MACRA Year 2 Proposed Rule

30010 Federal Register / Vol. 82, No.
125 / Friday, June 30, 2017 / Proposed Rules
DEPARTMENT OF HEALTH AND following addresses prior to the close of ACO Accountable Care Organization
HUMAN SERVICES the comment period: API Application Programming Interface
a. For delivery in Washington, DC APM Alternative Payment Model
Centers for Medicare & Medicaid Centers for Medicare & Medicaid APRN Advanced Practice Registered Nurse
ASC Ambulatory Surgical Center
Services Services, Department of Health and ASPE HHS Office of the Assistant
Human Services, Room 445G, Hubert Secretary for Planning and Evaluation
42 CFR Part 414 H. Humphrey Building, 200 BPCI Bundled Payments for Care
[CMS5522P]
Independence Avenue SW., Improvement
Washington, DC 20201. CAH Critical Access Hospital
RIN 0938AT13 (Because access to the interior of the CAHPS Consumer Assessment of
Hubert H. Humphrey Building is not Healthcare Providers and Systems
Medicare Program; CY 2018 Updates to readily available to persons without CBSA Core Based Statistical Area
the Quality Payment Program CEHRT Certified EHR technology
Federal government identification, CFR Code of Federal Regulations
AGENCY: Centers for Medicare & commenters are encouraged to leave CHIP Childrens Health Insurance Program
Medicaid Services (CMS), HHS. their comments in the CMS drop slots CJR Comprehensive Care for Joint
located in the main lobby of the Replacement
ACTION: Proposed rule.
building. A stamp-in clock is available COI Collection of Information
SUMMARY: The Medicare Access and for persons wishing to retain a proof of CPR Customary, Prevailing, and Reasonable
filing by stamping in and retaining an CPS Composite Performance Score
CHIP Reauthorization Act of 2015 CPT Current Procedural Terminology
(MACRA) established the Quality extra copy of the comments being filed.) CQM Clinical Quality Measure
Payment Program for eligible clinicians. b. For delivery in Baltimore, MD CY Calendar Year
Under the Quality Payment Program, Centers for Medicare & Medicaid eCQM Electronic Clinician Quality Measure
eligible clinicians can participate via Services, Department of Health and ED Emergency Department
one of two tracks: Advanced Alternative Human Services, 7500 Security EHR Electronic Health Record
Payment Models (APMs); or the Merit- Boulevard, Baltimore, MD 212441850. EP Eligible Professional
If you intend to deliver your ESRD End-Stage Renal Disease
based Incentive Payment System FFS Fee-for-Service
(MIPS). We began implementing the comments to the Baltimore address, call
telephone number (410) 7867195 in FR Federal Register
Quality Payment Program through FQHC Federally Qualified Health Center
rulemaking for calendar year (CY) 2017. advance to schedule your arrival with GAO Government Accountability Office
This rule provides proposed updates for one of our staff members. Comments HIE Health Information Exchange
the second and future years of the erroneously mailed to the addresses HIPAA Health Insurance Portability and
Quality Payment Program. indicated as appropriate for hand or Accountability Act of 1996
courier delivery may be delayed and HITECH Health Information Technology for
DATES: To be assured consideration, Economic and Clinical Health
received after the comment period. For
comments must be received at one of HPSA Health Professional Shortage Area
information on viewing public
the addresses provided below, no later HHS Department of Health & Human
comments, see the beginning of the
than 5 p.m. on August 21, 2017. Services
SUPPLEMENTARY INFORMATION section. HRSA Health Resources and Services
ADDRESSES: In commenting, please refer
FOR FURTHER INFORMATION CONTACT: Administration
to file code CMS5522P. Because of Molly MacHarris, (410) 7864461, for IHS Indian Health Service
staff and resource limitations, we cannot inquiries related to MIPS. IT Information Technology
accept comments by facsimile (FAX) Benjamin Chin, (410) 7860679, for LDO Large Dialysis Organization
transmission. You may submit inquiries related to APMs. MACRA Medicare Access and CHIP
comments in one of four ways (please SUPPLEMENTARY INFORMATION:
Reauthorization Act of 2015
choose only one of the ways listed): MEI Medicare Economic Index
1. Electronically. You may submit Table of Contents MIPAA Medicare Improvements for
electronic comments on this regulation Patients and Providers Act of 2008
I. Executive Summary and Background MIPS Merit-based Incentive Payment
to http://www.regulations.gov. Follow II. Provisions of the Proposed Regulations System
the Submit a comment instructions. A. Introduction MLR Minimum Loss Rate
2. By regular mail. You may mail B. Definitions MSPB Medicare Spending per Beneficiary
written comments to the following C. MIPS Program Details MSR Minimum Savings Rate
address ONLY: Centers for Medicare & D. Overview of Incentives for Participation MUA Medically Underserved Area
Medicaid Services, Department of in Advanced Alternative Payment NPI National Provider Identifier
Health and Human Services, Attention: Models OCM Oncology Care Model
III. Collection of Information Requirements ONC Office of the National Coordinator for
CMS5522P, P.O. Box 8013, Baltimore,
IV. Response to Comments Health Information Technology
MD 212448013. V. Regulatory Impact Analysis PECOS Medicare Provider Enrollment,
Please allow sufficient time for mailed A. Statement of Need Chain, and Ownership System
comments to be received before the B. Overall Impact PFPMs Physician-Focused Payment Models
close of the comment period. C. Changes in Medicare Payments PFS Physician Fee Schedule
3. By express or overnight mail. You D. Impact on Beneficiaries PHI Protected Health Information
may send written comments to the E. Regulatory Review Costs PHS Public Health Service
following address ONLY: Centers for F. Accounting Statement PQRS Physician Quality Reporting System
mstockstill on DSK30JT082PROD with PROPOSALS2
Medicare & Medicaid Services, PTAC Physician-Focused Payment Model

Acronyms Technical Advisory Committee
Department of Health and Human
Services, Attention: CMS5522P, Mail Because of the many terms to which QCDR Qualified Clinical Data Registry
we refer by acronym in this rule, we are QP Qualifying APM Participant
Stop C42605, 7500 Security QRDA Quality Reporting Document
Boulevard, Baltimore, MD 212441850. listing the acronyms used and their
corresponding meanings in alphabetical Architecture
4. By hand or courier. Alternatively, QRUR Quality and Resource Use Reports
you may deliver (by hand or courier) order below: RBRVS Resource-Based Relative Value
your written comments ONLY to the ABCTM Achievable Benchmark of Care Scale
VerDate Sep<11>2014 19:16 Jun 29, 2017 Jkt 241001 PO 00000 Frm 00002 Fmt 4701 Sfmt 4702 E:\FR\FM\30JNP2.SGM 30JNP2
Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules 30011
RFI Request for Information high-value care and patient outcomes reform efforts, including ensuring a
RHC Rural Health Clinic while minimizing burden on eligible smooth transition to a healthcare system
RIA Regulatory Impact Analysis clinicians; the Program is also designed that promotes high-value, efficient care
RVU Relative Value Unit to be flexible, transparent, and through unification of CMS legacy
SGR Sustainable Growth Rate
structured to improve over time with programs.
TCPI Transforming Clinical Practice
Initiative input from clinicians, patients, and We previously finalized the transition
TIN Tax Identification Number other stakeholders. We have sought and year Quality Payment Program policies
VBP Value-Based Purchasing continue to seek feedback from the in the CY 2017 Quality Payment
VM Value-Based Payment Modifier health care community through various Program final rule. In that final rule, we
VPS Volume Performance Standard public avenues such as rulemaking, implemented policies to improve
listening sessions and stakeholder physician and other clinician payments
I. Executive Summary and Background by changing the way Medicare
engagement. Last year, when we
A. Overview engaged in rulemaking to establish incorporates quality measurement into
policies for effective implementation of payments and by developing new
This proposed rule would make
the Quality Payment Program, we did so policies to address and incentivize
payment and policy changes to the
with the explicit understanding that participation in APMs. The final rule
Quality Payment Program. The
technology, infrastructure, physician established the Quality Payment
Medicare Access and CHIP
support systems, and clinical practices Program and its two interrelated
Reauthorization Act of 2015 (MACRA)
will change over the next few years. For pathways: Advanced APMs, and the
(Pub. L. 11410, enacted April 16, 2015) MIPS. The final rule established
amended title XVIII of the Social more information, see the Merit-based
Incentive Payment System (MIPS) and incentives for participation in Advanced
Security Act (the Act) to repeal the APMs, supporting the goals of
Medicare sustainable growth rate (SGR), Alternative Payment Model (APM)
Incentive under the Physician Fee transitioning from fee-for-service (FFS)
to reauthorize the Childrens Health payments to payments for quality and
Insurance Program, and to strengthen Schedule, and Criteria for Physician-
Focused Payment Models final rule with value, including approaches that focus
Medicare access by improving physician on better care, smarter spending, and
and other clinician payments and comment period (81 FR 77008,
November 4, 2016), hereinafter referred healthier people. The final rule
making other improvements. included definitions and processes to
The MACRA advances a forward- to as the CY 2017 Quality Payment
Program final rule. In addition, we are identify Qualifying APM Participants
looking, coordinated framework for (QPs) in Advanced APMs and outlined
clinicians to successfully take part in aware of the diversity among clinician
practices in their experience with the criteria for use by the Physician-
the Quality Payment Program that Focused Payment Model Technical
rewards value and outcomes in one of quality-based payments. As a result of
these factors, we expect the Quality Advisory Committee (PTAC) in making
two ways: comments and recommendations to the
Advanced Alternative Payment Payment Program to evolve over
multiple years in order to achieve our Secretary on proposals for physician-
Models (Advanced APMs). focused payment models (PFPMs).
Merit-based Incentive Payment national goals. To date, we have laid the
The final rule also established
System (MIPS). groundwork for expansion toward an
policies to implement MIPS, a program
These policies are collectively innovative, outcome-focused, patient-
for certain eligible clinicians that makes
referred to as the Quality Payment centered, resource-effective health
Medicare payment adjustments based
Program. Recognizing that the Quality system that leverages health information
on performance on quality, cost and
Payment Program represents a major technology to support clinicians and other measures and activities, and that
milestone in the way that we bring patients and builds collaboration across consolidates components of three
quality measurement and improvement care settings. This proposed rule is the precursor programsthe Physician
together with payment, we have taken next part of a staged approach to Quality Reporting System (PQRS), the
efforts to review existing policies to develop policies that are reflective of Physician Value-based Payment
identify how to move the program system capabilities and grounded in our Modifier (VM), and the Medicare
forward in the least burdensome manner core strategies to drive progress and Electronic Health Record (EHR)
possible. Our goal is to support patients reform efforts. We commit to continue Incentive Program for eligible
and clinicians in making their own evolving these policies. professionals (EPs). As prescribed by
decisions about health care using data CMS strives to put patients first, MACRA, MIPS focuses on the following:
driven insights, increasingly aligned ensuring that they can make decisions qualityincluding a set of evidence-
and meaningful quality measures, and about their own healthcare along with based, specialty-specific standards; cost;
technology that allows clinicians to their clinicians. We want to ensure practice-based improvement activities;
focus on providing high quality innovative approaches to improve and use of certified electronic health
healthcare for their patients. We believe quality, accessibility and affordability record (EHR) technology (CEHRT) to
our existing APMs alongside the while paying particular attention to support interoperability and advanced
proposals in this proposed rule provide improving clinicians and beneficiaries quality objectives in a single, cohesive
opportunities that support state experience when interacting with CMS program that avoids redundancies.
flexibility, local leadership, regulatory programs. The Quality Payment In this proposed rule, we are building
relief and innovative approaches to Program aims to (1) support care and improving Quality Payment
improve quality accessibility and improvement by focusing on better Program policies that will be familiar to
affordability. By driving changes in how outcomes for patients, decreased stakeholders and are designed to
care is delivered, we believe the Quality clinician burden, and preservation of integrate easily across clinical practices
Payment Program supports eligible independent clinical practice; (2) during the second and future years of
clinicians in improving the health of promote adoption of APMs that align implementation. We strive to continue
their patients and increasing care incentives for high-quality, low-cost our focus on priorities that can drive
efficiency. To implement this vision, the care across healthcare stakeholders; and improvements toward better patient
Quality Payment Program emphasizes (3) advance existing delivery system outcomes without creating undue
30012 Federal Register / Vol. 82, No. 125 / Friday, June 30, 2017 / Proposed Rules
burden for clinicians. In this proposed operational excellence in program improvement activities), meaningful
rule, we also address elements of implementation and ongoing use of CEHRT (referred to as advancing
MACRA that were not included in the development. More information on care information), and resource use
first year of the program, including these objectives and the Quality (referred to as cost)and by
virtual groups, facility-based Payment Program can be found at emphasizing that the Quality Payment
measurement, and improvement www.qpp.cms.gov. Program is at its core about improving
scoring. We also include proposals to With these objectives, we recognize the quality of patient care.
continue implementing elements of that the Quality Payment Program Although there are two separate
MACRA that do not take effect in the provides new opportunities to improve pathways within the Quality Payment
first or second year of the Quality care delivery by supporting and Program, the Advanced APM and MIPS
Payment Program, including policies rewarding clinicians as they find new tracks both contribute toward the goal of
related to the All-Payer Combination ways to engage patients, families, and seamless integration of the Quality
Option for identifying QPs and caregivers and to improve care Payment Program into clinical practice
assessing eligible clinicians coordination and population health workflows. Advanced APMs promote
participation in Other Payer Advanced management. In addition, we recognize this seamless integration by way of
APMs. To provide unity and that by developing a program that is payment methodology and design that
consistency across the two paths of the flexible instead of one-size-fits-all, incentivize care coordination, and the
Quality Payment Program, MIPS and clinicians will be able to choose to MIPS builds the capacity of eligible
APMs, in this proposed rule we have participate in a way that is best for clinicians across the four pillars of MIPS
referred to the second year of the them, their practice, and their patients. to prepare them for participation in
program as Quality Payment Program For eligible clinicians interested in MIPS APMs and Advanced APMs in
Year 2. APMs, we believe that by setting later years of the Quality Payment
ambitious yet achievable goals, eligible Program. Indeed, the bedrock of the
B. Quality Payment Program Strategic clinicians will move with greater Quality Payment Program is high-value,
Objectives certainty toward these new approaches patient-centered care, informed by
As discussed in the CY 2017 Quality of delivering care. APMs are a vital part useful feedback, in a continuous cycle
Payment Program final rule (81 FR of bending the Medicare cost curve by of improvement. The principal way that
77010), after extensive outreach with encouraging the delivery of high- MIPS measures quality of care is
clinicians, patients and other quality, low-cost care. To these ends, through a set of clinical quality
stakeholders, we created six strategic and to allow this program to work for measures (CQMs) from which MIPS
objectives to drive continued progress all stakeholders, we further recognize eligible clinicians can select. The CQMs
and improvement. These objectives that we must provide ongoing are evidence-based, and the vast
guided our final policies and will guide education, support, and technical majority are created or supported by
our future rulemaking in order to assistance so that clinicians can clinicians. Over time, the portfolio of
design, implement, and evolve a Quality understand program requirements, use quality measures will grow and develop,
Payment Program that aims to improve available tools to enhance their driving towards outcomes that are of the
health outcomes, promote efficiency, practices, and improve quality and greatest importance to patients and
minimize burden of participation, and progress toward participation in APMs clinicians and away from process, or
provide fairness and transparency in if that is the best choice for their check the box type measures.
operations. These strategic objectives practice. Finally, we understand that we Through MIPS, we have the
are as follows: (1) To improve must achieve excellence in program opportunity to measure quality, not only
beneficiary outcomes and engage management, focusing on customer through evidence-based quality
patients through patient-centered needs, promoting problem-solving, measures, but also by accounting for
Advanced APM and MIPS policies; (2) teamwork, and leadership to provide activities that clinicians themselves
to enhance clinician experience through continuous improvements in the identify: namely, practice-driven quality
flexible and transparent program design Quality Payment Program. improvement. MIPS also requires us to
and interactions with easy-to-use assess whether CEHRT is used
program tools; (3) to increase the C. One Quality Payment Program meaningfully. Based on significant
availability and adoption of Advanced Clinicians have told us that they do feedback, this area was simplified to
APMs; (4) to promote program not separate their patient care into support the exchange of patient
understanding and maximize domains, and that the Quality Payment information, engagement of patients in
participation through customized Program needs to reflect typical clinical their own care through technology, and
communication, education, outreach workflows in order to achieve its goal of the way technology specifically
and support that meet the needs of the better patient care. Advanced APMs, the supports the quality goals selected by
diversity of physician practices and focus of one pathway of the Quality the practice. The cost performance
patients, especially the unique needs of Payment Program, contribute to better category was simplified and weighted at
small practices; (5) to improve data and care and smarter spending by allowing zero percent of the final score for the
information sharing to provide accurate, physicians and other clinicians to transition year of CY 2017 to allow
timely, and actionable feedback to deliver coordinated, customized, high- clinicians an opportunity to ease into
clinicians and other stakeholders; and value care to their patients in a the Quality Payment Program. We
(6) to promote IT systems capabilities streamlined and cost-effective manner. further note the cost performance
that meet the needs of users and are Within MIPS, the second pathway of the category requires no separate
seamless, efficient and valuable on the Quality Payment Program, we believe submissions for participation which
front and back-end. We also believe it is that integration into typical clinical minimizes burden on clinicians. The
important to ensure the Quality workflows can best be accomplished by assessment of cost is a vital part of
Payment Program maintains operational making connections across the four ensuring that clinicians are providing
excellence as the program develops. statutory pillars of the MIPS incentive Medicare beneficiaries with high-value
Therefore we are adding a seventh structurequality, clinical practice care. Given the primary focus on value,
objective, specifically to ensure improvement activities (referred to as we indicated in the CY 2017 Quality
Payment Program final rule our equal to $90,000 in Medicare Part B incentive payments for their Advanced
intention to align cost measures with allowed charges or less than or equal to APM participation. In the CY 2017
quality measures over time in the 200 Medicare Part B patients; adding a Quality Payment Program final rule (81
scoring system (81 FR 77010). That is, significant hardship exception from the FR 77516), we estimated that 70,000 to
we established special policies for the advancing care information performance 120,000 eligible clinicians would be
first year of the Quality Payment category for MIPS eligible clinicians in QPs for payment year 2019 based on
Program, which enabled a ramp-up and small practices; and providing bonus Advanced APM participation in
gradual transition with less financial points that are added to the final scores performance year 2017. With new
risk for clinicians in the transition year. of MIPS eligible clinicians who are in Advanced APMs expected to be
We called this approach pick your small practices. We believe that these available for participation in 2018,
pace and allowed clinicians and additional flexibilities and reduction in including the Medicare ACO Track 1
groups to participate in MIPS through barriers will further enhance the ability Plus (1+) Model, and the reopening of
flexible means while avoiding a of small practices to participate the application process to new
negative payment adjustment. In this successfully in the Quality Payment participants for some current Advanced
proposed rule, we continue the slow Program. APMs, such as the Next Generation
ramp-up of the Quality Payment In keeping with the objectives to ACO Model and Comprehensive
Program by establishing special policies provide education about the Quality Primary Care Plus Model, we anticipate
for Program Year 2 aimed at Payment Program and maximize higher numbers of QPs in subsequent
encouraging successful participation in participation, and as mandated by the years of the program. We currently
the program while reducing burden, statute, during a period of 5 years, $100 estimate that approximately 180,000 to
reducing the number of clinicians million in funding was provided for 245,000 eligible clinicians may become
required to participate, and preparing technical assistance to be available to QPs for payment year 2020 based on
clinicians for the CY 2019 performance provide guidance and assistance to Advanced APM participation in
period (CY 2021 payment year). MIPS eligible clinicians in small performance year 2018.
