. stakeholders to submit new the public comments received on the
Response: We believe that this improvement activities and Criteria for Nominating New
comprehensive Improvement Activities modifications to existing improvement Improvement Activities for the Annual
Inventory includes a broad range of activities through the upcoming Annual Call for Activities proposals and our
activities that can be used by multiple Call for Activities. responses.
clinician and practice types to Final Action: After consideration of Comment: Several commenters
demonstrate improvement activities and the public comments we received, we provided suggested additional selection
activities that may lend themselves to are finalizing our proposal, as proposed, criteria: (1) Improvement activities
being measured for improvement in to formalize the Annual Call for should focus on meaningful activities
future years. We will take this concern Activities process for Quality Payment from the person and familys point of
into consideration, however, as we craft Program Year 3 and future years, as view, not structural processes that do
future policy, and we encourage discussed in this final rule with not improve clinical care; and (2) there
stakeholders to submit new activities or comment period. should be consideration for adding new
suggestions for modifications to existing activities that focus on identifying and
activities for consideration during our (b) Criteria for Nominating New supporting the patients family or
Annual Call for Activities. Improvement Activities for the Annual personal caregiver. A few commenters
Comment: One commenter urged Call for Activities requested that CMS expand the
CMS to accept input from stakeholders In the CY 2017 Quality Payment final definition of eligible activities to
regarding the weighting of several rule (81 FR 77190), we discussed include actions that reduce barriers to
activities already included in the guidelines for the selection of care, and to include interpretation and
inventory that are resource intensive improvement activities. In the CY 2018 transportation services explicitly.
and currently have a medium weighting, Quality Payment Program proposed rule Response: We acknowledge
and reconsider the weighting of these (82 FR 30055 and 30485), we formally commenters suggestions for additional
activities. proposed that for the Quality Payment criteria, and in response to these
Response: We refer the commenter Program Year 3 and future years, that comments, we are expanding the
and readers to Tables F and G in the stakeholders would apply one or more proposed criteria to also include: (1)
Appendices of this final rule with of the following criteria when Improvement activities that focus on
comment period where we received meaningful actions from the person and
submitting improvement activities in
public input on the weighting of a familys point of view; and (2)
response to the proposed formal Annual
number of existing improvement improvement activities that support the
Call for Activities. We intend to also use
activities. We previously stated that we patients family or personal caregiver.
these criteria in selecting improvement
believe high weighting should be used We believe these are appropriate to add,
activities for inclusion in the program.
for activities that directly address areas because they closely align with one of
Relevance to an existing
with the greatest impact on beneficiary our MIPS strategic goals, to use a
care, safety, health, and well-being, as improvement activities subcategory (or a
patient-centered approach to program
explained in the CY 2017 Quality proposed new subcategory);
development that leads to better,
Payment Program final rule (81 FR Importance of an activity toward
smarter, and healthier care.
77194). While we are not making any achieving improved beneficiary health In addition, we currently include
changes to this approach in this final outcome; several activities in the Improvement
rule with comment period, we will take Importance of an activity that could Activities Inventory that address
the commenters suggestions into lead to improvement in practice to barriers to care, such as IA_CC_16,
consideration for future rulemaking. We reduce health care disparities; Primary Care Physician and Behavioral
also encourage commenter to submit Aligned with patient-centered Health Bilateral Electronic Exchange of
new improvement activities, or medical homes; Information for Shared Patients, which
recommendations for modifications to Activities that may be considered rewards primary care and behavioral
existing activities (including weighting) for an advancing care information health practices using the same
to us for consideration during the bonus; electronic health record system for
Annual Call for Activities. Representative of activities that shared patients or for exchanging
Comment: Several commenters multiple individual MIPS eligible information bilaterally and IA_PM_18
proposed additional concepts for clinicians or groups could perform (for Provide Clinical-Community Linkages,
improvement activities for the Quality example, primary care, specialty care); which rewards MIPS eligible clinicians
Payment Program Year 2, including Feasible to implement, recognizing engaging community health workers to
improvement activities that address importance in minimizing burden, provide a comprehensive link to
participation in self-assessment or especially for small practices, practices community resources through family-
ongoing learning activities; improving in rural areas, or in areas designated as based services focusing on success in
access to care; engaging patients and geographic HPSAs by HRSA; health, education, and self-sufficiency.
families in practice governance; using Evidence supports that an activity However, we will consider criteria that
telehealth for patient interactions; and has a high probability of contributing to address actions that reduce barriers to
collaborating and data-sharing with improved beneficiary health outcomes; care and those that identify
Regional Health Improvement or interpretation and transportation

Networks. Several comments were CMS is able to validate the activity. services as we craft future policies.
received requesting various new We also noted in our proposal that in Final Action: After consideration of
improvement activities for inclusion in future rulemaking, activities that the public comments received, we are
the Improvement Activities Inventory. overlap with other performance finalizing with modification, for the
Response: We thank the commenters categories may be proposed to be Quality Payment Program Year 3 and
for their suggestions. While the informal included if such activities support the future years, that stakeholders should
process for the nominating key goals of the program. apply one or more of the criteria when
submitting improvement activities in of this informal process, we solicited in MIPS undergo the pre-rulemaking
response to the Annual Call for and received input from various MIPS process with review by the Measures
Activities. In addition to the criteria eligible clinicians and organizations Application Partnership (MAP) (81 FR
listed in the proposed rule for suggesting possible new activities via a 77153). In order to decrease the
nominating new improvement activities nomination form that was posted on the timeframe for activity implementation,
for the Annual Call for Activities policy CMS Web site at https://www.cms.gov/ we did not propose that improvement
we are modifying and expanding the Medicare/Quality-Initiatives-Patient- activities also undergo MAP review. Our
proposed criteria list to also include: (1) Assessment-Instruments/MMS/ intention is that while we we will
Improvement activities that focus on Downloads/CallForMeasures.html. accept improvement activities at any
meaningful actions from the person and It is our intention that the nomination time throughout the year, we will close
familys point of view, and (2) and acceptance process for the Annual Call for Activities
improvement activities that support the improvement activities, to the best submissions by March 1 before the
patients family or personal caregiver. extent possible, parallel the Annual Call applicable performance period, which
The finalized list of criteria for for Measures process that is already would enable us to propose the new
submitting improvement activities in conducted for MIPS quality measures. improvement activities for adoption in
response to the Annual Call for We refer readers to the CY 2017 Quality the same years rulemaking cycle for
Activities is as follows: Payment Program final rule (81 FR implementation in the following year.
Relevance to an existing 77147 through 77153) and section When submissions are received after the
improvement activities subcategory (or a II.C.6.c.(1) of this final rule with March 1 deadline then that submission
proposed new subcategory); comment period for more information. will be included in the next
Importance of an activity toward Therefore, aligned with this process, in performance period activities cycle. For
achieving improved beneficiary health the CY 2018 Quality Payment Program example, an improvement activity
outcome; proposed rule (82 FR 30056), we submitted to the IAUR prior to March 1,
Importance of an activity that could proposed to accept submissions for 2018 could be considered for
lead to improvement in practice to prospective improvement activities at performance periods beginning in 2019.
reduce health care disparities; any time during the performance period If an improvement activity submission
Aligned with patient-centered for the Annual Call for Activities and is submitted April 1, 2018 then the
medical homes; create an Improvement Activities Under submission could be considered for
Focus on meaningful actions from Review (IAUR) list which will be performance periods beginning in 2020.
the person and familys point of view; displayed on a CMS Web site. For In addition, in the CY 2018 Quality
Support the patients family or example, the CY 2019 performance Payment Program proposed rule (82 FR
personal caregiver; period spans January 1, 2019 through 30056), we proposed that we would add
Activities that may be considered December 31, 2019, therefore, the new improvement activities to the
for an advancing care information submission period for CY 2019 inventory through notice-and-comment
bonus; prospective improvement activities rulemaking.
Representative of activities that would be March 2, 2017 through March We invited public comment on our
multiple individual MIPS eligible 1, 2018. When submissions are received proposals.
clinicians or groups could perform (for after the March 1 deadline then that Final Action: We did not receive any
example, primary care, specialty care); submission will be included in the next public comments on these proposals.
Feasible to implement, recognizing performance period activities cycle. We Therefore, we are finalizing our
importance in minimizing burden, will consider the IAUR list we make proposals, as proposed, to: (1) Accept
especially for small practices, practices decisions on which improvement submissions for prospective
in rural areas, or in areas designated as activities to include in a future improvement activities at any time
geographic HPSAs by HRSA; Improvement Activities Inventory. We during the performance period for the
Evidence supports that an activity will analyze the IAUR list while Annual Call for Activities and create an
has a high probability of contributing to considering the criteria for inclusion of Improvement Activities under Review
improved beneficiary health outcomes; improvement activities as finalized in (IAUR) list; (2) only consider
or section II.C.6.e.(7)(b) of this final rule prospective activities submitted by
CMS is able to validate the activity. with comment period. March 1 for inclusion in the
In addition, in the CY 2018 Quality Improvement Activities Inventory for
(c) Submission Timeline for Nominating
Payment Program proposed rule (82 FR the performance periods occurring in
New Improvement Activities for the
30056), we proposed that for the formal the following calendar year; and (3) add
Annual Call for Activities
Annual Call for Activities, only new improvement activities to the
During the informal process, we activities submitted by March 1 would inventory through notice-and-comment
accepted nominations from February 16 be considered for inclusion in the rulemaking.
through Febuary 28, 2017. For the Improvement Activities Inventory for
Quality Payment Program Year 2, we the performance periods occurring in (8) Removal of Improvement Activities
provided an informal process for the following calendar year. In other In future years, we anticipate
submitting new improvement activities words, we will accept improvement developing a process and establishing
for potential inclusion in the activities at any time throughout the criteria for identifying activities for
comprehensive Improvement Activities year, however, we will only consider removal from the Improvement
Inventory for the Quality Payment those improvement activities that are Activities Inventory through the Annual
Program Year 2 and future years through received by the March 1 deadline for the Call for Activities process. We
subregulatory guidance (https:// following performance period. This anticipate proposing these requirements
www.cms.gov/Medicare/Quality- proposal was slightly different than the in the future through notice-and-
Initiatives-Patient-Assessment- Call for Measures timeline. The Annual comment rulemaking. In the CY 2018
Instruments/MMS/Downloads/Annual- Call for Measures requires a 2-year Quality Payment Program proposed rule
Call-for-Measures-and-Activities-for- implementation timeline, because the (82 FR 30056), we invited public
MIPS_Overview-Factsheet.pdf). As part measures being considered for inclusion comments on what criteria should be
used to identify improvement activities advancing care information performance a more rigorous statistical analysis with
for removal from the Improvement category as well. In the CY 2018 Quality the 2018 data, which will require a
Activities Inventory. Payment Program proposed rule (82 FR larger sample size. Therefore, in the CY
We received a few comments on this 30056), we sought suggestions on how 2018 Quality Payment Program
topic and will take them into a health IT subcategory within the proposed rule (82 FR 30056), we
consideration for future rulemaking. improvement activities performance proposed increasing the sample size for
(9) Approach for Adding New category could be structured to provide CY 2018 and beyond to provide the
Subcategories MIPS eligible clinicians with flexible minimum sample needed to get a
opportunities to gain experience in significant result with adequate power;
In the CY 2017 Quality Payment using CEHRT and other health IT to that is, we proposed increasing the
Program final rule (81 FR 77197), we improve their practice. number of the study participants to
finalized the following criteria for We received many comments on this provide the minimum needed to make
adding a new subcategory to the topic and will take these into a meaningful and factual conclusion out
improvement activities performance consideration for future rulemaking. of the study. This is described in more
category: detail below. The sample size, as
The new subcategory represents an (10) CMS Study on Burdens Associated
finalized in the CY 2017 Quality
area that could highlight improved With Reporting Quality Measures
beneficiary health outcomes, patient (a) Background 77196), for performance periods
engagement and safety based on
In the CY 2017 Quality Payment occurring in CY 2017 consisted of 42
evidence.
MIPS groups as stated by MIPS criteria
The new subcategory has a Program final rule (81 FR 77195), we
finalized specifics regarding the CMS from the following seven categories:
designated number of activities that
Study on Improvement Activities and 10 urban individual or groups of <3
meet the criteria for an improvement
Measurement including the study eligible clinicians.
activity and cannot be classified under
purpose, study participation credit and 10 rural individual or groups of <3
the existing subcategories.
Newly identified subcategories requirements, and the study procedure. eligible clinicians.
would contribute to improvement in In the CY 2018 Quality Payment 10 groups of 38 eligible clinicians.
patient care practices or improvement in Program proposed rule (82 FR 30056), 5 groups of 820 eligible clinicians.
performance on quality measures and we proposed to modify the name of the 3 groups of 20100 eligible
cost performance categories. study to the CMS Study on Burdens clinicians.
In the CY 2018 Quality Payment Associated with Reporting Quality 2 groups of 100 or greater eligible
Program proposed rule at (82 FR 30056), Measures to more accurately reflect the clinicians.
while we did not propose any changes purpose of the study. The study assesses 2 specialty groups.
to the approach for adding new clinician burden and data submission In the CY 2018 Quality Payment
subcategories for the improvement errors associated with the collection and Program proposed rule (82 FR 30057),
activities performance category, we did submission of clinician quality we proposed to increase the sample size
propose that in future years of the measures for MIPS, enrolling groups of for the performance periods occurring in
Quality Payment Program, we would different sizes and individuals in both CY 2018 to a minimum of:
add new improvement activities rural and non-rural settings and also 20 urban individual or groups of <3
subcategories through notice-and- different specialties. We previously eligible clinicians,(broken down into
comment rulemaking. We did not finalized that study participants receive 10 individuals and 10 groups).
receive any comments on this proposal full credit in the improvement activities 20 rural individual or groups of <3
and are finalizing, as proposed, that in performance category if they eligible clinicians(broken down into
future years of the Quality Payment successfully elect, participate, and 10 individuals and 10 groups).
Program, we will add new improvement submit data to CMS for the full calendar 10 groups of 38 eligible clinicians.
activities subcategories through notice- year (81 FR 77196). In the CY 2017 final 10 groups of 820 eligible
and-comment rulemaking. rule (81 FR 77195 through 77197), we clinicians.
In the CY 2018 Quality Payment requested comments on the study and 10 groups of 20100 eligible
Program proposed rule at (82 FR 30056), received generally supportive feedback clinicians.
we also sought comments on new for the study. 10 groups of 100 or greater eligible
improvement activities subcategories for In the CY 2018 Quality Payment clinicians.
future consideration. In particular, in Program proposed rule (82 FR 30056 6 groups of >20 eligible clinicians
the CY 2017 Quality Payment Program through 30057), we did not propose any reporting as individuals(broken down
final rule (81 FR 77194), several changes to the study purpose. However, into 3 urban and 3 rural).
stakeholders have suggested that a we proposed changes to the study 6 specialty groups(broken down
separate subcategory for improvement participation credit and requirements into 3 reporting individually and 3
activities specifically related to health for sample size, how the study sample reporting as a group).
IT would make it easier for MIPS is categorized into groups, and the study Up to 10 non-MIPS eligible
eligible clinicians and vendors to procedures for the frequency of surveys, clinicians reporting as a group or
understand and earn points toward their focus groups, and quality data individual (any number of individuals
final score through the use of health IT. submission. These proposals are and any group size).
Such a health IT subcategory could discussed in more detail below. (c) Study Procedures
include only improvement activities
that are specifically related to the (b) Sample Size (i) Frequency of Survey and Focus
advancing care information performance In addition to performing descriptive Group
category measures and allow MIPS statistics to compare the trends in errors In the CY 2018 Quality Payment
eligible clinicians to earn credit in the and burden between study years 2017 Program proposed rule (82 FR 30057),
improvement activities performance and 2018 as previously finalized in the we also proposed changes to the study
category, while receiving a bonus in the (81 FR 77196), we would like to perform procedures. In the CY 2017 Quality
Payment Program final rule (81 FR As a result, in the CY 2018 Quality CMS Study on Burdens Associated
77196), we finalized that for transition Payment Program proposed rule (82 FR with Reporting Quality Measures; (2)
year of MIPS, study participants were 30057), we proposed, for the Quality increase the sample size for CY 2018
required to attend a monthly focus Payment Program Year 2 and future and beyond as discussed previously in
group to share lessons learned in years, to offer study participants this final rule with comment period; (3)
submitting quality data along with flexibility in their submissions such that require study participants to attend as
providing survey feedback to monitor they could submit all their quality frequently as four monthly surveys and
effectiveness. However, an individual measures data at once, as allowed in the focus group sessions throughout the
MIPS eligible clinician or group who MIPS program, and participate in study year; and (4) for the Quality Payment
chooses to report all 6 measures within surveys and focus groups, while still Program Year 2 and future years, offer
a period of 90 days may not need to be earning improvement activities credit. study participants flexibility in their
a part of all of the focus groups and We invited public comments on our
submissions such that they can submit
survey sessions after their first focus proposals.
Comment: A few commenters all their quality measures data at once
group and survey following the and participate in study surveys and
measurement data submission (81 FR supported the proposal to examine the
challenges and costs of reporting quality focus groups while still earning
77196). This is because they may have improvement activities credit.
nothing new to contribute in terms of measures by expanding, and aptly
discussion of errors or clinician burdens renaming the CMS Study on Burdens It must be noted that although the
(81 FR 77196). This also applied to Associated with Reporting Quality aforementioned activities constitute an
MIPS eligible clinicians that submitted Measures. information collection request as
only three MIPS measures within the Response: We thank the commenters defined in the implementing regulations
performance period, if all three for their support. of the Paperwork Reduction Act (PRA)
Comment: A few commenters of 1995 (5 CFR 1320), the associated
measures within the 90-day period or at
encouraged CMS to automate the burden is exempt from application of
one submission (81 FR 77196). We
process to reduce administrative burden
finalized that all study participants the Paperwork Reduction Act.
and publicly share the survey results.
would participate in surveys and focus Response: We note the suggestion to Specifically, section 1848(s)(7) of the
group meetings at least once after each automate the process (that is, the Act, as added by section 102 of the
measures data submission (81 FR measure data submission process) to MACRA (Pub. L. 11410) states that
77196). For those who elect to report reduce administrative burden, and will Chapter 35 of title 44, United States
data for a 90-day period, we made take this into consideration as we craft Code, shall not apply to the collection
further engagement optional (81 FR future policies. We also note that the of information for the development of
77196). current study survey and focus group quality measures. Our goals for new
In order to prevent or reduce study have open ended questions that ask measures are to develop new high
participants from incurring any more study participants about their quality, low cost measures that are
significant additional administrative recommendations and opinions on the meaningful, easily understandable and
work as compared to other MIPS eligible ease and complexities of technology on operable, that also, reliably and validly
clinicians not participating in the study, the process. Furthermore, we intend to measure what they purport. This study
in the CY 2018 Quality Payment make the results of the study public shall inform us on the root causes of
Program proposed rule (82 FR 30057), immediately after the end of the study clinicians performance measure data
we proposed that for Quality Payment year CY 2018 (summer 2019) to all collection and data submission burdens
Program Year 2 and future years, that study participants, relevant and challenges that hinders accurate
study participants would be required to stakeholders, and on the CMS Web site. and timely quality measurement
attend as frequently as four monthly Comment: A few commenters activities. In addition, this study will
surveys and focus group sessions suggested that CMS consider additional inform us on the characteristic attributes
throughout the year, but certain study study inclusion factors, such as: that our new measures must possess to
participants would be able to attend less Practices and clinicians located in both be able to accurately capture and
frequently. In other words, study urban and rural HPSAs and clinicians measure the priorities and gaps MACRA
participants would be required to attend who serve a high proportion of low- aims for, as described in the Quality
a maximum of four surveys and focus income patients and patients of color.
group sessions throughout the year. Measures Development Plan.2 This
Response: The study selection criteria
study, therefore, serves as the initial
(ii) Data Submission already includes; but is not limited to,
stage of developing new measures and
rural, urban and geographical location
We previously required study also adapting existing measures. We
(based on demographic characteristics)
measurement data to be collected at believe that understanding clinicians
(81 FR 77195). For study years CY 2017
baseline and then at every 3 months and CY 2018, we are able to analyze and challenges and skepticisms, and
(quarterly basis) afterwards for the compare clinicians who serve at both especially, understanding the factors
duration of the calendar year (81 FR rural and urban HPSAs, based on that undermine the optimal functioning
77196). We also finalized a minimum participants zip codes collected during and effectiveness of quality measures
requirement of three MIPS quality recruitment. Additionally, we will are requisites of developing measures
measures, four times within the year (81 consider for future rulemaking further that are not only measuring what it
FR 77196). We stated that we believe efforts to include proportionate HPSAs purports but also that are user friendly
this is inconsistent with clinicians and minority patients in the recruitment and understandable for frontline
reporting a full years data, as we and screening of the study participants. cliniciansour main stakeholders in
believe some study participants may Final Action: After consideration of measure development. This will lead to
choose to submit data for all measures the public comments we received, we the creation of practice-derived, tested
at one time, or alternatively, may choose are finalizing our proposals for the CY measures that reduces burden and
to submit data up to six times during the 2018 and beyond as proposed, to: (1) create a culture of continuous
1-year period (82 FR 30057). Modify the name of the study to the improvement in measure development.
f. Advancing Care Information MIPS eligible clinician cannot fulfill the access to immunization registries;
Performance Category Immunization Registry Reporting however, they stated our proposal to
(1) Background Measure, we proposed that the MIPS award 5 percentage points for reporting
eligible clinician could earn 5 to each additional public health agency
Section 1848(q)(2)(A) of the Act percentage points in the performance or clinical data registry minimized the
includes the meaningful use of CEHRT score for each public health agency or value of reporting to other types of
as a performance category under the clinical data registry to which the public health information beyond
MIPS. We refer to this performance clinician reports for the following immunization information. Commenters
category as the advancing care measures, up to a maximum of 10 suggested that we award 10 percentage
information performance category, and percentage points: Syndromic points in the performance score for
it is reported by MIPS eligible clinicians Surveillance Reporting; Electronic Case reporting to a single agency or registry.
as part of the overall MIPS program. As Reporting; Public Health Registry Response: We appreciate the
required by sections 1848(q)(2) and (5) Reporting; and Clinical Data Registry suggestion and did not intend to
of the Act, the four performance Reporting. A MIPS eligible clinician disadvantage MIPS eligible clinicians
categories of the MIPS shall be used in who chooses to report to more than one who lack access to immunization
determining the MIPS final score for public health agency or clinical data registries or do not administer
each MIPS eligible clinician. In general, registry may receive credit in the immunizations. The Public Health and
MIPS eligible clinicians will be performance score for the submission to Clinical Data Registry Reporting
evaluated under all four of the MIPS more than one agency or registry; Objective focuses on the importance of
performance categories, including the however, the MIPS eligible clinician the ongoing lines of communication that
advancing care information performance would not earn more than a total of 10 should exist between MIPS eligible
category. percentage points for such reporting. clinicians and public health agencies
We further proposed similar and clinical data registries, and we want
(2) Scoring
flexibility for MIPS eligible clinicians to encourage reporting to them. These
Section 1848(q)(5)(E)(i)(IV) of the Act who choose to report the measures registries play an important part in
states that 25 percent of the MIPS final specified for the Public Health monitoring the health status of patients
score shall be based on performance for Reporting Objective of the 2018 and some, for example syndromic
the advancing care information Advancing Care Information Transition surveillance registries, help in the early
performance category. We established at Objective and Measure set. (In section detection of outbreaks, which is critical
414.1380(b)(4) that the score for the II.C.6.f.(6)(b) of the proposed rule, we to public health overall. For these
advancing care information performance proposed to allow MIPS eligible reasons, we are finalizing our proposal
category would be comprised of a base clinicians to report using the 2018 with modification so that a MIPS
score, performance score, and potential Advancing Care Information Transition eligible clinician may earn 10
bonus points for reporting on certain Objectives and Measures in 2018.) We percentage points in the performance
measures and activities. For further proposed if a MIPS eligible clinician score for reporting to any single public
explanation of our scoring policies for fulfills the Immunization Registry health agency or clinical data registry,
the advancing care information Reporting Measure, the MIPS eligible regardless of whether an immunization
performance category, we refer readers clinician would earn 10 percentage registry is available to the clinician.
to 81 FR 7721677227. points in the performance score. If a Comment: One commenter requested
MIPS eligible clinician cannot fulfill the that we clarify that the exclusion for
(a) Base Score Immunization Registry Reporting is still
Immunization Registry Reporting
For the CY 2018 performance period, Measure, we proposed that the MIPS available to those who do not routinely
we did not propose any changes to the eligible clinician could earn 5 provide vaccinations.
base score methodology as established percentage points in the performance Response: No exclusion is available
in the CY 2017 Quality Payment score for each public health agency or for the Immunization Registry Reporting
Program final rule (81 FR 7721777223). specialized registry to which the Measure for the advancing care
clinician reports for the following information performance category. The
(b) Performance Score Immunization Registry Reporting
measures, up to a maximum of 10
In the CY 2017 Quality Payment percentage points: Syndromic Measure is part of the performance score
Program final rule (81 FR 77223 through Surveillance Reporting; Specialized in which clinicians can select which
77226), we finalized that MIPS eligible Registry Reporting. A MIPS eligible measures they wish to report. If they do
clinicians can earn 10 percentage points clinician who chooses to report to more not provide vaccinations, then they
in the performance score for meeting the than one specialized registry or public would not report on the Immunization
Immunization Registry Reporting health agency to submit syndromic Registry Reporting Measure. The final
Measure. We proposed to modify our surveillance data may earn 5 percentage policy we are adopting should provide
policy for scoring the Public Health and points in the performance score for flexibility for clinicians who do not
Clinical Data Registry Reporting reporting to each one, up to a maximum administer immunizations by allowing
Objective beginning with the of 10 percentage points. them to earn performance score points
performance period in CY 2018 because The following is a summary of the for public health reporting that is not
we have learned that there are areas of public comments received on these related to immunizations.
the country where immunization proposals and our responses: Final Action: After consideration of
registries are not available, and we did Comment: Commenters supported the the public comments and for the reasons
not intend to disadvantage MIPS eligible flexibility that we proposed to complete noted above, we are finalizing our
clinicians practicing in those areas. We the objective and earn points in the proposal with modification. Rather than
proposed if a MIPS eligible clinician performance score. Other commenters awarding 5 percentage points in the
fulfills the Immunization Registry stated that they appreciate the options performance score for each public
Reporting Measure, the MIPS eligible for earning a performance score. Most health agency or clinical data registry
clinician would earn 10 percentage commenters appreciated our intent not that a MIPS eligible clinician reports to
points in the performance score. If a to disadvantage those clinicians without (for a maximum of 10 percentage
points), we are finalizing that a MIPS associated with the Public Health and and bonus score for reporting to the
eligible clinician may earn 10 Clinical Data Registry Reporting same agency or registry.
percentage points in the performance Objective: Syndromic Surveillance Response: We appreciate the support
score for reporting to any single public Reporting; Electronic Case Reporting; for our proposal. As we proposed, MIPS
health agency or clinical data registry to Public Health Registry Reporting; or eligible clinician cannot receive credit
meet any of the measures associated Clinical Data Registry Reporting. We under both the performance score and
with the Public Health and Clinical Data proposed that for the 2018 Advancing bonus score for reporting to the same
Registry Reporting Objective (or any of Care Information Transition Objectives public health agency or registry.
the measures associated with the Public and Measures, a bonus of 5 percent Final Action: After consideration of
Health Reporting Objective of the 2018 would be awarded if the MIPS eligible the public comments that we received,
Advancing Care Information Transition clinician reports yes for any one of we are adopting our proposal as
Objectives and Measures, for clinicians the following measures associated with proposed and updating the regulation
who choose to report on those the Public Health Reporting Objective: text at 414.1380(b)(4)(C)(1).
measures), regardless of whether an Syndromic Surveillance Reporting or (d) Improvement Activities Bonus Score
immunization registry is available to the Specialized Registry Reporting. We under the Advancing Care Information
clinician. A MIPS eligible clinician can proposed that to earn the bonus score, Performance Category
earn only 10 percentage points in the the MIPS eligible clinician must be in
performance score under this policy, no In the CY 2017 Quality Payment
active engagement with one or more
matter how many agencies or registries Program final rule (81 FR 77202), we
additional public health agencies or
they report to. This policy will apply discussed our approach to the
clinical data registries that is/are
beginning with the 2018 performance measurement of the use of health IT to
different from the agency or registry that
period. allow MIPS eligible clinicians and
they identified to earn a performance
groups the flexibility to implement
(c) Bonus Score score.
health IT in a way that supports their
The following is a summary of the
In the CY 2017 Quality Payment clinical needs. Toward that end, we
public comments received on these
Program final rule (81 FR 77220 through adopted a policy to award a bonus score
proposals and our responses:
77226), for the Public Health and to MIPS eligible clinicians who use
Comment: Commenters supported the CEHRT to complete certain activities in
Clinical Data Registry Reporting
awarding of bonus points for reporting the improvement activities performance
Objective and the Public Health
to an additional agency or registry. A category based on our belief that the use
Reporting Objective, we finalized that
commenter supported providing bonus of CEHRT in carrying out these
MIPS eligible clinicians who report to
one or more public health agencies or points for registry reporting rather than activities could further the outcomes of
clinical data registries beyond the mandating registry reporting. clinical practice improvement.
Immunization Registry Reporting Response: We appreciate the support We adopted a final policy to award a
Measure will earn a bonus score of 5 for our proposal. 10 percent bonus for the advancing care
percentage points in the advancing care Comment: One commenter requested information performance category if a
information performance category. that we make it explicitly clear that MIPS eligible clinician attests to
Based on our proposals discussed above MIPS eligible clinicians cannot earn a completing at least one of the
to allow MIPS eligible clinicians who bonus score for reporting to the same improvement activities we have
cannot fulfill the Immunization Registry agency or registry that they identified specified using CEHRT (81 FR 77209).
Reporting Measure to earn additional for the purposes of earning a We referred readers to Table 8 in the CY
points in the performance score, we performance score. 2017 Quality Payment Program final
proposed to modify this policy so that Response: Under our final policy rule (81 FR 7720277209) for a list of
MIPS eligible clinicians cannot earn discussed above, MIPS eligible the improvement activities eligible for
points in both the performance score clinicians may report to a single public the advancing care information
and bonus score for reporting to the health or clinical data registry and earn performance category bonus. We
same public health agency or clinical 10 percentage points in the performance proposed to expand this policy
data registry. We proposed to modify score. Reporting to a different public beginning with the CY 2018
our policy beginning with the health or clinical data registry may earn performance period by identifying
performance period in CY 2018. We the MIPS eligible clinician five additional improvement activities in
proposed that a MIPS eligible clinician percentage points in the bonus score. In Table 6 (82 FR 3006030063) that would
may earn the bonus score of 5 order to earn the bonus score, the MIPS be eligible for the advancing care
percentage points for reporting to at eligible clinician must be in active information performance category bonus
least one additional public health engagement with a different public score if they are completed using
agency or clinical data registry that is health agency or clinical data registry CEHRT functionality.
different from the agency/agencies or than the one to which they reported to The following is a summary of the
registry/or registries to which the MIPS earn the 10 percentage points for the public comments received on this
eligible clinician reports to earn a performance score. We expect to engage proposal and our responses:
performance score. A MIPS eligible in education and outreach efforts to Comment: One commenter supported
clinician would not receive credit under ensure MIPS eligible clinicians are rewarding clinicians who used CEHRT
both the performance score and bonus aware of the policies adopted in this to perform improvement activities.
score for reporting to the same agency final rule with comment period Other commenters appreciated the
or registry. including the policy for earning bonus proposed additions to the list of
We proposed that for the Advancing points for the advancing care improvement activities using CEHRT
Care Information Objectives and information performance category. that would be eligible for the bonus.
Measures, a bonus of 5 percentage Comment: One commenter supported Response: We appreciate the support
points would be awarded if the MIPS closing the loophole so that a MIPS as we continue to believe that offering
eligible clinician reports yes for any eligible clinician cannot receive double this bonus will encourage MIPS eligible
one of the following measures credit under both the performance score clinicians to use CEHRT not only to
document patient care, but also to earn the base score for the advancing improvement activities shown in Table
improve their clinical practices by using care information performance category, 6 that will be eligible for the advancing
CEHRT in a meaningful manner that amounting to 50 percent of the care information performance category
supports clinical practice improvement. advancing care information performance bonus score beginning with the 2018
We refer readers to Table 6 which lists category. performance period if they are
all improvement activities eligible for Response: We appreciate the completed using CEHRT. We refer
the advancing care information commenters input and continue to be readers to Table F: New Improvement
performance category improvement interested in options for incentivizing Activities for the Quality Payment
activity bonus in 2018. clinicians to use CEHRT in the Program Year 2 and Future Years and
Comment: One commenter completion of improvement activities.
Table G: Improvement Activities with
recommended that MIPS eligible We will take this comment under
clinicians and groups that attest to Changes for the Quality Payment
consideration for future rulemaking on
completing one or more of the Program Year 2 and Future Years for
this topic.
improvement activities using CEHRT Final Action: After consideration of more information on modifications to
should not only earn improvement the public comments, we are finalizing the Improvement Activities that were
activity credit but also automatically with modifications the list of proposed.
TABLE 6IMPROVEMENT ACTIVITIES ELIGIBLE FOR THE ADVANCING CARE INFORMATION PERFORMANCE CATEGORY
BONUS BEGINNING WITH THE 2018 PERFORMANCE PERIOD
Improvement
Improvement activity Related
activity Activity name Activity performance advancing care
performance category category information measure(s) *
subcategory weight
Expanded Practice Access .. Provide 24/7 access to eli- Provide 24/7 access to MIPS eligible clinicians, groups, Medium .......... Provide Patient Access.
gible clinicians or groups or care teams for advice about urgent and emergent Secure Messaging.
who have real-time ac- care (for example, MIPS eligible clinician and care Send A Summary of Care.
cess to patients medical team access to CEHRT, cross-coverage with access Request/Accept Summary
record. to CEHRT, or protocol-driven nurse line with access of Care.
to CEHRT) that could include one or more of the fol-
lowing:
Expanded hours in evenings and weekends with ac-
cess to the patient medical record (for example, co-
ordinate with small practices to provide alternate hour
office visits and urgent care);
Use of alternatives to increase access to care team
by MIPS eligible clinicians and groups, such as e-vis-
its, phone visits, group visits, home visits and alter-
nate locations (for example, senior centers and as-
sisted living centers); and/or
Provision of same-day or next-day access to a con-
sistent MIPS eligible clinician, group or care team
when needed for urgent care or transition manage-
ment.
Patient Safety and Practice Communication of Un- A MIPS eligible clinician providing unscheduled care Medium .......... Secure Messaging.
Assessment. scheduled Visit for Ad- (such as an emergency room, urgent care, or other Send A Summary of Care.
verse Drug Event and unplanned encounter) attests that, for greater than 75 Request/Accept Summary
Nature of Event. percent of case visits that result from a clinically sig- of Care.
nificant adverse drug event, the MIPS eligible clini-
cian transmits information, including through the use
of CEHRT to the patients primary care clinician re-
garding both the unscheduled visit and the nature of
the adverse drug event within 48 hours. A clinically
significant adverse event is defined as a medication-
related harm or injury such as side-effects,
supratherapeutic effects, allergic reactions, laboratory
abnormalities, or medication errors requiring urgent/
emergent evaluation, treatment, or hospitalization.
Patient Safety and Practice Consulting AUC using clin- Clinicians attest that they are consulting specified appli- High ................ Clinical Decision Support
Assessment. ical decision support cable AUC through a qualified clinical decision sup- (CEHRT function only).
when ordering advanced port mechanism for all applicable imaging services
diagnostic imaging. furnished in an applicable setting, paid for under an
applicable payment system, and ordered on or after
January 1, 2018. This activity is for clinicians that are
early adopters of the Medicare AUC program (2018
performance year) and for clinicians that begin the
Medicare AUC program in future years as specified in
our regulation at 414.94. The AUC program is re-
quired under section 218 of the Protecting Access to
Medicare Act of 2014. Qualified mechanisms will be

able to provide a report to the ordering clinician that
can be used to assess patterns of image-ordering
and improve upon those patterns to ensure that pa-
tients are receiving the most appropriate imaging for
their individual condition.
Patient Safety and Practice Cost Display for Laboratory Implementation of a cost display for laboratory and radi- Medium .......... Clinical Decision Support
Assessment. and Radiographic Orders. ographic orders, such as costs that can be obtained (CEHRT function only).
through the Medicare clinical laboratory fee schedule.
BONUS BEGINNING WITH THE 2018 PERFORMANCE PERIODContinued
Improvement
subcategory weight
Population Management ...... Glycemic Screening Serv- For at-risk outpatient Medicare beneficiaries, individual Medium .......... Patient-Specific Education.
ices. MIPS eligible clinicians and groups must attest to im- Patient Generated Health
plementation of systematic preventive approaches in Data or Data from Non-
clinical practice for at least 60 percent for the 2018 clinical Settings.
performance period and 75 percent in future years, of
CEHRT with documentation of screening patients for
abnormal blood glucose according to current U.S.
Preventive Services Task Force (USPSTF) and/or
American Diabetes Association (ADA) guidelines.
Population Management ...... Glycemic management For outpatient Medicare beneficiaries with diabetes and High ................ Patient Generated Health
services. who are prescribed antidiabetic agents (for example, Data.
insulin, sulfonylureas), MIPS eligible clinicians and Clinical Information Rec-
groups must attest to having: onciliation.
Clinical Decision Support,
CCDS, Family Health
History (CEHRT functions
only).
For the first performance period, at least 60 percent of
medical records with documentation of an individual-
ized glycemic treatment goal that:
Takes into account patient-specific factors, including,
at least (1) age, (2) comorbidities, and (3) risk for
hypoglycemia, and
Is reassessed at least annually.
The performance threshold will increase to 75 percent
for the second performance period and onward.
Clinicians would attest that, 60 percent for first year, or
75 percent for the second year, of their medical
records that document individualized glycemic treat-
ment represent patients who are being treated for at
least 90 days during the performance period.
Population Management ...... Glycemic Referring Serv- For at-risk outpatient Medicare beneficiaries, individual Medium .......... Patient-Specific Education.
ices. MIPS eligible clinicians and groups must attest to im- Patient Generated Health
plementation of systematic preventive approaches in Data or Data from Non-
clinical practice for at least 60 percent for the CY clinical Settings.
2018 performance period and 75 percent in future
years, of CEHRT with documentation of referring eli-
gible patients with prediabetes to a CDC-recognized
diabetes prevention program operating under the
framework of the National Diabetes Prevention Pro-
gram.
Population Management ...... Anticoagulant management Individual MIPS eligible clinicians and groups who pre- High ................ Provide Patient Access.
improvements. scribe oral Vitamin K antagonist therapy (warfarin) Patient-Specific Education.
must attest that, for 60 percent of practice patients in View, Download, Transmit.
the transition year and 75 percent of practice patients Secure Messaging.
in Quality Payment Program Year 2 and future years, Patient Generated Health
their ambulatory care patients receiving warfarin are Data or Data from Non-
being managed by one or more of the following im- Clinical Setting.
provement activities;. Send a Summary of Care.
Patients are being managed by an anticoagulant Request/Accept Summary
management service, that involves systematic and of Care.
coordinated care, incorporating comprehensive pa- Clinical Information Rec-
tient education, systematic prothrombin time (PT onciliation Exchange.
INR) testing, tracking, follow-up, and patient commu- Clinical Decision Support
nication of results and dosing decisions; (CEHRT Function Only).
Patients are being managed according to validated
electronic decision support and clinical management
tools that involve systematic and coordinated care, in-
corporating comprehensive patient education, sys-
tematic PTINR testing, tracking, follow-up, and pa-
tient communication of results and dosing decisions;
For rural or remote patients, patients are managed
using remote monitoring or telehealth options that in-
volve systematic and coordinated care, incorporating
comprehensive patient education, systematic PTINR
testing, tracking, follow-up, and patient communica-

tion of results and dosing decisions; and/or
For patients who demonstrate motivation, com-
petency, and adherence, patients are managed using
either a patient self-testing (PST) or patient-self-man-
agement (PSM) program.
Improvement
subcategory weight
Population Management ...... Provide Clinical-Community Engaging community health workers to provide a com- Medium .......... Provide Patient Access.
Linkages. prehensive link to community resources through fam- Patient-Specific Education.
ily-based services focusing on success in health, edu- Patient-Generated Health
cation, and self-sufficiency. This activity supports indi- Data.
vidual MIPS eligible clinicians or groups that coordi-
nate with primary care and other clinicians, engage
and support patients, use of CEHRT, and employ
quality measurement and improvement processes. An
example of this community based program is the
NCQA Patient-Centered Connected Care (PCCC)
Recognition Program or other such programs that
meet these criteria.
Population Management ...... Advance Care Planning ...... Implementation of practices/processes to develop ad- Medium .......... Patient-Specific Education.
vance care planning that includes: Documenting the Patient-Generated Health
advance care plan or living will within CEHRT, edu- Data.
cating clinicians about advance care planning moti-
vating them to address advance care planning needs
of their patients, and how these needs can translate
into quality improvement, educating clinicians on ap-
proaches and barriers to talking to patients about
end-of-life and palliative care needs and ways to
manage its documentation, as well as informing clini-
cians of the healthcare policy side of advance care
planning.
Population Management ...... Chronic care and preventa- Proactively manage chronic and preventive care for Medium .......... Provide Patient Access.
tive care management for empanelled patients that could include one or more of Patient-Specific Education.
empanelled patients. the following: View, Download, Transmit.
Provide patients annually with an opportunity for de- Secure Messaging.
velopment and/or adjustment of an individualized plan Patient Generated Health
of care as appropriate to age and health status, in- Data or Data from Non-
cluding health risk appraisal; gender, age and condi- Clinical Setting.
tion-specific preventive care services; plan of care for Send A Summary of Care.
chronic conditions; and advance care planning; Request/Accept Summary
Use condition-specific pathways for care of chronic of Care.
conditions (for example, hypertension, diabetes, de- Clinical Information Rec-
pression, asthma and heart failure) with evidence- onciliation.
based protocols to guide treatment to target; Clinical Decision Support,
Use pre-visit planning to optimize preventive care and Family Health History
team management of patients with chronic conditions; (CEHRT functions only).
Use panel support tools (registry functionality) to
identify services due;
Use reminders and outreach (for example, phone
calls, emails, postcards, patient portals and commu-
nity health workers where available) to alert and edu-
cate patients about services due; and/or
Routine medication reconciliation
Population Management ...... Implementation of meth- Provide longitudinal care management to patients at Medium .......... Provide Patient Access.
odologies for improve- high risk for adverse health outcome or harm that Patient-Specific Education.
ments in longitudinal care could include one or more of the following: Patient Generated Health
management for high risk Use a consistent method to assign and adjust global Data or Data from Non-
patients. risk status for all empaneled patients to allow risk clinical Settings.
stratification into actionable risk cohorts. Monitor the Send A Summary of Care.
risk-stratification method and refine as necessary to Request/Accept Summary
improve accuracy of risk status identification; of Care.
Use a personalized plan of care for patients at high Clinical information rec-
risk for adverse health outcome or harm, integrating onciliation.
patient goals, values and priorities; and/or Clinical Decision Support,
Use on-site practice-based or shared care managers CCDS, Family Health
to proactively monitor and coordinate care for the History, Patient List
highest risk cohort of patients. (CEHRT functions only).
Population Management ...... Implementation of episodic Provide episodic care management, including manage- Medium .......... Send A Summary of Care.
care management prac- ment across transitions and referrals that could in- Request/Accept Summary
tice. clude one or more of the following: of Care.
Routine and timely follow-up to hospitalizations, ED Clinical Information Rec-
visits and stays in other institutional settings, includ- onciliation.
ing symptom and disease management, and medica-
tion reconciliation and management; and/or

Managing care intensively through new diagnoses, in-
juries and exacerbations of illness.
Improvement
subcategory weight
Population Management ...... Implementation of medica- Manage medications to maximize efficiency, effective- Medium .......... Clinical Information Rec-
tion management practice ness and safety that could include one or more of the onciliation.
improvements. following: Clinical Decision Support,
Reconcile and coordinate medications and provide Computerized Physician
medication management across transitions of care Order Entry Electronic
settings and eligible clinicians or groups; Prescribing (CEHRT
Integrate a pharmacist into the care team; and/or functions only).
Conduct periodic, structured medication reviews.
Achieving Health Equity ...... Promote use of patient-re- Demonstrate performance of activities for employing pa- High ................ Public Health Registry Re-
ported outcome tools. tient-reported outcome (PRO) tools and cor- porting.
responding collection of PRO data (e.g., use of PQH- Clinical Data Registry Re-
2 or PHQ-9 and PROMIS instruments) such as pa- porting.
tient reported Wound Quality of Life (QoL), patient re- Patient-Generated Health
ported Wound Outcome, and patient reported Nutri- Data.
tional Screening.
Care Coordination ............... Practice Improvements that Develop pathways to neighborhood/community-based Medium .......... Send a Summary of Care.
Engage Community Re- resources to support patient health goals that could Request/Accept Summary
sources to Support Pa- include one or more of the following: of Care.
tient Health Goals. Maintain formal (referral) links to community-based Patient-Generated Health
chronic disease self-management support programs, Data.
exercise programs and other wellness resources with
the potential for bidirectional flow of information and
provide a guide to available community resources.
Including through the use of tools that facilitate elec-
tronic communication between settings;
Screen patients for health-harming legal needs;
Screen and assess patients for social needs using
tools that are CEHRT enabled and that include to any
extent standards-based, coded question/field for the
capture of data as is feasible and available as part of
such tool; and/or
............................................. Provide a guide to available community resources.
Care Coordination ............... Primary Care Physician and The primary care and behavioral health practices use Medium .......... Send a Summary of Care.
Behavioral Health Bilat- the same CEHRT system for shared patients or have Request/Accept Summary
eral Electronic Exchange an established bidirectional flow of primary care and of Care.
of Information for Shared behavioral health records.
Patients.
Care Coordination ............... PSH Care Coordination ...... Participation in a Perioperative Surgical Home (PSH) Medium .......... Send a Summary of Care.
that provides a patient-centered, physician-led, inter- Request/Accept Summary
disciplinary, and team-based system of coordinated of Care.
patient care, which coordinates care from pre-proce- Clinical Information Rec-
dure assessment through the acute care episode, re- onciliation.
covery, and post-acute care. This activity allows for Health Information Ex-
reporting of strategies and processes related to care change.
coordination of patients receiving surgical or proce-
dural care within a PSH. The clinician must perform
one or more of the following care coordination activi-
ties:
Coordinate with care managers/navigators in pre-
operative clinic to plan and implementation com-
prehensive post discharge plan of care;
Deploy perioperative clinic and care processes to re-
duce post-operative visits to emergency rooms;.
Implement evidence-informed practices and stand-
ardize care across the entire spectrum of surgical pa-
tients; or.
Implement processes to ensure effective communica-
tions and education of patients post-discharge in-
structions.
Care Coordination ............... Implementation of use of Performance of regular practices that include providing Medium .......... Send A Summary of Care.
specialist reports back to specialist reports back to the referring MIPS eligible Request/Accept Summary
referring clinician or clinician or group to close the referral loop or where of Care.
group to close referral the referring MIPS eligible clinician or group initiates Clinical Information Rec-
loop. regular inquiries to specialist for specialist reports onciliation.
which could be documented or noted in the CEHRT.
Care Coordination ............... Implementation of docu- Implementation of practices/processes, including a dis- Medium .......... Secure Messaging.
mentation improvements cussion on care, to develop regularly updated indi- Send A Summary of Care.
for developing regular in- vidual care plans for at-risk patients that are shared Request/Accept Summary
dividual care plans. with the beneficiary or caregiver(s). Individual care of Care.
plans should include consideration of a patients Clinical Information Rec-
goals and priorities, as well as desired outcomes of onciliation.
care.
Improvement
subcategory weight
Care Coordination ............... Implementation of practices/ Implementation of practices/processes to develop regu- Medium .......... Provide Patient Access (for-
processes for developing larly updated individual care plans for at-risk patients merly Patient Access).
regular individual care that are shared with the beneficiary or caregiver(s). View, Download, Transmit.
plans. Secure Messaging.
Patient Generated Health
Data or Data from Non-
Clinical Setting.
Care Coordination ............... Practice improvements for Ensure that there is bilateral exchange of necessary pa- Medium .......... Send A Summary of Care.
bilateral exchange of patient information to guide patient care, such as Open Request/Accept Summary
tient information. Notes, that could include one or more of the fol- of Care.
lowing: Clinical Information Rec-
Participate in a Health Information Exchange if avail- onciliation.
able; and/or
Use structured referral notes
Beneficiary Engagement ..... Engage Patients and Fami- Engage patients and families to guide improvement in High ................ Patient-Generated Health
lies to Guide Improve- the system of care by leveraging digital tools for on- Data.
ment in the System of going guidance and assessments outside the encoun- Provide Patient Access.
Care. ter, including the collection and use of patient data for View, Download, or Trans-
return-to-work and patient quality of life improvement. mit.
Platforms and devices that collect patient-generated
health data (PGHD) must do so with an active feed-
back loop, either providing PGHD in real or near-real
time to the care team, or generating clinically en-
dorsed real or near-real time automated feedback to
the patient. Includes patient reported outcomes
(PROs). Examples include patient engagement and
outcomes tracking platforms, cellular or web-enabled
bi-directional systems, and other devices that transmit
clinically valid objective and subjective data back to
care teams.
Because many consumer-grade devices capture PGHD
(for example, wellness devices), platforms or devices
eligible for this improvement activity must be, at a
minimum, endorsed and offered clinically by care
teams to patients to automatically send ongoing guid-
ance (one way). Platforms and devices that addition-
ally collect PGHD must do so with an active feedback
loop, either providing PGHD in real or near-real time
to the care team, or generating clinically endorsed
real or near-real time automated feedback to the pa-
tient (e.g. automated patient-facing instructions based
on glucometer readings). Therefore, unlike passive
platforms or devices that may collect but do not trans-
mit PGHD in real or near-real time to clinical care
teams, active devices and platforms can inform the
patient or the clinical care team in a timely manner of
important parameters regarding a patients status, ad-
herence, comprehension, and indicators of clinical
concern.
Beneficiary Engagement ..... Use of CEHRT to capture In support of improving patient access, performing addi- Medium .......... Provide Patient Access.
patient reported out- tional activities that enable capture of patient reported Patient-Specific Education.
comes. outcomes (for example, home blood pressure, blood Care Coordination through
glucose logs, food diaries, at-risk health factors such Patient Engagement.
as tobacco or alcohol use, etc.) or patient activation
measures through use of CEHRT, containing this
data in a separate queue for clinician recognition and
review.
Beneficiary Engagement ..... Engagement of patients Access to an enhanced patient portal that provides up Medium .......... Provide Patient Access.
through implementation. to date information related to relevant chronic disease Patient-Specific Education.
health or blood pressure control, and includes inter-
active features allowing patients to enter health infor-
mation and/or enables bidirectional communication
about medication changes and adherence.
Beneficiary Engagement ..... Engagement of patients, Engage patients, family and caregivers in developing a Medium .......... Provide Patient Access.
family and caregivers in plan of care and prioritizing their goals for action, Patient-specific Education.
developing a plan of care. documented in the CEHRT. View, Download, Transmit

(Patient Action).
Secure Messaging.
Patient Safety and Practice Use of decision support and Use decision support and protocols to manage workflow Medium .......... Clinical Decision Support
standardized treatment in the team to meet patient needs. (CEHRT function only).
protocols.
Improvement
subcategory weight
Achieving Health Equity ...... Promote Use of Patient-Re- Demonstrate performance of activities for employing pa- Medium .......... Patient Generated Health
ported Outcome Tools. tient-reported outcome (PRO) tools and cor- Data or Data from a Non-
responding collection of PRO data such as the use of Clinical Setting.
PQH-2 or PHQ-9, PROMIS instruments, patient re- Public Health and Clinical
ported Wound Quality of Life (QoL), patient reported Data Registry Reporting.
Wound Outcome, and patient reported Nutritional
Screening.
Behavioral and Mental Implementation of inte- Offer integrated behavioral health services to support High ................ Provide Patient Access.
Health. grated Patient Centered patients with behavioral health needs, dementia, and Patient-Specific Education.
Behavioral Health poorly controlled chronic conditions. The services View, Download, Transmit.
(PCBH) model. could include one or more of the following:. Secure Messaging.
Use evidence-based treatment protocols and treat- Patient Generated Health
ment to goal where appropriate; Data or Data from Non-
Use evidence-based screening and case finding strat- Clinical Setting.
egies to identify individuals at risk and in need of Care coordination through
services; Patient Engagement.
Ensure regular communication and coordinated Send A Summary of Care.
workflows between eligible clinicians in primary care
and behavioral health;
Conduct regular case reviews for at-risk or unstable
patients and those who are not responding to treat-
ment;
Use of a registry or certified health information tech-
nology functionality to support active care manage-
ment and outreach to patients in treatment; and/or
Integrate behavioral health and medical care plans Request/Accept Summary
and facilitate integration through co-location of serv- of Care.
ices when feasible; and/or
Participate in the National Partnership to Improve De-
mentia Care Initiative, which promotes a multidimen-
sional approach that includes public reporting, state-
based coalitions, research, training, and revised sur-
veyor guidance.
Behavioral and Mental Electronic Health Record Enhancements to CEHRT to capture additional data on Medium .......... Patient Generated Health
Health. Enhancements for BH behavioral health (BH) populations and use that data Data or Data from Non-
data capture. for additional decision-making purposes (for example, Clinical Setting.
capture of additional BH data results in additional de- Send A Summary of Care.
pression screening for at-risk patient not previously Request/Accept Summary
identified). of Care.
Clinical Information Rec-
onciliation.
(3) Performance Periods for the Comment: Commenters supported the Comment: A few commenters
Advancing Care Information continuation of a performance period of expressed their disappointment that we
Performance Category a minimum of 90 consecutive days of proposed another 90-day performance
data in CY 2019. Some stated that period for 2019 and urged us to move
In the CY 2017 Quality Payment maintaining the 90-day performance to full calendar year reporting as soon
Program final rule (81 FR 77210 through period for the first 3 years of MIPS is as possible. They stated that patients
77211), we established a performance important to add stability for the and families should be able to
period for the advancing care reporting on the performance category. experience the benefits of health IT
information performance category to One commenter requested that we
align with the overall MIPS performance getting questions answered through
maintain the 90-day performance period
period of one full year to ensure all four secure email, or having summary of care
for the advancing care information
performance categories are measured records incorporated into new
performance category in perpetuity as a
and scored based on the same period of shorter period enables physicians to providers health records any day of
time. We stated for the first and second adopt innovative uses of technology and the year, rather than a particular three-
performance periods of MIPS (CYs 2017 permits flexibility to test new health IT month period.
and 2018), we will accept a minimum solutions. Response: Although we proposed that
of 90 consecutive days of data and Response: While we believe a 90-day the MIPS performance period for the
encourage MIPS eligible clinicians to performance period is appropriate for advancing care information performance
report data for the full year performance advancing care information for the 2017, category would be a minimum of 90
period. We proposed the same policy for 2018 and 2019 performance periods, we consecutive days, MIPS eligible
the advancing care information believe it is premature to establish the clinicians have the option to submit
performance category for the performance periods for any additional data for longer periods up to a full
performance period in CY 2019, Quality years at this time. We will consider calendar year. Furthermore, we believe
Payment Program Year 3, and would creating a 90-day performance period
accept a minimum of 90 consecutive for 2020 and beyond and may address
days of data in CY 2019. this issue in future rulemaking.
that once the functionality in the 2015 for 2018. Thus, we proposed that MIPS performance period so that they can
Edition CEHRT is implemented, MIPS eligible clinicians may use EHR plan accordingly.
eligible clinicians will use it all the technology certified to either the 2014 Response: Under our current policy as
time. or 2015 Edition certification criteria, or reflected in 414.1305, 2015 Edition
Final Action: After consideration of a combination of the two for the CY CEHRT will be required in the
the public comments, we are adopting 2018 performance period. We proposed performance period in 2019. We believe
our policy as proposed. We will accept to amend 414.1305 to reflect this that there are many benefits for MIPS
a minimum of 90 consecutive days of change. eligible clinicians and their patients
data in CY 2019 and are revising We further noted, that to encourage implementing the 2015 Edition of
414.1320(d)(1). new participants to adopt certified CEHRT. These include enabling health
health IT and to incentivize participants information exchange through new and
(4) Certification Requirements
to upgrade their technology to 2015 enhanced certification criteria
In the CY 2017 Quality Payment Edition products which better support standards, as well as through
Program final rule (81 FR 77211 through interoperability across the care implementation specifications for
77213), we outlined the requirements continuum, we proposed to offer a interoperability. The 2015 Edition also
for MIPS eligible clinicians using bonus of 10 percentage points under the incorporates changes that are designed
CEHRT during the CY 2017 performance advancing care information performance to spur innovation and provide more
period for the advancing care category for MIPS eligible clinicians choices to health care providers and
information performance category as it who report the Advancing Care patients for the exchange of electronic
relates to the objectives and measures Information Objectives and Measures for health information, including new
they select to report, and also outlined the performance period in CY 2018 Application Programming Interface
requirements for the CY 2018 using only 2015 Edition CEHRT. We (API) certification criteria.
performance period. We additionally proposed to amend 414.1380(b)(4)C)(3) Comment: Several commenters stated
adopted a definition of CEHRT at to reflect this change. We proposed this their disappointment with the proposed
414.1305 for MIPS eligible clinicians one-time bonus for CY 2018 to support delayed transition to 2015 Edition
that is based on the definition that and recognize MIPS eligible clinicians CEHRT as they believe that it includes
applies in the EHR Incentive Programs and groups that invest in implementing significant patient-facing technologies
under 495.4. certified EHR technology in their and new functionalities to support
For the CY 2017 performance period, practice. We sought comment on the patient engagement and improve
we adopted a policy by which MIPS proposed bonus, the proposed amount interoperability.
eligible clinicians may use EHR of percentage points for the bonus, and Response: While we understand the
technology certified to either the 2014 whether the bonus should be limited to concern, we believe that it is important
or 2015 Edition certification criteria, or new participants in MIPS and small to provide MIPS eligible clinicians with
a combination of the two. For the CY practices. flexibility and more time to adopt and
2018 performance period, we previously The following is a summary of the implement 2015 CEHRT We recognize
stated that MIPS eligible clinicians must public comments received on these there is burden associated with the
use EHR technology certified to the proposals and our responses: development and deployment of each
2015 Edition to meet the objectives and Comment: Most commenters new version of CEHRT, which may be
measures specified for the advancing supported our proposal to allow the use labor intensive and expensive for
care information performance category. of 2014 Edition or 2015 Edition CEHRT clinicians so we believe the additional
We received significant comments from or a combination for the 2018 time will be welcomed. In addition if
the CY 2017 Quality Payment Program performance period. One stated that MIPS eligible clinicians are ready to
final rule and feedback from allowing flexibility allows clinicians report using the 2015 Edition, we
stakeholders through meetings and more time to fully evaluate their EHR encourage them to do so.
listening sessions requesting that we optimization in a meaningful way that Comment: Most commenters
extend the use of 2014 Edition CEHRT ensures EHR systems are in place, tested supported our proposal to award a 10
beyond CY 2017 into CY 2018. Many thoroughly and operating as intended. percentage point bonus for using 2015
commenters expressed concern over the Many stated that an additional Edition CEHRT exclusively in 2018.
lack of products certified to the 2015 transition year would be very helpful in Response: We appreciate the support
Edition. Other commenters stated that allowing physicians to plan for the for this proposal and believe the bonus
switching from the 2014 Edition to the required upgrades, which can be costly will incentivize MIPS eligible clinicians
2015 Edition requires a large amount of and time-consuming. A few commenters to work to implement 2015 Edition
time and planning and if it is rushed supported our proposal because they CEHRT by 2018.
there is a potential risk to patient health. believed it would delay the requirement Comment: Some commenters
Also, our experience with the transition to report on the Advancing Care suggested that we offer a bonus to those
from EHR technology certified to the Information Objectives and Measures MIPS eligible clinicians who use a
2011 Edition to EHR technology derived from meaningful use Stage 3 in combination of 2014 Edition and 2015
certified to the 2014 Edition did make 2018. Edition CEHRT in 2018. Others
us aware of the many issues associated Response: We thank commenters for suggested that the bonus be available
with the adoption of EHR technology their feedback and support of CEHRT not only in 2018 but also in 2019. Other
certified to a new Edition. These flexibility in 2018. We hope that commenters requested that the bonus be
include the time that will be necessary allowing MIPS eligible clinicians to use available to all MIPS eligible clinicians
to effectively deploy EHR technology 2014 Edition or 2015 Edition CEHRT or regardless of whether they are new to
certified to the 2015 Edition standards a combination of the two in 2018 will the MIPS program or not. Other
and certification criteria and to make allow for a smooth transition to 2015 commenters believed that CMS has
the necessary patient safety, staff Edition CEHRT. struck an appropriate balance of
training, and workflow investments to Comment: One commenter requested minimizing the regulatory burden on
be prepared to report for the advancing that we affirm that 2015 Edition CEHRT clinicians not yet prepared to transition
care information performance category will be required for the 2019 to 2015 Edition CEHRT, while
incentivizing those clinicians who have receive full credit for the category (25 the Act, to estimate the proportion of
transitioned to 2015 Edition CEHRT. percentage points) in the final score. physicians as defined in section 1861(r)
Response: We believe it is appropriate Comment: One commenter did not of the Act who are meaningful EHR
to award the bonus only to those MIPS support bonus points for clinicians that users, as those physician MIPS eligible
eligible clinicians who are able to use adopt 2015 Edition CEHRT in 2018 clinicians who earn an advancing care
only the 2015 Edition of CEHRT in because they do not agree that 2015 information performance category score
2018. We understand that it is Edition CEHRT enhances a physicians of at least 75 percent for a performance
challenging to transition from the 2014 ability to provide higher quality care. period. We established that we will base
Edition to the 2015 Edition of CEHRT Another commenter indicated that this estimation on data from the relevant
and wish to incentivize clinicians to providing bonus points may performance period, if we have
complete the transition. We believe this disadvantage clinicians who have prior sufficient data available from that
bonus will help to incentivize experience with CEHRT but are unable period. We stated that we will not
participants to continue the process of to fully implement the 2015 Edition due include in the estimation physicians for
upgrading from 2014 Edition to 2015 to vendor issues beyond their control. whom the advancing care information
Edition, especially small practices Response: While we appreciate these performance category is weighted at
where the investment in updated concerns, we believe that the zero percent under section 1848(q)(5)(F)
workflows and implementation may availability of the bonus is appropriate of the Act, which we relied on in the CY
present unique challenges. We agree and we wish to incentivize clinicians to 2017 Quality Payment Program final
with commenters that the bonus should complete the transition to 2015 Edition rule (81 FR 77226 through 77227) to
be available to all MIPS eligible CEHRT in 2018. establish policies under which we
Final Action: After consideration of would weigh the advancing care
clinicians who use 2015 Edition CEHRT
the public comments, we are adopting information performance category at
exclusively in 2018. In addition, we
as proposed our proposal to allow the zero percent of the final score. In
intend this bonus to support and
use of 2014 Edition or 2015 Edition addition, we proposed not to include in
recognize the efforts to report on the
CEHRT, or a combination of the two the estimation physicians for whom the
Advancing Care Information Measures
Editions, for the performance period in
using EHR technology certified to the advancing care information performance
2018. We will offer a one-time bonus of
2015 Edition, which include more category would be weighted at zero
10 percentage points under the
robust measures using updated percent under the proposal in section
advancing care information performance
standards and functions which support II.C.6.f.(7) of the proposed rule to
category for MIPS eligible clinicians
interoperability. implement certain provisions of the 21st
who report the Advancing Care
Comment: Several commenters Century Cures Act (that is, physicians
Information Objectives and Measures for
requested that the bonus points who are determined hospital-based or
the performance period in CY 2018
available for using 2015 Edition CEHRT ambulatory surgical center-based, or
using only 2015 Edition CEHRT. We
be raised from 10 percentage points to who are granted an exception based on
will not limit the bonus to new
20 percentage points because it would significant hardship or decertified EHR
participants. We are revising
provide stronger incentive for clinicians technology).
414.1305 and 414.1380(b)(4) of the
to upgrade to and implement 2015 regulation text to reflect this policy. We stated that we were considering
Edition CEHRT for use in 2018, thereby modifications to the policy we
expanding the availability of 2015 (5) Scoring Methodology Considerations established in last years rulemaking to
Edition enhancements, such as the new Section 1848(q)(5)(E)(i)(IV) of the Act base our estimation of physicians who
open APIs. A few commenters states that 25 percent of the MIPS final are meaningful EHR users for a MIPS
recommended that we provide a bonus score shall be based on performance for payment year (for example, 2019) on
of 15 percentage points. Commenters the advancing care information data from the relevant performance
expressed concern that adding only 10 performance category. Further, section period (for example, 2017). We stated
percentage points to the score for the 1848(q)(5)(E)(ii) of the Act, provides that our concern that if in future rulemaking
use of 2015 Edition CEHRT is too trivial in any year in which the Secretary we decide to propose to change the
an incentive and would do little to estimates that the proportion of eligible weight of the advancing care
offset the work participants must do to professionals (as defined in section information performance category based
prepare to participate in the Quality 1848(o)(5) of the Act) who are on our estimation, such a change may
Payment Program. meaningful EHR users (as determined cause confusion to MIPS eligible
Response: We disagree and believe under section 1848(o)(2) of the Act) is clinicians who are adjusting to the MIPS
that a 10 percentage point bonus 75 percent or greater, the Secretary may program and believe this performance
provides an adequate incentive for MIPS reduce the applicable percentage weight category will make up 25 percent of the
eligible clinicians to use 2015 Edition of the advancing care information final score for the 2019 MIPS payment
CEHRT exclusively for a minimum of a performance category in the MIPS final year. We noted the earliest we would be
90-day performance period in 2018. score, but not below 15 percent, and able to make our estimation based on
Additionally, the addition of this 10 increase the weightings of the other 2017 data and propose in future
percentage point bonus would bring the performance categories such that the rulemaking to change the weight of the
total bonus points available under the total percentage points of the increase advancing care information performance
advancing care information performance equals the total percentage points of the category for the 2019 MIPS payment
category to 25 percentage points. We reduction. We noted that section year would be in mid-2018, as the
remind readers that a MIPS eligible 1848(o)(5) of the Act defines an eligible deadline for data submission is March
clinician may earn a maximum score of professional as a physician, as defined 31, 2018. We requested public
165 percentage points (including the in section 1861(r) of the Act. comments on whether this timeframe is
2015 Edition CEHRT bonus) for the In CY 2017 Quality Payment Program sufficient, or whether a more extended
advancing care information performance final rule (81 FR 7722677227), we timeframe would be preferable. We
category, but all scores of 100 established a final policy, for purposes proposed to modify our existing policy
percentage points and higher will of applying section 1848(q)(5)(E)(ii) of such that we would base our estimation
of physicians who are meaningful EHR from the relevant performance period reduced, it should not all be
users for a MIPS payment year on data for the MIPS payment year. For redistributed to the quality category.
from the performance period that occurs example, for the 2019 MIPS payment Many commenters suggested that it be
4 years before the MIPS payment year. year, the performance period is two redistributed to quality and
The following is a summary of the years prior to the payment year, in 2017. improvement activities performance
public comments received on these We proposed to extend the look-back categories particularly for physicians for
proposals and our responses: period to the performance period that whom there are not the required number
Comment: Some commenters occurs 4 years before the MIPS payment of meaningful quality measures.
supported our proposal because they year, which would give additional time Response: We appreciate this input.
believed it was appropriate to allow for MIPS eligible clinicians and health We intend to make our decision about
additional time to ensure that clinicians IT developers to adjust to the new whether to change the performance
are aware of the percentage weighting of weighting prior to the start of the actual category weight based on data from the
each MIPS performance category. A few performance period for the MIPS performance period that is 4 years prior
commenters stated that more certainty payment year. We continue to believe to the MIPS payment year. We have not
and advance notice will offer MIPS that this timeframe is sufficient. yet proposed a new weight for the
eligible clinicians more time to prepare Comment: Some commenters advancing care information performance
and focus resources on areas of most expressed concern with the proposal to category or to which category or
significance. base CMS estimation of meaningful categories the points would be
Response: We thank commenters for EHR users on data from the performance distributed.
their support and agree that additional period that occurs 4 years before the Comment: A few commenters stated
time to determine whether the MIPS payment year. According to the that it is too early to consider
advancing care information category commenters, the 4-year look-back reweighting a category before any data
weight should be reduced is necessary. period is unreasonably long given the has been received or analyzed. When
Once we make a determination we will rapid pace of technology, especially reweighting is implemented, they urged
communicate such a change to the given continued delays in adopting CMS to ensure that clinicians are
percentage weighting of each of the 2015 Edition technology. Commenters informed of the reweighting prior to the
MIPS performance categories to MIPS encouraged CMS to shorten this look- performance period. Changing the
eligible clinicians. back period. Prematurely reducing the weight of a performance category
Comment: Some commenters stated advancing care information performance retrospectively would add confusion to
that the timeline that we proposed was categorys weight could impair progress an already complex program.
not sufficient. Commenters stated that a towards robust, person-centered uses of Response: We have not yet proposed
proposal to change the weight would health IT. to reduce the weight of the performance
not be finalized until late in 2018 and Response: While we appreciate these category. We are simply establishing the
would be applied to the 2019 MIPS concerns, we also believe that it is timeframe for when we would decide
performance period/2021 payment year important to give MIPS eligible whether to reduce and redistribute the
which does not give clinicians sufficient clinicians sufficient notice before we weight.
time to be educated and respond to the change the weighting of a category so Comment: Several commenters
changes in the category weights. Other that they can plan appropriately. We suggested that any proposed changes to
commenters stated that any change to note that the earliest data we can use to the weight of the advancing care
the MIPS program, specifically the calculate the proportion of physicians information performance category
possibility of a change in the weight of who are meaningful EHR users will be resulting from an assessment of the
the advancing care information the data from the 2017 performance proportion of clinicians who are
performance category, will have a period, which will not be available until meaningful EHR users, for example,
domino effect on various aspects of the 2018. Under our current policy, 2018 is those who achieve an advancing care
program, as well as within the health IT the earliest we would be able to propose information performance category score
space. Based on updated category in rulemaking to reduce and redistribute of at least 75 percent, should be based
weight allocation, which would change the weight of the advancing care on at least two to three MIPS
the overall computation of a MIPS score, information performance category for performance periods worth of data to
health IT developers will need to make the 2019 MIPS payment year, based on ensure an accurate baseline.
adjustments to their products and the proportion of physicians who were Response: We agree that this decision
software accordingly. In turn, those meaningful EHR users during the should be made with consideration for
products must be implemented by performance period in 2017. As the reliability and validity of data,
clinicians. For product lifecycles, there previously stated, we believe it is however, we disagree that it would
needs to be at least 12 months notice important for MIPS eligible clinicians to require multiple performance periods to
given for all parties to adequately plan be aware of this reweighting prior to the obtain the necessary data to make this
and execute these changes. The relevant performance period during determination. We also note that we are
proposed timeline that CMS has which they would be measured for the not proposing to base this decision on
outlined (for performance period 2017/ MIPS payment year, which is why we any particular year at this point in time,
payment year 2019, the earliest feedback believe the proposed 4-year timeline is we are only addressing the timeframe
would be in mid-2018 that would in more appropriate. relationship between when the data is
turn effect the weight of performance Comment: Some commenters reported and when the reweighting
period 2019/payment year 2021) would recommended keeping the advancing would take place. For example, should
allow for notification of less than a year, care information performance category the data show that 75 percent or more
and is therefore not sufficient. as 25 percent of the MIPS final score in physicians are considered meaningful
Response: While we understand these years in which 75 percent or more of users based on data submitted for the
concerns, we previously finalized our physicians are meaningful EHR users. 2017 performance period, we would
policy to base our estimation of Other commenters recommended that if propose to reweight the advancing care
physicians who are meaningful EHR the weight of the advancing care information performance category
users for a MIPS payment year on data information performance category is weight in 2021 instead of 2019. We
believe this policy would allow erroneously described the actions in the in active engagement with a public
adequate time for MIPS eligible measure (viewing, downloading or health agency to submit syndromic
clincians, EHR vendors and other transmitting; or accessing through an surveillance data from a non-urgent care
stakeholders to adjust to the new API) as being taken by the MIPS eligible ambulatory setting where the
scoring structure prior to submitting clinician rather than the patient or the jurisdiction accepts syndromic data
data for the effected payment year. patient-authorized representatives. We from such settings and the standards are
Final Action: Based on the public proposed this change would apply clearly defined.
comments and for the reasons discussed beginning with the performance period Proposed change to the Syndromic
in the proposed rule, we are adopting in 2017. Surveillance Reporting Measure: The
our proposal as proposed. Our ability to Objective: Health Information MIPS eligible clinician is in active
implement this policy will be Exchange. engagement with a public health agency
dependent on the availability of data Objective: The MIPS eligible clinician to submit syndromic surveillance data.
from the performance period that occurs provides a summary of care record We proposed this change because we
4 years before the MIPS payment year. when transitioning or referring their inadvertently finalized the measure
patient to another setting of care, description that we had proposed for
(6) Objectives and Measures receives or retrieves a summary of care Stage 3 of the EHR Incentive Program
(a) Advancing Care Information record upon the receipt of a transition (80 FR 62866) and not the measure
Objectives and Measures Specifications or referral or upon the first patient description that we finalized (80 FR
encounter with a new patient, and 62970). We are modifying the proposed
We proposed to maintain for the CY incorporates summary of care change so that it does align with the
2018 performance period the Advancing information from other health care measure description finalized for Stage
Care Information Objectives and clinician into their EHR using the 3 by adding the phrase from an urgent
Measures as finalized in the CY 2017 functions of CEHRT. care setting to the end of the measure
Quality Payment Program final rule (81 Proposed change to the Objective: The description.
FR 77227 through 77229). We proposed MIPS eligible clinician provides a In the proposed rule, we noted that
the following modifications to certain summary of care record when we have split the Specialized Registry
objectives and measures. transitioning or referring their patient to Reporting Measure that we adopted
Provide Patient Access Measure: For another setting of care, receives or under the 2017 Advancing Care
at least one unique patient seen by the retrieves a summary of care record upon Information Transition Objectives and
MIPS eligible clinician: (1) The patient the receipt of a transition or referral or Measures into two separate measures,
(or the patient-authorized upon the first patient encounter with a Public Health Registry Reporting and
representative) is provided timely new patient, and incorporates summary Clinical Data Registry Reporting, to
access to view online, download, and of care information from other health better define the registries available for
transmit his or her health information; care providers into their EHR using the reporting. We proposed to allow MIPS
and (2) The MIPS eligible clinician functions of CEHRT. eligible clinicians and groups to
ensures the patients health information We inadvertently used the term continue to count active engagement in
is available for the patient (or patient- health care clinician and proposed to electronic public health reporting with
authorized representative) to access replace it with the more appropriate specialized registries. We proposed to
using any application of their choice term health care provider. We allow these registries to be counted for
that is configured to meet the technical proposed this change would apply purposes of reporting the Public Health
specifications of the Application beginning with the performance period Registry Reporting Measure or the
Programing Interface (API) in the MIPS in 2017. Clinical Data Registry Reporting
eligible clinicians CEHRT. Send a Summary of Care Measure: Measure beginning with the 2018
Proposed definition of timely: For at least one transition of care or performance period. A MIPS eligible
Beginning with the 2018 performance referral, the MIPS eligible clinician that clinician may count a specialized
period, we proposed to define timely transitions or refers their patient to registry if the MIPS eligible clinician
as within 4 business days of the another setting of care or health care achieved the phase of active engagement
information being available to the MIPS clinician (1) creates a summary of care as described under active engagement
eligible clinician. This definition of record using CEHRT; and (2) option 3: production in the 2015 EHR
timely is the same as we adopted under electronically exchanges the summary Incentive Programs final rule with
the EHR Incentive Programs (80 FR of care record. comment period (80 FR 62862 through
62815). Proposed Change to the Send a 62865), meaning the clinician has
Proposed change to the View, Summary of Care Measure: For at least completed testing and validation of the
Download, Transmit (VDT) Measure: one transition of care or referral, the electronic submission and is
During the performance period, at least MIPS eligible clinician that transitions electronically submitting production
one unique patient (or patient- or refers their patient to another setting data to the public health agency or
authorized representatives) seen by the of care or health care provider (1) clinical data registry.
MIPS eligible clinician actively engages creates a summary of care record using
with the EHR made accessible by the (b) 2017 and 2018 Advancing Care
CEHRT; and (2) electronically
MIPS eligible clinician by either (1) Information Transition Objectives and
exchanges the summary of care record.
viewing, downloading or transmitting to We inadvertently used the term Measures Specifications
a third party their health information; or health care clinician and proposed to In the CY 2017 Quality Payment
(2) accessing their health information replace it with the more appropriate Program final rule (81 FR 77229 through
through the use of an API that can be term health care provider. We 77237), we finalized the 2017
used by applications chosen by the proposed this change would apply Advancing Care Information Transition
patient and configured to the API in the beginning with the 2017 performance Objectives and Measures for MIPS
MIPS eligible clinicians CEHRT; or (3) period. eligible clinicians using EHR technology
a combination of (1) and (2). We Syndromic Surveillance Reporting certified to the 2014 Edition. Because
proposed this change because we Measure: The MIPS eligible clinician is we proposed in section II.C.6.f.(4) of the
proposed rule to continue to allow the summary of care record when 2017 Quality Payment Program
use of EHR technology certified to the transitioning or referring their patient to proposed and final rules, as follows:
2014 Edition in the 2018 performance another setting of care, receives or Proposed Objective: The MIPS eligible
period, we also proposed to allow MIPS retrieves a summary of care record upon clinician who receives a patient from
eligible clinicians to report the 2017 the receipt of a transition or referral or another setting of care or provider of
Advancing Care Information Transition upon the first patient encounter with a care or believes an encounter is relevant
Objectives and Measures in 2018. We new patient, and incorporates summary performs medication reconciliation.
proposed to make several modifications of care information from other health This description aligns with the
identified and described below to the care providers into their EHR using the objective adopted for Modified Stage 2
2017 Advancing Care Information functions of CEHRT. at 80 FR 62811.
Transition Objectives and Measures for We inadvertently used the term Medication Reconciliation Measure:
the advancing care information health care clinician and proposed to The MIPS eligible clinician performs
performance category of MIPS for the replace it with the more appropriate medication reconciliation for at least
2017 and 2018 performance periods. term health care provider. We one transition of care in which the
Objective: Patient Electronic Access. proposed this change would apply patient is transitioned into the care of
Objective: The MIPS eligible clinician beginning with the performance period the MIPS eligible clinician.
provides patients (or patient-authorized in 2017. Numerator: The number of
representative) with timely electronic Health Information Exchange transitions of care or referrals in the
access to their health information and Measure: The MIPS eligible clinician denominator where the following three
patient-specific education. that transitions or refers their patient to clinical information reconciliations
Proposed Change to the Objective. another setting of care or health care were performed: Medication list,
We proposed to modify this objective clinician (1) uses CEHRT to create a Medication allergy list, and current
beginning with the 2017 performance summary of care record; and (2) problem list.
period by removing the word electronically transmits such summary Proposed Modification to the
electronic from the description of to a receiving health care clinician for Numerator.
timely access as it was erroneously Proposed Numerator: The number of
at least one transition of care or referral.
included in the final rule (81 FR 77228). transitions of care or referrals in the
Proposed change to the measure: The
Objective: Patient-Specific Education. denominator where medication
Objective: The MIPS eligible clinician MIPS eligible clinician that transitions
reconciliation was performed.
provides patients (or patient authorized or refers their patient to another setting We proposed to modify the numerator
representative) with timely electronic of care or health care provider (1) uses by removing medication list, medication
access to their health information and CEHRT to create a summary of care allergy list, and current problem list.
patient-specific education. record; and (2) electronically transmits These three criteria were adopted for
Proposed Change to the Objective: such summary to a receiving health care Stage 3 (80 FR 62862) but not for
The MIPS eligible clinician uses provider for at least one transition of Modified Stage 2 (80 FR 62811). We
clinically relevant information from care or referral. proposed this change would apply
CEHRT to identify patient-specific We inadvertently used the term beginning with the performance period
educational resources and provide those health care clinician and proposed to in 2017.
resources to the patient. We replace it with the more appropriate The following is a summary of the
inadvertently finalized the description term health care provider. We public comments received on the
of the Patient Electronic Access proposed this change would apply Advancing Care Information Objectives
Objective for the Patient-Specific beginning with the performance period and Measures and the 2017 and 2018
Education Objective, so that the Patient- in 2017. Advancing Care Information Transition
Specific Education Objective had the Denominator: Number of transitions Objectives and Measures proposals and
wrong description. We proposed to of care and referrals during the our responses:
correct this error by adopting the performance period for which the EP Comment: Several commenters were
description of the Patient-Specific was the transferring or referring health confused by our proposal related to
Education Objective adopted under care clinician. specialized registries and active
modified Stage 2 in the 2015 EHR Proposed change to the denominator: engagement option 3, production,
Incentive Programs final rule (80 FR Number of transitions of care and believing that the only way to receive
62809 and 80 FR 62815). We proposed referrals during the performance period credit for the Public Health Agency and
this change would apply beginning with for which the MIPS eligible clinician Clinical Data Registry Reporting
the performance period in 2017. was the transferring or referring health Objective is through the production
Objective: Health Information care provider. This change reflects the option.
Exchange. change proposed to the Health Response: MIPS eligible clinicians
Objective: The MIPS eligible clinician Information Exchange Measure may fulfill the Public Health Agency
provides a summary of care record replacing health care clinician with and Clinical Data Registry Reporting
when transitioning or referring their health care provider. We also Objective or the Public Health Reporting
patient to another setting of care, inadvertently referred to the EP in the Objective through any of the active
receives or retrieves a summary of care description and are replacing EP with engagement options as described at 80
record upon the receipt of a transition MIPS eligible clinician. We proposed FR 6281862819: completed registration
or referral or upon the first patient this change would apply beginning with to submit data; testing and validation; or
encounter with a new patient, and the performance period in 2017. production. Our proposal pertained to
incorporates summary of care Objective: Medication Reconciliation. MIPS eligible clinicians who choose to
information from other health care Proposed Objective: We proposed to use option 3, production, for specialized
clinicians into their EHR using the add a description of the Medication registries.
functions of CEHRT. Reconciliation Objective beginning with Comment: Several commenters
Proposed change to the Objective: The the CY 2017 performance period, which supported the proposed definition of
MIPS eligible clinician provides a we inadvertently omitted from the CY timely for the Patient Electronic Access
Measure. One stated that the proposed Portability and Accountability Act stated that until an overhaul of the
definition supports practice workflows (HIPAA) is appropriate. The commenter advancing care information performance
where patient information may become stated that under the HIPAA Privacy category is undertaken, they support the
available prior to a weekend or holiday. Rule, a covered entity must act on an modifications as proposed and urged
This proposal would allow the individuals request for access no later CMS to finalize them as described.
necessary time for an eligible clinician than 30 calendar days after receipt of Response: We thank commenters for
to review and ensure accurate the request. their support of the proposed
information is made available to Response: We disagree and believe modifications and agree that these
patients. that 4 business days will provide MIPS modifications should be finalized.
Response: We appreciate the support eligible clinicians with an adequate Comment: Some commenters
for our proposal. We sought to give amount of time to provide their patients suggested that we clarify that MIPS
MIPS eligible clinicians sufficient time with electronic access to their health eligible clinicians may report either the
to make information available. We information. We further note that the Advancing Care Information Objectives
specified 4 business days so as not to HIPAA timeframe relates to an and Measures or the Advancing Care
include holidays and weekends. individuals request for their Information Transition Objectives and
Comment: In the interest of reducing information and the Patient Electronic Measures using 2015 Edition or 2014
administrative burden, a commenter Access Measure relates to information Edition CEHRT.
encouraged the alignment of the being made available regardless of Response: For the 2018 performance
definition of timely for the Provide whether a request is made. period, MIPS eligible clinicians will
Patient Access Measure in the Comment: One commenter cautioned have the option to report the Advancing
Medicaid EHR Incentive Program and CMS of the unintended consequences Care Information Transition Objectives
the Quality Payment Program. For both related to the proposed definition of and Measures using 2014 Edition
programs, they supported defining providing timely access for patients CEHRT, 2015 Edition CEHRT, or a
timely as follows: Providing access to or their authorized representatives. The combination of 2014 and 2015 Edition
health information within 4 business commenter stated that the proposed CEHRT, as long as the EHR technology
days of the information being available definition of timely (4 business days) they possess can support the objectives
to the MIPS eligible clinician, as may result in the inability of clinicians and measures to which they plan to
opposed to the 48 hour standard in to achieve the base score, and thus, any attest. Similarly, MIPS eligible
Stage 3 of the Medicaid EHR Incentive advancing care information performance clinicians will have the option to attest
Program. category score. to the Advancing Care Information
Response: We understand that there Response: While we appreciate this Objectives and Measures using 2015
are two different definitions of timely. concern, we believe that by establishing Edition CEHRT or a combination of
We proposed 4 business days for MIPS the definition of timely as 4 business 2014 and 2015 Edition CEHRT, as long
because we believe it provides an days MIPS eligible clinicians should as their EHR technology can support the
adequate timeframe for a new program have a sufficient amount of time to objectives and measures to which they
and the clinicians who may not have fulfill the Patient Electronic Access plan to attest.
previously participated in the Medicare Measure. We also note that you only Final Action: After considering the
and Medicaid EHR Incentive Programs. need to provide timely access for one public comments that we received, we
We may consider aligning the Medicaid patient to achieve the base score for the are finalizing our proposals as proposed
EHR Incentive Program definition in the advancing care information performance with one modification to the description
future. category. of the Syndromic Surveillance Reporting
Comment: One commenter disagreed Comment: Most commenters Measure: The MIPS eligible clinician is
with our proposal related to the Patient supported the proposed modifications in active engagement with a public
Electronic Access Objective and to the Advancing Care Information health agency to submit syndromic
suggested that the definition of timely Objectives and Measures as reasonable surveillance data from an urgent care
access under the Health Insurance and appropriate. Another commenter setting.
TABLE 72018 PERFORMANCE PERIOD ADVANCING CARE INFORMATION PERFORMANCE CATEGORY SCORING
METHODOLOGY ADVANCING CARE INFORMATION OBJECTIVES AND MEASURES
Required/not Performance
2018 advancing care information 2018 advancing care information required for Reporting
score
objective measure base score requirement
(up to 90%)
(50%)
Protect Patient Health Information .......... Security Risk Analysis ............................ Required ...... 0 .................. Yes/No Statement.
Electronic Prescribing ............................. e-Prescribing ** ....................................... Required ...... 0 .................. Numerator/Denominator.
Patient Electronic Access ....................... Provide Patient Access ........................... Required ...... Up to 10% ... Numerator/Denominator.
Patient-Specific Education ...................... Not Required Up to 10% ... Numerator/Denominator.
Coordination of Care Through Patient View, Download, or Transmit (VDT) ....... Not Required Up to 10% ... Numerator/Denominator.
Engagement.
Secure Messaging .................................. Not Required Up to 10% ... Numerator/Denominator.
Patient-Generated Health Data .............. Not Required Up to 10% ... Numerator/Denominator.
Health Information Exchange .................. Send a Summary of Care ** ................... Required ...... Up to 10% ... Numerator/Denominator.
Request/Accept Summary of Care ** ..... Required ...... Up to 10% ... Numerator/Denominator.

Clinical Information Reconciliation .......... Not Required Up to 10% ... Numerator/Denominator.
Public Health and Clinical Data Registry Immunization Registry Reporting ........... Not Required 0 or 10% * .... Yes/No Statement.
Reporting.
Syndromic Surveillance Reporting ......... Not Required 0 or 10%* .... Yes/No Statement.
Electronic Case Reporting ...................... Not Required 0 or 10%* .... Yes/No Statement.
Public Health Registry Reporting ........... Not Required 0 or 10%* .... Yes/No Statement.
Clinical Data Registry Reporting ............ Not Required 0 or 10%* .... Yes/No Statement.
Required/not Performance
2018 advancing care information 2018 advancing care information required for Reporting
score
objective measure base score requirement
(up to 90%)
(50%)
Bonus (up to 25%)
Report to one or more additional public health agencies or clinical data registries 5% bonus Yes/No Statement.
beyond the one identified for the performance score.
Report improvement activities using CEHRT ............................................................... 10% bonus Yes/No Statement.
Report using only 2015 Edition CEHRT ...................................................................... 10% bonus Based on measures sub-
mitted.
* A MIPS eligible clinician may earn 10 percent for each public health agency or clinical data registry to which the clinician reports, up to a
maximum of 10 percent under the performance score.
** Exclusions are available for these measures.
TABLE 82018 PERFORMANCE PERIOD ADVANCING CARE INFORMATION PERFORMANCE CATEGORY SCORING
METHODOLOGY FOR 2018 ADVANCING CARE INFORMATION TRANSITION OBJECTIVES AND MEASURES
Required/not
2018 advancing care information 2018 advancing care information required for Performance score Reporting
transition objective transition measure base score (Up to 90%) requirement
(50%)
Protect Patient Health Information ....... Security Risk Analysis ......................... Required ............... 0 ............................ Yes/No Statement.
Electronic Prescribing ........................... E-Prescribing** .................................... Required ............... 0 ............................ Numerator/Denom-
inator.
Patient Electronic Access ..................... Provide Patient Access ....................... Required ............... Up to 20% ............ Numerator/Denom-
inator.
View, Download, or Transmit (VDT) ... Not Required ........ Up to 10% ............ Numerator/Denom-
inator.
Patient-Specific Education .................... Patient-Specific Education .................. Not Required ........ Up to 10% ............ Numerator/Denom-
inator.
Secure Messaging ................................ Secure Messaging ............................... Not Required ........ Up to 10% ............ Numerator/Denom-
inator.
Health Information Exchange ............... Health Information** Exchange ........... Required ............... Up to 20% ............ Numerator/Denom-
inator.
Medication Reconciliation ..................... Medication Reconciliation .................... Not Required ........ Up to 10% ............ Numerator/Denom-
inator.
Public Health Reporting ........................ Immunization Registry Reporting ........ Not Required ........ 0 or 10%* ............. Yes/No Statement.
Syndromic Surveillance Reporting ...... Not Required ........ 0 or 10% * ............. Yes/No Statement.
Specialized Registry Reporting ........... Not Required ........ 0 or 10% * ............. Yes/No Statement.
Bonus up to 15%
Report to one or more additional public health agencies or clinical data registries beyond the one 5% bonus ............. Yes/No Statement.
identified for the performance score.
Report improvement activities using CEHRT ............................................................................................ 10% bonus ........... Yes/No Statement.
* A MIPS eligible clinician may earn 10% for each public health agency or clinical data registry to which the clinician reports, up to a maximum
of 10% under the performance score.
** Exclusions are available for these measures.
To facilitate readers in identifying the and Measures, we are including the criteria required to meet the objectives
requirements of CEHRT for the Table 9, which includes the 2015 and measures.
Advancing Care Information Objectives Edition and 2014 Edition certification
TABLE 9ADVANCING CARE INFORMATION AND ADVANCING CARE INFORMATION TRANSITION OBJECTIVES AND MEASURES
AND CERTIFICATION CRITERIA FOR 2014 AND 2015 EDITIONS
Objective Measure 2015 Edition 2014 Edition
Protect Patient Health Security Risk Analysis The requirements are a part of CEHRT spe- The requirements are included in the Base
Information. cific to each certification criterion. EHR Definition.
Electronic Prescribing .. e-Prescribing .............. 170.315(b)(3) (Electronic Prescribing). 170.314(b)(3) (Electronic Prescribing).
170.315(a)(10) (Drug-Formulary and Pre- 170.314(a)(10) (Drug-Formulary and Pre-

ferred Drug List checks. ferred Drug List checks.
AND CERTIFICATION CRITERIA FOR 2014 AND 2015 EDITIONSContinued
Patient Electronic Ac- Provide Patient Ac- 170.315(e)(1) (View, Download, and Trans- 170.314(e)(1) (View, Download, and Trans-
cess. cess. mit to 3rd Party). 170.315(g)(7) (Applica- mit to 3rd Party).
tion AccessPatient Selection).
170.315(g)(8) (Application AccessData
Category Request). 170.315(g)(9) (Appli-
cation AccessAll Data Request). The
three criteria combined are the API cer-
tification criteria.
Patient Electronic Ac- Patient Specific Edu- 170.315(a)(13) (Patient-specific Education 170.314(a)(13) (Patient-specific Education
cess/Patient Specific cation. Resources). Resources).
Education.
Coordination of Care View, Download, or 170.315(e)(1) (View, Download, and Trans- 170.314(e)(1) (View, Download, and Trans-
Through Patient En- Transmit (VDT). mit to 3rd Party). 170.315(g)(7) (Applica- mit to 3rd Party).
gagement/Patient tion AccessPatient Selection).
Electronic Access. 170.315(g)(8) (Application AccessData
Category Request). 170.315(g)(9) (Appli-
cation AccessAll Data Request) The
three criteria combined are the API cer-
tification criteria.
Coordination of Care Secure Messaging ..... 170.315(e)(2) (Secure Messaging) .............. 170.314(e)(3) (Secure Messaging).
Through Patient En-
gagement.
Coordination of Care Patient-Generated 170.315(e)(3) (Patient Health Information N/A.
Through Patient En- Health Data. Capture) Supports meeting the measure,
gagement. but is NOT required to be used to meet the
measure. The certification criterion is part
of the CEHRT definition beginning in 2018.
Health Information Ex- Send a Summary of 170.315(b)(1) (Transitions of Care) ............. 170.314(b)(2) (Transitions of Care-Create
change. Care. and Transmit Transition of Care/Referral
Summaries or 170.314(b)(8) (Optional
Transitions of Care).
Health Information Ex- Request/Accept Sum- 170.315(b)(1) (Transitions of Care) ............. 170.314(b)(1) (Transitions of Care-Receive,
change. mary of Care. Display and Incorporate Transition of Care/
Referral Summaries or 170.314(b)(8)
(OptionalTransitions of Care).
Health Information Ex- Clinical Information 170.315(b)(2) (Clinical Information Rec- 170.314(b)(4) (Clinical Information Rec-
change. Reconciliation. onciliation and Incorporation). onciliation or 170.314(b)(9) (Optional
Clinical Information Reconciliation and In-
corporation).
Health Information Ex- Health Information Ex- N/A .................................................................. 170.314(b)(2) (Transitions of Care-Create
change. change. and Transmit Transition of Care/Referral
Summaries or 170.314(b)(8) (Optional
Transitions of Care).
Medication Reconcili- Medication Reconcili- N/A .................................................................. 170.314(b)(4) (Clinical Information Rec-
ation. ation. onciliation) or 170.314(b)(9) (Optional
Clinical Information Reconciliation and In-
corporation).
Public Health and Clin- Immunization Registry 170.315(f)(1) (Transmission to Immunization N/A.
ical Data Registry Reporting. Registries).
Reporting/Public
Health Reporting.
Public Health and Clin- Syndromic Surveil- 170.315(f)(2) (Transmission to Public Health 170.314(f)(3) (Transmission to Public Health
ical Data Registry lance Reporting. AgenciesSyndromic Surveillance) Urgent AgenciesSyndromic Surveillance) or
Reporting/Public Care Setting Only. 170.314(f)(7) (Optional-Ambulatory Set-
Health Reporting. ting OnlyTransmission to Public Health
AgenciesSyndromic Surveillance).
Public Health and Clin- Electronic Case Re- 170.315(f)(5) (Transmission to Public Health N/A.
ical Data Registry porting. AgenciesElectronic Case Reporting).
Reporting.
Public Health and Clin- Public Health Registry EPs may choose one or more of the fol- 170.314(f)(5) (OptionalAmbulatory Setting
ical Data Registry Reporting. lowing: 170.315(f)(4) (Transmission to OnlyCancer Case Information and
Reporting. Cancer Registries). 170.315(f)(7) (Trans- 170.314(f)(6) (OptionalAmbulatory Set-
mission to Public Health AgenciesHealth ting OnlyTransmission to Cancer Reg-
Care Surveys). istries).
Public Health and Clin- Clinical Data Registry No 2015 Edition health IT certification criteria N/A.
ical Data Registry Reporting. at this time.
Reporting.
AND CERTIFICATION CRITERIA FOR 2014 AND 2015 EDITIONSContinued
Public Health Reporting Specialized Registry N/A .................................................................. 170.314(f)(5) (OptionalAmbulatory Setting
Reporting. OnlyCancer Case Information) and
170.314(f)(6) (Optional Ambulatory Set-
ting OnlyTransmission to Cancer Reg-
istries).
(c) Exclusions or referral or upon the first patient clinicians into their EHR using the
We proposed to add exclusions to the encounter with a new patient, and functions of CEHRT.
incorporates summary of care Health Information Exchange
measures associated with the Health
information from other health care Measure: The MIPS eligible clinician
Information Exchange and Electronic
clinician into their EHR using the that transitions or refers their patient to
Prescribing Objectives required for the
functions of CEHRT. another setting of care or health care
base score, as described below. We
Send a Summary of Care Measure: clinician (1) uses CEHRT to create a
proposed these exclusions would apply
For at least one transition of care or summary of care record; and (2)
beginning with the CY 2017
referral, the MIPS eligible clinician that electronically transmits such summary
performance period.
transitions or refers their patient to to a receiving health care clinician for
Proposed Exclusion for the another setting of care or health care at least one transition of care or referral.
E-Prescribing Objective and Measure clinician (1) creates a summary of care We note that we finalized our
Advancing Care Information Objective record using CEHRT; and (2) proposal to replace health care
and Measure electronically exchanges the summary clinician with health care provider
of care record. in the objective and measure.
Objective: Electronic Prescribing. Proposed Exclusion: Any MIPS
We note that we finalized our
Objective: Generate and transmit eligible clinician who transfers a patient
proposal to replace health care
permissible prescriptions electronically. to another setting or refers a patient
clinician with health care provider
E-Prescribing Measure: At least one fewer than 100 times during the
in the objective and measure.
permissible prescription written by the performance period.
MIPS eligible clinician is queried for a Proposed Exclusion: Any MIPS
drug formulary and transmitted eligible clinician who transfers a patient
public comments received on these
electronically using CEHRT. to another setting or refers a patient is
Proposed Exclusion: Any MIPS fewer than 100 times during the Comment: Commenters
eligible clinician who writes fewer than performance period. overwhelmingly supported the addition
100 permissible prescriptions during the Request/Accept Summary of Care of exclusions for the Electronic
performance period. Measure: For at least one transition of Prescribing, Health Information
care or referral received or patient Exchange, Send a Summary of Care, and
2017 and 2018 Advancing Care encounter in which the MIPS eligible Request/Accept Summary of Care
Information Transition Objective and clinician has never before encountered Measures.
Measure the patient, the MIPS eligible clinician Response: We appreciate the support
Objective: Electronic Prescribing. receives or retrieves and incorporates of the proposed modifications, and for
Objective: MIPS eligible clinicians into the patients record an electronic the reasons discussed in the proposed
must generate and transmit permissible summary of care document. rule, agree that it is appropriate to
prescriptions electronically. Proposed Exclusion: Any MIPS establish these exclusions.
E-Prescribing Measure: At least one eligible clinician who receives Comment: One commenter supported
permissible prescription written by the transitions of care or referrals or has establishing exclusions but
MIPS eligible clinician is queried for a patient encounters in which the MIPS recommended that the thresholds be set
drug formulary and transmitted eligible clinician has never before at fewer than 200 instead of fewer than
electronically using CEHRT. encountered the patient fewer than 100 100 as proposed.
Proposed Exclusion: Any MIPS times during the performance period. Response: We disagree. We proposed
eligible clinician who writes fewer than 2017 and 2018 Advancing Care the exclusions because these measures
100 permissible prescriptions during the Information Transition Objective and may be outside a MIPS eligible
performance period. Measures clinicians licensing authority or outside
their scope of practice. By claiming the
Proposed Exclusion for the Health Objective: Health Information exclusion, the MIPS eligible clinician is
Information Exchange Objective and Exchange. indicating that the measure is
Measures Advancing Care Information Objective: The MIPS eligible clinician inapplicable to them, because they have
Objective and Measures provides a summary of care record few patients or insufficient number of
Objective: Health Information when transitioning or referring their actions that would allow calculation of
Exchange. patient to another setting of care, the measure. We proposed the fewer
Objective: The MIPS eligible clinician receives or retrieves a summary of care than 100 threshold to align with the
provides a summary of care record record upon the receipt of a transition exclusions for these measures that were
when transitioning or referring their or referral or upon the first patient established for the Medicare and
patient to another setting of care, encounter with a new patient, and Medicaid EHR Incentive Programs. We
receives or retrieves a summary of care incorporates summary of care believe that the threshold of fewer than
record upon the receipt of a transition information from other health care 100 will enable MIPS eligible clinicians
who do not prescribe, or transfer or refer allowing these clinicians to exclude or The MACRA did not maintain these
patients or rarely do so to claim the to attest to the measures as they stated statutory exceptions for the advancing
exclusion(s) and still fulfill the base that both measures are key objectives in care information performance category
score of the advancing care information the advancing care information of the MIPS. Thus, we had previously
performance category. We believe a performance category and also stated stated that the provisions under sections
threshold of 200 is too high, and believe that it will be beneficial to encourage 1848(a)(7)(B) and (D) of the Act are
that a MIPS eligible clinician who is clinicians to attest to both measures, limited to the meaningful use payment
prescribing, transferring or referring even if they qualify to exclude them. adjustment under section 1848(a)(7)(A)
more than 100 times during the Response: MIPS eligible clinicians of the Act and do not apply in the
performance period is taking the actions may claim these exclusions if they context of the MIPS.
described in the measures often enough qualify, although they do not have to Following the publication of the CY
to be able to report on the measures for claim the exclusions and may report on 2017 Quality Payment Program final
at least one patient to fulfil the base the measures if they choose to do so. rule, the 21st Century Cures Act (Pub.
score requirement. Comment: One commenter requested L. 114255) was enacted on December
Comment: One commenter was that for the Request/Accept a Summary 13, 2016. Section 4002(b)(1)(B) of the
pleased to see CMSs intent to establish of Care Measure, that the exclusion be 21st Century Cures Act amended section
an exclusion for the e-Prescribing more closely tied to the logic for the 1848(o)(2)(D) of the Act to state that the
Measure. They stated that as doctors of denominator of that measure, so that the provisions of sections 1848(a)(7)(B) and
chiropractic are statutorily prohibited in exclusion is specified in terms of new (D) of the Act shall apply to assessments
most states from prescribing medication, patients for whom a summary of care is of MIPS eligible clinicians under section
this measure created a great deal of available. 1848(q) of the Act with respect to the
concern over the last year that doctors Response: While we understand this performance category described in
of chiropractic would be adversely concern, we disagree that the exclusion subsection (q)(2)(A)(iv) (the advancing
affected by not reporting this measure. should be limited to new patients. care information performance category)
Response: We did not intend to While we believe the exclusion should in an appropriate manner which may be
disadvantage chiropractors or other include instances where the MIPS similar to the manner in which such
types of clinicians who may be eligible clinician has never before provisions apply with respect to the
prohibited by law from prescribing encountered the patient, we do not want meaningful use payment adjustment
medication. We are establishing this to limit it to just those instances. made under section 1848(a)(7)(A) of the
exclusion for the e-Prescribing Measure Final Action: After consideration of Act. As a result of this legislative
beginning with the 2017 performance the public comments, we are finalizing change, we believe that the general
period. these proposals as proposed. We note exceptions described under sections
Comment: One commenter requested that the exclusions apply beginning 1848(a)(7)(B) and (D) of the Act are
that if a MIPS eligible clinician claims with the 2017 performance period. applicable under the MIPS program. We
an exclusion for the base score for the included the proposals described below
Health Information Exchange Measure, (7) Additional Considerations to implement these provisions as
they should also be able to claim an (a) 21st Century Cures Act applied to assessments of MIPS eligible
exclusion for the performance score for clinicians under section 1848(q) of the
this measure so their total advancing As we noted in the CY 2017 Quality Act with respect to the advancing care
care information points are not Payment Program final rule (81 FR information performance category.
adversely affected. 77238), section 101(b)(1)(A) of the
Response: We disagree. MIPS eligible MACRA amended section 1848(a)(7)(A) (i) MIPS Eligible Clinicians Facing a
clinicians have many options to earn of the Act to sunset the meaningful use Significant Hardship
performance score points. If a measure payment adjustment at the end of CY In the CY 2017 Quality Payment
is not applicable to a clinician, they 2018. Section 1848(a)(7) of the Act Program final rule (81 FR 77240 through
have the flexibility to select other includes certain statutory exceptions to 77243), we recognized that there may
performance score measures on which the meaningful use payment adjustment not be sufficient measures applicable
to report. under section 1848(a)(7)(A) of the Act. and available under the advancing care
Comment: One commenter asked if Specifically, section 1848(a)(7)(D) of the information performance category to
these exclusions are available if Act exempts hospital-based EPs from MIPS eligible clinicians facing a
reporting as a group. the application of the payment significant hardship, such as those who
Response: Yes, MIPS eligible adjustment under section 1848(a)(7)(A) lack sufficient internet connectivity,
clinicians may claim the exclusion if of the Act. In addition, section face extreme and uncontrollable
they are reporting as a group. In the CY 1848(a)(7)(B) of the Act provides that circumstances, lack control over the
2017 Quality Payment Program final the Secretary may, on a case-by-case availability of CEHRT, or do not have
rule (81 FR 77215), we stated that the basis, exempt an EP from the face-to-face interactions with patients.
group will need to aggregate data for all application of the payment adjustment We relied on section 1848(q)(5)(F) of the
the individual MIPS eligible clinicians under section 1848(a)(7)(A) of the Act if Act to establish a final policy to assign
within the group for whom they have the Secretary determines, subject to a zero percent weighting to the
data in CEHRT, and if an individual annual renewal, that compliance with advancing care information performance
MIP eligible clinician meets the criteria the requirement for being a meaningful category in the final score if there are
to exclude a measure, their data can be EHR user would result in a significant not sufficient measures and activities
excluded from the calculation of that hardship, such as in the case of an EP applicable and available to MIPS
particular measure only. who practices in a rural area without eligible clinicians within the categories
Comment: One commenter questioned sufficient internet access. The last of significant hardship noted above (81
whether clinicians who qualify to sentence of section 1848(a)(7)(B) of the FR 77243). Additionally, under the final
exclude these measures will be allowed Act also provides that in no case may an policy (81 FR 77243), we did not impose
to report on the measures. The exemption be granted under a limitation on the total number of MIPS
commenter encouraged CMS to consider subparagraph (B) for more than 5 years. payment years for which the advancing
care information performance category Medicare EHR Incentive Program for insufficient internet connectivity,
could be weighted at zero percent, in more than 5 years. We proposed not to extreme and uncontrollable
contrast with the 5-year limitation on apply the 5-year limitation under circumstances, lack of control over the
significant hardship exceptions under section 1848(a)(7)(B) of the Act to availability of CEHRT, and lack of face-
the Medicare EHR Incentive Program as significant hardship exceptions for the to-face patient interaction. We believe
required by section 1848(a)(7)(B) of the advancing care information performance that the submission of data indicates
Act. category under MIPS. that there are sufficient measures
We did not propose substantive We solicited comments on the applicable and available for the MIPS
changes to this policy; however, as a proposed use of the authority provided eligible clinician, and therefore, the
result of the changes in the law made by in the 21st Century Cures Act in section significant hardship exception is not
the 21st Century Cures Act discussed 1848(o)(2)(D) of the Act as it relates to necessary.
above, we will not rely on section application of significant hardship Comment: One commenter
1848(q)(5)(F) of the Act and instead exceptions under MIPS and the recommended that CMS outline more
proposed to use the authority in the last proposal not to apply a 5-year limit to specific criteria for hardship exceptions
sentence of section 1848(o)(2)(D) of the such exceptions. because allowing too many exceptions
Act for significant hardship exceptions The following is a summary of the could hinder adoption of the changes
under the advancing care information public comments received on these required to create a more efficient, value
performance category under MIPS. proposals and our responses: focused health care system. They
Section 1848(o)(2)(D) of the Act, as Comment: Many commenters suggested that hardship exceptions only
amended by section 4002(b)(1)(B) of the supported our proposal not to apply the be available for unusual and unique
21st Century Cures Act, states in part 5-year limit for significant hardship clinician circumstances.
that the provisions of section exceptions. Some commenters stated Response: While we understand the
1848(a)(7)(B) of the Act shall apply to that the 5-year limit was arbitrary and concern expressed in this comment, we
assessments of MIPS eligible clinicians should be eliminated. Other decline to adopt narrower criteria for
with respect to the advancing care commenters stated that the issue significant hardship exceptions at this
information performance category in an causing the hardship may not be time. We understand that the transition
appropriate manner which may be rectified within a 5-year period, and to MIPS has created challenges for MIPS
similar to the manner in which such thus, could create undue burdens on the eligible clinicians, and we believe the
provisions apply with respect to the clinicians in the future. Assigning a zero significant hardship exception policy
payment adjustment made under percent weighting to the advancing care we proposed would encourage more
section 1848(a)(7)(A) of the Act. We information performance category for clinicians to participate successfully in
would assign a zero percent weighting those who successfully demonstrate a the other performance categories of
to the advancing care information significant hardship through the MIPS.
performance category in the MIPS final application process would provide Comment: One commenter questioned
score for a MIPS payment year for MIPS significant relief. the proposed requirement to reapply for
eligible clinicians who successfully Response: We thank commenters for a hardship exception on an annual basis
demonstrate a significant hardship their support and agree it is possible a and recommended that exceptions
through the application process. We clinician could experience a hardship should be granted for 2 years.
would use the same categories of for more than 5 years. Response: We disagree and believe it
significant hardship and application Comment: One commenter suggested is appropriate to limit a hardship
process as established in the CY 2017 that under the EHR Incentive Program, exception to 1 year. We want to
Quality Payment Program final rule (81 a significant hardship exception would encourage MIPS eligible clinicians to
FR 7724077243). We would apply even if a health care provider adopt and use CEHRT and allowing
automatically reweight the advancing attested to meaningful use. They multi-year exceptions would not
care information performance category requested that we not penalize eligible accomplish that goal. We believe that
to zero percent for a MIPS eligible clinicians who choose to submit data, granting hardship exceptions for 1 year
clinician who lacks face-to-face patient and to apply the exception if they at a time will enable clinicians to work
interaction and is classified as a non- qualify. harder to successfully participate in the
patient facing MIPS eligible clinician Response: We disagree. Under the advancing care information performance
without requiring an application. If a EHR Incentive Program, if a health care category while knowing that there may
MIPS eligible clinician submits an provider submits a request for or is be the possibility of receiving a
application for a significant hardship otherwise granted a significant hardship significant hardship exception if it is
exception or is classified as a non- exception, and also successfully attests needed and they qualify. Furthermore
patient facing MIPS eligible clinician, to meaningful use, we would consider we have created a streamlined
but also reports on the measures that provider to be a meaningful EHR mechanism for the submission of
specified for the advancing care user based on its attestation and thus Quality Payment Program Hardship
information performance category, they would not apply the exception. Under Exception Applications. Applications
would be scored on the advancing care MIPS, we continue to believe that this that are submitted are reviewed on a
information performance category like approach is warranted. If a MIPS rolling basis.
all other MIPS eligible clinicians, and eligible clinician chooses to submit data Comment: One commenter expressed
the category would be given the for the advancing care information concern about occupational therapists
weighting prescribed by section performance category, they will be participating in MIPS as they were
1848(q)(5)(E) of the Act regardless of the scored. As we explained in the CY 2017 never eligible for the EHR Incentive
MIPS eligible clinicians score. Quality Payment Program final rule (81 Program. They stated that many
As required under section FR 77241), we believe there may not be clinicians in solo or very small therapy
1848(a)(7)(B) of the Act, eligible sufficient advancing care information practices cannot afford the expense of
professionals were not granted measures applicable and available to purchasing an EHR documentation
significant hardship exceptions for the MIPS eligible clinicians who experience system. For this reason, the commenter
payment adjustments under the a significant hardship, such as requested that in CY 2018 and future
years CMS grant them exceptions. to CEHRT or unforeseen environmental period and 2020 MIPS payment year.
Further, they recommended that CMS circumstances may constitute a We proposed a MIPS eligible clinician
dedicate staff to engage therapists in an significant hardship, the age of an MIPS seeking to qualify for this exception
effort to provide consistent and targeted eligible clinician alone or the preference would submit an application in the form
education regarding CEHRT to not obtain CEHRT does not. We note and manner specified by us by
requirements, applicable electronic that solo practitioners would be December 31st of the performance
measures, and other new criteria so they included in the small practice period or a later date specified by us.
may be successful under the advancing significant hardship that we proposed at We also proposed MIPS eligible
care information performance category. 82 FR 30076 so a separate hardship clinicians seeking this exception must
Response: We appreciate this exception category for them is demonstrate in the application that
comment and point out that under unnecessary. there are overwhelming barriers that
section 1848(q)(1)(C)(i)(II) of the Act, Final Action: After consideration of prevent the MIPS eligible clinician from
additional eligible clinicians such as the comments we received, we are complying with the requirements for the
occupational therapists could be finalizing our policy as proposed. advancing care information performance
considered MIPS eligible clinicians category. In accordance with section
(ii) Significant Hardship Exception for
starting in the third year of the program. 1848(a)(7)(B) of the Act, the exception
MIPS Eligible Clinicians in Small
If we decide to add additional clinician would be subject to annual renewal.
Practices
types to the definition of a MIPS eligible Under the proposal in section
clinician, it would be proposed and Section 1848(q)(2)(B)(iii) of the Act II.C.6.f.(7)(a) of the proposed rule, the 5-
finalized through notice and comment requires the Secretary to give year limitation under section
rulemaking. We would support these consideration to the circumstances of 1848(a)(7)(B) of the Act would not apply
clinicians and help them to become small practices (consisting of 15 or to this significant hardship exception
successful program participants. fewer professionals) and practices for MIPS eligible clinicians in small
Comment: One commenter expressed located in rural areas and geographic practices.
concern over the proposal to not apply HPSAs in establishing improvement While we would be making this
the 5-year limit to significant hardship activities under MIPS. In the CY 2017 significant hardship exception available
exceptions. They stated that although it Quality Payment Program final rule (81 to small practices in particular, we are
is important to acknowledge FR 77187 through 77188), we finalized considering whether other categories or
circumstances outside of a clinicians that for MIPS eligible clinicians and types of clinicians might similarly
control, it does not seem necessary to groups that are in small practices or require an exception. We solicited
grant these hardship exceptions in located in rural areas, or geographic comment on what those categories or
perpetuity. health professional shortage areas types are, why such an exception is
Response: While we appreciate this (HPSAs), to achieve full credit under the required, and any data available to
comment, we disagree. We believe that improvement activities category, one support the necessity of the exception.
a variety of circumstances may arise, high-weighted or two medium-weighted We noted that supporting data would be
and the application of the 5-year limit improvement activities are required. particularly helpful to our consideration
could unfairly disadvantage MIPS While there is no corresponding of whether any additional exceptions
eligible clinicians whose circumstances statutory provision for the advancing would be appropriate.
warrant a hardship exception. For care information performance category, The following is a summary of the
example, a MIPS eligible clinician may we believe that special consideration public comments received on these
lack control over the availability of should also be available for MIPS proposals and our responses:
CEHRT and apply annually for and eligible clinicians in small practices. We Comment: Commenters supported
receive a hardship exception for 5 years. proposed a significant hardship and appreciated the significant hardship
If their practice is later significantly exception for the advancing care exception that we proposed for MIPS
affected by a natural disaster, such as a information performance category for eligible clinicians in small practices.
hurricane, they would be unable to MIPS eligible clinicians who are in Many commenters stated that there are
receive a hardship exception due to the small practices, under the authority in a number of administrative and
5-year limit, even though they would section 1848(o)(2)(D) of the Act, as financial barriers that small practices
otherwise qualify for the exception. amended by section 4002(b)(1)(B) of the would be required to negotiate in order
Comment: Commenters recommended 21st Century Cures Act (see discussion to be successful in the advancing care
adding additional hardship exception of the statutory authority for significant information performance category.
categories such as those eligible for hardship exceptions in section Response: We appreciate this support
Social Security benefits, those who have II.C.6.f.(7)(ii) of the proposed rule). We and believe it is appropriate to provide
changed specialty taxonomy, those who proposed that this hardship exception a significant hardship exception for
practice in Tribal health care facilities would be available to MIPS eligible MIPS eligible clinicians in small
and those who are solo practitioners. clinicians in small practices as defined practices, in part due to the barriers
Response: While we appreciate the under 414.1305. We proposed in identified by the commenters.
suggestions, we are declining to adopt section II.C.1.e. of the proposed rule, Comment: One commenter disagreed
these suggestions at this time. We will that CMS would make eligibility with our proposal to establish a
monitor performance on the advancing determinations regarding the size of significant hardship exception for small
care information performance category small practices for performance periods practices. They stated that while there
to determine if additional hardship occurring in 2018 and future years. We are challenges that clinicians in small
exception categories are appropriate. As proposed to reweight the advancing care practices face in implementing HIT,
we have previously stated, we do not information performance category to well-implemented HIT can add to a
believe that it is appropriate to reweight zero percent of the MIPS final score for practices capacity to deliver high
this category solely on the basis of a MIPS eligible clinicians who qualify for quality care. For a practice with limited
MIPS eligible clinicians age or Social this hardship exception. We proposed support staff, HIT can make it easier for
Security status, and believe that while this exception would be available clinicians to communicate with their
other factors such as the lack of access beginning with the 2018 performance patients, know in real time about the
care their patients are receiving at other is comprised of 11 professional and for the MIPS program and choose to
practices, and actively manage the experienced organizations who are align the definition for purposes of this
population health of their entire patient ready to help clinicians in small significant hardship exception with the
panel. They recommended that CMS practices and rural areas prepare for and definition under 414.1305.
help and encourage small practices to participate in the Quality Payment Comment: Some commenters stated
adopt and meaningfully use HIT, rather Program. We try to ensure that priority that practices located in rural areas
than sending the message that HIT is a is given to small practices in rural often experience many of the same
significant hardship that small locations, health professional shortage barriers as small practices such as
practices should consider avoiding. areas, and medically underserved areas. financial limitations and workforce
Response: While we agree that the use The organizations within the Small, shortages. The effects of these
of HIT has many benefits and ideally all Underserved, and Rural Support challenges are magnified because
MIPS eligible clinicians would utilize initiative can help clinicians determine clinicians in rural areas serve as critical
CEHRT, we understand it may not be if they are included in the program, access points for care and often provide
feasible at this time for all practices. We choose whether they will participate a safety net for vulnerable populations.
hope that over time more and more individually or as a part of a group, Commenters stated that CMS includes
practices will realize the benefits of determine their data submission both small practices and practices
CEHRT and interoperability with other method, identify appropriate measures located in rural areas in many of its
clinicians and successfully adopt and and activities, and much more. To find policies proposed to reduce burden,
utilize CEHRT. We do offer no-cost your local Small, Underserved, and including the low-volume threshold and
technical assistance to small practices Rural Support organization please flexibility under the improvement
through the Small, Underserved, and review the Technical Assistance activities category, but neglected to
Rural Support initiative. To find your Resource Guide on qpp.cms.gov, or use include practices located in rural areas
local Small, Underserved, and Rural the search feature on the Small in its hardship exception proposal for
Support organization please review the Practices Web page. advancing care information.
Technical Assistance Resource Guide on Comment: Commenters questioned Commenters believed this was an
qpp.cms.gov, or use the search feature the requirement that MIPS eligible oversight and urged CMS to create a
on the Small Practices Web page. clinicians must demonstrate that there hardship exception for clinicians that
Comment: Some commenters are overwhelming barriers that prevent practice in rural areas. Others requested
recommended other significant them from complying with the that CMS modify the proposed
hardship exceptions such as for MIPS requirements of the advancing care advancing care information hardship
eligible clinicians practicing in information performance category. They exception so that it applies to both small
medically underserved areas or MIPS believe that such a requirement is not practices and practices located in rural
eligible clinicians caring for a medically clear or concise, and detracts from
areas. They also requested that CMS
underserved population. program goals.
Response: We are adopting several make this an automatic exemption so as
Response: We understand these
policies in this final rule with comment concerns; however, we believe that not to add to the burden of clinicians in
period that will reduce its impact on adopting and implementing CEHRT may these practices by requiring them to
small and solo practices, including the not be a significant hardship for some demonstrate overwhelming barriers to
creation of a hardship exception for small practices. For small practices compliance. To recognize more
MIPS eligible clinicians in small experiencing a significant hardship, we advanced practices, the commenter
practices. We will be monitoring proposed that they demonstrate, suggested that CMS could offer an opt-
participation in MIPS and in the through their application, there are in that would allow small and rural
advancing care information performance overwhelming barriers to complying practices that believe they are prepared
category to determine if it is appropriate with the requirements of the advancing to participate in the advancing care
to establish additional hardship care information performance category. information performance category to do
exceptions for clinicians in medically We do not anticipate any additional so.
underserved areas and those who serve burden associated with this requirement Response: We disagree that the
underserved populations. Further, this as we do not intend to require hardship exception should be
final rule with comment periods documentation of the overwhelming automatic for small practices because
provisions are designed to encourage barriers. While we sincerely hope that we believe many small practices will be
participation, incentivize continuous MIPS eligible clinicians will be able to able to successfully report on the
improvement, and move participants on successfully report for the advancing advancing care information performance
a glide path to improved health care care information performance category, category. For those small practice that
delivery in the Quality Payment we understand that small practices do wish to apply for this significant
Program. have challenges that would benefit from hardship exception, we have simplified
Comment: One commenter applauded added flexibility and time to adopt the application process for hardship
CMS for proposing a hardship exception CEHRT. exceptions under MIPS as compared
for small practices and requested that Comment: One commenter with the process available for the
CMS provide more assistance to small recommended expanding the definition Medicare EHR Incentive Program. We
practices that are willing to try to of small practice so that it is not limited will be monitoring participation in
integrate information technology. They to practices with 15 or fewer clinicians. MIPS and in the advancing care
stated the invaluable assistance Another suggested a threshold of 18 information performance category to
provided by the Regional Extension clinicians. determine if it is appropriate to
Centers for the Medicare and Medicare Response: While we understand the establish an additional hardship
EHR Incentive Programs. concern that the proposed definition exception for clinicians practicing in
Response: We do offer no-cost could be under-inclusive, we are not rural areas in future rulemaking.
technical assistance to small practices modifying our proposal. We believe it is Final Action: After consideration of
through the Small, Underserved, and more important to reduce burden by the comments that we received, we are
Rural Support initiative. This initiative having one definition of small practice adopting our policy as proposed.
(iii) Hospital-Based MIPS Eligible scored on the advancing care Comment: Commenters stated that
Clinicians information performance category like under the current hospital-based group
In the CY 2017 Quality Payment all other MIPS eligible clinicians, and definition, if less than 100 percent of the
Program final rule (81 FR 77238 through the category would be given the clinicians in a group are considered
77240), we defined a hospital-based weighting prescribed by section hospital-based, then the group is
MIPS eligible clinician under 414.1305 1848(q)(5)(E) of the Act regardless of expected to submit advancing care
as a MIPS eligible clinician who their score. information performance category data
furnishes 75 percent or more of his or We proposed to amend for the portion of clinicians who are not
her covered professional services in 414.1380(c)(1) and (2) of the regulation hospital-based, even if that is only a
sites of service identified by the Place of text to reflect this proposal. small percentage. Commenters stated
We requested comments on the they believe the intent of the group
Service (POS) codes used in the HIPAA
proposed use of the authority provided reporting option is to ease the
standard transaction as an inpatient
in the 21st Century Cures Act in section administrative burden of reporting on
hospital (POS 21), on-campus outpatient
1848(o)(2)(D) of the Act as it relates to behalf of an entire group. Commenters
hospital (POS 22), or emergency room
hospital-based MIPS eligible clinicians. also stated it is unreasonable to expect
(POS 23) setting, based on claims for a The following is a summary of the
period prior to the performance period a group, where the majority of clinicians
public comments received on these are hospital-based, to parse out the
as specified by CMS. We discussed our proposals and our responses: minority of clinicians who are not
assumption that MIPS eligible clinicians Comment: One commenter hospital-based and to report their
who are determined hospital-based do recommended that this policy be advancing care information performance
not have sufficient advancing care effective as soon as possible. category data to CMS.
information measures applicable to Response: We note that this policy They suggested that CMS adopt a
them, and we established a policy to would apply beginning with the first policy whereby if the simple majority of
reweight the advancing care information year of the Quality Payment Program, the groups clinicians meet the
performance category to zero percent of the 2017 performance period. We did definition of hospital-based, as
the MIPS final score for the MIPS not propose substantive changes to our individuals, then the group as a whole
payment year in accordance with existing policy for hospital-based MIPS would be exempt from the advancing
section 1848(q)(5)(F) of the Act (81 FR eligible clinicians; rather, we proposed care information performance category.
77240). to rely on different statutory authority Response: We disagree and note that
We did not propose substantive for the policy. the group would not be expected to
changes to this policy; however, as a Comment: The majority of parse out any data, but would instead
result of the changes in the law made by commenters supported our proposal. report the aggregated data of the entire
the 21st Century Cures Act discussed Many stated that there are insufficient group (hospital-based MIPS eligible
above, we will not rely on section measures applicable and available to clinicians included), thus, there would
1848(q)(5)(F) of the Act and instead hospital-based MIPS eligible clinicians be no additional burden to prepare the
proposed to use the authority in the last for the advancing care information data for reporting. We direct readers to
sentence of section 1848(o)(2)(D) of the performance category of MIPS. the discussion of Scoring for MIPS
Act for exceptions for hospital-based Response: We appreciate the support Eligible Clinicians in Groups in section
MIPS eligible clinicians under the of commenters. We continue to believe II.6.f(c)(7) of this final rule with
advancing care information performance that hospital-based MIPS eligible comment period.
category. Section 1848(o)(2)(D) of the clinicians may not have control over the Final Action: After consideration of
Act, as amended by section decisions that the hospital makes the comments we received, we are
4002(b)(1)(B) of the 21st Century Cures regarding the use of health IT and finalizing our policy as proposed. We
Act, states in part that the provisions of CEHRT. These MIPS eligible clinicians will amend 414.1380(c)(1) and (2) of
section 1848(a)(7)(D) of the Act shall therefore may have no control over the the regulation text to reflect this policy.
apply to assessments of MIPS eligible type of CEHRT available, the way that
clinicians with respect to the advancing (iv) Ambulatory Surgical Center (ASC)
the technology is implemented and
care information performance category Based MIPS Eligible Clinicians
used, or whether the hospital
in an appropriate manner which may be continually invests in the technology to Section 16003 of the 21st Century
similar to the manner in which such ensure it is compliant with ONC Cures Act amended section
provisions apply with respect to the certification criteria. 1848(a)(7)(D) of the Act to provide that
payment adjustment made under Comment: Commenters urged us to be no payment adjustment may be made
section 1848(a)(7)(A) of the Act. We transparent and give MIPS eligible under section 1848(a)(7)(A) of the Act
would assign a zero percent weighting clinicians timely notice well in advance for 2017 and 2018 in the case of an
to the advancing care information of the start of the performance period eligible professional who furnishes
performance category in the MIPS final whether or not they are hospital-based substantially all of his or her covered
score for a MIPS payment year for and therefore not required to participate professional services in an ambulatory
hospital-based MIPS eligible clinicians in the advancing care information surgical center (ASC). Section
as previously defined. A hospital-based performance category. 1848(a)(7)(D)(iii) of the Act provides
MIPS eligible clinician would have the Response: We agree. We want to that determinations of whether an
option to report the advancing care inform MIPS eligible clinicians as soon eligible professional is ASC-based may
information measures for the as possible of their hospital-based be made based on the site of service as
performance period for the MIPS status. Unfortunately, in this first year of defined by the Secretary or an
payment year for which they are the Quality Payment Program, we were attestation, but shall be made without
determined hospital-based. However, if unable to provide this information as regard to any employment or billing
a MIPS eligible clinician who is soon as we had hoped. It became arrangement between the eligible
determined hospital-based chooses to available in August 2017, but for future professional and any other supplier or
report on the advancing care performance periods it is expected that provider of services. Section
information measures, they would be the information will be available sooner. 1848(a)(7)(D)(iv) of the Act provides that
the ASC-based exception shall no longer notify MIPS eligible clinicians of their clinicians status based on one setting.
apply as of the first year that begins ASC-based status prior to the start of the To determine if a MIPS eligible clinician
more than 3 years after the date on performance period and to align with is hospital-based, we currently consider
which the Secretary determines, the hospital-based MIPS eligible the percentage of covered professional
through notice and comment clinician determination period. For the services furnished in POS codes 21, 22,
rulemaking, that CEHRT applicable to 2019 MIPS payment year, we would not and 23 collectively and not separately.
the ASC setting is available. be able to notify MIPS eligible clinicians Comment: One commenter urged
Under section 1848(o)(2)(D) of the of their ASC-based status until after the CMS to allow ASC-based MIPS eligible
Act, as amended by section final rule with comment period is clinicians the ability to apply for a
4002(b)(1)(B) of the 21st Century Cures published, which we anticipate would significant hardship exception to
Act, the ASC-based provisions of be later in 2017. We expect that we reweight their advancing care
section 1848(a)(7)(D) of the Act shall would provide this notification through information performance category score
apply to assessments of MIPS eligible QPP.cms.gov. even if their ASC-based status changes
clinicians under section 1848(q) of the For MIPS eligible clinicians who we subsequent to the deadline to apply for
Act with respect to the advancing care determine are ASC-based, we proposed the significant hardship exception. The
information performance category in an to assign a zero percent weighting to the commenter stated that these clinicians
appropriate manner which may be advancing care information performance likely would not have control over the
similar to the manner in which such category in the MIPS final score for the CEHRT in their practice and should
provisions apply with respect to the MIPS payment year. However, if a MIPS have their advancing care information
payment adjustment made under eligible clinician who is determined performance category score reweighted
section 1848(a)(7)(A) of the Act. We ASC-based chooses to report on the to zero.
believe the proposals for ASC-based Advancing Care Information Measures Response: We note that we will make
MIPS eligible clinicians are an or the Advancing Care Information the determination about whether a MIPS
appropriate application of the Transition Measures, if applicable, for
eligible clinician is ASC-based by
provisions of section 1848(a)(7)(D) of the performance period for the MIPS
looking claims with dates of service
the Act to MIPS eligible clinicians. payment year for which they are
between September 1 of the calendar
Under the Medicare EHR Incentive determined ASC-based, we proposed
year 2 years preceding the performance
Program an approved hardship they would be scored on the advancing
period through August 31 of the
exception exempted an EP from the care information performance category
calendar year preceding the
payment adjustment. We believe that like all other MIPS eligible clinicians,
performance period. It is our intent to
weighting the advancing care and the performance category would be
make determinations prior to the close
information performance category to given the weighting prescribed by
of the submission period for significant
zero percent is similar in effect to an section 1848(q)(5)(E) of the Act
exemption from the requirements of that regardless of their advancing care hardship exceptions.
performance category. information performance category score. Final Action: After consideration of
To align with our hospital-based We proposed these ASC-based the comments we received, we are
MIPS eligible clinician policy, we policies would apply beginning with the finalizing our policy as proposed. We
proposed to define at 414.1305 an 2017 performance period/2019 MIPS are amending 414.1305 and
ASC-based MIPS eligible clinician as a payment year. 414.1380(c)(1) and (2) to reflect this
MIPS eligible clinician who furnishes We proposed to amend policy.
75 percent or more of his or her covered 414.1380(c)(1) and (2) of the regulation (v) Exception for MIPS Eligible
professional services in sites of service text to reflect these proposals. Clinicians Using Decertified EHR
identified by the Place of Service (POS) The following is a summary of the Technology
code 24 used in the HIPAA standard public comments received on these
transaction based on claims for a period proposals and our responses: Section 4002(b)(1)(A) of the 21st
prior to the performance period as Comment: One commenter requested Century Cures Act amended section
specified by us. We requested comments that the ASC-based MIPS eligible 1848(a)(7)(B) of the Act to provide that
on this proposal and solicit comments clinician determination be added to the the Secretary shall exempt an eligible
as to whether other POS codes should hospital-based determination so that we professional from the application of the
be used to identify a MIPS eligible would make a determination based on payment adjustment under section
clinicians ASC-based status or if an the sum of services performed in an 1848(a)(7)(A) of the Act with respect to
alternative methodology should be used. ASC, inpatient hospital, emergency a year, subject to annual renewal, if the
We noted that the ASC-based room and on-campus outpatient Secretary determines that compliance
determination will be made hospital as they believe that application with the requirement for being a
independent of the hospital-based is in line with congressional intent. meaningful EHR user is not possible
determination. Response: We disagree. We proposed because the CEHRT used by such
To determine a MIPS eligible that the ASC-based MIPS eligible professional has been decertified under
clinicians ASC-based status, we clinician determination be made ONCs Health IT Certification Program.
proposed to use claims with dates of separately from the hospital-based Section 1848(o)(2)(D) of the Act, as
service between September 1 of the determination because section amended by section 4002(b)(1)(B) of the
calendar year 2 years preceding the 1848(a)(7)(D) of the Act, as amended by 21st Century Cures Act, states in part
performance period through August 31 section 16003 of the 21st Century Cures that the provisions of section
of the calendar year preceding the Act, distinguishes between hospital- 1848(a)(7)(B) of the Act shall apply to
performance period, but in the event it based and ASC-based clinicians, and assessments of MIPS eligible clinicians
is not operationally feasible to use continue to believe this approach is with respect to the advancing care
claims from this time period, we would most consistent with the statute. information performance category in an
use a 12-month period as close as However, we note that the commenter appropriate manner which may be
practicable to this time period. We incorrectly described our hospital-based similar to the manner in which such
proposed this timeline to allow us to policy by stating we determine a provisions apply with respect to the
payment adjustment made under terms made a good faith effort and Act, as amended by section
section 1848(a)(7)(A) of the Act. through supporting documentation 4002(b)(1)(A) of the 21st Century Cures
We proposed that a MIPS eligible are vague and requested further Act, provides authority for an exception
clinician may demonstrate through an guidance. in the event of decertification, not
application process that reporting on the Response: While we understand the suspension of certification.
measures specified for the advancing concern, MIPS eligible clinicians Final Action: After consideration of
care information performance category frequently change EHR vendors, and we the comments we received, we are
is not possible because the CEHRT used would not know that they are using a finalizing our policy as proposed. We
by the MIPS eligible clinician has been product that has been decertified unless are amending 414.1380(c)(1) and (2) of
decertified under ONCs Health IT they notified CMS. We have a fairly the regulation text to reflect this policy.
Certification Program. We proposed that simple system through which MIPS
(b) Hospital-Based MIPS Eligible
if the MIPS eligible clinicians eligible clinicians may apply for an
Clinicians
demonstration is successful and an exception. Documentation does not
exception is granted, we would assign a need to be submitted with the In the CY 2017 Quality Payment
zero percent weighting to the advancing application, but MIPS eligible clinicians Program final rule (81 FR 77238 through
care information performance category should retain documentation that 77240, we defined a hospital-based
in the MIPS final score for the MIPS supports their request for an exception MIPS eligible clinician as a MIPS
payment year. In accordance with based on decertified EHR technology. eligible clinician who furnishes 75
section 1848(a)(7)(B) of the Act, the Comment: One commenter percent or more of his or her covered
exception would be subject to annual recommended that we communicate the professional services in sites of services
renewal, and in no case may a MIPS availability of this hardship exception identified by the Place of Service (POS)
eligible clinician be granted an for clinicians who learn that their codes used in the HIPAA standard
exception for more than 5 years. We CEHRT does not conform to the ONC transaction as an inpatient hospital
proposed this exception would be certification requirements. (POS 21), on campus outpatient hospital
available beginning with the CY 2018 Response: We plan to add this (POS 22) or emergency room (POS 23)
performance period and the 2020 MIPS decertification exception category to the setting, based on claims for a period
payment year. Quality Payment Program Hardship prior to the performance period as
We proposed that a MIPS eligible Exception Application on qpp.cms.gov. specified by CMS.
clinician may qualify for this exception Comment: One commenter urged We proposed to modify our policy to
if their CEHRT was decertified either CMS to use at least a 2-year exemption include covered professional services
during the performance period for the period and allow clinicians to seek furnished by MIPS eligible clinicians in
MIPS payment year or during the additional time if necessary before they an off-campus-outpatient hospital (POS
calendar year preceding the are subject to the advancing care 19) in the definition of hospital-based
performance period for the MIPS information performance category MIPS eligible clinician. POS 19 was
payment year. In addition, we proposed reporting requirements. A few developed in 2015 in order to capture
that the MIPS eligible clinician must commenters stated it was more the numerous physicians that are paid
demonstrate in their application and appropriate to allow a 3-year exemption for a portion of their services in an off
through supporting documentation if period because of the time necessary to campus-outpatient hospital versus an
available that the MIPS eligible clinician acquire a new system, move data, on campus-outpatient hospital, (POS
made a good faith effort to adopt and redesign workflows and train clinical 22). We also believe that these MIPS
implement another CEHRT in advance and administrative staffs. eligible clinicians would not typically
of the performance period. We proposed Response: All exceptions for the have control of the development and
a MIPS eligible clinician seeking to advancing care information performance maintenance of their EHR systems, just
qualify for this exception would submit category are approved for 1 year only, like those who bill using POS 22. We
an application in the form and manner and the exception application would be proposed to add POS 19 to our existing
specified by us by December 31st of the subject to annual renewal. We stated definition of a hospital-based MIPS
performance period, or a later date that MIPS eligible clinician may qualify eligible clinician beginning with the
specified by us. for this exception if their CEHRT was performance period in 2018.
We proposed to amend decertified either during the The following is a summary of the
414.1380(c)(1) and (2) of the regulation performance period for the MIPS public comments received on these
text to reflect these proposals. payment year or during the calendar proposals and our responses:
The following is a summary of the year preceding the performance period Comment: Commenters expressed
public comments received on these for the MIPS payment year. If the their support for the addition of off-
proposals and our responses: transition to a new CEHRT takes much campus-outpatient hospital (POS 19) to
Comment: Commenters supported the longer than expected for reasons beyond the definition of hospital-based.
creation of a hardship exception for the clinicians control, they could Response: We appreciate the support
clinicians whose EHR becomes potentially apply for a significant and believe it is appropriate to add off-
decertified. One commenter stated that hardship exception based on extreme campus-outpatient hospital (POS 19) in
the proposal was a sensible approach and uncontrollable circumstances. the definition of hospital-based MIPS
that supports clinicians who encounter Comment: Several commenters eligible clinician because this setting is
serious issues with EHR technology that recommended expanding this proposal similar to the on-campus outpatient
are outside their control. to include CEHRT that has its hospital setting in that the MIPS eligible
Response: We appreciate the support certification suspended. Commenters clinicians lack control over CEHRT.
of commenters for this proposal. indicated a suspension would occur Comment: A few commenters urged
Comment: One commenter only when ONC identifies that CEHRT CMS to automatically reweight the
recommended that clinicians be held poses a potential risk to public health advancing care information performance
harmless in an automated fashion if or safety. category for clinicians who
there CEHRT becomes decertified. The Response: While we understand these predominantly practice in settings such
commenter expressed concern that the concerns, section 1848(a)(7)(B) of the as Comprehensive Inpatient
Rehabilitation Facility (IRF; POS 61) category described in the CY 2017 Comment: One commenter requested
and Skilled Nursing Facility (SNF: POS Quality Payment Program final rule (81 clarification as to how the advancing
31) as clinicians who practice in these FR 77215) state that group data should care information performance category
settings will struggle to meet advancing be aggregated for all MIPS eligible of MIPS applies to group reporting.
care information requirements much clinicians within the group. This Specifically, the commenter stated that
like inpatient hospital-based eligible includes those MIPS eligible clinicians CMS regulations and guidance are
clinicians. For example, they may not who may qualify for a zero percent unclear as to whether it is permissible
have control over the decisions that the weighting of the advancing care for a MIPS eligible clinician who
facilities make regarding the use of information performance category due participates in group reporting to not
health IT and CEHRT, and requirements to the circumstances as described above, utilize CEHRT without disqualifying the
under the Protect Patient Health such as a significant hardship or other entire group from attempting to report
Information Objective to conduct a type of exception, hospital-based or successfully on the advancing care
security risk analysis would rely on the ASC-based status, or certain types of information performance category.
actions of the facilities, rather than the non-physician practitioners (NPs, PAs, Another commenter asked if groups are
actions of the MIPS eligible clinicians. CNSs, and CRNAs). If these MIPS able to report their advancing care
Response: We thank the commenters eligible clinicians report as part of a information data by aggregating data for
for bringing these settings to our group or virtual group, they will be the entire TIN and including a
attention, and although we did not scored on the advancing care denominator value only for the patients
include them in our proposals, we will information performance category like who were seen in a location with the
monitor MIPS participation of clinicians all other MIPS eligible clinicians and use of CEHRT, or if the whole group
who practice in these settings to the performance category will be given would receive a zero for the advancing
determine if they are able to meet the the weighting prescribed by section care information performance category
requirements of the advancing care 1848(q)(5)(E) of the Act regardless of the because not all MIPS eligible clinicians
information performance category. groups advancing care information in the group use CEHRT.
Final Action: After consideration of performance category score. Response: In the CY 2017 Quality
the public comments, we are adopting Payment Program final rule (81 FR
our proposal as proposed. 77215), we stated that the group will
public comments received and our
(c) Scoring for MIPS Eligible Clinicians responses: need to aggregate data for all the
in Groups individual MIPS eligible clinicians
Comment: One commenter urged
within the group for whom they have
In any of the situations described in CMS not to finalize this policy and
data in CEHRT. The group should
the sections above, we would assign a instead to reweight the advancing care
submit the data that they have in
zero percent weighting to the advancing information category to zero percent for
CEHRT and exclude data not collected
care information performance category any group or virtual group in which the
from a non-certified EHR system. While
in the MIPS final score for the MIPS majority of individual clinicians would we do not expect that every MIPS
payment year if the MIPS eligible be exempt from scoring in that category. eligible clinician in the group will have
clinician meets certain specified Another commenter suggested that access to CEHRT, or that every measure
requirements for this weighting. We groups should have the option to will apply to every clinician in the
noted that these MIPS eligible clinicians include or to not include data from non- group, only those data contained in
may choose to submit Advancing Care patient facing and hospital-based MIPS CEHRT should be reported for the
Information Measures or the Advancing eligible clinicians in their aggregated advancing care information performance
Care Information Transition Measures, if advancing care information performance category.
applicable; however, if they choose to category data. We will take these comments into
report, they will be scored on the Response: We did not propose any consideration and may address the
advancing care information performance changes to our policy related to MIPS issues raised in future rulemaking.
category like all other MIPS eligible eligible clinicians in groups. We were
clinicians and the performance category simply restating the policy finalized for (d) Timeline for Submission of
will be given the weighting prescribed groups reporting data for the advancing Reweighting Applications
by section 1848(q)(5)(E) of the Act care information performance category In the CY 2017 Quality Payment
regardless of their advancing care as described in the CY 2017 Quality Program final rule (81 FR 7724077243),
information performance category score. Payment Program final rule (81 FR we established the timeline for the
This policy includes MIPS eligible 77215) that group data should be submission of applications to reweight
clinicians choosing to report as part of aggregated for all MIPS eligible the advancing care information
a group or part of a virtual group. clinicians within the group. This performance category in the MIPS final
Groups as defined at 414.1310(e)(1) includes those MIPS eligible clinicians score to align with the data submission
are required to aggregate their who may qualify for a zero percent timeline for MIPS. We established that
performance data across the TIN in weighting of the advancing care all applications for reweighting the
order for their performance to be information performance category based advancing care information performance
assessed as a group (81 FR 77058). on a significant hardship or other type category be submitted by the MIPS
Additionally, groups that elect to have of exception, hospital-based or ASC- eligible clinician or designated group
their performance assessed as a group based status, or certain types of non- representative in the form and manner
will be assessed as a group across all physician practitioners (NPs, PAs, specified by us. All applications may be
four MIPS performance categories. By CNSs, and CRNAs). Our policy is 100 submitted on a rolling basis, but must be
reporting as part of a group, MIPS percent of the MIPS eligible clinicians received by us no later than the close of
eligible clinicians are subscribing to the in the group must qualify for a zero the submission period for the relevant
data reporting and scoring requirements percent weighting in order for the performance period, or a later date
of the group. We noted that the data advancing care information performance specified by us. An application would
submission criteria for groups reporting category to be reweighted in the final need to be submitted annually to be
advancing care information performance score. considered for reweighting each year.
The Quality Payment Program submission deadline to align with the assess their participants on quality and
Exception Application will be used to end of the performance period. cost are assessed as consistently as
apply for the following exceptions: Comment: Commenters supported the possible across MIPS and their
Insufficient Internet Connectivity; change in the application submission respective APMs. Given that many
Extreme and Uncontrollable deadline because it will reduce the APMs already assess their participants
Circumstances; Lack of Control over the reporting burden for those who are on cost and quality of care and require
Availability of CEHRT; Decertification approved for a hardship exception. engagement in certain improvement
of CEHRT; and Small Practice. Response: We appreciate the support activities, we believe that without the
We proposed to change the for our proposal. APM scoring standard, misalignments
submission deadline for the application Comment: One commenter could be quite common between the
as we believe that aligning the data recommended that the submission evaluation of performance under the
submission deadline with the deadline for hardship exceptions be terms of the APM and evaluation of
reweighting application deadline could changed to July 31, 2018 as they stated performance on measures and activities
disadvantage MIPS eligible clinicians. that the inclusion of the phrase or at under MIPS.
We proposed to change the submission a later date specified by us indicates In the CY 2017 Quality Payment
deadline for the CY 2017 performance that CMS acknowledges that the Program final rule, we identified the
period to December 31, 2017, or a later December 31st deadline may not be types of APMs for which the APM
date specified by us. We believe this appropriate. scoring standard would apply as MIPS
change would help MIPS eligible Response: We disagree. We believe APMs (81 FR 77249). We finalized at
clinicians by allowing them to learn that it is appropriate to align the 414.1370(b) that to be a MIPS APM, an
whether their application is approved submission period for hardship APM must satisfy the following criteria:
prior to the data submission deadline exception applications with the (1) APM Entities participate in the APM
for the CY 2017 performance period, performance period so that MIPS under an agreement with CMS or by law
March 31, 2018. We noted that if a MIPS eligible clinicians will know whether or regulation; (2) the APM requires that
eligible clinician submits data for the their application was approved prior to APM Entities include at least one MIPS
advancing care information performance the MIPS data submission deadline. eligible clinician on a Participation List;
category after an application has been Final Action: After consideration of (3) the APM bases payment incentives
submitted, the data would be scored, the the public comments, we are adopting on performance (either at the APM
application would be considered voided our policy as proposed. We note that the Entity or eligible clinician level) on
and the advancing care information submission of Quality Payment Program cost/utilization and quality measures;
performance category would not be Hardship Exception Applications began and (4) the APM is not either a new
reweighted. during the 2017 performance period (in APM for which the first performance
We further proposed that the August 2017) and will close at the end period begins after the first day of the
submission deadline for the 2018 of the calendar year 2017. MIPS performance period for the year or
performance period will be December an APM in the final year of operation for
31, 2018, or a later date as specified by g. APM Scoring Standard for MIPS which the APM scoring standard is
us. We believe this would help MIPS Eligible Clinicians in MIPS APMs impracticable. We specified that we will
eligible clinicians by allowing them to (1) Overview post the list of MIPS APMs prior to the
learn whether their application is first day of the MIPS performance
approved prior to the data submission Under section 1848(q)(1)(C)(ii)(1) of period for each year, though we expect
deadline for the CY 2018 performance the Act, Qualifying APM Participants that any new models would likely be
period, March 31, 2019. (QPs) are not MIPS eligible clinicians announced 2 or more months before the
The following is a summary of the and are thus excluded from MIPS start of the performance period for a
public comments received on these reporting requirements and payment year (81 FR 77250). We finalized in our
proposals and our responses: adjustments. Similarly, under section regulations at 414.1370(b) that for a
Comment: One commenter requested 1848(q)(1)(c)(ii)(II) of the Act, Partial new APM to be a MIPS APM, its first
that MIPS eligible clinicians be able to Qualifying APM Participants (Partial performance period must start on or
submit applications throughout the QPs) are also not MIPS eligible before the first day of the MIPS
performance period and did not support clinicians unless they opt to report and performance period. A list of MIPS
the change to the application deadline. be scored under MIPS. All other MIPS APMs is available at www.qpp.cms.gov.
Another commenter suggested that eligible clinicians, including those We also note that while it is possible
MIPS eligible clinicians should be able participating in MIPS APMs, are subject to be both a MIPS APM and an
to submit their applications throughout to MIPS reporting requirements and Advanced APM, the criteria for the two
the performance period and receive a payment adjustments unless they are are distinct, and a determination that an
timely response from CMS. excluded on another basis such as being APM is an Advanced APM does not
Response: We agree that MIPS eligible newly enrolled in Medicare or not guarantee that it will be a MIPS APM
clinicians should be able to submit exceeding the low volume threshold. and vice versa. We refer eligible
applications throughout the In the CY 2017 Quality Payment clinicians to our Web site, qpp.cms.gov,
performance period. Under our Program final rule, we finalized the for more information about participating
proposal, MIPS eligible clinicians could APM scoring standard, which is in MIPS APMs and Advanced APMs.
submit applications anytime during CY designed to reduce reporting burden for We established in the regulations at
2017, which is the performance period. participants in certain APMs by 414.1370(c) that the MIPS performance
We believe that if the application minimizing the need for them to make period under 414.1320 of our
submission period is open during the duplicative data submissions for both regulations applies for the APM scoring
data submission period, MIPS eligible MIPS and their respective APMs (81 FR standard.
clinicians may not know whether their 77246 through 77269, 77543). We also We finalized that under section
application is approved prior to the data sought to ensure that MIPS eligible 414.1370(f) of our regulations, for the
submission period, and thus we clinicians in APM Entities that APM scoring standard, MIPS eligible
proposed to change the application participate in certain types of APMs that clinicians will be scored at the APM
Entity group level, and each MIPS performance period and described the MIPS policies should be made explicitly
eligible clinician will receive the APM scoring methodology for quality applicable to the APM scoring standard.
Entity groups final score. The MIPS improvement for Other MIPS APMs. We
(2) Assessment Dates for Inclusion of
payment adjustment is applied at the proposed to align the MIPS performance
MIPS Eligible Clinicians in APM Entity
TIN/NPI level for each of the MIPS category weights for Other MIPS APMs Groups Under the APM Scoring
eligible clinicians in the APM Entity. with those used for Web Interface Standard
The MIPS final score is comprised of the reporter APMs under the APM scoring
four MIPS performance category scores, standard; and proposed policies to In the CY 2017 Quality Payment
as described in our regulation at address situations where a MIPS eligible Program final rule, we specified in our
414.1370(g): Quality, cost, clinician qualifies for reweighting to regulations at 414.1370(e) that the
improvement activities, and advancing zero percent in the advancing care APM Entity group for purposes of
care information. Both the Medicare information performance category. We scoring under the APM scoring standard
Shared Savings Program and Next also proposed, beginning with the 2018 is determined in the manner prescribed
Generation ACO Model are MIPS APMs performance period, to provide MIPS at 414.1425(b)(1), which provides that
for the 2017 performance period. For eligible clinicians scored using the APM eligible clinicians who are on a
these two MIPS APMs, in accordance scoring standard with performance Participation List on at least one of three
with our regulations at 414.1370(h), feedback as specified under section dates (March 31, June 30, and August
the MIPS performance category scores 1848(q)(12) of the Act for the quality, 31) would be considered part of the
are weighted as follows: Quality at 50 advancing care information, and APM Entity group. Under these
percent; cost at zero percent; improvement activities performance regulations, MIPS eligible clinicians
improvement activities at 20 percent; categories to the extent data are who are not on a Participation List on
and advancing care information at 30 available (82 FR 30080 through 30091). one of these three assessment dates are
percent of the final score. For all other We discuss these final policies in this not scored under the APM scoring
MIPS APMs for the 2017 performance section of this final rule with comment standard. Instead, they would need to
period, quality and cost are each period. submit data to MIPS through one of the
weighted at zero percent, improvement MIPS data submission mechanisms and
In reviewing these proposals, we their performance would be assessed
activities at 25 percent, and advancing reminded readers that the APM scoring either as individual MIPS eligible
care information at 75 percent of the standard is built upon regular MIPS but clinicians or as a group according to the
final score. provides for special policies to address generally applicable MIPS criteria.
In the CY 2018 Quality Payment the unique circumstances of MIPS We stated that we will continue to use
Program proposed rule, for the APM eligible clinicians who are in APM the three assessment dates of March 31,
scoring standard, we proposed to: Entities participating in MIPS APMs. June 30, and August 31 to identify MIPS
Amend 414.1370(e) to add an APM For the cost, improvement activities, eligible clinicians who are on an APM
Entity group assessment date for MIPS and advancing care information Entitys Participation List and determine
eligible clinicians in full TIN APMs; performance categories, unless a the APM Entity group that is used for
continue to weight the cost performance separate policy has been established or purposes of the APM scoring standard
category at zero and, in alignment with is being proposed for the APM scoring (82 FR 30081). In addition, beginning in
that proposal, to not take improvement standard, the generally applicable MIPS the 2018 performance period, we
into account for the cost performance policies would be applicable to the proposed to add a fourth assessment
category for 2020 and subsequent years; APM scoring standard. Additionally, date of December 31 to identify those
add the CAHPS for ACOs survey to the unless we included a proposal to adopt MIPS eligible clinicians who participate
list of Shared Savings Program and Next a unique policy for the APM scoring in a full TIN APM. We proposed to
Generation ACO Model quality standard, we proposed to adopt the define full TIN APM at 414.1305 to
measures that are used to calculate the same generally applicable MIPS policies mean an APM where participation is
MIPS APM quality performance proposed elsewhere in the CY 2018 determined at the TIN level, and all
category score beginning with the 2018 Quality Payment Program proposed rule eligible clinicians who have assigned
performance period; define Other and would treat the APM Entity group their billing rights to a participating TIN
MIPS APMs under 414.1305; as the group for purposes of MIPS. For are therefore participating in the APM.
establish a separate MIPS APM list of the quality performance category, An example of a full TIN APM is the
quality measures for each Other MIPS however, the APM scoring standard we Shared Savings Program, which requires
APM and use that list for scoring in the proposed is presented as a separate, all individuals and entities that have
quality performance category; calculate unique standard, and therefore, reassigned their right to receive
the MIPS quality performance category generally applicable MIPS policies Medicare payment to the TIN of an ACO
score for Other MIPS APMs using the would not be applied to the quality participant to participate in the ACO
APM-specific quality measures and performance category under the APM and comply with the requirements of
score only those measures that are tied scoring standard unless specifically the Shared Savings Program.
to payment as described under the terms stated. We sought comment on whether If an eligible clinician elects to
of the APM, are available for scoring there may be potential conflicts or reassign their billing rights to a TIN
near the close of the MIPS submission inconsistencies between the generally participating in a full TIN APM, the
period, have a minimum of 20 cases applicable MIPS policies and those eligible clinician is necessarily
available for reporting and have an proposed under the APM scoring participating in the full TIN APM. We
available benchmark; and add scoring standard, particularly where these could proposed to add this fourth date of
for quality improvement to the MIPS impact our goals to reduce duplicative December 31 only for MIPS eligible
APM quality performance category for and potentially incongruous reporting clinicians in a full TIN APM, and only
all MIPS APMs beginning in 2018. We requirements and performance for purposes of applying the APM
also proposed a quality scoring evaluations that could undermine our scoring standard. We did not propose to
methodology for Other MIPS APMs ability to test or evaluate MIPS APMs, use this additional assessment date of
beginning in the 2018 MIPS or whether certain generally applicable December 31 for purposes of QP
determinations. Therefore, we proposed Comment: CMS received many Comment: A few commenters
to amend 414.1370(e) to identify the comments in support of our proposal to requested that CMS provide more
four assessment dates that would be add the December 31 snapshot date for information as to whether an eligible
used to identify the APM Entity group full TIN APMs. clinician is counted as a participant in
for purposes of the APM scoring Response: We thank commenters for a MIPS APM so that they know whether
standard, and to specify that the their support of our proposal. or not they are required to report to
December 31 date would be used only Comment: Several commenters MIPS.
to identify MIPS eligible clinicians on recommended that CMS make the fourth Response: In the CY 2017 Quality
the APM Entitys Participation List for snapshot date policy retroactive so that Payment Program final rule, we stated
a MIPS APM that is a full TIN APM in it would apply for the 2017 performance that it is important to ensure that the
order to add them to the APM Entity period. appropriate parties are properly notified
group that is scored under the APM Response: We understand of their status for purposes of MIPS. We
scoring standard. commenters desire for the proposed also stated that we would provide
We proposed to use this fourth policy to be applied retroactively to the additional information on the format of
assessment date of December 31 to 2017 performance period. However, in such notifications and the data we will
extend the APM scoring standard to consideration of the requirement that include as part of our public
only those MIPS eligible clinicians we give the public notice of proposed communications following the issuance
participating in MIPS APMs that are full changes and an opportunity to comment of that final rule (81 FR 77450).
TIN APMs, ensuring that a MIPS eligible on them, we refrain from making Comment: Numerous comments
clinician who joins the full TIN APM retroactive regulatory changes unless recommended that CMS extend the
between August 31 and December 31 in there is specific and articulable fourth snapshot date to all MIPS APM
the performance period would be scored authority and a reason why it is participants.
under the APM scoring standard. We necessary and appropriate to do so; and Response: In addition to avoiding
considered proposing to use the fourth we do not believe we have those in this duplicative or potentially inconsistent
assessment date more broadly for all situation. reporting requirements or incentives
MIPS APMs. However, we noted that we Comment: A few commenters between MIPS and a MIPS APM, the
believe that approach would have requested a switch to 90 day assessment APM scoring standard is intended to
allowed MIPS eligible clinicians to
periods to determine participation in reduce the reporting burden of
inappropriately leverage the fourth
MIPS APMs. participants in MIPS APMs who have
assessment date to avoid reporting and
Response: We believe it is simplest to focused their practice transformation
scoring under the generally applicable
generally align the snapshot dates used activities in the preceding performance
MIPS scoring standard when they were
for purposes of the APM scoring period on the requirements of
part of the MIPS APM for only a very
standard for MIPS APMs with those participation in the APM. As such, we
limited portion of the performance
used to identify eligible clinicians in believe it is appropriate to ensure that
period. That is, for MIPS APMs that
allow split TIN participation, we were Advanced APMs for purposes of QP the APM scoring standard applies only
concerned that it would be possible for determinations. for those who are genuinely committed
MIPS eligible clinicians to briefly join a We anticipate that the current to participation in MIPS APMs. By
MIPS APM principally in order to snapshot policy will identify the vast limiting applicability of the APM
benefit from the APM scoring standard, majority of MIPS eligible clinicians in scoring standard to eligible clinicians
despite having limited opportunity to MIPS APMs at the first snapshot, and who are on a MIPS APMs Participation
contribute to the APM Entitys then at subsequent snapshot dates will List on one of the first three snapshot
performance in the MIPS APM. In add those MIPS eligible clinicians who dates, we hope to minimize any
contrast, we believe MIPS eligible join a MIPS APM later in the year but potential opportunity for certain MIPS
clinicians would be less likely to join a still have a significant opportunity to eligible clinicians to take inappropriate
full TIN APM principally to avail contribute to the APM Entitys advantage of the APM scoring standard.
themselves of the APM scoring performance in the MIPS APM. As such, Full TIN APMs, however, require that
standard, since doing so would require we believe this policy would more all individuals and entities billing
either that the entire TIN join the MIPS appropriately identify MIPS eligible through a TIN agree to participate in the
APM or the administratively clinicians for purposes of applying the APM in which the TIN is a participant.
burdensome act of the MIPS eligible APM scoring standard. As a result, to avail themselves of the
clinician reassigning their billing rights Comment: A few commenters APM scoring standard, clinicians or
to the TIN of an entity participating in suggested adding the fourth snapshot entities would have to undergo the
the full TIN APM. date of December 31 for QP additional burden of joining a different
We will continue to use only the three determinations as well. billing TIN before starting their
dates of March 31, June 30, and August Response: We reiterate that we did participation in the APM. Therefore, we
31 to determine, based on Participation not propose to add a fourth snapshot believe that the risk of a MIPS eligible
Lists, the MIPS eligible clinicians who date of December 31 for QP clinician inappropriately leveraging the
participate in MIPS APMs that are not determinations and we will not adopt a APM scoring standard by joining an
full TIN APMs. We sought comment on policy to do so in this rulemaking. We APM late in the year is significantly
the proposed addition of the fourth date believe that the snapshot policy that we diminished in full-TIN APMs, and we
of December 31 to assess Participation finalized in the CY 2017 Quality are comfortable allowing for the use of
Lists to identify MIPS eligible clinicians Payment Program final rule will allow the fourth snapshot date at the end of
who participate in MIPS APMs that are for us to make QP determinations such the performance period to identify the
full TIN APMs for purposes of the APM that eligible clinicians, including those eligible clinicians participating in these
scoring standard. who fail to become QPs and who may APMs. We will continue to monitor this
The following is a summary of the need to report to MIPS, would know issue and may consider in future
public comments received on this their QP status in advance of the end of rulemaking whether there are other
proposal and our responses: the MIPS reporting period. APM designs for which using a fourth
snapshot date would also be the APM. We also believe imposition of resources for engaging in efforts to
appropriate. MIPS reporting requirements would improve quality and lower costs for a
Final Action: After considering public result in reporting activity that provides specified beneficiary population,
comments, we are finalizing our little or no added value to the measurement of the population
proposal to define full TIN APM at assessment of MIPS eligible clinicians, identified through the APM must take
414.1305 to mean an APM where and could confuse these eligible priority in order to ensure that the goals
participation is determined at the TIN clinicians as to which CMS incentives and the model evaluation associated
level, and all eligible clinicians who should take priority over others in with the APM are as clear and free of
have assigned their billing rights to a designing and implementing care confounding factors as possible. The
participating TIN are therefore improvement activities. potential for different, conflicting
participating in the APM. We are also results across APMs and MIPS
finalizing our proposal to add a fourth (a) Cost Performance Category
assessments may create uncertainty for
date of December 31 only for MIPS In the CY 2017 Quality Payment MIPS eligible clinicians who are
eligible clinicians in a full TIN APM Program final rule, for MIPS eligible attempting to strategically transform
only for purposes of applying the APM clinicians participating in MIPS APMs, their respective practices and succeed
scoring standard and we are finalizing we used our authority to waive certain under the terms of the APM.
our proposal to amend 414.1370(e) to requirements under the statute to reduce We sought comment on our proposal
identify the four assessment dates that the scoring weight for the cost to continue to waive the weighting of
would be used to identify the APM performance category to zero (81 FR the cost performance category for the
Entity group for purposes of the APM 77258, 77262, and 77266). For MIPS 2020 payment year forward (82 FR
scoring standard. We are also finalizing APMs authorized under section 1115A 30082). The following is a summary of
our proposal to specify that the of the Act using our authority under the public comments we received on
December 31 date would be used only section 1115A(d)(1) of the Act, we this proposal and our responses:
to identify MIPS eligible clinicians on waived the requirement under section Comment: Several commenters
the APM Entitys Participation List for 1848(q)(5)(E)(i)(II) of the Act, which supported our proposal.
a MIPS APM that is a full TIN APM in specifies the scoring weight for the cost Response: We thank commenters for
order to add them to the APM Entity performance category. Having reduced their support of our proposal.
group that is scored under the APM the cost performance category weight to Comment: One commenter requested
scoring standard. zero, we further used our authority that the cost performance category be
under section 1115A(d)(1) of the Act to scored for MIPS APMs to further
(3) Calculating MIPS APM Performance waive the requirements under sections incentivize efficient and appropriate
Category Scores 1848(q)(2)(B)(ii) and 1848(q)(2)(A)(ii) of care delivery.
In the CY 2017 Quality Payment the Act to specify and use, respectively, Response: We agree that encouraging
Program final rule, we established a cost measures in calculating the MIPS efficient and appropriate care delivery is
scoring standard for MIPS eligible final score for MIPS eligible clinicians an important aim of MIPS. We also
clinicians participating in MIPS APMs participating in MIPS APMs (81 FR believe that the MIPS APMs specifically
to reduce participant reporting burden 7726177262; 81 FR 77265 through are working toward achieving this goal
by reducing the need for MIPS eligible 77266). Similarly, for MIPS eligible in diverse and innovative ways by
clinicians participating in these types of clinicians participating in the Shared basing participants Medicare payment
APMs to make duplicative data Savings Program, we used our authority on their performance on cost/utilization
submissions for both MIPS and their under section 1899(f) of the Act to and quality measures. Because
respective APMs (81 FR 77246 through waive the same requirements of section participants in MIPS APMs are already
77271). In accordance with section 1848 of the Act for the MIPS cost scored and have payment based on their
1848(q)(1)(D)(i) of the Act, we finalized performance category (81 FR 77257 performance on cost/utilization
a policy under which we assess the through 77258). We finalized this policy measures under their respective APM,
performance of a group of MIPS eligible because: (1) APM Entity groups are we continue to believe scoring of the
clinicians in an APM Entity that already subject to cost and utilization cost performance category is
participates in one or more MIPS APMs performance assessment under the MIPS unnecessary and could create
based on their collective performance as APMs; (2) MIPS APMs usually measure conflicting incentives for participants in
an APM Entity group, as defined in cost in terms of total cost of care, which MIPS APMs if their MIPS payment
regulations at 414.1305. is a broader accountability standard that adjustment is also based in part on their
In addition to reducing reporting inherently encompasses the purpose of performance in the MIPS cost
burden, we sought to ensure that MIPS the claims-based measures that have performance category.
eligible clinicians in MIPS APMs are not relatively narrow clinical scopes, and Comment: One commenter supported
assessed in multiple ways on the same MIPS APMs that do not measure cost in the reweighting of the cost performance
performance activities. Depending on terms of total cost of care may depart category to zero, but requested that CMS
the terms of the particular MIPS APM, entirely from MIPS measures; and (3) provide performance feedback in the
we believe that misalignments could be the beneficiary attribution cost performance category to MIPS
common between the evaluation of methodologies differ for measuring cost eligible clinicians in MIPS APMs.
performance on quality and cost under under APMs and MIPS, leading to an Response: We understand
MIPS versus under the terms of the unpredictable degree of overlap (for commenters desire to have information
APM. We continue to believe that eligible clinicians and for CMS) between on MIPS eligible clinicians
requiring MIPS eligible clinicians in the sets of beneficiaries for which performance under the MIPS cost
MIPS APMs to submit data, be scored eligible clinicians would be responsible performance category, even if they are
on measures, and be subject to payment that would vary based on the unique not scored on cost under the APM
adjustments that are not aligned APM Entity characteristics such as scoring standard. However, each MIPS
between MIPS and a MIPS APM could which and how many eligible clinicians APMs payment design is unique and
potentially undermine the validity of comprise an APM Entity group. We distinct from MIPS. Comparing
testing or performance evaluation under believe that with an APM Entitys finite participants in these APMs to other
MIPS eligible clinicians may lead to proposed. We are codifying this policy (b) Quality Performance Category
misleading or not meaningful results. at 414.1370(g)(2). (i) Web Interface Reporters: Shared
Because we are unable to provide Savings Program and Next Generation
accurate and meaningful feedback for (i) Measuring Improvement in the Cost
Performance Category ACO Model
the MIPS cost performance category for
those MIPS eligible clinicians scored (A) Quality Measures
In setting performance standards with
under the APM scoring standard, we We finalized in the CY 2017 Quality
respect to measures and activities in
will not be including it in the Payment Program final rule that under
each MIPS performance category,
performance feedback. However, MIPS the APM scoring standard, participants
APMs may provide some level of section 1848(q)(3)(B) of the Act requires
us to consider historical performance in the Shared Savings Program and Next
feedback to their participants on cost/ Generation ACO Model would be
utilization measure performance. standards, improvement, and the
opportunity for continued assessed for the purposes of generating
Comment: One commenter suggested
improvement. Section 1848(q)(5)(D)(i)(I) a MIPS APM quality performance
that CMS should score the cost
of the Act requires us to introduce the category score based exclusively on
performance category for MIPS APMs,
quality measures submitted using the
but that CMS should first find a way to measurement of improvement into
CMS Web Interface (81 FR 77256,
align episodes between MIPS and performance scores in the cost
77261). We also recognized that ACOs
episode-based APMs. performance category for MIPS eligible
Response: Currently there is no way in both the Shared Savings Program and
clinicians for the 2020 MIPS Payment Next Generation ACO Model are
for us to align MIPS cost measures with Year if data sufficient to measure
episodes as defined within certain MIPS required to use the CMS Web Interface
improvement are available. Section to submit data on quality measures, and
APMs because each of those MIPS 1848(q)(5)(D)(i)(II) of the Act permits us
APMs uniquely identifies the period of that the measures they are required to
to take into account improvement in the report for 2017 were also MIPS
time over which performance is case of performance scores in other
assessed and scored. For example, the measures for 2017. We finalized a policy
performance categories. Given that we to use quality measures and data
Oncology Care Model has semi-annual
have in effect waivers of the scoring submitted by the participant ACOs
performance periods, with 6-month
episodes beginning on any day within a weight for the cost performance using the CMS Web Interface and MIPS
semi-annual performance period; initial category, and of the requirement to benchmarks for these measures to score
reconciliation occurs after a specify and use cost measures in quality for MIPS eligible clinicians in
performance period ends using a two calculating the MIPS final score for these MIPS APMs at the APM Entity
month claims runout from the final day MIPS eligible clinicians participating in level (81 FR 77256, 77261). For these
of the performance period, and MIPS APMs, and for the same reasons MIPS APMs, which we refer to as CMS
subsequent true-up reconciliations that we initially waived those Web Interface reporters going forward,
capture additional claims runout after 8 requirements, we proposed to use our we established that quality performance
and 14 months after the performance authority under section 1115A(d)(1) of data that are not submitted using the
period ends. This MIPS APM uses the Act for MIPS APMs authorized Web Interface, for example, the CAHPS
unique methods of defining when under section 1115A of the Act and for ACOs survey and claims-based
performance is measured and scores under section 1899(f) of the Act for the measures, will not be included in the
calculated; attempting to align a model Medicare Shared Savings Program to MIPS APM quality performance
like the Oncology Care Model with waive the requirement under section category score for 2017. We also
other MIPS APMs or MIPS would established a policy, codified at
1848(q)(5)(D)(i)(I) of the Act to take
require large-scale modifications to one 414.1370(f)(1), to allow Shared
improvement into account for
or more initiatives that would Savings Program participant TINs to
performance scores in the cost report quality on behalf of the TIN in
undermine their design. Further,
performance category beginning with the event that the ACO Entity fails to
changing a MIPS APMs performance
the 2018 MIPS performance period (82 report quality on behalf of the APM
period could be burdensome and
disruptive for health care providers FR 30082). Entity group, and for purposes of
participating in MIPS APMs. For these We sought comment on this proposal. scoring under the APM scoring standard
reasons, we do not believe it is The following is a summary of the to treat such participant TINs as unique
advisable to change an APMs episode public comments we received and our APM Entities.
timing or performance periods for MIPS response: (aa) Addition of New Measures
purposes. Comment: Several commenters
Because of the innovative and unique In the CY 2018 Quality Payment
supported CMSs proposal to waive cost
nature of each MIPS APM and the need Program proposed rule (82 FR 30082
improvement scoring as participants in through 30083), we proposed to score
to maintain flexibility in designing and
implementing them, we do not believe MIPS APMs are already scored and the CAHPS for ACOs survey in addition
it would be appropriate to attempt to reimbursed on their performance on to the CMS Web Interface measures that
conform programmatic elements of cost/utilization measures under the are used to calculate the MIPS APM
APMs to MIPS. terms of the MIPS APM quality performance category score for
Final Action: After considering public Response: We thank the commenters participants in the Shared Savings
comments, we are finalizing the for their support of our proposal. Program and Next Generation ACO
proposal to continue to use our Final Action: After considering public Model, beginning in the 2018
authority under sections 1115A(d)(1) performance period. The CAHPS for
comments, we are finalizing the policy
and 1899(f) of the Act to waive the ACOs survey is already required in the
to waive cost improvement scoring as
requirements of the statute to reweight Shared Savings Program and Next
the cost performance category to zero for proposed.
Generation ACO Model, and including
MIPS APMs for the 2020 payment year the CAHPS for ACOs survey would
and subsequent payment years as better align the measures on which
participants in these MIPS APMs are the CAHPS for MIPS survey. Under the be used for MIPS and the APM scoring
assessed under the APM scoring proposal, the CAHPS for ACOs survey standard in the 2018 performance
standard with the measures used to would be added to the total number of period.
assess participants quality performance quality performance category measures We noted that although each question
under the APM. available for scoring in these MIPS
We did not initially propose to in the CAHPS for ACOs survey can also
APMs.
include the CAHPS for ACOs survey as While the CAHPS for ACOs survey is be found in the CAHPS for MIPS survey,
part of the MIPS APM quality new to the APM scoring standard, the the CAHPS for ACOs survey will have
performance category scoring for the CGCAHPS survey upon which it is one fewer survey question in the
Shared Savings Program and Next based is also the basis for the CAHPS for Summary Survey Measure entitled
Generation ACO Model because we MIPS survey, which was included on Between Visit Communication, which
believed that the CAHPS for ACOs the MIPS final list for the 2017 has never been a scored measure in the
survey would not be collected and performance period. For further CAHPS for ACOs survey used in the
scored in time to produce a MIPS discussion of the CAHPS for ACOs Shared Savings Program or Next
quality performance category score. survey, and the way it will be scored, Generation ACO Model, and which we
However, operational efficiencies have we refer readers to section II.C.7.a.(2)(b) believe to be inappropriate to score for
recently been introduced that have of this final rule with comment period, MIPS, as it is not scored under the terms
made it possible to score the CAHPS for which describes the CAHPS for MIPS of the APM.
ACOs survey on the same timeline as survey and the scoring method that will
TABLE 10WEB INTERFACE REPORTERS: SHARED SAVINGS PROGRAM AND NEXT GENERATION ACO MODEL NEW
MEASURE
NQF/quality National quality Primary measure
Measure name number Measure description
strategy domain steward
(if applicable)
CAHPS for ACOs ......... Not Applica- Patient/Caregiver Ex- Consumer Assessment of Healthcare Providers and Systems Agency for Healthcare
ble. perience. (CAHPS) surveys for Accountable Care Organizations (ACOs) in the Research and Qual-
Medicare Shared Savings Program and Next Generation ACO ity (AHRQ).
Model ask consumers about their experiences with health care. The
CAHPS for ACOs survey is collected from a sample of beneficiaries
who get the majority of their care from participants in the ACO, and
the questions address care received from a named clinician within
the ACO.
Survey measures include:Getting Timely Care, Appointments,
and Information
How Well Your Providers Communicate.
Patients Rating of Provider.
Access to Specialists.
Health Promotion and Education.
Shared Decision Making.
Health Status/Functional Status.
Stewardship of Patient Resources.
We sought comment on this proposal. Notwithstanding the fact that the Final Action: After considering public
The following is a summary of the CAHPS for ACOs survey is mandatory comments, we are finalizing the policy
public comments we received and our for Shared Savings Program and Next to score the CAHPS for ACOs survey in
responses: Generation ACO participants, we note addition to the CMS Web Interface
Comment: Several commenters that MIPS eligible clinicians measures that are used to calculate the
supported the proposal. participating in ACOs will nonetheless MIPS APM quality performance
Response: We thank commenters for be eligible to receive bonus points for category score for participants in the
their support of our proposal. reporting this measure, which is Shared Savings Program and Next
Comment: One commenter expressed classified as a high-priority measure, Generation ACO Model, beginning in
confusion as to whether the CAHPS for beginning in 2018. the 2018 performance period, as
ACOs survey would be required under proposed, in accordance with
Comment: Some commenters objected
the APM scoring standard, or whether it 414.1370(g)(1)(i)(A).
to the subjective nature of the CAHPS
is an optional measure.
for ACOs survey and the difficulty in (B) Calculating Quality Scores
Response: Under the APM scoring
standard, it is our goal to score all acting on responses to improve quality. We refer readers to section II.C.7.a.(2)
measures required under the terms of Response: Under both the Shared of this final rule with comment period
the APM. As part of the quality Savings Program and Next Generation for a summary of our final policies
performance requirements for the ACO Model, ACOs are required to related to calculating the MIPS quality
Shared Savings Program and the Next report on all of the measures included performance category percent score for
Generation ACO Model, all participating in the CAHPS for ACOs survey, and the MIPS eligible clinicians, including APM
ACOs are already required to report all results of the survey are used to assess Entity groups, reporting through the
of the measures included in the CAHPS the quality performance of the ACO. CMS Web Interface, and a discussion of
for ACOs survey. Because we are able to Because the CAHPS for ACOs survey is our proposed and final changes to those
score the CAHPS for ACOs survey, and required under the terms of those policies for the 2018 performance
it is mandatory under these APMs, it initiatives, we believe it is appropriate period. The changes we are finalizing in
will be scored under the APM scoring to use the CAHPS for ACOs survey for section II.C.7.a.(2) of this final rule with
standard for participants in those APMs. purposes of the APM scoring standard. comment period apply in the same
manner under the APM scoring including those participating in MIPS quality improvement points. If the APM
standard for Web Interface reporters APMs, if data sufficient to measure Entity group did not exist or receive a
except as otherwise noted in this section quality improvement are available. We quality score but some of its participant
of this final rule with comment period. proposed to calculate the quality TIN/NPIs received quality scores in the
However, we proposed not to subject improvement score using the previous performance period, the mean
Web Interface reporters to a 3 point floor methodology described in the CY 2018 of those scores would be applied to the
because we do not believe it is Quality Payment Program proposed rule APM Entity group for the purpose of
necessary to apply this transition year for scoring quality improvement for calculating quality improvement points.
policy to MIPS eligible clinicians MIPS eligible clinicians submitting If the APM Entity group did not exist or
participating in previously established quality measures via the CMS Web receive a quality score and none of its
MIPS APMs (82 FR 30083). We sought Interface (82 FR 30113, 3011630119) participant MIPS eligible clinicians
comment on this proposal. and finalized at II.C.7.a.(2). In the CY received quality scores in the previous
Final Action: We received no public 2018 Quality Payment Program performance period, no quality
comments on this proposal. We are proposed rule, we stated that we believe improvement points will be awarded.
finalizing this policy as proposed at aligning the scoring methodology used Final Action: After considering the
414.1370(g)(1)(i)(A). for all Web Interface submissions will public comments, we are finalizing the
minimize confusion among MIPS policy for calculating the total quality
(C) Incentives To Report High Priority
eligible clinicians receiving a MIPS performance category score for Web
Measures
score, including those participating in Interface reporters as proposed at
In the CY 2017 Quality Payment MIPS APMs (82 FR 30083). 414.1370(g)(1)(i)(C).
Program final rule, we finalized that for The following is a summary of the
CMS Web Interface reporters, we will (ii) Other MIPS APMs
public comments we received on this
apply bonus points based on the proposal and our response: In the CY 2018 Quality Payment
finalized set of measures reportable Comment: Several commenters Program proposed rule (82 FR 20084),
through the Web Interface (81 FR 77291 expressed support for our proposal to we proposed to define the term Other
through 77294). We will assign two make quality improvement points MIPS APM at 414.1305 of our
bonus points for reporting each outcome available beginning in the 2018 regulations as a MIPS APM that does
measure (after the first required performance period. not require reporting through the Web
outcome measure) and for each scored Response: We thank commenters for Interface. We proposed to add this
patient experience measure. We will their support of our quality definition as we believe it will be useful
also assign one bonus point for improvement scoring proposal. in discussing our policies for the APM
reporting each other high priority Final Action: We are finalizing this scoring standard. For the 2018 MIPS
measure. policy as proposed at performance period, Other MIPS APMs
In the CY 2018 Quality Payment 414.1370(g)(1)(i)(B). will include the Comprehensive ESRD
Program proposed rule (82 FR 30083), Care Model, the Comprehensive Primary
we noted that in addition to the (E) Total Quality Performance Category Care Plus Model (CPC+), and the
measures required by the APM to be Score for Web Interface Reporters Oncology Care Model.
submitted through the CMS Web In the 2018 Quality Payment Program We sought comment on this proposal.
Interface, APM Entities in the Medicare proposed rule (82 FR 30083 through The following is a summary of the
Shared Savings Program and Next 30084), we proposed to calculate the public comments we received on this
Generation ACO Model must also report total quality percent score for APM proposal and our responses:
the CAHPS for ACOs survey, and we Entities in APMs that require Web Comment: One commenter objected to
proposed that, beginning for the 2020 Interface reporting according to the the use of the term Other MIPS APM
payment year forward, participants in methodology for scoring MIPS eligible and found the distinction between MIPS
the APM Entities may receive bonus clinicians reporting on quality through APMs and Other MIPS APMs confusing.
points under the APM scoring standard the CMS Web Interface described in Response: We clarify that MIPS APMs
for submitting that measure. section II.C.7.a.(2) of this final rule with are those APMs that meet the four
Participants in MIPS APMs, like all comment period. criteria of: (1) The APM Entities
MIPS eligible clinicians, are also subject We sought comment on our proposed participate in the APM under an
to the 10 percent cap on bonus points quality performance category scoring agreement with CMS by law or
for reporting high priority measures. methodology for Web Interface regulation, (2) the APM requires that
APM Entities reporting through the reporters. The following is a summary of Entities include at least one MIPS
CMS Web Interface will only receive the public comments we received and eligible clinician on a Participation List,
bonus points if they submit a high our responses: (3) the APM bases payment incentives
priority measure with a performance Comment: One commenter expressed on performance (either at the APM
rate that is greater than zero, and confusion as to how quality Entity or clinician level) on cost/
provided that the measure meets the improvement scoring will be calculated utilization and quality measures, and (4)
case minimum requirements. at the APM Entity level for MIPS the APM is not either a new APM for
Final Action: We received no public eligible clinicians in MIPS APMs. which the first performance period
comment on this proposal. We are Response: APM Entity groups, like begins after the first day of the MIPS
finalizing this policy as proposed at other MIPS groups, will receive quality performance period for the year or an
414.1370(g)(1)(i)(C). improvement scores for any year APM in the final year of operation for
following a year in which one or more which the APM scoring standard is
(D) Scoring Quality Improvement members of the APM Entity group was impracticable. Web Interface reporters
Beginning in the 2018 performance subject to MIPS and received a quality are a subset of MIPS APMs where the
period, section 1848(q)(5)(D)(i)(I) of the score. If the APM Entity group existed terms of the APM require participating
Act requires us to score improvement in the previous performance period and APM Entities to report quality data
for the MIPS quality performance received a quality score, we will use using the Web Interface. Other MIPS
category for MIPS eligible clinicians, that score for the purpose of calculating APMs include all MIPS APMs that are
not Web Interface reporters and are also systems and processes related to the our section 1115A(d)(1) waiver
a subset of MIPS APMs. alignment, submission and collection of authority to establish that the quality
Comment: Some commenters APM quality measures for purposes of measures and data that are used to
expressed confusion as to how Other MIPS, we used our authority under evaluate performance for APM Entities
MIPS APM policies will impact Next section 1115A(d)(1) of the Act to waive in Other MIPS APMs would be used to
Generation ACOs. certain requirements of section 1848(q) calculate a MIPS quality performance
Response: The APM scoring standard of the Act for APMs authorized under score under the APM scoring standard.
applies for MIPS eligible clinicians in section 1115A of the Act. We have since designed the means to
MIPS APMs. In discussing policies for In the CY 2017 Quality Payment overcome the operational constraints
the APM scoring standard, we Program final rule, we finalized that for that prevented us from scoring quality
developed terminology to describe two the first MIPS performance period only, for these MIPS APMs under the APM
subcategories of MIPS APMs: Web for MIPS eligible clinicians participating scoring standard in the first MIPS
Interface reporters (currently the Shared in APM Entities in Other MIPS APMs, performance period, and in the CY 2018
Savings Program and Next Generation the weight for the quality performance Quality Payment Program proposed rule
ACO Model), and Other MIPS APMs (all category is zero (81 FR 77268). To avoid we proposed to adopt quality measures
other MIPS APMs that are not Web risking adverse operational or program for use under the APM scoring standard,
Interface reporters). Policies for Other evaluation consequences for MIPS and to begin collecting MIPS APM
MIPS APMs will apply only to MIPS APMs while we worked toward quality measure performance data to
APMs that do not require reporting incorporating MIPS APM quality generate a MIPS quality performance
through the Web Interface. For the 2018 measures into scoring for future category score for APM Entities
performance period, only the Shared performance periods, we used the participating in Other MIPS APMs
Savings Program and Next Generation authority provided by section beginning with the 2018 MIPS
ACO Model are Web Interface reporter 1115A(d)(1) of the Act to waive the performance period.
APMs and therefore are not Other MIPS quality performance category weight We sought comment on this proposal.
APMs. required under section 1848(q)(5)(E)(i)(I) The following is a summary of the
Final Action: After considering public of the Act for Other MIPS APMs, all of public comments we received on this
comments, we are finalizing the policy which are currently authorized under proposal and our responses:
as proposed by defining the term Other section 1115A of the Act, and we Comment: Some commenters
MIPS APM at 414.1305. indicated that with the reduction of the expressed support for our proposal.
quality performance category weight to Response: We thank commenters for
(A) Quality Measures
zero, it was unnecessary to establish for their support of our proposal.
In the CY 2017 Quality Payment these MIPS APMs a final list of quality Final Action: After considering public
Program final rule, we explained that measures as required under section comments, we are finalizing our
current MIPS APMs have requirements 1848(q)(2)(D) of the Act or to specify proposal to use quality measure
regarding the number of quality and use quality measures in performance data reported for purposes
measures and measure specifications as determining the MIPS final score for of the Other MIPS APM to generate a
well as the measure reporting method(s) these MIPS eligible clinicians. As such, MIPS quality performance category
and frequency of reporting, and have an we further waived the requirements score for APM Entities participating in
established mechanism for submission under sections 1848(q)(2)(D), Other MIPS APMs beginning with the
of these measures to us within the 1848(q)(2)(B)(i), and 1848(q)(2)(A)(i) of 2018 MIPS performance period as
structure of the specific MIPS APM. We the Act to establish a final list of quality proposed. We are codifying this policy
explained that operational measures (using certain criteria and at 414.1370(g)(1)(ii)(A).
considerations and constraints processes); and to specify and use,
interfered with our ability to use the (aa) APM Measures for MIPS
respectively, quality measures in
quality measure data from some MIPS calculating the MIPS final score for the In the CY 2017 Quality Payment
APMs for the purpose of satisfying MIPS first MIPS performance period. Program final rule, we explained the
data submission requirements for the In the CY 2017 Quality Payment concerns that led us to express our
quality performance category for the Program final rule, we anticipated that intent to use the quality measures and
first performance period. We concluded beginning with the second MIPS data that apply in MIPS APMs for
that there was insufficient time to performance period, the APM quality purposes of the APM scoring standard,
adequately implement changes to the measure data submitted to us during the including concerns about the
current MIPS APM quality measure data MIPS performance period would be application of multiple, potentially
collection timelines and infrastructure used to derive a MIPS quality duplicative or inconsistent performance
in the first performance period to performance score for APM Entities in assessments that could negatively
conduct a smooth hand-off to the MIPS all MIPS APMs. We also anticipated that impact our ability to evaluate MIPS
system that would enable use of quality it may be necessary to propose policies APMs (81 FR 77246). Additionally, the
measure data from these MIPS APMs to and waivers of requirements of the quality and cost/utilization measures
satisfy the MIPS quality performance statute, such as section 1848(q)(2)(D) of that are used to calculate performance-
category requirements in the first MIPS the Act, to enable the use of non-MIPS based payments in MIPS APMs may
performance period (81 FR 77264). Out quality measures in the quality vary from one MIPS APM to another.
of concern that subjecting MIPS eligible performance category score. We Factors such as the type and quantity of
clinicians who participate in these MIPS anticipated that by the second MIPS measures required, the MIPS APMs
APMs to multiple, potentially performance period we would have had particular measure specifications, how
duplicative or inconsistent performance sufficient time to resolve operational frequently the measures must be
assessments could undermine the constraints related to use of separate reported, and the mechanisms used to
validity of testing or performance quality measure systems and to adjust collect or submit the measures all add
evaluation under the MIPS APMs; and quality measure data submission to the diversity in the quality and cost/
that there was insufficient time to make timelines. Accordingly, we stated our utilization measures used to evaluate
adjustments in operationally complex intention, in future rulemaking, to use performance among MIPS APMs. Given
these concerns and the differences Comment: One commenter voiced required to do any additional reporting
between and among the quality concern that CMS would add measures on quality measures beyond what they
measures used to evaluate performance to the APM scoring standard measure are already required to report as part of
within MIPS APMs as opposed to those set outside of notice-and-comment their participation in the MIPS APM.
used more generally under MIPS, in the rulemaking in order to include all Therefore, whatever specific reporting
CY 2018 Quality Payment Program measures used by a MIPS APM. mechanisms and measures are required
proposed rule, we proposed to use our Response: We clarify that we will not by each MIPS APM will also be used for
authority under section 1115A(d)(1) of be scoring performance for any purposes of MIPS under the APM
the Act to waive requirements under measures not included on the MIPS scoring standard.
section 1848(q)(2)(D) of the Act, which APM quality measure list included in Final Action: After considering public
requires the Secretary to use certain each years proposed rule. Any comments, we are finalizing our
criteria and processes to establish an measures that are added to an Other proposal to establish a MIPS APM
annual MIPS final list of quality MIPS APMs measure set after the quality measure list for purposes of the
measures from which all MIPS eligible proposed rule has been published will APM scoring standard at
clinicians may choose measures for not be scored under the APM scoring 414.1370(g)(1)(ii)(A).
purposes of assessment, and instead to standard until they have been proposed
(B) Measure Requirements for Other
establish a MIPS APM quality measure and adopted through notice-and-
MIPS APMs
list for purposes of the APM scoring comment rulemaking in the following
standard (82 FR 30084). The MIPS APM year. Because the quality measure sets for
quality measure list would be adopted Comment: One commenter expressed each Other MIPS APM are unique, in
as the final list of MIPS quality concern that the time it takes to develop the CY 2018 Quality Payment Program
and implement new measures upon proposed rule, we proposed to calculate
measures under the APM scoring
which eligible clinicians are scored may the MIPS quality performance category
standard for Other MIPS APMs, and
cause delays in the adoption of new score using Other MIPS APM-specific
would reflect the quality measures that
innovative technologies with value that quality measures (82 FR 30085). For
are used to evaluate performance on
cannot easily be captured by current purposes of the APM scoring standard,
quality within each Other MIPS APM.
measure types, particularly among MIPS we proposed to score only measures
The MIPS APM measure list we that: (1) Are tied to payment as
APM participants.
proposed in Table 13 of the CY 2018 described under the terms of the APM,
Response: We do not believe any
Quality Payment Program proposed rule (2) are available for scoring near the
policies under the APM scoring
would define distinct measure sets for close of the MIPS submission period, (3)
standard would diminish any existing
participants in each MIPS APM for have a minimum of 20 cases available
incentives for the adoption of new
purposes of the APM scoring standard, for reporting, and (4) have an available
technologies, or affect the flexibility for
based on the measures that are used by benchmark. We discuss our policies for
APMs to set their own incentives for the
the APM, and for which data will be each of these requirements for Other
adoption of such technologies.
collected by the close of the MIPS MIPS APM quality measures below.
Furthermore, we encourage the public
submission period. The measure sets on We sought comment on this proposal.
to respond to our annual call for
the MIPS APM measure list would The following is a summary of the
measures, as described at section
represent all possible measures which comments we have received and our
II.C.6.c.(1) of this final rule with
may contribute to an APM Entitys MIPS responses:
comment period, to help ensure that
score for the MIPS quality performance Comment: Some commenters
appropriate measures are quickly
category, and may include measures recommended that CMS exclude three
adopted by appropriate programs.
that are the same as or similar to those Comment: Several commenters additional categories from those that
used by MIPS. However, measures may requested more information about the will be used for scoring under the APM
ultimately not be used for scoring if a way measures and their benchmarks are scoring standard when including Other
measures data becomes inappropriate decided on for purposes of APMs. MIPS APM measures: pay-for-reporting
or unavailable for scoring; for example, Response: For questions about APM measures, utilization measures, and
if a measures clinical guidelines are measures and their benchmarks, we measures that are new within an APM.
changed or the measure is otherwise refer readers to https://qpp.cms.gov/ Response: We clarify that pay-for-
modified by the APM during the apms/overview or the CMS Measure reporting measures will not be scored
performance period, the data collected Development Plan: Supporting the because they do not have an available
during that performance period would Transition to the Quality Payment benchmark. As such, we do not believe
not be uniform, and as such may be Program 2017 Annual Report, which is it is necessary to explicitly state that we
rendered unusable for purposes of the available at https://www.cms.gov/ will exclude these measures. Measures
APM scoring standard (82 FR 30091). Medicare/Quality-Initiatives-Patient- that are new within an APM are often
We sought comment on this proposal. Assessment-Instruments/Value-Based- pay-for-reporting in their first year in
The following is a summary of Programs/MACRA-MIPS-and-APMs/ order to give time for APM participants
comments we received on this proposal 2017-CMS-MDP-Annual-Report.pdf. We to gain experience with the measure and
and our responses: did not address or propose to modify to establish a benchmark; in cases where
Comment: Several commenters policies relating to the development and new measures are immediately pay for
expressed support for the proposed adoption of measures or benchmarks for performance, we believe it would be
requirements for APM quality measures purposes of individual MIPS APMs. appropriate to score them because the
under the APM scoring standard. Comment: One commenter requested measures themselves would be used
Response: We thank commenters for that CMS provide more information under the terms of the APM, and to the
their support for our proposal to use about reporting requirements for quality extent possible it is our goal to align
quality measures that are used within measures under the APM scoring scoring under the APM scoring standard
Other MIPS APMs for purposes of standard for Other MIPS APMs. with scoring under the terms of the
scoring under the APM scoring Response: Under the APM scoring APM. Tying payment to cost/utilization
standard. standard, APM Entities will not be is a requirement of all MIPS APMs; cost/
utilization measures tied to payment are proposed to only use the MIPS APM that particular measure, which will be
often used by the APMs to meet this quality measure data that are submitted removed from the numerator and
requirement. Because we will not score by the close of the MIPS submission denominator when calculating the total
MIPS APMs on cost, we believe that period and are available for scoring in quality score, and will therefore have
cost/utilization measures should be time for inclusion to calculate a MIPS neither a positive nor negative impact
scored under the APM scoring standard quality performance category score (82 on the APM Entitys overall quality
as a means of incentivizing performance FR 30085). Measures are to be submitted performance category score.
within MIPS APMs in this MIPS priority according to requirements under the Final Action: After considering public
area. terms of the APM; the measure data will comments, we are finalizing the
Comment: One commenter voiced then be aggregated and prepared for proposal to establish a 20 case
concern that the new APM scoring submission to MIPS for the purpose of minimum for quality measures under
standard requirements would be creating a MIPS quality performance the APM scoring standard without
burdensome or confusing for APM category score. change.
Entities during the first performance We believe using the Other MIPS (dd) Available Benchmark
period, and suggested that CMS should APMs quality measure data that have
allow APM Entities to report according been submitted no later than the close An APM Entitys achievement score
to general MIPS quality reporting of the MIPS submission period and have on each quality measure would be
requirements for the APM scoring been processed and made available to calculated in part by comparing the
standard. MIPS for scoring in time to calculate a APM Entitys performance on the
Response: We thank commenters for MIPS quality performance category measure with a benchmark performance
their concern; however, there will be no score is consistent with our intent to score. Therefore, we would need all
added reporting burden for participants decrease duplicative reporting for MIPS scored measures to have a benchmark
in MIPS APMs because we will be using eligible clinicians who would otherwise available by the time that the MIPS
the quality measure performance data need to report quality measures to both quality performance category score is
that the APM Entity is already MIPS and their APM. Going forward, calculated in order to make that
submitting as part of the requirements these are the measures to which we are comparison.
for participation in the MIPS APM. referring in our proposal to limit scoring We proposed that, for the APM
Final Action: After considering public to measures that are available near the scoring standard, the benchmark score
comments, we are finalizing as close of the MIPS submission period. used for a quality measure would be the
proposed the policy to only score We sought comment on this proposal. benchmark used in the MIPS APM for
measures that (1) are tied to payment as We did not receive any comments on calculation of the performance based
described under the terms of the APM, this proposal. payments, where such a benchmark is
(2) are available for scoring near the Final Action: We are finalizing the available. If the MIPS APM does not
close of the MIPS submission period, (3) policy as proposed. produce a benchmark score for a
have a minimum of 20 cases available reportable measure that is included on
(cc) 20 Case Minimum the MIPS APM measures list, we would
for reporting, and (4) have an available
benchmark at 414.1370(g)(1)(ii)(A)(1) We also believe that a 20 case use the benchmark score for the
through (4). minimum, in alignment with the one measure that is used for the MIPS
finalized generally under MIPS in the quality performance category generally
(aa) Tied to Payment CY 2017 Quality Payment Program final (outside of the APM scoring standard)
As discussed in the CY 2018 Quality rule, is necessary to ensure the for that MIPS performance period,
Payment Program proposed rule (82 FR reliability of the measure data provided the measure specifications for
30085), for purposes of the APM scoring submitted, as we explained the CY 2017 the measure are the same under both the
standard, we proposed to consider a Quality Payment Program final rule (81 MIPS final list and the APM measures
measure to be tied to payment if an FR 77288). list. If neither the APM nor MIPS has a
APM Entity group will receive a We proposed that when an APM benchmark available for a reported
payment adjustment or other incentive Entity reports a quality measure that measure, the APM Entity that reported
payment under the terms of the APM, includes less than 20 cases, under the that measure would receive a null score
based on the APM Entitys performance APM scoring standard, the measure for that measures achievement points,
on the measure. would receive a null score for that and the measure would be removed
We sought comment on this proposal. measures achievement points, and the from both the numerator and the
We did not receive any comments on measure would be removed from both denominator of the quality performance
this proposal. the numerator and the denominator of category percentage.
Final Action: We are finalizing the the MIPS quality performance category We sought comment on this proposal.
policy as proposed. percentage. We proposed to apply this The following is a summary of the
policy under the APM scoring standard. comments we received on this proposal
(bb) Available for Scoring
We sought comment on this proposal. and our responses:
Some MIPS APM quality measure The following is a summary of the Comment: One commenter objected to
results are not available until late in the comments we received on this proposal CMSs proposal to remove measures
calendar year subsequent to the MIPS and our responses: from scoring for which no benchmark is
performance period, which would Comment: One commenter expressed available, and instead suggested that we
prevent us from including them in the concern as to how failure to report the assign three points for the measure in
MIPS APM quality performance 20 case minimum would impact an alignment with general MIPS policy.
category score under the APM scoring APM Entitys score. Response: We thank the commenter
standard due to the larger programmatic Response: We reiterate that entities for the suggestion. In general, we have
timelines for providing MIPS eligible that do not reach the 20 case minimum attempted to create consistency between
clinician performance feedback by July for a particular measure will not be the MIPS and the APM scoring standard
and issuing budget-neutral MIPS penalized for not reporting the measure, when practicable. However, in this case
payment adjustments. Consequently, we but instead will receive a null score for doing so would be inappropriate
because APM participants are required Response: While the use of MIPS quality points in the APM scoring
to report on all APM measures used in benchmarks in the absence of an APM standard quality performance category
the MIPS APM, whereas eligible benchmark would mean comparing the percent score for the three measures it
clinicians reporting under general MIPS performance of APM participants to the submitted, but would receive zero
are given the opportunity to choose six performance of the general MIPS points for each of the six remaining
of the measures from the MIPS measure population in order to create the measures that were required under the
set. We believe that it would be unfair measure score, for measures that are terms of the MIPS APM. On the other
to require APM Entities to report on used by MIPS as well as MIPS APMs, hand, if an APM Entity reports on more
measures for which they are unable to there would not be an advantage or than the minimum number of measures
achieve a score above three, which disadvantage given to APM participants required to be reported under the MIPS
could significantly impact their total relative to the general population of APM and the measures meet the other
quality performance category score. For MIPS eligible clinicians and their scores criteria for scoring, only the measures
example, if an APM requires that five would simply reflect how they would with the highest scores, up to the
measures be reported, and an APM have performed under general MIPS number of measures required to be
Entity received 10 points on 4 measures, scoring. reported under the MIPS APM, would
but did not meet the 20 case minimum Final Action: After considering public be counted; however, any bonus points
on the fifth measure, the formula for comments, we are finalizing the policy earned by reporting on measures beyond
calculating the quality score would be with respect to the use of quality the minimum number of required
[(10 + 10 + 10 + 10)/4] = 10 (or, 100 performance benchmarks as proposed. measures would be awarded.
percent), rather than [(10 + 10 + 10 + 10 (C) Calculating the Quality Performance If a measure is reported but fails to
+ 3)/5] = 8.6 (or, 86 percent). Category Percent Score meet the 20 case minimum or does not
Comment: One commenter expressed
Eligible clinicians who participate in have a benchmark available, there
concern that by limiting the use of
Other MIPS APMs are subject to specific would be a null score for that measure,
measures to those for which a
quality measure reporting requirements and it would be removed from both the
benchmark is available, CMS may be
within these APMs. To best align with numerator and the denominator, so as
overly restrictive of new models in their
APM design and objectives, in the CY not to negatively affect the APM Entitys
first years of operation, and that CMS 2018 Quality Payment Program quality performance category score.
should instead use any measure for proposed rule, we proposed that the
which a benchmark could be calculated We proposed to assign bonus points
minimum number of required measures for reporting high priority measures or
based on the current performance year. to be reported for the APM scoring
Response: To score quality for Other measures with end-to-end CEHRT
standard would be the minimum
MIPS APMs, we will use any available reporting as described for general MIPS
number of quality measures that are
benchmark that is being used by the scoring in the CY 2017 Quality Payment
required by the MIPS APM and are
APM. In the event an APM does not Program final rule (81 FR 77297 through
collected and available in time to be
have a benchmark for a given measure, 77299).
included in the calculation for the APM
we will use MIPS benchmarks for that Entity score under the APM scoring We sought comment on these
measure if available. With this level of standard. For example, if an Other MIPS proposals. The following is a summary
benchmark flexibility, we do not APM requires participating APM of the public comments we received and
anticipate lack of benchmarks will Entities to report nine of 14 quality our response:
eliminate a significant number of measures and the APM Entity fails to Comment: Some commenters
measures from the APM scoring submit them by the APMs submission recommended that CMS require APM
standard quality calculations. deadline, then for the purposes of Entities to report on the same number of
Comment: Several commenters calculating an APM Entity quality measures required under regular MIPS:
objected to scoring Web Interface performance category score, the APM Six.
reporters based on the same benchmarks Entity would receive a zero for those
and decile distribution as those in Other Response: We thank commenters for
measures. An APM Entity that does not
MIPS APMs reporting through other this input. However, we note that under
submit any APM quality measures by
mechanisms. the APM scoring standard, eligible
the submission deadline would receive
Response: Under the APM scoring clinicians participating in MIPS APMs
a zero for its MIPS APM quality
standard, Web Interface reporters will are not required to report any additional
performance category percent score for
be scored on a scale unique to Web measures for purposes of MIPS scoring
the MIPS performance period.
Interface reporters and based on We also proposed that if an APM beyond those reported under their MIPS
benchmarks generated through the Web Entity submits some, but not all of the APM, and they will only be scored on
Interface. Other MIPS APMs do not use measures required by the MIPS APM by the minimum number of measures
the Web Interface and therefore the close of the MIPS submission required by the APM. The purpose of
measures will be scored under the APM period, the APM Entity would receive this policy is to help align incentives
scoring standards Other MIPS APM points for the measures that were between the APMs and the Quality
scoring methodology using a decile submitted, but would receive a score of Payment Program, and not to emphasize
distribution unique to each Other MIPS zero for each remaining measure performance in one over the other.
APM. between the number of measures Given this, it would not be appropriate
Comment: One commenter objected to reported and the number of measures to set a minimum number of measures
the use of MIPS measure benchmarks in required by the APM that were available independent of the requirements of the
the absence of APM measure for scoring. APM.
benchmarks, despite the comparability For example, if an APM Entity in the Final Action: After considering public
of the measures, because the effect may above hypothetical MIPS APM submits comments, we are finalizing the policy
be to compare the performance of a quality performance data on three of the for calculating the quality performance
specific specialty against that of the APMs measures, instead of the required category score as proposed at
general health care provider population. nine, the APM Entity would receive 414.1370(g)(1)(ii)(A).
(aa) Quality Measure Benchmarks specifications are the same for both. If We proposed to score quality measure
neither the APM nor MIPS has a performance under the APM scoring
An APM Entitys MIPS APM quality benchmark available for a reported standard using a percentile distribution,
score will be calculated by comparing measure, the APM Entity that reported separated by decile categories, as
the APM Entitys performance on a that measure will receive a null score described in the finalized MIPS quality
given measure with a benchmark for that measures achievement points, scoring methodology (81 FR 77282
performance score. We proposed that and the measure will be removed from through 77284). For each benchmark,
the benchmark score used for a quality both the numerator and the we will calculate the decile breaks for
measure would be the benchmark used denominator of the quality performance measure performance and assign points
by the MIPS APM for calculation of the category percentage. based on the benchmark decile range
performance based payments within the We proposed that for measures that into which the APM Entitys measure
APM, if possible, in order to best align are pay-for-reporting or which do not performance falls.
the measure performance outcomes measure performance on a continuum of
between MIPS APMs and MIPS performance, we will consider these We proposed to use a graduated
generally. If the MIPS APM does not measures to be lacking a benchmark and points-assignment approach, where a
produce a benchmark score for a they will be treated as such. For measure is assigned a continuum of
reportable measure that will be available example, if a MIPS APM only requires points out to one decimal place, based
at the close of the MIPS submission that an APM Entity must surpass a on its place in the decile. For example,
period, the benchmark score for the threshold and does not measure APM as shown in Table 11, a raw score of 55
measure that is used for the MIPS Entities on performance beyond percent would fall within the sixth
quality performance category generally surpassing a threshold, we would not decile of 41.0 percent to 61.9 percent
for that performance period would be consider such a measure to measure and would receive between 6.0 and 6.9
used, provided the measure performance on a continuum. points.
TABLE 11BENCHMARK DECILE DISTRIBUTION

