The QPP Proposed Rule 2021: What’s in Store for MIPS and ACOs

By Matthew Fusan, General Manager, Population Health, SPH Analytics
Twitter: @SPHAnalytics

Recently CMS released the proposed rule for the 2021 Quality Payment Program (QPP), which covers both the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs).

For MIPS, there was speculation leading up to the release of the rule about how the COVID-19 pandemic would impact the program for 2020 and 2021. A thorough analysis of the proposed rule can be summarized at the highest level by saying that the COVID-related impacts are relatively minor, and ultimately, both 2020 and 2021 will require full participation for MIPS eligible clinicians and groups.

For APMs, and in particular Shared Savings ACOs, the proposed changes are much more significant, and have meaningful strategic and operational impacts on clinicians and entities participating in these payment models.

The most significant change CMS has proposed is the elimination of the Web Interface/GPRO submission method starting with performance year 2021. For organizations that have relied on this method to simplify MIPS quality submission in complex organizational and EHR ecosystems, 2021 will pose new strategic and operational challenges. These organizations will want to start analyzing the impact of this change, conduct scenario and cost analysis on the remaining submission methods, and have a plan in place going into 2021. This may necessitate changing submission partners/vendors or establishing a first-time relationship, depending upon internal IT resources within the submitting entity.

The Performance Threshold to achieve positive impacts to reimbursement would continue to rise under the proposed rule, moving from 45 to 50 points. 2021 is the final year of the initial 5 year MIPS Transition Period that CMS established in 2017, and by law, starting in 2022, the Performance threshold will be set at the mean or median score which is expected to be between 65 and 70 points. Organizations must take advantage of the final year of the transition period to prepare for 2022 when avoiding a penalty will become significantly more difficult. This is a good year to make sure the infrastructure and expertise to prepare for the future is resident either internally or via an expert vendor.

Another meaningful change is the continued move to align the weightings of the Quality and Cost categories. Under the proposed rule, in 2021 the Quality category decreases from 45 to 40 points, and the Cost category increases from 15 to 20 points. Again, by law, both Quality and Cost must be worth 30 points each in 2022. Note Quality and Cost are two of the four performance categories; the others are Performance Improvement and Promoting Interoperability.

Finally, in a change that won’t have much operational impact on today’s MIPS participants, CMS is proposing to delay the introduction of the MIPS Value Pathways (MVPs) program until at least 2022. In the proposed rule CMS clarified and expanded on the MVP Guiding Principles and created new MVP Development Guidelines to provide more structure for the various stakeholders that will develop the specific MVPs.

ACOs or other APMs
There are four potential big changes for Shared Savings ACOs in 2021 under the proposed rule:

  • The introduction of a new APM Performance Pathways (APP) model;
  • The elimination of the Web Interface/GPRO submission method that ACOs have used to report quality for both MIPS and the Shared Savings program;
  • The creation of options regarding who will submit the required data to CMS – moving from only having the ACO entity itself submit, to the options to have ACO participants submit at the TIN or individual clinician level
  • The CAHPS for ACOs surveys would be discontinued at the ACO entity level and would be replaced by CAHPS for MIPS surveys at the participating TIN level

The proposed new APP model would reduce the number of overall quality measures that ACOs are required to submit, but it also creates new strategic and operational challenges. Under the proposed rule, the number of quality measures for ACOs would drop from 23 to 6, with 1 measure tied to CAHPS for MIPS, 3 measures tied to existing quality measures, and 2 new claims-based population health measures.

Aligned with the proposed changes for MIPS, the proposed rule would eliminate the Web Interface/GPRO submission method. This would create challenges for any ACOs that fully relied on that methodology to aggregate and submit data. Instead, ACOs will need to submit quality data using eCQMs, MIPS CQMs (qualified registry), or QCDR measures.

In addition to changing how data is submitted by eliminating the Web Interface/GPRO option, the proposed rule would also change who can submit data. ACOs and their participating organizations will now have a choice to submit Quality data at the ACO, participating TIN, or Individual clinician level. Under this proposed change, participating TINs and clinicians could also choose to submit data for MIPS even as they are included in ACO-level reported data. CMS would then compare the results of reporting at these various entity levels and would award the provider with the higher of the two scores. These changes create a list of questions that ACOs and their participants need to work through. At what level will Quality reporting be done? If at the ACO level, what is the best model for collecting and calculating the quality measures? If at the TIN or clinician level, what level of insight and operational assistance will the ACOs provide? What type of scenario modeling is needed to determine the best submission model? Can the ACO and participants maximize reimbursement by submitting through both the APP and for MIPS? There is a lot to figure out in a relatively short period of time.

Finally, to align the patient experience processes with proposed quality reporting options, starting in 2021 the CAHPS for ACOs surveys, which were submitted at the ACO entity level, would be discontinued. In their place, ACO participants would instead conduct CAHPS for MIPS surveys which would be conducted at the participating TIN level. This is another change which will force ACOs and their participants to make significant decisions about how best to comply with the proposed rule. Will the ACOs provide assistance in sourcing and funding the CAHPS for MIPS surveys for their participants or will each participating organization be accountable on their own? Will information be shared or benchmarked? How much support ACOs decide to provide for CAPHS surveys for their participating organizations could certainly have a competitive advantage in recruiting and retention.

Implications for providers
There are several areas of impact in 2021 that participating providers should be aware of.

First and foremost, all provider organizations should recognize that there are still active participation and submission requirements for all Medicare-reimbursed providers, whether it be via MIPS or ACOs or other Alternative Payment Models.

In terms of timing, CMS states that the 2021 QPP Final Rule will be delayed 30 days which aligns with an early December release, leaving less than a month before the new performance year begins.

From a resource and expertise perspective, because of the shifting nature of the program, providers should ensure that they have experts internally or through relationships with expert vendors that can help them navigate the changing regulations and optimize their reimbursement and quality measurement opportunities.

For ACO providers, 2021 will introduce new submission requirements and options for how they participate in MIPS. Understanding the options and conducting scenario analysis will be critical to maximizing success. This won’t be a static reporting exercise, but rather a dynamic environment where ACOs make strategic choices regarding what is best for their patients, providers, and reimbursement.

For provider organizations that have utilized the Web Interface/GPRO submission option (whether ACOs or MIPS), they will need to analyze their options for performance year 2021 and beyond to determine which submission option will maximize their program performance. Outside experts may prove useful in making this determination for organizations that are not regulatory experts or lack the tools to do the scenario analyses required to make optimal choices.

Finally, it is important to remember that this Proposed Rule may differ somewhat from the Final Rule which will be released in December. However, In recent years, both the Final and Proposed rules have tended to be quite similar. This means organizations should not wait until the final rule is published to begin planning how best to adapt to the proposed changes.

This article was originally published on SPH Analytics and is republished here with permission.

Check out the recent webinar in which experts from SPH Analytics dissected the proposed changes and discussed how they could impact healthcare providers.