practices through contracts with b. Advanced APMs
D. Summary of the Major Provisions
regional health collaboratives, and
1. Quality Payment Program Year 2 others. Guidance and assistance on the In the CY 2017 Quality Payment
MIPS performance categories or the Program final rule (81 FR 77408), to be
We believe the second year of the considered an Advanced APM, we
Quality Payment Program should build transition to APM participation will be
available to MIPS eligible clinicians in finalized that an APM must meet all
upon the foundation that has been three of the following criteria, as
established which provides a trajectory practices of 15 or fewer clinicians with
priority given to practices located in required under section 1833(z)(3)(D) of
for clinicians to value-based care. This the Act: (1) The APM must require
trajectory provides to clinicians the rural areas or medically underserved
participants to use CEHRT; (2) The APM
ability to participate in the program areas (MUAs), and practices with low
must provide for payment for covered
through two pathways: MIPS and MIPS final scores. More information on
professional services based on quality
Advanced APMs. As we indicated in the the technical assistance support
measures comparable to those in the
CY 2017 Quality Payment Program final available to small practices can be found
quality performance category under
rule (81 FR 77011), we believed that a at https://qpp.cms.gov/docs/
MIPS and; (3) The APM must either
second transition period would be QPP_Support_for_Small_Practices.pdf.
require that participating APM Entities
necessary to build upon the iterative As discussed in section V.C. of this
bear risk for monetary losses of a more
learning and development period as we proposed rule, we have also performed
than nominal amount under the APM,
build towards a steady state. We an updated regulatory impact analysis,
or be a Medical Home Model expanded
continue to believe this to be true and accounting for flexibilities, many of
under section 1115A(c) of the Act.
have therefore crafted our policies to which are continuing into the Quality
We are proposing to maintain the
extend flexibilities into Quality Payment Program Year 2, that have been
generally applicable revenue-based
Payment Program Year 2. created to ease the burden for small and
nominal amount standard at 8 percent
solo practices. We estimate that at least
of the estimated average total Parts A
2. Small Practices 80 percent of clinicians in small
and B revenue of eligible clinicians in
The support of small, independent practices with 115 clinicians will
participating APM Entities for QP
practices remains an important thematic receive a positive or neutral MIPS
Performance Periods 2019 and 2020.
objective for the implementation of the payment adjustment. We refer readers to
Quality Payment Program and is section V.C. of this proposed rule for c. Qualifying APM Participant (QP) and
expected to be carried throughout future details on how this estimate was Partial QP Determination
rulemaking. For MIPS performance developed. QPs are eligible clinicians in an
periods occurring in 2017, many small 3. Summary of Major Provisions for Advanced APM who have met a
practices are excluded from new Advanced Alternative Payment Models threshold for a certain percentage of
requirements due to the low-volume (Advanced APMs) their patients or payments through an
threshold, which was set at less than or Advanced APM. QPs are excluded from
equal to $30,000 in Medicare Part B a. Overview MIPS for the year, and receive a 5
allowed charges or less than or equal to APMs represent an important step percent APM Incentive Payment for
100 Medicare Part B patients. We have forward in our efforts to move our each year they are QPs beginning in
heard feedback, however, from many healthcare system from volume-based to 2019 through 2024. The statute sets
small practices that challenges still exist value-based care. APMs that meet the thresholds for the level of participation
in their ability to participate in the criteria to be Advanced APMs provide in Advanced APMs required for an
program. We are proposing additional the pathway through which eligible eligible clinician to become a QP for a
flexibilities including: Implementing the clinicians, who would otherwise fall year. For Advanced APMs that start or
virtual groups provisions; increasing the under the MIPS, can become Qualifying end during the Medicare QP
low-volume threshold to less than or APM Participants (QPs), thereby earning Performance Period and operate
continuously for a minimum of 60 days than nominal financial risk if actual e. Physician-Focused Payment Models
during the Medicare QP Performance aggregate expenditures exceed expected (PFPMs)
Period for the year, we are proposing to aggregate expenditures; or be a The PTAC is an 11-member federal
make QP determinations using payment Medicaid Medical Home Model that advisory committee that is an important
or patient data only for the dates that meets criteria comparable to Medical avenue for the creation of innovative
APM Entities were able to participate in Home Models expanded under section payment models. The PTAC is charged
the Advanced APM per the terms of the 1115A(c) of the Act. Specifically, we are with reviewing stakeholders proposed
Advanced APM, not for the full proposing to add a revenue-based PFPMs, and making comments and
Medicare QP Performance Period. nominal amount standard in addition to recommendations to the Secretary
Eligible clinicians who participate in the benchmark-based nominal amount regarding whether they meet the PFPM
Advanced APMs but do not meet the QP standard that would be applicable only criteria established by the Secretary
or Partial QP thresholds are subject to to payment arrangements in which risk through rulemaking in the CY 2017
MIPS reporting requirements and is expressly defined in terms of revenue. Quality Payment Program final rule.
payment adjustments.
We are proposing modifications to our PTAC comments and recommendations
d. All-Payer Combination Option methodologies to determine whether will be reviewed by the CMS Innovation
The All-Payer Combination Option, eligible clinicians will meet the QP Center and the Secretary, and we will
which uses a calculation based on both thresholds using the All-Payer post a detailed response to them on the
the Medicare Option and the eligible Combination Option. Specifically, we CMS Web site. We are seeking
clinicians participation in Other Payer are proposing to conduct all QP comments on broadening the definition
Advanced APMs to conduct QP determinations under the All-Payer of PFPM to include payment
determinations, is applicable beginning Combination Option at the individual arrangements that involve Medicaid or
in performance year 2019. To become a eligible clinician level and are seeking the Childrens Health Insurance
QP through the All-Payer Combination comment on any possible exceptions to Program (CHIP) as a payer even if
Option, an eligible clinician must this proposed policy that would be Medicare is not included as a payer.
participate in an Advanced APM with warranted, such as a determination This broadened definition might be
CMS, as well as an Other Payer based on APM Entity group more inclusive of potential PFPMs that
Advanced APM. We identify Other performance under the All-Payer could focus on areas not generally
Payer Advanced APMs based on applicable to the Medicare population,
Combination Option for eligible
information submitted to us by eligible and could engage more stakeholders in
clinicians participating in CMS Multi-
clinicians, APM Entities, and in some designing PFPMs. In addition, as we
Payer Models. We are also proposing to
cases by payers, including states and gain experience with public submission
establish an All-Payer QP Performance
Medicare Advantage Organizations. In of PFPM proposals to the PTAC, we are
Period to assess participation in Other
addition, the eligible clinician or the seeking comments on the Secretarys
Payer Advanced APMs under the All- criteria and stakeholders needs in
APM Entity must submit information to
Payer Combination Option, and to developing PFPM proposals aimed at
CMS so that we can determine whether
rename the QP Performance Period we meeting the criteria.
other payer arrangements are Other
established in rulemaking last year as
Payer Advanced APMs and whether the 4. Summary of Major Provisions for the
eligible clinician meets the requisite QP the Medicare QP Performance Period.
Merit-Based Incentive Payment System
threshold of participation. To be an We are proposing to modify the
(MIPS)
Other Payer Advanced APM, as set forth information submission requirements
in section 1833(z)(2)(B)(ii) and (C)(ii) of for the All-Payer Combination Option. For Quality Payment Program Year 2
the Act and implemented in the CY Specifically, we are proposing which is the second year of the MIPS
2017 Quality Payment Program final modifications to the information we and includes the performance periods in
rule, a payment arrangement with a require to make APM Entity or eligible 2018 and the 2020 MIPS payment year,
payer (for example, payment clinician initiated determinations of we are proposing the following policies:
arrangements authorized under Title Other Payer Advanced APMs after the a. Quality
XIX, Medicare Health Plan payment All-Payer QP Performance Period, as
arrangements, and payment well as the information we require to We previously finalized that the
arrangements in CMS Multi-Payer perform QP determinations under the quality performance category would
Models) must meet all three of the All-Payer Combination Option. We are comprise 60 percent of the final score
following criteria: (1) CEHRT is used; (2) also proposing policies on the handling for the transition year and 50 percent of
the payment arrangement must require of information submitted for purposes of the final score for the 2020 MIPS
the use of quality measures comparable assessment under the All-Payer payment year (81 FR 77100). For the
to those in the quality performance Combination Option. 2020 MIPS payment year, now we are
category under MIPS and; (3) the proposing to maintain a 60 percent
payment arrangement must either We are proposing a Payer Initiated weight for the quality performance
require the APM Entities to bear more Other Payer Advanced APM category contingent upon our proposal
than nominal financial risk if actual Determination Process, which would to reweight the cost performance
aggregate expenditures exceed expected allow certain other payers, including category to zero for the 2020 MIPS
aggregate expenditures, or be a payment arrangements authorized under payment year as discussed in section
Medicaid Medical Home Model that Title XIX, Medicare Health Plans, and II.C.6.b.(2) in this proposed rule. Quality
meets criteria comparable to Medical payers with payment arrangements in measures are selected annually through
Home Models expanded under section CMS Multi-Payer Models, to request a call for quality measures, and a final
1115A(c) of the Act. that we determine whether their other list of quality measures will be
We are proposing modifications payer arrangements are Other Payer published in the Federal Register by
pertaining to the third criterion that the Advanced APMs starting prior to the November 1 of each year. Except as
payment arrangement must either 2019 All-Payer QP Performance Period discussed in section II.C.6.b.(3)(a)(iii) of
require the APM Entities to bear more and each year thereafter. this proposed rule with regard to the
CAHPS for MIPS survey, we are not category would comprise 15 percent of improve care in ways that our programs
proposing any changes to the the final score (81 FR 77179). For should recognize.
submission criteria for quality measures performance periods occurring in 2018,
c. Advancing Care Information
in this proposed rule. We are proposing we are not proposing any changes in
for the CAHPS for MIPS survey for the improvement activities scoring as For the Quality Payment Program
Quality Payment Program Year 2 and discussed in the CY 2017 Quality Year 2, the advancing care information
future years that the survey Payment Program final rule (81 FR performance category comprises 25
administration period would, at a 77312). percent of the final score. However, if a
minimum, span over 8 weeks and As discussed in the appendices of this MIPS eligible clinician is participating
would end no later than February 28th proposed rule, we are proposing new in a MIPS APM the advancing care
following the applicable performance improvement activities (Table F) and information performance category may
period. In addition, we are proposing for improvement activities with changes comprise 30 percent or 75 percent of the
the Quality Payment Program Year 2 (Table G) for the 2018 MIPS final score depending on the availability
and future years to remove two performance period and future years for of APM quality data for reporting.
Summary Survey Modules (SSM), inclusion in the Improvement Activities Objectives and measures in the
specifically, Helping You to Take Inventory. Activities proposed in this advancing care information performance
Medication as Directed and Between section would apply for the 2018 MIPS category focus on the secure exchange of
Visit Communication from the CAHPS performance period and future health information and the use CEHRT
for MIPS survey. performance periods unless further to support patient engagement and
For the 2018 MIPS performance modified via notice and comment improved healthcare quality. While we
period, we previously finalized that the rulemaking. We refer readers to Table H continue to recommend that physicians
data completeness threshold would and clinicians migrate to the
of the CY 2017 Quality Payment
increase to 60 percent for data implementation and use of EHR
Program final rule for a list of all the
submitted on quality measures using technology certified to the 2015 Edition
previously finalized improvement
QCDRs, qualified registries, via EHR, or so they may take advantage of improved
activities (81 FR 77817 through 77831).
Medicare Part B claims. We noted that functionalities, including care
As discussed in section II.C.6.e.3.(c) coordination and technical
these thresholds for data submitted on
of this proposed rule, we are proposing advancements such as application
quality measures using QCDRs,
to expand our definition of how we will programming interfaces, or APIs, we
qualified registries, via EHR, or
recognize an individual MIPS eligible recognize that some practices may have
Medicare Part B claims would increase
clinician or group as being a certified challenges in adopting new certified
for performance periods occurring in
patient-centered medical home or health IT. Therefore we are proposing
2019 and future years. However, as
comparable specialty practice. We that MIPS eligible clinicians may
discussed in section II.C.6.b. of this
finalized at 414.1380(b)(3)(iv) in the continue to use EHR technology
proposed rule, we are proposing for the
CY 2017 Quality Payment Program final certified to the 2014 Edition for the
2018 MIPS performance period to
maintain the transition year data rule that a certified patient-centered performance period in CY 2018. We are
completeness threshold of 50 percent medical home includes practice sites proposing minor modifications to the
for data submitted on quality measures with current certification from a advancing care information objectives
using QCDRs, qualified registries, EHR, national program, regional or state and measures and the 2017 advancing
or Medicare Part B claims to provide an program, private payer or other body care information transition objectives
additional year for individual MIPS that administers patient-centered and measures. We are also proposing to
eligible clinicians and groups to gain medical home accreditation. We are add an exclusion for the e-Prescribing
experience with the MIPS before proposing in section II.C.6.e.(3)(b) of and Health Information Exchange
increasing the data completeness this proposed rule that eligible Objectives. We are proposing to modify
threshold. However, we are proposing to clinicians in practices that have been our scoring policy for the Public Health
increase the data completeness randomized to the control group in the and Clinical Data Registry Reporting
threshold for the 2021 MIPS payment CPC+ model would also receive full Objectives and Measures for the
year to 60 percent for data submitted on credit as a Medical Home Model. In performance score and the bonus score.
quality measures using QCDRs, addition, for group reporters, for the We are also proposing to implement
qualified registries, EHR, or Medicare 2018 MIPS performance period and several provisions of the 21st Century
Part B claims. We anticipate that for future performance periods, we are Cures Act (Pub. L. 114255, enacted on
performance periods going forward, as proposing to require that at least 50 December 13, 2016) pertaining to
MIPS eligible clinicians gain experience percent of the practice sites within a hospital-based MIPS eligible clinicians,
with the MIPS, we would further TIN must be recognized as a certified or ambulatory surgical center-based MIPS
increase these thresholds over time. recognized patient-centered medical eligible clinicians, MIPS eligible
home or comparable specialty practice clinicians using decertified EHR
b. Improvement Activities to receive full credit in the improvement technology, and significant hardship
Improvement activities are those that activities performance category. exceptions under the MIPS. We are also
support broad aims within healthcare As discussed in section II.C.6.f.(2)(d) proposing to add a significant hardship
delivery, including care coordination, of this proposed rule, in recognition of exception for MIPS eligible clinicians in
beneficiary engagement, population improvement activities as supporting
small practices.
management, and health equity. In the central mission of a unified Quality
response to comments from experts and Payment Program, we propose to d. Cost
stakeholders across the healthcare continue to designate activities in the In this proposed rule, we are
system, improvement activities were Improvement Activities Inventory that proposing to weight the cost
given relative weights of high and will also qualify for the advancing care performance category at zero percent of
medium. For the 2020 MIPS payment information bonus score. This is the final score for the 2020 MIPS
year, we previously finalized that the consistent with our desire to recognize payment year in order to improve
improvement activities performance that CEHRT is often deployed to clinician understanding of the measures
and continue development of episode- virtual group as a combination of two or did not propose an option for the
based measures that will be used in this more TINs composed of a solo transition year of MIPS because there
performance category. practitioner (a MIPS eligible clinician were several operational considerations
For the 2018 MIPS performance (as defined at 414.1305) who bills that needed to be addressed before this
period, we are proposing to adopt for under a TIN with no other NPIs billing option could be implemented. After
the cost performance category the total under such TIN) or a group (as defined consideration of comments received on
per capita costs for all attributed at 414.1305) with 10 or fewer eligible the CY 2017 Quality Payment Program
beneficiaries measure and the Medicare clinicians under the TIN that elects to proposed rule (81 FR 28192) and other
Spending per Beneficiary (MSPB) form a virtual group with at least one comments received, we have decided to
measure that were adopted for the 2017 other such solo practitioner or group for implement facility-based measures for
MIPS performance period. For the 2018 a performance period for a year. the 2018 MIPS performance period and
MIPS performance period, we are not To provide support and reduce future performance periods to add more
proposing to use the 10 episode-based burden, we intend to make technical flexibility for clinicians to be assessed
measures that were adopted for the 2017 assistance (TA) available, to the extent in the context of the facilities at which
MIPS performance period. Although feasible and appropriate, to support they work. As discussed in section
data on the episode-based measures has clinicians who choose to come together II.C.7.b. of this proposed rule, we are
been made available to clinicians in the as a virtual group for the first 2 years of proposing facility-based measures
past, we are in the process of developing virtual group implementation applicable policies related to applicable measures,
new episode-based measures with to the 2018 and 2019 performance years. applicability to facility-based
significant clinician input and believe it Clinicians can access the TA measurement, group participation, and
would be more prudent to introduce infrastructure that they may be already facility attribution.