Sample quality Graduated points
Sample benchmark decile measure (with no floor)
(percent)
Example Benchmark Decile 1 ..................................................................................................................... 09.9 1.01.9

Example Benchmark Decile 2 ..................................................................................................................... 10.017.9 2.02.9
Example Benchmark Decile 10 ................................................................................................................... 85.0100 10.0
We sought comment on our proposal. Entitys MIPS quality measure score as cap on topped out measures for MIPS
The following is a summary of the proposed. APM participants being scored under
public comments received on this the APM scoring standard, which differs
(bb) Assigning Quality Measure Points
proposal and our response: from the policy for other MIPS eligible
Based on Achievement
Comment: One commenter voiced clinicians proposed in the CY 2018
concern that comparing performance of For the APM scoring standard quality Quality Payment Program proposed rule
MIPS APM participants against the performance category, we proposed that (82 FR 30101 through 30103).
performance of eligible clinicians each APM Entity that reports on quality Beginning in the 2018 MIPS
assessed under regular MIPS would measures would receive between 1 and
performance period, we proposed that
skew benchmarks and give MIPS APM 10 achievement points for each measure
APM Entities in MIPS APMs, like other
participants an unfair advantage in reported that can be reliably scored
calculating a MIPS score. MIPS eligible clinicians, would be
against a benchmark, up to the number
Response: In circumstances where an of measures that are required to be eligible to receive bonus points for the
APM does not have a benchmark reported by the APM (82 FR 30086 MIPS quality performance category for
available for a measure, but a MIPS through 30087). Because measures that reporting on high priority measures or
benchmark is available, we proposed to lack benchmarks or 20 reported cases measures submitted via CEHRT (for
use the MIPS benchmark to create a are removed from the numerator and example, end-to-end submission) (82 FR
measure score. These benchmark scores denominator of the quality performance 30109). For each Other MIPS APM, we
reflect performance of eligible clinicians category percentage, it is unnecessary to proposed to identify whether any of
in the MIPS program, against whom include a point-floor for scoring of their available measures meets the
MIPS APM participants will ultimately Other MIPS APMs. Similarly, because criteria to receive a bonus, and add the
be compared. As such, we do not the quality measures reported by the bonus points to the quality achievement
believe the use of these benchmarks is MIPS APM for MIPS eligible clinicians points. Further, we proposed that the
inappropriate in this context. under the APM scoring standard are total number of awarded bonus points
Final Action: After considering public required to be submitted to the APM may not exceed 10 percent of the APM
comments, we are finalizing the policy under the terms of the APM, and the Entitys total available achievement
for applying quality measure MIPS eligible clinicians do not select points for the MIPS quality performance
benchmarks to calculate an APM their APM measures, there will be no category score.
To generate the APM Entitys quality to monitor for opportunities to Quality Improvement Score = (Absolute
performance category percentage, minimize complexity and reduce Improvement/Previous Year Quality
achievement points would be added to burden for all parties. Performance Category Percent Score
any applicable bonus points, and then Final Action: After considering public Prior to Bonus Points) * 10
divided by the total number of available comments, we are finalizing the policy Final Action: After considering public
achievement points, with a cap of 100 on assigning quality measure points for comments, we are finalizing the
percent. For more detail on the MIPS achievement as proposed. proposed quality improvement score
quality performance category percentage calculation with the corrected formula
score calculation, we refer readers to (D) Quality Improvement Scoring
at 414.1370(g)(1)(ii)(B).
section II.C.7.a.(2)(j) of this final rule Beginning in the 2018 MIPS
with comment period. performance period, we proposed to (E) Calculating Total Quality
Under the APM scoring standard for score improvement, as well as Performance Category Score
Other MIPS APMs, the number of achievement in the quality performance We proposed that the APM Entitys
available achievement points would be category (82 FR 30087). total quality performance category score
the number of measures required under For the APM scoring standard, we would be equal to [(achievement points
the terms of the APM and available for proposed that the quality improvement + bonus points)/total available
scoring multiplied by ten. If, however, percentage points would be awarded achievement points] + quality
an APM Entity reports on a required based on the following formula: improvement score. The APM Entitys
measure that fails the 20 case minimum Quality Improvement Score = (Absolute total quality performance category score
requirement, or for which there is no Improvement/Previous Year Quality may not exceed 100 percent. We sought
available benchmark for that Performance Category Percent Score comment on the proposed quality
performance period, the measure would Prior to Bonus Points)/10 performance category scoring
receive a null score and all points from methodology for APM Entities
We sought comment on this proposal.
that measure would be removed from participating in Other MIPS APMs. The
both the numerator and the The following is a summary of the
following is a summary of the public
denominator. public comments we received on this
comments we received on this proposal
For example, if an APM Entity reports proposal and our responses: and our response:
on four out of four measures required to Comment: Several commenters Comment: Several commenters
be reported by the MIPS APM, and expressed support for this proposal. expressed support for this proposed
receives an achievement score of five on Response: We thank commenters for methodology.
each and no bonus points, the APM their support for this proposal. Response: We thank commenters for
Entitys quality performance category Comment: One commenter suggested their support of this proposal.
percentage would be [(5 points 4 that rather than declining to score Final Action: After considering public
measures) + 0 bonus points]/(4 quality improvement for the MIPS comments, we are finalizing the policy
measures 10 max available points), or eligible clinicians who had a quality for calculating the total quality
50 percent. If, however, one of those performance category score of 0 in the performance category score as proposed
measures failed the 20 case minimum previous performance year, or who did at 414.1370(g)(1)(ii)(C).
requirement or had no benchmark not participate in MIPS in the previous
performance year, CMS should instead (c) Improvement Activities Performance
available, that measure would have a Category
null value and would be removed from assign a minimum quality performance
both the numerator and denominator to category score of 1 for purposes of As we finalized in the CY 2017
create a quality performance category calculating an improvement score. Quality Payment Program final rule, for
percentage of [(5 points 3 measures) + Response: We thank the commenter all MIPS APMs we will assign the same
0 bonus points]/(3 measures 10 max for the suggestion. While assigning a improvement activities score to each
available points), or 50 percent. quality score of 1 in years in which no APM Entity based on the activities
If an APM Entity fails to meet the 20 quality score is available would enable involved in participation in a MIPS
case minimum on all available APM us to assign a quality improvement APM (81 FR 77262 through 77266). As
measures, that APM Entity would have score, it would also have the effect of described in the CY 2017 Quality
its quality performance category score giving all first year participants higher Payment Program final rule, APM
reweighted to zero, as described below. quality improvement scores that do not Entities will receive a minimum of one
We sought comment on these necessarily reflect improvement. half of the total possible points (81 FR
proposals. The following is a summary Instead, with this policy we seek to 77254). This policy is in accordance
of the public comments we received and encourage early and consistent with section 1848(q)(5)(C)(ii) of the Act.
our response: participation in MIPS by requiring two In the event that the assigned score does
Comment: One commenter was years of consecutive participation before not represent the maximum
concerned about the complexity of the the quality improvement score can be improvement activities score, the APM
program and suggested that the addition applied. Entity group will have the opportunity
of additional scoring opportunities We note that we inadvertently to report additional improvement
could become too burdensome for CMS described the formula in error in the activities to add points to the APM
to effectively administrate. APM scoring standard section, but Entity level score as described in section
Response: The APM scoring standard provided a cross-reference to the II.C.6.e. of this final rule with comment
was designed to simplify administration discussion and the correct formula period We note that in the 2017
of MIPS for both eligible clinicians in under the general MIPS scoring performance year, we determined that
certain types of APMs and for CMS. We standard (82 FR 30096). We are the improvement activities involved in
believe that we are prepared to correcting the error in this final rule participation in all MIPS APMs satisfied
effectively administer MIPS, including with comment period to clarify and the requirements for participating APM
the APM scoring standard. However, as resolve the inconsistency by changing entities to receive the maximum score of
we gain additional experience in the quality improvement score 100 percent in this performance
implementing MIPS, we will continue calculation to the following: category. In the 2018 Quality Payment
Program proposed rule, we did not qualifying MIPS eligible clinician, and commenters also expressed confusion as
propose any changes to this policy for the TIN would still report on behalf of to how TIN-level advancing care
the 2018 MIPS performance period (82 the entire group, although the TIN information data are to be reported for
FR 30087). We have made some would not need to report data for the the Shared Savings Program if a MIPS
clarifying edits to 414.1370(g)(3)(i). qualifying MIPS eligible clinician. All eligible clinician in an ACO participant
MIPS eligible clinicians in the TIN who TIN receives an exception or joins the
(d) Advancing Care Information
are participants in the MIPS APM TIN at various times in the year.
Performance Category
would count towards the TINs weight Response: We thank commenters for
In the CY 2017 Quality Payment when calculating an aggregated APM bringing our attention to this issue. We
Program final rule, we finalized our Entity score for the advancing care proposed that under the APM scoring
policy to attribute one score to each information performance category. standard, if a MIPS eligible clinician is
MIPS eligible clinician in an APM If, however, the MIPS eligible a solo practitioner and qualifies for a
Entity group by looking for both clinician is a solo practitioner and zero percent weighting in the advancing
individual and group TIN level data qualifies for a zero percent weighting, or care information performance category,
submitted for a MIPS eligible clinician if all MIPS eligible clinicians in a TIN or if all MIPS eligible clinicians in a TIN
and using the highest available score (81 qualify for the zero percent weighting, qualify for the zero percent weighting,
FR 77268). We will then use these the TIN would not be required to report the TIN would not be required to report
scores to create an APM Entitys score on the advancing care information on the advancing care information
based on the average of the highest performance category, and if the TIN performance category, and if the TIN
scores available for all MIPS eligible chooses not to report that TIN would be
clinicians in the APM Entity group. If an chooses not to report that TIN would be
assigned a weight of 0 when calculating
individual or TIN did not report on the assigned a weight of 0 when calculating
the APM Entitys advancing care
advancing care information performance the APM Entitys advancing care
information performance category score.
category, the individual or TIN will If advancing care information data are information performance category score.
contribute a zero to the APM Entitys reported by one or more TIN/NPIs in an If the MIPS eligible clinician would
aggregate score. Each MIPS eligible APM Entity, an advancing care have reported the advancing care
clinician in an APM Entity group will information performance category score information performance category as an
receive one score, weighted equally will be calculated for, and will be individual and therefore contributed to
with the scores of every other MIPS applicable to, all MIPS eligible the APM Entitys advancing care
eligible clinician in the APM Entity clinicians in the APM Entity group. If information score at the individual level
group, and we will use these scores to all MIPS eligible clinicians in all TINs but qualifies for a zero percent
calculate a single APM Entity-level in an APM Entity group qualify for a weighting of the advancing care
advancing care information performance zero percent weighting of the advancing information performance category, the
category score. care information performance category, individual will be removed from the
or in the case of a solo practitioner who numerator and denominator when
(i) Special Circumstances calculating the APM Entitys advancing
comprises an entire APM Entity and
As we explained in the CY 2017 qualifies for zero percent weighting, the care information performance category
Quality Payment Program final rule, advancing care information performance score, thereby contributing a null value.
under generally applicable MIPS scoring category would be weighted at zero If a MIPS eligible clinician qualifies for
policy, we will assign a weight of zero percent of the final score, and the a zero percent weighting of the
percent to the advancing care advancing care information performance advancing care information performance
information performance category in the categorys weight would be category as described in II.C.6.f.(6) of
final score for MIPS eligible clinicians redistributed to the quality performance this final rule with comment period as
who meet specific criteria: Hospital- category. an individual, but receives an advancing
based MIPS eligible clinicians, MIPS We sought comment on this proposal. care information score as part of a
eligible clinicians who are facing a The following is a summary of the group, we will use that group score for
significant hardship, and certain types public comments we received and our that eligible clinician when calculating
of non-physician practitioners (NPs, responses: the APM Entitys advancing care
PAs, CRNAs, CNSs) who are MIPS Comment: Some commenters information performance category score.
eligible clinicians (81 FR 77238 through supported the proposed policy to allow We note that group level advancing care
77245). In the CY 2018 Quality Payment participants in MIPS APMs to also information reporting is not negatively
Program proposed rule, we proposed to apply for advancing care information affected by the failure of a single
include in this weighting policy ASC- hardship exceptions like eligible individual to report because it is based
based MIPS eligible clinicians and MIPS clinicians participating under regular only on average reported performance
eligible clinicians who are using MIPS rules. within the group, not the average
decertified EHR technology (82 FR Response: We thank commenters for reported performance of all eligible
30077 through 30078). their support for this policy. clinicians in the groupthose who do
In the CY 2018 Quality Payment Comment: A few commenters not report are not factored into the
Program proposed rule, we proposed suggested that the advancing care denominator. If, however, all MIPS
that under the APM scoring standard, if information hardship exception policy eligible clinicians in a TIN qualify for a
a MIPS eligible clinician who qualifies for all MIPS APMs should be uniform zero percent weighting of the advancing
for a zero percent weighting of the and that MIPS eligible clinicians who care information performance category,
advancing care information performance qualify for an exception, and who bill the entire TIN will be removed from the
category in the final score is part of a through the TIN of an ACO participant numerator and denominator, and
TIN reporting at the group level that in a Shared Savings Program ACO therefore contribute a null value when
includes one or more MIPS eligible should not be counted when weighting calculating the APM Entity score. If all
clinicians who do not qualify for a zero the TIN for purposes of calculating the participant NPIs and TINs in an APM
percent weighting, we would not apply APM Entity advancing care information Entity are qualify for a zero percent
the zero percent weighting to the performance category score. Some weighting of the advancing care
information performance category and Quality Payment Program final rule (81 Comment: Some commenters
do not report, we will reweight the FR 7726277263). We believe it is suggested reweighting the performance
entire advancing care information appropriate to align the performance categories under the APM scoring
performance category to zero percent of category weights for APM Entities in standard to align with the weights used
the final score for the APM Entity as MIPS APMs that require reporting under regular MIPS in 2018.
described in Table 13. through the Web Interface with those in Response: While it is our intention to
Final Action: After considering public Other MIPS APMs. By aligning the align the policies under the APM
comments, we are finalizing the policy performance category weights among all scoring standard with the generally
for scoring the advancing care MIPS APMs, we would create greater applicable MIPS policies to the greatest
information performance category under scoring parity among the MIPS eligible extent possible, in this instance we
the APM scoring standard as proposed clinicians in MIPS APMs who are being believe alignment is inappropriate. As
at 414.1370(g)(4)(iii). scored under the APM scoring standard. previously noted, under the APM
(4) Calculating Total APM Entity Score We sought comment on this proposal. scoring standard, we proposed to use
The following is a summary of the our authority to waive the establishment
(a) Performance Category Weighting of measures and scoring in the cost
comments and our responses:
In the 2018 Quality Payment Program Comment: Some commenters performance category in all performance
proposed rule, we proposed to continue supported CMSs proposal to weight the periods (82 FR 30082), and we are
to use our authority to waive sections quality performance category to better finalizing that proposal in this final rule
1848(q)(2)(B)(ii) and 1848(q)(2)(A)(ii) of align the APM scoring standard with with comment period. As a result, we
the Act to specify and use, respectively, regular MIPS scoring. will not align with the generally
cost measures, and to maintain the cost applicable MIPS performance category
performance category weight of zero Response: We thank commenters for weighting.
under the APM scoring standard for the their support of our proposal. Comment: One commenter was
2018 performance period and Comment: Several commenters confused by Table 12 of the proposed
subsequent MIPS performance periods suggested delaying assigning a weight to rule (82 FR 30088), which indicates that
(82 FR 30082). Because the cost the quality performance category until all MIPS APMs will have the same
performance category would be MIPS eligible clinicians and performance category weighting, as well
reweighted to zero, that weight would participants in APMs have had time to as the same reweighting standards in the
need to be redistributed to other adjust to using these measures, as well event that a MIPS eligible clinician or
performance categories. We proposed to as to ensure that the measures have been TIN is exempted from the advancing
use our authority under section fully vetted. care information performance category,
1115A(d)(1) to waive requirements Response: We appreciate commenters or an APM Entity has no quality
under sections 1848(q)(5)(E)(i)(I)(bb), concerns that it may take time for MIPS measures available to create a quality
1848(q)(5)(E)(i)(III) and eligible clinicians to adjust to this new performance category score.
1848(q)(5)(E)(i)(IV) of the Act that program. However, we will be entering Response: All MIPS APMs will have
prescribe the weights, respectively, for our second year of the Quality Payment their performance categories weighted
the quality, improvement activities, and Program in 2018 after a transition year in the same way. For information about
advancing care information performance in which quality was not scored for performance category weighting for
categories (82 FR 30088). We proposed Other MIPS APMs. Furthermore, while MIPS APM under normal
to weight the quality performance we acknowledge that the Quality circumstances, we refer readers to Table
category score to 50 percent, the Payment Program is still relatively new 12. For information about performance
improvement activities performance program, APM participants are already category weighting in special
category to 20 percent, and the required to report the relevant quality circumstances, such as when a
advancing care information performance measures as part of their participation in performance category is reweighted to
category to 30 percent of the final score a MIPS APM, in order to receive zero, we refer readers to Table 13.
for all APM Entities in Other MIPS performance-based payments. By Final Action: After considering public
APMs. We proposed these weights to repurposing these quality measures, we comments, we are finalizing the
align the Other MIPS APM performance will enable MIPS APM participants to performance category weighting as
category weights with those assigned to avoid duplicative reporting and proposed at 414.1370(h).
the Web Interface reporters, which we inconsistent incentives between MIPS These final weights are summarized
adopted as explained in the CY 2017 and APM requirements. in Table 12.
TABLE 12APM SCORING STANDARD PERFORMANCE CATEGORY WEIGHTSBEGINNING WITH THE 2018 PERFORMANCE
PERIOD
Performance
MIPS performance category
APM entity submission requirement Performance category score
category weight
(%)
Quality ............................ The APM Entity will be required to submit quality CMS will assign the same quality category per- 50
measures to CMS as required by the MIPS formance score to each TIN/NPI in an APM
APM. Measures available at the close of the Entity group based on the APM Entitys total
MIPS submission period will be used to cal- quality score, derived from available APM
culate the MIPS quality performance category quality measures.
score. If the APM Entity does not submit any
APM required measures by the MIPS submis-
sion deadline, the APM Entity will be assigned
a zero.
TABLE 12APM SCORING STANDARD PERFORMANCE CATEGORY WEIGHTSBEGINNING WITH THE 2018 PERFORMANCE
PERIODContinued
Performance
MIPS performance category
APM entity submission requirement Performance category score
category weight
(%)
Cost ............................... The APM Entity group will not be assessed on Not Applicable ...................................................... 0
cost under the APM scoring standard.
Improvement Activities .. MIPS eligible clinicians are not required to report CMS will assign the same improvement activities 20
improvement activities data; if the CMS-as- score to each APM Entity based on the activi-
signed improvement activities score is below ties involved in participation in the MIPS APM.
the maximum improvement activities score, APM Entities will receive a minimum of one
APM Entities will have the opportunity to sub- half of the total possible points. In the event
mit additional improvement activities to raise that the assigned score does not represent the
the APM Entity improvement activity score. maximum improvement activities score, the
APM Entity will have the opportunity to report
additional improvement activities to add points
to the APM Entity level score.
Advancing Care Informa- Each MIPS eligible clinician in the APM Entity CMS will attribute the same score to each MIPS 30
tion. group is required to report advancing care ineligible clinician in the APM Entity group. This
formation to MIPS through either group TIN or score will be the highest score attributable to
individual reporting. the TIN/NPI combination of each MIPS eligible
clinician, which may be derived from either
group or individual reporting. The scores attrib-
uted to each MIPS eligible clinician will be
averaged for a single APM Entity score.
There could be instances where an We sought comment on these policies finalized in the CY 2017
Other MIPS APM has no measures proposals. The following is a summary Quality Payment Program final rule, and
available to score for the quality of the comments on these proposals and scoring policies under regular MIPS. We
performance category for a MIPS our responses: also continue to believe that it is
performance period; for example, it is Comment: A few commenters appropriate to use the available
possible that none of the Other MIPS suggested that in the event an entire performance category scores in order to
APMs measures would be available for performance category is unable to be encourage the continued performance
calculating a quality performance scored, its weight should be evenly and reporting of measures in any
category score by or shortly after the distributed among the remaining performance category that is available,
close of the MIPS submission period performance categories rather than including the advancing care
because the measures were removed due shifted entirely to either quality or information performance category,
to changes in clinical practice advancing care information. which is not necessarily required under
guidelines. In addition, as we explained Response: In a situation where either the terms of MIPS APMs. Having data
in the CY 2018 Quality Payment the quality or advancing care for as many performance categories as
Program proposed rule, the MIPS information performance categories possible is also important for purposes
eligible clinicians in an APM Entity may have been reweighted to zero, we do not of calculating improvement scoring in
qualify for a zero percent weighting for believe it is appropriate to give any future years and in helping to calculate
the advancing care information more weight to the improvement MIPS payment adjustments.
performance category (82 FR 30087 activities performance category because
under the APM scoring standard this Final Action: After considering public
through 30088). In such instances, comments, we are finalizing our
performance category score is
under the APM scoring standard, we proposals. If the quality performance
automatically assigned, rather than
proposed to reweight the affected category is reweighted to zero, we will
reported and scored like the advancing
performance category to zero, in reweight the improvement activities and
care information and quality
accordance with section 1848(q)(5)(F) of advancing care information performance
performance categories.
the Act (82 FR 30088 through 30089). Comment: Some commenters categories to 25 and 75 percent,
If the quality performance category is suggested that in the event a second respectively. If the advancing care
reweighted to zero, we proposed to performance category (in addition to information performance category is
reweight the improvement activities and cost) is weighted to zero, the APM reweighted to zero, the quality
advancing care information performance Entity or all APM Entities in the APM performance category weight will be
categories to 25 and 75 percent, should receive a neutral score for that increased to 80 percent and the
respectively. If the advancing care performance period. improvement activities performance
information performance category is Response: Our proposed policy of category will remain at 20 percent. The
reweighted to zero, the quality scoring an APM Entity for which two or final policies are summarized in Table
performance category weight would be more performance categories are 13. We are finalizing this policy at
increased to 80 percent. available to be scored is consistent with 414.1370(h)(5).
TABLE 13APM SCORING STANDARD PERFORMANCE CATEGORY WEIGHTS FOR MIPS APMS WITH PERFORMANCE
CATEGORIES WEIGHTED TO 0BEGINNING WITH THE 2018 PERFORMANCE PERIOD
Performance
Performance category
category weight
MIPS performance APM entity submission requirement Performance category score weight (no advancing
category (no quality) care
(%) information)
(%)
Quality ....................... The APM Entity will not be assessed on CMS will assign the same quality cat- 0 80
quality under MIPS if no quality data egory performance score to each TIN/
are available at the close of the MIPS NPI in an APM Entity group based on
submission period. The APM Entity will the APM Entitys total quality score, de-
submit quality measures to CMS as re- rived from available APM quality meas-
quired by the Other MIPS APM. ures.
Cost ........................... The APM Entity group will not be as- Not Applicable ........................................... 0 0
sessed on cost under APM scoring
standard.
Improvement Activi- MIPS eligible clinicians are not required CMS will assign the same improvement 25 20
ties. to report improvement activities data activities score to each APM Entity
unless the CMS-assigned improvement group based on the activities involved
activities score is below the maximum in participation in the MIPS APM.
improvement activities score. APM Entities will receive a minimum of
one half of the total possible points. In
the event that the assigned score does
not represent the maximum improve-
ment activities score, the APM Entity
will have the opportunity to report addi-
tional improvement activities to add
points to the APM Entity level score.
Advancing Care Infor- Each MIPS eligible clinician in the APM CMS will attribute the same score to 75 0
mation. Entity group reports advancing care in- each MIPS eligible clinician in the APM
formation to MIPS through either group Entity group. This score will be the
TIN or individual reporting. highest score attributable to the TIN/
NPI combination of each MIPS eligible
clinician, which may be derived from ei-
ther group or individual reporting. The
scores attributed to each MIPS eligible
clinicians will be averaged for a single
APM Entity score. For participants in
the Shared Savings Program, advanc-
ing care information will be scored at
the TIN level. A TIN will be exempt
from reporting only if all MIPS eligible
clinicians billing through the TIN qualify
for a zero percent weighting of the ad-
vancing care information performance
category.
(b) Risk Factor Score with comment period for a description practice adjustment and its application
Section 1848(q)(1)(G) of the Act of the complex patient bonus and its to APM Entities.
requires us to consider risk factors in application to APM Entities.
(d) Final Score Methodology
our scoring methodology. Specifically, (c) Small Practice Bonus
that section provides that the Secretary, In the CY 2017 Quality Payment
on an ongoing basis, shall, as the We believe an adjustment for eligible Program final rule, we finalized the
Secretary determines appropriate and clinicians in small practices (referred to methodology for calculating a final
based on individuals health status and herein as the small practice bonus) is score of 0100 based on the four
other risk factors, assess appropriate appropriate to recognize barriers faced performance categories (81 FR 77320).
adjustments to quality measures, cost by small practices, such as unique We refer readers to section II.C.7.b. of
measures, and other measures used challenges related to financial and other this final rule for a discussion of the
under MIPS and assess and implement resources, environmental factors, and changes we are making to the final score
appropriate adjustments to payment access to health information technology, methodology. We are codifying our
adjustments, final scores, scores for and to incentivize eligible clinicians in policy pertaining to the calculation of
performance categories, or scores for small practices to participate in the the total APM Entity score at
measures or activities under the MIPS. Quality Payment Program and to 414.1370(i).
We did not be create a separate overcome any performance discrepancy
(5) MIPS APM Performance Feedback
methodology to adjust for patient risk due to practice size.
factors for purposes of the APM scoring We refer readers to section II.C.7.b In the CY 2017 Quality Payment
standard. However, we refer readers to (1)(c) of this final rule with comment Program final rule, we finalized that all
section II.C.7.b.(1)(b) of this final rule period for a discussion of the small MIPS eligible clinicians scored under
the APM scoring standard will receive for which the weight for those categories Interface reporters may receive bonus
performance feedback as specified has been reweighted to zero. points under the APM scoring standard
under section 1848(q)(12) of the Act on The following is a summary of the for submitting the CAHPS for ACOs
the quality and cost performance public comments we received and our survey.
categories to the extent applicable, responses: We are finalizing our proposal to
based on data collected in the Comment: Several commenters calculate the quality improvement score
September 2016 QRUR, unless they did supported our proposal. for MIPS eligible clinicians submitting
not have data included in the September Response: We thank commenters for quality measures via the Web Interface
2016 QRUR. Those eligible clinicians their support of this policy. using the methodology described in
without data included in the September Final Action: After considering public section II.C.7.a.(2) of this final rule with
2016 QRUR will not receive any comments, we are finalizing the policy comment period at
performance feedback until performance on performance feedback for MIPS 414.1370(g)(1)(i)(B).
data is available for feedback (81 FR eligible clinicians participating in MIPS We are finalizing our proposal to
77270). APMs as proposed. calculate the total quality percent score
Beginning with the 2018 performance for MIPS eligible clinicians using the
(6) Summary of Final Policies
period, we proposed that MIPS eligible Web Interface according to the
In summary, we are finalizing the methodology described in section
clinicians whose MIPS payment
following policies in this section: II.C.7.a.(2) of this final rule with
adjustment is based on their score under We are finalizing our proposal to
the APM scoring standard will receive comment period at
define full TIN APM at 414.1305 and 414.1370(g)(1)(i)(C).
performance feedback as specified to amend 414.1370(e) to identify the We are finalizing our proposal to
under section 1848(q)(12) of the Act for four assessment dates that would be establish a separate MIPS APM measure
the quality, advancing care information, used to identify the APM Entity group list of quality measures for each Other
and improvement activities performance for full TIN APMs for purposes of the MIPS APM, which will be the quality
categories to the extent data are APM scoring standard, and to specify measure list used for purposes of the
available for the MIPS performance that the December 31 date will be used APM scoring standard for that Other
period (82 FR 30089 through 30090). only to identify MIPS eligible clinicians MIPS APM.
Further, we proposed that in cases on the APM Entitys Participation List We are finalizing our proposals to
where performance data are not for a MIPS APM that is a full TIN APM calculate the MIPS quality performance
available for a MIPS APM performance in order to add them to the APM Entity category score for Other MIPS APMs
category or the MIPS APM performance group that is scored under the APM using MIPS APM-specific quality
category has been weighted to zero for scoring standard. We will use this measures. For purposes of the APM
that performance period, we would not fourth assessment date of December 31 scoring standard, we will score only
provide performance feedback on that only to extend the APM scoring measures that: (1) Are tied to payment
MIPS performance category. standard to those MIPS eligible as described under the terms of the
We believe that with an APM Entitys clinicians participating in MIPS APMs APM, (2) are available for scoring near
finite resources for engaging in efforts to that are full TIN APMs, ensuring that a the close of the MIPS submission
improve quality and lower costs for a MIPS eligible clinician who joins a full period, (3) have a minimum of 20 cases
specified beneficiary population, the TIN APM late in the performance period available for reporting, and (4) have an
incentives of the APM must take would be scored under the APM scoring available benchmark at
priority over those offered by MIPS in standard. 414.1370(g)(1)(ii)(A)(1) through (4).
order to ensure that the goals and We are finalizing our proposal to We are finalizing our proposal to
evaluation associated with the APM are continue to weight the cost performance only use the MIPS APM quality measure
as clear and free of confounding factors category under the APM scoring data that are submitted by the close of
as possible. The potential for different, standard for Web Interface reporters at the MIPS submission period and are
conflicting messages in performance zero percent beginning with the 2020 available for scoring in time for
feedback provided by the APMs and MIPS payment year. inclusion to calculate a MIPS quality
that provided by MIPS may create We are finalizing our proposal not performance category score.
uncertainty for MIPS eligible clinicians to take improvement into account for We are finalizing our proposal that,
who are attempting to strategically performance scores in the cost for the APM scoring standard, the
transform their respective practices and performance category for Web Interface benchmark score used for a quality
succeed under the terms of the APM. reporters beginning with the 2020 MIPS measure would be the benchmark used
Accordingly, under sections payment year to align with our final in the MIPS APM for calculation of the
1115A(d)(1) and 1899(f) of the Act, for policy of weighting the cost performance based payments, where
all MIPS performance periods we performance category at zero percent. such a benchmark is available. If the
proposed to waivefor MIPS eligible We finalizing our proposal to score APM does not produce a benchmark
clinicians participating in MIPS APMs the CAHPS for ACOs survey in addition score for a reportable measure that is
authorized under sections 1115A and to the Web Interface measures to included on the APM measures list, we
1899 of the Act, respectivelythe calculate the MIPS APM quality will use the benchmark score for the
requirement under section performance category score for Web measure that is used for the MIPS
1848(q)(12)(A)(i)(I) of the Act to provide Interface reporters (including MIPS quality performance category generally
performance feedback for the cost eligible clinicians participating in the for that performance period, provided
performance category. Shared Savings Program and Next the measure specifications for the
We requested comment on these Generation ACO Model), beginning in measure are the same under both the
proposals to waive requirements for the 2018 performance period at MIPS final list and the MIPS APM
performance feedback on the cost 414.1370(e). measures list.
performance category beginning in the We are finalizing our proposal that, We are finalizing our proposal that
2018 performance year, and for the beginning with the 2018 performance the minimum number of quality
other performance categories in years period, MIPS eligible clinicians in Web measures required to be reported for the
APM scoring standard would be the We are finalizing our proposal to score under the APM scoring standard
minimum number of quality measures score improvement as well as will receive performance feedback as
that are required within the MIPS APM achievement in the quality performance specified under section 1848(q)(12) of
and are collected and available in time category beginning in the 2018 the Act for the quality, advancing care
to be included in the calculation for the performance period at information, and improvement activities
APM Entity score under the APM 414.1370(g)(1)(ii)(B). For the APM performance categories to the extent
scoring standard. We are also finalizing scoring standard, the improvement data are available for the MIPS
our proposal that that if an APM Entity percentage points will be awarded based performance period. Further, we are
submits some, but not all of the on the following formula: finalizing our proposal that in cases
measures required by the MIPS APM by Quality Improvement Score = (Absolute where the MIPS APM performance
the close of the MIPS submission Improvement/Previous Year Quality category has been weighted to zero for
period, the APM Entity would receive Performance Category Percent Score a performance period, we will not
points for the measures that were Prior to Bonus Points) * 10 provide performance feedback on that
submitted, but would receive a score of MIPS performance category. We are also
We are finalizing our proposal that finalizing our proposal to waive, using
zero for each remaining measure
the APM Entitys total quality our authority under sections
between the number of measures
performance category score would be 1115A(d)(1) and 1899(f) of the Act, the
reported and the number of measures
equal to [(achievement points + bonus requirement under section
required by the APM that were available
points)/total available achievement 1848(q)(12)(A)(i)(I) of the Act to provide
for scoring.
points] + quality improvement score.
We are finalizing our proposal that performance feedback for the cost
We are codifying this policy at performance category for MIPS eligible
the benchmark score used for a quality
414.1370(g)(1)(ii)(C). clinicians participating in MIPS APMs
measure would be the benchmark used We are finalizing at
by the MIPS APM for calculation of the authorized under sections 1115A and
414.1370(g)(4)(iii), our proposal for
performance based payments within the 1899 of the Act, respectively; this
scoring the advancing care information
APM, if possible, in order to best align waiver will be applicable in all years,
performance category if a MIPS eligible
the measure performance outcomes regardless of the availability of cost
clinician who qualifies for a zero
between the Quality Payment Program performance data for MIPS eligible
percent weighting of the advancing are
and the APM. We are finalizing our clinicians participating in these MIPS
information performance category. This
proposal that for measures that are pay- APMs.
policy will apply beginning with the We are finalizing at section II.C.4.b.
for-reporting or that do not measure 2019 payment year.
performance on a continuum of of this final rule with comment period
We are finalizing our proposal to
performance, we will consider these to apply the APM scoring standard score
maintain the cost performance category
measures to be lacking a benchmark and when calculating the MIPS payment
weight of zero for all MIPS APMs under
treat them as such. adjustment for MIPS eligible clinicians
the APM scoring standard for the 2020
We are finalizing our proposal to MIPS payment year and subsequent
participating in MIPS APMs, even for
score quality measure performance those whose TINs are participating in a
MIPS payment years. Because the cost
under the APM scoring standard using virtual group. We are codifying this
performance category will be
a percentile distribution, separated by policy at 414.1370(f)(2).
reweighted to zero, that weight will be We are not finalizing our proposal
decile categories, as described in the redistributed to other performance
finalized MIPS quality scoring to amend 414.1370(b)(4)(i).
categories. We are finalizing our policy
methodology. We are also finalizing our to align the Other MIPS APM (7) Measure Sets
proposal to use a graduated points- performance category weights with We sought comment on Tables 14, 15,
assignment approach, where a measure those for Web Interface reporters and and 16 in the CY 2018 Quality Payment
is assigned a continuum of points out to weight the quality performance category Program proposed rule (82 FR
one decimal place, based on its place in to 50 percent, the improvement 30091through 30095), which outlined
the decile. activities performance category to 20 the measures being introduced for
We are finalizing our proposal that percent, and the advancing care notice and comment, and would serve
each APM Entity that reports on quality information performance category to 30 as the measure set used by participants
measures would receive between 1 and percent of the APM Entity final score for in the identified MIPS APMs in order to
10 achievement points for each measure all MIPS APMs at 414.1370(h)(1) create a MIPS score under the APM
reported that can be reliably scored through (4). scoring standard, as described in section
against a benchmark, up to the number We are finalizing our proposal to II.C.6.g.(3)(b)(ii) of this final rule with
of measures that are required to be reweight the quality performance comment period.
reported by the APM. category to zero under the APM scoring The following is a summary of the
We are finalizing our proposal that standard in instances where none of a public comments we received and our
MIPS eligible clinicians in APM Entities MIPS APMs measures will be available responses:
participating in MIPS APMs, like other for calculating a quality performance Comment: One commenter requested
MIPS eligible clinicians, would be category score by or shortly after the that CMS include more immunization
eligible to receive bonus points for the close of the MIPS submission period, for measures for all MIPS APMs,
MIPS quality performance category for example, due to changes in clinical specifically the Comprehensive ESRD
reporting on high priority measures or practice guidelines. In addition, the Care and Comprehensive Primary Care
measures submitted via CEHRT. For MIPS eligible clinicians in an APM Plus (CPC+) APMs:
each Other MIPS APM, we are finalizing Entity may qualify for a zero percent NQF #0041/PQRS #110: Influenza
our proposal to identify whether any of weighting for the advancing care Immunization in the ESRD Population
the available measures meets the criteria information performance category. NQF #0043/PQRS #111:
to receive a bonus, and add the bonus We are finalizing our proposal that Pneumococcal Vaccination Status
points to the quality achievement MIPS eligible clinicians whose MIPS For the Comprehensive Primary Care
points. payment adjustment is based on their Plus (CPC+) APM:26
++ NQF #0041/PQRS #110: Influenza be removing it from the 2018 MIPS APM decile of 99.99 percent is inappropriate
Immunization measure list for APM Entities for primary care providers like those
++ NQF #0043/PQRS #111: participating in the CPC+ Model. participating in CPC+.
Pneumonia Vaccination Status for Comment: One commenter objected to Response: CPC+ uses the MIPS
Older Adults the use of CMS 156v5 (MIPS ID 238) benchmarks for electronic clinical
Use of High-Risk Medications in the quality measures (eCQMs). These
Response: The MIPS APM measures
Elderly (inverse metric) for the CPC+ benchmarks are based on data reported
list is comprised of only measures that
Model. The commenter stated that the to CMS by all cliniciansprimary care
are already in effect under the terms of
benchmark thresholds are effectively and specialists. The 2017 benchmarks
the MIPS APMs. The addition of
unattainable and therefore may reduce were based on data submitted in 2015
measures to MIPS APMs is a function of
the incentive for clinicians to strive for to the Physician Quality Reporting
each APMs model design and performance beyond the minimum 50th
objectives and is determined by the System. The percentile standards
percentile; further, the commenter
terms of each MIPS APM. mentioned in the comment are MIPS
stated that with an 80th percentile
Comment: One commenter objected to percentile standards.
benchmark of 0.01 percent, clinicians
the use of CMS 166v6 (MIPS ID 312) do not believe that the benchmark is Final Action: After considering public
Use of Imaging Studies for Low Back valid or appropriate for the best comments, we are finalizing the MIPS
Pain for the CPC+ Model. The interests of their varied patient APM measure sets as follows in Tables
commenter suggested the requirements population. 14, 15, and 16. We note that some
of the measure to be overly general, and Response: The MIPS APM measure proposed measures have been removed
that the measure may cause the list is comprised of measures that are from these MIPS APM measure lists
intervention to be inappropriately used under the terms of each MIPS because the measures have been
applied because exclusion criteria were APM. Because this measure has been removed from use under the terms of
too limited and not all indications for removed from the Comprehensive the individual APM, and therefore in
the intervention were included in the Primary Care Plus measure list for the order to maintain alignment between
measure requirements. The commenter 2018 performance year, we will also be the APM scoring standard and the
further objected to the benchmark for removing it from the 2018 MIPS APM APMs, we have also removed these
the measure, which requires 100 percent measure list for APM Entities measures from the MIPS APM measures
performance to achieve a perfect score. participating in CPC+. list. We have also updated the below
Response: The MIPS APM measure Comment: One commenter objected to measure list to reflect updates to
list is comprised of measures that are the use of CMS 131v5 (MIPS ID 117) measure descriptions provided by the
used under the terms of each MIPS Diabetes: Eye Exam for CPC+ because measure stewards, as well as corrected
APM. Because this measure has been the benchmarks for the measure may be National Quality Strategy Domains in
removed from the CPC+ measure list for appropriate for ophthalmologists or alignment with the most recent MIPS
the 2018 performance year, we will also optometrists, but the 80th percentile APM measure lists.
TABLE 14MIPS APM MEASURES LISTONCOLOGY CARE MODEL
NQF/quality No. National quality Primary measure
Measure name Measure description
(if applicable) strategy domain steward
Risk-adjusted proportion of patients with all- Not Applicable Effective Clinical Care Percentage of OCM-attributed FFS bene- Not Applicable.
cause hospital admissions within the 6- ficiaries who were had an acute-care hos-
month episode. pital stay during the measurement period.
Risk-adjusted proportion of patients with all- Not Applicable Effective Clinical Care Percentage of OCM-attributed FFS bene- Not Applicable.
cause ED visits or observation stays that did ficiaries who had an ER visit that did not re-
not result in a hospital admission within the sult in a hospital stay during the measure-
6-month episode. ment period.
Proportion of patients who died who were ad- Not Applicable Effective Clinical Care Percentage of OCM-attributed FFS bene- Not Applicable.
mitted to hospice for 3 days or more. ficiaries who died and spent at least 3 days
in hospice during the measurement time pe-
riod.
Oncology: Medical and RadiationPain Inten- 0384/143 ......... Person and Caregiver Percentage of patient visits, regardless of pa- Physician Consortium
sity Quantified. Centered Experience. tient age, with a diagnosis of cancer cur- for Performance Im-
rently receiving chemotherapy or radiation provement Founda-
therapy in which pain intensity is quantified. tions (PCPI).
Oncology: Medical and RadiationPlan of 0383/144 ......... Person and Caregiver Percentage of visits for patients, regardless of American Society of
Care for Pain. Centered Experience. age, with a diagnosis of cancer currently re- Clinical Oncology.
ceiving chemotherapy or radiation therapy
who report having pain with a documented
plan of care to address pain.
Preventive Care and Screening: Screening for 0418/134 ......... Community/Population Percentage of patients aged 12 and older Centers for Medicare &
Depression and Follow-Up Plan. Health. screened for depression on the date of the Medicaid Services.
encounter using an age appropriate stand-
ardized depression screening tool and if
positive, a follow-up plan is documented on
the date of the positive screen.

Patient-Reported Experience of Care ............... Not Applicable Person and Caregiver Summary/Survey Measures may include: Not Applicable.
Centered Experience. Overall measure of patient experience.
Exchanging Information with Patients.
Access.
Shared Decision Making.
Enabling Self-Management.
Affective Communication.
TABLE 14MIPS APM MEASURES LISTONCOLOGY CARE MODELContinued

NQF/quality No. National quality Primary measure
Measure name Measure description
(if applicable) strategy domain steward
Prostate Cancer: Adjuvant Hormonal Therapy 0390/104 ......... Effective Clinical Care Percentage of patients, regardless of age, American Urological
for High or Very High Risk Prostate Cancer. with a diagnosis of prostate cancer at high Association Edu-
or very high risk of recurrence receiving ex- cation and Re-
ternal beam and radiotherapy to the pros- search.
tate who were prescribed adjuvant hor-
monal therapy (GnRH [gonadotropin releas-
ing hormone] agonist or antagonist).
Adjuvant chemotherapy is recommended or 0223 ................ Communication and Percentage of patients under the age of 80 Commission on Can-
administered within 4 months (120 days) of Care Coordination. with AJCC III (lymph node positive) colon cer, American Col-
diagnosis to patients under the age of 80 cancer for whom adjuvant chemotherapy is lege of Surgeons.
with AJCC III (lymph node positive) colon recommended and not received or adminis-
cancer. tered within 4 months (120 days) of diag-
nosis.
Combination chemotherapy is recommended 0559 ................ Communication and Percentage of female patients, age >18 at di- Commission on Can-
or administered within 4 months (120 days) Care Coordination. agnosis, who have their first diagnosis of cer, American Col-
of diagnosis for women under 70 with AJCC breast cancer (epithelial malignancy), at lege of Surgeons.
T1cN0M0, or Stage IBIII hormone receptor AJCC stage T1cN0M0 (tumor greater than 1
negative breast cancer. cm), or Stage IBIII, whose primary tumor is
progesterone and estrogen receptor nega-
tive recommended for multiagent chemo-
therapy (recommended or administered)
within 4 months (120 days) of diagnosis.
Trastuzumab administered to patients with 1858/450 ......... Efficiency and Cost Proportion of female patients (aged 18 years American Society of
AJCC stage I (T1c)III and human epidermal Reduction. and older) with AJCC stage I (Tlc)Ill, Clinical Oncology.
growth factor receptor 2 (HER2) positive human epidermal growth factor receptor 2
breast cancer who receive adjuvant chemo- (HER2) positive breast cancer receiving ad-
therapy. juvant Chemotherapy.
Breast Cancer: Hormonal Therapy for Stage I 0387 ................ Communication and Percentage of female patients aged 18 years AMA-convened Physi-
(T1b)IIIC Estrogen Receptor/Progesterone Care Coordination. and older with Stage I (T1b) through IIIC, cian Consortium for
Receptor (ER/PR) Positive Breast Cancer. ER or PR positive breast cancer who were Performance Im-
prescribed tamoxifen or aromatase inhibitor provement.
(AI) during the 12-month reporting period.
Documentation of Current Medications in the 0419/130 ......... Patient Safety ............. Percentage of visits for patients aged 18 years Centers for Medicare &
Medical Record. and older for which the eligible clinician at- Medicaid Services.
tests to documenting a list of current medi-
cations using all immediate resources avail-
able on the date of the encounter. This list
must include ALL known prescriptions, over-
the counters, herbals, and vitamin/mineral/
dietary AND must contain the medications
name, dosage, frequency and route of ad-
ministration.
TABLE 15MIPS APM MEASURES LISTCOMPREHENSIVE ESRD CARE

NQF/quality No. National quality strategy
Measure name Measure description Primary measure steward
(if applicable) domain
ESCO Standardized Mor- 0369/154 ......... Patient Safety ..................... This measure is calculated as a ratio but can also be National Committee for
tality Ratio. expressed as a rate. Quality Assurance.
Falls: Screening, Risk As- 0101/154 ......... Communication and Coordi- (A) Screening for Future Fall Risk: Patients who were National Committee for
sessment and Plan of nation. screened for future fall risk at last once within 12 Quality Assurance.
Care to Prevent Future months.
Falls. (B) Multifactorial Falls Risk Assessment: Patients at risk
of future fall who had a multifactorial risk assessment
for falls completed within 12 months.
(C) Plan of Care to Prevent Future Falls: Patients at
risk of future fall with a plan of care for falls preven-
tion documented within 12 months.
Advance Care Plan ............ 0326/47 ........... Patient Safety ..................... Percentage of patients aged 65 years and older who National Committee for
have an advance care plan or surrogate decision Quality Assurance.
maker documented in the medical record or docu-
mentation in the medical record that an advance care
plan was discussed but the patient did not wish or
was not able to name a surrogate decision maker or
provide an advance care plan.
TABLE 15MIPS APM MEASURES LISTCOMPREHENSIVE ESRD CAREContinued

ICHCAHPS: 0258 ................ Person and Caregiver Cen- Summary/Survey Measures may include: Agency for Healthcare Re-
Nephrologists Commu- tered Experience and Getting timely care, appointments, and informa- search and Quality.
nication and Caring. Outcome. tion.
How well providers communicate.
Patients rating of provider.
Access to specialists.
Health promotion and education.
Shared Decision-making.
Health status and functional status.
Courteous and helpful office staff.
Care coordination.
Between visit communication.
Helping you to take medications as directed, and
Stewardship of patient resources.
ICHCAHPS: ICHCAHPS: 0258 ................ Person and Caregiver Cen- Comparison of services and quality of care that dialysis Not Applicable.
Rating of Dialysis Center. tered Experience and facilities provide from the perspective of ESRD pa-
Outcome. tients receiving in-center hemodialysis care. Patients
will assess their dialysis providers, including
nephrologists and medical and non-medical staff, the
quality of dialysis care they receive, and information
sharing about their disease.
ICHCAHPS: Quality of Di- 0258 ................ Person and Caregiver Cen- Comparison of services and quality of care that dialysis Agency for Healthcare Re-
alysis Center Care and tered Experience and facilities provide from the perspective of ESRD pa- search and Quality.
Operations. Outcome. tients receiving in-center hemodialysis care. Patients
ICHCAHPS: Providing In- 0258 ................ Person and Caregiver Cen- Comparison of services and quality of care that dialysis Agency for Healthcare Re-
formation to Patients. tered Experience and facilities provide from the perspective of ESRD pa- search and Quality.
ICHCAHPS: Rating of Kid- 0258 ................ Person and Caregiver Cen- Comparison of services and quality of care that dialysis Agency for Healthcare Re-
ney Doctors. tered Experience and facilities provide from the perspective of ESRD pa- search and Quality.
ICHCAHPS: Rating of Di- 0258 ................ Person and Caregiver Cen- Comparison of services and quality of care that dialysis Agency for Healthcare Re-
alysis Center Staff. tered Experience and facilities provide from the perspective of ESRD pa- search and Quality.
ICHCAHPS: Rating of Di- Outcome. tients receiving in-center hemodialysis care. Patients
alysis Center. will assess their dialysis providers, including
Medication Reconciliation 0554 ................ Communication and Care The percentage of discharges from any inpatient facility National Committee for
Post Discharge. Coordination. (e.g. hospital, skilled nursing facility, or rehabilitation Quality Assurance.
facility) for patients 18 years of age and older seen
within 30 days following the discharge in the office by
the physicians, prescribing practitioner, registered
nurse, or clinical pharmacist providing on-going care
for whom the discharge medication list was rec-
onciled with the current medication list in the out-
patient medical record.
This measure is reported as three rates stratified by
age group:
Reporting Criteria 1: 1864 years of age.
Reporting Criteria 2: 65 years and older.
Total Rate: All patients 18 years of age and Older.
Diabetes Care: Eye Exam .. 0055/117 ......... Effective Clinical Care ........ Percentage of patients 1875 years of age with diabe- National Committee for
tes who had a retinal or dilated eye exam by an eye Quality Assurance.
care professional during the measurement period or a
negative retinal exam (no evidence of retinopathy) in
the 12 months prior to the measurement period.
Diabetes Care: Foot Exam 0056/163 ......... Effective Clinical Care ........ Percentage of patients 1875 years of age with diabe- National Committee for
tes (type 1 and type 2) who received a foot exam Quality Assurance,
(visual inspection and sensory exam with mono fila-
ment and a pulse exam) during the previous meas-
urement year.
Influenza Immunization for 0041/110, 0226 Community/Population Percentage of patients aged 6 months and older seen Kidney Care Quality Alli-
the ESRD Population. Health. for a visit between July 1 and March 31 who received ance (KCQA).
an influenza immunization OR who reported previous
receipt of an influenza immunization.
Pneumococcal Vaccination 0043/111 ......... Community/Population Percentage of patients 65 years of age and older who National Committee for
Status. Health. have ever received a pneumococcal vaccine. Quality Assurance.
TABLE 15MIPS APM MEASURES LISTCOMPREHENSIVE ESRD CAREContinued

Screening for Clinical De- 0418/134 ......... Community/Population Percentage of patients aged 12 and older screened for Centers for Medicare and
pression and Follow-Up Health. depression on the date of the encounter and using an Medicaid Services.
Plan. age appropriate standardized depression screening
tool AND if positive, a follow-up plan is documented
on the date of the positive screen.
Tobacco Use: Screening 0028/226 ......... Community/Population Percentage of patients aged 18 years and older who Physician Consortium for
and Cessation Interven- Health. were screened for tobacco use one or more times Performance Improve-
tion. within 24 months AND who received cessation coun- ment Foundations
seling intervention if identified as a tobacco user. (PCPI).
TABLE 16MIPS APM MEASURES LISTCOMPREHENSIVE PRIMARY CARE PLUS (CPC+)

Controlling High Blood 0018/236 ......... Effective Clinical Care ........ Percentage of patients 1885 years of age who had a National Committee for
Pressure. diagnosis of hypertension and whose blood pressure Quality Assurance.
was adequately controlled (<140/90 mmHg) during
the measurement period.
Diabetes: Eye Exam ........... 0055/117 ......... Effective Clinical Care ........ Percentage of patients 1875 years of age with diabe- National Committee for
tes who had a retinal or dilated eye exam by an eye Quality Assurance.
care professional during the measurement period or a
negative retinal exam (no evidence of retinopathy) in
the 12 months prior to the measurement period.
Diabetes: Hemoglobin A1c 0059/001 ......... Effective Clinical Care ........ Percentage of patients 1875 years of age with diabe- National Committee for
(HbA1c) Poor Control tes who had hemoglobin A1c >9.0% during the meas- Quality Assurance
(<9%). urement period.
Use of High-Risk Medica- 0022/238 ......... Patient Safety ..................... Percentage of patients 66 years of age and older who National Committee for
tions in the Elderly. were ordered high-risk medications. Two rates are re- Quality Assurance.
ported
a. Percentage of patients who were ordered at
least one high risk medication.
b. Percentage of patients who were ordered at
least two different high risk medications.
Dementia: Cognitive As- 2872/281 ......... Effective Clinical Care ........ Percentage of patients, regardless of age, with a diag- Physician Consortium for
sessment. nosis of dementia for whom an assessment of cog- Performance Improve-
nition is performed and the results reviewed at least ment Foundation (PCPI).
once within a 12-month period.
Falls: Screening for Future 0101/318 ......... Patient Safety ..................... (A) Screening for Future Fall Risk: Patients who were National Committee for
Fall Risk. screened for future fall risk at least once within 12 Quality Assurance.
months.
(B) Multifactorial Falls Risk Assessment: Patients at risk
of future fall who had a multifactorial risk assessment
for falls completed within 12 months.
(C) Plan of Care to Prevent Future Falls: Patients at
risk of future fall with a plan of care for falls preven-
tion documented within 12 months.
Initiation and Engagement 0004/305 ......... Effective Clinical Care ........ Percentage of patients 13 years of age and older with a National Committee for
of Alcohol and Other new episode of alcohol and other drug (AOD) de- Quality Assurance.
Drug Dependence Treat- pendence who received the following. Two rates are
ment. reported
a. Percentage of patients who initiated treatment
within 14 days of the diagnosis.
b. Percentage of patients who initiated treatment
and who had two or more additional services
with an AOD diagnosis within 30 days of the initi-
ation visit.
Closing the Referral Loop: Not Applicable/ Communication and Care Percentage of Patients with referrals, regardless of age, Centers for Medicare and
Receipt of Specialist Re- 374. Coordination. for which the referring provider receives a report from Medicaid Services.
port. the provider to whom the patient was referred.
Cervical Cancer Screening 0032/309 ......... Effective Clinical Care ........ Percentage of women 2164 years of age, who were National Committee for
screened for cervical cancer using either of the fol- Quality Assurance.
lowing criteria
Women age 2164 who had cervical cytology per-
formed every 3 years.
Women age 3064 who had cervical cytology/human
papillomavirus (HPV) co-testing performed every 5
years.
Colorectal Cancer Screen- 0034/113 ......... Effective Clinical Care ........ Percentage of patients, 5075 years of age who had National Committee for
ing. appropriate screening for colorectal cancer. Quality Assurance.
Preventive Care and 0028/226 ......... Community/Population Percentage of patients aged 18 years and older who Physician Consortium for
Screening: Tobacco Use: Health. were screened for tobacco use one or more times Performance Improve-
Screening and Cessation within 24 months and who received cessation coun- ment Foundations
Intervention. seling intervention if identified as a tobacco user. (PCPI).
Breast Cancer Screening ... 2372/112 ......... Effective Clinical Care ........ Percentage of women 5074 years of age who had a National Committee for
mammogram to screen for breast cancer. Quality Assurance.
TABLE 16MIPS APM MEASURES LISTCOMPREHENSIVE PRIMARY CARE PLUS (CPC+)Continued

Preventive Care and 0041/110 ......... Community/Population Percentage of patients aged 6 months and older seen Physician Consortium for
Screening: Influenza Im- Health. for a visit between October 1 and March 31 who re- Performance Improve-
munization. ceived an influenza immunization OR who reported ment Foundations
previous receipt of an influenza immunization. PCPI(R) Foundation
(PCPI[R]).
Pneumonia Vaccination 0043/111 ......... Community/Population Percentage of patients 65 years of age and older who National Committee for
Status for Older Adults. Health. have ever received a pneumococcal vaccine. Quality Assurance.
Diabetes: Medical Attention 0062/119 ......... Effective Clinical Care ........ The percentage of patients 1875 years of age with dia- National Committee for
for Nephropathy. betes who had a nephropathy screening test or evi- Quality Assurance.
dence of nephropathy during the measurement period.
Ischemic Vascular Disease 0068/204 ......... Effective Clinical Care ........ Percentage of patients 18 years of age and older who National Committee for
(IVD): Use of Aspirin or were diagnosed with acute myocardial infarction Quality Assurance.
Another. (AMI), coronary artery bypass graft (CABG) or
percutaneous coronary interventions (PCI) in the 12
months prior to the measurement period, or who had
an active diagnosis of ischemic vascular disease
(IVD) during the measurement period, and who had
documentation of use of aspirin or another antiplatelet
during the measurement period.
Preventive Care and 0418/134 ......... Community/Population Percentage of patients aged 12 years and older Centers for Medicare &
Screening: Screening for Health. screened for depression on the date of the encounter Medicaid Services.
Depression and Follow- using an age appropriate standardized depression
Up Plan. screening tool AND if positive, a follow-up plan is
documented on the date of the positive screen.
Statin Therapy for the Pre- Not Applicable/ Effective Clinical Care ........ Percentage of the following patientsall considered at Centers for Medicare &
vention and Treatment of 438. high risk of cardiovascular eventswho were pre- Medicaid Services.
Cardiovascular Disease. scribed or were on statin therapy during the measure-
ment period:
* Adults aged >=21 years who were previously diag-
nosed with or currently have an active diagnosis of
clinical atherosclerotic cardiovascular disease
(ASCVD); OR
* Adults aged >=21 years who have ever had a fasting
or direct low-density lipoprotein cholesterol (LDLC)
level >=190 mg/dL or were previously diagnosed with
or currently have an active diagnosis of familial or
pure hypercholesterolemia; OR
* Adults aged 4075 years with a diagnosis of diabetes
with a fasting or direct LDLC level of 70189 mg/dL
Inpatient Hospital Utilization Not Applicable Not Applicable .................... For members 18 years of age and older, the risk-ad- National Committee for
(IHU). justed ratio of observed to expected acute inpatient Quality Assurance.
discharges during the measurement year reported by
Surgery, Medicine, and Total.
Emergency Department Uti- Not Applicable Not Applicable .................... For members 18 years of age and older, the risk-ad- National Committee for
lization (EDU). justed ratio of observed to expected emergency de- Quality Assurance.
partment (ED) visits during the measurement year.
CAHPS ............................... CPC+ specific; Person and Caregiver-Cen- CGCAHPS Survey 3.0 ................................................... Agency for Healthcare Re-
different than tered Experience and search and Quality.
CAHPS for Outcome.
MIPS.
7. MIPS Final Score Methodology with the ease of use, stability, and completeness criteria, to encourage
meaningfulness for MIPS eligible MIPS eligible clinicians to meet data
For the 2020 MIPS payment year, we clinicians, while also emphasizing completeness while providing an
intend to build on the scoring simplicity and scoring that is exception for small practices;
methodology we finalized for the understandable for MIPS eligible An improvement scoring
transition year, which allows for clinicians. We proposed refinements to methodology that rewards MIPS eligible
accountability and alignment across the the performance standards, the clinicians who improve their
performance categories and minimizes methodology for determining a score for performance in the quality and cost
burden on MIPS eligible clinicians, each of the four performance categories performance categories;
while continuing to prepare MIPS (the performance category score), and A new scoring option for the quality
eligible clinicians for the performance the methodology for determining a final and cost performance categories that
threshold required for the 2021 MIPS score based on the performance category allows facility-based MIPS eligible
payment year. Our rationale for our scores (82 FR 30140 through 30142). clinicians to be scored based on their
scoring methodology continues to be We intended to continue the facilitys performance;
grounded in the understanding that the transition of MIPS by proposing the Special considerations for MIPS
MIPS scoring system has many following policies: eligible clinicians in small practices or
components and numerous moving Continuation of many transition those who care for complex patients;
parts. year scoring policies in the quality and
As we continue to move forward in performance category, with an Policies that allow multiple
implementing the MIPS program, we adjustment to the number of pathways for MIPS eligible clinicians to
strive to balance the statutory achievement points available for receive a neutral to positive MIPS
requirements and programmatic goals measures that fail to meet the data payment adjustment.
We noted that these sets of proposed to the quality and cost performance we believe that a category-level
policies will help clinicians smoothly categories starting with the 2020 MIPS approach would provide a broader
transition from the transition year to the payment year. perspective, particularly in the absence
2021 MIPS payment year, for which the of a standard set of measures, because
(b) Policies Related to Scoring
performance threshold (which it would allow for a more flexible
Improvement approach that enables MIPS eligible
represents the final score that would
earn a neutral MIPS adjustment) would (i) Background clinicians to select measures and data
be either the mean or median (as In accordance with section submission mechanisms that can change
selected by the Secretary) of the MIPS 1848(q)(5)(D)(i) of the Act, beginning from year to year and be more
final scores for all MIPS eligible with the 2020 MIPS payment year, if appropriate to their practice in a given
clinicians from a previous period data sufficient to measure improvement year.
specified by the Secretary. are available, the final score We believe that both approaches are
Unless otherwise noted, for purposes viable options for measuring
methodology shall take into account
of this section II.C.7. of the final rule improvement. Accordingly, we noted
improvement of the MIPS eligible
with comment period on scoring, the that we believe that an appropriate
clinician in calculating the performance
term MIPS eligible clinician will refer approach for measuring improvement
score for the quality and cost
to MIPS eligible clinicians that submit for the quality performance category and
performance categories and may take
data and are scored at either the the cost performance category should
into account improvement for the
individual- or group-level, including consider the unique characteristics of
improvement activities and advancing
virtual groups, but will not refer to each performance category rather than
care information performance
MIPS eligible clinicians who elect necessarily applying a uniform
categories. In addition, section
facility-based scoring. The scoring rules approach across both performance
1848(q)(3)(B) of the Act provides that categories. For the quality performance
for facility-based measurement are the Secretary, in establishing
discussed in section II.C.7.a.(4) of this category, clinicians are offered a variety
performance standards for measures and of different measures which can be
final rule with comment period. We also activities for the MIPS performance
note that the APM scoring standard submitted by different mechanisms,
categories, shall consider: Historical rather than a standard set of measures
applies to APM Entities in MIPS APMs, performance standards; improvement;
and those policies take precedence or a single data submission mechanism.
and the opportunity for continued For the cost performance category,
where applicable; however, where those improvement. Section 1848(q)(5)(D)(ii)
policies do not apply, scoring for MIPS however, clinicians are scored on the
of the Act also provides that same set of cost measures to the extent
eligible clinicians as described in achievement may be weighted higher
section II.C.7. of this final rule with each measure is applicable and
than improvement. available to them; clinicians cannot
comment period will apply. We refer In the CY 2017 Quality Payment
readers to section II.C.6.g. of this final choose which cost measures they will
Program final rule, we summarized be scored on. In addition, all of the cost
rule with comment period for additional public comments received on the
information about the APM scoring measures are derived from
proposed rule regarding potential ways administrative claims data with no
standard. to incorporate improvement into the additional submission required by the
a. Converting Measures and Activities scoring methodology moving forward, clinician.
Into Performance Category Scores including approaches based on When considering the applicability of
methodologies used in the Hospital VBP these programs to MIPS, we also
(1) Policies That Apply Across Multiple Program, the Shared Savings Program, considered how scoring improvement is
Performance Categories and Medicare Advantage 5-star Ratings incorporated into the overall scoring
The policies for scoring the 4 Program (81 FR 77306 through 77308). system, including when only
performance categories are described in We did not finalize a policy at that time achievement or improvement is
detail in section II.C.7.a. of this final on this topic and indicated we would incorporated into a final score or when
rule with comment period. However, as take comments into account in improvement and achievement are both
the 4 performance categories developing a proposal for future incorporated into a final score.
collectively create a single MIPS final rulemaking. We refer readers to the proposed rule
score, there are several policies that When considering the applicability of (82 FR 30096 through 30098) where we
apply across categories, which we these programs to MIPS, we looked at considered how we might adapt for
discuss in section II.C.7.a.(1) of this the approach that was used to measure MIPS the various approaches used for
final rule with comment period. improvement for each of the programs scoring improvement under the Hospital
and how improvement was incorporated VBP Program, Medicare Shared Savings
(a) Performance Standards into the overall scoring system. An Program, and Medicare Advantage 5-
In accordance with section 1848(q)(3) approach that focuses on measure-level Star rating.
of the Act, in the CY 2017 Quality comparison enables a more granular We proposed two different
Payment Program final rule, we assessment of improvement because approaches for scoring improvement
finalized performance standards for the performance on a specific measure can from year to year. We proposed to
four performance categories. We refer be considered and compared from year measure improvement at the
readers to the CY 2017 Quality Payment to year. All options that we considered performance category level for the
Program final rule for a description of last year use a standard set of measures quality performance category score (82
the performance standards against that do not provide for choice of FR 30113 through 30114) and refer
which measures and activities in the measures to assess performance; readers to section II.C.7.a.(2)(i) of this
four performance categories are scored therefore, they are better structured to final rule with comment period for a
(81 FR 77271 through 77272). compare changes in performance based summary of the comments we received
As discussed in the proposed rule (82 on the same measure from year to year. and our responses. Because clinicians
FR 30096 through 30098), we proposed The aforementioned programs do not can elect the submission mechanisms
to add an improvement scoring standard use a category-level approach; however, and quality measures that are most
meaningful to their practice, and these category at this time, though we may clinicians should be able to understand
choices can change from year to year, address improvement scoring for these their progress in improving outcomes.
we want a flexible methodology that performance categories in future Response: We thank commenters for
allows for improvement scoring even rulemaking. their support for scoring improvement
when the quality measures change. This We proposed to amend for the quality and cost performance
is particularly important as we 414.1380(a)(1)(i) to add that categories starting with the 2020 MIPS
encourage MIPS eligible clinicians to improvement scoring is available for the payment year. We will implement
move away from topped out measures quality performance category and for the improvement scoring beginning with
and toward more outcome measures. We cost performance category at the 2020 MIPS payment year. We intend
do not want the flexibility that is offered 414.1380(a)(1)(ii) beginning with the to evaluate the implementation of
to MIPS eligible clinicians in the quality 2020 MIPS payment year. improvement scoring for the quality and
performance category to limit clinicians We solicited public comment on our cost performance categories to
ability to move towards outcome proposals to score improvement for the determine how the policies we establish
measures, or limit our ability to measure quality and cost performance categories in this final rule with comment period
improvement. Our final policies for starting with the 2020 MIPS payment are affecting MIPS eligible clinicians,
taking improvement into account as part year. including high-performing clinicians.
of the quality performance category The following is a summary of the We intend to implement improvement
score are addressed in detail in sections public comments received on our scoring in a transparent manner and we
II.C.7.a.(2)(i) and II.C.7.a.(2)(j) of this proposals and our responses: will address any changes in
final rule with comment period. improvement scoring through future
Comment: Several commenters
We noted our belief that there is rulemaking. Please refer to sections
supported CMSs proposal to score
reason to adopt a different methodology II.C.7.a.(2)(i) and II.C.7.a.(3)(a) of this
improvement for the quality and cost
for scoring improvement for the cost final rule with comment period for
performance categories to recognize and
performance category from that used for details for our proposals, comments,
reward improvement as well as
the quality performance category. In and final policies related to the
achievement. A few commenters
contrast to the quality performance implementation of improvement scoring
supported separate approaches for
category, for the cost performance for the quality and cost performance
scoring improvement for the cost and
category, MIPS eligible clinicians do not categories, respectively.
quality performance categories because Comment: Several commenters did
have a choice in measures or
submission mechanisms; rather, all of the specific characteristics of each not support scoring improvement for the
MIPS eligible clinicians are assessed on category. A few commenters quality and cost performance categories
all measures based on the availability recommended that CMS review the because they believed it would add a
and applicability of the measure to their impact of these proposals after the first layer of complexity for clinicians
practice, and all measures are derived year of implementation and refine them participating in the MIPS program.
from administrative claims data. as necessary to ensure that they achieve Several commenters did not support 2
Therefore, for the cost performance the intended goal of rewarding separate methods for improvement
category, we proposed to measure improvement and not penalizing high scoring for quality and cost because this
improvement at the measure level (82 performers. One commenter supported approach would lead to further
FR 30121). We also noted that we are the incorporation of improvement complexity in the MIPS program.
statutorily required to measure scoring because measuring changes in Several commenters recommended that
improvement for the cost performance year-to-year performance could create CMS delay implementation of
category beginning with the second strong incentives for clinicians to improvement scoring and that CMS seek
MIPS payment year if data sufficient to further improve upon the quality and feedback from stakeholders and analyze
measure improvement is available. value of care. One commenter believed data further because making
Because we had proposed to weight the that clinicians who make large gains in adjustments after implementation may
cost performance category at zero their performance could be rewarded be difficult. Commenters also believed
percent for the 2018 MIPS performance and incentivized toward continuous that there had not been sufficient
period/2020 MIPS payment year (82 FR quality improvement, even for the discussion with stakeholders about the
30047 through 30048), the improvement highest performers. One commenter challenges for certain specialties, sites
score for the cost performance category believed that scoring improvement of service, and other participants; that
would not have affected the MIPS final would help solo, small, and rural clinicians need more time to understand
score for the 2018 MIPS performance practices with administrative challenges the reporting requirements; and that the
period/2020 MIPS payment year and by incentivizing and offsetting upfront programs measures should be stable
would have been for informational costs of MIPS participation. One prior to implementing improvement
purposes only. However, as discussed in commenter believed that scoring scoring.
section II.C.6.d.(2) of this final rule with improvement could boost the success of Response: We acknowledge the
comment period, we are adopting our MIPS because it would improve the commenters concerns with the
alternative option to maintain a 10 quality of care patients receive, reduce complexity that scoring improvement
percent weight for the cost performance the inefficient use of care, increase the adds to the calculation of the MIPS
category, and therefore, the cost value of care provided, focus on an quality performance category score. We
improvement score will be reflected in enhanced reward system relative to also acknowledge the commenters
the cost performance category percent quality and cost as the primary concerns related to the challenges of
score and the final score for the 2018 measurements of care efficiency, and improvement scoring for specific types
MIPS performance period/2020 MIPS increase clinicians incentive to drive of clinician practices, the amount of
payment year. improvements in the performance time to understand the reporting
We did not propose to score categories. Finally, one commenter requirements, and the stability of the
improvement in the improvement recommended continued transparency programs measures. Section
activities performance category or the for the improvement scoring 1848(q)(5)(D)(i) of the Act requires us to
advancing care information performance methodology and calculations because take into account improvement when
calculating the quality and cost period (82 FR 30114 through 30116). We measure numerator, denominator,
performance category scores beginning also proposed that we would measure exclusions, or exceptions, could have an
with the 2020 MIPS payment year if improvement for the cost performance impact on the indicated performance on
data sufficient to measure improvement category when data is available which is the measure, although the impact may
is available. We intend to develop when there is sufficient case volume to not always be significant. In the CY
additional educational materials to help provide measurable data on measures in 2018 Quality Payment Program
explain improvement scoring. We also subsequent years with the same proposed rule, we proposed an annual
intend to monitor implementation of identifier (82 FR 30121). We refer review process to analyze the measures
improvement scoring for the quality and readers to sections II.C.7.a.(2)(i)(ii) and that have a code impact and assess the
cost performance categories and will II.C.7.a.(3)(a)(i) of this final rule with subset of measures significantly
address any changes to improvement comment period for details on these impacted by ICD10 coding changes
scoring through future rulemaking. proposals, the comments received and during the performance period (82 FR
Please refer to sections II.C.7.a.(2)(i)(ii) our responses, and final policies. 30098). Depending on the data
and II.C.7.a.(3)(a)(i) of this final rule available, we anticipated that our
(c) Scoring Flexibility for ICD10
with comment period for more determination as to whether a measure
Measure Specification Changes During
information about our proposal and is significantly impacted by ICD10
the Performance Period
discussion related to data sufficiency for coding changes would include these
the quality and cost performance The quality and cost performance factors: A more than 10 percent change
categories. We continue to believe that categories rely on measures that use in codes in the measure numerator,
the separate methodologies for the detailed measure specifications that denominator, exclusions, and
quality and cost performance categories include ICD10CM/PCS (ICD10) exceptions; clinical guideline changes
are warranted given the unique code sets. We annually issue new ICD or new products or procedures reflected
characteristics of each performance 10 coding updates, which are effective in ICD10 code changes; and feedback
category. from October 1 through September 30 on a measure received from measure
Comment: One commenter (https://www.cms.gov/Medicare/Coding/ developers and stewards (82 FR 30098).
recommended that, in future ICD10/ICD10OmbudsmanandICD10 In the CY 2018 Quality Payment
rulemaking, CMS advance an CoordinationCenterICC.html). As part of Program proposed rule, we considered
improvement score proposal for the this update, codes are added as well as an approach where we would consider
improvement activities and advancing removed from the ICD10 code set. any change in ICD10 coding to impact
care information performance categories To provide scoring flexibility for performance on a measure and thus
that aligns with the proposal set forth MIPS eligible clinicians and groups for only rely on the first 9 months of the 12-
for the quality performance category to measures impacted by ICD10 coding month performance period for such
measure improvement at the category changes in the final quarter of the measures; however, we believed such an
level. Quality Payment Program performance approach would be too broad and
Response: We will address periodwhich may render the measures truncate measurement for too many
improvement scoring for the no longer comparable to the historical measures where performance may not
improvement activities and advancing benchmarkwe proposed in the CY be significantly affected (82 FR 30098).
care information performance 2018 Quality Payment Program We believed that our proposed approach
categories, and alignment as proposed rule (82 FR 30098) to codify would ensure the measures on which
appropriate, in future rulemaking. at 414.1380(b)(1)(xviii) that we will individual MIPS eligible clinicians and
Final Action: After consideration of assess performance on measures groups will have their performance
the public comments, we are finalizing considered significantly impacted by assessed are accurate for the
our proposal to amend ICD10 updates based only on the first performance period and are consistent
414.1380(a)(1)(i) and 9 months of the 12-month performance with the benchmark set for the
414.1380(a)(1)(ii) to add that period (for example, January 1, 2018 performance period (82 FR 30098).
improvement scoring is available for the through September 30, 2018, for the We proposed to publish on the CMS
quality performance category and the 2018 MIPS performance period). As Web site which measures are
cost performance category beginning discussed in the CY 2018 Quality significantly impacted by ICD10
with the 2020 MIPS payment year. Payment Program proposed rule (82 FR coding changes and would require the
30098), we believed it would be 9-month assessment (82 FR 30098). We
(ii) Data Sufficiency Standard To appropriate to assess performance for proposed to publish this information by
Measure Improvement significantly impacted measures based October 1st of the performance period if
Section 1848(q)(5)(D)(i) of the Act on the first 9 months of the performance technically feasible, but by no later than
requires us to measure improvement for period, rather than the full 12 months the beginning of the data submission
the quality and cost performance because the indicated performance for period, which is January 2, 2019 for the
categories of MIPS if data sufficient to the last quarter could be affected by the 2018 MIPS performance period (82 FR
measure improvement are available, coding changes rather than actual 30098).
which we interpret to mean that we differences in performance. We noted We requested comment on the
would measure improvement when we that performance on measures that are proposal to address ICD10 measures
can identify data from a current not significantly impacted by changes to specification changes during the
performance period that can be ICD10 codes would continue to be performance period by relying on the
compared to data from a prior assessed on the full 12-month first 9 months of the 12-month
performance period or data that performance period (January 1 through performance period (82 FR 30098). We
compares performance from year to December 31) (82 FR 30098). also requested comment on potential
year. We proposed that we would In the CY 2018 Quality Payment alternate approaches to address
measure improvement for the quality Program proposed rule (82 FR 30098), measures that are significantly impacted
performance category when data is we noted that any measure that relies on due to ICD10 changes during the
available because there is a performance an ICD10 code which is added, performance period, including the
category score for the prior performance modified, or removed, such as in the factors we might use to determine
whether a measure is significantly based only on the first 9 months of the stewards and implementers as part of
impacted (82 FR 30098). 12-month performance period when we the annual review process. More
The following is a summary of the determine measures are significantly information will be available through
public comments received on these impacted by ICD10 coding changes. subregulatory guidance.
proposals and our responses: Our determination as to whether a Comment: Several commenters
Comment: A few commenters had measure is significantly impacted by expressed concern that for certain
suggestions to improve the proposed ICD10 coding changes will consider measures, truncated reporting would
ICD10 annual review process. Some one or more of the following factors: A not be appropriate due to their measure
commenters suggested that CMS more than 10 percent change in codes logic, and the measures would be
develop a centralized process for in the measure numerator, denominator, negatively impacted by a shorter
soliciting feedback on measures that exclusions, and exceptions; guideline reporting window since it can take a full
may be significantly impacted by ICD changes or new products or procedures year to capture the data needed to
10 coding changes and facilitate reflected in ICD10 code changes; and successfully report these measures. One
discussions between measure feedback on a measure received from commenter expressed concern that,
developers, stewards, clinicians, and measure developers and stewards. because certain standards used by
vendors who would be implementing Comment: Several commenters registries to support measure reporting
the changes to resolve ICD10 coding expressed concern about our proposed do not include timing information, such
changes as quickly as possible. A few approach to scoring flexibility based on as the QRDA III standard, it is unclear
commenters also recommended that the impact of the ICD10 update cycle how MIPS eligible clinicians would be
CMS address significant changes as a on measures and suggested alternatives. able to submit only 9 months of data.
result of ICD10 changes through notice The commenters noted that because it is This commenter urged CMS to, instead,
and comment rulemaking. possible for ICD10 updates to occur in adjust the value sets to account for the
Response: We will take commenters April as well as in October, CMSs updates and have those changes apply
suggestions for a centralized process for proposal does not solve the issue of to the entire performance year, with no
soliciting feedback on significantly ICD10 updates that occur midway change to full-year measure submission.
impacted measures and facilitating through the performance period. A few This commenter suggested that this
discussions into consideration as part of commenters recommended that CMS would allow clinicians to take
our annual review process. We are give full credit for reporting that would immediate advantage of critical updates
finalizing our proposal to assess be applied in future years, or to value sets without having to wait
measure performance based only on the alternatively, that CMS consider novel until the next performance year. The
first 9 months of the 12-month approaches that developers, stewards, commenters also noted that the very
performance period when we determine and implementers may have for short timeline between the discovery
that a measure is significantly impacted accounting for ICD10 changesfor and announcement of the error and the
by ICD10 coding changes. Measures example, releasing new measure end of the submission period would
impacted by ICD10 coding changes guidance or suspending the use of place an unreasonable burden on MIPS
will be identified during the certain new ICD10 codes until the eligible clinicians to revise and
performance period. We are unable to following performance period. revalidate their submissions. One
address each individual ICD10 code Response: While the list of ICD10 commenter also noted that CMSs
change through rulemaking in advance codes are available prior to October 1, approach adds complexity because
as the code changes are identified for Medicare Part A and Part B, all ICD clinicians and groups would have to
during the performance period and take 10 changes become effective October 1. track which measures require a full year
effect on October 1 of the performance As discussed further below, we are of reporting and which require only 9
period. However, any changes to this finalizing our proposal to measure the months.
policy, including our process for first 9 months of the performance period Response: We acknowledge the
identifying significantly impacted when we determine measures are commenters concerns that scoring
measures, and any substantive changes significantly impacted by ICD10 based on only 9 months of data raises
to quality or cost measures will be updates. We believe this approach issues with assessing MIPS eligible
addressed through future rulemaking. ensures our assessment of performance clinicians and groups on less than a full
We are also finalizing our proposal to will only be based on measures with year of data, particularly for some
publish which measures are ICD10 codes and measure measures. We also acknowledge that
significantly impacted by ICD10 specifications that are consistent with certain standards used by registries to
coding changes by October 1st of the the historical benchmark we set out for support measure reporting do not
performance period if technically the performance period when available, include timing information. In response
feasible, but by no later than the which are relied on by MIPS eligible to these concerns we note that where, as
beginning of the data submission clinicians and groups as they plan for part of our annual review process we
period, which is January 2, 2019 for the the performance period. While we determine that scoring a significantly
2018 MIPS performance period. We will acknowledge the other approaches impacted measure based on only 9
also provide further information recommended by commenters, such as months of data is inappropriate due to
through subregulatory guidance. providing full credit for reporting that the measure logic or other factors, we
Comment: Several commenters were would be applied in future years, we will communicate with MIPS eligible
supportive of the proposal to score believe the approach we are finalizing clinicians and groups and interested
measures that are considered allows comparisons to historical parties and provide information to them
significantly impacted by ICD10 benchmarks, which use similar codes, through subregulatory guidance.
updates based on only the first 9 months and ensures the measure specifications However, we expect that these instances
of the performance period to align with are accurate for the time period being would be rare based on our experience.
annual ICD10 updates. measured. As some commenters We also acknowledge the concerns
Response: We thank commenters for suggested, the input of stakeholders in raised by commenters about the burden
their support. We are finalizing our this process is valuable, and we will MIPS eligible clinicians may face to
proposal to assess measure performance consider the input of developers, revise and revalidate their submissions,
and clarify that CMS will monitor ICD impacted measures as early as possible numerator, denominator, exclusions,
10 updates and coding changes that and will take commenters concerns into and exceptions; clinical guideline
significantly impact measures during consideration to identify and publish changes or new products or procedures
the performance period to track which information on impacted measures as reflected in ICD10 code changes; and
measures require a full year of reporting soon as it is technically feasible for us feedback on a measure received from
and which require only 9 months, and to do so. We are finalizing that we will measure developers and stewards.
we will also provide this information to publish this information by October 1st Beginning with the 2018 MIPS
MIPS eligible clinicians, groups, and of the performance period if technically performance period, measures we
other interested parties, including feasible, but by no later than the determine to be significantly impacted
registries, through subregulatory beginning of the data submission by ICD10 updates will be assessed
guidance. We acknowledge the period, which is January 2, 2019 for the based only on the first 9 months of the
commenters suggestion that, 2018 MIPS performance period. We 12-month performance period. Lastly,
alternatively, we adjust the value sets to believe this timeline provides us needed we are finalizing as proposed that we
account for the updates and have those time to review whether ICD10 code will publish the list of measures
changes apply to the entire performance changes are significant or not as well as requiring a 9-month assessment process
year, with no change to full-year reviewing other guideline changes. on the CMS Web site by October 1st of
measure submission; however, this Comment: Some commenters the performance period if technically
approach is not operationally feasible recommended that CMS include how feasible, but by no later than the
for us to implement. the annual ICD10 update on October 1 beginning of the data submission
Comment: One commenter did not may impact quality measures, period, which is January 2, 2019 for the
support the approach that CMS performance scores, and benchmarks for 2018 MIPS performance period, as
considered but rejected, whereby CMS the last quarter of the year because this discussed in section II.C.6.a.(2) of this
would consider any change in ICD10 is vital information needed for final rule with comment period. We are
coding to impact performance on a clinicians and groups to make informed codifying these policies for the quality
measure, and thus, rely on the first 9 decisions about the performance period performance category at
months of the 12-month performance best suited for their practice, including 414.1380(b)(1)(xviii) in this final rule
period for such measures. those who may want to choose the last with comment period. As discussed in
Response: We acknowledge that such 90 days of 2018 as their performance section II.C.6.d.(3)(d) of this final rule
an approach would be too broad and period for the advancing care with comment period, we will apply a
truncate measurement for too many information and the improvement similar approach for measures in the
measures where performance may not activities performance categories, which cost performance category, although we
be significantly affected and have have 90-day performance periods. do not anticipate that the cost measures
rejected this approach. Response: We will consider for the 2018 MIPS performance period
Comment: Several commenters commenters suggestions about the (total per capita cost measure and the
supported the proposal to publish the information to include regarding MSPB) would be significantly affected
measures significantly impacted by significantly impacted measures as we by ICD10 changes.
ICD10 coding changes that would prepare our publication of significantly As we finalize this policy for
require the 9-month assessment, and impacted measures. We will monitor measures significantly impacted by
agreed with the factors listed to consider measure changes as they occur and rely ICD10 code changes, we are also
in determining whether a measure is on stakeholder input; we will also concerned about instances where
significantly impacted by an ICD10 provide subregulatory communication clinical guideline changes or other
coding update. and guidance to stakeholders as to how changes to a measure that occur during
Response: We thank the commenters changes we determine to be significant the performance period may
for their support. We are finalizing as may impact the quality measures, significantly impact a measure and
proposed our proposal to publish the performance scores, and benchmarks. render the measure no longer
list of measures requiring a 9-month We do not believe this policy will affect comparable to the historical benchmark.
assessment process on the CMS Web the improvement activities and As such, we seek comment in this final
site by October 1st of the performance advancing care information performance rule with comment period regarding
period if technically feasible, but by no categories because those performance whether we should apply similar
later than the beginning of the data categories have a 90-day reporting scoring flexibility to such measures.
submission period. For example, for the period.
2018 performance period, data Final Action: After consideration of (2) Scoring the Quality Performance
the public comments, we are finalizing Category for Data Submission via
submissions will begin on January 2,
as proposed our policy to provide Claims, EHR, Third Party Data
2019.
Comment: Several commenters scoring flexibility for ICD10 measure Submission Options, CMS Web
requested that CMS provide information specification changes during the Interface, and Administrative Claims
about significantly impacted measures performance period. We are finalizing Many comments submitted in
as soon as possible. The commenters that we will establish an annual review response to the CY 2017 Quality
suggested that CMS issue the impacted process to analyze the measures that Payment Program final rule requested
ICD10 list well before October 1 to have a code impact and assess the additional clarification on our finalized
allow clinician and groups to subset of measures significantly scoring methodology for the 2019 MIPS
appropriately prepare for the upcoming impacted by ICD10 coding changes payment year. To provide further clarity
submission cycle. A few commenters during the performance period. to MIPS eligible clinicians about the
recommended that clinicians and Depending on the data available, our transition year scoring policies, before
groups will need a 30- to 60-day determination as to whether a measure describing our proposed scoring policies
window of lead time, such as November is significantly impacted by ICD10 for the 2020 MIPS payment year, we
1 or December 1. coding changes will include one or provided a summary of the scoring
Response: We acknowledge that it more these factors: A more than 10 policies finalized in the CY 2017
would be useful to identify significantly percent change in codes in the measure Quality Payment Program final rule
along with examples of how they apply 414.1380(b)(1)(xvii)) to use this term groups for whom the readmission
under several scenarios (82 FR 30098 in place of quality performance measure applies, the denominator is
through 30100). category score. Thus, the formula for generally 70 points.
In the CY 2017 Quality Payment the quality performance category If we determined that a MIPS eligible
Program final rule (81 FR 77286 through percent score that we will use in this clinician has fewer than 6 measures
77287), we finalized that the quality section is as follows: available and applicable, we will score
performance category would be scored (Total measure achievement points + only the number of measures that are
by assigning achievement points to each total measure bonus points)/total available and adjust the denominator
submitted measure, which we refer to in available measure achievement accordingly to the total available
this section of the proposed rule as points = quality performance measure achievement points (81 FR
measure achievement points. In the category percent score. 77291). A description of the validation
CY 2018 Quality Payment Program process to determine measure
proposed rule (82 FR 30098 through This is a summary of the public
availability is provided in the proposed
30099), we proposed to amend various comments received on the changes to
rule (82 FR 30108 through 30109).
paragraphs in 414.1380(b)(1) to use the regulatory text and our responses:
Comment: One commenter expressed For the 2019 MIPS payment year, a
this term in place of achievement MIPS eligible clinician that submits
points. MIPS eligible clinicians can their belief that the continued changes
in terminology not based on statute quality measure data via claims, EHR, or
also earn bonus points for certain third party data submission options
measures (81 FR 77293 through 77294; serves to confuse clinicians and further
complicate the Quality Payment (that is, QCDR, qualified registry, EHR,
81 FR 77297 through 77299), which we or CMS-approved survey vendor for the
referred to as measure bonus points, Program.
Response: The amendments to the CAHPS for MIPS survey), can earn
and we proposed to amend
regulatory text are meant to clarify our between 3 and 10 measure achievement
414.1380(b)(1)(xiii) (which we
terminology to make the Quality points for quality measures submitted
proposed to redesignate as
Payment Program easier to understand. for the performance period of greater
414.1380(b)(1)(xiv) 3),
The changes to terminology are not than or equal to 90 continuous days
414.1380(b)(1)(xiv) (which we
intended to create confusion but to during CY 2017. A MIPS eligible
respond to feedback on the need for clinician can earn measure bonus points
414.1380(b)(1)(xv)), and
more clarity and meaningful terms than (subject to a cap) if they submit
414.1380(b)(1)(xv) (which we
those used in the Act. These additional high priority measures with a
amendments to regulation text are not performance rate that is greater than
414.1380(b)(1)(xvii)) to use this term
changes to the program policy. zero, and that meet the case minimum
in place of bonus points. The measure
Final Action: After consideration of and data completeness requirements, or
achievement points assigned to each
public comments, we are finalizing the submit a measure using an end-to-end
measure would be added with any
proposed clarifications and electronic pathway. An individual MIPS
measure bonus points and then divided
redesignations in 414.1380(b)(1) eligible clinician that has 6 or more
by the total possible points
related to measure achievement points quality measures available and
( 414.1380(b)(1)(xv) (which we
and the quality performance category applicable will have 60 total available
score. measure achievement points. An
414.1380(b)(1)(xvii)). We referred to
In the CY 2017 Quality Payment example was provided in Table 17 of
the total possible points as total
Program final rule, we finalized that for the proposed rule (82 FR 30099). We
available measure achievement points,
the quality performance category, an noted that in the CY 2017 Quality
and we proposed to amend
individual MIPS eligible clinician or Payment Program proposed rule, we
414.1380(b)(1)(xv) to use this term in
group that submits data on quality proposed that bonus points would be
place of total possible points. We also
measures via EHR, QCDR, qualified available for high priority measures that
proposed to amend these terms in
registry, claims, or a CMS-approved are not scored (not included in the top
414.1380(b)(1)(xiii)(D) (which we
survey vendor for the CAHPS for MIPS 6 measures for the quality performance
survey will be assigned measure category score) as long as the measure
414.1380(b)(1)(xiv)(D)), and
achievement points for 6 measures (1 has the required case minimum, data
414.1380(b)(1)(xiv) (which we
outcome or, if an outcome measure is completeness, and has a performance
not available, other high priority rate greater than zero, because we
414.1380(b)(1)(xv)).
measure and the next 5 highest scoring believed these qualities would allow us
This resulting quality performance
measures) as available and applicable, to include the measure in future
category score is a fraction from zero to
and will receive applicable measure benchmark development (81 FR 28255).
1, which can be formatted as a percent;
bonus points for all measures submitted Although we received public comments
therefore, for this section, we will
that meet the bonus criteria (81 FR on this policy, responded to those
present the quality performance
77282 through 77301). comments, and reiterated this proposal
category score as a percent and refer to
In addition, for groups of 16 or more in the CY 2017 Quality Payment
it as quality performance category
clinicians who meet the case minimum Program final rule (81 FR 77292), we
percent score. We also proposed to
of 200, we will also automatically score would like to clarify that our policy is
amend 414.1380(b)(1)(xv) (which we
the administrative claims-based all- to assign measure bonus points for high
cause hospital readmission measure as a priority measures, even if the measures

3 In section II.C.7.a.(2)(c) of this final rule with seventh measure (81 FR 77287). For achievement points are not included in
comment period, we are finalizing a new provision individual MIPS eligible clinicians and the total measure achievement points
to be codified at 414.1380(b)(1)(xiii), and in groups for whom the readmission for calculating the quality performance
section II.C.7.a.(2)(i) of this final rule with comment measure does not apply, the category percent score, as long as the
period, we are finalizing a new provision to be
codified at 414.1380(b)(1)(xvi). As a result, we are
denominator is generally 60 (10 measure has the required case
finalizing as well that the remaining paragraphs be available measure achievement points minimum, data completeness, and has a
redesignated in order following the new provisions. multiplied by 6 available measures). For performance rate greater than zero, and
that this applies beginning with the are created in the same manner as 77282). We refer readers to the CY 2018
transition year. historical benchmarks using decile Quality Payment Program proposed rule
We proposed to amend categories based on a percentile for a summary of the comments we
414.1380(b)(1)(xiii)(A) (which we distribution and that each benchmark received (82 FR 30101).
proposed to redesignate as must have a minimum of 20 individual We did not propose to change our
414.1380(b)(1)(xiv)(A)) to state that clinicians or groups who reported on policies related to stratifying
measure bonus points may be included the measure meeting the data benchmarks by practice size for the
in the calculation of the quality completeness requirement and case 2020 MIPS payment year. For many
performance category percent score minimum case size criteria and measures, the benchmarks may not need
regardless of whether the measure is performance greater than zero. We stratification as they are only
included in the calculation of the total referred readers to the discussion at 81 meaningful to certain specialties and
measure achievement points. We also FR 77282 for more details on that only expected to be submitted by those
proposed a technical correction to the policy. certain specialists. We further clarified
second sentence of that paragraph to We received no public comments on that in the majority of instances our
state that to qualify for high priority the proposed technical correction to current benchmarking approach only
measure bonus points, each measure 414.1380. compares like clinicians to like
must be reported with sufficient case Final Action: We are finalizing the clinicians. We noted that we continue to
volume to meet the required case technical corrections to believe that stratifying by practice size
minimum, meet the required data 414.1380(b)(1)(i) through (iii) related could have unintended negative
completeness criteria, and not have a to the measure benchmark data as consequences for the stability of the
zero percent performance rate. proposed. benchmarks, equity across practices,
We did not receive any public We noted that the proposal to increase and quality of care for beneficiaries.
comments on this proposal. the low-volume threshold could have an However, we sought comment on
Final Action: We are finalizing as impact on our MIPS benchmarks methods by which we could stratify
proposed the amendments and technical because we include MIPS eligible benchmarks, while maintaining
corrections to 414.1380(b)(1) related to clinicians and comparable APMs that reliability and stability of the
high priority measure bonus points. meet our benchmark criteria in our benchmarks, to use in developing future
In the CY 2017 Quality Payment measure benchmarks, which could rulemaking for future performance and
Program final rule, we also finalized reduce the number of individual eligible payment years. Specifically, we sought
scoring policies specific to groups of 25 clinicians and groups that meet the comment on methods for stratifying
or more that submit their quality definition of a MIPS eligible clinician benchmarks by specialty or by place of
performance measures using the CMS and contribute to our benchmarks (82 service. We also requested comment on
Web Interface (81 FR 77278 through FR 30101). Therefore, we sought specific criteria to consider for
77306). Although we did not propose to feedback on whether we should broaden stratifying measures, such as how we
change the basic scoring system that we the criteria for creating our MIPS should stratify submissions by multi-
finalized in the CY 2017 Quality benchmarks to include PQRS and any specialty practices or by practices that
Payment Program final rule for the 2020 data from MIPS, including voluntary operate in multiple places of service.
MIPS payment year, we noted that we reporters, that meet our benchmark We thank commenters for their
proposed several modifications to performance, case minimum and data suggestions on stratifying benchmarks
scoring the quality performance completeness criteria when creating our and measures for creating MIPS
category, including adjusting scoring for benchmarks. benchmarks. We will consider them in
measures that do not meet the data We thank commenters for their future rulemaking.
completeness criteria, adding a method responses on whether we should When we were developing the quality
for scoring measures submitted via broaden the criteria for creating our measure benchmarks, we were guided
multiple mechanisms, adding a method MIPS benchmarks. We will consider by the principles we used when
for scoring selected topped out them in future rulemaking. developing the MIPS unified scoring
measures, and adding a method for In the CY 2017 Quality Payment system (81 FR 28249 through 28250).
scoring improvement (82 FR 30100). We Program final rule, we did not stratify We sought a system that enables MIPS
also noted that we proposed an benchmarks by practice characteristics, eligible clinicians, beneficiaries, and
additional option for facility-based such as practice size, because we did stakeholders to understand what is
scoring for the quality performance not believe there was a compelling required for a strong performance in
category (82 FR 30123 through 30132). rationale for such an approach, and we MIPS while being consistent with
Further description of these proposals believed that stratifying could have statutory requirements. We also wanted
and finalized policies are discussed unintended negative consequences for the methodology to be as a simple as
below. the stability of the benchmarks, equity possible while providing flexibility for
across practices, and quality of care for the variety of practice types. Now that
(a) Quality Measure Benchmarks beneficiaries (81 FR 77282). We noted we have gone through 1 year of the
We did not propose to change the that we do create separate benchmarks program, we are asking for comments on
policies on benchmarking finalized in for each of the following submission how we can improve our quality
the CY 2017 Quality Payment Program mechanisms: EHR submission options; measure benchmarking methodology. In
final rule and codified at paragraphs QCDR and qualified registry submission the CY 2018 Quality Payment Program
(b)(1)(i) through (iii) of 414.1380; options; claims submission options; proposed rule, we requested comments
however, we proposed a technical CMS Web Interface submission options; on how we can specifically improve our
correction to paragraphs (i) and (ii) to CMS-approved survey vendor for benchmarking methodology (82 FR
clarify that measure benchmark data are CAHPS for MIPS submission options; 30100 through 30101). For this final rule
separated into decile categories based and administrative claims submission with comment period, we are requesting
on percentile distribution, and that, options (for measures derived from comments on whether our methodology
other than using performance period claims data, such as the all-cause has been successful in achieving the
data, performance period benchmarks hospital readmission measure) (81 FR goals we aimed to achieve, and, if not,
what other ways or approaches we We did not receive public comments the 3-point floor for such measures
could use that are in line with on this proposal. again in future rulemaking.
principles we discussed above. Final Action: We are finalizing as We invited public comment on this
proposed the technical corrections to proposal to again apply this 3-point
(b) Assigning Points Based on
414.1380(b)(1) related to quality floor for quality measures that can be
Achievement
measures. reliably scored against a baseline
In the CY 2017 Quality Payment benchmark in the 2018 MIPS
Program final rule, we finalized at (i) Floor for Scored Quality Measures performance period.
414.1380(b)(1) that a MIPS quality For the 2017 MIPS performance The following is a summary of the
measure must have a measure period, we also finalized at public comments received on the floor
benchmark to be scored based on 414.1380(b)(1) a global 3-point floor for quality measures proposal and our
performance. MIPS quality measures for each scored quality measure, as well responses:
that do not have a benchmark (for as for the hospital readmission measure Comment: Several commenters
example, because fewer than 20 MIPS (if applicable), such that MIPS eligible supported maintaining the 3-point floor
eligible clinicians or groups submitted clinicians would receive between 3 and for measures that can be reliably scored
data that met our criteria to create a 10 measure achievement points for each against a benchmark. A few commenters
reliable benchmark) will not be scored submitted measure that can be reliably supported the policy because the 3-
based on performance (81 FR 77286). In scored against a benchmark, which point floor maintains stability and
the CY 2018 Quality Payment Program requires meeting the case minimum and rewards participation in the Quality
proposed rule (82 FR 30101), we did not data completeness requirements (81 FR Payment Program. One commenter
propose any changes to this policy. We 77286 through 77287). For measures indicated that this will allow time for
did, however, propose a technical with a benchmark based on the eligible clinicians and groups to receive
correction to the regulatory text at performance period, rather than on the feedback on performance and
414.1380(b)(1) to delete the term incorporate changes into clinical
baseline period, we stated that we
MIPS before quality measure in the practice.
would continue to assign between 3 and
third sentence of that paragraph and to Response: We thank commenters for
10 measure achievement points for
delete the term MIPS before quality their support of the 3-point floor for the
performance years after the first
measures in the fourth sentence of that 2018 MIPS performance period and will
transition year because it would help to
paragraph because this policy applies to finalize this policy as proposed.
ensure that the MIPS eligible clinicians
all quality measures, including the Comment: One commenter
are protected from a poor performance
measures finalized for the MIPS recommended that CMS should lower
score that they would not be able to
program and the quality measures the 3-point floor for measures reliably
anticipate (81 FR 77282; 81 FR 77287).
submitted through a QCDR that have scored against a baseline benchmark,
been approved for MIPS. For measures with benchmarks based on
citing the need to move past transition
We also did not propose to change the the baseline period, we stated the 3-
year policies in the second year.
policies to score quality measure point floor was for the transition year
Response: The 3-point floor in the
performance using a percentile and that we would revisit the 3-point
2018 performance period affords MIPS
distribution, separated by decile floor in future years (81 FR 77286
eligible clinicians the ability to continue
categories and assign partial points through 77287).
to successfully transition into the
based on the percentile distribution We note, for clarification purposes, program and provides stability and
finalized in the CY 2017 Quality that we stated in the CY 2018 Quality consistency in the Quality Payment
Payment Program final rule and codified Payment Program proposed rule (82 FR Program. We will revisit this policy in
at paragraphs (b)(1)(ix), (x), and (xi) of 30102) that measures without a future years.
414.1380; however, we proposed a benchmark based on the baseline period Final Action: After consideration of
technical correction to paragraph (ix) to would be assigned between 3 and 10 public comments, we are finalizing the
clarify that measures are scored against measure achievement points for proposal to again apply the 3-point floor
measure benchmarks. We referred performance years after the first for quality measures that can be reliably
readers to the discussion at 81 FR 77286 transition year. However, we wanted to scored against a baseline benchmark in
for more details on those policies. clarify that only measures without a the 2018 MIPS performance period and
In Table 19 of the proposed rule (82 benchmark based on the baseline period to amend 414.1380(b)(1) accordingly.
FR 3010), we provided an example of that later have a benchmark based on
assigning points for performance based the performance period would be (ii) Additional Policies for the CAHPS
on benchmarks using a percentile assigned between 3 and 10 measure for MIPS Measure Score
distribution, separated by decile achievement points for performance In the CY 2017 Quality Payment
categories. We noted that for quality years after the first transition year. Program final rule, we finalized a policy
measures for which baseline period data Measures without a benchmark based for the CAHPS for MIPS measure, such
is available, we will publish the on the baseline or performance period that each Summary Survey Measure
numerical baseline period benchmarks would receive 3 points. (SSM) will have an individual
with deciles prior to the start of the For the 2018 MIPS performance benchmark, that we will score each SSM
performance period (or as soon as period, we proposed to again apply a 3- individually and compare it against the
possible thereafter) (see 81 FR 77282). point floor for each measure that can be benchmark to establish the number of
For quality measures for which there is reliably scored against a benchmark points, and the CAHPS score will be the
no comparable data from the baseline based on the baseline period, and to average number of points across SSMs
period, we will publish the numerical amend 414.1380(b)(1) accordingly. We (81 FR 77284).
performance period benchmarks after noted that we proposed to score As described in the CY 2018 Quality
the end of the performance period (81 measures in the CMS Web Interface for Payment Program proposed rule (82 FR
FR 77282). We will also publish further the Quality Payment Program for which 30102), we proposed to remove two
explanation of how we calculate partial performance is below the 30th SSMs from the CAHPS for MIPS survey,
points at qpp.cms.gov. percentile (82 FR 30113). We will revisit which would result in the collection of
10 SSMs in the CAHPS for MIPS survey. collection of the data for these two Health Status and Functional Status
Eight of those 10 SSMs have had high SSMs is appropriate even though we do and Access to Specialists SSMs even
reliability for scoring in prior years, or not propose to score them. though we will no longer score them.
reliability is expected to improve for the Other than these two SSMs, we Our concern is that the Health Status
revised version of the measure, and they proposed to score the remaining 8 SSMs and Functional Status SSM is not a
also represent elements of patient because they have had high reliability reliable indicator of patient care and
experience for which we can measure for scoring in prior years, or reliability experience for scoring purposes. As we
the effect one practice has compared to is expected to improve for the revised described above, the Health Status and
other practices participating in MIPS. version of the measure, and they also Functional Status SSM reflects more of
The Health Status and Functional represent elements of patient experience the characteristics of a groups patient
Status SSM, however, assesses for which we can measure the effect one population than patient experience and
underlying characteristics of a groups practice has compared to other practices does not allow for an adequate
patient population characteristics and is participating in MIPS. assessment of how much the score is a
less of a reflection of patient experience We invited comment on our proposal result of patient experience or aspects of
of care with the group. Moreover, to the not to score the Health Status and the underlying health of patients.
extent that health and functional status Functional Status and Access to Additionally, the Access to
reflects experience with the practice, Specialists SSMs beginning with the Specialists SSM has historically had
case-mix adjustment is not sufficient to 2018 MIPS performance period. small sample sizes, making it highly
separate how much of the score is due The following is a summary of the unreliable, and thus we feel it is not
to patient experience versus due to public comments received on our appropriate for it to be included in
aspects of the underlying health of proposal to not score Health Status and scoring.
patients. The Access to Specialists Functional Status and Access to
Final Action: After consideration of
SSM has low reliability; historically it Specialists SSMs beginning with the
public comments, we are finalizing the
has had small sample sizes, and 2018 MIPS performance period:
Comment: One commenter supported proposal to not score the Health Status
therefore, the majority of groups do not and Functional Status and Access to
achieve adequate reliability, which CMSs proposal not to score the two
SSMs in the CAHPS for MIPS measure, Specialists SSMs beginning with the
means there is limited ability to 2018 MIPS performance period, as
distinguish between practices agreeing that CMS should only use the
8 SSMs with high reliability to calculate proposed. We noted in the CY 2018
performance. Quality Payment Program proposed rule
the CAHPS for MIPS score.
For these reasons, we proposed not to Response: We appreciate commenters that we proposed to add the CAHPS for
score the Health Status and Functional support to not score the Health Status ACOs survey as an available measure for
Status SSM and the Access to and Functional Status and Access to calculating the MIPS APM score for the
Specialists SSM beginning with the Specialists SSMs beginning with the Shared Savings Program and Next
2018 MIPS performance period. Despite 2018 MIPS performance period. Generation ACO Model (82 FR 30082
not being suitable for scoring, both Comment: Several commenters did through 30083). We refer readers
SSMs provide important information not support the proposal to not score the participating in ACOs to section
about patient care. Qualitative work Health Status and Functional Status II.C.6.g.(3)(b) of this final rule with
suggests that Access to Specialists is SSM and argued that the functional comment period for the discussion of
a critical issue for Medicare FFS status SSM provides valuable insights the CAHPS for ACOs scoring
beneficiaries. The survey is also a useful and connect to health outcomes in a methodology.
tool for assessing beneficiaries self- meaningful way. Table 17 summarizes the newly
reported health status and functional Response: We agree with commenters finalized SSMs included in the CAHPS
status, even if this measure is not used on the value of the Health Status and for MIPS survey and illustrates
for scoring practices care experiences. Functional Status SSM and will application of our policy to score only
Therefore, we believed that continued continue to collect data on both the 8 measures.
TABLE 17NEWLY FINALIZED SSM FOR CAHPS FOR MIPS SCORING

Newly finalized for Newly finalized for
inclusion in the
Summary survey measure inclusion in CAHPS
CAHPS for MIPS for MIPS scoring?
survey?
Getting Timely Care, Appointments, and Information .............................................................................. Yes ........................ Yes.
How Well Providers Communicate ........................................................................................................... Yes ........................ Yes.
Patients Rating of Provider ...................................................................................................................... Yes ........................ Yes.
Health Promotion & Education ................................................................................................................. Yes ........................ Yes.
Shared Decision Making ........................................................................................................................... Yes ........................ Yes.
Stewardship of Patient Resources ........................................................................................................... Yes ........................ Yes.
Courteous and Helpful Office Staff ........................................................................................................... Yes ........................ Yes.
Care Coordination ..................................................................................................................................... Yes ........................ Yes.
Health Status and Functional Status ........................................................................................................ Yes ........................ No.
Access to Specialists ................................................................................................................................ Yes ........................ No.
(c) Identifying and Assigning Measure Quality Payment Program proposed rule the CY 2017 Quality Payment Program
Achievement Points for Topped Out (82 FR 30103 through 30106), we final rule at 414.1380(b)(1)(ii)(A) to
Measures proposed a phased in approach to apply use benchmarks from the corresponding
Section 1848(q)(3)(B) of the Act special scoring to topped out measures, reporting year of the Shared Savings
requires that, in establishing beginning with the 2018 MIPS Program. The Shared Savings Program
performance standards with respect to performance period (2020 MIPS adjusts some benchmarks to a flat
measures and activities, we consider, payment year), rather than modifying percentage when the 60th percentile is
among other things, the opportunity for the benchmark methodology for topped equal to or greater than 80.00 percent for
continued improvement. We finalized out measures as indicated in the CY individual measures (78 FR 74759
in the CY 2017 Quality Payment 2017 Quality Payment Program final through 74763), and, for other measures,
Program final rule that we would rule. We also provided a summary of benchmarks are set using flat
identify topped out process measures as comments received in response to the percentages when the 90th percentile
those with a median performance rate of CY 2017 Quality Payment Program final for a measure are equal to or greater
95 percent or higher (81 FR 77286). For rule (82 FR 30103 through 30104) on than 95.00 percent (79 FR 67925). Thus,
non-process measures we finalized a how topped out measures should be we did not propose to apply the topped
topped out definition similar to the scored provided that it is the second out measure cap to measures in the CMS
definition used in the Hospital VBP year the measure has been identified as Web Interface for the Quality Payment
Program: The truncated coefficient of topped out. Program.
variation is less than 0.10 and the 75th In the CY 2018 Quality Payment Starting with the 2019 MIPS
and 90th percentiles are within 2 Program proposed rule (82 FR 30045 performance period, we proposed to
standard errors (81 FR 77286). When a through 30047), we proposed a lifecycle apply the special topped out scoring
measure is topped out, a large majority for topped out measures by which, after method to all topped out measures,
of clinicians submitting the measure a measure benchmark is identified as provided it is the second (or more)
performs at or very near the top of the topped out in the published benchmark consecutive year the measure is
distribution; therefore, there is little or for 2 years, in the third consecutive year identified as topped out (82 FR 30103
no room for the majority of MIPS it is identified as topped out it will be through 30106). We sought comment on
eligible clinicians who submit the considered for removal through notice- our proposal to apply special topped out
measure to improve. We understand and-comment rulemaking or the QCDR scoring to all topped out measures,
that every measure we have identified approval process and may be removed provided it is the second (or more)
as topped out may offer room for from the benchmark list in the fourth consecutive year the measure is
improvement for some MIPS eligible year, subject to the phased in approach identified as topped out. We also sought
clinicians; however, we believe asking described in section II.C.6.c.(2) of this comment on the proposal not to apply
clinicians to submit measures that we final rule with comment period. the topped out measure cap to measures
We also stated in the CY 2017 Quality in the CMS Web Interface for the
have identified as topped out and
Payment Program final rule that we do Quality Payment Program. We refer
measures for which they already excel
not believe it would be appropriate to readers to section II.C.6.c.(2) of this final
is an unnecessary burden that does not
remove topped out measures from the rule with comment period for a
add value or improve beneficiary
CMS Web Interface for the Quality summary of the comments we received
outcomes.
Payment Program because the CMS Web and our responses.
Based on 2015 historic benchmark
Interface measures are used in MIPS and As part of the lifecycle for topped out
data,4 approximately 45 percent of the
in APMs such as the Shared Savings measures, we also proposed a method to
quality measure benchmarks currently
Program and because we have aligned phase in special scoring for topped out
meet the definition of topped out, with
policies, where possible, with the measure benchmarks starting with the
some submission mechanisms having a
Shared Savings Program, such as using 2018 MIPS performance period,
higher percent of topped out measures
the Shared Savings Program provided that is the second consecutive
than others. Approximately 70 percent
benchmarks for the CMS Web Interface year the measure benchmark is
of claims measures are topped out, 10
measures (81 FR 77285). In the CY 2017 identified as topped out in the
percent of EHR measures are topped
Quality Payment Program final rule, we benchmarks published for the
out, and 45 percent of registry/QCDR also finalized that MIPS eligible performance period (82 FR 30103
measures are topped out. clinicians submitting via the CMS Web through 30106). This special scoring
Interface must submit all measures would not apply to measures in the
Program final rule, we finalized that for
included in the CMS Web Interface (81 CMS Web Interface, as explained later
the 2019 MIPS payment year, we would
FR 77116). Thus, if a CMS Web Interface in this section. The phased-in approach
score topped out quality measures in the
measure is topped out, the CMS Web described in this section represents our
same manner as other measures (81 FR
Interface submitter cannot select other first step in methodically implementing
77286). We finalized that we would not
measures. Because of the lack of ability special scoring for topped out measures.
modify the benchmark methodology for to select measures, we did not propose We did not propose to remove topped
topped out measures for the first year to apply the proposed special scoring out measures for the 2018 MIPS
that the measure has been identified as adjustment to topped out measures for performance period because we
topped out, but that we would modify CMS Web Interface for the Quality recognize that there are currently a large
the benchmark methodology for topped Payment Program (82 FR 30106). number of topped out measures and
out measures beginning with the 2020 Additionally, because the Shared removing them may impact the ability
MIPS payment year, provided that it is Savings Program incorporates a of some MIPS eligible clinicians to
the second year the measure has been methodology for measures with high submit 6 measures and may impact
identified as topped out. In the CY 2018 performance into the benchmark, we some specialties more than others. We
4 The topped out determination is calculated on
noted that we do not believe capping noted, however, that we proposed a
historic performance data and the percentage of
benchmarks from the CMS Web timeline for removing topped out
topped out measures may change when evaluated Interface for the Quality Payment measures in future years (82 FR 30046).
for the most applicable annual period. Program is appropriate. We finalized in We believe this provides MIPS eligible
clinicians the ability to anticipate and submitting non-topped out measures allows for a methodical way to phase in
plan for the removal of specific topped without performing below the median topped out scoring.
out measures, while providing measure score. This methodology also would not We identified measures we believe
developers time to develop new impact scoring for those MIPS eligible should be scored with the special
measures. clinicians that do not perform near the topped out scoring for the 2018
We noted that because we create a top of the measure, and therefore, have performance period by using the
separate benchmark for each submission significant room to improve on the following set criteria, which are only
mechanism available for a measure, a measure. We noted that we may also intended as a way to phase in our
benchmark for one submission consider lowering the cap below 6 topped-out measure policy for selected
mechanism for the measure may be points in future years, especially if we measures and are not necessarily
identified as topped out while another remove the 3-point floor for intended to be criteria for use in future
submission mechanisms benchmark performance in future years. policies:
may not be topped out. The topped out Although we proposed a new Measure is topped out and there is
designation and special scoring apply methodology for assigning measure no difference in performance between
only to the specific benchmark that is achievement points for topped out decile 3 through decile 10. We applied
topped out, not necessarily every measures, we did not propose to change this limitation because, based on
benchmark for a measure. For example, the policy for awarding measure bonus historical data, there is no room for
the benchmark for the claims points for topped out measures. Topped improvement for over 80 percent of
submission mechanism may be topped out measures will still be eligible for MIPS eligible clinicians that reported on
out for a measure, but the benchmark for measure bonus points if they meet the these measures.
the EHR submission mechanisms for required criteria. We refer readers to
Process measures only because we
that same measure may not be topped sections II.C.7.a.(2)(f) and II.C.7.a.(2)(g)
want to continue to encourage reporting
out. In this case, the topped out scoring of this final rule with comment period
on high priority outcome measures, and
would only apply to measures for more information about measure
the small subset of structure measures
submitted via the claims submission bonus points.
While we believe it is important to was confined to only three specialties.
mechanism, which has the topped out
benchmark. We also described that only score topped out measures differently MIPS measures only (which does
the submission mechanism that is because they could have a not include measures that can only be
topped out for the measure would be disproportionate impact on the scores reported through a QCDR) given that
removed (82 FR 30104). for certain MIPS eligible clinicians and QCDR measures go through a separate
We proposed to cap the score of topped out measures provide little room process for approval and because we
topped out measures at 6 measure for improvement for the majority of want to encourage use of QCDRs
achievement points. We proposed a 6- MIPS eligible clinicians who submit required by section 1848(q)(1)(E) of the
point cap for multiple reasons. First, we them, we also recognize that numerous Act.
noted that we believe applying a cap to measure benchmarks are currently Measure is topped out for all
the current method of scoring a measure identified as topped out, and special mechanisms by which the measure can
against a benchmark is a simple scoring for topped out measures could be submitted. Because we create a
approach that can easily be predicted by impact some specialties more than separate benchmark for each submission
clinicians. Second, the cap will create others. Therefore, we considered ways mechanism available for a measure, a
incentives for clinicians to submit other to phase in special scoring for topped benchmark for one submission
measures for which they can improve out measures in a way that will begin mechanism for the measure may be
and earn future improvement points. to apply special scoring, but would not identified as topped out while another
Third, considering the proposed topped overwhelm any one specialty and would submission mechanisms benchmark
out measure lifecycle, we believed this also provide additional time to evaluate may not be topped out. For example, the
cap would only be used for a few years the impact of topped out measures benchmark for the claims submission
and the simplicity of a cap on the before implementing it for all topped mechanism may be topped out for a
current benchmarks would outweigh out measures, while also beginning to measure, but the benchmark for the EHR
more complicated approaches to scoring encourage submission of measures that submission mechanisms for that same
such as a cluster-based options or are not topped out. measure may not be topped out. We
applying a cap on benchmarks based on We believe the best way to decided to limit our criteria to only
flat-percentage (see 82 FR 30103 accomplish this is by applying special measures that were topped out for all
through 30104). The rationale for a 6- topped out scoring to a select number of mechanisms for simplicity and to avoid
point cap is that 6 points is the median measures for the 2018 MIPS confusion about what scoring is applied
score for any measure as it represents performance period and to then apply to a measure.
the start of the 6th decile for the special topped out scoring to all Measure is in a specialty set with at
performance and represents the spot topped out measures for the 2019 MIPS least 10 measures, because 2 measures
between the bottom 5 deciles and start performance period, provided it is the in the pathology specialty set, which
of the top 5 deciles. second consecutive year the measure is only has 8 measures total, would have
We believed the proposed capped topped out. We believe this approach been included.
scoring methodology would incentivize allows us time to further evaluate the Applying these criteria resulted in the
MIPS eligible clinicians to begin impact of topped out measures and 6 measures as listed in Table 18.
TABLE 18PROPOSED TOPPED OUT MEASURES FOR SPECIAL SCORING FOR THE 2018 MIPS PERFORMANCE PERIOD
Topped out for
Measure name Measure ID Measure type all submission Specialty set
mechanisms
Perioperative Care: Selection of Prophylactic 21 Process .......... Yes ................. General Surgery, Orthopedic Surgery, Oto-
AntibioticFirst OR Second Generation laryngology, Thoracic Surgery, Plastic Sur-
Cephalosporin. gery.
Melanoma: Overutilization of Imaging Studies 224 Process .......... Yes ................. Dermatology.
in Melanoma.
Perioperative Care: Venous Thrombo- 23 Process .......... Yes ................. General Surgery, Orthopedic Surgery, Oto-
embolism (VTE) Prophylaxis (When Indi- laryngology, Thoracic Surgery, Plastic Sur-
cated in ALL Patients). gery.
Image Confirmation of Successful Excision of 262 Process .......... Yes ................. n/a.
Image-Localized Breast Lesion.
Optimizing Patient Exposure to Ionizing Radi- 359 Process .......... Yes ................. Diagnostic Radiology.
ation: Utilization of a Standardized Nomen-
clature for Computerized Tomography (CT)
Imaging Description.
Chronic Obstructive Pulmonary Disease 52 Process .......... Yes ................. n/a.
(COPD): Inhaled Bronchodilator Therapy.
We proposed to apply the special proposal to apply special topped out outcome measures and cross cutting
topped out scoring method to only the scoring only to the 6 measures measures, which commenters believed
6 measures in Table 18 for the 2018 identified in Table 18 for the 2018 MIPS should be allowed a maximum point
MIPS performance period, provided performance period. We also sought value, to prevent penalizing eligible
they are again identified as topped out comment on our proposal to amend the clinicians with limited options for
in the benchmarks for the 2018 MIPS regulatory text to align with these measures when reporting topped out
performance period. If these measures proposed policies. measures due to limitations largely
are not identified as topped out in the The following is a summary of the outside of their control. One commenter
benchmarks published for the 2018 public comments received on the recommended that topped out measures
MIPS performance period, they will not proposal to cap topped out measures at be capped at 8 points in year 2 of the
be scored differently because they 6-points and our responses: designation as a topped out measure
would not be topped out for a second Comment: Many commenters and 6 points in year 3 of the
consecutive year. supported the proposal to cap topped designation, providing a more gradual
Finally, we proposed to add a new out measures at 6 points because reduction of points for reporting topped
paragraph at 414.1380(b)(1)(xiii) to commenters believed the proposal is a out measures. A few commenters
codify our proposal for the lifecycle for simplified approach to assigning points recommended capping topped out
removing topped out measures. We also to topped out measures, aligns with measures at 7.5 points, representing the
proposed to add at certain state programs, and will lowest possible points associated with
414.1380(b)(1)(xiii)(A) that for the encourage reporting of other measures the upper quartile of performance. The
2018 MIPS performance period, the 6 that are more meaningful. commenters believed that the 7.5 points
measures identified in Table 18 will Response: As we note below, we have would align with CMS definition of a
receive a maximum of 6 measure been persuaded by other commenters topped-out measure that the truncated
achievement points, provided that the that this adjustment is too abrupt a coefficient of variation is less than 0.10
measure benchmarks are identified as change to provide in the 2018 MIPS and the 75th and 90th percentiles are
topped out again in the benchmarks performance period, so as described within two standard errors (a test of
published for the 2018 MIPS below, we intend to apply a scoring cap whether the range of scores in the upper
performance period. We also proposed but are modifying the proposal as quartile is statistically meaningful). The
to add at 414.1380(b)(1)(xiii)(B) that described below. commenters believed this would still
beginning with the 2019 MIPS Comment: Several commenters discourage clinicians from continuing to
performance period, measure recommended a more gradual reduction report topped out measures because the
benchmarks, except for measures in the of points because commenters believed scores would be capped and the
CMS Web Interface, that are identified the 6-point cap did not acknowledge measures are ineligible for improvement
as topped out for two 2 or more high performance and was too steep a points. The commenters believed the
consecutive years will receive a drop in points because measure higher scores are more aligned with
maximum of 6 measure achievement benchmarks are not based on MIPS data, points assigned for upper quartile
points in the second consecutive year it selection of measures from a menu may performance, acknowledging high
is identified as topped out, and beyond. result in only high performers performance.
We requested comments on our submitting topped out measures which Response: We acknowledge the
proposal to score topped out measures could still provide opportunities for commenters concerns with the 6-point
differently by applying a 6-point cap, improvement, and submitters have cap and recommendations to increase
provided it is the second consecutive limited measure alternatives for the point value to acknowledge
year the measure is identified as topped reporting. Commenters recommended performance and allow a more gradual
out. Specifically, we sought feedback on higher point values ranging from 7 to 8, reduction in the achievement score of
whether 6 points is the appropriate cap when capping topped out measures. A topped out measures. The benchmarks
or whether we should consider another few commenters recommended 7 points for the 2017 performance period are
value. We also sought comment on our for topped out measures, excluding derived from the measures historical
performance data which would be commenters would have the latter and more clinicians report the
reflective of the measures anticipated opportunity to provide feedback on the measure, and we have a more robust
performance in the future. We believe measure before we finalize a measure benchmark and see variation in
our policy approach of using a cap set removal. performance, then we would no longer
at 6 points (which represents the Comment: One commenter indicated classify the measure as topped out.
median score in our benchmark) and that a cap of 6 points or a similar Thus, while we agree that some
phasing in this cap by only applying it median score would be appropriate if measures initially identified as topped
to selected measures for the 2018 MIPS performance improvement could not be out may later show room for
performance period (see section statistically measured. improvement if additional MIPS eligible
II.C.6.c.(2) in this final rule with Response: We continue to believe that clinicians report the measures, we note
comment period) provides a simple capping the score is a reasonable and that we have not seen any variation in
policy solution and addresses many simple way to score topped out performance on the 6 measures
concerns about a disproportionate measures, although we have been proposed for the scoring cap applied in
number of topped out measures persuaded by commenters that the 6- 2018 MIPS performance period. We
affecting clinicians for the 2018 point cap is potentially too large a continue to see a cap as a simple
performance period. However, we do change, and, as described above, we are approach that is predictable for
understand that a significant number of modifying the proposal slightly. While clinicians and creates incentives to
measures may qualify for this scoring we will still cap the score, we will cap select other non-topped out measures.
cap starting in the 2019 MIPS it at 7 points rather than 6. The However, we understand the concerns
performance period/2021 MIPS commenter did not provide additional of the commenters; therefore, we are
payment year, which could affect scores detail on how improvement should be finalizing an increase to the cap from 6
for MIPS eligible clinicians with a statistically measured, however, in measure achievement points to 7
limited choice of measures. Therefore, section II.C.7.a.(2)(i)(v) of this final rule measure achievement points, which
we have been persuaded by the with comment, we seek comments on does acknowledge better than average
comments to increase the scoring cap to how to adjust our scoring policies and performance on measure achievement.
7 points. We chose 7 points for several meet our policy goals and would We believe the scoring cap would only
reasons. First, for simplicity in the welcome additional discussion on how be used for a few years because we
scoring system, we believe we should this approach could be implemented in anticipate that topped out measures
have a single integer number cap for all MIPS. generally will be removed after 3 years
topped out measures that are subject to Comment: Many commenters did not through future rulemaking, and the
the cap. We believe it would be easier support a scoring cap for topped out simplicity of the cap on current
for clinicians to understand a cap of 7 measures because commenters believed benchmarks makes this scoring
points than a policy which uses partial that CMS should be rewarding an approach an attractive alternative to
points or a system that gradually eligible clinicians ability to achieve and more complex scoring schemes. We will
decreases points the longer a measure is maintain high performance, that all continue to consider if additional
topped out. One additional component MIPS measures should be scored in the factors need to be taken into account as
in assuring consistency in scoring is to same way to minimize scoring we score topped out measures, and if
apply the scoring cap to all identified complexity, and that many topped out needed, we will make further proposals
topped out measures, including measures may still represent an in future rulemaking. In addition, we
outcome and cross-cutting measures. opportunity to encourage quality expect to incorporate new measures into
Second, 7 points is higher than the improvement. In addition, some MIPS. We refer readers to section
median, so this cap provides credit for commenters believed that a scoring cap II.C.6.c.(1) of this final rule with
good performance. Finally, the 7 point should not be applied because topped comment period for further discussion
cap would mitigate to some degree the out measures reflect performance of on measure development.
scoring concerns for clinicians who only high performers who selected the Comment: A few commenters
have a large number of topped out measures and therefore should not be indicated that capping the score of
measures, while still providing considered topped out for all MIPS topped out measures may result in a gap
incentives to all eligible clinicians to eligible clinicians. in available achievement points
submit measures that are not topped Response: We disagree with the available for quality measures for some
out. We will monitor the scoring cap commenters that a scoring cap is MIPS eligible clinicians. A few
and address any changes through future inappropriate. We believe that MIPS commenters believed that some high-
rulemaking. eligible clinicians generally should have volume services may have only topped
Comment: One commenter supported the flexibility to select measures most out measures, which would limit the
the 6-point cap but recommended relevant to their practice, but a trade-off achievement points available to MIPS
maintaining measures at a reduced of this flexibility is that not all MIPS eligible clinicians providing care to
point cap rather than removing eligible clinicians are reporting the same those patients. Additionally, a few
measures that might have a critical measure. As MIPS is a performance- commenters believed that MIPS eligible
position in clinical care pathways. based program, we do not believe that clinicians do not have control over the
Response: We acknowledge concerns topped out measures should be scored measures available in the program and
about maintaining measures that the same way as other measures that can should be able to report, and potentially
support clinical care pathways, but we demonstrate achievement by showing receive full achievement points, on
believe that considering the removal of variation in performance and room for measures that are relevant to their
topped out measures beginning with the improvement. In particular, it is patient population and scope of
2019 MIPS performance period, subject difficult to assess whether the lack of practice.
to removal criteria, is more appropriate variation in performance is truly due to Response: We acknowledge the
than maintaining an indefinite cap on lack of variation among all clinicians or concern about the availability of
scoring. Measures considered for if it is just due to lack of variation measures that are eligible for the full 10
removal would need to go through among the clinicians who are measure achievement points. The
notice and comment rulemaking, and submitting the measures. If it is the majority of quality measures used in
MIPS are developed by external penalize clinicians and groups who topped out measures that would receive
stakeholders, and as discussed in have invested in EHR technology and the capped score or provide a bonus
section II.C.6.c.(1) of this final rule with workflow design required to perform structure to add extra points for
comment period, we intend to work well on topped out measures. reporting on capped topped out
with developers using the Measure Response: We want to encourage the measures to ensure that eligible
Development Plan as a strategic continued use of using EHR technology clinicians are not penalized for
framework to add new measures into for quality improvement. We continue submission of topped out measures. One
MIPS. While these measures are being to evaluate methods to encourage the commenter recommended that CMS
developed and refined, we have use of EHR technology, including the consider the ABC methodology to
multiple policies to mitigate the impact end-to-end electronic reporting bonus evaluate variation in performance when
of topped out measures. For the 2018 available to measures submitted through identifying topped out measures for the
MIPS performance period, we are only an EHR submission mechanism, scoring cap.
finalizing 6 topped out measures to regardless of whether they are topped Response: We believe that topped out
which the scoring cap will apply. In the out. We note that topped out measures measures should not be scored the same
2019 MIPS performance period, MIPS are identified through benchmarks for way as other measures that show
eligible clinicians will be able to submit each submission mechanism, and EHR variation and room for improvement,
quality data using more than one measures have a lower proportion of and that a measure cap is an appropriate
submission mechanism, which may topped out measures compared to other approach that does not add complexity
increase the availability of non-topped submission mechanisms, which limits to scoring. We believe the scoring cap
out measures for some MIPS eligible the impact of any topped out special should be applied to all topped out
clinicians. Finally, as discussed in scoring policy. We will monitor how the measures submitted and that, although
section II.C.6.c.(2) of this final rule with application of the scoring cap affects bonus points are available for topped
comment period, we will consider the measure selection during the topped out out measures that are additional high
impact of the topped out measure lifecycle. priority measures and/or submitted via
lifecycle on certain clinicians in future Comment: A few commenters end-to-end reporting, bonus points
rulemaking and refine our policies if recommended that clinicians caring for specifically for topped out measures
needed. American Indian and Alaska Native would not be appropriate or provide
Comment: A few commenters patients be excluded from the scoring incentives for eligible clinicians to
indicated that a scoring cap should not cap for topped out measures because the submit measures are not topped out. We
be used for QCDR measures because the commenters believed that if clinicians appreciate the commenters suggestions,
measures are relatively new and QCDRs are performing well on a quality which we may consider for future
have only recently begun collecting measure, they should be awarded rulemaking; however, we believe that
performance data. The commenters maximum points. the lifecycle finalized at section
noted that QCDRs should be allowed to Response: To our knowledge, there II.C.6.c.(2) of this final rule with
promote the submission of QCDR are no measures in MIPS that are comment period provides sufficient
measures for several years to understand specific to this population; however, notice to stakeholders, including
performance trends before identifying there is a large variety of measures measure developers, to create
topped out measures. One commenter overall for selection. We do not believe alternative measures if needed, and we
requested a delay in the implementation it would be appropriate to exclude believe that the scoring policy should be
of scoring caps for QCDR submissions clinicians caring for American Indian applied consistently across clinical
because the commenter believed that and Alaska Native patients at this time specialties and submissions
the additional time would increase because the policy for topped out mechanisms regardless of the number of
submission rates and support specialty measures encourages selection of non- topped out measures available and
MIPS eligible clinicians who are new to topped out measures that have an submitted. In the interim, we believe a
quality reporting. opportunity for improvement of value cap of 7 points addresses some
Response: We believe that the scoring and beneficiary outcomes, including stakeholder concerns while providing a
cap should be applied to measures this specific population. For clinicians simple way to score topped out
submitted through all submission in small practices caring for American measures. We will continue to evaluate
mechanisms. Although the scoring cap Indian and Alaskan Native patients, application of the scoring policy during
applies to measures submitted via there are flexibilities built into MIPS, the topped out lifecycle.
QCDR (including both MIPS measures including the low-volume threshold The following is a summary of the
and QCDR measures), the topped out affecting eligibility for MIPS and, for public comments received on the
measures identified for the scoring cap those participating, bonus points proposal to not apply the topped out
for the 2018 MIPS performance period applied when calculating the final measure scoring cap to measures in the
do not include any QCDR measures. score. CMS Web Interface and our responses:
Therefore, there is no immediate impact Comment: Several commenters had Comment: A few commenters did not
on the submission of additional data on specific recommendations to amend support CMSs proposal to exclude CMS
QCDR measures, which potentially CMSs proposed topped out measure Web Interface measures from the special
reduces the likelihood that any QCDR scoring. One commenter recommended scoring policy and encouraged CMS to
measures would be considered topped eliminating the cap or awarding full develop an approach to apply the
out in future years. Therefore, we do not points over an expanded timeline to topped out policy to the CMS Web
believe it is necessary to delay phase out topped out measures over a 6- Interface measures. One commenter
implementation of scoring caps for year period or longer. One commenter believed that allowing clinicians
QCDR submissions. We will monitor urged CMS to not apply a scoring cap reporting through the CMS Web
how the application of the scoring cap for clinical specialists with limited Interface to earn full points for reporting
affects measure selection and propose numbers of measures to report that are topped out measures would unfairly
any changes in future rulemaking. not topped out. One commenter advantage the final score for these
Comment: One commenter did not indicated that scoring should be reporters compared to other clinicians.
support the scoring cap because it might restructured to limit the number of The commenter recommended that CMS
work with developers on more are important to support patient safety. 2019 MIPS performance period should
meaningful measures for the CMS Web One commenter recommended that apply to SSMs in the CAHPS for MIPS
Interface. CMS consult stakeholders and literature survey measure or whether there is
Response: We continue to believe that on the importance of measures for another alternative policy that could be
it would be inappropriate to cap scoring patient safety and clinical significance, applied for the CAHPS for MIPS survey
for topped out measures from the CMS and consider developing a perioperative measure due to high, unvarying
Web Interface, which we believe composite measure rather than capping performance within the SSM. We noted
provides meaningful measures for MIPS and eventually removing the two that we would like to encourage groups
eligible clinicians. The CMS Web perioperative care measures. The to report the CAHPS for MIPS survey as
Interface measures are used in MIPS and commenter believed a replacement it incorporates beneficiary feedback.
APMs such as the Shared Savings process, including development of We thank the commenters for their
Program, and we have aligned policies composite measures, would ensure that feedback and will take their suggestions
where possible, including using the sufficient measures are available and into consideration in future rulemaking.
Shared Savings Programs benchmarks appropriate to specialties and We did not receive any public
for the CMS Web Interface measures. In potentially demonstrate variation in comments specific to our proposal to
addition, the lack of ability to select performance to identify opportunities change the regulatory text at
measures would mean that applying for improvement. 414.1380(b)(1)(xiii)(A) and
topped out scoring would create a Response: We acknowledge the 414.1380(b)(1)(xiii)(B).
disadvantage for CMS Web Interface concerns of commenters regarding the Final Action: After consideration of
submitters as they would not have the availability of measures. We note that all comments, we are finalizing with
ability to choose alternative measures. the finalized policy is to cap the score modifications the proposed policy to
We would be interested in working with of 6 specific measures for the CY 2018 apply the special scoring cap to topped
a broad stakeholder group and performance period, and that any out measures. Specifically, we are
developers as appropriate to identify potential removal of measures would finalizing a scoring cap of 7 points,
additional measures that should be in occur only through future rulemaking, rather than the proposed 6 points. We
CMS Web Interface. We will continue to which would be proposed after are finalizing a 7-point cap for multiple
coordinate with the Shared Savings consulting appropriate literature and reasons. First, we believe applying the
Program to discuss any future include stakeholder feedback. We refer special scoring cap is a simple approach
modifications to scoring or readers to section II.C.6.c.(2) of this final that can be easily predicted by
modifications to measures in the CMS rule with comment period for additional clinicians. Second, the cap will create
Web Interface. discussion on the lifecycle of topped out incentives for clinicians to submit other
The following is a summary of the measures, including the consideration measures for which they can improve
public comments received on the of criteria for the identification and and earn future improvement points.
proposal to apply topped out measure potential removal of measures. In terms Third, the rationale for the point value
policy for the 6 selected measures in of scoring, we do not believe that a is that 7 points is slightly higher than
Table 18 for the 2018 MIPS performance MIPS eligible clinician electing to report the median score for any measure and
period and our responses: topped out measures should be able to will address the near-term concerns that
Comment: A few commenters receive the same maximum score as clinicians have about the lack of
supported CMSs proposed special MIPS eligible clinicians electing to additional, non-topped out measures for
scoring for the 6 topped out measures in report other measures. Therefore, we submission and still provide an above
the 2018 MIPS performance period. believe that scoring of the 6 identified median award for good performance. In
Response: We appreciate the topped out measures, including addition, we are finalizing our proposed
commenters support. measures 52, 21 and 23 discussed policy that we will not apply the topped
Comment: A few commenters did not above, should be capped. In terms of out measure cap to measures in the CMS
support the special scoring and recommendations to replace measures Web Interface for the Quality Payment
potential future removal of the 6 topped and develop composite measures, we Program. We also appreciate the input
out measures proposed for special will consider these recommendations and suggestions on the best way to
scoring, citing specific measures that are for future rulemaking. As discussed in proceed with topped out SSMs in the
important to specialists and included in section II.C.6.c.(1) of this final rule with CAHPS for MIPS survey measures, and
specialty measurement sets. One comment period, we intend to work we will take it into consideration in
commenter recommended the inclusion with developers using the Measure future rulemaking. Additionally, we are
of a replacement measure if capping the Development Plan as a strategic finalizing our proposal to apply that the
score for the measure Chronic framework to add new measures into special scoring policy to the 6 selected
Obstructive Pulmonary Disease MIPS. We will share the commenters measures in Table 18 for the 2018 MIPS
(measure 52), because the commenter recommendations regarding the need for performance period and 2020 MIPS
believed without replacement there will new measures and a composite measure. payment year.
be a gap in the program. A few We encourage stakeholders to develop Finally, we are finalizing the
commenters did not support including and submit measures and composite proposed regulatory text changes with
the Perioperative Care Measure: measures for consideration. some modifications to reflect the other
Selection of Prophylactic Antibiotic We also sought comment on other policies we are finalizing. We are
(measure 21) because commenters possible options for scoring topped out finalizing amendments to
believed it is an important measure to measures that would meet our policy 414.1380(b)(1)(xiii)(A) to read that, for
identify patient outcomes and is crucial goals to encourage clinicians to begin to the 2020 MIPS payment year, the 6
to maintain high quality care. One submit measures that are not topped out measures identified in Table 18 will
commenter did not support the while also providing stability for MIPS receive a maximum of 7 measure
inclusion of the Perioperative Care eligible clinicians. We specifically achievement points, provided that for
measures (measures 21 and 23) in the sought comment on whether the the applicable submission mechanisms
list of topped out measures because the proposed policy to cap the score of the measure benchmarks are identified
commenter believed that the measures topped out measures beginning with the as topped out again in the benchmarks
published for the 2018 MIPS specific topped out measures, while considered, through notice-and-
performance period. We will also providing measure developers time to comment rulemaking, for removal for
amend 414.1380(b)(1)(xiii)(B) to read develop new measures. Below is an the 2020 MIPS performance period.
that, beginning with the 2021 MIPS illustration of the lifecycle for scoring Year 4: Topped out measures that
payment year, measure benchmarks, and removing topped out measures are finalized for removal are no longer
except for measures in the CMS Web based on our newly finalized policies: available for reporting. For example, the
Interface, that are identified as topped Year 1: Measure are identified as measures identified as topped out for
out for 2 or more consecutive years will topped out, which in this example the 2017, 2018 and 2019 MIPS
receive a maximum of 7 measure would be in the benchmarks published performance periods, if subsequently
achievement points in the second for the 2017 MIPS performance period. finalized for removal, will not be
consecutive year it is identified as The 2017 benchmarks are posted on the available on the list of measures for the
topped out, and beyond. We will Quality Payment Program Web site: 2020 MIPS performance period and
continue to consider if additional https://qpp.cms.gov/resources/ future years. For all other measures, the
factors need to be taken into account as education. timeline would apply starting with the
we score topped out measures, and if Year 2: Measures are identified as benchmarks for the 2018 MIPS
needed, we will make further proposals topped out in the benchmarks published performance period. Thus, the first year
in future rulemaking. for the 2018 MIPS performance period. any topped out measure other than
Together the finalized policies for Measures identified in Table 18 have those identified in Table 18 could be
phasing in capped scoring and removing special scoring applied, provided they proposed for removal would be in
topped out measures are intended to are identified as topped out for the 2018 rulemaking for the 2021 MIPS
provide an incentive for MIPS eligible MIPS performance period, meaning it is performance period, based on the
clinicians to begin to submit measures the second consecutive year they are benchmarks being topped out in the
that are not topped out while also identified as topped out. 2018, 2019, and 2020 MIPS performance
providing stability by allowing MIPS Year 3: Measures are identified as periods. If the measure benchmark is
eligible clinicians who have few topped out in the benchmarks published not topped out for three consecutive
alternative measures to continue to for the 2019 MIPS performance period. MIPS performance periods, then the
receive standard scoring for most The measures identified as topped out lifecycle would stop and start again at
topped out measures for an additional in the benchmarks published for the year 1 the next time the measure
year, and not perform below the median 2019 MIPS performance period and the benchmark is topped out.
score for those 6 measures that receive previous two consecutive performance An example of applying the proposed
special scoring. It also provides MIPS periods would continue to have special scoring cap compared to scoring applied
eligible clinicians the ability to scoring applied for the 2019 MIPS for the 2017 MIPS performance period
anticipate and plan for the removal of performance period and would be is provided in Table 19.
TABLE 19SCORING FOR TOPPED OUT MEASURES * STARTING IN THE CY 2018 MIPS PERFORMANCE PERIOD
COMPARED TO THE TRANSITION YEAR SCORING
Measure 1 Measure 2 Measure 3 Measure 4 Measure 5 Measure 6 Quality category
Scoring policy (topped out) (topped out) (topped out) (topped out) (not topped out) (not topped out) percent score *
2017 MIPS per- 10 measure 10 measure 10 measure 4 measure 10 measure 5 measure 49/60 = 81.67
formance period achieve-ment achieve-ment achieve-ment achieve-ment achieve-ment achieve-ment
Scoring. points. points. points. points (did not points. points.
get max score).
Capped Scoring 7 measure 7 measure 7 measure 4 measure 10 measure 5 measure 40/60 = 66.67.
applied. achieve-ment achieve-ment achieve-ment achieve-ment achieve-ment achieve-ment
points. points. points. points. points. points.
Notes ................... Topped out measures scored with 7-point measure achievement point cap. Cap Still possible to earn maximum meas-
does not impact score if the MIPS eligible clinicians score is below the cap. ure achievement points on the non-
topped out measures
* This example would only apply to the 6 measures identified in Table 18 for the CY 2018 MIPS Performance Period. This example also excludes bonus points and
improvement scoring proposed in section the proposed rule (82 FR 30113 through 30114).
(d) Case Minimum Requirements and requirement (81 FR 77288). We did not measures that can be scored based on
Measure Reliability and Validity propose any changes to these policies. performance because they have a
For the 2019 MIPS payment year, we benchmark, meet the case minimum
To help ensure reliable measurement, finalized in the CY 2017 Quality requirement, and meet the data
in the CY 2017 Quality Payment Payment Program final rule that if the completeness standard. We finalized
Program final rule (81 FR 77288), we measure is submitted but is unable to be that Class 1 measures would receive 3
finalized a 20-case minimum for all scored because it does not meet the to 10 points based on performance
quality measures except the all-cause required case minimum, does not have compared to the benchmark (81 FR
hospital readmission measure. For the a benchmark, or does not meet the data 77289). Class 2 measures are measures
all-cause hospital readmission measure, completeness requirement, the measure that cannot be scored based on
we finalized in the CY 2017 Quality would receive a score of 3 points (81 FR performance because they do not have
Payment Program final rule a 200-case 77288 through 77289). We identified a benchmark, do not have at least 20
minimum and finalized to apply the all- two classes of measures for the cases, or the submitted measure does
cause hospital readmission measure transition year. Class 1 5 measures are not meet data completeness criteria. We
only to groups of 16 or more clinicians
5 References to Classes of measures in this comment period are intended only to characterize
that meet the 200-case minimum
section II.C.7.a.(2)(d) of this final rule with the measures for ease of discussion.
finalized that Class 2 measures, which points; however, we believe that during practices may have less experience with
do not include measures submitted with the second year of transitioning to submitting quality performance category
the CMS Web Interface or MIPS, clinicians should continue to data and may not yet have systems in
administrative claims-based measures, receive at least 1 measure achievement place to ensure they can meet the data
receive 3 points (81 FR 77289). point for any submitted measure, even completeness criteria. Thus, we
We proposed to maintain the policy to if the measure does not meet the data proposed an exception to the proposed
assign 3 points for measures that are completeness standards. policy for measures submitted by small
submitted but do not meet the required We are concerned, however, that data practices, as defined in 414.1305. We
case minimum or do not have a completeness may be harder to achieve proposed that these clinicians would
benchmark for the 2020 MIPS payment for small practices. Small practices tend continue to receive 3 points for
year and amend 414.1380(b)(1)(vii) to have small case volume, and missing measures that do not meet data
accordingly (82 FR 30106 through one or two cases could cause the MIPS completeness.
30108). We also proposed a change to eligible clinician to miss the data Therefore, we proposed to revise
the policy for scoring measures that do completeness standard as each case may Class 2 measures to include only
not meet the data completeness represent multiple percentage points for measures that cannot be scored based on
requirement for the 2020 MIPS payment data completeness. For example, for a performance because they do not have
year. small practice with only 20 cases for a a benchmark or do not have at least 20
To encourage complete reporting, we measure, each case is worth 5 cases. We also proposed to create Class
proposed that in the 2020 MIPS percentage points, and if they miss 3 measures, which are measures that do
payment year, measures that do not reporting just 11 or more cases, they not meet the data completeness
meet data completeness standards will would fail to meet the data requirement. We proposed that the
receive 1 point instead of the 3 points completeness threshold, whereas for a revised Class 2 measure would continue
that were awarded in the 2019 MIPS practice with 200 cases, each case is to receive 3 points. The proposed Class
payment year. We proposed lowering worth 0.5 percentage points towards 3 measures would receive 1 point,
the point floor to 1 for measures that do data completeness, and the practice except if the measure is submitted by a
not meet data completeness standards would have to miss more than 100 cases small practice in which case the Class
for several reasons. First, we want to to fail to meet the data completeness 3 measure would receive 3 points.
encourage complete reporting because criteria. Applying 1 point for missing However, consistent with the policy
data completeness is needed to reliably data completeness based on missing a finalized in the CY 2017 Quality
measure quality. Second, unlike case relatively small number of cases could Payment Program final rule, these
minimum and availability of a disadvantage small practices, which policies for Class 2 and Class 3
benchmark, data completeness is within may have additional burdens for measures would not apply to measures
the direct control of the MIPS eligible reporting in MIPS, although we also submitted with the CMS Web Interface
clinician. In the future, we intend that recognize that failing to report on 10 or or administrative claims-based
measures that do not meet the more patients is undesirable. In measures. A summary of the proposals
completeness criteria will receive zero addition, we know that many small is provided in Table 20.
TABLE 20QUALITY PERFORMANCE CATEGORY: SCORING MEASURES BASED ON PERFORMANCE

