CMS has finalized the rule for the second year of Medicare Access and CHIP Reauthorization Act’s (MACRA) Quality Payment Program (QPP), raising the low-volume threshold for the Merit-based Incentive Payment System (MIPS) but not allowing clinicians the option to participate if they don’t meet the minimum requirements.

In 2018, clinicians will be exempt from MIPS if they receive less than $90,000 in Medicare Part B charges or treat fewer than 200 Medicare beneficiaries—an increase from the 2017 exemption levels of $30,000 and 100 beneficiaries. CMS said the additional exemptions would “further decrease burden on MIPS eligible clinicians that practice in rural areas or are part of a small practice or are solo practitioners.”

Left out of the final is the ability for clinicians to opt in to MIPS if they meet or exceed one, but not both of those thresholds. The agency said the choice would be a complex one for clinicians to make and may “impose additional burdens” in terms of notifying CMS, so the opt-in ability won’t be available until the 2019 performance year.

Major healthcare groups had largely praised the additional exemptions, with the American Hospital Association saying it “would provide needed relief and additional time to transition to MIPS.” Others had supported the change as long as there was an opt-in ability. Without it, the American Medical Group Association (AMGA) said MIPS “will amount to little more than a regulatory compliance exercise for the small percent of clinicians and groups that participate.”

“The transition to value is challenging and CMS understandably wants to ease providers into value,” AMGA president and CEO Jerry Penso, MD, MBA, said in a statement to HealthExec. “But excluding providers isn’t the same as learning how to deliver care in a value-based world. Taking accountability for the quality and cost of care requires years of experience. Despite CMS’ intentions to ensure a smooth transition, AMGA is concerned that this rule actually hinders the prospects for value-based care.”

More than 800,000 clinicians, around 65 percent of Medicare providers, had already been exempted from MIPS under the lower thresholds in place for 2017.

Along with the opt-in ability being axed, two other elements of the proposed rule weren’t finalized:

• The quality performance category’s weight in the final MIPS score was to stay at 60 percent in 2018, but CMS decided to drop the weight to 50 percent, as had been previously finalized
• Eligible clinicians randomized to the control group in the Comprehensive Primary Care Plus (CPC+) model won’t be able to receive full credit as a Medical Home Model, as CMS had proposed, because CPC+ Round 2 hasn’t randomized any practices into a control group

With keeping much of the proposed rule intact, CMS said it will offer “tailored flexibilities” to smaller practices in the Quality Payment Program. Solo practitioners and small practices will be able to form virtual groups to participate in MIPS in 2018, small practices will receive a five point bonus to their final score and a three point bonus to their quality score, along with a hardship exception for the Advancing Care Information category, the successor to Meaningful Use.

While the rule may represent a “gradual transition” into the QPP, it doesn’t continue the “pick your pace” options from 2017. The MIPS cost category will account for 10 percent of the total MIPS score in 2018 and the performance threshold will be increased from three to 15 points.

For the QPP’s other payment track, Advanced Alternative Payment Models (AAPMs), CMS said its goal was to increase participation:

• The 8 percent “generally applicable revenue based nominal amount standard” will be extended, allowing APMs to qualify as Advanced APM for two additional years, through performance year 2020.
• Exempting Round 1 CPC+ Round 1 from the 50 clinician limit on organizations which can earn incentive payments by participating in medical home models.
• Changing Medical Home Models requirements so the minimum required amount of total financial risk increases more gradually.

Looking ahead, the rule sought to lay out ways clinicians in other APMs could be incentivized to participate. For example, CMS will develop a demonstration project to test how Medicare Advantage plans can be included under the APM pathway before 2019 reporting begins.