these new measures over time. We will utilizing. For Quality Payment Program For clinicians whose primary
continue to offer performance feedback Year 3, we intend to provide an professional responsibilities are in a
on episode-based measures prior to electronic election process if technically healthcare facility we present a method
potential inclusion of these measures in feasible. Clinicians who do not elect to to assess performance in the quality and
MIPS to increase clinician familiarity contact their designated TA cost performance categories of MIPS
with the concept as well as specific representative would still have the based on the performance of that facility
episode-based measures. option of contacting the Quality in another value-based purchasing
Specifically, we intend to provide Payment Program Service Center. We program. While we propose to limit that
feedback on these new episode-based believe that our proposal will create an opportunity to clinicians who practice
cost measures in the fall of this year for election process that is simple and primarily in the hospital, we seek to
informational purposes only. We intend straightforward. expand the program to other value-
to provide performance feedback on the based payment programs as appropriate
g. MIPS APMs
MSPB and total per capita cost measures in the future. We discuss that new
by July 1, 2018, consistent with section In the CY 2017 Quality Payment method of scoring in section II.C.7.b.(4)
1848(q)(12) of the Act. In addition, we Program final rule (81 FR 77246), we of this proposed rule.
intend to offer feedback on another set finalized that MIPS eligible clinicians
who participate in MIPS APMs will be i. Scoring
of newly developed episode-based cost
measures in 2018 as well. Therefore, scored using the APM scoring standard In the CY 2017 Quality Payment
clinicians would have received feedback instead of the generally applicable MIPS Program final rule, we finalized a
on cost measures at several points prior scoring standard. For the 2018 unified scoring system to determine a
to the cost performance category performance period, we are proposing final score across the 4 performance
counting as part of the final score. modifications to the quality categories (81 FR 77273 through 77276).
performance category reporting For the 2018 MIPS performance period,
e. Submission Mechanisms requirements and scoring for MIPS we propose to build on the scoring
As discussed in section II.6.a. of this eligible clinicians in most MIPS APMs, methodology we finalized for the
proposed rule, we are proposing and other modifications to the APM transition year, focusing on encouraging
additional flexibility for submitting scoring standard. For purposes of the MIPS eligible clinicians to meet data
data. Individual MIPS eligible clinicians APM scoring standard, we are proposing completeness requirements.
or groups would be able to submit to add a fourth snapshot date that would For quality performance category
measures and activities, as available and be used only to identify APM Entity scoring, we are proposing to extend
applicable, via as many mechanisms as groups participating in those MIPS some of the transition year policies to
necessary to meet the requirements of APMs that require full TIN the 2018 MIPS performance period and
the quality, improvement activities, or participation. Along with the other APM are also proposing several modifications
advancing care information performance Entity groups, these APM Entity groups to existing policy. For the 2018 MIPS
categories. We expect that this option would be used for the purposes of performance period, we are proposing to
will provide clinicians the ability to reporting and scoring under the APM maintain the 3 point floor for measures
select the measures most meaningful to scoring standard described the CY 2017 that can be reliably scored against a
them, regardless of the submission Quality Payment Program final rule (81 benchmark. We are also proposing, to
mechanism. FR 77246). maintain the policy to assign 3 points to
measures that are submitted but do not
f. Virtual Groups h. Facility-Based Measurement have a benchmark or do not meet the

There are generally three ways to For the transition year of MIPS, we case minimum, which does not apply to
participate in MIPS: (1) As an considered an option for facility-based the CMS Web Interface measures and
individual; (2) as a group; and (3) as a MIPS eligible clinicians to elect to use administrative claims based measures.
virtual group. In this proposed rule, we their institutions performance rates as a For the 2018 MIPS performance period,
are proposing to establish requirements proxy for the MIPS eligible clinicians we are also proposing to lower the
for MIPS participation at the virtual performance in the quality and cost number of points available for measures
group level. We propose to define a performance categories. However, we that do not meet the data completeness
criteria, except for a measure submitted meaningful. In the CY 2017 Quality deadline, to become a CMS-approved
by a small practice, which we propose Payment Program final rule (81 FR survey vendor through additional
to continue to assign 3 points if the 77362), we finalized that qualified communications and postings.
measure does not meet data registries, QCDRs, health IT vendors,
m. Public Reporting
completeness. This does not apply to and CMS-approved survey vendors will
CMS Web Interface measures or have the ability to act as intermediaries As discussed in section II.C.11. of this
administrative claims based measures. on behalf of individual MIPS eligible proposed rule, we are proposing public
Beginning with the 2018 MIPS clinicians and groups for submission of reporting of certain eligible clinician
performance period, we are proposing to data to CMS across the quality, and group Quality Payment Program
add performance standards for scoring improvement activities, and advancing information, including MIPS and APM
improvement for the quality and cost care information performance data in an easily understandable format
performance categories. We are also categories. As discussed in section as required under the MACRA.
proposing a systematic approach to II.C.10.a.(3) of this proposed rule, we n. Eligibility and Exclusion Provisions
address topped out quality measures. propose to eliminate the self- of the MIPS Program
For the 2018 MIPS performance nomination submission method of email
period, we are proposing that 3 and require that QCDRs and qualified In section II.C.1.f. of this proposed
performance category scores (quality, registries submit their self-nomination rule, we are proposing to modify the
improvement activities, and advancing applications via a web-based tool for definition of a non-patient facing MIPS
care information) would be given weight future program years beginning with eligible clinician to apply to virtual
in the final score, or be reweighted if a performance periods occurring in 2018. groups. We are also proposing to specify
performance category score is not We are proposing, beginning with the that groups considered to be non-patient
available. We are also proposing to add 2019 performance period, a simplified facing (more than 75 percent of the NPIs
final score bonuses for small practices process in which existing QCDRs or billing under the groups TIN meet the
and for MIPS eligible clinicians that qualified registries in good standing definition of a non-patient facing
care for complex patients. may continue their participation in individual MIPS eligible clinician)
We are also proposing that the final MIPS by attesting that their approved during the non-patient facing
score will be compared against a MIPS data validation plan, cost, approved determination period would
performance threshold of 15 points, QCDR measures (applicable to QCDRs automatically have their advancing care
which can be achieved via multiple only), MIPS quality measures, activities, information performance category
pathways and continues the gradual services, and performance categories reweighted to zero. Additionally, in
transition into MIPS. offered in the previous years section II.C.3.c. of this proposed rule,
performance period of MIPS have no we are proposing to modify the low-
j. Performance Feedback changes. QCDRs and qualified registries volume threshold policy established in
We are proposing to provide Quality in good standing, may also make the CY 2017 Quality Payment Program
Payment Program performance feedback substantive or minimal changes to their final rule. As discussed in section
to eligible clinicians and groups. approved self-nomination application II.C.3.c of this proposed rule, we believe
Initially, we would provide performance from the previous year of MIPS that that increasing the low-volume
feedback on an annual basis. In future would be submitted during the self- threshold to less than or equal to
years, we aim to provide performance nomination period for CMS review and $90,000 in Medicare Part B charges or
feedback on a more frequent basis, approval. By attesting that certain 200 or fewer Part-B enrolled Medicare
which is in line with clinician requests aspects of their application will remain beneficiaries would further decrease
for timely, actionable feedback that they the same, as approved from the previous burden on MIPS eligible clinicians that
can use to improve care. year, existing QCDRs in good standing practice in rural areas or are part of a
and qualified registries will be spending small practice or are solo practitioners.
k. Targeted Review Process
less time completing the self- E. Payment Adjustments
In the CY 2017 Quality Payment nomination application, as was
Program final rule (81 FR 77353), we previously required. This process will As discussed in section V.C. of this
finalized a targeted review process be conducted on an annual basis. proposed rule, for the 2020 payment
under MIPS wherein a MIPS eligible In addition, we are proposing that the year based on Advanced APM
clinician or group may request that we term QCDR measures replace the term participation in 2018 performance
review the calculation of the MIPS non-MIPS measures, without period, we estimate that approximately
payment adjustment factor and, as proposing any changes to the definition, 180,000 to 245,000 clinicians will
applicable, the calculation of the criteria, or requirements that were become QPs, and therefore be exempt
additional MIPS payment adjustment finalized in the CY 2017 Quality from MIPS and qualify for lump sum
factor applicable to such MIPS eligible Payment Program final rule (81 FR incentive payments based on 5 percent
clinician or group for a year. We are not 77375). We are not proposing any of their Part B allowable charges for
proposing any changes to this process changes to the health IT vendors that covered professional services. We
for the second year of the MIPS. obtain data from CEHRT requirements. estimate that the total lump sum
Lastly, we are proposing for future incentive payments will be between
l. Third Party Intermediaries program years, beginning with approximately $590 and $800 million
We believe that third party performance periods occurring in 2018 for the 2020 Quality Payment Program
intermediaries that collect or submit that we remove the April 30th survey payment year. This expected growth in
data on behalf of individual eligible vendor application deadline. We are QPs between the first and second year
clinicians and groups participating in proposing for the Quality Payment of the program is due in part to
MIPS and allowing for flexible reporting Program Year 2 and future years that the reopening of CPC+ and Next Generation
options, will provide individual MIPS vendor application deadline be January ACO for 2018, and the ACO Track 1+
eligible clinicians and groups with 31st of the applicable performance year which is projected to have a large
options to accommodate different or a later date specified by CMS. We number of participants, with a large
practices and make measurement will notify vendors of the application majority reaching QP status.
Under the policies in this proposed improvements to the patients of the Merit-based Incentive Payment
rule, we estimate that approximately experience of care as MIPS eligible System, Promotion of Alternative
572,000 eligible clinicians would be clinicians respond to the incentives for Payment Models, and Incentive
required to participate in MIPS in the high-quality care provided by MIPS and Payments for Participation in Eligible
2018 MIPS performance period, implement care quality improvements Alternative Payment Models (herein
although this number may vary in their clinical practices. referred to as the MIPS and APMs RFI)
depending on the number of eligible We also quantify several costs (80 FR 59102 through 59113) and the
clinicians excluded from MIPS based on associated with this rule. We estimate CY 2017 Quality Payment Program final
their status as QPs or Partial QPs. After that this proposed rule will result in rule (81 FR 77008 through 77831). We
restricting the population to eligible approximately $857 million in intend to continue open communication
clinician types who are not newly collection of information-related with stakeholders, including
enrolled, the proposed increase in the burden. We estimate that the consultation with tribes and tribal
low-volume threshold is expected to incremental collection of information- officials, on an ongoing basis as we
exclude 585,560 clinicians who do not related burden associated with this develop the Quality Payment Program
exceed the low-volume threshold. In the proposed rule is approximately $12.4 in future years.
2020 MIPS payment year, MIPS million relative to the estimated burden
payment adjustments will be applied of continuing the policies the CY 2017 II. Provisions of the Proposed
based on MIPS eligible clinicians Quality Payment Program final rule, Regulations and Analysis of and
performance on specified measures and which is $869 million. We also estimate Responses to Comments
activities within three integrated regulatory review costs of $4.8 million A. Introduction
performance categories; the fourth for this proposed rule, comparable to
category of cost, as previously outlined, the regulatory review costs of the CY The Quality Payment Program,
would be weighted to zero in the 2020 2017 Quality Payment Program authorized by the Medicare Access and
MIPS payment year. Assuming that 90 proposed rule. We estimate that federal CHIP Reauthorization Act of 2015
percent of eligible clinicians of all expenditures will include $173 million (MACRA) is a new approach for
practice sizes participate in MIPS, we in revenue neutral payment adjustments reforming care across the health care
estimate that MIPS payment and $500 million for exceptional delivery system for eligible clinicians.
adjustments will be approximately performance payments. Additional Under the Quality Payment Program,
equally distributed between negative federal expenditures include eligible clinicians can participate via
MIPS payment adjustments ($173 approximately $590-$800 million in one of two pathways: Advanced
million) and positive MIPS payment APM incentive payments to QPs. Alternative Payment Models (APMs); or
adjustments ($173 million) to MIPS the Merit-based Incentive Payment
G. Stakeholder Input System (MIPS). We began implementing
eligible clinicians, as required by the
statute to ensure budget neutrality. In developing this proposed rule, we the Quality Payment Program through
Positive MIPS payment adjustments will sought feedback from stakeholders and rulemaking for calendar year (CY) 2017.
also include up to an additional $500 the public throughout the process, This rule provides proposed updates for
million for exceptional performance to including in the CY 2017 Quality the second and future years of the
MIPS eligible clinicians whose final Payment Program final rule with Quality Payment Program.
score meets or exceeds the additional comment period, listening sessions,
B. Definitions
performance threshold of 70 points. webinars, and other listening venues.
These MIPS payment adjustments are We received a high degree of interest At 414.1305, subpart O, we propose
expected to drive quality improvement from a broad spectrum of stakeholders. to define the following terms:
in the provision of MIPS eligible We thank our many commenters and All-Payer QP Performance Period.
clinicians care to Medicare acknowledge their valued input Ambulatory Surgical Center (ASC)-
beneficiaries and to all patients in the throughout the rulemaking process. We based MIPS eligible clinician.
health care system. However, the discuss the substance of relevant CMS Multi-Payer Model.
distribution will change based on the comments in the appropriate sections of Full TIN APM.
final population of MIPS eligible this proposed rule, though we were not Improvement Scoring.
clinicians for CY 2020 and the able to address all comments or all Medicare QP Performance Period.
distribution of scores under the issues that all commenters brought forth Other MIPS APM.
program. We believe that starting with due to the volume of comments and Virtual group.
these modest initial MIPS payment feedback. In general, commenters We propose to revise the definitions
adjustments is in the long-term best continue to support establishment of the of the following terms:
interest of maximizing participation and Quality Payment Program and maintain Affiliated practitioner.
starting the Quality Payment Program optimism as we move from pure FFS APM Entity.
off on the right foot, even if it limits the Medicare payment towards an enhanced Attributed beneficiary.
magnitude of MIPS positive adjustments focus on the quality and value of care. Certified Electronic Health Record
during the 2018 MIPS performance Public support for our proposed Technology (CEHRT).
period. The increased availability of approach and policies in the proposed Final Score.
Advanced APM opportunities, rule focused on the potential for Hospital-based MIPS eligible
improving the quality of care delivered clinician.
including through Medical Home

models, also provides earlier avenues to to beneficiaries and increasing value to Low-volume threshold.
earn APM incentive payments for those the publicwhile rewarding eligible Medicaid APM.
eligible clinicians who choose to clinicians for their efforts. Non-patient facing MIPS eligible
participate. We thank stakeholders again for their clinician.
considered responses throughout our Other Payer Advanced APM.