Scoring rules in 2017 MIPS Description for 2018 MIPS 2018 MIPS
Measure type Description in transition year performance period performance period performance period
Class 1 .............. Measures that can be scored 3 to 10 points based on per- Same as transition year ........ Same as transition year.
based on performance. formance compared to the 3 to 10 points based on per-
Measures that were sub- benchmark. formance compared to the
mitted or calculated that benchmark.
met the following criteria:
(1) The measure has a
benchmark;
(2) Has at least 20
cases; and
(3) Meets the data com-
pleteness standard
(generally 60 percent.)
Class 2 .............. Measures that cannot be 3 points ................................. Measures that were sub- 3 points.
scored based on perform- * This Class 2 measure policy mitted and meet data com- * This Class 2 measure policy
ance. Measures that were does not apply to CMS pleteness, but do not have would not apply to CMS
submitted, but fail to meet Web Interface measures both of the following: Web Interface measures
one of the Class 1 criteria. and administrative claims (1) a benchmark and administrative claims
The measure either based measures. (2) at least 20 cases. based measures.
(1) does not have a
benchmark,
(2) does not have at
least 20 cases, or
(3) does not meet data
completeness criteria.
TABLE 20QUALITY PERFORMANCE CATEGORY: SCORING MEASURES BASED ON PERFORMANCEContinued

Scoring rules in 2017 MIPS Description for 2018 MIPS 2018 MIPS
Measure type Description in transition year performance period performance period performance period
Class 3 .............. n/a ......................................... n/a ......................................... Measures that were sub- 1 point except for small prac-
mitted, but do not meet tices, which would receive
data completeness criteria, 3 points.
regardless of whether they * This Class 3 measure policy
have a benchmark or meet would not apply to CMS
the case minimum. Web Interface measures
and administrative claims
based measures
The following is a summary of the suggested approaches, it would be more small practice, in which case it would
public comments received on our advantageous for a MIPS eligible receive 3 points (82 FR 30108).
proposal for measures that do not meet clinician that submits measures without We invited comment on our proposal
the case minimum requirement or do a benchmark because points for those to assign 1 point to measures that do not
not have a benchmark (Class 2 measures would be higher than the floor meet data completeness criteria, with an
measures) and our responses: for Class 1 measures. For those exception for measures submitted by
Comment: A few commenters measures without a benchmark based on small practices.
supported maintaining the policy to the baseline period or the performance The following is a summary of the
assign 3 points to measures that are period (Class 2 measures), we selected public comments received on the data
submitted but do not have a benchmark 3 points because we did not want to completeness proposal and our
or meet the case minimum. provide more credit for reporting a responses:
Response: We appreciate commenters measure than cannot be reliably scored Comment: Several commenters
support for the policy to assign 3 points against a benchmark than for measures supported lowering the 3-point floor to
to Class 2 measures. for which we can measure performance 1 point for measures that do not meet
Comment: Several commenters against a benchmark. Providing null the data completeness criteria because it
recommended that more than 3 points values would reduce the final quality would encourage MIPS eligible
should be assigned to measures without score potential of 60 points and may clinicians to report more complete
a benchmark, citing the need to provide incentives for MIPS eligible performance data, in turn supporting
encourage MIPS eligible clinicians to clinicians to submit mostly measures the robust measurement underlying the
report new measures and ensure without a benchmark that cannot be Quality Payment Programs overall
adequate representation of quality of reliably scored, rather than encouraging assessments, bonuses, and penalties.
care provided. A few commenters the use of measures that can reliably One commenter suggested adjusting the
proposed assigning a null value, measure performance, provide points assigned to small practices in
maximum points, 6 points, or bonus meaningful distinctions and future years to align with large practices
points to these measures. A few performance and offer improvement and incentivize small practices to
commenters suggested measures with opportunities. We refer readers to collect quality measure data effectively.
no benchmarks should have an section II.C.6.g.(3)(b) of this final rule One commenter only supported
opportunity to earn a maximum or near with comment period for further awarding 1 point if the performance
maximum score or at least 5 or 6 points. discussion on the quality performance period for the quality performance
One commenter encouraged CMS to category for MIPS APMs including the category was not longer than 90 days.
align general MIPS and the APM scoring use of the null value score for measures Response: We thank commenters for
standard and suggested that measures that do not have a benchmark or meet their support for lowering the points
that do not have a benchmark or meet the case minimum. We will continue to assigned to measures that do not meet
the case minimum should not be monitor the impact of the policy as we the data completeness criteria from 3
removed from the numerator and gain experience with MIPS and evaluate points to 1 point. We will continue to
denominator of the quality performance whether we need to revisit these revisit ways to improve this policy in
category percent score, regardless of approaches in future rulemaking. future years. Additionally, we believe
whether general MIPS or the APM Final Action: After consideration of that it would not be in the best interest
scoring standard applies. public comments, we are finalizing our of MIPS eligible clinicians to have less
Response: We recognize stakeholders proposal to maintain the policy to than a full calendar year performance
concerns regarding the assignment of 3 assign 3 points for measures that are period for the quality performance
points to measures without a submitted but do not meet the required category. We refer readers to section
benchmark. However, assigning more case minimum or do not have a II.C.5. of this final rule with comment
than 3 points, a null value, or bonus benchmark for the 2020 MIPS payment period for future discussion on the
points increases the likelihood of year and amend 414.1380(b)(1)(vii) MIPS performance period.
potential gaming because new measures accordingly. Comment: Several commenters
and other measures without a We proposed to amend supported CMSs proposed policy to
benchmark based on the baseline period 414.1380(b)(1)(vii) to assign 3 points assign 3 points to small practices who
may still be scored based on for measures that do not meet the case submit measures that do not meet the
performance and receive between 310 minimum or do not have a benchmark data completeness requirement. A few
measure achievement points if the in the 2020 MIPS payment year, and to commenters requested that CMS extend
measure has a benchmark based on the assign 1 point for measures that do not the 3-point floor for small practices past
performance period (Class 1 measures). meet data completeness requirements, the 2018 MIPS performance period or
Therefore, if we were to use any of the unless the measure is submitted by a include other types of clinicians or
groups that may need a similar clinicians would be able to receive 3 Savings Program will not be scored. We
exception. One commenter who measure achievement points for refer readers to the discussion at section
supported the small practice exception submitting just one case. While that was II.C.7.a.(2)(h)(ii) of this final rule with
also expressed concern that it would not appropriate for year 1, it is less comment period for public comments
be enough to overcome the disparities appropriate as we transition into year 2 related to changes in CMS Web Interface
between small and rural practices and and future years. As discussed in scoring.
large and urban practices. section II.C.6.b.(3)(b) of this final rule We also did not propose any changes
Response: We thank commenters for with comment period, we are not to the policy to not include
their support for the small practice finalizing our proposal to lower the data administrative claims measures in the
exception. We will consider ways to completeness threshold to 50 percent quality performance category percent
improve this approach in future years, for the 2018 performance period, rather score if the case minimum is not met or
including assessing the exceptions it will remain at 60 percent for the 2018 if the measure does not have a
impact on any disparities between performance period as finalized in the benchmark finalized in the CY 2017
various types of practices. Next year we CY 2017 Quality Payment Program final Quality Payment Program final rule and
will revisit whether to extend the small rule with comment period. While we codified at paragraph (b)(1)(viii) of
practice exception beyond the 2018 acknowledge stakeholders concerns 414.1380. We referred readers to the
MIPS performance period. At this time, and suggestions for delaying the discussion at 81 FR 77288 for more
we do not believe it is appropriate to implementation of the 1-point policy, details on that policy.
extend this exception beyond small we believe this policy supports our To clarify the exclusion of measures
practices because we believe the policy program goals for complete and accurate submitted via the CMS Web Interface
supports our program goals for complete reporting that reflects meaningful efforts and based on administrative claims
and accurate reporting to support to improve the quality of care patients from the policy changes proposed to be
meaningful efforts to improve the receive. We will continue to consider codified at paragraph (b)(1)(vii)
quality of care patients receive. ways to improve the policy to achieve previously, we proposed to amend
Comment: Many commenters did not this aim as we work to stabilize and best paragraph (b)(1)(vii) to make it subject
support assigning 1 point to measures simplify the program reporting to paragraph (b)(1)(viii), which codifies
that do not meet the data completeness requirements. the exclusion.
criteria in the 2018 MIPS performance Comment: One commenter suggested We did not receive public comments
period and wanted to maintain the that measures that do not meet data on this proposal.
policy to assign 3 points. A few completeness should receive zero points Final Action: We are finalizing as
commenters cited the difficulty many instead of 1 point because it adds less proposed the technical corrections to
practices face in meeting the data complexity to the Quality Payment 414.1380(b)(1)(vii) related to the
completeness threshold, including Program. exclusion of measures submitted via the
disparate IT systems, the dearth of Response: At this time, we believe CMS Web Interface. We refer readers to
germane specialty quality measures that assigning 1 point is appropriate for the the discussion at section
can be reported electronically, and second transition year, as it is a step II.C.7.a.(2)(h)(ii) of this final rule with
limited numbers of cases. One towards meeting our goal for a more comment period for public comments
commenter wanted long term stability accurate assessment of a MIPS eligible related to changes in CMS Web Interface
in the program reporting requirements, clinicians performance on the quality scoring.
citing the administrative burden caused measures. We will continue to monitor
(e) Scoring for MIPS Eligible Clinician
by changes. A few commenters the impact of the policy and evaluate
That Do Not Meet Quality Performance
requested that the 3-point floor remain whether we need to apply more rigorous
Category Criteria
until there is data to show that sufficient standards in future rulemaking.
numbers of MIPS eligible clinicians are Final Action: After consideration of In the CY 2017 Quality Payment
able to meet the criteria to warrant a public comments, we are finalizing the Program final rule, we finalized that
reduction in points or at least until 2015 policy to assign 1 point to measures that MIPS eligible clinicians who fail to
CEHRT is required. Another commenter do not meet data completeness criteria, submit a measure that is required to
stated that having a different floor for with an exception for measures satisfy the quality performance category
small practices creates a disparity in submitted by small practices, which submission criteria would receive zero
scoring and further complicates the will receive 3 points, and amend points for that measure (81 FR 77291).
Quality Payment Program. One 414.1380(b)(1)(vii) accordingly. We did not propose any changes to the
commenter suggested that CMS We did not propose to change the policy to assign zero points for failing to
continue to assign 3 points if the MIPS methodology we use to score measures submit a measure that is required in this
eligible clinician makes a substantive submitted via the CMS Web Interface proposed rule.
effort to submit data, or provide a that do not meet the case minimum, do We would like to emphasize that
sliding scale for MIPS eligible clinicians not have a benchmark, or do not meet MIPS eligible clinicians that fail to
who make a good faith effort to achieve the data completeness requirement submit any measures under the quality
data completeness thresholds, thus finalized in the CY 2017 Quality performance category will receive a zero
rewarding physicians for submitting Payment Program final rule and codified score for this category. All MIPS eligible
data in a timely manner. at paragraph (b)(1)(viii) of 414.1380. clinicians are required to submit
Response: We believe assigning 1 We referred readers to the discussion at measures under the quality performance
point to measures that do not meet the 81 FR 77288 for more details on our category unless there are no measures
data completeness criteria reflects our previously finalized policy. However, that are applicable and available or
goals for MIPS eligible clinicians we noted that as described in the because of extreme and uncontrollable
performance under the Quality Payment proposed rule (82 FR 30113), we circumstances. For further discussion
Program. We also believe that data proposed to add that CMS Web Interface on extreme and uncontrollable
completeness is something that is measures with a benchmark that are circumstances, see sections
within a clinicians control, and without redesignated from pay for performance II.C.7.b.(3)(c) and III.B of this final rule
the data completeness requirement to pay for reporting by the Shared with comment period.
In the CY 2017 Quality Payment 2018 performance period as proposed, process should be limited to a single
Program final rule, we also finalized but instead beginning with the CY 2019 submission mechanism. Several
implementation of a validation process performance period. commenters were concerned that the
for claims and registry submissions to Given our proposal to score measures process may determine that a MIPS
validate whether MIPS eligible submitted via multiple mechanisms (see eligible clinician who reports via claims
clinicians have 6 applicable and 82 FR 30110 through 30113), we should have also reported via a
available measures, whether an outcome proposed to validate the availability and qualified registry to reach six measures
measure is available or whether another applicability of measures only if a MIPS adding an administrative and financial
high priority measure is available if an eligible clinician submits via claims burden for MIPS eligible clinicians. A
outcome measure is not available (81 FR submission options only, registry few commenters also recommended that
77290 through 77291). submission options only, or a in cases of claims reporting, CMS limit
We did not propose any changes to combination of claims and registry validation to measures applicable to
the process for validating whether MIPS submission options. In these cases, we claims reporting only or develop a
eligible clinicians that submit measures proposed that we will apply the process to determine in advance of the
via claims and registry submissions validation process to determine if other reporting year which quality measures
have measures available and applicable. measures are available and applicable are likely applicable to each MIPS
We stated in the CY 2017 Quality broadly across claims and registry eligible clinician and only hold them
Payment Program final rule (81 FR submission options. We will not check accountable for these relevant measures.
77290) that we did not intend to if there are measures available via EHR A few commenters requested
establish a validation process for QCDRs or QCDR submission options for these clarification on the validation process
because we expect that MIPS eligible reporters. We noted that groups cannot and how it would be implemented for
clinicians that enroll in QCDRs will report via claims, and therefore groups measures submitted via claims and
have sufficient meaningful measures to and virtual groups will only have registries in light of the proposal to use
meet the quality performance category validation applied across registries. We multiple submission mechanisms.
criteria (81 FR 77290 through 77291). would validate the availability and
Response: As mentioned in II.C.6.a.(1)
We did not propose any changes to this applicability of a measure through a
of this final rule with comment period,
policy. clinically related measure analysis
We also stated that if a MIPS eligible we are finalizing the policy for scoring
based on patient type, procedure, or
clinician did not have 6 measures measures submitted via multiple
clinical action associated with the
relevant within their EHR to meet the measure specifications. For us to mechanisms beginning with year 3 to
full specialty set requirements or meet recognize fewer than 6 measures, an allow additional time to communicate
the requirement to submit 6 measures, individual MIPS eligible clinician must how this policy intersects with our
the MIPS eligible clinician should select submit exclusively using claims or measure applicability policies. To align
a different submission mechanism to qualified registries or a combination of with that policy, we are finalizing our
meet the quality performance category the two, and a group or virtual group validation proposal with modification
requirements and should work with must submit exclusively using qualified beginning with year 3 and, for the year
their EHR vendors to incorporate registries. Given the proposal in the 2 validation process, will continue to
applicable measures as feasible (81 FR proposed rule (82 FR 30110 through apply the year 1 validation process,
77290 through 77291). Under our 30113) to permit scoring measures which is limited to a single submission
proposals discussed in section submitted via multiple mechanisms, mechanism. Also, given commenters
II.C.6.a.(1) of this final rule with validation will be conducted first by concerns regarding the impact of
comment period to allow measures to be applying the clinically related measure multiple submission mechanisms on the
submitted and scored via multiple analysis for the individual measure, and validation process for claims and
mechanisms within a performance then, to the extent technically feasible, registry submissions, we are modifying
category, we anticipated that MIPS validation will be applied to check for our validation proposal to provide that
eligible clinicians that submit fewer available measures available via both we will validate the availability and
than 6 measures via EHR will have claims and registries. applicability of quality measures only
sufficient additional measures available We would like to clarify that we with respect to the data submission
via a combination of submission expect that MIPS eligible clinicians mechanism(s) that a MIPS eligible
mechanisms to submit the measures would choose a single submission clinician utilizes for the quality
required to meet the quality mechanism that would allow them to performance category for a performance
performance category criteria. For report 6 measures. Multiple submission period. We will not apply the validation
example, the MIPS eligible clinician mechanisms give MIPS eligible process to any data submission
could submit 2 measures via EHR and clinicians additional flexibility in mechanism that the MIPS eligible
supplement that with 4 measures via reporting the 6 measures, and we do not clinician does not utilize for the quality
QCDR or registry. require using multiple submission performance category for the
Therefore, given the proposal to score mechanisms for reporting quality performance period. Thus, MIPS eligible
multiple mechanisms, if a MIPS eligible measures. clinicians who submit quality data via
clinician submits any quality measures The following is a summary of the claims only would be validated against
via EHR or QCDR, we would not public comments received on validation claims measures only, and MIPS eligible
conduct a validation process because we only if measures are submitted via clinicians who submit quality data via
expect these MIPS eligible clinicians to claims and/or registry options proposal registry only would be validated against
have sufficient measures available to and our responses: registry measures only. MIPS eligible
meet the quality performance category Comment: Several commenters were clinicians who, beginning with year 3,
requirements. As discussed in section concerned about the impact of multiple elect to submit quality data via claims
II.C.6.a.(1) of this final rule with submission mechanisms on the and registry would be validated against
comment period, we are not finalizing validation process for claims and both claims and registry measures;
the proposal to score multiple registry submissions. A few commenters however, they would not be validated
mechanisms beginning with the CY recommended that the validation against measures submitted via other
data submission mechanisms. Thus, clinicians to select the submission (f) Incentives To Report High Priority
under the modified validation process, mechanism that has 6 measures Measures
MIPS eligible clinicians who submit via available and applicable to their In the CY 2017 Quality Payment
claims or registry submission only or a specialty and practice type. The Program final rule, we finalized that we
combination of claims and registry multiple submission policy will help would award 2 bonus points for each
submissions would not be required to situations where people who do not outcome or patient experience measure
submit measures through multiple have 6 measures via the QCDR or EHR, and 1 bonus point for each additional
mechanisms to meet the quality would have the ability to report via high priority measure that is reported in
performance category criteria; rather, QCDR or EHR and supplement measures addition to the 1 high priority measure
utilizing multiple submission from other mechanisms. that is already required to be reported
mechanisms is an option available to
Final Action: After consideration of under the quality performance category
MIPS eligible clinicians beginning with
public comments, we are finalizing our submission criteria, provided the
year 3, which may increase their quality
validation proposal with modification measure has a performance rate greater
performance category score, but may
beginning with year 3 (CY 2019 than zero, and the measure meets the
also affect the scope of measures against
performance period and 2021 MIPS case minimum and data completeness
which they will be validated or whether
payment year). For year 2 (CY 2018 requirements (81 FR 77293). High
they qualify for the validation process.
We expect that MIPS eligible clinicians performance period and 2020 MIPS priority measures were defined as
would choose a single submission payment year), we will continue to outcome, appropriate use, patient safety,
mechanism that would allow them to apply the year 1 validation process. As efficiency, patient experience and care
report 6 measures. Our intention is to discussed above, we are modifying our coordination measures. We also
offer multiple submission mechanisms validation proposal to provide that we finalized that we will apply measure
to increase flexibility for MIPS will validate the availability and bonus points for the CMS Web Interface
individual clinicians and groups. We applicability of quality measures only for the Quality Payment Program based
are not requiring that MIPS individual with respect to the data submission on the finalized set of measures
clinicians and groups submit via mechanism(s) that a MIPS eligible reportable through that submission
multiple submission mechanisms; clinician utilizes for the quality mechanism (81 FR 77293). We noted
however, beginning with year 3, the performance category for a performance that in addition to the 14 required
option would be available for those that period. We will not apply the validation measures, CMS Web Interface reporters
have applicable measures and/or process to any data submission may also report the CAHPS for MIPS
activities available to them. mechanism that the MIPS eligible survey and receive measure bonus
Comment: A few commenters clinician does not utilize for the quality points for submitting that measure. We
recommended a validation process for performance category for the did not propose any changes to these
measures submitted via EHR and QCDR performance period. We seek comment policies for awarding measure bonus
reporting mechanisms to ensure that on how to modify the validation process points for reporting high priority
eligible clinicians who select an EHR or for year 3 when we have multiple measures in the proposed rule.
QCDR mechanism to report are not submission mechanisms. In the CY 2017 Quality Payment
unfairly disadvantaged. The Program final rule, we finalized a cap on
In the CY 2018 Quality Payment high priority measure bonus points at 10
commenters believed that such Program proposed rule (82 FR 30109),
clinicians may not have 6 relevant percent of the denominator (total
we recognized that in extremely rare possible measure achievement points
measures to report; therefore, a lack of
instances there may be a MIPS eligible the MIPS eligible clinician could receive
a validation process for QCDR and EHR
clinician who may not have available in the quality performance category) of
reporting disincentivizes QCDR- and
and applicable quality measures. For the quality performance category for the
EHR-based submission of quality
example, a subspecialist who focuses on first 2 years of MIPS (81 FR 77294). We
measures.
Response: As we mentioned in the a very targeted clinical area may not did not propose any changes to the cap
proposed rule (82 FR 30108 through have any measures available. However, on measure bonus points for reporting
30109), we expect that MIPS eligible in many cases, the clinician may be part high priority measures, which is
clinicians that enroll in QCDRs should of a broader group or would have the codified at 414.1380(b)(1)(xiv)(D),6 in
have sufficient measures to report and ability to select some of the cross- the proposed rule.
that those who submit via EHR and do cutting measures that are available.
not have a sufficient number of Given the wide array of submission (g) Incentives To Use CEHRT To
measures within their EHR should options, including QCDRs which have Support Quality Performance Category
select a different submission mechanism the flexibility to develop additional Submissions
to meet the quality performance measures, we believe this scenario Section 1848(q)(5)(B)(ii) of the Act
category requirements and should work should be extremely rare. If we are not outlines specific scoring rules to
with their EHR vendors to incorporate able to score the quality performance encourage the use of CEHRT under the
applicable measures as feasible. We category, we may reweight their score quality performance category. For more
recognize this may be a disadvantage for according to the reweighting policies of the statutory background and
MIPS eligible clinicians who submit via described in section II.C.7.b.(3)(b) and description of the proposed and
EHR in year 2; however, beginning in II.C.7.b.(3)(d) of this final rule with finalized policies, we referred readers to
the 2019 MIPS performance period, comment period. We noted that we the CY 2017 Quality Payment Program
MIPS eligible clinicians that submit anticipate this will be a rare final rule (81 FR 77294 through 77299).
fewer than 6 measures via EHR will circumstance given our proposals to In the CY 2017 Quality Payment
have sufficient additional measures allow measures to be submitted and Program final rule at
available via a combination of scored via multiple mechanisms within 414.1380(b)(1)(xiv), we codified that 1
submission mechanisms to meet the 6- a performance category and to allow bonus point is available for each quality
measure reporting requirement. We facility-based measurement for the
strongly encourage MIPS eligible quality performance category. 6 Redesignated from 414.1380(b)(1)(xiii)(D).
measure submitted with end-to-end finalized that if a MIPS eligible clinician multiple mechanisms if reported by the
electronic reporting, under certain elects to report more than the minimum same individual MIPS eligible clinician,
criteria described below (81 FR 77297). number of measures to meet the MIPS group, virtual group or APM Entity, as
We also finalized a policy capping the quality performance category criteria, described in Table 21.
number of bonus points available for then we will only include the scores for We did not propose to aggregate
electronic end-to-end reporting at 10 the measures with the highest number measure results across different
percent of the denominator of the of assigned points, once the first submitters to create a single score for an
quality performance category percent outcome measure is scored, or if an individual measure (for example, we are
score, for the first 2 years of the program outcome measure is not available, once
not going to aggregate scores from
(81 FR 77297). We also finalized that the another high priority measure is scored.
different TINs within a virtual group
CEHRT bonus would be available to all We did not propose any changes to the
TIN to create a single virtual group score
submission mechanisms except claims policy to score the measures with the
for the measures; rather, virtual groups
submissions. Specifically, MIPS eligible highest number of assigned points in
clinicians who report via qualified this proposed rule; however, we must perform that aggregation across
registries, QCDRs, EHR submission proposed refinements to account for TINs prior to data submission to CMS).
mechanisms, or the CMS Web Interface measures being submitted across Virtual groups are treated like other
for the Quality Payment Program, in a multiple submission mechanisms. groups and must report all of their
manner that meets the end-to-end In the CY 2017 Quality Payment measures at the virtual group level, for
reporting requirements, may receive 1 Program final rule, we sought comment the measures to be scored. Data
bonus point for each reported measure on whether to score measures submitted completeness and all the other criteria
with a cap (81 FR 77297). across multiple submission mechanisms will be evaluated at the virtual group
We did not propose changes to these (81 FR 77275) and on what approach we level. Then the same rules apply for
policies related to bonus points for should use to combine the scores for selecting which measures are used for
using CEHRT for end-to-end reporting quality measures from multiple scoring. In other words, if a virtual
in the proposed rule. However, we submission mechanisms into a single group representative submits some
sought comment on the use of health IT aggregate score for the quality measures via a qualified registry and
in quality measurement and how HHS performance category (81 FR 77275). We other measures via EHR, but an
can encourage the use of certified EHR summarized the comments that were individual TIN within the virtual group
technology in quality measurement as received in the proposed rule (82 FR also submits measures, we will only use
established in the statute (82 FR 30109 30110). the scores from the measures that were
through 30110). We proposed, beginning with the submitted at the virtual group level,
We thank commenters for their 2018 MIPS performance period, a because the TIN submission does not
response on the use of health IT in method to score quality measures if a use the virtual group identifier. This is
quality measurement and we will MIPS eligible clinician submits consistent with our other scoring
consider them in future rulemaking. measures via more than one of the principles, where, for virtual groups, all
following submission mechanisms: quality measures are scored at the
(h) Calculating Total Measure Claims, qualified registry, EHR or QCDR virtual group level.
Achievement and Measure Bonus Points submission options. We noted that we
Separately, as also described in
In the proposed rule (82 FR 30113 believe that allowing MIPS eligible
Table 21, because CMS Web Interface
through 30120), we proposed a new clinicians to be scored across these data
and facility-based measurement each
methodology to reward improvement submission mechanisms in the quality
performance category will provide have a comprehensive set of measures
based on achievement, from 1 year to
additional options for MIPS eligible that meet the proposed MIPS
another, which requires modifying the
calculation of the quality performance clinicians to report the measures submission requirements, we did not
category percent score. In the proposed required to meet the quality propose to combine CMS Web Interface
rule (82 FR 30110 through 30113), we performance category criteria, and measures or facility-based measurement
summarized the policies for calculating encourage MIPS eligible clinicians to with other group submission
the total measure achievement points begin using electronic submission mechanisms (other than CAHPS for
and total measure bonus points, prior to mechanisms, even if they may not have MIPS, which can be submitted in
scoring improvement and the final 6 measures to report via a single conjunction with the CMS Web
quality performance category percent electronic submission mechanism alone. Interface). We refer readers to section
score. We noted that we will refer to We noted that we also continue to score II.C.7.a.(2)(h)(ii) of this final rule with
policies finalized in the CY 2017 the CMS-approved survey vendor for comment period for discussion of
Quality Payment Program final rule that CAHPS for MIPS submission options in calculating the total measure
apply to the quality performance conjunction with other submission achievement and measure bonus points
category score, which is referred to as mechanisms (81 FR 77275) as noted in for CMS Web Interface reporters. We
the quality performance category Table 21. refer readers to section II.C.7.a.(4) of the
percent score in this proposed rule, in We proposed to score measures across final rule with comment period for a
this section. We also proposed some multiple mechanisms using the description of our policies on facility-
refinements to address the ability for following rules: based measurement. We list these
MIPS eligible clinicians to submit As with the rest of MIPS, we will submission mechanisms in Table 21, to
quality data via multiple submission only score measures within a single illustrate that CMS Web Interface
mechanisms. identifier. For example, as codified in submissions and facility-based
414.1310(e), eligible clinicians and measurement cannot be combined with
(i) Calculating Total Measure MIPS eligible clinicians within a group other submission options, except that
Achievement and Measure Bonus Points aggregate their performance data across the CAHPS for MIPS survey can be
for Non-CMS Web Interface Reporters the TIN in order for their performance combined with CMS Web Interface, as
In the CY 2017 Quality Payment to be assessed as a group. Therefore, described in the proposed rule (82 FR
Program final rule (81 FR 77300), we measures can only be scored across 30113).
TABLE 21SCORING ALLOWED ACROSS MULTIPLE MECHANISMS BY SUBMISSION MECHANISM

[Determined by MIPS identifier and submission mechanism] 1
MIPS identifier and submission mechanisms When can quality measures be scored across multiple mechanisms?
Individual eligible clinician reporting via claims, EHR, QCDR, and reg- Can combine claims, EHR, QCDR, and registry.
istry submission options.
Group reporting via EHR, QCDR, registry, and the CAHPS for MIPS Can combine EHR, QCDR, registry, and CAHPS for MIPS survey.
survey.
Virtual group reporting via EHR, QCDR, registry, and the CAHPS for Can combine EHR, QCDR, registry, and CAHPS for MIPS survey.
MIPS survey.
Group reporting via CMS Web Interface .................................................. Cannot be combined with other submission mechanisms, except for
the CAHPS for MIPS survey.
Virtual group reporting via CMS Web Interface ....................................... Cannot be combined with other submission mechanisms, except for
the CAHPS for MIPS survey.
Individual or group reporting facility-based measures ............................. Cannot be combined with other submission mechanisms.
MIPS APMs reporting Web Interface or other quality measures ............. MIPS APMs are subject to separate scoring standards and cannot be
combined with other submission mechanisms.
1 The all-cause readmission measure is not submitted and applies to all groups of 16 or more clinicians who meet the case minimum of 200.
If a MIPS eligible clinician submits priority measures by encouraging add that if the same measure is
the same measure via 2 different clinicians to report them even if they submitted via two or more submission
submission mechanisms, we will score may not have high performance on the mechanisms, as determined using the
each mechanism by which the measure measure. We also want to encourage measure ID, the measure will receive
is submitted for achievement and take MIPS eligible clinicians to submit to us measure bonus points only once for the
the highest measure achievement points all of their available MIPS data, not only measure. The total measure bonus
of the 2 mechanisms. the data that they or their intermediary points for end-to-end electronic
Measure bonus points for high deem to be their best data. We believe reporting would still be capped at 10
priority measures would be added for it will be in the best interest of all MIPS percent of the total available measure
all measures submitted via all the eligible clinicians that we determine achievement points.
different submission mechanisms which measures will result in the
available, even if more than 6 measures Although we provided a policy to
clinician receiving the highest MIPS
are submitted, but high priority measure account for scoring in those
score. If the same measure is submitted
bonus points are only available once for through multiple submission circumstances when the same measure
each unique measure (as noted by the mechanisms, we would apply the bonus is submitted via multiple mechanisms,
measure number) that meets the criteria points only once to the measure. We we anticipated that this will be a rare
for earning the bonus point. For proposed to amend 414.1380(b)(1)(xiv) circumstance and do not encourage
example, if a MIPS eligible clinician (as redesignated from clinicians to submit the same measure
submits 8 measures6 process and 2 414.1380(b)(1)(xiii)) to add paragraph via multiple mechanisms. Table 22
outcomeand both outcome measures (b)(1)(xiv)(E) that if the same high illustrates how we would assign total
meet the criteria for a high priority priority measure is submitted via two or measure achievement points and total
bonus (meeting the required data more submission mechanisms, as measure bonus points across multiple
completeness, case minimum, and has a determined using the measure ID, the submission mechanisms under the
performance rate greater than zero), the measure will receive high priority proposal. In this example, a MIPS
outcome measure with the highest measure bonus points only once for the eligible clinician elects to submit
measure achievement points would be measure. The total measure bonus quality data via 3 submission
scored as the required outcome measure points for high-priority measures would mechanisms: 3 measures via registry, 4
and then the measures with the next 5 still be capped at 10 percent of the total measures via claims, and 5 measures via
highest measure achievement points possible measure achievement points. EHR. The 3 registry measures are also
will contribute to the final quality score. Measure bonus points that are submitted via claims (as noted by the
This could include the second outcome available for the use of end-to-end same measure letter in this example).
measure but does not have to. Even if electronic reporting would be calculated The EHR measures do not overlap with
the measure achievement points for the for all submitted measures across all either the registry or claims measures. In
second outcome measure are not part of submission mechanisms, including this example, we assign measure
the quality performance category measures that cannot be reliably scored achievement and bonus points for each
percent score, measure bonus points against a benchmark. If the same measure. If the same measure (as
would still be available for submitting a measure is submitted through multiple determined by measure ID) is submitted,
second outcome measure and meeting submission mechanisms, then we would then we use the highest achievement
the requirement for the high priority apply the bonus points only once to the points for that measure. For the bonus
measure bonus points. The rationale for measure. For example, if the same points, we assess which of the outcome
providing measure bonus points for measure is submitted using end-to-end measures meets the outcome measure
measures that do not contribute measure reporting via both a QCDR and EHR requirement and then we identify any
achievement points to the quality reporting mechanism, the measure other unique measures that qualify for
performance category percent score is would only get a measure bonus point the high priority bonus. We also identify
that it would help create better one time. We proposed to amend the unique measures that qualify for
benchmarks for outcome and other high 414.1380(b)(1)(xv) (as redesignated) to end-to-end electronic reporting bonus.
TABLE 22EXAMPLE OF ASSIGNING TOTAL MEASURE ACHIEVEMENT AND BONUS POINTS FOR AN INDIVIDUAL MIPS
ELIGIBLE CLINICIAN THAT SUBMITS MEASURES ACROSS MULTIPLE SUBMISSION MECHANISMS
High priority Incentive for CEHRT
Measure achievement points 6 scored measures measure measure
bonus points bonus points
Registry:
Measure A (Outcome) .......... 7.1 ............................................... 7.1 (Outcome measure with (required outcome measure does
highest achievement points). not receive bonus points).
Measure B ............................ 6.2 (points not considered be-
cause it is lower than the 8.2
points for the same claims
measure).
Measure C (high priority pa- 5.1 (points not considered be- ..................................................... 1.
tient safety measure that cause it is lower than the 6.0
meets requirements for ad- points for the same claims
ditional bonus points). measure).
Claims:
Measure A (Outcome) .......... 4.1 (points not considered be- ..................................................... No bonus points because the
cause it is lower than the 7.1 registry submission of the
points for the same measure same measure satisfies re-
submitted via a registry). quirement for outcome meas-
ure.
Measure B ............................ 8.2 ............................................... 8.2.
Measure C (High priority pa- 6.0 ............................................... 6.0 ............................................... No bonus (Bonus applied to the
tient safety measure that registry measure).
meets requirements for ad-
ditional bonus points).
Measure D (outcome meas- 1.0 2 ............................................. ..................................................... (no high priority bonus points be-
ure <50% of data sub- cause below data complete-
mitted). ness).
EHR (using end-to-end) Reporting that meets

CEHRT bonus point
criteria
Measure E ................................... 5.1 ............................................... 5.1 ............................................... ..................................................... 1.

Measure F .................................... 5.0 ............................................... 5.0 ............................................... ..................................................... 1.
Measure G ................................... 4.1 ............................................... ..................................................... ..................................................... 1.
Measure H ................................... 4.2 ............................................... 4.2 ............................................... ..................................................... 1.
Measure I (high priority patient 3.0 ............................................... ..................................................... (no high priority bonus points be- 1.
safety measure that is below cause below case minimum).
case minimum).
35.6 ............................................. 1 (below 10% cap 1) ................... 5 (below 10% cap).
Quality Performance Category ..................................................... (35.6 + 1 + 5)/60 = 69.33%

Percent Score Prior to Im-
provement Scoring.
1 In
this example the cap would be 6 points, which is 10 percent of the total available measure achievement points of 60.
2 Thistable in the CY 2018 Quality Payment Program proposed rule (82 FR 30112) inadvertently indicated that this would contribute 1 point to the quality perform-
ance category percent score for being one of the 6 measures submitted. In the example, more than 6 measures were submitted and the 6 with the highest scores
would be used, therefore, Measure D would not contribute points to the final score.
We proposed to amend We invited comments on the proposal submitted using 2 different

414.1380(b)(1)(xii) to add paragraph to calculate the total measure mechanisms, the measure will receive
(A) to state that if a MIPS eligible achievement points by using the measure bonus points once.
clinician submits measures via claims, measures with the 6 highest measure We did not propose any changes to
qualified registry, EHR, or QCDR achievement points across multiple our policy that if a MIPS eligible
submission options, and submits more submission mechanisms. We invited clinician does not have any scored
than the required number of measures, comments on the proposal that if the measures, then a quality performance
they are scored on the required same measure is submitted via 2 or category percent score will not be
measures with the highest assigned more mechanisms, we will only take the calculated as finalized in the CY 2017
measure achievement points. MIPS one with the highest measure Quality Payment Program final rule at
eligible clinicians that report a measure achievement points. We invited 81 FR 77300. We referred readers to the
via more than 1 submission mechanism comments on the proposal to assign discussion at 81 FR 77299 through
can be scored on only 1 submission high priority measure bonus points to 77300 for more details on that policy.
all measures, with performance greater We noted in the proposed rule (82 FR
mechanism, which will be the
than zero, that meet case minimums, 30108 through 30109) that we anticipate
submission mechanism with the highest
and that meet data completeness that it will be only in rare case that a
measure achievement points. Groups
requirements, regardless of submission MIPS eligible clinician does not have
that submit via these submission any scored measures and a quality
mechanism and to assign measure
mechanisms may also submit and be bonus points for each unique measure performance category percent score
scored on CMS-approved survey vendor submitted using end-to-end electronic cannot be calculated.
for CAHPS for MIPS submission reporting. We invited comments on the The following is a summary of the
mechanisms. proposal that if the same measure is public comments received on
calculating total achievement and bonus ways to provide more information on reports for the quality performance
points when using multiple submission the impact of the policy on quality category by using multiple EHRs then
mechanisms proposals and our measure scoring, including through all the submissions would be scored and
responses: provider feedback reports. We refer the quality measures with the highest
Comment: A few commenters readers to section II.C.6.a.(1) of this final performance would be utilized for the
supported the policy to assign high rule with comment period for more quality performance category score. If
priority measures bonus points to all discussion on the delay. the same measure is reported through
measures, with performance greater Comment: A few commenters did not multiple submission mechanisms for
than zero, that meet case minimum, and support the scoring policy for measures the same performance period, then each
that meet data completeness submitted through multiple submission submission would be scored, and only
requirement and to assign measure mechanisms. One commenter cited the highest scored submission would be
bonus points for each unique measure uncertainty in the administration of the applied. We would not aggregate
using end-to-end electronic reporting. policy and recommended it not be multiple submissions of the same
One commenter expressed support for instituted until CMS can demonstrate measure towards the quality
bonus points, agreeing with CMS that the ability to receive data and send performance category score. However,
this would aid future benchmark feedback in a timely and accurate we do not anticipate clinicians will
development. Another commenter manner. Another commenter requested want to submit the same measure
stated that the policy offers the best that CMS re-evaluate its scoring policies through multiple submission
opportunities for eligible clinicians to for the affected MIPS eligible clinicians mechanisms. As discussed in section
perform well and maximize the bonus who do not have the opportunity to II.C.6.a.(1) of this final rule with
points offered. achieve bonus points or take advantage comment period, we are not finalizing
Response: As discussed in section of this policy due to measure scarcity. the proposed multiple data submission
II.C.6.a.(1) of this final rule with One commenter also expressed concerns mechanisms policy beginning with the
comment period, we are not finalizing that potential cross-over measures (that CY 2018 performance period as
the proposal to score multiple is, measures that can be reported proposed, but instead beginning with
mechanisms beginning with the CY through multiple submission the CY 2019 performance period. The
2018 performance period as proposed, mechanisms) limit the ability to capabilities will be in place for us to
but instead beginning with the CY 2019 aggregate the data and shared concerns administer the policy for CY 2019
performance period. To align with that regarding how MIPS eligible clinicians performance period. We do not believe
policy, we are not finalizing for the CY would track their progress across that MIPS eligible clinicians who have
2018 performance period the policy for multiple platforms. One commenter was a scarcity of measures will be
calculating total achievement points and concerned about the difficulty in disadvantaged because of the validation
bonus points when using multiple calculating a quality performance process discussed in section
submission mechanisms, but we are category score via multiple submission II.C.7.a.(2)(e) of this final rule with
finalizing it for the CY 2019 mechanisms. Another expressed comment period would adjust the
performance period and future. We will concern about how the same measure scoring for lack of measures. We refer
continue to review this policy in future submitted through two different readers to section II.C.6.a.(1) of this final
rulemaking. submission mechanisms, during rule with comment period for further
Comment: Several commenters different timeframes would be discussion on the multiple submission
supported taking the highest measure calculated and scored. The commenter mechanism policy, including specialists
achievement point if the same measure stated that calculating a score for half of who report on a specialty set or do not
is submitted via 2 or more mechanisms. the year using one submission have 6 measures to report. Over the next
A few commenters stated that this offers mechanism would not be fair, given the year, we intend to work with and
MIPS eligible clinicians the best MIPS eligible clinician reported for the educate stakeholders regarding this
opportunity to perform well and entire year and it would be important to change and make them aware of any
eliminates the risk that a MIPS eligible rectify as longer reporting durations are potential advantages or disadvantages of
clinician will be penalized for reporting mandatory. One commenter who this policy and discuss how MIPS
the same measure via multiple supported the policy expressed concern eligible clinicians who participate in
mechanisms. Another commenter about the number of MIPS eligible this policy can receive feedback.
remarked that CMS is providing a clinicians who would need to submit Final Action: After consideration of
necessary transition to more robust via multiple mechanisms because of the public comments, we are finalizing our
submission mechanism reporting. One limited number of specialty measure proposal to calculate the total measure
commenter who supported the policy sets that can be reported electronically. achievement and bonus points when
also requested that CMS include in Response: We understand the using multiple submission mechanisms
provider feedback reports eligible commenters concerns with regards to proposals for year 3 to align with the
clinicians scores on all measures burden and complexity around the use multiple submission mechanisms policy
reported via multiple submission of multiple submission mechanisms. We which will be finalized for year 3 and
mechanisms to help MIPS eligible believe that allowing MIPS eligible amend 414.1380(b)(1)(xii) accordingly.
clinicians select submission clinicians to be scored across multiple
mechanisms in future reporting periods. submission mechanisms will provide (ii) Calculating Total Measure
Response: As noted above, we are additional options for MIPS eligible Achievement and Measure Bonus Points
finalizing the implementation of this clinicians to meet the quality for CMS Web Interface Reporters
policy for the 2019 MIPS performance performance category requirement, thus In the CY 2017 Quality Payment
period and future years to align with the maximizing their ability to achieve the Program final rule, we finalized that
multiple submission mechanisms policy highest possible score and encouraging CMS Web Interface reporters are
and so that stakeholders can more fully them to use electronic reporting. We required to report 14 measures, 13
understand the impact of multiple would like to clarify that for individual measures, and a 2-
submissions on the measure performance periods beginning in 2019, component measure for diabetes (81 FR
applicability policies. We will consider if a MIPS eligible clinician or group 77302 through 77305). We noted that for
the transition year, 3 measures did not 425.502(a)(5)). Therefore, we proposed CMS Web Interface measures
have a benchmark in the Shared Savings to amend 414.1380(b)(1)(viii) to add redesignated as pay for reporting by the
Program. Therefore, for the transition that CMS Web Interface measures that Shared Savings Program. We will
year, CMS Web Interface reporters are have a measure benchmark but are communicate with registered CMS Web
scored on 11 of the total 14 required redesignated as pay for reporting for all Interface participants about the re-
measures, provided that they report all Shared Savings Program ACOs by the designation and the changes will be
14 required measures. Shared Savings Program will not be posted on a CMS Web site.
In the CY 2017 Quality Payment scored, as long as the data completeness Final Action: After consideration of
Program final rule, we finalized a global requirement is met. public comments, we are finalizing our
floor of 3 points for all CMS Web We invited comment on our proposal proposal to not score CMS Web
Interface measures submitted in the to not score CMS Web Interface Interface measures redesignated as pay
transition year, even with measures at measures redesignated as pay for for reporting by the Shared Savings
zero percent performance rate, provided reporting by the Shared Savings Program and to amend
that these measures have met the data Program. 414.1380(b)(1)(viii) accordingly.
completeness criteria, have a benchmark We also noted that, while we did not
and meet the case minimum state explicitly in the CY 2017 Quality (i) Scoring Improvement for the MIPS
requirements (82 FR 77305). Therefore, Payment Program final rule, groups that Quality Performance Category Percent
measures with performance below the choose to report quality measures via Score
30th percentile will be assigned a value the CMS Web Interface may, in addition (i) Calculating Improvement at the
of 3 points during the transition year to to the 14 required measures, also submit Quality Performance Category Level
be consistent with the floor established the CAHPS for MIPS survey in the
for other measures and because the quality performance category (81 FR
77094 through 77095; 81 FR 77292). If Program final rule, we noted that we
Shared Savings Program does not
they do so, they can receive bonus consider achievement to mean how a
publish benchmarks below the 30th
points for submitting this high priority MIPS eligible clinician performs relative
percentile (82 FR 77305). We stated that
measure and will be scored on it as an to performance standards, and
we will reassess scoring for measures
additional measure. Therefore, we improvement to mean how a MIPS
below the 30th percentile in future
proposed to amend 414.1380(b)(1)(xii) eligible clinician performs compared to
years.
We proposed to continue to assign 3 to add paragraph (B) to state that groups the MIPS eligible clinicians own
points for measures with performance that submit measures via the CMS Web previous performance on measures and
below the 30th percentile, provided the Interface may also submit and be scored activities in the performance category
measure meets data completeness, has a on CMS-approved survey vendor for (81 FR 77274). We also solicited public
benchmark, and meets the case CAHPS for MIPS submission options. comments in the CY 2017 Quality
minimum requirements for the 2018 In addition, groups of 16 or more Payment Program proposed rule on
MIPS performance year; we made this eligible clinicians that meet the case potential ways to incorporate
proposal in order to continue to align minimum for administrative claims improvement in the scoring
with the 3-point floor for other measures measures will automatically be scored methodology. In the CY 2018 Quality
and because the Shared Savings on the all-cause hospital readmission Payment Program proposed rule (82 FR
Program does not publish benchmarks measure and have that measure score 30096 through 30098), we explained
with values below the 30th percentile included in their quality category why we believe that the options set
(82 FR 30113). We will reassess this performance percent score. forth in the CY 2017 Quality Payment
policy again next year through We did not propose any changes to Program proposed rule, including the
rulemaking. calculating the total measure Hospital VBP Program, the Shared
We did not propose any changes to achievement points and measure bonus Savings Program, and Medicare
our previously finalized policy to points for CMS Web Interface measures Advantage 5-star Ratings Program, were
exclude from scoring CMS Web in the proposed rule, although we not fully translatable to MIPS.
Interface measures that are submitted proposed to add improvement to the Beginning with the 2018 MIPS
but that do not meet the case minimum quality performance category percent performance period, we proposed to
requirement or that lack a benchmark, score for such submissions (as well as score improvement, as well as
or to our policy that measures that are other submission mechanisms) in the achievement in the quality performance
not submitted and measures submitted proposed rule (82 FR 30119 through FR category level when data is sufficient
below the data completeness 30120). (82 FR 30113 through 30114). We
requirements will receive a zero score The following is a summary of the believe that scoring improvement at the
(82 FR 77305). However, to further public comments received on the performance category level, rather than
increase alignment with the Shared scoring for CMS Web Interface proposal measuring improvement at the measure
Savings Program, we proposed to also and our responses: level, for the quality performance
exclude CMS Web Interface measures Comment: A few commenters category would allow improvement to
from scoring if the measure is supported not scoring CMS Web be available to the broadest number of
redesignated from pay for performance Interface measures re-designated as pay MIPS eligible clinicians because we are
to pay for reporting for all Shared for reporting by the Shared Savings connecting performance to previous
Savings Program ACOs, although we Program, citing the need for alignment MIPS quality performance as a whole
will recognize the measure was across programs and consistency with rather than changes in performance for
submitted. While the Shared Savings the goals of the Quality Payment individual measures. Just as we believe
Program designates measures that are Program. One commenter requested that it is important for a MIPS eligible
pay for performance in advance of the CMS clarify which pay for reporting clinician to have the flexibility to
reporting year, the Shared Savings measures will be excluded from MIPS choose measures that are meaningful to
Program may redesignate a measure as Quality Performance category scoring. their practice, we want them to be able
pay for reporting under certain Response: We appreciate commenters to adopt new measures without concern
circumstances (see 42 CFR support for our proposal to not score about losing the ability to be measured
on improvement. In addition, we Comment: Many commenters encourage clinician participation and

encouraged MIPS eligible clinicians to supported improvement scoring at the offset negative payment adjustments for
select more outcome measures and to category level for the quality clinicians acclimating to pay for
move away from topped out measures. performance category score and adding performance programs.
We did not want to remove the the improvement percent score to the Response: We thank the commenters
opportunity to score improvement from quality performance category percent for their support.
those who select different measures score. Many commenters noted it Comment: One commenter requested
between performance periods for the provides a bonus incentive, rather than an increase in the number of bonus
quality performance category; therefore, a penalty for MIPS eligible clinicians. points available for improvement
we proposed to measure improvement Many commenters supported flexibility scoring.
at the category level which can be in measure choice because clinicians Response: We believe that capping the
calculated with different measures. could choose the most clinically improvement percent score at 10
We proposed at relevant measures; the approach is less percentage points is consistent with the
414.1380(b)(1)(xvi)(E) to define an complicated than others; clinicians are bonuses available in the quality
improvement percent score to mean the adjusting to the MIPS program; and performance category and appropriate
score that represents improvement for would encourage clinicians to adopt for rewarding year-to-year improvement
the purposes of calculating the quality more difficult measures. A few in the quality performance category.
commenters believed the approach Comment: One commenter did not
performance category percent score. We
would incentivize clinician progress support the proposed bonus of 10
also proposed at 414.1380(b)(1)(xvi)(C)
toward achieving quality outcomes and percentage points because it is excessive
that an improvement percent score
care efficiency because it would and would penalize consistently high-
would be assessed at the quality
encourage clinicians to move away from performing practices.
performance category level and Response: We disagree with the
included in the calculation of the reporting topped out measures and
begin reporting new, more meaningful characterization of the proposed bonus
quality performance category percent points for improvement as excessive.
score. When we evaluated different quality measures. One commenter noted
it was administratively burdensome to Ten percentage points is consistent with
improvement scoring options, we saw other bonuses in the quality
two general methods for incorporating report new measures; therefore,
clinicians would only change measures performance category and therefore
improvement. One method measures simpler to describe and understand.
both achievement and improvement and if they are relevant and the category
scoring allows them the flexibility to Additionally, we believe it is a
takes the higher of the two scores for sufficient incentive for both high and
each measure that is compared. The change their measures. One commenter
supported the approach because it low performers, appropriately provides
Hospital VBP Program incorporates a larger incentive for low performers to
such a methodology. The second recognizes and encourages higher
standards of quality among all clinicians improve, and will have the greatest
method is to calculate an achievement impact on improving quality for
score and then add an improvement and increases opportunities for
providers to succeed despite challenges beneficiaries.
score if improvement is measured. The Comment: Many commenters did not
Shared Savings Program utilizes a associated with serving patients with
high social risk factors. One commenter support measuring quality improvement
similar methodology for measuring at the performance category level
improvement. For the quality believed that the proposal would
encourage smaller practices to because it could lead to inadvertently
performance category, we proposed to rewarding eligible clinicians who have
participate in the MIPS program.
calculate improvement at the category not improved, but rather selected
Response: We thank the commenters
level and believe adding improvement different measures, and instead
for their support, and we are finalizing
to an existing achievement percent score these policies as proposed. recommended the adoption of a
would be the most straight-forward and Comment: A few commenters measure level approach, which is more
simple way to incorporate supported category level improvement precise. Commenters noted that this
improvement. For the purpose of scoring, but suggested that CMS should would align with the cost performance
improvement scoring methodology, the monitor for the frequency of clinicians category. A few commenters
term quality performance category switching measures, which could recommended that, should CMS
achievement percent score means the potentially warrant consideration of implement a measure level approach,
total measure achievement points alternative approaches, and whether improvement could only be assessed on
divided by the total possible available category level improvement scoring was any measure that meets the data
measure achievement points, without needed in the future. completeness threshold and is reported
consideration of bonus points or Response: We intend to monitor the year over year. One commenter
improvement adjustments and is MIPS scoring methodology, including suggested that CMS restrict
discussed in the proposed rule (82 FR frequency of clinicians switching improvement to MIPS eligible clinicians
30116 through 30117). measures and the need for category level and groups that report on at least half
Consistent with bonuses available in improvement scoring, as the program of the measures reported in the prior
the quality performance category, we transitions. We will address any MIPS performance period during the
proposed at 414.1380(b)(1)(xvi)(B) that changes of improvement scoring current MIPS performance period. One
the improvement percent score may not through future rulemaking. commenter suggested restricting
total more than 10 percentage points. Comment: A few commenters improvement to the first few years that
We invited public comments on these supported the proposed capping of a measure is used because this would
proposals. improvement points at no more than 10 incentivize lower performers to invest
The following is a summary of the percentage points as proposed at time and resources to improve.
public comments received on the 414.1380(b)(1)(xvi)(B). One commenter Response: We appreciate the
proposal for scoring improvement at the supported the proposed 10 percentage commenters concerns with measuring
quality performance category level and points available in the quality improvement at the performance
our responses: performance category because it would category level and support for an
alternative approach to measure taken into account for the quality there will be sufficient measure choice
improvement at the measure level for performance category and the cost and flexibility for clinicians to choose
the quality performance category. We performance category if data sufficient measures that represent areas for
believe that, particularly in the early to measure improvement is available. performance category level
years of MIPS implementation, We do not believe the concerns noted by improvement. In addition, we believe
providing clinicians the flexibility to the commenters make the data that measuring improvement at the
choose the measures for the quality insufficient or unavailable. Please see performance category level will
performance category, rather than a section II.C.7.a.(2)(i)(ii) of this final rule encourage movement away from topped
more restrictive approach that would with comment period for a discussion of out measures toward new high priority
limit the choice of measures, will enable why we believe that data is sufficient to measures that may have additional
them to select measures that are most measure improvement in the quality measure bonus points. We also believe
appropriate for their practice from 1 performance category and a delay is not that improvement should be made
year to the next, will encourage warranted. broadly available to clinicians to
participation in the MIPS program, and Comment: Several commenters encourage MIPS participation, and
will incentivize clinicians to invest in believed the proposed approach adds therefore, do not support restricting
improving their quality of care delivery. complexity because it would be difficult improvement scoring to clinicians that
We believe that restricting improvement to communicate to clinicians, is not submit a specific number of outcomes
scoring to measures which meet data straightforward and transparent, and measures or only outcome measures.
completeness and MIPS eligible clinicians would not understand how Comment: Several commenters
clinicians who reported one or more they are being rewarded for suggested the adoption of alternative
measures over multiple years would improvement. A few commenters approaches to implementing
unduly limit the availability of this believed that the proposed approach is improvement at the performance
incentive, particularly for those who are too new and too complex to ensure that category level, such as the Hospital VBP
transitioning away from topped out quality improvement is being measured Program, because with the proposed
measures. As described in section validly and reliably. category level scoring MIPS eligible
II.C.6.d. of this final rule with comment Response: While improvement is an clinicians could achieve a higher
period, the cost performance category additional factor to be considered in the performance by changing the measures
does not allow for the selection of MIPS quality performance category they choose, whereas with the alternate
measures, so we believe it is appropriate score calculation, we are required to approaches, the stability in the
for the quality performance to have a take improvement into account for the measures reported could foster greater
different methodology. quality performance category and the improvement in those areas, and this
We do not believe our improvement cost performance category if data approach would provide a clearer
scoring methodology will drive sufficient to measure improvement is picture of the change in the quality of
clinicians to select different measures in available. Given the flexibility in quality care over time. A few commenters
order to earn a higher improvement measurement, we wanted to have suggested that CMS develop an
score, nor do we anticipate that improvement scoring be broadly alternative approach that does not put
clinicians will make investments to available to MIPS eligible clinicians. We already-high-performing physicians or
change and excel at quality measures intend to develop additional groups at a disadvantage compared to
solely to earn a higher improvement educational materials to explain the lower-performing practices and that
score. As noted in section improvement scoring. We believe that builds on the existing benchmark
II.C.7.a.(1)(b)(i) of this final rule with encouraging continued improvement in structure. One commenter
comment period, we intend to evaluate clinician quality performance will raise recommended that CMS test each of the
the implementation of improvement the quality of care delivered and benefit proposed methodologies in clinician
scoring for the quality and cost the health outcomes of beneficiaries. practices before introducing them in
performance categories to determine Comment: Several commenters MIPS. One commenter recommended
how the policies we establish in this expressed concerns about the impact of that CMS seek a method that is
final rule with comment period are topped out measures because they straightforward and transparent.
affecting MIPS eligible clinicians. potentially confound the accurate Response: As we described in the CY
Comment: Many commenters measurement of improvement. These 2018 Quality Payment Program
recommended a delay in implementing commenters believed that clinicians proposed rule (82 FR 30096 through
improvement scoring because they should not be penalized for changes in 30098), we do not believe the Hospital
believed that CMS should focus on quality reporting that are out of their VBP Program approach would be
quality reporting and assessment; seek control such as elimination of measures appropriate for MIPS because it does not
feedback and experience; and develop or the learning curve for reporting new reward points for achievement in the
more robust, valid, and accurate sets of measures; believed that specialists same manner and would require
measures. They were also concerned could have difficulty demonstrating significant changes to the scoring
with the consistency of quality measure improvement; and recommended that methodology for the quality
benchmarks. improvement focus on outcome performance category. We continue to
Response: We appreciate the measures. believe that flexibility for clinicians to
commenters concerns related to the Response: We understand the select meaningful measures is
validity and accuracy of current commenters concerns about the impact appropriate for MIPS, especially for the
measure sets and the consistency of of topped out measures and measure quality performance category. The
quality measure benchmark. We also availability and appreciate the Hospital VBP Program methodology,
recognize commenters recommendation recommendation to focus on outcome which relies on consistent measures
of a delay in the implementation of measures. We do not believe that topped from year to year in order to track
improvement scoring to allow for a out measures and the identification and improvement, would limit our ability to
focus on quality reporting and removal of topped out measures will measure improvement in MIPS. As
assessment. Section 1848(q)(5)(D)(i) of significantly impact the accurate noted above, we do not anticipate that
the Act requires improvement to be measurement of improvement because clinicians would change measures
solely for the purposes of improvement difficult to communicate to clinicians improvement is available, then we shall
scoring. We do not expect that there will and would obscure a clinicians overall measure improvement for the quality
be a disadvantage for high performing progress. One commenter believed that performance category. Measuring
clinicians as they already would already the lag time between performance and improvement requires a direct
have a high performance score and are feedback does not allow adequate time comparison of data from one Quality
potentially eligible for improvement. to implement actionable changes the Payment Program year to another.
We believe that improvement scoring drive improvement. Starting with the 2020 MIPS payment
will provide relatively larger incentives Response: We believe that year, we proposed that a MIPS eligible
for lower performers who raise their improvement scoring, while adding a clinicians data would be sufficient to
performance level at a greater rate, but layer of complexity to MIPS scoring score improvement in the quality
we anticipate this will benefit quality overall, is an easy to understand performance category if the MIPS
for beneficiaries. We believe the approach that will provide important eligible clinician had a comparable
proposed approach is transparent and insight into clinician performance from quality performance category
provides clarity on a clinician 1 year to the next. As discussed in achievement percent score for the MIPS
performance from 1 year to the next. section II.C.9.a.(1) of this final rule with performance period immediately prior
Comment: A few commenters comment period, we continue to work to the current MIPS performance period
requested clarity regarding how the on ways to improve performance (82 FR 30114); we explain our proposal
improvement score would be calculated feedback. to identify how we will identify
for clinicians who are changing CEHRT Comment: One commenter comparable quality performance
systems or adopting a CEHRT system. recommended that improvement should category achievement percent scores
Response: Improvement scoring be defined more broadly to encourage below. We noted that we believe that
would not be directly impacted by participants to report new aspects of the this approach would allow
clinicians changing or adopting a MIPS program, participate in pilots, use improvement to be broadly available to
CEHRT system because it would be registries, or other tools that CMS seeks MIPS eligible clinicians and encourage
calculated at the performance category to promote. One commenter continued participation in the MIPS
level. recommended a phased-in approach, program. Moreover, this approach
Comment: One commenter believed such as with a pilot test with a limited would encourage MIPS eligible
that scoring for improvement was number of clinicians. clinicians to focus on efforts to improve
unnecessary because a clinicians Response: We do not believe that that the quality of care delivered. We noted
improvement is reflected in their final reporting or participation by itself meets that, by measuring improvement based
score, which can be compared to the a requirement for improvement for only on the overall quality performance
previous years final score with a higher purposes of the quality performance category achievement percent score,
score, potentially resulting in the category. In addition, our MIPS quality some MIPS eligible clinicians and
clinician receiving a higher payment performance category scoring policies groups may generate an improvement
adjustment. already include bonuses to promote the score simply by switching to measures
Response: We are accounting for use of high priority measures and end- on which they perform more highly,
improvement for the quality to-end electronic reporting. We believe rather than actually improving at the
performance category as required under that a phased-in approach or pilot study same measures. We will monitor how
section 1848(q)(5)(D) of the Act. The would limit the availability of frequently improvement is due to actual
commenter is correct that clinicians improvement scoring, especially to improvement versus potentially
who qualify for improvement scoring clinicians who may best benefit from perceived improvement by switching
would have a higher quality improvement scoring. measures and will address through
performance category achievement Final Action: As a result of the public future rulemaking, as needed. We also
percent score; however, we believe it is comments, we are finalizing as solicited comment on whether we
appropriate to provide an improvement proposed at 414.1380(b)(1)(xvi)(E) to should require some level of year to year
adjustment on top of that score to create define an improvement percent score to consistency when scoring improvement.
incentives for continuous improvement. mean the score that represents We proposed that comparability of
Comment: One commenter believed improvement for the purposes of quality performance category
that the nature of different calculating the quality performance achievement percent scores would be
organizations practices, including category score. We are also finalizing as established by looking first at the
region, payer mix, specialty, and mode proposed at proposed at submitter of the data. As discussed in
of practice, may well require adjusted 414.1380(b)(1)(xvi)(C) that an more detail in the proposed rule (82 FR
treatment of reported scores to ensure improvement percent score would be 300113 through 300114), we are
that a valid measure of improvement is assessed at the quality performance comparing results at the category, rather
being calculated. category level and included in the than the performance measure level
Response: The performance category calculation of the quality performance because we believe that the performance
level approach is based on improvement category percent score. We are also category score from 1 year is comparable
in a MIPS eligible clinicians finalizing as proposed at to the performance category score from
performance from the current MIPS 414.1380(b)(1)(xvi)(B) that the the prior performance period, even if
performance period compared to a improvement percent score may not the measures in the performance
comparable score from the previous total more than 10 percentage points. category have changed from year to
MIPS performance period. Because we year.

are making the comparison to the MIPS (ii) Data Sufficiency Standard to We proposed to compare results from
eligible clinician and not to other Measure Improvement for Quality an identifier when we receive
organizations or practices, we do not see Performance Category submissions with that same identifier
the need to adjust improvement scores Section 1848(q)(5)(D)(i) of the Act (either TIN/NPI for individual, or TIN
in consideration of these factors. stipulates that beginning with the for group, APM entity, or virtual group
Comment: One commenter believed second year to which the MIPS applies, identifier) for two consecutive
the proposed approach would be if data sufficient to measure performance periods. However, if we do
not have the same identifier for 2 group, and APM entity submissions. For period, we would not have a
consecutive performance periods, we individual submissions, if we do not comparable TIN, virtual group, or APM
proposed a methodology to create a have a quality performance category Entity score to use for scoring
comparable performance category score achievement percent score for the same improvement. Therefore, we proposed
that can be used for improvement individual identifier in the immediately to calculate a score by taking the average
measurement. Just as we did not want prior period, then we proposed to apply of the individual quality performance
to remove the opportunity to earn an the hierarchy logic that is described in category achievement scores for the
improvement score from those who section II.C.8.a.(2) of the proposed rule MIPS eligible clinicians that were in the
elect new measures between (82 FR 30146 through 30147) to identify group for the current performance
performance periods for the quality the quality performance category period. If we have more than one quality
performance category, we also did not achievement score associated with the performance category achievement
want to restrict improvement for those final score that would be applied to the percent score for the same individual
MIPS eligible clinicians who elect to TIN/NPI for payment purposes. For identifier in the immediately prior
participate in MIPS using a different example, if there is no historical score period, then we proposed to apply the
identifier. for the TIN/NPI, but there is a TIN score hierarchy logic that is described in
There are times when submissions (because in the previous period the TIN section II.C.8.a.(2) of the proposed rule
from a particular individual clinician or submitted as a group), then we would (82 FR 30146 through 30147) to identify
group of clinicians use different use the quality performance category the quality performance category score
identifiers between 2 years. For achievement percent score associated associated with the final score that
example, a group of 20 MIPS eligible with the TINs prior performance. If the would be applied to the TIN/NPI for
clinicians could choose to submit as a NPI had changed TINs and there was no payment purposes. We would exclude
group (using their TIN identifier) for the historical score for the same TIN/NPI, any TIN/NPIs that did not have a final
current performance period. If the group then we would take the highest prior score because they were not eligible for
also submitted as a group for the score associated with the NPI. MIPS. We would include quality
previous years performance period, we When we do not have a comparable performance category achievement
would simply compare the group scores TIN group, virtual group, or APM Entity percent scores of zero in the average.
associated with the previous score, we proposed to calculate a score
performance period to the current based on the individual TIN/NPIs in the There are instances where we would
performance period (following the practice for the current performance not be able to measure improvement
methodology explained in the proposed period. For example, in a group of 20 due to lack of sufficient data. For
rule (82 FR 30116 through 30117)). clinicians that previously participated example, if the MIPS eligible clinicians
However, if the group members had in MIPS as individuals, but now want did not participate in MIPS in the
previously elected to submit to MIPS as to participate as a group, we would not previous performance period because
individual clinicians, we would not have a comparable TIN score to use for they were not eligible for MIPS, we
have a group score at the TIN level from scoring improvement. We believe could not calculate improvement
the previous performance period to however it is still important to provide because we would not have a previous
which to compare the current to the MIPS eligible clinicians the quality performance category
performance period. improvement points they have earned. achievement percent score.
In circumstances where we do not Similarly, in cases where a group of Table 26 in the proposed rule (82 FR
have the same identifier for 2 clinicians previously participated in 30115) summarized the different cases
consecutive performance periods, we MIPS as individuals, but now when a group or individual would be
proposed to identify a comparable score participates as a new TIN, or a new eligible for improvement scoring under
for individual submissions or calculate virtual group, or a new APM Entity the proposal which we have replicated
a comparable score for group, virtual submitting data in the performance for convenience in Table 23.
TABLE 23PROPOSED ELIGIBILITY FOR IMPROVEMENT SCORING EXAMPLES

Prior MIPS
Current MIPS performance period Eligible for
Scenario performance Identifier improvement Data comparability
period identifier (with score scoring
greater than zero)
No change in identifier ............................. Individual (TIN ....... Individual (TIN ....... Yes ............... Current individual score is compared to
A/NPI 1) A/NPI 1) individual score from prior perform-
ance period.
No change in identifier ............................. Group (TIN A) ........ Group (TIN A) ........ Yes ............... Current group score is compared to
group score from prior performance
period.
Individual is with same group, but selects Individual (TIN ........ Group (TIN A) ........ Yes ............... Current individual score is compared to
to submit as an individual whereas A/NPI 1) the group score associated with the
previously the group submitted as a TIN/NPI from the prior performance
group. period.
Individual changes practices, but sub- Individual (TIN ....... Individual (TIN ........ Yes ............... Current individual score is compared to
mitted to MIPS previously as an indi- B/NPI) A/NPI) the individual score from the prior
vidual. performance period.
Individual changes practices and has Individual (TIN ........ Group (TIN A/NPI); Yes ............... Current individual score is compared to
multiple scores in prior performance C/NPI) Individual (TIN B/ highest score from the prior perform-
period. NPI). ance period.
TABLE 23PROPOSED ELIGIBILITY FOR IMPROVEMENT SCORING EXAMPLESContinued

Prior MIPS
Current MIPS performance period Eligible for
Scenario performance Identifier improvement Data comparability
period identifier (with score scoring
greater than zero)
Group does not have a previous group Group (TIN A) ........ Individual scores Yes ............... The current group score is compared to
score from prior performance period. (TIN A/NPI 1, TIN the average of the scores from the
A/NPI 2, TIN. prior performance period of individ-
A/NPI 3, etc.) uals who comprise the current group.
Virtual group does not have previous Virtual Group (Vir- Individuals (TINA/ Yes ............... The current group score is compared to
group score from prior performance tual Group Identi- NPI 1, TIN A/NPI the average of the scores from the
period. fier A) (Assume 2, TIN B/NPI 1, prior performance period of individ-
virtual group has TIN B/NPI 2). uals who comprise the current group.
2 TINs with 2 cli-
nicians.).
Individual has score from prior perform- Individual (TIN ........ APM Entity (APM Yes ............... Current individual score is compared to
ance period as part of an APM Entity. A/NPI 1) Entity Identifier). the score of the APM entity from the
prior performance period.
Individual does not have a quality per- Individual (TIN ....... Individual was not No ................ The individual quality performance cat-
formance category achievement score A/NPI 1) eligible for MIPS egory score is missing for the prior
for the prior performance period. and did not vol- performance period and not eligible
untarily submit for improvement scoring.
any quality meas-
ures to MIPS.
We proposed at category achievement percent score data sufficiency standard. As required

414.1380(b)(1)(xvi)(A) to state that associated with the final score from the by section 1848(q)(5)(D) of the Act,
improvement scoring is available when prior performance period that will be improvement must be incorporated into
the data sufficiency standard is met, used for payment for each of the the MIPS scoring methodology for the
which means when data are available individuals in the group. As noted 2018 MIPS performance period if data
and a MIPS eligible clinician or group above, the proposals were designed to sufficient to measure improvement is
has a quality performance category offer improvement scoring to all MIPS available. By the end of the 2018 MIPS
achievement percent score for the eligible clinicians with sufficient data in performance period, we will have
previous performance period. We also the prior MIPS performance period. We collected data for the 2017 MIPS
proposed at 414.1380(b)(1)(xvi)(A)(1) invited public comments on our performance period. While this data
that data must be comparable to meet proposals as they relate to data may have limitations due to the pick
the requirement of data sufficiency, sufficiency for improvement scoring. your pace transition, clinicians will
which means that the quality We also sought comment on an have a quality performance category
performance category achievement alternative to the proposal: whether we achievement percent score which is
percent score is available for the current should restrict improvement to those sufficient to measure quality. As
performance period and the previous who submit quality performance data discussed in section II.C.7.a.(2)(i)(ii) of
performance period and, therefore, using the same identifier for two this final rule with comment period, we
quality performance category consecutive MIPS performance periods. should not be similarly limited in the
achievement percent scores can be We believed this option would be availability of sufficient data for year 2.
compared. We also proposed at simpler to apply, communicate and Comment: Several commenters
414.1380(b)(1)(xvi)(A)(2) that quality understand than our proposal is, but supported the proposal for a comparable
performance category achievement this alternative could have the identifier because this approach would
percent scores are comparable when unintended consequence of not not penalize clinicians changing jobs,
submissions are received from the same allowing improvement scoring for changes in group composition, or new
identifier for two consecutive certain MIPS eligible clinicians, groups, elections to report as a group. One
performance periods. We also proposed virtual groups and APM entities. commenter believed this approach
an exception at The following is a summary of the would support the establishment of
414.1380(b)(1)(xvi)(A)(3) that if the public comments received on our virtual groups. One commenter believed
identifier is not the same for 2 proposals related to data sufficiency for limitations to the same identifier would
consecutive performance periods, then improvement scoring and our responses: restrict those eligible for improvement.
for individual submissions, the Comment: Many commenters believed Response: We thank the commenters
comparable quality performance there was not sufficient data to score for their support. We agree that this
category achievement percent score is improvement because MIPS data has not approach provides flexibility for
the quality performance category yet been collected, the data in pick- clinicians to allow for changes in their
achievement percent score associated your-pace approach for the 2017 MIPS practice that could include establishing
with the final score from the prior performance period may not be and reporting as part of a virtual group.
performance period that will be used for representative, and some practices may Comment: A few commenters
payment. For group, virtual group, and not understand that they must fully recommended restricting improvement
APM entity submissions, the participate in the quality category in to those who submit quality
comparable quality performance order to receive an improvement score. performance data using the same
category achievement percent score is Response: We disagree that there is identifier for two consecutive MIPS
the average of the quality performance not enough data collected to meet the performance periods as it is a simpler
approach and easier to understand. One which means when data are available measure is not available, and meeting
commenter supported restricting and a MIPS eligible clinician has a the 60 percent data completeness
improvement to those MIPS eligible quality performance category criteria for each of the 6 measures.
clinicians who use the same identifier achievement percent score for the We believe that improvement is most
and same mechanism of reporting for previous performance period and the meaningful and valid when we have a
two consecutive performance periods. current performance period. We are also full set of quality measures. A
One commenter requested clarification finalizing as proposed at comparison of data resulting from full
on the impact on group practices when 414.1380(b)(1)(xvi)(A)(1) that data participation of a MIPS eligible clinician
the entity was participating in an APM must be comparable to meet the from 1 year to another enables a more
entity in the prior performance period. requirement of data sufficiency, which accurate assessment of improvement
One commenter believed that tracking means a quality performance category because the performance being
different identifiers would require achievement percent score is available compared is based on the applicable
physicians to factor in additional for the current and previous and available measures for the
considerations when they are just trying performance periods and quality performance periods and not from
to learn the program, such as the performance category achievement changes in participation. While we did
requirement that MIPS eligible percent scores can be compared. We are not require full participation for both
clinicians must fully participate in the also finalizing as proposed at performance periods, requiring full
quality performance category in order to 414.1380(b)(1)(xvi)(A)(2) that the participation for the current
receive an improvement score. One quality performance category performance period means that any
commenter expressed concerns that the achievement percent scores are future improvement scores for a
requirement for data from two comparable when submissions are clinician or group would be derived
consecutive performance periods for received from the same identifier for solely from changes in performance and
specific clinicians may reward stable two consecutive performance periods. not because the clinician or group
and high performing practices and We are also finalizing as proposed at submitted more measures. We proposed
clinicians while struggling practices 414.1380(b)(1)(xvi)(A)(3) that if the at 414.1380(b)(1)(xvi)(C)(5) that the
with high turnover rates may fall further identifier is not the same for 2 quality improvement percent score is
behind. One commenter believed that consecutive performance periods, then zero if the clinician did not fully
tracking clinician scores from previous for individual submissions, the participate in the quality performance
years would increase the overhead costs comparable quality performance category for the current performance
for Qualified Registries and QCDRs. category achievement percent score is period.
Response: Within MIPS, we must the highest available quality Because we want to award
balance complexity with flexibility. We performance category achievement improvement for net increases in
believe improvement scoring should be percent score associated with the final performance and not just improved
available to the broadest number of score from the prior performance period participation in MIPS, we want to
eligible clinicians to incentivize that will be used for payment for the measure improvement above a floor for
increases in the quality performance individual. For group, virtual group, the 2018 MIPS performance period, to
category scores and have the greatest and APM Entity submissions, the account for our transition year policies.
impact on increasing quality of care. comparable quality performance We considered that MIPS eligible
Thus, we have provided for the use of category achievement percent score is clinicians who chose the test option
a comparable identifier when we do not the average of the quality performance of the pick your pace approach for the
have the same identifier from 1 year to category achievement percent score transition year may not have submitted
another. Table 23 summarizes different associated with the final score from the all the required measures and, as a
cases when a group or individual would prior performance period that will be result, may have a relatively low quality
be eligible for improvement scoring used for payment for each of the performance category achievement score
under our proposal including when we individuals in the group. for the 2017 MIPS performance period.
do not have identical identifiers. For a Due to the transition year policy to
MIPS eligible clinician reporting as an (iii) Additional Requirement for Full award at least 3 measure achievement
individual in the current performance Participation To Measure Improvement points for any submitted measure via
period who reported as part of an APM for Quality Performance Category claims, EHR, QCDR, qualified registry,
entity in the previous performance To receive a quality performance and CMS-approved survey vendor for
period, we would use the score of the category improvement percent score CAHPS for MIPS, and the 3-point floor
APM entity as a point of comparison greater than zero, we also proposed that for the all-cause readmission measure (if
with the MIPS eligible clinicians score MIPS eligible clinicians must fully the measure applies), a MIPS eligible
in the current performance period to participate, which we proposed in clinician that submitted some data via
determine eligibility for improvement. 414.1380(b)(1)(xvi)(F) to mean these mechanisms on the required
Improvement scoring can only increase compliance with 414.1330 and number of measures would
a quality performance category score, 414.1340, in the current performance automatically have a quality
not decrease it. The burden to track and year (81 FR 30116). Compliance with performance category achievement score
calculate this score will not impact those referenced regulations entails the of at least 30 percent because they
external stakeholders and should not submission of all required measures, would receive at least 3 of 10 possible
impact clinician decisions on how to including meeting data completeness, measure achievement points for each
submit data, as our systems will help do for the quality performance category for required measure. For example, if a solo
the tracking of clinician scores from the current performance period. For practitioner submitted 6 measures and
previous years. example, for MIPS eligible clinicians received 3 points for each measure, then
Final Action: As a result of the public submitting via QCDR, full participation the solo practitioner would have 18
comments, we are finalizing as would generally mean submitting 6 measure achievement points out of a
proposed at 414.1380(b)(1)(xvi)(A) that measures including 1 outcome measure possible 60 total possible measure
improvement scoring is available when if an outcome measure is available or 1 achievement points (3 measure
the data sufficiency standard is met high priority measure if an outcome achievement points 6 measures). The
quality performance category full participation will add complexity eligible for improvement scoring and
achievement percent score is 18/60 when clinicians are trying to learn the have data available for future
which equals 30 percent. For groups program and may not understand that performance measurement. In addition,
with 16 or more clinicians that they must fully participate in the quality our proposal to measure improvement
submitted 6 measures and receive 3 performance category in order to receive above 30 percent helps to ensure that
measure achievement points for each an improvement score. One commenter we are measuring true changes in
submitted measure as well as the all- recommended a separate improvement performance and not just changes in the
cause hospital readmission measure, calculation or bonus for clinicians who level of participation.
then the group would have 21 measure do not meet full participation for the Comment: A few commenters
achievement points out of 70 total early years of MIPS performance supported the implementation of
possible measure achievement points or because incentivizing incremental additional requirements for
a quality performance category increases in performance in the early improvement scoring, including the
achievement percent score of 21/70 years will be an important way to requirement of participation during the
which equals 30 percent (3 measure encourage clinicians and groups to transition year at a level to achieve a
achievement points 7 measures). For participate in MIPS without adding too quality category achievement percent
the CMS Web Interface submission much administrative burden in a single score of at least 30 percent. A few
option, MIPS eligible clinicians that year. commenters suggested that
fully participate by submitting and Response: We understand that adding improvement bonuses only be available
meeting data completeness for all in the full participation requirement to those who fully participate in both
measures, would also be able to achieve adds a layer of complexity; however, the current and the previous year to
a quality performance category MIPS is required to measure close this loophole. One commenter
achievement percent score of at least 30 performance, not participation. We note suggested that 30 percent should be the
percent, as each scored measure would that full participation would generally minimum improvement score
receive 3 measure achievement points mean submitting 6 measures, including percentage floor because it would
out of 10 possible measure achievement 1 outcome measure if available, or 1 encourage continued participation by
points. high priority measure if an outcome clinicians, including specialists.
Therefore, we proposed at measure is not available, and meeting Response: As noted earlier, we
414.1380(b)(1)(xvi)(C)(4) that if a MIPS the data completeness criteria for each disagree that the clinicians should need
eligible clinician has a previous year of the 6 measures; for eligible clinicians to have fully participated in the prior
quality performance category score less who do not have 6 measures available period in order to be measured for
than or equal to 30 percent, we would or applicable, full participation is met improvement. We think our proposal to
compare 2018 performance to an by submitting the measures that are require full participation in the current
assumed 2017 quality performance available and applicable and the data performance period and not necessarily
category achievement percent score of completeness requirement for those the prior performance period creates an
30 percent. In effect, for the MIPS 2018 submitted measures. We do not believe additional incentive to fully participate
performance period, improvement increased participation is sufficient in the current performance period in
would be measured only if the enough to warrant receiving an order to be eligible for improvement
clinicians 2018 quality performance improvement score, and we believe that scoring and have data available for
category achievement percent score for we need the full participation future performance measurement. We
the quality performance category requirement to ensure that we are also believe improvement scoring
exceeds 30 percent. We believe this capturing data that can be used to should be available to the broadest
approach appropriately recognizes the measure performance. number of eligible clinicians to
participation of MIPS eligible clinicians Comment: One commenter suggested incentivize increases in the quality
who participated in the transition year that the regulatory language be changed performance category scores and have
and accounts for MIPS eligible to: 414.1380(b)(1)(xvi)(A) the greatest impact on increasing quality
clinicians who participated minimally Improvement scoring is available when of care. In addition, our proposal to
and may otherwise be awarded for an the data sufficiency standard is met, measure improvement above 30 percent
increase in participation rather than an which means when data are available helps to ensure that we are measuring
increase in achievement performance. and a MIPS eligible clinician fully true changes in performance and not
We invited public comment on these participated in the previous just changes in participation.
proposals. performance period. This references the Final Action: As a result of the public
The following is a summary of the definition of fully participate given in comments, we are finalizing as
public comments received on our 414.1380(b)(1)(xvi)(F): For the purpose proposed that MIPS eligible clinicians
proposal for full participation related to of improvement scoring methodology, must fully participate, which we
improvement scoring and our responses: the term fully participate means the propose in 414.1380(b)(1)(xvi)(F) to
Comment: Several commenters MIPS eligible clinician met all mean compliance with 414.1330 and
supported the requirement for full requirements in 414.1330 and 414.1340, in the current performance
participation in the performance period. 414.1340. year. We are also finalizing as proposed
Response: We appreciate your support Response: We disagree that the at 414.1380(b)(1)(xvi)(C)(5) that the
of our proposal. clinicians should need to have fully quality improvement percent score is
Comment: One commenter requested participated in the prior period in order zero if the clinician did not fully
the expansion of the eligibility criteria to have sufficient data to measure participate in the quality performance
to include those clinicians that were improvement. We believe our proposal category for the current performance
unable to report complete data in the to require full participation in the period. We are also finalizing as
previous year because moving from current performance period and not proposed at 414.1380(b)(1)(xvi)(C)(4)
incomplete data to complete data in 1 necessarily the prior performance that if a MIPS eligible clinician has a
year is a significant achievement and period creates an additional incentive to previous year quality performance
should be recognized by CMS. One fully participate in the current category score less than or equal to 30
commenter believed the requirement of performance period in order to be percent, we would compare 2018
performance to an assumed 2017 quality improvement percent score adjustments performance category recognizes the
performance category achievement made to the category score in the prior rate of increase in quality performance
percent score of 30 percent. or current performance period are not category scores of MIPS eligible
taken into account when determining clinicians from one performance period
(iv) Measuring Improvement Based on
whether an improvement has occurred to another performance period so that a
Changes in Achievement
or the size of any improvement percent higher rate of improvement results in a
To calculate improvement with a score. higher improvement percent score. We
focus on quality performance, we We invited public comment on our believe this is particularly true for those
proposed to focus on improvement proposal to award improvement based clinicians with lower performance who
based on achievement performance and on changes in the quality performance will be incentivized to begin improving
would not consider measure bonus category achievement percent score. with the opportunity to increase their
points in our improvement algorithm The following is a summary of the improvement significantly and achieve
(82 FR 30116 through 30117). Bonus public comments received on our a higher improvement percent score.
points may be awarded for reasons not proposal to measure improvement based We proposed to award an
directly related to performance such as on changes in achievement in the improvement percent score based on
the use of end-to-end electronic quality performance category and our the following formula:
reporting. We believe that improvement responses: Improvement percent score = (increase
points should be awarded based on Comment: A few commenters agreed in quality performance category
improvement related to achievement. with not including bonus points in the achievement percent score from
Accordingly, we are proposing to use an calculation. prior performance period to current
individual MIPS eligible clinicians or Response: We appreciate the support performance period/prior
groups total measure achievement of our proposal. performance period quality
points from the prior MIPS performance Comment: One commenter
performance category achievement
period without the bonus points the recommended including the bonus for
percent score) *10 percent.
individual MIPS eligible clinician or end-to-end electronic reporting in the
calculation for the improvement percent In the proposed rule (82 FR 30117),
group may have received, to calculate we provided an example of how to score
improvement. Therefore, to measure score. One commenter suggested
counting bonus points for scenarios the improvement percent score. We
improvement at the quality performance noted that we believe that this
category level, we will use the quality where additional outcome or high
priority measures are reported because improvement scoring methodology
performance category achievement provides an easily explained and
percent score excluding measure bonus the bonus point does have a stronger tie
to performance and will help provide applied approach that is consistent for
points (and any improvement score) for all MIPS eligible clinicians.
the applicable years. We proposed at incentives for eligible clinicians to move
toward reporting of more outcome Additionally, it provides additional
414.1380(b)(1)(xvi)(D) to call this incentives for MIPS eligible clinicians
score, which is based on achievement measures in the future.
Response: We appreciate your who are lower performers to improve
only, the quality performance category performance. We believe that providing
achievement percent score which is suggestions to incorporate bonus points
into improvement scoring, but MIPS larger incentives for MIPS eligible
calculated using the following formula: clinicians with lower quality
Quality performance category already has bonuses to reward end-to-
end electronic reporting and high performance category scores to improve
achievement percent score = total will not only increase the quality
measure achievement points/total priority measures. We do not believe it
would be appropriate to reward changes performance category scores but also
available measure achievement will have the greatest impact on
points. in the quality performance due to these
bonuses. improving quality for beneficiaries.
The current MIPS performance period Final Action: As a result of the public We also proposed that the
quality performance category comments, we are finalizing as improvement percent score cannot be
achievement percent score is compared proposed to amend the regulatory text at negative (that is, lower than zero
to the previous performance period 414.1380(b)(1)(xvi) to state that percentage points). The improvement
quality performance category improvement scoring is available to percent score would be zero for those
achievement percent score. If the MIPS eligible clinicians that who do not have sufficient data or who
current score is higher, the MIPS demonstrate improvement in are not eligible under our proposal for
eligible clinician may qualify for an performance in the current MIPS improvement points. For example, a
improvement percent score to be added performance period compared to the MIPS eligible clinician would not be
into the quality performance category performance in the previous MIPS eligible for improvement if the clinician
percent score for the current performance period, based on measure was not eligible for MIPS in the prior
performance year. Table 27 of the achievement points. performance period and did not have a
proposed rule (82 FR 30117) illustrated We are also finalizing as proposed to quality performance category
how the quality performance category call the score at 414.1380(b)(1)(xvi)(D), achievement percent score. We also
achievement percent score is calculated. which is based on achievement only, proposed to cap the size of the
We proposed to amend the regulatory the quality performance category improvement award at 10 percentage
text at 414.1380(b)(1)(xvi) to state that achievement percent score, which is points, which we believe appropriately
improvement scoring is available to calculated using the formula as rewards improvement and does not
MIPS eligible clinicians and groups that proposed. outweigh percentage points available
demonstrate improvement in through achievement. In effect, 10
performance in the current MIPS (v) Improvement Scoring Methodology percentage points under our proposed
performance period compared to the for the Quality Performance Category formula would represent 100 percent
performance in the previous MIPS We noted that we believe the improvementor doubling of
performance period, based on improvement scoring methodology that achievement measure pointsover the
achievement. Bonus points or we are proposing for the quality immediately preceding period. For the
reasons stated, we anticipated that this determined by an improvement in the improvement are awarded to MIPS
amount will encourage participation by quality performance category eligible clinicians whose category scores
individual MIPS eligible clinicians and achievement percent score from 1 year improved across years according to the
groups and will provide an appropriate to the next year to determine band level, up to a maximum of 10
recognition and award for the largest improvement in the same manner as set percent of the total score. In Table 29 of
increases in performance improvement. forth in the rate of improvement the proposed rule (82 FR 30118), we
Table 28 of the proposed rule (82 FR methodology. However, for the band illustrated the band levels we
30118), and included in Table 24, level methodology, an improvement considered as part of this alternative
illustrated examples of the proposed percent score would then be assigned by proposal. Table 30 of the proposed rule
improvement percent scoring taking into account a portion (50, 75 or (82 FR 30119) illustrated examples of
methodology, which is based on rate of 100 percent) of the improvement in the improvement scoring methodology
increase in quality performance category achievement, based on the clinicians based on band levels. Generally, this
achievement percent scores. We also performance category achievement methodology would generate a higher
considered an alternative to measuring percent score for the prior performance improvement percent score for
the rate of improvement. The alternative period. Bands would be set for category clinicians; however, we noted that we
would use band levels to determine the achievement percent scores, with believe the policy we proposed would
improvement points for MIPS eligible increases from lower category provide a score that better represents
clinicians who qualify for improvement achievement scores earning a larger true improvement at the performance
points. Under the band level portion (percentage) of the improvement category level, rather than comparing
methodology, a MIPS eligible clinicians points. Under this alternative, simple simple increases in performance
improvement points would be improvement percentage points for category scores.
TABLE 24IMPROVEMENT SCORING EXAMPLES BASED ON RATE OF INCREASE IN QUALITY PERFORMANCE CATEGORY
ACHIEVEMENT PERCENT SCORES
Year 2 quality
Year 1 quality performance performance
category achievement category Increase in improvement Rate of improvement Improvement percent score
percent score achievement
percent score
Individual Eligible Clinician 5% (Will substitute 30% 50 20% Because the year 1 20%/30% = 0.67 ................ 0.67 * 10% = 6.7% No cap
#1 (Pick your Pace Test which is the lowest score score is below 30%, we needed.
Option). a clinician can achieve measure improvement
with complete reporting above 30%.
in year 1.).
Individual Eligible Clinician 60% .................................... 66 6% ...................................... 6%/60% = 0.10 .................. 0.10 * 10% = 1.0% No cap
#2. needed.
Individual Eligible Clinician 90% .................................... 93 3% ...................................... 3%/90% = 0.033 ................ 0.033 * 10% = 0.3% No
#3. cap needed.
Individual Eligible Clinician 30% .................................... 70 40% .................................... 40%/30% = 1.33 ................ 1.33 * 10% = 13.3% Apply
#4. cap at 10%.
In addition, we considered another improvement score approach would level approach for all quality
alternative that would adopt the align MIPS with these other programs. performance category scores encourages
improvement scoring methodology of We believed it could be beneficial to a uniformity in our approach to
the Shared Savings Program 7 for CMS align improvement between the improvement scoring and simplifies the
Web Interface submissions in the programs because it would align scoring rules for MIPS eligible
quality performance category, but incentives for those who participate in clinicians. It also allows us greater
decided to not adopt this approach. the Shared Savings Program or ACOs. flexibility to compare performance
Under the Shared Savings Program The Shared Savings Program approach scores across the diverse submission
approach, eligible clinicians and groups would test each measure for statistically mechanisms, which makes
that submit through the CMS Web significant improvement or statistically improvement scoring more broadly
Interface would have been required to significant decline. We would sum the available to eligible clinicians and
submit on the same set of quality number of measures with a statistically groups that elect different ways of
measures, and we would have awarded significant improvement and subtract participating in MIPS.
improvement for all eligible clinicians the number of measures with a We proposed to add regulatory text at
or groups who submitted complete data statistically significant decline to 414.1380(b)(1)(xvi)(C)(3) to state that
in the prior performance period. As determine the Net Improvement. We an improvement percent score cannot be
Shared Savings Program and Next would next divide the Net Improvement negative (that is, lower than zero
Generation ACOs report using the CMS in each domain by the number of percentage points). We also proposed to
Web Interface, using the same eligible measures in the domain to add regulatory text at
calculate the Improvement Score. We 414.1380(b)(1)(xvi)(C)(1) to state that
7 For additional information on the Shared would cap the number of possible improvement scoring is awarded based
Savings Programs scoring methodology, we refer improvement percentage points at 10.
readers to the Quality Measurement Methodology
on the rate of increase in the quality
and Resources, September 2016, Version 1 and the We considered the Shared Savings performance category achievement
Medicare Shared Savings Program Quality Measure Program methodology because it would percent score of individual MIPS
Benchmarks for the 2016 and 2017 Reporting Years promote alignment with ACOs. We eligible clinicians or groups from the
(available at https://www.cms.gov/Medicare/
Medicare-Fee-for-Service-Payment/
ultimately decided not to adopt this current MIPS performance period
sharedsavingsprogram/Downloads/MSSP-QM- scoring methodology because we believe compared to the score in the year
Benchmarks-2016.pdf). having a single performance category immediately prior to the current MIPS
performance period. We also proposed the quality performance category scores percent score of individual MIPS
to add regulatory text at and address any changes through future eligible clinicians from the previous
414.1380(b)(1)(xvi)(C)(2) to state that rulemaking. performance period to the current
an improvement percent score is Comment: One commenter believed performance period. We also are
calculated by dividing the increase in that the rate of improvement mainly finalizing as proposed to add
the quality performance category benefits lower performers who show requirements at
achievement percent score of an improvement. One commenter believed 414.1380(b)(1)(xvi)(C)(2) to state that
individual MIPS eligible clinician or that the proposed methodology an improvement percent score is
group, which is calculated by disadvantages clinicians who are calculated by dividing the increase in
comparing the quality performance already performing well in the program. the quality performance category
category achievement percent score the One commenter believed that this achievement percent score of an
current MIPS performance period to the approach might discourage high- individual MIPS eligible clinician or
quality performance category performing practices from continuing to group, which is calculated by
achievement percent score from the invest in their practices to achieve comparing the quality performance
MIPS performance period in the year small, incremental, yet vital category achievement percent score
immediately prior to the current MIPS improvements in quality. One from the prior performance period to the
performance period, by the prior commenter requested an alternative current performance period, by the prior
performance period quality performance approach that would more equitably performance periods quality
category achievement percent score, and incentivize clinicians at all-stages of performance category achievement
multiplying by 10 percent. practice transformation to value-based percent score, and multiplying by 10
We invited public comments on our care and to continuously improve their percent.
proposal to calculate improvement performance.
scoring using a methodology that Response: While we understand the (j) Calculating the Quality Performance
awards improvement points based on commenters concerns, we believe the Category Percent Score Including
the rate of improvement and, improvement methodology provides an Improvement
alternatively, on rewarding adequate incentive and award for In the CY 2017 Quality Payment
improvement at the band level or using improvement in performance for high Program final rule, we finalized at
the Shared Savings Program approach performers and low performers and 414.1380(b)(1)(xv) that the quality
for CMS Web Interface submissions. encourages movement toward value- performance category score is the sum
The following is a summary of the based care. Improvement is available to of all points assigned for the measures
public comments received on our all clinicians, although initially the required for the quality performance
proposal for the methodology to chance to improve is higher for those category criteria plus bonus points,
calculate improvement of the quality who either low-performers or those who divided by the sum of total possible
performance category and our response: have not participated before. We believe points (81 FR 77300). Using the
Comment: Many commenters that increasing the scores for those who terminology proposed in section
supported the proposed rate of increase raise their performance level at a greater II.C.7.a.(2) of the proposed rule (82 FR
for measuring improvement. Several rate will have the greatest impact on 30098 through 30099), this formula can
commenters believed it is fairer and quality for beneficiaries. be represented as:
easier to understand the rate of Comment: A few commenters
improvement instead of the supported the band methodology over Quality performance category percent
improvement at the band level. One the proposed methodology for score = (total measure achievement
commenter believed that the proposed calculating improvement because points + measure bonus points)/
methodology more accurately captures clinicians with high performance who total available measure achievement
improvement levels than the band level demonstrate even modest improvement points.
methodology and would provide more should benefit from improvement We proposed to incorporate the
equivalent scoring because the band scoring. improvement percent score, which was
level methodology provides less Response: We agree that the band proposed in section II.C.7.a.(2)(i)(i) of
opportunity to improve scores for high methodology is a viable approach; the proposed rule (82 FR 30113 through
performers. One commenter believed however, given the general support for 30114), into the quality performance
the band level and the Shared Savings our proposal, we are finalizing our category percent score. We proposed to
Program approach for CMS Web proposal of using rate of increase in amend 414.1380(b)(1)(xv)
Interface submissions are too complex. achievement. (redesignated as 414.1380(b)(1)(xvii))
One commenter believed the rate of Final Action: As a result of the public to add the improvement percent score
improvement appropriately incentivizes comments, we are finalizing as (as calculated pursuant to proposed
lower performers to improve their proposed to base the improvement paragraph (b)(1)(xvi)(A) through (F)) to
performance. One commenter believed percent score on the rate of increase in the quality performance score. We also
the proposed approach redresses achievement methodology. We are proposed to amend 414.1380(b)(1)(xv)
inadvertent biases that would otherwise finalizing as proposed to add (redesignated as 414.1380(b)(1)(xvii))
disadvantage smaller specialty, rural, requirements at to amend the text that states the quality
and other professionals. 414.1380(b)(1)(xvi)(C)(3) to state that performance category percent score
Response: We appreciate the an improvement percent score cannot be cannot exceed the total possible points
commenters support for our proposal. negative (that is, lower than zero for the quality performance category to
Comment: One commenter suggested percentage points). We also are clarify that the total possible points for
adjustments in future years based on an finalizing as proposed to add a the quality performance category cannot
analysis of the impact of the current requirement at exceed 100 percentage points. Thus, the
proposal on practices and their ability to 414.1380(b)(1)(xvi)(C)(1) to state that calculation for the proposed quality
ramp up to full reporting. improvement scoring is awarded based performance category percent score
Response: We will monitor the impact on the rate of increase in the quality including improvement, can be
of the rate of increase methodology on performance category achievement summarized in the following formula:
Quality performance category percent FR 77309), we codified at propose any changes to the
score = ([total measure achievement 414.1380(b)(2) that a MIPS eligible methodology for scoring achievement in
points + measure bonus points]/ clinician receives 1 to 10 achievement the cost performance category for the
total available measure achievement points for each cost measure attributed 2020 MIPS payment year other than the
points) + improvement percent to the MIPS eligible clinician based on method used for facility-based
score, not to exceed 100 percent. the MIPS eligible clinicians measurement described in the CY 2018
This same formula and logic will be performance compared to the measure Quality Payment Program proposed rule
applied for both CMS Web Interface and benchmark. We establish a single (82 FR 30128 through 30132). We
Non-CMS Web Interface reporters. benchmark for each cost measure and proposed a change in terminology to
Table 31 of the proposed rule (82 FR base those benchmarks on the refer to the cost performance category
30120) illustrated an example of performance period (81 FR 77309). percent score in order to be consistent
calculating the quality performance Because we base the benchmarks on the with the terminology used in the quality
category percent score including performance period, we will not be able performance category (82 FR 30120). We
improvement for a non-CMS Web to publish the actual numerical proposed to revise 414.1380(b)(2)(iii)
Interface reporter. We noted that the benchmarks in advance of the to provide that a MIPS eligible
quality performance category percent performance period (81 FR 77309). We clinicians cost performance category
score is then multiplied by the develop a benchmark for a cost measure percent score is the sum of the
performance category weight for only if at least 20 groups (for those MIPS following, not to exceed 100 percent:
calculating the points towards the final eligible clinicians participating in MIPS The total number of achievement points
score. as a group practice) or TIN/NPI earned by the MIPS eligible clinician
We invited public comment on this combinations (for those MIPS eligible divided by the total number of available
overall methodology and formula for clinicians participating in MIPS as an achievement points (which can be
calculating the quality performance individual) can be attributed the case expressed as a percentage); and the cost
category percent score. minimum for the measure (81 FR improvement score (82 FR 30121). This
The following is a summary of the 77309). If a benchmark is not developed, terminology change to refer to the score
public comments received on the the cost measure is not scored or as a percentage is consistent with the
Calculating the Quality Performance included in the performance category proposed change in the CY 2018 Quality
Category Percent Score Including (81 FR 77309). For each set of Payment Program proposed rule (82 FR
Improvement proposals and our benchmarks, we calculate the decile 30099) for the quality performance
responses: breaks based on cost measure category. We discussed the proposals for
Comment: Several commenters performance during the performance improvement scoring in the cost
supported the quality category period and assign 1 to 10 achievement performance category in of the CY 2018
improvement scoring formula. points for each measure based on which Quality Payment Program proposed rule
Response: We appreciate the benchmark decile range the MIPS (82 FR 30121).
commenters support of our proposal. eligible clinicians performance on the The following is a summary of the
Final Action: As a result of the public measure is between (81 FR 77309 public comments received on these
comments, we are finalizing as through 77310). We also codified at proposals and our responses:
proposed to incorporate the 414.1380(b)(2)(iii) that a MIPS eligible Comment: Several commenters
improvement percent score, which was clinicians cost performance category supported the addition of improvement
proposed in section II.C.7.a.(2)(i)(i) of score is the equally-weighted average of scoring in the cost performance
the proposed rule (see 82 FR 30113 all scored cost measures (81 FR 77311). category, noting that it was consistent
through 30114), into the quality In the CY 2017 Quality Payment with the statutory requirements.
performance category percent score. We Program final rule (81 FR 77311), we Response: We thank the commenters
are also finalizing as proposed to amend adopted a final policy to not calculate for their support.
414.1380(b)(1)(xv) (redesignated as a cost performance category score if a Comment: Several commenters
414.1380(b)(1)(xvii)) to add the MIPS eligible clinician or group is not opposed the proposal to add
improvement percent score (as attributed any cost measures because improvement scoring in the cost
calculated pursuant to proposed the MIPS eligible clinician or group has performance category for the 2020 MIPS
paragraph (b)(1)(xvi)(A) through (F)) to not met the case minimum requirements payment year. Many of these
the quality performance score. We are for any of the cost measures or a commenters expressed concern with the
also finalizing as proposed to amend benchmark has not been created for any measures used in the cost performance
414.1380(b)(1)(xv) (redesignated as of the cost measures that would category, suggesting that the measures
414.1380(b)(1)(xvii) to amend the text otherwise be attributed to the clinician were not well suited to determine
that states the quality performance or group. We inadvertently failed to achievement and therefore not suitable
category percent score cannot exceed include this policy in the regulation text to determine improvement. A few
the total possible points for the quality and proposed to codify it under commenters recommended that
performance category to clarify that the 414.1380(b)(2)(v) (82 FR 30120). clinicians be given more time to
total possible points for the quality For more of the statutory background understand cost measures before
performance category cannot exceed 100 and descriptions of our current policies assessing improvement. A few
percentage points. for the cost performance category, we commenters expressed concern that this
refer readers to the CY 2017 Quality increased the complexity of scoring in
(3) Scoring the Cost Performance Payment Program final rule (81 FR the cost performance category. A few
Category 77308 through 77311). commenters suggested that
We score the cost performance In the CY 2018 Quality Payment improvement scoring should not be
category using a methodology that is Program proposed rule (82 FR 30098), added until episode-based measures
generally consistent with the we proposed to add improvement were included as cost measures.
methodology used for the quality scoring to the cost performance category Response: We understand the
performance category. In the CY 2017 scoring methodology starting with the concerns with adding improvement
Quality Payment Program final rule (81 2020 MIPS payment year. We did not scoring to the cost performance
category. We have recognized that improvement in performance in the on the part of clinicians in reviewing
clinicians still need time to better current MIPS performance period and understanding their contribution to
understand cost measures, as well as compared to their performance in the patient costs, we believed that
our method of scoring them. Under our immediately preceding MIPS improvement should be evaluated only
proposed methodology for scoring performance period (for example, when there is a consistent identifier.
improvement, only two cost measures demonstrating improvement in the 2018 Therefore, for the cost performance
would be eligible for improvement MIPS performance period over the 2017 category, we proposed at
scoring for the 2018 MIPS performance MIPS performance period). 414.1380(b)(2)(iv)(B) that we would
period. Many clinicians will not be In the CY 2018 Quality Payment calculate a cost improvement score only
scored on those two cost measures Program proposed rule (82 FR 30113 when data sufficient to measure
because they will not meet the case through 30114), we noted the various improvement is available (82 FR 30121).
minimums for either of those measures challenges associated with attempting to We proposed that sufficient data would
due to the nature of their specialty or measure improvement in the quality be available when a MIPS eligible
practice. However, section performance category at the measure clinician participates in MIPS using the
1848(q)(5)(D)(i)(I) of the Act compels us level, given the many opportunities same identifier in 2 consecutive
to take improvement into account in available to clinicians to select which performance periods and is scored on
addition to achievement in scoring the measures to report. We noted that these the same cost measure(s) for 2
cost performance category beginning challenges are not present in the cost consecutive performance periods (for
with the second year of MIPS, if data performance category and explained our example, in the 2017 MIPS performance
sufficient to measure improvement is reasons for believing that there are period and the 2018 MIPS performance
available. advantages to measuring cost period) (82 FR 30121). If the cost
Final Action: After consideration of improvement at the measure level. improvement score cannot be calculated
the public comments, we are finalizing Therefore, we proposed at section because sufficient data is not available,
our proposal to add improvement 414.1380(b)(2)(iv)(A) to measure cost we proposed to assign a cost
scoring to the cost performance category improvement at the measure level for improvement score of zero percentage
scoring methodology starting with the the cost performance category. points (82 FR 30121). While the total
2020 MIPS payment year. We are In the CY 2018 Quality Payment available cost improvement score would
finalizing our proposal to change the Program proposed rule, we described be limited at first because only 2 cost
terminology to refer to a cost our reasons for believing that we would measures would be included in both the
performance category percent score and have data sufficient to measure first and second performance periods of
to make corresponding changes to the improvement when we can measure the program (total per capita cost and
regulation text at 414.1380(b)(2)(iii). performance in the current performance MSPB), more opportunities for
We are also finalizing our proposal to period compared to the prior improvement scoring would be
add regulatory text at 414.1380(b)(2)(v) performance period. Due to the available in the future as additional cost
reflecting our previously finalized differences in our proposals for measures, including episode-based
policy not to calculate a cost measuring improvement for the quality measures, are added in future
and cost performance categories, such as rulemaking. MIPS eligible clinicians
performance category score if a MIPS
measuring improvement at the measure would be able to review their
eligible clinician or group is not
level versus the performance category performance feedback and make
attributed any cost measures because
level, we proposed a different data improvements compared to the score in
the MIPS eligible clinician or group has
sufficiency standard for the cost their previous feedback.
not met the case minimum requirements
performance category than for the The following is a summary of the
for any of the cost measures or a
quality performance category. First, for public comments received on these
benchmark has not been created for any
data sufficient to measure improvement proposals and our responses:
of the cost measures that would Comment: Several commenters
to be available for the cost performance
otherwise be attributed to the clinician supported our proposal to evaluate
category, we proposed that the same
or group. cost measure(s) would need to be improvement for the cost performance
(a) Measuring Improvement specified for the cost performance category at the measure level because
category for 2 consecutive performance the measures are likely to remain
(i) Calculating Improvement at the Cost
periods (82 FR 30121). For the 2020 consistent over time and this approach
Measure Level
MIPS payment year, only 2 cost may enable clinicians the ability to
In the CY 2018 Quality Payment measures, the MSPB measure and the target process improvements on a
Program proposed rule (82 FR XXX), we total per capita cost measure, would be specific measurement that results in
proposed to make available to MIPS eligible for improvement scoring under improved performance.
eligible clinicians and groups a method this proposal. For a measure to be Response: We thank the commenters
of measuring improvement in the scored in either performance period, a for their support.
quality and cost performance categories. MIPS eligible clinician would need to Comment: A few commenters
In the CY 2018 Quality Payment have a sufficient number of attributed suggested that data sufficient to measure
Program proposed rule (82 FR 30113 cases to meet or exceed the case improvement in the cost performance
through 30114), for the quality minimum for the measure. category would not be available, and
performance category, we proposed to In addition, we proposed that a therefore we are not required to
assess improvement on the basis of the clinician would have to report for MIPS consider improvement in determining
score at the performance category level. using the same identifier (TIN/NPI the cost performance category score.
For the cost performance category, combination for individuals, TIN for These commenters suggested that
similar to the quality performance groups, or virtual group identifiers for sufficient data would not be available
category, we proposed at virtual groups) and be scored on the because we did not propose to retain for
414.1380(b)(2)(iv) that improvement same measure(s) for 2 consecutive the 2020 MIPS payment year the
scoring is available to MIPS eligible performance periods (82 FR 30121). episode-based measures used for the
clinicians and groups that demonstrate Because we wanted to encourage action 2019 MIPS payment year and that new
episode-based measures could be added focus on a particular measure as consideration of improvement at the
for the 2021 MIPS payment year. One opposed to an overall category score measure level, we noted that the
commenter suggested that sufficient that may represent multiple measures. methodology used in the Shared
data would not be available to measure Comment: One commenter opposed Savings Program would best reward
improvement for specialist clinicians our proposal to measure improvement achievement and improvement for the
because episode-based measures would only when a clinician participates in cost performance category because this
not be available for all clinicians. MIPS using the same identifier (TIN/NPI program includes measures for
Response: We continue to believe that combination for individuals, TIN for clinicians, the methodology is
data sufficient to measure improvement groups, or virtual group identifiers for straightforward, and it only recognizes
will be available under our proposed virtual groups) for two consecutive significant improvement (82 FR 30122).
methodology for measuring performance periods. This commenter We proposed to quantify improvement
improvement for the cost performance suggested that some clinicians work in in the cost performance category by
category. Under our proposal, we would multiple practices in a year and that this comparing the number of cost measures
measure improvement only when a requirement would limit their with significant improvement in
MIPS eligible clinician participates in opportunity to receive an improvement performance and the number of cost
MIPS using the same identifier in two score. measures with significant declines in
consecutive performance periods and is Response: We wish to encourage performance (82 FR 30122). We
scored on the same cost measure(s) for action on the part of clinicians in proposed at 414.1380(b)(2)(iv)(C) to
two consecutive performance periods. reviewing and understanding their determine the cost improvement score
This same policy would apply as we contribution to patient costs. We believe by subtracting the number of cost
continue to implement our plan to an approach that evaluates measures with significant declines from
introduce new episode-based measures improvement only for those who report the number of cost measures with
in future years of the program. We note using the same identifier in consecutive significant improvement, and then
measures would not be eligible for years is more likely to reward targeted dividing the result by the number of
improvement scoring in the first year improvement by the clinician or group. cost measures for which the MIPS
they are adopted for MIPS, as we would A clinician who reported as part of a eligible clinician or group was scored in
have no way of assessing how a group in 1 year and as an individual in both performance periods, and then
clinician might have improved on a another year would be likely to have a multiplying the result by the maximum
measure that was not previously different patient population and other cost improvement score (82 FR 30122).
included in the program. factors that could affect the For the 2020 MIPS payment year,
Comment: Several commenters improvement score. In the case of improvement scoring would be possible
supported our proposal to measure clinicians who work at more than one for the total per capita cost measure and
improvement in the cost performance practice (and bill under more than one the MSPB measure as those 2 measures
category if a clinician is scored on the TIN) in a given year and continue at would be available for 2 consecutive
same measure and with the same group those practices in future years, they performance periods under the
or individual identifier in subsequent could be scored on their improvement if proposals in the CY 2018 Quality
years. they continue to participate in MIPS Payment Program proposed rule (82 FR
Response: We thank the commenters using the same practice identifier from 30122). As in our proposed quality
for their support. year to year. improvement methodology, we
Comment: A few commenters Final Action: After consideration of proposed at 414.1380(b)(2)(iv)(D) that
opposed our approach to measuring the public comments, we are finalizing the cost improvement score could not be
improvement in the cost performance all of these proposals related to lower than zero, and therefore, could
category at the measure level, suggesting measuring improvement in the cost only be positive (82 FR 30122).
that the approach proposed for the performance category at the measure We proposed to determine whether
quality performance category would be level. there was a significant improvement or
simpler and better understood by decline in performance between the two
clinicians, and having more than one (ii) Improvement Scoring Methodology
performance periods by applying a
method of evaluating improvement is In the CY 2018 Quality Payment common standard statistical test, a t-
confusing. Program proposed rule (82 FR 30096 test, as is used in the Shared Savings
Response: We strive to maintain through 30097), we discussed a number Program (79 FR 67930 through 67931,
consistency and simplicity in the of different programs and how they 82 FR 30122). We also welcomed public
Quality Payment Program to the greatest measure improvement at the category or comments on whether we should
extent possible. However, we continue measure level as part of their scoring consider instead adopting an
to believe that the methods for systems. In the proposed method for the improvement scoring methodology that
measuring achievement in the quality quality performance category, we measures improvement in the cost
and cost performance categories are proposed to compare the overall rate of performance category the same way we
different enough to warrant a different achievement on all the underlying proposed to do in the quality
approach for measuring improvement. measures in the quality performance performance category; that is, using the
Most importantly, clinicians are not category and measure a rate of overall rate of improvement and without
given the opportunity to select the improvement to calculate an requiring statistical significance which
measures in the cost performance improvement percent score. We then was discussed in the CY 2018 Quality
category, as they are in the quality add the improvement percent score after Payment Program proposed rule (82 FR
performance category, so there should taking into account measure 30113 through 30114).
be greater consistency in the measures achievement points and measure bonus Section 1848(q)(5)(D)(ii) of the Act
on which clinicians are assessed from points as described in proposed specifies that the Secretary may assign
year to year. One benefit to scoring 414.1380(b)(1)(xvii). In reviewing the a higher scoring weight under
improvement at the cost measure level methodologies that are specified in the subparagraph (F) with respect to the
is that clinicians who wish to take CY 2018 Quality Payment Program achievement of a MIPS eligible clinician
action to improve their performance can proposed rule that include than with respect to any improvement
of such clinician with respect to a proposed, we believe a maximum cost more measures are added in future years
measure, activity, or category described improvement score of zero would be of the program, we do not believe that
in paragraph (2). We noted that we effectively the same as a scoring weight we can award additional credit for
believe that there are many of zero. Under this proposal, the cost improvement for each measure without
opportunities for clinicians to actively improvement score would not considering the total numbers of cost
work on improving their performance contribute to the cost performance measures that are scored for an
on cost measures, through more active category percent score calculated for the individual or group. Doing so could
care management or reductions in 2020 MIPS payment year. provide an advantage to an individual
certain services. However, we recognize In the CY 2018 Quality Payment or group with more measures than
that most clinicians are still learning Program proposed rule, we considered others. We also believe that recognizing
about their opportunities in cost an alternative to make no changes to the significant declines reduces the chance
measurement. We noted that we aim to previously finalized weight of 10 of rewarding random variation from
continue to educate clinicians about percent for the cost performance year to year.
opportunities in cost measurement and category for the 2020 MIPS payment We recognize that some clinicians
continue to develop opportunities for year. We proposed that if we maintain will not have cost measures available
robust feedback and measures that a weight of 10 percent for the cost and applicable during the 2018 MIPS
better recognize the role of clinicians. performance category for the 2020 MIPS performance period and, therefore, will
Since MIPS is still in its beginning years payment year, the maximum cost be unable to demonstrate improvement
and we understand that clinicians are improvement score available in the cost in either the 2018 or 2019 MIPS
performance category would be 1 performance periods. However, we wish
working hard to understand how we
percentage point out of 100 percentage to reward clinicians who do achieve
measure costs for purposes of the cost
points available for the cost improvement and who are measured
performance category, as well as how
performance category percent score (82 using the same identifier on the same
we score their performance in all other
FR 30122). If a clinician were measured measure in consecutive years. We will
aspects of the program, we believe
on only one measure consistently from evaluate changes to the maximum cost
improvement scoring in the cost
one performance period to the next and improvement score for future years in
performance category should be limited
met the requirements for improvement, future rulemaking.
to avoid creating additional confusion. Comment: A few commenters
the clinician would receive one
Based on these considerations, we supported the proposal for the
improvement percentage point in the
proposed in the CY 2018 Quality maximum cost improvement score to be
cost performance category percent score.
Payment Program proposed rule to zero percentage points for the 2020
If a clinician were measured on 2
weight the cost performance category at MIPS payment year because we had also
measures consistently, improved
zero percent for the 2018 MIPS proposed to set the weight for the cost
significantly on one, and did not show
performance period/2020 MIPS performance category at zero percent of
significant improvement on the other (as
payment year (82 FR 30122). With the the final MIPS score for that same
measured by the t-test method described
entire cost performance category period.
above), the clinician would receive 0.5
proposed to be weighted at zero percent, Response: We thank the commenters
improvement percentage points.
we noted that the focus of clinicians We invited comments on these for their support. However, as discussed
should be on achievement as opposed to proposals, as well as alternative ways to in section II.C.6.d.(2) of this final rule
improvement, and therefore, we measure changes in statistical with comment period, we are not
proposed at 414.1380(b)(2)(iv)(E) that significance for the cost measure. finalizing our proposal to weigh the cost
although improvement would be The following is a summary of the performance category at zero percent for
measured according to the method public comments received on these the 2020 MIPS payment year. Instead,
described above, the maximum cost proposals and our responses: we are adopting the alternative option to
improvement score for the 2020 MIPS Comment: A few commenters maintain a 10 percent weight for the
payment year would be zero percentage supported our proposed methodology to cost performance category. We proposed
points (82 FR 30122). Section determine cost improvement score on that if we maintain a weight of 10
1848(q)(5)(D)(ii) of the Act provides the basis of a statistical test at the percent for the cost performance
discretion for the Secretary to assign a measure level. category for the 2020 MIPS payment
higher scoring weight under Response: We thank the commenters year, the maximum cost improvement
subparagraph (F), which refers to for their support. score available in the cost performance
section 1848(q)(5)(F) of the Act, with Comment: A few commenters category would be 1 percentage point
respect to achievement than with expressed concern that our proposed out of 100 percentage points available
respect to improvement. Section method of determining cost for the cost performance category
1848(q)(5)(F) of the Act provides if there improvement would be unfair once percent score. We believe that we
are not sufficient measures and multiple episode-based measures are should set a maximum cost
activities applicable and available to included in the cost performance improvement score that is higher than
each type of MIPS eligible clinician, the category because it would be difficult to zero and are finalizing the maximum
Secretary shall assign different scoring demonstrate improvement on all score at 1 percentage point as proposed.
weights (including a weight of zero) for measures. A few commenters suggested Final Action: After consideration of
measures, activities, and/or performance that clinicians receive credit for the public comments, we are finalizing
categories. When read together, we improvement in each cost measure but all of our proposals related to the
interpreted sections 1848(q)(5)(D)(ii) that declines in performance not be improvement scoring methodology for
and 1848(q)(5)(F) of the Act to provide considered as part of their improvement the cost performance category, with the
discretion to the Secretary to assign a score. exception of our proposal to set the
scoring weight of zero for improvement Response: Because there will be some maximum cost improvement score at 0
on the measures specified for the cost variability in the number of cost percentage points for the 2020 MIPS
performance category. Under the measures that are attributed to payment year. Because we are finalizing
improvement scoring methodology we clinicians and groups, particularly if the alternative option to weight the cost
performance category at 10 percent of consistent with other Medicare We provided an example of cost
the final score for the 2020 MIPS programs that reward improvement. performance category scores with the
payment year (see II.C.6.d.(2) of this As noted in the CY 2018 Quality determination of improvement and
final rule with comment period), we are Payment Program proposed rule, we decline in Table 32 of the proposed rule
adopting at 414.1380(b)(2)(iv)(E) our proposed a change in terminology to (82 FR 30123). We invited public
alternative of a maximum cost comments on these proposals.
express the cost performance category
improvement score of 1 percentage The following is a summary of the
percent score as a percentage (82 FR
point out of 100 percentage points public comments received on these
30123). We proposed to revise proposals and our responses:
available for the cost performance 414.1380(b)(2)(iii) to provide that a
category. Comment: One commenter supported
MIPS eligible clinicians cost the proposed formula to calculate the
(b) Calculating the Cost Performance performance category percent score is cost performance category percent score
Category Percent Score With the sum of the following, not to exceed with achievement and improvement.
Achievement and Improvement 100 percent: The total number of Response: We thank the commenter
achievement points earned by the MIPS for the support.
For the cost performance category, we eligible clinician divided by the total Final Action: After consideration of
proposed to evaluate improvement at number of available achievement points the public comments, we are finalizing
the measure level, unlike the quality (which can be expressed as a the method of calculating the cost
performance category where we percentage); and the cost improvement performance category percent score as
proposed to evaluate improvement at score (82 FR 30123). With these two proposed.
the performance category level. For both proposed changes, the formula would In Table 25, we provide an example
the quality performance category and be: of cost performance category percent
the cost performance category, we scores along with the determination of
proposed to add improvement to an (Cost Achievement Points/Available improvement or decline. This example
existing category percent score. We Cost Achievement Points) + (Cost is for group reporting where the group
noted that we believe this is the most Improvement Score) = (Cost is measured on both the total per capita
straight-forward and simple way to Performance Category Percent cost measure and the MSPB measure for
incorporate improvement. It is also Score). 2 consecutive performance periods.
TABLE 25EXAMPLE OF ASSESSING ACHIEVEMENT AND IMPROVEMENT IN THE COST PERFORMANCE CATEGORY
Significant Significant
Measure Total possible improvement decline from
achievement measure
Measure from prior prior
points earned achievement performance performance
by the group points period period
Total per Capita Cost Measure ....................................................................... 8.2 10 Yes ................. No.
MSPB Measure ............................................................................................... 6.4 10 No .................. No.
Total ......................................................................................................... 14.6 20 N/A ................. N/A.
In this example, there are 20 total category (10 percent of the final score) best use this authority. We refer readers
possible measure achievement points and by 100 to determine the points to to the CY 2017 Quality Payment
and 14.6 measure achievement points the final score. The group would have Program final rule (81 FR 77127) for a
earned by the group, and the group 73.5 percent 10 percent 100 = 7.35 summary of these comments.
improved on one measure but not the points for the cost performance category As noted in the CY 2017 Quality
other, with both measures being scored contributed towards the final score. Payment Program proposed rule (81 FR
in each performance period. The first (4) Facility-Based Measures Scoring 28192), we considered an option for
part of the formula is calculating (Cost Option for the 2020 MIPS Payment Year facility-based MIPS eligible clinicians to
Achievement Points/Available Cost for the Quality and Cost Performance elect to use their institutions
Achievement Points) which is 14.6/20, Categories performance rates as a proxy for the
which equals .730 and can be MIPS eligible clinicians quality score.
represented as 73.0 percent. The cost (a) Background
However, we did not propose an option
improvement score will be determined Section 1848(q)(2)(C)(ii) of the Act for the transition year of MIPS because
as follows: ((1 measure with significant provides that the Secretary may use there were several operational
improvementzero measures with measures used for payment systems considerations that we believed needed
significant decline)/2 measures) * 1 other than for physicians, such as to be addressed before this option could
percentage point = 0.5 percentage measures for inpatient hospitals, for be implemented. At that time, we
points. Under the formula, the cost purposes of the quality and cost requested comments on the following
performance category percent score will performance categories. However, the issues: (1) Whether we should attribute
be (14.6/20 or 73.0 percent) + 0.5 Secretary may not use measures for a facilitys performance to a MIPS
percent = 73.5 percent. To determine hospital outpatient departments, except eligible clinician for purposes of the
how many points the cost performance in the case of items and services quality and cost performance categories
category contributes to the final score, furnished by emergency physicians, and under what conditions such
we will multiply the performance radiologists, and anesthesiologists. In attribution would be appropriate and
category percent score (73.5 percent) by the MIPS and APMs RFI (80 FR 59108), representative of the MIPS eligible
the weight of the cost performance we sought comment on how we could clinicians performance; (2) possible
criteria for attributing a facilitys Care Hospital Prospective Payment conclusion of the MIPS performance
performance to a MIPS eligible clinician System final rule (82 FR 38259 through period is appropriate, or if we should
for purposes of the quality and cost 38260)), and the Hospital VBP Program consider notifying facility-based
performance categories; (3) the specific scoring reports (referred to as the clinicians later in the MIPS performance
measures and settings for which we can Percentage Payment Summary Reports) period or even after its conclusion.
use the facilitys quality and cost data as will be provided to participating The performance periods proposed in
a proxy for the MIPS eligible clinicians hospitals not later than 60 days prior to the CY 2018 Quality Payment Program
quality and cost performance categories; the beginning of FY 2019, pursuant to proposed rule (82 FR 30034) for the
and (4) if attribution should be the Hospital VBP Programs statutory 2020 MIPS payment year occur in part
automatic or if an individual MIPS requirement at section 1886(o)(8) of the in 2018, with data submission for most
eligible clinician or group should elect Act. We discuss eligibility for facility- mechanisms starting in January 2019.
for it to be done and choose the facilities based measurement in the CY 2018 To provide potential facility-based
through a registration process. We Quality Payment Program proposed rule scores to clinicians by the time the data
summarized the comments on these (82 FR 30125 through 30126), and we submission period for the 2018 MIPS
questions in the proposed rule (82 FR noted that the determination of the performance period begins (assuming
30123 through 30124). applicable hospital will be made on the that timeframe is operationally feasible),
basis of a period that overlaps with the we noted that we believe that the FY
(b) Facility-Based Measurement 2019 Hospital VBP Program, including
applicable Hospital VBP Program
We believe that facility-based performance period. Although Hospital the corresponding performance periods,
measurement is intended to reduce VBP Program measures have different is the most appropriate program year to
reporting burden on facility-based MIPS measurement periods, the FY 2019 use for purposes of facility-based
eligible clinicians by leveraging existing measures all overlap from January to measurement under the quality and cost
quality data sources and value-based June in 2017, which also overlaps with performance categories for the 2020
purchasing experiences and aligning our first 12-month period to determine MIPS payment year. However, we noted
incentives between facilities and the MIPS eligibility for purposes of the CY also that Hospital VBP Program
MIPS eligible clinicians who provide 2018 performance period and 2020 performance periods can run for periods
services there. In addition, we believe MIPS payment year. as long as 36 months, and for some FY
that facility-based MIPS eligible 2019 Hospital VBP Program measures,
clinicians contribute substantively to We believe that MIPS eligible the performance period begins in 2014.
their respective facilities performance clinicians electing the facility-based We requested comment on whether this
on facility-based measures of quality measurement option under MIPS should lengthy performance period duration
and cost, and that their performance be able to consider as much information should outweigh our desire to include
may be better reflected by their as possible when making that decision, all Hospital VBP Program measures as
facilities performance on such including how their attributed hospital discussed further below (82 FR 30125).
measures. performed in the Hospital VBP Program We proposed at 414.1380(e)(6)(iii) that
We proposed to limit facility-based because an individual clinician is a part the performance period for facility-
reporting to the inpatient hospital in the of the clinical team in the hospital, based measurement is the performance
first year for a number of reasons, rather than the sole clinician period for the measures for the measures
including that there is a more diverse responsible for care as tracked by adopted under the value-based
group of clinicians (and specialty types) quality measures. Therefore, we purchasing program of the facility of the
providing services in an inpatient concluded that we should be as year specified (82 FR 30125).
setting compared to other settings and transparent as possible with MIPS We considered whether we should
that the Hospital Value-Based eligible clinicians about their potential include the entire set of Hospital VBP
Purchasing (VBP) Program adjusts facility-based scores before they begin Program measures for purposes of
payment in connection with both data submission for the MIPS facility-based measurement under MIPS
increases and decreases in performance. performance period since this policy or attempt to differentiate those which
The Hospital VBP Program is large and option is intended to minimize may be more influenced by clinicians
mature (82 FR 30124). We also proposed reporting burdens on clinicians that are contribution to quality performance
to only use measures from a pay-for- already participating in quality than others. However, we believe that
performance program and not a pay-for- improvement efforts through other CMS clinicians have a broad and important
reporting program and proposed to limit programs. We expect that MIPS eligible role as part of the healthcare team at a
the measures for facility-based clinicians that would consider facility- hospital and that attempting to
measurement to those used in the based scoring would generally be aware differentiate certain measures
Hospital VBP Program (82 FR 30124) of their hospitals performance on its undermines the team-based approach of
because it compares facilities on a series quality measures, but believe that facility-based measurement. We
of different measures intended to providing this information directly to proposed at 414.1380(e)(6)(i) that the
capture the breadth of care in the clinicians ensures that such clinicians quality and cost measures are those
facility. are fully aware of the implications of adopted under the value-based
We also considered program timing their scoring elections under MIPS. purchasing program of the facility
when determining what Hospital VBP However, we noted that this policy program for the year specified (82 FR
Program year to use for facility-based could conceivably place non-facility- 30125).
measurement for the 2020 MIPS based MIPS eligible clinicians at a We proposed for the 2020 MIPS
payment year. Quality measurement for competitive disadvantage since they payment year to include all the
the FY 2019 Hospital VBP Programs would not have any means by which to measures adopted for the FY 2019
performance period will be concluded ascertain their MIPS measure scores in Hospital VBP Program on the MIPS list
by December 31, 2017 (we refer readers advance. We viewed that compromise as of quality measures and cost measures
to the finalized FY 2019 performance a necessity to maximize transparency, (82 FR 30125). Under the proposal, we
periods in the FY 2018 Inpatient and we requested comment on whether considered the FY 2019 Hospital VBP
Prospective Payment System/Long-Term this notification in advance of the Program measures to meet the definition
of additional system-based measures clinicians, we plan to delay Comment: Several commenters

provided in section 1848(q)(2)(C)(ii) of implementation of this policy by 1 year. supported our plan to inform clinicians
the Act, and we proposed at Comment: Many commenters about their eligibility for facility-based
414.1380(e)(1)(i) that facility-based recommended that eligibility for measurement and which hospital their
measures available for the 2018 MIPS facility-based measurement be score would be based on during the
performance period are the measures expanded to include a wide range of MIPS performance period. A few
adopted for the FY 2019 Hospital VBP facilities. Commenters recommended commenters recommended that
Program year authorized by section that facility-based measurement be facilities be informed of which
1886(o) of the Act and codified in our extended in the future to include clinicians could have their scores based
regulations at 412.160 through inpatient rehabilitation facilities, skilled on that facility as well. These
412.167 (82 FR 30125). Measures in the nursing facilities, hospice programs, commenters expressed that informing
FY 2019 Hospital VBP Program have critical access hospitals, hospital clinicians and hospitals of their status
different performance periods as noted outpatient departments, and ambulatory would allow clinicians to make the best
in Table 33 of the CY 2018 Quality surgical centers. decisions for MIPS participation for
Payment Program proposed rule. Response: As we stated in the their practices and increase alignment
We requested comments on these proposed rule, we believe that clinicians between facilities and clinicians.
proposals. We also requested comments play an important role in many facilities Response: We agree with the
on what other programs, if any, we and programs that include quality commenters and intend to provide as
should consider including for purposes reporting elements and value-based much information as possible as early as
of facility-based measurement under purchasing program. Because we believe possible to clinicians about their
MIPS in future program years (82 FR that the program used for the inpatient eligibility and the hospital performance
30125). hospital is the largest and among the upon which a MIPS eligible clinicians
The following is a summary of the most established value-based score would be based. We will work to
purchasing programs, we have provide information about facility-based
public comments received on the
proposed, and are finalizing, that measurement eligibility and facility
Facility-Based Measurement
clinicians practicing in the inpatient attribution to clinicians in 2018, if
hospital will be eligible for facility- technically feasible. We will investigate
Comment: Many commenters
based measurement. As discussed in whether it would be technically feasible
supported our proposal to offer the
more detail below, this final rule will be and appropriate to distribute
opportunity for facility-based
applicable beginning with the 2019 information to attributed facilities about
measurement for purposes of MIPS performance period and 2021 the clinicians that could elect
determining the quality and cost MIPS payment year. However, in the attribution of facility performance
performance category scores for the future we will consider opportunities to measures for purposes of the MIPS
2020 MIPS payment year. These expand the program to other facilities, program.
commenters noted their longstanding based on the status of the facility value- Comment: One commenter opposed
interest in such an opportunity and based purchasing program, the our plan to notify clinicians about their
stated that it would reduce burden and applicability of measures, and the facility-based status before the close of
align incentives between facilities and ability to appropriately attribute a the MIPS performance period because
clinicians who provide a substantial clinician to a facility. Any new settings the commenter noted that this choice
amount of services there. for facility-based measurement would should be made earlier rather than to
Response: We thank the commenters be proposed in future rulemaking. make up for a failure to report in
for their support. We agree that facility- Comment: A few commenters another fashion.
based measurement is important and a expressed concern that the facility- Response: Although we understand
step forward in alignment of incentives based measurement would not be the commenters concerns, we disagree
between clinicians and facilities. As we applicable to certain clinicians who are that an earlier deadline will be
discuss below, we believe that it is not MIPS eligible because they are beneficial. We also need to balance the
prudent to delay implementation of excluded by statute or bill under a issue of informing clinicians of their
facility-based measurement for an facility provider identification number. eligibility and giving them an
additional year so that clinicians better These commenters suggested that we opportunity to consider their options.
understand the opportunity and ensure develop options to allow for these Comment: A few commenters
that we are operationally ready to clinicians to participate in facility-based requested clarification on whether the
support this measurement option. measurement. facility-based measurement would
Comment: A few commenters Response: MIPS eligibility is apply to the advancing care information
expressed general support for the idea of discussed in section II.C.1 of this final or improvement activity performance
facility-based measurement but concern rule with comment period. Eligibility categories.
that they did not have enough for MIPS must be established at the Response: Clinicians that participate
information or preparation to individual or group level in order for in facility-based measurement will have
adequately understand the proposal. facility-based measurement to also be their scores in the quality and cost
These commenters recommended that applicable. We do not believe we have performance categories determined on
CMS develop a 1-year pilot program and the authority to determine MIPS the basis of the performance of that
inform clinicians more about their eligibility through facility-based facility. However, we did not propose
status. measurement. We note that certain that those scored under facility-based
Response: We acknowledge the clinicians practice primarily in an measurement would have different
commenters concerns. In order to FQHC or CAH but bill for some items requirements for the advancing care
increase understanding of the policy, and services under Part B. Those information or improvement activities
better educate clinicians on eligibility clinicians, even though they typically performance categories. Clinicians or
and applicability of the program, and bill for services through an FQHC or groups would still be scored based on
ensure CMSs operational readiness to CAH, could be eligible for MIPS on the their own performance (not a facilitys
offer this measurement option to basis of their other billing. performance) on those performance
categories unless other exclusions of facility-based measurement with the (c) Facility-Based Measurement
apply. In addition, section modification that facility-based Applicability
1848(q)(2)(C)(ii) of the Act states that we measurement will not be available for (i) General
may use measures used for a payment clinicians until the 2019 MIPS
system other than that used for performance period/2021 MIPS The percentage of professional time a
physicians for the purposes of the payment year. We are finalizing clinician spends working in a hospital
quality and cost performance categories, regulation text at 414.1380(e) that varies considerably. Some clinicians
but does not address the advancing care provides that for payment in the 2021 may provide services in the hospital
information and improvement activities MIPS payment year and subsequent regularly, but also treat patients
performance categories. years, a MIPS eligible clinician or group extensively in an outpatient office or
Comment: A few commenters may elect to be scored in the quality and another environment. Other clinicians
expressed concern that offering facility- cost performance categories using may practice exclusively within a
based measurement could distract from facility-based measures. We discuss the hospital. Recognizing the various levels
other quality improvement efforts, such measures used to determine facility- of presence of different clinicians
as those that use registries or QCDRs. based measurement in section within a hospital environment, we
One commenter expressed concern that II.C.7.a.(4)(f) of this final rule with proposed to limit the potential
offering facility-based measurement comment period, but are finalizing our applicability of facility-based
could disadvantage those who are not proposals and our proposal at measurement to those MIPS eligible
offered the opportunity to participate in clinicians with a significant presence in
414.1380(e)(6)(i) that the quality and
facility-based measurement. the hospital.
cost measures are those adopted under
Response: One of our primary goals in In the CY 2017 Quality Payment
the value-based purchasing program of Program final rule (81 FR 77238 through
structuring the Quality Payment the facility program for the year
Program is to allow clinicians as much 77240), we adopted a definition of
specified at 414.1380(e)(6)(iii) that the hospital-based MIPS eligible clinician
flexibility as possible. We view the performance period for facility-based
option of facility-based measurement as under 414.1305 for purposes of the
measurement is the performance period advancing care information performance
advancing that goal. As noted in the for the measures adopted under the
2018 Quality Payment Program category. Section 414.1305 defines a
value-based purchasing program of the hospital-based MIPS eligible clinician as
proposed rule (82 FR 30124), we have facility of the year specified (82 FR
heard concerns that clinicians who a MIPS eligible clinician who furnishes
30125). We appreciate the broad support 75 percent or more of his or her covered
work in certain facilities would be more for the implementation of facility-based
accurately measured in the context of professional services in sites of service
measurement and the general support identified by the POS codes used in the
those facilities and that separately for many of the policies that are
identifying and reporting quality HIPAA standard transaction as an
outlined below. inpatient hospital, on-campus
measures could distract from the
broader quality mission of the facility However, we are concerned that we outpatient hospital, or emergency room
while adding administrative burden on might not have the operational ability to setting, based on Medicare Part B claims
clinicians. We agree with that statement. inform these clinicians soon enough for a period prior to the performance
For those clinicians who may meet our during the MIPS performance period in period as specified by CMS. We
definition of facility-based and find that 2018 for them to know that they could considered whether we should simply
the measurement does not reflect their select facility-based measurement as use this definition to determine
practice, there are other opportunities to opposed to another method. We also eligibility for facility-based
submit quality measures data. For those believe that the comments reflect some measurement under MIPS. However, we
for which facility-based measurement is lack of understanding of how elements expressed concern that this definition
not available, we continue to work to of the policy might apply to clinicians could include many clinicians that have
offer as much flexibility in measurement that may qualify for facility-based limited or no presence in the inpatient
as possible. We have very clearly heard measurement. We plan to use this hospital setting. We discuss the
that facility-based measurement should additional year for outreach and, if differences between the approach of
not be mandatory and have made it an technically feasible, informing defining hospital-based clinicians for
option for those who are eligible. clinicians if they would have met the the purposes of the advancing care
Comment: A few commenters requirements for facility-based information category and defining
recommended that rather than measurement based on the finalized facility-based measurement in the CY
developing a new system of assessing policy and what their scoring might 2018 Quality Payment Program
facility-based clinicians based on the have been based on an attributed proposed rule. (82 FR 30125 through
performance of a facility that those hospital. We believe this additional year 30126) The measures used in the
clinicians instead be made exempt from of outreach will best prepare clinicians Hospital VBP Program are focused on
the MIPS program. to make decisions about participating in care provided in the inpatient setting.
Response: MIPS eligibility is facility-based measurement. As We noted that we do not believe it is
determined based on the requirements discussed in section II.C.7.a.(4)(c) of this appropriate for a MIPS eligible clinician
of section 1848(q)(2)(C) of the Act and final rule with comment period, the use to use a hospitals Hospital VBP
discussed in section II.C.1 of this final of facility-based measurement will be Program performance for MIPS scoring
rule with comment period. We do not available for individual clinicians and if the clinician did not provide services
believe we have the authority to exempt groups. Therefore, we are finalizing the in the inpatient setting or in the
clinicians that are otherwise eligible for introductory text at 414.1380(e) with a emergency department, through which
MIPS from the Quality Payment minor change to refer to a MIPS many inpatients arrive at the inpatient
Program based on their eligibility for eligible clinician or group in place of setting.
facility-based measurement. MIPS eligible clinicians in the We stated our belief that establishing
Final Action: After consideration of proposed text. We discuss the election a definition for purposes of facility-
the public comments, we are finalizing in section II.C.7.a.(4)(e) of this final rule based measurement that is different
our proposals on the general availability with comment period. from the hospital-based definition used
for the advancing care information contribute to inpatient care from those clinicians with a significant presence in
category is necessary to implement this who do not. The inclusion of any POS the facility play a role in the overall
option. We also noted that, since we code in our definition is pending performance of a facility, and therefore,
were seeking comments on other technical feasibility to link a clinician to did not propose to further limit this
programs to consider including for a facility under the method described in option based on characteristics other
purposes of facility-based measurement section II.C.7.b.(4)(d) of the CY 2018 than the percentage of covered
in future years, we believed that Quality Payment Program proposed rule professional services furnished in an
establishing a separate definition that (82 FR 30126 through 30127). inpatient hospital or emergency room
could be expanded as needed for this We noted that this more limited setting.
purpose is appropriate. We proposed at definition would mean that a clinician The following is a summary of the
414.1380(e)(2) that a MIPS eligible who is determined to be facility-based public comments received on these
clinician is eligible for facility-based likely would also be determined to be proposals and our responses:
measurement under MIPS if they are hospital-based for purposes of the Comment: Several commenters
determined facility-based as an advancing care information performance supported our proposal that a MIPS
individual (82 FR 30126) or as a part of category, because the proposed eligible clinician is considered facility-
a group (82 FR 30126). definition of facility-based is narrower based as an individual if the MIPS
than the hospital-based definition eligible clinician furnishes 75 percent or
(ii) Facility-Based Measurement by established for that purpose. We more of their covered professional
Individual Clinicians proposed to identify clinicians as services in sites of service identified by
Based on those background facility-based (and thus eligible to elect the POS codes used in the HIPAA
considerations, we proposed at facility-based measurement) through an standard transaction as an inpatient
414.1380(e)(2)(i) that a MIPS eligible evaluation of covered professional hospital, as identified by POS code 21,
clinician is considered facility-based as services between September 1 of the or an emergency room, as identified by
an individual if the MIPS eligible calendar year 2 years preceding the POS code 23.
clinician furnishes 75 percent or more performance period through August 31 Response: We appreciate the
of their covered professional services (as of the calendar year preceding the commenters support. We are finalizing
defined in section 1848(k)(3)(A) of the performance period with a 30-day this policy as proposed, but as
Act) in sites of service identified by the claims run out. For example, for the discussed below, we intend to continue
POS codes used in the HIPAA standard 2020 MIPS payment year, where we analyzing refinements to facility-based
transaction as an inpatient hospital, as have adopted a performance period of eligibility for potential future
identified by POS code 21, or an CY 2018 for the quality and cost rulemaking or to inform our
emergency room, as identified by POS performance categories, we would use interpretation of this final rule.
code 23, based on claims for a period the data available at the end of October Comment: Many commenters did not
prior to the performance period as 2017 to determine whether a MIPS support our proposal that a MIPS
specified by CMS (82 FR 30126). We eligible clinician is considered facility- eligible clinician is considered facility-
understand that the services of some based under our proposed definition. At based as an individual if the MIPS
clinicians who practice solely in the that time, those data would include eligible clinician furnishes 75 percent or
hospital are billed using place of service Medicare Part B claims with dates of more of their covered professional
codes such as code 22, reflecting an on- service between September 1, 2016 and services in sites of service identified by
campus outpatient hospital for patients August 31, 2017. If it is not the POS codes used in the HIPAA
who are in observation status. Because operationally feasible to use claims from standard transaction as an inpatient
there are limits on the length of time a this exact time period, we noted that we hospital, as identified by POS code 21,
Medicare patient may be seen under would use a 12-month period as close or an emergency room, as identified by
observation status, we noted that we as practicable to September 1 of the POS code 23. Many of these
believe that these clinicians would still calendar year 2 years preceding the commenters recommended that POS
furnish 75 percent or more of their performance period and August 31 of code 22, used for on-campus outpatient
covered professional services using POS the calendar year preceding the hospitals, be added to the POS codes
code 21, but sought comment on performance period. This determination used to determine applicability of
whether a lower or higher threshold of would allow clinicians to be made facility-based measurement. They noted
inpatient services would be appropriate. aware of their eligibility for facility- that this place of service code is used for
We did not propose to include POS based measurement near the beginning providing observation services, which
code 22 in determining whether a of the MIPS performance period. were indistinguishable from inpatient
clinician is facility-based because many We also recognized that in addition to services because they are typically
clinicians who bill for services using the variation in the percentage of time provided in the same physical space as
this POS code may work on a hospital a clinician is present in the hospital, inpatient services and on similar
campus but in a capacity that has little there is also great variability in the types patients. They indicated that many
to do with the inpatient care in the of services that clinicians perform. We clinicians that provide exclusively
hospital. In contrast, we noted our belief considered whether certain clinicians hospital services may not meet this
that those who provide services in the should be identified as eligible for this definition due to the preponderance of
emergency room or the inpatient facility-based measurement option observation services which they bill.
hospital clearly contribute to patient based on characteristics in addition to Some commenters recommended that
care that is captured as part of the their percentage of covered professional the facility-based definition be aligned
Hospital VBP Program because many services furnished in the inpatient with the hospital-based definition used
patients who are admitted are admitted hospital or emergency room setting, in the advancing care information
through the emergency room. We sought such as by requiring a certain specialty performance category, and therefore
comments on whether POS 22 should be such as hospital medicine or by limiting include POS code 19, which was
included in determining if a clinician is eligibility to those who served in proposed to be added for determination
facility-based and how we might patient-facing roles. However, we noted of hospital-based eligibility in addition
distinguish those clinicians who our belief that all MIPS eligible to POS code 22 and the codes we did
propose for inclusion. These all clinicians who quality for facility- performance period/2021 MIPS
commenters noted that aligning based measurement would also qualify payment year so clinicians will not be
definitions would simplify for hospital-based under the advancing eligible until that time. We understand
understanding of the program. A few care information category. If we were to that there are concerns that some
commenters suggested the addition of adopt a lower threshold for facility- clinicians who practice primarily or
POS codes 51 (inpatient psychiatric based measurement, this would no exclusively in hospitals will not be
facility) and POS codes 52 (psychiatric longer be the case. We believe that it is eligible for facility-based measurement,
facility partial hospital). to the benefit of clinicians to know that particularly due to the complicating
Response: We remain concerned that even though the two definitions are not factor of observation services. We will
including codes for outpatient hospital perfectly aligned, they have similar use the next year to further examine this
services could make eligible for facility- parameters and that qualifying for one issue and determine if changes in
based measurement clinicians who have (facility-based) would generally mean eligibility should be proposed in future
little or no contribution to a hospitals qualifying for the other (hospital-based). rulemaking. We are also finalizing
performance in the Hospital VBP However, a clinician may qualify to be technical and grammatical changes to
Program. We recognize that observation hospital-based but not qualify to be the introductory text at paragraph (e)(2).
services are similar to services provided facility-based. If technically feasible, we
in the inpatient hospital setting in many (iii) Facility-Based Measurement Group
will use 2018 as an opportunity to offer
cases. However, there are many services, Participation
information to clinicians on their
such as outpatient clinic visits, which eligibility and applicability of facility- We proposed at 414.1380(e)(2) that a
include patients who may never visit based measurement. While we are MIPS eligible clinician is eligible for
the hospital in question as inpatients. finalizing our proposal, we will facility-based measurement under MIPS
We are finalizing our proposal for continue to examine the 75 percent if they are determined facility-based as
eligibility; however, we intend to threshold to determine if this part of a group (82 FR 30126). We
further study the impact of including consistency is not necessary and will proposed at 414.1380(e)(2)(ii) that a
outpatient services on eligibility for propose changes in future rulemaking if facility-based group is a group in which
facility-based clinicians and to analysis suggests that this presents a 75 percent or more of the MIPS eligible
determine if there is another method to significant barrier. clinician NPIs billing under the groups
distinguish observation services from Comment: A few commenters TIN are eligible for facility-based
other outpatient services. As noted suggested that our proposal to measurement as individuals as defined
above, we are finalizing our proposal, determine facility-based measurement in 414.1380(e)(2)(i) (82 FR 30126). We
but with a delay in the implementation status not be limited to a review of place also considered an alternative proposal
of facility-based measurement until the of service codes. One commenter in which a facility-based group would
2019 MIPS performance period/2021 suggested that we review the specialty be a group where the TIN overall
MIPS payment year. This will provide of a clinician to determine if the furnishes 75 percent or more of its
additional time for analysis and clinician is a hospitalist. Another covered professional services (as
outreach to clinicians. We hope that this commenter suggested that facility-based defined in section 1848(k)(3)(A) of the
outreach will help to inform clinicians measurement should be limited to Act) in sites of service identified by the
about the applicability of facility-based clinicians for whom the Hospital VBP POS codes used in the HIPAA standard
measurement. We will make future Program measures are related to their transaction as an inpatient hospital, as
changes to the applicability of facility- clinical area. identified by POS code 21, or the
based measurement in the context of Response: As we noted in the emergency room, as identified by POS
that outreach and additional analysis. proposed rule, we considered whether code 23, based on claims for a period
Any changes would be proposed in to further limit facility-based prior to the performance period as
future rulemaking. We are specifically measurement on characteristics such as specified by CMS (82 FR 30126). Groups
seeking comments on ways to identify specialty. However, we believe that would be determined to be facility-
clinicians who have a significant there are clinicians other than those based through an evaluation of covered
presence within the inpatient setting who are identified with the hospitalist professional services between
and address the concerns that we have specialty code who significantly September 1 of the calendar year 2 years
noted above. contribute to the quality of care in the preceding the performance period
Comment: Several commenters facility setting. We do not typically use through August 31 of the calendar year
recommended that we adopt a threshold a specialty code to determine special preceding the performance period with
lower than 75 percent of services with status in MIPS. In addition, the a 30 day claims run out period (or if not
particular place of service codes because hospitalist specialty code was only operationally feasible to use claims from
some clinicians who work primarily or established in 2017 so many clinicians this exact time period, a 12-month
exclusively in a hospital might not meet who practice hospital medicine are not period as close as practicable to
our proposed definition. Some of these currently identified by that specialty September 1 of the calendar year 2 years
commenters recommended that code. We are unable to identify another preceding the performance period and
clinicians be eligible if at least a way to identify a strong connection August 31 of the calendar year
majority of their services were provided between a facility and a clinician at this preceding the performance period).
with an eligible place of service code. time but will continue to analyze and We requested comments on our
Response: Because the 75 percent welcome comments on this issue. proposal and alternative proposal.
threshold is used in our determination Final Action: After consideration of The following is a summary of the
of hospital-based eligible clinicians in the public comments, we are finalizing public comments received on the
the advancing care information our proposals codified at Facility-Based Measurement Group
performance category, we believe that a 414.1380(e)(2) for the determination of Participation proposals and our
similar threshold would be appropriate eligibility for facility-based responses:
to use in the determination of measurement as an individual. We note Comment: Several commenters
applicability of facility-based that facility-based measurement will not recommended that groups be eligible for
measurement. On an individual basis, be available until the 2019 MIPS facility-based measurement if they meet
the requirements of either our proposal measurement, but we also believe that a group is primarily one that focuses on
(75 percent or more of the MIPS eligible our proposed approach would hospital care. It aligns with our proposal
clinician NPIs billing under the groups appropriately identify groups that to identify non-patient facing groups
TIN are eligible for facility-based should be eligible for facility-based and ensures that majority of clinicians
measurement as individuals) or our measurement. We are able to identify in the group are involved in care that
alternative proposal (TIN overall through claims data all the individual may be related to the measures in
furnishes 75 percent or more of its NPIs that bill under a group TIN. In facility-based measurement. As we
covered professional services in sites of addition, we have several MIPS group develop outreach in 2018, we aim to
service identified by the POS codes status indicators that are determined by inform clinicians and groups about what
used to determine individual 75 percent or more of the of the MIPS their facility-based measurement
eligibility). These commenters noted eligible clinician NPIs billing under the eligibility would have been had we
that this would increase the number of groups TIN meeting a certain finalized these policies for application
groups eligible for this opportunity. designation. By finalizing our policy as to the 2020 MIPS payment year; we
Response: We understand the interest proposed, we are aligning with those hope this will clarify the application of
in providing multiple methods of other group policies. For example, as this rule.
eligibility but believe that establishing discussed in section II.C.1.e. of this final Comment: One commenter
multiple methods increases complexity. rule with comment period, a group is recommended that there not be an
In this case, we do not believe that the determined to be non-patient facing option to establish a facility-based
interests of flexibility outweigh those of provided that more than 75 percent of group, because, as proposed, a group
simplicity, given that facility-based the NPIs billing under the groups TIN could include many clinicians who do
measurement will be available only for meet the definition of a non-patient not practice in the facility setting.
groups that are primarily composed of facing individual MIPS eligible clinician Response: We believe that the
those who provide services in the during the non-patient facing establishment of an opportunity for a
hospital setting. We are finalizing our determination period. As discussed in group to be eligible for facility-based
proposal that a facility-based group is section II.C.1.d. of this final rule with measurement is consistent with our
one in which 75 percent or more of the comment period, we use a similar general approach to group measurement
of the MIPS eligible clinician NPIs threshold to determine which groups in MIPS. A large group may include
billing under the groups TIN are should have a rural or HPSA some clinicians who focus on the
eligible for facility-based measurement designation. However, as we perform patients associated with submitted
as individuals. We are finalizing outreach in 2018, we hope that we can quality measures and others who focus
regulation text at 414.1380(e)(2)(ii) to clarify and address any concerns related on a different population. However,
codify this standard for determining that to our ability to identify the clinicians under group-based reporting in MIPS,
a clinician group is a facility-based that are associated with a particular all members of the group receive the
group and are making minor revisions to practice and would be considered for same score. Facility-based measurement
the regulatory text to match the facility-based measurement. If needed, will only be available to those groups
proposed policy by explicitly we will revisit this policy through with a significant connection to the
referencing clinician NPIs billing under future rulemaking. hospital (as measured by the settings of
the groups TIN. In 2018, we will Comment: One commenter services for which claims are paid) and
provide more information to clinicians recommended that groups of clinicians we believe only those groups that
and groups on their eligibility for within a TIN be eligible as a facility- believe the hospital scores reflect their
facility-based measurement and hope based group rather than requiring the performance will elect the option. We
that sharing this information will help entire group to be scored based on believe that limiting the facility-based
to provide more clarity. We will revisit facility-based measurement. measurement to individuals would
this standard for identifying when a Response: Because of the scoring make the option less tenable and less
clinician group is a facility-based group approach that we are adopting for consistent with our overall approach to
eligible for facility-based measurement facility-based measurement (discussed MIPS, which is intended to provide
in future rulemaking if changes are in section II.C.7.a.(4) of this final rule flexibility to participate as a group or as
needed. with comment period), a group is scored an individual to the greatest extent
Comment: A few commenters for the quality and cost performance possible. We also noted that facility-
supported our alternative proposal in category on the basis of facility-based based measurement applies only to the
which a facility-based group would be measurement or through another quality and cost performance categories;
a group where the TIN overall furnishes method. We are unable to establish a groups and individuals must separately
75 percent or more of its covered group reporting mechanism that is not consider their participation in the
professional services (as defined in applicable for portions of a TIN. This advancing care information and
section 1848(k)(3)(A) of the Act) in sites score will be combined with scores on improvement activities performance
of service identified by the POS codes the improvement activity and advancing categories. We believe that groups will
used to establish individual eligibility care information performance select the quality measures that they
for facility-based measurement. These categories. Please refer to section II.C.3. believe are most applicable to reflecting
commenters expressed concern that of this final rule with comment period the overall quality of the group.
CMS would be unable to properly for additional information about Final Action: After consideration of
identify all of the clinicians in the group reporting for groups. the public comments, we are finalizing
and therefore unable to properly make Comment: One commenter our proposal for determining which
this determination. One of the recommended that a group be eligible groups are facility-based groups in
commenters suggested that it was easier for facility-based measurement if more regulation text at 414.1380(e)(2)(ii).
to determine eligibility at the TIN level. than 50 percent of the MIPS eligible We note that facility-based
Response: We agree that our proposed clinicians met the requirements of measurement will not be available until
alternative approach of using all the facility-based measurement. the 2019 MIPS performance period/2021
claims submitted by a group is one way Response: We believe that the 75 MIPS payment year so a facility-based
to calculate eligibility for facility-based percent threshold better establishes that group will not exist before that time. As
noted earlier, we are delaying the Program measures. We proposed that for We were also (and continue to be)
implementation of facility-based the first year, the value-based concerned that permitting the clinician
measurement until the 2019 MIPS purchasing score for the facility would or group to choose could result in
performance period to ensure clinician be the FY 2019 Hospital VBP Programs clinician or group selecting a hospital at
understanding and operational Total Performance Score. In cases in which they did not provide care, either
readiness. We will propose any changes which there was an equal number of inadvertently due to selection error, or
to this definition in future rulemaking. Medicare beneficiaries treated at more fraudulently.
than one facility, we proposed to use the Comment: A few commenters noted
(d) Facility Attribution for Facility- that the proposed method of attributing
value-based purchasing score from the
Based Measurement clinicians to a facility did not identify
facility with the highest score (82 FR
Many MIPS eligible clinicians provide 30127). a method that would determine
services at more than one hospital, so The following is a summary of the attribution for a facility-based group. A
we need a method to identify which public comments received on these few commenters suggested that in this
hospitals scores should be associated proposals and our responses: situation that CMS use the score from
with each MIPS eligible clinician that Comment: Several commenters the hospital attributed to an individual
elects facility-based measurement under supported our proposal that MIPS clinician in the group with the highest
this option. We considered whether a eligible clinicians that elect facility- score on the Hospital VBP Program.
clinician should be required to identify based measurement would receive Response: Although we did not
for us the hospital with which the scores derived from the value-based specifically address the issue of how
clinician is affiliated, but believe that purchasing score for the facility at facility-based groups would be assigned
such a requirement would add which they provided services for the to a facility (for purposes of attributing
unnecessary administrative burden in a most Medicare beneficiaries during the facility performance to the group) in the
process that we believe was intended to period of September 1 of the calendar preamble of the CY 2018 Quality
reduce burden. We also considered year 2 years preceding the performance Payment Program proposed rule, our
whether we could combine scores from period through August 31 of the proposed regulation at 414.380(e)(5)
multiple hospitals, but noted our belief calendar year. did apply the same standard to
that such a combination would reduce Response: We thank the commenters individuals and groups. Although we
the alignment between a single hospital for their support. believe that this provided sufficient
and a clinician or group and could be Comment: A few commenters notice of the policy, we will plan to
confusing for participants. We further opposed our proposed time period that address this issue as part of the next
noted that we believed we must would determine the facility that would Quality Payment Program rulemaking
establish a reasonable threshold for a determine the MIPS quality and cost cycle. We encourage all interested
MIPS eligible clinicians participation in score, noting that the clinician may have parties to review that proposal when it
clinical care at a given facility to allow moved on to another facility by the time is issued and submit comments.
that MIPS eligible clinician to be scored of the MIPS performance period. One Comment: A few commenters
using that facilitys measures. We noted commenter suggested that because of expressed concern that our proposed
that we do not believe it to be this issue that clinicians be given the approach for facility attribution would
appropriate to allow MIPS eligible opportunity to identify the hospital not reflect the quality of care for
clinicians to claim credit for facilities upon which their scores should be clinicians that practice at multiple
measures if the MIPS eligible clinician based. facilities. These commenters suggested
does not participate meaningfully in the Response: We recognize that that CMS consider future changes to the
care provided at the facility. clinicians may move from one facility to methodology to accommodate multiple
Therefore, we proposed at another over time and a specific facilities, such as using a weighted
414.1380(e)(5) that MIPS eligible clinician may see a majority of his or average of the facility scores.
clinicians who elect facility-based her patients at one facility during 1 year Response: We have designed the
measurement would receive scores but at a different facility in later years. facility-based measurement option to
derived from the value-based However, our proposal to use the align incentives between clinicians and
purchasing score (using the September through August period facilities. Therefore, the intention is for
methodology described in section beginning 2 calendar years before the a clinician or a group that spends
II.B.7.b.4. of the CY 2018 Quality MIPS performance period begins for significant time in a facility to be
Payment Program proposed rule (82 FR attribution of facility performance supporting the efforts to improve the
30128 through 30129) for the facility at matched our proposed timeframe for score of that particular facility,
which they provided services for the claims used to determine whether a particularly because we believe a desire
most Medicare beneficiaries during the clinician (or group) is facility-based. to improve scores drives high quality
period of September 1 of the calendar This time period overlaps with parts of care for patients. While we recognize
year 2 years preceding the performance the performance period for the that clinicians do practice in multiple
period through August 31 of the applicable Hospital VBP Program facilities, we are concerned that
calendar year preceding the measures. If these timelines did not developing a composite score based on
performance period with a 30-day overlap, it would increase the likelihood the performance of multiple facilities
claims run out (82 FR 30127). This that we determine a clinician met the would reduce that alignment by
period for identifying the facility whose requirements for facility- based diffusing focus from a single facility and
performance will be attributed to a measurement but did not have a complicating scoring.
facility-based clinician (or group) is the hospital from which we could attribute Final Action: After consideration of
same as the time period for services we performance. As noted in the proposed the public comments, we are finalizing
will use to determine if a clinician (or rule, we considered whether a clinician our proposal for clinicians in facility-
group) is eligible for facility-based should be required to identify the based measurement to receive scores
measurement; this time period also hospital on which their scores should be derived from the value-based
overlaps with parts of the performance based, but concluded that was more purchasing score for the facility at
period for the applicable Hospital VBP likely to be a burden on the clinician. which they provided services for the
most Medicare beneficiaries during the facility-based measurement score is Response: We appreciate the interest
period of September 1 of the calendar higher than the quality and cost in minimizing administrative burden for
year 2 years preceding the performance performance category scores as clinicians. We will aim to minimize
period through August 31 of the determined based on data submitted by administrative burden on clinicians and
calendar year preceding the the MIPS eligible clinician or group groups for whichever method would be
performance period with a 30-day through any available reporting used for determination of facility-based
claims run out. We are not finalizing mechanism. This facility-measurement measurement.
regulation text associated with this score would be calculated even if an Comment: A few commenters
specific policy (that is, identifying the individual MIPS eligible clinician or expressed concern about the details of
period of the claims data used) as we group did not submit any data for the the opt-in process. One commenter
consider implementation of this policy. quality performance category. We expressed concern that an administrator
We note that facility-based explained how this alternative approach would be unable to opt in on behalf of
measurement will not be available until might work in the CY 2018 Quality clinicians in a group. One commenter
the 2019 MIPS performance period/2021 Payment Program proposed rule in recommended that third party
MIPS payment year so clinicians will connection with choosing the time intermediaries be able to receive
not be assigned to a facility for period of the hospital performance in information on facility-based
attribution of the facilitys performance the Hospital VBP Program (82 FR measurement through an API
before that time. We will address the 30127). We noted our concern that a framework.
issue of attribution for facility-based method that does not require active Response: As described further above,
groups in future rulemaking. selection may result in MIPS eligible we are not implementing facility-based
(e) Election of Facility-Based clinicians being scored on measures at measurement until the 2019 MIPS
Measurement a facility and being unaware that such performance period. We will use the
scoring is taking place. We also additional year to better explain to
We proposed at 414.1380(e)(3) that expressed concern that such a method clinicians how the facility-based
individual MIPS eligible clinicians or could provide an advantage to those measurement will work under the
groups who wish to have their quality facility-based clinicians who do not regulatory provisions we are finalizing
and cost performance category scores submit quality measures in comparison at 414.1380(e), including the
determined based on a facilitys to those who work in other determination of when a clinician or
performance must elect to do so through environments. We also noted that this
an attestation. We proposed that those group is facility-based and thus able to
option may not be technically feasible elect to use facility measurement, the
clinicians or groups who are eligible for
for us to implement for the 2018 MIPS time period for making that
and wish to elect facility-based
performance period. determination, and the use of the
measurement would be required to
We invited comments on this facilitys Hospital VBP Program
submit their election during the data
proposal and alternate proposal. performance to score the clinician or
submission period as determined at
414.1325(f) through the attestation The following is a summary of the group.
submission mechanism established for public comments received on these Final Action: After consideration of
the improvement activities and proposals and our responses: the public comments, we are not
advancing care information performance Comment: Many commenters finalizing either our proposal or our
categories. (82 FR 30127). We further supported our proposal to require alternative option for how an individual
proposed that, if technically feasible, we clinicians or groups to opt-in through a clinician or group will elect to use and
would let the MIPS eligible clinician voluntary election process in order to be identified as using facility-based
know that they were eligible for facility- participate in facility-based measurement for the MIPS program.
based measurement prior to the measurement. These commenters noted Because we are not offering facility-
submission period, so that MIPS eligible that clinicians should be given the based measurement until the 2019 MIPS
clinicians would be informed if this opportunity to determine if the quality performance period, we do not need to
option is available to them. of a hospital reflected the quality of the finalize either of these for the 2018
We also considered an alternative clinician or if they would be better MIPS performance period. We will use
approach of not requiring an election represented using a different submission the additional time to examine the
process but instead automatically mechanism. attestation process we proposed and the
applying facility-based measurement to Response: We appreciate the support alternative opt-out process. We intend
MIPS eligible clinicians and groups who of the commenters. As noted below, we to work with stakeholders to identify a
are eligible for facility-based are not finalizing the attestation procedure that best balances
measurement, if technically feasible. mechanism aspect of our proposal or administrative burden and clinician
Under this approach, we would our alternative, but we will revisit choice for proposal in next years
calculate a MIPS eligible clinicians through future rulemaking how to proposed rule. We are not finalizing our
facility-based measurement score based permit an individual clinician or group proposed regulatory text at
on the hospitals (as identified using the to elect facility-based measurement. 414.1380(e)(3), but will reserve that
process described in section Comment: A few commenters section for our future proposals.
II.C.7.a.(4)(d) of the CY 2018 Quality supported our alternative approach of In light of our interest in reducing
Payment Program proposed rule (82 FR not requiring an election process but burden, we do prefer an option that
30126 through 30127)) performance instead automatically applying facility- would not require a clinician or practice
using the methodology described in based measurement to MIPS eligible to notify CMS through attestation or
section II.C.7.a.(4)(f) of the CY 2018 clinicians and groups who are eligible other method. We therefore seek
Quality Payment Program proposed rule for facility-based measurement unless comment on whether a process by
(82 FR 30128 through 30132), and they opt out. These commenters noted which a clinician or group would be
automatically use that facility-based that this would reduce administrative automatically assigned a score under
measurement score for the quality and burden and some clinicians who would facility-based measurement but be
cost performance category scores if the be eligible would fail to opt in. notified and given the opportunity to
opt out of facility-based measurement closely aligns with our cost performance high-priority. Therefore, we proposed
would be appropriate. category. We believe this set of that facility-based individual MIPS
(f) Facility-Based Measures measures covering 4 domains and eligible clinicians or groups that are
composed primarily of measures that attributed to a hospital would be scored
For FY 2019, the Hospital VBP would be considered high priority on all the measures on which the
Program has adopted 12 quality and under the MIPS quality performance hospital is scored for the Hospital VBP
efficiency measures. The Hospital VBP Program via the Hospital VBP Programs
category capture a broad picture of
Program currently includes 4 domains:
hospital-based care. Additionally, the Total Performance Score scoring
Person and community engagement,
Hospital VBP Program has adopted methodology (82 FR 30127).
clinical care, safety, and efficiency and
cost reduction. These domains align several measures of clinical outcomes in The Hospital VBP Programs FY 2019
with many MIPS high priority measures the form of 30-day mortality measures, measures, and their associated
(outcome, appropriate use, patient and clinical outcomes are a high- performance periods, were reproduced
safety, efficiency, patient experience, priority topic for MIPS. The Hospital in Table 33 in the proposed rule (82 FR
and care coordination measures) in the VBP Program includes several measures 30128). Here, we are including, in Table
quality performance category and the in a safety domain, which meets our 26, a list of the finalized FY2019
efficiency and cost reduction domain definition of patient safety measures as Hospital VBP Program Measures.
TABLE 26FY 2019 HOSPITAL VBP PROGRAM MEASURES
Short name Domain/measure name NQF No. Performance period
Person and Community Engagement Domain
HCAHPS .................... Hospital Consumer Assessment of Healthcare Providers and Systems 0166 CY 2017.
(HCAHPS) (including Care Transition Measure). (0228)
Clinical Care Domain
MORT30AMI .......... Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Fol- 0230 July 1, 2014June 30, 2017.
lowing Acute Myocardial Infarction (AMI) Hospitalization.
MORT30HF ............ Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Fol- 0229 July 1, 2014June 30, 2017.
lowing Heart Failure (HF) Hospitalization.
MORT30PN ........... Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Fol- 0468 July 1, 2014June 30, 2017.
lowing Pneumonia Hospitalization.
THA/TKA .................... Hospital-Level Risk-Standardized Complication Rate (RSCR) Following 1550 January 1, 2015June 30,
Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee 2017.
Arthroplasty (TKA).
Safety Domain
CAUTI ........................ National Healthcare Safety Network (NHSN) Catheter-Associated Urinary 0138 CY 2017.
Tract Infection (CAUTI) Outcome Measure.
CLABSI ...................... National Healthcare Safety Network (NHSN) Central Line-Associated 0139 CY 2017.
Bloodstream Infection (CLABSI) Outcome Measure.
Colon and Abdominal American College of SurgeonsCenters for Disease Control and Preven- 0753 CY 2017.
Hysterectomy SSI. tion (ACSCDC) Harmonized Procedure Specific Surgical Site Infection
(SSI) Outcome Measure.
MRSA Bacteremia ..... National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hos- 1716 CY 2017.
pital-onset Methicillin-resistant Staphylococcus aureus (MRSA)
Bacteremia Outcome Measure.
CDI ............................. National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hos- 1717 CY 2017.
pital-onset Clostridium difficile Infection (CDI) Outcome Measure.
PC01 ........................ Elective Delivery ............................................................................................ 0469 CY 2017.
Efficiency and Cost Reduction Domain
MSPB ......................... Payment-Standardized Medicare Spending Per Beneficiary (MSPB) .......... 2158 CY 2017.
We noted that the Patient Safety those adopted for facility-based option through attestation as proposed
Composite Measure (PSI90) was measurement in the MIPS program if in the CY 2018 Quality Payment
proposed for removal beginning with that proposal was finalized. The Program proposed rule (82 FR 30128).
the FY 2019 measure set in the FY 2018 proposal to remove the PSI90 measure The following is a summary of the
was finalized in the FY 2018 IPPS/
Hospital Inpatient Prospective Payment public comments received on the

