CMS Releases 2018 Quality Payment Program Year 2 Proposed Rule

This evening, the Centers for Medicare and Medicaid Services (CMS) released the 2018 Quality Payment Program (QPP) proposed rule, which proposes policies for the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Model (APM) programs for CY 2018 to impact 2020 Medicare physician payments. The proposed rule includes a 60-day comment period; ASCRS will be submitting comments. The proposed rule includes several policy changes recommended by ASCRS and the medical community in comments submitted last year on the 2017 final rule including: continuation of transition flexibility for the performance period and scoring, continuation of 0% weighting of the Cost category, continued use of 2014-certified EHR (CEHRT) technology, and further accommodations for physicians in small practices of 15 or fewer providers.

Specifically, CMS is proposing the following policies in an effort to offer flexibility and reduce burden:

  • Offering the Virtual Groups participation option.
  • Increasing the low-volume threshold to $90,000 in allowed Medicare Part B charges or 200 patients.
  • Allowing the continued use of 2014 Edition CEHRT.
  • Adding bonus points in the scoring methodology for:
    • Caring for complex patients.
    • Using 2015 Edition CEHRT exclusively.
  • Including MIPS performance improvement in the quality performance scoring.
  • Including the option to use facility-based scoring for facility-based clinicians.
  • Flexibility for clinicians in small practices, including: a new hardship exemption under the ACI performance category; bonus points added to final score; and bonus points for measures in the Quality performance category that don't meet data completeness requirements.

Additional details of the program are below:

CMS also released a press release and a fact sheet along with the proposed rule.


MIPS Category Weights

For 2018, CMS proposes to weight each of the categories at the same weight as 2017:

  • Quality Category: 60%
  • Cost Category: 0%
  • Advancing Care Information Category (ACI): 25%
  • Improvement Activities: 15%

CMS is also proposing to implement policies enacted under the 21st Century Cures Act, which would exempt providers practicing solely in ASCs from the ACI category, and to provide a hardship exemption for small practices. In both cases, the provider's category score would be re-weighted to the Quality category.

Performance Period

For 2018, CMS proposes to extend the performance period for the Quality and Cost categories to the full calendar year, but maintain a performance period of at least 90 days for the ACI and Improvement Activities categories. 

Continued Scoring Flexibility for 2018 to Impact 2020 Payment

Following ASCRS and medical community advocacy to continue transition year policies in 2018 to reduce provider burden, CMS proposes to maintain scoring flexibility to assist physicians and practices transitioning to MIPS in the 2018 performance year, but proposes to increase the requirements to avoid a penalty. In 2018, MIPS participants must achieve a MIPS final score of at least 15 points to avoid the 2020 -5% penalty as required by statute. CMS proposes to maintain the exceptional performance threshold of 70 MIPS points for 2018. 

MIPS Categories

Quality: 60% of MIPS Final Score

In accordance with ASCRS and medical community recommendations, CMS is proposing to maintain the current category requirements in 2018. Physicians and groups are required to report on 6 quality measures, with at least one outcome measure, or one high-priority measure if no outcome measures are available. Measures must be reported on at least 50% of all patients if submitting via registry or EHR, and 50% of Medicare Part B patients if submitting via claims. CMS is proposing to score any measure that does not meet the thresholds at 1 point, but for practices with 15 or fewer providers, proposes to score those measures not meeting thresholds at 3 points.

Cost: 0% of MIPS Final Score

Following ASCRS and medical community advocacy, CMS proposes not to include the Cost category in the 2018 MIPS final score to give additional time for physicians transitioning to the program to get used to the measures and for cost measures to be further refined. CMS is not proposing to retain the episode-based measures finalized in 2017 and notes that new episode-based measures are currently being developed. ASCRS is participating in the development of an episode-based measure for cataract surgery to ensure the measure is accurately attributed and risk adjusted.

Advancing Care Information: 25% of the MIPS Final Score

CMS proposes to maintain the scoring methodology for the ACI category, which includes a base score of 4 or 5 measures, depending on EHR certification year, and a performance score. Following ASCRS and medical community advocacy, CMS proposes to allow participants to continue to use 2014-certified technology, but proposes a bonus for those who use 2015 technology. The proposed measures in the category are the same as 2017, but CMS is proposing some exclusions. Physicians who do not write 100 eligible prescriptions will be excluded from the e-Prescribing measure, and those who do not have 100 eligible referrals or transitions of care will be excluded from the health information exchange measures. CMS is also proposing to readjust the bonus structure so physicians who cannot report to immunization registries are not disadvantaged.

Improvement Activities: 15% of the MIPS Final Score

CMS is not proposing any major changes to this category. Physicians practicing in groups of 15 or fewer are still eligible for full credit in the category if they report one high-weighted or two medium-weighted activities. CMS is also proposing several new improvement activities.

Virtual Groups

CMS is proposing to implement virtual groups for MIPS in 2018. Solo practitioners and physicians in practices of 10 or fewer would be able to elect to participate "virtually" as a group and be scored collectively.

Advanced APMs

CMS is proposing to maintain the scoring for MIPS APMs, such as Track 1 ACOs, that do not meet criteria to be considered Advanced APMs. CMS is proposing a modified Track 1 Plus ACO, which incorporates some down-side risk to be considered an Advanced APM and eligible for the 5% bonus.

ASCRS/ASOA will continue to review this proposed rule and will provide additional analysis in upcoming issues of Washington Watch Weekly. If you need additional information on the MACRA program, visit ASCRS/ASOA's MACRA Center web page, call the MACRA hotline at 703-383-5724, or email Allison Madson at