F. Benefits and Costs of Proposed Rule process, in various venues, including Rural areas.
The Quality Payment Program may comments on the Request for We propose to remove the following
result in quality improvements and Information Regarding Implementation terms:
Advanced APM Entity. which Part B services are included for portion of its NPIs participating in MIPS
QP Performance Period. eligibility determinations. We note that according to the generally applicable
These terms and definitions are when Part B items or services are scoring criteria while the remaining
discussed in detail in relevant sections rendered by suppliers that are also MIPS portion of its NPIs is participating in a
of this proposed rule. eligible clinicians, there may be MIPS APM or an Advanced APM
circumstances in which it is not according to the MIPS APM scoring
C. MIPS Program Details operationally feasible for us to attribute standard. In the CY 2017 Quality
1. MIPS Eligible Clinicians those items or services to a MIPS Payment Program final rule (81 FR
a. Definition of a MIPS Eligible eligible clinician at an NPI level in order 77058), we noted that except for groups
Clinician to include them for purposes of containing APM participants, we are not
applying the MIPS payment adjustment permitting groups to split TINs if they
In the CY 2017 Quality Payment or making eligibility determinations. choose to participate in MIPS as a
Program final rule (81 FR77040 through To further clarify, there are group. Thus, we would like to clarify
77041), we defined at 414.1305 a MIPS circumstances that involve Part B that we consider a group to be either an
eligible clinician, as identified by a prescription drugs and durable medical entire single TIN or portion of a TIN
unique billing TIN and NPI combination equipment where the supplier may also that: (1) Is participating in MIPS
used to assess performance, as any of be a MIPS eligible clinician. In according to the generally applicable
the following (excluding those circumstances in which a MIPS eligible scoring criteria while the remaining
identified at 414.1310(b)): A physician clinician furnishes a Part B covered item portion of the TIN is participating in a
(as defined in section 1861(r) of the or service such as prescribing Part B MIPS APM or an Advanced APM
Act), a physician assistant, nurse drugs that are dispensed, administered, according to the MIPS APM scoring
practitioner, and clinical nurse and billed by a supplier that is a MIPS standard; and (2) chooses to participate
specialist (as such terms are defined in eligible clinician, or ordering durable in MIPS at the group level. Also, we
section 1861(aa)(5) of the Act), a medical equipment that is administered defined an APM Entity group at
certified registered nurse anesthetist (as and billed by a supplier that is a MIPS 414.1305 as a group of eligible
defined in section 1861(bb)(2) of the eligible clinician, it is not operationally clinicians participating in an APM
Act), and a group that includes such feasible for us at this time to associate Entity, as identified by a combination of
clinicians. We established at those billed allowable charges with a the APM identifier, APM Entity
414.1310(b) and (c) that the following MIPS eligible clinician at an NPI level identifier, TIN, and NPI for each
are excluded from this definition per the in order to include them for purposes of participating eligible clinician.
statutory exclusions defined in section applying the MIPS payment adjustment
1848(q)(1)(C)(ii) and (v) of the Act: (1) or making eligibility determinations. For c. Small Practices
QPs; (2) Partial QPs who choose not to Part B items and services furnished by In the CY 2017 Quality Payment
report on applicable measures and a MIPS eligible clinician such as Program final rule (81 FR 77188), we
activities that are required to be purchasing and administering Part B defined the term small practices at
reported under MIPS for any given drugs that are billed by the MIPS 414.1305 as practices consisting of 15
performance period in a year; (3) low- eligible clinician, such items and or fewer clinicians and solo
volume threshold eligible clinicians; services may be subject to MIPS practitioners. In section II.C.4.d. of this
and (4) new Medicare-enrolled eligible adjustment based on the MIPS eligible proposed rule, we discuss how small
clinicians. In accordance with sections clinicians performance during the practice status would apply to virtual
1848(q)(1)(A) and (q)(1)(C)(vi) of the applicable performance period or groups. Also, in the final rule, we noted
Act, we established at 414.1310(b)(2) included for eligibility determinations. that we would not make an eligibility
that eligible clinicians (as defined at For those billed Medicare Part B determination regarding the size of
414.1305) who are not MIPS eligible allowable charges relating to the small practices, but indicated that small
clinicians have the option to voluntarily purchasing and administration of Part B practices would attest to the size of their
report measures and activities for MIPS. drugs that we are able to associate with group practice (81 FR 77057). However,
Additionally, we established at a MIPS eligible clinician at an NPI level, we have since realized that our system
414.1310(d) that in no case will a such items and services furnished by needs to account for small practice size
MIPS payment adjustment apply to the the MIPS eligible clinician would be in advance of a performance period for
items and services furnished during a included for purposes of applying the operational purposes relating to
year by eligible clinicians who are not MIPS payment adjustment or making assessing and scoring the improvement
MIPS eligible clinicians, as described in eligibility determinations. activities performance category,
414.1310(b) and (c), including those determining hardship exceptions for
who voluntarily report on applicable b. Group Practice (Group) small practices as proposed in this
measures and activities specified under As discussed in the CY 2017 Quality proposed rule, calculating the small
MIPS. Payment Program final rule (81 FR practice bonus for the final score as
In the CY 2017 Quality Payment 77088 through 77831), we indicated that proposed in this proposed rule, and
Program final rule (81 FR 77340), we we will assess performance either for identifying small practices eligible for
noted that the MIPS payment individual MIPS eligible clinicians or technical assistance. As a result, we
adjustment applies only to the amount for groups. We defined a group at believe it is critical to modify the way
otherwise paid under Part B with 414.1305 as a single Taxpayer in which small practice size would be
respect to items and services furnished Identification Number (TIN) with two or determined. To make eligibility
by a MIPS eligible clinician during a more eligible clinicians (including at determinations regarding the size of
year, in which we will apply the MIPS least one MIPS eligible clinician), as small practices for performance periods
payment adjustment at the TIN/NPI identified by their individual NPI, who occurring in 2018 and future years, we
level. We have received requests for have reassigned their Medicare billing propose that CMS would determine the
additional clarifications on which rights to the TIN. We recognize that size of small practices as described in
specific Part B services are subject to the MIPS eligible clinicians participating in this section of the proposed rule. As
MIPS payment adjustment, as well as MIPS may be part of a TIN that has one noted in the CY 2017 Quality Payment
Program final rule, the size of a group category and identification of small proposing to modify the definition of a
(including a small practice) would be practices eligible for technical rural areas at 414.1305 as ZIP codes
determined before exclusions are assistance prior to the performance designated as rural, using the most
applied (81 FR 77057). We note that period. Specifically, our system needs to recent Health Resources and Services
group size determinations are based on capture small practice determinations in Administration (HRSA) Area Health
the number of NPIs associated with a advance of the performance period in Resource File data set available. We
TIN, which would include clinicians order for the system to reflect the recognize that there are cases in which
(NPIs) who may be excluded from MIPS applicable requirements for the an individual MIPS eligible clinician
participation and do not meet the improvement activities performance (including a solo practitioner) or a group
definition of a MIPS eligible clinician. category and when a small practice may have multiple practice sites
To make eligibility determinations bonus would be applied. A second associated with its TIN and as a result,
regarding the size of small practices for option would include an attestation it is critical for us to outline the
performance periods occurring in 2018 component, in which a small practice application of rural area and HPSA
and future years, we propose that CMS that was not identified as a small practice designations to such practices.
would determine the size of small practice during the proposed small For performance periods occurring in
practices by utilizing claims data. For practice size determination period 2017, we consider an individual MIPS
purposes of this section, we are coining would be able to attest to the size of eligible clinician or a group with at least
the term small practice size their group practice prior to the one practice site under its TIN in a ZIP
determination period to mean a 12- performance period. However, this code designated as a rural area or HPSA
month assessment period, which second option would require us to to be a rural area or HPSA practice. For
consists of an analysis of claims data develop several operational performance periods occurring in 2018
that spans from the last 4 months of a improvements, such as a manual and future years, we believe that a
calendar year 2 years prior to the process or system that would provide an higher threshold than one practice
performance period followed by the first attestation mechanism for small within a TIN is necessary to designate
8 months of the next calendar year and practices, and a verification process to an individual MIPS eligible clinician, a
includes a 30-day claims run out. This ensure that only small practices are group, or a virtual group as a rural or
would allow us to inform small identified as eligible for technical
HPSA practice. We recognize that the
practices of their status near the assistance. Since individual MIPS
establishment of a higher threshold
beginning of the performance period as eligible clinicians and groups are not
it pertains to eligibility relating to starting in 2018 would more
required to register to participate in
technical assistance, applicable appropriately identify groups and
MIPS (except for groups utilizing the
improvement activities criteria, the virtual groups with multiple practices
CMS Web Interface for the Quality
proposed hardship exception for small under a groups TIN or TINs that are
Payment Program or administering the
practices under the advancing care part of a virtual group as rural or HPSA
CAHPS for MIPS survey), requiring
information performance category, and practices and ensure that groups and
small practices to attest to the size of
the proposed small practice bonus for virtual groups are assessed and scored
their group practice prior to the
the final score. performance period could increase according to requirements that are
Thus, for purposes of performance burden on individual MIPS eligible applicable and appropriate. We note
periods occurring in 2018 and the 2020 clinicians and groups that are not that in the CY 2017 Quality Payment
MIPS payment year, we would identify already utilizing the CMS Web Interface Program final rule (81 FR 77048 through
small practices based on 12 months of for the Quality Payment Program or 77049), we defined a non-patient facing
data starting from September 1, 2016 to administering the CAHPS for MIPS MIPS eligible clinician at 414.1305 as
August 31, 2017. We would not change survey. We solicit public comment on including a group provided that more
an eligibility determination regarding the proposal regarding how CMS would than 75 percent of the NPIs billing
the size of a small practice once the determine small practice size. under the groups TIN meet the
determination is made for a given definition of a non-patient facing
performance period and MIPS payment d. Rural Area and Health Professional individual MIPS eligible clinician
year. We recognize that there may be Shortage Area Practices during the non-patient facing
circumstances in which the small In the CY 2017 Quality Payment determination period. We refer readers
practice size determinations made by Program final rule (81 FR 77188), we to section II.C.1.e. of this proposed rule
CMS do not reflect the real-time size of finalized at 414.1380 that for for our proposal to modify the definition
such practices. We considered two individual MIPS eligible clinicians and of a non-patient facing MIPS eligible
options that could address such groups that are located in rural areas or clinician. We believe that using a
potential discrepancies. One option geographic HPSAs, to achieve full credit similar threshold for applying the rural
would include an expansion of the under the improvement activities and HPSA designation to an individual
proposed small practice size performance category, one high- MIPS eligible clinician, a group, or
determination period to 24 months with weighted or two medium-weighted virtual group with multiple practices
two 12-month segments of data analysis improvement activities are required. In under its TIN or TINs within a virtual
(before and during the performance addition, we defined rural areas at group will add consistency for such
period), in which CMS would conduct 414.1305 as clinicians in ZIP codes practices across the MIPS as it pertains
a second analysis of claims data during designated as rural, using the most to groups and virtual groups obtaining
the performance period. Such an recent Health Resources and Services such statuses. Also, we believe that
expanded determination period may Administration (HRSA) Area Health establishing a 75 percent threshold
better capture the real-time size of small Resource File data set available; and renders an adequate representation of a
practices, but determinations made Health Professional Shortage Areas group or virtual group where a
during the performance period prevent (HPSAs) at 414.1305 as areas significant portion of a group or a
our system from being able to account designated under section 332(a)(1)(A) of virtual group is identified as having
for the assessment and scoring of the the Public Health Service Act. For such status. Therefore, for performance
improvement activities performance technical accuracy purposes, we are periods occurring in 2018 and future
years, we propose that an individual determination period. In order to included in the payment for the single
MIPS eligible clinician, a group, or a account for the formation of virtual code instead of separately reported.
virtual with multiple practices under its groups starting in the 2018 performance Patient-facing encounter codes from
TIN or TINs within a virtual group year and how non-patient facing both of these categories describe direct
would be designated as a rural or HPSA determinations would apply to virtual services furnished by eligible clinicians
practice if more than 75 percent of NPIs groups, we need to modify the with impact on patient safety, quality of
billing under the individual MIPS definition of a non-patient facing MIPS care, and health outcomes.
eligible clinician or groups TIN or eligible clinician. Therefore, for For purposes of the non-patient facing
within a virtual group, as applicable, are performance periods occurring in 2018 policies under MIPS, the utilization of
designated in a ZIP code as a rural area and future years, we propose to modify E&M codes and Surgical and Procedural
or HPSA. We solicit public comment on the definition of a non-patient facing codes allows for accurate identification
these proposals. MIPS eligible clinician at 414.1305 to of patient-facing encounters, and thus
mean an individual MIPS eligible accurate eligibility determinations
e. Non-Patient Facing MIPS Eligible
clinician that bills 100 or fewer patient- regarding non-patient facing status. As a
Clinicians
facing encounters (including Medicare result, MIPS eligible clinicians
Section 1848(q)(2)(C)(iv) of the Act telehealth services defined in section considered non-patient facing are able
requires the Secretary, in specifying 1834(m) of the Act) during the non- to prepare to meet requirements
measures and activities for a patient facing determination period, and applicable to non-patient facing MIPS
performance category, to give a group or virtual group provided that eligible clinicians. We propose to
consideration to the circumstances of more than 75 percent of the NPIs billing continue applying these policies for
professional types (or subcategories of under the groups TIN or within a purposes of the 2020 MIPS payment
those types determined by practice virtual group, as applicable, meet the year and future years.
characteristics) who typically furnish definition of a non-patient facing
services that do not involve face-to-face As described in the CY 2017 Quality
individual MIPS eligible clinician Payment Program final rule, we
interaction with a patient. To the extent during the non-patient facing
feasible and appropriate, the Secretary established the non-patient facing
determination period. determination period for purposes of
may take those circumstances into We considered a patient-facing
account and apply alternative measures identifying non-patient facing MIPS
encounter to be an instance in which
or activities that fulfill the goals of the eligible clinicians in advance of the
the individual MIPS eligible clinician or
applicable performance category to such group billed for items and services performance period and during the
non-patient facing MIPS eligible furnished such as general office visits, performance period using historical and
clinicians. In carrying out these outpatient visits, and procedure codes performance period claims data. This
provisions, we are required to consult under the PFS. We published the list of eligibility determination process allows
with non-patient facing MIPS eligible patient-facing encounter codes for us to begin identifying non-patient
clinicians. performance periods occurring in 2017 facing MIPS eligible clinicians prior to
In addition, section 1848(q)(5)(F) of at qpp.cms.gov/resources/education. We or shortly after the start of the
the Act allows the Secretary to re-weight intend to publish the list of patient- performance period. The non-patient
MIPS performance categories if there are facing encounter codes for performance facing determination period is a 24-
not sufficient measures and activities periods occurring in 2018 at month assessment period, which
applicable and available to each type of qpp.cms.gov by the end of 2017. The list includes a two-segment analysis of
MIPS eligible clinician. We assume of patient-facing encounter codes is claims data regarding patient-facing
many non-patient facing MIPS eligible used to determine the non-patient facing encounters during an initial 12-month
clinicians will not have sufficient status of MIPS eligible clinicians. period prior to the performance period
measures and activities applicable and The list of patient-facing encounter followed by another 12-month period
available to report under the codes include two general categories of during the performance period. The
performance categories under MIPS. We codes: Evaluation and Management initial 12-month segment of the non-
refer readers to section II.C.6.f.(7) of this (E&M) codes; and Surgical and patient facing determination period
proposed rule for the discussion Procedural codes. E&M codes capture spans from the last 4 months of a
regarding how we address performance clinician-patient encounters that occur calendar year 2 years prior to the
category weighting for MIPS eligible in a variety of care settings, including performance period followed by the first
clinicians for whom no measures or office or other outpatient settings, 8 months of the next calendar year and
activities are applicable and available in hospital inpatient settings, emergency includes a 60-day claims run out, which
a given 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 additional individual MIPS eligible
definition of a non-patient facing clinicians to treat medical conditions. In clinicians and groups of their non-
individual MIPS eligible clinician the case of many of these services, patient status during the performance
during the non-patient facing evaluation and management work is period.
However, based on our analysis of day claims run out. This proposal be non-patient facing will have their
data from the initial segment of the non- would only change the duration of the advancing care information performance
patient facing determination period for claims run out, not the 12-month category automatically reweighted to
performance periods occurring in 2017 timeframes used for the first and second zero (81 FR 77241). For groups that are
(that is, data spanning from September segments of data analysis. considered to be non-patient facing (that
1, 2015 to August 31, 2016), we found For purposes of the 2020 MIPS is, more than 75 percent of the NPIs
that it may not be necessary to include payment year, we would initially billing under the groups TIN meet the
a 60-day claims run out since we could identify individual MIPS eligible definition of a non-patient facing
achieve a similar outcome for such clinicians and groups who are individual MIPS eligible clinician)
eligibility determinations by utilizing a considered non-patient facing MIPS during the non-patient facing
30-day claims run out. In our eligible clinicians based on 12 months determination period, we are proposing
comparison of data analysis results of data starting from September 1, 2016, in section II.C.7.b.(3) of this proposed
utilizing a 60-day claims run out versus to August 31, 2017. To account for the rule to automatically reweight their
a 30-day claims run out, there was a 1 identification of additional individual advancing care information performance
percent decrease in data completeness MIPS eligible clinicians and groups that category to zero.
(see Table 1 for data completeness may qualify as non-patient facing during We propose to continue applying
regarding comparative analysis of a 60- performance periods occurring in 2018, these policies for purposes of the 2020
day and 30-day claims run out). The we would conduct another eligibility MIPS payment year and future years.
small decrease in data completeness determination analysis based on 12 We solicit public comment on these
would not negatively impact individual months of data starting from September proposals.
MIPS eligible clinicians or groups 1, 2017, to August 31, 2018.