Systems for Acute Care Hospitals and LTCH PPS final rule (82 FR 38244). Facility-Based Measures proposals
the Long Term Care Hospital We proposed at 414.1380(e)(4) that and our responses:
Prospective Payment System (IPPS/ there are no data submission Comment: Several commenters
LTCH PPS) proposed rule (82 FR 19970) requirements for the facility-based supported our proposal to adopt all
due to issues with calculating the measures used to assess performance in measures and performances from the FY
measure score and that we would the quality and cost performance 2019 Hospital VBP Program for the
remove the measure from the list of categories, other than electing the purposes of facility-based measurement
in the MIPS program for the 2018 MIPS programs, as opposed to other new finalized our proposal to remove the
performance period/2020 MIPS measures that reflect a facilitys PSI90 measure from the FY 2019
payment year because those measures performance. We note that there may be Hospital VBP Program measure set. We
represented the total performance of the opportunities for clinicians to noted in the proposed rule that if this
hospital and were well known by participate in MIPS using qualified measure was to be removed from that
clinicians. registries or QCDRs that measure quality measure set, we would also remove it
Response: We thank the commenters for services that may be provided in a from the measures set used for facility-
for their support. Because we are facility setting, without being measured based measurement. We will consider
delaying the implementation of facility- in facility-based measurement. issues of measures included in future
based measure until the 2019 MIPS Comment: Several commenters years of other programs in future
performance period, these measures will expressed concern that the performance rulemaking for the Quality Payment
not be available for the 2018 MIPS periods for the measures that we Program.
performance period. We intend to proposed for inclusion for facility-based Comment: Several commenters
propose in next years rulemaking the measurement did not align with the opposed the inclusion of the MSPB
facility measures that will be used for performance period used for other measure from the FY 2019 Hospital VBP
purpose of the 2019 MIPS performance measures and requested that the Program as a measure for facility-based
period. performance periods be aligned. measurement. These commenters noted
Comment: Several commenters Response: We recognize that the that we had also proposed to weight the
recommended that clinicians be able to performance periods adopted for the cost performance category at zero
select measures from the Hospital VBP measures under the Hospital VBP percent, so clinicians in facility-based
Program and the Hospital Inpatient Program differ from the performance measurement would be disadvantaged
Quality Reporting (IQR) Program in period for MIPS measures. As we have by including this similar measure.
order to better identify those that they discussed with respect to the Hospital Response: As noted earlier in this
noted were relevant to their practice. VBP Program (such as in the FY 2013 section, we will not offer the
These commenters indicated that using IPPS/LTCH PPS final rule, 77 FR opportunity to participate in facility-
all measures from the Hospital VBP 53594), we take several considerations based measurement for the 2020 MIPS
Program was not necessarily into account when adopting payment year. When facility-based
representative of the individual performance periods for the Hospital measurement is offered beginning with
clinicians quality. VBP Program, including previously- the 2021 MIPS payment year, the cost
Response: We have a policy goal to adopted performance periods under the performance category will be equally
align incentives between clinicians and Hospital VBP Program, the possible weighted to the quality performance
facilities through facility-based duration of the performance period, and category. The MSPB measure is part of
measurement. We believe that any the reliability of the data that we collect. the overall Hospital VBP Program score
efforts to measure clinicians on a subset We also consider the statutory and reflects an important measure of the
of measures rather than the entire requirement that hospitals be notified of overall value of care in that
measure set reduces that alignment. In their Total Performance Scores and environment. Our scoring methodology
addition, we believe that a measure payment adjustments no later than 60 is intended to translate the overall score
selection process would introduce days prior to the fiscal year involved, as of value in the Hospital VBP Program to
unnecessary administrative burden. If well as the time necessary for quality a measure of value in the MIPS quality
clinicians do not believe that the measures submission and Total and cost performance categories.
measures that are included for that Performance Score computations. Section II.C.7.a.(4)(g) of this final rule
facility measurement program are When developing our facility-based with comment period discusses the
appropriate, there are opportunities to measurement policy under MIPS, we scoring for facility-based measurement.
participate in MIPS that offer more also took into account our beliefs that Final Action: After consideration of
flexibility in measure selection other aligning incentives and informing the public comments, we are not
than the use of facility-based clinicians about their opportunity to finalizing our proposal that the facility-
measurement. participate in MIPS outweighs the based measures available for the 2018
Comment: A few commenters interest in aligning the performance MIPS performance period are the
recommended that instead of using period between the Hospital VBP measures adopted for the FY 2019
measures that are part of the Hospital Program and MIPS. We believe that we Hospital VBP Program. We are also not
VBP Program or other pay-for-reporting must encourage participation in MIPS, finalizing our proposal that for the 2020
or pay-for-performance program, that we and we view the facility-based MIPS payment year facility-based
use measures from registries or other measurement option as one policy that individual MIPS eligible clinicians or
sources. These measures might reflect enables us to so encourage participating groups that are attributed to a hospital
the performance of an entire facility but clinicians. We will consider ways to would be scored on all the measures on
would be more closely tied to the align performance periods between the which the hospital is scored for the
activities of a particular clinician. Hospital VBP Program and the Quality Hospital VBP Program via the Hospital
Response: Section 1848(q)(2)(C)(ii) of Payment Program in the future. VBP Programs Total Performance Score
the Act provides that the Secretary may Comment: A few commenters methodology. (As discussed in section
use measures used for payment systems opposed the inclusion of the PSI90 II.C.7.a.(4)(g) of this final rule with
other than for physicians, such as measure as a measure to be used for comment period, we are finalizing a
measures for inpatient hospitals, for facility-based measurement. Others facility-based measurement scoring
purposes of the quality and cost expressed concern about the inclusion standard, but not the specific instance of
performance categories. Based on this of measures that are part of future years using FY 2019 Hospital VBP Program
statutory requirement and because we of the Hospital VBP Program, such as Total Performance Score methodology.)
want to align incentives between condition-specific episode-based We believe that the policy approach
clinicians and hospitals, we have payment measures. of using all measures from a value-based
elected to use measures that are Response: In the FY 2018 IPPS/LTCH purchasing program is appropriate.
developed and implemented into other PPS final rule (82 FR 38244), we However, we are not adopting these
proposals because we are not (ii) Applying Hospital VBP Program applying Hospital VBP Program scoring
implementing facility-based Scoring to the MIPS Quality and Cost to the MIPS quality and cost
measurement for the 2018 MIPS Performance Categories performance categories.
performance period/2020 MIPS Response: We thank the commenters
We summarized in the proposed rule
payment year and as such cannot for their support.
(82 FR 30129) what we considered prior
finalize any measures or scoring under Final Action: After consideration of
to proposing at 414.1380(e) that the public comments, we are finalizing
this program for that performance facility-based scoring be available for
period and payment year for the our proposed methodology applying
cost and quality performance categories. Hospital VBP Program scoring to MIPS
purpose of facility-based measurement We considered several methods to
in MIPS. We intend to propose quality and cost performance categories
incorporate facility-based measures into with modifications. As noted, we are
measures that would be available for scoring for the 2020 MIPS payment year,
facility-based measurement for the 2019 delaying the implementation of facility-
including selecting hospitals measure based measurement by 1 year in order
MIPS performance period/2021 MIPS scores, domain scores, and the Hospital
payment year in future rulemaking. As to increase clinician understanding and
VBP Program Total Performance Scores operational readiness to offer the
noted in section II.C.7.a.(4)(a) of this to form the basis for the cost and quality
final rule with comment period, we are program. As such, we are finalizing the
performance category scores for introductory regulation text at
adopting at 414.1380(e)(6)(i) that individual MIPS eligible clinicians and
quality and cost measures for which 414.1380(e)(1) (that the facility-based
groups that are eligible to participate in measurement scoring standard is the
facility-based measurement will be facility-based measurement. We
available are those adopted under the MIPS scoring methodology applicable
proposed the option that we believed for MIPS eligible clinicians identified as
value-based purchasing program of the provided the fairest comparison meeting the requirements in paragraph
facility for the year specified and at between performance in the 2 programs (e)(2) and (3) of this section) but are not
414.1380(e)(6)(iii) that the and would best allow us to expand the finalizing the text proposed for
performance period for facility-based opportunity to other programs in the paragraphs (e)(1)(A) and (B) that would
measurement is the performance period future. specifically identify use of the FY 2019
for the measures adopted under the Unlike MIPS, the Hospital VBP Hospital VBP Program for this purpose.
value-based purchasing program of the Program does not have performance We will address this issue in future
facility program for the year specified. categories. There are instead four rulemaking to identify the specifics of
These provisions refer to the general domains of measures. We considered the Hospital VBP Program performance
parameters of our method of facility- whether we should try to identify and scoring to be used for facility-based
based measurement. Specific programs certain domains or measures that were measurement in MIPS.
and years would be addressed in future more closely aligned with those
rulemaking. identified in the quality performance (iii) Benchmarking Facility-Based
We are finalizing our proposal at category or the cost performance Measures
414.1380(e)(4) with modification to category. We also considered whether Measures in the MIPS quality
state that there are no data submission we should limit the application of performance category are benchmarked
requirements for clinicians for the facility-based measurement to the to historical performance on the basis of
facility-based measures used to assess quality performance category and performance during the 12-month
performance in the quality and cost calculate the cost performance category calendar year that is 2 years prior to the
performance categories. Because we score as we do for other clinicians. performance period for the MIPS
have not finalized a method of electing However, we believe that value-based payment year. If a historical benchmark
facility-based measurement in purchasing programs are generally cannot be established, a benchmark is
414.1380(e)(3), we are deleting the constructed to assess an overall picture calculated during the performance
phrase other than electing the option of the care provided by the facility, period. In the cost performance
through attestation as described in taking into account both the costs and category, benchmarks are established
paragraph (e)(3) of this section. In the quality of care provided. Given our during the performance period because
addition, we are revising the text to focus on alignment between quality and changes in payment policies year to year
clarify that the lack of data submission cost, we also do not believe it is can make it challenging to compare
requirements is for individual clinicians appropriate to measure quality on one performance on cost measure year to
and groups of clinicians, rather than a unit (a hospital) and cost on another year. Although we proposed a different
statement about the submission by (such as an individual clinician or TIN). performance period for MIPS eligible
facilities for the facility performance Therefore, we proposed at 414.1380(e) clinicians in facility-based
program. that facility-based scoring is available measurement, the baseline period used
for the quality and cost performance for creating MIPS benchmarks is
(g) Scoring Facility-Based Measurement categories and that the facility-based generally consistent with this approach.
(i) Hospital VBP Program Scoring measurement scoring standard is the We noted that the Hospital VBP
MIPS scoring methodology applicable Program uses measures for the same
We believe that the Hospital VBP for those who meet facility-based fiscal year even if those measures do not
Program represents the most appropriate eligibility requirements and who elect have the same performance period
value-based purchasing program with facility-based measurement. length, but the baseline period closes
which to begin implementation of the The following is a summary of the well before the performance period. The
facility-based measurement option public comments received on MSPB is benchmarked in a manner that
under MIPS. We offered a summary of Applying Hospital VBP Program is similar to measures in the MIPS cost
the Hospital VBP Program scoring and Scoring to the MIPS Quality and Cost performance category. The MSPB only
compared it to MIPS scoring in the CY Performance Categories proposals and uses a historical baseline period for
2018 Quality Payment Program our responses: improvement scoring and bases its
proposed rule (82 FR 30128 through Comment: Several commenters achievement threshold and benchmark
30129). supported our proposed methodology of solely on the performance period (81 FR
57002). We proposed at We noted that we believe that we noted that this method will make it
414.1380(e)(6)(ii) that the benchmarks should recognize relative performance simpler to apply the concept of facility-
for facility-based measurement are those in the facility programs that reflect their based measurement to additional
that are adopted under the value-based different designs. Therefore, we programs in the future.
purchasing program of the facility for proposed at 414.1380(e)(6)(iv) that the The following is a summary of the
the year specified (82 FR 30130). quality performance category score for public comments received on the
Final Action: We did not receive any facility-based measurement is reached Assigning MIPS Performance Category
comments specifically on the by determining the percentile Scores based on Hospital VBP
Benchmarking Facility-Based performance of the facility determined Performance proposals and our
Measures proposals, and we are in the value-based purchasing program responses:
finalizing the policy as proposed in for the specified year as described under Comment: Several commenters
414.1380(e)(6)(ii). While we are not 414.1380(e)(5) and awarding a score supported our proposed approach to
making facility-based measurement associated with that same percentile translate performance in the Hospital
available until the 2019 MIPS performance in the MIPS quality VBP Program into MIPS quality and cost
performance period/2021 MIPS performance category score for those performance category scores using a
payment year (and are therefore not clinicians who are not scored using percentile distribution.
finalizing use of the FY 2019 Hospital facility-based measurement (82 FR Response: We thank the commenters
VBP Program measurement), we are 30130). We also proposed at for their support.
finalizing that benchmarks are those Final Action: After consideration of
414.1380(e)(6)(v) that the cost
adopted under the value-based the public comments, we are finalizing
performance category score for facility-
purchasing program of the facility our proposal to determine the percentile
based measurement is established by
program for the year specified. We will performance of the facility determined
determining the percentile performance
identify the particular value-based for the specified year and awarding a
of the facility determined in the value-
purchasing program in future score associated with that same
based purchasing program for the
rulemaking but would routinely use the percentile performance in the MIPS
specified year as described in
benchmarks associated with that quality performance category score and
414.1380(e)(5) and awarding the
program. MIPS cost performance category score
number of points associated with that
for those clinicians who are not scored
(iv) Assigning MIPS Performance same percentile performance in the
using facility-based measurement, but
Category Scores Based on Hospital VBP MIPS cost performance category score
are not finalizing use of the FY 2019
Performance for those clinicians who are not scored
Hospital VBP Program measurement
using facility-based measurement (82 FR
Performance measurement in the and scoring. We are modifying the
Hospital VBP Program and MIPS is 30130). (In the context of our proposal,
regulatory text at 414.1380(e) to clarify
quite different in part due to the design this year would have been the FY 2019
that this determination will be based on
and the maturity of the programs. The year for the Hospital VBP program, as
the year the claims are drawn from in
Hospital VBP Program only assigns we proposed in section II.C.7.a.(4)(e) to
414.1380(e)(2). We note that facility-
achievement points to a hospital for its use that as the attributed performance
based measurement will not be available
performance on a measure if the for MIPS eligible clinicians and groups
until the 2019 MIPS performance
hospitals performance during the that elected facility-based
period/2021 MIPS payment year so
performance period meets or exceeds measurement.) For example, if the
clinicians will not be scored through
the median of hospital performance on median Hospital VBP Program Total
facility-based measurement until that
that measure during the applicable Performance Score was 35 out of 100
time.
baseline period (or in the case of the possible points and the median quality
MSPB measure, if the hospitals performance category percent score in (v) Scoring Improvement for Facility-
performance during the performance MIPS was 75 percent and the median Based Measurement
period meets or exceeds the median of cost performance category score was 50 The Hospital VBP Program includes a
hospital performance during that percent, then a clinician or group that methodology for recognizing
period), whereas MIPS assigns is evaluated based on a hospital that improvement on individual measures
achievement points to all measures that received an Hospital VBP Program Total which is then incorporated into the total
meet the required data completeness Performance Score of 35 points would performance score for each participating
and case minimums. In addition, the receive a score of 75 percent for the hospital. A hospitals performance on a
Hospital VBP Program has removed quality performance category and 50 measure is compared to a national
many process measures and topped out percent for the cost performance benchmark, as well as its own
measures since its first program year category. The percentile distribution for performance from a corresponding
(FY 2013), while both process and both the Hospital VBP Program and baseline period.
topped out measures are available in MIPS would be based on the We proposed to consider
MIPS. With respect to the FY 2017 distribution during the applicable improvement in the quality and cost
program year, for example, the median performance periods for each of the performance categories. In the CY 2018
Total Performance Score for a hospital programs and not on a previous Quality Payment Program proposed rule
in Hospital VBP Program was 33.88 out benchmark year. (82 FR 30113), we proposed to measure
of 100 possible points. If we were to We noted in the proposed rule our improvement in the quality performance
simply assign the Hospital VBP Program belief that the proposal offers a fairer category based on improved
Total Performance Score for a hospital comparison of the performance among achievement for the performance
to a clinician, the performance of those participants in MIPS and the Hospital category percent score and award
MIPS eligible clinicians electing facility- VBP Program compared to other options improvement even if, under certain
based measurement would likely be we considered and provides an circumstances, a clinician moves from
lower than most who participated in the objective means to normalize one identifier to another from 1 year to
MIPS program, particularly in the differences in measured performance the next. For those who may be
quality performance category. between the programs. In addition, we measured under facility-based
measurement, improvement is already MIPS eligible clinicians that participate category score for using end-to-end
captured in the scoring method used by in MIPS using the same identifier and electronic submission of quality
the Hospital VBP Program, so we do not are scored on the same cost measure(s) measures. The Hospital VBP Program
believe it is appropriate to separately in 2 consecutive performance periods, does not capture whether or not
measure improvement using the those MIPS eligible clinicians who elect measures are reported using end-to-end
proposed MIPS methodology for facility-based measurement would not electronic reporting; however, our
clinicians and groups that elect facility- be eligible for a cost improvement score proposed facility-based scoring method
based measurement. Although the in the cost performance category under described above is based on a percentile
improvement methodology is not the proposed methodology because they distribution of scores within the quality
identical in the Hospital VBP Program would not be scored on the same cost and cost performance categories.
compared to our MIPS proposal, measure(s) for 2 consecutive Because the MIPS quality performance
improvement is reflected in the performance periods. category scores already account for
underlying Hospital VBP Program The following is a summary of the bonus points, including end-to-end
measurement because a hospital that public comments received on the electronic reporting, when we translate
demonstrated improvement in the Scoring Improvement for Facility- the Total Performance Score, the overall
individual measures would in turn Based Measurement proposals and our effect of end-to-end electronic reporting
receive points under the Hospital VBP responses: would be captured in the translated
Program methodology if the Comment: One commenter supported score. For this reason, we did not
improvement score is higher than their our proposal to not assess improvement propose to calculate additional end-to-
achievement score. In addition, for participants in facility-based end electronic reporting bonus points
improvement is already captured in the measurement. for facility-based measurement.
distribution of MIPS performance scores Response: We appreciate the support
that is used to translate Hospital VBP of the commenter.
public comments received on the
Program Total Performance Score into a Final Action: After consideration of
the public comments, we are finalizing Bonus Points for Facility-Based
MIPS quality performance category Measurement proposals and our
score. Therefore, we did not propose our proposal that a clinician or group
participating in facility-based responses:
any additional improvement scoring for Comment: A few commenters
facility-based measurement for either measurement would not be given the
opportunity to earn improvement points supported our proposal to not calculate
the quality or cost performance bonus points for additional high priority
category. based on prior performance in the MIPS
quality and cost performance categories. or end-to-end electronic reporting of
Because we indicated our intention to measures.
allow clinicians the flexibility to elect We did not propose and are not
finalizing regulation text on this aspect Response: We thank the commenters
facility-based measurement on an
of facility-based measurement because for their support of the proposal.
annual basis, we noted that some
we believe it is unnecessary. Comment: A few commenters
clinicians may be measured through
facility-based measurement in 1 year opposed our proposal to not calculate
(vi) Bonus Points for Facility-Based bonus points for additional high priority
and through another MIPS method in Measurement
the next. We sought comment on how measures or end-to-end electronic
to assess improvement for those that MIPS eligible clinicians that report on reporting. One of the commenters noted
switch from facility-based scoring to quality measures are eligible for bonus the similarity of facility-based
another MIPS method in a later year. We points for the reporting of additional measurement to the CMS Web Interface
requested comment on whether it is outcome and high priority measures because there was no opportunity to
appropriate to include measurement of beyond the one that is required. Two select measures in either method, and
improvement in the MIPS quality bonus points are awarded for each noted that those who submitted via web
performance category for MIPS eligible additional outcome or patient interface did receive bonus points for
clinicians and groups that use facility- experience measure, and one bonus both additional high priority measures
based measures given that the Hospital point is awarded for each additional and end-to-end electronic reporting.
VBP Program already takes other high priority measure. These Response: Because our scoring
improvement into account in its scoring bonus points are intended to encourage approach to facility-based measurement
methodology (82 FR 30130). the use of measures that are more is based on a translation of the facilitys
In the CY 2018 Quality Payment impactful on patients and better reflect performance under the Hospital VBP
Program proposed rule, we discussed the overall goals of the MIPS program. Program scoring methodology to the
our proposal to measure improvement Many of the measures in the Hospital MIPS quality and cost performance
in the cost performance category at the VBP Program meet the criteria that we categories, we do not believe it is
measure level (82 FR 30121). We have adopted for high-priority appropriate to add bonus points based
proposed that clinicians under facility- measures. We support measurement that on measure selection. The CMS Web
based measurement would not be takes clinicians focus away from Interface method is scored in a manner
eligible for a cost improvement score in clinical process measures; however, the that determines performance on
the cost performance category (82 FR proposed scoring method described individual measures and is scored in the
30130). As in the quality performance above is based on a percentile same way as other MIPS submission
category, we believe that a clinician distribution of scores within the quality mechanisms with a few exceptions.
participating in facility-based and cost performance categories that Final Action: After consideration of
measurement in subsequent years already accounts for bonus points. For the public comments, we are finalizing
would already have improvement this reason, we did not propose to our proposal to not award bonus points
recognized as part of the Hospital VBP calculate additional high priority bonus for additional high priority and end-to-
Program methodology and therefore, points for facility-based measurement. end electronic reporting for clinicians
should not be given additional credit. In We noted that clinicians have an scored under facility-based
addition, because we proposed to limit additional opportunity to receive bonus measurement. We did not propose and
measurement of improvement to those points in the quality performance are not finalizing regulation text on this
aspect of facility-based measurement purposes of the facility-based scoring score is higher, facility-based
because we believe it is unnecessary. policy, we do not wish to disadvantage measurement is used for quality and
those clinicians and groups that select cost) (82 FR 30131). Since this policy
(vii) Special Rules for Facility-Based
this measurement method. In the CY may result in a higher final score, it may
Measurement
2018 Quality Payment Program provide facility-based clinicians with a
Some hospitals do not receive a Total proposed rule, we proposed to retain a substantial incentive to elect facility-
Performance Score in a given year in the policy equivalent to the 3-point floor for based measurement, whether or not the
Hospital VBP Program, whether due to all measures with complete data in the clinician believes such measures are the
insufficient quality measure data, failure quality performance category scored most accurate or useful measures of that
to meet requirements under the Hospital against a benchmark in the 2020 MIPS clinicians performance. Therefore, this
IQR Program, or other reasons. In these payment year (82 FR 30131). However, policy may create an advantage for
cases, we would be unable to calculate the Hospital VBP Program does not have facility-based clinicians over non-
a facility-based score based on the a corresponding scoring floor. facility-based clinicians, since non-
hospitals performance, and facility- Therefore, we proposed to adopt a floor facility-based clinicians would not have
based clinicians would be required to on the Hospital VBP Program Total the opportunity to use the higher of two
participate in MIPS via another method. Performance Score for purposes of scores. Therefore, we sought comment
Most hospitals which do not receive a facility-based measurement under MIPS on whether this proposal to use the
Total Performance Score in the Hospital so that any score in the quality higher score is the best approach to
VBP Program are routinely excluded, performance category, once translated score the performance of facility-based
such as hospitals in Maryland. In such into the percentile distribution clinicians in comparison to their non-
cases, facility-based clinicians would described above, that would result in a facility-based peers (82 FR 30131).
know well in advance that the hospital score of below 30 percent would be The following is a summary of the
would not receive a Total Performance reset to a score of 30 percent in the public comments received on the
Score, and that they would need to quality performance category (82 FR Special Rules for Facility-Based
participate in MIPS through another 30131). We believe that this adjustment Measurement proposals and our
method. However, we noted that we are is important to maintain consistency responses:
concerned that some facility-based with our other policies. There is no Comment: Several commenters
clinicians may provide services in similar floor established for measures in supported our proposal that, if a
hospitals which they expect will receive the cost performance category under clinician or a group elects facility-based
a Total Performance Score but do not MIPS, so we did not propose any floor measurement but also submits quality
due to various rare circumstances such for the cost performance category for data through another MIPS mechanism,
as natural disasters. In the CY 2018 facility-based measurement. we use the higher of the two scores for
Quality Payment Program proposed rule Some MIPS eligible clinicians who
(82 FR 30142 through 30143) we the quality performance category and
select facility-based measurement could
proposed a process for requesting a base the score of the cost performance
have sufficient numbers of attributed
reweighting assessment for the quality, category on the same method.
patients to meet the case minimums for
cost and improvement activities Response: We thank the commenters
the cost measures established under
performance categories due to extreme for their support.
MIPS. Although there is no additional
and uncontrollable circumstances, such data reporting for cost measures, we Comment: A few commenters stated
as natural disasters. We proposed that believe that, to facilitate the relationship that giving the higher score of the
MIPS eligible clinicians who are between cost and quality measures, they facility-based measurement or another
facility-based and affected by extreme should be evaluated covering the same submission was an unfair advantage for
and uncontrollable circumstances, such population as opposed to comparing a facility-based clinicians. Some of these
as natural disasters, may apply for hospital population and a population commenters recommended that those
reweighting (82 FR 30131). attributed to an individual clinician or who elect facility-based measurement
In addition, we noted that hospitals group. In addition, we believe that always be scored on it, regardless if
may submit correction requests to their including additional cost measures in another mechanism for submitting
Total Performance Scores calculated the cost performance category score for quality measurement was used.
under the Hospital VBP Program, and MIPS eligible clinicians who elect Response: We believe that this policy
may also appeal the calculations of their facility-based measurement would to use the higher of two available
Total Performance Scores, subject to reduce the alignment of incentives performance scores is consistent with
Hospital VBP Program requirements between the hospital and the clinician. our other approaches to scoring where
established in prior rulemaking. Our Thus, we proposed at we have the opportunity to assess
proposal was to use the final Hospital 414.1380(e)(6)(v)(A) that MIPS eligible performance based on two different
VBP Program Total Performance Score clinicians who elect facility-based methods. If another clinician were to
for the facility-based measurement measurement would not be scored on submit through two different methods of
option under MIPS. In the event that a other cost measures specified for the MIPS reporting, we would base the
hospital obtains a successful correction cost performance category, even if they score of that clinician on the submission
or appeal of its Total Performance Score, meet the case minimum for a cost that resulted in the highest score.
we would update MIPS eligible measure (82 FR 30131). Comment: One commenter supported
clinicians quality and cost performance If a clinician or a group elects facility- our proposed 30 percent floor for the
category scores accordingly, as long as based measurement but also submits quality performance category for
the update could be made prior to the quality data through another MIPS participants in facility-based
application of the MIPS payment mechanism, we proposed to use the measurement, noting that it was
adjustment for the relevant MIPS higher of the two scores for the quality equitable to other clinicians with
payment year. performance category and base the score complete data submission in the quality
Additionally, although we wish to tie of the cost performance category on the performance category.
the hospital and clinician performance same method (that is, if the facility- Response: We thank the commenter
as closely together as possible for based quality performance category for the support.
Comment: Several commenters Final Action: After consideration of We refer readers to 414.1380(b)(3) and
opposed our proposal to establish a the public comments, we are finalizing the CY 2017 Quality Payment Program
floor of 30 percent for the quality our proposals that clinicians or groups final rule (81 FR 78312) for further
performance category for clinicians and that elect facility-based measurement detail on improvement activities
groups participating in facility-based but also submit quality data through scoring.
measurement. A few commenters noted another MIPS mechanism would be Activities will be weighted as high
that score of 30 percent in the quality measured on the method that results in based on the extent to which they align
category is equal to 18 points (assuming the higher quality score and to establish with activities that support the certified
a quality performance category weight a 30 percent floor for the quality patient-centered medical home, since
of 60 percent), which is higher than the performance category for those who that is consistent with the standard
15 point performance threshold that participate in facility-based under section 1848(q)(5)(C)(i) of the Act
CMS has proposed. These commenters measurement. We are finalizing all other for achieving the highest potential score
suggested that such a floor was unfair to special rules discussed in this section as for the improvement activities
other clinicians who would be required well. We note that facility-based performance category, as well as with
to submit data in order to receive a score measurement will not be available until our priorities for transforming clinical
that higher than the performance the 2019 MIPS performance period/2021 practice (81 FR 77311). Additionally,
threshold. MIPS payment year so these special activities that require performance of
Response: We continue to believe that rules will not apply until that time. multiple actions, such as participation
this policy is consistent with the score in the Transforming Clinical Practice
that might be received for a clinician (5) Scoring the Improvement Activities Initiative (TCPI), participation in a MIPS
who submitted data that meet data Performance Category eligible clinicians state Medicaid
completeness on six measures through Section 1848(q)(5)(C) of the Act program, or an activity identified as a
another mechanism. Measures scored in specifies scoring rules for the public health priority (such as emphasis
the Hospital VBP Program have to meet improvement activities performance on anticoagulation management or
the criteria required for submission category. For more of the statutory utilization of prescription drug
through the Hospital IQR Program; background and description of the monitoring programs) are justifiably
therefore, we do not believe it would be proposed and finalized policies, we weighted as high (81 FR 77311 through
appropriate to allow a clinician to refer readers to the CY 2017 Quality 77312).
receive a lower score based on the Payment Program final rule (81 FR We refer readers to Table 26 of the CY
selection of this measurement option. 77311 through 77319). We have also 2017 Quality Payment Program final
We will continue to evaluate this floor codified certain requirements for the rule for a summary of the previously
in the context of scoring policies that improvement activities performance finalized improvement activities that are
are established in the quality category at 414.1380(b)(3). Based on weighted as high (81 FR 77312 through
performance category for other methods these criteria, we finalized at 77313), and to Table H of the same final
of participating in MIPS. We also note 414.1380(b)(3) in the CY 2017 Quality rule, for a list of all the previously
that this option is not being finalized for Payment Program final rule the scoring finalized improvement activities, both
the 2018 MIPS performance period, so methodology for this category, which medium- and high-weighted (81 FR
concerns about the minimum score assigns points based on certified 77817 through 77831). We also refer
being higher than the performance patient-centered medical home readers to Table F and Table G in the
threshold for the 2018 MIPS participation or comparable specialty appendices of the proposed rule for our
performance period is no longer practice participation, APM proposed additions and changes to the
relevant at this time. We will consider participation, and the improvement Improvement Activities Inventory for
comments on this topic in future activities reported by the MIPS eligible Quality Payment Program Year 2 and
rulemaking. clinician (81 FR 77312). A MIPS eligible future years (82 FR 30479 and 82 FR
Comment: One commenter clinicians performance will be 30486 respectively). In this final rule
recommended that if a clinician or evaluated by comparing the reported with comment period, we are finalizing
group participates in facility-based improvement activities to the highest the proposed new activities and changes
measurement and submits through possible score (40 points). In the CY to previously adopted activities, some
another mechanism that we use the 2018 Quality Payment Program with modification, and refer readers to
highest combined quality and cost proposed rule (82 FR 30132), we did not the tables in the appendices of this final
performance category score as opposed propose any changes to the scoring of rule with comment period for details.
to the method which would have the the improvement activities performance Consistent with our unified scoring
highest quality performance category category. system principles, we finalized in the
score. CY 2017 Quality Payment Program final
Response: Because many of the (a) Assigning Points to Reported
rule that MIPS eligible clinicians will
clinicians who qualify for facility-based Improvement Activities
know in advance how many potential
measurement would also qualify for an We assign points for each reported points they could receive for each
exemption from the advancing care improvement activity within 2 improvement activity (81 FR 77311
information performance category, their categories: Medium-weighted; and high- through 77319).
quality performance category will carry weighted activities. Generally, each
more weight than the cost performance medium-weighted activity is worth 10 (b) Improvement Activities Performance
category. Because of the possibility of points toward the total category score of Category Highest Potential Score
reweighting of this category for many 40 points, and each high-weighted At 414.1380(b)(3), we finalized that
clinicians who would use facility-based activity is worth 20 points toward the we will require a total of 40 points to
measurement, we believe it is too total category score of 40 points. These receive the highest score for the
complex to use the higher combined points are doubled for small practices, improvement activities performance
score. We believe that using the option practices in rural areas, or practices category (81 FR 77315). For more of the
with the higher quality score is simpler located in geographic HPSAs, and non- statutory background and description of
and more appropriate. patient facing MIPS eligible clinicians. the proposed and finalized policies, we
refer readers to the CY 2017 Quality (c) Points for Certified Patient-Centered Reporting of one medium-weighted
Payment Program final rule (81 FR Medical Home or Comparable Specialty activity will result in 10 points which
77314 through 77315). Practice is one- fourth of the highest score.
For small practices, practices in rural Section 1848(q)(5)(C)(i) of the Act Reporting of two medium-weighted
areas or geographic HPSAs, and non- specifies that a MIPS eligible clinician activities will result in 20 points which
patient facing MIPS eligible clinicians, who is in a practice that is certified as is one- half of the highest score.
the weight for any activity selected is a patient-centered medical home or Reporting of three medium-
doubled so that these practices and comparable specialty practice for a weighted activities will result in 30
eligible clinicians only need to select performance period, as determined by points which is three-fourths of the
one high- or two medium-weighted the Secretary, must be given the highest highest score.
activities to achieve the highest score of
potential score for the improvement Reporting of four medium-weighted
activities performance category for the activities will result in 40 points which
40 points (81 FR 77312).
performance period. Accordingly, at is the highest score.
In accordance with section 414.1380(b)(3)(iv), we specified that a Reporting of one high-weighted
1848(q)(5)(C)(ii) of the Act, we codified MIPS eligible clinician who is in a activity will result in 20 points which
at 414.1380(b)(3)(ix) that individual practice that is certified as a patient- is one-half of the highest score.
MIPS eligible clinicians or groups who centered medical home, including a
Medicaid Medical Home, Medical Home Reporting of two high-weighted
are participating in an APM (as defined
Model, or comparable specialty practice, activities will result in 40 points which
in section 1833(z)(3)(C) of the Act) for
will receive the highest potential score is the highest score.
a performance period will automatically
for the improvement activities Reporting of a combination of
earn at least one half of the highest
performance category (81 FR 77196 medium-weighted and high-weighted
potential score for the improvement
through 77180). activities where the total number of
activities performance category for the
In the CY 2018 Quality Payment points achieved are calculated based on
performance period (81 FR 30132). In the number of activities selected and the
Program proposed rule, we did not
addition, MIPS eligible clinicians that weighting assigned to that activity
propose any changes specifically to the
are participating in MIPS APMs are (number of medium-weighted activities
scoring of the patient-centered medical
assigned an improvement activity score, home or comparable specialty practice; selected 10 points + number of high-
which may be higher than one half of however, we did propose a change to weighted activities selected 20 points)
the highest potential score (81 FR how groups qualify for this activity (82 (81 FR 78318).
30132). This assignment is based on the FR 30054). We refer readers to section In the CY 2018 Quality Payment
extent to which the requirements of the II.C.6.e.(2)(a) of this final rule with Program proposed rule (82 FR 30133),
specific model meet the list of activities comment period for more details. we did not propose any changes to how
in the Improvement Activities Inventory we will calculate the improvement
(81 FR 30132). For a further description (d) Calculating the Improvement
activities performance category score.
of improvement activities and the APM Activities Performance Category Score
scoring standard for MIPS, we refer (i) Generally (ii) Small Practices, Practices Located in
Rural Areas or Geographic HPSAs, and
readers to the CY 2017 Quality Payment In the CY 2017 Quality Payment Non- Patient Facing MIPS Eligible
Program final rule (81 FR 77246). For all Program final rule (81 FR 77318), we Clinicians
other individual MIPS eligible finalized that individual MIPS eligible
clinicians or groups, we refer readers to clinicians and groups must earn a total Section 1848(q)(2)(B)(iii) of the Act
the scoring requirements for individual of 40 points to receive the highest score requires the Secretary to give
MIPS eligible clinicians and groups in for the improvement activities consideration to the circumstances of
the CY 2017 Quality Payment Program performance category. To determine the small practices and practices located in
final rule (81 FR 77270). An individual improvement activities performance rural areas and in geographic HPSAs (as
MIPS eligible clinician or group is not category score, we sum the points for all designated under section 332(a)(1)(A) of
required to perform activities in each of a MIPS eligible clinicians reported the PHS Act) in defining activities.
improvement activities subcategory or activities and divide by the Section 1848(q)(2)(C)(iv) of the Act also
participate in an APM to achieve the improvement activities performance requires the Secretary to give
highest potential score in accordance category highest potential score of 40. A consideration to non- patient facing
with section 1848(q)(5)(C)(iii) of the Act perfect score will be 40 points divided MIPS eligible clinicians. Further,
(81 FR 77178). by 40 possible points, which equals 100 section 1848(q)(5)(F) of the Act allows
percent. If MIPS eligible clinicians have the Secretary to assign different scoring
In the CY 2017 Quality Payment more than 40 improvement activities weights for measures, activities, and
Program final rule, we also finalized points, we will cap the resulting performance categories, if there are not
that individual MIPS eligible clinicians improvement activities performance sufficient measures and activities
and groups that successfully participate category score at 100 percent (81 FR applicable and available to each type of
and submit data to fulfill the 77318). For example, if more activities eligible clinician.
requirements for the CMS Study on are selected than 4 medium-weighted Accordingly, in the CY 2017 Quality
Improvement Activities and activities, the total points that could be Payment Program final rule (81 FR
Measurement will receive the highest achieved is still 40 points (81 FR 77318), we finalized that the following
score for the improvement activities 77318). As stated at (81 FR 77318), the scoring applies to MIPS eligible
performance category (81 FR 77315). We following scoring applies to MIPS clinicians who are a non-patient facing
refer readers to the CY 2018 Quality eligible clinicians generally (who are MIPS eligible clinician, a small practice
Payment Program proposed rule (82 FR not a non-patient facing clinician, a (consisting of 15 or fewer professionals),
30056) and section II.C.6.e.(10) of this small practice, a practice located in a a practice located in a rural area, or
final rule with comment period for rural area, or a practice in a geographic practice in a geographic HPSA, or any
further detail on this study. HPSA): combination thereof:
Reporting of one medium-weighted (e) Self-Identification Policy for MIPS area, or a practice in a geographic
activity will result in 20 points or one- Eligible Clinicians HPSA, or any combination thereof to
half of the highest score. In the CY 2017 Quality Payment self-identify, stating that this will lower
Reporting of two medium-weighted Program final rule (81 FR 77319), we the burden of reporting. One commenter
activities will result in 40 points or the established that individual MIPS urged us to also consider ways of
highest score. eligible clinicians or groups eliminating the self-identification
requirements for MIPS eligible
Reporting of one high-weighted participating in APMs would not be
clinicians who participate in patient-
activity will result in 40 points or the required to self-identify as participating
in an APM, but that all MIPS eligible centered medical homes or comparable
highest score. specialty practices, for example, by
clinicians would be required to self-
In the CY 2018 Quality Payment requiring the certification and
identify if they were part of a certified
Program proposed rule (82 FR 30133), recognition organizations to submit to
patient-centered medical home or
we did not propose any changes to our CMS lists of the MIPS eligible clinicians
comparable specialty practice, a non-
policy to give consideration to the or groups that meet their standards and
patient facing MIPS eligible clinician, a
circumstances of small practices and are certified/recognized, similar to how
small practice, a practice located in a
practices located in rural areas and in participation lists are utilized to
rural area, or a practice in a geographic
geographic HPSAs. determine the participants in certain
HPSA, or any combination thereof, and
APMs.
(iii) Advancing Care Information that we would validate these self- Response: We thank commenters for
Performance Category Bonus identifications as appropriate. their support and suggestions. We are
In the CY 2018 Quality Payment attempting to eliminate burden where
We finalized in the CY 2017 Quality Program proposed rule (82 FR 30133),
Payment Program final rule that certain possible and will continue to explore
we did not propose any changes to this technically feasible ways to reduce
activities in the improvement activities policy for certified patient-centered
performance category will also qualify burden. We will consider the suggestion
medical homes or comparable specialty to also eliminate the need for MIPS
for a bonus under the advancing care practices. MIPS eligible clinicians that
information performance category (81 eligible clinicians who participate in
are part of a certified patient-centered patient-centered medical homes or
FR 78318). This bonus is applied under medical home a recognized or certified
the advancing care information comparable specialty practices to self
patient-centered medical home or identify as we craft future policy.
performance category and not under the comparable specialty practice are still
improvement activities performance Final Action: After consideration of
required to self-identify for the 2018 the public comments received, we are
category (81 FR 78318). For more MIPS performance period, and we will
information about our finalized finalizing our proposal, as proposed, to
validate these self-identifications as no longer require these self-
improvement activities scoring policies appropriate.
and for several sample scoring charts, identifications for non-patient facing
For the criteria for recognition as a MIPS eligible clinicians, small practices,
we refer readers to the CY 2017 Quality recognized or certified patient-centered
Payment Program final rule (81 FR practices located in rural areas or
medical home or comparable specialty geographic HPSAs, or any combination
78318 through 78319). In the CY 2018 practice, we refer readers to the CY 2017
Quality Payment Program proposed rule thereof, beginning with the 2018 MIPS
Quality Payment Program final rule (81 performance period and for future years.
(82 FR 30059), we did not propose any FR 77179 through 77180) and section
changes to this policy and refer readers II.C.6.e.(2)a of this final rule with (6) Scoring the Advancing Care
to section II.C.6.f.(2)(d) of this final rule comment period. Information Performance Category
with comment period for more details in However, in the CY 2018 Quality In the CY 2018 Quality Payment
the advancing care information Payment Program proposed rule (82 FR Program proposed rule, we referred
performance discussion. 30133), we proposed to no longer readers to section II.C.6. of the proposed
(iv) MIPS APMs require these self-identifications for rule, (82 FR 30057 through 82 FR 30080)
non-patient facing MIPS eligible where we discussed scoring the
Finally, in the CY 2017 Quality clinicians, small practices, or practices advancing care information performance
Payment Program final rule (81 FR located in rural areas or geographic category. We refer readers to section
77319), we codified at HPSAs beginning with the 2018 MIPS II.C.6.f. of this final rule with comment
414.1380(b)(3)(ix) that MIPS eligible performance period, because it is period for finalized policies related to
clinicians participating in APMs that are technically feasible for us to identify scoring the advancing care information
not certified patient-centered medical these MIPS eligible clinicians during performance category.
homes will automatically earn a attestation for the performance of
minimum score of one-half of the improvement activities following the b. Calculating the Final Score
highest potential score for the performance period. We define these For a description of the statutory basis
performance category, as required by MIPS eligible clinicians in the CY 2017 and our policies for calculating the final
section 1848(q)(5)(C)(ii) of the Act. For Quality Payment Program final rule (81 score for MIPS eligible clinicians, we
any other MIPS eligible clinician who FR 77540). refer readers to the discussion in the CY
does not report at least one activity, The following is a summary of the 2017 Quality Payment Program final
including a MIPS eligible clinician who public comments received on the Self- rule (81 FR 77319 through 77329) and
does not identify to us that they are Identification Policy for MIPS Eligible 414.1380. In the proposed rule, we
participating in a certified patient- Clinicians proposals and our proposed to add a complex patient
centered medical home or comparable responses. scoring bonus (82 FR 30135 through 82
specialty practice, we will calculate a Comment: Several commenters FR 30139) and add a small practice
score of zero points (81 FR 77319). In supported our proposal to remove the bonus to the final score (82 FR 30139
the CY 2018 Quality Payment Program requirement for MIPS eligible clinicians through 82 FR 30140). In addition, we
proposed rule (82 FR 30132), we did not that are non-patient facing, a small reviewed the final score calculation for
propose any changes to this policy. practice, a practice located in a rural the 2020 MIPS payment year (82 FR
30140) and proposed refinements to the first of several Reports to Congress on a stratifying the scores of MIPS eligible
reweighting policies (82 FR 30141 study it was required to conduct under clinicians based on the proportion of
through 82 FR 30146). section 2(d) of the IMPACT Act of 2014. their patients who are dual eligible);
The first study analyzed the effects of confidential reporting of stratified
(1) Accounting for Risk Factors
certain social risk factors in Medicare measure rates to MIPS eligible
Section 1848(q)(1)(G) of the Act beneficiaries on quality measures and clinicians; public reporting of stratified
requires us to consider risk factors in measures of resource use used in one or measure results; risk adjustment of a
our scoring methodology. Specifically, more of nine Medicare value-based particular measure as appropriate based
that section provides that the Secretary, purchasing programs.8 The report also on data and evidence; and redesigning
on an ongoing basis, shall, as the included considerations for strategies to payment incentives (for instance,
Secretary determines appropriate and account for social risk factors in these rewarding improvement for clinicians
based on individuals health status and programs. A second report due October caring for patients with social risk
other risk factors, assess appropriate 2019 will expand on these initial factors or incentivizing clinicians to
adjustments to quality measures, cost analyses, supplemented with non- achieve health equity). We requested
measures, and other measures used Medicare datasets to measure social risk comments on whether any of these
under MIPS and assess and implement factors. In a January 10, 2017 report methods should be considered, and if
appropriate adjustments to payment released by the National Academies of so, which of these methods or
adjustments, final scores, scores for Sciences, Engineering, and Medicine, combination of methods would best
performance categories, or scores for that body provided various potential account for social risk factors in MIPS,
measures or activities under the MIPS. methods for accounting for social risk if any.
In doing this, the Secretary is required factors, including stratified public In addition, we requested public
to take into account the relevant studies reporting.9 comment on which social risk factors
conducted under section 2(d) of the In addition, the National Quality might be most appropriate for stratifying
Improving Medicare Post-Acute Care Forum (NQF) has concluded their initial measure scores and/or potential risk
Transformation (IMPACT) Act of 2014 trial on risk adjustment for quality adjustment of a particular measure.
and, as appropriate, other information, measures. Based on the findings from Examples of social risk factors include,
including information collected before the initial trial, NQF will continue its but are not limited to the following:
completion of such studies and work to evaluate the impact of social Dual eligibility/low-income subsidy;
recommendations. risk factor adjustment on intermediate race and ethnicity; and geographic area
In this section, we summarize our outcome and outcome measures for an of residence. We also requested
efforts related to social risk and the additional 3 years. The extension of this comment on which of these factors,
relevant studies conducted under work will allow NQF to determine including current data sources where
section 2(d) of the IMPACT Act of 2014. further how to effectively account for this information would be available,
We also finalize some short-term social risk factors through risk could be used alone or in combination,
adjustments to address patient adjustment and other strategies in and whether other data should be
complexity. quality measurement. collected to better capture the effects of
As we continue to consider the social risk. We noted that we will take
(a) Considerations for Social Risk
analyses and recommendations from commenters input into consideration as
We understand that social risk factors these and any future reports, we are we continue to assess the
such as income, education, race and continuing to work with stakeholders in appropriateness and feasibility of
ethnicity, employment, disability, this process. As we have previously accounting for social risk factors in
community resources, and social communicated, we are concerned about MIPS. We noted that any such changes
support (certain factors of which are holding providers to different standards would be proposed through future
also sometimes referred to as for the outcomes of their patients with notice and comment rulemaking.
socioeconomic status (SES) factors or social risk factors because we do not We look forward to working with
socio-demographic status (SDS) factors) want to mask potential disparities or stakeholders as we consider the issue of
play a major role in health. One of our minimize incentives to improve the accounting for social risk factors and
core objectives is to improve beneficiary outcomes for disadvantaged reducing health disparities in CMS
outcomes, including reducing health populations. Keeping this concern in programs. Of note, implementing any of
disparities, and we want to ensure that mind, while we sought input on this the above methods would be taken into
all beneficiaries, including those with topic previously, we requested public consideration in the context of how this
social risk factors, receive high quality comment on whether we should and other CMS programs operate (for
care. In addition, we seek to ensure that account for social risk factors in the example, data submission methods,
the quality of care furnished by MIPS, and if so, what method or availability of data, statistical
providers and suppliers is assessed as combination of methods would be most considerations relating to reliability of
fairly as possible under our programs appropriate for accounting for social data calculations, among others); we
while ensuring that beneficiaries have risk factors in the MIPS. Examples of also welcome comment on operational
adequate access to excellent care. methods include: Adjustment of MIPS considerations. CMS is committed to
We have been reviewing reports eligible clinician scores (for example, ensuring that its beneficiaries have
prepared by the Office of the Assistant access to and receive excellent care, and
Secretary for Planning and Evaluation 8 Office of the Assistant Secretary for Planning
that the quality of care furnished by
(ASPE) and the National Academies of and Evaluation. 2016. Report to Congress: Social providers and suppliers is assessed
Risk Factors and Performance Under Medicares
Sciences, Engineering, and Medicine on Value-Based Purchasing Programs. Available at fairly in CMS programs.
the issue of accounting for social risk https://aspe.hhs.gov/pdf-report/report-congress- In response to our requests for
factors in CMSs value-based purchasing social-risk-factors-and-performance-under- comments described previously in this
and quality reporting programs, and medicares-value-based-purchasing-programs. final rule with comment period, many
9 National Academies of Sciences, Engineering,
considering options on how to address and Medicine. 2017. Accounting for social risk
commenters provided feedback on
the issue in these programs. On factors in Medicare payment. Washington, DC: The addressing social risk. As we have
December 21, 2016, ASPE submitted the National Academies Press. previously stated, we are concerned
about holding providers to different (2020 MIPS payment year) and noted we period). We proposed the second 12-
standards for the outcomes of their will assess on an annual basis whether month segment of the eligibility period
patients with social risk factors, because to continue the bonus and how the to align with other MIPS policies and to
we do not want to mask potential bonus should be structured (82 FR ensure we have sufficient time to
disparities. We believe that the path 30135 through 30139). determine the necessary calculations.
forward should incentivize When considering approaches for a The second period 12-month segment
improvements in health outcomes for complex patient bonus, we reviewed overlaps 8-months with the MIPS
disadvantaged populations while evidence to identify how indicators of performance period which means that
ensuring that beneficiaries have patient complexity have an impact on many of the patients in our complex
adequate access to excellent care. We performance under MIPS as well as patient bonus would have been cared
thank commenters for this important availability of data to implement the for by the clinician, group, virtual
feedback and will continue to consider bonus. We estimated the impact on group, or APM Entity during the MIPS
options to account for social risk factors performance using our proposed scoring performance period.
that would allow us to view disparities model, described in more detail in the HCC risk scores for beneficiaries
and potentially incentivize regulatory impact analysis of the CY would be calculated based on the
improvement in care for patients and 2018 Quality Payment Program calendar year immediately prior to the
beneficiaries. We will consider the proposed rule (82 FR 30235 through performance period. For the 2018 MIPS
comments we received in preparation 30238) that uses historical PQRS data to performance period, the HCC risk scores
for future rulemaking. simulate scores for MIPS eligible would be calculated based on
clinicians including estimates for the beneficiary services from the 2017
(b) Complex Patient Bonus quality, advancing care information, and calendar year. We proposed this
While we work with stakeholders on improvement activities performance approach because CMS uses prior year
these issues as we have described, categories, and the small practice bonus diagnoses to set Medicare Advantage
under the authority within section (82 FR 30149 through 30150). These rates prospectively every year and has
1848(q)(1)(G) of the Act, which allows estimates reflect scoring proposals with employed this approach in the VM (77
us to assess and implement appropriate the cost performance category weight at FR 69317 through 69318). Additionally,
adjustments to payment adjustments, zero percent. We identified two this approach mitigates the risk of
MIPS final scores, scores for potential indicators for complexity: upcoding to get higher expected costs,
performance categories, or scores for Medical complexity as measured which could happen if concurrent risk
measures or activities under MIPS, we through Hierarchical Condition adjustments were incorporated. We
proposed to implement a short-term Category (HCC) risk scores and social noted that we realized using the 2017
strategy for the Quality Payment risk as measured through the proportion calendar year to assess beneficiary HCC
Program to address the impact patient of patients with dual eligible status. We risk scores overlaps by 4 months with
complexity may have on final scores (82 identified these indicators because they the 12-month data period to identify
FR 30135 through 82 FR 30139). The are common indicators of patient beneficiaries (which is September 1,
overall goal when considering a bonus complexity in the Medicare program 2017 to August 31, 2018 for the 2018
for complex patients is two-fold: (1) To and the data is readily available. Please MIPS performance period); however, we
protect access to care for complex refer to the CY 2018 Quality Payment annually calculate the beneficiary HCC
patients and provide them with Program proposed rule for a detailed risk score and use it for multiple
excellent care; and (2) to avoid placing discussion of our analysis of both purposes (like the Physician and Other
MIPS eligible clinicians who care for indicators that informed our proposal Supplier Public Use File).
complex patients at a potential (82 FR 30135 through 30138). For MIPS APMs and virtual groups,
disadvantage while we review the We proposed at 414.1380(c)(3) to we proposed at 414.1380(c)(3)(ii) to
completed studies and research to add a complex patient bonus to the final use the beneficiary weighted average
address the underlying issues. We used score for the 2020 MIPS payment year HCC risk score for all MIPS eligible
the term patient complexity to take for MIPS eligible clinicians that submit clinicians, and if technically feasible,
into account a multitude of factors that data for at least one performance TINs for models and virtual groups
describe and have an impact on patient category (82 FR 30138). We proposed at which rely on complete TIN
health outcomes; such factors include 414.1380(c)(3)(i) to calculate an participation, within the APM Entity or
the health status and medical conditions average HCC risk score, using the model virtual group, respectively, as the
of patients, as well as social risk factors. adopted under section 1853 of the Act complex patient bonus. We would
We believe that as the number and for Medicare Advantage risk adjustment calculate the weighted average by taking
intensity of these factors increase for a purposes, for each MIPS eligible the sum of each individual clinicians
single patient, the patient may require clinician or group, and to use that (or TINs as appropriate) average HCC
more services, more clinician focus, and average HCC risk score as the complex risk score multiplied by the number of
more resources in order to achieve patient bonus. We proposed to calculate unique beneficiaries cared for by the
health outcomes that are similar to those the average HCC risk score for a MIPS clinician and then divide by the sum of
who have fewer factors. In developing eligible clinician or group by averaging the beneficiaries cared for by each
the policy for the complex patient HCC risk scores for beneficiaries cared individual clinician (or TIN as
bonus, we assessed whether there was a for by the MIPS eligible clinician or appropriate) in the APM Entity or
MIPS performance discrepancy by clinicians in the group during the virtual group.
patient complexity using two well- second 12-month segment of the We proposed at 414.1380(c)(3)(iii)
established indicators in the Medicare eligibility period, which spans from the that the complex patient bonus cannot
program. The proposal was intended to last 4 months of a calendar year 1 year exceed 3 points. We divided clinicians
address any discrepancy, without prior to the performance period and groups into quartiles based on
masking performance. Because this followed by the first 8 months of the average HCC risk score and percentage
bonus is intended to be a short-term performance period in the next calendar of patients who are dual eligible. A cap
strategy, we proposed the bonus only for year (September 1, 2017 to August 31, of 3 points was selected because the
the 2018 MIPS performance period 2018 for the 2018 MIPS performance differences in performance we observed
in simulated scores (based on our clinician with a final score of 55.11 with a full-benefit or partial-benefit dual
proposed scoring methodology) between an average HCC risk score of 2.01 would patient in the state MMA files at the
the first and fourth quartiles of average receive a final score of 57.12. We conclusion of the second 12-month
HCC risk scores was approximately 4 proposed (82 FR 30140) to modify the segment of the eligibility determination
points for individuals and final score calculation formula so that if period.
approximately 5 points for groups. The the result of the calculation is greater We proposed to define the proportion
95th percentile of average HCC risk than 100 points, then the final score of full-benefit or partial-benefit dual
score values for individual clinicians would be capped at 100 points. eligible beneficiaries as the proportion
was 2.91 which we rounded to 3 for We also sought comment on an of dual eligible patients among all
simplicity. Although we considered alternative complex patient bonus unique Medicare patients seen by the
using a higher cap to reflect the methodology, similarly for the 2020 MIPS eligible clinician or group during
differences in performance above 4 MIPS payment year only (82 FR 30139). the second 12-month segment of the
points, we believed that 3 points was Under the alternative, we would apply eligibility period which spans from the
appropriate in order to not mask poor a complex patient bonus based on a last 4 months of a calendar year prior to
performance and because we estimated ratio of patients who are dual eligible the performance period followed by the
that most MIPS eligible clinicians because dual eligible status is a common first 8 months of the performance period
would have an average HCC risk score indicator of social risk for which we in the next calendar year (September 1,
below 3 points. currently have data available. We 2017 to August 31, 2018 for the 2018
We expressed our belief that applying expressed our belief that the advantage MIPS performance period), to identify
this bonus to the final score is of this option is its relative simplicity MIPS eligible clinicians for calculation
appropriate because caring for complex and that it creates a direct incentive to of the complex patient bonus. This date
and vulnerable patients can affect all care for dual eligible patients, who are range aligns with the second low-
aspects of a practice and not just often medically complex and have volume threshold determination and
specific performance categories. It may concurrent social risk factors. In also represents care provided during the
also create a small incentive to provide addition, whereas the HCC risk scores performance period.
access to complex patients. We rely on the diagnoses a beneficiary We proposed to multiply the dual
considered whether we should apply a receives which could be impacted by eligible ratio by 5 points to calculate a
set number of points to those in a variations in coding practices among complex patient bonus for each MIPS
specific quartile (for example, for the clinicians, the dual eligibility ratio is eligible clinician. For example, a MIPS
highest risk quartile only), but did not not impacted by variations in coding eligible clinician who sees 400 patients
want to restrict the bonus to only certain practices. For this alternative option, we with dual eligible status out of 1,000
MIPS eligible clinicians. Rather than would calculate a dual eligible ratio total Medicare patients seen during the
assign points based on quartile, we (including both full and partial second 12-month segment of the
believed that adding the average HCC Medicaid beneficiaries) for each MIPS eligibility period would have a complex
risk score directly to the final score eligible clinician based on the patient ratio of 0.4, which would be
would achieve our goal of accounting proportion of unique patients who have multiplied by 5 points for a complex
for patient complexity without masking dual eligible status seen by the MIPS patient bonus of 2 points toward the
low performance and does provide a eligible clinician among all unique final score. We believe this approach
modest effect on the final score. patients seen during the second 12- would be simple to explain and would
Finally, we proposed that the MIPS month segment of the eligibility period, be available to all clinicians who care
eligible clinician, group, virtual group, which spans from the last 4 months of for dual eligible beneficiaries. We also
or APM Entity must submit data on at a calendar year 1 year prior to the believed a complex patient bonus
least one measure or activity in a performance period followed by the first ranging from 1 to 5 points (with most
performance category during the 8 months of the performance period. For MIPS eligible clinicians receiving a
performance period to receive the MIPS APMs and virtual groups, we bonus between 1 and 3 points) would be
complex patient bonus. Under this would use the average dual eligible appropriate because, in our analysis, we
proposal, MIPS eligible clinicians patient ratio for all MIPS eligible estimated differences in performance
would not need to meet submission clinicians, and if technically feasible, between the 1st and 4th quartiles of
requirements for the quality TINs for models and virtual groups dual eligible ratios to be approximately
performance category in order to receive which rely on complete TIN 3 points for individuals and
the bonus (they could instead submit participation, within the APM Entity or approximately 6 points for groups. A
improvement activities or advancing virtual group, respectively. bonus of less than 5 points would help
care information measures only or Under this alternative option, we to mitigate the impact of caring for
submit fewer than the required number would identify dual eligible status patients with social risk factors while
of measures for the quality performance (numerator of the ratio) using data on not masking poor performance. Using
category). dual-eligibility status sourced from the this approach, we estimated that the
Based on our data analysis using our state Medicare Modernization Act bonus would range from 0.45 (first dual
proposed scoring model with the cost (MMA) files, which are files each state quartile) to 2.42 (fourth dual quartile)
performance category weighted at zero submits to CMS with monthly Medicaid for individual reporters, and from 0.63
percent, we estimated that this bonus on eligibility information. We would use (first dual quartile) to 2.19 (fourth dual
average would range from 1.16 points in dual-eligibility status data from the state quartile) for group reporters. Under this
the first quartile of MIPS eligible MMA files because it is the best alternative option, we would also
clinicians when ranked by average HCC available data for identifying dual include the complex patient bonus in
risk scores to 2.49 points in the fourth eligible beneficiaries. Under this the calculation of the final score. We
quartile for individual reporters alternative option, we would include proposed that if the result of the
submitting 6 or more measures, and 1.26 both full-benefit and partial benefit calculation is greater than 100 points,
points in the first quartile to 2.23 points beneficiaries in the dual eligible ratio, then the final score would be capped at
in the fourth quartile for group and an individual would be counted as 100 points (82 FR 30140). We sought
reporters. For example, a MIPS eligible a dual patient if they were identified as comments on our proposed bonus for
complex patients based on average HCC raising the cap to 5 points could be score. A few commenters requested that
risk scores, and our alternative option supported by the data and would align CMS adopt the same cap for HCC risk
using a ratio of dual eligible patients in with the small practice bonus. Using our scores that is used in the Next
lieu of average HCC risk scores. We proposed scoring model, we observed a Generation ACO Model or Shared
reiterated that the complex patient decrease in simulated scores of Savings Program, where the HCC risk
bonus is intended to be a short-term approximately 4 points (for individuals score cannot increase by more than 3
solution, which we plan to revisit on an who report 6 or more quality measures) percent.
annual basis, to incentivize clinicians to and approximately 5 points (for groups) Response: We acknowledge the
care for patients with medical from the top quartile to the bottom commenters concern that a 3-point cap
complexity. We noted that we may quartile for the average patient HCC risk would have only a modest impact on
consider alternate adjustments in future score. Our updated model showed the final score and would not be aligned
years after methods that more fully similar distribution. We believe that the with the small practice bonus. For the
account for patient complexity in MIPS 3-point cap we proposed was justified reasons described earlier, we believe a
have been developed. We also requested in order to not mask poor performance, 5-point cap for the complex patient
comments on alternative methods to given the differences in quartiles scores, bonus is justified and are finalizing it
construct a complex patient bonus. and we believe a cap of 5 points could for the 2020 MIPS payment year. We
The following is a summary of the also be supported. Using our updated think the 5 points will have slightly
public comments received on these scoring model (described in the more impact on the final score (while
proposals and our responses: regulatory impact analysis section VI.D not masking poor performance) and is
Comment: Several commenters of this final rule with comment period), justified by the data. In response to
requested that CMS base the complex we estimate a decrease in simulated comments to adopt the cap used in the
patient bonus on both HCC risk scores scores of 5.4 points (for individuals who Next Generation ACO Model or Shared
and dual eligibility. The commenters report 6 or more quality measures) and Savings Program, we note that we are
expressed the belief that both of these 4.5 points (for groups) from the top not currently measuring increases in
indicators capture important aspects of quartile to the bottom quartile for the HCC risk scores over time but will
patient risk, and together provide a average patient HCC risk scores and 4.8 evaluate any impacts on diagnosis
more complete picture. The commenters points (for individuals who report 6 or coding should the complex patient
suggested that CMS apply a complex more quality measures) and 4.5 points bonus continue.
patient bonus if a MIPS eligible (for groups) from the top quartile to the Comment: Many commenters
clinician meets a defined threshold for bottom quartile for the dual eligible supported CMSs proposal to apply a
either HCC risk scores or proportion of ratio. Therefore, we believe a cap for the complex patient bonus to the final score
patients who are dual eligible. One complex patient bonus of 5 points is based on HCC risk scores. The
commenter requested that CMS provide supported by this updated data with commenters agreed that the complex
separate bonuses based on HCC risk slightly higher differences in patient bonus will help address the
scores and the proportion of patients performance based on HCC risk scores resources needed to treat complex
who are dual eligible. and dual eligibility. patients, without masking clinician
Response: We appreciate these We do not believe that adopting a performance. Furthermore, the
comments and have decided to finalize threshold is appropriate at this time commenters believe that the complex
a modified complex patient bonus because it would add additional patient bonus will help protect access to
which will be added to the final score complexity. In addition, a threshold care and offset incentives to avoid
that includes the sum of the average would likely create an artificial cliff, treating the sickest patients. The
HCC risk scores and proportion of dual where MIPS eligible clinicians just commenters supported HCC risk scores
eligible beneficiaries (multiplied by 5 above the threshold would receive a as a valid proxy for medical complexity,
points), subject to a 5-point cap. We bonus while those just below the believing that it is familiar to
believe combining these two indicators threshold would not, even though the stakeholders.
is appropriate because, while these two differences in patient populations Response: We appreciate the support
indicators are correlated (with a between these two groups may be very of commenters for the proposed
correlation coefficient of 0.487 based on minimal. We also believe that separate complex patient bonus for the 2020
our updated model, which includes bonuses for complex patients (as MIPS payment year. We continue to
2016 PQRS data and the cost opposed to a single combined score) believe HCC risk scores is a valid
performance category weighted at 10 may add unnecessary confusion to MIPS complex patient indicator and will be
percent of the final score), they are not eligible clinicians. incorporating this into the complex
interchangeable. We believe adding Comment: Many commenters patient bonus along with the dual
these two indicators together recognizes supported the complex patient bonus eligible ratio, for the reasons described
the strengths of both approaches, as well but requested that CMS increase the earlier. As we stated in the CY 2018
as the limitations of either approach in maximum number of points for the Quality Payment Program proposed
fully accounting for patient complexity. bonus. Most of these commenters rule, we intend to monitor the effect of
We believe including both indicators supported a cap of 5 points. The the complex patient bonus and revisit
will account for MIPS eligible clinicians commenters expressed the belief that future adjustments or the continued
who see medically complex patients but MIPS eligible clinicians should have the need for an extension of the bonus
do not see many patients who are dual opportunity to receive as many points through rulemaking.
eligible, as well as MIPS eligible for the complex patient bonus as they Comment: Several commenters
clinicians who see dual eligible patients receive for the small practice bonus supported CMSs proposal to apply a
but do not see many medically complex because commenters believe patient complex patient bonus but expressed
patients as defined by HCC risk scores. complexity can have as much of an the belief that the bonus, particularly
As discussed later in this section, a 5- impact on performance as practice size. when combined with other bonuses at
point cap was requested by several The commenters furthermore believe the performance category level and at
commenters. While we did not want to that a bonus of only 1 to 3 points would the final score level, creates confusion
mask poor performance, we believe have only a modest impact on the final for MIPS eligible clinicians.
Commenters urged CMS to align our eligibility ratio in the calculation of the Response: We thank the commenter
approaches across these various bonuses complex patient bonus. for this suggestion. We take into
as much as possible to enhance stability Comment: Some commenters who consideration better accounting for the
and predictability for MIPS eligible supported CMSs proposal to apply a complexity of patients in these facility
clinicians. Several commenters complex patient bonus based on HCC settings in future rulemaking.
requested that CMS extend the complex risk scores pointed out some limitations Comment: One commenter requested
patient bonus to future years, in order in using HCC risk scores for this that the complex patient bonus be
to increase stability in the Quality purpose for our consideration as we determined based on new patient
Payment Program and to help MIPS consider alternate methods in future relationship codes, with a field to
eligible clinicians better predict which years. For example, some commenters document patient complexity.
bonuses they will receive. The expressed the belief that HCC risk scores Response: Thank you for this
commenters expressed the belief that are subject to differences in coding, comment. We do not believe it is
modifying bonus points each year will rather than being completely tied to feasible to include patient complexity
add complexity to the program and patient complexity. A few commenters with patient relationship codes at this
increase confusion for MIPS eligible stated that HCC risk scores are of time, but we will take it into
clinicians. limited value due to the inadequacy of consideration in future rulemaking.
Response: We acknowledge the need coding systems. For example, a few Comment: A few commenters
for simplicity and predictability in our commenters noted that inadequate suggested that CMS offer education to
MIPS scoring policies. For the reasons coding exists for behavioral health MIPS eligible clinicians on appropriate
described earlier in this final rule conditions, oncology, pediatrics, and coding practices to enhance the validity
comment period, we are modifying the rare diseases. Further, the commenters of HCC risk scores.
complex patient bonus to incorporate expressed the belief that, even though Response: Our intent in adopting a
dual eligibility and HCC risk scores with HCC risk scores include dual eligibility methodology for the complex patient
a 5-point cap to better align with the as one component, they do not bonus based on HCC risk scores is to
small practice bonus. We also agree adequately capture social determinants capture differences in patient
with commenters that, to the extent of health. Some commenters further complexity, rather than differences in
possible, we should try to maintain pointed out that in the VM program, clinician coding practices. We are aware
stability over time in our approach to clinicians who cared for patients with that variations in coding practices may
account for social risk in order to high HCC risk scores were more likely impact HCC risk scores, but are unaware
minimize confusion and complexity for to receive negative payment of other readily available indicators that
MIPS eligible clinicians. However, as adjustments. A few commenters urged would better capture medical
we note earlier in this final rule with CMS to identify appropriate adjustment complexity. We intend to provide
comment period, we intend this mechanisms for quality measures in guidance to MIPS eligible clinicians on
complex patient bonus as a short-term addition to the complex patient bonus. calculation of the complex patient
solution to account for risk factors in Response: We understand that HCC bonus. As described earlier, we are also
MIPS as we continue to evaluate risk scores have some limitations, incorporating proportion of dual eligible
ongoing research in this area as well as particularly in that the HCC values beneficiaries in to the complex patient
review available data to support various depends on coding to capture medical bonus and plan to develop appropriate
approaches to accounting for risk complexity and coding may not capture educational materials.
factors. We plan to review results of all of a patients medical conditions. Comment: Several commenters did
implementation of the complex patient However, we are unaware of other not support the proposed complex
bonus in the 2020 MIPS payment year, options that are readily available that patient bonus for the 2020 MIPS
as well as available reports, and as would be a more complete index of a payment year. Several commenters
appropriate, update our approach to patients medical complexity. We have expressed the belief that the proposed
accounting for risk factors. decided to pair the HCC risk score with approach is too complex, while others
Comment: A few commenters the proportion of dual eligible patients stated that because CMS have not yet
expressed support for CMSs alternative to create a more complete complex identified an ideal method to adjust for
approach to calculate a complex patient patient indicator than can be captured patient complexity, CMS should delay
bonus based on proportion of patients using HCC risk scores alone. We note any bonus at this time. A few
who are dual eligible. The commenters that the complex patient bonus would commenters expressed the belief that
supported dual eligibility as a proxy for be available to all MIPS eligible implementing a complex patient bonus
social risk factors, an approach that is clinicians who submit data on at least that CMS plans to modify in future
currently used in the Medicare one measure or activity in a years will add unnecessary confusion
Advantage star ratings methodology. performance category, unlike in the VM for MIPS eligible clinicians. A few
The commenters stated that dual program, which limits the bonus for commenters stated that all of the various
eligible patients are a high-cost, high- caring for high-risk beneficiaries to bonuses available under MIPS add a
risk population, and, therefore, the clinicians who qualify for upward great deal of complexity and uncertainty
proportion of patients who are dual adjustments. We will evaluate to the program. One commenter stated
eligible is an appropriate indicator of additional options in future years in that HCC risk scores tend to be lower for
social risk. The commenters further order to better account for social risk rural practices, citing MedPACs 2012
expressed concern with limitations in factors while minimizing unintended report on rural providers.
using HCC risk scores, which they consequences. Response: While we work with
believe are subject to variations in Comment: One commenter urged stakeholders to identify a more
coding practices. CMS to look to POS codes (POS 31 SNF; comprehensive, long-term approach to
Response: We thank the commenters POS 32 NF) to provide further account for social risk factors, we
for their support. We agree that dual granularity in assessing the complexity continue to believe a short-term strategy
eligibility is an appropriate indicator, of clinicians patient populations given for the Quality Payment Program based
and for the reasons explained the complexity of populations in these on data we have available to us is
previously, we are including a dual settings. appropriate, despite its limitations, to
address the impact of patient would be eligible for a complex patient excellent care; and (2) to avoid placing
complexity. We are also finalizing a bonus under each of the two options, as MIPS eligible clinicians who care for
revised complex patient bonus based on well as the overlap between the two. complex patients at a potential
HCC risk scores and dual eligibility with Response: Under both options, all disadvantage while we review the
a 5-point cap for reasons described MIPS eligible clinicians would receive a completed studies and research to
earlier. We intend to identify additional complex patient bonus as long as they address the underlying issues. Keeping
ways we can minimize complexity in submit data on at least one measure or these goals in mind, we also recognize
our approach to accounting for social activity in a performance category; the value of maintaining stability
risk factors in future rulemaking. We however, those with higher complexity wherever possible to reduce clinician
also intend to monitor for any would receive a higher bonus score. confusion. Therefore, we intend to take
disparities in HCC risk scores based on Based on our updated analysis, we into consideration feedback we have
whether a practice is located in a rural estimate the median complex patient received as we consider approaches to
area, but in the meantime, we are also bonus would be just under 3 points account for social risk in future years
incorporating a dual eligibility (2.97). Additional information can be that minimize confusion and
component to the complex patient found in Table 27 of this final rule with complexity in the Quality Payment
bonus which we believe will mitigate comment period. Program.
some concerns about basing the Comment: Several commenters Comment: One commenter suggested
complex patient bonus on HCC risk suggested additional risk factors to that CMS provide an exclusion to the
scores alone. consider for bonuses. Several Quality Payment Program for clinicians
Comment: Several commenters did commenters requested that CMS who treat complex patients because
not support the use of dual eligibility for incorporate a bonus for MIPS eligible such an exclusion would reduce
calculating a complex patient bonus. clinicians who care for American unnecessary risks and uncertainties for
For example, several commenters Indian/Alaska Native patients because MIPS eligible clinicians and impact
expressed their belief that dual these patients tend to be more complex, treatment access.
eligibility is not a good proxy for social with a greater disease burden, and
Response: We do not have statutory
risk factors. The commenters pointed because clinicians caring for these
authority to exclude MIPS eligible
out that Medicaid eligibility varies by patients tend to have decreased
clinicians based on patient complexity.
state, particularly based on recent trends resources. The commenters also
requested that CMS provide bonus Final Action: After consideration of
in Medicaid expansion. A few
commenters stated that HCC risk scores points based on frailty, Adverse the public comments, we are finalizing
are a more familiar concept to MIPS Childhood Events (ACE), social risk our proposal with modification for the
eligible clinicians than dual eligibility. factors, and other factors not currently 2020 MIPS payment year. We are
Response: We continue to believe that captured in the HCC risk score finalizing at 414.1380(c)(3) a complex
dual eligibility is a valid proxy for social methodology. Several commenters patient bonus for MIPS eligible
risk factors which impacts performance offered suggestions for future clinicians, groups, APM Entities, and
in MIPS, which has been used to enhancements of the complex patient virtual groups that submit data for at
account for social risk in other CMS bonus to ensure that it achieves the least one MIPS performance category
programs, such as Medicare Advantage goals CMS has outlined while reducing during the applicable performance
star ratings. We note that HCC risk confusion and complexity for MIPS period, which will be added to the final
scores include dual eligibility as one eligible clinicians wherever possible. score. We are finalizing at
factor; however, we acknowledge that The commenters acknowledged that the 414.1380(c)(3)(i) to calculate the
these two indicators are not proposed approach has several complex patient bonus for MIPS eligible
interchangeable (correlation coefficient limitations that must be addressed over clinicians and groups by adding the
of 0.487) as HCC risk scores also include time. The commenters urged CMS to use average HCC risk score to the dual
other aspects of social complexity (such the first year of the complex patient eligible ratio, based on full benefit and
as medical diagnoses). We are aware bonus to monitor the impact of the partial benefit dual eligible
that dual eligibility may vary by state, complex patient bonus, receive feedback beneficiaries, multiplied by 5. We are
and we plan to continue to monitor from stakeholders, and explore more finalizing at 414.1380(c)(3)(ii) to
alternative approaches to accounting for appropriate methods of accounting for calculate the complex patient bonus for
social risk in the future. patient complexity, while continuing to APM Entities and virtual groups by
Comment: One commenter requested monitor reports released by NQF, ASPE, adding the beneficiary weighted average
that CMS use data from the performance and others. The commenters also HCC risk score for all MIPS eligible
period rather than prospective data requested that CMS identify ways to clinicians, and if technically feasible,
because this approach does not account better account for certain patient TINs for models and virtual groups
for new diagnoses. populations, such as patients with rare which rely on complete TIN
Response: As we discussed above, diseases. participation, within the APM Entity or
Medicare Advantage uses prior year Response: We appreciate these virtual group, respectively, to the
diagnoses to set rates prospectively comments suggesting ways that we can average dual eligible ratio for all MIPS
every year and we have employed this continue to enhance the complex eligible clinicians, and if technically
approach in the VM (77 FR 69317 patient bonus. We intend to explore feasible, TINs for models and virtual
through 69318). While using data from additional risk factors, as appropriate, as groups which rely on complete TIN
a prior period may not capture any new we consider approaches to account for participation, within the APM Entity or
diagnoses for a patient, it also mitigates social risk in the future in the Quality virtual group, respectively, multiplied
the risk of upcoding which could Payment Program. As noted in the CY by 5. We will calculate the average HCC
happen if concurrent risk adjustments 2018 Quality Payment Program risk score and dual eligible ratio as
were incorporated. proposed rule (82 FR 30135), our goals described in the proposed rule (82 FR
Comment: One commenter requested for the complex patient bonus are (1) to 30138 through 30139). We are finalizing
that CMS provide information on the protect access to care for complex at 414.1380(c)(3)(iii) that the complex
number of MIPS eligible clinicians who patients and provide them with patient bonus cannot exceed 5 points.
Using our scoring model, we estimate quartile for all MIPS eligible clinicians. on the proposed approach (based on
that the average complex patient bonus Table 27 includes the distribution for HCC risk scores only) and the alternate
will range from 2.52 in the first HCC the complex patient bonus under our approach (based on dual eligible ratio).
quartile to 3.72 in the highest HCC final policy, along with bonuses based
TABLE 27ESTIMATED COMPLEX PATIENT BONUS FOR FINALIZED, PROPOSED, AND ALTERNATE APPROACH
Dual bonus **
HCC bonus * (2018 QPP HCC + dual
(2018 QPP proposed rule bonus
proposed rule) alternate pro- (final policy)
posal)
HCC Quartile
Quartile 1Lowest Average HCC Score .................................................................................... 1.26 1.33 2.52

Quartile 2 ..................................................................................................................................... 1.51 1.56 3.06
Quartile 3 ..................................................................................................................................... 1.63 1.81 3.43
Quartile 4Highest Average HCC Score ................................................................................... 1.86 1.97 3.72
Dual Eligible Quartile
Quartile 1Low Proportion of Dual Eligible ................................................................................ 1.42 0.84 2.19

Quartile 2 ..................................................................................................................................... 1.54 1.36 2.85
Quartile 3 ..................................................................................................................................... 1.68 2.01 3.68
Quartile 4Highest Proportion of Dual Eligible .......................................................................... 1.64 2.46 4.02
* Includes a 3-point cap.
** Calculated as dual eligible ratio times 5.
(c) Small Practice Bonus for the 2020 percent, respectively). As we indicate in Interface reporting mechanism is only
MIPS Payment Year our regulatory impact analysis in the CY available to small practices participating
2018 Quality Payment Program in the Shared Savings Program or Next
Eligible clinicians and groups who proposed rule (82 FR 30233 through Generation ACO Model).10
work in small practices are a crucial 30241), we believe participation rates These two factors have financial
part of the health care system. The based only on historic 2015 quality data implications based on the MIPS scoring
Quality Payment Program provides submitted under PQRS significantly model described in the CY 2018 Quality
options designed to make it easier for underestimate the expected Payment Program proposed rule (82 FR
these MIPS eligible clinicians and participation in MIPS particularly for 30233 through 30241). Looking at the
groups to report on performance and small practices. Therefore, we have combined impact performance, we
quality and participate in advanced modeled the regulatory impact analysis observed consistent trends for small
alternative payment models for using minimum participation practices in various scenarios. A
incentives. We have heard directly from assumptions of 80 percent and 90 combined impact of performance
clinicians in small practices that they percent participation for each practice measurement looks at the aggregate net
face unique challenges related to size category (115 clinicians, 1624 percent change (the combined impact of
financial and other resources, clinicians, 2599 clinicians, and 100 or MIPS negative and positive
environmental factors, and access to more clinicians). However, even with adjustments). The MIPS payment
health information technology. We these enhanced participation adjustment is connected to the final
heard from many commenters that the assumptions, MIPS eligible clinicians in score because final scores below the
Quality Payment Program gives an small practices would have lower performance threshold receive a
advantage to large organizations because participation in MIPS than MIPS negative MIPS payment adjustment and
such organizations have more resources eligible clinicians in larger practices final scores above the performance
invested in the infrastructure required have had in PQRS, as 80 or 90 percent threshold receive a positive MIPS
to track and report measures to MIPS. participation is still much lower than payment adjustment. In analyzing the
We also observed that, based on our the 99.4 percent PQRS participation for combined impact performance, we see
scoring model, which is described in the MIPS eligible clinicians in practices MIPS eligible clinicians in small
regulatory impact analysis in the CY with 100 or more clinicians. practices consistently have a lower
2018 Quality Payment Program In addition, the most recent PQRS combined impact performance than
proposed rule (82 FR 30233 through data (from CY 2016) indicates practices larger practices based on actual
30241), practices with more than 100 with 100 or more MIPS eligible historical data and after we apply the 80
clinicians may perform better in the clinicians are more likely to report as a and 90 percent participation
Quality Payment Program, on average, group, rather than individually, which assumptions.
compared to smaller practices. We reduces burden to individuals within Due to these challenges, we proposed
believe this trend is due primarily to those practices due to the unified nature an adjustment to the final score for
two factors: participation rates and of group reporting. Specifically, 62.1 MIPS eligible clinicians in small
submission mechanism. Based on the percent of practices with 100 or more practices (referred to herein as the
most recent PQRS data available, MIPS eligible clinicians have reported small practice bonus) to recognize
practices with 100 or more MIPS via CMS Web Interface (either through these barriers and to incentivize MIPS
eligible clinicians have participated in the Shared Savings Program or as a
the PQRS at a higher rate than small group practice) compared to 22.4 10 Groups must have at least 25 clinicians to
practices (99.4 percent compared to 69.7 percent of small practices (the CMS Web participate in Web Interface.
eligible clinicians in small practices to in rural areas, we would use the bonus in future rulemaking. However,
participate in the Quality Payment definition for rural specified in section we also believe it is important to
Program and to overcome any II.C.1.d. of this final rule with comment maintain consistency within the Quality
performance discrepancy due to period for individuals and groups Payment Program, so we intend to align
practice size (82 FR 30139 through (including virtual groups). this bonus with our definition of small
30140). To receive the small practice The following is a summary of the practices under 414.1305. In addition,
bonus, we proposed that the MIPS public comments received on these we have not seen the same
eligible clinician must participate in the proposals and our responses: discrepancies in simulated MIPS final
program by submitting data on at least Comment: Many commenters scores among practices of 1624
one performance category in the 2018 supported the proposed small practice clinicians that we have observed for
MIPS performance period. Therefore, bonus for the 2020 MIPS payment year. practices of 15 or fewer clinicians.
MIPS eligible clinicians would not need The commenters expressed the belief Comment: One commenter suggested
to meet submission requirements for the that this bonus will help address the that CMS reduce the small practice
quality performance category in order to particular challenges that small bonus to 3 points, instead of 5 points.
receive the bonus (they could instead practices experience in participating in The commenter expressed the belief that
submit improvement activities or MIPS, including the resources needed to the small practice bonus represented too
advancing care information measures create an infrastructure to meet MIPS great a proportion of the performance
only or submit fewer than the required reporting requirements. Several threshold (5 points of the proposed 15-
number of measures for the quality commenters believe that the small point performance threshold which
performance category). Additionally, we practice bonus will help to encourage represents 30 percent of the points).
proposed that group practices, virtual small practices to participate in MIPS. A Response: We believe a bonus of 5
groups, or APM Entities that consist of few commenters supported the points is appropriate to acknowledge
a total of 15 or fewer clinicians may application of the small practice bonus the challenges small practices face in
receive the small practice bonus. to group practices, virtual groups, and participating in MIPS, and to help them
We proposed at 414.1380(c)(4) to APM Entities. achieve the performance threshold
add a small practice bonus of 5 points Response: We thank commenters for finalized at section II.C.8.c. of this final
to the final score for MIPS eligible their support. We agree that the small rule with comment period at 15 points
clinicians who participate in MIPS for practice bonus will help to alleviate the for the 2020 MIPS payment year, as this
the 2018 MIPS performance period and impact of some of the particular bonus represents one-third of the total
are in small practices, virtual groups, or challenges that small practices points needed to meet or exceed the
APM Entities with 15 or fewer experience in participating in MIPS on performance threshold and receive a
clinicians (the entire virtual group or performance, and believe that the bonus neutral or positive payment adjustment.
APM Entity combined must include 15 will help incentivize these practices to With a small practice bonus of 5 points,
or fewer clinicians to qualify for the participate in MIPS. small practices could achieve this
bonus). We proposed in the CY 2018 Comment: A few commenters performance threshold by reporting 3
Quality Payment Program proposed rule requested that CMS extend the small quality measures or 1 quality measure
that if the result of the calculation is practice bonus to future years of MIPS and 1 medium weighted improvement
greater than 100 points, then the final to maintain stability. One commenter activity.11
score would be capped at 100 points (82 requested that CMS reevaluate the small Comment: One commenter suggested
FR 30140). This bonus is intended to be practice bonus in future years to ensure that CMS require small practices to
a short-term strategy to help small that it is sufficient to overcome any report on at least 2 performance
practices transition to MIPS; therefore, discrepancies due to practice size. categories in order to receive the small
we proposed the bonus only for the Response: We are finalizing the small practice bonus.
2018 MIPS performance period (2020 practice bonus for the 2020 MIPS Response: We continue to believe that
MIPS payment year) and will assess on payment year only. We intend to it is appropriate to require MIPS eligible
an annual basis whether to continue the continue to evaluate options to address clinicians to report on only one
bonus and how the bonus should be challenges small practices face to performance category in order to receive
structured. participate in MIPS in future the small practice bonus because we
We invited public comment on our rulemaking, including continuation of
11 Assuming the small practice did not submit
proposal to apply a small practice bonus the small practice bonus, as appropriate.
Comment: A few commenters data for the advancing care information
for the 2020 MIPS payment year. performance category and applied for the hardship
We also considered applying a bonus expressed the belief that some practices exception and had the advancing care information
for MIPS eligible clinicians that practice may not meet the definition of a small performance category weight redistributed to the
in either a small practice or a rural area. practice due to the use of part-time, quality performance category, the small practice
However, on average, because we saw temporary staff that will cause them to would have a final score with 75 percent weight
from the quality performance category score, 15
less than a 1-point difference between exceed the 15-clinician threshold. One percent from improvement activities, and 10
scores for MIPS eligible clinicians who commenter suggested that CMS revise percent from cost. With the proposed scoring for
practice in rural areas and those who do the definition of a small practice to small practices, submitting one measure one time
not, we did not propose a bonus for would provide at least 3 measure achievement
include full-time employees only. One points out of 60 total available measure points.
those who practice in a rural area, but commenter requested that CMS expand With 75 percent quality performance category
plan to continue to monitor the Quality the small practice bonus to practices of weight, each quality measure would be worth at
Payment Programs impacts on the 16 to 24 clinicians. least 3.75 points towards the final score. ((3/60)
75% 100 = 3.75 points). For improvement
performance of those who practice in Response: We thank the commenters activities, each medium weighted activity is worth
rural areas. We also sought comment on for alerting us to this potential 20 out of 40 possible points which translates to 7.5
the application of a rural bonus in the limitation in our definition of a small points to the file score. (20/40) 15% 100 = 7.5
future, including available evidence practice, and we will monitor the points). The final score would be at least 3.75
points for quality + 7.5 points for improvement
demonstrating differences in clinician impact of part-time and temporary staff activities + 5 point small practice bonus which
performance based on rural status. If we to determine whether we should equals 16.5 points without considering cost or the
implement a bonus for practices located propose changes to the small practice complex patient bonus.
want to encourage small practices to practice, but these practices face unique is equal to the performance threshold
participate in MIPS and we are still in challenges in meeting MIPS reporting (81 FR 77326 through 77328) (we noted
a transition phase. We may reconsider requirements. For example, the that we inadvertently failed to codify
the need for the bonus or augment commenters expressed the belief that this policy in 414.1380(c)). We
requirements for small practices to rural practices face particular challenges proposed this revision to the policy to
receive the small practice bonus in in adopting health information account for our proposal in the CY 2018
future rulemaking. technology. Commenters further noted Quality Payment Program proposed rule
Comment: Some commenters did not that rural practices lack resources to (82 FR 30144 through 30146) for
support the small practice bonus as help achieve high performance on extreme and uncontrollable
proposed. Some commenters expressed quality measures. One commenter circumstances which, if finalized, could
the belief that CMS should instead focus expressed the belief that relying on data result in a scenario where a MIPS
on providing technical assistance to from preceding programs such as PQRS eligible clinician is not scored on any
small and rural practices who may and the VM to estimate the impact of performance categories. To reflect this
struggle to meet MIPS reporting rural status on performance may proposal, we proposed to add to
requirements. One commenter suggested provide an incomplete picture due to 414.1380(c) that a MIPS eligible
that CMS calculate different low participation rates for rural clinician with fewer than 2 performance
performance thresholds based on practices in these legacy programs. One category scores would receive a final
practice size. A few commenters commenter expressed the belief that a score equal to the performance
expressed the belief that the small rural practice bonus may signal that threshold.
practice bonus, along with additional quality standards for patients in rural With the proposed addition of the
available bonuses, may make it difficult areas do not need to be as high as those complex patient and small practice
for other MIPS eligible clinicians to for patients in non-rural areas. bonuses, we also proposed to strike the
succeed in MIPS and earn a positive Response: As we discussed in the CY following phrase from the final score
adjustment. One commenter expressed 2018 Quality Payment Program definition at 414.1305: The final
the belief that small practices can be proposed rule (82 FR 30140), we score is the sum of each of the products
competitive in MIPS by participating in observed that performance for rural of each performance category score and
a virtual group or reporting quality MIPS eligible clinicians is very similar each performance categorys assigned
measures above the minimum number. to performance for non-rural MIPS weight, multiplied by 100. We believed
Another commenter expressed the belief eligible clinician once we account for this portion of the definition would be
that the small practice bonus is not practice size, so we do not believe a incorrect and redundant of the proposed
sufficient to overcome the disparities bonus for MIPS eligible clinicians revised regulation at 414.1380(c).
small practices face to succeed in MIPS. practicing in a rural setting is We requested public comment on the
Response: We intend to explore other appropriate at this time. We proposed final score methodology and
approaches to account for the impact of acknowledge that legacy program data associated revisions to regulation text.
practice size on MIPS performance in may not provide a complete picture of The following is a summary of the
future rulemaking as well as monitor for MIPS participation rates for practices public comments received on these
any unintended consequences of the located in rural areas. We will continue proposals and our responses:
bonus in the MIPS program, including to monitor impacts of rural status on Comment: One commenter supported
impact on MIPS eligible clinicians who performance in the MIPS program and the proposal for MIPS eligible clinicians
are not in small practices. We are not if warranted, propose adjustments who are scored on fewer than two
able to create different performance through future rulemaking. performance categories to receive a final
thresholds based on practice size Final Action: After consideration of score equal to the performance
because we believe section 1848(q)(6)(D) the public comments, we are finalizing threshold.
of the Act requires us to establish one at 414.1380(c)(4) our proposal to add Response: We thank the commenter
performance threshold applicable to all a small practice bonus of 5 points to the for their support of our proposal.
MIPS eligible clinicians for a year. We final score for MIPS eligible clinicians, Comment: Several commenters
believe that technical support is critical groups, APM Entities, and virtual expressed the belief that calculation of
for the success of small practices in groups that meet the definition of a the final score is overly confusing for
reporting for MIPS, but we also believe small practice as defined at 414.1305 MIPS eligible clinicians. A few
that a bonus is appropriate at this time and submit data on at least one commenters suggested that CMS modify
due to the discrepancies in performance performance category in the 2018 our scoring methodology so that
we observed for clinicians in small performance period. performance category points are equal to
practices as compared with clinicians in We seek comment on approaches to points in the final score. This would
practices with 100 or more clinicians. better align final score and performance mean that, for example, the advancing
We have launched the Small, category level bonuses for simplicity in care information performance category
Underserved, and Rural Support future rulemaking. total possible points would be 25 points
initiative, a 5-year program, to provide which would be equal to the generally
technical support to MIPS eligible (2) Final Score Calculation applicable weighting for the advancing
clinicians in small practices. The We proposed a formula for the final care information performance category
program provides assistance to practices score calculation for MIPS eligible of 25 points.
in selecting and reporting on quality clinicians, groups, virtual groups, and Response: Simplification in scoring is
measures, education and outreach, and APM Entities at 414.1380(c), which a core goal of the MIPS program so that
support for optimizing health includes the proposed complex patient MIPS eligible clinicians can easily
information technology. and small practice bonuses. We also understand how the final score is
Comment: Several commenters proposed to revise the policy finalized calculated. In determining scoring
requested that CMS implement a similar in the CY 2017 Quality Payment policies for the MIPS program, we kept
bonus for rural practices. The Program final rule to assign MIPS this goal in mind whenever possible.
commenters noted that not all rural eligible clinicians with only 1 scored The weighting of performance categories
practices meet the definition of a small performance category a final score that can vary for different MIPS eligible
clinicians, such as when there are not (3) Final Score Performance Category 60 percent for the 2020 MIPS payment
sufficient measures or activities Weights year, we are finalizing a weight of 10
applicable and available to a clinician, (a) General Weights percent for cost for the 2020 MIPS
and the performance categories are payment year, so the quality
reweighted in their final score. For Section 1848(q)(5)(E)(i) of the Act performance category weight will be 50
example, non-patient facing MIPS specifies weights for the performance percent (82 FR 30037 through 30038).
eligible clinicians can qualify for categories included in the MIPS final We refer readers to sections II.C.6.b. and
reweighting of the advancing care score: In general, 30 percent for the
II.C.6.d. of this final rule with comment
information performance category. If a quality performance category, 30
period for further information on the
non-patient facing MIPS eligible percent for the cost performance
final policies related to the weight of the
clinician does not submit advancing category, 25 percent for the advancing
care information performance category, quality and cost performance categories,
care information data, then the including our rationale for our
advancing care information performance and 15 percent for the improvement
activities performance category. weighting for each category.
category score would be redistributed to
the quality performance category and However, that section also specifies As specified in section 1848(q)(5)(E)(i)
non-patient facing MIPS eligible different weightings for the quality and of the Act, the weights for the other
clinician would have a 75 percent cost performance categories for the first performance categories are 25 percent
weighting for quality instead of 50 and second years for which the MIPS for the advancing care information
percent (see Table 28 of this final rule applies to payments. Section performance category and 15 percent for
with comment period for the different 1848(q)(5)(E)(i)(II)(bb) of the Act the improvement activities performance
potential redistribution combinations). specifies that for the transition year, not category. Section 1848(q)(5)(E)(ii) of the
Therefore, it is not possible to have a more than 10 percent of the final score Act provides that in any year in which
single scoring system that generates the will be based on the cost performance the Secretary estimates that the
exact number of points toward the final category, and for the 2020 MIPS proportion of eligible professionals (as
score. Instead, we have created a system payment year, not more than 15 percent defined in section 1848(o)(5) of the Act)
where a clinician receives a will be based on the cost performance who are meaningful EHR users (as
performance category score and then category. Under section determined in section 1848(o)(2) of the
that score is multiplied by the weight 1848(q)(5)(E)(i)(I)(bb) of the Act, the Act) is 75 percent or greater, the
assigned to the performance category. weight of the quality performance Secretary may reduce the applicable
We intend to continue to explore category for each of the first 2 years will percentage weight of the advancing care
approaches to simplify MIPS scoring in increase by the difference of 30 percent information performance category in the
future rulemaking. minus the weight specified for the cost final score, but not below 15 percent.
In the meantime, we seek comment on performance category for the year. For more on our policies concerning
approaches to display scores and In the CY 2017 Quality Payment
section 1848(q)(5)(E)(ii) of the Act and
provide feedback to MIPS eligible Program final rule, we established the
a review of our proposal for reweighting
clinicians in a way that MIPS eligible weights of the cost performance
the advancing care information
clinicians can easily understand how category as 10 percent of the final score
(81 FR 77166) and the quality performance category in the event that
their scores are calculated, including the proportion of MIPS eligible
how performance category scores are performance category as 50 percent of
the final score (81 FR 77100) for the clinicians who are meaningful EHR
translated to a final score. We also seek
2020 MIPS payment year. While we users is 75 percent or greater starting
comment on how to simplify the scoring
proposed in the CY 2018 Quality with the 2019 MIPS performance
system while still recognizing
differences in clinician practices. Payment Program proposed rule (82 FR period, we refer readers to section
Final Action: After consideration of 30047 through 30048) to change the II.C.6.f.(5) of this final rule with
public comments, we are finalizing the weight of the cost performance category comment period.
revisions to 414.1380(c) and to zero percent and to change the weight Table 28 summarizes the weights
414.1305 as proposed. of the quality performance category to specified for each performance category.
TABLE 28WEIGHTS BY MIPS PERFORMANCE CATEGORY

2021 MIPS
Transition 2020 MIPS payment year
Performance category year payment year and beyond
(%) (%) (%)
Quality .......................................................................................................................................... 60 50 30
Cost .............................................................................................................................................. 0 10 30
Improvement Activities ................................................................................................................. 15 15 15
Advancing Care Information* ....................................................................................................... 25 25 25
* As described in section II.C.6.f.(5) of this final rule with comment period, the weight for advancing care information could decrease (not below
15 percent) starting with the 2021 MIPS payment year if the Secretary estimates that the proportion of physicians who are meaningful EHR users
is 75 percent or greater.
(b) Flexibility for Weighting involved, the Secretary shall assign extent to which the measure or activity
Performance Categories different scoring weights (including a is applicable and available to the type
Under section 1848(q)(5)(F) of the weight of zero) for each performance of MIPS eligible clinician involved. For
Act, if there are not sufficient measures category based on the extent to which the 2020 MIPS payment year, we
and activities applicable and available the category is applicable and for each proposed to assign a scoring weight of
to each type of MIPS eligible clinician measure and activity based on the zero percent to a performance category
and redistribute its weight to the other any relevant quality measures available (82 FR 30075 through 30079) for a
performance categories in the following to report or the MIPS eligible clinician detailed discussion of our proposals and
scenarios. is approved for reweighting the quality policies under which we would not
For the quality performance category, performance category based on extreme score the advancing care information
we proposed that having sufficient and uncontrollable circumstances as performance category and would assign
measures applicable and available proposed in the CY 2018 Quality a weight of zero percent to that category
means that we can calculate a quality Payment Program proposed rule (82 FR for a MIPS eligible clinician.
performance category percent score for 30142 through 30144), that we would We invited public comment on our
the MIPS eligible clinician because at reweight the quality performance interpretation of sufficient measures
least one quality measure is applicable category. available and applicable in the
and available to the MIPS eligible For the cost performance category, we performance categories.
clinician. Based on the volume of stated that we continue to believe that Final Action: We did not receive any
measures available to MIPS eligible having sufficient measures applicable comments. We are finalizing our
clinicians via the multiple submission and available means that we can reliably proposed policies for our interpretation
mechanisms, we stated that we calculate a score for the cost measures of measures available and applicable for
generally believe there will be at least 1 that adequately captures and reflects the the quality, cost, and improvement
quality measure applicable and performance of a MIPS eligible activities for the 2020 MIPS payment
available to every MIPS eligible clinician, and that MIPS eligible year.
clinician. If we receive no quality clinicians who are not attributed enough (c) Extreme and Uncontrollable
performance category submission from a cases to be reliably measured should not Circumstances
MIPS eligible clinician, the MIPS be scored for the cost performance
eligible clinician generally will receive category (82 FR 30142). We established In the CY 2017 Quality Payment
a performance category score of zero (or a policy in the CY 2017 Quality Program final rule (81 FR 77241 through
slightly above zero if the all-cause Payment Program final rule that if a 77243), we discussed our belief that
hospital readmission measure applies MIPS eligible clinician is not attributed extreme and uncontrollable
because the clinician submits data for a enough cases for a measure (in other circumstances, such as a natural disaster
performance category other than the words, has not met the required case in which an EHR or practice location is
quality performance category).12 minimum for the measure), or if a destroyed, can happen at any time and
However, as described in the CY 2018 measure does not have a benchmark, are outside a MIPS eligible clinicians
Quality Payment Program proposed rule then the measure will not be scored for control. We stated that if a MIPS eligible
(82 FR 30108 through 30109), there may that clinician (81 FR 77323). If we do clinicians CEHRT is unavailable as a
be rare instances that we believe could not score any cost measures for a MIPS result of such circumstances, then the
affect only a very limited subset of MIPS eligible clinician in accordance with measures specified for the advancing
eligible clinicians (as well as groups and this policy, then the clinician would not care information performance category
virtual groups) that may have no quality receive a cost performance category may not be available for the MIPS
measures available and applicable and percent score. Because we proposed in eligible clinician to report. We
for whom we receive no quality the CY 2018 Quality Payment Program established a policy allowing a MIPS
performance category submission (and proposed rule to set the weight of the eligible clinician affected by extreme
for whom the all-cause hospital cost performance category to zero and uncontrollable circumstances to
readmission measure does not apply). In percent of the final score for the 2020 submit an application to us to be
those instances, we would not be able MIPS payment year, we did not propose considered for reweighting of the
to calculate a quality performance to redistribute the weight of the cost advancing care information performance
category percent score. performance category to any other category under section 1848(q)(5)(F) of
The proposed quality performance performance categories for the 2020 the Act. Although we proposed (82 FR
category scoring policies for the 2020 MIPS payment year. In the event we did 30075 through 30078) to use the
MIPS payment year continue many of not finalize this proposal, we proposed authority in the last sentence of section
the special scoring policies from the to redistribute the weight of the cost 1848(o)(2)(D) of the Act, as amended by
transition year which would enable us performance category as described in section 4002(b)(1)(B) of the 21st Century
to determine a quality performance the CY 2018 Quality Payment Program Cures Act, as the authority for this
category percent score whenever a MIPS proposed rule (82 FR 30144 through policy, rather than section 1848(q)(5)(F)
eligible clinician has submitted at least 30146). of the Act, we continue to believe that
1 quality measure. In addition, MIPS For the improvement activities extreme and uncontrollable
eligible clinicians that do not submit performance category, we stated the circumstances could affect the
quality measures when they have them belief that all MIPS eligible clinicians availability of a MIPS eligible clinicians
available and applicable would receive will have sufficient activities applicable CEHRT and the measures specified for
a quality performance category percent and available; however, as discussed in the advancing care information
score of zero percent. It is only in the the CY 2018 Quality Payment Program performance category.
rare scenarios when we determine that proposed rule (82 FR 30142 through While we had not adopted a similar
a MIPS eligible clinician does not have 30144), we believe there are limited reweighting policy for the other
extreme and uncontrollable performance categories in the transition
12 As discussed in the CY 2017 Quality Payment
circumstances, such as natural disasters, year, we stated that we believe a similar
Program final rule (81 FR 77300), groups of 16 or where a clinician is unable to report reweighting policy may be appropriate
more eligible clinicians that meet the applicable
case minimum requirement are automatically improvement activities. Barring these for the quality, cost, and improvement
scored on the all-cause readmission measure, even circumstances, we did not propose any activities performance categories
if they do not submit any other data under the changes that would affect our ability to beginning with the 2020 MIPS payment
quality performance category, provided that they calculate an improvement activities year (82 FR 30142). For these
submit data under one of the other performance
categories. If such groups do not submit data under performance category score. performance categories, we proposed to
any performance category, the readmission measure We refer readers to the CY 2018 define extreme and uncontrollable
is not scored. Quality Payment Program proposed rule circumstances as rare (that is, highly
unlikely to occur in a given year) events disasters, that affect the MIPS eligible such cases, we believe that the measures
entirely outside the control of the clinicians ability to submit data to the are available to the clinician, but are
clinician and of the facility in which the third-party intermediary, which in turn, likely not applicable, because the
clinician practices that cause the MIPS could affect the ability of the clinician extreme and uncontrollable
eligible clinician to not be able to collect (or the third-party intermediary acting circumstance has disrupted practice and
information that the clinician would on their behalf) to successfully submit measurement processes. Therefore, we
submit for a performance category or to measures and activities to MIPS. believed an approach similar to that in
submit information that would be used We also proposed to use this policy the Hospital VBP Program (78 FR 50705)
to score a performance category for an for measures which we derive from is warranted under MIPS, and we
extended period of time (for example, 3 claims data, such as the all-cause proposed that we would exempt a MIPS
months could be considered an hospital readmission measure and the eligible clinician from all quality and
extended period of time with regard to cost measures. Other programs, such as cost measures calculated from
information a clinician would collect for the Hospital VBP Program, allow administrative claims data if the
the quality performance category). For hospitals to submit exception clinician is granted an exception for the
example, a tornado or fire destroying the applications when a hospital is able to respective performance categories based
only facility in which a clinician continue to report data on measures on extreme and uncontrollable
practices likely would be considered an . . . but can demonstrate that its circumstances.
extreme and uncontrollable Hospital VBP Program measure rates are Beginning with the 2020 MIPS
circumstance; however, neither the negatively impacted as a result of a payment year, we proposed that we
inability to renew a leaseeven a long natural disaster or other extraordinary
would reweight the quality, cost, and/or
or extended leasenor a facility being circumstance and, as a result, the
improvement activities performance
found not compliant with federal, state, hospital receives a lower value-based
categories if a MIPS eligible clinician,
or local building codes or other incentive payment (78 FR 50705). For
group, or virtual groups request for a
requirements would be considered the Hospital VBP Program, we
reweighting assessment based on
extreme and uncontrollable interpret[ed] the minimum numbers of
extreme and uncontrollable
circumstances. We proposed that we cases and measures requirement in the
circumstances is granted. We proposed
would review both the circumstances Act to enable us to not score . . . all
that MIPS eligible clinicians could
and the timing independently to assess applicable quality measure data from a
request a reweighting assessment if they
the availability and applicability of performance period and, thus, exclude
the hospital from the Hospital VBP believe extreme and uncontrollable
measures and activities independently circumstances affect the availability and
for each performance category. For Program for a fiscal year during which
the hospital has experienced a disaster applicability of measures for the quality,
example, in 2018 the performance cost, and improvement activities
period for improvement activities is or other extraordinary circumstance
(78 FR 50705). Hospitals that request performance categories. To the extent
only 90 days, whereas it is 12 months possible, we noted we would seek to
for the quality performance category, so and are granted an exception are
exempted from the Program entirely for align the requirements for submitting a
an issue lasting 3 months may have reweighting assessment for extreme and
more impact on the availability of the applicable year.
For the 2020 MIPS payment year, we uncontrollable circumstances with the
measures for the quality performance requirements for requesting a significant
would score quality measures and
category than for the improvement hardship exception for the advancing
assign points even for those clinicians
activities performance category, because care information performance category.
who do not meet the case minimums for
the MIPS eligible clinician, conceivably, the quality measures they submit. For example, we proposed to adopt the
could participate in improvement However, we established a policy not to same deadline (December 31, 2018 for
activities for a different 90-day period. score a cost measure unless a MIPS the 2018 MIPS performance period) for
We stated that we believe that eligible clinician has met the required submission of a reweighting assessment
extreme and uncontrollable case minimum for the measure (81 FR (see 82 FR 30075 through 30078), and
circumstances, such as natural disasters, 77323), and not to score administrative we encouraged the requests to be
may affect a clinicians ability to access claims measures, such as the all-cause submitted on a rolling basis. We
or submit quality measures via all hospital readmission measure, if they proposed the reweighting assessment
submission mechanisms (effectively cannot be reliably scored against a must include the nature of the extreme
rendering the measures unavailable to benchmark (81 FR 77288 through and uncontrollable circumstance,
the clinician), as well as the availability 77289). Even if the required case including the type of event, date of the
of numerous improvement activities. In minimums have been met and we are event, and length of time over which the
addition, damage to a facility where care able to reliably calculate scores for the event took place, performance categories
is provided due to a natural disaster, measures that are derived from claims, impacted, and other pertinent details
such as a hurricane, could result in we believe a MIPS eligible clinicians that impacted the ability to report on
practice management and clinical performance on those measures could measures or activities to be considered
systems that are used for the collection be adversely impacted by a natural for reweighting of the quality, cost, or
or submission of data to be down, thus disaster or other extraordinary improvement activities performance
impacting a clinicians ability to submit circumstance, similar to the issues we categories (for example, information
necessary information via Qualified identified for the Hospital VBP Program. detailing how exactly the event
Registry, QCDR, CMS Web Interface, or For example, the claims data used to impacted availability and applicability
claims. This policy would not include calculate the cost measures or the all- of measures). We stated that if we
issues that third-party intermediaries, cause hospital readmission measure finalize the policy to allow reweighting
such as EHRs, Qualified Registries, or could be significantly affected if a based on extreme and uncontrollable
QCDRs, might have submitting natural disaster caused wide-spread circumstances beginning with the 2020
information to MIPS on behalf of a MIPS injury or health problems for the MIPS payment year, we would specify
eligible clinician. Instead, this policy is community, which could not have been the form and manner in which these
geared towards events, such as natural prevented by high-value healthcare. In reweighting applications must be
submitted outside of the rulemaking clinicians to be scored based on include in the definition of extreme and
process after the final rule is published. multiple performance categories (81 FR uncontrollable circumstances. A few
For virtual groups, we proposed to 77326 through 77328). commenters requested that CMS include
request that virtual groups submit a We requested comment on our extreme and uncontrollable events
reweighting assessment for extreme and extreme and uncontrollable caused by a third-party intermediary
uncontrollable circumstances similar to circumstances proposals. We also submitting information to CMS on
groups, and we would evaluate whether sought comment on the types of the behalf of a MIPS eligible clinician. In
sufficient measures and activities are extreme and uncontrollable addition, a few commenters requested
applicable and available to the majority circumstances we should consider for that CMS include physician illness and
of TINs in the virtual group. We this policy given the general parameters maternity leave in the definition of
proposed that a majority of TINs in the we describe in this section. extreme and uncontrollable events.
virtual group would need to be The following is a summary of the Response: We continue to believe it is
impacted before we grant an exception. public comments received on these appropriate to maintain a narrow
We still found it important to measure proposals and our responses: definition of extreme and uncontrollable
the performance of virtual group Comment: Many commenters circumstances for the quality, cost, and
members unaffected by an extreme and supported our proposal to reweight the improvement activities performance
uncontrollable circumstance even if performance categories based on categories. For third-party
some of the virtual groups TINs are extreme and uncontrollable intermediaries, we believe it more
affected. circumstances. These commenters appropriate to monitor the third-party
We also sought comment on what stated that MIPS eligible clinicians who issues and take additional action if
additional factors we should consider experience extreme and uncontrollable needed in the future rather than address
for virtual groups. We proposed that the events are already significantly it through the extreme and
reweighting assessment due to extreme burdened and should not be subject to uncontrollable circumstances policy
and uncontrollable circumstances for MIPS reporting requirements. A few here at this time. We refer readers to
the quality, cost, and improvement commenters stated that claims data section II.C.10. in this final rule with
activities would not be available to APM could be impacted by extreme and comment period for additional
Entities in the APM scoring standard for uncontrollable events. information on third party vendors. We
the following reasons. First, all MIPS Response: We thank commenters for believe many clinicians affected by
eligible clinicians scored under the their support of our proposed policy to illness or who are on maternity leave
APM scoring standard will reweight the performance categories in would be excluded from MIPS due to
automatically receive an improvement the event of extreme and uncontrollable not exceeding the low-volume
activities category score based on the circumstances. threshold; however, we will review each
terms of their participation in a MIPS Comment: One commenter requested application on a case-by-case basis and
APM and need not report anything for that CMS modify our proposal to allow determine whether reweighting is
this performance category. Second, the MIPS eligible clinicians who are eligible warranted based on the circumstances
cost performance category has no weight for an improvement score to receive the described and information provided.
under the APM scoring standard. improvement score points, believing Comment: One commenter requested
Finally, for the quality performance that this will provide recognition of that CMS allow flexibility in our process
category, each MIPS APM has its own improvement. for reviewing reweighting applications
rules related to quality measures and we Response: Because MIPS eligible because they believe certain events may
believe any decisions related to clinicians would not report or receive a impact certain MIPS eligible clinicians
availability and applicability of score for the quality and cost more than others.
measures should reside within the performance categories if those Response: We intend for the review
model. As noted in the CY 2018 Quality categories are reweighted based on process to be flexible and take into
Payment Program proposed rule (82 FR extreme and uncontrollable consideration various factors, including
30087 through 30088), APM entities in circumstances, we would not have data the duration, type, and severity of the
MIPS APMs would be able to request sufficient to measure improvement for circumstances. We agree with
reweighting of the advancing care the current or future performance commenters that additional flexibility is
information performance category. periods. We refer readers to sections appropriate, especially for virtual
We noted that if we finalize these II.C.7.a.(2)(i) and II.C.7.a.(3)(a) of this groups because we have finalized the
proposals for reweighting the quality, final rule with comment period for a virtual group reporting option to
cost, and improvement activities summary of our policies related to data support MIPS eligible clinicians who
performance categories based on sufficiency. We believe it is important to may have a difficult time reporting in
extreme and uncontrollable measure improvement for as many MIPS MIPS individually. We believe that
circumstances, then it would be eligible clinicians as possible, and we there may be cases where less than a
possible that one or more of these seek comment on ways we can modify majority of the TINs in a virtual group
performance categories would not be our improvement scoring policies to are impacted by an extreme and
scored and would be weighted at zero account for clinicians who have been uncontrollable event, but reweighting is
percent of the final score for a MIPS affected by extreme and uncontrollable still appropriate. For example, there
eligible clinician. We proposed to assign circumstances. For example, in cases may be one TIN in the virtual group
a final score equal to the performance where sufficient data from the prior which is impacted by an extreme and
threshold if fewer than 2 performance performance period are not available to uncontrollable event; however, that TIN
categories are scored for a MIPS eligible measure improvement due to extreme may be the one coordinating data
clinician. This is consistent with our and uncontrollable circumstances, collection and submission for the entire
policy finalized in the CY 2017 Quality should we use data from 2 years prior virtual group. Conversely, we believe
Payment Program final rule that because to the performance period if such data there may be cases where more than a
the final score is a composite score, we is available. majority of the TINs in a virtual group
believe the intention of section Comment: A few commenters are impacted by an extreme and
1848(q)(5) of the Act is for MIPS eligible suggested additional types of events to uncontrollable event, but reweighting
may still not be appropriate. One (d) Redistributing Performance Category the advancing care information
example may be when the TINs Weights performance category for a MIPS eligible
impacted by the event experience the In the CY 2017 Quality Payment clinician, we proposed (82 FR 30144) to
event; however, the event did not Program final rule, we codified at continue our policy from the transition
impede data collection. As a result, we 414.1380(c)(2) that we will assign year and redistribute the weight of the
are not finalizing the proposal that a different scoring weights for the advancing care information performance
majority of TINs in the virtual group performance categories if we determine category to the quality performance
would need to be impacted by extreme there are not sufficient measures and category (assuming the quality
and uncontrollable circumstances in activities applicable and available to performance category does not qualify
order for the virtual group to qualify for MIPS eligible clinicians (81 FR 77327). for reweighting). We believe
reweighting. We also finalized a policy to assign redistributing the weight of the
Final Action: After consideration of MIPS eligible clinicians with only one advancing care information performance
the public comments, we are finalizing scored performance category a final category to the quality performance
the proposed policies for reweighting score that is equal to the performance category (rather than redistributing to
the quality, cost, and improvement threshold, which means the clinician both the quality and improvement
would receive a MIPS payment activities performance categories) is
activities performance categories based
adjustment factor of zero percent for the appropriate because MIPS eligible
on extreme and uncontrollable
year (81 FR 77326 through 77328). We clinicians have more experience
circumstances, beginning with the 2018
proposed in the CY 2018 Quality reporting quality measures through the
performance period/2020 MIPS
Payment Program proposed rule (82 FR PQRS program, and measurement in
payment year with one minor exception.
30140) to refine this policy such that a this performance category is more
We are not finalizing the proposal that MIPS eligible clinician with fewer than mature.
a virtual group submitting a reweighting 2 performance category scores would
application must have a majority of its We noted in the CY 2018 Quality
receive a final score equal to the Payment Program proposed rule (82 FR
TINs impacted by extreme and performance threshold. This refinement
uncontrollable circumstances in order 30144) that if we do not finalize our
is to account for the proposal in the CY proposal to weight the cost performance
for the virtual group to qualify for 2018 Quality Payment Program
reweighting, but instead we will review category at zero percent (which means
proposed rule (82 FR 30142 through
each virtual group application on a case- the weight of the cost performance
30144) for extreme and uncontrollable
by-case basis and make a determination category is greater than zero percent),
circumstances, which could result in a
based on the information provided on then we would not redistribute the
scenario where a MIPS eligible clinician
the practices impacted and nature of the weight of any other performance
is not scored on any performance
event. As we noted in the CY 2018 categories to the cost performance
categories. We referred readers to the CY
Quality Payment Program proposed rule category. We believed this would be
2017 Quality Payment Program final
(82 FR 30143), we will specify the form consistent with our policy of
rule for a description of our policies for
and manner in which the reweighting introducing cost measurement in a
redistributing the weights of the
applications must be submitted outside deliberate fashion and recognition that
performance categories (81 FR 77325
of the rulemaking process after this final through 77329). For the 2020 MIPS clinicians are more familiar with other
payment year, we proposed to elements of MIPS. In the rare and
rule with comment period is published.
redistribute the weights of the unlikely scenario where a MIPS eligible
We also invite public comment on
performance categories in a manner that clinician qualifies for reweighting of the
alternatives to these policies, such as
is similar to the transition year. quality performance category percent
using a shortened performance period,
However, we also proposed new scoring score (because there are not sufficient
which may allow us to measure
policies to incorporate our proposals for quality measures applicable and
performance, rather than reweighting
extreme and uncontrollable available to the clinician or the clinician
the performance categories to zero
circumstances. is facing extreme and uncontrollable
percent.
In the CY 2018 Quality Payment circumstances) and the MIPS eligible
These policies for reweighting the Program proposed rule, (82 FR 30075 clinician is eligible to have the
quality, cost, and improvement through 30078) we proposed to use the advancing care information performance
activities performance categories based authority in the last sentence of section category reweighted to zero and the
on extreme and uncontrollable 1848(o)(2)(D) of the Act, as amended by MIPS eligible clinician has sufficient
circumstances will apply beginning section 4002(b)(1)(B) of the 21st Century cost measures applicable and available
with the 2018 MIPS performance Cures Act, as the authority for certain to have a cost performance category
period/2020 MIPS payment year. We policies under which we would assign percent score that is not reweighted,
recognize, however, that MIPS eligible a scoring weight of zero percent for the then we would redistribute the weight
clinicians have been affected by the advancing care information performance of the quality and advancing care
recent hurricanes Harvey, Irma, and category, and to amend 414.1380(c)(2) information performance categories to
Maria, which affected large regions of to reflect the proposals. We did not, the improvement activities performance
the United States in August and however, propose substantive changes category and would not redistribute the
September of 2017. We are adopting to the policy established in the CY 2017 weight to the cost performance category.
interim final policies for the 2017 Quality Payment Program final rule to We also proposed that if we finalize the
performance period/2019 MIPS redistribute the weight of the advancing cost performance category weight at
payment year for MIPS eligible care information performance category zero percent for the 2020 MIPS payment
clinicians who have been affected by to the other performance categories for year, then we would set the final score
these hurricanes and other natural the transition year (81 FR 77325 through at the performance threshold because
disasters and refer readers to the interim 77329). the final score would be based on the
final rule with comment period in For the 2020 MIPS payment year, if improvement activities performance
section III.B. we assign a weight of zero percent for category which would not be a
composite of 2 or more performance weight of the quality performance However, for simplicity, we wanted to
category scores. category to the remaining performance redistribute the weights in increments of
For the 2020 MIPS payment year, we category that is not weighted at zero 5 points. Because MIPS eligible
proposed to redistribute the weight of percent. We would not redistribute the clinicians have more experience
the cost performance category to the weight to the cost performance category. reporting quality measures and because
quality performance category if we did We believe that all MIPS eligible these measures are more mature, under
not finalize the proposal to set the cost clinicians will have sufficient this alternative option, we would
performance category at a zero percent improvement activities applicable and redistribute slightly more to the quality
weight, and if a MIPS eligible clinician available. It is possible that a MIPS performance category (15 percent vs. 10
does not receive a cost performance eligible clinician might face extreme percent). Should the cost performance
category percent score because there are and uncontrollable circumstances that category have available and applicable
not sufficient cost measures applicable render the improvement activities not measures and the cost performance
and available to the clinician or the applicable or available to the clinician; category weight is not finalized at zero
clinician is facing extreme and however, in that scenario, we believe it percent and the quality performance
uncontrollable circumstances. In the is likely that the measures specified for category is reweighted to zero percent,
rare scenarios where a MIPS eligible the other performance categories also then we would redistribute the weight
clinician does not receive a quality would not be applicable or available to of the advancing care information
performance category percent score the clinician based on the performance category to the
because there are not sufficient quality circumstances. In the rare event that the improvement activities performance
measures applicable and available to the improvement activities performance category. This alternative approach,
clinician or the clinician is facing category would qualify for reweighting which assumed a cost performance
extreme and uncontrollable based on extreme and uncontrollable category weight of zero percent was
circumstances, we proposed to circumstances, and the other detailed in Table 39 of the CY 2018
redistribute the weight of the cost performance categories would not also Quality Payment Program proposed rule
performance category equally to the qualify for reweighting, we proposed to (82 FR 30146).
remaining performance categories that redistribute the improvement activities We invited comments on our proposal
are not reweighted. performance category weight to the for reweighting the performance
In the rare event a MIPS eligible quality performance category consistent categories for the 2020 MIPS payment
clinician is not scored on at least one with the redistribution policies for the year and our alternative option for
measure in the quality performance cost and advancing care information reweighting the advancing care
category because there are not sufficient performance categories. We noted in the information performance category.
measures applicable and available or the CY 2018 Quality Payment Program The following is a summary of the
clinician is facing extreme and proposed rule (82 FR 30145) that, public comments received and our
uncontrollable circumstances, we should the cost performance category responses:
proposed for the 2020 MIPS payment have available and applicable measures Comment: Several commenters
year to continue our policy from the and the cost performance category supported CMSs proposed reweighting
transition year and redistribute the 60 weight is not finalized at zero percent, policies for the 2020 MIPS payment
percent weight of the quality and the quality performance category is year. Commenters noted that CMSs
performance category so that the reweighted to zero percent, then we reweighting policies would alleviate
performance category weights are 50 would redistribute the weight of the burdens for small and rural practices.
percent for the advancing care improvement activities performance Some commenters expressed the belief
information performance category and category to the advancing care that reweighting to the quality
50 percent for the improvement information performance category. performance category was appropriate
activities performance category Table 38 in the CY 2018 Quality because it is the category with which
(assuming these performance categories Payment Program proposed rule MIPS eligible clinicians are most
do not qualify for reweighting). While summarized the potential reweighting familiar.
clinicians have more experience scenarios based on our proposals for the Response: We thank commenters for
reporting advancing care information 2020 MIPS payment year should the their support of our proposed
measures, we believe equal weighting to cost performance category be weighted reweighting policies. We are finalizing
both the improvement activities and at zero percent (82 FR 30145). our reweighting policies as proposed for
advancing care information performance We also considered an alternative the 2020 MIPS payment year, with the
categories is appropriate for simplicity. approach for the 2020 MIPS payment exception of the policies that assume
Additionally, in the absence of quality year to redistribute the weight of the the cost performance category will be
measures, we believe increasing the advancing care information performance weighted at zero percent in the final
relative weight of the improvement category to the quality and improvement score as proposed, because we have
activities performance category is activities performance categories, to decided to finalize the cost performance
appropriate because both the minimize the impact of the quality category weight at 10 percent in section
improvement activities and advancing performance category on the final score. II.C.6.d.(2) of this final rule with
care information performance categories For this approach, we proposed to comment period. We agree that quality
have elements of quality and care redistribute 15 percent to the quality is the performance category with which
improvement which are important to performance category (60 percent + 15 MIPS eligible clinicians are most
emphasize. Should the cost performance percent = 75 percent) and 10 percent to familiar (compared with the
category have available and applicable the improvement activities performance improvement activities performance
measures and the cost performance category (15 percent + 10 percent = 25 category). The commenters did not
category weight is not zero, but either percent). We considered redistributing specify how this policy would benefit
the improvement activities or advancing the weight of the advancing care small and rural practices, but we agree
care information performance category information performance category that collectively our policies for MIPS
is reweighted to zero percent, then we equally to the quality and improvement aim to minimize burden for these
proposed that we would redistribute the activities performance categories. practices.
Comment: Several commenters were consideration in future rulemaking, a quality performance category percent
supportive of CMSs alternative when MIPS eligible clinicians have score because there are not sufficient
approach to reweight the advancing care more experience reporting on the quality measures applicable and
information performance category to the improvement activities performance available to the clinician, to redistribute
quality and improvement activities category. the cost performance category weight
performance categories, in order to not Comment: One commenter requested equally to the remaining performance
place undue emphasis on the quality that CMS not redistribute the cost categories that are not reweighted.
performance category. A few performance category weight in future
years for non-patient facing MIPS Final Action: After consideration of
commenters suggested that, in cases
eligible clinicians who do not have public comments, we are finalizing our
where a MIPS eligible clinicians
advancing care information performance sufficient cost measures. proposals for redistributing the
category is reweighted to quality, CMS Response: We appreciate the feedback performance category weights for the
provide a 50 percent base score for the and will take into consideration in 2020 MIPS payment year, with the
quality performance category to better future rulemaking. We note that in exception of the proposals that assume
align with scoring for the advancing section II.C.6.d.(2) of this final rule with the cost performance category will be
care information performance category comment period, we finalized that the weighted at zero percent in the final
and to not unfairly penalize these MIPS cost performance category weight for the score as proposed, because in section
eligible clinicians. 2018 MIPS performance period and the II.C.6.d.(2) of this final rule with
Response: We continue to believe that 2020 MIPS payment year is 10 percent. comment period, we finalized that the
redistributing the advancing care As a result, if there are not sufficient cost performance category weight for the
information weight to quality is cost measures applicable and available 2018 MIPS performance period and the
appropriate because of the experience to a MIPS eligible clinician, we are 2020 MIPS payment period is 10
MIPS eligible clinicians have reporting finalizing the proposal to redistribute percent. Table 29 summarizes the final
on quality measures under other CMS the cost performance category weight to reweighting policies for the 2018 MIPS
programs. We appreciate these the quality performance category, or if a performance period and 2020 MIPS
comments and will take them into MIPS eligible clinician does not receive payment year.
TABLE 29PERFORMANCE CATEGORY REDISTRIBUTION POLICIES FOR THE 2020 MIPS PAYMENT YEAR
Advancing
Improvement
Quality Cost care
Reweighting scenario activities
(%) (%) information
(%) (%)
No Reweighting Needed
Scores for all four performance categories .................................................. 50 10 15 25
Reweight One Performance Category
No Cost ........................................................................................................ 60 0 15 25
No Advancing Care Information ................................................................... 75 10 15 0
No Quality .................................................................................................... 0 10 45 45
No Improvement Activities ........................................................................... 65 10 0 25
Reweight Two Performance Categories
No Cost and no Advancing Care Information .............................................. 85 0 15 0

No Cost and no Quality ............................................................................... 0 0 50 50
No Cost and no Improvement Activities ...................................................... 75 0 0 25
No Advancing Care Information and no Quality .......................................... 0 10 90 0
No Advancing Care Information and no Improvement Activities ................. 90 10 0 0
No Quality and no Improvement Activities ................................................... 0 10 0 90
8. MIPS Payment Adjustments a TIN/NPI may receive a final score payment adjustment. We also proposed
a. Payment Adjustment Identifier and based on individual, group, or APM the following policies, and, although we
Final Score Used in Payment Entity group performance, but the MIPS received public comments on them and
Adjustment Calculation payment adjustment would be applied responded to those comments, we
at the TIN/NPI level. inadvertently failed to state that we
(1) Payment Adjustment Identifier were finalizing these policies, although
We did not propose any changes to
For purposes of applying the MIPS the MIPS payment adjustment it was our intention to do so. Thus, we
payment adjustment under section identifier. clarify that the following final policies
1848(q)(6)(E) of the Act, we finalized a apply beginning with the transition

(2) Final Score Used in Payment
policy in the CY 2017 Quality Payment year. For groups submitting data using
Adjustment Calculation
Program final rule to use a single the TIN identifier, we will apply the
identifier, TIN/NPI, for all MIPS eligible In CY 2017 Quality Payment Program group final score to all the TIN/NPI
clinicians, regardless of whether the final rule (81 FR 77330 through 77332), combinations that bill under that TIN
TIN/NPI was measured as an individual, we finalized a policy to use a TIN/NPIs during the performance period. For
group or APM Entity group (81 FR performance from the performance individual MIPS eligible clinicians
77329 through 77330). In other words, period associated with the MIPS submitting data using TIN/NPI, we will
use the final score associated with the modify the policies to address the scores for the TIN/NPI and agreed that
TIN/NPI that is used during the addition of virtual groups. Section this prioritization will help encourage
performance period. For MIPS eligible 1848(q)(5)(I)(i) of the Act provides that eligible clinicians to move towards
clinicians in MIPS APMs, we will assign MIPS eligible clinicians electing to be a APMs.
the APM Entity groups final score to all virtual group must: (1) Have their Response: We thank the commenters
the APM Entity Participant Identifiers performance assessed for the quality for their support.
that are associated with the APM Entity. and cost performance categories in a Comment: One commenter did not
For MIPS eligible clinicians that manner that applies the combined support the prioritization of the APM
participate in APMs for which the APM performance of all the MIPS eligible Entity final score and suggested that a
scoring standard does not apply, we will clinicians in the virtual group to each group practice should have the option to
assign a final score using either the MIPS eligible clinician in the virtual report both as a group and through an
individual or group data submission group for the applicable performance APM Entity, and the final score should
assignments. period; and (2) be scored for the quality be the higher of the two scores. One
In the case where a MIPS eligible and cost performance categories based commenter believes that APM Entities
clinician starts working in a new on such assessment. Therefore, when may receive lower scores for certain
practice or otherwise establishes a new identifying a final score for payment performance categories, such as the
TIN that did not exist during the adjustments, we must prioritize a virtual advancing care information performance
performance period, there would be no group final score over other final scores category, compared to their group.
corresponding historical performance such as individual and group scores. Response: We believe it is important
information or final score for the new Because we also wish to encourage to align MIPS with APMs and believe
TIN/NPI. In cases where there is no final movement towards APMs, we will prioritizing APM Entity scores over
score associated with a TIN/NPI from prioritize using the APM Entity final other scores creates that alignment. We
the performance period, we will use the score over any other score for a TIN/ want MIPS eligible clinicians to be able
NPIs performance for the TIN(s) the NPI NPI, including a TIN/NPI that is in a to focus on the requirements and
was billing under during the virtual group. If a TIN/NPI is in both a redesign required in the APM.
performance period. If the MIPS eligible virtual group and a MIPS APM, we Comment: One commenter requested
clinician has only one final score proposed to use the waiver authority for additional clarity on how payment
associated with the NPI from the Innovation Center models under section adjustments will be applied when a
performance period, then we will use 1115A(d)(1) of the Act and the Shared MIPS eligible clinician bills under more
that final score. In the event that an NPI Savings Program waiver authority under than one TIN/NPI combination. One
bills under multiple TINs in the section 1899(f) of the Act to waive commenter expressed concern with the
performance period and bills under a section 1848(q)(5)(I)(i)(I) and (II) of the approach of applying the payment
new TIN in the MIPS payment year, we Act so that we could use the APM Entity adjustment at the TIN/NPI level because
finalized a policy of taking the highest final score instead of the virtual group of the potential complexities from MIPS
final score associated with that NPI in final score for a TIN/NPI. As discussed eligible clinicians changing practices.
the performance period (81 FR 77332). in the CY 2018 Quality Payment Response: MIPS payment adjustments
In some cases, a TIN/NPI could have Program proposed rule (82 FR 30033 will be determined for each TIN/NPI
more than one final score associated through 30034), the use of waiver combination. We will use only one final
with it from the performance period, if authority is to avoid creating competing score for a TIN/NPI for purposes of
the MIPS eligible clinician submitted incentives between MIPS and the APM. determining the MIPS payment
duplicative data sets. In this situation, We want MIPS eligible clinicians to adjustment that will be applied to that
the MIPS eligible clinician has not focus on the requirements of the APM TIN/NPI. If a MIPS eligible clinician
changed practices; rather, for example, a to ensure that the models produce valid bills under more than one TIN, that
MIPS eligible clinician has a final score results that are not confounded by the MIPS eligible clinician will receive a
for an APM Entity and a final score for incentives created by MIPS. separate MIPS payment adjustment for
a group TIN. If a MIPS eligible clinician We also proposed to modify our each TIN/NPI combination. In addition,
has multiple final scores, the following hierarchy to state that if a MIPS eligible since we allow each MIPS eligible
hierarchy will apply. If a MIPS eligible clinician is not in an APM Entity and is clinician to decide how they want to
clinician is a participant in MIPS APM, in a virtual group, the MIPS eligible reportindividually, through a group,
then the APM Entity final score would clinician would receive the virtual or through an APM Entity as a MIPS
be used instead of any other final score. group final score over any other final APM participantwe cannot control the
If a MIPS eligible clinician has more score. Our policies remain unchanged number of submissions that one TIN/
than one APM Entity final score, we for TIN/NPIs who are not in an APM NPI may have for a performance period.
will apply the highest APM Entity final Entity or virtual group. Tables 40 and 41 To address scenarios where we have
score to the MIPS eligible clinician. If a in the CY 2018 Quality Payment multiple submissions for one TIN/NPI,
MIPS eligible clinician reports as a Program proposed rule summarized the we have established the policies
group and as an individual and not as final and proposed policies (82 FR described earlier in this section to
an APM Entity, we will calculate a final 30147). articulate the hierarchy of which final
score for the group and individual We will only apply the associated score we will use to determine the MIPS
identifier and use the highest final score final score to clinicians or groups who payment adjustment for a TIN/NPI.
for the TIN/NPI (81 FR 77332). are not otherwise excluded from MIPS. Final Action: After consideration of
For a further description of our We invited public comment on our the public comments received, we are
policies, we referred readers to the CY proposals. finalizing our policies as proposed.
2017 Quality Payment Program final The following is a summary of the Tables 30 and 31 illustrate the final
rule (81 FR 77330 through 77332). public comments received and our policies for determining which final
In addition to the above policies from responses: score will be used when more than one
the CY 2017 Quality Payment Program Comment: A few commenters final score is associated with a TIN/NPI
final rule, beginning with the 2020 supported the prioritization of the APM (Table 30) and the final policies that
MIPS payment year, we proposed to Entity final score over any virtual group apply if there is no final score
associated with a TIN/NPI from the a new practice or otherwise establishes

performance period, such as when a a new TIN (Table 31).
MIPS eligible clinician starts working in
TABLE 30HIERARCHY FOR FINAL SCORE WHEN MORE THAN ONE FINAL SCORE IS ASSOCIATED WITH A TIN/NPI
Example Final score used to determine payment adjustments
TIN/NPI has more than one APM Entity final score ................................ The highest of the APM Entity final scores.
TIN/NPI has an APM Entity final score and also has an individual score APM Entity final score.
TIN/NPI has an APM Entity final score that is not a virtual group score APM Entity final score.
and also has a group final score.
TIN/NPI has an APM Entity final score and also has a virtual group APM Entity final score.
score.
TIN/NPI has a virtual group score and an individual final score ............. Virtual group score.
TIN/NPI has a group final score and an individual final score, but no The highest of the group or individual final score.
APM Entity final score and is not in a virtual group.
TABLE 31NO FINAL SCORE ASSOCIATED WITH A TIN/NPI

TIN/NPI
MIPS eligible Performance billing in Final score used to determine
clinician period MIPS payment payment adjustments
(NPI 1) final score year
(yes/no)
TIN A/NPI 1 ..... 90 ............................................ Yes (NPI 1 is still billing under 90 (Final score for TIN A/NPI 1 from the performance pe-
TIN A in the MIPS payment riod)
year).
TIN B/NPI 1 ..... 70 ............................................ No (NPI 1 has left TIN B and n/a (no claims are billed under TIN B/NPI 1)
no longer bills under TIN B
in the MIPS payment year).
TIN C/NPI 1 ..... n/a (NPI 1 was not part of TIN Yes (NPI 1 has joined TIN C 90 (No final score for TIN C/NPI 1, so use the highest final
C during the performance and is billing under TIN C in score associated with NPI 1 from the performance period)
period). the MIPS payment year).
b. MIPS Payment Adjustment Factors the Secretary, prior to the performance threshold of 3 points for the transition
period for such years, to establish a year (81 FR 77334 through 77338). We
For a description of the statutory inadvertently failed to codify the
performance threshold for purposes of
background and further description of performance threshold for the 2019
our policies, we refer readers to the CY determining the MIPS payment
adjustment factors under section MIPS payment year in the CY 2017
2017 Quality Payment Program final Quality Payment Program final rule,
rule (81 FR 77332 through 77333). 1848(q)(6)(A) of the Act and an
additional performance threshold for although it was our intention to do so.
Although we did not propose any Thus, we now codify the performance
purposes of determining the additional
changes to these policies, nor did we threshold of 3 points for the 2019 MIPS
MIPS payment adjustment factors under
request public comments, we did payment year at 414.1405(b)(4).
receive comments on this topic, which section 1848(q)(6)(C) of the Act, each of
which shall be based on a period prior Our goal was to encourage
we will consider in preparation for participation and provide an
future rulemaking. to the performance period and take into
opportunity for MIPS eligible clinicians
account data available for performance
c. Establishing the Performance to become familiar with the MIPS
on measures and activities that may be
Threshold program. We determined that it would
used under the performance categories
have been inappropriate to set a
Under section 1848(q)(6)(D)(i) of the and other factors determined performance threshold that would result
Act, for each year of the MIPS, the appropriate by the Secretary. We in downward adjustments to payments
Secretary shall compute a performance codified the term performance threshold for many clinicians who may not have
threshold with respect to which the at 414.1305 as the numerical threshold had time to prepare adequately to
final scores of MIPS eligible clinicians for a MIPS payment year against which succeed under MIPS. By providing a
are compared for purposes of the final scores of MIPS eligible pathway for many clinicians to succeed
determining the MIPS payment clinicians are compared to determine under MIPS, we believed that we would
adjustment factors under section the MIPS payment adjustment factors. encourage early participation in the
1848(q)(6)(A) of the Act for a year. The We codified at 414.1405(b) that a program, which may enable more robust
performance threshold for a year must performance threshold will be specified and thorough engagement with the
be either the mean or median (as for each MIPS payment year. We program over time. We set the
selected by the Secretary, and which referred readers to the CY 2017 Quality performance threshold at a low number
may be reassessed every 3 years) of the Payment Program final rule for further to provide MIPS eligible clinicians an
final scores for all MIPS eligible discussion of the performance threshold opportunity to achieve a minimum level
clinicians for a prior period specified by (81 FR 77333 through 77338). In of success under the program, while
the Secretary. Section 1848(q)(6)(D)(iii) accordance with the special rule set gaining experience with reporting on
of the Act outlines a special rule for the forth in section 1848(q)(6)(D)(iii) of the the measures and activities and
initial 2 years of MIPS, which requires Act, we finalized a performance becoming familiar with other program
policies and requirements. We believed all MIPS eligible clinicians for a prior submitting 2 quality measures with
if we set the threshold too high, using period, we proposed to set the required data completeness or one high-
a new formula that is unfamiliar and performance threshold at 15 points for weighted improvement activity. While
confusing to clinicians, many could be the 2020 MIPS payment year (82 FR this lower performance threshold may
discouraged from participating in the 30147 through 30149). provide a sharp increase to the required
first year of the program, which may We proposed a performance threshold performance threshold in the 2021 MIPS
lead to lower participation rates in of 15 points because it represents a payment year (the mean or median of
future years. Additionally, we believed meaningful increase, compared to 3 the final scores for all MIPS eligible
a lower performance threshold was points in the transition year, while clinicians for a prior period), it would
particularly important to reduce the maintaining flexibility for MIPS eligible continue to reward clinicians for
initial burden for MIPS eligible clinicians in the pathways available to participation in MIPS as they transition
clinicians in small or solo practices. We achieve this performance threshold. We into the program.
believed that active participation of refer readers to the CY 2018 Quality We also considered an alternative of
MIPS eligible clinicians in MIPS will Payment Program proposed rule (82 FR setting the performance threshold at 33
improve the overall quality, cost, and 30148) for examples of how clinicians points, which would require full
care coordination of services provided could meet or exceed a performance participation both in improvement
to Medicare beneficiaries. In accordance threshold of 15 points based on our activities and in the quality performance
with section 1848(q)(6)(D)(iii) of the proposed policies. category (either for a small group or for
Act, we took into account available data We believed the proposed a large group that meets data
regarding performance on measures and performance threshold would mitigate completeness standards) to meet the
activities, as well as other factors we concerns from MIPS eligible clinicians performance threshold. Such a
determined appropriate. We refer about participating in the program for threshold would make the step to the
readers to 81 FR 77333 through 77338 the second year. However, we remained required mean or median performance
for details of our analysis. We also concerned that moving from a threshold in the 2021 MIPS payment
stated our intent to increase the performance threshold of 15 points for year less steep but could present further
performance threshold in the 2020 MIPS the 2020 MIPS payment year to a challenges to clinicians who have not
payment year, and that, beginning in the performance threshold of the mean or previously participated in legacy quality
2021 MIPS payment year, we will use median of the final scores for all MIPS reporting programs.
the mean or median final score from a eligible clinicians for a prior period for As required by section
prior period as required by section the 2021 MIPS payment year may be a 1848(q)(6)(D)(iii) of the Act, for the
1848(q)(6)(D)(i) of the Act (81 FR steep jump. purposes of determining the
By the 2021 MIPS payment year, performance threshold, we considered
77338).
MIPS eligible clinicians would likely data available for performance on
For the 2020 MIPS payment year, we need to submit most of the required measures and activities that may be
again wanted to use the flexibility information and perform well on the used under the MIPS performance
provided in section 1848(q)(6)(D)(iii) to measures and activities to receive a categories. We refer readers to the CY
help transition MIPS eligible clinicians positive MIPS payment adjustment. 2018 Quality Payment Program
to the 2021 MIPS payment year, when Therefore, we also sought comment on proposed rule (82 FR 30147 through
the performance threshold will be the setting the performance threshold either 30149) for a discussion of the data we
mean or median of the final scores for lower or higher than the proposed 15 considered.
all MIPS eligible clinicians from a prior points for the 2020 MIPS payment year. We invited public comments on the
period. We wanted to encourage A performance threshold lower than the proposal to set the performance
continued participation and the proposed 15 points for the 2020 MIPS threshold at 15 points, and also sought
collection of meaningful data by MIPS payment year presents the potential for comment on setting the performance
eligible clinicians. A higher a significant increase in the final score threshold at the alternative of 6 points
performance threshold would help a MIPS eligible clinician must earn to or at 33 points for the 2020 MIPS
MIPS eligible clinicians strive to meet the performance threshold in the payment year. We also sought public
achieve more complete reporting and 2021 MIPS payment year, as well as comments on principles and
better performance and prepare MIPS providing for a potentially smaller total considerations for setting the
eligible clinicians for the 2021 MIPS amount of negative MIPS payment performance threshold beginning with
payment year. However, a performance adjustments upon which the total the 2021 MIPS payment year, which
threshold set too high could also create amount of the positive MIPS payment will be the mean or median of the final
a performance barrier, particularly for adjustments would depend due to the scores for all MIPS eligible clinicians
MIPS eligible clinicians who did not budget neutrality requirement under from a prior period.
previously participate in PQRS or the section 1848(q)(6)(F)(ii) of the Act. A The following is a summary of the
EHR Incentive Programs. We have heard performance threshold higher than the public comments received on our
from stakeholders requesting that we proposed 15 points would increase the proposals for the performance threshold
continue a low performance threshold final score required to receive a neutral and our responses:
and from stakeholders requesting that MIPS payment adjustment, which may Comment: Many commenters
we ramp up the performance threshold be particularly challenging for small supported the performance threshold of
to help MIPS eligible clinicians prepare practices, even with the proposed 15 points because it will provide an
for the 2021 MIPS payment year and to addition of the small practice bonus. A incremental increase over the 3-point
meaningfully incentivize higher higher performance threshold would performance threshold from the
performance. Given our desire to also allow for potentially higher positive transition year; provide a helpful
provide a meaningful ramp between the MIPS payment adjustments for those ramping up of performance standards;
transition years 3-point performance who exceed the performance threshold. encourage more participation in MIPS;
threshold and the 2021 MIPS payment We considered an alternative of prepare clinicians to focus on the
year performance threshold using the setting a performance threshold of 6 delivery of high quality care to help
mean or median of the final scores for points, which could be met by them eventually advance toward APM
participation; and represents a data completeness, MIPS eligible the 2021 MIPS payment year. We also
meaningful increase in the performance clinicians would earn a quality do not believe that increasing the
threshold while maintaining flexibility performance category percent score of at performance threshold to 15 points is a
for clinicians to achieve the threshold in least 30 percent (which is at least 3 significant increase, but is rather a
multiple ways. One commenter measure achievement points out of 10 moderate step that provides an
recommended a performance threshold measure points for each required opportunity for clinicians to gain
higher than 5 points. measure). If the quality performance experience with all MIPS performance
Response: We thank the commenters category is weighted at 50 percent, then categories before the performance
for their support. We are finalizing the the quality performance category would threshold changes in the 2021 MIPS
performance threshold at 15 points. be 30 percent 50 percent 100 which payment year and a clinician will likely
Please refer to section II.C.8.g.(2) of this equals 15 points toward the final score need to participate more fully and
final rule with comment period for and meets the performance threshold. perform well on multiple performance
additional details on multiple ways Finally, a MIPS eligible clinician could categories to earn a score high enough
clinicians and groups can meet or achieve a final score of 15 points to receive a positive adjustment. We
exceed the performance threshold. through an advancing care information have based our regulatory impact
Comment: Many commenters performance category score of 60 analysis estimates on the best available
supported a lower performance percent or higher (60 percent advancing data and two sets of participation
threshold without a specific numerical care information performance category assumptions; we do not believe our
recommendation because the score 25 percent performance category participation assumptions are overly
commenters believe that the increase to weight 100 equals 15 points towards inflated or inaccurate based on the data
15 points would put an increased the final score). Please refer to section available. We refer readers to the CY
burden of additional requirements on II.C.8.g.(2) of this final rule with 2018 Quality Payment Program
MIPS eligible clinicians, that a lower comment period for additional details proposed rule (82 FR 30147 through
threshold would encourage clinician on ways to meet or exceed the 30149) for details on the data
participation, provide flexibility for performance threshold. considered. While we anticipate we will
clinicians to meet the performance Comment: A few commenters stated have more accurate program
threshold, and would allow clinicians to that setting a lower performance information after the first year of MIPS,
become more familiar with MIPS and threshold is especially important we do not believe it is appropriate to
more successful, particularly for because stakeholders do not have data have a performance threshold below 15
gastroenterologists. One commenter from the first performance period and points as our program estimates do not
encouraged CMS to maintain as low a are unsure how well clinicians impact the statutory requirement to set
performance threshold as possible for understand MIPS requirements and the performance threshold at either the
2018 since the second year of MIPS is whether clinicians are ready for a more mean or median of the final scores for
still considered a transition year, and challenging program. The commenters all MIPS eligible clinicians for a prior
the commenter indicated many expressed their belief that CMSs period starting in the 2021 MIPS
clinicians are still expected to be at current program estimates are overly payment year.
various levels of readiness and comfort optimistic and may be inflated. A few Comment: A few commenters believe
with the program. One commenter commenters suggested that CMS delay a performance threshold of 15 points is
believes that the lower performance implementing a significant increase in excessively steep because clinicians will
threshold would allow CRNAs and the performance threshold until a no longer be able to report on only one
other MIPS eligible clinicians to gain complete analysis of the 2017 data is measure to avoid a negative payment
greater familiarity with QCDR measure performed because that would be adjustment and because some clinicians
reporting and improvement activities. consistent with efforts to ensure a may not be ready to submit enough data
Response: We acknowledge the smooth transition in the 2018 to reach the proposed performance
concerns expressed by many performance period. threshold of 15 points. One commenter
commenters. We recognize that the 2020 Response: We appreciate the recommended only a minimal increase
MIPS payment year is still a transition commenters concerns with the (something less than the proposed 15
year for MIPS, and we believe the proposed performance threshold and points) in the performance threshold
proposed performance threshold of 15 their request for a delay in increasing because of concern with drastic
points modestly increases the threshold the performance threshold until we fluctuations in performance threshold
from the transition year, while have more information about how numbers. One commenter
encouraging increased engagement and clinicians are performing under MIPS. recommended that CMS simplify and
participation in the MIPS program and However, beginning with the 2021 MIPS clarify performance scoring through
preparing clinicians for additional payment year, section 1848(q)(6)(D)(i) of future regulation to allow clinicians to
participation requirements in the 2021 the Act requires the performance better assess the scoring and weighting
MIPS performance period. We note that threshold to be either the mean or of each performance category because
this performance threshold would allow median of the final scores for all MIPS any increases in the performance
for many options for a MIPS eligible eligible clinicians for a prior period, threshold make it more difficult for
clinician to succeed under MIPS. For which could result in a significant clinicians to combine reporting on
example, submitting the maximum increase in the performance threshold in measures and activities to avoid a
number of improvement activities could the 2021 MIPS payment year. We negative payment adjustment.
qualify for a final score of 15 points believe that setting the performance Response: We disagree with the
because improvement activities threshold at 15 points for the 2020 MIPS characterization that a performance
performance category is worth 15 payment year is appropriate because it threshold of 15 points is excessively
percent of the final score. The encourages increased participation and steep. We believe a performance
performance threshold could also be prepares clinicians for the additional threshold of 15 points is an incremental
met by full participation in the quality participation requirements to meet or increase over the 3-point performance
performance categoryby submitting all exceed the increased performance threshold from the transition year and
required measures with the necessary threshold that is statutorily required in will provide a modest increase in what
clinicians need to do to succeed in year appropriately encourages clinicians supported a performance threshold at 6
MIPS. As discussed earlier in this to actively participate in MIPS. We points to be implemented along with
section, there are many ways a clinician believe a meaningful increase to a provisions, such as additional bonus
can earn a final score of 15 points from performance threshold of 15 points points, that protect clinicians and
reporting for just a single performance maintains appropriate flexibility for groups whose final scores are below the
category. We also believe this provides clinicians to meet or exceed the performance threshold due to
an opportunity for clinicians to gain threshold, while requiring increased performance category reweighting. One
experience with all MIPS performance participation over the level of commenter believes 6 points would be
categories before the performance engagement required to meet or exceed a more modest performance threshold
threshold changes in the 2021 MIPS the 3-point threshold used in the which would enable practices to
payment year, and a clinician will likely transition year. We also believe the upgrade their EHR software and more
need to perform well on multiple increased participation better prepares effectively track measures and
performance categories to earn a score clinicians to succeed under MIPS in improvement activities and comply
high enough to receive a positive future years and will improve the with interoperability expectations. One
payment adjustment. We will continue overall quality, cost, and care commenter urged CMS to consider the
to address any changes to the MIPS coordination of services to Medicare impact of the level of participation that
program in future rulemaking. beneficiaries. We are also mindful of the would be required to meet a
Comment: One commenter did not impact of meeting additional performance threshold of 6 points in the
support the increase from 3 points in requirements on small practices and MIPS program.
the 2019 MIPS payment year to 15 have added a small practice bonus as Response: We believe that increasing
points for the 2020 MIPS payment year discussed in section II.C.7.b.(1)(c) of this the performance threshold to 6 points
because of the impact on clinicians final rule with comment period, which for the 2020 MIPS payment year would
integrating CEHRT into their practices. may help them meet the performance not adequately encourage increased
Response: We do not believe CEHRT threshold. Additionally, we have clinician participation in MIPS and
integration will impact the ability of modified our quality performance would not prepare clinicians for the
MIPS eligible clinicians to meet or category scoring policy, which allows additional participation requirements in
exceed the performance threshold small practices to receive a minimum of the 2021 MIPS payment year in order to
because in section II.C.6.f.(4) of this 3 measure achievement points for every avoid a negative adjustment. We
final rule with comment period, we measure submitted, even if the measure recognize the challenges unique to
adopted a policy to allow the use of does not meet the data completeness clinicians in solo and small group
2014 Edition or 2015 Edition CEHRT, or criteria. practices participating in MIPS, but note
a combination of the two Editions, for that solo and small group practices must
the performance period in 2018. A Comment: Several commenters also meet the additional participation
clinician can also meet a performance recommended a performance threshold requirements in the 2021 MIPS payment
threshold of 15 points without of 6 points, rather than the proposed 15 year, and refer readers to section
participating in the advancing care points, because it would relieve some of II.C.7.b.(1)(c) of this final rule with
information performance category. the burden of increased participation comment for the provisions related to
Comment: Several commenters from the transition year, particularly for the small practice bonus for the 2020
recommended CMS maintain the solo practitioners and small group MIPS payment year. We also do not
performance threshold at 3 points practices, and would encourage agree that setting a performance
because the 2020 MIPS payment year is participation providing clinicians with threshold at 6 points for 2018 MIPS
a transition year, MIPS is complex, and the opportunity to avoid a negative performance period will preclude a
CMS should continue to offer an on- MIPS payment adjustment by significant increase in the performance
ramp for clinicians to transition and submitting a minimal amount of data. A threshold for the 2019 MIPS
integrate into MIPS. One commenter few commenters stated that lowering the performance period because
stated that an increase could harm MIPS threshold to 6 points would be performance data does not support that
eligible clinicians ability to provide the appropriate for another transition year, the mean or median of clinician scores
care that patients need. One commenter keep the program stable, and minimize for a particular performance period is
believes that 15 points would be too the potential of penalizing clinicians limited to a number at or near the
steep an increase at this early juncture who are still learning about the program performance threshold. We refer readers
in the MIPS program. One commenter and care for the most vulnerable to the CY 2018 Quality Payment
stated that clinicians are still trying to patients in our country. A few Program proposed rule (82 FR 30147
understand the program requirements commenters acknowledged CMSs through 30149) for a discussion of the
and invest in submission mechanisms concerns that setting a lower data we considered. Finally, we believe
that make the most sense for their performance threshold in the 2018 MIPS that 15 point performance threshold is
practice. One commenter recommended performance period could lead to a attainable even for those who have a
that the performance threshold remain jump in the performance threshold for performance category score reweighted.
at 3 points until MIPS eligible clinician the 2019 MIPS performance period, We refer readers to section II.C.8.g.(2)
participation can be assessed so that when CMS is required to use either the for scoring examples where the
impact on small practices could be mean or median final score from a prior advancing care information performance
evaluated. One commenter believes that period. However, the commenters category is reweighted and yet MIPS
current threshold of 3 points would believes that setting a lower eligible clinicians are able to receive a
reward clinicians who are implementing performance threshold in 2018 would final score higher than 15 points.
quality measures into their practices lead to a lower performance threshold Comment: A few commenters
while encouraging those who are in the future because many clinicians recommended a performance threshold
reluctant to do so as well. would be aiming to meet the lower between 8 and 13 points. One
Response: We do not believe that performance threshold of 6 points commenter supported a performance
maintaining the performance threshold which would lower the mean or median threshold between 8 and 10 points to
at 3 points for the 2020 MIPS payment final score for 2018. A few commenters lessen the increase from the 2017
performance period and to have less of commenter recommended setting the because they believe it is attainable,
an impact on small practices. One performance threshold closer to the would better prepare clinicians for the
commenter recommended that CMS set cumulative number of points a clinician steep increase expected for the 2021
the performance threshold at 7 to 10 would earn for minimum participation MIPS payment year, send the message to
points because of the lower expected across all MIPS performance categories clinicians that focusing on quality and
participation rate of small practices. to incentivize clinicians who are almost improvement activities are critical steps
One commenter recommended that the ready for full participation to make the in moving towards value-based care,
performance threshold be increased by necessary practice changes and reward high-performing clinicians who
no more than 7 to 10 points in any given investments. have invested in performance
year because any more is too much of Response: We understand the improvement, and result in higher
an increase to implement in a year. One perspective expressed by some positive MIPS payment adjustments for
commenter encouraged CMS to consider commenters that a higher performance MIPS eligible clinicians who exceed the
a longer transition period and suggested threshold would better prepare performance threshold thereby
that 10 points would be an appropriate clinicians for the expected increase in incentivizing higher performance. One
performance threshold because it would the performance threshold for the 2021 commenter supported a performance
enable growth over the 2019 MIPS MIPS payment year and would threshold of 33 points because if a
payment year, but at not as steep a encourage increased clinician clinician that had a neutral adjustment
climb as the proposed 15 points. participation in the MIPS program and in the VM program and had successfully
Response: We appreciate the the movement toward value-based care. demonstrated meaningful use under the
suggestions for a range of increases in While we acknowledge these advantages EHR Incentive Program delivered the
the performance threshold from 7 points to setting a higher performance same performance under MIPS, then the
to 13 points. We also appreciate the threshold for the 2020 MIPS payment clinician could expect to receive a final
concerns expressed by many year, we also believe that we should score of 53 points. This commenter
commenters about clinicians needing provide MIPS eligible clinicians with a believes that this status quo
more clarity around MIPS program smooth transition to the second year of performance threshold of 53 points,
requirements and additional time to the program to encourage continued which is significantly higher than either
prepare to participate in MIPS and meet participation. We believe that a the proposed 15 point or the alternative
program requirements. We agree that performance threshold of 15 points is a 33 point threshold, supported a
setting the performance threshold for sufficient increase over the 2017 MIPS performance threshold of 33 points.
the 2018 MIPS performance period performance period that would One commenter supported a
significantly higher than the encourage continued clinician performance threshold of 33 points
performance threshold for the 2017 participation with an increased because it would require participation
MIPS performance period would be engagement whereas a higher in both the improvement activities and
inappropriate because many clinicians performance threshold may discourage quality performance categories to avoid
need time to become familiar with the clinicians from participating in MIPS, a negative adjustment. One commenter
program policies and requirements and which in the long run does not improve supported a 33-point performance
gain experience with increased quality of care for beneficiaries. We threshold because the combined effect
participation under the MIPS program. appreciate the suggestion to set the of the proposed changes for 2018,
However, we believe that clinicians performance threshold at a number to including the performance threshold,
should be prepared to meet the encourage minimum participation in all the low-volume threshold, small
additional requirements for meeting, or of the performance categories, however, practice bonus, and EHR certification
exceeding, the significantly increased we believe that the additional requirements, would reduce the
performance threshold statutorily performance threshold, which we are opportunity for high-performing MIPS
required in the 2021 MIPS payment establishing at 70 points as discussed in eligible clinicians to earn a reasonable
year. As such, we believe that the section II.C.8.d. of this final rule with increase to their Medicare payments in
performance threshold of 15 points will comment period, will provide incentive the 2020 MIPS payment year. One
encourage increased participation and for reporting on all of the performance commenter recommended for those
adequately prepare clinicians for these categories. practices where a 33-point performance
additional participation requirements in Comment: A few commenters threshold may present a challenge
the 2021 MIPS payment year. expressed concerns that the proposed because they have not participated in
Additionally, we refer readers to section performance threshold would limit the the legacy Medicare programs, CMS can
II.C.7.b.(1)(c) of this final rule with opportunity for MIPS eligible clinicians assist them through the existing
comment where we finalize the small performing above average to earn up to Transforming Clinical Practice Initiative
practice bonus for the 2020 MIPS a 5 percent positive payment adjustment (TCPI) that would help clinicians
payment year which may help in 2020 because of the proposals to identify and report quality measures
clinicians in small practices meet the expand exclusions from reporting and under the MIPS quality performance
performance threshold of 15 points. make more bonus points available. category.
Comment: Many commenters Response: We acknowledge that Response: We appreciate the
supported a higher performance setting the performance threshold at a commenters feedback regarding the
threshold with no specific numerical low number may limit the maximum alternative of 33 points. We believe the
recommendation because the additional payment adjustment amount that high proposed performance threshold of 15
increase would encourage participation performers could receive, due to the points is appropriate for the 2020 MIPS
in multiple performance categories, budget neutrality requirement in the payment year because it represents a
appropriately focus clinicians on quality statute, but we believe that this is meaningful increase compared to 3
and improvement activities that are warranted in a transition year to points in the transition year, while
critical steps in moving towards value- encourage clinician participation in maintaining multiple pathways for
based care, and would make a higher MIPS. MIPS eligible clinicians to achieve and
performance threshold for the 2021 Comment: A few commenters or exceed the performance threshold.
MIPS payment year less steep. One supported the alternative of 33 points We want to encourage clinician
participation and believe that setting a with the programs reporting We believe the proposed performance
performance threshold too high for the requirements so that they can better threshold of 15 points provides a
2020 MIPS payment year could create a focus on performance in future program pathway to success for many clinicians
performance barrier, particularly for years. in the MIPS program through increased
clinicians that have not previously Response: We appreciate the participation and do not want to add
participated in PQRS or the EHR commenters suggestions for alternative additional complexity with establishing
Incentive Programs. We want to higher performance thresholds of 30 a performance threshold or placing
encourage MIPS eligible clinicians to points, 42.5 points, and a number additional requirements for submitting
participate because that will provide between 40 and 45 points. However, we for multiple performance categories. We
better data for us to measure believe that setting the performance believe that requiring MIPS eligible
performance and ultimately help drive threshold too high could discourage clinicians to submit on more than one
the delivery of value-based, quality clinician participation which may lead performance category to meet the
health care. In the long run, we would to lower clinician participation in future performance threshold to avoid a
prefer the negative MIPS payment years. Accordingly, we believe negative payment adjustment could be a
adjustments to be caused by poor clinicians should have an opportunity barrier to participation, particularly for
performance rather than non- to become more familiar with the MIPS clinicians gaining experience with
participation. Because the statute program and gain experience with reporting on the measures and activities
requires the MIPS payment adjustments reporting on measures and activities for and becoming familiar with program
to be budget neutral, a performance the different MIPS performance policies and requirements. However, we
threshold of 15 points could lower the categories with only a modest increase also believe that a performance
potential positive MIPS payment in the MIPS performance threshold from threshold of 15 points does not preclude
adjustment for high performers the 2017 MIPS performance period to clinicians from participating in multiple
compared to a higher performance the 2018 MIPS performance period. We performance categories and that
threshold. However, we believe the believe that a performance threshold of clinicians can and should participate in
trade-off to encourage participation is 15 points does not preclude clinicians all performance categories. In addition,
warranted in the second transition year. from participating in multiple the scoring policies in the MIPS
We agree that technical assistance can performance categories and that program take into account the needs of
help practices understand MIPS and clinicians can and should participate in small practices and the impact on
transform care and have set up the all performance categories. We are clinicians serving complex patients;
Small, Underserved, and Rural Support encouraged clinicians are investing in however, the statute requires a single
initiative, a 5-year program, to provide the time and resources to perform well performance threshold for all MIPS
technical support to MIPS eligible in MIPS and expect that will benefit eligible clinicians. Please refer to
clinicians in small practices. The these clinicians through receiving a sections II.C.7.b.(1)(b) and II.C.7.b.(1)(c)
program provides assistance to practices positive MIPS payment adjustment and of this final rule with comment period
in selecting and reporting on quality additional MIPS payment adjustment for a discussion of these policies.
measures, education and outreach, and (for those with a final score equal or Comment: Several commenters
support for optimizing health IT. greater than 70 points, as discussed in offered input on the 2021 MIPS
section II.C.8.d. of this final rule with payment year requirement that the
Comment: A few commenters comment period.) While having a lower performance threshold be either the
suggested a performance threshold performance threshold many limit the median or mean of the final scores for
higher of at least 30 points and up to 45 amount of the positive payment a prior period and other suggested
points. One commenter supported a adjustment, we believe the trade-off to modifications to the performance
threshold of at least 30 points because encourage participation is warranted in threshold.
this would better prepare clinicians for the second transition year. Response: We thank the commenters
the likely higher performance threshold Comment: One commenter for their input, and although we did not
for the 2019 MIPS performance period recommended setting the performance propose or request comments on the
and would be fair for groups that have threshold at a level that would require performance threshold for the 2021
invested time and resources preparing eligible clinicians to participate in at MIPS payment year, we will take these
for the MIPS program. One commenter least 2 performance categories to avoid comments into consideration in future
recommended a performance threshold a negative payment adjustment, rulemaking.
of approximately 40 to 45 points including the quality performance Final Action: After consideration of
because that would incentivize category, because this would incentivize the public comments, we are finalizing
clinicians to familiarize themselves with clinicians to familiarize themselves with the performance threshold for the 2020
the reporting requirements and all the reporting requirements in the MIPS payment year as proposed at 15
accelerate initial improvement efforts to program, particularly the quality points. We are codifying the
ensure higher performance in future performance category, so that they can performance threshold for the 2020
program years. One commenter focus on performance improvement in MIPS payment year at 414.1405(b)(5).
recommended a performance threshold future program years. One commenter
of 42.5 points because that would be suggested that CMS consider alternative d. Additional Performance Threshold
closer to the cumulative number of approaches to setting the performance for Exceptional Performance
points a clinician would earn for threshold that would reduce the burden Section 1848(q)(6)(D)(ii) of the Act
minimum participation across all MIPS on small practices and clinicians and requires the Secretary to compute, for
performance categories, ensure that groups practicing in rural and each year of the MIPS, an additional
eligible clinicians participate in the underserved areas by establishing performance threshold for purposes of
quality performance category to avoid a different performance thresholds for determining the additional MIPS
negative payment adjustment, and specific groups. payment adjustment factors for
would encourage clinicians to gain Response: We appreciate your exceptional performance under
experience in each performance suggestions for alternative approaches paragraph (C). For each such year, the
category and familiarize themselves when setting the performance threshold. Secretary shall apply either of the
following methods for computing the clinicians with very high performance points for the quality performance
additional performance threshold: (1) on the MIPS measures and activities. category, which is below the 70-point
The threshold shall be the score that is We took into account the data available additional performance threshold. In
equal to the 25th percentile of the range and the modeling described in section addition, 70 points is at a high enough
of possible final scores above the II.E.7.c.(1) of the CY 2017 Quality level that MIPS eligible clinicians must
performance threshold determined Payment Program final rule in selecting submit data for the quality performance
under section 1848(q)(6)(D)(i) of the Act; the additional performance threshold category to achieve this target. For
or (2) the threshold shall be the score for the transition year (81 FR 77338 example, if a MIPS eligible clinician
that is equal to the 25th percentile of the through 77339). gets a perfect score for the improvement
actual final scores for MIPS eligible As we discussed in the CY 2018 activities and advancing care
clinicians with final scores at or above Quality Payment Program proposed rule information performance categories, but
the performance threshold for the prior (82 FR 30147 through 30149), we relied does not submit quality measures data,
period described in section on the special rule under section then the MIPS eligible clinician would
1848(q)(6)(D)(i) of the Act. 1848(q)(6)(D)(iii) of the Act to establish only receive 40 points (0 points for
We codified at 414.1305 the the performance threshold at 15 points quality + 15 points for improvement
definition of additional performance for 2020 MIPS payment year. We activities + 25 points for advancing care
threshold as the numerical threshold for proposed to again decouple the information), which is below the
a MIPS payment year against which the additional performance threshold from additional performance threshold. We
final scores of MIPS eligible clinicians the performance threshold. Because we believed an additional performance
are compared to determine the do not have actual MIPS final scores for threshold of 70 points would maintain
additional MIPS payment adjustment a prior performance period, if we do not the incentive for excellent performance
factors for exceptional performance. We decouple the additional performance while keeping the focus on quality
also codified at 414.1405(d) that an threshold from the performance performance. Finally, we noted that we
additional performance threshold will threshold, then we would have to set believed keeping the additional
be specified for each of the MIPS the additional performance threshold at performance threshold at 70 points
payment years 2019 through 2024. We the 25th percentile of possible final maintains consistency with the 2019
referred readers to the CY 2017 Quality scores above the performance threshold. MIPS payment year which helps to
Payment Program final rule for further With a performance threshold set at 15 simplify the overall MIPS framework.
discussion of the additional points, the range of total possible points We invited public comment on the
performance threshold (81 FR 77338 above the performance threshold is 16 proposals. We also sought feedback on
through 77339). We inadvertently failed to 100 points. The 25th percentile of whether we should raise the additional
to codify the additional performance that range is 36.25 points, which is performance threshold to a higher
threshold for the 2019 MIPS payment barely more than one third of the number which would in many instances
year in the CY 2017 Quality Payment possible 100 points in the MIPS final require the use of an EHR for those to
Program final rule, although it was our score. We do not believe it would be whom the advancing care information
intention to do so. Thus, we now codify appropriate to lower the additional performance category requirements
the additional performance threshold performance threshold to 36.25 points, would apply. In addition, a higher
for the 2019 MIPS payment year at as we do not believe a final score of additional performance threshold would
414.1405(d)(3). 36.25 points demonstrates exceptional incentivize better performance and
Based on the special rule for the performance by a MIPS eligible would also allow MIPS eligible
initial 2 years of MIPS in section clinician. We believe these additional clinicians to receive a higher additional
1848(q)(6)(D)(iii) of the Act, for the incentives should only be available to MIPS payment adjustment.
transition year, we decoupled the those clinicians with very high We also sought public comment on
additional performance threshold from performance on the MIPS measures and which method we should use to
the performance threshold and activities. Therefore, we relied on the compute the additional performance
established the additional performance special rule under section threshold beginning with the 2021 MIPS
threshold at 70 points. We selected a 70- 1848(q)(6)(D)(iii) of the Act to propose payment year. Section 1848(q)(6)(D)(ii)
point numerical value for the additional the additional performance threshold at of the Act requires the additional
performance threshold, in part, because 70 points for the 2020 MIPS payment performance threshold to be the score
it would require a MIPS eligible year, which is higher than the 25th that is equal to the 25th percentile of the
clinician to submit data for and perform percentile of the range of the possible range of possible final scores above the
well on more than one performance final scores above the performance performance threshold for the year, or
category (except in the event the threshold. the score that is equal to the 25th
advancing care information performance We took into account the data percentile of the actual final scores for
category is reweighted to zero percent available and the modeling described in MIPS eligible clinicians with final
and the weight is redistributed to the the CY 2018 Quality Payment Program scores at or above the performance
quality performance category making proposed rule (82 FR 30147 through threshold for the prior period described
the quality performance category worth 30148) to estimate final scores for the in section 1848(q)(6)(D)(i) of the Act.
85 percent of the final score). Under 2020 MIPS payment year. We believed The following is a summary of the
section 1848(q)(6)(C) of the Act, a MIPS 70 points is appropriate because it public comments received and our
eligible clinician with a final score at or requires a MIPS eligible clinician to responses:
above the additional performance submit data for and perform well on Comment: Many commenters
threshold will receive an additional more than one performance category supported the proposal to keep the
MIPS payment adjustment factor and (except in the event the advancing care additional performance threshold at 70
may share in the $500,000,000 of information measures are not applicable points for the 2018 MIPS performance
funding available for the year under and available to a MIPS eligible period because this number is high
section 1848(q)(6)(F)(iv) of the Act. We clinician). Generally, under our enough to necessitate what could be
believed these additional incentives proposals, a MIPS eligible clinician construed as exceptional performance
should only be available to those could receive a maximum score of 60 and low enough to be reasonably
attainable; is sufficient to drive clinicians to participate more fully. We 77339 through 77340). We did not
improvement and reward those with disagree with the characterization that propose any changes to determine the
high performance; is close to full the proposal of 70 points will reduce additional MIPS payment adjustment
participation in addition to requiring clinician motivation to perform because factors.
good performance in the quality and there is no certainty about the number
g. Application of the MIPS Payment
advancing care information categories; of clinicians who will qualify for the
avoids shifting program requirements; additional MIPS payment adjustment Adjustment Factors
rewards those who submit data on and the impact of this number on the (1) Application to the Medicare Paid
multiple MIPS performance categories; size of the additional MIPS payment Amount
and is more appropriate than raising the adjustment. We also believe that
bar after just 1 year. keeping the additional performance Section 1848(q)(6)(E) of the Act
Response: We thank the commenters threshold the same as in the 2017 MIPS provides that for items and services
for their support. We are finalizing the performance period will encourage furnished by a MIPS eligible clinician
additional performance threshold at 70 continued participation from clinicians during a year (beginning with 2019), the
points. who have experience with and amount otherwise paid under Part B for
Comment: Several commenters understand what is required to meet and such items and services and MIPS
recommended an additional exceed the 70-point threshold. eligible clinician for such year, shall be
performance threshold higher than the Comment: Several commenters multiplied by 1 plus the sum of the
proposal of 70 points because they offered input on the 2021 MIPS MIPS payment adjustment factor
believe it was merited and that payment year statutory requirements for determined under section 1848(q)(6)(A)
establishing an additional performance the additional performance threshold of the Act divided by 100, and as
threshold that allows 4 out of 5 and other suggested modifications to the applicable, the additional MIPS
participants to qualify as exceptional additional performance threshold. payment adjustment factor determined
performers would dilute the impact of Response: We thank the commenters under section 1848(q)(6)(C) of the Act
these important incentives and for their input, and although we did not divided by 100.
potentially reduce clinician motivation propose or request comments on the We codified at 414.1405(e) the
to improve performance, particularly for additional performance threshold for application of the MIPS payment
those clinicians who expended the 2021 MIPS payment year, we will adjustment factors. For each MIPS
resources and effort preparing to be take these comments into consideration payment year, the MIPS payment
successful in MIPS in 2017 and 2018. in future rulemaking. adjustment factor, and if applicable the
A few commenters supported raising Final Action: After consideration of additional MIPS payment adjustment
the additional performance threshold the public comments, we are finalizing factor, are applied to Medicare Part B
for the 2018 MIPS performance period/ our proposal to set the additional payments for items and services
2020 MIPS payment year to 75 points performance threshold at 70 points for furnished by the MIPS eligible clinician
because this would allow for a the 2020 MIPS payment year. We are during the year.
potentially larger additional MIPS codifying the additional performance We proposed to apply the MIPS
payment adjustment for qualifying threshold for the 2020 MIPS payment payment adjustment factor, and if
clinicians compared to an additional year in this final rule at
performance threshold of 70 points. The applicable, the additional MIPS
414.1405(d)(4). payment adjustment factor, to the
increase would allow those MIPS
eligible clinicians who expended e. Scaling/Budget Neutrality Medicare paid amount for items and
significant effort and resources to services paid under Part B and
We codified at 414.1405(b)(3) that a
perform at higher levels and earn a furnished by the MIPS eligible clinician
scaling factor not to exceed 3.0 may be
higher incentive for their achievement; during the year. This proposal is
applied to positive MIPS payment
would account for improvements in consistent with the approach taken for
adjustment factors to ensure budget
technology and processes; would align the value-based payment modifier (77
neutrality such that the estimated
with a proposed increase in the FR 69308 through 69310) and would
increase in aggregate allowed charges
performance threshold; and would mean that beneficiary cost-sharing and
resulting from the application of the
better prepare the MIPS eligible coinsurance amounts would not be
positive MIPS payment adjustment
clinician community for the statutory affected by the application of the MIPS
factors for the MIPS payment year
requirements for the 2021 MIPS payment adjustment factor and the
equals the estimated decrease in
payment year additional performance additional MIPS payment adjustment
aggregate allowed charges resulting from
threshold. factor. The MIPS payment adjustment
the application of negative MIPS
One commenter supported an applies only to the amount otherwise
payment adjustment factors for the
additional performance threshold of 80 paid under Part B for items and services
MIPS payment year. We referred readers
points because it would be possible for furnished by a MIPS eligible clinician
to the CY 2017 Quality Payment
a MIPS eligible clinician to exceed 70 during a year. Please refer to the CY
Program final rule for further discussion
points without reporting on the 2017 Quality Payment Program final
of budget neutrality (81 FR 77339).
advancing care information measures. We did not propose any changes to rule at 81 FR 77340 and the CY 2018
Response: We appreciate commenters the scaling and budget neutrality Quality Payment Program proposed rule
suggestions for higher additional requirements as they are applied to at 82 FR 30019 and section II.C.1.a. of
performance thresholds in general and MIPS payment adjustment factors in this final rule with comment period for
your specific recommendations of 75 this proposed rule. further discussion and our proposals
points and 80 points. We applaud MIPS regarding which Part B covered items
eligible clinicians that have invested in f. Additional Adjustment Factors and services would be subject to the
performing well in MIPS. We want to We referred readers to the CY 2017 MIPS payment adjustment.
reward exceptional performance, yet Quality Payment Program final rule for The following is a summary of the
also have an achievable additional further discussion of the additional public comments received on these
performance threshold that encourages MIPS payment adjustment factor (81 FR proposals and our responses:
Comment: A few commenters both MIPS eligible clinicians as well as line for the positive MIPS adjustment
supported the proposal to apply the non-participating clinicians, and factor is adjusted by the scaling factor,
adjustment to the Medicare paid amount whether there are different limiting which cannot be higher than 3.0 (as
because it would not affect the Medicare charge amounts for MIPS eligible discussed in section II.C.8.e. of this final
beneficiary deductible and coinsurance clinicians receiving the MIPS payment rule with comment and in the CY 2018
amounts. adjustment and for clinicians not Quality Payment Program proposed rule
Response: We thank the commenters subject to MIPS. at 82 FR 30150). If the scaling factor is
for their support. Response: We appreciate the greater than zero and less than or equal
Comment: One commenter did not commenters questions and note that to 1.0, then the adjustment factor for a
support the proposal and recommended although we did not address these final score of 100 would be less than or
that the MIPS payment adjustment issues in the proposed rule, we intend equal to 5 percent. If the scaling factor
apply to the full fee schedule amount. to address them in rulemaking next is above 1.0, but less than or equal to
The commenter questioned the statutory year. 3.0, then the adjustment factor for a
authority for the proposal and expressed Final Action: After consideration of final score of 100 would be higher than
a belief that section 1848(q)(6)(E) of the the public comments, we are finalizing 5 percent. Only those MIPS eligible
Act applies the adjustment to the full our proposal to apply the MIPS payment clinicians with a final score equal to 15
fee schedule amount. In addition, the adjustment factor, and if applicable, the points (which is the performance
commenter stated that the proposal additional MIPS payment adjustment threshold in this example) would
would not accomplish its objective as factor, to the Medicare paid amount for receive a neutral MIPS payment
savings would be passed on to the items and services paid under Part B adjustment. Because the performance
supplemental insurance industry and and furnished by the MIPS eligible threshold is 15 points, we anticipate
not to beneficiaries. clinician during the year. We refer that the scaling factor would be less
Response: We disagree with the readers to section II.C.1.a. of this final than 1.0 and the payment adjustment for
commenters interpretation of the rule with comment period, where we MIPS eligible clinicians with a final
statute. We assume the commenter is discuss the items and services to which score of 100 points would be less than
referring to the Medicare Physician Fee the MIPS payment adjustment could be 5 percent.
Schedule. Section 1848(q)(6)(E) of the applied under Part B. Figure A illustrates an example of the
Act, requires us to apply the adjustment slope of the line for the linear
to the amount otherwise paid under (2) Example of Adjustment Factors adjustments. In this example, the
this part, which we interpret to refer to In the CY 2018 Quality Payment scaling factor for the adjustment factor
Medicare Part B payments, with respect Program proposed rule (82 FR 30152) is 0.06 which is much lower than 1.0.
to items and services furnished by a we provided a figure and several tables In this example, MIPS eligible clinicians
MIPS eligible clinician. We believe the as illustrative examples of how various with a final score equal to 100 would
language of this section gives us final scores would be converted to an have an adjustment factor of 0.31
discretion to apply the adjustment to the adjustment factor, and potentially an percent (5 percent 0.06).
Medicare paid amount as we proposed. additional adjustment factor, using the The additional performance threshold
We also disagree with the statutory formula and based on is 70 points. An additional adjustment
characterization that the proposal would proposed policies. We repeat these factor of 0.5 percent starts at the
not accomplish its objective because the examples using our final policies. In additional performance threshold and
MIPS program is focused on rewarding Figure A, the performance threshold is increases on a linear sliding scale up to
value and outcomes for MIPS eligible 15 points. The applicable percentage is 10 percent. This linear sliding scale line
clinicians and is intended to improve 5 percent for 2020. The adjustment is also multiplied by a scaling factor that
the overall quality, cost, and care factor is determined on a linear sliding is greater than zero and less than or
coordination of services provided to scale from zero to 100, with zero being equal to 1.0. The scaling factor will be
Medicare beneficiaries. the lowest negative applicable determined so that the estimated
Comment: One commenter requested percentage (negative 5 percent for the aggregate increase in payments
guidance on how the MIPS payment 2020 MIPS payment year), and 100 associated with the application of the
adjustment will be applied for non- being the highest positive applicable additional adjustment factors is equal to
participating clinicians. Specifically, the percentage. However, there are two $500,000,000. In Figure A, the example
commenter expressed concerns about modifications to this linear sliding scaling factor for the additional
the administrative burden of scale. First, there is an exception for a adjustment factor is 0.175. Therefore,
maintaining a separate fee schedule for final score between zero and one-fourth MIPS eligible clinicians with a final
MIPS eligible clinicians and non- of the performance threshold (zero and score of 100 would have an additional
participating clinicians. The commenter 3.75 points based on the performance adjustment factor of 1.75 percent (10
also requested guidance regarding threshold of 15 points for the 2020 MIPS percent 0.175). The total adjustment
whether the MIPS adjustment is used in payment year). All MIPS eligible for a MIPS eligible clinician with a final
calculating the Medicare limiting charge clinicians with a final score in this score equal to 100 would be 1 + 0.0031
amount for non-participating clinicians, range would receive the lowest negative + 0.0175 = 1.0205, for a total positive
whether we will provide the annual applicable percentage (negative 5 MIPS payment adjustment of 2.05
Medicare Physician Fee Schedule with percent for the 2020 MIPS payment percent.
the relating limiting charge amount for year). Second, the linear sliding scale BILLING CODE 412001P
BILLING CODE 412001C adjustment. More MIPS eligible Table 32 illustrates the changes in
The final MIPS payment adjustments clinicians below the performance payment adjustments from the
will be determined by the distribution threshold means the scaling factors transition year to the 2020 MIPS
of final scores across MIPS eligible
would increase because more MIPS payment year based on the final
clinicians and the performance
eligible clinicians would have negative policies, as well as the statutorily-
threshold. More MIPS eligible clinicians
above the performance threshold means MIPS payment adjustments and required increase in the applicable
the scaling factors would decrease relatively fewer MIPS eligible clinicians percent as required by section
because more MIPS eligible clinicians would receive positive MIPS payment 1848(q)(6)(B) of the Act.
receive a positive MIPS payment adjustments.
TABLE 32ILLUSTRATION OF POINT SYSTEM AND ASSOCIATED ADJUSTMENTS COMPARISON BETWEEN TRANSITION YEAR
AND THE 2020 MIPS PAYMENT YEAR
Transition year 2020 MIPS payment year
Final score Final score

MIPS adjustment MIPS adjustment
points points
0.00.75 .............. Negative 4 percent .................................................... 0.03.75 Negative 5 percent.