Similarly, for future years, we would f. MIPS Eligible Clinicians Who Practice
regarding non-patient facing in Critical Access Hospitals Billing
determinations. We believe that a 30- conduct an initial eligibility
determination analysis based on 12 Under Method II (Method II CAHs)
day claims run out would allow us to
months of data (consisting of the last 4 In the CY 2017 Quality Payment
complete the analysis and provide such
months of the calendar year 2 years Program final rule (81 FR 77049), we
determinations in a more timely
prior to the performance period and the noted that MIPS eligible clinicians who
manner.
first 8 months of the calendar year prior practice in CAHs that bill under Method
to the performance period) to determine I (Method I CAHs), the MIPS payment
TABLE 1PERCENTAGES OF DATA adjustment would apply to payments
the non-patient facing status of
COMPLETENESS FOR 60-DAY AND individual MIPS eligible clinicians and made for items and services billed by
30-DAY CLAIMS RUN OUT groups, and conduct another eligibility MIPS eligible clinicians, but it would
determination analysis based on 12 not apply to the facility payment to the
30-day 60-day
Incurred claims claims months of data (consisting of the last 4 CAH itself. For MIPS eligible clinicians
year months of the calendar year prior to the who practice in Method II CAHs and
run out * run out *
performance period and the first 8 have not assigned their billing rights to
2015 .......... 97.1% 98.4% months of the performance period) to the CAH, the MIPS payment adjustment
* Note: Completion rates are estimated and determine the non-patient facing status would apply in the same manner as for
averaged at aggregated service categories of additional individual MIPS eligible MIPS eligible clinicians who bill for
and may not be applicable to subsets of these clinicians and groups. We would not items and services in Method I CAHs.
totals. For example, completion rates can vary change the non-patient facing status of As established in the CY 2017 Quality
by provider due to claim processing practices,
service mix, and post payment review activity. any individual MIPS eligible clinician Payment Program final rule (81 FR
Completion rates vary from subsections of a or group identified as non-patient facing 77051), the MIPS payment adjustment
calendar year; later portions of a given cal- during the first eligibility determination will apply to Method II CAH payments
endar year will be less complete than earlier analysis based on the second eligibility under section 1834(g)(2)(B) of the Act
ones. Completion rates vary due to variance in determination analysis. Thus, an
loading patterns due to technical, seasonal, when MIPS eligible clinicians who
policy, and legislative factors. Completion individual MIPS eligible clinician or practice in Method II CAHs have
rates are a function of the incurred date used group that is identified as non-patient assigned their billing rights to the CAH.
to process claims, and these factors will need facing during the first eligibility We refer readers to the CY 2017
to be updated if claims are processed on a determination analysis would continue Quality Payment Program final rule (81
claim from date or other methodology.
to be considered non-patient facing for FR 77049 through 77051) for our
For performance periods occurring in the duration of the performance period discussion of MIPS eligible clinicians
2018 and future years, we propose a and MIPS payment year regardless of who practice in Method II CAHs.
modification to the non-patient facing the results of the second eligibility
determination period, in which the determination analysis. We would g. MIPS Eligible Clinicians Who Practice
initial 12-month segment of the non- conduct the second eligibility in Rural Health Clinics (RHCs) or
patient facing determination period determination analysis to account for Federally Qualified Health Centers
would span from the last 4 months of a the identification of additional, (FQHCs)
calendar year 2 years prior to the previously unidentified individual As established in the CY 2017 Quality
performance period followed by the first MIPS eligible clinicians and groups that Payment Program final rule (81 FR
8 months of the next calendar year and are considered non-patient facing. 77051 through 77053), services rendered
include a 30-day claims run out; and the Additionally, in the CY 2017 Quality by an eligible clinician under the RHC
second 12-month segment of the non- Payment Program final rule (81 FR or FQHC methodology, will not be
patient facing determination period 77241), we established a policy subject to the MIPS payments
would span from the last 4 months of a regarding the re-weighting of the adjustments. As noted, these eligible
calendar year 1 year prior to the advancing care information performance clinicians have the option to voluntarily
performance period followed by the first category for non-patient facing MIPS report on applicable measures and
8 months of the performance period in eligible clinicians. Specifically, MIPS activities for MIPS, in which the data
the next calendar year and include a 30- eligible clinicians who are considered to received will not be used to assess their
performance for the purpose of the 77057), we established that the use of 2. Exclusions
MIPS payment adjustment. multiple identifiers that allow MIPS a. New Medicare-Enrolled Eligible
We refer readers to the CY 2017 eligible clinicians to be measured as an Clinician
Quality Payment Program final rule (81 individual or collectively through a
FR 77051 through 77053) for our groups performance and that the same As established in the CY 2017 Quality
discussion of MIPS eligible clinicians Payment Program final rule (81 FR
identifier be used for all four
who practice in RHCs or FQHCs. 77061 through 77062), we defined a
performance categories. While we have
new Medicare-enrolled eligible clinician
h. MIPS Eligible Clinicians Who multiple identifiers for participation at 414.1305 as a professional who first
Practice in Ambulatory Surgical Centers and performance, we established the use becomes a Medicare-enrolled eligible
(ASCs), Home Health Agencies (HHAs), of a single identifier, TIN/NPI, for clinician within the PECOS during the
Hospice, and Hospital Outpatient applying the MIPS payment adjustment, performance period for a year and had
Departments (HOPDs) regardless of how the MIPS eligible not previously submitted claims under
Section 1848(q)(6)(E) of the Act clinician is assessed. Medicare such as an individual, an
provides that the MIPS payment (1) Individual Identifiers entity, or a part of a physician group or
adjustment is applied to the amount under a different billing number or tax
otherwise paid under Part B with As established in the CY 2017 Quality identifier. Additionally, we established
respect to the items and services Payment Program final rule (81 FR at 414.1310(c) that these eligible
furnished by a MIPS eligible clinician 77058), we define a MIPS eligible clinicians will not be treated as a MIPS
during a year. Some eligible clinicians clinician at 414.1305 to mean the use eligible clinician until the subsequent
may not receive MIPS payment of a combination of unique billing TIN year and the performance period for
adjustments due to their billing and NPI combination as the identifier to such subsequent year. We established at
methodologies. If a MIPS eligible 414.1310(d) that in no case would a
assess performance of an individual
clinician furnishes items and services in MIPS payment adjustment apply to the
MIPS eligible clinician. Each unique
an ASC, HHA, Hospice, and/or HOPD items and services furnished during a
and the facility bills for those items and TIN/NPI combination is considered a
different MIPS eligible clinician, and year by new Medicare-enrolled eligible
services (including prescription drugs) clinicians for the applicable
under the facilitys all-inclusive MIPS performance is assessed
performance period.
payment methodology or prospective separately for each TIN under which an We used the term new Medicare-
payment system methodology, the MIPS individual bills. enrolled eligible clinician determination
adjustment would not apply to the (2) Group Identifiers for Performance period to refer to the 12 months of a
facility payment itself. However, if a calendar year applicable to the
MIPS eligible clinician furnishes other As established in the CY 2017 Quality performance period. During the new
items and services in an ASC, HHA, Payment Program final rule (81 FR Medicare-enrolled eligible clinician
Hospice, and/or HOPD and bills for 77059), we codified the definition of a determination period, we conduct
those items and services separately, group at 414.1305 to mean a group that eligibility determinations on a quarterly
such as under the PFS, the MIPS consists of a single TIN with two or basis to the extent that is technically
adjustment would apply to payments more eligible clinicians (including at feasible to identify new Medicare-
made for such items and services. Such least one MIPS eligible clinician), as enrolled eligible clinicians that would
items and services would also be identified by their individual NPI, who be excluded from the requirement to
considered for purposes of applying the participate in MIPS for the applicable
have reassigned their billing rights to
low-volume threshold. Therefore, we performance period.
the TIN.
propose that services rendered by an
eligible clinician that are payable under (3) APM Entity Group Identifier for b. Qualifying APM Participant (QP) and
the ASC, HHA, Hospice, or HOPD Partial Qualifying APM Participant
Performance
methodology would not be subject to (Partial QP)
the MIPS payments adjustments. As described in the CY 2017 Quality In the CY 2017 Quality Payment
However, these eligible clinicians have Payment Program final rule (81 FR Program final rule (81 FR 77062), we
the option to voluntarily report on 77060), we established that each eligible established at 414.1305 that a QP (as
applicable measures and activities for clinician who is a participant of an APM defined at 414.1305) is not a MIPS
MIPS, in which the data received would Entity is identified by a unique APM eligible clinician, and is therefore
not be used to assess their performance participant identifier. The unique APM excluded from MIPS. Also, we
for the purpose of the MIPS payment participant identifier is a combination of established that a Partial QP (as defined,
adjustment. We note that eligible four identifiers: (1) APM Identifier at 414.1305) who does not report on
clinicians who bill under both the PFS (established by CMS; for example, applicable measures and activities that
and one of these other billing XXXXXX); (2) APM Entity identifier are required to be reported under MIPS
methodologies (ASC, HHA, Hospice, (established under the APM by CMS; for for any given performance period in a
and/or HOPD) may be required to example, AA00001111); (3) TIN(s) (9 year is not a MIPS eligible clinician.
participate in MIPS if they exceed the numeric characters; for example, c. Low-Volume Threshold
low-volume threshold and are otherwise XXXXXXXXX); (4) EP NPI (10 numeric Section 1848(q)(1)(C)(ii)(III) of the Act
eligible clinicians; in such case, data characters; for example, 1111111111).

reported would be used to determine provides that the definition of a MIPS
We codified the definition of an APM eligible clinician does not include MIPS
their MIPS payment adjustment. We
Entity group at 414.1305 to mean a eligible clinicians who are below the
solicit public comments on this
proposal. group of eligible clinicians participating low-volume threshold selected by the
in an APM Entity, as identified by a Secretary under section 1848(q)(1)(C)(iv)
i. MIPS Eligible Clinician Identifier combination of the APM identifier, of the Act for a given year. Section
As described in the CY 2017 Quality APM Entity identifier, TIN, and NPI for 1848(q)(1)(C)(iv) of the Act requires the
Payment Program final rule (81 FR each participating eligible clinician. Secretary to select a low-volume
threshold to apply for the purposes of small practices or practicing in analysis of claims data, we found that
this exclusion which may include one designated rural areas face unique increasing the low-volume threshold to
or more of the following: (1) The dynamics and challenges such as fiscal to exclude individual eligible clinicians
minimum number, as determined by the limitations and workforce shortages, but or groups that have Medicare Part B
Secretary, of Part B-enrolled individuals serve as a critical access point for care allowed charges less than or equal to
who are treated by the MIPS eligible and provide a safety net for vulnerable $90,000 or that provide care for 200 or
clinician for a particular performance populations. Claims data shows that fewer Part B-enrolled Medicare
period; (2) the minimum number, as approximately 15 percent of individual beneficiaries will exclude
determined by the Secretary, of items MIPS eligible clinicians (TIN/NPIs) are approximately 134,000 additional
and services furnished to Part B- considered to be practicing in rural clinicians from MIPS from the
enrolled individuals by the MIPS areas after applying all exclusions. Also, approximately 700,000 clinicians that
eligible clinician for a particular we have heard from stakeholders that would have been eligible based on the
performance period; and (3) the MIPS eligible clinicians practicing in low-volume threshold that was finalized
minimum amount, as determined by the small practices and designated rural in the CY 2017 Quality Payment
Secretary, of allowed charges billed by areas tend to have a patient population Program final rule. Almost half of the
the MIPS eligible clinician for a with a higher proportion of older adults, additionally excluded clinicians are in
particular performance period. as well as higher rates of poor health small practices and approximately 17
In the CY 2017 Quality Payment outcomes, co-morbidities, chronic percent are clinicians from practices in
Program final rule (81 FR 77069 through conditions, and other social risk factors, designated rural areas. Applying this
77070), we defined individual MIPS which can result in the costs of criterion decreases the percent of the
eligible clinicians or groups who do not providing care and services being MIPS eligible clinicians that come from
exceed the low-volume threshold at significantly higher compared to nonsmall practices. For example, prior to
414.1305 as an individual MIPS rural areas. We also have heard from any exclusions, clinicians in small
eligible clinician or group who, during many solo practitioners and small practices represent 35 percent of all
the low-volume threshold determination practices who still face challenges and clinicians billing Part B services. After
period, has Medicare Part B allowed additional resource burden in applying the eligibility criteria for the
charges less than or equal to $30,000 or participating in the MIPS. CY 2017 Quality Payment Program final
provides care for 100 or fewer Part B- In the CY 2017 Quality Payment rule, MIPS eligible clinicians in small
enrolled Medicare beneficiaries. We Program final rule, we did not establish practices represent approximately 27
established at 414.1310(b) that for a an adjustment for social risk factors in percent of the clinicians eligible for
year, MIPS eligible clinicians who do assessing and scoring performance. In MIPS; however, with the increased low-
not exceed the low-volume threshold (as response to the CY 2017 Quality volume threshold, approximately 22
defined at 414.1305) are excluded Payment Program final rule, we received percent of the clinicians eligible for
from MIPS for the performance period public comments indicating that MIPS are from small practices. In our
for a given calendar year. individual MIPS eligible clinicians and analysis, the proposed changes to the
In the CY 2017 Quality Payment groups practicing in designated rural low-volume threshold showed little
Program final rule (81 FR 77069 through areas would be negatively impacted and impact on MIPS eligible clinicians from
77070), we defined the low-volume at a disadvantage if assessment and practices in designated rural areas.
threshold determination period to mean scoring methodology did not adjust for MIPS eligible clinicians from practices
a 24-month assessment period, which social risk factors. Additionally,
in designated rural areas account for 15
includes a two-segment analysis of commenters expressed concern that
to 16 percent of the total MIPS eligible
claims data during an initial 12-month such individual MIPS eligible clinicians
period prior to the performance period population. We note that, due to data
and groups may be disproportionately
followed by another 12-month period limitations, we assessed rural status
more susceptible to lower performance
during the performance period. The based on the status of individual TIN/
scores across all performance categories
initial 12-month segment of the low- NPI and did not model any group
and negative MIPS payments
volume threshold determination period definition for practices in designated
adjustments, and as a result, such
spans from the last 4 months of a rural areas.
outcomes may further strain already
calendar year 2 years prior to the limited fiscal resources and workforce We believe that increasing the number
performance period followed by the first shortages, and negatively impact access of such individual eligible clinicians
8 months of the next calendar year and to care (reduction and/or elimination of and groups excluded from MIPS
includes a 60-day claims run out, which available services). participation would reduce burden and
allows us to inform eligible clinicians After the consideration of stakeholder mitigate, to the extent feasible, the issue
and groups of their low-volume status feedback provided during informal surrounding confounding variables
during the month (December) prior to listening sessions since the publication impacting performance under the MIPS.
the start of the performance period. The of the CY 2017 Quality Payment Therefore, beginning with the 2018
second 12-month segment of the low- Program final rule, we are proposing to MIPS performance period, we are
volume threshold determination period modify the low-volume threshold policy proposing to increase the low-volume
spans from the last 4 months of a established in the CY 2017 Quality threshold. Specifically, at 414.1305,
calendar year 1 year prior to the Payment Program final rule. We believe we are proposing to define an
performance period followed by the first that increasing the dollar amount and individual MIPS eligible clinician or
8 months of the performance period in beneficiary count of the low-volume group who does not exceed the low-
the next calendar year and includes a threshold would further reduce the volume threshold as an individual MIPS
60-day claims run out, which allows us number of eligible clinicians that are eligible clinician or group who, during
to inform additional eligible clinicians required to participate in the MIPS, the low-volume threshold determination
and groups of their low-volume status which would reduce the burden on period, has Medicare Part B allowed
during the performance period. individual MIPS eligible clinicians and charges less than or equal to $90,000 or
We recognize that individual MIPS groups practicing in small practices and provides care for 200 or fewer Part B-
eligible clinicians and groups that are designated rural areas. Based on our enrolled Medicare beneficiaries. This
would mean that 37 percent of eligibility determinations by utilizing a eligibility determination analyses in
individual MIPS eligible clinicians and 30-day claims run out. order to prevent any potential confusion
groups would be in MIPS based on the In our comparison of data analysis for an individual eligible clinician or
low-volume threshold exclusion (and results utilizing a 60-day claims run out group to know whether or not
the other exclusions). However, 65 versus a 30-day claims run out, there participate in MIPS; also, such policy
percent of Medicare payments would was a 1 percent decrease in data makes it clear from the onset as to
still be captured under MIPS compared completeness. The small decrease in which individual eligible clinicians and
to 72.2 percent of Medicare payments data completeness would not groups would be required to participate
under the CY 2017 Quality Payment substantially impact individual MIPS in MIPS. We would conduct the second
Program final rule. eligible clinicians or groups regarding eligibility determination analysis to
We recognize that increasing the low-volume threshold determinations. account for the identification of
dollar amount and beneficiary count of We believe that a 30-day claims run out additional, previously unidentified
the low-volume threshold would would allow us to complete the analysis individual eligible clinicians and groups
increase the number of individual MIPS and provide such determinations in a who do not exceed the low-volume
eligible clinicians and groups excluded more timely manner. For performance threshold. We note that low-volume
from MIPS. We assessed various levels periods occurring in 2018 and future threshold determinations are made at
of increases and found that $90,000 as years, we propose a modification to the the individual and group level, and not
the dollar amount and 200 as the low-volume threshold determination at the virtual group level.
beneficiary count balances the need to period, in which the initial 12-month We note that section 1848(q)(1)(C)(iv)
account for individual MIPS eligible segment of the low-volume threshold of the Act requires the Secretary to
clinicians and groups who face determination period would span from select a low-volume threshold to apply
additional participation burden while the last 4 months of a calendar year 2 for the purposes of this exclusion which
not excluding a significant portion of years prior to the performance period may include one or more of the
the clinician population. followed by the first 8 months of the following: (1) The minimum number, as
next calendar year and include a 30-day determined by the Secretary, of Part B-
MIPS eligible clinicians who do not
claims run out; and the second 12- enrolled individuals who are treated by
exceed the low-volume threshold (as
month segment of the low-volume the MIPS eligible clinician for a
defined at 414.1305) are excluded
threshold determination period would particular performance period; (2) the
from MIPS for the performance period
span from the last 4 months of a minimum number, as determined by the
with respect to a year. The low-volume
calendar year 1 year prior to the Secretary, of items and services
threshold also applies to MIPS eligible
performance period followed by the first furnished to Part B-enrolled individuals
clinicians who practice in APMs under
8 months of the performance period in by the MIPS eligible clinician for a
the APM scoring standard at the APM
the next calendar year and include a 30- particular performance period; and (3)
Entity level, in which APM Entities do
day claims run out. This proposal the minimum amount, as determined by
not exceed the low-volume threshold. In would only change the duration of the the Secretary, of allowed charges billed
such cases, the MIPS eligible clinicians claims run out, not the 12-month by the MIPS eligible clinician for a
participating in the MIPS APM Entity timeframes used for the first and second particular performance period. We have
would be excluded from the MIPS segments of data analysis. established a low-volume threshold that
requirements for the applicable For purposes of the 2020 MIPS accounts for the minimum number of
performance period and not subject to a payment year, we would initially Part-B enrolled individuals who are
MIPS payment adjustment for the identify individual eligible clinicians treated by a MIPS eligible clinician and
applicable year. Such an exclusion and groups that do not exceed the low- that accounts for the minimum amount
would not affect an APM Entitys QP volume threshold based on 12 months of allowed charges billed by a MIPS
determination if the APM Entity is an of data starting from September 1, 2016 eligible clinician. We have not made
Advanced APM. to August 31, 2017. To account for the proposals specific to a minimum
In the CY 2017 Quality Payment identification of additional individual number of items and service furnished
Program final rule, we established the eligible clinicians and groups that do to Part-B enrolled individuals by a MIPS
low-volume threshold determination not exceed the low-volume threshold eligible clinician.
period to refer to the timeframe used to during performance periods occurring In order to expand the ways in which
assess claims data for making eligibility in 2018, we would conduct another claims data could be analyzed for
determinations for the low-volume eligibility determination analysis based purposes of determining a more
threshold exclusion (81 FR 77069 on 12 months of data starting from comprehensive assessment of the low-
through 77070). We defined the low- September 1, 2017 to August 31, 2018. volume threshold, we have assessed the
volume threshold determination period We would not change the low-volume option of establishing a low-volume
to mean a 24-month assessment period, status of any individual eligible threshold for items and services
which includes a two-segment analysis clinician or group identified as not furnished to Part-B enrolled individuals
of claims data during an initial 12- exceeding the low-volume threshold by a MIPS eligible clinician. We have
month period prior to the performance during the first eligibility determination considered defining items and services
period followed by another 12-month analysis based on the second eligibility by using the number of patient
period during the performance period. determination analysis. Thus, an encounters or procedures associated
Based on our analysis of data from the individual eligible clinician or group with a clinician. Defining items and
initial segment of the low-volume that is identified as not exceeding the services by patient encounters would
threshold determination period for low-volume threshold during the first assess each patient per visit or
performance periods occurring in 2017 eligibility determination analysis would encounter with the MIPS eligible
(that is, data spanning from September continue to be excluded from MIPS for clinician. We believe that defining items
1, 2015 to August 31, 2016), we found the duration of the performance period and services by using the number of
that it may not be necessary to include regardless of the results of the second patient encounters or procedures is a
a 60-day claims run out since we could eligibility determination analysis. We simple and straightforward approach for
achieve a similar outcome for such established our policy to include two stakeholders to understand. However,
we are concerned that using this unit of opts-in to participate in MIPS. We II.C.1.d. of this proposed rule, we are
analysis could incentivize clinicians to therefore seek comment on any proposing to modify the way in which
focus on volume of services rather than additional considerations we should size would be determined for small
the value of services provided to address when establishing this opt-in practices by establishing a process
patients. Defining items and services by policy. Such as, should we establish under which CMS would utilize claims
procedure would tie a specific clinical parameters for individual clinicians or data to make small practice size
procedure rendered to a patient to a groups who elect to opt-in to participate determinations. Also, in section II.C.4.e.
clinician. We solicit public comment on in MIPS such as required length of of this proposed rule, we are proposing
the methods of defining items and participation? Additionally, we note to establish a policy under which CMS
services furnished by clinicians that there is the potential with this opt- would utilize claims data to determine
described above and alternate methods in policy for there to be an impact on group size for groups of 10 or fewer
of defining items and services. our ability to create quality benchmarks eligible clinicians seeking to form or
For the individual MIPS eligible that meet our sample size requirements. join a virtual group.
clinicians and groups that would be For example, if particularly small As noted in the CY 2017 Quality
excluded from MIPS participation as a practices or solo practitioners with low Payment Program final rule, a group size
result of an increased low-volume Part B beneficiary volumes opt-in, such would be determined before exclusions
threshold, we believe that in future clinicians may lack sufficient sample are applied (81 FR 77057). We note that
years it would be beneficial to provide, size to be scored on many quality group size determinations are based on
to the extent feasible, such individual measures, especially measures that do the number of NPIs associated with a
MIPS eligible clinicians and groups not apply to all of a MIPS eligible TIN, which would include clinicians
with the option to opt-in to MIPS clinicians patients. We therefore seek (NPIs) who may be excluded from MIPS
participation if they might otherwise be comment on how to address any participation and do not meet the
excluded under the low-volume potential impact on our ability to create definition of a MIPS eligible clinician.
threshold such as where they only meet quality benchmarks that meet our b. Registration
one of the threshold determinations sample size requirements.
(including a third determination based As described in the CY 2017 Quality
We solicit public comments on these
on Part B items and services, if Payment Program final rule (81 FR
proposals.
established). For example, if a clinician 77072 through 77073), we established,
meets the low-volume threshold of 3. Group Reporting the following policies:
$90,000 in allowed charges, but does a. Background A group must adhere to an election
not meet the threshold of 200 patients process established and required by
or, if established, the threshold As described in the CY 2017 Quality CMS ( 414.1310(e)(5)), which includes:
pertaining to Part B items and services, Payment Program final rule, we ++ Groups will not be required to
we believe the clinician should, to the established the following requirements register to have their performance
extent feasible, have the opportunity to for groups (81 FR 77072): assessed as a group except for groups
choose whether or not to participate in Individual eligible clinicians and submitting data on performance
the MIPS and be subject to MIPS individual MIPS eligible clinicians will measures via participation in the CMS
payment adjustments. We recognize that have their performance assessed as a Web Interface or groups electing to
this choice would present additional group as part of a single TIN associated report the CAHPS for MIPS survey for
complexity to clinicians in with two or more eligible clinicians the quality performance category. For all
understanding all of their available (including at least one MIPS eligible other data submission mechanisms,
options and may impose additional clinician), as identified by a NPI, who groups must work with appropriate
burden on clinicians by requiring them have reassigned their Medicare billing third party intermediaries as necessary
to notify CMS of their decision. Because rights to the TIN (at 414.1310(e)(1)). to ensure the data submitted clearly
of these concerns and our desire to A group must meet the definition of indicates that the data represent a group
establish options in a way that is a low- a group at all times during the submission rather than an individual
burden and user-focused experience for performance period for the MIPS submission.
all MIPS eligible clinicians, we would payment year in order to have its ++ In order for groups to elect
not be able to offer this additional performance assessed as a group (at participation via the CMS Web Interface
flexibility until performance periods 414.1310(e)(2)). or administration of the CAHPS for
occurring in 2019. Therefore, as a means Individual eligible clinicians and MIPS survey, such groups must register
of expanding options for clinicians and individual MIPS eligible clinicians by June 30 of the applicable
offering them the ability to participate within a group must aggregate their performance period (that is, June 30,
in MIPS if they otherwise would not be performance data across the TIN to have 2018, for performance periods occurring
included, for the purposes of the 2021 their performance assessed as a group in 2018). We note that groups
MIPS payment year, we propose to (at 414.1310(e)(3)). participating in APMs that require APM
provide clinicians the ability to opt-in to A group that elects to have its Entities to report using the CMS Web
the MIPS if they meet or exceed one, but performance assessed as a group will be Interface are not required to register for
not all, of the low-volume threshold assessed as a group across all four MIPS the CMS Web Interface or administer
determinations, including as defined by performance categories (at the CAHPS for MIPS survey separate
414.1310(e)(4)). from the APM.
dollar amount, beneficiary count or, if

established, items and services. We As noted in the CY 2017 Quality When groups submit data utilizing
request public comment on this Payment Program final rule, we would third party intermediaries, such as a
proposal. not make an eligibility determination qualified registry, QCDR, or EHR, we are
We note that there may be additional regarding group size, but indicated that able to obtain group information from
considerations we should address for groups would attest to their group size the third party intermediary and discern
scenarios in which an individual for purpose of using the CMS Web whether the data submitted represents
eligible clinician or a group does not Interface or a group identifying as a group submission or individual
exceed the low-volume threshold and small practice (81 FR 77057). In section submission once the data are submitted.
In the CY 2017 Quality Payment policies for performance periods accordance with section
Program final rule (81 FR 77072 through occurring in 2018 and future years. In 1848(q)(5)(I)(iii) of the Act, the
77073), we discussed the this rule, we are proposing to establish establishment and implementation of a
implementation of a voluntary requirements for MIPS participation at process that allows an individual MIPS
registration process if technically the virtual group level. eligible clinician or group consisting of
feasible. Since the publication of the CY Section 1848(q)(5)(I) of the Act not more than 10 MIPS eligible
2017 Quality Payment Program final provides for the use of voluntary virtual clinicians to elect, for a given
rule, we have determined that it is not groups for certain assessment purposes, performance period, to be a virtual
technically feasible to develop and including the election of practices to be group with at least one other such
build a voluntary registration process. a virtual group and the requirements for individual MIPS eligible clinician or
Until further notice, we are not the election process. Section group. Given that section
implementing a voluntary registration 1848(q)(5)(I)(i) of the Act provides that 1848(q)(5)(I)(iii)(V) of the Act provides
process. MIPS eligible clinicians electing to be a that a virtual group is a combination of
Also, in the CY 2017 Quality Payment virtual group must: (1) Have their TINs, we interpret the references to an
Program final rule (81 FR 77075), we performance assessed for the quality individual MIPS eligible clinician in
expressed our commitment to pursue and cost performance categories in a section 1848(q)(5)(I)(ii) of the Act to
the active engagement of stakeholders manner that applies the combined mean a solo practitioner, which, for
throughout the process of establishing performance of all the MIPS eligible purposes of section 1848(q)(5)(I) of the
and implementing virtual groups. We clinicians in the virtual group to each Act, we propose to define as a MIPS
received public comments in response MIPS eligible clinician in the virtual eligible clinician (as defined at
to the CY 2017 Quality Payment group for the applicable performance 414.1305) who bills under a TIN with
Program final rule and additional period; and (2) be scored for the quality no other NPIs billing under such TIN.
stakeholder feedback by hosting several and cost performance categories based Also, we recognize that a group (TIN)
virtual group listening sessions and on such assessment. Section may include not only NPIs who meet
convening user groups. Many 1848(q)(5)(I)(ii) of the Act requires, in the definition of a MIPS eligible
stakeholders requested that CMS accordance with section clinician, but also NPIs who do not meet
provide an option that would permit a 1848(q)(5)(I)(iii) of the Act, the the definition of a MIPS eligible
portion of a group to participate in MIPS establishment and implementation of a clinician at 414.1305 and who are
outside the group by reporting as a process that allows an individual MIPS excluded from MIPS under
separate subgroup or forming a virtual eligible clinician or a group consisting
414.1310(b) or (c) based on one of four
group. Stakeholders indicated that the of not more than 10 MIPS eligible
exclusions (new Medicare-enrolled
option would measure performance clinicians to elect, for a given
eligible clinician; QP; Partial QP who
more effectively, enable groups to performance period, to be a virtual
chooses not to report on measures and
identify areas for improvement at a group with at least one other such
activities under MIPS; and eligible
granular level that would further individual MIPS eligible clinician or
clinicians that do not exceed the low-
improve quality of care and health group. The virtual group may be based
volume threshold). Thus, we interpret
outcomes, and increase coordination of on appropriate classifications of
the references to a group consisting of
care. providers, such as by geographic areas
not more than 10 MIPS eligible
We recognize that groups, including or by provider specialties defined by
nationally recognized specialty boards clinicians in section 1848(q)(5)(I)(ii) of
multi-specialty groups, have requested the Act to mean that a group with 10 or
over the years that we make an option of certification or equivalent
certification boards. fewer eligible clinicians (as defined at
available to them that would allow a 414.1305) would be eligible to form or
Section 1848(q)(5)(I)(iii) of the Act
portion of a group to report as a separate join a virtual group. For purposes of the
provides that the virtual group election
subgroup on measures and activities MIPS payment adjustment, the
process must include the following
that are more applicable to the subgroup adjustment would apply only to NPIs in
requirements: (1) An individual MIPS
and be assessed and scored accordingly the virtual group who meet the
eligible clinician or group electing to be
based on the performance of the definition of a MIPS eligible clinician at
in a virtual group must make their
subgroup. In future rulemaking, we 414.1305 and who are not excluded
election prior to the start of the
intend to explore the feasibility of from MIPS under 414.1310(b) or (c).
applicable performance period and
establishing group-related policies that We note that such groups, as defined at
cannot change their election during the
would permit participation in MIPS at 414.1305, would need to include at
performance period; (2) an individual
a subgroup level and create such least one MIPS eligible clinician in
MIPS eligible clinician or group may
functionality through a new identifier. order to be eligible to join or form a
elect to be in no more than one virtual
We solicit public comment on the ways virtual group. We refer readers to
group for a performance period, and, in
in which participation in MIPS at the section II.C.4.g. of this proposed rule for
the case of a group, the election applies
subgroup level could be established. discussion regarding the assessment and
to all MIPS eligible clinicians in the
4. Virtual Groups group; (3) a virtual group is a scoring of groups participating in MIPS
combination of TINs; (4) the as a virtual group.
a. Background We propose to define a virtual group
requirements must provide for formal
There are generally three ways to at 414.1305 as a combination of two or
written agreements among individual

participate in MIPS: (1) Individual-level MIPS eligible clinicians and groups more TINs composed of a solo
reporting; (2) group-level reporting; and electing to be a virtual group; and (5) practitioner (a MIPS eligible clinician
(3) virtual group-level reporting. We such other requirements as the Secretary (as defined at 414.1305) who bills
refer readers to sections II.C.1., II.C.3., determines appropriate. under a TIN with no other NPIs billing
and II.C.5. of this proposed rule for a under such TIN), or a group (as defined
discussion of the previously established b. Definition of a Virtual Group at 414.1305) with 10 or fewer eligible
requirements for individual- and group- As noted above, section clinicians under the TIN that elects to
level participation and our proposed 1848(q)(5)(I)(ii) of the Act requires, in form a virtual group with at least one
other such solo practitioner or group for of the TIN that is being scored for MIPS a limit at this time. We did consider
a performance period for a year. according to the generally applicable however proposing to establish such a
Lastly, we note that qualifications as scoring criteria (TIN/NPI) receives a limit, such as 50 or 100 participants. In
a virtual group for purposes of MIPS do MIPS adjustment based on the entire particular, we are concerned that virtual
not change the application of the groups performance assessment (entire groups of too substantial a size (for
physician self-referral law to a financial TIN). The remaining portion of the TIN example, 10 percent of all MIPS eligible
relationship between a physician and an that is being scored according to the clinicians in a given specialty or sub-
entity furnishing designated health APM scoring standard (TIN/NPI) specialty) may make it difficult to
services, nor does it change the need for receives a MIPS adjustment based on compare performance between and
such a financial relationship to comply that standard, or may be exempt from among clinicians. We believe that
with the physician self-referral law. MIPS if they achieve QP or Partial QP limiting the number of virtual group
We note that while entire TINs status. participants could eventually assist
participate in a virtual group, including We propose to apply a similar policy virtual groups as they aggregate their
each NPI under a TIN, and are assessed to groups, including groups containing performance data across the virtual
and scored collectively as a virtual participants in a MIPS APM or an group. However, we believe that as we
group, only NPIs that meet the Advanced APM, that are participating in initially implement virtual groups, it is
definition of a MIPS eligible clinician MIPS as part of a virtual group. important for virtual groups to have the
would be subject to a MIPS payment Specifically, for groups other than flexibility to determine their own size,
adjustment. However, we note that, as groups containing participants in a and thus, a better approach is to not
discussed in section II.C.4.h. of this MIPS APM or an Advanced APM, each place such a limit on virtual group size.
proposed rule, any MIPS eligible MIPS eligible clinician (TIN/NPI) would We will, however, monitor the ways in
clinician who is part of a TIN receive a MIPS adjustment based on the which solo practitioners and groups
participating in a virtual group and virtual groups combined performance with 10 or fewer eligible clinicians form
participating in a MIPS APM or assessment (combination of TINs). For virtual groups and may propose to
Advanced APM under the MIPS APM groups containing participants in a establish appropriate classifications
scoring standard would not receive a MIPS APM or an Advanced APM, only regarding virtual group composition or
MIPS payment adjustment based on the the portion of the TIN that is being a limit on the number of TINs that may
virtual groups final score, but would scored for MIPS according to the form a virtual group in future
receive a payment adjustment based on generally applicable scoring criteria rulemaking as necessary. We solicit
the MIPS APM scoring standard. (TIN/NPI) would receive a MIPS public comment on these proposals, as
Additionally, we recognize that there adjustment based on the virtual groups well as our approach of not establishing
are circumstances in which a TIN may combined performance assessment appropriate classifications (such as
have one portion of its NPIs (combination of TINs). As discussed in classification by geographic area or
participating under the generally section II.C.4.h. of this proposed rule, specialty) regarding virtual group
applicable MIPS scoring criteria while we are proposing to use waiver composition or a limit on the number of
the remaining portion of NPIs under the authority to ensure that any participants TINs that may form a virtual group at
TIN is participating in a MIPS APM or in the group who are participating in a this time.
an Advanced APM under the MIPS MIPS APM receive their payment In the CY 2017 Quality Payment
APM scoring standard. In the CY 2017 adjustment based on their score under Program final rule (81 FR 77073 through
Quality Payment Program final rule (81 the APM scoring standard (TIN/NPI). 77077), we expressed our commitment
FR 77058), we noted that except for Such participants may be exempt from to pursue the active engagement of
groups containing APM participants, we MIPS if they achieve QP or Partial QP stakeholders throughout the process of
are not permitting groups to split status. establishing and implementing virtual
TINs if they choose to participate in We refer readers to section II.C.4.e. of groups. We received public comments
MIPS as a group (81 FR 77058). Thus, this proposed rule for a discussion of in response to the CY 2017 Quality
we consider a group to mean an entire the proposed virtual group election Payment Program final rule and
single TIN that elects to participate in process and section II.C.4.g. of this additional stakeholder feedback by
MIPS at the group or virtual group level, proposed rule for discussion of our hosting several virtual group listening
including groups that have a portion of proposals regarding the assessment and sessions and convening user groups.
its NPIs participating in a MIPS APM or scoring of virtual groups. Many stakeholders requested that CMS
an Advanced APM. We note that such We recognize that virtual groups provide an option that would permit a
groups would participate in MIPS would each have unique characteristics portion of a group to participate in MIPS
similar to other groups. and varying patient populations. As outside the group by reporting
To clarify, for all groups, including noted in section II.C.4.a. of this separately or forming a virtual group.