ER16NO17.000</GPH>
TABLE 32ILLUSTRATION OF POINT SYSTEM AND ASSOCIATED ADJUSTMENTS COMPARISON BETWEEN TRANSITION YEAR
AND THE 2020 MIPS PAYMENT YEARContinued
Transition year 2020 MIPS payment year
Final score Final score

MIPS adjustment MIPS adjustment
points points
0.762.99 ............ Negative MIPS payment adjustment greater than 3.7614.99 Negative MIPS payment adjustment greater than
negative 4 percent and less than 0 percent on a negative 5 percent and less than 0 percent on a
linear sliding scale. linear sliding scale.
3.00 ..................... 0 percent adjustment ................................................. 15.00 0 percent adjustment.
3.0169.99 .......... Positive MIPS payment adjustment greater than 0 15.0169.99 Positive MIPS payment adjustment greater than 0
percent on a linear sliding scale. The linear sliding percent on a linear sliding scale. The linear sliding
scale ranges from 0 to 4 percent for scores from scale ranges from 0 to 5 percent for scores from
3.00 to 100.00. This sliding scale is multiplied by 15.00 to 100.00. This sliding scale is multiplied by
a scaling factor greater than zero but not exceed- a scaling factor greater than zero but not exceed-
ing 3.0 to preserve budget neutrality. ing 3.0 to preserve budget neutrality.
70.00100 ........... Positive MIPS payment adjustment greater than 0 70.00100 Positive MIPS payment adjustment greater than 0
percent on a linear sliding scale. The linear sliding percent on a linear sliding scale. The linear sliding
scale ranges from 0 to 4 percent for scores from scale ranges from 0 to 5 percent for scores from
a scaling factor greater than zero but not exceed- a scaling factor greater than zero but not exceed-
ing 3.0 to preserve budget neutrality; PLUS. ing 3.0 to preserve budget neutrality; PLUS.
An additional MIPS payment adjustment for excep- An additional MIPS payment adjustment for excep-
tional performance. The additional MIPS payment tional performance. The additional MIPS payment
adjustment starts at 0.5 percent and increases on adjustment starts at 0.5 percent and increases on
a linear sliding scale. The linear sliding scale a linear sliding scale. The linear sliding scale
ranges from 0.5 to 10 percent for scores from ranges from 0.5 to 10 percent for scores from
a scaling factor not greater than 1.0 in order to a scaling factor not greater than 1.0 in order to
proportionately distribute the available funds for proportionately distribute the available funds for
exceptional performance. exceptional performance.
In the CY 2018 Quality Payment activity. The practice does not submit only measure submitted. Because the
Program proposed rule, we provided a data for the advancing care information MIPS eligible clinician does not meet
few examples for the 2020 MIPS performance category, but does submit a full participation requirements, the
payment year to demonstrate scenarios significant hardship exception MIPS eligible clinician does not qualify
in which MIPS eligible clinicians can application which is approved; for improvement scoring. We refer
achieve a final score at or above the therefore, the weight for the advancing readers to section II.C.7.a.(2)(i)(iii) of
performance threshold of 15 points. We care information performance category this final rule with comment period for
note a calculation error was included in is reweighted to the quality performance a discussion on full participation
Example 3. Because the MIPS eligible category due to final reweighting requirements. Therefore, the quality
clinician did not submit advancing care policies discussed in section II.C.7.b.(3) performance category is (3 measure
information, the quality performance of this final rule with comment period achievement points + zero measure
category should have been 85 percent to (82 FR 30141 through 30146). We also bonus points)/60 total available measure
reflect reweighting, while the advancing assumed the small practice has a cost points + zero improvement percent
care information performance category performance category percent score of score which is 5 percent.
should have been zero percent. Earned 50 percent. Finally, we assumed a The advancing care information
points (column D) should have been complex patient bonus of 3 points performance category weight is
42.5 for quality to reflect reweighting which represents the average HCC risk redistributed to the quality performance
and the final score should have been score for the beneficiaries seen by the category so that the quality performance
listed as 51.5. MIPS eligible clinician as well as the category score is worth 75 percent of the
We have provided updated examples proportion of Medicare beneficiaries final score. We refer readers to section
below for the 2020 MIPS payment year that are dual eligible. There are several II.C.7.b.(3)(d) of this final rule with
to demonstrate scenarios in which MIPS special scoring rules which affect MIPS comment period for a discussion of this
eligible clinicians can achieve a final eligible clinicians in a small practice: policy.
score at or above the performance 3 Measure achievement points for MIPS eligible clinicians in small
threshold of 15 points based on our final each quality measure even if the practices qualify for special scoring for
policies. measure does not meet data improvement activities so a medium
completeness standards. We refer weighted activity is worth 20 points out
Example 1: MIPS Eligible Clinician in
readers to section II.C.7.a.(2)(d) of this of a total 40 possible points for the
Small Practice Submits 1 Quality
final rule with comment period for improvement activities performance

Measure and 1 Improvement Activity
discussion of this policy. Therefore, a category. We refer readers to section
In the example illustrated in Table 32, quality measure submitted one time II.C.6.e.(5) of this final rule with
a MIPS eligible clinician in a small would receive 3 points. Because the comment period for a discussion of this
practice reporting individually meets measure is submitted via claims, it does policy.
the performance threshold by reporting not qualify for the end-to-end electronic MIPS eligible clinicians in small
one quality measure one time via claims reporting bonus, nor would it qualify for practices qualify for the 5-point small
and one medium-weight improvement the high-priority bonus because it is the practice bonus which is applied to the
final score. We refer readers to section comment period for a discussion of this (but does not exceed the additional
II.C.7.b.(1)(c) of this final rule with policy. performance threshold). This score is
This MIPS eligible clinician exceeds summarized in Table 33.
the performance threshold of 15 points
TABLE 33SCORING EXAMPLE 1, MIPS ELIGIBLE CLINICIAN IN A SMALL PRACTICE

Earned points
Performance category Performance score Category weight ([B] * [C] * 100)
[A] [B] [C] [D]
Quality ................................................... 5% ........................................................ 75% ...................................................... 3.75

Cost ....................................................... 50% ...................................................... 10% ...................................................... 5.0
Improvement Activities .......................... 20 out of 40 points50% .................... 15% ...................................................... 7.5
Advancing Care Information ................. N/A ....................................................... 0% (reweighted to quality) ................... 0
Subtotal (Before Bonuses) ................... .............................................................. .............................................................. 16.25
Complex Patient Bonus ........................ .............................................................. .............................................................. 3
Small Practice Bonus ........................... .............................................................. .............................................................. 5
Final Score (not to exceed 100) ........... .............................................................. .............................................................. 24.25
Example 2: Group Submission Not in a percent for the advancing care additional performance threshold of 70
Small Practice information and improvement activities are exceeded. Again, for simplicity, we
performance categories. There are many assume a complex patient bonus of 3
In the example illustrated in Table 34, paths for a practice to receive a 75 points. In this example, the group
a MIPS eligible clinician in a medium percent score in the quality performance practice does not qualify for any special
size practice participating in MIPS as a category, so for simplicity we are scoring, yet is able to exceed the
group receives performance category assuming the score has been calculated additional performance threshold and
scores of 75 percent for the quality at this amount. The final score is will receive the additional MIPS
performance category, 50 percent for the calculated to be 85.5, and both the payment adjustment.
cost performance category, and 100 performance threshold of 15 and the
TABLE 34SCORING EXAMPLE 2, MIPS ELIGIBLE CLINICIAN IN A MEDIUM PRACTICE

Earned points
Performance category Performance score Category weight ([B] * [C] * 100)
[A] [B] [C] [D]
Quality ................................................... 75% ...................................................... 50% ...................................................... 37.5

Cost ....................................................... 50% ...................................................... 10% ...................................................... 5
Improvement Activities .......................... 40 out of 40 points 100% .................... 15% ...................................................... 15
Advancing Care Information ................. 100% .................................................... 25% ...................................................... 25
Subtotal (Before Bonuses) ................... .............................................................. .............................................................. 82.5
Final Score (not to exceed 100) ........... .............................................................. .............................................................. 85.5
Example 3: Non-Patient Facing MIPS there are many paths for a practice to for the automatic reweighting of the
Eligible Clinician receive a 50 percent score in the quality advancing care information performance
performance category, so for simplicity category to the quality performance
In the example illustrated in Table 35, we are assuming the score has been category. Again, for simplicity, we
an individual MIPS eligible clinician calculated. Because the MIPS eligible assume a complex patient bonus of 3
that is non-patient facing and not in a clinician is non-patient facing, they points. The MIPS eligible clinician is
small practice receives performance qualify for special scoring for not in a small practice so does not
category scores of 50 percent for the improvement activities and receive 20 qualify for the small practice bonus.
quality performance category, 50 points (out of 40 possible points) for the In this example, the final score is 53
percent for the cost performance medium weighted activity. Also, this and the performance threshold of 15 is
category, and 50 percent for 1 medium- individual did not submit advancing exceeded while the additional
weighted improvement activity. Again, care information measures and qualifies performance threshold of 70 is not.
TABLE 35SCORING EXAMPLE 3, NON-PATIENT FACING MIPS ELIGIBLE CLINICIAN

Performance category Performance score Category weight Earned points
[A] [B] [C] ([B] * [C] * 100) = [D]
Quality ................................................... 50% ...................................................... 75% ...................................................... 37.5

Cost ....................................................... 50% ...................................................... 10% ...................................................... 5
Improvement Activities .......................... 20 out of 40 points for 1 medium 15% ...................................................... 7.5
weight activity.
50% ......................................................
TABLE 35SCORING EXAMPLE 3, NON-PATIENT FACING MIPS ELIGIBLE CLINICIANContinued

Performance category Performance score Category weight Earned points
[A] [B] [C] ([B] * [C] * 100) = [D]
Advancing Care Information ................. 0% ........................................................ 0% (reweighted to quality) ................... 0

Subtotal (Before Bonuses) ................... .............................................................. .............................................................. 50
Final Score (not to exceed 100) ........... .............................................................. .............................................................. 53
We note that these examples are not data via our Web site or a third party For cost measures, since we can
intended to be exhaustive of the types submits data via our Application measure performance using any 12-
of participants nor the opportunities for Program Interface (API), they will know month period of prior claims data, we
reaching and exceeding the performance immediately if their submission was requested comment on whether it would
threshold. successful. be helpful to provide more frequent
We will continue to provide feedback on the cost performance
9. Review and Correction of MIPS Final category using rolling 12-month periods
Score information for stakeholders who wish
to participate in user research via our or quarterly snapshots of the most
a. Feedback and Information To education and communication recent 12-month period; how frequent
Improve Performance channels. Suggestions can also be sent that feedback should be; and the format
(1) Performance Feedback via the Contact Us information on in which we should make it available to
qpp.cms.gov. However, we noted that clinicians and groups. In addition, as
As we have stated previously in the described in sections II.C.6.b. and
CY 2017 Quality Payment Program final suggestions provided through this
channel would not be considered as II.C.6.d. of the proposed rule, we stated
rule (81 FR 77345), we will continue to in the proposed rule our intent to
engage in user research with front-line comments on the proposed rule.
provide cost performance feedback in
clinicians to ensure we are providing (a) MIPS Eligible Clinicians the fall of 2017 and the summer of 2018
the performance feedback data in a user- on new episode-based cost measures
friendly format, and that we are Under section 1848(q)(12)(A)(i) of the
Act, we are at a minimum required to that are currently under development by
including the data most relevant to CMS. With regard to the format of
clinicians. Any suggestions from user provide MIPS eligible clinicians with
timely (such as quarterly) confidential feedback on cost measures, we noted
research would be considered as we how we are considering utilizing the
develop the systems needed for feedback on their performance under
the quality and cost performance parts of the Quality and Resource Use
performance feedback, which would Reports (QRURs) that user testing has
occur outside of the rulemaking process. categories beginning July 1, 2017, and
we have discretion to provide such revealed beneficial while making the
Over the past year, we have overall look and feel usable to
conducted numerous user research feedback regarding the improvement
activities and advancing care clinicians. We requested comment on
sessions to determine what the whether that format is appropriate or if
community most needs in performance information performance categories.
other formats or revisions to that format
feedback. In summary, we have found We proposed to provide, beginning should be used to provide performance
the users want the following: July 1, 2018, performance feedback to feedback on cost measures.
(1) To know as soon as possible how MIPS eligible clinicians and groups for The following is a summary of the
I am performing based on my submitted the quality and cost performance public comments received on the MIPS
data so that I have confidence that I categories for the 2017 performance Eligible Clinicians proposals and our
performed the way I thought I would. period, and if technically feasible, for responses:
(2) To be able to quickly understand the improvement activities and Comment: Many commenters asked
how and why my payments will be advancing care information performance for more timely feedback. Some
adjusted so that I can understand how categories. We proposed to provide this commenters expressed concern that the
my business will be impacted. performance feedback at least annually, data in existing reports may be more
(3) To be able to quickly understand and as, technically feasible, we would
how I can improve my performance so than 2 or more years out of date and that
provide it more frequently, such as more recent feedback is needed to
that I can increase my payment in future quarterly. If we are able to provide it
program years. improve quality and change behaviors.
(4) To know how I am performing more frequently, we would Several commenters noted the need for
over time so I can improve the care I am communicate the expected frequency to real time feedback in order to be
providing patients in my practice. our stakeholders via our education and actionable. Many commenters noted
(5) To know how my performance outreach communication channels. feedback reports should be available
compares to my peers. Based on public comments quarterly, semi-annually, or more
Based on that research, we have summarized and responded to in the CY frequently than annually. A few
already begun development of real-time 2017 Quality Payment Program final commenters noted receiving feedback in
feedback on data submission and rule (81 FR 77347), we also proposed mid-2018 would be too late to make the
scoring where technically feasible (some that the measures and activities necessary adjustments to ensure success
scoring requires all clinician data be specified for the CY 2017 performance in the following MIPS performance
submitted, and therefore, cannot occur period (for all four MIPS performance period and requested mid-year
until the end of the submission period). categories), along with the final score, performance reports for the start of the
By real-time feedback, we mean would be included in the performance performance period. One commenter
instantaneous receipt recognition; for feedback provided on or about July 1, stated that CMS should hold itself
example, when a clinician submits their 2018. accountable for annual reports to be
available no later than the following is to provide even more timely feedback Response: We are continuing to
August, but CMS should aim for having under MIPS as the program evolves, and evaluate ways to make the data in
them available no later than July. Half- we are continuing to work with performance feedback more easily
year performance should be available no stakeholders as we build performance accessible to practice managers who
later than the following March, but CMS feedback to incorporate technology to manage large numbers of clinicians
should aim for January. The commenter improve the usability of performance (TINs).
stated that if CMS is unable to provide feedback. We do note that there are a Comment: One commenter noted that
timely reports, then clinicians should be number of challenges with providing cost category elements could be
exempt from MIPS. feedback more frequently than annually, submitted to other entities using APIs.
One commenter noted that it is namely that for the MIPS performance Response: We note that the cost
important that CMS reduce the amount period, we can only provide feedback category measures for MIPS require no
of time between the performance period on performance as often as data are submission, and are entirely claims
and performance feedback from CMS to reported to us; for MIPS, this will be an based. Therefore, identifying additional
allow practices time to make necessary annual basis for all quality submission submission mechanisms for cost
adjustments before the next reporting mechanisms except for claims and category data appears unnecessary.
period begins. The commenter also administrative claims. As soon as the Comment: Several commenters
requested that feedback to clinicians data are available on a more frequent suggested feedback on cost measures
should be delivered by CMS to basis we can continue exploring the and cost performance category as it
clinicians beginning no later than April path to provide performance feedback relates to performance feedback. Some
1, 2019. A few commenters requested on a more frequent basis, such as commenters agreed it would be helpful
technology and system upgrades, so that quarterly. The inability to provide more to provide more frequent and actionable
CMS could improve the way frequent feedback, other than annually, feedback on the cost performance
performance information is is not a reason to be exempted from the category using rolling 12-month periods
disseminated to physicians and Quality Payment Program, and by or quarterly snapshots of the most
practices, such as dashboards or reports recent 12-month period. One
statute there is no authority to create
on demand. One commenter requested commenter asked for the agency to do
such exemptions. For eligible clinicians
quarterly information to ensure the this in a transparent manner. A few
and groups who use a third party
accuracy of the information, especially commenters asked for information on
intermediary to report data, we expect
as CMS has proposed posting MIPS cost performance to include cost metrics
those intermediaries to provide
performance scores on the Physician related to episodes of care and
additional performance feedback on top
Compare Web site. comparative data.
of what CMS is providing through the Another commenter expressed
Another commenter encouraged CMS annual performance feedback. Lastly,
to release the reports as early as concerns that there is limited
we are working with stakeholders on an experience in episode grouper and
possible, at minimum following the
API alpha where registries, and other urged CMS to test and evaluate its
MACRA recommendation that data be
third party intermediaries as technically episode grouper methodology and
available on a quarterly basis, so that
feasible, are currently testing real-time ensure that their application will not
clinicians are not well into the next
feedback capabilities with the result in unintended consequences,
reporting cycle before they learn of their
intermediary directly sharing the such as stinting on needed care as a way
MIPS results and performance and can
feedback with the eligible clinician or to ensure that costs within the defined
institute workflow changes to ensure
group. Lastly, we refer readers to section episode are contained. Another
success under MIPS. One commenter
II.C.5. of this final rule with comment commenter noted that issues such as
expressed that measure-based feedback
is helpful as eligible clinicians period for more information on the identifying the correct length of the
determine performance improvement MIPS performance period. episode window and assigning services
plans and select measures for future Comment: One commenter requested to the episode (like rehabilitation
performance periods. One commenter CMS include the advancing care therapy or imaging, etc.) each take hours
believes that patient-level data is information and improvement activities to resolve and asked that CMS think
helpful to eligible clinicians as they categories in the report as well in order critically about the MIPS timeline
determine areas in which additional for eligible clinicians to familiarize needed to build out every episode of
resources can be allocated. themselves with the program and care in the Medicare population. That
Response: Under section scoring and to enable them to make commenter further requested that CMS
1848(q)(12)(A)(i) of the Act, we are at a decisions to support their success under provide stakeholders with a time-table
minimum required to provide MIPS MIPS. for developing Medicare Cost measure
eligible clinicians with timely (such as Response: We agree that all four episodes as well as a list of future
quarterly) confidential feedback on their performance categories are beneficial to episodes under consideration and that
performance under the quality and cost include in performance feedback, and once developed, the proposed details of
performance categories beginning July 1, are working to incorporate these data the new episode-based cost measures
2017, and we have discretion to provide into the July 1, 2018 performance should be subject to notice and
such feedback regarding the feedback, as technically feasible. We comment rulemaking in a future
improvement activities and advancing will continue to work with stakeholders proposed rule. Finally, the commenter
care information performance on the best way to include all four noted that while this performance
categories. We are finalizing our policy performance categories in performance category relies solely on administrative
as proposed to provide performance feedback. claims data, critical resource use related
feedback annually on the quality and Comment: One commenter suggested questions like attribution and risk
cost performance categories, and as that one person should be able to obtain adjustment for medically complex
technically feasible the improvement feedback for an entire TIN or even group patients still need solutions that can
activities and advancing care of TINs at once because seeking out a only be answered with additional time
information performance categories. As report on each NPI is not sustainable for and through CMS collaboration with the
we have indicated previously, our goal larger organizations. relevant professions.
Response: We will take this into submission was successful; and (4) of MIPS (or any subsequent year) may
consideration as we continue to build scoring feedback on claim-based voluntarily report on measures and
the mechanisms and formats for universal population quality measures activities under MIPS, but will not be
performance feedback for the Quality and cost measures which is often not subject to the payment adjustment. In
Payment Program. Additionally, we are available to eligible clinicians and the CY 2017 Quality Payment Program
actively developing new episode-based groups until after the performance final rule (81 FR 77346), we
cost measures, which includes field period. summarized public comments
testing the measures that will share such Response: We agree with commenters requesting that eligible clinicians who
information with clinicians. We will about continually improving the are not required, but who voluntarily
continue to engage in user research with usability of performance feedback, and report on measures and activities under
front-line clinicians and other will continue doing stakeholder MIPS, should receive the same access to
stakeholders to ensure we are providing outreach with the goal that the template performance feedback as MIPS eligible
the performance feedback data in a user- for performance feedback will be clinicians; there, we indicated that we
friendly format, and that we are available in a usable and user-friendly would take the comments into
including the data most relevant to format. We intend to consider different consideration in the future development
clinicians. In particular, we have held a optionsincluding all the comments of performance feedback. We proposed
Technical Expert Panel focused on risk submitted on the proposed rulebefore to furnish performance feedback to
adjustment for episode-based cost the performance feedback is displayed eligible clinicians and groups that do
measures, which has informed the in a web-based application to MIPS not meet the definition of a MIPS
development of potential new episode- eligible clinicians. eligible clinician but voluntarily report
based cost measures. Any new cost Final Action: As a result of the public on measures and activities under MIPS.
measures would be proposed through comments, we are finalizing these We proposed that this would begin with
rulemaking. In terms of clinician policies as proposed. Specficially, on an data collected in performance period
involvement, the cost measure annual basis, beginning July 1, 2018, 2017, and would be available beginning
development contractor has brought performance feedback will be provided July 1, 2018. Based on user and market
together nearly 150 clinicians affiliated to MIPS eligible clinicians and groups research, we believe that making this
with nearly 100 specialty societies to for the quality and cost performance information available would provide
both recommend which new cost categories for the 2017 performance value in numerous ways. First, it would
measures to build first and to review period, and if technically feasible, for help clinicians who are excluded from
and make recommendations for every the improvement activities and MIPS in the 2017 performance period,
step of cost measure development advancing care information performance but who may be considered MIPS
including which claims to include and categories. eligible clinicians in future years, to
risk adjustment. We also solicited comment only on prepare for participation in the Quality
how often cost data should be provided Payment Program when there are
Comment: One commenter suggested payment consequences associated with
in performance feedback under the
including the following information in participation. Second, it would give all
Quality Payment Program, as well as,
standardized feedback reports as fields: clinicians equal access to the CMS
which data fields in the QRUR that
(1) Indications for individual or group claims and benchmarking data available
would be useful to include in the
classification for non-patient facing, in performance feedback. And third, it
Quality Payment Program performance
small group practice, and rural area and would allow clinicians who may be
feedback.
health professional shortage area; (2) We received a number of comments interested in participating in an APM to
indications for performance category on this item and appreciate the input make a more informed decision.
reweighting and special scoring received. As this was a request for The following is a summary of the
considerations; (3) for the quality comment only, we will take the public comments received on the
performance category, including the feedback provided into consideration Voluntary Clinician and Group
title of the quality measure submitted, for the future as we continue to build Reporting proposals and our responses:
measure type, the total points that can performance feedback. Comment: A few commenters
be achieved based on the benchmark, supported providing feedback reports to
whether data completeness has been (b) MIPS APMs clinicians who do not meet the
met for the quality measure, decile level We proposed that MIPS eligible definition of MIPS eligible clinician, but
achieved, measure achievement points, clinicians who participate in MIPS voluntarily report measures and
bonus points awarded, and performance APMs would receive performance activities to MIPS, beginning July 1,
score; and (4) for the improvement feedback in 2018 and future years of the 2018, and containing information on
activities category, including the title of Quality Payment Program, as data submitted in the 2017 performance
the improvement activity submitted, technically feasible. We referred readers period, because MIPS provides a
weighting of the improvement activity, to section II.C.6.g.(5) of the proposed valuable introduction to value-based
total points that can be earned, special rule for additional information related payment for clinicians that may not
scoring applied; and points earned for to the proposal. A summary of have previously encountered it, which
the measure performance score. Another comments on those proposals can be will help them better understand the
commenter recommended including the found in section II.C.6.g.(5) of this final program and prepare for successful
following information in standardized rule with comment period. participation in the future if they
feedback reports: (1) Eligibility status for become MIPS eligible.

both eligible clinicians and group (c) Voluntary Clinician and Group Response: We agree this data will be
practices; (2) for a group practice Reporting useful and are finalizing this proposal.
especially, a defined and updated list of As noted in the CY 2017 Quality Final Action: As a result of the public
NPIs for which the group is responsible Payment Program final rule (81 FR comments, we are finalizing this policy
when reporting at group TIN level; (3) 77071), eligible clinicians who are not as proposed. Specifically, starting with
submission status tracking files included in the definition of a MIPS data collected in the performance period
submitted and whether or not the eligible clinician during the first 2 years 2017 that would be available beginning
July 1, 2018, we will furnish In what other ways can health IT we continue to develop the mechanisms
performance feedback to eligible support clinicians seeking to leverage for performance feedback, to see where
clinicians and groups that do not meet quality data reports to inform clinical we may be able to develop and
the definition of a MIPS eligible improvement efforts? For example, are implement efficiencies for the Quality
clinician but voluntarily report on there existing or emerging tools or Payment Program. We are exploring
measures and activities under MIPS. resources that could leverage an API to options with an API, which could allow
provide timely feedback on quality authenticated third party intermediaries
(2) Mechanisms
improvement activities? to access the same data that we use to
Under section 1848(q)(12)(A)(ii) of the Are there opportunities to expand provide confidential feedback to the
Act, the Secretary may use one or more existing tracking and reporting for use individual clinicians and groups on
mechanisms to make performance by clinicians, for example expanding whose behalf the third party
feedback available, which may include the feedback loop for patient intermediary reports for purposes of
use of a web-based portal or other engagement tools to support remote MIPS, in accordance with applicable
mechanisms determined appropriate by monitoring of patient status and access law, including, but not limited to, the
the Secretary. For the quality to education materials? HIPAA Privacy and Security Rules. Our
performance category, described in We welcomed public comment on goal is to enable individual clinicians
section 1848(q)(2)(A)(i) of the Act, the these questions. and groups to more easily access their
feedback shall, to the extent an eligible We also noted in the proposed rule feedback via the mechanisms and
clinician chooses to participate in a data that we intend to continue to leverage relationships they already have
registry for purposes of MIPS (including third party intermediaries as a established. We referred readers to
registries under sections 1848(k) and mechanism to provider performance section II.C.10. of the proposed rule for
(m) of the Act), be provided based on feedback (82 FR 30155 through 30156). additional information on Third Party
performance on quality measures In the CY 2017 Quality Payment Data Submission.
reported through the use of such Program final rule (81 FR 77367 through We solicited comment only on
registries. For any other performance 77386) we finalized that at least 4 times mechanisms used for performance
category (that is, cost, improvement per year, qualified registries and QCDRs feedback but did not propose any
activities, or advancing care will provide feedback on all of the MIPS specific policy.
information), the Secretary shall performance categories that the We received a number of comments
encourage provision of feedback qualified registry or QCDR reports to us on this item and appreciate the input
through qualified clinical data registries (improvement activities, advancing care received. As this was a request for
(QCDRs) as described in section information, and/or quality performance comment only, we will take the
1848(m)(3)(E) of the Act. category). The feedback should be given feedback provided into consideration
As previously stated in the CY 2017 to the individual MIPS eligible clinician for the future as we continue to build
Quality Payment Program final rule (81 or group (if participating as a group) at performance feedback.
FR 77347 through 77349), we will use the individual participant level or group
a CMS-designated system as the level, as applicable, for which the (3) Receipt of Information
mechanism for making performance qualified registry or QCDR reports. The Section 1848(q)(12)(A)(v) of the Act,
feedback available, which we expect qualified registry or QCDR is only states that the Secretary may use the
will be a web-based application. We required to provide feedback based on mechanisms established under section
expect to use a new and improved the MIPS eligible clinicians data that is 1848(q)(12)(A)(ii) of the Act to receive
format for the next performance available at the time the performance information from professionals. This
feedback, anticipated to be released feedback is generated. In regard to third allows for expanded use of the feedback
around July 1, 2018. It will be provided party intermediaries, we also noted we mechanism to not only provide
via the Quality Payment Program Web would look to propose real time feedback on performance to MIPS
site (qpp.cms.gov), and we intend to feedback as soon as it is technically eligible clinicians, but to also receive
leverage additional mechanisms, such feasible. information from professionals.
as health IT vendors, registries, and We also noted in the proposed rule In the CY 2017 Quality Payment
QCDRs to help disseminate data and (82 FR 30156) that, per the policies Program final rule (81 FR 77350), we
information contained in the finalized in the CY 2017 Quality discussed that we intended to explore
performance feedback to eligible Payment Program final rule (81 FR the possibility of adding this feature to
clinicians, where applicable. 77367 through 77386), we require the CMS-designated system, such as a
We also sought comment on how qualified registries and QCDRs, as well portal, in future years under MIPS.
health IT, either in the form of an EHR as encourage other third party Although we did not make any specific
or as a supplemental module, could intermediaries (such as health IT proposals at this time, we sought
better support the feedback related to vendors that submit data to us on behalf comment on the features that could be
participation in the Quality Payment of a MIPS eligible clinician or group), to developed for the expanded use of the
Program and quality improvement in provide performance feedback to feedback mechanism. This could be a
general. Specifically individual MIPS eligible clinicians and feature where eligible clinicians and
Are there specific health IT groups via the third party intermediary groups can send their feedback (for
functionalities that could contribute with which they are already working. example, if they are experiencing issues
significantly to quality improvement? We also noted that we understand that accessing their data, technical questions
Are there specific health IT performance feedback is valuable to about their data, etc.) to us through the
functionalities that could be part of a individual clinicians and groups, and Quality Payment Program Service
certified EHR technology or made seek feedback from third party Center or the Quality Payment Program
available as optional health IT modules intermediaries on when real-time Web site. We noted that we appreciate
in order to support the feedback loop feedback could be provided. that eligible clinicians and groups may
related to Quality Payment Program As discussed in the proposed rule (see have questions regarding the Quality
participation or participation in other 82 FR 30156), we plan to continue to Payment Program information contained
HHS reporting programs? work with third party intermediaries as in their performance feedback. To assist
eligible clinicians and groups, we furnished. We proposed that the to audit and potentially recover money
intend to utilize existing resources, such additional information would include with the opportunity for an eligible
as a helpdesk or offer technical historical data regarding the total, and clinician to seek an informal review.
assistance, to help address questions components of, allowed charges (and Furthermore, the commenter observed
with the goal of linking these resource other figures as determined that current feedback reports lack key
features to the Quality Payment Program appropriate). We proposed that this details for understanding the
Web site and Service Center. information be provided on the methodologies used to arrive at the
We solicited comment only on the aggregate level; with the exception of benchmarks and other calculations and
receipt of information on features that data on items and services, as we could encouraged CMS to generate a summary
could be developed for the expanded consider providing this data at the report of all measures across the MIPS
use of the feedback mechanism but did patient level, if clinicians find that level domains per specialty and TIN size,
not propose any specific policy. of data to be useful, although we noted including the success of each measure
We received a number of comments it may contain personally identifiable assessed.
on this item and appreciate the input information and protected health Response: We appreciate the feedback
received. As this was a request for information. We proposed the date provided and will consider these ideas
comment only, we will take the range for making this information as we continue to build performance
feedback provided into consideration available would be based on what is feedback. We are continuing to work
for the future as we continue to build most helpful to clinicians, which could with registries, QCDRs, and health IT
performance feedback. As a reminder, include the most recent data we have vendors to test new APIs and plan to
we have already established a single available, which as technically feasible continue to develop new APIs as the
helpdesk to address all questions related would be from the previous 3 to 12- Quality Payment Program progresses.
to the Quality Payment Program. Please month period. We proposed to make We also continue to evaluate what
visit our Web site at qpp.cms.gov for this information available via the additional information and type of
more information. Quality Payment Program Web site, and information as required by section
(4) Additional InformationType of as technically feasible, as part of the 1848(q)(12)(B)(i) of the Act would be
Information performance feedback. Finally, because useful to clinicians and groups, and are
data on items and services furnished is currently working with stakeholders to
Section 1848(q)(12)(B)(i) of the Act generally kept confidential, we establish what to include in
states that beginning July 1, 2018, the proposed that access would be provided performance feedback.
Secretary shall make available to MIPS only after secure credentials are Final Action: As a result of the public
eligible clinicians information about the obtained. comments, we are finalizing these
items and services for which payment is The following is a summary of the policies as proposed. Section
made under Title 18 that are furnished public comments received on the 1848(q)(12)(B)(i) of the Act states that
to individuals who are patients of MIPS Additional InformationType of beginning July 1, 2018, the Secretary
eligible clinicians by other suppliers Information proposals and our shall make available to MIPS eligible
and providers of services. This responses: clinicians information about the items
information may be made available Comment: One commenter supported and services for which payment is made
through mechanisms determined providing additional information about under Title 18 that are furnished to
appropriate by the Secretary, such as the the items and services for which individuals who are patients of MIPS
CMS-designated system that would also payment is made under Title XVIII. The eligible clinicians by other suppliers
provide performance feedback. Section commenter urged CMS to make the and providers of services.
1848(q)(12)(B)(ii) of the Act specifies information more robust by identifying
that the type of information provided (5) Performance Feedback Template
alternatives to the items or services
may include the name of such provided that would have been more In the proposed rule, we noted our
providers, the types of items and cost effective to the patient while still intent (82 FR 30157), to do as much as
services furnished, and the dates that delivering the same quality of care. we can of the development of the
items and services were furnished. Two commenters provided template for performance feedback by
Historical data regarding the total, and recommendations for the type of working with the stakeholder
components of, allowed charges (and additional information to include in community in a transparent manner. We
other figures as determined appropriate performance feedback. One commenter stated our belief that this will encourage
by the Secretary) may also be provided. recommended that CMS create machine- stakeholder commentary and make sure
We proposed, beginning with the readable APIs for the feedback the result is the best possible format(s)
performance feedback provided around mechanism so that vendors could then for feedback.
July 1, 2018, to make available to MIPS interpret raw data, thereby enabling To continue with our collaborative
eligible clinicians and eligible clinicians them to develop visualization and goal of working with the stakeholder
information about the items and processing tools to better understand community, we sought comment on the
services for which payment is made this data. The commenter believes that structure, format, content (for example,
under Title 18 that are furnished to providing all data and allowing detailed goals, data fields, and elements)
individuals who are patients of MIPS community tools to filter out irrelevant that would be useful for MIPS eligible
eligible clinicians and eligible clinicians data would provide more useful insights clinicians and groups to include in
by other suppliers and providers of to MIPS eligible clinicians. Another performance feedback, including the
services. We proposed to include as commenter suggested inclusion of data on items and services furnished, as
many of the following data elements as information about which patients are discussed above. Additionally, we
technically feasible: The name of such attributed to particular clinicians, which understand the term performance
suppliers and providers of services; the other clinicians have partnered in that feedback may not be a meaningful
types of items and services furnished care, and the care directly attributed to phrase to communicate to clinicians or
and received; the dollar amount of the clinician. The commenter believes groups the scope of the data. Therefore,
services provided and received; and the that inclusion of this information would we sought comment on a more suitable
dates that items and services were better balance the power between CMS term than performance feedback. User
testing to date has provided some (2) We will respond to each request (2) Provide substantive, primary
considerations for a name in the Quality for targeted review timely submitted source documents as requested. These
Payment Program, such as Progress and determine whether a targeted documents may include: Copies of
Notes, Reports, Feedback, Performance review is warranted. Examples under claims, medical records for applicable
Feedback, or Performance Reports. which a MIPS eligible clinician or group patients, or other resources used in the
Any suggestions on the template to be may wish to request a targeted review data calculations for MIPS measures,
used for performance feedback or what include, but are not limited to: objectives, and activities. Primary
to call performance feedback can be The MIPS eligible clinician or source documentation also may include
submitted to the Quality Payment group believes that measures or verification of records for Medicare and
Program Web site at qpp.cms.gov. activities submitted to us during the non-Medicare beneficiaries where
We received a number of comments submission period and used in the applicable. We did not propose any
on this item and appreciate the input calculations of the final score and changes to the requirements in section
received. As this was a request for determination of the adjustment factors 414.1390(a).
comment only and we did nto make a have calculation errors or data quality We indicated in the CY 2017 Quality
proposal, we will take the feedback issues. These submissions could be with Payment Program final rule that all
provided into consideration for the or without the assistance of a third party MIPS eligible clinicians and groups that
future as we continue to build intermediary; or submit data to us electronically must
The MIPS eligible clinician or attest to the best of their knowledge that
performance feedback. We intend to do
group believes that there are certain the data submitted to us is accurate and
as much as we can of the development
errors made by us, such as performance complete (81 FR 77362). We also
of the template for performance
category scores were wrongly assigned indicated in the final rule that
feedback by working with the
to the MIPS eligible clinician or group attestation requirements would be part
stakeholder community in a transparent
(for example, the MIPS eligible clinician
manner. We invite clinicians and groups of the submission process (81 FR
or group should have been subject to the
that may have ideas they want to share, 77360). We neglected to codify this
low-volume threshold exclusion, or a
or if they would like to participate in requirement in regulation text of the CY
MIPS eligible clinician should not have
user testing to email partnership@ 2017 Quality Payment Program final
received a performance category score).
cms.hhs.gov. We think this will both rule. Additionally, after further
(3) The MIPS eligible clinician or
encourage stakeholder commentary and consideration since the final rule, the
group may include additional
make sure we end up with the best requirement is more in the nature of a
information in support of their request
possible format(s) for feedback. We certification, rather than an attestation.
for targeted review at the time the
intend for this performance feedback to Thus, we proposed to revise 414.1390
request is submitted. If we request
be available in the new format on the to add a new paragraph (b) that requires
additional information from the MIPS
2017 performance period by summer all MIPS eligible clinicians and groups
eligible clinician or group, it must be
2018, after the 2017 reporting closes. that submit data and information to
provided and received by us within 30
CMS for purposes of MIPS to certify to
b. Targeted Review days of the request. Non-responsiveness
the best of their knowledge that the data
to the request for additional information
In the CY 2017 Quality Payment submitted to CMS is true, accurate, and
may result in the closure of the targeted
Program final rule (81 FR 77546), we complete. We also proposed that the
review request, although the MIPS
finalized at 414.1385 that MIPS certification by the MIPS eligible
eligible clinician or group may submit
eligible clinicians or groups may request clinician or group must accompany the
another request for targeted review
a targeted review of the calculation of submission.
before the deadline.
the MIPS payment adjustment factor (4) Decisions based on the targeted We also indicated in the CY 2017
under section 1848(q)(6)(A) of the Act review are final, and there is no further Quality Payment Program final rule that
and, as applicable, the calculation of the review or appeal. if a MIPS eligible clinician or group is
additional MIPS payment adjustment found to have submitted inaccurate data
factor under section 1848(q)(6)(C) of the c. Data Validation and Auditing for MIPS, we would reopen and revise
Act applicable to such MIPS eligible In the CY 2017 Quality Payment the determination in accordance with
clinician or group for a year. We noted Program final rule (81 FR 77546 through the rules set forth at 405.980 through
MIPS eligible clinicians who are scored 77547), we finalized at 414.1390(a) 405.984 (81 FR 77362). We neglected to
under the APM scoring standard that we will selectively audit MIPS codify this policy in regulation text of
described in section II.C.6.g. of the eligible clinicians and groups on a the CY 2017 Quality Payment Program
proposed rule may request this targeted yearly basis. If a MIPS eligible clinician final rule and further, we did not
review. Although we did not propose or group is selected for audit, the MIPS include 405.986, which is also an
any changes to the targeted review eligible clinician or group will be applicable rule in our reopening policy.
process, we provided information on the required to do the following in We also finalized our approach to
process that was finalized in the CY accordance with applicable law and recoup incorrect payments from the
2017 Quality Payment Program final timelines we establish: MIPS eligible clinician by the amount of
rule (81 FR 77353 through 77358). (1) Comply with data sharing any debts owed to us by the MIPS
(1) MIPS eligible clinicians and requests, providing all data as requested eligible clinician and likewise, we
groups have a 60-day period to submit by us or our designated entity. All data would recoup any payments from the
a request for targeted review, which must be shared with us or our group by the amount of any debts owed
begins on the day we make available the designated entity within 45 days of the to us by the group. Thus, we proposed
MIPS payment adjustment factor, and if data sharing request, or an alternate to revise 414.1390 to add a new
applicable the additional MIPS payment timeframe that is agreed to by us and the paragraph (c) that states we may reopen
adjustment factor, for the MIPS payment MIPS eligible clinician or group. Data and revise a MIPS payment
year and ends on September 30 of the will be submitted via email, facsimile, determination in accordance with the
year prior to the MIPS payment year or or an electronic method via a secure rules set forth at 405.980 through
a later date specified by us. Web site maintained by us. 405.986.
In the CY 2017 Quality Payment MIPS is inappropriate because the False Response: MIPS eligible clinicians
Program final rule, we also indicated Claims Act relates to instances where a and groups are responsible for retaining
that MIPS eligible clinicians and groups party knowingly files a false claim for data. Please note, in the CY 2017
should retain copies of medical records, payment, and therefore, is an unduly Quality Payment Program final rule, we
charts, reports and any electronic data burdensome and inappropriate baseline required at 414.1390(a)(1) that MIPS
utilized for reporting under MIPS for up for data retention policies in a quality eligible clinicians and groups must
to 10 years after the conclusion of the program. A few commenters therefore provide all data as requested by CMS or
performance period (81 FR 77360). We recommended CMS reduce the record its designated entity, and at
neglected to codify this policy in retention policy to 3 years, as the 414.1390(a)(2) that MIPS eligible
regulation text of the CY 2017 Quality commenters stated it is comparable to clinicians and groups must provide
Payment Program final rule. Thus, we rules for CMS Recovery Audit substantive, primary source documents
proposed to revise 414.1390 to add a Contractors and it would allow eligible as requested. Such documents may
new paragraph (d) that states that all clinicians to retain the performance year include: Copies of claims, medical
MIPS eligible clinicians or groups that data that would be used for payment records for applicable patients, or other
submit data and information to CMS for adjustments. Whereas other commenters resources used in the data calculations
purposes of MIPS must retain such data recommended using a 6-year retention for MIPS measures, objectives, and
and information for a period of 10 years period, stating that it would be similar activities; and verification of records for
from the end the MIPS Performance to the requirements under the EHR Medicare and non-Medicare
Period. Incentive Program. Two commenters beneficiaries where applicable. We will
Finally, we indicated in the CY 2017 specifically recommended adopting a 5- continue providing clarification through
Quality Payment Program final rule, year retention period, with one subregulatory guidance. We also
that, in addition to recouping any commenter noting state law record encourage MIPS eligible clinicians and
incorrect payments, we intend to use retention rules which use a 5 to 7-year groups to review the current guidance
data validation and audits as an record retention time period. available on the Quality Payment
educational opportunity for MIPS Response: We appreciate the Program Web site at https://
eligible clinicians and groups and we commenters concerns and suggestions qpp.cms.gov/docs/QPP_MIPS_Data_
note that this process will continue to to reduce the record retention period. Validation_Criteria.zip.
include education and support for MIPS We understand concerns regarding the Additionally, we note that the
eligible clinicians and groups selected financial and time burdens associated certification policy we finalized in the
for an audit. with retaining data and information. CY 2017 Quality Payment Program final
The following is a summary of the Therefore, we are modifying our rule (81 FR 77362) and proposed to
public comments received on the Data proposed record retention policy at codify at 414.1390(b) in the CY 2017
Validation And Auditing proposals 414.1390(d) to require all MIPS Quality Payment Program proposed rule
and our responses: eligible clinicians and groups that (82 FR 30254), requires MIPS eligible
Comment: One commenter supported submit data and information to CMS for clinicians and groups to certify to the
CMS proposals regarding data purposes of MIPS to retain such data best of their knowledge that the data
validation and auditing requirements. and information for a period of 6 years submitted to CMS is true, accurate, and
Response: We thank the commenter from the end of the performance period. complete. Thus, the evidence needed to
for their support. We believe our final 6-year record support such an assertion would be the
Comment: Several commenters retention requirement reduces burden types of data and information we would
expressed concern regarding CMSs and cost on MIPS eligible clinicians and request under 414.1390. Finally, we
proposal to codify the requirement that groups and, is consistent with HIPAA refer readers to section II.C.10.g. of this
eligible clinicians and groups must record retention requirements and other final rule with comment period where
retain data utilized for reporting under Medicare program requirements. we discuss the record retention policy
MIPS for a period of 10 years from the Comment: Several commenters for third party intermediaries. This
end of the MIPS performance period. A requested additional guidance regarding policy is found at 414.1400(j)(2),
few commenters noted the 10-year the specific data eligible clinicians and which we proposed to update in the CY
retention requirement is excessive, and groups must retain for auditing 2018 Quality Payment Program
will create undue financial and time purposes and who should be proposed rule (82 FR 30255).
burden for eligible clinicians associated responsible for retaining this data. A Comment: A few commenters
with managing, storing, and retrieving few commenters urged CMS to further provided specific recommendations
data for audit. Some of these specify the data retention required for regarding CMS auditing process for
commenters also noted the 10-year auditing purposes prior to the beginning MIPS data, focusing on the need for a
retention requirement is inconsistent of the performance period so eligible process that is not excessively
with data retention requirements for clinicians and groups have adequate burdensome for eligible clinicians and
other CMS programs, such as the EHR notice of what is expected of and provides sufficient time to respond to
Incentive Program, the record retention required from them. One commenter auditing requests in light of eligible
requirements for non-Quality Payment specifically requested additional clinicians patient care obligations and
Program Part B payments, the rules information regarding what evidence an resource availability. One commenter
governing CMSs Recovery Audit eligible clinician should retain to specifically recommended CMS
Contractors, and state laws on medical support attestations, and encouraged establish an ombudsman for the sole
records retention. As a result, using a CMS to provide eligible clinicians purpose of monitoring and responding
10-year retention period would create additional education regarding their to eligible clinicians complaints and
multiple disparate data retention data retention responsibilities. Another concerns regarding the burden
requirements for eligible clinicians commenter requested clarification on associated with audits. Another
participating in MIPS. A few whether the data retention requirements commenter recommended CMS develop
commenters also asserted using the apply to third-party entities who submit a process to protect eligible clinicians
outer limit of False Claims Act liability data to CMS on behalf of eligible rights and offer recourse for eligible
as the data retention requirement for clinicians. clinicians in instances where there are
issues with third-party intermediaries 10. Third Party Data Submission Below is a summary of the public
retaining data on their behalf. A third a. Generally comments received on our proposals to:
commenter requested CMS establish a (1) Allow third party intermediaries to
fair and transparent auditing process Flexible reporting options will also submit on behalf of virtual groups;
with clear documentation requirements provide eligible clinicians with options (2) require that all data submitted to us
and data validation criteria for each to accommodate different practices and by a third party intermediary on behalf
MIPS category in order to lower the make measurement meaningful. We of a MIPS eligible clinician, group, or
likelihood of misinterpretation by believe that allowing eligible clinicians virtual group must be certified by the
eligible clinicians and groups. to participate in MIPS through the use third party intermediary to the best of
of third party intermediaries that will its knowledge as true, accurate, and
Response: We believe the audit
collect or submit data on their behalf, complete; and (3) require that this
process established is reasonable and is
will help us accomplish our goal of certification occur at the time of the
no more burdensome than other existing submission and accompany the
implementing a flexible program. We
Medicare audit processes, which submission.
strongly encourage all third party
similarly require providers and Comment: One commenter supported
intermediaries to work with their MIPS
suppliers to furnish documentation to the proposal to permit third-party
eligible clinicians to ensure the data
support the accuracy of previous intermediaries to submit data on behalf
submitted are representative of the
statements made to CMS. We do not of not only individual eligible clinicians
individual MIPS eligible clinicians or
believe an ombudsman is necessary, but and groups, but also on behalf of virtual
groups overall performance for that
we will closely monitor concerns from groups.
measure or activity.
MIPS eligible clinicians and groups Response: We thank the commenter
regarding audit burdens and third-party We use the term third party to refer
for their support.
intermediary issues. We believe that to a qualified registry, QCDR, a health
Comment: One commenter supported
MIPS eligible clinicians and groups IT vendor, or other third party that
the proposal that third-party
should incorporate appropriate obtains data from a MIPS eligible intermediaries submitting data on behalf
clinicians Certified Electronic Health of a MIPS eligible clinician, group, or
protections into their agreements with
Record Technology, or a CMS approved virtual group must certify and attest that
third party intermediaries. Additionally,
survey vendor. We refer readers to the the data are true, accurate, and complete
in regards to establishing a fair and
CY 2017 Quality Payment Program final at the time of submission but
transparent auditing process, we refer
rule (81 FR 77363) and 414.1400 of the recommended that CMS define true,
readers to our response above and
CFR for our previously established accurate, and complete. One
reiterate that we believe 414.1390(a)
policies regarding third party commenter expressed concern that the
sets forth what must be retained for
intermediaries. term true, accurate, and complete is
purposes of an audit. We will continue
providing clarification through (1) Expansion to Virtual Groups too vague, particularly the complete
subregulatory guidance. element; that because the third parties
In the CY 2018 Quality Payment act as an intermediary and are not the
Final Action: After consideration of Program proposed rule (82 FR 30158), original source of data means it is not
the public comments, we are finalizing we proposed to allow third party reasonable to request that they certify to
our proposal as proposed to add a new intermediaries to also submit on behalf that criteria; and that because MIPS
paragraph (b) to 414.1390 that requires of virtual groups. We proposed to revise eligible clinicians themselves are the
all MIPS eligible clinicians and groups 414.1400(a)(1) to state that MIPS data source of some of the information, data
that submit data and information to may be submitted by third party being attested to would be burdensome
CMS for purposes of MIPS to certify to intermediaries on behalf of an to verify. The commenter recommended
the best of their knowledge that the data individual MIPS eligible clinician, studying data quality, possibly through
submitted to CMS is true, accurate, and group, or virtual group. We also refer a task force made up of all stakeholders
complete. Further, we finalize that the readers to section II.C.4. of this final engaged in this process because they
certification by the MIPS eligible rule with comment period for a detailed suspect that standard checks of the
clinician or group must accompany the discussion about virtual groups. quality of information retention from
submission and be made at the time of source to intermediary could be
the submission. We are also finalizing (2) Certification
devised, but it should be done in a
with clarification our proposal to revise Additionally, we believe it is deliberative manner that leaves all
414.1390 to add a new paragraph (c). important that the MIPS data submitted constituents comfortable with the
Specifically, we are clarifying that we by third party intermediaries is true, recommended process and
may reopen and revise a MIPS payment accurate, and complete. To that end, in requirements. One commenter also
adjustment rather than a payment the CY 2018 Quality Payment Program recommended that the certification
determination. Thus, we are finalizing proposed rule (82 FR 30158), we requirement occur not with each
our proposal to add a new paragraph (c) proposed to add a requirement at individual submission, but rather on a
at 414.1390 that states we may reopen 414.1400(a)(5) stating that all data registry level; and that individual
and revise a MIPS payment adjustment submitted to CMS by a third party practices or registries should not be
in accordance with the rules set forth at intermediary on behalf of a MIPS punished if the attestation is found to be
405.980 through 405.986. Finally, we eligible clinician, group or virtual group incorrect.
are finalizing our proposal with must be certified by the third party Response: We appreciate the
modification to revise 414.1390 to add intermediary to the best of its commenters recommendations. The
a new paragraph (d) stating that all knowledge as true, accurate, and true, accurate, and complete standard
MIPS eligible clinicians and groups that complete. We also proposed that this is used throughout the Medicare
submit data and information to CMS for certification accompany the submission program and is commonly used in
purposes of MIPS must retain such data and be made at the time of the Medicare certifications. We do not
and information for 6 years from the end submission. We solicited comments on believe that it is ambigious or vague.
of the MIPS performance period. these proposals. Additionally, we understand that third
party intermediaries may not always be individual MIPS eligible clinician, the capabilities of a QCDR. However, we
the original source of data. In the CY group, or virtual groups, while the did propose changes to the self-
2017 Quality Payment Program final certification requirement we finalized in nomination process and the QCDR
rule with comment period (81 FR the CY 2017 QPP Final Rule (81 FR measure nomenclature. Additionally,
77388), we clarified that MIPS eligible 77362) is imposed upon MIPS eligible we proposed a policy in which a QCDR
clinicians are ultimately responsible for clinicians and groups that submit data may support an existing QCDR measure
the data that is submitted by their third and information to CMS for purposes of that is owned by another QCDR. The
party intermediary and expect that MIPS. We believe it is important that all details of these proposals are discussed
MIPS eligible clinicians and groups MIPS data submitted to CMS, whether in more detail below.
should ultimately hold their third party it is submitted by MIPS eligible
intermediary accountable for accurate clinicians, groups, virtual groups, or a (1) Establishment of an Entity Seeking
reporting. However, we also expect third party intermediary on behalf of To Qualify as a QCDR
third party intermediaries to develop MIPS eligible clinicians, groups, or In the CY 2017 Quality Payment
processes to ensure that the data and virtual groups, be certified as true, Program final rule (81 FR 77365), we
information they submit to us on behalf accurate, and complete. Thus, we finalized the criteria to establish an
of MIPS eligible clinicians, groups, and believe both certifications are necessary. entity seeking to qualify as a QCDR. In
virtual groups is true, accurate, and Moreover, we do not believe additional the CY 2018 Quality Payment Program
complete. We rely on the third party guidance is needed, we believe that this proposed rule (82 FR 30159), we did not
intermediaries to address these issues in requirement provides sufficent guidance propose any changes to the criteria and
its arrangements and agreements with for third party intermediaries to execute refer readers to the CY 2017 Quality
other entities, including MIPS eligible this certification requirement in a Payment Program final rule for the
clinicians, groups, and virtual groups. manner that is feasible in their business criteria to qualify as a QCDR.
We thank the commenter for their operations while remaining compliant
recommendation to develop a task force with requirements of the policy. We also (2) Self-Nomination Process
and will take this into consideration as refer readers to our response to the (a) Generally
we develop future policy. Additionally, previous comment for additional In the CY 2017 Quality Payment
we thank the commenter for their discussion.
recommendation that the certification Final Action: After consideration of
77366), we finalized procedures and
requirement be at the registry level. the public comments received, we are
finalizing our proposals, as proposed: requirements for QCDRs to self-
However, we are clarifying that the third
(1) To revise 414.1400(a)(1) to include nominate. Additional details regarding
party intermediary must certify each
virtual groups; and (2) that we will self-nomination requirements for both
submission and that the certification
require at 414.1400(a)(5) that all data the self-nomination form and the QCDR
must be for each MIPS eligible clinician,
submitted to CMS by a third party measure specification criteria and
group, and virtual group on whose
intermediary on behalf of a MIPS requirements can be found in the QCDR
behalf it is submitting data to us.
eligible clinician, group or virtual group fact sheet and the self-nomination user
Finally, a third party intermediary that
knowingly submits false data to the must be certified by the third party guide, that are posted in the resource
government, whether the third party intermediary to the best of its library of the Quality Payment Program
intermediary was the original source of knowledge as true, accurate, and Web site at https://qpp.cms.gov/about/
the data or not, would be subject to complete; and require that this resource-library.
penalty under federal law. certification occur at the time of the In the CY 2017 Quality Payment
Comment: One commenter did not submission and accompany the Program final rule (81 FR 77365 through
support the proposal that all data must submission. 77366), we finalized the self-nomination
be certified by the third party period for the 2017 performance period
b. Qualified Clinical Data Registries to begin on November 15, 2016, and end
intermediary because the commenter
(QCDRs) on January 15, 2017. We also finalized
believed the current regulations and
attestations are adequate and In the CY 2017 Quality Payment for future years of the program,
broadening the attestation without Program final rule (81 FR 77364), we beginning with the 2018 performance
providing guidance to third party finalized the definition and capabilities period, for the self-nomination period to
intermediaries on how they can of a QCDR. We finalized to require other begin on September 1 of the year prior
confidently make such an expansive information (described below) of QCDRs to the applicable performance period
assertion is not reasonable. at the time of self-nomination. As until November 1 of the same year. As
Response: This certification previously established, if an entity an example, the self-nomination period
requirement is not duplicative of becomes qualified as a QCDR, they will for the 2018 performance period will
current requirements nor is it an need to sign a statement confirming this begin on September 1, 2017, and will
expansive assertion. Rather, it is a information is correct prior to listing it end on November 1, 2017. We believe
change for consistency across the on our Web site (81 FR 77363). Once we an annual self-nomination process is the
program, that all data submissions are post the QCDR on our Web site, best process to ensure accurate
certified by the one who submitted it. including the services offered by the information is conveyed to MIPS
We do not believe the certification QCDR, we will require the QCDR to individual eligible clinicians and groups
requirement at 414.1400(a)(5) is an support these services and measures for and accurate data is submitted for MIPS.
expansive assertion because the third its clients as a condition of the entitys Having qualified as a QCDR in a prior
party intermediary is certifying to the participation as a QCDR in MIPS (81 FR year does not automatically qualify the
best of their knowledge that the data it 77366). Failure to do so will preclude entity to participate in MIPS as a QCDR
submits is true, accurate, and complete. the QCDR from participation in MIPS in in subsequent performance periods (82
The certification we are requiring at the subsequent year (81 FR 77366). In FR 30159). As discussed in the CY 2017
414.1400(a)(5) is imposed upon a third the CY 2018 Quality Payment Program Quality Payment Program final rule (81
party intermediary and the data it proposed rule (82 FR 30159), we did not FR 77365), a QCDR may chose not to
submits to CMS on behalf of an propose any changes to the definition or continue participation in the program in
future years, or may be precluded from attesting that all aspects of their completing the entire application
participation in a future year due to approved application from the previous annually, as is required in the existing
multiple data or submission errors. year have not changed, these existing process, and in alignment with the
QCDRs may also want to update or QCDRs in good standing would be existing timeline. We requested
change the measures, services or spending less time completing the entire comments on this proposal.
performance categories they intend to self-nomination form, as was previously
(A) Multi-Year Approval of QCDRs
support (82 FR 30159). Thus, we require required on a yearly basis.
that QCDRs must self-nominate each In the development of the above
(ii) Existing QCDRs in Good Standing policy, we had also reviewed the
year, and note that the prior
With Minimal Changes possibility of offering a multi-year
performance of the QCDR (when
applicable) is taken into consideration Beginning with the 2019 performance approval, in which QCDRs would be
in approval of their self-nomination for period, existing QCDRs in good standing approved for a continuous 2-year
subsequent years (82 FR 30159). In this that would like to make minimal increment of time. However, we are
final rule, we are establishing a changes to their previously approved concerned that utilizing a multi-year
simplified self-nomination process for self-nomination application from the approval process would restrict QCDRs
existing QCDRs in good standing, previous year, may submit these by having them support the same fixed
beginning with the CY 2019 changes, and attest to no other changes services they had for the first year, and
performance period. from their previously approved QCDR would not provide QCDRs with the
application, for CMS review during the flexibility to add or remove services,
(b) Simplified Self-Nomination Process self-nomination period, from September measures, and/or activities based on
for Existing QCDRs in MIPS, That Are 1 to November 1. In the CY 2018 Quality their QCDR capabilities for the
in Good Standing Payment Program proposed rule (82 FR upcoming program year. Furthermore,
We do understand that some QCDRs 30159), we proposed that minimal under a multi-year approval process,
may not have any changes to the changes include: Limited changes to QCDRs would not be able to make
measure and/or activity inventory they their performance categories, adding or changes to their organizational structure
offer to their clients, and intend to removing MIPS quality measures, and (as described above) and would also
participate in the MIPS for many years. adding or updating existing services create complications in our process for
In the CY 2018 Quality Payment offered, and/or the cost associated with placing QCDRs who perform poorly
Program proposed rule (82 FR 30159), using the QCDR. (during the first year) on probation or
we proposed beginning with the 2019 disqualifying them (as described below).
(iii) Existing QCDRs in Good Standing
performance period, a simplified self- Moreover, a multi-year approval process
With Substantive Changes
nomination process, to reduce the would not take into consideration
burden of self-nomination for those In the CY 2018 Quality Payment potential changes in criteria or
existing QCDRs that have previously Program proposed rule (82 FR 30159) requirements of participation for
participated in MIPS and are in good we stated that existing QCDRs in good QCDRs, that may occur as the MIPS
standing (not on probation or standing, may also submit for CMS program develops through future
disqualified, as described below), and to review and approval, substantive program years. For the reasons stated
allow for sufficient time for us to review changes to measure specifications for above, we believe an annual self-
data submissions and make existing QCDR measures that were nomination period is appropriate. We
determinations. Our proposals to approved the previous year, or submit understand that stakeholders are
simplify the process for QCDRs in good new QCDR measures for CMS review interested in a multi-year approval
standing with no changes, minimal and approval without having to process, for that reason we intend to
changes, and those with substantive complete the entire self-nomination revisit the topic once we have gained
changes are discussed below. application process, which is required additional experience with the self-
to be completed by a new QCDR. By nomination process under MIPS. We
(i) Existing QCDRs in Good Standing attesting that certain aspects of their
With No Changes seek comment from stakeholders as to
approved application from the previous how they believe our aforementioned
In the CY 2018 Quality Payment year have not changed, existing QCDRs concerns with multi-year approvals of
Program proposed rule (82 FR 30159), in good standing would be spending QCDRs can be resolved.
we proposed, beginning with the 2019 less time completing the entire self-
performance period, a simplified nomination form, as was previously (B) Web-Based Submission of Self-
process for which existing QCDRs in required on a yearly basis. We are Nomination Forms
good standing may continue their proposing such a simplified process to In the CY 2018 Quality Payment
participation in MIPS, by attesting that reduce the burden of self-nomination for Program proposed rule (82 FR 30159),
the QCDRs previously approved: Data those existing QCDRs who have for the 2018 performance period and
validation plan, services offered, cost previously participated in MIPS, and are beyond, we proposed that self-
associated with using the QCDR, in good standing (not on probation or nomination information must be
measures, activities, and performance disqualified, as described later in this submitted via a web-based tool, and to
categories supported in the previous section) and to allow for sufficient time eliminate the submission method of
years performance period of MIPS have for us to review data submissions and to email. We noted that we will provide
no changes and will be used for the make determinations on the standing of further information about the web-based
upcoming performance period. the QCDRs. We note that substantive tool at www.qpp.cms.gov.
Specifically, existing QCDRs in good changes to existing QCDR measure Below is a summary of the public
standing with no changes may attest specifications or any new QCDR comments received on the following
during the self-nomination period, measures would have to be submitted proposals: (1) A simplified self-
between September 1 and November 1, for CMS review and approval by the nomination process for existing QCDRs
that they have no changes to their close of the self-nomination period. This in good standing; and (2) To eliminate
approved self-nomination application proposed process will allow existing the self-nomination submission method
from the previous year of MIPS. By QCDRs in good standing to avoid of email.
Comment: Many commenters from MIPS quality measures) as a part the same from the previous year. We are
supported the proposal allowing a of their self-nomination, which are clarifying here that substantive changes
simplified self-nomination process for reviewed and approved or rejected include, but are not limited to: Updates
QCDRs in good standing to continue separately from the self-nomination to existing (approved) QCDR measure
their participation in MIPS by attesting form. MIPS quality measures have gone specifications, new QCDR measures for
to certain information, for reasons through extensive review prior to consideration, changes in the QCDRs
including: It would require less time to rulemaking and are approved or rejected data validation plan, or changes in the
complete the self-nomination for inclusion in the program through the QCDRs organizational structure (for
application; it would minimize rule-making cycle as discussed in the example, if a regional health
confusion and miscommunication with CY 2018 Quality Payment Program collaborative or specialty society wishes
CMS; it should enable CMS to dedicate proposed rule (82 FR 3004330045). to partner with a different data
more time to the review of the QCDR QCDR measures, on the other hand, are submission platform vendor that would
measures; it would help reduce reviewed for consideration under a support the submission aspect of the
reporting burden for QCDRs; it will different timeline and must be reviewed QCDR). This process mirrors that for
encourage the use and development of to the extent needed to determine minimal changes. For example, if a
QCDR; it will allow for more time to be whether they are appropriate for previously approved QCDR in good
spent developing new measures; and inclusion in the program, and align standing would like to submit changes
decreasing application burden will within the goals of the MIPS program only to its QCDR measures, the QCDR
enhance their ability to assist clients and provide meaningful measurement to can attest that there are no changes to
with quality improvement and data eligible clinicians and groups (82 FR their self-nomination form, and provide
submission and may create efficiency by 30160 through 30161). Details regarding the updated QCDR measures
encouraging registries to make many self-nomination requirements for both specifications for CMS review and
measure changes at one time versus the self-nomination form and the QCDR approval. We are also clarifying that the
submitting small changes annually. measure specification criteria and information required to be submitted for
Response: We thank commenters for requirements can be found in the QCDR any changes would be the same as that
their support with regards to a fact sheet and the self-nomination user required under the normal self-
simplified self-nomination process for guide, that are posted in the resource nomination process. We refer reader to
existing QCDRs in good standing library of the Quality Payment Program the CY 2017 Quality Payment Program
beginning with the 2019 performance Web site at https://qpp.cms.gov/about/ final rule (81 FR 77366 through 77367),
period. resource-library. as well as (81 FR 77374 through 77375)
Comment: One commenter Under our proposals, we are clarifying and 414.1400(f). For example, if a
recommended simplifying the QCDR that beginning with the 2019 QCDR would like to include one new
self-nomination process by de-coupling performance period, we are clarifying QCDR measure, it would be required to
the QCDR self-nomination and measure that any previously approved QCDR in submit: Descriptions and narrative
selection processes. One commenter good standing (meaning, those that are specifications for each measure, the
recommended that CMS make exception not on probation or disqualified) that name or title of the QCDR measure, NQF
to this proposal to allow a QCDR to wishes to self nominate using the number (if NQF endorsed), descriptions
replace a measure if deems necessary. simplified process can attest, in whole of the denominator, numerator,
One commenter recommended that the or in part, that their previously denominator exceptions (when
self-nomination could be used if QCDR approved form is still accurate and
applicable), denominator exclusions
measures changes because they believed applicable. Specifically, under this
(when applicable), risk adjustment
that QCDR measure changes should be process, QCDRs with no changes can
considered independent of the self- variables (when applicable), and risk
attest that their previously submitted
nomination process. One commenter adjustment algorithms. We expect that
QCDR self-nomination form in its
recommended that CMS consider self- the measure will address a gap in care,
entirety remains the same. Similarly,
populating self-nomination forms based and prefer outcome or high priority
previously approved QCDRs in good
on the previous application. One measures. Documentation or check
standing that wish to self nominate
commenter recommended that CMS box measures are discouraged.
using the simplified process and have
consider a system under which QCDRs Measures that have a very high
minimal changes can attest to aspects of
only need to reapply if they make their previously submitted form that performance rate already, or extremely
substantial organizational or operational remain the same, but would rare gaps in care will unlikely be
changes. additionally be required to update the approved for inclusion (81 FR 77374
Response: We recognize that the self-nomination form to reflect any through 77375).
existing process and our proposals minimal changes for CMS review. As We disagree with the
could use additional clarification. The stated in our proposal above, minimal recommendation that QCDRs only need
existing process for QCDR self- changes include, but are not limited to: to reapply if they make substantial
nomination and QCDR measure Limited changes to performance organization or operational changes.
approval is a two-part process. The categories, adding or removing MIPS This would not take into consideration
QCDR self-nomination form requires quality measures, and adding or potential changes in criteria or
contact information, services, costs updating existing services and/or cost requirements of participation for
associated with using the QCDR, information. QCDRs, as the MIPS program develops
performance categories supported, MIPS Furthermore, under our proposal, we through future program years.
quality measures, and data validation are also clarifying that any previously Furthermore, we believe self-
plan to be considered for the next approved QCDR in good standing that nomination should occur on an annual
performance period (82 FR 30159). wishes to self nominate using the basis to account for QCDRs that may
Currently, QCDRs may also submit for simplified process and has substantive perform poorly and thereby need to be
consideration QCDR measures changes may submit those substantive placed on probation or precluded from
(previously referred to as non-MIPS changes while attesting that the participation the following year. We
measures (81 FR 77375) and separate remainder of their application remains thank the commenter for their
suggestion of automatically self- comment period, in which we clarify Medicare/Quality-Initiatives-Patient-

nomination forms based off of the that the existing process for QCDR self- Assessment-Instruments/Value-Based-
previous years application; we are nomination and QCDR measure Programs/MACRA-MIPS-and-APMs/
looking into the technical capabilities of approval is a two-part process. To MACRA-MIPS-and-APMs.html where
the system, and will make any potential reiterate, the QCDR self-nomination additional self-nomination guidance can
updates based on the feasibility of the form requires contact information, be found. Furthermore, we intend to
system for future self-nomination form services, costs associated with using the assign specific personnel to
updates. QCDR, performance categories communicate self-nomination and
Comment: One commenter supported, MIPS quality measures, and QCDR decisions as appropriate and will
recommended that in light of data validation plan to be considered for continue to use our internal decision
Congressional intent to encourage the the next performance period (82 FR tracker to track all decisions made on
use of QCDRs, CMS should not only 30159). Currently, QCDRs may also QCDRs and their QCDR measures, as we
simplify the process for re-approval of submit for consideration QCDR did during the review of 2017 self-
QCDRs, but should also consider measures (previously referred to as non- nominations and QCDR measures. We
substantially streamlining and MIPS measures (81 FR 77375) and appreciate that commenters provided
simplifying the process for approval of separate from MIPS quality measures) as recommendations to standardize a
new QCDRs. The commenter suggests a part of their self-nomination, which process and timeframe for self-
including a revision or elimination of are reviewed and approved or rejected nomination review and will take them
any requirement that the Scientific separately from the self-nomination into consideration for future policies.
Registry for Transplant Recipients form. MIPS quality measures have gone We are currently working through such
(SRTR) must report quality performance through extensive review prior to efforts to standardize the process and
on an individual level in order to be rulemaking and are approved or rejected timelines to the best of our ability.
approved as a QCDR. for inclusion in the program through the Comment: One commenter
Response: As indicated in the CY rulemaking cycle as discussed in the CY appreciated the adjusted timeline that
2017 Quality Payment Program final 2018 Quality Payment Program ends on November 1, but expressed
rule (81 FR 77363) the Secretary proposed rule (82 FR 3004330045). concern about the feasibility of this
encourages the use of QCDRs in carrying QCDR measures, on the other hand, are timeline because the commenter
out MIPS. We believe the current self- reviewed for consideration under a believed QCDRs will have less than a
nomination application for new QCDRs different timeline and must be reviewed full years worth of data to evaluate
is comprehensive and collects to the extent needed to determine when making decisions about whether
information needed to make a whether they are appropriate for to retire or modify existing measures for
determination as to whether the entity inclusion in the program, and align the upcoming year. The commenter
has or has not met the requirements and requested that CMS adopt a multi-year
within the goals of the MIPS program
criteria of participation as a QCDR measure approval process, such as 5
and provide meaningful measurement to
under MIPS. We believe that this years, to allow QCDRs to adjust or retire
eligible clinicians and groups (82 FR
simplified self-nomination policy will a QCDR measure from year-to-year, as
30160 through 30161). Details regarding
help us streamline the existing self- long as they request such changes by
self-nomination requirements for both
nomination process. As a requirement, CMSs self-nomination deadline so
the self-nomination form and the QCDR
QCDRs must support reporting under QCDRs would not be expected to invest
measure specification criteria and
the quality performance category at the time and resources on defending their
requirements can be found in the QCDR
individual and/or group level (81 FR measures from year to year and could
fact sheet and the self-nomination user
77368). instead shift their focus to more
Comment: A few commenters guide, that are posted in the resource
meaningful analytics to help improve
expressed concern with the current library of the Quality Payment Program
patient care. A few commenters that
QCDR self-nomination process for Web site at https://qpp.cms.gov/about/
supported the simplified process also
reasons including inconsistent feedback, resource-library.
expressed concerns about the timelines
impractical timelines, and a lack of We understand the commenters for the self-nomination process and
rationale for rejected measures. A few concerns, but would like to note we ability to update or change information
commenters recommended that QCDR have been working to implement given that they will not have a full year
self-nomination application and process improvements and develop of data by the deadline.
materials should be updated to outline additional standardization for the 2018 Response: We appreciate the
all of the information needed to performance period self-nomination and commenters support regarding the
determine QCDR status to avoid delays QCDR measure review, in which change in the self-nomination period
and misunderstandings. A few consistent feedback is communicated to timeline. We understand that that there
commenters recommended that CMS vendors, additional time is given to is concern around the timeline as
develop a standardized process for vendors to respond to requests for QCDRs believe they will have less than
reviewing QCDR measures, including information, and more detailed a full years worth of data to evaluate
structured timeframes for an initial rationales are provided for rejected prior to making decisions about whether
review period, an appeals process, and QCDR measures. Furthermore, through to retire or modify an existing QCDR
a final review. One commenter also our review, we intend to communicate measure before the next self-nomination
recommended mechanisms to ensure the timeframe in which a decision re- period. We acknowledge that the
transparency and predictability, examination can be requested should timeframe may, in some instances, limit
assigning a coordinator for each QCDR we reject QCDR measures. In order to the QCDRs ability to make a
and creating an official database improve predictability and avoid delays determination about changing or retiring
containing decisions on measures to or misunderstandings, we have made their QCDR measure, however we heard
ensure there are no conflicting updates to the self-nomination form to overwhelmingly from stakeholders in
messages. outline all of the information needed the CY 2017 Quality Payment Program
Response: We refer readers to our during the review process. We refer final rule, that having the ability to
previous response in this final rule with readers to: https://www.cms.gov/ make their quality measure selections
prior to the beginning of the will simplify the process, reduce the Beginning with the 2019 performance
performance period is critical. CMS will time to complete self-nomination period, previously approved QCDRs in
review the measure, data submissions applications, and would minimize good standing (meaning, those that are
and performance data (as available) to confusion and miscommunication with not on probation or disqualified) that
ensure that the measure is appropriate CMS. wishes to self nominate using the
for inclusion. We will also take into Response: We thank the commenters simplified process can attest, in whole
consideration whether or not the for their support and believe the web- or in part, that their previously
measure is topped out, reflects current based tool will help reduce burden and approved form is still accurate and
clinical guidelines and is not considered confusion. applicable. Specifically, under this
standard of care prior to making a final Comment: A few commenters process, QCDRs with no changes can
determination on the QCDR measure. recommended revising the application attest that their previously submitted
We refer readers to 414.1400(f) for process to eliminate the duplication QCDR self-nomination form in its
additional information. Furthermore, as when applying as both a QCDR and entirety remains the same. Similarly,
stated in our proposal, we are concerned qualified registry. One commenter also previously approved QCDRs in good
that utilizing a multi-year approval recommended eliminating duplicate standing that wish to self nominate
process would restrict QCDRs by having applications for Qualified Registries and using the simplified process and have
them support the same fixed services QCDRs because they believed a majority minimal changes can attest to aspects of
they had for the first year, and would of the qualified registry questions were their previously submitted form that
not provide QCDRs with the flexibility also on the QCDR application, and remain the same, but would
to add or remove services, measures, therefore, the application could be additionally be required to outline any
and/or activities based on their QCDR duplicated within the web portal. minimal changes for CMS review and
capabilities for the upcoming program Response: We believe having distinct approval. Minimal changes include, but
year. Moreover, a multi-year approval applications for QCDRs and Qualified are not limited to: Limited changes to
process would not take into Registries is important because each performance categories, adding or
consideration potential changes in specifies specific measures, removing MIPS quality measures, and
criteria or requirements of participation performance categories, and services adding or updating existing services
for QCDRs. Furthermore, our concerns offered by the entity. Though we and/or cost information. Furthermore, a
with multi-year approval of QCDR understand that application questions previously approved QCDRs in good
measures stem from the possibility of are the same under the QCDR and standing that wishes to self nominate
clinical guidance changes, that may Qualified Registries self-nomination using the simplified process and has
include the addition, removal, or update applications, we note that QCDRs have substantive changes may submit those
to a new class of medications, substantive changes while attesting that
additional capabilities as compared to
procedures, diagnosis codes (for the remainder of their application
Qualified Registries. QCDRs have the
example, ICD10 code updates), or remains the same from the previous
capability to develop and submit for
treatment methodology. Thus, at this year. Substantive changes include, but
consideration up to 30 QCDR measures
time, we believe an annual self- are not limited to: Updates to existing
for CMS review and approval.
nomination and QCDR measure (approved) QCDR measure
Furthermore, as defined in the CY 2017
approval process is most appropriate. specifications, new QCDR measures for
Quality Payment Program final rule (81
We will however take such consideration, changes in the QCDRs
FR 77366) for QCDR measures, if the
recommendations into consideration, data validation plan, or changes in the
measure is risk adjusted, the QCDR is
for future years as we gain further QCDRs organizational structure (for
experience with QCDRs and QCDR required to provide us with details on
their risk adjustment methodology (risk example, if a regional health
measures under MIPS. collaborative or speciality society
Comment: One commenter supported adjustment variables, and applicable
calculation formula) at the time of self- wishes to partner with a different data
the registry self-nomination period
nomination. However, we will take submission platform vendor that would
deadline of November 1, 2017, because
these comments into consideration as support the submission aspect of the
they believed with this deadline, CMS
we develop future policy. QCDR). We are also clarifying that the
will be able to better accommodate
Final Action: After consideration of information required to be submitted for
registries, other third-party
the public comments received, we are any changes would be the same as that
intermediaries, and eligible clinicians
and groups as they implement and finalizing our proposals with required under the normal self-
prepare for MIPS reporting each year. clarification. Specifically at nomination process as discussed
The commenter recommended that CMS 414.1400(b) we are finalizing our previously in this final rule with
approve 2018 QCDR measure proposal, beginning with the 2019 comment period.
specifications by December 1, 2017, to performance period, that previously Furthermore, we are finalizing our
allow for adequate time to prepare for approved QCDRs in good standing (that proposal, as proposed, that beginning
the 2018 performance year. are not on probation or disqualified) with the 2018 performance period, that
Response: We interpret the comment that wish to self nominate using the self-nomination applications must be
to refer to QCDRs and thank the simplified process can attest, in whole submitted via a web-based tool, and that
commenter for its support. We intend to or in part, that their previously the email method of submission will be
have QCDR measure specification approved form is still accurate and eliminated.
approvals and/or rejections completed applicable. We are clarifying our For the 2018 performance period and
by early December. proposals by elaborating on what would future performance periods, we are
Comment: A few commenters be required for previously approved finalizing the following proposal: That
supported CMSs proposal that QCDRs in good standing that wish to self-nomination submissions will occur
beginning with the 2018 performance self-nominate and have minimal or via a web-based tool rather than email;
period, self-nomination information substantive changes. For abundant and for the 2019 performance period
must be submitted via a web-based tool, clarity, we are restating our finalized and future performance periods, we are
rather than email, because they noted it proposals with clarifications here: finalizing the availability of a simplified
self-nomination process for existing non-MIPS measure with QCDR Must have in place mechanisms for
QCDRs in good standing. measure noting that there is likely to transparency of data elements and
be greater understanding and familiarity specifications, risk models and
(3) Information Required at the Time of
with the current terminology of non- measures. That is, we expect that the
Self-Nomination
MIPS measures. The commenter QCDR measures, and their data
In the CY 2017 Quality Payment recommended that, instead, these elements (that is, specifications)
Program final rule (81 FR 77366 through measures could be referred to as non- comprising these measures be listed on
77367), we finalized the information a MIPS (QCDR defined, specialty-specific) the QCDRs Web site unless the measure
QCDR must provide to us at the time of measures, non-MIPS (QCDR-specific) is a MIPS measure, in which case the
self-nomination. In the CY 2018 Quality measures, or non-MIPS (QCDR- specifications will be posted by us.
Payment Program proposed rule (82 FR defined) measures to promote clarity QCDR measure specifications should be
30159 through 30160), we proposed to for clinicians. provided at a level of detail that is
replace the term non-MIPS measures Response: Although we understand comparable to what is posted by us on
with QCDR measures for future the commenters perspective, that there the CMS Web site for MIPS quality
program years, beginning with the 2018 is greater familiarity with the current measure specifications.
performance period. We noted that terminology of non-MIPS measures, Approved QCDRs may post the
although we proposed a change in the we believe that the term may lead MIPS quality measure specifications on
term referring to such measures, we did clinicians and groups new to MIPS to their Web site, if they so choose. If the
not propose any other changes to the believe that the measures are not in the MIPS quality measure specifications are
information a QCDR must provide to us MIPS program and they may then chose posted by the QCDRs, they must be
at the time of self-nomination under the not to report on measures developed by replicated exactly the same as the MIPS
process finalized in the CY 2017 Quality quality measure specifications as posted
QCDRs. QCDR measures will clearly
Payment Program final rule. We referred on the CMS Web site.
construe that the measure is owned by
readers to the CY 2017 Quality Payment Enter into and maintain with its
a QCDR and avoid any misinterpretation
Program final rule for specific participating MIPS eligible clinicians,
that the measures are not reportable
information requirements. However, we an appropriate Business Associate
under MIPS. The term QCDR
refer readers to section II.C,10,a,(5)(b) of Agreement that complies with the
measure, previously referred to as
this final rule with comment period, HIPAA Privacy and Security Rules.
non-MIPS measure is used to identify
where we are modifying our proposal Ensure that Business Associate
measures that are developed by QCDRs.
that as a part of the self-nomination Agreement provides for the QCDRs
The term is used to distinguish them
review process for 2018 and future receipt of patient-specific data from an
years, we will assign QCDR measure IDs from the quality measures that are in the
individual MIPS eligible clinician or
to approved QCDR measures, and the MIPS program that have been reviewed
group, as well as the QCDRs disclosure
same measure ID must be used by any and approved through the rule making of quality measure results and
other QCDRs that have received cycle. The term is used in the QCDR numerator and denominator data or
permission to also report the measure. self-nomination form and in the QCDR patient specific data on Medicare and
We also note that information required qualified posting to identify which non-Medicare beneficiaries on behalf of
under the newly finalized simplified QCDR developed measures have been MIPS eligible clinicians and groups.
process is discussed in the previous approved for use in the upcoming Must provide timely feedback at
section of this final rule with comment performance period. least 4 times a year, on all of the MIPS
period. Additionally, as finalized in Final Action: After consideration of performance categories that the QCDR
section II.C.10.b.(2)(b)(iii) of this final the public comments, we are finalizing will report to us. We refer readers to
rule with comment period, we will only as proposed, our proposal to replace the section II.C.9.a. of the CY 2018 Quality
accept self-nomination applications term non-MIPS measures with Payment Program proposed rule for
through the web-based tool and will QCDR measures for future program additional information on third party
provide additional guidance as to what years, beginning with the 2018 intermediaries and performance
information needs to be submitted for performance period. We have also feedback.
QCDR measure specifications through updated the regulation text to reflect For purposes of distributing
the 2018 Self-Nomination User Guide this change, and refer readers to performance feedback to MIPS eligible
that will be posted on our Web site. 414.1400(e) for the updated language. clinicians, we encourage QCDRs to
The following is a summary of the For the 2018 performance period and assists MIPS eligible clinicians in the
public comments received on the future performance periods, we are update of their email addresses in CMS
Information Required at the Time of finalizing the following proposal: That systemsincluding PECOS and the
Self-Nomination proposal and our the term QCDR measures will replace Identity and Access Systemso that
response: the term non-MIPS measures. they have access to feedback as it
Comment: A few commenters becomes available on www.qpp.cms.gov
(4) QCDR Criteria for Data Submission
supported the proposal that the term and have documentation from the MIPS
QCDR measures replace the term In the CY 2017 Quality Payment eligible clinician authorizing the release
non-MIPS measures for reasons Program final rule (81 FR 77367 through of his or her email address.
including a belief that the term non- 77374), we finalized that a QCDR must As noted in the CY 2017 Quality
MIPS has caused confusion and perform specific functions to meet the Payment Program final rule (81 FR
created the impression that the criteria for data submission. While we 77370), we will on a case-by-case basis
measures are not eligible to be reported did not propose any changes to the allow QCDRs and qualified registries to
under the MIPS program when in fact criteria for data submission in the CY request review and approval for
they are. 2018 Quality Payment Program additional MIPS measures throughout
Response: We thank the commenters proposed rule (82 FR 30160), we the performance period. In the CY 2018
for their support. clarified the criteria for QCDR data Quality Payment Program proposed rule
Comment: One commenter did not submission. For data submissions, (82 FR 30160), we clarified and
support the proposal to replace the term QCDRs: explained that this flexibility would
only apply for MIPS measures; QCDRs address a gap in care and outcome or beginning with the 2018 performance
will not be able to request additions of other high priority measures are period and for future program years, we
any new QCDR measures throughout the preferred. In the CY 2018 Quality proposed that QCDR vendors may seek
performance period. Furthermore, Payment Program proposed rule (82 FR permission from another QCDR to use
QCDRs will not be able to retire any 30160), we clarified that we encourage an existing measure that is owned by
measures they are approved for during alignment with our Measures the other QCDR. If a QCDR would like
the performance period (82 FR 30160). Development Plan.13 report on an existing QCDR measure
Should a QCDR encounter an issue In the CY 2017 Quality Payment that is owned by another QCDR, they
regarding the safety or change in Program final rule (81 FR 77375), we must have permission from the QCDR
evidence for a measure during the finalized that measures that have very that owns the measure that they can use
performance period, it must inform high performance rates already or the measure for the performance period.
CMS by email of said issue and indicate address extremely rare gaps in care Permission must be granted at the time
whether it will or will not be reporting (thereby allowing for little or no quality of self-nomination, so that the QCDR
on the measure; we will review measure distinction between MIPS eligible that is using the measure can include
issues on a case-by-case basis (82 FR clinicians) are also unlikely to be the proof of permission for CMS review
30160). Any measures QCDRs wish to approved for inclusion. In the CY 2018 and approval for the measure to be used
retire would need to be retained until Quality Payment Program proposed rule in the performance period. The QCDR
the next annual self-nomination process (82 FR 30160), we also clarified that we measure owner (QCDR vendor) would
and applicable performance period (82 will likely not approve retired measures still own and maintain the QCDR
FR 30160). that were previously in one of CMSs measure, but would allow other
quality programs, such as the Physician approved QCDRs to utilize their QCDR
(5) QCDR Measure Specifications Quality Reporting System (PQRS) measure with proper notification. We
Criteria program, if proposed as QCDR noted that the proposal would help to
In the CY 2017 Quality Payment measures. This includes measures that harmonize clinically similar measures
Program final rule (81 FR 77374 through were retired due to being topped out, as and limit the use of measures that only
77375), we specified at 414.1400(f) defined in section II.C.6.c.(2) of the CY slightly differ from another. We invited
that the QCDR must provide specific 2018 Quality Payment Program comments on this proposal.
QCDR measures specifications criteria. proposed rule, due to high-performance
We generally intend to apply a process (c) Full Development and Testing of
or measures retired due to a change in
similar to the one used for MIPS QCDR Measures by Self-Nomination
the evidence supporting the use of the
measures to QCDR measures that have measure. In the CY 2018 Quality Payment
been identified as topped out. In the CY Lastly, in the CY 2017 Quality Program proposed rule (82 FR 30160),
2018 Quality Payment Program Payment Program final rule (81 FR we sought comment for future
proposed rule (82 FR 30160), we did not 77375), we finalized that the QCDR rulemaking, on requiring QCDRs that
propose any changes to the QCDR must publicly post the measure develop and report on QCDR measures,
measure specifications criteria and refer specifications (no later than 15 days to fully develop and test (that is,
readers to the CY 2017 Quality Payment following our approval of these measure conduct reliability and validity testing)
Program final rule (81 FR 77374 through specifications) for each QCDR measure their QCDR measures, by the time of
77375) for the specification it intends to submit for MIPS. In the CY submission of the new measure during
requirements a QCDR must submit for 2018 Quality Payment Program the self-nomination process. We
each measure, activity, or objective the proposed rule (82 FR 30160), we received a number of comments on this
QCDR intends to submit to CMS. clarified that 15 days refers to 15 item and appreciate the input received.
Though we did not make proposals calendar days, not business days. The As this was a request for comment only,
around the QCDR measure QCDR must publicly post the measure we will take the feedback provided into
specifications themselves, in the CY specifications no later than 15 calendar consideration for possible inclusion in
2018 Quality Payment Program days following our approval of these future rulemaking.
proposed rule, (82 FR 30160) we did measures specifications for each QCDR The following is a summary of the
make a number of clarifications around measure it intends to submit for MIPS. public comments received on the
alignment with the measures It is important for QCDRs to post their QCDR Measure Specifications Criteria
development plan, previously retired QCDR measure specifications on their proposals and our responses:
measures, and the public posting of the Comment: Several commenters
Web site in a timely manner, so that the
QCDR measure specifications. supported the proposal to allow QCDRs
specifications are readily available for
Additionally, we proposed to allow to seek permission to use another
MIPS eligible clinicians and groups to
QCDR vendors to seek permission from vendors QCDRs measures for reasons
access and review in determining which
another QCDR to use an existing including that developing and testing
QCDR measures they intend to report on
approved QCDR measure. Lastly, we measures is a costly process; the
for the performance period.
sought comment from stakeholders measure steward has the resources and
around requiring QCDRs to fully (b) QCDRs Seeking Permission From clinical guidance to ensure appropriate
develop and test their QCDR measures Another QCDR To Use an Existing, use for consistency that will assist with
by the time of self-nomination. These Approved QCDR Measure reporting; it is intended to harmonize
are discussed in more detail below. In the CY 2018 Quality Payment measures; it could allow similar types of
Program proposed rule (82 FR 30160), clinicians to report the same measure
(a) Clarifications to Previously regardless of their TIN structure;
Established Policies 13 The CMS Quality Measures Development Plan: allowing the same measures to be
In the CY 2017 Quality Payment Supporting the Transition to The Quality Payment collected by the QCDR registries for
Program final rule (81 FR 77375), we Program 2017 Annual Report, available at https:// different specialties at the same time
www.cms.gov/Medicare/Quality-Initiatives-Patient-
finalized that we will consider all QCDR Assessment-Instruments/Value-Based-Programs/
would give CMS and the physician
(non-MIPS) measures submitted by the MACRA-MIPS-and-APMs/2017-CMS-MDP-Annual- community a more complete picture
QCDR, but that the measures must Report.pdf. regarding the quality of care being
provided to Medicare beneficiaries; and approved by us during the QCDR For the 2018 performance period and
it will reduce the proliferation of similar measure review process (as outlined future performance periods, we are
measures that may be duplicative. One previously in this final rule with finalizing the following proposal: That
commenter also sought clarity as to the comment period), secondary QCDRs QCDRs may report on QCDR measures
mechanism the Agency will use to borrowing the QCDR measure must use owned by another QCDR with the
identify shared measures and the updated specifications. appropriate permissions; and we clarify
recommended that CMS do the Comment: One commenter requested that QCDRs must publicly post QCDR
following to increase clarity, that CMS clarify what form proof of measure specifications no later than 15
harmonization, and transparency permission must take to satisfy the calendar days following our approval of
including: (1) Require that if the requirements of the self-nomination the measures specifications.
specifications are not identical to the application process. Another (6) Identifying QCDR Quality Measures
original QCDRs measure(s), the commenter recommended that CMS
borrowing QCDR must identify, provide reconsider the proposal to require that In the CY 2017 Quality Payment
a rationale, and make public any a QCDR must, by the time of self- Program final rule (81 FR 77375 through
changes made to the measure nomination, have permission from the 77377), we finalized the definition and
specifications; (2) require the original QCDR that owns the measure that they types of QCDR quality measures for
measure steward/owner be identified in can use the measure for the performance purposes of QCDRs submitting data for
the borrowing QCDRs list of measures; period and rather provide the ability to the MIPS quality performance category.
and (3) establish some system of add reportable measures throughout the In the CY 2018 Quality Payment
identification (that is, tags or numbers year. Program proposed rule (82 FR 30160),
similar to MIPS measures) so it is clear Response: As a clarification to the we did not propose any changes to the
when one measure is used in multiple proposal, for the 2018 self-nomination criteria on how to identify QCDR quality
QCDRs. period and for future performance measures. However, in the proposed
periods, the self-nomination form that is rule, we clarified that QCDRs are not
Response: We thank the commenters
available through the Web-based tool, limited to reporting on QCDR measures,
for their recommendations. Similar to
will include two additional fields: One and may also report on MIPS measures
how we identify the stewards of MIPS
that questions whether the QCDR as indicated in section II.C.10.b.(4) of
quality measures, we agree that it is
measure is owned by another QCDR, this final rule with comment period, the
important to identify when QCDR
and another that questions the QCDR data submission criteria section.
measures are owned by another QCDR. As the MIPS program progresses in its
In response, we are modifying our secondary QCDR to attest that it has
implementation, we are interested in
proposal, such that as a part of the self- received written permission to use
elevating the standards for which QCDR
nomination review process for the 2018 another QCDRs measure. We leave
measures are selected and approved for
performance period and future years, we these agreements and their details to
use. We are interested in further
will assign QCDR measure IDs once the QCDRs to determine. We may request
aligning our QCDR measure criteria
QCDR measure has been approved, and that the secondary QCDR provide proof
with that used under the Call for
the same measure ID must be used by that permission was received in
Quality Measures process, as is
any other QCDRs that have received instances where we seek further
described in the CY 2017 Quality
permission to also report the measure. If verification. As stated in our proposal,
a QCDR measure has been assigned a permission must be established by the
77151). We seek comment in this final
measure ID from a previous QCDR at the time of self-nomination.
rule with comment period, on whether
performance period, the secondary Final Action: After consideration of the standards used for selecting and
QCDR must use the previously assigned the public comments received, we are approving QCDR measures should align
measure ID and identify the QCDR that finalizing, with modification that more closely with the standards used for
the measure belongs to as a part of their beginning with the 2018 performance the Call for Quality Measures process
self-nomination application. As stated period and for future program years, for consideration in future rule making.
in our proposal above, permission must QCDRs can report on an existing QCDR
be granted at the time of self- measure that is owned by another (7) Collaboration of Entities To Become
nomination, so that the borrowing QCDR. In response to comments, we are a QCDR
QCDR using the measure can include modifying our proposal to also include In the CY 2017 Quality Payment
proof of permission in their application. that we will assign QCDR measure IDs Program final rule (81 FR 77377), we
Additionally, as finalized in section after the QCDR measure has been finalized policy on the collaboration of
II.C.10.b.(2)(b)(iii) of this final rule with approved, and the same measure ID entities to become a QCDR. In the CY
comment period, we will only accept must be used by other QCDRs that have 2018 Quality Payment Program
self-nomination applications through received permission to also report the proposed rule (82 FR 30161), we did not
the Web-based tool and will provide measure. Furthermore, the self- propose any changes to this policy.
additional guidance as to what nomination form that is available via the
information needs to be submitted for Web-based tool will be modified to c. Health IT Vendors That Obtain Data
QCDR measure specifications through include a field that will request QCDR From MIPS Eligible Clinicians Certified
the 2018 Self-Nomination User Guide measure IDs if the measure has been EHR Technology (CEHRT)
that will be posted on our Web site. To previously approved and assigned a In the CY 2017 Quality Payment
be clear, if a QCDR is requesting MIPS QCDR measure ID. Program final rule (81 FR 77382), we
permission to use another QCDRs We are also clarifying and updating at finalized definitions and criteria around
measure, the borrowing QCDR must use 414.1400(f)(3) that the QCDR must health IT vendors that obtain data from
the exact measure specification as publicly post the measure specifications MIPS eligible clinicians CEHRT. We
provided by the QCDR measure owner. no later than 15 calendar days, not note that, a health IT vendor that serves
We expect that if a QCDR measure business days, following our approval of as a third party intermediary to collect
owner implements a change to their these measures specifications for each or submit data on behalf MIPS eligible
QCDR measure, and the change is approved QCDR measure. clinicians may or may not also be a
health IT developer. We refer readers (2) Self-Nomination Process participate in MIPS for many years. In
to the CY 2018 Quality Payment (a) Generally the CY 2018 Quality Payment Program
Program proposed rule (82 FR 30161) proposed rule (82 FR 30161), we
for additional information regarding In the CY 2017 Quality Payment proposed, beginning with the 2019
health IT vendors. Throughout this rule, Program final rule (81 FR 77383 through performance period, a simplified
we used the term health IT vendor to 77384), we finalized procedures and process, to reduce the burden of self-
refer to entities that support the health requirements for qualified registries to nomination for those existing qualified
IT requirements of a clinician self-nominate. Additional details registries that have previously
participating in the Quality Payment regarding self-nomination requirements participated in MIPS and are in good
Program. for the self-nomination form can be standing (not on probation or
In the CY 2018 Quality Payment found in the qualified registry fact sheet disqualified, as described below), and to
Program proposed rule (82 FR 30161), and the self-nomination user guide, that allow for sufficient time for us to review
we did not propose any changes to this are posted in the resource library of the data submissions and make
policy in the proposed rule. However, Quality Payment Program Web site at determinations. Our proposals to
we sought comment for future https://qpp.cms.gov/about/resource- simplify the process for existing
rulemaking regarding the potential shift library. qualified registries in good standing
to seeking alternatives which might For the 2018 performance period, and with no changes, minimal changes, and
fully replace the QRDA III format in the for future years of the program, we those with substantive changes are
Quality Payment Program in future finalized in the CY 2017 Quality discussed below.
program years. We received a number of Payment Program final rule (81 FR
comments on this item and appreciate 77383) and 414.1400(g) a self- (i) Existing Qualified Registries in Good
the input received. As this was a request nomination period for qualified Standing, With No Changes
for comment only, we will take the registries from September 1 of the year In the CY 2018 Quality Payment
feedback provided into consideration prior to the applicable performance Program proposed rule (82 FR 30161),
for possible inclusion in future period, until November 1 of the same we proposed, beginning with the 2019
rulemaking. year. For example, for the 2018 performance period, a simplified
performance period, the self-nomination process for which existing qualified
d. Qualified Registries period would begin on September 1, registries in good standing may continue
In the CY 2017 Quality Payment 2017, and end on November 01, 2017. their participation in MIPS, by attesting
Program final rule (81 FR 77382 through Entities that desire to qualify as a that the qualified registrys previously
77386), we finalized the definition and qualified registry for purposes of MIPS approved: Data validation plan, cost to
capability of qualified registries. As for a given performance period will use the qualified registry, measures,
previously established, if an entity need to provide all requested activities, services, and performance
becomes qualified as a qualified information to us at the time of self- categories used in the previous years
registry, they will need to sign a nomination and would need to self- performance period of MIPS have no
statement confirming that this nominate for that performance period changes and will be used for the
information is currect prior to listing it (81 FR 77383). Having previously upcoming performance period.
on our Web site (81 FR 77383). Once we qualified as a qualified registry does not Specifically, existing qualified registries
post the qualified registry on our Web automatically qualify the entity to in good standing with no changes may
site, including the services offered by participate in subsequent MIPS attest during the self-nomination period,
the qualified registry, we will require performance periods (81 FR 77383). between September 1 and November 1,
the qualified registry to support these Furthermore, prior performance of the that they have no changes to their
services and measures for its clients as qualified registry (when applicable) will approved self-nomination application
a condition of the entitys participation be taken into consideration in approval from the previous year from the
as a qualified registry in MIPS (81 FR of their self-nomination. For example, a previous year of MIPS. By attesting that
77383). Failure to do so will preclude qualified registry may choose not to all aspects of their approved application
the qualified registry from participation continue participation in the program in from the previous year have not
in MIPS in the subsequent year (81 FR future years, or the qualified registry changed, these existing qualified
77383). In the CY 2018 Quality Payment may be precluded from participation in registries in good standing would be
Program proposed rule (82 FR 30161), a future year, due to multiple data or spending less time completing the entire
we did not propose any changes to the submission errors as noted in section self-nomination form, as was previously
definition or the capabilities of qualified II.C.10.f. of this final rule with comment required on a yearly basis.
registries. However, we did propose period. As such, we believe an annual
(ii) Existing Qualified Registries in Good
changes to the self-nomination process self-nomination process is the best
Standing With Minimal Changes
for the 2019 performance period. This is process to ensure accurate information
discussed in detail below. is conveyed to MIPS eligible clinicians Beginning with the 2019 performance
and accurate data is submitted to MIPS. period, existing qualified registries in
(1) Establishment of an Entity Seeking good standing that would like to make
In this final rule with comment period,
To Qualify as a Registry minimal changes to their previously
we are establishing a simplified process
In the CY 2017 Quality Payment for existing qualified registries in good approved self-nomination application
Program final rule (81 FR 77383), we standing. from the previous year, may submit
finalized the requirements for the these changes, and attest to no other
establishment of an entity seeking to (b) Simplified Self-Nomination Process changes from their previously approved
qualify as a registry. In the CY 2018 for Existing Qualified Registries in qualified registry application, for CMS
Quality Payment Program proposed rule MIPS, That Are in Good Standing review during the self-nomination
(82 FR 30161), we did not propose any We do understand that some qualified period, from September 1 to November
changes to the criteria regarding the registries may not have any changes to 1. In the CY 2018 Quality Payment
establishment of an entity seeking to the measures and/or activity inventory Program proposed rule (82 FR 30161),
qualify as a registry criteria. they offer to their clients and intend to we proposed that minimal changes
include: Limited changes to their in addition to minimal changes as (d) Web-Based Submission of Self-
supported performance categories, discussed in the section above, to their Nomination Forms
adding or removing MIPS quality previously approved self-nomination In the CY 2018 Quality Payment
measures, adding or updating existing form from the previous year, during the Program proposed rule (82 FR 30162),
services and/or the costs to use the annual self-nomination period. We are for the 2018 performance period and
registry. also clarifying that substantive changes beyond, we proposed that self-
may include, but are not limited to: nomination information must be
(iii) Existing Qualified Registries in
Updates to a qualified registrys data submitted via a Web-based tool, and to
Good Standing With Substantive
validation plan, or a change in the eliminate the submission method of
Changes
qualified registrys organization
In the CY 2018 Quality Payment email. We noted that we will provide
structure that would impact any aspect
Program proposed rule (82 FR 30161), further information about the web-based
of the qualified registry. We are also
we inadvertently left out language in the tool at www.qpp.cms.gov.
clarifying that the information required
preamble that explained our proposed We invited public comment on: (1)
to be submitted for any changes would
updates to 414.1400(g), which were Our proposals regarding a simplified
be the same as that required under the
included in the proposed amendments self-nomination process beginning with
normal self-nomination process as
to 42 CFR chapter IV at 82 FR 30255, the 2019 performance period for
previously finalized. We refer readers to
and stated that: previously approved qualified registries
the CY 2017 Quality Payment Program
For the 2018 performance period and in good standing; (2) multi-year
final rule (81 FR 77383 through 77384),
future years of the program, the approvals; and (3) our proposal to
where we finalized the information a
qualified registry must self-nominate submit self-nomination information via
qualified registry must provide to us at
from September 1 of the prior year until a web-based tool. The following is a
the time of self-nomination as well as
November 1 of the prior year. Entities (82 FR 30162) and 414.1400(g). summary of the public comments
that desire to qualify as a qualified received on the Self-Nomination
registry for a given performance period (c) Multi-Year Approval of Qualified Period proposals and our responses:
must self-nominate and provide all Registries Comment: A few commenters
information requested by CMS at the In the development of the above supported the proposal to allow a
time of self-nomination. Having proposal, we had also reviewed the simplified self-nomination process for
qualified as a qualified registry does not possibility of offering a multi-year qualified registries in good standing for
automatically qualify the entity to approval, in which qualified registries reasons including a belief it would be
participate in subsequent MIPS would be approved for a 2-year more efficient.
performance periods. Beginning with increment of time. However, we are Response: We thank the commenters
the 2019 performance period, existing concerned that utilizing a multi-year for their support.
qualified registries that are in good approval process would restrict Comment: A few commenters
standing may attest that certain aspects qualified registries by having them supported the proposal that beginning
of their previous years approved self- support the same fixed services they with the 2018 performance period self-
nomination have not changed and will had for the first year, and would not nomination information for a qualified
be used for the upcoming performance provide qualified registries with the registry must be submitted via a Web-
period. CMS may allow existing flexibility to add or remove services, based tool, rather than email, because
qualified registries in good standing to measures, and/or activities based on they believed it will simplify the
submit minimal or substantive changes their qualified registrys capabilities for process.
to their previously approved self- the upcoming year. Furthermore, under Response: We thank the commenters
nomination form from the previous a multi-year approval process, qualified for their support.
year, during the annual self-nomination registries would not be able to make Comment: One commenter requested
period, for CMS review and approval changes to their organizational structure clarification on the proposal for
without having to complete the entire (as noted above) and would also create simplification of the self-nomination
qualified registry self-nomination complications in our process for placing process for qualified registries,
application process. qualified registries who perform poorly specifically to confirm: (1) For 2018, the
This language mirrors that proposed (during the first year) on probation or only proposed change from 2017 is that
for QCDRs (82 FR 30255) and finalized disqualifying them (as described below). the self-nomination submission process
above in section II.C.10.b. of this final Moreover, a multi-year approval process will be via a web-based tool rather than
rule with comment period. Our would not take into consideration email; and (2) it is not until 2019 that
intention was to parallel the simplified potential changes in criteria or the self-nomination submission process
self-nomination process available to requirements of participation for will be replaced with the attestation for
QCDRs in good standing beginning with qualified registries, that may occur as existing qualified registries.
the 2019 performance period, including the MIPS program develops through Response: For the 2018 performance
for substantive changes, such that future program years. For the reasons period, the only change proposed is that
Qualified Registries could do the same. stated above, we believe an annual self- self-nomination submission will occur
The update to 414.1400(g), as included nomination period is appropriate. We via a web-based tool rather than email.
in the proposed rule, allows a qualified understand that stakeholders are The simplified self-nomination process
registry to also submit substantive interested in a multi-year approval would be available for qualified
changes, in addition to minor changes, process, for that reason we intend to registries in good standing beginning
through the simplified self-nomination revisit the topic once we have gained with the 2019 performance period. In
process. Therefore, we are clarifying additional experience with the self- addition, in order to align with the
here in this final rule with comment nomination process under MIPS. We QCDR process finalized above, we are
period that beginning with the 2019 seek comment from stakeholders as to providing clarification here. We
performance period, CMS may allow how they believe our aforementioned recognize that the existing process and
existing qualified registries in good concerns with multi-year approvals of our proposals could use additional
standing to submit substantive changes, qualified registries can be resolved. clarification. The qualified registry self-
nomination form requires: contact changes only to its MIPS quality (that are not on probation or
information, services, costs associated measures, the qualified registry can disqualified) that wish to self nominate
with using the qualified registry, attest that there are no changes to their using the simplified process can attest,
performance categories supported, MIPS self-nomination form, and provide in whole or in part, that their previously
quality measures, and data validation updated MIPS quality measures approved form is still accurate and
plan to be considered for the next information for CMS review and applicable. We are clarifying our
performance period (81 FR 77383 approval. We are also clarifying that the proposals by elaborating on what would
through 77384). Details regarding self- information required to be submitted for be required for previously approved
nomination requirements can be found any changes would be the same as that qualified registries in good standing that
in the qualified registry fact sheet and required under the normal self- wish to self-nominate and have changes.
the self-nomination user guide, that are nomination process. We refer readers to For abundant clarity, we are restating
posted in the resource library of the the CY 2017 Quality Payment Program our finalized proposals with
Quality Payment Program Web site at final rule (81 FR 77383 through 77384), clarifications here:
https://qpp.cms.gov/about/resource- where we finalized the information a Beginning with the 2019 performance
library. qualified registry must provide to us at period, any previously approved
Under our proposals, we are clarifying the time of self-nomination as well as qualified registry in good standing
that beginning with the 2019 (82 FR 30162) and 414.1400(g). (meaning, those that are not on
performance period, any previously Comment: One commenter supported probation or disqualified) that wishes to
approved qualified registry in good the simplified self-nomination process self nominate using the simplified
standing (meaning, those that are not on available for QCDRs and qualified process can attest, in whole or in part,
probation or disqualified) that wishes to registries. Specifically that existing that their previously approved form is
self nominate using the simplified QCDRs and qualified registries in good still accurate and applicable.
process can attest, in whole or in part, standing may also make substantive or Specifically, under this process,
that their previously approved form is minimal changes to their approved self- qualified registries with no changes can
still accurate and applicable. nomination application from the attest that their previously submitted
Specifically, under this process, previous year of MIPS that would be qualified registry self-nomination form
qualified registries with no changes can submitted during the self-nomination in its entirety remains the same.
attest that their previously submitted period for CMS review and approval. Similarly, previously approved
qualified registry self-nomination form Response: We thank the commenter qualified registries in good standing that
in its entirety remains the same. for their support. As clarified above, in wish to self nominate using the
Similarly, previously approved the CY 2018 Quality Payment Program simplified process and have minimal
qualified registries in good standing that proposed rule, we inadvertently left out changes can attest to aspects of their
wish to self nominate using the language in the preamble that explained previously submitted form that remain
simplified process and have minimal our proposed updates to 414.1400(g), the same, but would additionally be
changes can attest to aspects of their which were included in the proposed required to update and describe any
previously submitted form that remain rule at 82 FR 30255. The update to minimal changes in their self-
the same, but would additionally be 414.1400(g) would allow a qualified nomination application for our review
required to outline any minimal changes registry to also submit substantive and approval. Minimal changes include,
for our review and approval through the changes, in addition to minor changes, but are not limited to: limited changes
self-nomination review process. through the simplified self-nomination to performance categories, adding or
Additional instructions regarding the process. We refer readers to our removing MIPS quality measures, and
completion of this simplified self- clarification for existing Qualified adding or updating existing services
nomination form will be available on Registries in good standing with and/or cost information.
our Web site prior to the start of the self- substantive changes as discussed above. We are also clarifying that any
nomination process for the 2019 Comment: One commenter previously approved qualified registry
performance period. As stated in our recommended that CMS allow qualified in good standing that wishes to self
proposal above, minimal changes registries to report existing QCDR nominate using the simplified process
include, but are not limited to: Limited measures, using the same approval and has substantive changes may submit
changes to performance categories, process that QCDRs would use. those substantive changes while
adding or removing MIPS quality Response: Currently, qualified attesting that the remainder of their
measures, and adding or updating registries are limited to reporting MIPS application remains the same from the
existing services and/or cost quality measures that currently exist in previous year. Substantive changes
information. the program, as described in the CY include, but are not limited to: Changes
Furthermore, we are also clarifying 2017 Quality Payment Program final in the qualified registrys data validation
that any previously approved qualified rule (81 FR 77384). Should an entity plan, or changes in the qualified
registry in good standing that wishes to wish to report on existing, approved registrys organizational change in the
self nominate using the simplified QCDR measures they should consider qualified registrys organization
process can submit substantive changes self-nominating as a QCDR. However, structure that would impact any aspect
while attesting that the remainder of we will take the commenters feedback of the qualified registry. We are
their application remains the same from into consideration as we develop future clarifying that the information required
the previous year. Substantive changes policies. to be submitted for any changes would
include, but are not limited to: Updates Final Action: After consideration of be the same as that required under the
to the qualified registrys data validation the public comments received, we are normal self-nomination process as
plan, or a change in the qualified finalizing our proposals with previously finalized. Therefore, we are
registrys organization structure that clarifications. Specifically at 414.1400 finalizing at 414.1400(g) the following:
would impact any aspect of the (5)(g), we are finalizing our proposal, for the 2018 performance period and
qualified registry. For example, if a beginning with the 2019 performance future years of the program, the
previously approved qualified registry period, that previously approved qualified registry must self-nominate
in good standing would like to submit qualified registries in good standing from September 1 of the prior year until
November 1 of the prior year. Entities eligible clinician or group; as well as the period conflicts with the timeframe in
that desire to qualify as a qualified qualified registrys disclosure of quality which groups can elect to participate in
registry for a given performance period measure results and numerator and the CAHPS for MIPS survey. We would
must self-nominate and provide all denominator data or patient specific like to clarify that the current CAHPS
information requested by us at the time data on Medicare and non-Medicare for MIPS survey vendor application
of self-nomination. Having qualified as beneficiaries on behalf of individual deadline from the 2017 performance
a qualified registry does not MIPS eligible clinicians and groups. As period of April 30th conflicts with the
automatically qualify the entity to stated in the CY 2018 Quality Payment timeframe in which groups can elect to
participate in subsequent MIPS Program proposed rule (82 FR 30162), participate in the CAHPS for MIPS
performance periods. Beginning with we are clarifying that the Business survey, of April 1st to June 30th. In
the 2019 performance period, existing Associate agreement must comply with order to provide a final list of CMS-
qualified registries that are in good the HIPAA Privacy and Security Rules. approved survey vendors earlier in the
standing may attest that certain aspects We had finalized in the CY 2017 timeframe during which groups can
of their previous years approved self- Quality Payment Program final rule (81 elect to participate in the CAHPS for
nomination have not changed and will FR 77384) that timely feedback be MIPS survey, an earlier vendor
be used for the upcoming performance provided at least four times a year, on application deadline would be
period. We may allow existing qualified all of the MIPS performance catgeories necessary. This could be accomplished
registries in good standing to submit that the qualified registry will report to by having a rolling application period,
minimal or substantive changes to their us. We are clarifying that readers should where vendors would be able to submit
previously approved self-nomination refer to section II.C.9.a. of this rule for an application by the end of the first
form from the previous year, during the additional information on third party quarter. The rolling application period
annual self-nomination period, for our intermediaries and performance that would end by the first quarter
review and approval without having to feedback. would allow us to adjust the application
complete the entire qualified registry We refer readers to the CY 2017 deadline beyond January 31st on a year
self-nomination application process. Quality Payment Program final rule (81 to year basis, based on program needs.
We are also finalizing, as proposed, FR 77370) for additional information on However, in addition to submitting a
that for the 2018 performance period allowing qualified registries ability to vendor application, vendors must also
and beyond: (1) Self-nomination request CMS approval to support complete vendor training and submit a
information must be submitted via a additional MIPS quality measures. Quality Assurance Plan and we need to
web-based tool, and (2) we are e. CMS-Approved Survey Vendors allow sufficient time for these
eliminating the submission method of requirements as well.
email. We will provide further In the CY 2017 Quality Payment Therefore, in the CY 2018 Quality
information on the web-based tool at Program final rule (81 FR 77386), we Payment Program proposed rule (82 FR
www.qpp.cms.gov. finalized the definition, criteria, 30162 through 30163), we proposed for
required forms, and vendor business the 2018 performance period of the
(3) Information Required at the Time of requirements needed to participate in Quality Payment Program and future
Self-Nomination MIPS as a survey vendor. In the CY years that the vendor application
We finalized in the CY 2017 Quality 2018 QPP proposed rule (82 FR 30162), deadline would be January 31st of the
Payment Program final rule (81 FR we did not propose changes to those applicable performance year or a later
77384) that a qualified registry must policies. However, in the CY 2016 PFS date specified by CMS. The proposal
provide specific information to us at the rule (80 FR 71143) we heard from some would allow us to adjust the application
time of self-nomination. In the CY 2018 groups that it would be useful to have deadline beyond January 31st on a year
Quality Payment Program proposed rule a final list of CMS-approved survey to year basis, based on program needs.
(82 FR 30162), we did not propose any vendors to inform their decision on We would notify vendors of the
changes to this policy. whether or not to participate in the application deadline to become a CMS-
CAHPS for MIPS survey. Therefore, in approved survey vendor through
(4) Qualified Registry Criteria for Data the proposed rule, we proposed to additional communications and
Submission change the survey vendor application postings on the Quality Payment
In the CY 2017 Quality Payment deadline in order to timely display a Program Web site, qpp.cms.gov. We
Program final rule (81 FR 77386), we final list of CMS-approved survey requested comments on this proposal
finalized the criteria for qualified vendors. This is discussed in more and other alternatives that would allow
registry data submission. In the CY 2018 detail below. us to provide a final list of CMS-
Quality Payment Program proposed rule approved survey vendors early in the
(82 FR 30162), we did not propose any (1) Updated Survey Vendor Application
timeframe during which groups can
changes to this policy. Although no Deadline
elect to participate in the CAHPS for
changes were proposed, however we In the CY 2017 Quality Payment MIPS survey.
made two clarifications to the existing Program final rule (81 FR 77386), we We did not receive any comments
criteria: finalized a survey vendor application related to this proposal.
In the CY 2017 Quality Payment deadline of April 30th of the Final Action: We are finalizing our
Program final rule (81 FR 77385), we performance period. We also finalized policy, as proposed, therefore beginning
specify that qualified registries must that survey vendors would be required with the 2018 performance period and
enter into and maintain with its to undergo training, to meet our for future years, the vendor application
participating MIPS eligible clinicians an standards on how to administer the deadline will be January 31st of the
appropriate MIPS eligible clinicians an survey, and submit a quality assurance applicable performance year or a later
appropriate Business Associate plan (81 FR 77386). In the CY 2018 date specified by CMS as discussed in
agreement. The Business Associate Quality Payment Program proposed rule this final rule with comment period.
agreement should provide for the (82 FR 3016230163), we noted that the Therefore, we are finalizing at
qualified registrys receipt of patient- current CAHPS for MIPS survey 414.1400(i), the following: Vendors are
specific data from an individual MIPS timeframe from the 2017 performance required to undergo the CMS approval
process for each year in which the as a condition of their qualification and same changes and allow us to request
survey vendor seeks to transmit survey approval to participate in MIPS as a any records or data retained for the
measures data to CMS. Applicants must third party intermediary: purposes of MIPS for up to 6 years from
adhere to any deadlines specified by (1) The entity must make available to the end of the MIPS performance
CMS. us the contact information of each MIPS period. We believe this change will
eligible clinician or group on behalf of promote consistent and cohesive
f. Probation and Disqualification of a whom it submits data. The contact policies across this program.
Third Party Intermediary information will include, at a minimum,
At 414.1400(k), we finalized the the MIPS eligible clinician or groups 11. Public Reporting on Physician
process for placing third party practice phone number, address, and if Compare
intermediaries on probation and for available, email; This section contains the approach for
disqualifying such entities for failure to (2) The entity must retain all data public reporting on Physician Compare
meet certain standards established by us submitted to us for MIPS for a minimum for year 2 of the Quality Payment
(81 FR 77386). Specifically, we of 10 years; and Program (2018 data available for public
proposed that if at any time we (3) For the purposes of auditing, we reporting in late 2019) and future years,
determine that a third party may request any records or data retained including MIPS, APMs, and other
intermediary (that is, a QCDR, health IT for the purposes of MIPS for up to 6 information as required by the MACRA
vendor, qualified registry, or CMS- years and 3 months. and building on the MACRA public
approved survey vendor) has not met all In the CY 2018 Quality Payment reporting policies previously finalized
of the applicable criteria for Program proposed rule (82 FR 30163), (81 FR 77390 through 77399).
qualification, we may place the third we proposed to update 414.1400(j)(2) Physician Compare draws its
party intermediary on probation for the from stating that the entity must retain operating authority from section
current performance period or the all data submitted to us for MIPS for a 10331(a)(1) of the Affordable Care Act.
following performance period, as minimum of 10 years to state that the As required by section 10331(a)(1) of the
applicable (81 FR 77389). We refer entity must retain all data submitted to Affordable Care Act, by January 1, 2011,
readers to the CY 2018 Quality Payment us for purposes of MIPS for a minimum we developed a Physician Compare
Program proposed rule (81 FR 30163) of 10 years from the end of the MIPS Internet Web site with information on
for additional information regarding the performance period. physicians enrolled in the Medicare
probation and disqualification process. We invited public comment on our program under section 1866(j) of the
In the CY 2017 Quality Payment proposal, but did not receive any. Act, as well as information on other EPs
Program final rule with comment (81 FR Final Action: We are finalizing our who participate in the PQRS under
77388), we stated that MIPS eligible proposal with modification. We are section 1848 of the Act. More
clinicians are ultimately responsible for modifying the record retention information about Physician Compare
the data that are submitted by their third provision at 414.1400(j)(2) to align can be accessed on the Physician
party intermediaries and expect that with the record retention provisions Compare Initiative Web site at https://
MIPS eligible clinicians and groups elsewhere in this final rule with www.cms.gov/medicare/quality-
should ultimately hold their third party comment period. We refer readers to initiatives-patient-assessment-
intermediaries accountable for accurate section II.C.9.c. of this final rule with instruments/physician-compare-
reporting. We also stated that we would comment period where we discuss and initiative/.
consider from the MIPS eligible respond to public comments we The first phase of Physician Compare
clinicians and groups perspective, cases received on our proposal to add a new was launched on December 30, 2010
of vendors leaving the marketplace (81 paragraph (d) at 414.1390, codifying (http://www.medicare.gov/
FR 77388) during the performance our record retention policy for MIPS physiciancompare). Since the initial
period on a case by case basis, but that eligible clinicians and groups. Based on launch, Physician Compare has been
we will not consider cases prior to the comments we received on the 10 year continually improved, and more
performance period. Furthermore, we record retention period at 414.1390(d) information has been added. In
stated that we would need proof that the regarding time and financial burden in December 2016, the site underwent a
MIPS eligible clinician had an managing, storing, and retrieving data complete user-informed, evidenced-
agreement in place with the vendor at and information, and our interest in based redesign to further enhance
the time of their withdrawal from the reducing financial and time burdens usability and functionality on both
marketplace. under this program and having desktop computers and mobile devices
While we did not propose any consistent policies across this program, and to begin to prepare the site for the
changes to the process of probation and we are modifying our proposed 10-year inclusion of more data as required by
disqualification of a third party retention requirement at 414.1400(j)(2) the MACRA.
intermediary in the CY 2018 Quality to a 6-year retention requirement. Consistent with section 10331(a)(2) of
Payment Program proposed rule (82 FR Similarly, we finalized in the CY 2017 the Affordable Care Act, Physician
30163), we received a number of Quality Payment Program final rule (81 Compare initiated a phased approach to
comments on this item and appreciate FR 7738977390) at 414.1400(j)(3) that public reporting performance scores that
the input received. for the purposes of auditing, we may provide comparable information on
request any records or data retained for quality and patient experience measures
g. Auditing of Third Party the purposes of MIPS for up to 6 years for reporting periods beginning January
Intermediaries Submitting MIPS Data and 3 months. While we did not 1, 2012. The first set of quality measures
In the CY 2017 Quality Payment propose any changes or updates to this were publicly reported on Physician
Program final rule (81 FR 77389), we policy in the CY 2018 QPP proposed Compare in February 2014. A complete
finalized at 414.1400(j) that any third rule, based on our modifications to history of public reporting on Physician
party intermediary (that is, a QCDR, 414.1390(d) and 414.1400(j)(2), as Compare is detailed in the CY 2016 PFS
health IT vendor, qualified registry, or discussed previously in this final rule final rule (80 FR 71117 through 71122).
CMS-approved survey vendor) must with comment period, we are also The Physician Compare Initiative Web
comply with the following procedures updating 414.1400(j)(3) to reflect these site at https://www.cms.gov/medicare/
quality-initiatives-patient-assessment- Affordable Care Act, and like all and the four performance categories of
instruments/physician-compare- measure data included on Physician MIPS. All data available for public
initiative/ is regularly updated to Compare, will be comparable. In reportingmeasure rates, scores, and
provide information about what is addition, section 10331(b) of the attestations, etc.are available for
currently available on the Web site. Affordable Care Act requires that we review and correction during the
As finalized in the CY 2015 and CY include, to the extent practicable, targeted review process, which will
2016 PFS final rules (79 FR 67547 and processes to ensure that data made begin at least 30 days in advance of the
80 FR 70885, respectively), Physician public are statistically valid, reliable, publication of new data. Data under
Compare will continue to expand public and accurate, including risk adjustment review is not publicly reported until the
reporting. This expansion includes mechanisms used by the Secretary. In review is complete. All corrected
publicly reporting both individual addition to the public reporting measure rates, scores, and attestations
eligible professional (now referred to as standards identified in the Affordable submitted as part of this process are
eligible clinician) and group-level QCDR Care Act, we have established a policy available for public reporting. The
measures starting with 2016 data that, as determined through user testing, technical details of the process are
available for public reporting in late the data we disclose generally should communicated directly to affected
2017, as well as the inclusion of a 5-star resonate with and be accurately eligible clinicians and groups and
rating based on a benchmark in late interpreted by Web site users to be detailed outside of rulemaking with
2017 based on 2016 data (80 FR 71125 included on Physician Compare profile specifics made public on the Physician
and 71129), among other additions. pages. Together, we refer to these Compare Initiative page on
This expansion will continue under conditions as the Physician Compare www.cms.gov and communicated
the MACRA. Sections 1848(q)(9)(A) and public reporting standards (80 FR 71118 through Physician Compare and other
(D) of the Act facilitate the continuation through 71120). Section 10331(d) of the CMS listservs (81 FR 77391).
of our phased approach to public Affordable Care Act also requires us to In addition, section 1848(q)(9)(D) of
reporting by requiring the Secretary to consider input from multi-stakeholder the Act requires that aggregate
make available on the Physician groups, consistent with sections information on the MIPS be periodically
Compare Web site, in an easily 1890(b)(7) and 1890A of the Act. We posted on the Physician Compare Web
understandable format, individual MIPS continue to receive general input from site, including the range of final scores
eligible clinician and group stakeholders on Physician Compare for all MIPS eligible clinicians and the
performance information, including: through a variety of means, including range of performance for all MIPS
The MIPS eligible clinicians final rulemaking and different forms of eligible clinicians for each performance
score; stakeholder outreach (for example, category.
The MIPS eligible clinicians Town Hall meetings, Open Door Lastly, section 104(e) of the MACRA
performance under each MIPS Forums, webinars, education and requires the Secretary to make publicly
performance category (quality, cost, outreach, the Technical Expert Panel available, on an annual basis, in an
improvement activities, and advancing convened by our Physician Compare easily understandable format,
care information); support team contractor, etc.). information for physicians and, as
Names of eligible clinicians in In addition, section 1848(q)(9)(C) of appropriate, other eligible clinicians
Advanced APMs and, to the extent the Act requires the Secretary to provide related to items and services furnished
feasible, the names of such Advanced an opportunity for eligible clinicians to to people with Medicare, and to
APMs and the performance of such review the information that will be include, at a minimum:
models; and, publicly reported prior to such Information on the number of
Aggregate information on the MIPS, information being made public. This is services furnished by the physician or
posted periodically, including the range generally consistent with section other eligible clinician under Part B,
of final scores for all MIPS eligible 10331(a)(2) of the Affordable Care Act, which may include information on the
clinicians and the range of the under which we have established a 30- most frequent services furnished or
performance of all MIPS eligible day preview period for all measurement groupings of services;
clinicians for each performance performance data that allows physicians Information on submitted charges
category. and other eligible clinicians to view and payments for Part B services; and,
Initial plans to publicly report this their data as it will appear on the Web A unique identifier for the
performance information on Physician site in advance of publication on physician or other eligible clinician that
Compare were finalized in the CY 2017 Physician Compare (80 FR 77392). is available to the public, such as an
Quality Payment Program final rule (81 Section 1848(q)(9)(C) of the Act also NPI.
FR 77390). The proposals related to requires that eligible clinicians be able The information is further required to
each of these requirements for year 2 of to submit corrections for the be made searchable by at least specialty
the Quality Payment Program are information to be made public with or type of physician or other eligible
summarized below in this section. respect to the eligible clinician. We clinician; characteristics of the services
Section 1848(q)(9)(B) of the Act also finalized a policy to continue the furnished (such as volume or groupings
requires that this information indicate, current Physician Compare 30-day of services); and the location of the
where appropriate, that publicized preview period for MIPS eligible physician or other eligible clinician.
information may not be representative clinicians starting with data from the In accordance with section 104(e) of
of the eligible clinicians entire patient 2017 MIPS performance period, which the MACRA, we finalized a policy in the
population, the variety of services will be available for public reporting in CY 2016 PFS final rule (80 FR 71130)
furnished by the eligible clinician, or late 2018. Therefore, we finalized a 30- to add utilization data to the Physician
the health conditions of individuals day preview period in advance of the Compare downloadable database.
treated. The information mandated for publication of data on Physician Utilization data is currently available at
Physician Compare under section Compare (81 FR 77392). http://www.cms.gov/Research-Statistics-
1848(q)(9) of the Act will generally be We will coordinate data review and Data-and-Systems/Statistics-Trends-
publicly reported consistent with any relevant data resubmission or and-Reports/Medicare-Provider-Charge-
sections 10331(a)(2) and 10331(b) of the correction between Physician Compare Data/Physician-and-Other-
Supplier.html. This information is performance categories. After the first provide the public with potentially
integrated on the Physician Compare year, CMS reevaluates measures to valuable information after clinicians
Web site via the downloadable database determine when and if they are suitable and groups have had a chance to review
each year using the most current data, for public reporting. At 414.1395(d), and understand the initial results and
starting with the 2016 data, targeted for we proposed to specify the 30-day the measure is deemed to meet all
initial release in late 2017 (80 FR preview period to state that for each public reporting criteria. We believe the
71130). Not all available data will be program year, CMS provides a 30-day benefit of releasing the data in a timely
included. The specific HCPCS codes preview period for any clinician or manner is significant, especially for the
included are to be determined based on group with Quality Payment Program more established quality data. We will
analysis of the available data, focusing data before the data are publicly carefully evaluate the cost measure data
on the most used codes. Additional reported on Physician Compare. after the first year, understanding this is
details about the specific HCPCS codes The following is a summary of the new and complex information. With the
that are included in the downloadable public comments received on the exception of data that must be
database will be provided to the public proposed changes and additions to the mandatorily reported on Physician
in advance of data publication. All data regulation text at 414.1395(a) through Compare, if certain cost measure data is
available for public reportingon the 414.1395(d) and our responses: determined under our established
public-facing Web site pages or in the Comment: No specific comments were public reporting standards not to be
downloadable databaseare available received regarding our proposal at suitable for public reporting, it will not
for review during the 30-day preview 414.1395(a) of the regulation text. be reported. Also, as discussed in
period. Multiple commenters supported our greater detail in this final rule with
proposal at 414.1395(b) to only comment period, we will proceed with
We proposed to revise the public include information on Physician
reporting regulation at 414.1395(a) to our phased approach to public
Compare that meets our established reporting, addressing requests to move
more completely and accurately public reporting standards. One
reference the data available for public forward with public reporting gradually.
commenter questioned how CMS would Concerning the support for our 30-day
reporting on Physician Compare and to determine which measures meet these preview period, we do understand the
remove from the heading and text criteria. All commenters supported our concerns raised about having ample
references to MIPS and public Web proposal at 414.1395(c) not to publicly time to review and contest data, if
site and instead reference Quality report first year quality and cost needed, but we do not believe a longer
Payment Program and Physician measures. Several commenters preview period is necessary.
Compare. Specifically, we proposed to requested that CMS not report quality or Historically, clinicians and groups have
modify 414.1395(a) to read as follows: cost measures for the first 3 years a not initiated the preview process until
Public reporting of eligible clinician measure is in use. Commenters near the end of the process, so we do
and group Quality Payment Program specifically requested that CMS add not think that extending the preview
information. For each program year, data to Physician Compare gradually, period will provide additional value.
CMS posts on Physician Compare, in an specifically new data such as cost We are actively working to ensure the
easily understandable format, information. Finally, multiple preview process is more streamlined
information regarding the performance commenters supported our proposal at and user-friendly under the Quality
of eligible clinicians or groups under the 414.1395(d) to provide a30-day Payment Program, which should also
Quality Payment Program. We also preview period for data prior to facilitate more easily obtaining the
proposed to add paragraphs (b), (c), and publication on Physician Compare. information needed to assist with
(d) at 414.1395, to capture previously However, many commenters requested previewing data. In addition, we are
established policies for Physician that the preview period be extended. actively working to provide more
Compare relating to the public reporting Specifically, commenters requested an information about the preview timeline
standards, first year measures, and the extension to 45 days, 60 days, and 90 and process each year through
30-day preview period. Specifically, at days. Commenters explained this would stakeholder outreach and the Physician
414.1395(b), we proposed that, with provide more time to review data, Compare listserv. In light of these
the exception of data that must be identify possible errors, and provide the efforts, we believe the 30-day preview
mandatorily reported on Physician needed documentation to CMS for period is sufficient.
Compare, for each program year, we rely consideration. Some commenters noted Final Action: After consideration of
on the established public reporting a longer preview period would be the public comments, we are finalizing
standards to guide the information consistent with the Open Payments our proposed changes and additions to
available for inclusion on Physician Program. the regulation text at 414.1395(a)
Compare. The public reporting Response: As indicated in the through 414.1395(d).
standards require data included on proposed rule (82 FR 30164), substantial We believe section 10331 of the
Physician Compare to be statistically statistical testing and user testing with Affordable Care Act supports the
valid, reliable, and accurate; be patients and caregivers is conducted to overarching goals of the MACRA by
comparable across submission determine which measures meet these providing the public with quality
mechanisms; and, meet the reliability criteria. Additional information about information that will help them make
threshold. And, to be included on the this testing and our findings will be informed decisions about their health
public facing profile pages, the data shared on the Physician Compare care, while encouraging clinicians to
must also resonate with Web site users, Initiative page on www.cms.gov. improve the quality of care they provide
as determined by CMS. At 414.1395(c), Concerning the commenters support to their patients. In accordance with
we proposed to codify our policy for not including first year quality and section 10331 of the Affordable Care
regarding first year measures to state cost measures, we understand the Act, section 1848(q)(9) of the Act, and
that for each program year, CMS does request to further delay measures, but as section 104(e) of the MACRA, we plan
not publicly report any first year we discuss in more detail later in this to continue to publicly report
measure, meaning any measure in its final rule with comment period, we do performance information on Physician
first year of use in the quality and cost not find added value in waiting to Compare. As such, we proposed the
inclusion of the following information wait to publish composite or aggregate program to ensure the data made public
on Physician Compare. information until further testing is most accurately represents clinical
completed, though some of these performance and is best understood by
a. Final Score, Performance Categories,
commenters supported the inclusion of Web site users. Regarding concerns
and Aggregate Information
as much information as possible in the raised about the interpretation of
Sections 1848(q)(9)(A) and (D) of the downloadable database. Commenters missing data or a lack of data, this is a
Act require that we publicly report on noted concern that the Pick Your Pace concept that has been tested with users
Physician Compare the final score for option of participation in the early years under the legacy PQRS program. To
each MIPS eligible clinician and the of MIPS could make final score and date, we have found that users
performance of each MIPS eligible aggregate information non-comparable understand there are many reasons a
clinician for each performance category, and thus recommended against clinician or group may not have data on
and that we periodically post aggregate reporting it. the Web site, and they understand this
information on the MIPS, including the Response: We appreciate both the is just the start of the public reporting
range of final scores for all MIPS eligible support for this proposal and the process. We will actively work to ensure
clinicians and the range of performance concern raised regarding additional that the language on the Web site and
of all the MIPS eligible clinicians for testing. Analysis and user testing of the the additional education and outreach
each performance category. We finalized final score and aggregate information, as conducted for patients and caregivers
such data for public reporting on with all data available for public continues to make this message clear.
Physician Compare for the transition reporting, will be ongoing, and we will Comment: Three commenters did not
year (81 FR 77393), and we proposed to actively work to share the results of this support publicly reporting individual
add these data each year to Physician testing with stakeholders through measures, and noted that more testing of
Compare for each MIPS eligible outreach and via the Physician Compare these measures was needed prior to
clinician or group, either on the profile Initiative page on cms.gov. User testing public reporting. Another commenter
pages or in the downloadable database, will also address the concern as to supported including all data in the
as technically feasible (82 FR 30165 whether these data help patients and downloadable database, but not
through 30166). We will use statistical caregivers make health care decisions. including the data on profile pages until
testing and user testing, as well as We are taking steps to address concerns more patient testing was done. This
consultation with the Physician around the comparability of data and commenter also suggested that CMS
Compare Technical Expert Panel the Pick Your Pace options. With the obtain feedback on specific measures
convened by the Physician Compare exception of data that must be being considered for inclusion on
support team contractor, to determine mandatorily reported on Physician profile pages. Another commenter
how and where these data are best Compare, all data considered for public cautioned that data included in the
reported on Physician Compare. As the reporting must meet our established downloadable database could be
MACRA requires that this information public reporting standards. These misinterpreted by third-party users and
be available for public reporting on include ensuring the data are used to mislead the public.
Physician Compare, we proposed to comparable. Therefore, analyses will be Response: We have started the process
include it each year moving forward, as done to ensure the chosen participation of testing the data available under the
technically feasible. We requested approach does not lead to non- Quality Payment Program with patients
comment on this proposal to publicly comparable data on Physician Compare. and caregivers. All data considered for
report on Physician Compare the final Comment: Many commenters inclusion on Physician Compare profile
score for each MIPS eligible clinician or supported publicly reporting all MIPS pages must be tested with patients and
group and the performance of each measures, activities, and objectives caregivers prior to being included on the
MIPS eligible clinician or group for each across the four performance categories Web site. We conduct extensive one-on-
performance category, and to as proposed. One commenter one testing to review all performance
periodically post aggregate information specifically requested that CMS release information under consideration for
on the MIPS, including the range of all data, not subsets of data. If subsets inclusion on the profile pages with both
final scores for and the range of are reported, the commenter requested patients and caregivers around the
performance of all the MIPS eligible that more information be made public country to ensure they understand the
clinicians or groups for each about what was not released so it is information, accurately interpret it, and
performance category, as technically clear what was and was not being find it useful in decision-making. Again,
feasible. provided to the public. Multiple all data that are considered for public
The following is a summary of the commenters raised concerns about how reporting on Physician Compare profile
public comments received on the Final missing data or a lack of data would be pages must meet our public reporting
Score, Performance Categories, and interpreted by Web site users. In standards, and this includes that the
Aggregate Information proposals and general, commenters who supported our data be accurately interpreted by
our responses: proposals to publicly report the MIPS patients and caregivers. We do
Comment: Many commenters data cited the importance of understand concerns around the use of
supported the inclusion of final score transparency and the benefit for patients the downloadable database by third-
and other aggregate information on the and caregivers to have access to these party users and will take these into
Web site, appreciating that public data when making health care decisions. account when considering the data to be
reporting is statutorily-mandated. Response: We agree that reporting included. As noted, final decisions on
However, multiple commenters opposed these data facilitates transparency and which data are included will be
reporting these data, citing concerns provides useful information to patients determined based on statistical and user
regarding whether the data reflect and caregivers. We also understand the testing. In order for data to be reported
clinicians true performance, as well as desire to have full transparency, but as in as timely a manner as possible, we
concerns regarding whether patients can we begin the Quality Payment Program, will not provide the specific subset of
appropriately use the data to make we believe we should employ the same measures targeted for public reporting
health care decisions. Alternatively, phased approach used at the start of for review and comment once testing is
some commenters suggested that CMS public reporting under the legacy PQRS complete. All data are available for
preview for 30 days prior to publication, Physician Compare, either on profile measures that have been in use for less
however. pages or in the downloadable database, than 1 year, regardless of submission
Comment: Several commenters the final score for each MIPS eligible method used, for the MIPS quality
supported our phased approach to clinician and the performance of each performance category. After a measures
public reporting MIPS data, but some MIPS eligible clinician for each first year in use, we will evaluate the
commenters requested the information performance category, and to measure to see if and when the measure
not be reported immediately. One periodically post aggregate information is suitable for public reporting (81 FR
commenter specifically suggested MIPS on the MIPS, including the range of 77395).
reporting be delayed until clinicians final scores for all MIPS eligible Currently, there is a minimum sample
could review and improve on their data. clinicians and the range of performance size requirement of 20 patients for
Other commenters cautioned against of all the MIPS eligible clinicians for performance data to be included on
reporting data in the transition years of each performance category, as Physician Compare. In the CY 2017
the MIPS program when the program technically feasible. We will use Quality Payment Program final rule, we
and information collected was new. statistical testing and user testing, as finalized instituting a minimum
Response: We understand the desire well as consultation with the Physician reliability threshold for public reporting
to delay reporting but note that, as Compare Technical Expert Panel data on Physician Compare starting with
discussed below in more detail, for the convened by our contractor, to 2017 data available for public report in
transition year (2017 data available for determine how and where these data are late 2018 and each year moving forward
public reporting in late 2018), no first best reported on Physician Compare. (81 FR 77395).
year measures, activities, or objectives A summary of the proposals related to We will conduct analyses to
will be publicly reported on Physician each performance category of MIPS data determine the reliability of the data
Compare because we do appreciate that follows. collected and use this to calculate the
these are new data and would like minimum reliability threshold for the
clinicians and groups to have the b. Quality data. Once an appropriate minimum
opportunity to learn from the first year (1) Generally reliability threshold is determined, we
of reporting. However, as part of our will only publicly report those
phased approach, as we move into year As detailed in the CY 2017 Quality performance rates for any given measure
2 of the program (2018 data available for Payment Program final rule (81 FR that meet the minimum reliability
public reporting in late 2019), 77395), and consistent with the existing threshold. We note that reliability
additional information will become policy making all current PQRS standards for public reporting and
available for public reporting in an measures available for public reporting, reliability for scoring need not align;
effort to continue to advance the we finalized a decision to make all reliability for public reporting is unique
program, ensure increasing transparency measures under the MIPS quality because, for example, public reporting
and value to patients and caregivers, performance category available for requires ensuring additional protections
and help drive improvement. public reporting on Physician Compare to maintain confidentiality. In addition,
Comment: Some commenters in the transition year of the Quality because publicly reported measures can
requested that CMS make statistical Payment Program, as technically be compared across clinicians and
analysis and user testing results public feasible. This included all available across groups, it is particularly
prior to publicly reporting any data on measures reported via all available important for the most stringent
Physician Compare. Many commenters submission methods, and applied to reliability standards to be in place to
noted that it is important that the data both MIPS eligible clinicians and ensure differences in performance
included on Physician Compare be groups. scores reflect true differences in quality
accurately understood by patients and Also consistent with current policy, of care to promote accurate comparisons
caregivers. although all measures will be available by the public. For further information
Response: We agree that accurate for public reporting, not all measures on reliability as it relates to scoring of
interpretation is of utmost importance, will be made available on the public- cost measures see section II.C.7.a.(3) of
which is why one of our public facing Web site profile pages. As this final rule with comment period.
reporting criteria states that all data explained in the CY 2017 Quality In the CY 2017 Quality Payment
must resonate with users to be included Payment Program final rule (81 FR Program final rule, we established that
on the Web site, as determined by CMS 77394), providing too much information we will include the total number of
through user testing. We also can overwhelm Web site users and lead patients reported on each measure in
understand that more actively and to poor decision making. Therefore, the downloadable database to facilitate
frequently sharing the results of consistent with section transparency and more accurate
statistical testing and user testing can 1848(q)(9)(A)(i)(II) of the Act, all understanding and use of the data (81
help continue our ongoing conversation measures in the quality performance FR 77395). We will begin publishing the
with our stakeholders about the future category that meet the statistical public total number of patients reported on
of public reporting and Physician reporting standards will be included in each measure in the downloadable
Compare. As a result, as noted, we will the downloadable database, as database with 2017 data available for
actively work to share the results of this technically feasible. We also finalized a public reporting in late 2018 and for
testing with stakeholders through policy that a subset of these measures each year moving forward.
outreach and via the Physician Compare will be publicly reported on the Web Understanding that we will continue
Initiative page on cms.gov prior to sites profile pages, as technically our policies to not publicly report first
reporting the data each year. feasible, based on Web site user testing. year quality measures, that we will only
Final Action: After consideration of We will use statistical testing and user report those measures that meet the
the public comments, we are finalizing testing to determine how and where reliability threshold and meet the public
our proposal for year 2 of the Quality measures are reported on Physician reporting standards, and include the
Payment Program (2018 data available Compare. In addition, we adopted our total number of patients reported on for
for public reporting in late 2019) and existing policy of not publicly reporting each measure in the downloadable
future years, to publicly report on first year measures, meaning new database, we again proposed to make all
measures under the MIPS quality decisions. Withholding new measure the Clinician & Groups CAHPS survey,
performance category available for data beyond the first year if all public on which CAHPS for MIPS is modeled.
public reporting on Physician Compare, reporting criteria are met prevents us These five questions have been
as technically feasible (82 FR 30166). from considering valuable new data for developed and tested to work to capture
This would include all available inclusion on the Web site in a timely patient narratives in a scientifically
measures reported via all available manner. And, withholding data for rural grounded and rigorous way, setting it
submission methods for both MIPS and small practices would also prevent apart from other patient narratives
eligible clinicians and groups, for 2018 us from providing this useful collected by various health systems and
data available for public reporting in information to the patients they serve. It patient rating sites. More scientifically
late 2019, and for each year moving is important to remember, however, that rigorous patient narrative data would
forward. Continuing to publicly report our public reporting standards do not only greatly benefit patients, but it
these data ensures continued ensure data comparability, and our would also greatly aid clinicians and
transparency and provides people with phased approach to public reporting groups as they work to assess how their
Medicare and their caregivers valuable ensures a gradual approach to reporting. patients experience care. We also sought
information they can use to make Our reporting standards, and gradual comment on potentially reporting these
informed health care decisions. We approach to public reporting, will help five open-ended questions for the
requested comment on this proposal. ensure rural and small practices are CAHPS for MIPS survey on Physician
The following is a summary of the accurately and appropriately Compare for consideration in future
public comments received on the represented. rulemaking. We direct readers to the
Quality proposals and our responses: Final Action: After consideration of Quality Performance Criteria in section
Comment: Many commenters the public comments, we are finalizing II.C.6.b.(3)(a) of this final rule with
supported publicly reporting quality our proposal to make all measures comment period for additional
performance category data at the under the MIPS quality performance information related to seeking comment
measure level, with one commenter category available for public reporting on adding these questions to the CAHPS
noting that performance data helps on Physician Compare, either on profile for MIPS survey.
patients select clinicians. One pages or in the downloadable database, We received a number of comments
commenter encouraged user testing as technically feasible. This includes all on this item and appreciate the input
prior to public reporting to ensure that available measures reported via all received. As this was a request for
patients accurately understand the available submission methods for both comment only, we will take the
measures. Another commenter MIPS eligible clinicians and groups, for feedback provided into consideration
requested that CMS obtain multi- year 2 of the Quality Payment Program for possible inclusion in future
stakeholder feedback on the display of (2018 data available for public reporting rulemaking.
data prior to publication. Multiple in late 2019) and future years. We will
commenters supported not publicly c. Cost
use statistical testing and user testing to
reporting first year quality measures. determine how and where measures are Consistent with section
Several commenters requested that CMS reported on Physician Compare. We will 1848(q)(9)(A)(i)(II) of the Act, we
not report quality measures for the first also continue our policies to not finalized in the CY 2017 Quality
3 years a measure is in use. One publicly report first year quality Payment Program final rule a decision
commenter requested additional time measures, to only report those measures to make all measures under the MIPS
for rural and small practice clinicians to that meet the reliability threshold and cost performance category available for
gain more experience with meet the public reporting standards, and public reporting on Physician Compare
documentation improvement prior to to include the total number of patients (81 FR 77396). This included all
having their quality data publicly reported on for each measure in the available measures reported via all
reported. downloadable database. available submission methods, and
Response: We reiterate that all data applied to both MIPS eligible clinicians
available for public reporting on (2) Request for Comment on Patient and groups. However, as noted in the
Physician Compare will be tested with Experience Narrative Data final rule, we may not have data
users to ensure it meets our public We sought comment on expanding the available for public reporting in the
reporting criteria and is accurately patient experience data available for transition year of the Quality Payment
understood prior to being considered for public reporting on Physician Compare. Program for the cost performance
publication. We agree that publicly Currently, the CAHPS for MIPS survey category (2017 data available for public
reporting performance data helps is available for groups to report under reporting in late 2018).
patients select clinicians. Regarding the the MIPS. This patient experience As discussed in the final rule (81 FR
request for stakeholder input on survey data is highly valued by patients 77395), cost data are difficult for
measure display, we will continue to and their caregivers as they evaluate patients to understand, and, as a result,
conduct outreach to provide their health care options. However, in publicly reporting these measures could
opportunities for all stakeholders to testing with patient and caregivers, they lead to significant misinterpretation and
provide input on the Web site outside regularly ask for more information from misunderstanding. For this reason, we
of rulemaking, as appropriate. We patients like them in their own words. again proposed to include on Physician
encourage all stakeholders to contact the Patients regularly request that we Compare a subset of cost measures that
Physician Compare support team at include narrative reviews of clinicians meet the public reporting standards,
PhysicianCompare@Westat.com with and groups on the Web site. The Agency either on profile pages or in the
any suggestions and feedback on Web for Healthcare Research and Quality downloadable database, if technically
site display. In addition, although we (AHRQ) is fielding a beta version of the feasible, for 2018 data available for
appreciate the desire to delay use of CAHPS Patient Narrative Elicitation public reporting in late 2019, and for
new measures beyond the first year, we Protocol (https://www.ahrq.gov/cahps/ each year moving forward (82 FR
also appreciate the need to provide surveys-guidance/item-sets/elicitation/ 30167).
Medicare patients and their caregivers index.html). This includes five open- These data are required by the
useful information to make informed ended questions designed to be added to MACRA to be available for public
reporting on Physician Compare, but we We agree it is best to continue to not available activities reported via all
want to ensure we only share those cost report first year cost measures, but as available submission methods, and
measures on profile pages that can help with quality measures, we believe that applies to both MIPS eligible clinicians
patients and caregivers make informed delaying consideration for inclusion if and groups. For those eligible clinicians
health care decisions. For transparency all public reporting criteria are met or groups that successfully meet the
purposes, the cost measures that meet beyond the first year could improvement activities performance
all other public reporting standards unnecessarily prevent us from including category requirements, this information
would be included in the downloadable valuable, timely information on the Web will be posted on Physician Compare as
database. We would use statistical site. Through the rulemaking process, an indicator. This information is
testing and Web site user testing to which provides an opportunity to required by the MACRA to be available
determine how and where measures are comment on the universe of cost for public reporting on Physician
reported on Physician Compare to measures available for public reporting, Compare, but the improvement
minimize passing the complexity of and through stakeholder outreach and activities performance category is a new
these measures on to patients and to the 30-day preview period, we will field of data for Physician Compare, so
ensure those measures included are provide ample opportunity for concept and Web site user testing is still
accurately understood and correctly stakeholders to review the available data needed to ensure these data are
interpreted. Under this proposal, we and provide feedback. understood by stakeholders. Therefore,
noted that the policies we previously We will take the recommendation to we again proposed that we would use
mentioned regarding first year link quality and cost data under statistical testing and user testing to
measures, the minimum reliability consideration and evaluate feasibility determine how and where improvement
threshold, and all public reporting for including this in future rulemaking. activities are reported on Physician
standards would apply. The proposal Final Action: After consideration of Compare, as appropriate.
applied to all available measures the public comments, we are finalizing For the transition year, we excluded
reported via all available submission our proposal to include on Physician first year activities from public reporting
methods, and to both MIPS eligible Compare a subset of cost measures that (81 FR 77396). First year activities are
clinicians and groups. We requested meet the public reporting standards,
any improvement activities in their first
comment on this proposal. either on profile pages or in the
year of use. Starting with year 2 (2018
downloadable database, if technically
The following is a summary of the data available for public reporting in
feasible, for year 2 of the Quality
public comments received on the Cost late 2019), we proposed publicly
Payment Program (2018 data available
proposal and our responses: reporting first year activities if all other
for public reporting in late 2019) and
Comment: Two commenters public reporting criteria are satisfied.
future years. We will use statistical
supported publicly reporting cost This evolution in our Quality Payment
testing and Web site user testing to
performance category data. These Program public reporting plan provides
determine how and where measures are
commenters supported user testing to an opportunity to make more valuable
reported on Physician Compare. We will
ensure the cost data are accurately continue our policies to not publicly information public given that
interpreted and of value to patients in report first year quality measures, and completion of or participation in first
their health care decision making. we will only report those measures that year activities is different from reporting
Multiple commenters did not support meet the reliability threshold and meet first year quality or cost measures.
reporting cost performance category the public reporting standards. This Clinicians and groups can learn from
data, indicating concern that patients includes all available measures reported the first year of quality and cost data,
and caregivers cannot accurately via all available submission methods, understand why their performance rate
interpret these data, and suggested and applies to both MIPS eligible is what it is, and take time to improve.
caution especially in years when the clinicians and groups. A waiting period for indicating
cost performance category will be completion or participation in an
weighted at zero percent for MIPS d. Improvement Activities improvement activity is unlikely to
scoring. If reported, multiple Consistent with section produce the same benefit. We requested
commenters supported not publicly 1848(q)(9)(A)(i)(II) of the Act, we comments on these proposals.
reporting first year cost measures. Three finalized a decision to make all The following is a summary of the
commenters requested that CMS not activities under the MIPS improvement public comments received on the
report cost measures for the first 3 years activities performance category Improvement Activities proposals
a measure is in use. One commenter available for public reporting on and our responses:
suggested that CMS provide the specific Physician Compare (81 FR 77396). This Comment: Some commenters
subset of cost measures under included all available improvement supported reporting improvement
consideration for public reporting for activities reported via all available activity information, including first year
public comment. Other commenters submission methods, and applied to activities. However, several commenters
suggested that cost measures be linked both MIPS eligible clinicians and did not support reporting improvement
to quality measures to better groups. activity information. Multiple
demonstrate value. Consistent with the policy finalized commenters noted CMS should add new
Response: We understand the for the transition year, we again data, such as improvement activities, to
commenters concerns that patients and proposed to include a subset of Physician Compare gradually. One
caregivers cannot accurately interpret improvement activities data on commenter noted that improvement
these data. As noted, we appreciate that Physician Compare that meet the public activity information should be withheld
these data can be difficult to interpret, reporting standards, either on the profile from public reporting until statistical
and therefore, extensive user testing is pages or in the downloadable database, and user testing could be completed to
planned to ensure that any cost measure if technically feasible, for 2018 data confirm accuracy. Other commenters
considered for public reporting meets available for public reporting in late noted that CMS should gain more
all public reporting standards, including 2019, and for each year moving forward experience with improvement activity
resonating with Web site users. (82 FR 30167). This again includes all information before publicly reporting it.
Response: The primary concerns this practice but also include a wider standards applicable to data posted on
raised regarding publicly reporting range of information on participation Physician Compare, either on the profile
improvement activities information and performance. In that rule, we stated pages or in the downloadable database.
focused on the need for statistical and our intent to publish the performance This would include all available
user testing and concern regarding and participation data on Stage 3 objectives, activities, or measures
whether patients and caregivers would objectives and measures of meaningful reported via all available submission
accurately understand this information. use in alignment with quality programs methods, and would apply to both MIPS
We have already started testing this data which utilize publicly available eligible clinicians and groups. We
with Web site users and have found that performance data such as Physician would use statistical testing and Web
this data is not only easily understood Compare. At this time there is only an site user testing to determine how and
but believed to be of great value to Web indicator on Physician Compare profile where objectives and measures are
site users. Many of the activities pages to show that an eligible clinician reported on Physician Compare.
included in the program resonate with successfully participated in the current As with improvement activities, we
users and provide them with valuable Medicare EHR Incentive Program. also proposed to allow first year
information in their decision making As MIPS will include advancing care advancing care information objectives,
process. In addition, as noted, because information as one of the four MIPS activities, and measures to be available
we are just indicating if an activity was performance categories, we decided, for public reporting starting in year 2
completed and not also reporting consistent with section 1848(q)(9)(i)(II) (2018 data available for public reporting
performance on the activity, we do not of the Act, to include more information in late 2019). Again, especially if we are
find added benefit in waiting beyond on an eligible clinicians or groups including an indicator over a
year 2 of the Quality Payment Program performance on the objectives and performance rate, the benefits of waiting
to report first year activities. As with all measures of meaningful use on 1 year are not the same and thus, we
data under consideration for inclusion Physician Compare for the transition believe it is more important to make
on Physician Compare, we are looking year (81 FR 77387). An important more information available for public
to include data per our phased approach consideration was that to meet the reporting as the Quality Payment
recognizing the need to add new data public reporting standards, the data Program matures. We requested
gradually. added to Physician Compare must comment on these proposals.
Final Action: After consideration of resonate with Medicare patients and The following is a summary of the
the public comments, we are finalizing their caregivers. Testing to date has public comments received on the
our proposal to include a subset of shown that people with Medicare value Advancing Care Information
improvement activities data on the use of certified EHR technology and proposals and our responses:
Physician Compare that meet the public see EHR use as something that if used Comment: Several commenters
reporting standards, either on the profile well can improve the quality of their supported including advancing care
pages or in the downloadable database, care. In addition, we believe the information as proposed and noted that
if technically feasible, for year 2 of the inclusion of indicators for clinicians including advancing care information as
Quality Payment Program (2018 data and groups who achieve high indicators rather than performance rates
available for public reporting in late performance in key care coordination will aid accurate interpretation of the
2019 and future years. This includes all and patient engagement activities information. Other commenters
available activities reported via all provide significant value for patients requested clarification regarding what
available submission methods, and and their caregivers as they make health would constitute high and low
applies to both MIPS eligible clinicians care decisions. performance or successful completion
and groups. For those eligible clinicians Consistent with our transition year of the advancing care information
or groups that successfully meet the final policy, and understanding the performance category. One commenter
improvement activities performance value of this information to Web site did not support reporting an indicator
category requirements, this information users, we again proposed to include an for low performance. If successful
will be posted on Physician Compare as indicator on Physician Compare for any completion was defined as attaining
an indicator. We are also finalizing our eligible clinician or group who the base score, one commenter
proposal that we will use statistical successfully meets the advancing care supported its inclusion as an indicator.
testing and user testing to determine information performance category, as This commenter did not, however,
how and where improvement activities technically feasible (82 FR 30168). Also, support reporting an indicator for
are reported on Physician Compare, as as technically feasible, we proposed to high performance. Another
appropriate. include additional indicators, including commenter requested clarification as to
We are also finalizing our proposal, but not limited to, objectives, activities, whether Physician Compare would
for year 2 of the Quality Payment or measures specified in section II.C.6.f. indicate whether 2014 or 2015 CEHRT
Program (2018 data available for public of the proposed rule (see 82 FR 30057 was used to meet successful
reporting in late 2019) and future years, through 30080), such as identifying if completion.
to publicly reporting first year activities the eligible clinician or group scores Response: We appreciate the support
if all other public reporting criteria are high performance in patient access, care for including advancing care
satisfied. coordination and patient engagement, or information as indicators on Physician
health information exchange. The Compare as we know patients and
e. Advancing Care Information proposals applied to 2018 data available caregivers find value in this
Since the beginning of the EHR for public reporting in late 2019, and for information. We also appreciate
Incentive Programs in 2011, participant each year moving forward, as this concerns around indicating low
performance data has been publicly information is required by the MACRA performance in the early years of the
available in the form of public use files to be available for public reporting on Quality Payment Program. To clarify,
on the CMS Web site. In the 2015 EHR Physician Compare. We also proposed successful completion of this
Incentive Programs final rule (80 FR that any advancing care information performance category will be defined as
62901), we addressed comments objectives, activities, or measures would obtaining the base score of 50 percent,
requesting that we not only continue need to meet the public reporting as supported by commenters. High
performance will be defined as site users to more easily evaluate the has given foot exams. There are four
obtaining a score of 100 percent. information published by providing a steps to establishing the benchmark for
Because the information is technically point of comparison between groups this measure.
complex and of less value to the average and between clinicians. In the CY 2016 (1) We look at the total number of
patient and caregiver, we will not PFS final rule (80 FR 71129), we patients with diabetes for all clinicians
indicate the version of CEHRT used on finalized a decision to publicly report who reported this diabetes measure.
Physician Compare, but we will on Physician Compare an item, or (2) We rank clinicians that reported
evaluate this further to see if there is measure-level, benchmark by this diabetes measure from highest
value in adding it to the documentation submission mechanism, using the performance score to lowest
for the clinicians and groups reporting Achievable Benchmark of Care performance score to identify the set of
the data and/or third parties using the (ABCTM) 14 methodology annually based top clinicians who treated at least 10
data. on the PQRS performance rates most percent of the total number of patients
Final Action: After consideration of recently available by submission with diabetes.
the public comments, we are finalizing mechanism. As a result, in late 2017, we (3) We count how many of the
our proposal, for year 2 of the Quality expect to publicly report a benchmark patients with diabetes who were treated
Payment Program (2018 data available based on the 2016 PQRS performance by the top clinicians also got a foot
for public reporting in 2019) and future rates for each measure by each available exam.
years, to include an indicator on submission mechanism for a subset of (4) This number is divided by the
Physician Compare for any eligible measures that meet the necessary public total number of patients with diabetes
clinician or group who successfully reporting standards and the added who were treated by the top clinicians,
meets the advancing care information reliability testing necessary to determine producing the ABCTM benchmark.
performance category, as technically the benchmark and the resulting star To account for low denominators,
feasible. We are also finalizing our rating cut-offs. The specific measures for ABCTM suggests the calculation of an
proposal to include, as technically which the benchmark will be calculated adjusted performance fraction (AFP)
feasible, additional information, will be determined once the data are using a Bayesian Estimator or use of
including but not limited to, objectives, available and analyzed. another statistical methodology. After
activities, or measures specified in We believe ABCTM is a well-tested, analysis, we have determined that the
section II.C.6.f. of this final rule with data-driven methodology that allows us use of a beta binomial model adjustment
comment period. We are finalizing that to account for all of the data collected is most appropriate for the type of data
we will indicate high performance, as for a quality measure, evaluate who the we are working with. The beta binomial
technically feasible and appropriate, but top performers are, and then use that to method moves extreme values toward
we will not indicate low performance set a point of comparison for all of those the average for a given measure, while
in year 2 of the Quality Payment clinicians or groups who report the the Bayesian Estimator moves extreme
Program (2018 data available for public measure. ABCTM starts with the pared- values toward 50 percent. Using the beta
reporting in late 2019). We will revisit mean, which is the mean of the best binomial method is a more
the value of indicating low performers on a given measure for at methodologically sophisticated
performance for possible consideration least 10 percent of the patient approach to address the issue of extreme
in future rulemaking. populationnot the population of values based on small sample sizes.
We are also finalizing our proposal reporters. To find the pared-mean, we This ensures that all clinicians are
that any advancing care information will rank order clinicians or groups (as accounted for and appropriately figured
objectives, activities, or measures will appropriate per the measure being in to the benchmark.
need to meet the public reporting evaluated) in order from highest to The benchmarks for Physician
standards applicable to data posted on lowest performance score. We will then Compare developed using the ABCTM
Physician Compare, either on the profile subset the list by taking the best methodology will be based on the
pages or in the downloadable database. performers moving down from best to current years data, so the benchmark
This will include all available worst until we have selected enough will be appropriate regardless of the
objectives, activities, or measures reporters to represent 10 percent of all unique circumstances of data collection
reported via all available submission patients in the denominator across all or the measures available in a given
methods, and will apply to both MIPS reporters for that measure. reporting year. We also finalized (80 FR
eligible clinicians and groups. We will We finalized that the benchmark 71129) a decision to use the ABCTM
use statistical testing and Web site user would be derived by calculating the methodology to generate a benchmark
testing to determine how and where total number of patients in the highest which will be used to systematically
objectives, activities, and measures are scoring subset receiving the intervention assign stars for the Physician Compare
reported on Physician Compare. or the desired level of care, or achieving 5-star rating. We conducted outreach
In addition, we are finalizing our the desired outcome, and dividing this with stakeholders, and consulted CMS
proposal to allow first year advancing number by the total number of patients programs, measure experts, and the
care information objectives, activities, that were measured by the top Physician Compare Technical Expert
and measures to be available for public performing doctors. This would produce Panel convened by our contractor to
reporting for year 2 of the Quality a benchmark that represents the best determine the best method for
Payment Program (2018 data available care provided to the top 10 percent of determining the 5-star categories based
for public reporting in late 2019) and patients by measure, by submission on the benchmark. This consultation in
future years, as appropriate. mechanism. combination with extensive analysis led