groups containing participants in a proposed rule, the statute provides the We refer readers to section II.C.b.3. of
MIPS APM or an Advanced APM, the Secretary with discretion to establish this proposed rule for discussion
groups performance assessment appropriate classifications regarding the regarding a potential option for
consists of the entire TIN regardless of composition of virtual groups such as by addressing such issue.
whether the group participates in MIPS geographic area or specialty. However,
as part of a virtual group. Generally, for we believe it is important for virtual c. MIPS Virtual Group Identifier for
groups other than groups containing groups to have the flexibility to Performance
participants in a MIPS APM or an determine their own composition at this To ensure that we have accurately
Advanced APM, each MIPS eligible time, and, as a result, we are not captured all of the MIPS eligible
clinician under the TIN (TIN/NPI) proposing to establish any such clinicians participating in a virtual
receives a MIPS adjustment based on classifications regarding virtual group group, we propose that each MIPS
the entire groups performance composition. We further note that the eligible clinician who is part of a virtual
assessment (entire TIN). For groups statute does not limit the number of group would be identified by a unique
containing participants in a MIPS APM TINs that may form a virtual group, and virtual group participant identifier. The
or an Advanced APM, only the portion we are not proposing to establish such unique virtual group participant
identifier would be a combination of clinicians in a virtual group provided be available to virtual groups. Virtual
three identifiers: (1) Virtual group that more than 75 percent of the NPIs groups would be required to meet the
identifier (established by CMS; for billing under the virtual groups TINs reporting requirements for each measure
example, XXXXXX); (2) TIN (9 numeric meet the definition of a non-patient and activity, and the virtual group
characters; for example, XXXXXXXXX); facing individual MIPS eligible clinician would be responsible for ensuring that
and (3) NPI (10 numeric characters; for during the non-patient facing their measures and activities are
example, 1111111111). For example, a determination period. We refer readers aggregated across the virtual group (for
virtual participant identifier could be to section II.C.4.f. of this rule for the example, across their TINs). We note
VGXXXXXX, TINXXXXXXXXX, NPI proposed modification. We note that that other previously established group-
11111111111. We solicit public other policies previously established related policies and proposed policies
comment on this proposal. and proposed in this proposed rule for in this proposed rule pertaining to the
non-patient facing groups would apply four performance categories would
d. Application of MIPS Group Policies
to virtual groups. For example, as apply to virtual groups.
to Virtual Groups Therefore, we propose to apply MIPS
discussed in section II.C.1.e. of this
In the CY 2017 Quality Payment proposed rule, virtual groups group policies to virtual groups except
Program final rule (81 FR 77070 through determined to be non-patient facing as otherwise specified. We solicit public
77072), we finalized various would have their advancing care comment on this proposal. We are also
requirements for groups under MIPS at information performance category interested on receiving feedback on how
414.1310(e), under which groups automatically reweighted to zero. such group-related policies previously
electing to report at the group level are In regard to the application of small established and proposed in this
assessed and scored across the TIN for practice status to virtual groups, we are proposed rule either would or would
all four performance categories. We proposing that a virtual group would be not apply to virtual groups. In addition,
propose to apply our previously identified as having a small practice we request public comment on any
finalized and proposed group policies to status if the virtual group does not have other policies that may need to be
virtual groups, unless otherwise 16 or more members of a virtual group clarified or modified with respect to
specified. We recognize that there are (NPIs). We refer readers to section virtual groups, such as those that
instances in which we may need to II.C.4.d. of this proposed rule for require a calculation of the number of
clarify or modify the application of discussion regarding how small practice NPIs across a TIN (given that a virtual
certain previously finalized or proposed status would apply to virtual groups for group is a combination of TINs), the
group-related policies to virtual groups, scoring under MIPS. In the CY 2017 application of any virtual group
such as the definition of a non-patient Quality Payment Program final rule (81 participants status or designation to the
facing MIPS eligible clinician; small FR 77188), we defined the term small entire virtual group, the application of
practice, rural area and HPSA practices at 414.1305 as practices the group reporting requirements for the
designations; and groups that have a consisting of 15 or fewer clinicians and individual performance categories to
portion of its NPIs participating in a solo practitioners. In section II.C.1.c. of virtual groups, and the applicability and
MIPS APM or an Advanced APM (see this proposed rule, we are proposing for availability of certain measures and
section II.C.4.b. of this proposed rule). performance periods occurring in 2018 activities to any virtual group
More generally, such policies may and future years to identify small participant and to the entire virtual
include those that require a calculation practices by utilizing claims data. For group.
of the number of NPIs across a TIN performance periods occurring in 2018,
(given that a virtual group is a e. Election Process
we would identify small practices based
combination of TINs), the application of on 12 months of data starting from As noted above, section
any virtual group participants status or September 1, 2016 to August 31, 2017. 1848(q)(5)(I)(iii)(I) and (II) of the Act
designation to the entire virtual group, In section II.C.1.e. of this rule, we provides that the virtual group election
and the applicability and availability of propose to determine rural area and process must include certain
certain measures and activities to any HPSA practice designations for groups requirements, including that: (1) An
virtual group participant and to the participating in MIPS at the group level. individual MIPS eligible clinician or
entire virtual group. We note that in section II.C.7.b we group electing to be in a virtual group
With regard to the applicability of the describe our scoring proposals for must make their election prior to the
non-patient facing policies to virtual practices that are in a rural area or start of the applicable performance
groups, in the CY 2017 Quality Payment HPSA practice. For performance periods period and cannot change their election
Program final rule (81 FR 77048 through occurring in 2018 and future years, we during the performance period; and (2)
77049), we defined the term non-patient are proposing that a group with 75 an individual MIPS eligible clinician or
facing MIPS eligible clinician at percent or more of the TINs practice group may elect to be in no more than
414.1305 as an individual MIPS sites designated as rural areas or HPSA one virtual group for a performance
eligible clinician that bills 100 or fewer practices would be designated as a rural period, and, in the case of a group, the
patient facing encounters (including area or HPSA at the group level. We are election applies to all MIPS eligible
Medicare telehealth services defined in proposing that a virtual group with 75 clinicians in the group. We propose to
section 1834(m) of the Act) during the percent or more of the virtual groups codify at 414.1315(a) that a solo
non-patient facing determination TINs designated as rural areas or HPSA practitioner or a group of 10 or fewer
period, and a group provided that more practices would be designated as a rural eligible clinicians must make their
than 75 percent of the NPIs billing area or HPSA practice at the virtual election prior to the start of the
under the groups TIN meet the group level. We note that other policies applicable performance period and
definition of a non-patient facing previously established and proposed in cannot change their election during the
individual MIPS eligible clinician this proposed rule for rural area and performance period. Virtual group
during the non-patient facing HPSA groups would apply to virtual participants may elect to be in no more
determination period. We are proposing groups. than one virtual group for a performance
to modify the definition of a non-patient We recognize that the measures and period and, in the case of a group, the
facing MIPS eligible clinician to include activities available to groups would also election applies to all MIPS eligible
clinicians in the group. For the 2018 eligible clinicians that do not engage in duration of the election period and the
performance year and future years, we any activity during stage 1, they would applicable performance period. TINs
are proposing to establish an election begin the election process at stage 2. For could determine their status by
period. solo practitioners and groups who contacting their designated TA
We propose to codify at 414.1315(b) engage in stage 1 and were determined representative or the Quality Payment
that, beginning with performance eligible for virtual group participation, Program Service Center; otherwise, the
periods occurring in 2018, a solo they would proceed to stage 2. Engaging TINs status would be determined at the
practitioner, or group of 10 or fewer in stage 1 would provide solo time that the TINs virtual group
eligible clinicians electing to be in a practitioners and groups with the option election is submitted. For example, if a
virtual group must make their election to confirm whether or not they are group contacted their designated TA
by December 1 of the calendar year eligible to join or form a virtual group representative or the Quality Payment
preceding the applicable performance before going to the lengths of executing Program Service Center on October 20,
period. For example, a solo practitioner formal written agreements, submitting a 2017, the claims data analysis would
or group would need to make their formal election registration, allocating include the months of July through
election by December 1, 2017 to resources for virtual group September of 2017, and if determined
participate in MIPS as a virtual group implementation, and other related not to exceed 10 eligible clinicians, such
during the 2018 performance period. activities; whereas, engaging directly in TINs size status would be identified at
Prior to the election deadline, a virtual stage 2 as an initial step, solo such time and would be retained for the
group representative would have the practitioners and groups may have duration of the election period and the
opportunity to make an election, on conducted all such efforts to only have 2018 performance period. If another
behalf of the members of a virtual group, their election registration be rejected group contacted their designated TA
regarding the formation of a virtual with no recourse or remaining time to representative or the Quality Payment
group for an applicable performance amend and resubmit. Program Service Center on November
period. We intend to publish the During stage 1 of the virtual group 20, 2017, the claims data analysis would
beginning date of the virtual group election process, we would determine include the months of July through
election period applicable to the 2018 whether or not a TIN is eligible to form October of 2017, and if determined not
performance period and future years in or join a virtual group. In order for a to exceed 10 eligible clinicians, such
subregulatory guidance. solo practitioner to be eligible to form or TINs size status would be identified at
In order to provide support and join a virtual group, the solo practitioner such time and would be retained for the
reduce burden, we intend to make would need to be considered a MIPS duration of the election period and the
technical assistance (TA) available, to eligible clinician (defined at 414.1305) 2018 performance period.
the extent feasible and appropriate, to who bills under a TIN with no other
support clinicians who choose to come We believe such a virtual group
NPIs billing under such TIN, and not
together as a virtual group. Clinicians determination period process provides a
excluded from MIPS under
can access TA infrastructure and relative representation of real-time
414.1310(b) and (c). In order for a
resources that they may already be group size for purposes of virtual group
group to be eligible to form or join a
utilizing). For Quality Payment Program eligibility and allows groups to know
virtual group, a group would need to
year 3, we intend to provide an their real-time size status immediately
have a TIN size that does not exceed 10
electronic election process if technically and plan accordingly for virtual group
eligible clinicians and not excluded
feasible. We propose that clinicians who from MIPS based on the low-volume implementation. It is anticipated that
do not elect to contact their designated threshold exclusion at the group level. starting in September of each calendar
TA representative would still have the For purposes of determining TIN size year prior to the applicable performance
option of contacting the Quality for virtual group participation year beginning in 2018, groups would
Payment Program Service Center. eligibility, we coin the term virtual be able to contact their designated TA
We propose to codify at 414.1315(c) group eligibility determination period representative or the Quality Payment
a two-stage virtual group election and define it to mean an analysis of Program Service Center and inquire
process, stage 1 of which is optional, for claims data during an assessment period about virtual group participation
the applicable 2018 and 2019 of up to five months that would begin eligibility. We note that TIN size
performance periods. Stage 1 pertains to on July 1 and end as late as November determinations are based on the number
virtual group eligibility determinations. 30 of a calendar year prior to the of NPIs associated with a TIN, which
In stage 1, solo practitioners and groups performance year and includes a 30-day would include clinicians (NPIs)
with 10 or fewer eligible clinicians claims run out. excluded from MIPS participation and
interested in forming or joining a virtual To capture a real-time representation who do not meet the definition of a
group would have the option to contact of TIN size, we propose to analyze up MIPS eligible clinician.
their designated TA representative or to five months of claims data on a For groups that do not choose to
the Quality Payment Program Service rolling basis, in which virtual group participate in stage 1 of the election
Center in order to obtain information eligibility determinations for each TIN process (that is, the group does not
pertaining to virtual groups and/or would be updated and made available request an eligibility determination), we
determine whether or not they are monthly. We note that an eligibility will make an eligibility determination
eligible, as it relates to the practice size determination regarding TIN size is during stage 2 of the election process. If
requirement of a solo practitioner or a based on a relative point in time within a group began the election process at
group of 10 or fewer eligible clinicians, the five-month virtual group eligibility stage 2 and if its TIN size is determined
to participate in MIPS as a virtual group determination period, and not an not to exceed 10 eligible clinicians and
( 414.1315(a)(1)(i)). We note that eligibility determination made at the not excluded based on the low-volume
activity involved in stage 1 is not end of such five-month determination threshold exclusion at the group level,
required, but a resource available to solo period. If at any time a TIN is the group is determined eligible to
practitioners and groups with 10 or determined to be eligible to participate participate in MIPS as part of a virtual
fewer eligible clinicians; otherwise, solo in MIPS as part of a virtual group, the group, and such virtual group eligibility
practitioners or groups with 10 or fewer TIN would retain that status for the determination status would be retained
for the duration of the election period eligible to participate in MIPS as part of (reporting at the virtual group level),
and applicable performance period. a virtual group; identify the NPIs within then the low-volume threshold
Stage 2 pertains to virtual group each TIN participating in a virtual group determination at the individual or group
formation. For stage two, we propose that are excluded from MIPS in order to level would be applicable to such solo
the following: ensure that such NPIs would not receive practitioner or group with 10 or fewer
TINs comprising a virtual group a MIPS payment adjustment or, when eligible clinicians. Thus, solo
must establish a written formal applicable and when information is practitioners (individual MIPS eligible
agreement between each member of a available, would receive a payment clinicians) or groups with 10 or fewer
virtual group prior to an election adjustment based on a MIPS APM eligible clinicians that are determined
( 414.1315(c)(2)(i)). scoring standard; calculate the low- not to exceed the low-volume threshold
On behalf of a virtual group, the volume threshold at the individual and at the individual or group level would
official designated virtual group group levels in order to determine not be eligible to participate in MIPS as
representative must submit an election whether or not a solo practitioner or an individual, group, or virtual group.
by December 1 of the calendar year prior group is eligible to participate in MIPS As we engaged in various discussions
to the start of the applicable as part of a virtual group; and notify with stakeholders during the
performance period. virtual groups as to whether or not they rulemaking process through listening
( 414.1315(c)(2)(ii)). We anticipate this are considered official virtual groups for sessions and user groups, stakeholders
election will occur via email to the the applicable performance period. For indicated that many solo practitioners
Quality Payment Program Service virtual groups that are determined to and small groups have limited resources
Center using the following email have met the virtual group formation and technical capacities, which may
address: MIPS_VirtualGroups@ criteria and identified as an official make it difficult for the entities to form
cms.hhs.gov. virtual group participating in MIPS for virtual groups without sufficient time
The submission of a virtual group and technical assistance. Depending on
an applicable performance period, we
election must include, at a minimum, the resources and technical capacities of
would contact the official designated
information pertaining to each TIN and the entities, stakeholders conveyed that
virtual group representative via email
NPI associated with the virtual group it may take entities 3 to 18 months to
notifying the virtual group of its official
and contact information for the virtual prepare to participate in MIPS as a
virtual group status and issuing a virtual
group representative virtual group. The majority of
( 414.1315(c)(2)(iii). A virtual group group identifier for performance (as
described in section II.C.4.c. of this stakeholders indicated that virtual
representative would submit the groups would need at least 6 to 12
following type of information: each TIN proposed rule) that would accompany
the virtual groups submission of months prior to the start of the 2018
associated with the virtual group; each performance period to form virtual
NPI associated with a TIN that is part of performance data during the submission
period. groups, prepare health IT systems, and
the virtual group; name of the virtual train staff to be ready for the
group representative; affiliation of the In regard to virtual group implementation of virtual group related
virtual group representative to the determinations pertaining to the low- activities by January 1, 2018.
virtual group; contact information for volume threshold, we recognize that We recognize that for the first year of
the virtual group representative; and such determinations are made at the virtual group formation and
confirm through acknowledgment that a individual and group level, but not at implementation prior to the start of the
written formal agreement has been the virtual group level. The low-volume 2018 performance period, the timeframe
established between each member of the threshold determinations are applicable for virtual groups to make an election by
virtual group prior to election and each to the way in which individual eligible registering would be relatively short,
member of the virtual group is aware of clinicians and groups participate in particularly from the date we issue the
participating in MIPS as a virtual group MIPS as individual MIPS eligible publication of a final rule toward the
for an applicable performance period. clinicians (solo practitioners) or groups. end of the 2017 calendar year. To
Each member of the virtual group must For example, if an individual MIPS provide solo practitioners and groups
retain a copy of the virtual groups eligible clinician is part of a practice with 10 or fewer eligible clinicians with
written agreement. We note that the that is participating in MIPS at the additional time to assemble and
virtual group agreement is subject to the individual level (reporting at the coordinate resources, and form a virtual
MIPS data validation and auditing individual level), then the low-volume group prior to the start of the 2018
requirements as described in section threshold determination is made at the performance period, we are providing
II.C.9.c. of this rule. individual level. Whereas, if an virtual groups with an opportunity to
Once an election is made, the individual MIPS eligible clinician is make an election prior to the
virtual group representative must part of a practice that is participating in publication of our final rule. We intend
contact their designated CMS contact to MIPS at the group level (reporting at the for the virtual group election process to
update any election information that group level), then the low-volume be available as early as mid-September
changed during an applicable threshold determination at the group of 2017; we will publicize the specific
performance period one time prior to level would be applicable to such MIPS opening date via subregulatory
the start of an applicable submission eligible clinician regardless of the low- guidance. Virtual groups would have
period ( 414.1315(c)(2)(iv)). We volume threshold determination made from mid-September to December 1,
anticipate that virtual groups will use at the individual level because such 2017 to make an election for the 2018
the Quality Payment Program Service individual MIPS eligible clinician is performance year. In regard to our
Center as their designated CMS contact; part of a group reporting at the group proposed policies pertaining to virtual
however, we will define this further in level and the low-volume threshold group implementation (for example,
subregulatory guidance. determinations for groups applies to the definition of a virtual group and
For stage 2 of the election process, we group as a whole. Similarly, if a solo election process requirements), we
would review all submitted election practitioner or a group with 10 or fewer intend to closely align with the statutory
information; confirm whether or not eligible clinicians seeks to participate in requirements in order to establish clear
each TIN within a virtual group is MIPS at the virtual group level expectations for solo practitioners and
small groups, and have an opportunity would continue to be attributed to the We propose, at 414.1315(c)(3), that a
to begin the preparation of forming virtual group. The remaining members formal written agreement between each
virtual groups in advance of the of a virtual group would continue to be member of a virtual group must include
publication of our final rule. However, part of the virtual group even if only one the following elements:
any MIPS eligible clinicians applying to solo practitioner or group remains. We Expressly state the only parties to
be a virtual group that does not meet all consider a TIN that is acquired or the agreement are the TINs and NPIs of
finalized virtual group requirements merged with another TIN, or no longer the virtual group (at 414.1315(c)(3)(i)).