An Example: A clinician reports on us to a decision to use the equal ranges
f. Achievable Benchmark of Care how many patients with diabetes she method.
(ABCTM) During outreach, stakeholders
Benchmarks are important to ensuring 14 Kiefe CI, Weissman NW, Allison JJ, Farmer R,
expressed the importance of assigning
Weaver M, Williams OD. Identifying achievable star ratings in a way that is
that the quality data published on benchmarks of care: concepts and methodology.
Physician Compare are accurately International Journal of Quality Health Care. 1998 understandable to Web site users. The
understood. A benchmark allows Web Oct; 10(5):4437. equal ranges method is intuitive to
interpret, and has tested well with More information about this star care.15 16 17 Appreciating this and the
patients and caregivers. We also attribution method can also be found on support this methodology received in
repeatedly heard from stakeholders that the Physician Compare Initiative page previous rulemaking and throughout
we should choose a method of assigning on cms.gov. As part of our phased our outreach process to date, we again
stars that reflects true performance on approach to public reporting, we expect proposed to use the ABCTM
the measure rather than forcing a to publicly report the benchmark and 5- methodology to determine a benchmark
distribution. Our testing has shown that star rating for the first time on Physician for the quality, cost, improvement
the equal ranges method best reflects Compare in late 2017 using the 2016 activities, and advancing care
true performance on the measure. Our PQRS performance scores for a subset of information data, as feasible and
analyses also show that the equal ranges available group-level measures. appropriate, by measure and by
method generates more stable star rating As a result of stakeholder feedback submission mechanism for each year of
cut-offs than the other methods we asking that we consider one consistent the Quality Payment Program, starting
evaluated. Additionally, we expect star approach for benchmarking and parsing with the transition year data (2017 data
rating assignments based on the equal the data based on the benchmark across available for public reporting in late
ranges method to be more stable across the Quality Payment Program, we did 2018) (82 FR 30169). We also proposed
years allowing the ability to better consider an alternative approach. We to use this benchmark to determine a 5-
assess year-to-year performance. The reviewed the benchmark and decile star rating for each MIPS measure, as
equal ranges method also provides a breaks being used to assign points and feasible and appropriate. As previously
more reliable and meaningful determine payment under MIPS (see 82 finalized, only those measures that meet
classification than other methods FR 30168 through 30169). This the public reporting standards would be
evaluated. In this way, using equal approach was not considered ideal for considered, and the benchmark would
ranges ensures that a 4-star performance public reporting for several reasons. A be based on the most recently available
is statistically better than and distinct primary concern was that the decile data.
from a 3-star performance on a measure approach when used for public We believe that displaying the
and so forth. reporting would force a star rating appropriate and relevant MIPS data in
After we determine the benchmark distribution inconsistent with the raw this user-friendly format provides more
using the ABCTM methodology for a distribution of scores on a given opportunities to present these data to
given measure, and determine that the measure. If applied to star ratings, there people with Medicare in a way that is
would need to be an equal distribution most likely to be accurately understood
benchmark meets our public reporting
of clinicians in each of the star rating and interpreted. We requested comment
standards, we move on to assigning star
categories. on these proposals.
ratings. Any clinicians or groups who Using the ABCTM methodology for the
meet or exceed the benchmark by The following is a summary of the
benchmark sets the 5-star rating at the public comments received on the
measure, by mechanism, will be performance rate that is the best
assigned 5-stars for the measure. Next, Achievable Benchmark of Care
achievable rate in the current clinical (ABCTM) proposals and our responses:
we use the equal ranges method to climate based on the current set of
assign 1 to 4 stars. The equal ranges Comment: Many commenters
measures and the current universe of supported the proposals with caveats.
method is based on the difference reporters. The star ratings are then
between the benchmark and the lowest Commenters requested a phased
derived from there consistent with the approach to publicly reporting the star
performance score for a given measure raw score distribution. In this way, if
and uses that range to assign 1 to 4 stars. ratings based on the ABCTM benchmark.
the majority of clinicians performed Also, commenters asked that we share
Clinicians or groups who meet or well on a measure, the majority would
exceed the established benchmark for a additional information about the equal
receive a high star rating. If we used the ranges method, the use of the beta
measure will be assigned 5-stars. To decile approach some clinicians would
determine the 4-star cut-off using the binomial, and more data to understand
be reported as having a low star rating the overall approach, specifically as it
equal ranges method, we subtract the despite their relative performance on
lowest performance score from the relates to measures that do not have
the measure. much variation in performance rates.
benchmark to get the range of It is not always ideal to use the same
performance scores, and then divide by Commenters also stressed the
methodology across the program as
4 to get quarters. The 4-star cut-off is importance of deriving the benchmark
scoring for payment purposes may be
one quarter of the distance between the designed in a somewhat different way by measure and submission mechanism.
ABCTM benchmark and the lowest that may incorporate factors that are not In addition, commenters indicated the
performance score. Clinicians or groups necessarily as applicable for public importance of ample Web site user
who score at or above the 4-star cut-off, reporting, while the key consideration testing to ensure the resulting star rating
but below the benchmark will be for public reporting is that the was fully understood by patients and
assigned 4 stars. The 3-star cut-off is two methodology used best helps patients caregivers. Multiple commenters also
quarters of the distance between the and caregivers easily interpret the data 15 Kiefe CI, Weissman NW, Allison JJ, Farmer R,
benchmark and lowest performance accurately. Testing with Web site users Weaver M, Williams OD. Identifying achievable
score. Clinicians or groups who score at has shown that the star rating based on benchmarks of care: concepts and methodology.
or above the 3-star cut-off but below the the ABCTM benchmark helps patients International Journal of Quality Health Care. 1998
4-star cut-off are assigned 3 stars. We and caregivers interpret the data Oct; 10(5):4437.
16 Kiefe CI, Allison JJ, Williams O, Person SD,

follow the same method to get the 2-star accurately. Weaver MT, Weissman NW. Improving Quality
cut-off, which is 3 quarters of the ABCTM has been historically well Improvement Using Achievable Benchmarks For
distance between the benchmark and received by the clinicians and entities it Physician Feedback: A Randomized Controlled
the lowest performance score. Finally, is measuring because the benchmark Trial. JAMA. 2001;285(22):28712879.
17 Wessell AM, Liszka HA, Nietert PJ, Jenkins RG,
any scores that are greater than three represents quality while being both
Nemeth LS, Ornstein S. Achievable benchmarks of
quarters of the distance between the realistic and achievable; it encourages care for primary care quality indicators in a
benchmark and the lowest performance continuous quality improvement; and, it practice-based research network. American Journal
score are assigned 1 star. is shown to lead to improved quality of of Medical Quality 2008 Jan-Feb;23(1):3946.
supported using the ABCTM Regarding the commenters concerns of the Quality Payment Program (2018
methodology instead of the decile that not having clinicians broken out by data available for public reporting in
approach for purposes of MIPS scoring. subspecialty or not having more 2019) and for each year moving forward,
Three commenters raised concerns that subspecialty specific measures means to make available for public reporting
not having clinicians broken out by that some comparisons may not be all data submitted voluntarily across all
subspecialty or not having more appropriate with respect to certain MIPS performance categories, regardless
subspecialty specific measures meant subspecialties, we note that all searches of submission method, by eligible
that some comparisons may not be on Physician Compare are by specialty clinicians and groups that are not
appropriate. Specifically, concerns were and location. Therefore, there is some subject to the MIPS payment
raised in relation to emergency level of stratification by specialty for adjustments, as technically feasible (82
department doctors, retina specialists, Web site users. We do appreciate the FR 30169).
and psychiatrists. desire for more detailed specialty-level If an eligible clinician or group that is
Response: We appreciate that many information. However, at this time, this not subject to the MIPS payment
commenters would like to move forward level of detailed information adjustments chooses to submit quality,
with the ABCTM benchmark and subspecialty informationis not cost (if applicable), improvement
resulting star rating via a phased available through the Provider activity, or advancing care information,
approach. Just as we started the process Enrollment, Chain, and Ownership these data would become available for
of public reporting with a phased System (PECOS), the sole source of public reporting. However, because
approach, we intend to reset and apply specialty information available to these data would be submitted
the same phased approach to public Physician Compare, and thus not voluntarily, we proposed that during the
reporting measures as star ratings. available for use on Physician Compare. 30-day preview period, these eligible
Understanding the additional We will, however, continue to evaluate clinicians and groups would have the
information requested about the equal options for providing more sub- option to opt out of having their data
ranges method, the use of the beta specialty level information for future publicly reported on Physician
binomial, and more data to understand consideration, as feasible. Compare. If eligible clinicians and
the overall approach, specifically as it Final Action: After consideration of groups do not take the action to opt out
relates to measures that do not have the public comments, we are finalizing at this time, their data would be
much variation in performance rates, our proposal to use the ABCTM available for inclusion on Physician
resources have been added to the methodology to determine a benchmark Compare if the data meet all previously
Physician Compare Initiative page that for the quality, cost, improvement stated public reporting standards and
cover these topics and explain the activities, and advancing care the minimum reliability threshold. As
benchmark methodology and the star information data, as feasible and eligible clinicians and groups that are
rating attribution process using the appropriate, by measure and by not required to report under MIPS,
equal ranges method. Also, consistent submission mechanism for each year of particularly in the first years of the
with our position to actively share the Quality Payment Program, starting Quality Payment Program, are taking
additional information on analysis and with the transition year (2017 data additional steps to show their
user testing and our overall approach to available for public reporting in late commitment to quality care, we want to
implementing star ratings based on the 2018) and each year forward. We are ensure they have the opportunity to
ABCTM benchmark, more information also finalizing our proposal to use this report their data and have it included on
about the analysis conducted in benchmark as the basis of a 5-star rating Physician Compare. We requested
preparation for the release of the first for each available measure, as feasible comment on the proposal.
star ratings is being made available to and appropriate. Only those measures The following is a summary of the
stakeholders via the Physician Compare that meet the public reporting standards public comments received on the
Initiative page on cms.gov. User testing will be considered for benchmarking Voluntary Reporting proposals and
results will also be made available to and star ratings, and the benchmark will our responses:
address concerns about the need for be based on the most recently available Comment: Many commenters
sufficient user testing prior to reporting data each year. supported this proposal to allow
star ratings. As previously finalized and voluntarily reported data to be included
g. Voluntary Reporting on Physician Compare. However, some
as proposed (82 FR 30169), the
benchmark is being derived by measure In CY 2017 Quality Payment Program commenters supported an opt in
and by submission mechanism, which is proposed rule (81 FR 28291), we versus an opt out approach during the
consistent with commenters requests. solicited comment on the advisability 30-day preview period. One commenter
We also appreciate the commenters and technical feasibility of including on recommended that CMS only publicly
support for using the ABCTM Physician Compare data voluntarily report the information for which it is
methodology instead of the decile reported by eligible clinicians and legally mandated and that posting too
approach for purposes of MIPS scoring. groups that are not subject to MIPS much information could be confusing
We will take this recommendation into payment adjustments, such as excluded for patients.
consideration for the future. However, clinician types, to be addressed through Response: We do understand the
we do reiterate that it is not always ideal separate notice-and-comment support for an opt in versus an opt
or necessary to use the same rulemaking. out approach during the 30-day
methodology for scoring and public As indicated in the CY 2017 Quality preview period. However, we also
reporting given the unique Payment Program final rule (81 FR appreciate that voluntary reporters (that
considerations and goals of each. 77394), comments received were is, eligible clinicians and groups that are
Testing with Web site users has shown favorable overall. Stakeholders generally not subject to the MIPS payment
that the star rating based on the ABCTM support clinicians and groups being adjustments) are already taking
benchmark helps patients and permitted to have data available for additional steps to provide their data to
caregivers interpret the data accurately, public reporting when submitting these CMS and believe it is reasonable to
which is the main goal of public data voluntarily under MIPS. As a presume based on previously received
reporting. result, we proposed starting with year 2 comments and feedback that such
reporters want to have their data Compare when the eligible clinician or exception of data that must be
included on Physician Compare. Given group is participating in an APM (81 FR mandatorily reported on Physician
the additional burden an opt in 77398). We also finalized a decision to Compare, this will be determined based
approach would impose and the value link eligible clinicians and groups to on statistical and user testing, and in
these data provide to users, we will their APMs data, as technically feasible, consultation with the Physician
move forward with the opt out through Physician Compare. The Compare Technical Expert Panel
approach as proposed. As with all data finalized policy provides the convened by our contractor. As noted
considering for inclusion on Physician opportunity to publicly report data for above, section 1848(q)(9)(A)(i)(I) of the
Compare, we will conduct user testing both Advanced APMs and APMs that Act requires that we publicly report on
to ensure that any additional data are not considered Advanced APMs for Physician Compare each MIPS eligible
considered for the Web site are clear the transition year, as technically clinicians final score and performance
and add value to the users Web site feasible. category scores. As with all data
experience. At the outset, APMs will be very new considered for inclusion on Physician
Final Action: After consideration of concepts for Medicare patients and their Compare, these data must also meet our
the public comments, we are finalizing caregivers. In these early years, public reporting standards to be
our proposal for year 2 of the Quality indicating who participated in APMs publicly reported.
Payment Program (2018 data available and testing language to accurately Final Action: After consideration of
for public reporting in 2019) and future explain that to Web site users provides the public comments, we are finalizing
years, to make available for public useful and valuable information as we our proposal to publicly report names of
reporting all data submitted voluntarily continue to evolve Physician Compare. eligible clinicians in Advanced APMs
across all MIPS performance categories, As we come to understand how to best and the names and performance of
regardless of submission method, by explain this concept to patients and Advanced APMs and APMs that are not
eligible clinicians and groups that are their caregivers, we can continue to considered Advanced APMs related to
not subject to the MIPS payment assess how to most fully integrate these the Quality Payment Program for year 2
adjustments, as technically feasible. If data on the Web site. Understanding of the Quality Payment Program (2018
an eligible clinician or group that is not this and understanding the value of data available for public reporting in
subject to the MIPS payment adding APM data to Physician Compare, late 2019) and future years, as
adjustments chooses to submit quality, we again proposed to publicly report technically feasible. We are also
cost (if applicable), improvement names of eligible clinicians in finalizing our proposal to continue to
activity, or advancing care information, Advanced APMs and the names and find ways to more clearly link clinicians
these data will become available for performance of Advanced APMs and and groups and the APMs they
public reporting. We are also finalizing APMs that are not considered Advanced participate in on Physician Compare, as
our proposal that during the 30-day APMs related to the Quality Payment technically feasible.
preview period, these eligible clinicians Program starting with year 2 (2018 data
i. Stratification by Social Risk Factors
and groups will have the option to opt available for public reporting in late
out of having their data publicly 2019), and for each year moving We understand that social risk factors
reported on Physician Compare. If forward, as technically feasible (82 FR such as income, education, race and
eligible clinicians and groups do not 30170). In addition, we again proposed ethnicity, employment, disability,
actively take the action to opt out at this to continue to find ways to more clearly community resources, and social
time, their data will be available for link clinicians and groups and the support play a major role in health. One
inclusion on Physician Compare if the APMs they participate in on Physician of our core objectives is to improve the
data meet all public reporting standards Compare, as technically feasible. We outcomes of people with Medicare, and
and the minimum reliability threshold. requested comment on the proposals. we want to ensure that complex
The following is a summary of the patients, as well as those with social
h. APM Data public comments received on the APM risk factors receive excellent care. In
Section 1848(q)(9)(A)(ii) of the Act Data proposals and our responses: addition, we seek to ensure that all
requires us to publicly report names of Comment: Two commenters clinicians are treated as fairly as
eligible clinicians in Advanced APMs expressed support for CMS thoughtful possible within all CMS programs. In
and, to the extent feasible, the names and measured approach to reporting the CY 2017 Quality Payment Program
and performance of Advanced APMs. APM data and continuing to find ways final rule (81 FR 77395), we noted that
We see this as an opportunity to to more clearly explain the intricacies of we would review the first of several
continue to build on the ACO reporting APMs to patients and caregivers. reports by the Office of the Assistant
we are now doing on Physician Another commenter requested Secretary for Planning and Evaluation
Compare. At this time, if a clinician or clarification whether CMS will publish, (ASPE) 18. In addition, we have been
group submitted quality data as part of for Advanced APM participants and reviewing the report of the National
an ACO, there is an indicator on the participants of APMs that are not Academies of Sciences, Engineering,
clinicians or groups profile page considered Advanced APMs, a total and Medicine on the issue of accounting
indicating this. In this way, it is known performance score or only performance for social risk factors in CMS
which clinicians and groups scores at the measure-level. programs.19 ASPEs first report, as
participated in an ACO. Also, currently, Response: We appreciate the support required by the Improving Medicare
all ACOs have a dedicated page on the of our efforts to continue publishing
Physician Compare Web site to APM performance information on 18 ASPE, Report to Congress: Social Risk Factors
Physician Compare in a way that will be and Performance Under Medicares Value-Based
showcase their data. For the transition Purchasing Programs. 21 Dec 2016. Available at
year of the Quality Payment Program, meaningful for patients and caregivers. https://aspe.hhs.gov/pdf-report/report-congress-
we decided to use this model as a guide Regarding whether we will publish, for social-risk-factors-and-performance-under-
as we add APM data to Physician Advanced APMs and APMs that are not medicares-value-based-purchasing-programs.
19 National Academies of Sciences, Engineering,
Compare. Specifically, we finalized a considered Advanced APMs, a total and Medicine. 2017. Accounting for social risk
policy to indicate on eligible clinician performance score or only performance factors in Medicare payment. Washington, DC: The
and group profile pages of Physician scores at the measure-level, with the National Academies Press.
Post-Acute Care Treatment (IMPACT) physician or other clinician by a board The following is a summary of the
Act, was released on December 21, of specialists in the relevant field. We public comments received on the
2016, and analyzed the effects of social currently include American Board of Board Certification proposals and our
risk factors of people with Medicare on Medical Specialties (ABMS), American responses:
clinician performance under nine Osteopathic Association (AOA), and Comment: Several commenters
Medicare value-based purchasing American Board of Optometry (ABO) supported these proposals. A couple of
programs. A second report due in data as part of clinician profiles on commenters encouraged CMS to
October 2019 will expand on these Physician Compare. We appreciate that establish very clear criteria for what
initial analyses, supplemented with there are additional, well respected constitutes a suitable board for
non-Medicare datasets to measure social boards that are not included in the inclusion, in line with the criteria used
risk factors. The National Academies of ABMS, AOA, and ABO data currently by ABMS, which are reviewed and
Sciences, Engineers, and Medicine available on Physician Compare that accepted through a multi-stakeholder
released its fifth and final report on represent clinicians and specialties process. One commenter requested that
January 10, 2017, and provided various included on the Web site. Such board CRNA board certification be posted on
potential methods for accounting for certification information is of interest to Physician Compare as well.
social risk factors, including stratified users as it provides additional Response: We understand that Web
public reporting, as well as information to use to evaluate and site users value this information, and we
recommended next steps. distinguish between clinicians on the look forward to the opportunity to be
As we continue to consider the Web site, which can help in making an able to include valid and reliable
analyses and recommendations from informed health care decision. The more information in a timely manner. We
these and any future reports, we look data of immediate interest that is proposed that, for purposes of CMSs
forward to working with stakeholders in included on Physician Compare, the selection, the board would need to
this process. Therefore, we sought more users will come to the Web site demonstrate that it: Fills a gap in
comment only on accounting for social and find data that can help them make currently available board certification
risk factors through public reporting on informed decisions. Please note we are information listed on Physician
Physician Compare (82 FR 30170). not endorsing any particular boards. Compare, can make the necessary data
Specifically, we sought comment on Another board, the American Board of available, and, if appropriate, can make
stratified public reporting by risk factors Wound Medicine and Surgery arrangements and enter into agreements
and ask for feedback on which social (ABWMS), has shown interest in being to share the needed information for
risk factors or indicators should be used added to Physician Compare and have inclusion on Physician Compare. We
and from what sources. Examples of demonstrated that they have the data to also proposed that boards contact the
social risk factor indicators include but facilitate inclusion of this information Physician Compare support team at
are not limited to dual eligibility/low- on the Web site. We believe this board PhysicianCompare@Westat.com to
income subsidy, race and ethnicity, fills a gap for a specialty that is not indicate interest and initiate the review
social support, and geographic area of currently covered by the ABMS, so we and discussion process. We will provide
residence. We also sought comment on proposed to add ABWMS Board more technical information on the
the process for accessing or receiving Certification information to Physician finalized process and selection criteria,
the necessary data to facilitate stratified Compare. as well as any boards selected for
reporting. Finally, we sought comment Additionally, for all years moving inclusion, on the Physician Compare
on whether strategies such as forward, for any board that would like Initiative page on cms.gov. We also
confidential reporting of stratified rates to be considered for addition to the appreciate the suggestion to post board
using social risk factor indicators should Physician Compare Web site, we certification information for CRNAs on
be considered in the initial years of the proposed to establish a process for Physician Compare and encourage the
Quality Payment Program in lieu of reviewing interest from these boards as relevant board(s) to contact the
publicly reporting stratified it is brought to our attention on a case- Physician Compare support team to
performance rates for quality and cost by-case basis, and selecting boards as initiate the process.
measures under the MIPS on Physician possible sources of additional board Final Action: After consideration of
Compare. We sought comment only on certification information for Physician the public comments, we are finalizing
these items for possible consideration in Compare. We further proposed that, for our proposal to add additional Board
future rulemaking. purposes of CMSs selection, the board Certification information to the
The following is a summary of the would need to demonstrate that it: fills Physician Compare Web site.
public comments received on the a gap in currently available board Specifically, we are finalizing our
Stratification by Social Risk Factors certification information listed on proposal to add ABWMS Board
request for comment: Physician Compare, can make the Certification information to Physician
We received a number of comments necessary data available, and, if Compare. We are also finalizing our
on this item and appreciate the input appropriate, can make arrangements and proposal to establish a process for
received. As this was a request for enter into agreements to share the reviewing interest from these boards as
comment only, we will take the needed information for inclusion on it is brought to our attention on a case-
feedback provided into consideration Physician Compare. We proposed that by-case basis, and selecting boards as
for possible inclusion in future boards contact the Physician Compare possible sources of additional board
rulemaking. support team at PhysicianCompare@ certification information for Physician
Westat.com to indicate interest and Compare. We are also finalizing our

j. Board Certification initiate the review and discussion proposal that, for purposes of CMSs
Finally, we proposed adding process. Once decisions are made, they selection, the board would need to
additional Board Certification will be communicated via the CMS.gov demonstrate that it: Fills a gap in
information to the Physician Compare Physician Compare initiative Web page currently available board certification
Web site (82 FR 30170). Board and via the Physician Compare listserv. information listed on Physician
Certification is the process of reviewing We requested comments on these Compare, can make the necessary data
and certifying the qualifications of a proposals. available, and, if appropriate, can make
arrangements and enter into agreements deletions, and changes to some of the rule, in connection with our proposals
to share the needed information for definitions previously finalized in our to calculate Threshold Scores for QP
inclusion on Physician Compare. We are regulations at 414.1305 (82 FR 30171). determinations under the All-Payer
also finalizing our proposal that boards In the CY 2018 Quality Payment Combination Option, we did not
contact the Physician Compare support Program proposed rule, we proposed to anticipate having or receiving
team at PhysicianCompare@Westat.com change the timeframe of the QP information about attributed
to indicate interest and initiate the Performance Period under the All-Payer beneficiaries as we do under the
review and discussion process. Once Combination Option so that it would Medicare Option. This is because under
decisions are made, they will be begin on January 1 and end on June 30 the All-Payer Combination Option, APM
communicated via the CMS.gov of the calendar year that is 2 years prior Entities or eligible clinicians would
Physician Compare initiative Web page to the payment year. We proposed to only submit aggregate payment and
and via the Physician Compare listserv. add the definition of All-Payer QP patient data. We would not have
Performance Period using this anything similar to a Participation List
D. Overview of the APM Incentive timeframe. We also proposed to add the or an Affiliated Practitioner List for
1. Overview definition of Medicare QP Performance Other Payer Advanced APMs.
Period, which would begin on January Therefore, we proposed to change the
Section 1833(z) of the Act requires 1 and end on August 31 of the calendar definition of attributed beneficiary so
that an incentive payment be made to year that is 2 years prior to the payment that it only applies to Advanced APMs,
QPs for participation in Advanced year. We would replace the single not to Other Payer Advanced APMs (82
APMs. In the CY 2017 Quality Payment definition we established in the CY FR 30171).
Program final rule (81 FR 77399 through 2017 Quality Payment Program final We sought comment on this proposal.
77491), we finalized policies relating to rule for QP Performance Period with the The following is a summary of the
the following topics: definitions of All-Payer QP Performance public comments received on these
Beginning in 2019, if an eligible Period and Medicare QP Performance proposals and our responses:
clinician participated sufficiently in an Period. To update the regulation to Comment: One commenter supported
Advanced APM during the QP incorporate this proposal, we also our proposal.
Performance Period, that eligible proposed to remove QP Performance Response: We appreciate the
clinician may become a QP for the year. Period each time it occurs in our commenters support of our proposal.
Eligible clinicians who are QPs are regulations and replace it with either Comment: One commenter noted that
excluded from the MIPS reporting All-Payer QP Performance Period or this proposal is designed to facilitate
requirements for the performance year Medicare QP Performance Period as making QP determinations at the
and payment adjustment for the relevant (82 FR 30171). individual eligible clinician level under
payment year. We sought comment on these the All-Payer Combination Option. The
For years from 2019 through 2024, proposals. The following is a summary commenter suggested that not all Other
QPs receive a lump sum incentive of the public comments received on Payer Advanced APMs will use
payment equal to 5 percent of their prior these proposals and our responses: attribution and also suggested that we
years payments for Part B covered Comment: Three commenters create an alternate term to reflect Other
professional services. Beginning in supported our proposals to distinguish Payer Advanced APMs where the
2026, QPs receive a higher update under between the Medicare QP Performance beneficiary may or may not be
the PFS for the year than non-QPs. Period and the All-Payer QP attributed.
For 2019 and 2020, eligible Performance Period in light of our Response: We appreciate the
clinicians may become QPs only proposal to make each last a different comment. Because we are collecting
through participation in Advanced period of time. aggregate patient and payment data for
APMs. Response: We appreciate the the Other Payer Advanced APM part of
For 2021 and later, eligible commenters support of these proposals. QP determinations under the All-Payer
clinicians may become QPs through a Final Action: We are not finalizing Combination Option, we do not need to
combination of participation in these proposals. As we discuss in collect information about how an Other
Advanced APMs and Other Payer section II.D.6.d.(3)(a) through (b) of this Payer Advanced APM establishes or
Advanced APMs (which we refer to as final rule with comment period, we are conducts attribution.
the All-Payer Combination Option). not finalizing our proposal to create a Final Action: After considering public
In the CY 2018 Quality Payment separate All-Payer QP Performance comments, we are finalizing the policy
Program proposed rule, we proposed Period. The QP Performance Period will as proposed at 414.1305 to modify the
clarifications and modifications to some begin on January 1 and end on August definition of attributed beneficiary so
of the policies that we previously 31 of the calendar year that is 2 years that it only applies to Advanced APMs.
finalized and provided additional prior to the payment year for both the We sought comment on these terms,
details and proposals regarding the All- Medicare Option and the All-Payer including how we have defined the
Payer Combination Option (82 FR Combination Option. Therefore, we will terms, the relationship between terms,
3017030207). In this CY 2018 Quality continue to use the term QP any additional terms that we should
Payment Program final rule with Performance Period to refer to the formally define to clarify the
comment period, we respond to public performance period under both the explanation and implementation of this
comments on those proposals and Medicare Option and the All-Payer program, and potential conflicts with
announce our final policies. Combination Option, and the separate other terms we use in similar contexts.
terms All-Payer QP Performance We also sought comment on the naming
2. Terms and Definitions of the terms and whether there are ways
Period and Medicare QP Performance
In the CY 2018 Quality Payment Period and the corresponding revisions to name or describe their relationships
Program proposed rule, we explained to our regulations are no longer to one another that make the definitions
that as we continue to develop the necessary. more distinct and easier to understand.
Quality Payment Program, we identified As we discussed in the CY 2018 For instance, we would consider
the need to propose additions, Quality Payment Program proposed options for a framework of definitions
that might more intuitively distinguish An APM Entity can participate in an discussion of the All-Payer Combination
between APMs and Other Payer APM that is, or is not, an Advanced Option (82 FR 30195).
Advanced APMs and between APMs APM. We finalized in the CY 2017 Quality
and Advanced APMs. Comment: One commenter agreed that Payment Program final rule at
The comments we received in Medicaid APMs should be classified as 414.1460(d) that for any QPs who are
response to this comment solicitation Other Payer Advanced APMs, and one terminated from an Advanced APM or
are discussed throughout this section as commenter supported our proposed found to be in violation of any Federal,
they are responsive to specific proposals technical changes generally. State, or tribal statute, regulation, or
regarding defined terms. We note that Response: We appreciate the binding guidance during the QP
we may consider the creation of commenters support of our proposed Performance Period or Incentive
additional terms or revision of existing technical changes in general. Regarding Payment Base Period or terminated after
terms in future rulemaking. the proposed technical changes to the these periods as a result of a violation
definition of Medicaid APM in occurring during either period, we may
3. Regulation Text Changes rescind such eligible clinicians QP
414.1305, we believe these changes
a. Clarifications and Corrections clarify that these arrangements must determinations and, if necessary, recoup
meet the Other Payer Advanced APM part or all of any such eligible
criteria set forth in 414.1420, and not clinicians APM Incentive Payment or
Program proposed rule, we proposed to
just the criteria under 414.1420(a). deduct such amount from future
revise the definition of APM Entity in
Final Action: After considering public payments to such individuals. We also
the regulation at 414.1305 to clarify
comments, we are finalizing these finalized that we may reopen and
that a payment arrangement with a
technical changes as proposed. recoup any payments that were made in
non-Medicare payer is an other payer
error (81 FR 77555).
arrangement as defined in 414.1305. We proposed technical changes to
We proposed to make technical changes correct the references in the first Program proposed rule, we
to the definition of Medicaid APM in sentence of the regulation at 414.1415 acknowledged that rescinding QP
414.1305 to clarify that these to refer to the financial risk standard determinations and reopening and
arrangements must meet the Other Payer under paragraph (c)(1) or (2) and the recouping APM Incentive Payments are
Advanced APM criteria set forth in nominal amount standard under separate policies. For this reason, we
414.1420, and not just the criteria paragraph (c)(3) or (4). Due to proposed to reorganize 414.1460 so
under 414.1420(a) as provided under typographical errors, the regulation that paragraph (b) sets forth our policy
the definition finalized in the CY 2017 finalized in the CY 2017 Quality on rescinding QP determinations and
Quality Payment Program final rule. Payment Program final rule refers to paragraph (d) sets forth our policy on
To consolidate our regulations and paragraphs (d)(1) through (4), and there reopening and recouping APM Incentive
avoid unnecessarily defining a term, we is no paragraph (d) in this section. We Payments. We proposed to revise
proposed to remove the defined term for also proposed to correct typographical 414.1460(b) to specify when we may
Advanced APM Entity in 414.1305 errors in 414.1420(a)(3)(i), (a)(3)(ii), (d) rescind a QP determination. In addition,
and to replace Advanced APM Entity and (d)(1). In 414.1420(d), we we proposed to remove the last sentence
where it appears throughout the proposed to correct the reference to the of 414.1460(d), which provides that an
regulations with APM Entity. We also nominal risk standard to instead refer APM Incentive Payment would be
proposed to make this substitution in to the nominal amount standard. We recouped if an audit reveals a lack of
the definitions of Affiliated Practitioner proposed technical, non-substantive support for attested statements provided
and Attributed Beneficiary in clarifications in 414.1425(a)(1) by eligible clinicians and APM Entities.
414.1305. Similarly, we proposed to through (3), and (b)(2); and We explained that we believe that this
replace Advanced APM Entity group 414.1435(d). We also proposed to provision is duplicative of the
with APM Entity group where it correct a typographical error in immediately preceding sentence, which
appears throughout our regulations. We 414.1460(b) to refer to participation permits us to reopen and recoup any
noted that these proposed changes are during a QP Performance Period erroneous payments in accordance with
technical and would not have a instead of during the QP Performance existing procedures set forth at
substantive effect on our policies. Periods. 405.980 through 405.986 and
We sought comment on these We sought comment on these 405.370 through 405.379. We
proposals. The following is a summary proposals. We received no comments in proposed to codify our recoupment
of the public comments received on response to these proposals. policy at 414.1460(d)(2), which
these proposals and our responses: Final Action: We are finalizing these provides that we may reopen, revise,
Comment: A few commenters technical revisions to our regulations as and recoup an APM Incentive Payment
encouraged us not to delete the defined proposed. that was made in error in accordance
term Advanced APM Entity as with procedures similar to those set
b. Changes to 414.1460
proposed. Two of these commenters forth at 405.980 through 405.986 and
stated that if we delete the term In the CY 2018 Quality Payment 405.370 through 405.379 or as
Advanced APM Entity, we must Program proposed rule, we proposed to established under the relevant APM.
revise the definition of APM Entity to reorganize and revise the monitoring In the CY 2017 Quality Payment
explicitly include Advanced APMs. and program integrity provisions at Program final rule, we indicated at
Response: We appreciate the 414.1460. We proposed changes to 414.1460(b) that we may reduce or
comment. One of our goals in designing paragraphs (a), (b), and (d) in this deny an APM Incentive Payment to
the Quality Payment Program is to section of the proposed rule as these eligible clinicians who are terminated
minimize complexity and confusion. policies apply to both the Medicare by APMs or whose APM Entities are
We believe that deleting the term Option and the All-Payer Combination terminated by APMs for non-
Advanced APM Entity supports that Option. We explained that we addressed compliance with Medicare conditions of
goal. We do not believe that revising the the changes we proposed to paragraphs participation or the terms of the relevant
definition of APM Entity is necessary. (c) and (e) of 414.1460 in our Advanced APMs in which they
participate during the QP Performance care items and services. The commenter Quality Payment Program proposed
Period. We also finalized at was especially concerned because no rule:
414.1460(a) that for QPs who we judicial or administrative review is We proposed to amend
determines are not in compliance with available for a QP determination, and 414.1415(c)(2) to exempt any APM
all Medicare conditions of participation thus asserted that an eligible clinician Entities in Round 1 of the
and the terms of the relevant Advanced could be determined not to be a QP for Comprehensive Primary Care Plus
APMs in which they participate during irrelevant reasons with no recourse to (CPC+) Model as of January 1, 2017 from
the QP Performance Period, there may appeal. The commenter suggested that the requirement that, beginning in the
be a reduction or denial of the APM the regulation could instead say any 2018 QP Performance Period, the
Incentive Payment. In the CY 2018 relevant Federal, State, or tribal statute Medical Home Model financial risk
Quality Payment Program proposed or regulation. standard applies only to an APM Entity
rule, we proposed to consolidate our Response: We appreciate and agree that is participating in a Medical Home
policy on reducing and denying APM with the commenters concern. Our Model if it has fewer than 50 eligible
Incentive Payments and redesignate it to intent is to rescind QP determinations clinicians in its parent organization (82
414.1460(d)(1). Thus, we proposed to based on violations of Federal, State, or FR 3017230173).
remove provisions regarding reducing tribal statutes or regulations that are We proposed to amend
and denying APM Incentive Payments relevant to the Quality Payment 414.1415(c)(3)(i)(A) and (c)(4)(i)(A)
from paragraphs (a) and (b) of Program, including our interest in through (D) to more clearly define the
414.1460, and revise paragraph (d) to maintaining the integrity of the Quality generally applicable revenue-based
discuss when CMS may reduce or deny Payment Program. Therefore, we are nominal amount standard and the
an APM Incentive Payment to an modifying 414.1460(b)(3) so that we Medical Home Model revenue-based
eligible clinician. We sought comment may rescind a QP determination if a QP nominal amount standard as a
on these proposals. is found to be in violation of the terms
The following is a summary of the percentage of the average estimated total
of the relevant Advanced APM or any Medicare Parts A and B revenue of all
public comments received on these relevant Federal, State, or tribal statute
proposed changes to 414.1460 and our providers and suppliers in participating
or regulation. APM Entities (82 FR 30173).
responses: Final Action: After considering public
Comment: Two commenters We proposed to amend
comments, we are finalizing our 414.1415(c)(3)(i)(A) to state that the
supported our proposals to revise the proposal to reorganize and revise
monitoring and program integrity generally applicable revenue-based
414.1460 with one modification. nominal amount standard remains at 8
provisions in order to separate Specifically, we are finalizing with
rescinding QP determinations from percent of the average estimated total
modification 414.1460(b)(3) so that we Medicare Parts A and B revenue of
recouping APM incentive payments and
may rescind a QP determination if a QP providers and suppliers in participating
to consolidate APM incentive payment
is found to be in violation of the terms APM Entities for the 2019 and 2020 QP
reduction and denial policies.
Response: We appreciate the feedback of the relevant Advanced APM or any Performance Periods, and to address the
and support for our proposals. relevant Federal, State, or tribal statute standard for QP Performance Periods
Comment: One commenter suggested or regulation. after 2020 through subsequent
that we reconsider having an unlimited 4. Advanced APMs rulemaking (82 FR 3017330174).
time to reopen, revise, and recoup
a. Overview We proposed to amend
Advanced APM payments made in 414.1415(c)(4)(i)(A) through (D) to
error. In the CY 2017 Quality Payment provide that, to be an Advanced APM,
Response: It appears that the Program final rule, we finalized the a Medical Home Model must require
commenter misunderstood the criteria that define an Advanced APM that the total annual amount that an
proposals we made in the CY 2018 based on the requirements set forth in APM Entity potentially owes us or
Quality Payment Program proposed sections 1833(z)(3)(C) and (D) of the Act foregoes under the Medical Home
rule. We proposed that we may reopen, (81 FR 77408). An Advanced APM is an Model be at least the following amounts:
revise, and recoup an APM Incentive APM that: ++ For QP Performance Period 2018,
Payment that was made in error in Requires its participants to use 2 percent of the average estimated total
accordance with procedures similar to certified EHR technology (CEHRT) (81 Medicare Parts A and B revenue of all
those set forth at 405.980 through FR 7740944414); providers and suppliers in participating
405.986 and 405.370 through 405.379 Provides for payment for covered APM Entities.
of this chapter or as established under professional services based on quality
the relevant APM. The procedures we measures comparable to measures under ++ For QP Performance Period 2019,
referenced in the proposal apply the quality performance category under 3 percent of the average estimated total
broadly to providers and suppliers paid MIPS (81 FR 7741477418); and Medicare Parts A and B revenue of all
under Medicare Part A and B and Either requires its participating providers and suppliers in participating
impose reasonable time limits on APM Entities to bear financial risk for APM Entities.
reopenings and recoupments. monetary losses that are in excess of a ++ For QP Performance Period 2020,
Comment: One commenter sought nominal amount, or the APM is a 4 percent of the average estimated total
clarification regarding the rescinding of Medical Home Model expanded under Medicare Parts A and B revenue of all
a QP determination for a violation of section 1115A(c) of the Act (81 FR providers and suppliers in participating
any Federal, State, or tribal statute or 7741877431). We refer to this criterion APM Entities.
regulation. This commenter was as the financial risk criterion. ++ For QP Performance Periods 2021
concerned that this provision is too and later, 5 percent of the average
broad and could be interpreted to b. Summary of Proposals estimated total Medicare Parts A and B
include a violation of a law or We proposed the following changes revenue of all providers and suppliers
regulation that has no impact on a QP and modifications to aspects of the in participating APM Entities (82 FR
determination or the provision of health financial risk criterion in the CY 2018 30174).
c. Bearing Financial Risk for Monetary The following is a summary of the commenters who opposed applying the
Losses public comments received on this 50 eligible clinician limit to any
(1) Medical Home Model Eligible proposal and our responses: Medical Home Model expressed
Comment: Several commenters concern that the limit could distort
Clinician Limit
supported our proposal. market dynamics and have unintended
In the CY 2017 Quality Payment Response: We thank commenters for consequences. These commenters also
Program final rule, we finalized that their support our proposal. suggested the 50 eligible clinician limit
beginning in the 2018 QP Performance Comment: The majority of reflects a preference for larger practices
Period, the Medical Home Model commenters on this issue supported to participate in ACOs instead of
financial risk and nominal amount CMSs proposal to exempt participants Medical Home Models, which the
standards would only apply to APM in Round 1 of the CPC+ Model from the commenters disagreed with.
Entities that participate in Medical 50 eligible clinician limit, but also Response: We established the 50
Home Models and that have fewer than requested that we go further. Some eligible clinician limit because we
50 eligible clinicians in the organization commenters stated that all CPC+ Model believe larger group practices, and
through which the APM Entity is owned participants should be exempted from particularly those that are a part of
and operated (81 FR 77430). We refer to the 50 eligible clinician limit and stated larger parent organizations, have the
this policy throughout this final rule that applying the 50 eligible clinician capacity to assume levels of risk that
with comment period as the 50 eligible limit to other CPC+ Model participants meet the generally applicable financial
clinician limit. Under this policy, the would discourage them from risk and nominal amount standards. We
Medical Home Model financial risk and participating or continuing to appreciate the commenters concerns,
nominal amount standards would be participate in the CPC+ Model. Some of but we believe that the 50 eligible
applicable only for those APM Entities these commenters were concerned that clinician limit is a reasonable way to
owned and operated by organizations future rounds of CPC+ Model distinguish larger organizations more
with fewer than 50 eligible clinicians. participants would likely not become capable of bearing risk from smaller
We note this policy does not apply to QPs, but they would instead be subject organizations for which the generally
Medical Home Models expanded under to MIPS under the APM scoring applicable financial risk and nominal
section 1115A of the Act. standard because they would not meet amount standards would represent a
In the CY 2018 Quality Payment the generally applicable financial risk substantial, genuine barrier to
Program proposed rule, we stated that and nominal amount standards for an participation in Advanced APMs.
we finalized the 50 eligible clinician Advanced APM through participation in As we discussed in the CY 2017
limit after practices applied and signed the CPC+ Model. A few commenters Quality Payment Program final rule, the
agreements with CMS to participate in suggested that CMS exempt risk-bearing 50 eligible clinician limit was intended
Round 1 of the CPC+ Model. As such, State models that would be Medical to encourage larger organizations to
practices applying to participate in Home Models from the 50 eligible move into Advanced APMs with greater
Round 1 of the CPC+ Model were not clinician limit. These commenters levels of risk. We did not intend to
necessarily aware of the eligible suggested that CMS apply this imply that participation in Medical
clinician limit policy and, by the exemption in the same way as for Home Models is necessarily
beginning of 2018, will have already Round 1 of the CPC+ Model and stated inappropriate for larger organizations;
participated in the CPC+ Model for one that the 50 eligible clinician limit could and we recognize that Medical Home
year without this requirement applying deter participation in, and negatively Models differ from other APMs, such as
to them. Thus, to permit continued and impact the overall efficacy of such ACO initiatives, in that Medical Home
uninterrupted testing of the CPC+ models. Models focus on improving primary
Model in existing regions, we stated that Many commenters requested that care through much more targeted
we believe it is necessary to exempt CMS remove the 50 eligible clinician interventions than those commonly
practices participating in Round 1 of the limit for all Medical Home Models, not found in other APMs. We encourage
CPC+ Model from this requirement. just exempt those practices in Round 1 organizations that can effectively
Additionally, we noted that because in of the CPC+ Model. These commenters participate in Medical Home Models to
the future all APM Entities would know suggested that the 50 eligible clinician do so, regardless of whether that
about this requirement prior to their limit is arbitrary and expressed concern participation results in the participating
enrollment, and in order to ensure that that it may exclude clinicians and eligible clinicians in the APM Entity
large APM Entities that are able to bear practices who could benefit most from becoming QPs in a given year (81 FR
more risk enroll in models with higher the Medical Home Model financial risk 77429). However, we believe it is
levels of risk, we proposed that CPC+ and nominal amount standards. Some of appropriate for larger organizations that
Model participants who enroll in the these commenters also expressed exceed the 50 eligible clinician limit to
future (for example, in Round 2 of the concern that the 50 eligible clinician assume risk that meets the generally
CPC+ Model) would not be exempt from limit could discourage larger group or applicable financial risk and nominal
this requirement (82 FR 3017230173). multispecialty practices from amount standards, commensurate with
Therefore, we proposed to amend participating in in Medical Home their capability, in order for their
414.1415(c)(2) to exempt any APM Models, which could limit access for participation in a Medical Home Model
Entity participating in Round 1 of the beneficiaries to primary care medical to be treated as participation in an
CPC+ Model from the requirement that home services. The commenters noted Advanced APM for purposes of QP
beginning in the 2018 QP Performance that many health care providers determinations.
Period, the Medical Home Model associated with large group or Comment: Some commenters
financial risk standard applies only to multispecialty practices are well suggested alternative approaches to
an APM Entity that is participating in a positioned to deliver primary care limiting the application of the Medical
Medical Home Model if it has fewer medical home services, but they might Home Model financial risk and nominal
than 50 eligible clinicians in its parent be discouraged from participating amount standards such as applying the
organization. We sought comment on because they would exceed the 50 50 eligible clinician limit at the APM
this proposal. eligible clinician limit. Some of the Entity level, using patient panel size
attributed to the APM Entity, or proposal to exempt any entities in providers and suppliers that are at risk
applying the Medical Home Model Round 1 of the CPC+ Model as of for each APM Entity, and if that average
financial risk and nominal amount January 1, 2017 from the requirement estimated total Medicare Part A and B
standards based on each APM Entitys that, beginning in the 2018 QP revenue that is at risk for all APM
demonstrated ability to assume financial Performance Period, the Medical Home Entities was equal to or greater than 8
risk. Model financial risk standard applies percent, the APM would satisfy the
Response: We appreciate the only to an APM Entity that is generally applicable revenue-based
commenters suggestions. We disagree participating in a Medical Home Model nominal amount standard (82 FR
that it would be appropriate to apply the if it has fewer than 50 eligible clinicians 30173). The same approach would be
50 eligible clinician limit to the number in its parent organization by amending taken for assessing whether a Medical
of eligible clinicians in the APM Entity. 414.1415(c)(2) and adding Home Model meets the Medical Home
We believe an organizations ability to 414.1415(c)(7). Model nominal amount standard.
bear risk is more likely to be correlated We are also making accompanying We requested comment on this
with its overall size in terms of eligible edits to our discussion of the 50 eligible proposal.
clinicians in the entire organization, clinician limit for Medicaid Medical The following is a summary of the
rather than with the number of eligible Home Models by amending public comments received on this
clinicians that participate in a given 414.1420(d)(2) and 414.1415(d)(4) proposal and our responses:
APM Entity. Establishing the limit based and adding 414.1420(d)(8). Comment: Two commenters
on the size of the APM Entity could also supported CMSs proposal. One
incentivize APM Entities to artificially (2) Nominal Amount of Risk commenter stated that it would be easier
limit the number of clinicians who (a) Generally Applicable Revenue-Based for eligible clinicians and practices to
participate in each APM Entity. We Nominal Amount Standard understand.
believe that using patient panel size Response: We appreciate the
In the CY 2017 Quality Payment commenters support of our proposal.
would share some of the drawbacks
Program final rule, we finalized two Comment: Several commenters
associated with basing the limit on APM
generally applicable standards for suggested that the revenue-based
Entity size, and would also add
considerable variability and complexity defining what is a nominal amount of nominal amount standards should be
to the implementation of the Medical riska benchmark-based standard and a based on the revenues of the individual
Home Model standard. Lastly, we do not revenue-based standard. We also APM Entities participating in the APM
have any standardized or consistent way finalized an alternative nominal amount that would responsible for repayment of
of assessing individual APM Entities standard applicable only to Medical any losses. These commenters expressed
ability to assume financial risk, thus we Home Models. Both the generally concern with CMSs proposal, assuming
do not believe that implementing such applicable revenue-based nominal that the risk for smaller APM Entities to
a standard would be feasible. amount standard and the Medical Home participate in the APM would
Comment: One commenter expressed Model revenue-based nominal amount effectively be higher than 8 percent if
concern that it is operationally difficult standards state the standard in terms of there was also participation by large
to identify the parent organization of a average estimated total Medicare Parts A APM entities. These commenters stated
billing entity and even more so to and B revenue of participating APM that if the calculation was made at the
decipher the relationships between Entities (81 FR 77424). individual APM entity level, smaller
multiple parent and subsidiary entities. In the CY 2018 Quality Payment APM entities would be protected from
This commenter also noted that the Program proposed rule, we being at risk for more than 8 percent of
application of different financial risk acknowledged that this language may be their revenues. These commenters
and nominal amount standards for ambiguous as to whether it is intended stated that CMSs proposal would create
organizations of different sizes would to include payments to all providers and barriers to Advanced APM participation
require complex rules governing how suppliers in an APM Entity or only for smaller APM Entities and cause such
the APM entities are treated after payments directly to the APM Entity APM entities to not participate in
acquisition by, merger with, or itself. To eliminate this potential Advanced APMs, eventually only
separation from, another organization ambiguity, we proposed to amend allowing for larger APM Entities capable
with 50 or more eligible clinicians. This 414.1415(c)(3)(i)(A) and (c)(4)(i)(A) of bearing such risk to participate.
commenter also urged CMS to recognize through (D) to more clearly define the Several commenters suggested that the
that many medium size organizations generally applicable revenue-based proposed clarification would lead to a
may fluctuate in their size at or near the nominal amount standard and the lack of predictability in terms of
50 eligible clinician limit, potentially Medical Home Model revenue-based financial risk that could disadvantage
deterring these organizations from nominal amount standard as a smaller APM Entities, as participants
participating in a Medical Home Model. percentage of the average estimated total would not know whether an APM met
Response: We agree that it may be Medicare Parts A and B revenue of the risk standard or what the risk to any
operationally difficult to identify the providers and suppliers in participating individual APM Entity would be until
parent organizations of APM Entities, as APM Entities. Under the proposed after the end of each year, when all of
well as the relationships to, and policy, when assessing whether an APM the participating entities and their
between, multiple subsidiary entities. meets the generally applicable revenue- revenues were known.
That said, we believe that we will be based nominal amount standard, where Response: We disagree that our
able to do so. We intend to rely total risk under the model is not proposal to clarify the way we evaluate
primarily on information submitted by expressly defined in terms of revenue, the generally applicable nominal
the APM Entities themselves, who we would calculate the estimated total amount standard would disadvantage
should be most familiar with their own Medicare Parts A and B revenue of smaller APM Entities. We emphasize
corporate structures, to implement this providers and suppliers that are at risk that we make Advanced APM
policy. for each APM Entity. We would then determinations at the APM level. The
Final Action: After considering public calculate an average of all the estimated inquiry we make is whether the APM
comments, we are finalizing our total Medicare Parts A and B revenue of itself requires participating APM
Entities to bear risk that meets the essentially requiring the assumption of foregoes under an APM is equal to 8
relevant risk standard. It appears that more risk by these entities. These percent of the estimated average total
the commenter may not have commenters suggested that CMS finalize Medicare Part A and B revenues.
understood that only APMs, and not a revenue-based nominal amount Response: We reiterate that the
APM Entities, can be Advanced APMs standard that only includes Part B financial risk criterion is applied for the
as defined in our regulations. As such, revenues. purpose of making Advanced APM
we would calculate the average Response: We reiterate that we did determinations with respect to an APM
estimated total Medicare Parts A and B not propose to make changes to the as a whole, and as such, is assessed at
revenue of providers and suppliers in types of revenue are included in the the APM level. Specifically, an APM
APM Entities that are participating in an generally applicable revenue-based meets the generally applicable revenue-
APM, which pertains to an entire APM, nominal amount standard. Rather, we based nominal amount standard either
not to individual APM Entities. The proposed to clarify that we would because the design of the APM
Advanced APM determination that is include revenues of all providers and mandates that participating APM
based in part on this calculation would suppliers in an APM Entity (as opposed Entities assume total risk of at least 8
apply to all APM Entities participating to only the revenues of the APM Entity percent of Medicare Parts A and B
in that APM (except in the case of an itself.) We disagree that the generally revenues, or because we calculate that
APM Entity that exceeds the 50 eligible applicable revenue-based nominal under the terms of the APM the average
clinician limit and participates in a amount standard should only include estimated amount of total risk, across all
Medical Home Model). In particular, Part B revenues, as many APM Entities participating APM Entities, is greater
large APM Entities would not be treated participating in current Advanced than 8 percent of the estimated average
any differently than smaller APM APMs include hospitals and other types total Part A and B revenues. We further
Entities, as their individual revenues of institutional providers or suppliers clarify that the generally applicable
would have no impact on their QP that may receive both Part A and B revenue-based nominal amount
status. We also disagree that our revenues and APM Entities that could standard does not limit or cap an
proposed clarification would introduce potentially participate in future individual APM Entitys losses at 8
unpredictability, as we would make this Advanced APMs may also receive both percent of that individual APM Entitys
calculation prior to the relevant Part A and B revenues. We note that the revenues, but rather represents a
performance period of the APM. generally applicable revenue-based minimum amount of risk the average
We also note that, for APMs that nominal amount standard is inclusive participating APM Entity must be
expressly limit total risk in terms of only of the Medicare Part A and B exposed to in order for the APM to be
revenue, we do not assess whether an revenues of providers and suppliers in an Advanced APM. The total amount of
APM meets the generally applicable participating APM Entities; therefore, if risk an individual APM Entity is
revenue-based nominal amount the providers and suppliers in a given exposed to may be higher than 8 percent
standard based on the percentage of APM Entity have only Medicare Part B of the total combined Medicare Part A
average estimated total Medicare Parts A revenues, only such revenues will be and B revenues for the eligible
and B revenue of providers and considered. clinicians and any other providers and
suppliers in participating APM Entities. We also disagree that including Part A suppliers that make up the APM Entity.
For example, the Medicare ACO Track revenues would discourage Comment: Many commenters
1+ Model expressly caps risk for certain collaboration between physicians and suggested that CMS expand the
ACOs in terms of participant revenue). hospitals. While APM Entities that definition of financial risk to include
For these APMs, if the amount of total include both physicians and hospitals the investment and business risk
risk, in terms of revenue, required under may, depending on an individual APMs assumed by providers and suppliers
the terms of the APM is equal to or design, be exposed to greater risk, they who comprise APM Entities that
greater than 8 percent, then the APM would also presumably have greater participate in APMs. These commenters
would meet the revenue-based nominal capacity to assume this risk and may disagreed with CMSs contention in the
amount standard. also have greater capacity to manage CY 2017 Quality Payment Program final
Comment: Several commenters their beneficiaries across the spectrum rule that CMS could not accurately
suggested that CMS modify the revenue- of care. assess business risk without exceptional
based nominal amount standards to Comment: Several commenters administrative burden on both the
exclude Part A revenues as many APMs expressed confusion regarding CMSs agency and APM Entities in order to
do not include hospitals and therefore, proposed clarification and requested quantify and verify such expenditures.
should not accept risk for Part A that CMS provide additional clarity on These commenters stated that CMS
revenues. These commenters suggested what CMS intends to calculate as the could design standards for business risk
that including Part A revenues in the average estimated revenues of the and required documentation and
risk calculation encourages health care participants in the APM entity when attestation from APM Entities. These
providers, including eligible clinicians, making a determination as to whether commenters also disagreed with CMSs
to not partner with hospitals in an APM an APM meets the financial risk statements in the CY 2017 Quality
and may further fragment markets by criterion. Many of these commenters Payment Program final rule that
discouraging collaboration between believe that the generally applicable investment and business risk are not
hospitals, physician groups, and other revenue-based nominal amount analogous to performance risk.
health care providers, in turn making standard meant that an individual APM Response: We recognize the
participation in risk bearing models Entitys losses could be limited to 8 substantial investments that many APM
more difficult. These commenters also percent of that individual entitys Entities make in order to become
expressed concern that the proposed revenues. As such, many of these successful APM participants.
clarification would discriminate against commenters suggested that CMS modify Nonetheless, as we discussed in the CY
physician practices and health systems the regulation to clearly state that APM 2017 Quality Payment Program final
that are owned or affiliated with Entities meet the nominal risk standard rule, we continue to believe that there
hospitals, because they would have no if the total amount that each individual would be significant complexity
choice but to include Part A revenues, APM Entity potentially owes CMS or involved in creating an objective and
enforceable standard for determining The following is a summary of the nominal financial risk. We established a
whether an entitys business risk public comments received on this gradual progression of financial risk
exceeds a nominal amount, and that the proposal and our responses: within the Medical Home Model
statutory framework for the APM Comment: Many commenters nominal amount standard in recognition
Incentive Payment recognizes that not supported CMSs proposal. Some of of the fact that few APM Entities in
all alternative payment arrangements these commenters suggested that CMS Medical Home Models have had
will meet the criteria to be considered maintain the 8 percent generally experience assuming financial risk and
for purposes of the QP determination. applicable revenue-based nominal because the MACRA statute specifically
We also reiterate that business risk is amount standard for the 2021 QP makes medical homes an instrumental
generally a cost that is unrelated to Performance Period and later. Several piece of the law (81 FR 77403). We
performance-based payment under an commenters also suggested that until believe that most APM Entities in
APM. No matter how well or poorly an CMS can determine how the current Advanced APMs that are not Medical
APM Entity performs, those costs are generally applicable revenue-based Home Models generally have some
not reduced or increased nominal amount standard affects APM previous experience in assuming
correspondingly. Therefore, we Entities and eligible clinicians, CMS financial risk.
maintain the position that business risk should not consider increases or We also note that establishing a more
is not analogous to performance risk in decreases in the generally applicable gradual progression of financial risk
the APM context because those revenue-based nominal amount required for purposes of deciding
activities and investments are costs that standard. whether an APM to be considered is an
are not incorporated into the financial Response: We appreciate commenters Advanced APM would not reduce the
calculations of an APM (81 FR 77420). support of our proposal. We agree that level of risk under any particular APM,
Final Action: After considering public additional time is needed for us to nor would it likely change the list of
comments, we are finalizing assess how the current generally Advanced APMs in 2018.
amendments to 414.1415(c)(3)(i)(A) applicable revenue-based nominal Final Action: After considering public
and (c)(4)(i)(A) through (E) to clarify amount standard is affecting comments, we are finalizing our
that the revenue-based nominal amount participation in Advanced APMs before proposal to maintain the current
standards are based on a percentage of we propose to change the generally revenue-based nominal amount
the average estimated total Medicare applicable revenue-based nominal standard at 8 percent of the average
Part A and B revenue of providers and amount standard. estimated total Medicare Parts A and B
suppliers in the participating APM Comment: Many commenters revenue of all providers and suppliers
Entities. suggested that CMS not increase the in participating APM Entities for the
In the CY 2017 Quality Payment generally applicable revenue-based 2019 and 2020 QP Performance Periods
Program final rule, we finalized the nominal amount standard beyond 8 at 414.1415(c)(3)(i)(A). We will
amount of the generally applicable percent. Some commenters suggested address the standard for QP
revenue-based nominal amount that CMS reduce the amount of revenue- Performance Periods after 2020 in future
standard at 8 percent for the first two based financial risk an APM Entity must rulemaking.
QP Performance Periods only, and we bear under the terms of an APM to meet We also sought comment on whether
sought comment on what the revenue- the requirements for an APM to qualify we should consider either a lower or
based nominal amount standard should as an Advanced APM. Some of these higher revenue-based nominal amount
be for the third and subsequent QP commenters also recommended that we standard for the 2019 and 2020 QP
Performance Periods. Specifically, we phase in the revenue-based nominal Performance Periods, and we sought
sought comment on: (1) setting the amount standard at 4 percent for the comment on the amount and structure
revenue-based standard for 2019 and 2018 QP Performance Period, 6 percent of the revenue-based nominal amount
later at up to 15 percent of revenue; or for the 2019 and 2020 QP Performance standard for QP Performance Periods
(2) setting the revenue-based standard at Periods, and 8 percent beginning for the 2021 and later. In particular, we sought
10 percent so long as risk is at least 2021 QP Performance Period and comment on whether we should
equal to 1.5 percent of expected beyond. These commenters suggested consider a different, potentially lower,
expenditures for which an APM Entity that APM Entities in Advanced APMs revenue-based nominal amount
is responsible under an APM (81 FR will be facing de facto higher levels of standard only for small practices and
77427). risk as QP payment amount and patient those in rural areas (82 FR 30173
After considering public comments count thresholds increase in future 30174).
submitted on the potential options for years, and stated that 8 percent The following is a summary of the
increasing the generally applicable represents a level or risk that is already public comments received in response
revenue-based nominal amount more than nominal. to our request for comment and our
standard for 2019 QP Performance One commenter stated that in the CY responses:
Period and later, in the CY 2018 Quality 2017 Quality Payment Program final Comment: Many commenters
Payment Program proposed rule, we rule, CMS used discretionary authority supported CMS establishing a lower
proposed to maintain the current to establish a different Medical Home nominal amount standard for small and
generally applicable revenue-based Model financial risk standard and lower rural practices participating in
nominal amount standard at 8 percent level of risk in the Medical Home Model Advanced APMs. Some of these
of the average estimated total Medicare nominal amount standard. This commenters stated that a lower revenue-
Part A and B revenue of all providers commenter suggested that CMS use the based nominal amount standard for
and suppliers in participating APM same discretionary authority to establish small practices and those in rural areas
Entities for the 2019 and 2020 QP a more gradual progression of financial should apply to both practices that are
Performance Periods, and to address the risk for Advanced APMs in general. separate participants in Advanced
standard for QP Performance Periods Response: We continue to believe that APMs as well as those that join larger
after 2020 through subsequent 8 percent of Medicare Part A and B APM Entities to participate in Advanced
rulemaking (82 FR 30173). revenues generally represents an APMs. Several commenters suggested
We sought comment on this proposal. appropriate standard for more than that CMS extend the Medical Home
Nominal financial risk and nominal this schedule for incremental annual these commenters also noted that a
amount standards to small and rural increases in the nominal amount more gradual increase would enable
practices participating in all Advanced standard that we finalized for Medical greater flexibility in setting financial
APMs. These commenters also Home Models. We acknowledged that risk thresholds, encourage greater
suggested that CMS use the same establishing an even more gradual participation in Medical Home Models,
definitions for small and rural practices increase in risk for Medical Home reinforcing the overall sustainability of
currently used for MIPS. A few Models with a lower risk floor for the Medical Home Models.
commenters did not support the notion 2018 QP Performance Period may be Response: We appreciate these
of creating a lower revenue-based better suited to the circumstances of commenters support of this proposal.
nominal amount standard for small or many APM Entities in Medical Home We agree that the proposed change to a
rural practices. These commenters Models that have little experience with more gradual increase in the Medical
suggested the CMS avoid creating risk. We also reiterated, as we noted for Home Model nominal amount standard
unnecessary distinctions in the the generally applicable nominal will allow for greater participation in
application of the generally applicable amount standard, that the terms and current and future Medical Home
revenue-based nominal amount conditions in the particular APM govern Models.
standard. These commenters noted that the actual risk that participants Comment: Some commenters, while
establishing a lower revenue-based experience; the nominal amount supporting the proposal, expressed
nominal amount standard for small or standard merely sets a floor on the level concern that increasing the standard to
rural practices creates an unnecessary of risk required for the APM to be 5 percent of average estimated total
division and possibly competition considered an Advanced APM. To that Medicare Parts A and B revenue by 2021
where affected practices may terminate end, we noted that we believe a small might represent too much risk for
their participation in an ACO or other reduction of risk in the Medical Home Medical Home Model participants.
APM Entity to benefit from lower risk Model nominal amount standard These commenters cited the upfront
thresholds available to them on their beginning in the 2018 QP Performance costs of establishing the infrastructure
own, creating division among providers Period, along with a more gradual required to deliver services within
based on practice size and geography. progression toward a 5 percent nominal Medical Home Models and the limited
These commenters also urged CMS to amount standard, would allow for ability of most primary care practices to
explore alternative methods to address greater flexibility at the APM level in take on any downside risk as reasons to
the issue of resource adequacy rather setting financial risk thresholds that cap the Medical Home Model nominal
than just lowering the nominal amount would encourage more participation in amount standard at 2 or 2.5 percent and
standards for small and rural practices. Medical Home Models and be more maintain the standard at that level until
Response: We appreciate this sustainable for the type of APM Entities it is determined that a sufficient number
feedback from commenters. We may that would potentially participate in participants in Medical Home Models
address the topic of a different, Medical Home Models (82 FR 30174). have demonstrated the ability to
potentially lower revenue-based Therefore, we proposed that to be an succeed.
Advanced APM, a Medical Home Model Response: We do not agree that
nominal amount standard for small or
must require that the total annual increasing the standard to 5 percent of
rural practices in future rulemaking. We
amount that an APM Entity potentially average estimated total Medicare Parts A
welcome further public comment on
owes CMS or foregoes under the and B revenue by 2021 represents too
this issue.
Final Action: We are not taking any Medical Home Model be at least the much risk for Medical Home Model
action at this time. following: participants. As we stated in the CY
For QP Performance Period 2018, 2 2017 Quality Payment Program final
(b) Medical Home Model Nominal percent of the average estimated total rule, we continue to believe that setting
Amount Standard Medicare Parts A and B revenue of all the standard at 5 percent of Parts A and
In the CY 2017 Quality Payment providers and suppliers in participating B revenue strikes the appropriate
Program final rule, we finalized that for APM Entities. balance to reflect the meaning of
a Medical Home Model to be an For QP Performance Period 2019, 3 nominal in the Medical Home Model
Advanced APM, the total annual percent of the average estimated total context (81 FR 77428).
amount that an APM Entity potentially Medicare Parts A and B revenue of all Comment: Several commenters
owes CMS or foregoes must be at least: providers and suppliers in participating disagreed with the proposed change to
For QP Performance Period 2017, APM Entities. the Medical Home Model nominal
2.5 percent of the estimated average For QP Performance Period 2020, 4 amount standard and to the Medical
total Medicare Parts A and B revenues percent of the average estimated total Home Model nominal amount standard
of participating APM entities. Medicare Parts A and B revenue of all more generally. These commenters
For QP Performance Period 2018, 3 providers and suppliers in participating expressed concern that CMS has not
percent of the estimated average total APM Entities. complied with Congressional intent that
Medicare Parts A and B revenues of For QP Performance Periods 2021 Medical Home Models should be able to
participating APM entities. and later, 5 percent of the average qualify as Advanced APMs without
For QP Performance Period 2019, 4 estimated total Medicare Parts A and B being required to bear more than
percent of the estimated average total revenue of all providers and suppliers nominal risk. Some of these commenters
Medicare Parts A and B revenues of in participating APM Entities. suggested it would be more appropriate
participating APM entities. We sought comment on this proposal. for primary care clinicians in Medical
For QP Performance Period 2020 The following is a summary of the Home Models to accept investment or
and later, 5 percent of the estimated public comments received on this business risk, and not financial risk,
average total Medicare Parts A and B proposal and our responses: arguing that investment or business risk
revenues of participating APM entities Comment: Many commenters reflects Congressional intent regarding
(81 FR 77428). expressed support for a more gradual the qualification of Medical Home
In the CY 2018 Quality Payment increase in the Medical Home Model Models as Advanced APMs. One
Program proposed rule, we reconsidered nominal amount standard. Some of commenter strongly recommended that
CMS remove the Medical Home Model to qualify as Advanced APMs, which is establishing an even more gradual
standard in its entirety and stated that substantially lower than the risk increase in risk for Medical Home
medical homes should not be subject to required to participate as an ACO in Models, while also avoiding the
any financial risk. other Advanced APMs. The commenter counterintuitive situation where the
Response: We disagree with these expressed that the difference in nominal minimum risk level is lower in the 2018
commenters, and we believe that the amount standards creates a disparity QP Performance Period than it was in
Medical Home Model financial risk and that may lead health care providers to the 2017 QP Performance Period. We
nominal amount standard is reflective of join a Medical Home Model over an also note that this policy will also allow
Congressional intent as expressed in ACO model because of the lower risk for a smaller increase in the standard
section 1833(z)(3)(D) of the Act. We thresholds. from the 2018 QP Performance Period
continue to believe that the application Response: We thank this commenter (2.5 percent) to the 2019 Performance
of this standard is appropriate for for their feedback. While we understand Period (3 percent). We are finalizing our
Medical Home Models, especially since the concern that the separate Medical more gradual ramp-up between the 2019
the statute expressly calls out medical Home Model financial risk and nominal and 2021 QP Performance Periods as
homes for special consideration in amount standards set a lower bar to be proposed.
certain situations. We believe it is an Advanced APM than the generally We are finalizing in
appropriate to exercise our discretion to applicable financial risk and nominal 414.1415(c)(4)(i)(B) through (E) that to
separately set financial risk and nominal amount standards, in most cases we do be an Advanced APM, a Medical Home
amount standards for Medical Home not believe that this difference will Model must require that the total annual
Models that are below an amount we encourage providers or practices to join amount that an APM Entity potentially
consider to be a more than nominal Medical Home Models rather than owes us or foregoes under the Medical
amount in the context of other types of Advanced APMs that have ACOs as the Home Model be at least the following:
APMs (81 FR 77427). The generally APM Entities or other types of For QP Performance Period 2018,
applicable and Medical Home Model Advanced APMs. We note that an APM 2.5 percent of the average estimated
financial risk and nominal amount only qualifies as a Medical Home Model total Medicare Parts A and B revenue of
standards represent our interpretation of if it meets the criteria specified in the all providers and suppliers in
the statutory requirement for Advanced definition at 414.1305, including that participating APM Entities.
APMs to bear more than a nominal it has a primary care focus with For QP Performance Period 2019, 3
amount of financial risk, and we believe participants that primarily include percent of the average estimated total
those standards, including the primary care practices or multispecialty Medicare Parts A and B revenue of all
modifications we proposed to the practices that include primary care providers and suppliers in participating
Medical Home Model nominal amount physicians and practitioners and offer APM Entities.
standard, are appropriate for the QP primary care services. Therefore, For QP Performance Period 2020, 4
Performance Periods in which they participation in Medical Home Models percent of the average estimated total
apply. is generally unavailable to eligible Medicare Parts A and B revenue of all
We also reiterate that, as described in clinicians who in APM Entities that do providers and suppliers in participating
the CY 2017 Quality Payment Program not principally provide primary care APM Entities.
final rule, a Medical Home Model that services. For QP Performance Periods 2021
has been expanded under section In addition, many APMs that have and later, 5 percent of the average
1115A(c) of the Act would meet the ACOs as the APM Entities use estimated total Medicare Parts A and B
expanded Medical Home Model beneficiary attribution or alignment revenue of all providers and suppliers
criterion under section methodologies that rely on determining in participating APM Entities.
1833(z)(3)(D)(ii)(II) of the Act, and thus where a beneficiary received the
would not need to meet the financial plurality of evaluation and management d. Summary of Final Policies
risk criterion under section services, which are often furnished by In summary, we are finalizing the
1833(z)(3)(D)(ii)(I) of the Act in order to primary care practitioners. This creates following policies:
be an Advanced APM. Under this an incentive for larger organizations We are finalizing our proposal to
policy, an APM would have to be both such as health systems and multi- exempt any APM Entities in Round 1 of
determined to be a Medical Home specialty group practices that join to the Comprehensive Primary Care Plus
Model and in fact be expanded using form ACOs to include primary care (CPC+) Model, which is a Medical
the authority under section 1115A(c) of providers in the ACO in order to Home Model as of January 1, 2017 from
the Act in order to be an Advanced maintain adequate patient attribution. the requirement that, beginning in the
APM without considering the financial Final Action: After considering public 2018 QP Performance Period, the
risk and nominal amount standards (81 comments, we are finalizing our Medical Home Model financial risk
FR 77431). proposal with one modification. Upon standard applies only to an APM Entity
Lastly, we disagree with commenters further consideration, we do not believe that is participating in a Medical Home
that costs not encompassed by an APMs it would be appropriate to lower the Model if it has fewer than 50 eligible
financial risk arrangements should be Medical Home Model nominal amount clinicians in its parent organization by
considered when assessing financial standard to 2 percent for the 2018 QP amending 414.1415(c)(2) and adding
risk under the APM. For a more Performance Period after the standard 414.1415(c)(7). We are also making
extensive discussion of this issue, we has been set at 2.5 percent for the 2017 accompanying edits to our discussion of
refer readers to the CY 2017 Quality QP Performance Period. Instead, we the 50 eligible clinician limit in
Payment Program final rule (81 FR believe it would be more judicious to Medicaid Medical Home Models at
77420; 81 FR 77467). maintain the Medical Home Model 414.1420(d)(2), 414.1415(d)(4), and
Comment: One commenter expressed nominal amount standard at 2.5 percent adding 414.1420(d)(8).
concern that CMSs proposed change to for the 2018 QP Performance Period as We are amending
the Medical Home Model nominal well. We believe finalizing this level of 414.1415(c)(3)(i)(A) and (c)(4)(i)(A)
amount standard further reduces the risk for the 2018 QP Performance Period through (E) as proposed to more clearly
risk required for Medical Home Models is consistent with our goal of define the generally applicable revenue-
based nominal amount standard and the b. Summary of Proposals beneficiaries and those services will
Medical Home Model revenue-based Because some Advanced APMs may count toward the APM Entitys
nominal amount standard as a start or end during a QP Performance performance in the Advanced APM. We
percentage of the average estimated total Period, we proposed the following in proposed to modify our policies
Medicare Parts A and B revenue of all the CY 2018 Quality Payment Program regarding the timeframe(s) for which
providers and suppliers in participating proposed rule: payment amount and patient count data
APM Entities. We proposed to calculate QP are included in the QP payment amount
We are amending Threshold Scores for APM Entities in and patient count threshold calculations
414.1415(c)(3)(i)(A) to state that the Advanced APMs that are actively tested for Advanced APMs that start after
generally applicable revenue-based January 1 or end before August 31 in a
continuously for a minimum of 60 days
nominal amount standard remains at 8 given QP Performance Period (82 FR
during the QP Performance Period and
percent of the average estimated total 30175). In these situations, we would
start or end during the QP Performance
Medicare Parts A and B revenue of calculate QP Threshold Scores using
Period using only the dates that APM
providers and suppliers in participating only data in the numerator and
Entities were able to participate in
APM Entities for the 2019 and 2020 QP denominator for the dates that APM
active testing in the Advanced APM per
Performance Periods. We will address Entities were able to participate in
the terms of the Advanced APM, not the
the standard for QP Performance active testing of the Advanced APM, per
full QP Performance Period. We
Periods after 2020 through subsequent the terms of the Advanced APM, so long
proposed to add this policy to
rulemaking. as APM Entities were able to participate
414.1425(c)(6) (82 FR 30175).
We are amending We proposed to make QP
in the Advanced APM for 60 or more
414.1415(c)(4)(i)(B) through (E) to continuous days during the QP
determinations under 414.1425(c)(4), Performance Period. We proposed to
provide that, to be an Advanced APM, for eligible clinicians participating in
a Medical Home Model must require add this policy to 414.1425(c)(6) (82
multiple Advanced APMs using the full FR 30175). The QP Threshold Score
that the total annual amount that an QP Performance Period even if the
APM Entity potentially owes CMS or would be calculated at the APM Entity
eligible clinician participates in one or level or the Affiliated Practitioner level
foregoes under the Medical Home more Advanced APMs that start or end
Model be at least the following amounts: as set forth in 414.1425(b); this change
during the QP Performance Period (82 would not affect our established policy
++ For QP Performance Period 2018, FR 30175 through 30176).
2.5 percent of the average estimated as to which list of eligible clinicians, the
We proposed to amend our Participation List or Affiliated
total Medicare Parts A and B revenue of regulations to make clear that under
all providers and suppliers in Practitioner List, would be used.
414.1425(c)(4), if an eligible clinician We sought comment on these
participating APM Entities. is determined to be a QP based on
++ For QP Performance Period 2019, proposals.
participation in multiple Advanced The following is a summary of the
3 percent of the average estimated total APMs, but any of the APM Entities in
Medicare Parts A and B revenue of all public comments received on these
which the eligible clinician participates proposals and our responses:
providers and suppliers in participating voluntarily or involuntarily terminates Comment: The majority of
APM Entities. from the Advanced APM before the end commenters supported our proposals.
++ For QP Performance Period 2020, of the QP Performance Period, the These commenters agreed with CMSs
4 percent of the average estimated total eligible clinician is not a QP (82 FR view that in situations where active
Medicare Parts A and B revenue of all 30176). testing of the Advanced APM begins
providers and suppliers in participating
c. Advanced APMs Starting or Ending after January 1 or ended prior to August
APM Entities. 31 of the QP Performance Period, using
++ For QP Performance Period 2021 During a QP Performance Period
the full QP Performance Period data in
and later, 5 percent of the average We acknowledged in the CY 2018 the denominator of the QP threshold
estimated total Medicare Parts A and B Quality Payment Program proposed rule calculation could be unfair to eligible
revenue of all providers and suppliers that there may be Advanced APMs that clinicians. These commenters suggested
in participating APM Entities. start after January 1 of the QP that making QP determinations based on
5. Qualifying APM Participant (QP) and Performance Period for a year and that dates on which APM Entities
Partial QP Determinations there may also be Advanced APMs that participated in active testing of the
end prior to the August 31 end of the Advanced APM would prevent those
a. Overview QP Performance Period for a year (82 FR APM Entities and eligible clinicians
We finalized policies relating to QP 30175). By start and end, in this from being unfairly disadvantaged in QP
and Partial QP determinations in the CY context, we explained that we mean that determinations. These commenters
2017 Quality Payment Program final the period of active testing of the model supported our proposal to require at
rule (81 FR 7743377450). We finalized starts or ends such that there is no least 60 continuous days of active
that the QP Performance Period will run opportunity for any APM Entity to testing of and Advanced APM during
from January 1 through August 31 of the participate in the Advanced APM before the QP Performance Period, stating that
calendar year that is 2 years prior to the it starts or to participate in it after it 60 days is an acceptable minimum
payment year (81 FR 77446). In the CY ends. We explained that we consider the length of time for APM Entities to be
2018 Quality Payment Program active testing period to mean the dates participating in the active testing of an
proposed rule, we proposed to refer to within the performance period specific Advanced APM.
this time period for the Medicare Option to the model, which is also the time Response: We appreciate the
as the Medicare QP Performance Period period for which we consider payment commenters support of our proposals.
(82 FR 30171). As we discuss in sections amounts or patient counts through the Comment: Some commenters stated
II.D.6.d.(3)(a) and II.D.6.d.(3)(b) of this Advanced APM when we make QP that CMS should calculate QP
final rule with comment period, we are determinations. We explained that an Threshold Scores for APM entities in
not finalizing the term Medicare QP Advanced APM is in active testing if Advanced APMs that are actively tested
Performance Period. APM Entities are furnishing services to continuously for a minimum of 90
rather than 60 days. These commenters dates. As such, it would be unclear The following is a summary of the
noted that while 60 days is the shortest which time period should be used when public comments received on this
period between two snapshot dates making the QP threshold calculations proposal and our responses:
(June 30 through August 31), 90 days is especially as we will make QP Comment: Two commenters
currently the shortest possible length of determinations under both the Medicare supported CMSs proposal, suggesting
time we would use to make QP Option and All-Payer Combination that for eligible clinicians participating
determinations (January 1 through Option based on one period of time in multiple Advanced APMs, using the
March 31). These commenters also (e.g., January 1March 31; January 1 full QP Performance Period to make QP
stated that a 90 day active testing period June 30; January 1August 31). determinations is appropriate even if
is also more appropriate as it provides Comment: One commenter that the eligible clinician participates in one
additional time for the participating supported CMSs proposal was under or more Advanced APMs that start or
APM entities to be able to meet the the impression that CMS proposed to end during the Medicare QP
relevant QP threshold. change the QP Performance Period to Performance Period.
Response: We appreciate the run from January 1 through June 30.
commenters feedback. Although 90 Response: We thank commenters for
days is currently the shortest period of Response: We clarify that we did not their support of our proposal.
time we use to make QP determinations propose to change the Medicare QP
Final Action: After considering public
(January 1March 31) we believe that Performance Period to begin from
comments, we are finalizing our
calculating QP threshold scores for January 1 and end on June 30. We did
proposal to make QP and Partial QP
Advanced APMs that are actively tested not propose to revise the Medicare QP
determinations for eligible clinicians
continuously for a minimum of 60 days Performance Period that runs from
who participate in multiple Advanced
rather than 90 days will allow more January 1 and ends on August 31 of the
APMs as set forth by 414.1425(c)(4)
eligible clinicians the opportunity to calendar year that is 2 years prior to the
and 414.1425(d)(2) using the full QP
attain QP status. While 90 days may payment year. We proposed to modify
Performance Period even if the eligible
provide more time to meet the relevant the All-Payer QP Performance Period
clinician participates in one or more
QP thresholds, we believe 60 days from January 1 through August 31 to
Advanced APMs that start or end during
provides sufficient time to measure the instead establish a performance period
the QP Performance Period. We are
participation of APM entities and from January 1 through June 30 of the
codifying this policy at
eligible clinicians in Advanced APMs. calendar year that is 2 years prior to the
414.1425(c)(7)(ii).
We also note that some eligible payment year (82 FR 30171). As we
clinicians may attain QP status based on discuss further in sections II.D.6.d.(3)(a) With the exception of QP
60 days of participation, and we believe and (b) of this final rule with comment determinations for individual eligible
that it is appropriate to make that period, we note that we are not clinicians who participate in multiple
opportunity available in circumstances finalizing separate Medicare and All- Advanced APMs, we believe it is
where active testing of the Advanced Payer QP Performance Periods as appropriate to require that an Advanced
APM begins after January 1 or ended proposed. The term QP Performance APM must be actively tested for a
prior to August 31 of the QP Period will be used for both the minimum of 60 continuous days during
Performance Period. Medicare and All-Payer Combination the QP Performance Period in order for
Comment: One commenter suggested Option, and the QP Performance Period the payment amount or patient count
that CMS should apply this proposed will begin on January 1 and end on data to be considered for purposes of QP
policy to all QP determinations, August 31 of the calendar year that is 2 determinations for the year because it is
including those made under the All- years prior to the payment year. important that the QP determination be
Payer Combination Option. The based on a measure of meaningful
commenter suggested that doing so participation in an Advanced APM.
would benefit APM Entities and eligible proposal to calculate QP Threshold Accordingly, we proposed to make QP
clinicians who participate in multiple Scores using only data in the numerator determinations for all QP determination
Advanced APMs and Other Payer and denominator for the dates that APM snapshot dates that fall after the
Advanced APMs. Entities were able to participate in Advanced APM meets the minimum
Response: We note that we did not active testing of the Advanced APM, per time requirement of 60 continuous days
propose a similar policy for the All- the terms of the Advanced APM, so long whether the Advanced APM starts or
Payer Combination Option. While we as APM Entities were able to participate ends during the QP Performance Period.
generally seek to align the policies in in the Advanced APM for 60 or more We would not make a QP or Partial QP
the Medicare Option and the All-Payer continuous days during the QP determination for participants in
Combination Option, we do not believe Advanced APMs that are not actively
Performance Period. We clarify that we
that a similar policy is appropriate for tested for a period of at least 60
are adding this policy to
the All-Payer Combination Option. We continuous days during the Medicare
414.1425(c)(7)(i).
believe that doing so could be QP Performance Period (82 FR 30176).
burdensome to payers, APM Entities, We also proposed to make QP and
and eligible clinicians because it may Partial QP determinations for eligible We sought comment on this proposal.
require the submission of additional clinicians who participate in multiple We received no comments in response
information. Moreover, in order for an Advanced APMs as set forth by to this proposal.
eligible clinicians to become a QP 414.1425(c)(4) and 414.1425(d)(2) of Final Action: We are finalizing our
through the All Payer Combination our regulation using the full QP proposal to make QP determinations for
Option, the eligible clinician must Performance Period even if the eligible all QP determination snapshot dates
participate in at least one Advanced clinician participates in one or more that fall after the Advanced APM meets
APM and at least one Other Payer Advanced APMs that start or end during the minimum time requirement of 60
Advanced APM. It is unlikely that these the QP Performance Period (82 FR continuous days whether the Advanced
two (or more) payment arrangements 3017530176). APM starts or ends during the QP
would have the same start and end We sought comment on this proposal. Performance Period.
d. Participation in Multiple Advanced APM Entity that eligible clinician the APM Entities in which the eligible
APMs participates in that counts towards the clinician participates meets the QP
In the CY 2018 Quality Payment QP determination voluntarily or threshold, the eligible clinician becomes
Program proposed rule, we proposed to involuntarily terminates from the a QP.
amend 414.1425(c)(4) and (d)(4) to Advanced APM before the end of the QP Response: We appreciate the
better reflect our intended policy for QP Performance Period, the eligible commenters support.
clinician is no longer a QP. Comment: Two commenters
determinations and Partial QP
We sought comment on these supported CMSs proposal to clarify that
proposals. if an eligible clinician is determined to
who are included in more than one
The following is a summary of the be a QP or Partial QP based on his or
APM Entity group and none of the APM
public comments received on these her combined participation in multiple
Entity groups in which the eligible
proposals and our responses: Advanced APMs, if any APM entity that
clinician is included meets the Comment: Three commenters is included for purposes of the QP
corresponding QP or Partial QP expressed concern that CMSs polices determination voluntarily or
threshold, or those who are Affiliated are different for individuals than they involuntarily terminates from the
Practitioners (82 FR 30176). As we are for APM Entities. One commenter Advanced APM before the end of the QP
explained in the CY 2017 Quality questioned why this policy would be Performance Period, the eligible
Payment Program final rule, eligible different for individuals than for APM clinician is no longer a QP.
clinicians may become QPs through any Entities. Specifically, the commenter Response: We thank commenters for
of the assessments conducted for the noted that when an eligible clinician their support of this proposal.
three snapshot dates: March 31, June 30, participates in multiple Advanced Comment: Three commenters did not
and August 31 (81 FR 7744677447). If APMs, but neither APM Entity through support CMSs proposal that eligible
the APM Entity group meets the QP which they participate obtain QP status, clinicians who participate in multiple
threshold under this first assessment, the eligible clinicians data are then Advanced APMs will lose QP status if
then all eligible clinicians in the APM used to make an individual QP any of the APM Entities through which
Entity group will be QPs unless the threshold calculation, including data they participated in the Advanced APM
APM Entitys participation in the from the entire QP Performance Period terminate their participation from the
Advanced APM is voluntarily or regardless of any of their Advanced Advanced APM before the end of the QP
involuntarily terminated before the end APM start or end dates. One of these Performance Period. These commenters
of the QP Performance Period, or in the commenters believes that this policy is believe this policy would unfairly
event of a program integrity violation by contradictory to the proposal that an penalize eligible clinicians that may
eligible clinician or APM as set forth in eligible clinician reaching QP status otherwise have obtained QP status and
414.1460. We stated these same through an individual calculation will qualified for the APM incentive
procedures apply to the QP lose QP status if any of the APM Entities payment. These commenters noted that
determination made for individual through which they participated eligible clinicians are only assessed
eligible clinicians on an APM Entitys terminates from its Advanced APM individually using their participation in
Affiliated Practitioner List or individual before the end of the Medicare QP multiple Advanced APMs if none of the
eligible clinicians in multiple Advanced Performance Period. APM Entities through which they
APMs whose APM Entity groups did not Response: We clarify that it is participated meet the QP thresholds.
meet the QP threshold. necessary to include data from the These commenters expressed concern
We also proposed to amend our entire QP Performance Period, that as the QP thresholds increase in
regulations to make clear that under regardless of any Advanced APM start later years of the Quality Payment
414.1425(c)(4), if an eligible clinician or end dates, to make an individual QP Program, this situation will be more
is determined to be a QP based on threshold calculation when an eligible common. These commenters
participation in multiple Advanced clinician participates in multiple recommended that CMS remove the
APMs, but any of the APM Entities in Advanced APMs to ensure that the APM Entity that terminates from the QP
which the eligible clinician participates period of assessment for calculating threshold calculation, but still calculate
voluntarily or involuntarily terminates their QP threshold score is consistent the QP thresholds for the eligible
from the Advanced APM before the end across the Advanced APMs in which the clinicians in these circumstances using
of the QP Performance Period, the eligible clinician participates. We their participation in APM Entities that
eligible clinician is not a QP. We further clarify that our policy for did not terminate.
proposed to make the same clarification rescinding an eligible clinicians QP Response: These public comments
for Partial QP determinations under status upon the voluntary or involuntary have led us to consider a situation
414.1425(d)(4). These clarifying edits termination of an APM Entity from an which an individual eligible clinician is
specify that this policy applies only Advanced APM before the end of the QP in more than two APM Entities and
within the context of QP and Partial QP Performance Period is consistent, Advanced APMs. We acknowledge that
determinations based on participation whether the eligible clinician initially there could be a situation where one of
in multiple Advanced APMs, not for all achieved QP status through a those APM Entities through which the
QP determinations. Accordingly, for determination at the APM Entity level eligible clinician participates in an
example, if an eligible clinician is a QP or as an individual. In both scenarios, if Advanced APM terminates prior to the
through participation in each of two the APM Entity through which the end of the QP Performance Period, but
Advanced APMs under 414.1425(b)(1), eligible clinician participated in the the individual eligible clinician is in
and one APM Entity voluntarily or Advanced APM terminates from the multiple other APM Entities, through
involuntarily terminates from one of Advanced APM before the end of the QP which the eligible clinician is in other
those Advanced APMs, the eligible Performance Period, the eligible Advanced APMs, and those APM
clinician is still a QP. However, if the clinician participating as part of that Entities have not terminated their
eligible clinician is a QP through APM Entity will lose QP status. participation in an Advanced APM prior
participation in multiple Advanced Comment: One commenter supported to the end of the QP Performance
APMs under 414.1425(c)(4), and any CMSs proposal that if one or more of Period. Because it would be possible for
such a eligible clinician to attain QP or Advanced APMs would meet the and Medicare Payment Threshold
Partial QP status based solely on relevant QP or Partial QP Threshold. Option, which we refer to as the All-
performance in remaining APM Entities Payer Combination Option. In the CY
e. Summary of Final Policies
that did not terminate prior to the end 2017 Quality Payment Program final
of the QP Performance Period, in this In summary, we are finalizing the rule, we finalized our overall approach
scenario, we will evaluate whether the following policies: to the All-Payer Combination Option (81
individual eligible clinicians We are finalizing that we will FR 77459). The Medicare Option
participation in the remaining calculate QP Threshold Scores for focuses on participation in Advanced
Advanced APMs would meet the participants in Advanced APMs that are APMs, and we make determinations
relevant QP or Partial QP Threshold. actively tested continuously for a under this option based on Medicare
minimum of 60 days during the QP Part B covered professional services
Comment: One commenter questioned
Performance Period and start or end attributable to services furnished
how CMS will identify the services
during the QP Performance Period based through an APM Entity. The All-Payer
furnished by the eligible clinician
on data only for the dates that APM Combination Option does not replace or
through the APM Entity that terminated
Entities were able to participate in the
and to exclude other services performed supersede the Medicare Option; instead,
Advanced APM per the terms of the
by the eligible clinician when these it will allow eligible clinicians to
Advanced APM, not for the full QP
calculations are made at the individual become QPs by meeting the QP
Performance Period. We are codifying
level, but also supported our intent to thresholds through a pair of calculations
this policy at 414.1425(c)(7)(i).
ensure that services are not double- We are finalizing that we will make that assess Medicare Part B covered
counted. QP determinations under professional services furnished through
Response: As we discussed in the CY 414.1425(c)(4) for eligible clinicians Advanced APMs, and a combination of
2017 Quality Payment Program final participating in multiple Advanced both Medicare Part B covered
rule, because we will make QP APMs using the full QP Performance professional services furnished through
determinations using claims analyses, Period even if the eligible clinician Advanced APMs and services furnished
which enables us to connect services for participates in one or more Advanced through Other Payer Advanced APMs.
beneficiaries to an eligible clinicians APMs that start or end during the QP We finalized that beginning in payment
NPI, we would only need to add the Performance Period. We are codifying year 2021, we will conduct QP
numerator and denominator values this policy at 414.1425(c)(7)(ii). determinations sequentially so that the
together and adjust for any duplication We are finalizing amendments to Medicare Option is applied before the
in the numerator or denominator. The 414.1425(c)(6) and (d)(4) to reflect All-Payer Combination Option (81 FR
formulas would be the same as if our policy for the situation where an 77438). The All-Payer Combination
calculated for the group but based on eligible clinician is in multiple APM Option encourages eligible clinicians to
the individual eligible clinicians Entities participating in multiple participate in payment arrangements
activity at the NPI level (81 FR 77443). Advanced APMs, and it would be with payers other than Medicare that
We did not propose any changes to this possible for this eligible clinician to have payment designs that satisfy the
approach. attain QP or Partial QP status based Other Payer Advanced APM criteria. It
Final Action: After considering public solely on performance in non- also encourages sustained participation
comments, we are amending terminating APM Entities when one of in Advanced APMs across multiple
414.1425(c)(6) and (d)(4) to reflect the APM Entities terminates prior to the payers.
our policy for the situation where an end of the QP Performance Period. We We finalized that the QP
eligible clinician is in multiple APM will evaluate whether the individual determinations under the All-Payer
Entities participating in multiple eligible clinicians participation in the Combination Option are based on
Advanced APMs, and it would be remaining Advanced APMs would meet payment amounts or patient counts as
possible for this eligible clinician to the relevant QP or Partial QP Threshold. illustrated in Tables 36 and 37, and
attain QP or Partial QP status based 6. All-Payer Combination Option Figures 1 and 2 (81 FR 7746077461).
solely on performance in non- We also finalized that, in making QP
terminating APM Entities when one of a. Overview determinations, we will use the
the APM Entities terminates prior to the Section 1833(z)(2)(B)(ii) of the Act Threshold Score that is most
end of the QP Performance Period. In requires that beginning in payment year advantageous to the eligible clinician
this situation, we will evaluate whether 2021, in addition to the Medicare toward achieving QP status for the year,
the individual eligible clinicians Option, eligible clinicians may become or if QP status is not achieved, Partial
participation in the remaining QPs through the Combination All-Payer QP status for the year (81 FR 77475).
BILLING CODE 412001P

ER16NO17.002</GPH>
ER16NO17.001</GPH>
BILLING CODE 412001C We finalized the process that eligible participation in Other Payer Advanced
Unlike the Medicare Option, where clinicians can use to seek a QP APMs and Advanced APMs.
we have access to all of the information determination under the All-Payer In the CY 2018 Quality Payment
necessary to determine whether an APM Combination Option (81 FR 77478 Program proposed rule, we proposed
meets the criteria to be an Advanced 77480): additional details around our plans for
APM, we cannot determine whether an The eligible clinician submits to implementing the All Payer
other payer arrangement meets the CMS sufficient information on all Combination Option and we also
criteria to be an Other Payer Advanced relevant payment arrangements with proposed certain modifications to our
APM without receiving the required other payers; previously finalized policies (82 FR
information from an external source. 30177 through 30207).
Based upon that information CMS
Similarly, we do not have the necessary We address the following topics in

payment amount and patient count determines that at least one of those this section of this final rule with
information to determine under the All- payment arrangements is an Other Payer comment period: (1) Other Payer
Payer Combination Option whether an Advanced APM; and Advanced APM Criteria; (2)
eligible clinician meets the payment The eligible clinician meets the Determination of Other Payer Advanced
amount or patient count threshold to be relevant QP thresholds by having APMs; and (3) Calculation of All-Payer
a QP without receiving the required sufficient payments or patients Combination Option Threshold Scores
ER16NO17.003</GPH>
information from an external source. attributed to a combination of and QP Determinations.
b. Other Payer Advanced APM Criteria revenues from the payer of providers At least four of the following:
(1) In General and suppliers in participating APM ++ Planned coordination of chronic
Entities. and preventive care.
Our goal is to align the Advanced We proposed that to be an Other ++ Patient access and continuity of
APM criteria under the Medicare Option Payer Advanced APM, a Medicaid care.
and the Other Payer Advanced APM Medical Home Model must require that ++ Risk-stratified care management.
criteria under the All-Payer the total annual amount that an APM ++ Coordination of care across the
Combination Option as permitted by Entity potentially owes or foregoes medical neighborhood.
statute and as feasible and appropriate. under the Medicaid Medical Home ++ Patient and caregiver engagement.
We believe this alignment will help Model must be at least: ++ Shared decision-making.
simplify the Quality Payment Program ++ For QP Performance Period 2019, ++ Payment arrangements in addition
and encourage participation in Other 3 percent of the APM Entitys total to, or substituting for, fee-for-service
Payer Advanced APMs. revenue under the payer. payments (for example, shared savings
In the CY 2017 Quality Payment ++ For QP Performance Period 2020, or population-based payments).
Program final rule, we finalized that in 4 percent of the APM Entitys total We also explained that similar to
general, an other payer arrangement revenue under the payer. Medical Home Models and Medicaid
with any payer other than traditional ++ For QP Performance Period 2021
Medical Home Models, we believe that
Medicare, including Medicare Health and later, 5 percent of the APM Entitys
Other Payer Medical Home Models
Plans, which include Medicare total revenue under the payer.
could be considered unique types of
Advantage, Medicaid-Medicaid Plans,
(3) Other Payer Medical Home Models other payer arrangements for purposes
1876 Cost Plans, and Programs of All
In the CY 2017 Quality Payment of the Quality Payment Program. We
Inclusive Care for the Elderly (PACE)
Program final rule, we finalized anticipate that participants in these
plans, will be an Other Payer Advanced
definitions of Medical Home Model and arrangements may generally be more
APM if it meets all three of the
Medicaid Medical Home Model at limited in their ability to bear financial
following criteria:
The other payer arrangement 414.1305. The statute does not define risk than other entities because they
requires at least 50 percent of medical homes, but sections may be smaller and predominantly
participating eligible clinicians in each 1848(q)(5)(C)(i), include primary care practitioners,
participating APM Entity, or each 1833(z)(2)(B)(iii)(II)(cc)(BB), whose revenues are a smaller fraction of
hospital if hospitals are the APM 1833(z)(2)(C)(iii)(II)(cc)(BB), and the patients total cost of care than those
Entities, to use CEHRT to document and 1833(z)(3)(D)(ii)(II) of the Act make of other eligible clinicians. Because of
communicate clinical care (81 FR medical homes an instrumental piece of these factors, we explained that we
7746477465); the Quality Payment Program. believe it may be appropriate to
The other payer arrangement We recognize that there may be determine whether an Other Payer
requires that quality measures medical homes that are operated by Medical Home Model satisfies the
comparable to measures under the MIPS other payers that may be appropriately financial risk criterion by using special
quality performance category apply, considered medical home models under Other Payer Medical Home Model
which means measures that are the All-Payer Combination Option. financial risk and nominal amount
evidence-based, reliable and valid; and, Examples of these arrangements may standards, which could be different
if available, at least one measure must include those aligned with the from the generally applicable Other
be an outcome measure (81 FR 77466); Comprehensive Primary Care Plus Payer Advanced APM standards and
and (CPC+) Model. Therefore, in the CY would be identical to the Medicaid
The other payer arrangement either: 2018 Quality Payment Program Medical Home Model financial risk and
(1) Requires APM Entities to bear more proposed rule, we sought comment on nominal amount standards (82 FR
than nominal financial risk if actual whether we should define the term 30180).
aggregate expenditures exceed expected Other Payer Medical Home Model as an We noted a particular interest in, and
aggregate expenditures (under either the other payer arrangement that is sought comment on, whether there are
generally applicable or Medicaid determined by us to have the following payment arrangements that currently
Medical Home Model standards for characteristics: exist that would meet this definition.
nominal amount of financial risk, as The other payer arrangement has a We encouraged commenters to suggest
applicable); or (2) is a Medicaid Medical primary care focus with participants whether such payment arrangements
Home Model that meets criteria that primarily include primary care would meet the existing generally
comparable to Medical Home Models practices or multispecialty practices that applicable Other Payer Advanced APM
expanded under section 1115A(c) of the include primary care physicians and financial risk and nominal amount
Act (81 FR 7746677467). practitioners and offer primary care standards. We also requested comments
services. For the purposes of this on any special considerations that might
(2) Summary of Proposals provision, primary care focus means the be relevant when establishing a
In the CY 2018 Quality Payment inclusion of specific design elements definition for a medical home model
Program proposed rule, we proposed the related to eligible clinicians practicing standard for payers with payment
following: under one more of the following arrangements that would not fit under
We proposed that an other payer Physician Specialty Codes: 01 General the Medical Home Model or Medicaid
arrangement would be considered to Practice; 08 Family Medicine; 11 Medical Home Model definitions,
meet the nominal amount standard if, Internal Medicine; 16 Obstetrics and including how the 50 clinician cap we
under the terms of the other payer Gynecology; 37 Pediatric Medicine; 38 finalized in the CY 2017 Quality
arrangement, the total amount that an Geriatric Medicine; 50 Nurse Payment Program final rule (81 FR
APM Entity potentially owes the payer Practitioner; 89 Clinical Nurse 7742877429) Medical Home Model
or foregoes is equal to at least: for the Specialist; and 97 Physician Assistant; nominal amount standard would apply.
2019 and 2020 QP Performance Periods, Empanelment of each patient to a The following is a summary of the
8 percent of the total combined primary clinician; and public comments received in response
to our request for comment and our arrangement requires participating APM First, the finalized generally
responses: Entities to bear more than nominal applicable nominal amount standard for
Comment: Several commenters financial risk if aggregate expenditures Advanced APMs only requires an APM
supported CMS creating an Other Payer exceed expected aggregated to meet one measure of risktotal risk
Medical Home Model definition. One expenditures. This Other Payer (81 FR 77424). The finalized generally
commenter stated that there is no reason Advanced APM criterion has two applicable nominal amount standard for
to allow for a Medical Home Model components: A financial risk standard Other Payer Advanced APMs involves
standard under both Medicare and and a nominal amount standard. The assessment of the following three
Medicaid but not for other payers. Some financial risk standard defines what it measures of risk:
of these commenters also suggested that means for an APM Entity to bear Marginal riskthe percentage of the
we align the Other Payer Medical Home financial risk if actual aggregate amount by which actual expenditures
Model definition with the Medical expenditures exceed expected aggregate exceed expected expenditures for which
Home Model and Medicaid Medical expenditures under an other payer an APM Entity would be liable under
Home Model definitions. arrangement. We finalized a generally the payment arrangement.
Response: We appreciate the support applicable financial risk standard and a Minimum loss ratea percentage
from these commenters. Given that we Medicaid Medical Home Model by which actual expenditures may
still have limited knowledge about financial risk standard for Other Payer exceed expected expenditures without
payment arrangements between private Advanced APMs. (81 FR 77466 through triggering financial risk.
payers and eligible clinicians, we 77474). Total riskthe maximum potential
believe that it is appropriate for us to We finalized that for an other payer payment for which an APM Entity could
continue to evaluate whether an Other arrangement to meet the generally be liable under a payment arrangement.
Payer Medical Home Model definition is We reiterate that as we described in
applicable financial risk standard for
appropriate. We note that throughout the CY 2017 Quality Payment Program
Other Payer Advanced APMs, if an APM
the APM incentive portions of the final rule, although we did not formally
Entitys actual aggregate expenditures
Quality Payment Program, one of our adopt marginal risk or minimum loss
exceed expected aggregate expenditures
goals is to align policies between the rate criteria for Advanced APMs, we
during a specified performance period,
Medicare Option and the All-Payer pointed out that all current Advanced
the payer must:
Combination Option to the extent APMs would meet these standards, and
Withhold payment of services to the
feasible and appropriate. that we intend that all future Advanced
APM Entity and/or the APM Entitys
Comment: Some commenters APMs would meet the three measures of
eligible clinicians;
suggested that CMS consider making risk as well (81 FR 77426). Therefore,
Reduce payment rates to APM
some changes to the suggested Other we do not expect the application of the
Entity and/or the APM Entitys eligible
Payer Medical Home Model definition. different criteria between Advanced
clinicians; or
A few commenters suggested that APMs and Other Payer Advanced APMs
Require direct payments by the
specialty-focused medical homes should to produce meaningfully different
APM Entity to the payer (81 FR 77467).
be included in the Other Payer Medical results in terms of actual risk faced by
We also finalized that for a Medicaid
Home Model definition. A few participants.
Medical Home Model to be an Other Second, the finalized generally
commenters also suggested that CMS do Payer Advanced APM, if the APM
not include the 50 eligible clinician applicable Advanced APM nominal
Entitys actual aggregate expenditures amount standard allows for total risk to
limit in the Other Payer Medical Home exceed expected aggregate expenditures
Model definition. be defined in one of two ways, based on
during a specified performance period, expected expenditures (the benchmark-
Response: One of our goals is to align
the Medicaid Medical Home Model based standard) or based on revenue
policies between the Medicare Option
must: (the revenue-based standard) (81 FR
and the All-Payer Combination Option
Withhold payment of services to the 77427). In contrast, the finalized Other
to the extent possible. In the CY 2017
APM Entity and/or the APM Entitys Payer Advanced APM generally
Quality Payment Program final rule, in
eligible clinicians; applicable nominal amount standard is
our discussion of the Medical Home Reduce payment rates to APM
Model and Medicaid Medical Home only based on expected expenditures
Entity and/or the APM Entitys eligible (81 FR 77471).
Model definitions, we noted that we clinicians;
believe an APM cannot be a Medical In the CY 2017 Quality Payment
Require direct payments by the program final rule, we sought comments
Home Model unless it has a primary APM Entity to the payer; or
care focus with an explicit relationship on using the expected expenditures
Require the APM Entity to lose the approach for the generally applicable
between patients and practitioners (81 right to all or part of an otherwise
FR 77403). If we propose this definition Other Payer Advanced APM nominal
guaranteed payment or payments (81 FR amount standard.
or a similar definition in the future, we 7746877469).
will consider at that time whether a 50 In the CY 2018 Quality Payment
eligible clinician limit or other similar (a) Generally Applicable Nominal Program proposed rule, we did not
limit would be appropriate. Amount Standard propose to modify the marginal risk and
Final Action: We are not establishing minimum loss rates as finalized in the
(i) Marginal Risk and Minimum Loss 2017 Quality Payment Program final
a definition of Other Payer Medical Rate
Home Model. However, we may rule as part of the generally applicable
consider creating such a definition in The generally applicable nominal nominal amount standard for Other
future rulemaking. We welcome further amount standard that we finalized in Payer Advanced APMs. We noted that
public comment on this topic. the CY 2017 Quality Payment Program we continue to believe that using these
final rule for Other Payer Advanced measures of risk will ensure that
(4) Financial Risk for Monetary Losses APMs differs from the generally payment arrangements involving other
In the CY 2017 Quality Payment applicable nominal amount standard for payers and APM Entities or eligible
Program final rule, we finalized policies Advanced APMs in two ways (81 FR clinicians cannot be engineered in such
to assess whether an other payer 77471). a way as to provide eligible clinicians
an avenue to QP status through an Other future rulemaking, as we gain more into account, as doing so may not
Payer Advanced APM that technically experience in implementing the All capture the wide variety of potential
meets the financial risk criterion but Payer Combination Option. We request payment arrangements and types of
carries a very low risk of losses based on additional comment on whether we entities in those arrangements.
performance. Because we do not have should continue to require the marginal Comment: One commenter stated that
direct control over the design of Other risk and minimum loss rate it was still unclear how the nominal
Payer Advanced APMs, we noted that requirements, and also on whether there amount standard under the Medicare
we believe the use of a multi-factor are alternative approaches to achieving Option aligns with the nominal amount
nominal amount standard to assess our goals. standard under the All-Payer
financial risk provides greater assurance Combination Option.
(ii) Generally Applicable Revenue-Based Response: Where possible, we aim to
that Other Payer Advanced APMs will
Nominal Amount Standard align the Medicare Option and the All-
involve true financial risk in accordance
with statutory requirements. We stated In the CY 2018 Quality Payment Payer Combination Option. We believe
that including marginal risk and Program proposed rule, we proposed to that this proposal, by creating a
minimal loss rate requirements as add a revenue-based nominal amount revenue-based standard that requires the
components of the nominal amount standard to the generally applicable same percentage of revenue be at risk for
standard assures that the payment nominal amount standard for Other Other Payer Advanced APMs as is
arrangements that we could determine Payer Advanced APMs that is parallel to required for Advanced APMs and
are Other Payer Advanced APMs and the generally applicable revenue-based defines revenue in a comparable way,
could contribute to the attainment of QP nominal amount standard for Advanced advances that goal.
status are similarly rigorous to APMs. Specifically, we proposed that an Final Action: After considering public
Advanced APMs. We requested other payer arrangement would meet the comments, we are finalizing our
additional comments on this approach, total risk component of the proposed proposal with one clarification. As we
and on whether there are potential nominal risk standard if, under the clarified in section II.D.4.c.(2)(a) of this
alternative approaches to achieving terms of the other payer arrangement, final rule with comment period
these goals (82 FR 30181). the total amount that an APM Entity regarding the generally applicable
The following is a summary of the potentially owes the payer or foregoes is revenue-based nominal amount
public comments received in response equal to at least: For the 2019 and 2020 standard for Advanced APMs, we will
to this request for comment and our QP Performance Periods, 8 percent of look at the average estimated total
responses: the total combined revenues from the Medicare Parts A and B revenue of
Comment: Many commenters payer of providers and suppliers in providers and other entities
supported consistency between the participating APM Entities. This participating in APM Entities. Similarly,
nominal amount standards in the standard would be in addition to the for the generally applicable revenue-
Medicare Option and the All-Payer previously finalized expenditure-based based nominal amount standard under
Combination Option. Several standard. We explained that a payment the All-Payer Combination Option, we
commenters expressed support for arrangement would only need to meet will look at the total combined revenues
removing the marginal risk and one of the two standards. We would use of the providers or other entities under
minimum loss rate requirements from this standard only for other payer the payment arrangement to determine
the Other Payer Advanced APM arrangements where financial risk is that an other payer arrangement would
generally applicable nominal amount expressly defined in terms of revenue in meet the total risk component of the
standard, while two commenters the payment arrangement. We sought nominal standard if, under the terms of
supported maintaining the current comment on this proposal. the other payer arrangement, the total
Other Payer Advanced APM generally The following is a summary of the amount that an APM Entity potentially
applicable nominal amount standard. public comments received on this owes the payer or foregoes is equal to
Response: We agree with these proposal and our responses: at least: For the 2019 and 2020 QP
commenters that creating alignment Comment: Many commenters Performance Periods, 8 percent of the
between the Medicare Option and the supported CMSs proposal. One total combined revenues from the payer
All-Payer Combination Option is commenter requested that this 8 percent to providers and other entities under the
generally desirable, wherever possible. generally applicable revenue-based payment arrangement by revising
We also recognize that including nominal amount standard be 414.1420(d)(3)(i).
marginal risk and minimum loss rate maintained beyond the 2019 and 2020 For Advanced APMs, we may
requirements adds significant QP Performance Periods. determine that an APM still meets the
complexity and may make it more Response: We appreciate commenters generally applicable revenue-based
challenging for both payers and eligible support of this proposal. We will nominal amount standard, even if risk is
clinicians to participate in the All Payer establish this standard for QP not explicitly defined in terms of
Combination Option. That said, we Performance Periods 2019 and 2020 as revenue, by comparing model downside
continue to believe that the use of a proposed, and we anticipate adopting a risk to the estimated average Medicare
multi-factor nominal amount standard generally applicable revenue-based revenue of model participants. Because
to assess financial risk provides us with nominal amount standard for QP we have direct access to Medicare
an important guardrail to ensure that Performance Periods after 2020 through claims data, we can estimate such an
Other Payer Advanced APMs will future rulemaking. average. For other payers, we do not
involve true financial risk. Comment: One commenter suggested have similar direct access to claims
Final Action: We are not making any that the revenue-based nominal amount data. As such, there are significant
changes to this policy at this time. We standard should only include physician operational challenges to identifying
welcome additional comment on this revenue. whether an other payer arrangement
approach. We note that we are looking Response: We do not believe that it would satisfy the revenue-based
to explore ways to reduce burden within would be appropriate to limit the nominal amount standard when the
the All-Payer Combination Option, and revenue-based nominal amount other payer arrangement does not define
may consider additional changes in standard to only take physician revenue risk explicitly in terms of revenue.
Because we do not have direct access to specifically for small and rural In the CY 2018 Quality Payment
other payer revenue data, we could not organizations may allow for increased Program proposed rule, we reconsidered
do this calculation without significant participation in Other Payer Advanced the incremental annual increases we
assistance from the relevant payer. For APMs, which may help increase the had established for the Medicaid
this reason, we proposed that the quality and coordination of care Medical Home Model nominal amount
revenue-based nominal amount beneficiaries receive as a result. standard to take effect over several
standard would only be applied to other Specifically, we sought comment on years. Our policy finalized in the CY
payer arrangements in which risk is whether such a standard should apply 2017 Quality Payment Program final
explicitly defined in terms of revenue, only to small and, or, rural practices rule set forth what we envisioned was
as specified in an agreement covering that are participants in an Other Payer a gradually increasing but achievable
the other payer arrangement. Advanced APM, or also to small and/or amount of risk that would apply over
We sought comment on this proposal. rural practices that join larger APM time. In general, we still believe this to
We did not receive any comments in Entities to participate in APMs. We also be true, but recognize that establishing
response to this proposal. sought comment on how we should an even more gradual increase in risk
Final Action: We are finalizing our decide where a practice is located to for Medicaid Medical Home Models
proposal that the revenue-based determine whether it is operating in a may better suit many APM Entities in
standard would only be applied to other rural area is defined in 414.1305. Medicaid Medical Home Models that
payer arrangements in which risk is The following is a summary of the have little experience with risk. To that
explicitly defined in terms of revenue, public comments received in response end, we explained that we believe a
as specified in an agreement covering to this request for comments and our small reduction of risk in the Medicaid
the other payer arrangement. We are responses: Medical Home Model nominal amount
codifying this policy by revising Comment: Some commenters standard beginning in the 2019 QP
414.1420(d)(3)(i). supported a different, lower revenue- Performance Period may allow for
In the CY 2018 Quality Payment based nominal amount standard for greater flexibility in setting financial
Program proposed rule, we proposed small and rural practices. One risk thresholds that would encourage
that under the generally applicable commenter urged CMS to further assess more participation in Medicaid Medical
nominal amount standard for Other rural communities to determine how Home Models and be more sustainable
Payer Advanced APMs, an other payer much risk they can handle and the most for the type of APM Entities that would
arrangement would need to meet either appropriate kinds of risksymmetric, potentially participate in Medicaid
the benchmark-based nominal amount asymmetric, or another alternative. Medical Home Models.
standard or the revenue-based nominal Another commenter stated that creating Therefore, in the CY 2018 Quality
amount standard and need not meet a different, lower revenue-based Payment Program proposed rule, we
both. We noted that we believe the nominal amount standard would give us proposed that to be an Other Payer
proposed approach to the nominal the opportunity to engage new practices Advanced APM, a Medicaid Medical
amount standard would expand the that would not otherwise participate in Home Model must require that the total
opportunities for other payer higher risk models, or those that tried annual amount that an APM Entity
arrangements to meet the generally the existing higher risk models found potentially owes or foregoes under the
applicable nominal amount standard, the risk levels unworkable and would Medicaid Medical Home Model must be
and would allow closer alignment no longer participate anyway. at least:
between Medicare and other payers as Response: We appreciate the For QP Performance Period 2019, 3
new payment arrangements are comments submitted, and we will percent of the APM Entitys total
introduced and evolve. continue to assess the need for a revenue under the payer.
We sought comment on this proposal. different revenue-based nominal For QP Performance Period 2020, 4
We received no comments in response amount standard for small or rural percent of the APM Entitys total
to this proposal. practices or organizations. revenue under the payer.
Final Action: We are finalizing our Final Action: We are not creating a For QP Performance Period 2021
proposal that under the generally different revenue-based nominal and later, 5 percent of the APM Entitys
applicable nominal amount standard for amount standard for either small total revenue under the payer (82 FR
Other Payer Advanced APMs, an other practices or rural areas at this time. We 30182 through 30183).
payer arrangement would need to meet may address this topic in future We sought comment on this proposal.
either the benchmark-based nominal rulemaking. The following is a summary of the
amount standard or the revenue-based public comments received on this
nominal amount standard and need not (b) Medicaid Medical Home Model proposal and our responses:
meet both. Nominal Amount Standard Comment: Several commenters
We also sought comment on whether In the CY 2017 Quality Payment expressed support for this proposal.
we should consider a different, Program final rule, in addition to the Response: We appreciate the
potentially lower, revenue-based financial risk standard for Medicaid commenters support for this proposal.
nominal amount standard only for small Medical Home Models, we finalized that Comment: Some commenters
practices and those in rural areas that to be an Other Payer Advanced APM, a suggested that the proposed total levels
are not participating in a Medicaid Medicaid Medical Home Model must of revenue at risk are too high for
Medical Home Model for the 2019 and require that the total annual amount that Medicaid clinicians and should be
2020 QP Performance Periods (82 FR an APM Entity potentially owes or lowered. One of these commenters
30182). We noted we would use the foregoes be at least the following recommended that ultimately 2.5
definition of small practices and rural amounts in a given performance year: percent of the APM Entitys total
areas that is in 414.1305. We noted In 2019, 4 percent of the APM revenue under the payer should be at
that we believe that a different, Entitys total revenues under the payer. risk, not 5 percent as we have proposed.
potentially lower, revenue-based In 2020 and later, 5 percent of the Another commenter suggested that
nominal amount standard for the 2019 APM Entitys total revenues under the states should have the ability and
and 2020 QP Performance Periods payer (81 FR 77472). flexibility to set nominal risk levels.
Response: We believe that we have an APM Entity potentially owes a payer and in a manner determined by us,
taken into account the circumstances or foregoes under the Medicaid Medical information necessary to identify
that eligible clinicians with a significant Home Model must be at least: whether a given payment arrangement
Medicaid practice face, particularly the For QP Performance Period 2019, 3 satisfies the Other Payer Advanced APM
potential that they may have limited percent of the average estimated total criteria (81 FR 77480). We finalized that
experience with bearing financial risk, revenue of the participating providers or we will identify Medicaid APMs and
in the development of the Medicaid other entities under the payer. Medicaid Medical Home Models that
Medical Home Model nominal amount For QP Performance Period 2020, 4 meet the Other Payer Advanced APM
standard. We continue to believe that a percent of the average estimated total criteria before the beginning of the QP
gradual ramp-up to a 5 percent revenue of the participating providers or Performance Period (81 FR 77478
Medicaid Medical Home Model nominal other entities under the payer. 77480). We also sought comment on the
amount standard is appropriate as For QP Performance Period 2021 overall process for reviewing payment
eligible clinicians with a significant and later, 5 percent of the average arrangements to determine whether they
Medicaid practice may not have much estimated total revenue of the are Other Payer Advanced APMs, and
experience in assuming risk. We also do participating providers or other entities we also sought comment on whether we
not believe that this more gradual ramp- under the payer. should create a separate pathway to
up will constrain state flexibility or identify whether other payer
discourage eligible clinicians from (5) Summary of Final Policies
arrangements with Medicaid as a payer
participating arrangements that we may In summary, we are finalizing the meet the Other Payer Advanced APM
determine are Medicaid Medical Home following policies: criteria (81 FR 77463).
Models. We are finalizing that an other We note that in the CY 2017 Quality
Comment: One commenter stated that payer arrangement would meet the Payment Program final rule, we codified
Medicaid Medical Home Models generally applicable revenue-based some of our final policies pertaining to
participating in a State Innovation nominal amount standard we are the Determination of Other Payer
Model (SIM) initiative should be exempt finalizing if, under the terms of the Advanced APMs at 414.1410(b)(2). In
from the Medicaid Medical Home other payer arrangement, the total this CY 2018 Quality Payment Program
Model nominal amount standard. amount that an APM Entity potentially final rule with comment period, we are
Response: Our determination of owes the payer or foregoes is equal to
whether an other payer arrangement removing 414.1410(b)(2) and are
at least: For the 2019 and 2020 QP codifying policies pertaining to Other
meets the Other Payer Advanced APM Performance Periods, 8 percent of the
criteria, including the Medicaid Medical Payer Advanced APM determinations at
total combined revenues from the payer 414.144.
Home Model nominal amount standard, to providers and other entities in the
is based on whether the terms of the payment arrangement only for (a) Summary of Proposals
other payer arrangement itself meet the arrangements that are expressly defined
Other Payer Advanced APM criteria. In the CY 2018 Quality Payment
in terms of revenue. We are codifying Program proposed rule, we proposed the
While we appreciate and encourage this policy by revising
continued and further participation in following:
414.1420(d)(3)(i).
the State Innovation Model (SIM) We are finalizing at Payer Initiated Process
initiative, that participation has no 414.1420(d)(4)(i) and (iii) that a
bearing on whether an other payer We proposed to allow certain other
Medicaid Medical Home Model would payers, including payers with payment
arrangement would be considered a meet the benchmark-based Medicaid
Medicaid Medical Home Model. arrangements authorized under Title
Home Model nominal amount standard XIX, Medicare Health Plan payment
if, under the terms of the other payer arrangements, and payers with payment
arrangement, the total annual amount arrangements aligned with a CMS Multi-
proposal with one clarification. As we
clarified in section II.D.4.c.(2)(a) of this that an APM Entity potentially owes or Payer Model to request that we
final rule with comment period foregoes under the Medicaid Medical determine whether their other payer
regarding the generally applicable Home Model must be at least: arrangements are Other Payer Advanced
revenue-based nominal amount ++ For QP Performance Period 2019, APMs starting prior to the 2019 QP
standard, and as we state in the Medical 3 percent of the average estimated total Performance Period and each year
Home Model nominal amount standard, revenue of the participating providers or thereafter. We proposed to allow
we will look at the average estimated other entities under the payer. remaining other payers, including
total Medicare Parts A and B revenue of ++ For QP Performance Period 2020, commercial and other private payers, to
providers and other entities 4 percent of the average estimated total request that we determine whether other
participating in APM Entities. Similarly, revenue of the participating providers or payer arrangements are Other Payer
for the Medicaid Medical Home Model other entities under the payer. Advanced APMs starting in 2019 prior
nominal amount standard, we will look ++ For QP Performance Period 2021 to the 2020 QP Performance Period, and
at the total revenues of the participating and later, 5 percent of the average annually each year thereafter. We
providers or other entities under the estimated total revenue of the proposed to generally refer to this
payment arrangement to determine participating providers or other entities process as the Payer Initiated Other
whether an other payer arrangement under the payer. Payer Advanced APM Determination
meets the Medicaid Medical Home c. Determination of Other Payer Process (Payer Initiated Process), and
Model nominal amount standard. Advanced APMs we proposed that the Payer Initiated
Therefore, we are amending Process would generally involve the
414.1420(d)(4)(i) and (iii) to state that (1) Overview same steps for each payer type for each
meet the Medicaid Medical Home For other payer arrangements, in the QP Performance Period. We proposed
Model nominal amount standard, a CY 2017 Quality Payment Program final that these Other Payer Advanced APM
Medicaid Medical Home Model must rule, we specified that an APM Entity or determinations would be in effect for
require that the total annual amount that eligible clinician must submit, by a date only one year at a time. We proposed
that the Payer Initiated Process would payer arrangements are Other Payer Initiated Submission Form by the
be voluntary for all payers. Advanced APMs. We proposed that relevant Submission Deadline.
We proposed that payers would be payers with other payer arrangements
required to use the Payer Initiated Eligible Clinician Initiated Process
aligned with a CMS Multi-Payer Model
Submission Form to request that we may request that we determine prior to We proposed that through the
make an Other Payer Advanced APM the QP Performance Period whether Eligible Clinician Initiated Process,
determination. We proposed that the those other payer arrangements are APM Entities and eligible clinicians
Submission Period opening date and Other Payer Advanced APMs. We participating in other payer
Submission Deadline would vary by proposed that payers that want to arrangements would have an
payer type to align with existing CMS request that we determine whether opportunity to request that we
processes for payment arrangements those arrangements are Other Payer determine for the relevant QP
authorized under Title XIX, Medicare Advanced APMs would use the Performance Period whether those other
Health Plan payment arrangements, and processes specified for payment payer arrangements are Other Payer
payers with payment arrangements arrangements authorized under Title Advanced APMs. The Eligible Clinician
aligned with a CMS Multi-Payer Model XIX and Medicare Health Plan payment Initiated Process could also be used to
to the extent possible and appropriate. arrangements. We proposed that the request determinations before the
We proposed that if we determine Submission Period would open on beginning of a QP Performance Period
that the payer has submitted incomplete January 1 of the calendar year prior to for other payer arrangements authorized
or inadequate information, we would the relevant QP Performance Period. We under Title XIX.
inform the payer and allow the payer to also proposed that the Submission We proposed that APM Entities or
submit additional information no later Period would close on June 30 of the eligible clinicians would be required to
than 10 business days from the date we use the Eligible Clinician Initiated
calendar year prior to the relevant QP
inform the payer. For each other payer Submission Form to request that we
Performance Period. We proposed that,
arrangement for which the payer does make an Other Payer Advanced APM
in CMS Multi-Payer Models where a
not submit sufficient information, we determination.
state prescribes uniform payment We proposed that if we determine
would not make a determination in arrangements across all payers
response to that request submitted via that an APM Entity or eligible clinician
statewide, the state would submit on has submitted incomplete or inadequate
the Payer Initiated Submission Form. behalf of payers in the Payer Initiated
We proposed that if a payer uses the information, we would inform the payer
Process for Other Payer Advanced and allow the payer to submit
same other payer arrangement in other
APMs. We would seek information for additional information no later than 10
commercial lines of business that the
the determination from the state, rather business days from the date we inform
payer has submitted for determination
than individual payers. The same Payer the APM Entity or eligible clinician. For
as a Title XIX, Medicare Health Plan, or
Initiated Process and timeline described each other payer arrangement for which
CMS Multi-Payer Model payment
that applies for CMS Multi-Payer the APM Entity or eligible clinician
arrangement, we will allow the payer to
concurrently request that we determine Models would apply. does not submit sufficient information,
whether those other payer arrangements Medicare Health Plans: We we would not make a determination in
are Other Payer Advanced APMs as proposed that the Submission Period response to that request submitted via
well. would begin and end at the same time the Eligible Clinician Initiated
Title XIX (Medicaid): We proposed as the annual Medicare Advantage bid Submission Form.
that any states and territories (states) timeframe. We proposed the Submission Title XIX (Medicaid): We proposed
that have in place a state plan under Period would begin when the bid that beginning in the first QP
Title XIX may request that we determine packages are sent out to plans in April Performance Period under the All-Payer
prior to the QP Performance Period of the year prior to the relevant QP Combination Option, APM Entities and
whether other payer arrangements Performance Period. We also proposed eligible clinicians may submit
authorized under Title XIX are Other that the Submission Deadline would be information on payment arrangements
Payer Advanced APMs under the Payer the annual bid deadline, which would authorized under Title XIX to request
Initiated Process beginning in the year be the first Monday in June in the year that we determine whether those
prior to the first QP Performance Period prior to the relevant QP Performance arrangements that are not already
under the All-Payer Combination Period. determined to be Other Payer Advanced
Option. We proposed to allow states to Remaining Other Payers: We APMs through the Payer Initiated
request determinations for both proposed to allow the remaining other Process are Medicaid APMs or Medicaid
Medicaid fee-for-service and Medicaid payers not specifically addressed in Medical Home Models that meet the
managed care plan payment other proposals above, including Other Payer Advanced APM criteria
arrangements. We proposed that the commercial and other private payers prior to the QP Performance Period. We
Submission Period for the Payer that are not states, Medicare Health proposed that APM Entities or eligible
Initiated Process would open on January Plans, or payers with arrangements that clinicians may submit Eligible Clinician
1 of the calendar year prior to the are aligned with a CMS Multi-Payer Initiated Submission Forms for payment
relevant QP Performance Period. We Model, to request that we determine arrangements authorized under Title
proposed that the Submission Deadline whether their other payer arrangements XIX beginning on September 1 of the
for these submissions is April 1 of the are Other Payer Advanced APMs calendar year prior to the QP
year prior to the QP Performance Period starting prior to the QP Performance Performance Period. We also proposed
for which we would make the Period for 2020 and annually each year that the Submission Deadline is
determination. thereafter. November 1 of the calendar year prior
CMS Multi-Payer Models: We We proposed that, for each other to the QP Performance Period.
proposed that payers with other payer payer arrangement for which a payer CMS Multi-Payer Models: We
arrangements aligned with a CMS Multi- requests us to determine whether it is an proposed that through the Eligible
Payer Model may request that we Other Payer Advanced APM, the payer Clinician Initiated Process, APM
determine whether their aligned other must complete and submit the Payer Entities and eligible clinicians
participating in other payer Submission of Information for Other submit the Eligible Clinician Initiated
arrangements in CMS Multi-Payer Payer Advanced APM Determinations Submission Form by the relevant
Models may request that we determine We proposed that, for each other Submission Deadline.
whether those other payer arrangements payer arrangement for which a payer We proposed to add a new
that are not already determined to be requests us to determine whether it is an requirement at 414.1445(d) stating that
Other Payer Advanced APMs through a payer that submits information
Other Payer Advanced APM, all payers
the Payer Initiated Process are Other pursuant to 414.1445(c) must certify to
must complete and submit the Payer
Payer Advanced APMs. We proposed the best of its knowledge that the
Initiated Submission Form by the
that APM Entities or eligible clinicians information submitted to us through the
relevant Submission Deadline. We
Payer Initiated Process is true, accurate,
may request Other Payer Advanced proposed that the Payer Initiated
and complete. Additionally, we
APM determinations beginning on Submission Form would allow payers to
proposed that this certification must
August 1 of the same year as the include descriptive language for each of
accompany the Payer Initiated
relevant QP Performance Period. We the required information elements. We
Submission Form and any supporting
proposed that the Submission Deadline proposed to require the name and
documentation that payers submit to us
for requesting Other Payer Advanced description of the arrangement, nature through the Payer Initiated Process.
APM determinations, as well as to of the arrangement, QP Performance We also proposed to revise the
request QP determinations under the Period for which the arrangement is monitoring and program integrity
All-Payer Combination Option, is available, participant eligibility criteria, provisions at 414.1460 to ensure the
December 1 of the same year as the and location(s) where the arrangement integrity of the Payer Initiated Process.
relevant QP Performance Period. will be available so that we can verify Specifically, we proposed to require
whether eligible clinicians who may tell payers that choose to submit
Medicare Health Plans: We us that they participate in such
proposed that through the Eligible information through the Payer Initiated
arrangements are eligible to do so. We Process to maintain such books,
Clinician Initiated Process, APM proposed to require that payers submit
Entities and eligible clinicians contracts, records, documents, and other
documentation that supports the evidence as necessary to audit an Other
participating in other payer information they provided in the Payer Payer Advanced APM determination,
arrangements in Medicare Health Plans Initiated Submission Form and that is and that such information and
would have an opportunity to request sufficient to enable us to determine supporting documentation must be
that we determine whether those other whether the other payer arrangement is maintained for 10 years after submission
payer arrangements that are not already an Other Payer Advanced APM. and must be provided to CMS upon
determined to be Other Payer Advanced We proposed that, for each other request. We also proposed to specify
APMs through the Payer Initiated payer arrangement for which an APM that information submitted by payers for
Process are Other Payer Advanced Entity or eligible clinician requests us to purposes of the All-Payer Combination
APMs. We proposed that APM Entities determine whether it is an Other Payer Option may be subject to audit by CMS.
or eligible clinicians may request Other Advanced APM, all eligible clinicians We proposed to remove the
Payer Advanced APM determinations must complete and submit the Eligible requirement at 414.1445(b)(3) that
beginning on August 1 of the same year Clinician Initiated Submission Form by payers must attest to the accuracy of
as the relevant QP Performance Period. the relevant Submission Deadline. We information submitted by eligible
We proposed that the Submission proposed that the Eligible Clinician clinicians. We also proposed to remove
Deadline for requesting Other Payer Initiated Submission Form would allow the attestation requirement at
Advanced APM determinations, as well APM Entities or eligible clinicians to 414.1460(c) and add a requirement at
as to request QP determinations under include descriptive language for each of 414.1445(d) that an APM Entity or
the All-Payer Combination Option, is the required information elements. We eligible clinician that submits
December 1 of the same year as the proposed to require the name and information pursuant to 414.1445(c)
relevant QP Performance Period. description of the arrangement, nature must certify to the best of its knowledge
of the arrangement, QP Performance that the information it submitted to us
Remaining Other Payers: We
Period for which the arrangement is is true, accurate, and complete. We also
proposed that, through the Eligible available, participant eligibility criteria, proposed that this certification must
Clinician Initiated Process, APM and location(s) where the arrangement accompany the submission.
Entities and eligible clinicians will be available so that we can verify We proposed to remove the record
participating in other payer whether eligible clinicians who may tell retention requirement at 414.1445(c)
arrangements through a remaining other us that they participate in such and only address the record retention
payer may request that we determine arrangements are eligible to do so. We issue at 414.1460(e) stating that APM
whether or not the payment proposed to require that APM Entities or Entities and eligible clinicians must
arrangement is an Other Payer eligible clinicians submit maintain such books, contracts, records,
Advanced APM. We proposed that APM documentation that supports the documents, and other evidence as
Entities or eligible clinicians may information they provided in the necessary to enable the audit of an
request Other Payer Advanced APM Eligible Clinician Initiated Submission Other Payer Advanced APM
determinations beginning on August 1 Form and that is sufficient to enable us determination, QP determination, and
of the same year as the relevant QP to determine whether the other payer the accuracy of an APM Incentive
Performance Period. We proposed that arrangement is an Other Payer Payment.

the Submission Deadline for requesting Advanced APM. We proposed that, with the
Other Payer Advanced APM We proposed that, for each other exception of the specific information we
determinations, as well as to request QP payer arrangement for which an APM proposed to make publicly available as
determinations under the All-Payer Entity or eligible clinician requests us to stated above, the information a payer
Combination Option, is December 1 of determine whether it is an Other Payer submits to us through the Payer
the same year as the relevant QP Advanced APM, the APM Entity or Initiated Process and the information an
Performance Period. eligible clinician must complete and APM Entity or eligible clinician submits
to us through the Eligible Clinician additional opportunities to reduce codifying these policies at
Initiated Process would be kept burden that we can incorporate into 414.1445(a) and 414.1445(b)(1).
confidential to the extent permitted by how we determine whether other payer In the CY 2018 Quality Payment
federal law, in order to avoid arrangements meet the Other Payer Program proposed rule, if a payer
dissemination of potentially sensitive Advanced APM criteria. requests that we determine whether a
contractual information or trade secrets. Comment: Two commenters opposed payment arrangement authorized under
We proposed that we would the proposed Payer Initiated Process. Title XIX, a Medicare Health Plan
presume that an other payer These commenters stated that group payment arrangement, or a payment
arrangement would satisfy the 50 practices and eligible clinicians should arrangement in a CMS Multi-Payer
percent CEHRT use criterion if we be responsible for submitting payment Model is an Other Payer Advanced
receive information and documentation arrangement information, not payers. APM, and the payer uses the same other
from the APM Entity or eligible One commenter stated that this process payer arrangement in other commercial
clinician through the Eligible Clinician is confusing. lines of business, we proposed to allow
Initiated Process showing that the other Response: We note that the Payer the payer to concurrently request that
payer arrangement requires the Initiated Process is voluntary. Payers we determine whether those other payer
requesting eligible clinician(s) to use who do not wish to submit information arrangements are Other Payer Advanced
CEHRT to document and communicate through the Payer Initiated Process are APMs as well. We proposed to make
clinical information. not required to do so. APM Entities and Other Payer Advanced APM
eligible clinicians can choose to submit determinations for each individual
(b) Payer Initiated Other Payer payment arrangement (82 FR 30183).
Advanced APM Determination Process payment information on those same
other payer arrangements through the We sought comment on this proposal.
(Payer Initiated Process) The following is a summary of the
Eligible Clinician Initiated Process. We
In the CY 2018 Quality Payment public comments received on this
believe that offering payers the option to
Program proposed rule, we proposed to proposal and our responses:
submit payment arrangement
allow certain other payers, including Comment: One commenter suggested
information can help with the
payers with payment arrangements that if a payer has the same payment
implementation of the All-Payer
authorized under Title XIX, Medicare arrangement in place across multiple
Combination Option, including by
Health Plan payment arrangements, and plans, that payer should be allowed to
reducing some of the burden for APM
payers with payment arrangements submit one form for a determination
Entities and eligible clinicians. We
aligned with a CMS Multi-Payer Model that would apply to all of those plans.
reiterate that one of our goals is to Response: We appreciate the
to request that we determine whether
reduce burden and complexity, and we suggestion. We will continue to identify
their other payer arrangements are Other
will continue to look for opportunities ways where we can simplify the Payer
Payer Advanced APMs starting prior to
to further streamline this process. Initiated Process, and we will provide
the 2019 QP Performance Period and
Comment: One commenter supported further detailed instructions and
each year thereafter. We proposed to
the overall approach of the Payer guidance on how to complete the Payer
generally refer to this process as the
Initiated Process, but the commenter Initiated Submission Form. It is our
Payer Initiated Other Payer Advanced
suggested that CMS consider intent that if a payer has the same
APM Determination Process (Payer
simplifying the process significantly by payment arrangement in place across
Initiated Process) (82 FR 30183).
The following is a summary of the requiring payers to submit their multiple plans, or multiple payer types,
public comments received on these arrangements to us at the group (TIN) that payer should be allowed to submit
proposals and our responses: level. one Payer Initiated Submission Form for
Comment: Several commenters Response: We will rely on payers to a determination that will apply to all of
supported CMSs proposed general tell us how the payment arrangement is those plans or payer types.
approach for Other Payer Advanced designed and who is eligible to Final Action: After considering public
APM determinations, and many participate, and we believe we have comments, we are finalizing this policy
commenters supported our proposed allowed for significant flexibility in this as proposed with one modification. We
general approach to the Payer Initiated decision, which we think is particularly are finalizing that we will allow payers
Process. important given the likely variation in with payment arrangements under Title
Response: We appreciate the support the structure of payment arrangements XIX or aligned with a CMS Multi-Payer
for our proposed general approach for for which payers may request Other Model to submit a single submission
Other Payer Advanced APM Payer Advanced APM determinations. form when the same payment
determinations and the Payer Initiated Final Action: After considering public arrangement is in place with other
Process. comments, we are finalizing our plans. However, we are not currently
Comment: Some commenters stated proposals to allow certain other payers, extending this policy to Medicare
that CMSs general proposed approach including payers with payment Health Plans as we continue to address
is overly complicated and requested that arrangements authorized under Title the feasibility of operational changes to
CMS simplify how it makes Other Payer XIX, Medicare Health Plan payment the Health Plan Management System
Advanced APM determinations. arrangements, and payers with payment (HPMS) that would be necessary to
Response: One of our goals is to arrangements aligned with a CMS Multi- implement this policy.
minimize the burden on payers, APM Payer Model to request that we In the CY 2018 Quality Payment
Entities, and eligible clinicians to the determine whether their other payer Program proposed rule, we proposed
extent possible while collecting the arrangements are Other Payer Advanced that these Other Payer Advanced APM
information that we need in order to APMs starting prior to the 2019 QP determinations would be in effect for
make Other Payer Advanced APM Performance Period and each year only one year at a time (82 FR 30183).
determinations. As we continue to thereafter. We will generally refer to this We sought comment on this proposal.
implement the All-Payer Combination process as the Payer Initiated Other The following is a summary of the
Option, we will continue to evaluate Payer Advanced APM Determination public comments received on this
and adjust policies if there are Process (Payer Initiated Process). We are proposal and our responses:
Comment: Many commenters Advanced APM determination. We will determination. We stated that we intend
expressed concern with an annual consider in future rulemaking whether for the Payer Initiated Submission Form
determination process and generally to introduce an option where Other to include questions that are applicable
preferred a policy where Other Payer Payer Advanced APM determinations to all payment arrangements and some
Advanced APM determinations would could be extended for more than one that are specific to a particular type of
be in effect for multiple years. Some of year a time in future rulemaking. payment arrangement, and we intend
these commenters requested a multi- We also proposed to allow remaining for it to include a way for payers to
year policy specifically for Medicaid other payers, including commercial and attach supporting documentation. We
payment arrangements. Some other private payers, to request that we proposed that payers may submit
commenters stated that some of these determine whether other payer requests for review of multiple other
arrangements take years to develop and arrangements are Other Payer Advanced payer arrangements through the Payer
that they last for more than one year, APMs starting in 2019 prior to the 2020 Initiated Process, though we would
and some commenters recommended QP Performance Period and annually make separate determinations as to each
that we renew Other Payer Advanced each year thereafter. In the CY 2018 other payer arrangement and a payer
APM determinations automatically if Quality Payment Program proposed would be required to use a separate
either the payer or eligible clinician rule, we stated that we believe that Payer Initiated Submission Form for
attests that the key characteristics of the phasing in the Payer Initiated Process each other payer arrangement. Payers
Other Payer Advanced APM are not would allow us to gain experience with may submit other payer arrangements
changing from year to year. Some the determination process on a limited with different tracks within that
commenters were concerned that an basis with payers where we have the arrangement as one request along with
annual determination process would strongest relationships and existing information specific to each track.
introduce an unnecessary element of processes that we believe can help The following is a summary of the
uncertainty to eligible clinicians, facilitate submitting this information, public comments received on these
particularly those in Other Payer and that we anticipated making proposals and our responses:
Advanced APMs that have an agreement improvements and refinements to this Comment: Several commenters
term of more than one year. Several process, which we believe will help us requested that submission forms and
commenters suggested that CMS facilitate receiving this information from guidance be made available for payers
establish a multi-year process, such as a the remaining other payers (82 FR and eligible clinicians as soon as
3 or 5 year process, so that an Other 30183). We refer readers to section possible, potentially earlier than the
Payer Advanced APM determination II.D.6.c.(5)(a) of this final rule with beginning of calendar year or in the case
would remain valid throughout that comment period for a discussion of of Medicare Health Plans, before the bid
period and that payers only need to these policies. process. These commenters stated that
report changes as they occur. These We proposed that the Payer Initiated making the forms and guidance
commenters suggested that these Process would be voluntary for all available earlier would give payers more
alternatives would reduce burden and payers. lead time to prepare and submit the
also encourage the development of We sought comment on this proposal. necessary information.
multi-year Other Payer Advanced We did not receive any comments in Response: We agree that it is
APMs. response to this proposal. important to make the Payer Initiated
Response: We will start out for the Final Action: We are finalizing that Submission Form and related guidance
first year of Other Payer Advanced APM the Payer Initiated Process will be available as soon as possible so that
determinations with an annual voluntary for all payers. payers have time to prepare and submit
submission and determination process, In the CY 2018 Quality Payment the information and we intend to do so.
and then evaluate whether there is an Program proposed rule, we proposed We note that the Payer Initiated
appropriate, less burdensome, and that the Payer Initiated Process would Submission Form is subject to the
administratively feasible way to extend generally involve the same steps for Paperwork Reduction Act (PRA)
determinations for subsequent years. We each payer type as listed below for each approval process, which includes an
believe it is necessary to obtain more QP Performance Period, and we opportunity for public comment. We
information on the characteristics of, elaborated on details within this refer readers to section IV.O. of this final
and more experience with, other payer framework that are specific to payer rule with comment period for more
arrangements and the determination type (82 FR 30183 through 30184). We information about that process. After the
process before we change our approach. discuss our final policies below. first year, if any updates or amendments
We are also interested in what impact Guidance and Submission Form: We are necessary, we also intend to make
multiple year determinations might noted that we intend to make guidance those available as soon as possible.
have on payers, for example, would it available regarding the Payer Initiated Comment: One commenter suggested
encourage payers to develop multi-year Process for each payer type prior to the that CMS should use the Quality
payment arrangements. first Submission Period, which would Reporting Document Architecture
Final Action: After considering public occur during 2018. We also noted that (QRDA) III as the submission content
comments, we are finalizing this policy we intend to develop a submission form standard because it is already an
as proposed. We seek comment (which we refer to as the Payer Initiated industry standard, and the commenter
regarding the current duration of the Submission Form) that would be used also suggested that CMS should align
contracts governing such arrangements by payers to request Other Payer their work with industry standards to
and whether creating some multi-year Advanced APM determinations, and avoid increasing physician burden by
determination would encourage the that we intend to make this Payer introducing proprietary formats that
creation of more multi-year payment Initiated Submission Form available to differ from what is used for submission
arrangements as opposed to payment payers prior to the first Submission to other payers or state Medicaid
arrangements that are one year. We also Period. We proposed that payers would programs. The commenter also noted
seek comment on what kind of be required to use the Payer Initiated that HHS has already required industry-
information should be submitted Submission Form to request that we wide investment in QRDA III through
annually to update an Other Payer make an Other Payer Advanced APM their ONC certification program, so
using QRDA III would facilitate experience in operating the Payer arrangements authorized under Title
implementation. Initiated Process. XIX, Medicare Health Plan payment
Response: We appreciate the Comment: One commenter suggested arrangements, and payers with payment
suggestion and will consider these ideas that payers submitting information for arrangements aligned with a CMS Multi-
as we continue to develop and refine the Other Payer Advanced APM Payer Model to the extent possible and
Submission Form. determinations should be required to appropriate. We discuss the specific
Final Action: After considering public notify their APM Entities and eligible Submission Period for each payer type
comments, we are finalizing our clinicians that they are submitting in sections II.D.6.c.(2)(a), II.D.6.c.(3)(a),
proposal that payers with payment information, which would help reduce and II.D.6.c.(4)(a) of this final rule with
arrangements authorized under Title burden on APM Entities and eligible comment period.
XIX, Medicare Health Plan payment clinicians and avoid duplicate CMS Determination: Upon the timely
arrangements, and payment submissions. receipt of a Payer Initiated Submission
arrangements aligned with a CMS Multi- Response: While we would generally Form, we would use the information
Payer Model will be required to use the encourage this type of communication, submitted to determine whether the
Payer Initiated Submission Form in we do not believe that we should set other payer arrangement meets the
order to request that we make an Other requirements for how payers interact Other Payer Advanced APM criteria. We
Payer Advanced APM determination. with APM Entities and eligible proposed that if we find that the payer
We are also finalizing our proposal that clinicians in their payment has submitted incomplete or inadequate
payers may submit requests for review arrangements, and we note that payers information, we would inform the payer
of multiple other payer arrangements can choose to notify their participating and allow the payer to submit
through the Payer Initiated Process, APM Entities and eligible clinicians additional information no later than 10
though we will make separate either that they submitted information business days from the date we inform
determinations as to each other payer to request an Other Payer Advanced the payer. For each other payer
arrangement, and a payer will be APM determination, as well as the arrangement for which the payer does
required to use a separate Payer determination that the payers receive. not submit sufficient information in a
Initiated Submission Form for each We also note that the public posting of timely fashion, we would not make a
other payer arrangement. Other Payer Advanced APMs on the determination in response to that
Submission Period: We proposed that CMS Web site may reduce duplicative request submitted via the Payer Initiated
the Submission Period opening date and submissions by APM Entities or eligible Submission Form. As a result, the other
Submission Deadline would vary by clinicians. payer arrangement would not be
payer type to align with existing CMS Comment: One commenter suggested considered an Other Payer Advanced
processes for payment arrangements that CMS make public all other payer APM for the year. These determinations
authorized under Title XIX, Medicare arrangements that are under review are final and not subject to
Health Plan payment arrangements, and prior to the determination of whether reconsideration.
payers with payment arrangements they are Other Payer Advanced APMs, We sought comment on this proposal.
aligned with a CMS Multi-Payer Model so that APM Entities and eligible The following is a summary of the
to the extent possible and appropriate. clinicians are aware the review is taking public comments received on this
We sought comment on this proposal. place. proposal and our responses:
The following is a summary of the Response: While we appreciate the Comment: Several commenters
comments received on this proposal and suggestion, we believe that making this opposed the 10 business day limit for
our responses: information public would do more to responding to a request for additional
Comment: A few commenters confuse APM Entities and eligible information, noting that 10 business
supported CMSs proposed general clinicians, especially as we already days is too short a timeframe to
approach and efforts to align with intend to post a list of Other Payer adequately address such requests.
existing programs. Advanced APMs on the CMS Web site. Response: We believe that responding
Response: We appreciate the Also, we anticipate that all to requests for additional information
commenters support of our proposed determinations under the Payer Initiated will generally be a straightforward
general approach. Process will be made prior to the process, and that the process and
Comment: Some commenters relevant QP Performance Period. We timeline for these requests will allow us
requested that CMS create a rolling reiterate that the Eligible Clinician to verify information while making
determination process where Payer Initiated Process takes place after the determinations in an expeditious
Initiated Submission Forms could be conclusion of the QP Performance manner. At the same time, we recognize
submitted at any time. Period. For this reason, we believe that that payers may need some additional
Response: We believe that it is there would be limited, if any, utility to time to respond to requests.
important for both payers and us, posting a list of other payer Comment: Some commenters objected
particularly in the first year of arrangements for which there are that determinations are final and not
implementing the Payer Initiated pending Other Payer Advanced APM subject to reconsideration. Some
Process, to have a clear structure for the determinations because we will have commenters were concerned that there
Payer Initiated Process that can be easily already posted a list of the payment may be instances where we do not
understood. We reiterate that our goal is arrangements determined to be Other appropriately consider the information
to align with existing CMS processes Payer Advanced APMs on the CMS Web submitted. These commenters requested
and deadlines to the extent possible. We site prior to the start of the relevant QP that determinations be reconsidered at
also believe that the deadlines are Performance Period. least once and that a formal appeals
important so that we can timely Final Action: After considering public process be installed, and one of these
generate and publish the list of Other comments, we are finalizing our commenters suggested that CMS should
Payer Advanced APMs on the CMS Web proposal that the Submission Period allow such appeals to be submitted
site. We may consider making changes opening date and Submission Deadline within 30 days of the determination.
to our overall approach to the would vary by payer type to align with Response: We appreciate the
Submission Periods when we have more existing CMS processes for payment comment. We continue to believe that it
is appropriate for us to make final Other CMS Posting of Other Payer Advanced consuming and burdensome. Another
Payer Advanced APM determinations. APMs: We noted that we intend to post commenter stated that ultimately the
We are considering whether it would be on the CMS Web site a list (which we onus for submitting information on
beneficial to provide for an informal refer to as the Other Payer Advanced payment arrangements should be with
review process, and we may address APM List) of all other payer payers as they have all the relevant
this issue in future rulemaking. arrangements that we determine to be information and relying on eligible
Comment: A few commenters Other Payer Advanced APMs. Prior to clinicians to submit information would
requested that CMS to commit to the start of the relevant QP Performance result in duplication.
specific timeframes for making Other Period, we intend to post the Other Response: We do not have the
Payer Advanced APM determinations. Payer Advanced APMs that we authority to require payers to submit
Response: We are trying to provide as determine through the Payer Initiated information regarding their payment
much certainty and notice in the Payer Process and Other Payer Advanced arrangements. Therefore, we believe it is
Initiated Process as possible especially APMs under Title XIX that we important for an option to be available
because this coming year will be the determine through the Eligible Clinician for eligible clinicians or APM Entities to
first year where we implement the Payer Initiated Process. After the QP submit such information. If an eligible
Initiated Process. We note that we are Performance Period, we would update clinician requests a QP determination
committed to making Other Payer this list to include Other Payer under the All-Payer Combination
Advanced APM determinations as soon Advanced APMs that we determine Option, the eligible clinician or APM
as practicable. based on other requests through the Entity has the opportunity to submit
Final Action: After considering public Eligible Clinician Initiated Process. information to allow us to determine
comments, we are finalizing a modified We still intend to post this list prior whether an other payer arrangement is
version of the proposed policy. We will to the start of the relevant QP an Other Payer Advanced APM. Our
extend the required timeframe for Performance Period and then update it goal is to minimize the burden
responding to a request for additional to include Other Payer Advanced APMs associated with the Eligible Clinician
information from 10 days to 15 business that we determine based on requests Initiated Process. We also note that
days in order to provide payers more received through the Eligible Clinician payers may voluntarily submit other
time to respond while still allowing for Initiated Process. payer arrangement information through
Other Payer Advanced APM the Payer Initiated Process so that we
(c) APM Entity or Eligible Clinician can determine whether those
determinations to be made Initiated Other Payer Advanced APM arrangements are Other Payer Advanced
expeditiously. We are finalizing this Determination Process (Eligible APMs, which may reduce or eliminate
policy for the determination process for Clinician Initiated Process) the need for some APM Entities or
payment arrangements authorized under In the CY 2018 Quality Payment eligible clinicians to submit information
Title XIX, Medicare Health Plan Program proposed rule, we proposed through the Eligible Clinician Initiated
payment arrangements, and payment that through the Eligible Clinician Process.
arrangements aligned with a CMS Multi- Initiated Process, APM Entities and Comment: One commenter suggested
Payer Model. eligible clinicians participating in other that Other Payer Advanced APM
CMS Notification: We noted that we payer arrangements would have an determinations made through the
intend to notify payers of our opportunity to request that we Eligible Clinician Initiated Process be
determination for each request as soon determine for the year whether those made for multiple years if the contracts
as practicable after the relevant other payer arrangements are Other involved are for multiple years.
Submission Deadline. APM Entities or Payer Advanced APMs. The Eligible Response: As we stated regarding the
eligible clinicians may submit Clinician Initiated Process could also be Payer Initiated Process above, we will
information regarding an other payer used to request determinations before start out for the first year with an annual
arrangement for a subsequent QP the beginning of a QP Performance submission and determination process
Performance Period even if we have Period for other payer arrangements and then evaluate next year whether
determined that the other payer authorized under Title XIX. The Eligible there is an appropriate, less
arrangement is not an Other Payer Clinician Initiated Process would not be burdensome, and administratively
Advanced APM for a prior year. necessary for, or applicable to, other feasible way to extend determinations
The following is a summary of the payer arrangements that are already for subsequent years. We believe it is
public comments received on this topic determined to be Other Payer Advanced necessary to get more information on
and our responses: APMs through the Payer Initiated the characteristics of, and more
Comment: One commenter sought Process (82 FR 30184). experience with, other payer
clarification regarding when we would The following is a summary of the arrangements and the determination
notify payers of the results of Other public comments received on this process before we change our approach.
Payer Advanced APM determinations. proposal and our responses: Final Action: After considering public
Response: We reiterate that we intend Comment: Some commenters comments, we are finalizing our
to notify payers of the results as soon as expressed support for our proposed proposal that through the Eligible
practicable and clarify that this general approach to the Eligible Clinician Initiated Process, APM
notification to payers is independent of Clinician Initiated Process. Entities and eligible clinicians
posting the list of Other Payer Advanced Response: We appreciate commenters participating in other payer
APMs on the CMS Web site. support of this proposed general arrangements would have an
Final Action: After considering public approach to the Eligible Clinician opportunity to request that we
comments, we reiterate that we intend Initiated Process. determine for the year whether those
to notify payers of our determination for Comment: One commenter stated that other payer arrangements are Other
each request under the Payer Initiated the proposed Eligible Clinician Initiated Payer Advanced APMs. We seek
Process as soon as practicable after the Process presents operational challenges additional comment regarding the
relevant Submission Deadline. We to eligible clinicians, particularly that current duration of payment
codify this policy at 414.1445(f). reporting the information would be time arrangements and whether creating a
multi-year determination process would Form for an Other Payer Advanced APM Submission Periods when we have more
encourage the creation of more multi- determination. information and experience with the
year payment arrangements as opposed Response: We agree with this Eligible Clinician Initiated Process. We
to payment arrangements that are one commenter and we clarify here that only are also concerned that a rolling process
year. We also seek comment on what APM Entities or eligible clinicians that where we receive requests to make
kind of information should be submitted hold contracts to participate in an Other Payer Advanced APM
annually after the first year to update an payment arrangement with an other determinations after December 1 could
Other Payer Advanced APM payer can submit an Eligible Clinician delay QP determinations; and timely QP
determination. We will consider in Initiated Submission Form for an Other determinations are important so that
future rulemaking whether to introduce Payer Advanced APM determination. eligible clinicians can make other
an option where Other Payer Advanced We will make this limitation clear in important and time sensitive decisions
APM determinations could be last for guidance and instructions for the if necessary, such as preparing for MIPS
more than one year a time. Eligible Clinician Initiated Submission reporting.
Guidance and Submission Form: We Form. Comment: One commenter requested
intend to make guidance available Final Action: After considering public clarification regarding why some
regarding the Eligible Clinician Initiated comments, we are finalizing our eligible clinicians are required to submit
Process for each payer type prior to the proposal that APM Entities and eligible information prior to the QP Performance
first Submission Period for clinicians would be required to use the Period and others are allowed to submit
arrangements authorized under Title Eligible Clinician Initiated Submission information after the QP Performance
XIX, which would occur during 2018. Form to request that we make an Other Period.
We intend to develop a submission form Payer Advanced APM determination. Response: We clarify that the only
(which we refer to as the Eligible We are also finalizing our proposal that category of payment arrangements
Clinician Initiated Submission Form) APM Entities or eligible clinicians may where APM Entities or eligible
that will be used by APM Entities or submit requests for review of multiple clinicians must submit information
other payer arrangements through the prior to the QP Performance Period is
eligible clinicians to request Other Payer
Eligible Clinician Initiated Process, for Medicaid payment arrangements,
Advanced APM determinations, and we
though we will make separate and as we discuss in section
intend to make this Eligible Clinician
determinations as to each other payer II.D.6.c.(2)(a) of this final rule with
Initiated Submission Form available to
arrangement, and an APM Entity or comment period, we allow this early
APM Entities and eligible clinicians
eligible clinician will be required to use submission so that we can carry out the
prior to the first Submission Period. We
a separate Eligible Clinician Initiated required exclusion of Title XIX
proposed that APM Entities and eligible
Submission Form for each other payer payments and patients from the other
clinicians would be required to use the
arrangement. We are finalizing this payer portion of certain QP
Eligible Clinician Initiated Submission
policy for all of the Eligible Clinician determination calculations under the
Form to request that we make an Other Initiated Process regardless of the type All-Payer Combination Option. For
Payer Advanced APM determination. of payment arrangement being other payer arrangements for which
We intend for the Eligible Clinician submitted. Medicaid is not the payer, APM Entities
Initiated Submission Form to include Submission Period: In general, we or eligible clinicians can submit
questions that are applicable to all other proposed that APM Entities or eligible requests for determinations of Other
payer arrangements and some that are clinicians may request Other Payer Payer Advanced APMs after the QP
specific to a particular type of other Advanced APM determinations Performance Period. We note that the
payer arrangements, and we intend for beginning on August 1 of the same year distinction is based on the type of
it to include a way for APM Entities or as the relevant QP Performance Period. payment arrangement, not the type of
eligible clinicians to attach supporting We proposed that the Submission APM Entity or eligible clinician. An
documentation. We proposed that APM Deadline for requesting Other Payer APM Entity could be in a Medicaid
Entities or eligible clinicians may Advanced APM determinations, as well payment arrangement and also a
submit requests for review of multiple as to request QP determinations under payment arrangement with a
other payer arrangements through the the All-Payer Combination Option, is commercial payer, and the APM Entity
Eligible Clinician Initiated Process, December 1 of the same year as the may request Other Payer Advanced
though we would make separate relevant QP Performance Period. APM determinations for both
determinations as to each other payer The following is a summary of the arrangements. To request an Other Payer
arrangement, and an APM Entity or public comments received on these Advanced APM determination for the
eligible clinician would be required to proposals and our responses: Medicaid payment arrangement, the
use a separate Eligible Clinician Comment: A few commenters were APM Entity would submit the Eligible
Initiated Submission Form for each concerned that having a Submission Clinician Initiated Submission Form
other payer arrangement. APM Entities Deadline would be burdensome to APM prior to the QP Performance Period.
or eligible clinicians may submit other Entities and eligible clinicians, and they That same APM Entity would submit
payer arrangements with different tracks suggested that CMS institute a rolling the Eligible Clinician Initiated
within that arrangement as one request process without a set deadline would Submission Form after the QP
along with information specific to each provide additional flexibility. Performance Period, but before
track. Response: We believe that it is December 1, for the arrangement with
The following is a summary of the important for eligible clinicians, APM the commercial payer.
public comments received on these Entities, and us, particularly in the first Final Action: After considering public
proposals and our responses: year of implementing the Eligible comments, we are finalizing our
Comment: One commenter suggested Clinician Initiated Process, to have a proposal that APM Entities or eligible
that CMS clarify that only APM Entities clear structure for the Eligible Clinician clinicians may request Other Payer
or eligible clinicians that hold contracts Initiated Process that can be easily Advanced APM determinations
with an other payer should submit an understood. We may consider making beginning on August 1 of the same year
Eligible Clinician Initiated Submission changes to the overall approach to as the relevant QP Performance Period
for payment arrangements authorized the commenter stated that eligible submitting payment amount and patient
under Title XIX. We note that eligible clinicians should be allowed to respond count information for that payment
clinicians may request Other Payer via fax, email or other electronic arrangement. We intend to make these
Advanced APM determinations for methods as necessary. early notifications to the extent possible.
payment arrangements authorized under Response: We are implementing an We proposed that APM Entities or
Title XIX prior to the relevant QP electronic method to facilitate the rapid eligible clinicians may submit
Performance Period, beginning in 2018. exchange of information between us and information regarding an other payer
We are also finalizing our proposal that APM Entities or eligible clinicians. We arrangement for a subsequent QP
the Submission Deadline for requesting believe that routinely providing both Performance Period even if we have
Other Payer Advanced APM electronic and hard copy documents determined that the other payer
determinations, as well as to request QP would create additional burden and arrangement is not an Other Payer
determinations under the All-Payer unnecessary cost to CMS with very little Advanced APM for a prior year (82 FR
Combination Option, is December 1 of benefit. 30185).
the same year as the relevant QP Final Action: After considering public The following is a summary of the
Performance Period. comments, we are finalizing our public comments received on these
CMS Determination: Upon timely proposal that, if we determine that the proposals and our responses:
receipt of an Eligible Clinician Initiated APM Entity or eligible clinician has Comment: Two commenters stated
Submission Form, we would use the submitted incomplete or inadequate that for eligible clinicians who submit
information submitted to determine information, we would inform the APM their information after December 1, CMS
whether the other payer arrangement Entity or eligible clinician. We are should commit to make a determination
meets the Other Payer Advanced APM finalizing a modification to our within 30 calendar days of when the
criteria. We proposed that, if we proposal, which is that we will allow applicable information is submitted.
determine that the APM Entity or the APM Entity or eligible clinician to Two other commenters stated that CMS
eligible clinician has submitted submit additional information no later should establish a firm deadline for
incomplete or inadequate information, than 15 business days from the date we
notifying eligible clinicians the results
we would inform the APM Entity or inform the APM Entity or eligible
of Other Payer Advanced APM
eligible clinician and allow the APM clinician that the submission contains
determinations.
Entity or eligible clinician to submit incomplete or inadequate information.
Response: We are trying to provide as
additional information no later than 10 For each other payer arrangement for
much certainty and notice in the
business days from the date we inform which the APM Entity or eligible
clinician does not submit sufficient Eligible Clinician Initiated Process as
the APM Entity or eligible clinician. For
information, we would not make a possible especially because this coming
each other payer arrangement for which
determination in response to that year will be the first year where we
the APM Entity or eligible clinician
request submitted via the Eligible implement the Eligible Clinician
does not submit sufficient information,
Clinician Initiated Submission Form. As Initiated Process. We note that we are
we would not make a determination in
a result, the other payer arrangement committed to making Other Payer
response to that request submitted via
would not be considered an Other Payer Advanced APM determinations as soon
the Eligible Clinician Initiated
Submission Form. As a result, the other Advanced APM for the year. These as practicable.
payer arrangement would not be determinations are final and not subject Final Action: After considering public
considered an Other Payer Advanced to reconsideration. We are finalizing comments, we are finalizing our
APM for the year. These determinations this policy for all of the Eligible proposal to notify APM Entities and
are final and not subject to Clinician Initiated Process, regardless of eligible clinicians of our determinations
reconsideration. the type of payment arrangement being for each other payer arrangement for
The following is a summary of the submitted. which a determination was requested as
public comments received on these CMS Notification: We proposed to soon as practicable after the Submission
proposals and our responses: notify APM Entities and eligible Deadline. We are finalizing this
Comment: A few commenters clinicians of our determinations for each proposal for all of the Eligible Clinician
expressed concern with the requirement other payer arrangement for which a Initiated Process, regardless of the type
that additional information be determination was requested as soon as of payment arrangement being
submitted within 10 business days, and practicable after the Submission submitted. We codify this policy at
one commenter suggested that 30 days Deadline. 414.1445(f).
would be a better timeframe. In the CY 2018 Quality Payment CMS Posting of Other Payer Advanced
Response: We believe that responding Program proposed rule, we noted that APMs: We noted that we intend to post
to requests for additional information APM Entities and eligible clinicians on the CMS Web site a list (which we
will generally be a straightforward who submit complete Eligible Clinician refer to as the Other Payer Advanced
process, and that the process and Initiated Submission Forms by APM List) of all of the other payer
timeline for responding to these September 1 of the same calendar year arrangements that we determine to be
requests will allow us to verify as the relevant QP Performance Period Other Payer Advanced APMs. Prior to
information while making may allow for us to make Other Payer the start of the relevant QP Performance
determinations in an expeditious Advanced APM determinations and Period, we intend to post the Other
manner. That said, we also recognize inform APM Entities or eligible Payer Advanced APMs that we
that APM Entities and eligible clinicians clinicians of those determinations prior determine through the Payer Initiated
may need some additional time to to the December 1 QP Determination Process and Other Payer Advanced
respond to requests. Submission Deadline. If we determine APMs under Title XIX that we
Comment: One commenter suggested that an other payer arrangement is not determine through the Eligible Clinician
that CMS send both an electronic and an Other Payer Advanced APM, Initiated Process. After the QP
hard copy of the request for additional notifying APM Entities or eligible Performance Period, we would update
information to ensure rapid response clinicians of such a determination may this list to include Other Payer
from the eligible clinician. In addition, help them avoid the burden of Advanced APMs that we determine
based on other requests through the make determinations for other payer Response: We appreciate the
Eligible Clinician Initiated Process. arrangements that could be Medicaid commenters support for our proposal.
We still intend to post this list prior APMs or Medicaid Medical Home Comment: Some commenters
to the start of the relevant QP Models that are Other Payer Advanced requested Medicaid managed care plans
Performance Period and update it to APMs for the year through either the be allowed to submit their payment
include Other Payer Advanced APMs Payer Initiated Process or the Eligible arrangement information directly to us.
that we determine based on requests Clinician Initiated Process, we would These commenters stated that it would
received through the Eligible Clinician assume that there are no Medicaid be a burden for state agencies to submit
Initiated Process. APMs or Medicaid Medical Home all of the Medicaid payment
(2) Medicaid APMs and Medicaid Models that meet the Other Payer arrangements within the state as we
Medical Home Models Advanced APM criteria in that state for proposed. These commenters also
the relevant QP Performance Period. pointed out that some Medicaid
In the CY 2018 Quality Payment Accordingly, we would exclude Title managed care organizations operate
Program proposed rule, we noted that XIX payments and patients from the All- Medicaid payments across multiple
payers, APM Entities, and eligible Payer Combination Option calculations states and the proposed process would
clinicians may request that we for eligible clinicians in that state (82 FR create an additional burden on the
determine whether payment 30185). Medicaid managed care organizations.
arrangements authorized under Title
(a) Payer Initiated Process Alternatively, a few commenters
XIX of the Act are Medicaid APMs or
suggested that states be given the option
Medicaid Medical Home Models that In the CY 2018 Quality Payment of either submitting all information
meet the Other Payer Advanced APM Program proposed rule, we proposed regarding Medicaid payment
criteria. We explained that there are that any states and territories (which we arrangements in their state, or
some differences between the refer to as states) that have in place a
delegating the submission of Medicaid
determination process for other payer state plan under Title XIX may request
managed care plan payment
arrangements where Medicaid is the that we determine prior to the QP
payer and the process for other payer arrangement to the plans.
Performance Period whether other payer
arrangements with other types of payers. arrangements authorized under Title Response: We believe that our
These differences stem in part from the XIX are Medicaid APMs or Medicaid proposal allows for states to prepare the
requirements specified in sections Medical Home Models that meet the Payer Initiated Submission Form for
1833(z)(2)(B)(ii)(bb) and Other Payer Advanced APM criteria, in Medicaid payment arrangements and
1833(z)(2)(C)(ii)(bb) of the Act for QP other words, are Other Payer Advanced provides a uniform process for all states
determinations under the All-Payer APMs, under the Payer Initiated to follow. We believe that this approach
Combination Option. We noted that we Process. States include the 50 states, the would create one source of information
interpret those statutory provisions to District of Columbia, the from each state on Medicaid APMs and
direct us, when making QP Commonwealth of Puerto Rico, the Medicaid Medical Home Models that
determinations under the All-Payer Virgin Islands, Guam, American Samoa, could be determined to be Other Payer
Combination Option, to exclude from and the Northern Mariana Islands. Advanced APMs, which will allow us to
the calculation of all other payments We proposed to allow states to request properly carry out the statutory
any payments made (or patients under determinations for both Medicaid fee- Medicaid exclusion. We note that if
the patient count method) under Title for-service and Medicaid managed care Medicaid managed care plans were to
XIX in a state in which there is no plan payment arrangements. We submit information on payment
available Medicaid APM (which by explained that states often use managed arrangements directly, states might not
definition at 414.1305 meets the Other care plan contracts to implement be aware of all of the Medicaid payment
Payer Advanced APM criteria) or payment arrangements, and a arrangements submitted from Medicaid
Medicaid Medical Home Model that substantial portion of the Medicaid managed care plans in their state. This
meets the Other Payer Advanced APM beneficiary population receives their may require additional follow-up
criteria (82 FR 30185). health care services through Medicaid inquiries with states to confirm the
To implement this requirement, we managed care plans. We noted that we existence and characteristics of certain
explained in the CY 2018 Quality expect that states would work closely Medicaid managed care payment
Payment Program proposed rule that we with their managed care plans to arrangements. Similarly, if states were
need to determine which states have no identify and collect relevant given the option of either submitting the
available Medicaid APMs or Medicaid information. However, we proposed to information regarding all Medicaid
Medical Home Models that meet the accept requests regarding payment payment arrangements in their state, or
Other Payer Advanced APM criteria arrangements authorized under Title delegating the submission of Medicaid
during a given QP Performance Period. XIX under the Payer Initiated Process managed care plans, an additional up-
We noted that we believe that it is only from the state, not from a Medicaid front survey of states regarding which
important for us to make this managed care plan, as states are option they will be pursuing would be
determination prior to the QP responsible ultimately for the needed. We do not think such a survey
Performance Period, and to announce administration of their Medicaid is feasible, given other program
the Medicaid APMs and Medicaid programs (82 FR 30186). deadlines. We also believe that having
Medical Home Models that meet the The following is a summary of the multiple standards across different
Other Payer Advanced APM criteria and public comments received on these states is likely to add to the complexity
the locations where they are available, proposals and our responses: of the process, and may be confusing to
so that eligible clinicians can assess Comment: One commenter supported stakeholders.
whether their Title XIX payments and CMSs proposal that, under the Payer Comment: One commenter suggested
patients would be excluded under the Initiated Process, states alone are that states be allowed to submit
All-Payer Combination Option for that responsible for submission of information on payment arrangements
particular performance year. If, for a information on payment arrangements across other public payers, such as
given state, we receive no requests to authorized under Title XIX. public employee benefit programs.
Response: For the first year, we will for a determination. This information make the determination for a Medicaid
limit the types of payment arrangements could include, for example, submissions APM or a Medicaid Medical Home
for which states can submit information. that states typically make to us to obtain Model that is an Other Payer Advanced
As we discuss in section II.D.6.c.(3)(a) of authorization to modify their Medicaid APM and that the Submission Deadline
this final rule with comment period, if payment arrangements, such as a State is April 1 of the year prior to the QP
a payment arrangement with a public Plan Amendment or an 1115 Performance Period for which we would
payer is aligned with a payment demonstrations waiver application, make the determination.
arrangement authorized under Title Special Terms and Conditions CMS Determination: Upon the timely
XIX, a state may also submit that document, implementation protocol receipt of a Payer Initiated Submission
payment arrangement for an Other Payer document, or other document Form, we would use the information
Advanced APM determination. We note describing the 1115 demonstration submitted to determine whether the
that APM Entities or eligible clinicians arrangements approved by CMS. other payer arrangement meets the
may submit payment arrangement Submission Period: We proposed that Other Payer Advanced APM criteria. We
information for a payment arrangement the Submission Period for the Payer proposed that, if we determine that the
with a public payer that is not Initiated Process for use by states to state has submitted incomplete or
authorized under Title XIX after the QP request Other Payer Advanced APM inadequate information, we would
Performance Period beginning in the determinations for other payer inform the state and allow the state to
first year. We expect that states will be arrangements authorized under Title submit additional information no later
able to directly submit information XIX will open on January 1 of the than 10 business days from the date we
about these arrangements, even if they calendar year prior to the relevant QP inform the state. For each other payer
are not aligned with a payment Performance Period for which we would arrangement for which the state does
arrangement authorized under Title make Other Payer Advanced APM not submit sufficient information, we
XIX, when we allow for all payer types determinations. We proposed that the would not make a determination in
to submit payment arrangement Submission Deadline is April 1 of the response to that request submitted via
information in 2019, prior to year prior to the QP Performance Period the Payer Initiated Submission Form. As
performance year 2020. for which we would make the a result, the other payer arrangement
Final Action: After considering public determination. would not be considered an Other Payer
comments, we are finalizing our The following is a summary of the Advanced APM for the year. These
proposal that states that have in place a public comments received on these
determinations are final and not subject
payment arrangement authorized under proposals and our responses:
to reconsideration.
Title XIX may request that we determine Comment: One commenter suggested
that states should be allowed to submit The following is a summary of the
prior to the QP Performance Period
information on Medicaid payment public comments received on this
whether other payer arrangements
arrangements on a rolling basis rather proposal and our responses:
authorized under Title XIX are
than following a set schedule. Comment: One commenter stated that
Medicaid APMs or Medicaid Medical
Response: We believe that it is certain Medicaid programs, such as the
Home Models that meet the Other Payer
important for both payers and us, New York Delivery System Reform
Advanced APM criteria, in other words,
are Other Payer Advanced APMs, under particularly in the first year of Incentive Program (DSRIP), should be
the Payer Initiated Process. We are also implementing the Payer Initiated deemed Other Payer Advanced APMs
finalizing our proposal to allow states to Process, to have a clear structure for the because participants in such programs
request determinations for both Eligible Clinician Initiated Process that that accept two-sided risk are likely to
Medicaid fee-for-service and Medicaid can be easily understood. We may meet the Other Payer Advanced APM
managed care plan payment consider making changes to the overall criteria.
arrangements, and we are finalizing our approach to the Submission Period for Response: While any Medicaid
proposal to accept requests regarding payment arrangements authorized under payment arrangement may meet the
payment arrangements authorized under Title XIX when we have more Other Payer Advanced APM criteria,
Title XIX under the Payer Initiated information and experience in operating such determinations are made through
Process only from the state, not from a the Payer Initiated Process. We are also the Other Payer Advanced APM
Medicaid managed care plan. concerned that if we have a rolling determination process as described in
Below we discuss our final policies process, especially because we need the this final rule with comment period. For
for the Payer Initiated Process for information to implement the Medicaid example, New York State can choose to
payment arrangements authorized under exclusion prior to the QP Performance submit information about this program
Title XIX. Period, accepting requests for Other to us through the Payer Initiated Process
Guidance and Submission Form: We Payer Advanced APMs on a rolling basis and we can make that determination.
discuss our final policies pertaining to may prevent us from having a complete Alternatively, APM Entities or eligible
the Guidance and Submission Form in list of Medicaid APMs and Medicaid clinicians can submit information about
section II.D.6.c.(1)(b) of this final rule Medical Home Models that are Other this program to us through the Eligible
with comment period as to all payer Payer Advanced APMs prior to the Clinician Initiated Process. We will
types in the Payer Initiated Process, relevant QP Performance Period. work with states as they develop
including payment arrangements Final Action: After considering public innovative Medicaid models and assist
authorized under Title XIX. comments, we are finalizing our then in designing payment
We intend to work with states as they proposals that the Submission Period arrangements that meet the criteria to be
prepare and submit Payer Initiated for the Payer Initiated Process for use by Other Payer Advanced APMs.
Submission Forms for our review. In states to request Other Payer Advanced Final Action: We discuss our final
completing the Payer Initiated APM determinations for other payer policies pertaining to the CMS
Submission Form, states could refer to arrangements authorized under Title Determination in section II.D.6.c.(1)(b)
information they have already XIX will open on January 1 of the of this final rule with comment period
submitted to us regarding their payment calendar year prior to the relevant QP as to all payer types in the Payer
arrangements to support their request Performance Period for which we would Initiated Process, including payment
arrangements authorized under Title begin discussions with us regarding the section II.D.6.c.(1)(c) of this final rule
XIX. development of other payer with comment period for all of the
CMS Notification: We proposed to arrangements through the different legal Eligible Clinician Initiated Process,
notify states of our determinations for authorities available under Title XIX or including for requests that are payment
each request as soon as practicable after Title XI of the Act, we would help states arrangements authorized under Title
the relevant Submission Deadline. We consider and address the Other Payer XIX.
proposed that states may submit Advanced APM criteria. Submission Period: We proposed that
information regarding an other payer APM Entities or eligible clinicians may
arrangement for a subsequent QP (b) Eligible Clinician Initiated Process
submit Eligible Clinician Initiated
Performance Period even if we have In the CY 2018 Quality Payment
Forms for payment arrangements
determined that the other payer Program proposed rule, we proposed
authorized under Title XIX beginning
arrangement is not an Other Payer that APM Entities and eligible clinicians
on September 1 of the calendar year
Advanced APM for a prior year. may request determinations for any
prior to the QP Performance Period. We
The following is a summary of the Medicaid payment arrangements in
also proposed that the Submission
public comments received on these which they are participating at an
Deadline is November 1 of the calendar
proposals and our responses: earlier point, prior to the QP
Comment: One commenter expressed year prior to the QP Performance Period.
Performance Period. This would allow
concern about the timeline, stating that all clinicians in a given state or county We sought comment on this proposal.
because CMS may make Other Payer to know before the beginning of the QP We received no comments in response
Advanced APM determinations as late Performance Period whether their Title to this proposal.
as the September preceding the QP XIX payments and patients would be Final Action: We are finalizing this
Performance Period, there may be excluded from the all-payer calculations policy as proposed.
insufficient time for the Medicaid that are used for QP determinations for CMS Determination: We discuss our
agency, Medicaid managed care the year under the All-Payer final policies pertaining to the CMS
organizations, and contracted health Combination Option. Determination in section II.D.6.c.(1)(c)
care providers to negotiate and update We sought comment on this proposal. of this final rule with comment period
contracts. The following is a summary of the for all of the Eligible Clinician Initiated
Response: We appreciate the concern. public comments received on this Process, including for requests that are
We note that we will notify states of proposal and our responses: payment arrangements authorized under
Other Payer Advanced APM Comment: One commenter supported Title XIX.
determinations as soon as they are CMSs proposed approach for obtaining CMS Notification: We discuss our
completed after the April 1 Submission information from eligible clinicians final policies pertaining to the CMS
Deadline. participating in Medicaid payment Notification in section II.D.6.c.(1)(c) of
Final Action: We discuss our final arrangements and doing so prior to the this final rule with comment period for
policies pertaining to the CMS QP Performance Period. all of the Eligible Clinician Initiated
Notification in section II.D.6.c.(1)(b) of Response: We appreciate the support
Process, including for requests that are
this final rule with comment period as of our proposed approach.
Final Action: After considering public payment arrangements authorized under
to all payer types in the Payer Initiated
comments, we are finalizing our Title XIX.
Process, including payment
arrangements authorized under Title proposal that APM Entities and eligible CMS Posting of Other Payer Advanced
XIX. clinicians may request determinations APMs: We explained our policy in
CMS Posting of Other Payer Advanced for any Medicaid payment arrangements section II.D.6.c.(1)(c) of this final rule
APMs: We explained our policy in in which they are participating prior to with comment period.
section II.D.6.c.(1)(b) of this final rule the relevant QP Performance Period. (c) Final Timeline
with comment period. Below we discuss our policies for the
We intend to provide ongoing Eligible Clinician Initiated Process for The final timelines for both the Payer
assistance through existing payment arrangements authorized under Initiated and Eligible Clinician Initiated
conversations or negotiations as states Title XIX. Other Payer Advanced APM
design and develop new payment Guidance and Submission Form: We Determination Processes for payment
arrangements that may be identified as discuss our final policies pertaining to arrangements authorized under Title
Other Payer Advanced APMs. As states the Guidance and Submission Form in XIX are summarized in Table 38.
TABLE 38OTHER PAYER ADVANCED APM DETERMINATION PROCESS FOR PAYMENT ARRANGEMENTS AUTHORIZED
UNDER TITLE XIX FOR QP PERFORMANCE PERIOD 2019
Payer initiated process Date Eligible clinician (EC) initiated process * Date
Medicaid ................... Guidance sent to states, then Submission Jan. 2018 ..... Guidance made available to ECs, then Sept. 2018.
Period Opens. Submission Period Opens.
Submission Period Closes ......................... April 2018 ..... Submission Period Closes ......................... Nov. 2018.
CMS contacts states and posts Other Sept. 2018 ... CMS contacts ECs and states and posts Dec. 2018.
Payer Advanced APM List. Other Payer Advanced APM List.
* Note that APM Entities or eligible clinicians may use the Eligible Clinician Initiated Process.
(3) CMS Multi-Payer Models Model at 414.1305 as an Advanced designed to align with the terms of that
APM that CMS determines, per the Advanced APM. Examples of CMS
For purposes of carrying out the
terms of the Advanced APM, has at least Multi-Payer Models include the
Quality Payment Program, we proposed
one other payer arrangement that is Comprehensive Primary Care Plus
to define the term CMS Multi-Payer
(CPC+) Model, the Oncology Care Model payment arrangement by virtue of their for payment arrangements authorized
(OCM) (2-sided risk arrangement), and alignment with a CMS Multi-Payer under Title XIX and Medicare Health
beginning in 2019, the Vermont All- Model. Where feasible, we will use Plan payment arrangements.
Payer ACO Model.20 information that we already have to
We sought comment on this proposal. (a) Payer Initiated Process
help streamline the process to make
We received no comments in response Other Payer Advanced APM Below we discuss our policies for the
to this proposal. determinations. Payers with payment Payer Initiated Process for payment
Final Action: We are finalizing our arrangements aligned with a CMS Multi- arrangements aligned with a CMS Multi-
proposal to define the term CMS Multi- Payer Model will only be required to Payer Model.
Payer Model as an Advanced APM that submit any additional information Guidance and Submission Form: We
CMS determines, per the terms of the needed to make a determination, which discuss our final policies pertaining to
Advanced APM, has at least one other would be identified in communications the Guidance and Submission Form in
payer arrangement that is designed to between the payer and CMS. We do not section II.D.6.c.(1)(b) of this final rule
align with the terms of that Advanced believe it would be appropriate, with comment period as to all payer
APM at 414.1305. however, for other payment types in the Payer Initiated Process,
Other payer arrangements that are arrangements to automatically be including payment arrangements that
aligned with a CMS Multi-Payer Model, determined to be Other Payer Advanced are aligned with a CMS Multi-Payer
by definition, are not APMs, and thus, APMs. The payment arrangements Model.
cannot be Advanced APMs under the offered by non-Medicare payers aligned Submission Period: We proposed that
Medicare Option. We recognize, though, with a Multi-Payer Model are not the Submission Period would open on
that these other payer arrangements necessarily required to align completely January 1 of the calendar year prior to
could be Other Payer Advanced APMs. with the Advanced APM components of the relevant QP Performance Period. We
We therefore proposed that beginning in the model. In addition, the criteria for also proposed that the Submission
the first QP Performance Period under determining Advanced APMs and Other Period would close on June 1 of the
the All-Payer Combination Option, Payer Advanced APMs, while similar, calendar year prior to the relevant QP
payers with other payer arrangements are not identical. As such, simply being Performance Period.
aligned with a CMS Multi-Payer Model aligned as part of a Multi-Payer Model
may request that we determine whether We sought comment on this proposal.
is not in itself sufficient evidence that We received no comments in response
those aligned other payer arrangements a payment arrangement meets the
are Other Payer Advanced APMs. to this proposal.
criteria to be an Other Payer Advanced Final Action: We are finalizing this
Because there may be differences APM.
between the other payer arrangements policy as proposed with one
that are aligned with an Advanced APM modification. Due to technical error, we
in a CMS Multi-Payer Model, we inadvertently stated that June 30 is the
proposal that beginning in the first QP
proposed to make separate deadline for this Submission Period. We
Performance Period under the All-Payer
determinations about each of those Combination Option, payers with a are finalizing that the Submission
other payer arrangements on an payment arrangement aligned with a Period will close on June 1 of the
individual basis. In other words, an CMS Multi-Payer Model may request calendar year prior to the relevant QP
other payer arrangement aligned with an that we determine whether that aligned Performance Period.
Advanced APM in a CMS Multi-Payer payment arrangement is an Other Payer CMS Determination: We discuss our
Model is not automatically an Other Advanced APM. We are also finalizing final policies pertaining to the CMS
Payer Advanced APM by virtue of its our proposal to make separate Determination in section II.D.6.c.(1)(b)
alignment. determinations about each of those of this final rule with comment period
The following is a summary of the other payer arrangements on an as to all payer types in the Payer
public comments received on these individual basis. Initiated Process, including payment
proposals and our responses: In the CY 2018 Quality Payment arrangements that are aligned with a
Comment: A few commenters Program proposed rule, we stated that CMS Multi-Payer Model.
suggested that CMS streamline the because there can be payment CMS Notification: We discuss our
determination process for a payment arrangements authorized under Title final policies pertaining to the CMS
arrangement aligned with a CMS Multi- XIX or Medicare Health Plan payment Determination in section II.D.6.c.(1)(b)
Payer Model by using information that arrangements that are aligned with a of this final rule with comment period
CMS has already collected for other CMS Multi-Payer Model, we proposed as to all payer types in the Payer
purposes. One commenter also that payers, APM Entities, or eligible Initiated Process, including payment
suggested that CMS automatically clinicians who want to request that we arrangements that are aligned with a
determine whether a payment determine whether those arrangements CMS Multi-Payer Model.
arrangement aligned with a CMS Multi- are Other Payer Advanced APMs would CMS Posting of Other Payer Advanced
Payer Model are Other Payer Advanced use the processes specified for payment APMs: We explained our policy in
APMs, and the commenter stated that arrangements authorized under Title section II.D.6.c.(1)(b) of this final rule
this automatic determination would be XIX and Medicare Health Plan payment with comment period as to all payer
an opportunity for us to reduce arrangements (82 FR 30188). types in the Payer Initiated Process,
administrative burden on payers and We sought comment on this proposal. including payment arrangements that
eligible clinicians. We received no comments in response are aligned with a CMS Multi-Payer
Response: We have, or will have, to this proposal. Model.
some information regarding these other Final Action: We are finalizing our
proposal that payers, APM Entities, or (b) Eligible Clinician Initiated Process
20 Vermont ACOs will be participating in an eligible clinicians who want to request Below we discuss our policies for the
Advanced APM during 2018 through a modified
version of the Next Generation ACO Model. The
that we determine whether those Eligible Clinician Initiated Process for
Vermont Medicare ACO Initiative will be an arrangements are Other Payer Advanced payment arrangements aligned with a
Advanced APM beginning in 2019. APMs would use the processes specified CMS Multi-Payer Model.
Guidance and Submission Form: We arrangements that are aligned with a submit on behalf of payers in the Payer
discuss our final policies pertaining to CMS Multi-Payer Model. Initiated Process for Other Payer
the Guidance and Submission Form in CMS Notification: We discuss our Advanced APMs; we would seek
II.D.6.c.(1)(c) of this final rule with final policies pertaining to the CMS information for the determination from
comment period for all of the Eligible Notification in section II.D.6.c.(1)(c) of the state, rather than individual payers.
Clinician Initiated Process, including this final rule with comment period for The same Payer Initiated Process and
payment arrangements that are aligned all of the Eligible Clinician Initiated timeline described above for CMS
with a CMS Multi-Payer Model. Process, including payment Multi-Payer Models would apply. We
Submission Period: We proposed that arrangements that are aligned with a sought comment on this proposal.
APM Entities or eligible clinicians may CMS Multi-Payer Model. Additionally, we sought comment
request Other Payer Advanced APM CMS Posting of Other Payer Advanced regarding the effectiveness of taking a
determinations beginning on August 1 APMs: We explained our policy in similar approach in cases where the
of the same year as the relevant QP section II.D.6.c.(1)(c) of this final rule state does not require uniform payment
Performance Period. We proposed that with comment period for all of the arrangements across payers.
the Submission Deadline for requesting Eligible Clinician Initiated Process, We sought comment on this proposal.
Other Payer Advanced APM including payment arrangements that We received no comments in response
determinations, as well as to request QP are aligned with a CMS Multi-Payer to our proposal.
determinations under the All-Payer Model.
Combination Option, is December 1 of Final Action: We are finalizing our
(c) State All-Payer Models proposal that where a state prescribes
the same year as the relevant QP
Performance Period. Some CMS Multi-Payer Models uniform payment arrangements across
We sought comment on this proposal. involve an agreement with a state to test all payers statewide, the state would use
We received no comments in response an APM and one or more associated the Payer Initiated Process to submit
to this proposal. other payer arrangements in that state information on behalf of payers to
Final Action: We are finalizing our where the state prescribes uniform support Other Payer Advanced APM
proposals that the Submission Period payment arrangements across state- determination(s); we would seek
will open on August 1 of the same year based payers. As such, we believe it information for the determination from
as the relevant QP Performance Period may be appropriate and efficient for the state, rather than individual payers.
and close on December 1 of the same states, rather than any other payer, to (d) Final Timeline
year as the relevant QP Performance submit information to us on these
Period. payment arrangements for purposes of The final timelines for both the Payer
CMS Determination: We discuss our requesting an Other Payer Advanced Initiated and Eligible Clinician Initiated
final policies pertaining to the CMS APM determination. Other Payer Advanced APM
Determination in section II.D.6.c.(1)(c) We proposed that, in CMS Multi- Determination Processes for payment
of this final rule with comment period Payer Models where a state prescribes arrangements aligned with a CMS Multi-
for all of the Eligible Clinician Initiated uniform payment arrangements across Payer Model are summarized in Table
Process, including payment all payers statewide, the state would 39.
TABLE 39OTHER PAYER ADVANCED APM DETERMINATION PROCESS FOR CMS MULTI-PAYER MODELS FOR QP
PERFORMANCE PERIOD 2019
Eligible clinician (EC) *
Payer initiated process Date Date
initiated process
CMS Multi-Payer Guidance made available to payersSub- Jan. 2018 ..... Guidance made available to ECsSub- Aug. 2019.
Models. mission Period Opens. mission Period Opens.
Submission Period Closes ......................... June 2018 .... Submission Period Closes ......................... Dec. 2019.
CMS contacts payers and Posts Other Sept. 2018 ... CMS contacts ECs and Posts Other Payer Dec. 2019.
Payer Advanced APM Lists. Advanced APM List.
(4) Medicare Health Plans included in the QP determination In light of these statutory limitations,
In the CY 2018 Quality Payment calculations under the Medicare Option as noted in the CY 2018 Quality
Program proposed rule, we noted that (81 FR 7747377474). Instead, eligible Payment Program proposed rule, we
the Medicare Option for QP clinicians who participate in Other received feedback in support of the idea
determinations under sections Payer Advanced APMs, including those of also incentivizing eligible clinician
1833(z)(2)(A), (2)(B)(i), and (2)(C)(i) of with Medicare Advantage as a payer, participation in alternative payment
the Act, is based only on the percentage could become QPs based on that arrangements under Medicare
of Part B payments for covered participation during the 2019 QP Advantage by providing credit for that
professional services, or patients, that is Performance Period in payment year participation in QP determinations
attributable to payments through an 2021 (82 FR 30190). However, eligible under the Medicare Option. We noted in
Advanced APM. As such, payment clinicians who participate in Other the CY 2018 Quality Payment Program
amounts or patient counts under Payer Advanced APMs with Medicare proposed rule that we were considering
Medicare Health Plans, including Advantage as the payer can only achieve opportunities to address this issue, and
Medicare Advantage, Medicare- QP status if they also participate in an we sought comment on such
Medicaid Plans, 1876 Cost Plans, and Advanced APM with Medicare fee-for- opportunities, including potential
Programs of All Inclusive Care for the service. models and uses of our waiver and
Elderly (PACE) plans, cannot be demonstration authorities. Under the
All-Payer Combination Option, eligible eligible clinicians to participate in this is the least complex and
clinicians can become QPs based in part innovative alternative payment burdensome option available for
on payment amounts or patient counts arrangements under Medicare Medicare Health Plans. As we gain
associated with other payer Advantage that qualify as Advanced experience with the All-Payer
arrangements through Medicare Health APMs, by allowing credit for Combination Option, we will continue
Plans, provided that such arrangements participation in such Medicare to explore additional opportunities to
meet the criteria to be Other Payer Advantage arrangements prior to 2019 minimize the burden associated with
Advanced APMs. We note that the and incentivizing participation in such completing the Payer Initiated
financial relationship between the arrangements in 2018 through 2024, Submission Form.
Medicare Health Plan and CMS is not which we believe is especially Final Action: After considering public
relevant to determination of whether a important for eligible clinicians who do comments, we are finalizing our
plan is an Other Payer Advanced APM. not participate in Advanced APMs with proposal to allow Medicare Health Plans
We note that under our approach to Medicare fee-for-service. We expect that to request that we determine whether
making Other Payer Advanced APM this will give us an opportunity to test their payment arrangements are Other
determinations, because QP whether giving clinicians incentives for Payer Advanced APMs in the year prior
determinations are made for eligible participation in Advanced APMs with to the QP Performance Period by
clinicians, only the payment Medicare Advantage alone (without submitting information
arrangement between a Medicare Health having to concurrently participate in an contemporaneously with the annual
Plan and an eligible clinician is relevant Advanced APM with Medicare fee-for- bidding process for Medicare Advantage
when determining whether a payment service) encourages more clinicians to contracts.
arrangement is an Other Payer move to the Advanced APM path under Below we discuss our policies for the
Advanced APM. the Quality Payment Program. Unless Payer Initiated Process for Medicare
The following is a summary of the there are significant methodological or Health Plan payment arrangements.
public comments received in response other obstacles, we plan to proceed with Guidance and Submission Form: We
to our request for comment and our providing an option along these lines. discuss our final policies pertaining to
responses: the Guidance and Submission Form in
Comment: Many commenters (a) Payer Initiated Process section II.D.6.c.(1)(b) of this final rule
supported CMSs exploring ways, In the CY 2018 Quality Payment with comment period as to all payer
perhaps through a demonstration Program proposed rule, we proposed types in the Payer Initiated Process,
project testing the effects of doing so, that Medicare Health Plans may request including Medicare Health Plans. We
that eligible clinician participation in that we determine whether their note that for Medicare Health Plans, the
alternative Medicare Advantage payment arrangements are Other Payer Payer Initiated Submission Form will be
payment arrangements could be counted Advanced APMs prior to the QP incorporated into the Health Plan
in the QP determinations under the Performance Period by submitting Management System (HPMS).
Medicare Option. Many of these information contemporaneously with Submission Period: We proposed that
commenters suggested potential models the annual bidding process for Medicare the Submission Period would begin and
and ways to use CMS waiver and Advantage contracts (that is, submitted end at the same time as the annual
demonstration authorities. One by the first Monday in June of the year Medicare Advantage bid timeframe. We
commenter urged CMS to proceed prior to the payment and coverage year) proposed the Submission Period would
cautiously in undertaking a (82 FR 30190). begin when the bid packages are sent
demonstration to include Medicare The following is a summary of the out to plans in April of the year prior
Advantage under the Medicare Option, public comments received on this to the relevant QP Performance Period.
suggesting that the MACRA statute does proposal and our responses: We also proposed that the Submission
not provide credit for such participation Comment: Some commenters Deadline would be the annual bid
under the Medicare Option. Another expressed support for our proposal. deadline, which would be the first
commenter stated that Medicare Response: We appreciate the Monday in June in the year prior to the
Advantage plans currently have a large commenters support of our proposal. relevant QP Performance Period.
degree of flexibility and should not be Comment: One commenter requested We sought comment on this proposal.
given special consideration within the that CMS clarify that provider- We received no comments in response
Quality Payment Program beyond that sponsored Medicare Advantage to this proposal.
already provided for in the statute. payment arrangements could qualify as Final Action: We are finalizing our
Response: We appreciate the Other Payer Advanced APMs. proposal that the Submission Period
comments, and agree that there is merit Response: We clarify that all Medicare would begin and end at the same time
in testing the effects of incentives for Advantage payment arrangements may as the annual Medicare Advantage bid
eligible clinicians to participate in be submitted to us for Other Payer timeframe.
alternative payment arrangements with Advanced APM determinations. CMS Determination: The following is
Medicare Advantage, especially in the Comment: Another commenter a summary of the public comments
case of eligible clinicians who would suggested that the process for Medicare received on this proposal and our
not receive credit for such participation Advantage is too complex and should be responses:
under the regular APM incentive rules. simplified. Comment: One commenter suggested
We are pursuing this idea, and we are Response: We proposed that Medicare that CMS should assume that qualified
considering potential demonstration Health Plans may request that we risk contracts between payers and
project designs that would do so. determine whether their payment eligible clinicians in Medicare
Final Action: While we are not taking arrangements are Other Payer Advanced Advantage are Other Payer Advanced
any formal action with respect to APMs prior to the QP Performance APMs.
commenters suggestions in this final Period by submitting information Response: We do not believe that it
rule with comment period, we intend to contemporaneously with the annual would be appropriate for us to presume
develop a demonstration project to test bidding process for Medicare Advantage that a payment arrangement meets the
the effects of expanding incentives for contracts. We continue to believe that Other Payer Advanced APM criteria
without conducting an Other Payer Guidance and Submission Form: We of the same year as the relevant QP
Advanced APM determination. While discuss our final policies pertaining to Performance Period.
some qualified risk contracts may meet the Guidance and Submission Form in CMS Determination: We discuss our
the Other Payer Advanced APM criteria, section II.D.6.c.(1)(c) of this final rule final policies pertaining to the CMS
others may not. with comment period for all of the Determination in section II.D.6.c.(1)(c)
Final Action: We discuss our final Eligible Clinician Initiated Process, of this final rule with comment period
policies pertaining to the CMS including Medicare Health Plan for all of the Eligible Clinician Initiated
Determination in section II.D.6.c.(1)(b) payment arrangements. Process, including Medicare Health Plan
of this final rule with comment period Submission Period: We proposed that payment arrangements.
as to all payer types in the Payer APM Entities or eligible clinicians may
CMS Notification: We discuss our
Initiated Process, including Medicare request Other Payer Advanced APM
final policies pertaining to the CMS
Health Plan payment arrangements. determinations beginning on August 1
of the same year as the relevant QP Notification in section II.D.6.c.(1)(c) of
CMS Notification: We discuss our
Performance Period. We proposed that this final rule with comment period for
final policies pertaining to the CMS
the Submission Deadline for requesting all of the Eligible Clinician Initiated
Notification in section II.D.6.c.(1)(b) of
Other Payer Advanced APM Process, including Medicare Health Plan
this final rule with comment period as
determinations, as well as to request QP payment arrangements.
to all payer types in the Payer Initiated
Process, including Medicare Health Plan determinations under the All-Payer CMS Posting of Other Payer Advanced
payment arrangements. Combination Option, is December 1 of APMs: We explained our policy on this
CMS Posting of Other Payer Advanced the same year as the relevant QP topic for all eligible clinicians,
APMs: We explained our policy in Performance Period. regardless of payer type, including
section II.D.6.c.(1)(b) of this final rule We sought comment on this proposal. Medicare Health Plan payment
with comment period as to all payer We received no comments in response arrangements, in section II.D.6.c.(1)(c) of
types in the Payer Initiated Process, to this proposal. this final rule with comment period.
including Medicare Health Plan Final Action: We are finalizing our (c) Final Timeline
payment arrangements. proposal that APM Entities or eligible
clinicians may request Other Payer The final timelines for both the Payer
(b) Eligible Clinician Initiated Process Advanced APM determinations Initiated and Eligible Clinician Initiated
We discuss policies for the Eligible beginning on August 1 of the same year Other Payer Advanced APM
Clinician Initiated Process for Medicare as the relevant QP Performance Period, Determination Processes for Medicare
Health Plan payment arrangements and we are finalizing our proposal that Health Plan payment arrangements are
below. the Submission Deadline is December 1 summarized in Table 40.
TABLE 40OTHER PAYER ADVANCED APM DETERMINATION PROCESS FOR MEDICARE HEALTH PLAN PAYMENT
ARRANGEMENTS FOR QP PERFORMANCE PERIOD 2019
Eligible clinician (EC) *
Payer initiated process Date Date
initiated process
Medicare Health Guidance sent to Medicare Health Plans April 2018 ..... Guidance made available to ECsSub- Aug. 2019.
Plans. Submission Period Opens. mission Period Opens.
Submission Period Closes ......................... June 2018 .... Submission Period Closes ......................... Dec. 2019.
CMS contacts Medicare Health Plans and Sept. 2018 ... CMS contacts ECs and Posts Other Payer Dec. 2019.
Posts Other Payer Advanced APM List. Advanced APM List.
(5) Remaining Other Payers intend to discuss the Payer Initiated Response: We appreciate the
(a) Payer Initiated Process Process for remaining other payers in comments and the interest in remaining
more detail in future rulemaking (82 FR other payers ability to request Other
In the CY 2018 Quality Payment 30192). Payer Advanced APM determinations.
Program proposed rule, we proposed to The following is a summary of the We believe that limiting the payer types
allow the remaining other payers not public comments received on this for the first year of implementation to
specifically addressed in proposals, proposal and our responses: those with which we already have a
including commercial and other private relationship is necessary for orderly
Comment: Many commenters opposed initial implementation of the Payer
payers that are not states, Medicare
Health Plans or payers with our proposal. These commenters stated Initiated Process. The payers for whom
arrangements that are aligned with a that not allowing remaining other we have proposed to make the Payer
CMS Multi-Payer Model, to request that payers to submit payment arrangements Initiated Process available in 2019 have
we determine whether other payer for the 2019 QP Performance Period significant and long-standing pre-
arrangements are Other Payer Advanced would limit eligible clinicians ability to existing relationships with us, which we
APMs starting prior to the 2020 QP become QPs and believes that this believe will significantly ease the
Performance Period and each year approach is arbitrary. These burden of collecting the required
thereafter. We sought comment on this commenters urged CMS to allow information. We also note that we
proposal, and we also sought comment remaining other payers to submit believe there is value in gradually
on potential challenges to these other payment arrangement information for implementing the Payer Initiated
payers submitting information to us for Other Payer Advanced APM Process, as it requires us to collect
Other Payer Advanced APM determinations prior to the 2019 QP categories of information with which we
determinations. We noted that we Performance Period. have little experience and may involve
unanticipated challenges. We look Advanced APM beginning in the 2019 Final Action: We are finalizing our
forward to using our experience during QP Performance Period (82 FR 30192). proposal that APM Entities or eligible
the first year of implementation as a We sought comment on this proposal. clinicians may request Other Payer
basis for developing the capacity to We received no comments in response Advanced APM determinations
make this process available to remaining to this proposal. beginning on August 1 of the same year
other payers prior to the 2020 QP Final Action: We are finalizing our as the relevant QP Performance Period,
Performance Period, which we believe proposal that APM Entities and eligible and we are finalizing our proposal that
will include collecting information clinicians may request that we the Submission Deadline for these
about the identity and type of such determine whether an other payer requests is December 1 of the same year
payers. arrangement with one of these other as the relevant QP Performance Period.
We also note that APM Entities and payers is an Other Payer Advanced CMS Determination: We discuss our
eligible clinicians will be able to submit APM beginning in the 2019 QP final policies pertaining to the CMS
information about payment Performance Period. Determination in section II.D.6.c.(1)(c)
arrangements with remaining other of this final rule with comment period
Below we discuss our final policies
payers through the Eligible Clinician for all of the Eligible Clinician Initiated
for the Eligible Clinician Initiated
Initiated Process for the 2019 QP Process, including payment
Process.
Performance Period. Therefore, our arrangements with remaining other
proposal does not in any way prevent Guidance and Submission Form: We payers.
eligible clinicians from receiving credit discuss our final policies pertaining to CMS Notification: We discuss our
for participation in such payment the Guidance and Submission Form in final policies pertaining to the CMS
arrangements and thereby becoming section II.D.6.c.(1)(c) of this final rule Notification in section II.D.6.c.(1)(c) of
QPs for the 2019 QP Performance with comment period for all of the this final rule with comment period for
Period. Eligible Clinician Initiated Process, all of the Eligible Clinician Initiated
Final Action: After considering public including payment arrangements with Process, including payment
comments, we are finalizing our remaining other payers. arrangements with remaining other
proposal that the remaining other Submission Period: We proposed that payers.
payers, including commercial and other APM Entities or eligible clinicians may CMS Posting of Other Payer Advanced
private payers, may request that we request Other Payer Advanced APM APMs: We explained our policy for this
determine whether other payer determinations beginning on August 1 topic in section II.D.6.c.(1)(c) of this
arrangements are Other Payer Advanced of the same year as the relevant QP final rule with comment period,
APMs starting prior to the 2020 QP Performance Period. We proposed that including for requests that are payment
Performance Period and each year the Submission Deadline for requesting arrangements with remaining other
thereafter. Other Payer Advanced APM payers.
determinations, as well as to request QP
(b) Eligible Clinician Initiated Process determinations under the All-Payer (c) Final Timeline
In the CY 2018 Quality Payment Combination Option, is December 1 of The final timelines for both the Payer
Program proposed rule, we proposed the same year as the relevant QP Initiated and Eligible Clinician Initiated
that APM Entities and eligible clinicians Performance Period. Other Payer Advanced APM
may request that we determine whether We sought comment on this proposal. Determination Processes for payment
an other payer arrangement with one of We received no comments in response arrangements for remaining other payers
these other payers is an Other Payer to this proposal. are summarized in Table 41.
TABLE 41OTHER PAYER ADVANCED APM DETERMINATION PROCESS FOR REMAINING OTHER PAYER PAYMENT
ARRANGEMENTS FOR QP PERFORMANCE PERIOD 2019
Eligible clinician (EC) initiated process * Date
Remaining Other Payers ........................... Guidance made available to ECsSubmission Period Opens .................................... Aug. 2019.
Submission Period Closes ............................................................................................ Dec. 2019.
CMS contacts ECs and Posts Other Payer Advanced APM List ................................. Dec. 2019.
(6) Final Timeline for the Other Payer Other Payer Advanced APM
Advanced APM Determination Determination Processes for all payer
Processes types is presented in Table 42.
The final timeline for both the Payer
Initiated and Eligible Clinician Initiated
TABLE 42TIMELINE FOR OTHER PAYER ADVANCED APM DETERMINATION PROCESS FOR THE 2019 QP PERFORMANCE
PERIOD BY PAYER TYPE *
Payment Payment Medicare health plan Remaining other payer
arrangements arrangements
Year Date payment payment
authorized under aligned with a CMS arrangements arrangements
Title XIX multi-payer model
2018 ............ January ........................ Guidance sent to Guidance made avail-

statesSubmission able to payersSub-
Period Opens. mission Period
Opens.
April .............................. Submission Period ...................................... Guidance sent to Medi-
Closes for states. care Health Plans
Submission Period
Opens.
June ............................. ...................................... Submission Period Submission Period
Closes for payers. Closes for Medicare
Health Plans.
JulyAugust .................. CMS makes Other CMS makes Other CMS makes Other
Payer Advanced Payer Advanced Payer Advanced
APM Determinations APM Determinations APM Determinations
for states. for payers. for Medicare Health
Plans.
September .................... CMS posts Other Payer CMS posts Other Payer CMS posts Other Payer
Advanced APM List. Advanced APM List. Advanced APM List.
Guidance made avail-
able to ECsSub-
mission Period
Opens for ECs.
November ..................... Submission Period
Closes for ECs.
December ..................... CMS posts Other Payer
Advanced APM List.
2019 ............ August .......................... ...................................... Submission Period Submission Period Submission Period
Opens for ECs. Opens for ECs. Opens for ECs.
September .................... Submission Period for Latest time where ECs Latest time where ECs Latest time where ECs
QP determination can request Other can request Other can request Other
data opens. Payer Advanced Payer Advanced Payer Advanced
APM determinations APM determinations APM determinations
to get notification to get notification to get notification
prior to close of data prior to close of data prior to close of data
submission period. submission period. submission period.
Submission Period for Submission Period for Submission Period for
QP determination QP determination QP determination
data opens. data opens. data opens.
December ..................... ...................................... Submission Period Submission Period Submission Period
Closes for EC re- Closes for EC re- Closes for EC re-
quests for Other quests for Other quests for Other
Payer Advanced Payer Advanced Payer Advanced
APM determinations APM determinations APM determinations
and QP determina- and QP determina- and QP determina-
tion data. tion data. tion data.
CMS makes Other CMS posts Other Payer CMS makes Other
Payer Advanced Advanced APM List. Payer Advanced
APM Determinations APM Determinations
for ECs. for ECs.
CMS posts Other Payer CMS makes Other CMS posts Other Payer
Advanced APM List. Payer Advanced Advanced APM List.
APM Determinations
for ECs.
* The process repeats beginning in 2019 for the 2020 QP Performance Period.
The timeline for Other Payer submission will open, for payments Response: We appreciate the support
Advanced APM Determination Process authorized under Title XIX in for the overall timeline for Other Payer
for the 2019 QP Performance Period by September 2018, not June 2018. Advanced APM determinations.
Payer Type table included in the CY The following is a summary of the Final Action: After considering public
2018 Quality Payment Program public comments received on the
comments, we are finalizing the overall
proposed rule had one typographical overall timeline and our responses:
timeline for Other Payer Advanced APM
error (82 FR 30193). We correct and Comment: One commenter expressed
clarify in Table 42 in this final rule with support for the overall timeline for determinations as proposed.
comment period that guidance will be Other Payer Advanced APM
made to eligible clinicians, and determinations.
(7) Submission of Information for Other include descriptive language for each of support the responses in the Payer
Payer Advanced APM Determinations the required information elements. We Initiated Submission Form. We believe
In the CY 2017 Quality Payment proposed to require the name and that more than a simple attestation is
Program final rule, we finalized that to description of the arrangement, nature necessary to ensure the integrity of the
be assessed under the All-Payer of the arrangement, QP Performance Payer Initiated Process. The Payer
Combination Option, APM Entities or Period for which the arrangement is Initiated Submission Form and
eligible clinicians must submit, in a available, participant eligibility criteria, guidance will provide clarity on what
manner and by a date that we specify, and location(s) where the arrangement information is needed and what
payment arrangement information will be available so that we can verify supporting documentation is required.
whether eligible clinicians who may tell We note that for a payment arrangement
necessary to assess whether the other
us that they participate in such that we have determined is Other Payer
payer arrangement meets the Other
arrangements are eligible to do so. We Advanced APM for a particular year, we
Payer Advanced APM criteria (81 FR
proposed that a submission for an Other may consider in future rulemaking
77480). We are codifying the final
Payer Advanced APM determination methods to extend Other Payer
policies pertaining to submission of
submitted by the payer is complete only Advanced APM determinations for a
information for Other Payer Advanced
if all of these information elements are period longer than a single year,
APM determinations in this section at
submitted to us. especially in cases where we can verify
414.1445(c). We proposed to require that payers that the design and structure of the
(a) Required Information submit documentation that supports the arrangement have not changed since we
information they provided in the Payer made our determination.
(i) Payer Initiated Process
Initiated Submission Form and that is Comment: One commenter stated that
In the CY 2018 Quality Payment sufficient to enable us to determine it would be administratively
Program proposed rule, we noted that whether the other payer arrangement is burdensome and, particularly in the
we intend to create a Payer Initiated an Other Payer Advanced APM. case of states, could potentially impede
Submission Form that would allow Examples of such documentation would the states goals if we were to require the
payers to submit the information include contracts and other relevant submission of information each year in
necessary for us to determine whether a documents that govern the other payer order to consider whether to extend the
payment arrangement is an Other Payer arrangement that verify each required determination that the arrangement is
Advanced APM. We proposed that, for information element, copies of their full an Other Payer Advanced APM. This
each other payer arrangement for which contracts governing the arrangement, or
commenter recommended that CMS
a payer requests that we determine some other documents that detail and
allow for multi-year determinations for
whether it is an Other Payer Advanced govern the payment arrangement.
The following is a summary of the Medicaid APMs when such
APM, the payer must complete and
public comments received on these determinations would align with the
submit the Payer Initiated Submission
proposals and our responses: states overall delivery system and
Form by the relevant Submission
Comment: A few commenters stated payment reform strategies, or at
Deadline (82 FR 30194). We finalized
that while it is difficult to tell without minimum, CMS should create a
these proposals in section II.D.6.c.(1)(b)
the official form available, they streamlined redetermination process for
of this final rule with comment period.
expressed concerned that this level of Other Payer Advanced APMs that do
For us to make these determinations,
documentation will be burdensome for not change from year to year.
in the CY 2018 Quality Payment
Program proposed rule, we proposed to both payers and eligible clinicians. One Response: In section II.D.6.c.(1)(b) of
require that payers submit the following of these commenters also stated that it this final rule with comment period, we
information for each other payer was unclear what evidence or other finalized that Other Payer Advanced
arrangement on the Payer Initiated potentially necessary documentation APM determinations are only effective
Submission Form: would be needed short of providing the for one year at a time. As we mentioned
Arrangement name; actual contract. above, we believe that is important to
Brief description of the nature of Response: One of our goals in establish regular review of payment
the arrangement; developing the processes for arrangements to ensure the criteria for
QP Performance Period for which determining Other Payer Advanced Other Payer Advanced APMs are being
the arrangement is available; APMs is to reduce burden to the extent met. In addition, we believe that annual
Participant eligibility criteria; possible. We plan to issue guidance to review of Medicaid payment
Locations (nationwide, state, or provide clarity on what supporting arrangements will facilitate the
county) where this other payer documentation is required. We clarify implementation of the Medicaid
arrangement will be available; that we will accept redacted contracts or exclusion. We also note that some
Evidence that the CEHRT criterion portions of contracts if the information payment arrangements may change from
set forth in 414.1420(b) is satisfied; submitted will allow us to make an one year to the next. We also recognize,
Evidence that the quality measure Other Payer Advanced APM however, that some payment
criterion set forth in 414.1420(c) is determination. arrangements may not change from year
satisfied, including an outcome Comment: Some commenters to year. Once a payment arrangement
measure; recommended that the Payer Initiated has been determined to be an Other
Evidence that the financial risk Process be simplified to require only the Payer Advanced APM, we may consider
criterion set forth in 414.1420(d) is submission of an attestation that the in future rulemaking whether we should
satisfied; and payment arrangement is an Other Payer establish a process to extend Other
Other documentation as may be Advanced APM. Payer Advanced APM determinations
necessary for us to determine that the Response: We continue to believe that for a period longer than a single year if
other payer arrangement is an Other when information on a payment we can verify that the design and
Payer Advanced APM (82 FR 30194). arrangement is first submitted for the structure of the arrangement have not
We proposed that the Payer Initiated Payer Initiated Process, it is necessary changed since our previous
Submission Form would allow payers to that documentation be provided to determination.
Final Action: After considering public the other payer arrangement is an Other allowing us to receive the information
comments, we are finalizing the policy Payer Advanced APM. necessary to make such determinations.
as proposed. We seek additional We proposed that the Eligible We received no comments in response
comment regarding the duration of the Clinician Initiated Submission Form to these proposals.
agreements for other payer arrangements would allow APM Entities and eligible Final Action: We are finalizing these
that may be submitted for Other Payer clinicians to include descriptive policies as proposed.
Advanced APM determinations and language for each of the required (b) Certification and Program Integrity
how frequently portions of those information elements. We proposed to
arrangements that are relevant to Other require the name and description of the (i) Payer Initiated Process
Payer Advanced APM determinations arrangement, nature of the arrangement, In the CY 2018 Quality Payment
may change. We seek comment on QP Performance Period for which the Program proposed rule, we believe that
whether we should allow for arrangement is available, participant it is important that the information
determinations that would be for eligibility criteria, and, in the case of submitted by payers through the Payer
multiple years, and if so, what kind of Title XIX arrangements only, location(s) Initiated Process is true, accurate, and
information, if any, should be submitted where the arrangement will be available. complete. To that end, we proposed to
annually to allow us to determine that We proposed to require evidence that all add a new requirement at 414.1445(d)
there have been no changes to an other of the Other Payer Advanced APM stating that a payer that submits
payer arrangement that would affect our criteria are met in order for us to information pursuant to 414.1445(c)
previous determination that the determine that the arrangement is an must certify to the best of its knowledge
arrangement is an Other Payer Other Payer Advanced APM. We that the information it submitted to us
Advanced APM. proposed that a submission for an Other through the Payer Initiated Process is
Payer Advanced APM determination true, accurate, and complete.
(ii) Eligible Clinician Initiated Process submitted by the APM Entity or eligible Additionally, we proposed that this
In the CY 2018 Quality Payment clinician is complete only if all of these certification must accompany the Payer
Program proposed rule, we explained information elements are submitted to Initiated Submission Form and any
that we intend to create an Eligible us. supporting documentation that payers
Clinician Initiated Submission Form We proposed to require that APM submit to us through the Payer Initiated
that would allow for APM Entities or Entities or eligible clinicians submit Process (82 FR 30195).
eligible clinicians to submit the documentation that supports the We proposed to revise and clarify the
information necessary for us to information they provided in the monitoring and program integrity
determine whether a payment Eligible Clinician Initiated Submission provisions at 414.1460. First, we
arrangement is an Other Payer Form and that is sufficient to enable us proposed to modify 414.1460(c) to
Advanced APM. We proposed that, for to determine whether the other payer specify that information submitted by
each other payer arrangement an APM arrangement is an Other Payer payers for purposes of the All-Payer
Entity or eligible clinician requests us to Advanced APM. Examples of such Combination Option may be subject to
determine whether it is an Other Payer documentation would include contracts audit by us. We anticipate that the
Advanced APM, the APM Entity or and other relevant documents that purpose of any such audit would be to
eligible clinician must complete and govern the other payer arrangement that verify the accuracy of an Other Payer
verify each required information Advanced APM determination. We
submit the Eligible Clinician Initiated
element, copies of their full contracts sought comment on how this might be
Submission Form by the relevant
governing the arrangement, or some done with minimal burden to payers.
Submission Deadline (82 FR 30194
other documents that detail and govern Second, we proposed at 414.1460(e)(1)
through 30195). We are finalizing these
the payment arrangement. In addition to to require payers who choose to submit
policies in section II.D. 6.c.(1)(c) of this
requesting that we determine whether information through the Payer Initiated
final rule with comment period.
one or more other payer arrangements Process to maintain such books,
For us to make these determinations, are Other Payer Advanced APMs for the
we proposed to require that the APM contracts, records, documents, and other
year, APM Entities or eligible clinicians evidence as necessary to audit an Other
Entity or eligible clinician submit the may also inform us that they are
following information for each other Payer Advanced APM determination.
participating in an other payer We proposed that such information
payer arrangement: arrangement that we determine to be an must be maintained for 10 years after
Arrangement name; Other Payer Advanced APM for the submission. We also proposed at
Brief description of the nature of year. To do so, we proposed that an 414.1460(e)(3) that such information
the arrangement; APM Entity or eligible clinician would and supporting documentation must be
QP Performance Period for which indicate, upon submission of Other provided to us upon request. We
the arrangement is available; Payer Advanced APM participation data requested comments on this proposal,
Locations (nationwide, state, or for purposes of QP determinations, including comment on the length of
county) where this other payer which Other Payer Advanced APMs time payers typically maintain such
arrangement will be available; they participated in during the QP information. We also sought comment
Evidence that the CEHRT criterion Performance Period, and include copies on how this might be done with
set forth in 414.1420(b) is satisfied; of participation agreements or similar minimal burden to payers.
Evidence that the quality measure contracts (or relevant portions of them) The following is a summary of the
criterion set forth in 414.1420(c) is to document their participation in those public comments received on these
satisfied, including an outcome payment arrangements. proposals and our responses:
measure; We acknowledged that there is some Comment: One commenter supported
Evidence that the financial risk burden associated with requesting Other CMSs proposal.
criterion set forth in 414.1420(d) is Payer Advanced APM determinations. Response: We appreciate the
satisfied; and We sought comment on ways to reduce commenters support of our proposal.
Other documentation as may be burden on states, payers, APM Entities, Comment: Some commenters stated
necessary for us to determine whether and eligible clinicians while still that 10 years is too long for payers to
maintain information submitted for the (ii) Eligible Clinician Initiated Process the last sentence of 414.1460(c)
Other Payer Advanced APM In the CY 2017 Quality Payment regarding record retention and address
determinations. One commenter Program final rule, we finalized a the record retention issue only in the
recommended 5 years, and this requirement at 414.1445(b)(3) that maintenance of records provision at
commenter suggested that 5 years is payers must attest to the accuracy of 414.1460(e).
standard business practice in the health information submitted by eligible Finally, we proposed to clarify the
insurance industry. Another commenter clinicians (81 FR 77480). After nature of the information subject to the
encouraged CMS to contemplate the publication of the CY 2017 Quality record retention requirements at
statutes of limitation in enforcement, Payment Program final rule, we received 414.1460(e). Specifically, we proposed
standards set by accreditation comments from stakeholders opposing that an APM Entity or eligible clinician
organizations, and state law record must maintain such books, contracts,
this requirement. Commenters suggested
retention rules that require providers to records, documents, and other evidence
that payers may not have any existing
retain records for 5 to 7 years. One as necessary to enable the audit of an
relationship with us, that payers do not
commenter suggested a 6 year record Other Payer Advanced APM
have any direct stake in the QP status
retention period as an alternative, and determination, QP determination, and
of eligible clinicians, and that there may
the commenter stated that 6-year record the accuracy of an APM Incentive
be operational and legal barriers to
retention period would be more Payment.
payers attesting to this information. In The following is a summary of the
consistent with existing requirements consideration of these comments, in the
including the statute of limitations public comments received on these
CY 2018 Quality Payment Program proposals and our responses:
under the False Claims Act and Civil
proposed rule, we proposed to eliminate Comment: One commenter stated that
Monetary Penalty authorities. One
the requirement at 414.1445(b)(3) that requiring APM entities and eligible
commenter noted that the Health
payers attest that the information clinicians to maintain all data submitted
Insurance Portability and
submitted by eligible clinicians is for a period of 10 years poses liability,
Accountability Act (HIPAA) also
accurate. Instead, we proposed that storage, and cost issues, and places a
requires a covered entity, to retain
payers must certify the truth, accuracy, significant burden on eligible clinicians,
required documentation for 6 years. The
and completeness of only the particularly those in small practices.
commenter also stated that in 2016, we
information they submit directly to us The commenter was also concerned that
proposed a 10 year record retention
period for the recovery of overpayments, (82 FR 30195). this requirement would place eligible
In the CY 2017 Quality Payment clinicians and APM Entities at greater
but we ultimately concluded that a 6
Program final rule, we finalized a risk of exposing health and other
year record retention period was the
requirement at 414.1460(c) that information and encouraged us to
most appropriate because it addressed
eligible clinicians and APM Entities contemplate the statutes of limitation in
many of the concerns about burden and
must attest to the accuracy and enforcement, standards set by
costs to providers.
Response: We appreciate the completeness of data submitted to meet accreditation organizations, and state
commenters concerns and suggestions the requirements under the All-Payer law record retention rules that require
to reduce the record retention period for Combination Option. We believe this providers to retain records for 5 to 7
the Payer Initiated Process. We requirement would be more years. The commenter recommended
understand concerns regarding the appropriately placed in the regulatory that CMS reduce the record retention
burden associated with maintaining the provisions that discuss the submission policy to 5 years. Another commenter
required information for a program in of information related to requests for stated that 10 years is excessive and
which payers do not participate. We do Other Payer Advanced APM asserted that 7 years is a sufficient
not wish to lengthen existing record determinations. Accordingly, we amount of time that would benefit APM
retention requirements for parties that proposed to remove this requirement at Entities and eligible clinicians in terms
do not participate in Medicare. 414.1460(c) and proposed at of administrative burden in the storage
Therefore, we are modifying our 414.1445(d) that an APM Entity or and retrieval of records.
proposed record retention policy to eligible clinician that submits Response: We appreciate the
require payers who choose to submit information under 414.1445(c) must commenters concerns and suggestions
information through the Payer Initiated certify to the best of its knowledge that to reduce the record retention period.
Process to maintain such books, the information it submitted to us is We understand the commenters
contracts, records, documents, and other true, accurate, and complete. In the case concerns with the liability, cost, and
evidence as necessary to audit an Other of information submitted by the APM storage burdens associated with
Payer Advanced APM determination for Entity, we proposed that the maintaining data and information.
6 years after submission. We believe certification be made by a person with Therefore, we are modifying our
that our final 6 year record retention the authority to bind the APM Entity. proposed record retention policy at
requirement reduces the burden on We also proposed that this certification 414.1460(e)(2) to set forth a 6 year
payers in a manner that is consistent accompany the Eligible Clinician record retention requirement.
with industry standards and adequately Initiated Submission Form and any Specifically, this final rule with
protects the integrity of Other Payer supporting documentation that eligible comment period requires an APM Entity
Advanced APM determinations. clinicians submit to us through this or eligible clinician that submits
Final Action: After considering public process. We noted that under information to us under 414.1445 for
comments, we are finalizing our 414.1460(c), APM Entities or eligible assessment under the All-Payer
proposed changes to 414.1445. We are clinicians may be subject to audit of the Combination Option to maintain such
finalizing our proposed changes to information and supporting books, contracts, records, documents,
414.1460(e)(1) as proposed, except that documentation provided under the and other evidence as necessary to
we are finalizing a 6 year record certification. We also proposed to add a enable the audit of an Other Payer
retention requirement for payers that similar certification requirement at Advanced APM determination for a
choose to submit information through 414.1440(f)(2) for QP determinations. period of 6 years from the end of the QP
the Payer Initiated Process. We noted that we proposed to remove Performance Period or from the date of
completion of any audit, evaluation, or Payer Advanced APM, the other payer to them. We sought comment on
inspection, whichever is later. We arrangement must use an outcome whether posting this information would
believe that our final 6 year record measure if there is an applicable be helpful to APM Entities or eligible
retention requirement reduces the outcome measure on the MIPS quality clinicians.
burden on APM Entities and eligible measure list; but if there is no outcome In the CY 2017 Quality Payment
clinicians and is more consistent with measure available for use in the other Program final rule, we finalized that, to
HIPAA record retention requirements payer arrangement, the APM Entity the extent permitted by federal law, we
and other Medicare program must attest that there is no applicable would maintain confidentiality of
requirements. In addition, we note that measure on the MIPS quality measure certain information that APM Entities or
we are also reducing the record list. While we did not propose eligible clinicians submit for purposes
retention burden by revising substantive changes to this policy in the of Other Payer Advanced APM
414.1460(e)(2) to remove the CY 2018 Quality Payment Program determinations to avoid dissemination
requirements to retain records for an proposed rule, we did propose technical of potentially sensitive contractual
additional period of time under certain revisions to our regulations to codify information or trade secrets (81 FR
circumstances. Specifically, for a special this policy at 414.1445(c)(3) and we 7747877480).
need, as determined by us, or for an clarify that a payer, APM entity, or In the CY 2018 Quality Payment
additional 6 years from the date of any eligible clinician must certify that there Program proposed rule, we proposed
final resolution of a termination, is no applicable measure on the MIPS that, with the exception of the specific
dispute, or allegation of fraud or similar quality measure list if the payment information we proposed to make
fault against an APM Entity or eligible arrangement does not use an outcome publicly available as stated above, the
clinician. measure. information a payer submits to us
Final Action: After considering public The following is a summary of the through the Payer Initiated Process and
comments, we are finalizing the public comments received on this the information an APM Entity or
proposed changes to 414.1445(b)(3), proposal and our responses: eligible clinician submits to us through
414.1460(c), 414.1445(d), 414.1440(f)(2), Comment: One commenter supported the Eligible Clinician Initiated Process
414.1460(c), and 414.1460(e). We note CMSs proposal. would be kept confidential to the extent
that the record retention requirements Response: We appreciate the permitted by federal law, in order to
set forth in 414.1460(e)(2) are reduced. commenters support of our proposal. avoid dissemination of potentially
Specifically, the policies at Final Action: After considering public sensitive contractual information or
414.1460(e)(2) in this final rule with comments, we are finalizing this policy trade secrets.
comment period provide that an APM as proposed at 414.1445(c)(3). We sought comment on this proposal.
Entity or eligible clinician that submits The following is a summary of the
(c) Use of Information Submitted
information to us under 414.1445 for public comments received on this
assessment under the All-Payer In the CY 2018 Quality Payment proposal and our responses:
Combination Option must maintain Program proposed rule, we noted that Comment: Several commenters
such books, contracts, records, we intend to post, on the CMS Web site, expressed concern about the submission
documents, and other evidence as only the following information about of potentially proprietary or
necessary to enable the audit of an other payer arrangements that we commercially sensitive information.
Other Payer Advanced APM determine are Other Payer Advanced Some of these commenters urged CMS
determination for a period of 6 years APMs: The names of payers with Other to develop procedures to ensure that
from the end of the QP Performance Payer Advanced APMs as specified in any proprietary or commercially
Period or from the date of completion of either the Payer Initiated or Eligible sensitive information remains
any audit, evaluation, or inspection, Clinician Initiated Submission Form, confidential, short of fraud and abuse
whichever is later. Additionally, the location(s) in which the Other Payer reviews or other enforcement
414.1460(e)(2) no longer require an Advanced APMs are available whether proceedings. One commenter requested
APM Entity or eligible clinician to at the nationwide, state, or county level, that CMS provide examples of when our
retain records for a longer period of time and the names of the specific Other disclosure of such information would be
due to a special need, as determined by Payer Advanced APMs (82 FR 30196). lawful in this final rule. A couple of
CMS, or for an additional 6 years from We explained that we believe that commenters urged CMS to provide
the date of any final resolution of a making this information publicly assurance that the limited information
termination, dispute, or allegation of available is particularly important for to be posted on the CMS Web site will
fraud or similar fault against an APM Medicaid APMs and Medicaid Medical not be expanded without further
Entity or eligible clinician. We are Home Models determined to meet the rulemaking.
revising the regulatory text at Other Payer Advanced APM criteria so Some commenters requested that
414.1445(d)(2) to ensure that whoever that eligible clinicians can assess CMS clarify whether any of the
signs the certification is capable of whether their Medicaid payments and information that is required to be
binding the party. Therefore, when a patients would be excluded in submitted would be subject to
payer or APM Entity submits calculations under the All-Payer disclosure under the Freedom of
information to request an Other Payer Combination Option. More generally, Information Act (FOIA), and several
Advanced APM determination, the we believe that making this information commenters requested that CMS clarify
certification must be made by an publicly available would help eligible that this information would be
individual with the authority to bind clinicians to identify which of their predesignated as falling under a FOIA
the payer or APM Entity. other payer arrangements are Other exemption, either under Exemption 4 or
Payer Advanced APMs so they can Exemption 5 of FOIA.
(iii) Outcome Measure include information on those Other Response: We appreciate the
In the CY 2017 Quality Payment Payer Advanced APMs in their requests commenters concerns. As we stated in
Program final rule, we finalized at for QP determinations; and to learn the CY 2018 quality payment program
414.1420(c)(3) that to meet the quality about, and potentially join, Other Payer proposed rule, we reiterate that we will
measure use criterion to be an Other Advanced APMs that may be available keep confidential information submitted
to us for Other Payer Advanced APM for purposes of the All-Payer which eligible clinicians may request
determinations to the extent permitted Combination Option and the Quality determinations as Other Payer
by federal law. Payment Program more generally. Advanced APMs, may only require
Additionally, we note that records Comment: Two commenters urged CEHRT use at the individual eligible
that a submitter marks as confidential CMS to ensure that public descriptions clinician level in the contract the
will be protected from disclosure to the of Other Payer Advanced APMs do not eligible clinician has with the payer. We
extent permitted by federal law. include commercially sensitive also believe that it may be challenging
Specifically, Exemption 4 of the information. Some commenters stated for eligible clinicians to submit
Freedom of Information Act (FOIA) that it was unclear whether posting the information sufficient for us to
authorizes us to withhold trade secrets location of Other Payer Advanced APMs determine that at least 50 percent of
and commercial or financial information will be helpful, suggesting that it may be eligible clinicians under the other payer
obtained from a person and privileged more helpful to include a short arrangement are required to use CEHRT
or confidential. (45 CFR 5.31(d)). A descriptor of the model where eligible to document and communicate clinical
person who submits records to the clinicians would know based on care (82 FR 30196).
government may designate part or all of communication with their payer which To address this issue, we proposed
the information in such records that model was applicable to their situation, that we would presume that an other
they may consider to be exempt from but the public would not be able to payer arrangement would satisfy the 50
disclosure under Exemption 4 of the determine any of the specific details of percent CEHRT use criterion if we
FOIA. The person may make this the model. Another commenter receive information and documentation
designation either at the time the recommended that CMS redact from the eligible clinician through the
records are submitted to the government individual plan identities or aggregate Eligible Clinician Initiated Process
or within a reasonable time thereafter. data before releasing the information showing that the other payer
The designation must be in writing. Any publicly. arrangement requires the requesting
such designation will expire 10 years Response: We believe that it is eligible clinician(s) to use CEHRT to
after the records were submitted to the appropriate to limit the information we document and communicate clinician
government. (45 CFR 5.41). If records share about Other Payer Advanced information. We sought comment on
provided by a submitter become the APMs to the categories of information this proposal. We also sought comment
subject of a FOIA request, the agency we proposed, particularly to help avoid
on what kind of requirements for
will engage the submitter in the pre- the disclosure of commercially sensitive
CEHRT currently exist in other payer
disclosure notification process, unless information. We believe that the limited
arrangements, particularly if they are
the agency determines that the categories of information that we will
written to apply at the eligible clinician
information should be withheld, or the post on the CMS Web site will help
level.
designation of confidential appears avoid the disclosure of commercially
obviously frivolous. The pre-disclosure sensitive information without the need
public comments received on this
notification process can be found at 45 for any redaction of information that we
proposal and our responses:
CFR 5.42. post on the CMS Web site. We also
Comment: One commenter believe that posting the location of Comment: Two commenters
recommended that payers should have Other Payer Advanced APMs can help supported CMSs proposal. Four
the opportunity, but not an obligation, APM Entities and eligible clinicians see commenters suggested that because
to review their Other Payer Advanced where Other Payer Advanced APMs are contracts between payers and APMs
APM information before it is posted operating and find potential Other Payer may not use precise language
publicly. Advanced APMs to join. identifying the use of CEHRT and
Response: We appreciate the Final Action: After considering public clinicians have little control over the
suggestion. We may take this suggestion comments, we are finalizing our exact language used in these contracts,
into consideration in future rulemaking proposal that, with the exception of the we should give deference to common
as we gain experience with the Payer specific information we proposed to synonyms, such as Electronic Health
Initiated and Eligible Clinician Initiated make publicly available as stated above, Records (EHR) and Electronic Medical
Determination Processes. the information a payer submits to us Records (EMR). Two commenters also
Comment: One commenter suggested through the Payer Initiated Process and suggested that if CMS is not able to be
that cybersecurity is a significant the information an APM Entity or more flexible in accepting varying
consideration in both the Payer Initiated eligible clinician submits to us through contract terminology, CMS should
Process and Eligible Clinician Initiated the Eligible Clinician Initiated Process accept the EHR vendors Certified
Process. The commenter requested that would be kept confidential to the extent Health IT Product List (CHPL)
CMS reconsider the amount and types permitted by federal law. identification number as verification of
of information required for these the use of CEHRT.
processes. The commenter also (d) Use of Certified EHR Technology Response: We appreciate the support
recommended strong protections in (CEHRT) of our proposal. While we recognize that
these processes and to make these In the CY 2017 Quality Payment the use of the terms EHR and EMR
processes public. A commenter also Program final rule, we finalized that to could amount to use of CEHRT in
urged CMS to conduct periodic testing be an Other Payer Advanced APM, the certain circumstances and will attempt
of database confidentiality and report other payer arrangement must require at to identify and appropriately credit
the results to plans and health care least 50 percent of participating eligible instances where this is the case, we
providers. clinicians in each APM Entity to use cannot give deference to the terms EHR
Response: We appreciate these CEHRT to document and communicate or EMR alone as those terms do not
concerns. We are committed to clinical care (81 FR 77465). categorically meet the definition of
preventing, mitigating, and responding In the CY 2018 Quality Payment CEHRT in 414.1305. While a CHPL
to cyber incidents to the extent possible Program proposed rule, we stated that identification number may be evidence
and we will develop safeguards to we believe that some other payer that CEHRT is being used, it is not
protect the information submitted to us arrangements, particularly those for evidence that CEHRT use is required
through a particular payment Final Action: After considering public We are finalizing our proposal that
arrangement. comments, we are finalizing our payers would be required to use the
Comment: A few commenters stated proposal to presume that an other payer Payer Initiated Submission Form to
that the CERHT requirements would arrangement meets the 50 percent request that we make an Other Payer
require 50 percent of participating CEHRT use criterion if we receive Advanced APM determination. We are
eligible clinicians in each APM Entity to information and documentation from finalizing our proposal that the
use CEHRT. The commenter stated that the eligible clinician through the Submission Period opening date and
operationalizing this standard would be Eligible Clinician Initiated Process Submission Deadline would vary by
challenging, and the commenter showing that the other payer payer type to align with existing CMS
opposed setting such a threshold for arrangement requires the requesting processes for payment arrangements
Other Payer Advanced APMs. The eligible clinician to use CEHRT to authorized under Title XIX, Medicare
commenter also stated that this document and communicate clinician Health Plan payment arrangements, and
regulation is a more stringent information at 414.1445(c)(2). We seek payers with payment arrangements
requirement than what is in the statute. comment on whether we should aligned with a CMS Multi-Payer Model
One commenter stated concern that the consider revising the 50 percent CEHRT to the extent possible and appropriate.
requirement that Other Payer Advanced use requirement in future years, and if We are finalizing that, if we
APMs must include at least 50 percent so what standard we should use in its determine that the payer has submitted
of eligible clinicians to use CEHRT may place. incomplete or inadequate information,
limit Medicaid APM participation. The we would inform the payer and allow
(8) Summary of Final Policies the payer to submit additional
commenter recommended that CMS
develop a pathway for states to develop In summary, we are finalizing the information no later than 15 business
their own EHR adoption thresholds for following policies: days from the date we inform the payer.
Medicaid APM participation. Two For each other payer arrangement for
Payer Initiated Process which the payer does not submit
commenters recommended that CMS
gradually phase in the CEHRT use We are finalizing our proposal to sufficient information, we would not
requirement for Medicaid arrangements. allow certain other payers, including make a determination in response to
One commenter recommended that payers with payment arrangements that request submitted via the Payer
CMS allow for flexibility with respect to authorized under Title XIX, Medicare Initiated Submission Form.
Health Plan payment arrangements, and Title XIX (Medicaid): We are
this requirement.
payers with payment arrangements finalizing that states that have in place
Response: We note that this
aligned with a CMS Multi-Payer Model a state plan under Title XIX may request
requirement aligns with the CEHRT that we determine prior to the QP
Advanced APM criterion in the to request that we determine whether
Performance Period whether other payer
Medicare Option, and we aim to align their other payer arrangements are Other
arrangements authorized under Title
the Medicare Option and the All-Payer Payer Advanced APMs starting prior to
XIX are Other Payer Advanced APMs
Combination Option to the extent the 2019 QP Performance Period and
under the Payer Initiated Process. We
possible. While it may be initially each year thereafter. We are finalizing
are finalizing our proposal to allow
difficult to operationalize, we continue our proposal to allow remaining other
states to request determinations for both
to believe that aligning this requirement payers, including commercial and other
Medicaid fee-for-service and Medicaid
between the two options is appropriate. private payers, to request that we
managed care plan payment
We seek comment on this issue and determine whether other payer
arrangements. We are finalizing our
whether in future years we should arrangements are Other Payer Advanced proposal that the Submission Period for
consider revising the 50 percent CEHRT APMs starting in 2019 prior to the 2020 the Payer Initiated Process for use by
use requirement and instead use some QP Performance Period, and annually states to request Other Payer Advanced
other standard to identify other payer each year thereafter. We will generally APM determinations for other payer
arrangements that meet the criterion to refer to this process as the Payer arrangements authorized under Title
require CEHRT use. We intend to Initiated Other Payer Advanced APM XIX will open on January 1 of the
monitor this requirement and may Determination Process (Payer Initiated calendar year prior to the relevant QP
reconsider this topic in future Process), and we are finalizing our Performance Period for which we would
rulemaking. proposal that the Payer Initiated Process make Other Payer Advanced APM
Comment: One commenter stated that would generally involve the same steps determinations. We are finalizing our
CMS should not require payers to for each payer type for each QP proposal that the Submission Deadline
collect, or clinicians to provide, Performance Period. If a payer uses the for these submissions is April 1 of the
documentation on each provider groups same other payer arrangement in other year prior to the QP Performance Period
CEHRT use. The commenter stated that commercial lines of business, we are for which we would make the
CMS should determine that an other finalizing our proposal to allow the determination.
payer arrangement meets the CEHRT payer to concurrently request that we CMS Multi-Payer Models: We are
use criterion if the contract between the determine whether those other payer finalizing our proposal that payers with
payer and the provider requires use of arrangements are Other Payer Advanced other payer arrangements aligned with a
CEHRT. APMs as well. We are codifying these CMS Multi-Payer Model may request
Response: We clarify that our policy policies at 414.1445(a) and that we determine whether their aligned
is to use the contract between the payer 414.1445(b)(1). other payer arrangements are Other
and the eligible clinician, and the We are finalizing our proposal that Payer Advanced APMs. We are
requirements it specifies for CEHRT use, Other Payer Advanced APM finalizing our proposal that payers with
to determine whether an other payer determinations would be in effect for other payer arrangements in a CMS
arrangement meets this criterion to be only one year at a time. Multi-Payer Model may request that we
an Other Payer Advanced APM. We do We are finalizing our proposal that determine prior to the QP Performance
not require documentation for an the Payer Initiated Process would be Period whether those other payer
individual or groups use of CEHRT. voluntary for all payers. arrangements are Other Payer Advanced
APMs. We are finalizing our proposal Payer Advanced APMs. We are Payer Model may request that we
that payers that want to request that we finalizing our proposal that through the determine whether those other payer
determine whether those arrangements Eligible Clinician Initiated Process, arrangements are Other Payer Advanced
are Other Payer Advanced APMs would APM Entities and eligible clinicians APMs. We are finalizing our proposal
use the processes specified for payment participating in other payer that APM Entities or eligible clinicians
arrangements authorized under Title arrangements would have an may request Other Payer Advanced
XIX and Medicare Health Plan payment opportunity to request that we APM determinations beginning on
arrangements. We are finalizing our determine for the year whether those August 1 of the same year as the
proposal that the Submission Period other payer arrangements are Other relevant QP Performance Period. We are
would open on January 1 of the calendar Payer Advanced APMs. The Eligible finalizing that the Submission Deadline
year prior to the relevant QP Clinician Initiated Process could be for requesting Other Payer Advanced
Performance Period. We are also used to request determinations before APM determinations, as well as to
finalizing our proposal that the the beginning of an QP Performance request QP determinations under the
Submission Period would close on June Period for other payer arrangements All-Payer Combination Option, is
1 of the calendar year prior to the authorized under Title XIX. We are December 1 of the same year as the
relevant QP Performance Period. We are codifying these policies at relevant QP Performance Period.
finalizing our proposal that, in CMS 414.1445(a) and 414.1445(b)(2). Medicare Health Plans: We are
Multi-Payer Models where a state We are finalizing our proposal that finalizing our proposal that through the
prescribes uniform payment APM Entities or eligible clinicians Eligible Clinician Initiated Process,
arrangements across all payers would be required to use the Eligible APM Entities and eligible clinicians
statewide, the state would submit on Clinician Initiated Submission Form to participating in other payer
behalf of payers in the Payer Initiated request that we make an Other Payer arrangements in Medicare Health Plans
Process for Other Payer Advanced Advanced APM determination. would have an opportunity to request
APMs; we would seek information for We are finalizing our proposal that that we determine whether those other
the determination from the state, rather if we determine that the APM Entity or payer arrangements that are not already
than individual payers. The same Payer eligible clinician has submitted determined to be Other Payer Advanced
Initiated Process and timeline described incomplete or inadequate information, APMs through the Payer Initiated
above for CMS Multi-Payer Models we would inform the payer and allow Process are Other Payer Advanced
would apply. the payer to submit additional APMs. We are finalizing that APM
Medicare Health Plans: We are information no later than 15 business Entities or eligible clinicians may
finalizing our proposal that the days from the date we inform the APM request Other Payer Advanced APM
Submission Period would begin and end Entity or eligible clinician. For each determinations beginning on August 1
at the same time as the annual Medicare other payer arrangement for which the of the same year as the relevant QP
Advantage bid timeframe. We are APM Entity or eligible clinician does Performance Period. We are finalizing
finalizing our proposal the Submission not submit sufficient information, we our proposal that the Submission
Period would begin when the bid would not make a determination in Deadline for requesting Other Payer
packages are sent out to plans in April response to that request submitted via Advanced APM determinations, as well
of the year prior to the relevant QP the Eligible Clinician Initiated as to request QP determinations under
Performance Period. We are also Submission Form. the All-Payer Combination Option, is
finalizing our proposal that the Title XIX (Medicaid): We are December 1 of the same year as the
Submission Deadline would be the finalizing our proposal that for the first relevant QP Performance Period.
annual bid deadline, which would be QP Performance Period under the All- Remaining Other Payers: We are
the first Monday in June in the year Payer Combination Option, APM finalizing our proposal that through the
prior to the relevant QP Performance Entities and eligible clinicians may Eligible Clinician Initiated Process APM
Period. submit information on payment Entities and eligible clinicians
Remaining Other Payers: We are arrangements authorized under Title participating in other payer
finalizing our proposal that we will XIX to request that we determine arrangements through one of these other
allow the remaining other payers not whether those arrangements are payers is an Other Payer Advanced
specifically addressed in proposals Medicaid APMs or Medicaid Medical APM. We are finalizing that APM
above, including commercial and other Home Models that meet the Other Payer Entities or eligible clinicians may
private payers that are not states, Advanced APM criteria prior to the QP request Other Payer Advanced APM
Medicare Health Plans, or payers with Performance Period. We are finalizing determinations beginning on August 1
arrangements that are aligned with a our proposal that APM Entities or of the same year as the relevant QP
CMS Multi-Payer Model, to request that eligible clinicians may submit an Performance Period. We are finalizing
we determine whether their other payer Eligible Clinician Initiated Submission that the Submission Deadline for
arrangements are Other Payer Advanced Form for payment arrangements requesting Other Payer Advanced APM
APMs starting prior to the 2020 QP authorized under Title XIX beginning determinations, as well as to request QP
Performance Period and each year on September 1 of the calendar year determinations under the All-Payer
thereafter. prior to the QP Performance Period. We Combination Option, is December 1 of
are also finalizing our proposal that the the same year as the relevant QP
Eligible Clinician Initiated Process Submission Deadline is November 1 of Performance Period.
We are finalizing our proposal that the calendar year prior to the QP
through the Eligible Clinician Initiated Performance Period. Submission of Information for Other
Process, APM Entities and eligible CMS Multi-Payer Models: We are Payer Advanced APM Determinations
clinicians participating in other payer finalizing our proposal that through the We are finalizing that, for each
arrangements would have an Eligible Clinician Initiated Process, other payer arrangement for which a
opportunity to request that we APM Entities and eligible clinicians payer requests that we make an Other
determine for the year whether those participating in other payer Payer Advanced APM determination, all
other payer arrangements are Other arrangements aligned with a CMS Multi- payers must complete and submit the
Payer Initiated Submission Form by the or eligible clinician must complete and maintain such books, contracts, records,
relevant Submission Deadline. We are submit the Eligible Clinician Initiated documents, and other evidence as
finalizing that the Payer Initiated Submission Form by the relevant necessary to enable the audit of an
Submission Form would allow payers to Submission Deadline. Other Payer Advanced APM
include descriptive language for each of We are finalizing our proposal to determination for a period of 6 years
the required information elements. We add a new requirement at 414.1445(d) from the end of the QP Performance
are finalizing our proposal to require the stating that a payer that submits Period or from the date of completion of
name and description of the information pursuant to 414.1445(c) any audit, evaluation, or inspection,
arrangement, nature of the arrangement, must certify to the best of its knowledge whichever is later.
QP Performance Period for which the that the information submitted to us
arrangement is available, participant through the Payer Initiated Process is We are finalizing that, with the
eligibility criteria, and location(s) where true, accurate, and complete. exception of the specific information we
the arrangement will be available so that Additionally, we are finalizing that this propose to make publicly available as
we can verify whether eligible clinicians certification must accompany the Payer stated above, the information a payer
who may tell us that they participate in Initiated Submission Form and any submits to us through the Payer
such arrangements are eligible to do so. supporting documentation that payers Initiated Process and the information an
We are finalizing the requirement that submit to us through this process. APM Entity or eligible clinician submits
payers submit documentation that We are finalizing our proposed to us through the Eligible Clinician
supports the information they provided revisions to the monitoring and program Initiated Process would be kept
in the Payer Initiated Submission Form integrity provisions at 414.1460 to confidential to the extent permitted by
and that is sufficient to enable us to ensure the integrity of the Payer federal law.
determine whether the other payer Initiated Process. Specifically, we are
We are finalizing our proposal to
arrangement is an Other Payer requiring payers that choose to submit
information through the Payer Initiated presume that an other payer
Advanced APM.
arrangement would satisfy the 50
We are finalizing our proposal that, Process to maintain such books,
for each other payer arrangement an contracts, records, documents, and other percent CEHRT use criterion if we
APM Entity or eligible clinician requests evidence as necessary to enable the receive information and documentation
us to determine whether it is an Other audit of an Other Payer Advanced APM from the APM Entity or eligible
Payer Advanced APM, all APM Entities determination and that such clinician through the Eligible Clinician
or eligible clinicians must complete and information and supporting Initiated Process showing that the other
submit the Eligible Clinician Initiated documentation must be maintained for payer arrangement requires the
Submission Form by the relevant a period of 6 years after submission and requesting eligible clinician or those in
Submission Deadline. We are finalizing must be provided to CMS upon request. the requesting APM Entity to use
that the Eligible Clinician Initiated We are also finalizing our proposal to CEHRT to document and communicate
Submission Form would allow APM specify that information submitted by clinical information.
Entities or eligible clinicians to include payers for purposes of the All-Payer
Combination Option may be subject to d. Calculation of All-Payer Combination
descriptive language for each of the
required information elements. We are audit by CMS. Option Threshold Scores and QP
finalizing our proposal to require the We are removing the requirement at Determinations
name and description of the 414.1445(b)(3) that payers must attest (1) Overview
arrangement, nature of the arrangement, to the accuracy of information
QP Performance Period for which the submitted by eligible clinicians, and we In the CY 2017 Quality Payment
arrangement is available, participant are also removing the attestation Program final rule, we finalized our
eligibility criteria, and location(s) where requirement at 414.1460(c). Instead, overall approach to the All-Payer
the arrangement will be available so that we are finalizing our proposal to add a Combination Option (81 FR 77463).
we can verify whether eligible clinicians requirement at 414.1445(d) that an Beginning in 2021, in addition to the
who may tell us that they participate in APM Entity or eligible clinician that Medicare Option, an eligible clinician
such arrangements are eligible to do so. submits information pursuant to may alternatively become a QP through
We are finalizing our proposal to require 414.1445(c) must certify to the best of the All-Payer Combination Option, and
that APM Entities or eligible clinicians its knowledge that the information it an eligible clinician need only meet the
submit documentation that supports the submitted to us is true, accurate, and QP threshold under one of the two
information they provided in the complete. We are also finalizing that options to be a QP for the payment year
Eligible Clinician Initiated Submission this certification must accompany the (81 FR 77459). We finalized that we will
Form and that is sufficient to enable us submission, and in the case of conduct the QP determination
to determine whether the other payer information submitted by an APM sequentially so that the Medicare
arrangement is an Other Payer Entity, the certification must be made by Option is applied before the All-Payer
Advanced APM. an individual with the authority to bind Combination Option (81 FR 77439).
We are finalizing our proposal that, the APM Entity.
for each other payer arrangement a We are removing the record We finalized that we will calculate
payer requests us to determine whether retention requirement at 414.1445(c) Threshold Scores under the Medicare
it is an Other Payer Advanced APM, the and in this final rule with comment Option through both the payment
payer must complete and submit the period, we only address the record amount and patient count methods,
Payer Initiated Submission Form by the retention requirements for Other Payer compare each Threshold Score to the
relevant Submission Deadline. Advanced APM determinations at relevant QP and Partial QP Thresholds,
We are finalizing our proposal that, 414.1460(e)(1). We are finalizing that and use the most advantageous score to
for each other payer arrangement an an APM Entity and eligible clinician make QP determinations (81 FR 77457).
APM Entity or eligible clinician requests that submits information to us under We finalized the same approach for the
us to determine whether it is an Other 414.1445 for assessment under the All- All-Payer Combination Option (81 FR
Payer Advanced APM, the APM Entity Payer Combination Option must 77475).
(2) Summary of Proposals Advanced APMs in operation, but only We proposed to collect the
In the CY 2018 Quality Payment in certain counties, or only for eligible necessary payment amount and patient
Program proposed rule, we proposed the clinicians in certain specialties, we count information for QP
following policies: would further evaluate whether those determinations under the All-Payer
We proposed to establish the All- Medicaid APMs or Medicaid Medical Combination Option aggregated for the
Payer QP Performance Period, which Home Models were available to each two proposed snapshot timeframes:
would begin on January 1 and end on eligible clinician for whom we make a From January 1 through March 31 and
June 30 of the calendar year that is 2 QP determination under the All-Payer from January 1 through June 30. We
years prior to the payment year. We Combination Option. We would identify proposed that APM Entities may submit
proposed to add the term All-Payer QP the county in which the eligible this information on behalf of any of the
Performance Period to 414.1305. clinician practices by having the eligible clinicians in the APM Entity
We proposed to make QP individual eligible clinician submit group at the individual eligible clinician
determinations based on individual information so we can identify the level. If an APM Entity or eligible
eligible clinicians participation in county where an individual eligible clinician submits sufficient information
clinician saw the most patients during for either the payment amount or
Advanced APMs and Other Payer
the relevant QP Performance Period patient count method, but not for both,
Advanced APMs for 2 time periods:
when they request a QP determination. we proposed to make a QP
Between January 1 through March 31
We also proposed that if the eligible determination based on the one method
and between January 1 through June 30
clinicians practice is in a county or in for which we receive sufficient
of the All-Payer QP Performance Period
a specialty in which there is no information.
under the All-Payer Combination We proposed that APM Entities or
Medicaid APM or Medicaid Medical
Option. We proposed to use data for the eligible clinicians must submit all of the
Home Model in operation, all of that
same time periods for Medicare required information about the other
eligible clinicians Medicaid payments
payments or patients and that of other payer arrangements in which they
and patients would be excluded from
payers. We also proposed that in order the numerator and denominator of the participate, including those for which
for us to make a QP determination for calculations under the payment amount there is a pending request for an Other
an individual eligible clinician under or patient count method, respectively. Payer Advanced APM determination, as
the All-Payer Combination Option, the We proposed to first make a well as the payment amount and patient
individual eligible clinician must calculation under the Medicare Option count information sufficient for us to
request it and must submit payment using all Medicare payments for the make QP determinations by December 1
amount and patient count data from APM Entity for the payment amount of the calendar year that is 2 years to
other payers to support the QP method. If the minimum threshold score prior to the payment year, which we
determination. for the Medicare Option were met, we refer to as the QP Determination
We proposed to notify eligible would make calculations under the All- Submission Deadline.
clinicians of their QP status under the Payer Combination Option. Because we We proposed that an APM Entity or
All-Payer Combination Option as soon proposed to make QP determinations at eligible clinician who submits
as practicable after the proposed QP the individual eligible clinician level information to request a QP
Determination Submission Deadline. only, we proposed that under the All- determination under the All-Payer
We proposed to make QP Payer Combination Option the Combination Option must certify to the
determinations under the All-Payer numerator would be the aggregate of all best of their knowledge that the
Combination Option at the individual payments from all payers, except those information submitted is true, accurate
eligible clinician level only. excluded, that are made or attributable and complete. When this information is
We proposed to use the individual to the eligible clinician, under the terms submitted by an APM Entity, we
eligible clinician payment amounts and of all Advanced APMs and Other Payer proposed that the certification be made
patient counts for Medicare in the All- Advanced APMs. We also proposed that by an individual with the authority to
Payer Combination Option. We the denominator would be the aggregate bind the APM Entity. We also proposed
proposed that when an individual of all payments from all payers, except that this certification must accompany
eligible clinicians Medicare Threshold those excluded, that are made or the form that APM Entities or eligible
Score calculated at the individual attributed to the eligible clinician. clinicians submit to us when requesting
eligible clinician level would be a lower Because we proposed to make QP that we make QP determinations under
percentage than the one that is determinations at the individual eligible the All-Payer Combination Option.
calculated at the APM Entity group clinician level only, we proposed to We proposed that APM Entities and
level, we would apply a weighting count each unique patient one time in eligible clinicians who submit
methodology. the numerator and one time in the information to us under 414.1445 for
We proposed that we will denominator across all payers to align assessment under the All-Payer
determine whether a state operates a with our finalized policy for patient Combination Option or 414.1440 for
Medicaid APM or a Medicaid Medical counts at the eligible clinician level for QP determinations under the All-Payer
Home Model that has been determined the patient count method under the All- Combination Option must maintain
to be an Other Payer Advanced APM at Payer Combination Option. We such books, contracts, records,
a sub-state level. We proposed that we proposed that the numerator would be documents, and other evidence as
will use the county level to determine the number of unique patients the necessary to enable the audit of an
whether a state operates a Medicaid eligible clinician furnishes services to Other Payer Advanced APM
APM or a Medicaid Medical Home under the terms of all of their Advanced determination, QP determinations, and
Model that meets the Other Payer APMs or Other Payer Advanced APMs. the accuracy of APM Incentive
Advanced APM at a sub-state level. We proposed that the denominator Payments for a period of 10 years from
We proposed that in a state where would be the number of unique patients the end of the QP Performance Period or
we determine there are one or more the eligible clinician furnishes services from the date of completion of any
Medicaid APMs or Medicaid Medical to under all payers, except those audit, evaluation, or inspection,
Home Models that are Other Payer excluded. whichever is later.
We proposed that APM Entities and allow for a 90-day claims run out period the calculations under the All-Payer
eligible clinicians who submit before gathering the necessary payment Combination Option because we believe
information to us under 414.1445 or amount and patient count information. that would support the principle that
414.1440 must provide such We stated that we believe the same QP determinations should be based on
information and supporting claims run out timeframe should be an eligible clinicians performance over
documentation to us upon our request. adopted for other payers, and that if we a single period of time (82 FR 30199
We proposed that, to the extent were to maintain the current QP through 30200).
permitted by federal law, we will Performance Period through August 31, We sought comment on our proposal
maintain confidentiality of the eligible clinicians would be required to to create the All-Payer QP Performance
information that APM Entities or submit their other payer payment and Period and our proposals regarding
eligible clinicians submit to us for patient information to us on or very near alignment between time periods
purposes of QP determinations under the end of the 90 day claims run out assessed under the Medicare Option and
the All-Payer Combination Option, to period, leaving them with little or no the All-Payer Combination Option. The
avoid dissemination of potentially time to prepare the submission. We also following is a summary of the public
sensitive contractual information or stated that we believe that an additional comments received on these proposals
trade secrets. 60 days after the claims run out is a and our responses:
We proposed that eligible clinicians reasonable amount of time for the Comment: Several commenters
who are Partial QPs for the year under eligible clinician to collect and submit supported CMSs proposal to create an
the All-Payer Combination Option the payment and patient data. We All-Payer QP Performance Period. One
would make the election whether to sought comment on this proposal, commenter observed that this proposal
report to MIPS. specifically as to an appropriate claims would allow additional time for data to
run out standard for other payers. be analyzed and reviewed. One
(3) Timing of QP Determinations Under We noted that if we retained the commenter also preferred a 6 month
the All-Payer Combination Option current QP Performance Period and All-Payer QP Performance Period to a 3
(a) All-Payer QP Performance Period instead delayed the QP Determination month All-Payer QP Performance
and Medicare QP Performance Period Submission Deadline to allow eligible Period.
clinicians time comparable to the time Response: We appreciate the
In the CY 2018 Quality Payment provided under the Medicare Option to commenters support of our proposal.
Program proposed rule, we proposed to fully collect and submit this Comment: Several commenters stated
establish a separate QP Performance information, QP determinations under that introducing a different QP
Period for the All-Payer Combination the All-Payer Combination Option Performance Period for the Medicare
Option, which would begin on January would likely not be complete before the Option and All-Payer Combination
1 and end on June 30 of the calendar end of the MIPS reporting period, which Option would be confusing, and these
year that is 2 years prior to the payment would undermine our goal of giving commenters recommended that CMS
year. We proposed to define this term in eligible clinicians information about keep the QP Performance Periods for
414.1305 as the All-Payer QP their QP status prior to the end of the both the Medicare Option and the All-
Performance Period. We also proposed MIPS reporting period. Payer Combination Option the same.
that the QP Performance Period for the Alternatively, we considered whether One commenter suggested that aligning
Medicare Option would remain the to establish the All-Payer QP the two QP Performance Periods would
same as previously finalized, so it Performance Period from January 1 make it easier for APM Entities to
would begin on January 1 and end on through March 31 of the calendar year predict whether their eligible clinicians
August 31 of the calendar year that is 2 that is 2 years prior to the payment year. would become QPs. One commenter
years to the payment year. We proposed We sought comment on this alternative. preferred alignment between the
to define this term in 414.1305 as the Medicare Option and All-Payer
Medicare QP Performance Period (82 FR (b) Alignment of Time Periods Assessed Combination Option, but in the event
30171). Under the Medicare Option and the All- that CMS finalized a different
We explained that we proposed to Payer Combination Option timeframe, stated that January 1 through
establish the All-Payer QP Performance In the CY 2018 Quality Payment June 30 was preferable to January 1
Period because, to make QP Program proposed rule, consistent with through March 31.
determinations under the All-Payer our proposal to make the All-Payer QP Response: We appreciate these
Combination Option, we first need to Performance Period from January 1 comments, and we agree that aligning
collect information on eligible through June 30 of the calendar year the QP Performance Periods for the
clinicians payments and patients with that is 2 years prior to the payment year, Medicare Option and All-Payer
all other payers. And, in order to we proposed to make QP determinations Combination Option would help reduce
provide eligible clinicians with timely based on eligible clinicians confusion among APM Entities and
QP determinations that would enable participation in Advanced APMs and eligible clinicians. In general, it is our
them to make their own timely Other Payer Advanced APMs between goal to align the policies under the
decisions for purposes of MIPS based on January 1 through March 31 and January Medicare Option and the All-Payer
their QP status for the year, we need to 1 through June 30 under the All-Payer Combination Option to the extent
collect this information by December 1 Combination Option. We also proposed feasible and appropriate. We also
of the QP performance year. We that an eligible clinician would need to recognize that APM Entities and eligible
expressed concern that eligible meet the relevant QP or Partial QP clinicians may want a longer QP
clinicians would not be able to submit Threshold under the All-Payer Performance Period so that more
the necessary payment and patient Combination Option, and we would use payments or patients could be included
information from all of their other data for the same time periods for in the numerator and help them achieve
payers for the period from January 1 Medicare payments or patients and that QP status. While we remain concerned
through August 31 before the December of other payers. We also proposed to about whether APM Entities and eligible
1 QP Determination Submission align the time period assessed for the clinicians will be able to submit data
Deadline. For the Medicare Option, we Medicare and other payer portions of from January 1 through August 31 by
December 1, if sufficient data is Option and the All-Payer Combination continue to align the QP Performance
submitted by December 1, we believe Option, we do not currently believe that Period for the All-Payer Combination
that we will be able to notify eligible a similar policy is appropriate for the Option with the Medicare Option, so
clinicians of their QP status before the All-Payer Combination Option. We that the QP Performance Period for both
MIPS reporting deadline. believe that doing so would be options will begin on January 1 and end
Comment: One commenter stated that burdensome to payers, APM Entities, on August 31 of the calendar year that
CMSs proposal would not provide and eligible clinicians because it would is 2 years prior to the payment year. We
sufficient time to prepare and submit require the submission of additional are finalizing this approach to reduce
the information needed for a request for information. Moreover, in order for an complexity and, as several commenters
a QP determination under the All-Payer eligible clinician to become a QP expressed support for, promote
Combination Option and receive through the All Payer Combination alignment between the Medicare Option
notification of whether the eligible Option, the eligible clinician must and the All-Payer Combination Option.
clinician is a QP before that eligible participate in at least one Advanced As we discuss in section II.D.6.d.(3)(b).
clinician could have to begin submitting APM and at least one Other Payer of this final rule with comment period,
data in order to comply with MIPS. Advanced APM. It is unlikely that these we are not finalizing our proposal to
Another commenter noted that to be two (or more) payment arrangements create the terms and All-Payer QP
truly sufficient, notice of whether an would have the same start and end Performance Period and Medicare QP
eligible clinician is a QP would have to dates, and therefore, it would be unclear Performance Period and we will instead
occur prior to the performance year, which time period should be used when continue to use the term QP
particularly if MIPS eventually requires making the threshold calculations, Performance Period as finalized in the
reporting of quality data for the full especially as we make QP CY 2017 Quality Payment Program final
year. determinations under both the Medicare rule in 414.1305.
Response: We are committed to Option and All-Payer Combination As we do for the Medicare Option, we
making QP determinations and Option based on one period of time (for will make QP determinations based on
notifying eligible clinicians of their QP example, January 1March 31). three snapshot dates: March 31, June 30,
status as expeditiously as possible so Comment: One commenter suggested and August 31. We are finalizing our
the eligible clinicians can make that a 3 month All-Payer QP proposal that an eligible clinician would
appropriate decisions as necessary. We Performance Period would be too short need to meet the relevant QP or Partial
cannot notify an eligible clinician of QP given non-clinical drivers of variation in QP threshold under the All-Payer
status for a performance year in advance performance, such as seasonality, and Combination Option as of one of these
of the performance year, as we must rely urged us to use an All-Payer QP three dates, and to use data for the same
on data from that performance year to Performance Period of at least 12 time periods for Medicare and other
make QP determinations. We also note months in length to ensure eligible payer payments or patients in making
that, in order to potentially achieve QP clinicians are assessed fairly. One QP determinations. We recognize that it
status through the All-Payer commenter requested that CMS clarify may be challenging for some eligible
Combination Option, an eligible how the snapshots would be used to clinicians to submit data for the third
clinician must first achieve sufficient make QP determinations. snapshot, and in the event that an
participation in an Advanced APM. We Response: We clarify that, while an eligible clinician or APM Entity submits
also anticipate that in many instances eligible clinician may be able to attain only information for either of the first
eligible clinicians who do not become QP status based on a 3 month period, two snapshots, we will make QP
QPs or Partial QPs under the All-Payer eligible clinicians also have the determinations on that basis. We are
Combination Option would have opportunity to be assessed based on codifying this policy at 414.1440(e)(3).
already been required to submit longer periods based on subsequent
information that would be used for snapshots. For example, an eligible (c) Notification of QP Determinations
MIPS scoring, particularly if the eligible clinician could meet the relevant QP Under the All-Payer Combination
clinician is in an Advanced APM that is threshold based on performance Option
also a MIPS APM, because the majority between January 1 and March 31. In the CY 2018 Quality Payment
of information that would be required Alternatively, an eligible clinician can Program proposed rule, we explained
for MIPS would already be required attain QP status based on performance that we believe it is important to
under the terms of such an Advanced between January 1 and June 30. We provide eligible clinicians as much
APM. believe that establishing a QP information as possible about their QP
Comment: Two commenters urged Performance Period of 12 months would status under the Medicare Option prior
CMS to finalize a policy for Other Payer leave us unable to make QP to the proposed QP Determination
Advanced APMs under the All-Payer determinations and notify certain Submission Deadline.
Combination Option similar to the eligible clinicians of their QP status in We also believe that it is important to
policy CMS proposed for the Medicare advance of the MIPS reporting deadline. give eligible clinicians as much time as
Option to address the situation for We also note that our snapshots are for possible to prepare for MIPS reporting if
Advanced APMs that start after or end the purposes of determining QP status necessary. We therefore proposed to
before the QP Performance Period. In only. The snapshots do not affect the inform eligible clinicians of their QP
this circumstance, as discussed in terms of any specific payment status under the All-Payer Combination
section D.5.c. of this final rule with arrangement. In most cases, we expect Option as soon as practicable after the
comment period, CMS proposed to only that model specific assessments and proposed QP Determination Submission
count claims from the date that the incentives will occur over a longer Deadline (82 FR 30200).
Advanced APM was in active testing if period of time, such as the entire We sought comment on this proposal.
it was in active testing for at least 60 calendar year. We received no comments in response
consecutive days in the QP Performance Final Action: After considering public to this proposal.
Period. comments, we are not finalizing the Final Action: We are finalizing this
Response: While we generally seek to proposal to create a separate All-Payer policy as proposed. We are codifying
align the policies in the Medicare QP Performance Period. We will this policy at 414.1440(g).
(4) QP Determinations Under the All- clinicians may participate in Other our ability to make QP determinations at
Payer Combination Option Payer Advanced APMs at different rates the APM Entity group level.
within an APM Entity group (or not at The following is a summary of the
(a) QP Determinations at the Individual
all). public comments received on our
Eligible Clinician Level or APM Entity
We also discussed our concern that proposal and our responses:
Level Comment: Some commenters
eligible clinicians may participate in
In the CY 2017 Quality Payment Other Payer Advanced APMs whose supported our proposal.
Program final rule, we finalized that, participants do not completely overlap, Response: We appreciate the
similar to the Medicare Option, we will or do not overlap at all, with the APM commenters support of our proposal.
calculate the Threshold Scores used to Entity the eligible clinician is part of. Comment: Many commenters
make QP determinations under the All- disagreed with CMSs proposal. One
Therefore, we noted that we believe that
Payer Combination Option at the APM commenter expressed concerned that
looking at participation in Other Payer
Entity group level unless certain CMSs proposal runs counter to the idea
Advanced APMs at the individual
exceptions apply (81 FR 77478). that CMS would hold APM Entities
eligible clinician level may be a more
In the CY 2018 Quality Payment collectively accountable for
Program proposed rule, we proposed to meaningful way to assess their
performance and risk. Another
modify this policy and make QP participation across multiple payers. In
commenter disagreed with CMSs
determinations under the All-Payer addition, those risks and rewards
contention that making QP
Combination Option at the individual associated with participation in Other
determinations at the APM Entity level
eligible clinician level only. We stated Payer Advanced APMs may vary
made sense for the Medicare Option but
that we believe that there would be significantly among eligible clinicians not the All-Payer Combination Option.
significant challenges associated with depending on the Other Payer Some commenters suggested that CMS
making QP determinations under the Advanced APMs in which they make QP determinations under the All-
All-Payer Combination Option at the participate. Specifically, we expressed Payer Combination Option at either the
APM Entity group level as we finalized concern that if we were to make All- APM Entity or the TIN level. Some
in the CY 2017 Quality Payment Payer Combination Option QP commenters suggested that CMS allow
Program final rule (82 FR 30200). determinations at the APM Entity level, the APM Entity to decide whether QP
As we explained in the CY 2017 the denominator in QP threshold determinations under the All-Payer
Quality Payment Program final rule, an calculations could include all other Combination Option are made at the
APM Entity generally faces the risks and payments and patients from eligible APM Entity or eligible clinician level.
rewards of participation in an Advanced clinicians who had no, or limited, Other Some commenters urged CMS to offer a
APM as a single unit and is responsible Payer Advanced APM participation, flexible approach that that allows CMS
for performance metrics that are thereby disadvantaging those eligible to make QP determinations at the APM
aggregated to the APM Entity group clinicians who did have significant Entity level when possible, in order to
level as determined by the Advanced Other Payer Advanced APM accommodate varying organizational
APM. We note that there are certain participation. By contrast, this scenario structures.
exceptions for QP determinations, is unlikely to occur when making QP Response: We continue to believe that
specified in 414.1425(b)(1), for eligible determinations at the APM Entity level there will likely be operational
clinicians on Affiliated Practitioner under the Medicare Option because all challenges in making QP determinations
Lists. In light of these exceptions, we eligible clinicians in the APM Entity at the APM Entity level in some
noted that we believe it is generally group would be contributing to the APM circumstances. We also understand that
preferable to make QP determinations at Entitys performance under the making QP determinations at the
the APM Entity level unless we are Advanced APM. For these reasons, we individual eligible clinician level may
making QP determinations for eligible stated that we believe it would be most be burdensome to APM Entities and
clinicians identified on Affiliated appropriate to make all QP eligible clinicians, and that there may be
Practitioner Lists as specified at determinations under the All-Payer instances where making calculations at
414.1425(b)(1); or we are making QP Combination Option at the individual the APM Entity level is logical. As such,
determinations for eligible clinicians eligible clinician level (82 FR 30200). we are finalizing a flexible policy that
participating in multiple APM Entities, We sought comment on this proposal, takes into account the potential
none of which reach the QP Threshold specifically on the possible extent to diversity in organizational structures
as a group as specified at which APM Entity groups in Advanced while also trying to keep program
414.1425(c)(4) (81 FR 77439). APMs could agree to be assessed implementation as simple and
However, under the All-Payer collectively for performance in Other minimally burdensome as possible.
Combination Option, in the CY 2018 Payer Advanced APMs. We also sought Specifically, we are finalizing that an
Quality Payment Program proposed comment on whether there is variation, eligible clinician may request a QP
rule, we explained that we believe in and the extent of that variation, among determination at the individual eligible
many instances that the eligible eligible clinicians within an APM Entity clinician level, and that the APM Entity
clinicians in the APM Entity group we group in their participation in other may request a QP determination at the
would identify and use to make QP payer arrangements that we may APM Entity level.
determinations under the Medicare determine to be Other Payer Advanced Final Action: After considering public
Option would likely have little, if any, APMs. We sought comment on whether comments, and in order to provide
common APM Entity group level there are circumstances in which QP eligible clinicians with the most
participation in Other Payer Advanced determinations should be made at the opportunities to attain QP status that
APMs. The eligible clinicians in the APM Entity group level under the All- take into account their diverse
same APM Entity group would not Payer Combination Option. organizational structures and practice
necessarily have agreed to share risks We also sought comment on whether patterns, we are finalizing a modified
and rewards for Other Payer Advanced APM Entities in Other Payer Advanced version of our proposal. We are
APM participation as an APM Entity APMs could report this information at finalizing that an eligible clinician may
group, particularly when eligible the APM Entity group level to facilitate request a QP determination at the
eligible clinician level, and that an APM Payer Combination Option (82 FR determinations under the All-Payer
Entity may request a QP determination 30201). Combination Option. When we make
at the APM Entity level. We expect that We sought comment on this proposal. QP determinations at the APM Entity
this final policy will balance the We received no comments in response level, we will use APM Entity level
concerns raised by commenters and the to this proposal. payment amounts and patient counts for
concerns that we expressed in the CY Final Action: We are finalizing this the Medicare calculations in QP
2018 Quality Payment Program policy as proposed at 414.1440(d)(2). determinations under the All-Payer
proposed rule. In cases where QP Eligible clinicians who are assessed Combination Option. Eligible clinicians
determinations are requested at the individually under the Medicare Option assessed at the individual eligible
APM Entity level, we expect that the will be assessed only individually under clinician level under the Medicare
composition of the APM Entity will be the All Payer Combination Option. Option at 414.1425(b)(2) will be
generally consistent across the (b) Use of Individual or APM Entity assessed at the individual eligible
Advanced APM(s) and Other Payer Group Information for Medicare clinician level only under the All-Payer
Advanced APM(s). Eligible clinicians Payment Amount and Patient Count Combination Option. We codify these
may also request QP determinations at Calculations Under the All-Payer policies at 414.1440(d)(2).
the individual eligible clinician level, Combination Option
and we expect that this may occur in In the CY 2018 Quality Payment
situations where the composition of the In the CY 2018 Quality Payment Program proposed rule, we explained
APM Entity is not consistent across the Program proposed rule, we explained that we recognize that in many cases an
Advanced APM(s) and Other Payer that because we proposed to make QP individual eligible clinicians Medicare
Advanced APM(s). determinations at the individual eligible Threshold Scores would likely differ
In the event that we receive a request clinician level only, we proposed to use from the corresponding Threshold
for QP determination from an individual the individual eligible clinician Scores calculated at the APM Entity
eligible clinician and also separately payment amounts and patient counts for group level, which would benefit those
receive a QP determination request from the Medicare calculations in the All- eligible clinicians whose individual
that individual eligible clinicians APM Payer Combination Option. We noted Threshold Scores would be higher than
Entity, we would make a determination that we believe that matching the the group Threshold Scores and
at both levels. The eligible clinician information we use at the same level for disadvantage those eligible clinicians
could become a QP on the basis of either all payment amounts and patient counts whose individual Threshold Scores are
of the two determinations. for both the Medicare and other payer equal to or lower than the group
We are also requesting comments on portions of the calculations under the Threshold Scores. In situations where
whether in future rulemaking we should All-Payer Combination Option is most eligible clinicians are assessed under
also add a third alternative to allow QP consistent with sections 1833(z)(2)(B)(ii) the Medicare Option as an APM Entity
determinations at the TIN level when all and (C)(ii) of the Act because these group, and receive a Medicare
clinicians who have reassigned billing provisions require calculations that add Threshold Score at the group level, we
to the TIN are included in a single APM together the payments or patients from believe that the Medicare portion of
Entity. In particular, we are interested in Medicare and all other payers (except their All-Payer Combination Option
whether submitting information to those excluded). should not be lower than the Medicare
request QP determinations under the We noted, however, that we would Threshold Score that they received by
All-Payer Combination Option at the use the APM Entity group level payment participating in an APM Entity group
TIN level would more closely align with amounts and patient counts for all (82 FR 30201).
eligible clinicians existing Medicare Option Threshold Scores,
To accomplish this outcome, we
recordkeeping practices, and thereby be unless we are making QP
proposed a modified methodology. We
less burdensome. determinations for Affiliated
In the CY 2018 Quality Payment proposed that when the eligible
Practitioner Lists as specified at
Program proposed rule, we noted that clinicians Medicare Threshold Score
414.1425(b)(1) or we are making QP
when an Affiliated Practitioner List calculated at the individual level would
defines the eligible clinicians to be be a lower percentage than the one that
participating in multiple APM Entities,
assessed for QP determination in the is calculated at the APM Entity group
none of which reach the QP Threshold
Advanced APM, we make QP level we would apply a weighting
as a group as specified at
determinations under the Medicare methodology. This methodology would
414.1425(c)(4) (82 FR 30201).
Option at the individual level only. As We sought comment on this proposal. allow us to apply the APM Entity group
such, we proposed that even if we did We received no comments in response level Medicare Threshold Score (if
not finalize our proposal to conduct to this proposal. higher than the individual eligible
assessments under the All-Payer Final Action: Because we are clinician level Medicare Threshold
Combination Option at the individual finalizing a modified version of our Score), to the eligible clinician, under
eligible clinician level only, and instead proposal regarding the level at which either the payment amount or patient
adopted a mechanism to make QP we make QP determinations, we are count method, but weighted to reflect
determinations under the All-Payer finalizing a modified version of this the individual eligible clinicians
Combination Option at the APM Entity proposal. When we make QP Medicare volume.
group level, we would nonetheless determinations at the individual eligible We would multiply the eligible
assess eligible clinicians who meet the clinician level, we will use the clinicians APM Entity group Medicare
criteria to be assessed individually individual eligible clinician level Threshold Score by the total Medicare
under the Medicare Option at the payment amounts and patient counts for payments or patients made to that
individual level only under the All- the Medicare calculations in QP eligible clinician as follows:
As an example of how this weighting year 2021, consider the following APM whom participates in Other Payer
methodology would apply under the Entity group with two clinicians, one of Advanced APMs and one who does not.
payment amount method for payment
TABLE 43WEIGHTING METHODOLOGY EXAMPLEPAYMENT AMOUNT METHOD

Medicare Other payer
advanced Medicare advanced Other payer
APM total payments APM total payments
payments payments
Clinician A ........................................................................................................ $150 $200 $0 $500

Clinician B ........................................................................................................ 150 800 760 1,200
APM Entity ....................................................................................................... 300 1,000
In this example, the APM Entity The following is a summary of the corresponding APM Entity group
group Medicare Threshold Score is public comments received on this Threshold Scores under the Medicare
$300/$1000, or 30 percent. Eligible proposal and our responses: Option.
Clinicians A and B would not be QPs Comment: A few commenters
supported our proposal. (c) Title XIX Excluded Payments and
under the Medicare Option, but
Response: We appreciate the support Patients
Clinician B could request that we make
a QP determination at the individual for our proposal. Sections 1833(z)(2)(B)(ii)(I)(bb) and
eligible clinician level under the All- Comment: One commenter opposed 1833(z)(2)(C)(ii)(I)(bb) of the Act direct
Payer Combination Option since the this proposal. The commenter stated us to exclude payments made under
APM Entity group Threshold Score that it could lead to consequences such Title XIX in a state where no Medicaid
exceeded the 25 percent minimum as QP status changing within a year. The Medical Home Model or Medicaid APM
Medicare payment amount QP commenter expressed concern that is available under that state program. To
Threshold under the Medicare Option. unless we make QP determinations carry out this exclusion, in the CY 2017
When we calculate Clinician Bs based on participation volume from the Quality Payment Final Rule, we
payments individually, we would prior year, as payment changes, the QP finalized that for both the payment
calculate the Threshold Score as status of eligible clinicians may also amount and patient count methods,
follows: change during the year. Title XIX payments or patients will be
Response: We will make QP excluded from the numerator and
determinations under the All-Payer denominator for the QP determination
Combination Option based on unless:
performance through several intervals of (1) A state has in operation at least
Because Clinician Bs Threshold time, at the three snapshot dates. This one Medicaid APM or Medicaid
Score is less than the 50 percent QP weighting methodology is designed to Medical Home Model that is determined
Payment Amount Threshold, Clinician give an eligible clinician the more to be an Other Payer Advanced APM;
B would not be a QP based on this advantageous score when conducting and
result. However, if we apply the QP determinations at the individual (2) The relevant APM Entity is eligible
weighting methodology, we would eligible clinician level under the All- to participate in at least one of such
calculate the Threshold Score as Payer Combination Option. We Other Payer Advanced APMs during the
follows: emphasize that there is no situation in QP Performance Period, regardless of
which our application of this weighting whether the APM Entity actually
methodology would prevent an eligible participates in such Other Payer
clinician from attaining QP status. Nor Advanced APMs (81 FR 77475).
would it ever result in QP status for an For purposes of the discussion below
eligible clinician changing during the on the exclusion of Title XIX payments
Based upon this Threshold Score, course of a year. and patients in QP determinations, we
Clinician B would be a QP under the Final Action: After considering public note that when we refer to Medicaid
All-Payer Combination Option for the comments, we are finalizing this policy Medical Home Models, we are referring
year. as proposed with one modification at to those that are Other Payer Advanced
We would calculate the eligible 414.1440(d)(3). Because of our APMs. We also discussed that if a state
ER16NO17.005</GPH> ER16NO17.006</GPH>
clinicians Threshold Scores both modified policy regarding the level at operates such an Other Payer Advanced
individually and with this weighting which we will calculate QP APM at a sub-state level such that
methodology, and then use the more determinations under the All-Payer eligible clinicians who do not practice
advantageous score when making a QP Combination Option, we clarify that we in the area are not eligible to participate,
determination. We noted that we believe would only use this weighting Medicaid payments or patients should
that this approach promotes consistency methodology when QP determinations not be included in those eligible
between the Medicare Option and the are made at the individual eligible clinicians QP calculations because no
All-Payer Combination Option to the clinician level and when the individual Medicaid Medical Home Model or
extent possible. We sought comment on Threshold Scores under the Medicare Medicaid APM was available for their
ER16NO17.004</GPH>
this proposal. Option are lower than the participation (81 FR 77475).
In the CY 2018 Quality Payment The following is a summary of the Comment: One commenter expressed
Program proposed rule, we proposed public comments received on this support for excluding Title XIX
that we will use the county level to proposal and our responses: payments when the only Medicaid
determine whether a state operates a Comment: One commenter was APMs and Medicaid Medical Home
Medicaid APM or a Medicaid Medical concerned about the burden that our models available in a given county are
Home Model at a sub-state level. We proposal would place on eligible not available to the eligible clinician in
noted that we believe that the county clinicians. question based on their specialty.
level is appropriate as in our Response: We appreciate that we are Response: We appreciate the support
experience, the county level is the most requesting eligible clinicians to submit for these proposals.
common geographic unit used by states more information to us, but we continue Final Action: After considering public
when creating payment arrangements to believe that our proposal is the least comments, we are finalizing these
under Title XIX at the sub-state level. burdensome way for us to obtain policies as proposed at 414.1440(a)(2).
We explained that we believe that information necessary to determine how
(d) Payment Amount Method
applying this exclusion at the county to apply the Medicaid exclusion at the
county level. In the CY 2017 Quality Payment
level would allow us to carry out this
Final Action: After considering public Program final rule, we finalized that we
exclusion in accordance with the statute
comments, we are finalizing the policy will calculate an All-Payer Combination
in a way that would not penalize
as proposed. Option Threshold Score for eligible
eligible clinicians who have no
In addition to excluding payments clinicians in an APM Entity using the
Medicaid APMs or Medicaid Medical
based on county-level geography, we payment amount method (81 FR 77476
Home Models available to them (82 FR
proposed to exclude Title XIX payments 77477). We finalized that the numerator
30202). We sought comment on this
and patients from the QP determination will be the aggregate of all payments
proposal.
calculation when the only Medicaid from all payers, except those excluded,
The following is a summary of the APMs and Medicaid Medical Home to the APM Entitys eligible clinicians,
public comments received on this Models available in a given county are or the eligible clinician in the event of
proposal and our responses: not available to the eligible clinician in an individual eligible clinician
Comment: Two commenters question based on their specialty. We assessment, under the terms of all Other
supported this proposal. noted that we believe that this proposal Payer Advanced APMs during the QP
Response: We appreciate the support is consistent with the statutory Performance Period. We finalized that
for this proposal. requirement to exclude Title XIX the denominator will be the aggregate of
payment and patients from the all payments from all payers, except
Final Action: After considering public calculations when no Medicaid APM or excluded payments, to the APM Entitys
comments, we are finalizing this policy Medicaid Medical Home Model is eligible clinicians, or the eligible
as proposed at 414.1440(a). available. In cases where participation clinician in the event of an individual
In the CY 2018 Quality Payment in such a model is limited to eligible eligible clinician assessment during the
Program proposed rule, we also clinicians in certain specialties, we do QP Performance Period.
proposed that, in states where a not believe the Medicaid APM or We finalized that we will calculate
Medicaid APM or Medicaid Medical Medicaid Medical Home Model would the Threshold Score by dividing the
Home Model only exists in certain effectively be available to eligible numerator value by the denominator
counties, we would exclude Title XIX clinicians who are not in those value, which will result in a percent
data from an eligible clinicians QP specialties. We therefore believe it value Threshold Score. We will
calculations unless the county where would be inappropriate and inequitable compare that Threshold Score to the
the eligible clinician saw the most to include Title XIX payments and relevant QP Payment Amount
patients during the relevant QP patients in such eligible clinicians QP Threshold and the relevant Partial QP
Performance Period was a county where determination calculations. We Payment Amount Threshold and
a Medicaid APM or Medicaid Medical proposed to identify Medicaid APM or determine the QP status of the eligible
Home Model was available. We would Medicaid Medical Home Models that clinicians for the payment year (81 FR
require eligible clinicians to identify are only open to certain specialties 77475).
and certify the county where they saw through questions requested of states in In the CY 2018 Quality Payment
the most patients during the relevant QP the Payer Initiated Process and of APM Program proposed rule, we proposed to
Performance Period. If that county is not Entities and eligible clinicians in the maintain the policies we finalized for
in a county where a Medicaid APM or Eligible Clinician Initiated Process. We the payment amount method as
Medicaid Medical Home Model was would exclude Title XIX data from an finalized, with some proposed
available during the Performance eligible clinicians QP calculations modifications. We proposed these
Period, then Title XIX payments would unless the eligible clinician practiced changes to facilitate the implementation
be excluded from the eligible clinicians under one of the specialty codes eligible of the payment amount method while
QP calculations. We proposed this to participate in a Medicaid APM or providing eligible clinicians with some
approach to ensure that, before Medicaid Medical Home Model that was flexibility in choosing the timeframe for
including Title XIX payment or patient available in the county where the making QP determinations. To
count information in calculating QP eligible clinician saw the most patients. implement our proposal to make QP
determinations, eligible clinicians have We would use the method generally determinations at the eligible clinician
a meaningful opportunity to participate used in the Quality Payment Program to level only, we proposed that the
in a Medicaid APM or Medicaid identify an eligible clinicians specialty numerator would be the aggregate of all
Medical Home Model in a manner that or specialties (82 FR 30202 through payments from all payers, except those
would allow for both positive and 30203). We sought comment on these excluded, attributable to the eligible
negative contributions to their QP proposals. clinician only, under the terms of all
threshold score under the All-Payer The following is a summary of the Advanced APMs and Other Payer
Combination Option (82 FR 30202). We public comments received on these Advanced APMs from either January 1
sought comment on this proposal. proposals and our responses: through March 31 or January 1 through
June 30 of the QP Performance Period. determinations using the patient count but furnish care to very few of them
We also proposed that the denominator method as finalized with some proposed through an Other Payer Advanced APM
would be the aggregate of all payments modifications. We proposed these with Medicare Advantage as a payer. In
from all payers, except excluded changes to facilitate the implementation that case, the numerator may be
payments, to the eligible clinician from of the patient count method while significantly smaller than the
either January 1 through March 31, or providing eligible clinicians with some denominator, and those eligible
January 1 through June 30 of the QP flexibility in choosing the timeframe for clinicians may not meet a QP
Performance Period (82 FR 30203). We making QP determinations. To Threshold. However, we do not believe
sought comment on these proposals. implement the proposal to make QP there is any basis for making any special
The following is a summary of the determinations at the eligible clinician adjustment for this situation generally,
public comments received on these level only, we proposed to count each nor do we believe it would be
proposals our responses: unique patient one time in the appropriate to treat Medicare Advantage
Comment: One commenter stated numerator and one time in the differently from any other payer in this
support for these proposals. denominator across all payers to align situation.
Response: We appreciate the support with our finalized policy for patient Final Action: After considering public
for these proposals. counts at the eligible clinician level. We comments, and in light of operational
Final Action: After considering public proposed that the numerator would be challenges that our proposal would pose
comments, we are finalizing the policy the number of unique patients the for eligible clinicians or APM Entities,
as proposed with one modification. eligible clinician furnishes services to who would have to develop a process
Because we are retaining the January 1 under the terms of all of their Advanced for ensuring that a single patient is not
through August 31 QP Performance APMs or Other Payer Advanced APMs reported under two separate payers we
Period for the All-Payer Combination from either January 1 through March 31 are not finalizing these policies as
Option, we will also have an August 31 or January 1 through June 30 of the QP proposed.
snapshot date and thereby also make Performance Period. We proposed that We are retaining the policies as they
calculations based on the January 1 the denominator would be the number were finalized in the CY 2017 Quality
through August 31 time period. We are of unique patients the eligible clinician Payment Program final rule (81 FR
codifying our payment amount method furnishes services to under all payers, 7747777478). Specifically, for each
policy at 414.1440(b). except those excluded from either APM Entity, we would count each
(e) Patient Count Method January 1 through March 31 or January unique patient one time in the
1 through June 30 of the QP numerator and one time in the
In the CY 2017 Quality Payment Performance Period (82 FR 30203). We denominator. However, the same patient
Program final rule, we finalized that the sought comment on these proposals. could be counted separately in the
Threshold Score calculation for the The following is a summary of the numerator and denominator of two
patient count method would include public comments received on these separate payers (for example, Medicare
patients for whom the eligible clinicians proposals and our responses: and Medicaid for a dual eligible). Also,
in an APM Entity furnish services and Comment: One commenter supported because we are retaining the January 1
receive payment under the terms of an our proposals. through August 31 QP Performance
Other Payer Advanced APM, except for Response: We appreciate the Period for the All-Payer Combination
those excluded. We finalized that the commenters support of our proposals. Option, we will also have an August 31
numerator would be the number of Comment: A few commenters snapshot date and thereby also make
unique patients to whom eligible expressed concern that the patient count calculations based on the January 1
clinicians in the APM Entity furnish approach could include Medicare through August 31 time period. We are
services that are included in the Advantage patients in the denominator codifying our patient count method
aggregate expenditures used under the without commensurate addition to the policy at 414.1440(c).
terms of all their Other Payer Advanced numerator, which would dilute the
APMs during the QP Performance (5) Submission of Information for QP
patient count threshold for affected
Period plus the patient count numerator Determinations Under the All-Payer
eligible clinicians. One commenter
for Advanced APMs. We finalized that Combination Option
specifically recommended that CMS
the denominator would be the number would first carry out the patient count In the CY 2017 Quality Payment
of unique patients to whom eligible method with Medicare fee-for-service Program final rule, we finalized that
clinicians in the APM Entity furnish alone and only add Medicare Advantage either APM Entities or individual
services under all payers, except those patient data if the eligible clinician fails eligible clinicians must submit by a date
excluded. We finalized that we will to become a QP with just fee-for-service. and in a manner determined by us: (1)
calculate the Threshold Score by Response: We clarify that, as we Payment arrangement information
dividing the numerator value by the explained in the CY 2017 Quality necessary to assess whether each other
denominator value, which will result in Payment Program final rule, QP payer arrangement is an Other Payer
a percent value Threshold Score. We determinations are done sequentially, Advanced APM, including information
will compare that Threshold Score to meaning that calculations under the on financial risk arrangements, use of
the finalized QP Patient Count Medicare Option are conducted prior to CEHRT, and payment tied to quality
Threshold and the Partial QP Patient calculations under the All-Payer measures; (2) for each payment
Count Threshold and determine the QP Combination Option. The All-Payer arrangement, the amounts of payments
status of the eligible clinicians for the Combination Option is only available to for services furnished through the
payment year. We finalized that we eligible clinicians who have a sufficient arrangement, the total payments from
would count each unique patient one amount of Advanced APM participation the payer, the numbers of patients
time in the numerator and one time in to qualify, but who do not become QPs furnished any service through the
the denominator (81 FR 7747777478). under, the Medicare Option. arrangement (that is, patients for whom
In the CY 2018 Quality Payment We acknowledge that some eligible the eligible clinician is at risk if actual
Program proposed rule, we explained clinicians may have a significant expenditures exceed expected
that we intend to carry out QP number of Medicare Advantage patients expenditures), and (3) the total number
of patients furnished any service 1 through March 31, January 1 through eligible clinicians of their QP status
through the arrangement (81 FR 77480). June 30, and January 1 through August prior to the end of the MIPS reporting
We also finalized that if we do not 31. period, particularly because we would
receive sufficient information to The following is a summary of the also need to move the QP Determination
complete our evaluation of an other public comments received on this Submission Deadline to some time
payer arrangement and to make QP proposal and our responses: period after December 1.
determinations, we would not assess the Comment: One commenter expressed Final Action: After considering public
eligible clinicians under the All-Payer confusion about the timing of QP comments, we are finalizing the policy
Combination Option (81 FR 77480). determinations under the All-Payer as proposed with a modification to
Combination Option. The commenter reflect our final policy for the QP
(a) Required Information suggested that there may be a Performance Period in 414.1440(e).
In the CY 2018 Quality Payment misalignment between the timing of the Because the length of the QP
Program proposed rule, we explained snapshots and the time period for Performance Period for the All-Payer
that in order for us to make QP submitting requests for Other Payer Combination Option is from January 1
determinations under the All-Payer Advanced APM determinations. through August 31 of the calendar year
Combination Option using either the Response: We clarify that eligible that is 2 years prior to the payment year,
payment amount or patient count clinicians or APM Entities may request we will need to receive payment and
method, we would need to receive all of Other Payer Advanced APM patient information for the periods
the payment amount and patient count determinations of other payer January 1 through March 31, January 1
information: (1) Attributable to the arrangements that they participate in through June 30, and January 1 through
eligible clinician through every Other during a QP Performance Period after August 31. As we discuss in section
Payer Advanced APM; and (2) for all the QP Performance Period, and that to II.D.6.d.(3)(b) of this final rule with
other payments or patients, except from request a QP determination, the eligible comment period, we recognize that the
excluded payers, made or attributed to clinician or APM Entity will need to timing may be challenging for APM
the eligible clinician during the QP include payment and patient data for Entities or eligible clinicians to submit
Performance Period. We clarified that the snapshots of that same year. We information for the August 31 snapshot
eligible clinicians will not need to acknowledge that it is possible that an date. If we receive information for either
submit Medicare payment or patient eligible clinician or APM Entity may the March 31 or June 30 snapshots, but
information for QP determinations submit information about a payment not the August 31 snapshot, we will use
under the All-Payer Combination arrangement that we do not determine is that information to make QP
Option. an Other Payer Advanced APM, and we determinations under the All-Payer
In the CY 2018 Quality Payment encourage eligible clinicians or APM Combination Option.
Program proposed rule, we also noted Entities to submit this information on In the CY 2018 Quality Payment
that we will need this payment amount other payer arrangements earlier so that Program proposed rule, we proposed
and patient count information from we can tell them the status of the that all of this payment and patient
January 1 through June 30 of the payment arrangement in advance of information must be submitted at the
calendar year 2 years prior to the submitting payment and patient data to eligible clinician level, and not at the
payment year. We noted will need this avoid an unnecessary submission. APM Entity group level as we finalized
payment amount and patient count Comment: One commenter suggested in rulemaking last year.
information submitted in a way that that CMS utilize enough snapshot dates We sought comment on this proposal.
allows us to distinguish information to cover the entire year for both the We received no comments in response
from January 1 through March 31 and Medicare Option and the All-Payer to this proposal.
from January 1 through June 30 so that Combination Option. Final Action: Because we are
we can make QP determinations based Response: We are finalizing that there finalizing a policy where we may make
on the two proposed snapshot dates (82 will be three snapshot dates for both the QP determinations at either the
FR 30203 through 30204). Medicare Option and the All-Payer individual eligible clinician level or the
We explained that to meet the need Combination Option, which are March APM Entity level, we are finalizing a
for information in a way that we believe 31, June 30, and August 31. As we policy that payment and patient
minimizes reporting burden, we discussed in the CY 2017 Quality information must be submitted at either
proposed to collect this payment Payment Program final rule, we the individual or APM Entity level in
amount and patient count information continue to believe that this policy of order to request a QP determination.
aggregated for the two proposed using snapshots on March 31, June 30, Specifically, if an individual eligible
snapshot time frames: from January 1 and August 31 accommodates the clinician requests a QP determination
through March 31 and from January 1 variety of policies in different models under the All-Payer Combination
through June 30. We sought comment and initiatives regarding the addition Option, payment and patient
on this approach, particularly as to the and removal of APM participants so that information must be submitted at the
feasibility of submitting information in we capture the eligible clinicians who individual eligible clinician level. If an
this way and suggestions on how to have meaningfully participated in an APM Entity requests a QP determination
further minimize reporting burden. We APM Entity in an Advanced APM under the All-Payer Combination
also explained that alternatively, if we during the QP Performance Period (81 Option, payment and patient
finalized an All-Payer QP Performance FR 77444). We continue to believe that information must be submitted at the
Period of January 1 through March 31, this policy, and a parallel policy for the APM Entity level. We are codifying this
we would need payment amount and All-Payer Combination Option, allows policy at 414.1440(e).
patient count information only from for more certainty at an earlier point in In the CY 2018 Quality Payment
January 1 through March 31. We noted time of an eligible clinicians status. Program proposed rule, to minimize
that if we were to retain the current Additionally, for the All-Payer reporting burden on individual eligible
finalized QP Performance Period, we Combination Option, we are concerned clinicians and to allow eligible
would need information aggregated for that adding a December 31 snapshot clinicians to submit information to us as
three snapshot timeframes: from January date will leave us unable to notify efficiently as possible, we proposed to
allow eligible clinicians to have APM determination under the All-Payer well as the payment amount and patient
Entities submit information for them at Combination Option. The commenter count information sufficient for us to
the individual eligible clinician level on requested that CMS provide guidance make QP determinations by December 1
behalf of any of the eligible clinicians in on the format and the submission of the calendar year that is 2 years to
the APM Entity group. We sought mechanism and estimated expense and prior to the payment year, which we
comments on these proposals, time for clinicians to compile payment refer to as the QP Determination
particularly regarding the feasibility of and patient count information. Submission Deadline (82 FR 30204).
APM Entities reporting this information Response: We appreciate the In the CY 2017 Quality Payment
for some or all of the eligible clinicians comments. We intend to create a form Program final rule, we finalized that
in the APM Entity group. Additionally, that will be available for public without sufficient information we will
we proposed that if an APM Entity or comment through the Paperwork not make QP determinations under the
eligible clinician submits sufficient Reduction Act (PRA) process and to All-Payer Combination Option (81 FR
information only for the payment release subregulatory guidance to 77480). As such, we will not make QP
amount or patient count method, but facilitate the submission of this determinations for an eligible clinician
not for both, we will make a QP information. under the All-Payer Combination
determination based on the one method Comment: One commenter suggested Option if we do not receive information
for which we receive sufficient that the onus on submitting relevant sufficient to make a QP determination
information (82 FR 30204). We noted payment information should be on the under either the payment amount or
that we believe that the proposal was payer, especially as eligible clinicians patient count method by the QP
consistent with our overall approach, are already overburdened and that Determination Submission Deadline.
particularly because we finalized in the payers have a better understanding of We sought comment on this proposal.
CY 2017 Quality Payment Program final what information CMS would need and The following is a summary of the
rule that we will use the more would be in a better position to provide public comments received on this
advantageous of the Threshold Scores to that information than eligible clinicians. proposal and our responses:
make QP determinations (81 FR 77475). Response: We encourage payers to Comment: One commenter supported
We clarified that APM Entities or assist APM Entities and eligible CMSs proposal and encouraged CMS to
eligible clinicians can submit clinicians in compiling and submitting finalize it so that QP determinations
information to allow us to use both the data, but we have no clear basis for could be made in time to notify eligible
payment amount and patient count compelling payers to submit, or holding clinicians of their QP status prior to the
methods. payers accountable to the accuracy of, MIPS reporting deadline.
To facilitate and ease burden for the necessary information. We also note Response: We appreciate the support
information submissions, we also that no single payer is likely to have all of our proposal, and we agree that it is
proposed to create a form that APM of the necessary information for any important for us to develop this timeline
Entities or eligible clinicians would be given clinician, as such information will in a way that allows for QP
able to use to submit this payment typically involve payment and patient determinations to be made and
amount and patient count information. counts across multiple payers. notifications to be sent prior to the MIPS
APM Entities and eligible clinicians Final Action: After considering public reporting deadline.
would be required to use this form for comments, we are finalizing our Comment: Two commenters
submitting the payment and patient proposal to allow eligible clinicians to expressed concern that CMS seemed to
information. have APM Entities submit information be requesting that the requests for
We sought comment on these for them at the individual eligible determination must be submitted by
proposals. clinician level on behalf of any of the September 1 in order to be notified of
The following is a summary of eligible clinicians in the APM Entity their QP status prior to the MIPS
comments we received on these group. reporting deadline.
proposals and our responses: We are also finalizing our proposal Response: We clarify that September
Comment: One commenter supported that if an APM Entity or eligible 1 is the deadline for an APM Entity or
CMSs proposal to allow for APM clinician submits sufficient information eligible clinician to choose to submit
Entities to report on behalf of eligible only for the payment amount or patient information regarding any payment
clinicians, and one commenter count method, but not for both, we will arrangements they participate in so that
requested that any reporting make a QP determination based on the they can receive Other Payer Advanced
requirements minimize burden on one method for which we receive APM determinations for those
eligible clinicians. sufficient information. We are also arrangements prior to submitting
Response: We appreciate the finalizing our proposal to create a form payment and patient data. If eligible
commenters support of our proposal. that APM Entities or eligible clinicians clinicians and APM Entities are made
One of our goals is to reduce burden to would be able to use to submit this aware in advance that certain
the extent possible. payment amount and patient count arrangements are not Other Payer
Comment: One commenter stated that information. Advanced APMs, they will know with
CMS should make the forms to collect more specificity what payment or
this information available well in (b) QP Determination Submission patient information to submit. The
advance and that they should be subject Deadline deadline for submitting payment
to public comment to allow payers to In the CY 2018 Quality Payment amount and patient count data so that
clarify terminology and definitions and Program proposed rule, we proposed a QP determination can be made under
help ensure that information submitted that APM Entities or eligible clinicians the All-Payer Combination Option is
to us is appropriate. A few commenters must submit all of the required December 1.
requested that CMS release information about the Other Payer Comment: One commenter was
subregulatory guidance so that APM Advanced APMs in which they concerned that this timeline would
entities and eligible clinicians will participate, including those for which place APM entities and eligible
know what to collect and submit in there is a pending request for an Other clinicians in an awkward position of not
order for CMS to make a QP Payer Advanced APM determination, as knowing until the very end of the
performance year, or even later, whether eligible clinician that submits QP determinations and the accuracy of
they need to report to MIPS. They information to us under 414.1445 for APM Incentive Payments for a period of
suggested that CMS consider either assessment under the All-Payer 6 years from the end of the QP
some form of deemed status from one Combination Option must maintain Performance Period or from the date of
year to another. For example, data from such books contracts records, completion of any audit, evaluation, or
2017 could be used to establish QP documents, and other evidence for a inspection, whichever is later.
status for 2018 or CMS could adopt period of 10 years from the final date of Additionally, 414.1460(e)(2) no longer
some earlier deadline for part-year data the QP Performance Period or from the require an APM Entity or eligible
submission such as first 6 months of the date of completion of any audit, clinician to retain records for a longer
year, reportable starting July 1 of that evaluation, or inspection, whichever is period of time based on a special need,
year. later (81 FR 77555). We also finalized at as determined by us, or for an additional
Response: We appreciate the 414.1460(c) that eligible clinicians and 6 years from the date of any final
comments. We acknowledge that the APM Entities must maintain copies of resolution of a termination, dispute, or
timeframe between QP determinations any supporting documentation related allegation of fraud or similar fault
and MIPS reporting is narrow, and we to the All-Payer Combination Option for against an APM Entity or eligible
have designed this timeline to try to at least 10 years (81 FR 77555). We clinician.
provide as much advance notice to propose to revise 414.1460(e) to apply
eligible clinicians as possible. We will (d) Use of Information
to information submitted to us under
monitor how this timeline develops and 414.1440 for QP determinations. We In the CY 2017 Quality Payment
may consider changes in future also proposed to add paragraph (3) to Program final rule, we finalized that, to
rulemaking. 414.1460(e) stating that an APM Entity the extent permitted by federal law, we
Final Action: After considering public or eligible clinician who submits will maintain confidentiality of the
comments, we are finalizing our information to us under 414.1445 or information and data that APM Entities
proposal that APM Entities or eligible 414.1440 must provide such and eligible clinicians submit to support
clinicians must submit all of the information and supporting Other Payer Advanced APM
required information about the Other documentation to us upon our request. determinations in order to avoid
Payer Advanced APMs in which they We sought comments on these dissemination of potentially sensitive
participate, including those for which proposals. contractual information or trade secrets
there is a pending request for an Other The following is a summary of the (81 FR 7747977480).
Payer Advanced APM determination, as public comments received on these We believe that it is similarly
well as the payment amount and patient proposals and our responses: appropriate for us to maintain the
count information sufficient for us to Comment: One commenter stated that confidentiality of information submitted
make QP determinations by December 1 the 10-year record retention period is to us for the purposes of QP
of the calendar year that is 2 years to overly burdensome on eligible determinations to the extent permitted
prior to the payment year, which we clinicians. This commenter also stated by federal law. Therefore, we proposed
refer to as the QP Determination that the 10-year record retention period that, to the extent permitted by federal
Submission Deadline. We are codifying is based on the outer limit of the False law, we will maintain confidentiality of
this policy at 414.1440(e)(4). Claims Act, and the commenter the information that APM Entities or
suggested that our proposed timeframe eligible clinicians submit to us for
(c) Certification and Program Integrity
is unreasonable. The commenter purposes of QP determinations under
In the CY 2018 Quality Payment encouraged CMS to use either a 3 or 6 the All-Payer Combination Option.
Program proposed rule, we proposed year period. The following is a summary of the
that a new requirement be added at Response: We appreciate the public comments we received on this
414.1440(f)(2) stating that the APM commenters concerns and suggestions proposal and our responses:
Entity or eligible clinician that submits to reduce the record retention period. Comment: One commenter urged us
information to request a QP For the reasons set forth in section to keep commercially sensitive
determination under the All-Payer II.D.6.c.(7)(b) of this final rule with information confidential.
Combination Option must certify to the comment period, we are finalizing a 6 Response: We reiterate that we will
best of its knowledge that the year record retention requirement. In maintain confidentiality of the
information that they submitted to us is addition, we have modified the information that APM Entities or
true, accurate, and complete. If the regulation text to remove language that eligible clinicians submit to us for
information is submitted by an APM would require parties to retain records purposes of QP determinations under
Entity, we proposed that the for a longer period of time in certain the All-Payer Combination Option to the
certification must be made by an circumstances. full extent permitted by federal law.
individual with the authority to legally Final Action: After considering public Additionally, we also note that
bind the APM Entity. This certification comments, we are finalizing the records that a submitter marks as
would accompany the Eligible Clinician proposed changes to 414.1440(f)(2) confidential will be protected from
Initiated Submission Form, which both and 414.1460(e) without modification, disclosure to the extent permitted by
eligible clinicians and APM Entities use except that the record retention federal law. Specifically, Exemption 4 of
for the Eligible Clinician Initiated requirements set forth in the Freedom of Information Act (FOIA)
Process (82 FR 30204). We sought 414.1460(e)(2) are reduced. authorizes our agency to withhold trade
comment on these proposals. Specifically, the policies at secrets and commercial or financial
We proposed to revise the monitoring 414.1460(e)(2) in this final rule information obtained from a person and
and program integrity provisions at provide that an APM Entity or eligible privileged or confidential. (45 CFR
414.1460 to further promote the clinician that submits information to us 5.31(d)). A person who submits records
integrity of the All-Payer Combination under 414.1440 for QP determinations to the government may designate part or
Option. In the CY 2017 Quality Payment must maintain such books, contracts, all of the information in such records
Program final rule, we finalized at records, documents, and other evidence that they may consider to be exempt
414.1460(e) that an APM Entity or as necessary to enable the audit of an from disclosure under Exemption 4 of
the FOIA. The person may make this (6) Examples Medicare Option. For the payment
designation either at the time the In the CY 2018 Quality Payment amount method, as we show in Table 44
records are submitted to the government Program proposed rule, to illustrate how below, the APM Entity group would not
or within a reasonable time thereafter. we would conduct QP determinations attain QP status under the Medicare
The designation must be in writing. Any under the All-Payer Combination Option, which for payment year 2021
such designation will expire 10 years Option, we provided examples where an requires a QP payment amount
after the records were submitted to the eligible clinician is in a Medicare ACO Threshold Score of 50 percent. The
government (45 CFR 5.41). If records Model that we have determined to be an APM Entity group would also fail to
provided by a submitter become the Advanced APM, a commercial ACO attain Partial QP status under the
subject of a FOIA request, the agency arrangement, and a Medicaid APM from Medicare Option, which for payment
will engage the submitter in the pre- January 1 through June 30, 2019 (82 FR year 2021 requires a Partial QP payment
disclosure notification process, unless 30205 through 30206). Because we are amount Threshold Score of 40 percent.
the agency determines that the finalizing that one of the ways in which For the patient count method, as we
information should be withheld, or the we will make QP determinations is at show in Table 45, the APM Entity group
designation of confidential appears the individual eligible clinical level, would not attain QP status under the
obviously frivolous. The pre-disclosure this example illustrates how we will Medicare Option, which for payment
make individual eligible clinician level
notification process can be found at 45 year 2021 requires a QP patient count
QP determinations.
CFR 5.42. In this example, we would use the Threshold Score of 35 percent. The
Final Action: After considering public information below to determine that APM Entity group would not attain
comments, we are finalizing the policy eligible clinicians QP status for Partial QP status under the Medicare
as proposed. payment year 2021. We would calculate Option, which for payment year 2021
the Threshold Scores for the APM Entity requires a Partial QP patient count
group in the Advanced APM under the Threshold Score of 25 percent.
TABLE 44ALL-PAYER COMBINATION OPTION EXAMPLEPAYMENT AMOUNT METHOD FOR ELIGIBLE CLINICIANS
Total
Payments to payments to
group/eligible Threshold
group/eligible
Payer Level clinician score
clinician by
by payer (percentage)
payer
(in dollars) (in dollars)
Medicare Option
Advanced APM (Medicare) ............................. APM Entity Group .......................................... 300,000 1,000,000 30
All-Payer Combination Option
Advanced APM (Medicare) ............................. Eligible Clinician ............................................. 20,000 50,000 ........................
Other Payer Advanced APM (Commercial) .... Eligible Clinician ............................................. 20,000 50,000 ........................
Medicaid APM ................................................. Eligible Clinician ............................................. 80,000 100,000 ........................
Totals for All-Payer Combination Option Eligible Clinician ............................................. 120,000 200,000 60
TABLE 45ALL-PAYER COMBINATION OPTION EXAMPLEPATIENT COUNT METHOD FOR ELIGIBLE CLINICIANS
Total
Patients of patients of Threshold
group/eligible
Payer Level group/eligible score
clinician by clinician by (percentage)
payer payer
Medicare Option
Advanced APM (Medicare) ............................. APM Entity Group .......................................... 2,200 10,000 22
Advanced APM (Medicare) ............................. Eligible Clinician ............................................. 200 1,000 ........................
Other Payer Advanced APM (Commercial) .... Eligible Clinician ............................................. 100 500 ........................
Medicaid APM ................................................. Eligible Clinician ............................................. 500 1,000 ........................
Totals for All-Payer Combination Option Eligible Clinician ............................................. 800 2,500 32
The APM Entity group did not attain of calculation, the APM Entity group clinicians within the APM Entity group
QP or Partial QP status under either the meets or exceeds the required Medicare would be eligible to obtain QP status
payment amount or patient count threshold for the year under the All- through the All-Payer Combination
method under the Medicare Option. Payer Combination Option of 25 percent Option. The eligible clinicians in the
However, because under both methods and 20 percent, respectively, eligible APM Entity group would have been
notified of this result as we share clinician level, the eligible clinician clinician would be a QP for payment
information on a regular basis on their score exceeds the QP payment amount year 2021.
QP status under each snapshot. For Threshold under the All-Payer Alternatively, if we were to use the
payment year 2021, the eligible Combination Option, which for APM Entity weighting methodology for
clinicians in this APM Entity group payment year 2021 is 50 percent, but the
calculation of a Threshold Score using
would submit their payment amount or eligible clinician only exceeds the
the payment amount method as
patient count data from all payers to Partial QP patient count Threshold
under the All-Payer Combination described in the proposed rule, we
calculate their Threshold Score under
the All-Payer Combination Option. Option, which for payment year 2021 is would apply the weighted methodology
In this example above where we make 25 percent. We would use the more as follows:
the calculation at the individual eligible advantageous score, so the eligible
The eligible clinician would obtain a would be a QP under the All-Payer The APM Entity group score exceeds the
Threshold Score of 58 percent. This Combination Option. QP payment amount Threshold under
would be slightly below the Threshold Because we are finalizing that we will the All-Payer Combination Option, or 50
Score obtained from the individual in certain circumstances make QP percent, but the APM Entity group only
eligible clinician payment count determinations under the All-Payer exceeds the Partial QP patent count
calculation, but it would still exceed the Combination Option at the APM Entity Threshold under the All-Payer
QP payment amount threshold of 50 level, we provide an example below of Combination Option, which for
percent under the All-Payer how we will make QP determinations at payment year 2021 is 25 percent. Again,
Combination Option. Based upon this the APM Entity group level under the we would use the more advantageous
Threshold Score, the eligible clinician All-Payer Combination Option based on score, so the eligible clinician would be
information shown in Tables 46 and 47. a QP for the payment year 2021.
TABLE 46ALL-PAYER COMBINATION OPTION EXAMPLEPAYMENT AMOUNT METHOD FOR APM ENTITY
Total
Payments to payments to Threshold
group by
Payer Level group by score
payer payer (percentage)
(in dollars) (in dollars)
Medicare Option
Advanced APM (Medicare) ............................. APM Entity Group .......................................... 300,000 1,000,000 30
Advanced APM (Medicare) ............................. APM Entity Group .......................................... 300,000 1,000,000 ........................
Other Payer Advanced APM (Commercial) .... APM Entity Group .......................................... 200,000 500,000 ........................
Medicaid APM ................................................. APM Entity Group .......................................... 800,000 1,000,000 ........................
Totals for All-Payer Combination Option APM Entity Group .......................................... 1,300,000 2,500,000 52
TABLE 47ALL-PAYER COMBINATION OPTION EXAMPLEPATIENT COUNT METHOD FOR APM ENTITY
Patients of Total patients Threshold
Payer Level group by of group score
payer by payer (percentage)
Medicare Option
Advanced APM (Medicare) ............................. APM Entity Group .......................................... 2,200 10,000 22

ER16NO17.008</GPH>
Advanced APM (Medicare) ............................. APM Entity Group .......................................... 2,200 10,000 ........................
Other Payer Advanced APM (Commercial) .... APM Entity Group .......................................... 1,000 5,000 ........................
Medicaid APM ................................................. APM Entity Group .......................................... 5,000 10,000 ........................
Totals for All-Payer Combination Option APM Entity Group .......................................... 8,200 25,000 33
ER16NO17.007</GPH>
(7) Partial QP Election to Report to MIPS We are finalizing that we will use Clinician Initiated Process. We would
In the 2017 Quality Payment Program either individual eligible clinician level use the method generally used in the
final rule, we finalized under the or APM Entity level payment amounts Quality Payment Program to identify an
Medicare Option that, in the cases and patient counts for Medicare in the eligible clinicians specialty or
where the QP determination is made at All-Payer Combination Option, specialties. We are codifying our
the individual eligible clinician level, if depending on which level the request policies pertaining to Title XIX
the eligible clinician is determined to be for QP determination is made. We are excluded payments and patients at
finalizing that when the eligible 414.1440(a).
a Partial QP, the eligible clinician will
clinicians Medicare Threshold Score For the payment amount method,
make the election whether to report to
calculated at the individual eligible we are finalizing that we would first
MIPS and then be subject to MIPS make a calculation under the Medicare
clinician level would be a lower
reporting requirements and payment Option. If the minimum threshold score
percentage than the one that is
adjustments (81 FR 77449). To promote for the Medicare Option were met so
calculated at the APM Entity level, and
alignment with the Medicare Option that the eligible clinician could become
the eligible clinician requested that we
and to simplify requirements when a QP under the All-Payer Combination
make QP determinations at the
possible, we proposed that eligible Option, and did not become a QP under
individual eligible clinician level, we
clinicians who are Partial QPs for the the Medicare Option, we would make
would apply the weighting
year under the All-Payer Combination methodology. We are codifying this calculations under the All-Payer
Option would make the election policy at 414.1440(d)(3). Combination Option. We are finalizing
whether to report to MIPS and therefore We are finalizing that we will that under the All-Payer Combination
be subject to MIPS reporting determine whether a state operates a Option the numerator would be the
requirements and payment adjustments. Medicaid APM or a Medicaid Medical aggregate of all payments from all
We sought comment on this proposal. Home Model that has been determined payers, except those excluded, that are
We received no comments in response to be an Other Payer Advanced APM at made or attributable to the eligible
to this proposal. a sub-state level. We are finalizing that clinician, under the terms of all
Final Action: We are finalizing this we will use the county level to Advanced APMs and Other Payer
policy as proposed. determine whether a state operates a Advanced APMs. We are also finalizing
(8) Summary of Final Policies Medicaid APM or a Medicaid Medical that the denominator would be the
Home Model that meets the Other Payer aggregate of all payments from all
In summary, we are finalizing the Advanced APM at a sub-state level. We payers, except those excluded, that are
following policies: are codifying our policies pertaining to made or attributed to the eligible
We are finalizing at 414.1305 that Title XIX excluded payments and clinician. We are codifying our payment
the QP Performance Period begins on patients at 414.1440(a). amount method policy at 414.1440(b).
January 1 and ends on August 31 of the We are finalizing that in a state For the patient count method under
calendar year that is 2 years prior to the where we determine there are one or the All-Payer Combination Option, we
payment year applies to the All-Payer more Medicaid APMs or Medicaid are not finalizing our proposal and we
Combination Option. We are not Medical Home Models that are Other are maintaining the policy that we
finalizing the terms All-Payer QP Payer Advanced APMs in operation, but finalized in the CY 2017 Quality
Performance Period and Medicare QP only in certain counties, or only for Payment Program final rule.
Performance Period. eligible clinicians in certain specialties, Specifically, for each APM Entity, we
We are finalizing that we will make we would further evaluate whether would count each unique patient one
QP determinations based on eligible those Medicaid APMs or Medicaid time in the numerator and one time in
clinicians participation in Advanced Medical Home Models were available to the denominator. However, the same
APMs and Other Payer Advanced APMs each eligible clinician for whom we patient could be counted separately in
for 3 time periods: between January 1 make a QP determination under the All- the numerator and denominator of two
through March 31, between January 1 Payer Combination Option. We will separate payers (for example, Medicare
through June 30, and between January 1 identify the county in which the eligible and Medicaid). We are codifying our
through August 31 of the QP clinician practices by having the eligible patient count policy at 414.1440(c).
Performance Period under the All-Payer clinician submit that information to We are finalizing that we will
Combination Option. We are finalizing identify the county where they saw the require APM Entities or eligible
that we will use data for the same time most patients during the relevant QP clinicians to submit the necessary
periods for Medicare payments or Performance Period when they request a payment amount and patient count
patients and that of other payers. We are QP determination. We are also finalizing information for QP determinations
codifying this policy at 414.1440(d)(1). that if the eligible clinicians practice is under the All-Payer Combination
We are finalizing that we will notify in a county, or in a specialty, in which Option aggregated for the two proposed
eligible clinicians of their QP status there is no Medicaid APM or Medicaid snapshot timeframes: From January 1
under the All-Payer Combination Medical Home Model in operation, all through March 31, from January 1
Option as soon as practicable after the of that eligible clinicians Medicaid through June 30, and from January 1
QP Determination Submission Deadline. payments and patients would be through August 31. We are finalizing
We are codifying this policy at excluded from the numerator and that APM Entities may submit this
414.1440(g). denominator of the calculations under information on behalf of any of the
We are finalizing that eligible the payment amount or patient count eligible clinicians in the APM Entity
clinicians may request that we make QP method, respectively. We are also group at the individual eligible clinician
determinations at the individual eligible finalizing that we will identify Medicaid level. If we receive information for
clinician level and that APM Entities APMs or Medicaid Medical Home some, but not all of the snapshots dates,
may request that we make QP Models that are only open to certain we will use that information to make QP
determinations at the APM Entity level. specialties through questions requested determinations under the All-Payer
We are codifying this policy at of states in the Payer Initiated Process Combination Option. We are codifying
414.1440(e). and of eligible clinicians in the Eligible this policy at 414.1440(e).
We are finalizing that if an APM eligible clinician submits to us for In the CY 2018 Quality Payment
Entity or eligible clinician submits purposes of QP determinations under Program proposed rule, we sought
sufficient information for either the the All-Payer Combination Option. comment on whether to broaden the
payment amount or patient count We are finalizing that eligible definition of PFPM to include payment
method, but not for both, we will make clinicians who are Partial QPs for the arrangements that involve Medicaid or
a QP determination based on the one year under the All-Payer Combination the Childrens Health Insurance
method for which we receive sufficient Option would make the election Program (CHIP) as a payer, even if
information. We are codifying this whether to report to MIPS and then be Medicare is not included as a payer. A
policy at 414.1440(e)(3) and subject to MIPS reporting requirements PFPM would then include Medicaid,
414.1440(f)(1). and payment adjustments. CHIP, or Medicare (or some
We are finalizing that APM Entities combination of these) as a payer. A
or eligible clinicians must submit all of 7. Physician-Focused Payment Models
PFPM might still include other payers
the required information about the (PFPMs)
in addition to Medicaid, CHIP, or
Other Payer Advanced APMs in which a. Overview Medicare; however, another payer
they participate, including those for Section 1868(c) of the Act established arrangement or Other Payer Advanced
which there is a pending request for an an innovative process for individuals APM that includes only private payers,
Other Payer Advanced APM and stakeholder entities (stakeholders) including a Medicare Advantage (MA)
determination, as well as the payment to propose physician-focused payment plan, would not be a PFPM. As we
amount and patient count information models (PFPMs) to the Physician- indicated in the proposed rule, MA and
sufficient for us to make QP Focused Payment Model Technical other private plans paid to act as
determinations by December 1 of the Advisory Committee (PTAC). The insurers on the Medicare programs
calendar year that is 2 years to prior to PTAC, established under section behalf are considered to be private
the payment year, which we refer to as 1868(c)(1)(A) of the Act, is a federal payers (82 FR 30208).
the QP Determination Submission advisory committee comprised of 11 We sought comment on whether
Deadline. We are codifying this policy members that provides advice to the broadening the definition of PFPM
at 414.1440(e)(4). Secretary. A copy of the PTACs charter, would be inclusive of potential PFPMs
We are finalizing that an APM that could focus on areas not generally
established on January 5, 2016, is
Entity or eligible clinician that submits applicable to the Medicare population,
available at https://aspe.hhs.gov/
information to request a QP such as pediatric issues or maternal
charter-physician-focused-payment-
determination under the All-Payer health, and whether changing the
model-technical-advisory-committee.
Combination Option must certify to the definition of PFPM may engage more
Section 1868(c)(2)(C) of the Act
best of its knowledge that the stakeholders in designing PFPMs that
requires the PTAC to review
information submitted is true, accurate include more populations beyond
stakeholders proposed PFPMs, prepare
and complete. In the case of information Medicare FFS beneficiaries. We sought
comments and recommendations
submitted by the APM Entity, we are comment on how the PFPM criteria
regarding whether such proposed
finalizing that the certification needs to could be applied to these payment
PFPMs meet the PFPM criteria
be made by an individual with the arrangements. We sought comment on
established by the Secretary, and submit
authority to bind the APM Entity. We whether including more issues and
those comments and recommendations
are also finalizing that this certification populations fits within the PTACs
to the Secretary. Section 1868(c)(2)(D) of
must accompany the form that APM charge and whether stakeholders are
Entities or eligible clinicians submit to the Act requires the Secretary to review
interested in the opportunity to allow
us when requesting that we make QP the PTACs comments and
the PTAC to apply its expertise to a
determinations under the All-Payer recommendations on proposed PFPMs
broader range of proposals for PFPMs
Combination Option. We are codifying and to post a detailed response to
(82 FR 30208).
this policy at 414.1440(f)(2). those comments and recommendations The current definition of PFPM
We are finalizing that an APM on the CMS Web site. specifies that a PFPM is an APM. In the
Entity or eligible clinician that submits b. Definition of PFPM CY 2017 Quality Payment Program final
information to us under 414.1440 for rule (81 FR 77406), we noted that APM
Definition of PFPM
QP determinations must maintain such is defined under section 1833(z)(3)(C) of
books, contracts, records, documents, In the CY 2017 Quality Payment the Act as any of the following: (1) A
and other evidence as necessary to Program final rule (81 FR 77555), we model under section 1115A of the Act
enable the audit of QP determinations defined PFPM at 414.1465 as an (other than a health care innovation
and the accuracy of APM Incentive Alternative Payment Model (APM) in award); (2) the Shared Savings Program
Payments for a period of 6 years from which: Medicare is a payer; in which under section 1899 of the Act; (3) a
the end of the QP Performance Period or eligible clinicians that are eligible demonstration under section 1866C of
from the date of completion of any professionals as defined in section the Act; or (4) a demonstration required
audit, evaluation, or inspection, 1848(k)(3)(B) of the Act are participants by federal law. If a payment
whichever is later. and play a core role in implementing arrangement is a PFPM it must also be
We are finalizing that APM Entities the APMs payment methodology; and an APM. Under our current regulation,
and eligible clinicians that submit which targets the quality and costs of a model that does not meet the
information to us under 414.1440 must services that eligible clinicians definition of APM is not a PFPM.
provide such information and participating in the APM provide, order, However, a payment arrangement with
supporting documentation to us upon or can significantly influence. We stated Medicaid or CHIP as the payer, but not
request. We are codifying this policy at that a PFPM could include other payers Medicare, would not necessarily meet
414.1460(e)(3). in addition to Medicare, but that other the definition of APM. Therefore, we
We are finalizing that to the extent payer arrangements and Other Payer sought comment on whether we should,
permitted by federal law, we will Advanced APMs are not PFPMs. in conjunction with potentially
maintain confidentiality of the Therefore, PFPM proposals would need broadening the scope of PFPMs to
information that an APM Entity or to include Medicare as a payer. include payment arrangements with
Medicaid and CHIP, require that a definition of PFPM to include payment this could create during the PTACs
PFPM be an APM or a payment arrangements with MA or other private review, we believe it would be
arrangement operated under legal payers, but not Medicare, as a payer. premature to expand the definition of
authority for Medicaid or CHIP payment Response: We thank commenters for PFPM at this point. Rather, we believe
arrangements (82 FR 30208). their feedback. We appreciate the role the PTAC can have the greatest impact
We also sought comment on whether that private payment arrangements by focusing on those proposed models
states and stakeholders see value in could have in PFPMs. The current where the Secretary has the greatest
having the definition of PFPM definition of PFPM requires that authority to directly advance or
broadened to include payment Medicare be a payer, but includes contribute to the implementation of the
arrangements with Medicaid or CHIP PFPMs that also include additional proposed modelthat is, those that
but not Medicare as a payer, and payers, such as MA or other private include Medicare FFS as a payer.
whether they see value in having payers. However, we do not believe However, we may seek further comment
proposals for PFPMs with Medicaid or proposed PFPMs with only private or propose a change of this nature in
CHIP but not Medicare as a payer go payers are within the scope of models subsequent rulemaking.
through the PTACs review process (82 where the Secretary can effectuate or
FR 30209). contribute to an outcome. (2) Relationship Between PFPMs and
The following is a summary of the Comment: One commenter requested Advanced APMs
public comments received on the areas that if the PFPM definition is expanded, In the CY 2018 Quality Payment
where we sought comment related to the Medicaid Managed Care and MA plan Program proposed rule, we noted that
definition of PFPM and our responses: proposals should not seek review and section 1868(c) of the Act does not
Comment: Many commenters were in approval by the PTAC and should be require PFPMs to meet the criteria to be
favor of changing the definition of able to self-certify that their programs an Advanced APM, and we did not
PFPM to include payment arrangements meet the criteria. define PFPMs solely as Advanced
with Medicaid or CHIP, even if Response: The PTACs charge is to APMs. Stakeholders may therefore
Medicare is not a payer. A few review submitted proposals for PFPMs propose as PFPMs either Advanced
commenters suggested that the and provide comments and APMs or Medical Home Models, or
definition of PFPM be broadened to recommendations to the Secretary as to other APMs. We also noted that if we
include Medicaid and CHIP and a whether such proposals meet the PFPM were to broaden the definition to
combination of public and private criteria established by the Secretary. include payment arrangements with
payers, noting how coordination among The Secretary is required to review and Medicaid or CHIP but not Medicare as
such payers is critical for aligning post on the CMS Web site a detailed a payer, stakeholders could propose as
incentives across payers and response to the PTACs comments and PFPMs Medicaid APMs, Medicaid
populations. Some commenters recommendations. Medical Home Models, or other payer
suggested that if the PFPM definition is Comment: Many commenters arrangements involving Medicaid or
changed to include payment emphasized the importance of including CHIP as a payer.
arrangements with Medicaid or CHIP, clinicians other than physicians in Comment: Some commenters
then the PTAC should prioritize PFPMs. Many commenters suggested questioned whether the PFPM proposals
proposals that include Medicare. A few the PTAC consider payment models for that have been submitted to the PTAC
commenters were in favor of broadening ancillary services, such as long-term will be Advanced APMs. Some
the definition of PFPM to include care, durable medical equipment, and commenters recommended alternative
Medicaid and CHIP payment laboratories. pathways for PFPMs to be considered
arrangements under legal authorities Response: The definition of PFPM Advanced APMs. A few commenters
other than those included in the allows for proposals in which eligible requested that PFPM proposals
definition of APM. clinicians who are eligible professionals recommended by the PTAC and tested
Response: We thank commenters for as defined in section 1848(k)(3)(B) of the by CMS automatically be Advanced
their feedback. We did not propose Act are participants and play a core role APMs or MIPS APMs, even if they do
changes to the PFPM definition in this in implementing the APMs payment not meet criteria associated with those
rulemaking and are not making such methodology. Under section types of APMs.
changes at this time, but we will 1848(k)(3)(B) of the Act, eligible Response: We appreciate that there is
carefully consider all comments for professionals are defined as: Physicians; continued interest in the opportunities
future rulemaking. practitioners described in section available for eligible clinicians to
Comment: One commenter was 1842(b)(18)(C) of the Act, such as nurse participate in Advanced APMs and
concerned that broadening the practitioners and physician assistants; MIPS APMs. We did not propose
definition of PFPM to include Medicaid physical or occupational therapists or changes to the definition of PFPM in
and CHIP as payers (with or without qualified speech-language pathologists, this rulemaking. As stated above, to be
Medicare as a payer) goes beyond and qualified audiologists. a PFPM, a model must meet the
statutory intent of the PTAC. Final Action: We did not propose definition of APM under section
Response: While we did not propose changes and we are not making changes 1833(z)(3)(C) of the Act. If a PFPM is
changes to the definition of PFPM in at this time to the current definition of recommended by the PTAC and tested
this rulemaking, we do not believe the PFPM, which is an APM in which by CMS, and if it meets the criteria for
statutory language limits the scope of Medicare FFS is a payer, and thus does an Advanced APM under section
proposals under the PTAC review not include an APM in which Medicaid 1833(z)(3)(D) of the Act and as finalized
process exclusively to those in which or CHIP is the only payer. Compared to in 414.1415 of our regulations, it will
Medicare is a payer. We also note the APMs in which Medicare FFS is a be an Advanced APM. We do not
Secretary has authority to update the payer, the PTACs assessment of believe there is a reason that PFPMs, as
criteria for PFPMs under section proposed PFPMs with only Medicaid or a type of APM, should not be subject to
1868(c)(2)(A)(iii) of the Act. CHIP as a payer would be highly the same criteria as other APMs in order
Comment: Some commenters dependent on the role of states in the to be considered Advanced APMs. To
recommended CMS broaden the proposed PFPM. Given the uncertainties ensure consistency with our ability to
determine when a PFPM meets the the PTACs comments and the processes for testing proposed
criteria for an Advanced APM, we recommendations regarding proposed PFPMs depend on the nature of the
intend to keep PFPMs defined as a type PFPMs will be made available on the PFPMs design, among other factors. An
of APM. Similarly, classification as a CMS Web site, after the Secretarys attempt to impose a deadline on them
MIPS APM requires that a model meets review of the PTACs comments and would diminish our ability to tailor
the criteria finalized in 414.1370 of recommendations, at https:// review and development to the needs of
our regulations. The financial risk and innovation.cms.gov/initiatives/pfpms/. the PFPM proposal. However, we are
other characteristics of a PFPM may Comment: One commenter requested mindful of stakeholders interest in a
help inform a recommendation by the that we encourage the PTAC to establish timely process and are committed to
PTAC, but a PTAC recommendation a timeline for PFPM proposal review. reviewing (and where appropriate,
does not necessarily mean that the Response: The PTAC has described a implementing) PFPM proposals, with or
PFPM meets the criteria to be an proposal review process and timeline in without Medicaid or CHIP as a payer, as
Advanced APM or a MIPS APM. These a document entitled Proposal quickly as possible (81 FR 77492). We
determinations will be made if the Submission Instructions, available at did not seek comments on the public
proposed PFPM is tested by CMS. https://aspe.hhs.gov/system/files/pdf/ comment timeframe for PFPM
Final Action: We did not propose 255906/ProposalSubmission proposals, but the PTAC determines the
changes and we are not making changes Instructions.pdf. process for reviewing proposed PFPMs.
at this time to the definition of PFPM. Comment: A few commenters Currently, the PTAC generally allows
Stakeholders may propose PFPMs and if requested that we test all PFPM three weeks for public comments.
selected for testing, CMS will determine proposals recommended by the PTAC, Comment: Some commenters
the appropriate APM status of PFPMs. that there be a rebuttable presumption requested specific representation of
that any PFPM proposal recommended certain types of clinicians or experts on
c. PTAC Review Process of PFPM will be tested, or that we prioritize the PTAC.
Proposals With Medicaid or CHIP as a testing PFPM proposals recommended Response: While we appreciate the
Payer by the PTAC. comments, they are outside of the scope
In the CY 2017 Quality Payment Response: We intend to continue to of CMS authority in that section
Program final rule (81 FR 7749192), we give serious consideration to proposed 1868(c)(1)(B)(i) of the Act authorizes the
described the roles of the Secretary, the PFPMs recommended by the PTAC. Comptroller General of the United
PTAC, and CMS as they relate to PFPMs However, section 1868(c) of the Act States (GAO) to appoint members of the
and the PTACs review process. We does not require CMS to test proposals PTAC, not CMS.
provided additional information about that are recommended by the PTAC, Final Action: We did not propose and
the level of consideration the Secretary and, as we discussed in the CY 2017 are not making any additions or changes
will give proposed PFPMs Quality Payment Program final rule, we to the process or timeline for review of
recommended by the PTAC and why we are unable to commit to testing every proposed PFPMs. In order to preserve
decline committing to specific PFPM proposal recommended by the flexibility in considering diverse
timeframes for testing PFPMs. Although PTAC given that we are unable to proposals of varying scope and features,
we believe that proposed PFPMs that predict the volume, quality, or we continue to believe it would not be
meet all of the PFPM criteria and are appropriateness of the proposed PFPMs appropriate to establish through
recommended by the PTAC may need on which the PTAC will make rulemaking a single process or timeline
less time to go through the development comments and recommendations (81 FR for the PTACs review or for
process, we cannot guarantee that the 77491). implementation of proposed models
development process would be Comment: Many commenters recommended by the PTAC. Section
shortened or estimate by how much it requested a deadline for the Secretarys 1868(c)(2)(D) of the Act requires the
would be shortened. In the CY 2018 response to comments and Secretary to review the PTACs
Quality Payment Program proposed recommendations from the PTAC, such comments and recommendations on
rule, we reiterated these points and also as 60 or 90 days. Some commenters proposed PFPMs and to post a detailed
included a discussion of how these requested more information about the response to those comments and
principles might be applied were we to process for testing proposed PFPMs recommendations on the CMS Web site.
expand the definition of PFPM to recommended by the PTAC, including Therefore, the Secretary has a
include payment arrangements with requests that we make public a specific responsibility to review comments and
Medicaid or CHIP, but not Medicare, as process. A few commenters requested recommendations from the PTAC on
a payer (82 FR 30209). that we expedite approval of and begin PFPM proposals and a responsibility to
The following is a summary of the testing PFPM proposals recommended respond. However, we appreciate that
public comments received on the areas by the PTAC within an established commenters seek additional information
where we sought comment related to the timeframe. One commenter requested from us on our process. We are mindful
PTAC review process of PFPM the public comment timeframe for of stakeholders interest in a timely
proposals with Medicaid or CHIP as a PFPM proposals be extended. process and are committed to reviewing
payer and our responses: Response: As discussed in the CY (and where appropriate, implementing)
Comment: One commenter was in 2017 Quality Payment Program final PFPM proposals as quickly as possible.
favor of us retaining the authority to rule, setting a deadline for the
determine whether to test proposed Secretarys response would be difficult d. PFPM Criteria
models recommended by the PTAC but given that there may be variation in the In the CY 2017 Quality Payment
suggested that we should be transparent number and frequency of proposals (81 Program final rule (81 FR 77555), we
in why CMS will or will not test a PFPM FR 77492). The Secretary would need finalized the Secretarys criteria for
proposal and allow interested parties to varying lengths of time to review, PFPMs as required by section
seek more information about the comment on, and respond to PFPM 1868(c)(2)(A)(i) of the Act (PFPM
decision-making process. proposals depending on the volume and criteria). The PFPM criteria are for the
Response: We agree with the nature of each proposal. With respect to PTACs use in discharging its duties
commenter. The Secretarys response to processes for testing proposed PFPMs, under section 1868(c)(2)(C) of the Act to
make comments and recommendations which models to test, as described in other payment models within the CMS
to the Secretary on proposed PFPMs. the document available at https:// portfolio.
In the CY 2018 Quality Payment innovation.cms.gov/files/x/rfi- Response: We appreciate the
Program proposed rule, we sought websitepreamble.pdf. comment. The PTAC reviews all PFPM
comment on the PFPM criteria, Comment: A few commenters proposals that are complete based on
including, but not limited to, whether recommended additional criteria for the requirements outlined in PTACs
the criteria are appropriate for PFPMs, including a patient-centered Physician-Focused Payment Models:
evaluating PFPM proposals and are approach and having the model place PTAC Proposal Submission
clearly articulated. In addition, we the physician as the hub of care delivery Instructions, available at https://
sought comment on stakeholders needs and coordination. aspe.hhs.gov/system/files/pdf/255906/
in developing PFPM proposals that meet Response: While we are not proposing ProposalSubmissionInstructions.pdf.
the Secretarys criteria. In particular, we changes to the criteria, we believe these However, all complete proposals will be
want to know whether stakeholders considerations fall within the existing subject to the PTACs analysis of the
believe there is sufficient guidance criteria for PFPM proposals, specifically Scope criterion which reflects a desire
available on what constitutes a PFPM, the Integration and Care Coordination to maximize the diversity of CMS APM
the relationship between PFPMs, APMs, and Patient Choice criteria. portfolio by offering opportunities to
and Advanced APMs; and on how to Comment: One commenter requested propose PFPMs in areas not addressed
access data, or how to gather supporting that the criteria be revised to elevate the under existing APMs, including
evidence for a PFPM proposal (82 FR value and importance of specialists in Advanced APMs.
30209). PFPMs. Another commenter suggested Comment: One commenter
The following is a summary of the proposal submitters be required to recommended that the Secretarys
public comments received on the areas consult participating and affected Payment Methodology criterion require
where we sought comment related to the specialties prior to submission to the a neutral party determine and
PFPM criteria and our responses: PTAC. One commenter suggested that disseminate payments to participants to
Comment: One commenter requested we consider expanding the PFPM avoid financial conflict of interest,
that we provide actionable information Payment Methodology criterion to particularly in proposals involving
for clinicians to develop and propose include consideration of whether multiple specialties.
meaningful PFPMs, including episodes of care defined in the proposed Response: The PTAC assesses each
publication of relevant, objective PFPM have undergone stakeholder PFPM proposal against the PFPM
benchmarks that the PTAC will use to vetting. One commenter recommended criteria. If a PFPM proposal is
recommend proposed models and for us that the PTAC request submission of a recommended for implementation, and
to test proposed PFPMs. list of clinical experts either with the CMS decides to test the proposed PFPM,
Response: To help inform the PFPM letter of intent or with the PFPM then CMS would work to address any
development of APMs, PFPMs, and completed application. concerns related to the payment
Advanced APMs, including design, Response: While we appreciate the methodology, including conflicts of
evaluation, and APM elements, CMS comments, they are outside of the scope interest, and if necessary make changes
developed an APM Design Toolkit, of CMS rulemaking in that the PTAC to the PFPM design prior to
available at https://qpp.cms.gov/docs/ establishes guidance for PFPM proposal implementation.
QPP_APM_Design_Toolkit.pdf. submissions, not CMS. It is the PTACs Comment: One commenter
Additionally, the PTAC provides responsibility to assess if and how the recommended that we assign high
resources to guide proposal design of a proposed PFPM meets the priority to the Patient Safety criterion to
development and submission, and they PFPM criteria. We believe ensure access to necessary services is
are available at https://aspe.hhs.gov/ considerations related to an not compromised for the sake of
resources-public-comment-physician- interventions relationship to specialty establishing new models.
focused-payment-model-technical- care fall within the existing Scope, Response: The PTAC reviews each
advisory-committee. The PFPM criteria Flexibility, and Integration and Care PFPM proposal against the PFPM
were designed to promote payment Coordination PFPM criteria. We note criteria, and has designated three of
incentives for higher-value care, that section 1868(c) of the Act does not those criteria as High Priority: Scope;
including paying for value over volume require as part of the definition of a Quality and Cost; and Payment
and providing resources and flexibility PFPM or within the PFPM criteria that Methodology. The Secretary reviews the
necessary for practitioners to deliver a particular specialty or category of PTACs comments related to all PFPM
high-quality health care. The PTAC uses clinician be addressed. criteria, including Patient Safety. If
the PFPM criteria established by the Comment: One commenter suggested patient access is a concern within a
Secretary to frame its comments and that we amend the existing Flexibility proposed PFPM, then we would expect
recommendations. It is the PTACs criterion from provide the flexibility the PTACs comments on the Patient
responsibility to assess if and how each needed for practitioners to deliver high- Safety and Patient Choice criteria to
proposal meets every criterion. quality health care to provide the address access issues. The PTACs
Comment: One commenter requested flexibility needed for practitioners to Physician-Focused Payment Models:
that in evaluating PFPM proposals, the deliver high-quality health care, PTAC Proposal Submission Instructions
PTAC focus on and prioritize results including adapting to account for new direct individuals and organizations
and outcomes, as opposed to the technologies. submitting PFPM proposals to include
methods and means. Response: While we are not proposing certain supporting information specific
Response: When considering whether changes to the Flexibility criterion, we to each of the PFPM criteria, which the
and how to test PFPMs, along with the do recognize practitioners have varying PTAC will use to evaluate the extent to
implications of distinct model designs, capacities to adapt to and adopt new which submitted PFPM proposals meet
there are a number of operational and technologies. the PFPM criteria. For the Patient Safety
administrative factors we must consider, Comment: One commenter requested criterion, the PTAC recommends that
including those that the Innovation that the PTAC welcome all ideas and proposals explain how patients would
Center currently uses to determine proposals regardless of the existence of be protected from potential disruption
in health care delivery brought about by Comment: Some commenters III. Quality Payment Program: Extreme
the changes in payment methodology specifically requested that CMS also and Uncontrollable Circumstance
and provider incentives. The Patient interpret or assist stakeholders in Policy for the Transition Year Interim
Choice criterion encourages greater analyzing and interpreting data. Final Rule With Comment Period
attention to the health of the population
Response: We recognize the value of A. Background
served while also supporting the unique
data analysis in developing PFPM
needs and preferences of individual 1. Significant Hardship and Extreme
patients. We believe these criteria and proposals. We will continue to consider
and Uncontrollable Circumstances in
supplemental information allow the ways we may be able to support data the MIPS Program
PTAC to analyze potential adverse needs related to PFPM proposal
development. This interim final rule with comment
impact to access to necessary services. period is being issued in conjunction
Comment: One commenter urged Comment: One commenter suggested with the final rule with comment period
PTAC to guard against proposals that that for proposals the PTAC and its provisions discussed in sections
could create a chilling effect against recommends for testing, CMS should II.C.6.f.(7) and II.C.7.b.(3)(c) pertaining
innovation in techniques and treatment accept a qualitative description of the to the policies that apply to MIPS
modalities. payment with quantitative data in lieu
Response: We believe the PFPM eligible clinicians who are subject to
of a payment methodology with extreme and uncontrollable
criteria, the PTACs analysis of PFPM
payment amount(s). circumstances. As we discussed in
proposals using PFPM criteria, and the
Secretarys response to the PTACs Response: We recognize that proposal section II.C.6.f.(7) of the final rule with
recommendations are all intended to submitters may not have the resources comment period, we established a
safeguard against any chilling effects required to fully design a payment policy to assign a weight of zero percent
against innovation in techniques and methodology similar to that of models to the advancing care information
treatment modalities. currently being tested. For proposed performance category in the final score
Comment: Many commenters PFPMs that the PTAC recommends and for MIPS eligible clinicians who
requested that the Department provide demonstrate a significant hardship
CMS selects for testing, CMS will
technical assistance to stakeholders through an application process, and we
undertake a robust analysis of the
developing and submitting PFPM are relying on section 1848(o)(2)(D) of
proposed payment methodology as
proposals. One commenter the Act as the authority for that policy.
appropriate prior to testing. We recognized that one type of
recommended that CMS develop clear
guidance documents, tools, and efforts Final Action: We did not propose and significant hardship a clinician might
separate from the release of rulemaking are not making changes to the definition experience would be extreme and
for the Quality Payment Program to of PFPM at this time. We similarly did uncontrollable circumstances, such as a
better stimulate development of robust not propose and are not making changes natural disaster in which an EHR or
proposals. Many commenters requested to the PFPM criteria at this time. We practice building are destroyed (81 FR
that CMS make as much data available will consider the feedback on the PFPM 77241). This policy for the advancing
as possible to assist stakeholders in definition and PFPM criteria received care information performance category
developing PFPMs. from commenters as we continue to applies beginning with the transition
Response: We are committed to assess including APMs with Medicaid year of MIPS (2017 performance period/
continuing to explore and consider and CHIP as payers in the PFPM 2019 MIPS payment year) (81 FR 77240
ways to be responsive to stakeholders in definition and explore ways to provide through 77243). As we discussed in
developing PFPM proposals. To that additional guidance and information section II.C.6.f.(7) of the final rule with
end, we have developed a resource to related to PFPMs. We will also consider comment period, to be considered for
help inform the development of APMs, comments on whether there is sufficient reweighting of the advancing care
PFPMs, and Advanced APMs. This information performance category in the
guidance on what constitutes a PFPM;
resource, the APM Design Toolkit, is final score for the transition year based
the relationship between PFPMs, APMs,
available at https://qpp.cms.gov/docs/ on extreme and uncontrollable
QPP_APM_Design_Toolkit.pdf. and Advanced APMs; and on how to circumstances, a MIPS eligible clinician
Additionally, the PTAC provides access data, or how to gather supporting must submit an application by
resources to guide proposal evidence for a PFPM proposal. We will December 31, 2017. A MIPS eligible
development and submission, and they continue to consider how to provide clinician who is eligible for reweighting
are available at https://aspe.hhs.gov/ additional types of guidance in addition but chooses to report (as an individual,
resources-public-comment-physician- to the resources already available to group, or virtual group) for the
focused-payment-model-technical- those developing PFPM proposals. advancing care information performance
advisory-committee. We have made category will be scored on the
e. Summary
available a Model Design Factors performance category like all other
document, available at https:// In this final rule with comment MIPS eligible clinicians, and the
innovation.cms.gov/files/x/rfi- period, we are not proposing or making performance category will be given the
Websitepreamble.pdf, describing the changes to the existing definition of weighting prescribed by section
operational and administrative factors PFPM or the PFPM criteria. We will 1848(q)(5)(E) of the Act regardless of
that the Innovation Center currently consider the comments received on the their advancing care information
uses to determine which models to test. adequacy of guidance available on performance category score.
These factors are similarly important to PFPM criteria and, within the scope of In addition, as we discussed in
consider for PFPMs. We hope these section II.C.7.b.(3)(c) of the final rule
CMS authority, follow the guidance of
resources are helpful. CMS is currently with comment period, we are
the Secretary in the Secretarys
focused on developing additional establishing a similar policy for the
APMs, including PFPMs. We encourage responses to the PTAC comments and
quality, cost, and improvement
stakeholders to continue to submit recommendations. activities performance categories
proposals to the PTAC. beginning with the second year of MIPS
(2018 performance period/2020 MIPS submission of a request for an exception hurricane causing widespread power
payment year). For these performance are available on QualityNet.org. As part outages and damage to infrastructure
categories, we define extreme and of this ECE policy, CMS may grant an throughout the territory.24 25 We have
uncontrollable circumstances as rare exception to one or more hospitals that recently granted ECEs from reporting
(that is, highly unlikely to occur in a have not requested an exception if: CMS requirements for CMS programs
given year) events entirely outside the determines that a systemic problem (including value-based purchasing
control of the clinician and of the with CMS data collection systems programs for skilled nursing facilities,
facility in which the clinician practices directly affected the ability of the hospices, and inpatient rehabilitation
that cause the MIPS eligible clinician to hospital to submit data; or if CMS facilities) as a result of Hurricanes
be unable to collect information that the determines that an extraordinary Harvey, Irma, and Maria.26 Following
clinician would submit for a circumstance, such as an act of nature these events, we released
performance category or to submit (for example, hurricane), has affected an communication indicating the areas
information that would be used to score entire region or locale ( 412.140(c)(2) impacted, as well as the scope and
a performance category for an extended and 76 FR 51651). We stated that if we duration of the exceptions provided. For
period of time (for example, 3 months make the determination to grant an ECE example, CMS granted an ECE for
with respect to data collection for the to hospitals in a region or locale, we certain requirements under the Hospital
quality performance category). We would communicate this decision IQR Program for subsection (d) hospitals
provided the example of a tornado or through routine communication impacted by Hurricane Irma, including
fire destroying the only facility where a channels (76 FR 51652 and 82 FR the HCAHPS Survey and chart-
clinician practices as a likely extreme 38410). abstracted measures for discharges
and uncontrollable circumstance. We occurring in the 2nd and 3rd quarters of
3. Hurricanes Occurring in 2017
are establishing this policy under the 2017. However, for the Hospital Value-
authority of section 1848(q)(5)(F) of the The events of Hurricanes Harvey, Based Purchasing (VBP) Program,
Act and refer readers to section Irma, and Maria impacted large regions Hospital-Acquired Condition (HAC)
II.C.7.b.(3)(c) of the final rule with of the United States in August and Reduction Program, and Hospital
comment period for a discussion of how September of 2017. These events Readmissions Reduction Program, we
extreme and uncontrollable occurred over a period of several days requested that providers or facilities
circumstances, such as natural disasters, and led to widespread destruction of directly impacted by hurricane or
could affect whether there are sufficient infrastructure within impacted regions resulting flood damage submit
measures and activities applicable and which impacted residents ability to individual ECE Requests. 27 We refer
available to MIPS eligible clinicians. carry on normal functions in the months readers to the posting at https://
Under the policy, MIPS eligible following the events. Hurricane Harvey www.cms.gov/About-CMS/Agency-
clinicians who are affected by extreme made landfall in Texas as a category 4 Information/Emergency/Downloads/
and uncontrollable circumstances may hurricane on August 25, 2017, and Memo-Requirements-Facilities-Irma.pdf
submit a request for reweighting of the produced rainfall totals of 45 to 50 for more information on the ECE for
quality, cost, and/or improvement inches (depending on county) over a Hurricane Irma.
activities performance categories for the 5-day period. The rainfall caused
second year of MIPS by the deadline of catastrophic drainage issues and made B. Changes to the Extreme and
December 31, 2018. The policy does not rivers rise greatly. After moving Uncontrollable Circumstances Policies
apply to APM Entities under the APM offshore, Harvey made a third landfall for the MIPS Transition Year
scoring standard. just west of Cameron, Louisiana on the 1. Automatic Extreme and
2. Extraordinary Circumstances morning of August 30th and brought Uncontrollable Circumstance Policy for
Exceptions in Other CMS Quality more heavy rainfall to the Northern Gulf the 2017 MIPS Performance Period
Programs States.21 Hurricane Irma was a Category Due to Hurricanes Harvey, Irma, and
5 hurricane with peak sustained winds Maria, which occurred during the 2017
For many of our quality reporting and of 185 miles per hour and gusts in the
value-based purchasing programs for MIPS performance period, we believe
200s. Hurricane Irma inflicted that changes to our policies for extreme
hospitals and other types of facilities, devastating damage on the northernmost
we have adopted extraordinary and uncontrollable circumstances are
Leeward Islands, and U.S./British Virgin
circumstances exceptions (ECE) Islands. The storm made landfall in 24 More information can be found at https://
policies. In the FY 2018 IPPS/LTCH PPS Florida as a category 4 hurricane on www.cms.gov/About-CMS/Agency-Information/
final rule (82 FR 38410) and CY 2018 September 10th producing wind gusts of Emergency/Downloads/Memo-Requirements-
OPPS/ASC proposed rule (82 FR 33683), 120 to 142 miles per hour. Tropical Facilities-Maria.pdf.
we worked to align common processes rains and gusty winds then arrived to a
25 National Hurricane Center. Hurricane Maria
for our ECE policies across many of our Discussion Number 18. Available at http://
larger portion of the Southeastern www.nhc.noaa.gov/archive/2017/al15/
quality programs including the Hospital United States.22 Hurricane Maria al152017.discus.018.shtml.
IQR Program, Hospital OQR Program, brought maximum sustained winds of 26 CMS communication regarding these ECEs can
IPFQR Program, ASCQR Program, and 145 miles per hour to 230 miles per be found at the following links:
PCHQR Program, as well as the Hospital hour.23 Hurricane Maria hit Puerto Rico Irma: https://www.cms.gov/About-CMS/Agency-
VBP Program, HAC Reduction Program, on September 20th as a category 4
Information/Emergency/Downloads/Memo-
and the Hospital Readmissions Requirements-Facilities-Irma.pdf.
Harvey: https://www.cms.gov/About-CMS/
Reduction Program. Using the Hospital 21 National Weather Service. Hurricane Harvey Agency-Information/Emergency/Downloads/2017-
IQR Program as an example, generally, Info. Available at http://www.weather.gov/hgx/ 121-IP-Quality-Program-Exemptions-for-FEMA-
CMS may grant an exception with hurricaneharvey. Texas-Louisiana-Providerpdf.pdf.
respect to quality data reporting 22 National Weather Service. Impacts from Irma- Maria: https://www.cms.gov/About-CMS/Agency-
requirements in the event of September 2017. Available at http:// Information/Emergency/Downloads/Memo-
www.weather.gov/bmx/event_irma2017. Requirements-Facilities-Maria.pdf.
extraordinary circumstances beyond the 23 National Hurricane Center. Hurricane Maria 27 See https://www.cms.gov/About-CMS/Agency-
control of the hospital (42 CFR Update Statement. http://www.nhc.noaa.gov/text/ Information/Emergency/Downloads/Memo-
412.140(c)(2)). Specific requirements for MIATCUAT5.shtml. Requirements-Facilities-Irma.pdf.
warranted for the transition year for of a group practice, the policy does not circumstance policy based on triggering
individual MIPS eligible clinicians. We apply to groups for the transition year, events that affect an entire region or
do not currently have an extreme and although we may address its application locale, on a case-by-case basis.
uncontrollable circumstance policy for to groups in future rulemaking. We
b. Scoring Considerations for
the transition year for the quality, cost, believe there is less urgency to establish
Performance Categories Under the
and improvement activities performance a policy for groups given the low
Automatic Extreme and Uncontrollable
categories. As discussed above, the final performance threshold (three points) for
Circumstance Policy
policy we adopted in section the transition year, and the fact that
II.C.7.b.(3)(c) of the final rule with groups are only scored as groups if they If we determine that an event should
comment period applies beginning with submit information to MIPS as a group. trigger the automatic extreme and
the 2018 performance period/2020 MIPS For these reasons, we believe virtually uncontrollable circumstance policy,
payment year. In addition, our existing all groups (including those in the then we will assume that MIPS eligible
extreme and uncontrollable impacted areas) would not receive final clinicians in the affected areas do not
circumstance policy for the advancing scores below the performance threshold, have sufficient measures and activities
care information performance category and thus the MIPS eligible clinicians in available and applicable to them for the
requires MIPS eligible clinicians to those groups would not be subject to a quality and improvement activities
submit a request for reweighting to us negative payment adjustment. performance categories. Similarly, we
by December 31, 2017. We invite public comment on our will assume that MIPS eligible
automatic extreme and uncontrollable clinicians in the affected areas are
Given the broad impact of these three experiencing a significant hardship as a
circumstance policy for individual
hurricanes, in this interim final rule result of the triggering event and would
MIPS eligible clinicians for the 2017
with comment period, we are qualify for a significant hardship
MIPS performance period.
establishing a policy for the 2017 MIPS exception for the advancing care
performance period under which we a. Triggering Events for the Automatic information performance category. We
would apply the extreme and Extreme and Uncontrollable will not require MIPS eligible clinicians
uncontrollable circumstance policies for Circumstance Policy in the affected areas to submit an
the MIPS performance categories as Under the automatic extreme and application to CMS (as described in
described in sections II.C.6.f.(7) and uncontrollable circumstance policy, we sections II.C.6.f.(7) and II.C.7.b.(3)(c) of
II.C.7.b.(3)(c) of the final rule with will have discretion not to require MIPS the final rule with comment period)
comment period without requiring a eligible clinicians to submit an requesting that the performance
MIPS eligible clinician to submit an application for reweighting the categories be reweighted. We believe
application when we determine a performance categories in cases where requiring an application could be overly
triggering event, as described in section an extreme and uncontrollable burdensome to these MIPS eligible
III.B.1.a. of this interim final rule with circumstance, such as an act of nature clinicians who have been affected by
comment period, has occurred and the (for example, hurricane), affects an extreme events, such as hurricanes and
clinician is in an affected area. We refer entire region or locale. Generally, we other natural disasters, and who may
to this policy as the automatic extreme anticipate the types of events that could have been displaced from their homes
and uncontrollable circumstance trigger this policy would be events or practice locations as a result of such
policy. We believe the automatic designated a Federal Emergency events. Because the cost performance
extreme and uncontrollable Management Agency (FEMA) major category has a zero percent weight for
circumstance policy will reduce burden disasters or a public health emergency the 2017 MIPS performance period, we
for clinicians who have been affected by declared by the Secretary, although we are not including the cost performance
these catastrophes and will also align will review each situation on a case-by- category in the automatic extreme and
with existing Medicare policies in other case basis. We also generally intend to uncontrollable circumstances policy for
programs such as the Hospital IQR align the automatic extreme and the transition year.
Program. Further, we believe it is uncontrollable circumstance policy with For MIPS eligible clinicians who
necessary to adopt the automatic the ECE policies for other Medicare practice in the affected areas, if they do
extreme and uncontrollable programs such that events that trigger not submit data for the quality,
circumstance policy in an interim final ECE policies would also trigger the advancing care information, and/or
rule with comment period due to the automatic extreme and uncontrollable improvement activities performance
urgency of providing relief for MIPS circumstance policy. categories, then each category for which
eligible clinicians impacted by the We believe that Hurricanes Harvey, they do not submit data will not be
recent hurricane events during the 2017 Irma, and Maria are such triggering scored and will be assigned a weight of
MIPS performance period. In particular, events and have provided details about zero percent in the final score. Because
we are concerned about individual the affected regions in section III.B.1.d. we believe the final score should be a
MIPS eligible clinicians receiving a of this interim final rule with comment composite score, we adopted a policy in
negative MIPS payment adjustment for period. Should additional extreme and section II.C.7.b.(2) of the final rule with
failure to submit information on the uncontrollable circumstances arise for comment period that a MIPS eligible
MIPS measures and activities when the 2017 MIPS performance period that clinician with fewer than two
events outside of their control, such as trigger the automatic extreme and performance category scores will receive
the hurricanes, would likely constitute uncontrollable circumstance policy, a final score equal to the performance
a significant hardship for clinicians and then we would communicate that threshold, and we would apply this
affect whether sufficient measures and information through routine policy for the transition year as well as
activities are applicable and available to communication channels, including but 2018 and subsequent years.
them. As discussed in section III.B.1. of not limited to issuing memos, emails, It is possible that some MIPS eligible
this interim final rule with comment and notices on the QPP Web site, clinicians in the affected areas may not
period, although this policy includes qpp.cms.gov. be significantly impacted by the extreme
individual MIPS eligible clinicians who We invite comments on applying the and uncontrollable circumstance. These
practice in impacted areas and are part automatic extreme and uncontrollable clinicians might not experience a
significant hardship as a result of the and uncontrollable circumstance clinicians are in affected areas based on
extreme and uncontrollable policy); therefore, administrative claims practice location addresses listed in
circumstance, and thus, would not need measures are not included in our PECOS, and how we should apply the
an exception for the advancing care automatic extreme and uncontrollable automatic extreme and uncontrollable
information performance category, and circumstance policy for this interim circumstance policies for groups and
they might have sufficient MIPS final rule with comment period. virtual groups in future years.
measures and activities available and We invite public comments on these
applicable to them for the quality or policies related to scoring the e. Regions Impacted by Harvey, Irma,
improvement activities performance performance categories. and Maria
categories such that they would be able We believe the recent Hurricanes
d. Identifying MIPS Eligible Clinicians
to report on those categories. We believe Harvey, Irma, and Maria are triggering
in Affected Areas
it is important to ensure these clinicians events for the automatic extreme and
who are not significantly affected by the We will determine if an individual uncontrollable circumstance policy we
extreme and uncontrollable MIPS eligible clinician is in an are adopting in this interim final rule
circumstance can participate in MIPS. impacted area based on the practice with comment period. The regions
Therefore, under the policy we are location address listed in the Provider impacted by these events are defined as
adopting, if a MIPS eligible clinician in Enrollment, Chain and Ownership a major disaster county, municipal
an affected area submits data for any of System (PECOS). As discussed above, (municipio in Spanish), or county-
the MIPS performance categories by the the individual MIPS eligible clinician equivalent by the Federal Emergency
applicable submission deadline for the will receive a final score equal to the Management Agency (FEMA) and are:
2017 performance period, they will be performance threshold for the 2017 All 67 counties in Florida.
scored on each performance category for MIPS performance period if they do not All 159 counties in Georgia.
which they submit data, and the submit any data or submit data on only The following parishes of
performance category will not be one performance category by the Louisiana: Acadia; Allen; Assumption;
reweighted to zero percent in the final applicable submission deadline for the Beauregard; Calcasieu; Cameron; De
score. 2017 performance period. If the Soto; Iberia; Jefferson Davis; Lafayette;
For the 2017 MIPS performance individual MIPS eligible clinician Lafourche; Natchitoches; Plaquemines;
period, it is possible we may receive submits data on 2 or more performance Rapides; Red River; Sabine; St. Charles;
data from MIPS eligible clinicians in categories, then the clinician will be St. Mary; Vermilion; and Vernon.
affected areas that does not represent scored on their data submissions under All 78 municipios in Puerto Rico.
the entire performance period. In those the policies that apply to all other MIPS The following counties of South
cases, we will score the submitted data, eligible clinicians who are not in Carolina: Allendale; Anderson;
even if does not represent the entire affected areas. Bamberg; Barnwell; Beaufort; Berkeley;
performance period. For example, for As discussed above, groups are not Charleston; Colleton; Dorchester;
the claims submission mechanism for included in the automatic extreme and Edgefield; Georgetown; Hampton;
the quality performance category, uncontrollable circumstance policy in Jasper; McCormick; Oconee; and
measures are submitted by adding this interim final rule with comment Pickens.
quality data codes to a claim. It is period. We would consider expanding The following counties in Texas:
possible that a MIPS eligible clinician in this policy to include groups in future Aransas; Austin; Bastrop; Bee; Bexar;
an affected area could have submitted years, but we believe there are some Brazoria; Burleson; Caldwell; Calhoun;
some data prior to the triggering event policy questions that need to be Chambers; Colorado; Comal; Dallas;
for the automatic extreme and addressed through rulemaking first. For Dewitt; Fayette; Fort Bend; Galveston;
uncontrollable circumstance policy. example: Goliad; Gonzales; Grimes; Guadalupe;
However, due to the policy we adopted How should we determine whether Hardin; Harris; Jackson; Jasper;
in section II.C.7.b.(2) of the final rule a group, which may have multiple Jefferson; Jim Wells; Karnes; Kleberg;
with comment period that a MIPS practice sites, should qualify for the Lavaca; Lee; Liberty; Madison;
eligible clinician with fewer than two automatic extreme and uncontrollable Matagorda; Milam; Montgomery;
performance category scores will receive circumstance policy? Newton; Nueces; Orange; Polk; Refugio;
a final score equal to the performance Should it be based on whether a Sabine; San Augustine; San Jacinto; San
threshold, the clinician would also have certain percentage of the clinicians in Patricio; Tarrant; Travis; Tyler; Victoria;
to submit data for the improvement the group are located in an affected Walker; Waller; Washington; and
activities or the advancing care area? Wharton.
information performance categories in As we explained above, we believe it All of the U.S. Virgin Islands.
order to receive a final score higher than is less urgent to establish a policy for These lists may continue to be
the performance threshold. groups for the transition year. If an updated. The most current list of
For measures which we derive from individual MIPS eligible clinicians impacted areas can be found at https://
administrative claims data, such as the practice location address as listed in www.cms.gov/About-CMS/Agency-
all-cause hospital readmission measure PECOS is in an affected area, and the Information/Emergency/
and the cost measures, clinicians do not clinician is part of a group practice that index.html?redirect=/emergency.
submit data other than claims. However, reports as a group for MIPS for the 2017
for the 2017 MIPS performance period/ performance period and receives a final C. Changes to the Final Score and
2019 MIPS payment period, cost score below the performance threshold Policies for Redistributing the
measures are not used to determine the (as explained above, we believe this will Performance Category Weights for the
MIPS final score and the only be unlikely given the low performance Transition Year
administrative claims quality measure threshold of 3 points), that clinician still As discussed above, we adopted a
used to determine the MIPS final score will receive a final score equal to the policy in section II.C.7.b.(2) of the final
is the readmission measure, which is performance threshold under our rule with comment period that a MIPS
only applied to groups (which are policy. We seek comment on our policy eligible clinician with fewer than two
excluded from our automatic extreme to determine which MIPS eligible performance category scores will receive
a final score equal to the performance With the addition of the automatic performance category at zero percent of
threshold, and this policy will apply in extreme and uncontrollable the final score. Although we are not
2017 for MIPS eligible clinicians under circumstance policy in this interim final finalizing these proposals, as explained
the automatic extreme and rule with comment period, it is possible in section II.C.7.b.(2) of the final rule
uncontrollable circumstance policy. for a MIPS eligible clinician not to with comment period, we will adopt
In the CY 2017 Quality Payment receive a score for the improvement this redistribution policy (reflected in
Program final rule (81 FR 77325 through activities performance category and for Table 48) for the 2017 performance
77329), we adopted a policy for the category to be reweighted to zero period/2019 MIPS payment year. This
redistributing the weights of the percent in the final score; therefore, we policy is the same as our existing policy
performance categories in the final score need to modify our existing policy for
for the transition year, but also accounts
for the 2017 performance period/2019 redistributing the performance category
MIPS payment year. We stated that we for the scenario where a MIPS eligible
weights for 2017 to account for this
envisioned that all MIPS eligible clinician has a score for the quality and
situation.
clinicians would have sufficient In the CY 2018 Quality Payment advancing care information performance
improvement activities applicable and Program proposed rule (82 FR 30144 categories, but not an improvement
available to them (81 FR 77323), and our 30146), we proposed a policy for activities performance category score; in
policy did not include a scenario where redistributing the performance category this case we would redistribute the
a MIPS eligible clinician would not weights for the 2018 performance weight of the improvement activities
receive an improvement activities period/2020 MIPS payment year based performance category to the quality
performance category score for 2017. on our proposal to weight the cost performance category.
TABLE 48PERFORMANCE CATEGORY REDISTRIBUTION POLICIES FOR CY 2017 MIPS PERFORMANCE PERIOD
Reweight Reweight Reweight
scenario if scenario scenario
Weighting no advancing if no if no
for the 2019 care quality improvement
Performance category MIPS payment information performance activities
year performance category performance
(%) category score percent score category score
(%) (%) (%)
Quality .............................................................................................................. 60 85 0 75
Cost .................................................................................................................. 0 0 0 0
Improvement Activities ..................................................................................... 15 15 50 0
Advancing Care Information ............................................................................ 25 0 50 25
D. APM Scoring Standard for MIPS Entities scored under the APM scoring and section 1871(b)(2)(C) of the Act
Eligible Clinicians in MIPS APMs for the standard, which would include MIPS authorize an agency to dispense with
Transition Year eligible clinicians in affected areas who normal rulemaking requirements for
In the CY 2017 Quality Payment qualify for a zero percent weighting of good cause if the agency makes a
Program final rule (81 FR 77246 through the advancing care information finding that the notice and comment
77269, 77543), we finalized the APM performance category under the process is impracticable, unnecessary,
scoring standard, which is designed to automatic extreme and uncontrollable or contrary to the public interest.
reduce reporting burden for participants circumstance policy adopted in this We find that there is good cause to
in certain APMs by minimizing the need interim final rule with comment period. waive the notice and comment
for them to make duplicative data E. Waiver of Proposed Rulemaking for requirements under sections 553(b)(B)
submissions for both MIPS and their Provisions Related to Extreme and of the APA and section 1871(b)(2)(C)
respective APMs. Uncontrollable Circumstances due to the impact of Hurricanes Harvey,
We are not modifying the APM Irma, and Maria as described in section
scoring standard policies that apply in Under 5 U.S.C. 553(b) of the III.A.3. of this interim final rule with
2017 for MIPS eligible clinicians who Administrative Procedure Act (APA), comment period. Based on the size and
have been affected by extreme and the agency is required to publish a scale of the destruction and
uncontrollable circumstances. The cost notice of the proposed rule in the displacement caused by these natural
performance category has been waived Federal Register before the provisions disasters in the regions identified in
under the APM scoring standard (81 FR of a rule take effect. Similarly, section section III.A.3. of this interim final rule
77258, 77262, and 77266). We will 1871(b)(1) of the Act requires the with comment period, we believe it is
continue to apply the quality Secretary to provide for notice of the likely that some MIPS eligible clinicians
performance category scoring proposed rule in the Federal Register have been significantly adversely
methodology described in section and provide a period of not less than 60 affected by these events. It is possible
II.C.7.a.(2) of the final rule with days for public comment. Section that some MIPS eligible clinicians may
comment period. The improvement 553(b)(B) of the APA provides for have had to temporarily close their
activities performance category will exceptions from the notice and practice locations, or may lack access to
continue to be automatically scored (81 comment requirements; in cases in their EHR technology or other data they
FR 77266). The advancing care which these exceptions apply, section would need to submit for MIPS for the
information performance category will 1871(b)(2)(C) of the Act provides for 2017 performance period. We believe it
be scored according to the policies exceptions from the notice and 60-day is in the public interest to adopt these
described in section II.C.6.g.(3)(d) of the comment period requirements of the Act interim final policies to provide relief to
final rule with comment period for APM as well. Section 553(b)(B) of the APA impacted individual MIPS eligible
clinicians to assist them while they approved information collections for the Payment Program final rule based on the
direct their resources toward caring for legacy programs. We estimate that the initial QP determination file, which we
their patients and repairing structural policies finalized in this final rule with used to identify 100,649 QPs that would
damages to facilities. comment period would result in further have otherwise reported as part of a
We find that it would be reduction of approximately 171,264 group or as an individual clinician that
impracticable and contrary to the public burden hours and a further reduction in will be excluded from MIPS in 2017
interest to undergo notice and comment burden cost of approximately $13.9 based on policies established in the CY
procedures before finalizing, on an million relative to a $708 million 2017 Quality Payment Program final
interim basis with an opportunity for baseline of continuing the policies in rule. Our estimates assume clinicians
public comment, the policies described the CY 2017 Quality Payment Program who participated in the 2016 PQRS and
herein for individual MIPS eligible final rule. who are not QPs in Advanced APMs in
clinicians who have been affected by For our CY 2018 Quality Payment
the 2017 Quality Payment Program
extreme and uncontrollable events that Program final rule with comment period
performance period will continue to
impact an entire region or locale. burden estimates, we used several data
sources. We used the 2017 MIPS submit quality data as either MIPS
Therefore, we find good cause to waive eligible clinicians or voluntary reporters
the notice of proposed rulemaking as eligibility file and the initial QP
determination file for the 2017 Quality in the 2018 Quality Payment Program
provided under section 1871(b)(2)(C) of
Payment Program performance year to performance period. Our participation
the Act and section 553(b)(B) of the
account for which clinicians or groups estimates are reflected in Table 54 for
APA and to issue this interim final rule
would be excluded from or ineligible for the quality performance category, Table
with an opportunity for public
MIPS, and which clinicians and groups 65 for the advancing information
comment. We are providing a 60-day
public comment period as specified in would be exempt from the advancing performance category, and Table 67 for
the DATES section of this document. care information performance category. the improvement activities performance
We also used 2016 PQRS data and 2015 category. We estimate that 35 percent of
IV. Collection of Information and 2016 Medicare and Medicaid EHR the estimated 825,673 clinicians
Requirements Incentive Program data to estimate the (288,986 clinicians) that are not subject
Under the Paperwork Reduction Act number of participants (or respondents) to a MIPS payment adjustment in CY
of 1995 (PRA), we are required to for the performance categories. 2018, will report voluntarily and are
publish a 60-day notice in the Federal The Quality Payment Program Year 2 included in our CY 2018 burden
Register and solicit public comment reduction in burden based on this final estimates because they reported
before a collection of information rule with comment period reflects our previously under PQRS. We expect
requirement is submitted to the Office of decision to finalize several proposed them to continue to submit because (a)
Management and Budget (OMB) for policies from the CY 2018 Quality the collection and submission of quality
review and approval. To fairly evaluate Payment Program proposed rule, data has been integrated into their
whether an information collection including our proposal for significant clinician practice; and (b) the clinician
should be approved by OMB, section hardship or other type of exception, types that were ineligible from MIPS in
3506(c)(2)(A) of the PRA requires that including a new significant hardship the Quality Payment Program Years 1
we solicit comment on the following exception for small practices for the and 2 may potentially become eligible
issues: advancing care information performance in the future.
The need for the information category; our proposal to use a shorter
version of the CAHPS for MIPS survey; We also assume that previous PQRS
collection and its usefulness in carrying
and our proposal to allow MIPS eligible participants who are not QPs will also
out the proper functions of our agency.
The accuracy of our burden clinicians to form virtual groups which submit under the improvement
estimates. would create efficiencies in data activities performance category, and
The quality, utility, and clarity of submission. We chose to finalize the will submit under the advancing care
the information to be collected. following proposals beginning with the information performance category
Our effort to minimize the CY 2019 performance period rather than unless they receive a significant
information collection burden on the the CY 2018 performance period as hardship or other type of exception,
affected public, including the use of proposed: Implementing facility based including a new significant hardship
automated collection techniques. measurement (82 FR 30125) and exception for small practices or are
We solicited public comment in the allowing MIPS eligible clinicians (82 FR automatically assigned a weighting of
CY 2018 Quality Payment Program 30035 through 30035) to submit data via zero percent for the advancing care
proposed rule on each of the required multiple submission mechanisms for a information performance category.
issues under section 3506(c)(2)(A) of the single performance category and these Due to data limitations, these burden
PRA for the following information changes are reflected in our burden estimates may overstate the total burden
collection requirements (ICRs) (82 FR estimates. for data submission under the quality,
30213 through 30230). In addition to the decline in burden
advancing care information, and
due to the policies proposed in this rule,
Summary and Overview improvement activities performance
we anticipate further reduction in
In the CY 2017 Quality Payment categories. Because of the total expected
burden because of policies set forth in
Program final rule, we estimated a growth in Advanced APM participation,
the CY 2017 Quality Payment Program
reduction of burden costs of $7.4 final rule, including greater clinician the estimated number of QPs excluded
million relative to the legacy programs familiarity with the measures and data from our burden estimates based on data
(PQRS and EHR Incentive Program for submission methods set in their second from the 2017 Quality Payment Program
Eligible Professionals) it replaced (81 FR year of participation, operational performance period (100,649) is lower
77513). The streamlining and improvements streamlining registration than the summary level projection for
simplification of data submission and data submission. the 2018 Quality Payment Program
structures in the transition year resulted We also see a decline in burden performance period based on the total
in a reduction in burden relative to the compared to the CY 2017 Quality expected growth in APM participation
(185,000 to 250,000).28 We use the QP number 09381314. The CAHPS for ability to practice medicine. One
determination file for the transition year MIPS ICR was submitted as a request for commenter stated that burden estimates
because the performance year 2018 revision of OMB control number 0938 remain low by a factor of at least 10, and
summary estimate was not available at 1222. Due to the statutory requirement that the CY 2018 Quality Payment
the TIN/NPI level. The 185,000 to for the virtual group election process to Program proposed rule added more
250,000 eligible clinicians represent the take place prior to the start of the 2018 nuances and complications for
projected range of QPs for the MIPS performance period, the clinicians and organizations. While this
performance year 2018. We made our information collection request for the commenter did not specifically explain
estimate of 100,649 using the TIN/NPIs virtual group election process was why they believe burden estimates are
of clinicians in the initial QP submitted for OMB review and approval low by a factor of at least 10, they did
determination file for the transition separately from this rulemaking process explain that there are nuances involved
year. Because we excluded QPs based and is assigned to OMB control number with tracking and reporting multiple
on 2017 data, our burden estimates may 09381343. Please note that the 60-day TINs and NPIs as groups or individuals
be overestimating the number of Federal Register notice was published which are specific to larger
clinicians that will submit MIPS data. on June 14, 2017 (82 FR 27257) and the organizations and are not recognized as
This total expected growth in related comment period ended on burdensome. Similarly, one commenter
Advanced APM participation is due in August 14, 2017. The 30-day Federal stated that the proposed requirements
part to the addition of new participants Register notice (82 FR 39440) was for the 2018 MIPS performance period
in the CPC+ and Next Generation ACO published August 18, 2017 announcing are significantly more rigorous and
models for 2018, and the start of the that we were formally submitting the burdensome than those in place for the
Medicare ACO Track 1+ Model which is information collection request to OMB 2017 MIPS performance period. Several
projected to have a large number of and informing the public on its commenters cited the costly burden of
participants, with a large majority additional opportunity to review the documentation and paperwork to
reaching QP status. Hence, our model information collection request and comply with requirements. One
may overestimate the numbers of submit comments by September 18, commenter shared concerns that the
clinicians and groups that will report 2017. OMB approved the ICR on Quality Payment Program has evolved
data under the quality, advancing care September 27, 2017. into a program that includes even more
information, and improvement activities The following is a summary of general requirements, which continues to
performance categories. public comments received regarding our incentivize box-checking instead of
Our burden estimates assume that 35 request for information on our actions that improve patient care.
percent of the 825,673 clinicians who information collections and our Response: In general, we believe that
do not exceed the low-volume threshold responses. We received several general the changes in this final rule with
or are not eligible clinician types comments regarding the burden of data comment period will improve the
(288,986) will voluntarily submit collection. quality and value of care provided to
quality data under MIPS because they Comment: Several commenters Medicare beneficiaries. More broadly,
submitted quality data under the PQRS. supported CMSs efforts to reduce we expect that, over time, clinician
Hence, the finalized changes in low- burden, including CMSs efforts to engagement in the Quality Payment
volume threshold will increase our reduce burden for small practices or Program may result in improved quality
estimate of the proportion of clinicians practices in rural areas, as well as the of patient care, resulting in lower
who will submit data voluntarily, but ability to form virtual groups. One morbidity and mortality. We believe the
will not affect our overall burden commenter applauded CMSs efforts policies finalized in the CY 2017
thus far, and urged CMS to go further to Quality Payment Program final rule, as
estimate. As discussed in section
alleviate the burden placed on MIPS well as policies in this final rule with
II.C.2.c. of this final rule with comment
eligible clinicians participating in the comment period will lead to additional
period, we are finalizing at 414.1305
Quality Payment Program. growth in the participation of both MIPS
that clinicians or groups who have Response: We thank commenters for
Medicare Part B allowed charges less APMS and Advanced APMs. APMs
their support and will continue to work promote seamless integration by way of
than or equal to $90,000 or provide care to reduce burden for MIPS eligible
for 200 or fewer Part B-enrolled their payment methodology and design
clinicians. To reduce burden, we are that incentivize such care coordination.
Medicare beneficiaries are excluded raising the low-volume threshold so that We acknowledge clinician concerns
from MIPS. The CY 2017 Quality fewer clinicians in small practices are with reporting burden and have tried to
Payment Program final rule established required to participate in the MIPS reduce burden where possible, while
a low-volume threshold of less than or starting with the 2018 MIPS meeting the intent of the Act, including
equal to $30,000 in allowed Medicare performance period; including bonus our obligations to improve patient
Part B charges or less than or equal to points for clinicians in small practices; outcomes.
100 Medicare patients (81 FR 77069). adding a new significant hardship Further, absent specific information
The revised MIPS requirements and exception for the advancing care from the commenter as to why the
burden estimates for all ICRs listed information performance category for commenter believes our burden
below (except for CAHPS for MIPS and MIPS eligible clinicians in small estimates are low, we cannot
virtual groups election) were submitted practices; implementing virtual groups, specifically address commenters
as a request for revision of OMB control and extending the ability of MIPS burden concerns because no particular
28 70,732 QPs were excluded from our analysis

eligible clinicians and groups to use reference was made to any of the burden
who did not meet any of the other MIPS exclusion 2014 Edition CEHRT while providing hours or costs provided across our
or ineligibility criteria; in other words, they were bonus points for the use of the 2015 burden estimate tables. Generally, we
eligible clinician types and exceeded the low- Edition of CEHRT. believe that our burden estimates
volume threshold. An additional 29,917 QPs were Comment: Many commenters provide a reasonable and appropriate
excluded from our burden estimates who also met
other MIPS exclusion or ineligibility criteriathat
expressed concern that the Quality assessment of burden on clinicians in
is they were not eligible clinician types or did not Payment Program is too burdensome the Quality Payment Program. Our
exceed the low-volume threshold. and complex, and interferes with their estimates are grounded in reliable data
sources, our assumptions are based in activities) to avoid negative payment to provide guidance and assistance to
past program methodologies including adjustments. MIPS eligible clinicians in small
that of PQRS, and our analysis and Response: We have made an effort to practices through contracts with
justifications are detailed in this section focus on policies that remove as much regional health collaboratives, and
of the final rule with comment period. administrative burden as possible from others. Finally, the Regulatory Impact
In future program years, we anticipate MIPS eligible clinicians and their Analysis includes a general discussion
that the burden will be reduced as practices while still providing of the potential costs to clinicians of
eligible clinicians become more familiar meaningful incentives for high-quality, meeting MIPS requirements, including
with the requirements of the Quality efficient care. We established special implementation costs and the costs of
Payment Program. Consistent with the policies for the first year of the Quality reviewing this final rule with comment
requirements of the PRA, the burden Payment Program, which enabled a period. Consistent with the PRA, this
estimates in this section of the final rule ramp-up and gradual transition with section of the final rule with comment
with comment period only include the less financial risk for clinicians in the period only estimates the costs for
transition year. We called this approach submitting data (including reviewing
costs of data submission and related
pick your pace and allowed clinicians measure specifications) and associated
record keeping. The Regulatory Impact
and groups to participate in MIPS record keeping.
Analysis section of this rule also
through flexible means while avoiding a After consideration of the public
includes estimates of the costs of negative payment adjustment. In this comments, we are not making any
reviewing this final rule with comment final rule with comment period, we changes to our burden estimate
period. Therefore, we will not make any continue the slow ramp-up of the methodology, but we are making
changes to the burden estimates as a Quality Payment Program by changes to the burden to reflect the
result of these comments. establishing special policies for Quality decisions to finalize the following
Comment: A few commenters shared Payment Program Year 2 aimed at proposals beginning with the CY 2019
concerns regarding the complexity and encouraging successful participation in performance period rather than the CY
burden of the CY 2018 Quality Payment the program while reducing burden, and 2018 performance period as proposed:
Program proposed rule, citing preparing clinicians for compliance Implementing facility based
implementation costs and concerns with the 2019 performance period (2021 measurement (82 FR 30125) and
regarding the amount of effort needed to payment year) statutory requirements. allowing MIPS eligible clinicians (82 FR
avoid Quality Payment Program We are also finalizing that we will 30035 through 30035) to submit data via
negative payment adjustments. A few compare MIPS eligible clinicians final multiple submission mechanisms for a
commenters cited a Medical Group scores against a MIPS performance single performance category.
Management Association (MGMA) threshold of 15 points, which can be We note that we are also adopting
report that summarized data from 750 achieved via multiple pathways and policies in an interim final rule with
group practices that volunteered to continues the gradual transition into comment period that address extreme
respond to a survey about the costs of MIPS. While we acknowledge and uncontrollable circumstances MIPS
complying with federal regulations.29 commenters concerns that these more eligible clinicians may face as a result
Among the 750 group practices rigorous requirements for Quality of widespread catastrophic events
responding to the survey, 82 percent Payment Program Year 2 may lead to affecting a region or locale in CY 2017,
rated Quality Payment Program as increased data submission burden, we such as Hurricanes Irma, Harvey and
extremely or very burdensome. Further, clarify that our burden estimates in the Maria. We refer readers to section IV.P
study respondents were concerned with CY 2017 Quality Payment Program final of this document for the collection of
rule accounted for MIPS eligible information requirements related to the
overall implementation costs related to
clinicians choosing the full year interim final rule with comment period.
their participation in MIPS. One
participation option in MIPS with
commenter shared concerns that the A. Wage Estimates
complete data submission (as opposed
Quality Payment Program positive To derive wage estimates, we used
to reporting only the minimum 90 days
payment adjustments available for the data from the U.S. Bureau of Labor
of data required by the rule) for the 2017
commenters specialty do not cover the performance period and, therefore, we Statistics (BLS) May 2016 National
costs of compliance with MIPS quality did not adjust these estimates for this Occupational Employment and Wage
reporting requirements. Another final rule with comment period. Estimates for all salary estimates (http://
commenter noted that if the CY 2018 Further, we anticipate that the burden www.bls.gov/oes/current/oes_nat.htm).
Quality Payment Program proposed rule will be reduced as eligible clinicians Table 49 in this final rule with comment
is finalized as proposed, MIPS eligible become more familiar with the period presents the mean hourly wage
clinicians will face even more rigorous requirements of the Quality Payment (calculated at 100 percent of salary), the
and burdensome program requirements Program. cost of fringe benefits and overhead, and
since MIPS eligible clinicians will need Because eligible clinicians will need the adjusted hourly wage.
to report either complete data for at least to become familiar with the new As indicated, we are adjusting our
5 quality measures, fulfill all necessary requirements of this final rule with employee hourly wage estimates by a
improvement activities or report on all comment period, we will use our factor of 100 percent. This is necessarily
required advancing care information extensive outreach efforts to improve a rough adjustment, both because fringe
performance category measures, and clinician understanding to the greatest benefits and overhead costs vary
score an additional 10 performance extent possible. Additionally, in significantly from employer to

points (or a combination of these keeping with the objectives to provide employer, and because methods of
education about the Quality Payment estimating these costs vary widely from
29 Medical Group Management Association. Program and maximize participation, study to study. Nonetheless, there is no
MGMA Regulatory Burden Survey, August 2016. and as authorized by section 1848(q)(11) practical alternative, and we believe that
https://www.mgma.com/getattachment/
Government-Affairs/Advocacy/Advocacy-(1)/
of the Act, during a period of 5 years, doubling the hourly wage to estimate
MGMA-2017-Regulatory-Relief-Survey/MGMA- $100 million in funding was provided total cost is a reasonably accurate
Regulatory-Relief-Survey-Results.pdf. for technical assistance to be available estimation method. We have selected
the occupations in Table 49 based on a CAHPS for MIPS survey, we have used opportunity cost to beneficiaries
study (Casalino et al., 2016) that wage estimates for Civilian, All themselves for time spent completing
collected data on the staff in physicians Occupations, using the same BLS data the survey. To calculate time costs for
practices involved in the quality data discussed in the proposed rule (82 FR virtual groups to prepare their written
submission process.30 30010). We have not adjusted these formal agreements, we have used wage
In addition, to calculate time costs for costs for fringe benefits and overhead estimates for Legal Support Workers, All
beneficiaries who elect to complete the because direct wage costs represent the Others.
TABLE 49ADJUSTED HOURLY WAGES USED IN BURDEN ESTIMATES

Fringe
Mean hourly Adjusted
Occupational benefits and
Occupation title wage hourly wage
code overhead
($/hr.) ($/hr.)
($/hr.)
Billing and Posting Clerks ................................................................................ 433021 $18.06 $18.06 $36.12

Computer Systems Analysts ............................................................................ 151121 44.05 44.05 88.10
Physicians ........................................................................................................ 291060 101.04 101.04 202.08
Practice Administrator (Medical and Health Services Managers) ................... 119111 52.58 52.58 105.16
Licensed Practical Nurse (LPN) ...................................................................... 292061 21.56 21.56 43.12
Legal Support Workers, All Other .................................................................... 232099 31.81 31.81 63.62
Civilian, All Occupations .................................................................................. Not applicable 23.86 N/A 23.86
Source: Occupational Employment and Wage Estimates May 2016, U.S. Department of Labor, Bureau of Labor Statistics. https://www.bls.gov/
oes/current/oes_nat.htm.
B. Framework for Understanding the information and therefore claims data is 77185). We compare the requirements of
Burden of MIPS Data Submission not represented in Table 50. the specific MIPS APM with the list of
For MIPS APMs, the organizations activities in the Improvement Activities
Because of the wide range of submitting data on behalf of Inventory and score those activities in
information collection requirements participating MIPS eligible clinicians the same manner that they are otherwise
under MIPS, Table 50 presents a will vary across categories of data, and scored for MIPS eligible clinicians. If, by
framework for understanding how the in some instances across APMs. For the our assessment, the MIPS APM does not
organizations permitted or required to 2018 MIPS performance period, the receive the maximum improvement
submit data on behalf of clinicians quality data submitted by Shared activities performance category score
varies across the types of data, and Savings Program ACOs, Next Generation
whether the clinician is a MIPS eligible then the APM Entity can submit
ACOs, and APM Entities in Other MIPS
clinician, MIPS APM participant, or an additional improvement activities. We
APMs on behalf of their participant
Advanced APM participant. As shown assume that MIPS APMs available for
MIPS eligible clinicians will fulfill any
in the first row of Table 50, MIPS MIPS submission requirements for the the CY 2018 MIPS performance period
eligible clinicians that are not in MIPS quality performance category. will receive the maximum improvement
APMs and other clinicians voluntarily For the advancing care information activities performance category score,
submitting data will submit data either performance category, billing TINs will and therefore, will not require the APM
as individuals, groups, or virtual groups, submit data on behalf of participants Entity to submit additional
as applicable, to the quality, advancing who are MIPS eligible clinicians. For improvement activities. Advanced APM
care information, and improvement the improvement activities performance participants who are determined to be
activities performance categories. category, we will assume no reporting Partial QPs may incur additional burden
Because the cost performance category burden for MIPS APM participants. In if they elect to participate in MIPS,
relies on administrative claims data, the CY 2017 Quality Payment Program which is discussed in more detail in
MIPS eligible clinicians are not final rule, we describe how we section II.D.5. of this final rule with
requested to provide any additional determine MIPS APM scores (81 FR comment period.
30 Lawrence P. Casalino et al., US Physician to Report Quality Measures, Health Affairs, 35, no.
Practices Spend More than $15.4 Billion Annually 3 (2016): 401406.
TABLE 50CLINICIANS OR ORGANIZATIONS SUBMITTING MIPS DATA ON BEHALF OF CLINICIANS, BY TYPE OF DATA AND
CATEGORY OF CLINICIAN *
Other data submitted on
Quality performance Advancing care informa- Improvement activities per-
Category of clinician behalf of MIPS eligible
category tion performance category formance category clinicians
Type of Data Submitted
MIPS Eligible Clinicians As group, virtual groups, As group, virtual groups, As group, virtual groups, Groups electing to use a
(not in MIPS APMs) and or individual clinicians. or individuals. Clinicians or individual clinicians. CMS-approved survey
Other Clinicians Volun- who practice primarily in vendor to administer
tarily Submitting Data 31. a hospital, ambulatory CAHPS must register.
surgical center based Groups electing to sub-
clinicians, non-patient mit via CMS Web Inter-
facing clinicians, PAs, face for the first time
NPs, CNSs and CRNAs must register. Virtual
are automatically eligible groups must register via
for a zero percent email.
weighting for the ad-
vancing care information
Clinicians approved for
significant hardship ex-
ceptions are also eligible
for a zero percent
weighting.
Eligible Clinicians partici- ACOs submit to the CMS Each group TIN in the CMS will assign the im- Advanced APM Entities
pating in the Shared Web Interface and APM Entity reports ad- provement activities per- will make election for
Savings Program or CAHPS for ACOs on be- vancing care information formance category score participating MIPS eligi-
Next Generation ACO half of their participating to MIPS.33. to each APM Entity ble clinicians.
Model (both MIPS MIPS eligible clinicians. group based on the ac-
APMs). [Not included in burden tivities involved in par-
estimate because quality ticipation in the Shared
data submission to fulfill Savings Program.34
requirements of the [The burden estimates
Shared Savings Pro- assume no improvement
gram and Next Genera- activity reporting burden
tion ACO models are not for APM participants be-
subject to the PRA].32. cause we assume the
MIPS APM model pro-
vides a maximum im-
provement activity per-
formance category
score.].
Eligible Clinicians partici- MIPS APM Entities submit Each MIPS eligible clini- CMS will assign the same Advanced APM Entities
pating in Other MIPS to MIPS on behalf of cian in the APM Entity improvement activities will make election for
APMs. their participating MIPS reports advancing care performance category participating eligible cli-
eligible clinicians [Not in- information to MIPS score to each APM Enti- nicians.
cluded in burden esti- through either group TIN ty based on the activities
mate because quality or individual reporting. involved in participation
data submission to fulfill [The burden estimates in the MIPS APM. [The
requirements of Innova- assume group TIN-level burden estimates as-
tion Center models are reporting]. sume no improvement
not subject to the PRA.]. activities performance
category reporting bur-
den for APM participants
because we assume the
MIPS APM model pro-
vides a maximum im-
provement activity
score.].
* Because the cost performance category relies on administrative claims data, MIPS eligible clinicians are not requested to provide any addi-
tional information and therefore claims data is not represented in this table.
The policies finalized in the CY 2017 this final rule with comment period
testing, evaluation, and expansion of Innovation
Quality Payment Program final rule and
Center models are not subject to the PRA (42 U.S.C.
1395jjj and 42 U.S.C. 315a(d)(3), respectively). TIN/NPI scores are then aggregated for the APM
31 Virtual group participation is limited to MIPS 33 For MIPS APMs other than the Shared Savings
Entity score.
eligible clinicians, specifically, solo practitioners 34 APM Entities participating in MIPS APMs do
Program, both group TIN and individual clinician
and groups consisting of 10 eligible clinicians or not need to submit improvement activities data
fewer. advancing care information data will be accepted. unless the CMS-assigned improvement activities
32 Sections and 3021 and 3022 of the Affordable If both group TIN and individual scores are scores are below the maximum improvement
Care Act state the Shared Savings Program and submitted for the same MIPS APM Entity, CMS activities score.
would take the higher score for each TIN/NPI. The
create some additional data collection establishing an optional 2-stage process same submission mechanisms as
requirements not listed in Table 50. for enrollment. In stage 1, MIPS eligible groups, we are estimating based on
These additional data collections, some clinicians have the option to request a stakeholder feedback that the 16 virtual
of which were previously approved by determination of their eligibility to form groups reflected in Table 51 will report
OMB under control numbers 09381314 a virtual group before they form a group by registry. Table 51 also shows that we
and 09381222 are as follows: and begin the stage 2 submission of an estimate that approximately 765 MIPS
Self-nomination of new and election to participate in a virtual group. eligible clinicians will decide to join 16
returning QCDRs and registries (0938 For clinicians or groups that do not virtual groups for the 2018 MIPS
1314). choose to participate in stage 1 of the performance period. We assumed each
CAHPS for MIPS survey completion election process, we will make an of the 16 virtual groups would consist
by beneficiaries (09381222). eligibility determination during stage 2 of approximately 5 TINs (765 MIPS
Approval process for new and of the election process. We refer readers eligible clinicians 48 eligible
returning CAHPS for MIPS survey to section II.C.4.e. of this final rule with clinicians per virtual group) or 80 TINs
vendors. comment period for a discussion of the total that will participate in virtual
Call for new improvement activities finalized virtual group election process. groups (16 virtual groups 5 MIPS
(see section II.C.6.e.(7) of this final rule As established in section II.C.4.e. of eligible clinicians per TIN).
with comment period). this final rule with comment period, the
Call for new advancing care submission of a virtual group election We assume that the virtual election
information measures. must include, at a minimum, detailed process will require 10 hours per virtual
Other Payer Advanced APM information pertaining to each TIN and group, similar to the burden of the
determinations: Payer Initiated Process. NPI associated with the virtual group QCDR or registry self-nomination
Opt out of performance data display and detailed information for the virtual process finalized in 414.1400. We
on Physician Compare for voluntary group representative, as well as assume that 8 hours of the 10 burden
reporters under MIPS. confirmation of a written formal hours per virtual group will be
We did not receive comments specific agreement between members of the computer systems analysts time or the
to our framework for understanding the virtual group at the TIN level. equivalent with an average labor cost of
burden of MIPS data submission. We assume that virtual group $88.10/hour, and an estimated cost of
participation will be relatively low in $704.80 per virtual group ($88.10/hour
C. ICR Regarding Burden for Virtual the first year because we have heard 8 hours). We also assume that 2 hours
Group Election ( 414.1315) from stakeholders that they need at least of the 10 burden hours per virtual group
As described in section II.C.4.b. of 3 to 6 months to form groups and will be legal support services
this final rule with comment period, establish agreements before signing up. professionals assisting in formulating
virtual groups are defined by a We are not able to give them that much the written virtual agreement with an
combination of 2 or more TINs and must time in the first year, rather closer to 60 average labor cost of $63.62/hour, with
report as a virtual group on measures in days. Because of this, we expect the a cost of $127.24 per virtual group
all quality, improvement activities, and number of virtual groups will be very ($63.62/hour 2 hours). Therefore, the
advancing care information performance small in the first year of virtual group total burden cost per virtual group
categories as virtual groups. Virtual implementation. Our assumptions for associated with the election process is
groups may submit data through any of participation in a virtual group are $832.04 ($704.80 + $127.24). We also
the mechanisms available to groups. We shown in Table 51. We assume that only assume that 16 new virtual groups will
refer to section II.C.4. of this final rule those eligible clinicians that reported go through the election process leading
with comment period on additional historically will participate in virtual to a total burden of $13,313 ($832.04
requirements for virtual groups. groups in the first year because of the 16 virtual groups). We estimate that the
In section II.C.4.e. of this final rule limited lead time to create processes. total annual burden hours will be 160
with comment period, we are Also, while virtual groups may use the (16 virtual groups 10 hours).
TABLE 51ESTIMATED BURDEN FOR VIRTUAL GROUP ELECTION PROCESS

Burden
estimate
Total Estimated Number of MIPS eligible clinicians in TINs of 10 eligible clinicians or fewer submitting data in MIPS (a) ............. 765
Total Estimated Number of eligible TINs (10 eligible clinicians or fewer) (b) ..................................................................................... 80
Estimated # of virtual groups (c) ......................................................................................................................................................... 16
Estimated Total Annual Burden Hours for virtual group to prepare written formal agreement (d) .................................................... 2
Estimated Total Annual Burden Hours for Virtual Group Representative to submit application to form a virtual group (e) ............. 8
Estimated Total Annual Burden Hours per virtual group (f) ................................................................................................................ 10
Estimated Total Annual Burden Hours for virtual groups (g) = (c) * (f) .............................................................................................. 160
Estimated Cost to prepare formal written agreement (@legal support services professionals labor rate of $63.62) (h) ................. $127.24
Estimated Cost to elect per virtual group (@computer systems analysts labor rate of $88.10/hr.) (i) ............................................. $704.80
Estimated Total Annual Burden Cost per virtual group (j) .................................................................................................................. $832.04
Estimated Total Annual Burden Cost (k) = (c) * (j) ............................................................................................................................. $13,313
While the formation of virtual groups burden is the same for each organization by reducing the time needed to prepare
will result in a burden for virtual group (group, virtual group, or eligible data for submission, review measure
registration, we also estimate that the clinician) submitting quality, specifications, register or elect to submit
formation of virtual groups will result in improvement activities or advancing data via a mechanism such as QCDR,
a decline in burden from other forms of care information performance category registry, CMS Web Interface, or EHR.
data submission. Because we assume data, virtual groups will reduce burden This reduction in burden is described in
each of the quality, improvement responsible for the activities that are registries, QCDRs and health IT vendors.
activities, and advancing care included in our burden estimate for The CAHPS for MIPS survey data,
information performance category virtual group electionthe drafting and which counts as one quality
sections below. There is no burden submission of the virtual group performance category measure, can be
represented for the cost performance application via email and any associated submitted via CMS-approved survey
category because administrative claims recordkeeping. We acknowledge that if vendors. The burdens associated with
data is used to collect information on practices of heterogeneous specialists qualified registry and QCDR self-
cost measures from MIPS eligible form a virtual group, it may result in nomination and the CAHPS for MIPS
clinicians. that virtual group reporting more than 6 survey vendor applications are
As stated earlier, the information measures. We anticipate that most discussed below.
collection request for the virtual group virtual groups will involve only 1
election process was reviewed and specialty. Consistent with the PRA, 1. Burden for Qualified Registry and
approved by OMB (09381343) costs associated with forming a virtual QCDR Self-Nomination 35
separately from this rulemaking process. group as well as the time spent on day- For the 2017 MIPS performance
We announced the opportunity for the to-day clinical practice activities and on period, 120 qualified registries and 113
public to comment on the virtual group coordination across virtual group QCDRs were qualified to report quality
election process via a 60-day Federal members are not included in our burden measures data for purposes of the PQRS,
Register notice published on June 14, estimates. an increase from 114 qualified registries
2017 (82 FR 27257) and a 30-day After considerations of public and 69 QCDRs in CY 2016.36 For
Federal Register notice published comments, we are making no changes to purposes of the 2018 MIPS performance
August 18, 2017 (82 FR 3944039442). our virtual group election process period, we estimate the same number of
The following is a summary of the burden estimates as a result of public qualified registries and QCDRs, for a
public comments received regarding our comments received. The burden total of 233, although we believe that
request for on the 2018 Quality Payment estimates have not been updated from the number of QCDRs and qualified
Program proposed rule regarding our the CY 2018 Quality Payment Program registries will continue to increase
estimated burden for the virtual group proposed rule (82 FR 2013). because: (1) Many MIPS eligible
election process. clinicians will be able to use the
Comment: One commenter believed D. ICR Regarding Burden for Election of
Facility-Based Measurement qualified registry and QCDR for all
that CMS underestimated the time and MIPS submissions (not just for quality
cost involved in making the decision to Because we are not finalizing the submission), and (2) QCDRs will be able
form and create a virtual group. The policy to allow facility-based to provide innovative measures that
commenter noted that the estimated 10 measurement until the 2019 MIPS address practice needs. Qualified
burden hours per virtual group election performance period, we have revised registries or QCDRs interested in
included 8 hours for computer systems our burden estimates to include back submitting quality measure results and
analysts and 2 hours for legal support into our quality performance category numerator and denominator data on
but no allocation of costs for clinician data submission burden estimates quality measures to us on their
time, which could be substantial since 17,943 eligible clinicians who practice participants behalf will need to
many clinicians own small practices primarily in the hospital that did not complete a self-nomination process to
and are closely involved with such submit under the 2017 MIPS be considered to be qualified to submit
business decisions. The commenter performance period that would have on behalf of MIPS eligible clinicians or
believed that the burden for a virtual elected facility-based measurement as groups.
group to comply with MIPS reporting individuals in the 2018 MIPS In sections II.C.10.b.(2)(b) and
requirements would be greater than the performance period. We also revised our II.C.10.d.(2)(b) of this final rule with
10 estimated hours required for virtual burden estimates to include back into comment period, we finalized our
group election and noted the potential our quality performance category data proposals with clarification that
added burden associated with a virtual submission burden estimates 264 groups previously approved QCDRs and
group reporting as a group due to the who practice primarily in the hospital qualified registries in good standing
potential heterogeneity within the that previously submitted as groups (that are not on probation or
groups involved. under the 2017 MIPS performance disqualified) that wish to self nominate
Response: To clarify, we are assuming period that we projected would have using the simplified process can attest,
that the time to submit data via a virtual elected facility-based measurement in in whole or in part, that their previously
group would include the 10 burden the 2018 MIPS performance period. We approved form is still accurate and
hours per group to elect to become a also removed the burden estimate of 1 applicable . We clarified our proposals
virtual group, and then the additional hour of a billing clerks time at $36.12/ by elaborating on what would be
time required to submit data for the hr. for each of these individuals or required for previously approved
quality, advancing care information, and groups that would have otherwise entities in good standing that wish to
improvement activities performance elected facility-based measurement or a self-nominate and have minimal or
categories. The reduction in burden is total annual burden cost of $657,637 substantive changes. As we discussed in
due to the MIPS eligible clinicians, who (18,207 $36.12) for the election II.C.10.d.(2)(b)(i) and (ii) of this final
are forming the virtual group, and then process to participate in facility-based rule with comment period, existing
reporting at a more consolidated level. measurement.
We understand that clinicians may need 35 We do not anticipate any changes in the
to spend time (1) becoming familiar E. ICRs Regarding Burden for Third-
CEHRT process for health IT vendors as we
with the requirements to form a virtual Party Reporting ( 414.1400) transition to MIPS. Hence, health IT vendors are not
group and (2) making a decision about Under MIPS, quality, advancing care included in the burden estimates for MIPS.
36 The full list of qualified registries for 2017 is
whether to form a virtual group. information, and improvement activities
available at https://qpp.cms.gov/docs/QPP_MIPS_
Further, they may incur costs as a result performance categories data may be 2017_Qualified_Registries.pdf and the full list of
of those activities. However, we do not submitted via relevant third-party QCDRs is available at https://qpp.cms.gov/docs/
anticipate that the clinicians will be intermediaries, such as qualified QPP_2017_CMS_Approved_QCDRs.pdf.
QCDRs in good standing with no benchmarking capability (for QCDR also estimate that 233 qualified
changes may attest during the self- measures) that compares the quality of registries or QCDRs will go through the
nomination period, between September care a MIPS eligible clinician provides full self-nomination process leading to a
1 and November 1, that they have no with other MIPS eligible clinicians total burden of $205,273 ($881.00
changes to their approved self- performing the same quality measures. 233).
nomination application from the For QCDR measures the QCDR must Qualified registries and QCDRs must
previous year of MIPS. Existing QCDRs provide to us, if available, data from comply with requirements on the
in good standing that would like to years prior (for example, 2016 data for submission of MIPS data to CMS. The
make minimal changes to their the 2018 MIPS performance period) burden associated with the qualified
previously approved self-nomination before the start of the performance registry and QCDR submission
application from the previous year, may period. In addition, the QCDR must requirements will be the time and effort
submit these changes, and attest to no provide to us, if available, the entire associated with calculating quality
other changes from their previously distribution of the measures measure results from the data submitted
approved QCDR application, for CMS performance broken down by deciles. to the qualified registry or QCDR by its
review during the self-nomination As an alternative to supplying this participants and submitting these
period, from September 1 to November information to us, the QCDR may post results, the numerator and denominator
1. This simplified self-nomination this information on their Web site prior data on quality measures, the advancing
process would begin for the 2019 MIPS to the start of the performance period, care information performance category,
performance period. For purposes of to the extent permitted by applicable and improvement activities data to us
2018 MIPS performance period, we privacy laws. The time it takes to on behalf of their participants. We
assume all qualifying registries and perform these functions may vary expect that the time needed for a
QCDRs will go through the current depending on the sophistication of the qualified registry to accomplish these
process. entity, but we estimate that a qualified tasks will vary along with the number
We estimate that the self-nomination registry or QCDR will spend an of MIPS eligible clinicians submitting
process for qualified registries or QCDRs additional 9 hours performing various data to the qualified registry or QCDR
to submit on behalf of MIPS eligible other functions related to being a MIPS and the number of applicable measures.
clinicians or groups for MIPS will qualified registry or QCDR. However, we believe that qualified
involve approximately 1 hour per As shown in Table 52, we estimate registries and QCDRs already perform
qualified registry or QCDR to complete that the staff involved in the qualified many of these activities for their
the online self-nomination process. The registry or QCDR self-nomination participants. We believe the estimate
self-nomination form is submitted process will mainly be computer noted in this section represents the
electronically using a web-based tool. systems analysts or their equivalent, upper bound of QCDR burden, with the
We proposed to eliminate the option of who have an average labor cost of potential for less additional MIPS
submitting the self-nomination form via $88.10/hour. Therefore, assuming the burden if the QCDR already provides
email that was available in the total burden hours per qualified registry similar data submission services.
transition year. or QCDR associated with the self- Based on the assumptions previously
In addition to completing a self- nomination process is 10 hours, the discussed, we provide an estimate of
nomination statement, qualified annual burden hours is 2,330 ((113 total annual burden hours and total
registries and QCDRs will need to QCDRs + 120 qualified registries) 10 annual cost burden associated with a
perform various other functions, such as hours). We estimate that the total cost to qualified registry or QCDR self-
meeting with CMS officials when a qualified registry or QCDR associated nominating to be considered qualified
additional information is needed. In with the self-nomination process will be to submit quality measures results and
addition, QCDRs calculate their measure approximately $881.00 ($88.10 per hour numerator and denominator data on
results. QCDRs must possess 10 hours per qualified registry). We MIPS eligible clinicians.
TABLE 52ESTIMATED BURDEN FOR QCDR AND QUALIFIED REGISTRY SELF-NOMINATION

Burden
estimate
Estimated # of Qualified registries or QCDRs Self-Nominating (a) .................................................................................................... 233

Estimated Total Annual Burden Hours Per Qualified Registry or QCDR (b) ..................................................................................... 10
Estimated Total Annual Burden Hours for Qualified Registries or QCDRs (c) = (a) * (b) ................................................................. 2,330
Estimated Cost Per Qualified Registry or QCDR (@computer systems analysts labor rate of $88.10/hr.) (d) ................................ $881.00
Estimated Total Annual Burden Cost for Qualified registries or QCDRs (e) = (a) * (d) ..................................................................... $205,273
The following is a summary of the complete and submit a QCDR-vendor Response: We acknowledge the
public comments received on our application is significantly under- commenters concern regarding burden
estimated burden for QCDR and registry valued or incomplete, and it is unclear and cost for QCDR measure revisions
self-nomination. whether this estimate included the and the self-nomination process. Our
Comment: One commenter shared follow-up changes and discussions burden estimates consider the time
concerns that the process of revising QCDRs must also undergo subsequent to associated with submitting the
and changing measures during a QCDR- the self-nominations submission. This application, but do not include direct
vendor application window is quite is a very labor-intensive process and the financial costs such as those related to
burdensome and costly, as are potential technological changes required measure revisions and updates. Our
incorporating any changes within each to gain approval can be very costly to burden estimates do incorporate time
practice and facility. The commenter the QCDR vendor. estimates regarding the self-nomination
stated that the estimate of 10 hours to application and recordkeeping,
including follow-up changes and required forms, and vendor business completion of the Vendor Participation
discussions QCDRs must also undergo requirements needed to participate in Form and compiling documentation,
subsequent to the self-nominations MIPS as a survey vendor. For purposes including the quality assurance plan,
submission. of MIPS, we defined a CMS-approved that demonstrates that they comply with
We assume that many of the QCDRs survey vendor at 414.1305 as a survey Minimum Survey Vendor Business
that previously participated in the self- vendor that is approved by us for a Requirements. This is comparable to the
nomination process for the CY 2017 particular performance period to burden of the QCDR and qualified
Quality Payment Program will do so administer the CAHPS for MIPS survey registry self-nomination process. As
again for the CY 2018 Quality Payment and transmit survey measures data to us shown in Table 53, we assume that the
Program and will not need to have as (81 FR 77386). At 414.1400(i), we survey vendor staff involved in
many follow-up discussions as in the require that vendors undergo the CMS- collecting and submitting the
previous year. However, because the approval process each year in which the information required for the CAHPS for
estimate is an average, we maintained survey vendor seeks to transmit survey MIPS certification will be computer
our estimate of 10 hours which we measures data to us (81 FR 77386). We systems analysts, who have an average
included in our CY 2017 burden finalized the criteria for a CMS- labor cost of $88.10/hour. Therefore,
estimates even though we believe approved survey vendor for the CAHPS assuming the total burden hours per
continuing QCDRs will need fewer for MIPS survey (81 FR 77386). In CAHPS associated with the application
hours. The burden estimates in this section II.C.10.e.(1) of this final rule process is 10 hours, the annual burden
section addresses time costs of data with comment period, we finalized that hours is 150 (15 survey vendors 10
collection, not direct financial costs beginning with the 2018 performance hours). We estimate that the total cost to
such as those related to measure period and for future years, the vendor each survey vendor associated with the
updating. application deadline will be January application process will be
After consideration of public
31st of the applicable performance year approximately $881.00 ($88.10 per hour
comments, no changes were made to our
or a later date specified by CMS, which 10 hours per survey vendor). We
estimated burden for QCDR and registry
we do not anticipate would have any estimate that 15 survey vendors will go
self-nomination compared to those
burden impact on the CMS-approved through the process leading to a total
presented in the CY 2018 Quality
survey vendors. burden of $13,215 ($881.00 15 survey
Payment Program proposed rule (82 FR
We estimate that approximately 15 vendors).
30216).
CMS-approved survey vendors will Based on the assumptions previously
2. Burden for CMS-Approved Survey apply for the 2018 MIPS performance discussed, we provide an estimated
Vendors period. We estimate that it will take a number of total annual burden hours
In the CY 2017 Quality Payment survey vendor 10 hours to submit the and total annual cost burden associated
Program final rule (81 FR 77386), we information required for the CMS- with the survey vendor approval
finalized the definition, criteria, approval process, including the process in Table 53.
TABLE 53: ESTIMATED BURDEN FOR CMS-APPROVED SURVEY VENDOR APPLICATION

Burden
estimate
Estimated # of New Survey Vendors Applying (a) .............................................................................................................................. 15

Estimated # of Burden Hours Per Vendor to Apply (b) ...................................................................................................................... 10
Estimated Cost Per Vendor Reporting (@computer systems analysts labor rate of $88.10/hr.) (c) ................................................. $881.00
Estimated Total Annual Burden Hours (d) = (a) * (b) ......................................................................................................................... 150
Estimated Total Annual Burden Cost for Survey Vendor Application Process (e) = (a) * (c) ............................................................ $13,215
We received no public comments percent.37 For purposes of these groups, or virtual groups. We assume
related to the burden estimates for the analyses, we assume that a total of that 100 percent of APM Entities in
CMS-approved survey vendor 892,992 clinicians who participated in MIPS APMs will submit quality data to
application. The burden estimates have the 2016 PQRS and who are not QPs in CMS as required under their models.38
not been updated from the CY 2018 Advanced APMs in the 2017 Quality We anticipate that the professionals
Quality Payment Program proposed Payment Program performance period submitting data voluntarily will include
rule(82 FR 30216). will continue to submit quality data as clinicians that are ineligible for the
either MIPS eligible clinicians (604,006) Quality Payment Program, clinicians
F. ICRs Regarding the Quality or voluntary reporters (288,986) in the that do not exceed the low-volume
Performance Category ( 414.1330 and 2018 MIPS performance period. Based threshold, and newly enrolled Medicare
414.1335) on 2016 data from the PQRS, and 2017 clinicians. Based on those assumptions,
MIPS eligibility data and 2017 QP using 2017 MIPS eligibility data file and
Two groups of clinicians will submit determination data, we estimate that a data from the 2016 PQRS, we estimate
quality data under MIPS: Those who minimum of 90 percent of MIPS eligible that an additional 288,986 clinicians, or
submit as MIPS eligible clinicians and clinicians not participating in MIPS 35 percent of clinicians excluded from
other eligible clinicians who opt to APMs will submit quality performance or ineligible from MIPS, will submit
submit data voluntarily but will not be category data including those
subject to MIPS payment adjustments. participating as individual clinicians, 38 We estimate that 100,649 clinicians that
participated in the 2016 PQRS will be QPs who will

Historically, the PQRS has never not be not required to submit MIPS quality
experienced 100 percent participation; 37 https://www.cms.gov/Medicare/Quality- performance category data under MIPS, and are not
Initiatives-Patient-Assessment-Instruments/PQRS/ included in the numerator or denominator of our
the participation rate for 2015 was 69 Downloads/2015_PQRS_Experience_Report.pdf. participation rate.
MIPS quality data voluntarily. Because virtual groups will continue to use the determination file as described in the
of the exclusion of QPs from our burden same submission mechanism as they 2017 Quality Payment Program final
estimates, we are predicting a decline in did when reporting under the 2016 rule (81 FR 77444).
the rate of voluntary quality data PQRS, but the submission will be at the Based on these methods, Table 54
submission among clinicians excluded virtual group, rather than group level. shows that in the 2018 MIPS
from or ineligible for MIPS relative to Our burden estimates for the quality
performance period, an estimated
our estimated voluntary reporting rate of performance category do not include the
278,039 clinicians will submit as
44 percent in the CY 2017 Quality burden for the quality data that APM
Payment Program final rule (81 Entities in MIPS APMs submit to fulfill individuals via claims submission
FR77501). Historically, clinicians who the requirements of their models. mechanisms; 255,228 clinicians will
are expected to be QPs in 2018 MIPS Sections 3021 and 3022 of the submit as individuals, or as part of
performance period were much more Affordable Care Act state the Shared groups or virtual groups via qualified
likely to have submitted quality data Savings Program and the testing, registry or QCDR submission
under the 2016 PQRS than other evaluation, and expansion of Innovation mechanisms; 131,133 clinicians will
clinicians excluded from or ineligible Center models are not subject to the submit as individuals, or as part of
from MIPS. Due to data limitations, our PRA (42 U.S.C. 1395jjj and 42 U.S.C. groups or virtual groups via EHR
assumptions about quality performance 1315a(d)(3), respectively).40 Tables 54, submission mechanisms; and 93,867
category participation for the purposes 55, and 56 explain our revised estimates clinicians will submit as part of groups
of our burden estimates differs from our of the number of organizations via the CMS Web Interface.
assumptions about quality performance (including groups, virtual groups, and Although we did not finalize multiple
category participation in the impact individual MIPS eligible clinicians) submission mechanisms within a
analysis.39 submitting data on behalf of clinicians performance category for the 2018 MIPS
Our burden estimates for data via each of the quality submission performance period, we are capturing
submission combine the burden for mechanisms.
the burden of any eligible clinician that
MIPS eligible clinicians and other Table 54 provides our estimated
clinicians submitting data voluntarily. counts of clinicians that will submit may have historically submitted via
Apart from clinicians that became QPs quality performance category data as multiple mechanisms, as we assume
in the first QP performance period, we MIPS individual clinicians, groups, or they would continue to submit via
assume that clinicians will continue to virtual groups in the 2018 MIPS multiple mechanisms and that our MIPS
submit quality data under the same performance period. The first step was scoring methodology would take the
submission mechanisms that they used to estimate the number of clinicians to highest score. Hence, the estimated
under the 2016 PQRS. Further, as submit as an individual clinician or numbers of individual clinicians,
discussed in more detail in section IV.C. group via each mechanism during the groups, and virtual groups to submit via
of this final rule with comment period 2017 MIPS performance period using the various submission mechanisms are
when describing the burden for the 2016 PQRS data on individuals and not mutually exclusive, and reflect the
virtual group application process, we groups submitting through various occurrence of individual clinicians or
assume that the approximately 80 TINs mechanisms and excluding clinicians groups that submitted data via multiple
that elect to form the approximately 16 identified as QPs using the initial QP mechanism under the 2016 PQRS.
TABLE 54ESTIMATED NUMBER OF CLINICIANS SUBMITTING QUALITY PERFORMANCE CATEGORY DATA BY MECHANISM
CMS Web
Claims QCDR/registry EHR interface
Estimated number of clinicians to submit via mechanism (as individual clini-

cians, groups, or virtual groups) in Quality Payment Program Year 1 (ex-
cludes QPs) .................................................................................................. 278,039 255,228 131,133 93,867
Table 54 provides estimates of the individuals or part of groups or virtual mechanisms; and approximately 52,709
number of clinicians to submit quality groups. clinicians will submit as individuals via
measures via each mechanism, Table 55 uses methods similar to EHR submission mechanisms.
regardless of whether they decide to those described for Table 54 to estimate Individual clinicians cannot elect to
submit as individual clinicians or as the number of clinicians to submit as submit via CMS Web Interface.
part of groups or virtual groups. Because individual clinicians via each Consistent with the policy finalized in
our burden estimates for quality data mechanism in Quality Payment Program section II.C.7.a. of this final rule with
submission assume that burden is Year 2. We estimate that approximately comment period to score individual
reduced when clinicians elect to submit 278,039 clinicians will submit as clinicians on quality measures
as part of a group or virtual group, we individuals via claims submission independently for each submission
also separately estimate the expected mechanisms; approximately 104,281 mechanism submitted via multiple
number of clinicians to submit as clinicians will submit as individuals via mechanisms, our columns in Table 55
qualified registry or QCDR submission are not mutually exclusive.
39 As noted, the COI section of this rule uses the than 15 clinicians and assumes a minimum 90 40 Our estimates do reflect the burden that MIPS
actual overall average participation rate of 92 percent participation (standard assumption or 80 APM participants of submitting advancing care
percent in quality data submission based on 2015 percent participation (alternative assumption) for information data, which is outside the requirements
PQRS data. The RIA section of this rule uses the practices with 115 clinicians. of their models.
actual participation rate for practices with more
TABLE 55ESTIMATED NUMBER OF CLINICIANS SUBMITTING QUALITY PERFORMANCE CATEGORY DATA AS INDIVIDUALS
CMS Web
Estimated number of Clinicians to submit data as individuals in Quality Pay-

ment Program Year 1 (excludes QPs) (a) ................................................... 278,039 104,281 52,709 0
Table 56 provides our estimated used 2016 PQRS data on groups 8 virtual groups via EHR submission
counts of groups or virtual groups to submitting on behalf of clinicians via mechanisms. Hence, the third step in
submit quality data on behalf of various mechanisms and excluded Table 56 is to subtract out the estimated
clinicians via each mechanism in the groups comprised entirely of QPs using number of groups under each
2018 MIPS performance period and the initial QP determination file as submission mechanism that will elect to
reflects our assumption that the described in the 2017 Quality Payment form virtual groups, and the fourth step
formation of virtual groups will reduce Program final rule (81 FR 77444). The in Table 56 is to add in the estimated
burden. Except for groups comprised second and third steps in Table 56 number of virtual groups that will
entirely of QPs, we assume that groups reflect our assumption that virtual submit on behalf of clinicians via each
that submitted quality data as groups groups will reduce the burden for submission mechanism.
under the 2016 PQRS will continue to quality data submission by reducing the
submit quality data either as groups or number of organizations to submit Specifically, we assumed that 2,936
virtual groups via the same submission quality data on behalf of clinicians. We groups and virtual groups will submit
mechanisms as they did as a group or assume that 40 groups that previously data via QCDR/registry submission
TIN within a virtual group for the 2018 submitted on behalf of clinicians via mechanisms on behalf of 150,957
MIPS performance period. The first step QCDR or qualified registry submission clinicians; 1,509 groups and virtual
in estimating the numbers of groups or mechanisms will elect to form 8 virtual groups will submit via EHR submission
virtual groups to submit via each groups that will submit via QCDR and mechanisms on behalf of 78,424 eligible
mechanism in the 2018 MIPS qualified registry submission clinicians; and 296 groups will submit
performance period was to estimate the mechanisms. We assume that another 40 data via the CMS Web Interface on
number of groups to submit on behalf of groups that previously submitted on behalf of 93,867 clinicians. Groups
clinicians via each mechanism in the behalf of clinicians via EHR submission cannot elect to submit via claims
2017 MIPS performance period. We mechanisms will elect to form another submission mechanism.
TABLE 56ESTIMATED NUMBER OF GROUPS AND VIRTUAL GROUPS SUBMITTING QUALITY PERFORMANCE CATEGORY
DATA BY MECHANISM ON BEHALF OF CLINICIANS
CMS Web
Estimated number of groups to submit via mechanism (on behalf of clini-

cians) in Quality Payment Program Year 1 (excludes QPs) (a) .................. 0 2,968 1,541 296
Subtract out: Estimated number groups to submit via mechanism on behalf
of clinicians in Quality Payment Program Year 1 that will submit as virtual
groups in Quality Payment Program Year 2 (b) .......................................... 0 40 40 0
Add in: Estimated number of virtual groups to submit via mechanism on be-
half of clinicians in Quality Payment Program Year 2 (c) ............................ 0 8 8 0
Estimated number groups to submit via mechanism on behalf of clinicians
in Quality Payment Program Year 2 (d) = (a)(b) + (c) ............................. 0 2,936 1,509 296
These burden estimates have some the rate of participation in MIPS are submission options, select the most
limitations. We believe it is difficult to expected to differ. appropriate submission option, identify
quantify the burden accurately because We believe the burden associated the applicable measures or specialty
clinicians and groups may have with submitting the quality measures measure sets for which they can report
different processes for integrating will vary depending on the submission the necessary information, review the
quality data submission into their method selected by the clinician, group, measure specifications for the selected
practices work flows. Moreover, the or virtual group. As such, we break measures or measures group, and
time needed for a clinician to review down the burden estimates by incorporate submission of the selected
quality measures and other information, clinicians, groups, and virtual groups by measures or specialty measure sets into
select measures applicable to their the submission method used. the practice work flows. Building on
We anticipate that clinicians and
patients and the services they furnish, data in a recent article, Casalino et al.
groups using QCDR, qualified registry,
and incorporate the use of quality data and EHR submission mechanisms will (2016), we assume that a range of
codes into the practice workflows is have the same start-up costs related to expertise is needed to review quality
expected to vary along with the number reviewing measure specifications. As measure specifications: 2 hours of a
of measures that are potentially such, we estimate for clinicians, groups, practice administrators time, 1 hour of
applicable to a given clinicians and virtual groups using any of these a clinicians time, 1 hour of an LPN/
practice. Further, these burden three submission mechanisms a total of medical assistants time, 1 hour of a
estimates are based on historical rates of 6 staff hours needed to review the computer systems analysts time, and 1
participation in the PQRS program, and quality measures list, review the various
hour of a billing clerks time.41 In the data limitations. The number of specialties spend, on average, 785 hours
CY 2017 Quality Payment Program final respondents for CMS Web Interface has per physician and more than $15.4
rule we estimated 3 hours for a practice declined relative to the estimates in the billion on quality measure reporting
administrators time for data CY 2017 Quality Payment Program final programs that nearly three-quarters of
submission. Because the new CMS API rule because our estimates now exclude practices stated were not clinically
will be available for EHR, registry and QPs and CMS Web Interface data relevant.
QCDR, and CMS Web Interface submitted in 2016 by Shared Savings Response: In general, we believe that
submission mechanisms, we have Program and Next Generation and the changes in this final rule with
reduced our estimate to 2 hours of a Pioneer ACOs to fulfill the requirement comment period will improve the
practice administrators time for data of their models. As noted in this section quality and value of care provided to
submission for EHR and 2 hours using of the CY 2018 Quality Payment Medicare beneficiaries. We have
registry or QCDR. This CMS API will Program final rule with comment provided clinicians the flexibility to
streamline the process of reviewing period, information collections identify and select quality measures that
measure specifications and submitting associated with the Shared Savings are clinically relevant for their patients
measures for third-party submission Program and the testing, evaluation, and and practice. As a result, we expect that,
mechanisms. We have also reduced our expansion of CMS Innovation Center over time, clinician engagement in the
burden estimate for CMS Web Interface models are not subject to the PRA. Quality Payment Program may result in
to reflect the new CMS API in a separate The following is a summary of the improved quality of patient care,
section below.42 public comments received regarding our resulting in lower morbidity and
For the claims submission request for information on our general mortality. We appreciate clinician
mechanism, we estimate that the start- burden estimates regarding the quality concerns with reporting burden and
up cost for a MIPS eligible clinicians performance category. have tried to reduce burden where
practice to review measure Comment: One commenter believed possible while meeting the intent of the
specifications is $684.90, including 3 that the quality performance category Act, including our obligations to
hours of a practice administrators time costs were grossly underestimated improve patient outcomes. In future
(3 hours $105.16=$315.48), 1 hour of because CMS assumes that all practices program years, we anticipate that the
a computer systems analyst time (1 hour have a practice manager, IT support, burden will be reduced as MIPS eligible
$88.10/hou r= $88.10), 1 hour of an LPN, and billing clerk to assist clinicians become more familiar with
LPN/medical assistants time (1 hour clinicians in carrying out reporting the quality measures and submission
$43.12), 1 hour of a billing clerks time requirements; however, the commenter requirements.
(1 hour $36.12/hour = $36.12) and 1 noted that, for many small practices, Our estimated data submission
hour of a clinicians time (1 hour this work is done by the clinicians burden for the Quality Payment
$202.08/hour = $202.08). These start-up themselves, at a higher cost than CMS Program, approximately $695 million, is
costs pertain to the specific quality estimates. significantly lower than the estimated
submission methods below, and hence Response: We acknowledge $15.4 billion cost of quality reporting
appear in the burden estimate tables. commenters concerns regarding burden programs described in the Casalino et al.
For the purposes of our burden estimates for the quality performance (2016). Our burden estimates are based
estimates for the claims, qualified category for small practices. We clarify, on prorated versions of the estimates for
registry and QCDR, and EHR submission however, that time spent incorporating reviewing measure specifications in
mechanisms, we also assume that, on measures into practice workflow is not Casalino et al., US Physician Practices
average, each clinician, group, or virtual part of our time estimates given that Spend More than $15.4 Billion
group will submit 6 quality measures. time associated with day-to-day Annually to Report Quality Measures,
Our estimated number of respondents clinician practice is not included in the Health Affairs, 35, no. 3 (2016): 401
for the QCDR/qualified registry and EHR Collection of Information section, under 406. The estimates were annualized to
submission mechanisms increased the PRA, and therefore, not included in 50 weeks per year, and then prorated to
relative to the estimates in the CY 2017 our burden estimates. Further, while our reflect that Medicare revenue is 30
Quality Payment Program final rule. Our time estimates rely on assumptions, percent of all revenue paid by insurers,
estimated respondents for the claims including a list of possible staff who and then adjusted to reflect that the
submission mechanism has declined may assist clinicians in carrying out decrease from 9 required quality
relative to the CY 2017 Quality Payment reporting requirements, we highlight measures under PQRS to 6 required
Program final rule in part because we that these assumptions are focused on measures under MIPS. We also refer to
have excluded QPs from our burden the staff for an average practice. the CY 2017 Quality Payment Program
estimates; in the CY 2017 Quality However, we believe that are estimates final rule (81 FR 77502), where we
Payment Program final rule, QPs were are applicable to all practices because provided a footnote that describes the
included in our burden estimates due to these estimates are grounded in reliable prorated assumptions which are also
data sources, and past program included in this final rule with
41 Our burden estimates are based on prorated
methodologies including that of PQRS, comment period burden estimates.
versions of the estimates for reviewing measure and our analysis and justifications are After consideration of public
specifications in Lawrence P. Casalino et al., US
Physician Practices Spend More than $15.4 Billion detailed in this section of the final rule comments, no changes were made to the
Annually to Report Quality Measures, Health with comment period. quality performance category burden
Affairs, 35, no. 3 (2016): 401406. The estimates Comment: One commenter expressed estimate in response to comments
were annualized to 50 weeks per year, and then concern about the lack of clinical specific to that performance category.
prorated to reflect that Medicare revenue is 30
percent of all revenue paid by insurers, and then relevance to patient care in the Quality The burden estimates were updated
adjusted to reflect that the decrease from 9 required Payment Program and time to spent from the CY 2018 Quality Payment
quality measures under PQRS to 6 required reporting on quality measures, citing a Program proposed rule (82 FR 30218 to
measures under MIPS. 2016 Health Affairs study that CMS 30219) to reflect updated data sources
42 CMS: New API Will Automate MACRA Quality
Measure Data Sharing. http://healthitanalytics.com/

cited in the CY 2018 Quality Payment on the number of respondents, and to
news/cms-new-api-will-automate-macra-quality- Program proposed rule (82 FR 30219), reflect that we are not finalizing the
measure-data-sharing. which found that practices in 4 common policy to allow facility-based
measurement until the 2019 MIPS that the burden for submission of computer systems analysts time (1 hour
performance period. quality data will range from 0.22 hours $88.10 = $88.10), and 1 hour of a
to 10.8 hours per clinician. The wide billing clerks time (1 hour $36.12/
1. Burden for Quality Data Submission
range of estimates for the time required hour = $36.12).
by Clinicians: Claims-Based Submission
for a clinician to submit quality Considering both data submission and
As noted in Table 54, based on 2016 measures via claims reflects the wide start-up costs, the total estimated
PQRS data and 2017 MIPS eligibility variation in complexity of submission burden hours per clinician ranges from
data, we assume that 278,039 individual across different clinician quality a minimum of 7.22 hours (0.22 + 3 + 1
clinicians will submit quality data via measures. As shown in Table 57, we
claims. We anticipate the claims + 1 + 1 + 1) to a maximum of 17.8 hours
also estimate that the cost of quality
submission process for MIPS will be (10.8 + 3 + 1 + 1 + 1 + 1). The total
data submission using claims will range
estimated annual cost per clinician
operationally similar to the way the from $19.38 (0.22 hours $88.10) to
ranges from the minimum estimate of
claims submission process functioned $951.48 (10.8 hours $88.10). The total
under the PQRS. Specifically, clinicians estimated annual cost per clinician $704.28 ($19.38 + $315.48 + $88.10 +
will need to gather the required ranges from the minimum burden $43.12 + $36.12 + $202.08) to a
information, select the appropriate estimate of $704.28 to a maximum maximum estimate of $1,636.38
quality data codes (QDCs), and include burden estimate of $1,636.38. The ($951.48 + $315.48 + $88.10 + $43.12 +
the appropriate QDCs on the claims they burden will involve becoming familiar $36.12 + $202.08). Therefore, total
submit for payment. Clinicians will with MIPS data submission annual burden cost is estimated to range
collect QDCs as additional (optional) requirements. As noted in Table 57, we from a minimum burden estimate of
line items on the CMS1500 claim form believe that the start-up cost for a $195,817,307 (278,039 $704.28) to a
or the electronic equivalent HIPAA clinicians practice to review measure maximum burden estimate of
transaction 837P, approved by OMB specifications totals 7 hours, which $454,977,459 (278,039 $1,636.38).
under control number 09381197. includes 3 hours of a practice Based on the assumptions discussed
The total estimated burden of claims- administrators time (3 hours $105.16 in this section of this final rule with
based submission will vary along with = $315.48), 1 hour of a clinicians time comment period, Table 57 summarizes
the volume of claims on which the (1 hour $202.08/hour = $202.08), 1 the range of total annual burden
submission is based. Based on our hour of an LPN/medical assistants time associated with clinicians using the
experience with the PQRS, we estimate (1 hour $43.12 = $43.12), 1 hour of a claims submission mechanism.
TABLE 57BURDEN ESTIMATE FOR QUALITY PERFORMANCE CATEGORY: CLINICIANS USING THE CLAIMS SUBMISSION
MECHANISM
Maximum
Minimum Median burden
burden burden estimate
Estimated # of Clinicians (a) ....................................................................................................... 278,039 278,039 278,039

Burden Hours per Clinician to Submit Quality Data (b) .............................................................. 0.22 1.58 10.8
Estimated # of Hours Practice Administrator Review Measure Specifications (c) ..................... 3 3 3
Estimated # of Hours Computer Systems Analyst Review Measure Specifications (d) ............. 1 1 1
Estimated # of Hours LPN Review Measure Specifications (e) ................................................. 1 1 1
Estimated # of Hours Billing Clerk Review Measure Specifications (f) ...................................... 1 1 1
Estimated # of Hours Clinician Review Measure Specifications (g) ........................................... 1 1 1
Estimated Annual Burden hours per Clinician (h) = (b) + (c) + (d) + (e) + (f) + (g) ................... 7.22 8.58 17.8
Estimated Total Annual Burden Hours (i) = (a) * (h) .................................................................. 2,007,442 2,385,575 4,949,094
Estimated Cost to Submit Quality Data (@computer systems analysts labor rate of $88.10/
hr.) (j) ........................................................................................................................................ $19.38 $139.20 $951.48
Estimated Cost to Review Measure Specifications (@practice administrators labor rate of
$105.16/hr.) (k) ......................................................................................................................... $315.48 $315.48 $315.48
Estimated Cost to Review Measure Specifications (@computer systems analysts labor rate
of $88.10/hr.) (l) ....................................................................................................................... $88.10 $88.10 88.10
Estimated Cost to Review Measure Specifications (@LPNs labor rate of $43.12/hr.) (m) ....... $43.12 $43.12 $43.12
Estimated Cost to Review Measure Specifications (@billing clerks labor rate of $36.12/hr.)
(n) ............................................................................................................................................. $36.12 $36.12 $36.12
Estimated Cost to Review Measure Specifications (@physicians labor rate of $202.08/hr.)
(o) ............................................................................................................................................. $202.08 $202.08 $202.08
Estimated Total Annual Cost per Clinician (p) = (j) + (k) + (l) + (m) + (n) + (o) ........................ $704.28 $824.10 $1,636.38
Estimated Total Annual Burden Cost (q) = (a) * (p) ................................................................... $195,817,307 $229,131,940 $454,977,459
We received no public comment measurement until the 2019 MIPS clinicians will submit quality data as
specific to our burden estimates for the performance period. individuals, groups, or virtual groups
quality performance category claims via qualified registry or QCDR

2. Burden for Quality Data Submission
submission mechanism. The burden by Individuals, Groups, and Virtual submissions. Of these, we expect
estimates were updated from the CY Groups Using Qualified Registry and 104,281 clinicians, as shown in Table
2018 Quality Payment Program QCDR Submissions 55, to submit as individuals and 2,936
proposed rule to reflect updated data groups, as shown in Table 56, are
sources on the number of respondents, As noted in Table 54 and based on the expected to submit on behalf of the
and to reflect that we are not finalizing 2016 PQRS data and 2017 MIPS remaining 150,947 clinicians. Given that
the policy to allow facility-based eligibility data, we assume that 255,228 the number of measures required is the
same for clinicians, groups, and virtual costs for an individual clinician or measures to us on their behalf. We
groups, we expect the burden to be the group to review measure specifications estimate that the time and effort
same for each respondent submitting and submit quality data total $843.74. associated with authorizing or
data via qualified registry or QCDR, For review costs and data submission instructing the quality registry or QCDR
whether the clinician is participating in costs, this total includes 3 hours per to submit this data will be
MIPS as an individual, group or virtual respondent to submit quality data (3 approximately 5 minutes (0.083 hours)
group. hours $88.10/hour = $264.00), 2 hours per clinician or group (respondent) for
We estimate that burdens associated of a practice administrators time (2 a total burden cost of $7.31, at a
with QCDR submissions are similar to hours $105.16/hour = $210.32), 1 hour computer systems analysts labor rate
the burdens associated with qualified of a computer systems analysts time (1 (.083 hours $88.10/hour). Hence, we
registry submissions. Therefore, we hour $88.10/hour = $88.10), 1 hour of estimate 9.083 burden hours per
discuss the burden for both data an LPN/medical assistants time, (1 hour respondent, with annual total burden
submissions together below. For $43.12/hour = $43.12), 1 hour of a hours of 973,852 (9.083 burden hours
qualified registry and QCDR billing clerks time (1 hour $36.12/ 107,217 respondents). The total
submissions, we estimate an additional hour = $36.12) and 1 hour of a estimated annual cost per respondent is
time burden for respondents (individual clinicians time (1 hour $202.08). estimated to be approximately $851.05.
clinicians, groups, and virtual groups) to Clinicians, groups, and virtual groups Therefore, total annual burden cost is
become familiar with MIPS submission will need to authorize or instruct the estimated to be $91,247,028 (107,217
requirements and, in some cases, qualified registry or QCDR to submit $851.05). Based on these assumptions,
specialty measure sets and QCDR quality measures results and numerator we have estimated in Table 58 the
measures. Therefore, we believe that the and denominator data on quality burden for these submissions.
TABLE 58BURDEN ESTIMATE FOR QUALITY PERFORMANCE CATEGORY: CLINICIANS (PARTICIPATING INDIVIDUALLY OR AS
PART OF A GROUP OR VIRTUAL GROUP) USING THE QUALIFIED REGISTRY/QCDR SUBMISSION
Burden
estimate
# of clinicians submitting as individuals (a) ......................................................................................................................................... 104,281

# of groups or virtual groups submitting via QCDR or registry on behalf of individual clinicians (b) ................................................. 2,936
# of Respondents (groups and virtual groups plus clinicians submitting as individuals) (c) = (a) + (b) ............................................ 107,217
Estimated Burden Hours per Respondent to Report Quality Data (d) ............................................................................................... 3
Estimated # of Hours Practice Administrator Review Measure Specifications (e) ............................................................................. 2
Estimated # of Hours Computer Systems Analyst Review Measure Specifications (f) ...................................................................... 1
Estimated # of Hours LPN Review Measure Specifications (g) ......................................................................................................... 1
Estimated # of Hours Billing Clerk Review Measure Specifications (h) ............................................................................................. 1
Estimated # of Hours Clinician Review Measure Specifications (i) .................................................................................................... 1
Estimated # of Hours Per Respondent to Authorize Qualified Registry to Report on Respondents Behalf (j) ................................. 0.083
Estimated Annual Burden Hours Per Respondent (k) = (d) + (e) + (f) + (g) + (h) + (i) + (j) ............................................................. 9.083
Estimated Total Annual Burden Hours (l) = (c) * (k) ........................................................................................................................... 973,852
Estimated Cost per Respondent to Submit Quality Data (@computer systems analysts labor rate of $88.10/hr.) (m) ................... $264.00
Estimated Cost to Review Measure Specifications (@practice administrators labor rate of $105.16/hr.) (n) .................................. $210.32
Estimated Cost Computer Systems Analyst Review Measure Specifications (@computer systems analysts labor rate of $88.10/
hr.) (o) .............................................................................................................................................................................................. $88.10
Estimated Cost LPN Review Measure Specifications (@LPNs labor rate of $43.12/hr.) (p) ............................................................ $43.12
Estimated Cost Billing Clerk Review Measure Specifications (@clerks labor rate of $36.12/hr.) (q) ............................................... $36.12
Estimated Cost Clinician Review Measure Specifications (@physicians labor rate of $202.08/hr.) (r) ............................................ $202.08
Estimated Burden for Submission Tool Registration etc. (@computer systems analysts labor rate of $88.1/hr.) (s) ...................... $7.31
Estimated Total Annual Cost Per Respondent (t) = (m) + (n) + (o) + (p) + (q) + (r) + (s) ................................................................. $851.05
Estimated Total Annual Burden Cost (u) = (c) * (t) ............................................................................................................................ $91,247,028
The following is a summary of the will vary by QCDR or registry and we order to have a sufficient number of
public comments received regarding our do not know which MIPS eligible measures to report and file with CMS,
request for information on our qualified clinician will use which QCDR or clinicians will incur fees to a QCDR or
registry/QCDR burden estimates registry. registry (possibly several) followed by
regarding the quality performance The burden estimates in this section paying their staff or outside vendors and
category. address time costs, not direct financial consultants to assemble, test, and
Comment: One commenter believed costs for data submission to registries submit their information. This may
that the quality performance category and QCDRs. The CY 2017 Quality prove to be impractical financially for
costs were grossly underestimated Payment Program final rule established some clinicians. The commenter
because CMS does not consider the a policy to have QCDRs and registries suggested that QCDR and registry
direct cost of qualified registry/QCDR publish fees (81 FR 77505). The fees are
vendors should explore innovative

submission, which can be substantial, published at https://qpp.cms.gov/docs/ pricing options that help make MIPS
nor does CMS include the direct, often QPP_2017_Qualified_Registries.pdf.
participation more affordable.
considerable, cost of data mapping and Comment: One commenter expressed
maintaining the interface with qualified concern that multiple submission Response: We acknowledge the
registry/QCDR. options may increase the likelihood of commenters concerns with QCDR and
Response: We are unable to estimate successful participation in MIPS but registry fees in order to have sufficient
the potential costs of fees paid to QCDRs that it also drives up the costs of number of measures to report and file
and registries because this information participation incurred by clinicians. In with CMS given the proposed multiple
submissions options policy. As 3. Burden for Quality Data Submission believe takes less than 1 hour to obtain.
mentioned in II.C.6.a.(1) of the final rule by Clinicians, Groups, and Virtual Once a clinician or group has an
with comment period, we are finalizing Groups: EHR Submission account for this CMS-specified identity
the multiple submission mechanism As noted in Tables 54, 55 and 56, management system, they will need to
policy beginning with the 2019 MIPS based on 2016 PQRS data and 2017 extract the necessary clinical data from
performance period to allow additional MIPS eligibility data, we assume that their EHR, and submit the necessary
time to communicate how this policy 131,133 clinicians will submit quality data to the CMS-designated clinical data
intersects with our measure data as individuals or groups via EHR warehouse.
applicability policies. submissions; 52,709 clinicians are We estimate that obtaining an account
expected to submit as individuals; and on a CMS-specified identity
Our burden estimates for clinicians management system will require 1 hour
submitting through multiple or single 1,509 groups are expected to submit on
behalf of 78,424 clinicians. We expect per respondent for a cost of $88.10 (1
submission mechanism reflect the time hour $88.10/hour). For submitting the
the burden to be the same for each
costs, but not the direct financial costs respondent submitting data via EHR, actual data file, we believe that this will
of data submission. In the CY 2017 whether the clinician is participating in take clinicians or groups no more than
Quality Payment Program final rule (81 MIPS as an individual or group. 2 hours per respondent for a cost of
FR 77505) we finalized a policy to post Under the EHR submission submission of $176.20 (2 hours
QCDRs self-reported costs for MIPS mechanism, the individual clinician or $88.10/hour). The burden will involve
eligible clinicians or groups to use the group may either submit the quality becoming familiar with MIPS
QCDR on the CMS Web site alongside measures data directly to us from their submission. We believe that the start-up
their organizational contact information EHR or utilize an EHR data submission cost for a clinician or group to review
and the services and measures offered. vendor to submit the data to us on the measure specifications is a total of 6
In summary, no changes were made to clinicians or groups behalf. hours which includes 2 hours of a
the quality performance category To prepare for the EHR submission practice administrators time (2 hours
qualified registry/QCDR burden mechanism, the clinician or group must $105.16/hour = $210.32), 1 hour of a
estimate in response to comments review the quality measures on which clinicians time (1 hour $202.08/hour
received. The burden estimates were we will be accepting MIPS data = $202.08), 1 hour of a computer
updated from the CY 2018 Quality extracted from EHRs, select the systems analysts time (1 hour $88.10/
Payment Program proposed rule to appropriate quality measures, extract hour = $88.10), 1 hour of an LPN/
reflect updated data sources on the the necessary clinical data from their medical assistants time (1 hour
number of respondents, and to reflect EHR, and submit the necessary data to $43.12/hour = $43.12), and 1 hour of a
that we are not finalizing the policy to the CMS-designated clinical data billing clerks time (1 hour $36.12/
allow facility-based measurement until warehouse or use a health IT vendor to hour = $36.12). Hence, we estimated 9
the 2019 MIPS performance period. submit the data on behalf of the total burden hours per respondent with
clinician or group. We assume the annual total burden hours of 487,962 (9
After consideration of public burden for submission of quality burden hours 54,218 respondents).
comments, we made no changes to our measures data via EHR is similar for The total estimated annual cost per
qualified registry/QCDR burden clinicians, groups, and virtual groups respondent is estimated to be $844.04.
estimates. The burden estimates were who submit their data directly to us Therefore, total annual burden cost is
updated from the CY 2018 Quality from their CEHRT and clinicians, estimated to be $45,762,161 = (54,218
Payment Program proposed rule (82 FR groups, and virtual groups who use an respondents $844.04).
30222) to reflect updated data sources EHR data submission vendor to submit Based on the assumptions discussed
on the number of respondents, and to the data on their behalf. To submit data in section II.C.6.a of this final rule with
reflect that we are not finalizing the to us directly from their CEHRT, comment period, we have estimated the
policy to allow facility-based clinicians, groups, and virtual groups burden for the quality data submission
measurement until the 2019 MIPS must have access to a CMS-specified using EHR submission mechanism in
performance period. identity management system which we Table 59.
TABLE 59BURDEN ESTIMATE FOR QUALITY PERFORMANCE CATEGORY: CLINICIANS (SUBMITTING INDIVIDUALLY OR AS
PART OF A GROUP OR VIRTUAL GROUP) USING THE EHR SUBMISSION MECHANISM
Burden
estimate
# of clinicians submitting as individuals (a) ......................................................................................................................................... 52,709

# of Groups and virtual groups submitting via EHR on behalf of individual clinicians (b) ................................................................. 1,509
# of Respondents (groups and virtual groups plus clinicians submitting as individuals) (c) = (a) + (b) ............................................ 54,218
Estimated Burden Hours Per Respondent to Obtain Account in CMS-Specified Identity Management System (d) ......................... 1
Estimated Burden Hours Per Respondent to Submit MIPS Quality Data File to CMS (e) ................................................................ 2
Estimated # of Hours Practice Administrator Review Measure Specifications (f) .............................................................................. 2
Estimated # of Hours Computer Systems Analyst Review Measure Specifications (g) ..................................................................... 1
Estimated # of Hours LPN Review Measure Specifications (h) ......................................................................................................... 1

Estimated # of Hours Billing Clerk Review Measure Specifications (i) .............................................................................................. 1
Estimated # of Hours Clinicians Review Measure Specifications (j) .................................................................................................. 1
Estimated Annual Burden Hours Per Respondent (k) = (d) + (e) + (f) + (g) + (h) + (i) + (j) ............................................................. 9
Estimated Total Annual Burden Hours (l) = (c) * (k) ........................................................................................................................... 487,962
Estimated Cost Per Respondent to Obtain Account in CMS-specified identity management system (@computer systems ana-
lysts labor rate of $88.10/hr.) (m) ................................................................................................................................................... $88.10
Estimated Cost Per Respondent to Submit Quality Data (@computer systems analysts labor rate of $88.10/hr.) (n) .................... $176.20
Estimated Cost to Review Measure Specifications (@practice administrators labor rate of $105.16/hr.) (o) .................................. $210.32
TABLE 59BURDEN ESTIMATE FOR QUALITY PERFORMANCE CATEGORY: CLINICIANS (SUBMITTING INDIVIDUALLY OR AS
PART OF A GROUP OR VIRTUAL GROUP) USING THE EHR SUBMISSION MECHANISMContinued
Burden
estimate
Estimated Cost to Review Measure Specifications (@computer systems analysts labor rate of $88.10/hr.) (p) ............................. $88.10
Estimated Cost to Review Measure Specifications (@LPNs labor rate of $43.12/hr.) (q) ................................................................ $43.12
Estimated Cost to Review Measure Specifications (@clerks labor rate of $36.12/hr.) (r) ................................................................ $36.12
Estimated Cost to D21Review Measure Specifications (@physicians labor rate of $202.08/hr.) (s) ................................................ $202.08
Estimated Total Annual Cost Per Respondent (t) = (m) + (n) + (o) + (p) + (q) + (r) + (s) ................................................................. $844.04
Estimated Total Annual Burden Cost (u) = (c) * (t) ............................................................................................................................ $45,762,161
The following is a summary of the submission mechanism burden Medicare beneficiaries and then submit
public comments received regarding our estimate. The burden estimates were the data (we will partially pre-populate
request for information on our EHR updated from the CY 2018 Quality the CMS Web Interface with claims data
submission mechanism burden Payment Program proposed rule (82 FR from their Medicare Part A and B
estimates regarding the quality 30222) to reflect updated data sources beneficiaries). The patient data either
performance category. on the number of respondents, and to can be manually entered or uploaded
Comment: One commenter did not reflect that we are not finalizing the into the CMS Web Interface via a
support our quality performance policy to allow facility-based standard file format, which can be
category burden estimates because the measurement until the 2019 MIPS populated by CEHRT. Because the CMS
commenter believed costs were grossly performance period. API will streamline the measure
underestimated because CMS does not submission process for many groups, we
recognize time to train personnel in data 4. Burden for Quality Data Submission
via CMS Web Interface have reduced our estimate of the
capture, designing templates for data computer systems analyst time needed
capture, documentation time, or time to Based on 2016 PQRS data and as for submission from 79 hours in the CY
review data submission reports and shown in Table 60, we assume that 296 2017 Quality Payment Program final
work with vendors to correct groups will submit quality data via the rule to 74 hours. Because each group
submissions. The commenter also noted CMS Web Interface in the 2018 MIPS must provide data on 248 eligible
that CMS also does not include IT performance period. We anticipate that assigned Medicare beneficiaries (or all
consulting fees for small groups that approximately 93,867 clinicians will be eligible assigned Medicare beneficiaries
lack internal IT departments and fails to represented. if the pool of eligible assigned
consider direct fees from the EHR The burden associated with the group beneficiaries is less than 248) for each
vendors submitting on behalf of submission requirements under the measure, we assume that entering or
clinicians (approximately $300/ CMS Web Interface is the time and effort uploading data for one Medicare
physician). associated with submitting data on a beneficiary across all the measures
Response: We acknowledge sample of the organizations requires approximately 18 minutes of a
commenters concerns regarding our beneficiaries that is prepopulated in the computer systems analysts time (74
EHR submission mechanism burden CMS Web Interface. Based on hours 248 patients for each measure).
estimates. We note that under the PRA, experience with PQRS GPRO Web
costs associated with training personnel Interface submission mechanism, we The total annual burden hours are
is not included in the Collection of estimate that, on average, it will take estimated to be 21,904 (296 groups 74
Information section, and, therefore, not each group 74 hours of a computer annual hours), and the total annual
included in our burden estimates. We systems analysts time to submit quality burden cost is estimated to be
note that costs and benefits are measures data via the CMS Web $1,929,624 (296 groups $6,519).
discussed in section VI.F. of this final Interface at a cost of $88.10 per hour, for Based on the assumptions discussed
rule with comment period. The burden a total cost of $6,519 (74 hours $88.10/ in this section of the CY 2018 Quality
estimates in this section address time hour). Our estimate of 74 hours for Payment Program proposed rule, we
costs, not direct financial costs. submission includes the time needed for have calculated in Table 60 the
After consideration of public each group to populate data fields in the following burden estimate for groups
comments, we made no changes to the web interface with information on submitting to MIPS with the CMS Web
quality performance category EHR approximately 248 eligible assigned Interface.
TABLE 60BURDEN ESTIMATE FOR QUALITY DATA SUBMISSION VIA THE CMS WEB INTERFACE
Burden
estimate
Estimated # of Eligible Group Practices (a) ........................................................................................................................................ 296

Estimated Total Annual Burden Hours Per Group to Submit (b) ........................................................................................................ 74
Estimated Total Annual Burden Hours (c) = (a) * (b) ......................................................................................................................... 21,904
Estimated Cost Per Group to Report (@computer systems analysts labor rate of $88.10/hr.) (d) ................................................... $6,519
Estimated Total Annual Cost Per Group (e) = (d) .............................................................................................................................. $6,519
Estimated Total Annual Burden Cost (f) = (a) * (e) ............................................................................................................................ $1,929,624
By Eligible
Clinician or
Group
Estimated # of Participating Eligible Professionals (g) ....................................................................................................................... 252,808
TABLE 60BURDEN ESTIMATE FOR QUALITY DATA SUBMISSION VIA THE CMS WEB INTERFACEContinued
Burden
estimate
Average Burden Hours Per Eligible Professional (h) = (c) (g) ........................................................................................................ 0.09
Estimated Cost Per Eligible Professional to Report Quality Data (i) = (f) (g) ................................................................................. $7.63
The following is a summary of the After consideration of public beneficiaries will respond per group.
public comments received regarding our comments, we made no changes to the Therefore, the CAHPS for MIPS survey
request for information on our Web quality performance category Web will be administered to approximately
Interface submission mechanism burden Interface submission mechanism burden 132,307 beneficiaries per year (461
estimates regarding the quality estimate. The burden estimates were groups an average of 287 beneficiaries
performance category. updated from the CY 2018 Quality per group responding).
Payment Program proposed rule (82 FR In section II.C.6.b.(3)(1)(iii) of this
Comment: One commenter believed
30223) to reflect updated data sources final rule with comment period, we are
that the quality performance category
on the number of respondents. establishing a policy to use a shorter
costs were grossly underestimated
because the commenter believed that 5. Burden for Beneficiary Responses to version of the CAHPS for MIPS survey
CMS incorrectly stated that each group CAHPS for MIPS Survey with 58 items, as compared to 81 items
reports on 248 beneficiaries. The for the version that will be used in the
Under MIPS, groups of 2 or more transition year. The shorter survey is
commenter noted that instead, they clinicians can elect to contract with a
report on 248 beneficiaries per measure estimated to require an average
CMS-approved survey vendor and use
15 measures. The commenter noted administration time of 12.9 minutes (or
the CAHPS for MIPS survey as one of
that while some patients may be 0.22 hours) in English (at a pace of 4.5
their 6 required quality measures.
items per minute). We assume the
represented in more than one measure, Beneficiaries that choose to respond to
Spanish survey would require 15.5
this is not the norm. Also, the the CAHPS for MIPS survey will
minutes (assuming 20 percent more
commenter stated that CMS does not experience burden.
The usual practice in estimating the words in the Spanish translation).
consider the time, in manual hours,
burden on public respondents to Because less than 1 percent of surveys
needed to abstract data that is not
surveys such as CAHPS is to assume were administered in Spanish for
readily available electronically, which reporting year 2016, our burden
the commenter noted can be a large cost. that respondent time is valued, on
average, at civilian wage rates. As estimate reflects the length of the
For the above reasons, the commenter English survey. Our finalized policy
shared concerns that the quality previously explained, the BLS data
show the average hourly wage for will reduce beneficiary burden
performance category costs were grossly compared to the transition year; we
underestimated. civilians in all occupations to be $23.86.
Although most Medicare beneficiaries estimate that the 81-item survey
Response: Thank you for your are retired, we believe that their time requires an average administration time
comment on the CMS Web Interface value is unlikely to depart significantly of 18 minutes in English and 21.6
submission mechanism burden from prior earnings expense, and we minutes in Spanish. Compared to the
estimates. Our estimate of 74 hours is an have used the average hourly wage to survey for reporting year 2016, this is a
average across all groups that submit via compute the dollar cost estimate for reduction of 5.1 minutes (18 minutes to
the CMS Web Interface based on these burden hours. 12.9 minutes) in administration time for
historical data available updated for the Under the 2018 MIPS performance the English version and a reduction of
efficiencies of using API. Our estimate period, we assume that 461 groups will 6.1 (21.6 minutes15.5 minutes)
takes into consideration the 15 measures elect to report on the CAHPS for MIPS minutes in administration time for the
and 248 beneficiaries selected for each survey, which is equal to the number of Spanish version.
measure. Users will have access to a groups reporting via CAHPS for the Given that we expect approximately
redesigned CMS Web Interface and will PQRS for reporting period 2016.43 Table 132,307 respondents per year, the
no longer need to use an XML file to 61 shows the estimated annualized annual total burden hours are estimated
download and upload file. Instead users burden for beneficiaries to participate in to be 29,108 hours (132,307 respondents
will be able to use an Excel template to the CAHPS for MIPS Survey. Based on 0.22 burden hours per respondent).
upload and download files which we historical information on the numbers of The estimated total burden annual
believe will help to streamline the data CAHPS for PQRS survey respondents, burden cost is $694,612 (132,307
submission process. we assume that an average of 287 $5.25).
TABLE 61BURDEN ESTIMATE FOR BENEFICIARY PARTICIPATION IN CAHPS FOR MIPS SURVEY
Burden
estimate
Estimated # of Eligible Group Practices Administering CAHPS for Physician Quality Reporting Survey (a) .................................... 461
Estimated # of Beneficiaries Per Group Responding to Survey (b) ................................................................................................... 287
Estimated # of Total Beneficiary Respondents (c) = (a) * (b) ............................................................................................................ 132,307
43 Because the CAHPS for PQRS survey was MIPS, may be somewhat lower. Hence, we assume PQRS survey, which occurred in year 2015 when
required for groups of 100 or more clinicians under that the number of groups electing to use the 461 groups used the survey. The most popular year
the PQRS, we expect that group participation in CAHPS for MIPS survey will be equivalent to the of the CAHPS for PQRS survey was reporting year
CAHPS for MIPS survey, which is optional under second highest participation rate for CAHPS for 2016, when 514 groups used the survey.
TABLE 61BURDEN ESTIMATE FOR BENEFICIARY PARTICIPATION IN CAHPS FOR MIPS SURVEYContinued
Burden
estimate
Estimated # of Burden Hours Per Beneficiary Respondent (d) .......................................................................................................... 0.22

Estimated Cost Per Beneficiary (@labor rate of $23.86/hr.) (e) ......................................................................................................... $5.25
Estimated Total Annual Burden Hours (f) = (c) * (d) .......................................................................................................................... 29,108
Estimated Total Annual Burden Cost for Beneficiaries Responding to CAHPS MIPS (g) = (c) * (e) ................................................ $694,612
We received no public comments registration, groups will only need to registration process is 1 hour, we
related to the burden estimates for opt out if they are not going to continue estimate the total cost to a group
beneficiary participation in the CAHPS to submit via the CMS Web Interface. In associated with the group registration
for MIPS survey. The burden estimates Table 62 we estimate that the process to be approximately $88.10
have not been changed from the CY registration process for groups under ($88.10 per hour 1 hour per group).
2018 Quality Payment Program MIPS involves approximately 1 hour of We assume that approximately 10
proposed rule (82 FR 30224). administrative staff time per group. We groups will elect to use the CMS Web
assume that a billing clerk will be Interface submission mechanism in the
6. Burden for Group Registration for
responsible for registering the group and 2018 MIPS performance period. The
CMS Web Interface
that, therefore, this process has an total annual burden hours are estimated
Groups interested in participating in average computer systems analyst labor to be 10 (10 groups 1 annual hour),
MIPS using the CMS Web Interface for cost of $88.10 per hour. Therefore, and the total annual burden cost is
the first time must complete an on-line assuming the total burden hours per estimated to be $881.00 (10 groups
registration process. After first time group associated with the group $88.10).
TABLE 62TOTAL ESTIMATED BURDEN FOR GROUP REGISTRATION FOR CMS WEB INTERFACE
Burden
estimate
Estimated Number of New Groups Registering for CMS Web Interface (a) ...................................................................................... 10
Estimated Annual Burden Hours Per Group (b) ................................................................................................................................. 1
Estimated Total Annual Burden Hours (c) = (a) * (b) ......................................................................................................................... 10
Estimated Cost per Group to Register for CMS Web Interface @computer systems analysts labor rate of $88.10/hr.) (d) ........... $88.10
Estimated Total Annual Burden Cost for CMS Web Interface Group Registration (e) = (a) * (d) ..................................................... $881
We received no public comments the CAHPS for MIPS survey must well as select the CAHPS for MIPS
related to the burden estimates for group register by June of the applicable 12- Survey vendor. Therefore, assuming the
registration for the CMS Web Interface. month performance period, and total burden hours per registration is 1
The burden estimates have not been electronically notify CMS of which hour and 0.5 hours to select the CAHPS
updated from the CY 2018 Quality vendor they have selected to administer for MIPS Survey vendor that will be
Payment Program proposed rule (82 FR the survey on their behalf. In the 2018 used and electronically notify CMS of
30224). MIPS performance period, we assume their selection, the total burden hours
that 461 groups will enroll in the MIPS for CAHPS for MIPS registration is 1.5.
7. Burden for Group Registration for
for CAHPS survey. We estimate the total annual burden
CAHPS for MIPS Survey As shown in Table 63, we assume that
Under MIPS, the CAHPS for MIPS hours as 692 (461 groups 1.5 hours).
the staff involved in the group
survey counts for 1 measure towards the registration for CAHPS for MIPS Survey We estimate the cost per group for
MIPS quality performance category and, will mainly be computer systems CAHPS for MIPS Survey registration is
as a patient experience measure, also analysts or their equivalent, who have $132.15 ($88.10 1.5 hours). We
fulfills the requirement to submit at an average labor cost of $88.10/hour. We estimate that the total cost associated
least one high priority measure in the assume the CAHPS for MIPS Survey with the registration process is $60,921
absence of an applicable outcome registration burden estimate includes ($132.15 per hour 461 hours per
measure. Groups that wish to administer the time to register for the survey as group).
TABLE 63BURDEN ESTIMATE FOR GROUP REGISTRATION FOR CAHPS FOR MIPS SURVEY
Burden
estimate
Estimated # of Groups Registering for CAHPS (a) ............................................................................................................................. 461

Estimated Total Annual Burden Hours for CAHPS Registration (b) ................................................................................................... 1.5
Estimated Total Annual Burden Hours for CAHPS Registration (c) = (a) * (b) .................................................................................. 692
Estimated Cost to Register for CAHPS@computer systems analysts labor rate of $88.10/hr.) (d) ................................................. $132.15
Estimated Total Annual Burden Cost for CAHPS Registration (e) = (a) * (d) .................................................................................... $60,921
The following is a summary of the data submission process. Hence, the Table 64 shows the estimated
public comments received regarding our burden estimate for the submission of annualized burden for clinicians to
estimated burden for the group advancing care information data below apply for a reweighting to zero of their
registration for the CAHPS for MIPS shows only incremental hours required advancing care information performance
survey. above and beyond the time already category due to a significant hardship
Comment: One commenter shared accounted for in the quality data exception or as a result of a
concerns regarding our assumptions for submission process. While this analysis decertification of an EHR, as well as an
the burden estimates regarding CAHPS assesses burden by performance application for significant hardship by
registration costs. The commenter stated category and submission mechanism, small practices. Based on 2016 data
that CMS does not consider direct costs we emphasize that MIPS is a from the Medicare EHR Incentive
of group contracting with a CAHPS consolidated program and submission Program and the first 2019 payment year
vendor. analysis and decisions are expected to MIPS eligibility and special status file,
Response: We are unable to estimate be made for the program as a whole. we assume 40,645 respondents (eligible
the cost of fees paid to CAHPS for MIPS clinicians, groups, or virtual groups)
survey vendors because this information 1. Burden for Advancing Care
Information Application will submit a request for reweighting to
is not available and we believe it may zero of their advancing care information
vary by vendor. As stated in the CY 2017 Quality performance category due to a
Because the burden estimates in this
Payment Program final rule, some MIPS significant hardship exception,
section addresses time costs, not direct
eligible clinicians may not have decertification of an EHR or significant
financial costs, no changes were made
sufficient measures applicable and hardship for small practices through the
to the burden estimate for group
available to them for the advancing care Quality Payment Program. We estimate
registration for CAHPS for MIPS survey
information performance category, and that 5,812 respondents (eligible
as a result of this comment.
We received no public comments as such, they may apply to have the clinicians, groups, or virtual groups)
related to the burden estimates for group advancing care information performance will submit a request for a reweighting
registration for the CAHPS for MIPS category re-weighted to zero in the to zero for the advancing care
Survey. The burden estimates have not following circumstances: insufficient information performance category due
been updated from the CY 2018 Quality internet connectivity, extreme and to extreme and uncontrollable
Payment Program proposed rule (82 FR uncontrollable circumstances, lack of circumstances or as a result of a
30225). control over the availability of CEHRT decertification of an EHR, and 34,833
(81 FR 77240 through 77243). As respondents will submit a request for a
G. ICRs Regarding Burden Estimate for described in section II.C.6.f.(7) of this reweighting to zero for the advancing
Advancing Care Information Data final rule with comment period, we are care information performance category
( 414.1375) establishing a policy to allow MIPS as a small practice. The application to
During the 2018 MIPS performance eligible clinicians to apply to have their request a reweighting to zero for the
period, clinicians, groups, and virtual advancing care information performance advancing care information performance
groups can submit advancing care category re-weighted to zero due to a category due to significant hardship is a
information data through qualified significant hardship exception or short online form that requires
registry, QCDR, EHR, CMS Web exception for decertified EHR identifying which type of hardship or if
Interface, and attestation data technology. We are also establishing a decertification of an EHR applies and a
submission methods. We have worked policy that MIPS eligible clinicians who description of how the circumstances
to further align the advancing care are in small practices (15 or fewer impair the ability to submit the
information performance category with clinicians) may, beginning with the advancing care information data, as well
other MIPS performance categories. We 2018 MIPS performance period and as some proof of circumstances beyond
anticipate that most organizations will 2020 MIPS payment year, request a the submitters control. The estimate to
use the same data submission reweighting to zero for the advancing submit this application is 0.5 hours of
mechanism for the advancing care care information performance category a computer system analysts time. Given
information and quality performance due to a significant hardship. We are that we expect 40,645 applications per
categories and that the clinicians, finalizing our policy to rely on section year, the annual total burden hours are
practice managers, and computer 1848(o)(2)(D) of the Act, as amended by estimated to be 20,323 hours (40,645
systems analysts involved in supporting section 4002(b)(1)(B) of the 21st Century respondents 0.5 burden hours per
the quality data submission will also Cures Act, as our authority for the respondent). The estimated total annual
support the advancing care information significant hardship exceptions. burden is $1,790,412 (40,645 $44.05).
TABLE 64BURDEN ESTIMATE FOR APPLICATION FOR ADVANCING CARE INFORMATION HARDSHIP APPLICATIONS
Burden
estimate
# of Eligible Clinicians, Groups, or Virtual Groups Applying Due to Significant Hardship and Other Exceptions (a) ....................... 5,812
# of Eligible Clinicians, Groups, or Virtual Groups Applying Due to Significant Hardship as Small Practice (b) .............................. 34,833
Total respondents Due to Hardships, Other Exceptions and Hardships for Small Practices (c) ....................................................... 40,645
Estimated Burden Hours Per Applicant for Advancing Care Information (d) ..................................................................................... 0.5
Estimated Total Annual Burden Hours (e) = (a) * (c) ......................................................................................................................... 20,323
Estimated Cost Per Applicant for Advancing Care Information (@computer systems analysts labor rate of $88.10/hr.) (f) ........... $44.05
Estimated Total Annual Burden Cost (g) = (a) * (f) ............................................................................................................................ $1,790,412
We received no public comments application for reweighting for the category. The burden estimates have not
related to the burden estimates for advancing care information performance been updated from the CY 2018 Quality
Payment Program proposed rule (82 FR on behalf of partial QPs that elect to as amended by section 4002(b)(1)(B) of
30226). participate in MIPS. the 21st Century Cures Act, to assign a
As shown in Table 65, based on data scoring weight of zero percent for the
2. Number of Organizations Submitting from the 2015 and 2016 Medicare and advancing care information performance
Advancing Care Information Data on Medicaid EHR Incentive Programs, the category for MIPS eligible clinicians
Behalf of Eligible Clinicians 2016 PQRS data, and 2017 MIPS who are determined to be based in
eligibility data, we estimate that 195,022 ambulatory surgical centers (ASCs)
A variety of organizations will submit
individual MIPS eligible clinicians and (section II.C.6.f.(7)(a) of this final rule
advancing care information data on 668 groups or virtual groups, with comment period).
behalf of clinicians. Clinicians not representing 101,873 MIPS eligible
participating in a MIPS APM can submit clinicians, will submit advancing care Further, we anticipate that the 480
as individuals or as part of a group or information data. These estimates reflect Shared Savings Program ACOs will
virtual group. Group TINs may submit that under the policies finalized in CY submit data at the ACO participant
advancing care information data on 2017 Quality Payment Program final group TIN-level, for a total of 15,945
behalf of clinicians in MIPS APMs, or, rule, certain MIPS eligible clinicians group TINs. We anticipate that the three
except for participants in the Shared will be eligible for automatic APM Entities electing the one-sided
Savings Program, clinicians in MIPS reweighting of their advancing care track in the CEC model will submit data
APMs may submit advancing care information performance category score at the group TIN-level, for an estimated
information performance category data to zero, including MIPS eligible total of 100 group TINs submitting data.
individually. Because group TINs in clinicians that practice primarily in the We anticipate that the 195 APM Entities
hospital, physician assistants, nurse in the OCM (one-sided risk
APM Entities will be submitting
practitioners, clinician nurse specialists, arrangement) will submit data at APM
advancing care information data to
certified registered nurse anesthetists, Entity level, for an estimated total of
fulfill the requirements of submitting to
and non-patient facing clinicians. These 6,478 group TINs. Based on the initial
MIPS, we have included MIPS APMs in
estimates also account for the significant QP determination file, we estimate 2
our burden estimate for the advancing APM Entities in the CPC+ model will
hardships finalized in the CY 2017
care information performance category. submit at the group TIN-level, for an
Quality Payment Program final rule and
Consistent with the list of APMs that are estimated total of 2 group TINs
the final policies adopted in this rule for
MIPS APMs on the Quality Payment significant hardship exceptions, submitting data. Based on the initial QP
Program Web site,44 we assume that 3 including for MIPS eligible clinicians in determination file, we assume that 1
MIPS APMs that do not also qualify as small practices, as well as exceptions CPC+ APM entity will submit data
Advanced APMs will operate in the due to decertification of an EHR. Due to because one or more of its participants
2018 MIPS performance period: Track 1 data limitations, our estimate of the is a partial QP, and that 1 CPC+ APM
of the Shared Savings Program, CEC number of clinicians to submit Entity will submit data because some of
(one-sided risk arrangement), and the advancing care information data does its participants qualify as either as QPs
OCM (one-sided risk arrangement). not account for our policy finalized in or partial QPs. The total estimated
Further, we assume that group TINs will this final rule with comment period to number of respondents is estimated at
submit advancing care information data rely on section 1848(o)(2)(D) of the Act, 218,215.
TABLE 65ESTIMATED NUMBER OF RESPONDENTS TO SUBMIT ADVANCING CARE INFORMATION PERFORMANCE DATA ON
BEHALF OF CLINICIANS
Estimated Estimated
Number of Number of
respondents APM entities
Number of individual clinicians to submit advancing care information (a) .............................................................. 195,022 ........................
Number of groups or virtual groups to submit advancing care information (b) ...................................................... 668 ........................
Shared Savings Program ACO Group TINs (c) ...................................................................................................... 15,945 480
CEC one-sided risk track participants 45 (d) ............................................................................................................ 100 3
OCM one-sided risk arrangement Group TINs (e) .................................................................................................. 6,478 195
CPC+ TINs (f) .......................................................................................................................................................... 2 2
Total (g) = (a) + (b) + (c) + (d) + (e) + (f) ............................................................................................................... 218,215 680
We received no public comments 3. Burden for Submission of Advancing participating in CECs in the one-sided
related to the burden estimates for Care Information Data risk track, and 6,478 group TINs within
submitting advancing care information the OCM (one-sided risk arrangement),
In Table 66, we estimate that up to
performance data. The burden estimates and 2 CPC+ group TINs. We estimate
approximately 218,215 respondents will
have not been updated from the CY this is a significant reduction in
be submitting data under the advancing
2018 Quality Payment Program care information performance category, respondents from the 2017 MIPS
proposed rule 82 FR 30227). 195,022 clinicians, 668 groups or virtual performance period as a result of our
groups, 15,945 group TINs within the
Shared Savings Program ACOs, 100
group TINs within the APM Entity
44 https://qpp.cms.gov/docs/QPP_Advanced_ 45 The 3 CEC APM Entities reflected in the burden
APMs_in_2017.pdf. estimate are the non-large dialysis organizations

participating in the one-sided risk track.
policy to provide significant hardship clinician types eligible for automatic performance category with other
exceptions, including for MIPS eligible reweighting of their advancing care performance categories will reduce the
clinicians in small practices, as well as information performance category score, clinician time needed under this
for situations due to decertification of non-patient facing clinicians, and performance category in the 2018 MIPS
an EHR, and our policy to allow eligible clinicians facing a significant hardship. performance period. Further, for some
clinicians to participate as part of a The remaining decline in respondents is practices the staff mix requirements in
virtual group. due to policies established in this final the 2018 MIPS performance period may
In the CY 2017 Quality Payment rule with comment period, including be driven more by transition to 2015
Program final rule, our burden estimates 42,951 respondents who would be CEHRT. Therefore, as shown in Table
assumed all clinicians who submitted excluded under the finalized significant 66, the total burden hours for an
quality data would also submit under hardship exception for small practices. organization to submit data on the
the advancing care information We also do not include clinicians in
performance category. For this final rule specified Advancing Care Information
ambulatory surgical centers.
with comment period, MIPS special Our burden estimates in the CY 2017 Objectives and Measures is estimated to
status eligibility data were available to Quality Payment Program final rule be 3 incremental hours of a computer
model exceptions. The majority assumed that during the transition year, analysts time above and beyond the
(267,065) of the difference in our 3 hours of clinician time would be clinician, practice manager, and
estimated number of respondents is due required to collect and submit computer systems analyst time required
to the availability of MIPS special status advancing care information performance to submit quality data. The total
data to identify clinicians and groups category data. We anticipate that the estimated burden hours are 654,645
that would also not need to report year-over-year consistency of data (218,215 respondents 3 hours). At a
advancing care information data under submission processes, measures, and computer systems analysts hourly rate,
transition year policies, including activities and the further alignment of the total burden cost is $57,674,225
hospital-based eligible clinicians, the advancing care information (218,215 $264.30/hour).
TABLE 66ESTIMATED BURDEN FOR ADVANCING CARE INFORMATION PERFORMANCE CATEGORY DATA SUBMISSION
Burden
estimate
# of respondents submitting advancing care information data on behalf of clinicians (a) ................................................................. 218,215
Estimated Total Annual Burden Hours Per Respondent (b) ............................................................................................................... 3
Estimated Cost Per Respondent to Submit Advancing Care Information data (@computer systems analysts labor rate of
$88.10/hr.) (d) .................................................................................................................................................................................. $264.30
Estimated Total Annual Burden Cost (e) = (a) * (d) ........................................................................................................................... $57,674,225
The following is a summary of the commenter stated that, based on beyond the time already accounted for
public comments received regarding our feedback from the commenters in the quality data submission process.
request for information on our burden members, the burden estimates (for both Therefore, no changes were made to our
estimates regarding the advancing care clinician times and staff) are burden estimates as a result of this
information performance category. significantly underestimated and urged comment.
Comment: Several commenters shared CMS to review these estimates prior to After consideration of public
concerns regarding the complexity and increasing the reporting thresholds for comments, no changes were made to the
burden of the advancing care the advancing care information advancing care information performance
information performance category. performance category in the future. category burden estimates from the CY
Response: We acknowledge the 2018 Quality Payment proposed rules
commenters concerns regarding the Response: We acknowledge the (82 FR 30227) as a result of comments
advancing care information performance commenters concerns regarding our specific to that performance category.
categorys complexity. We anticipate a time and cost estimates. Our estimates The burden estimates were updated
reduction in the burden of reporting are grounded in reliable data sources, from the PQRS 2016 data to reflect
advancing care information performance our assumptions are based in past updated data sources on the number of
category measures as eligible clinicians, program methodologies, and our respondents. Our decision not to
and organizations reporting on their analysis and justifications are detailed finalize implementing facility-based
behalf, become more familiar with, and in this section of the final rule with measurement (82 FR 30125) until the
have adapted to, the measure comment period. We anticipate that beginning of the 2019 performance
specifications. most organizations will use the same period does not affect these numbers
Comment: One commenter believed data submission mechanism for the because we had selected facility-based
that CMS underestimated the amount of advancing care information and quality clinicians from a subset of clinicians
time and costs required to participate in performance categories and that the that could qualify for automatic
the advancing care information clinicians, practice managers, and reweighting.
performance category for its burden computer systems analysts involved in

estimates because the objectives and supporting the quality data submission H. ICR Regarding Burden for
measures require 3 incremental hours of will also support the advancing care Improvement Activities Submission
a computer analysts time in addition to information data submission process. ( 414.1355)
the clinicians, practice managers, and Hence, the burden estimate for the Requirements for submitting
computer systems analysts time submission of advancing care improvement activities did not exist in
required to submit quality data, at information data below shows only the legacy programs replaced by MIPS,
$88.10 per hour (wage) or $264.30. The incremental hours required above and and we do not have historical data
which is directly relevant. In section manner that they are otherwise scored groups to submit improvement activities
II.C.6.e.(3) of this final rule with for MIPS eligible clinicians. If, by our on behalf of clinicians during the 2018
comment period, we finalize that (1) for assessment, the MIPS APM does not MIPS performance period, and an
purposes of the 2020 MIPS payment receive the maximum improvement additional 16 virtual groups to submit
year and future years and future activities performance category score, improvement activities, resulting in
payment years, MIPS eligible clinicians then the APM Entity can submit 524,488 total respondents. However, the
or groups must submit data on MIPS additional improvement activities, burden estimates have been updated
improvement activities in one of the although, as we noted, we anticipate from the CY 2018 Quality Payment
following manners: via qualified that MIPS APMs in the 2018 MIPS Program proposed rule to reflect
registries; EHR submission mechanisms; performance period will not need to updated data sources on the number of
QCDR, CMS Web Interface; or submit additional improvement respondents.
attestation. For activities that are activities as the models will already In this final rule with comment
performed for at least a continuous 90 meet the maximum improvement period, we are updating our estimates to
days during the performance period, activities performance category score. reflect an additional 923 groups for a
MIPS eligible clinicians must submit a A variety of organizations and in total of 4,741 based using the more
yes response for activities within the some cases, individual clinicians, will recent 2016 PQRS data and 85,625 fewer
Improvement Activities Inventory. In submit improvement activity clinicians reporting as individuals for
sections II.C.6.e.(2)(a) and II.C.6.e.(3)(b) performance category data. For the improvement activities performance
of this final rule with comment period, clinicians who are not part of APMs, we category.
we finalized that the term recognized assume that clinicians submitting As represented in Table 67, we
is accepted as equivalent to the term quality data as part of a group or virtual estimate 435,029 clinicians will submit
certified when referring to the group through the QCDR and registry, improvement activities as individuals
requirements for a patient-centered EHR, and CMS Web Interface during the 2018 MIPS performance
medical home and would receive full submission mechanisms will also period, an estimated 4,741 groups to
credit for the improvement activities submit improvement activities data. As submit improvement activities on behalf
performance category. We also note that finalized in the CY 2017 Quality of clinicians during the 2018 MIPS
for the 2020 MIPS payment year and Payment Program final rule (82 FR performance period, and an additional
future years, to receive full credit as a 77264), APM Entities only need to 16 virtual groups to submit
certified or recognized patient-centered report improvement activities data if the improvement activities, resulting in
medical home or comparable specialty CMS-assigned improvement activities 439,786 total respondents. The burden
practice, at least 50 percent of the score is below the maximum estimates assume there will be no
practice sites within the TIN must be improvement activities score. Our CY improvement activities burden for MIPS
recognized as a patient-centered 2018 Quality Payment Program final APM participants. We will assign the
medical home or comparable specialty rule burden estimates assume all ACOs improvement activities performance
practice. Finally, in the CY 2017 Quality will receive the maximum CMS- category score at the APM level. We
Payment Program final rule, we describe assigned improvement activities score. assume that the MIPS APM models for
how we determine MIPS APM scores In the CY 2018 Quality Payment the 2018 MIPS performance period
(81 FR 77185). We compare the Program proposed rule (82 FR 30228), would qualify for the maximum
requirements of the specific MIPS APM we estimated 520,654 clinicians will improvement activities performance
with the list of activities in the submit improvement activities as category score and the APM Entities
Improvement Activities Inventory and individuals during the 2018 MIPS would not need to submit any
score those activities in the same performance period, an estimated 3,818 additional improvement activities.
TABLE 67ESTIMATED NUMBERS OF ORGANIZATIONS SUBMITTING IMPROVEMENT ACTIVITIES PERFORMANCE CATEGORY

DATA ON BEHALF OF CLINICIANS
Count
Estimated # of clinicians to participate in improvement activities data submission as individuals during the 2018 MIPS perform-
ance period (a) ................................................................................................................................................................................. 435,029
Estimated # of Groups to submit improvement activities on behalf of clinicians during the 2018 MIPS performance period (b) ..... 4,741
Estimated # of Virtual Groups to submit improvement activities on behalf of clinicians during the 2018 MIPS performance period
(c) ..................................................................................................................................................................................................... 16
Total # of Respondents (Groups, Virtual Groups, and Individual Clinicians) to submit improvement activities data on behalf of
clinicians during the 2018 MIPS performance period (d) = (a) + (b) + (c) ..................................................................................... 439,786
In Table 68, we estimate that hours to submit data on the specified will need to spend less time selecting
approximately 439,786 respondents will improvement activities will be 1 hour of activities because they may be able to
be submitting data under the computer system analyst time in select only two high-weighted activities
improvement activities performance addition to time spent on other instead of four medium-weighted
category. Our burden estimates in the performance categories. Our revised activities.
CY 2017 Quality Payment Program final estimate is based on changes we made Additionally, the same improvement
rule assumed that during the transition to include additional new high- activity may be reported across multiple
year, 2 hours of clinician time would be weighted activities that were in performance periods so many MIPS
required to submit data on the specified response to comments from eligible clinicians will not have any
improvement activities. For this final stakeholders (82 FR 30052). The additional information to develop for
rule with comment period, our burden addition of more high-weighted the 2018 MIPS performance period. The
estimate assumes that the total burden activities means that some clinicians total estimated burden hours are
439,786 (439,786 responses X 1 hour). (439,786 $88.10/hour). This is based

At a computer systems analysts hourly on updated data from PQRS 2016.
rate, the total burden cost is $38,745,147
TABLE 68ESTIMATED BURDEN FOR IMPROVEMENT ACTIVITIES SUBMISSION

Burden
estimate
Total # of Respondents (Groups, Virtual Groups, and Individual Clinicians) to submit improvement activities data on behalf of
clinicians during the 2018 MIPS performance period (a) ................................................................................................................ 439,786
Estimated Total Annual Burden Hours Per Respondent (b) ............................................................................................................... 1
Estimated Total Annual Burden Hours (c) .......................................................................................................................................... 439,786
Estimated Cost Per Respondent to submit improvement activities (@computer systems analysts labor rate of $88.10/hr.) (d) .... $88.10
Estimated Total Annual Burden Cost (e) = (a) * (d) ........................................................................................................................... $38,745,147
The following is a summary of the vendors for submitting improvement new improvement activities to us via
public comments received regarding our activities as a result of this comment. email. As shown in Table 69, based on
burden estimates for submission of After consideration of public a response to an informal call for new
improvement activities. comments, we made no changes to the proposed improvement activities during
Comment: One commenter did not improvement activities submission the transition year, we estimate that
dispute the time estimation (524,488 burden estimates from the CY 2018 approximately 150 organizations
clinicians that are not part of APMs will Quality Payment Program proposed rule (clinicians, groups or other relevant
submit improvement activities taking (82 FR 30228). The burden estimates stakeholders) will nominate new
one hour each) but expressed concern were updated from the CY 2018 Quality improvement activities. We estimate it
that CMS is not considering the direct Payment Program proposed rule to will take an estimated 0.5 hours per
costs charged by vendors for submitting reflect updated data sources on the
organization to submit an activity to us,
improvement activities via qualified number of respondents.
including an estimated 0.3 hours per
registry and/or EHR, which can be
I. ICR Regarding Burden for Nomination practice for a practice administrator to
substantial as reflected in the updated
of Improvement Activities 414.1360) make a strategic decision to nominate
qualified registries and QCDR lists for
the MIPS 2017 performance period. For the 2018 MIPS performance that activity and submit an activity to us
Response: The costs and benefits are period, we finalizing to formalize to via email at a rate of $105.16/hour for
discussed in section VI.F. of this final allow clinicians, groups, and other a total of $31.55 per activity and
rule with comment period. Since the relevant stakeholders to nominate new clinician review time of 0.2 hours at a
burden estimates in this section address improvement activities using a rate of $202.08/hour for a total of $40.42
time costs, not direct financial costs, no nomination form provided on the per activity. We estimate that the total
changes were made to the burden Quality Payment Program Web site at annual burden cost is $10,796 (150
estimate for direct costs charged by qpp.cms.gov, and to send their proposed $71.96).
TABLE 69ESTIMATED BURDEN FOR NOMINATION OF IMPROVEMENT ACTIVITIES

Burden
estimate
# of Organizations Nominating New Improvement Activities (a) ........................................................................................................ 150

Estimated # of Hours Per Practice Administrator to Identify and Propose Activity (b) ...................................................................... 0.30
Estimated # of Hours Per Clinician to Identify Activity (c) .................................................................................................................. 0.20
Estimated Annual Burden Hours Per Respondent (d) = (b) + (c) ...................................................................................................... 0.50
Estimated Total Annual Burden Hours (e) = (a) * (d) ......................................................................................................................... 75.00
Estimated Cost to Identify and Submit Activity (@practice administrators labor rate of $105.16/hr.) (f) .......................................... $31.55
Estimated Cost to Identify Improvement Activity (@physicians labor rate of $202.08/hr.) (g) .......................................................... $40.42
Estimated Total Annual Cost Per Respondent (h) = (f) + (g) ............................................................................................................. $71.97
Estimated Total Annual Burden Cost (i) = (a) * (h) ............................................................................................................................ $10,796
We did not receive comments specific eligible clinicians. MIPS eligible K. ICR Regarding Partial QP Elections
to our burden estimates for nomination clinicians are not requested to provide ( 414.1430)
of improvement activities. The burden any documentation by CD or hardcopy.
estimates have not been updated from Therefore, under the cost performance APM Entities may face a data
the CY 2018 Quality Payment Program category, we do not anticipate any new submission burden under MIPS related
proposed rule (82 FR 30229). or additional submission requirements to Partial QP elections. Advanced APM
participants will be notified about their

J. ICRs Regarding Burden for Cost for MIPS eligible clinicians. We did not
QP or Partial QP status before the end
( 414.1350) receive comments specific to cost
of the performance period. For
performance category and no changes
The cost performance category relies Advanced APMs the burden of partial
on administrative claims data. The were made to this section. QP election would be incurred by a
Medicare Parts A and B claims representative of the participating APM
submission process is used to collect Entity. For the purposes of this burden
data on cost measures from MIPS estimate, we assume that all MIPS
eligible clinicians determined to be approximately 17 APM Entities will face We estimate it will take the APM Entity
Partial QPs will participate in MIPS. the data submission requirement in the representative 15 minutes to make this
Based on our analyses of the initial 2018 performance period. election. Using a computer systems
QP determination file as described in As shown in Table 70, we assume that analysts hourly labor cost, we estimate
the 2017 Quality Payment Program final 17 APM Entities will make the election a total burden cost of just $375 (17
rule (81 FR 77444), we assume that to participate as a partial QP in MIPS. participant $22.03).
TABLE 70ESTIMATED BURDEN FOR PARTIAL QP ELECTION

Burden
estimate
# of APM Entities Electing Partial QP Status on behalf of their Participants (a) ............................................................................... 17
# of Organizations Electing Partial QP Status on Behalf of Advanced APM Participants (c) = (a) + (b) .......................................... 17
Estimated Burden Hours Per Respondent to Elect to Participate as Partial QP (d) .......................................................................... 0.25
Estimated Total Annual Burden Hours (e) = (c) * (d) ......................................................................................................................... 4.25
Estimated Cost Per Respondent to Elect to Participate as Partial QP (@computer systems analysts labor rate of $88.10/hr.) (f) $22.03
Estimated Total Annual Burden Cost (g) = (c) * (f) ............................................................................................................................ $375
We did not receive comments specific Advanced APMs. The All-Payer qualify as Other Payer Advanced APMs.
to our burden estimates for partial QP Combination Option allows for eligible This payer-initiated identification
elections. Our burden estimates for clinicians to achieve QP status through process of Other Payer Advanced APMs
partial QP elections have not been their participation in both Advanced will begin in CY 2018, and
changed from the CY 2018 Quality APMs and Other Payer Advanced determinations would be applicable for
Payment Program proposed rule (82 FR APMs. In order to include an eligible the Quality Payment Program Year 3.
30229). clinicians participation in Other Payer As shown in Table 71, we estimate
Advanced APMs in their QP threshold that 300 other payer arrangements will
L. ICRs Regarding Other Payer score, we will need to determine if be submitted (50 Medicaid payers, 150
Advanced APM Determinations: Payer- certain payment arrangements with Medicare Advantage Organizations, and
Initiated Process ( 414.1440) and other payers meet the criteria to be 100 Multi-payers) for identification as
Medicaid Specific Eligible Clinician Other Payer Advanced APMs. To Other Payer Advanced APMs. The
Initiated Process ( 414.1445) provide eligible clinicians with estimated burden to apply is 10 hours
1. Payer Initiated Process advanced notice prior to the start of the per payment arrangement, for a total
2019 performance period, and to allow annual burden hours of 3,000 (300 X
Beginning in Quality Payment other payers to be involved 100). We estimate a total cost per payer
Program Year 3, the All-Payer prospectively in the process, we of $881.00 using a computer system
Combination Option will be an available finalized in section II.D.6.c.(1)(b) of this analysts rate of $88.10/hour (10 X
pathway to QP status for eligible final rule with comment period a payer- 81.10). The total annual burden cost for
clinicians participating sufficiently in initiated identification process for all other payers is $264,300 (300 X
Advanced APMs and Other Payer identifying payment arrangements that $881.00).
TABLE 71BURDEN FOR OTHER PAYER ADVANCED APM IDENTIFICATION DETERMINATIONS: PAYER-INITIATED PROCESS
Burden
estimate
Estimated # of other payer payment arrangements (50 Medicaid, 150 Medicare Advantage Organizations, 100 Multi-payers) (a) 300
Estimated Total Annual Burden Hours Per other payer payment arrangement (b) ........................................................................... 10
Estimated Cost Per Other Payer (@computer systems analysts labor rate of $88.10/hr.) (d) ......................................................... $881.00
Estimated Total Annual Burden Cost for Other Payer Advanced APM determinations (e) = (a) * (d) .............................................. $264,300
The following is a summary of the Initiated Process, the commenter noted CMS should transparently acknowledge
public comments received regarding our that it is assumed this reflects the that it will be quite burdensome on
request for information on our burden number of plans that will request model these clinicians.
estimates for Other Payer Advanced approval. The commenter requested Response: In response to the public
APM identification: Payer-Initiated clarification regarding why CMS does comment, we have added a burden
Process. not include an estimate for the APM estimate, which is included in Table 72,
Comment: One commenter noted that Entity Initiated process and inquired for the Medicaid specific Eligible
in Table 84 of the CY 2018 Quality whether CMS does not believe any Clinician Initiated Process where APM
Payment Program proposed rule (82 FR clinicians will endeavor to get models Entities and eligible clinicians can
30230), CMS suggests that 300 approved. It is also unclear why the request to have Medicaid payment
organizations would request an Other process through which clinicians arrangements they are participating in
Payer Advanced APM Identification: request an All-Payer Combination QP assessed to determine if they are Other
Payer Initiated Process and that the total calculation does not appear to be Payer Advanced APMs. For non-
hours to prepare such requests per accounted for in CMSs burden Medicare payers other than Medicaid,
organization would be 10 hours at a cost estimates. The commenter believed that we did not include the burden estimate
of $88.10. Given that it says Payer clinicians will choose to do so, and that for the Eligible Clinician Initiated
process because in 2018, only the Payer clinicians participation in Other Payer eligible clinicians may request
Initiated Process through which other Advanced APMs in their QP threshold determinations for any Medicaid
payers can request CMS make score, we will need to determine if payment arrangements in which they
determinations prospectively as to certain payment arrangements with are participating at an earlier point,
whether payment arrangements qualify other payers meet the criteria to be prior to the start of the 2019
as Other Payer Advanced APMs is Other Payer Advanced APMs. performance period. This would allow
available. We will include the burden To provide eligible clinicians with all clinicians in a given state or county
estimate for the Eligible Clinician advanced notice prior to the start of the to know before the beginning of the
Initiated process in the CY 2019 Quality 2019 performance period, and to allow performance period whether their Title
Payment Program proposed rule. other payers to be involved XIX payments and patients would be
After consideration of public prospectively in the process, we excluded from the all-payer calculations
comments, we made no changes to the finalized in section II.D.6.c.(1) of this that are used for QP determinations for
Other Payer Advanced APM final rule with comment period a payer- the year under the All-Payer
Identification: Payer-Initiated Process initiated identification process for Combination Option. This Medicaid
burden from the CY 2018 Quality identifying payment arrangements that specific eligible clinician-initiated
Payment Program proposed rule (82 FR qualify as Other Payer Advanced APMs. determination process of Other Payer
30230), and have added the burden for However, to appropriately implement Advanced APMs will also begin in CY
the Medicaid specific Eligible Clinician the Title XIX exclusions, we determined 2018, and determinations would be
Initiated Process in this section of the it was not feasible to allow APM Entities applicable for the Quality Payment
final rule with comment period. and eligible clinicians to request
Program Year 3.
determinations for Title XIX payment
2. Medicaid Specific Eligible Clinician arrangements after the conclusion of the As shown in Table 72, we estimate
Initiated Process ( 414.1445) All-Payer QP. To do so would mean that that 75 other payer arrangements will be
Beginning in Quality Payment a single clinician requesting a submitted by APM Entities and eligible
Program Year 3, the All-Payer determination for a previously unknown clinicians for identification as Other
Combination Option will be an available Medicaid APM or Medicaid Medical Payer Advanced APMs. The estimated
pathway to QP status for eligible Home Model that meets the Other Payer burden to apply is 10 hours per
clinicians participating sufficiently in Advanced APM criteria could payment arrangement, for a total annual
Advanced APMs and Other Payer unexpectedly affect QP threshold burden hours of 1,500 (150 10). We
Advanced APMs. The All-Payer calculations for every other clinician in estimate a total cost per payer of
Combination Option allows for eligible that state (or county) as described in $881.00 using a computer system
clinicians to achieve QP status through section II.D.6.c.(3)(b) of the proposed analysts rate of $88.10/hour (10
their participation in both Advanced rule. Thus, we also finalized in section 81.10). The total annual burden cost for
APMs and Other Payer Advanced II.D.6.c.(3) of this final rule with all other payers is $66,075 (75
APMs. In order to include an eligible comment period that APM Entities and $881.00).
TABLE 72BURDEN FOR OTHER PAYER ADVANCED APM DETERMINATIONS: MEDICAID SPECIFIC ELIGIBLE CLINICIAN
INITIATED PROCESS
Burden
estimate
Estimated # of other payer payment arrangements from APM Entities and eligible clinicians .......................................................... 75
Estimated Total Annual Burden Hours Per other payer payment arrangement (b) ........................................................................... 10
Estimated Total Annual Burden Hours (c) = (a) * (b) ......................................................................................................................... 750
Estimated Cost Per Other Payer (@computer systems analysts labor rate of $88.10/hr.) (d) ......................................................... $881.00
Estimated Total Annual Burden Cost for Other Payer Advanced APM determinations (e) = (a) * (d) .............................................. $66,075
M. ICRs Regarding Burden for Voluntary in MIPS but also will elect not to labor rate of $88.10. The total annual
Participants to Elect Opt Out of participate in public reporting. Table 73 burden hours for opting out is estimated
Performance Data Display on Physician shows that for these voluntary at 5,600 hours (22,400 0.25). The total
Compare ( 414.1395) participants, they may submit a request annual burden cost for opting out for all
We estimate 22,400 clinicians and to opt out which is estimated at 0.25 requesters is estimated at $493,472
groups who will voluntarily participate hours of a computer system analysts (22,400 $22.03).
TABLE 73BURDEN FOR VOLUNTARY PARTICIPANTS TO ELECT OPT OUT OF PERFORMANCE DATA DISPLAY ON PHYSICIAN
COMPARE
Burden
estimate
Estimated # of Voluntary Participants Opting Out of Physician Compare (a) .................................................................................... 22,400
Estimated Total Annual Burden Hours Per Opt-out Requester (b) .................................................................................................... 0.25
Estimated Total Annual Burden Hours for Opt-out Requester (c) = (a) * (b) ..................................................................................... 5,600
Estimated Cost Per Physician Compare Opt-out Request@computer systems analysts labor rate of $88.10/hr.) (d) .................... $22.03
Estimated Total Annual Burden Cost for Opt-out Requester (e) = (a) * (d) ....................................................................................... $493,472
We did not receive comments specific the 2018 performance period. This from the advancing care information
to our burden estimates for voluntary estimated baseline burden of 7,760,708 performance category and to more
participants to elect opt out of hours and a total labor cost of accurately reflect the exclusion of QPs
performance data display on Physician $708,101,886 is lower than the burden from all MIPS performance categories.
Compare. The burden estimates are approved for information collection We estimate that this final rule with
unchanged from the CY 2018 Quality related to the CY 2017 Quality Payment
comment period will decrease burden
Payment Program proposed rule (82 FR Program final rule 46 because we
by 171,264 hours and $13.9 million in
30230). anticipate greater respondent familiarity
with the measures and data submission labor costs relative to the estimated
N. Summary of Annual Burden methods in their second year of baseline of continued transition year
Estimates participation. Our baseline estimates are policies. The Quality Payment Program
Table 74 includes our CY 2018 based on 2018 data, and therefore, do Year 2 reduction in burden based on
Quality Payment Program final rule not exclude those individuals that were policies established in this final rule
with comment period burden estimates impacted by the hurricanes of 2017, reflects several finalized policies,
for annual recordkeeping and data Harvey, Irma and Maria that are referred including our finalized policy for a new
submission of 7,589,445 hours with to in the interim final rule with significant hardship exception for small
total labor cost of $694,183,802. In order comment period pertaining to extreme practices for the advancing care
to understand the burden implications and uncontrollable circumstances for information performance category,
of the policies finalized in this rule, we the 2017 performance period. Further, reduced length of the CAHPS survey
have also estimated a baseline burden of our estimated baseline burden estimates and the finalized policy to allow MIPS
continuing the policies and information reflect the recent availability of data eligible clinicians to form virtual
collections set forth in the CY 2017 sources to more accurately reflect the groups, which would create efficiencies
Quality Payment Program final rule into number of the organizations exempt in data submission.
TABLE 74ANNUAL RECORDKEEPING AND SUBMISSION REQUIREMENTS

Respondents/ Hours per Total annual Labor cost Total annual
responses response burden hours of submission burden cost
Registration for Virtual Groups ............................ 16 10.0 160 Varies (See Table 51) ... $13,313
QCDR and Registries self-nomination ................ 233 10.0 2,330 $88.10 ............................ 439,786
CAHPS Survey Vendor Application .................... 15 10.0 150 $88.10 ............................ 13,215
(Quality Performance Category) Claims Submis- 278,039 17.8 4,949,094 Varies (See Table 57) ... 454,977,459
sion Mechanism.
(Quality Performance Category) Qualified Reg- 107,217 9.1 973,852 Varies (See Table 58) ... 91,247,028
istry or QCDR Submission Mechanisms.
(Quality Performance Category) EHR-Submis- 54,218 9.0 487,962 Varies (See Table 59) ... 45,762,161
sion Mechanism.
(Quality Performance Category) CMS Web 296 74.0 21,904 $88.10 ............................ 1,929,624
Interface Submission Mechanism.
(Quality Performance Category) Registration 10 1.0 10 $88.10 ............................ 881
and Enrollment for CMS Web Interface.
(CAHPS for MIPS Survey) Beneficiary Participa-

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53568 Federal Register / Vol. 82, No.

220 / Thursday, November 16, 2017 / Rules and Regulations

BPCI Bundled Payments for Care RIA Regulatory Impact Analysis

e. Submission Mechanisms practitioners or one or more groups g. MIPS APMs

practices. designated under section 332(a)(1)(A) of establishing a 75 percent threshold

Performance category/submission Individual reporting data submission mechanisms

Quality ................................................................. Claims.

Performance category/submission Group reporting data submission mechanisms

Quality ................................................................. QCDR.

Performance category/submission Group reporting data submission mechanisms

CMS Web Interface (groups of 25 or more).

finalized a reliability threshold of 0.4 for development. weight of 10 percent. Furthermore,

is a patient-centered medical home, we patient-centered medical home or 414.1380(3)(iv) for details. We

Regional Health Improvement or interpretation and transportation

Medicare Act of 2014. Qualified mechanisms will be

testing, tracking, follow-up, and patient communica-

tion reconciliation and management; and/or

developing a plan of care. documented in the CEHRT. View, Download, Transmit

Request/Accept Summary of Care ** ..... Required ...... Up to 10% ... Numerator/Denominator.

Bonus (up to 25%)

Objective Measure 2015 Edition 2014 Edition

170.315(a)(10) (Drug-Formulary and Pre- 170.314(a)(10) (Drug-Formulary and Pre-

Objective Measure 2015 Edition 2014 Edition

Objective Measure 2015 Edition 2014 Edition

TABLE 11BENCHMARK DECILE DISTRIBUTION

Example Benchmark Decile 1 ..................................................................................................................... 09.9 1.01.9

the date of the positive screen.

TABLE 14MIPS APM MEASURES LISTONCOLOGY CARE MODELContinued

TABLE 15MIPS APM MEASURES LISTCOMPREHENSIVE ESRD CARE

TABLE 15MIPS APM MEASURES LISTCOMPREHENSIVE ESRD CAREContinued

TABLE 15MIPS APM MEASURES LISTCOMPREHENSIVE ESRD CAREContinued

TABLE 16MIPS APM MEASURES LISTCOMPREHENSIVE PRIMARY CARE PLUS (CPC+)

TABLE 16MIPS APM MEASURES LISTCOMPREHENSIVE PRIMARY CARE PLUS (CPC+)Continued

cause hospital readmission measure as a priority measures, even if the measures

TABLE 17NEWLY FINALIZED SSM FOR CAHPS FOR MIPS SCORING

Access to Specialists ................................................................................................................................ Yes ........................ No.

TABLE 20QUALITY PERFORMANCE CATEGORY: SCORING MEASURES BASED ON PERFORMANCE

TABLE 20QUALITY PERFORMANCE CATEGORY: SCORING MEASURES BASED ON PERFORMANCEContinued

TABLE 21SCORING ALLOWED ACROSS MULTIPLE MECHANISMS BY SUBMISSION MECHANISM

EHR (using end-to-end) Reporting that meets

Measure E ................................... 5.1 ............................................... 5.1 ............................................... ..................................................... 1.

35.6 ............................................. 1 (below 10% cap 1) ................... 5 (below 10% cap).

Quality Performance Category ..................................................... (35.6 + 1 + 5)/60 = 69.33%

We proposed to amend We invited comments on the proposal submitted using 2 different

on improvement. In addition, we Comment: Many commenters encourage clinician participation and

MIPS performance period. Because we year.

TABLE 23PROPOSED ELIGIBILITY FOR IMPROVEMENT SCORING EXAMPLES

TABLE 23PROPOSED ELIGIBILITY FOR IMPROVEMENT SCORING EXAMPLESContinued

We proposed at category achievement percent score data sufficiency standard. As required

Total ......................................................................................................... 14.6 20 N/A ................. N/A.

of additional system-based measures clinicians, we plan to delay Comment: Several commenters

Person and Community Engagement Domain

Clinical Care Domain

Efficiency and Cost Reduction Domain

Hospital Inpatient Prospective Payment public comments received on the

Quartile 1Lowest Average HCC Score .................................................................................... 1.26 1.33 2.52

Dual Eligible Quartile

Quartile 1Low Proportion of Dual Eligible ................................................................................ 1.42 0.84 2.19

TABLE 28WEIGHTS BY MIPS PERFORMANCE CATEGORY

Scores for all four performance categories .................................................. 50 10 15 25

Reweight One Performance Category

Reweight Two Performance Categories

No Cost and no Advancing Care Information .............................................. 85 0 15 0

1848(q)(6)(E) of the Act, we finalized a apply beginning with the transition