would not be permitted to participate in operating as a TIN (e.g., a group practice For example, the agreement may not be
MIPS as a virtual group. closes) to mean a TIN that no longer between a virtual group and another
As previously noted, groups exists or operates under the auspices of entity, such as an independent practice
participating in a virtual group would such TIN during a performance year. association (IPA) or management
have the size of their TIN determined As outlined in section company that in turn has an agreement
for eligibility purposes. The virtual 1848(q)(5)(I)(iii) of the Act and with one or more TINs within the
group size would be determined one previously noted, a virtual group is a virtual group. Similarly, virtual groups
time for each performance period. We combination of TINs, which would should not use existing contracts
recognize that the size of a group may include at least two separate TINs between TINs that include third parties.
fluctuate during a performance period associated with a solo practitioner (TIN/ Be executed on behalf of the TINs
with eligible clinicians and/or MIPS NPI), or a group with 10 or fewer and the NPIs by individuals who are
eligible clinicians joining or leaving a eligible clinicians and another such solo authorized to bind the TINs and the
group. For groups within a virtual group practitioner, or group. However, given NPIs, respectively at
that are determined to have a group size that a virtual group must be a 414.1315(c)(3)(ii)).
of 10 eligible clinicians or less based on combination of TINs, we recognize that Expressly require each member of
the one time determination per the composition of a virtual group could the virtual group (including each NPI
applicable performance year, any new include, for example, one solo under each TIN) to agree to participate
eligible clinicians or MIPS eligible practitioner (NPI) who is practicing in MIPS as a virtual group and comply
clinicians that join the group during the under multiple TINs, in which the solo with the requirements of the MIPS and
performance period would participate practitioner would be able to form a all other applicable laws and regulations
in MIPS as part of the virtual group. In virtual group with his or her own self (including, but not limited to, federal
such cases, we recognize that a group based on each TIN assigned to the solo criminal law, False Claims Act, anti-
may exceed 10 eligible clinicians practitioner. For the number of TINs kickback statute, civil monetary
associated with its TIN during an able to form a virtual group, we note
penalties law, Health Insurance
applicable performance period, but at that there is not a limit to the number
Portability and Accountability Act, and
the time of election, such group would of TINs able to comprise a virtual group.
physician self-referral law) at
have been determined eligible to form or
f. Virtual Group Agreements 414.1315(c)(3)(iii)).
join a virtual group given that the TIN
The statute provides for formal Require each TIN within a virtual
did not have more than 10 eligible
written agreements among the MIPS group to notify all NPIs associated with
clinicians associated with its TIN. As
previously noted, the virtual group eligible clinicians electing to form a the TIN of their participation in the
representative would need to contact virtual group. We propose that each MIPS as a virtual group at
the Quality Payment Program Service virtual group member would be 414.1315(c)(3)(iv)).
Center to update the virtual groups required to execute formal written Set forth the NPIs rights and
information that was provided during agreements with each other virtual obligations in, and representation by,
the election period if any information group member to ensure that the virtual group, including without
changed during an applicable requirements and expectations of limitation, the reporting requirements
performance period one time prior to participation in MIPS are clearly and how participation in MIPS as a
the start of an applicable submission articulated, understood, and agreed virtual group affects the ability of the
period (for example, include new NPIs upon. We note that a virtual group may NPI to participate in the MIPS outside
who joined a TIN that is part of a virtual not include a solo practitioner or group of the virtual group at
group). Virtual groups must re-register as part of the virtual group unless an 414.1315(c)(3)(v)).
before each performance period. authorized person of the TIN has Describe how the opportunity to
The statute provides that a solo executed a formal written agreement. receive payment adjustments will
practitioner (TIN/NPI) and a group with During the election process and encourage each member of the virtual
10 or fewer eligible clinicians may elect submission of a virtual group election, group (including each NPI under each
to be in no more than one virtual group a designated virtual group TIN) to adhere to quality assurance and
for a performance period. We note that representative would be required to improvement at 414.1315(c)(3)(vi)).
such a solo practitioner or a group that confirm through acknowledgement that Require each member of the virtual
is part of a virtual group may not elect an agreement is in place between each group to update its Medicare enrollment
to be in more than one virtual group for member of the virtual group. An information, including the addition and
a performance period. Also, the statute agreement would be executed for at deletion of NPIs billing through a TIN
determines that a virtual group election least one performance period. If a NPI that is part of a virtual group, on a
by the group for an applicable joins or leaves a TIN, or a change is timely basis in accordance with
performance period applies to all MIPS made to a TIN that impacts the Medicare program requirements and to
eligible clinicians in the group. In the agreement itself, such as a legal business notify the virtual group of any such
case of a TIN within a virtual group name change, during the applicable changes within 30 days after the change
being acquired or merged with another performance year, a virtual group would at 414.1315(c)(3)(vii)).
TIN, or no longer operating as a TIN (for be required to update the agreement to Be for a term of at least one
example, a group practice closes) during reflect such changes and submit changes performance period as specified in the
a performance period, such solo to CMS via the Quality Payment formal written agreement at
practitioner or groups performance data Program Service Center. 414.1315(c)(3)(viii)).
Require completion of a close-out Individual eligible clinicians and proposed rule for scoring policies that
process upon termination or expiration individual MIPS eligible clinicians who would apply to virtual groups.
of the agreement that requires the TIN are part of a TIN participating in MIPS As previously noted, we propose to
(group part of the virtual group) or NPI at the virtual group level must aggregate allow solo practitioners and groups with
(solo practitioner part of the virtual their performance data across multiple 10 or fewer eligible clinicians that have
group) to furnish all data necessary in TINs in order for their performance to elected to be part of a virtual group to
order for the virtual group to aggregate be assessed as a virtual group (at have their performance measured and
its data across the virtual group at 414.1315(d)(3)). aggregated at the virtual group level
414.1315(c)(3)(ix)). MIPS eligible clinicians that elect to across all four performance categories;
As part of the virtual group election participate in MIPS at the virtual group however, we would apply payment
ICR, we filed a 60-day notice on June 14, level would have their performance adjustments at the individual TIN/NPI
2017 (82 FR 27257), which includes an assessed at the virtual group level across level. Each TIN/NPI would receive a
agreement template that could be used all four MIPS performance categories (at final score based on the virtual group
by virtual groups and will be made 414.1315(d)(4)). performance, but the payment
available via subregulatory guidance. Virtual groups would need to adjustment would still be applied at the
The agreement template is not required, adhere to an election process TIN/NPI level. We would assign the
but serves as a model agreement that established and required by CMS (at virtual group score to all TIN/NPIs
could be utilized by virtual groups. The 414.1315(d)(5)). billing under a TIN in the virtual group
agreement template includes all We solicit public comment on these during the performance period.
proposals. During the performance year, we
necessary elements required for such an
agreement. h. Assessment and Scoring for the MIPS recognize that NPIs in a TIN that has
Performance Categories joined a virtual group may also be
We solicit public comment on these
participants in an APM. The TIN, as
proposals. As noted above, section part of the virtual group, must submit
Through the formal written 1848(q)(5)(I)(i) of the Act provides that performance data for all eligible
agreements, we want to ensure that all eligible clinicians electing to be a virtual clinicians associated with the TIN,
members of a virtual group are aware of group will: (1) Have their performance including those participating in APMs,
their participation in a virtual group. As assessed for the quality and cost to ensure that all eligible clinicians
noted above, formal written agreements performance categories in a manner that associated with the TIN are being
must include a provision that requires applies the combined performance of all measured under MIPS.
each TIN within a virtual group to eligible clinicians in the virtual group to For participants in MIPS APMs, we
notify all NPIs associated with the TIN each MIPS eligible clinician (except for propose to use our authority under
regarding their participation in the those participating in a MIPS APM or an section 1115A(d)(1) for MIPS APM
MIPS as a virtual group in order to Advanced APM under the MIPS APM authorized under section 1115A of the
ensure that each member of a virtual scoring standard) in the virtual group Act, and under section 1899(f) for the
group is aware of their participation in for a performance period of a year; and Shared Savings Program, to waive the
the MIPS as a virtual group. We want to (2) be scored based on the assessment of requirement under section 1848
implement an approach that considers a the combined performance described (q)(2)(5)(I)(i)(II) of the Act that requires
balance between the need to ensure that above regarding the quality and cost performance category scores from
all members of a virtual group are aware performance categories for a virtual group reporting must be used to
of their participation in a virtual group performance period. We believe it is generate the composite score upon
and the minimization of administration critical for virtual groups to be assessed which the MIPS payment adjustment is
burden. We solicit public comment on and scored at the virtual group level for based for all TIN/NPIs in the virtual
approaches for virtual groups to ensure all performance categories; it eliminates group. Instead, we would use the score
that all members of a virtual group are the burden of virtual group members assigned to the MIPS eligible clinician
aware of their participation in the having to report as a virtual group and based on the applicable APM Entity
virtual group. separately outside of a virtual group. score to determine MIPS payment
g. Reporting Requirements Additionally, we believe that the adjustments for all MIPS eligible
assessment and scoring at the virtual clinicians that are part of an APM Entity
As we noted in this proposed rule, we group level provides for a participating in a MIPS APM, in
believe virtual groups should generally comprehensive measurement of accordance with 414.1370, instead of
be treated under the MIPS as groups. performance, shared responsibility, and determining MIPS payment adjustments
Therefore, for MIPS eligible clinicians an opportunity to effectively and for these MIPS eligible clinicians using
participating at the virtual group level, efficiently coordinate resources to also the composite score of their virtual
we propose the following requirements: achieve performance under the group.
Individual eligible clinicians and improvement activities and the APMs seek to deliver better care at
individual MIPS eligible clinicians who advancing care information performance lower cost and to test new ways of
are part of a TIN participating in MIPS categories. We propose at 414.1315 paying for care and measuring and
at the virtual group level would have that virtual groups would be assessed assessing performance. In the CY 2017
their performance assessed as a virtual and scored across all four MIPS Quality Payment Program final rule, we
group at 414.1315(d)(1). performance categories at the virtual established policies to the address
Individual eligible clinicians and group level for a performance period of concerns we have expressed in regard to
individual MIPS eligible clinicians who a year. the application of certain MIPS policies
are part of a TIN participating in MIPS In the CY 2017 Quality Payment to MIPS eligible clinicians in MIPS
at the virtual group level would need to Program final rule (81 FR 77319 through APMs (81 FR 77246 through 77269). In
meet the definition of a virtual group at 77329), we established the MIPS final section II.C.6.g. of this proposed rule,
all times during the performance period score methodology, which will apply to we reiterate those concerns and propose
for the MIPS payment year (at 414. virtual groups. We refer readers to additional policies for the APM scoring
1315(d)(2)). sections II.C.7.b. and II.C.8. of this standard. We believe it is important to
consistently apply the APM scoring 414.1320(b)(2) that for purposes of the 2019 (January 1, 2019 through December
standard under MIPS for eligible MIPS payment year 2020, the 31, 2019).
clinicians participating in MIPS APMs performance period for the We request comments on our
in order to avoid potential improvement activities and advancing proposals for the performance period for
misalignments between the evaluation care information performance categories MIPS payment year 2021 and future
of performance under the terms of the is a minimum of a continuous 90-day years.
MIPS APM and evaluation of period within CY 2018, up to and
performance on measures and activities including the full CY 2018 (January 1, 6. MIPS Performance Category Measures
under MIPS, and to preserve the 2018, through December 31, 2018). We and Activities
integrity of the initiatives we are testing. are not proposing any changes to these a. Performance Category Measures and
Therefore, we believe it is necessary to policies. Reporting
waive the requirement to only use the We also finalized at 414.1325(f)(2) to
virtual group scores under section (1) Submission Mechanisms
use claims with dates of service during
1848(q)(5)(I)(i)(II) of the Act, and instead the performance period that must be We finalized in the CY 2017 Quality
to apply the score under the APM processed no later than 60 days Payment Program final rule (81 FR
scoring standard for eligible clinicians following the close of the performance 77094) at 414.1325(a) that individual
in virtual groups who are also in an period for purposes of assessing MIPS eligible clinicians and groups
APM Entity participating in an APM. performance and computing the MIPS must submit measures and activities, as
We note that MIPS eligible clinicians payment adjustment. Lastly, we
who are participants in both a virtual applicable, for the quality, improvement
finalized that individual MIPS eligible activities, and advancing care
group and a MIPS APM would be clinicians or groups who report less
assessed under MIPS as part of the information performance categories. For
than 12 months of data (due to family the cost performance category, we
virtual group and under the APM leave, etc.) would be required to report
scoring standard as part of an APM finalized that each individual MIPS
all performance data available from the eligible clinicians and groups cost
Entity group, but would receive their applicable performance period (for
payment adjustment based only on the performance would be calculated using
example, CY 2018 or a minimum of a administrative claims data. As a result,
APM Entity score. In the case of an continuous 90-day period within CY
eligible clinician participating in both a individual MIPS eligible clinicians and
2018). groups are not required to submit any
virtual group and an Advanced APM
who has achieved QP status, the We are proposing at 414.1320(c) and additional information for the cost
clinician would be assessed under MIPS (c)(1) that for purposes of the MIPS performance category. For individual
as part of the virtual group, but would payment year 2021 and future years, for eligible clinicians and groups that are
still be excluded from the MIPS the quality and cost performance not MIPS eligible clinicians, such as
payment adjustment as a result of his or categories, the performance period physical therapists, but elect to report to
her QP status. We refer readers to under MIPS would be the full calendar MIPS, we will calculate administrative
section II.C.6.g.(2) of this proposed rule year (January 1 through December 31) claims-based cost measures and quality
for further discussion regarding the that occurs 2 years prior to the measures, if data are available. We
waiver and the CY 2017 Quality applicable payment year. For example, finalized in the CY 2017 Quality
Payment Program final rule (81 FR for the MIPS payment year 2021, the Payment Program final rule (81 FR
77013) for discussion regarding the performance period would be CY 2019 77094 through 77095) multiple data
timeframe used for determining QP (January 1, 2019 through December 31, submission mechanisms for MIPS,
status. 2019), and for the MIPS payment year which provide individual MIPS eligible
2022 the performance period would be clinicians and groups with the
5. MIPS Performance Period CY 2020 (January 1, 2020 through flexibility to submit their MIPS
In the CY 2017 Quality Payment December 31, 2020). measures and activities in a manner that
Program final rule (81 FR 77085), we We are proposing at 414.1320(d) and best accommodates the characteristics of
finalized at 414.1320(b)(1) that for (d)(1) that for purposes of the MIPS their practice, as indicated in Tables 2
purposes of the MIPS payment year payment year 2021, the performance and 3. Table 2 summarizes the data
2020, the performance period for the period for the improvement activities submission mechanisms for individual
quality and cost performance categories and advancing care information MIPS eligible clinicians that we
is CY 2018 (January 1, 2018 through performance categories would be a finalized at 414.1325(b) and (e). Table
December 31, 2018). For the minimum of a continuous 90-day period 3 summarizes the data submission
improvement activities and advancing within the calendar year that occurs 2 mechanisms for groups that are not
care information performance years prior to the applicable payment reporting through an APM that we
categories, we finalized at year, up to and including the full CY finalized at 414.1325(c) and (e).
TABLE 2DATA SUBMISSION MECHANISMS FOR MIPS ELIGIBLE CLINICIANS REPORTING INDIVIDUALLY
[TIN/NPI]
Performance category/submission combinations Individual reporting data submission mechanisms

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

QCDR.
Qualified registry.
EHR.
Cost ..................................................................... Administrative claims.1
TABLE 2DATA SUBMISSION MECHANISMS FOR MIPS ELIGIBLE CLINICIANS REPORTING INDIVIDUALLYContinued
[TIN/NPI]
Performance category/submission combinations Individual reporting data submission mechanisms

accepted
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 combinations Group reporting data submission mechanisms
accepted
Quality ................................................................. QCDR.

Qualified registry.
EHR.
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 to ones practice might be available maximum number of points under a
individual MIPS eligible clinicians and through a particular submission performance category. We considered an
groups may elect to submit information mechanism. The commenter also approach that would require MIPS
via multiple mechanisms; however, they believed that such flexibility would eligible clinicians to first submit data on
must use the same identifier for all encourage continued participation in as many required measures and
performance categories, and they may MIPS. activities as possible via one submission
only use one submission mechanism per We are proposing to revise mechanism before submitting data via
performance category. In response to the 414.1325(d) for purposes of the 2020 an additional submission mechanism,
CY 2017 Quality Payment Program final MIPS payment year and future years, but we believe that such an approach
rule (81 FR 77089), we received beginning with performance periods would limit flexibility.
comments supportive of the use of occurring in 2018, to allow individual If an individual MIPS eligible
multiple submission mechanisms for a MIPS eligible clinicians and groups to clinician or group submits the same
single performance category due to the submit data on measures and activities, measure through two different
flexibility it would provide clinicians. as applicable, via multiple data mechanisms, each submission would be
Another commenter supported such an submission mechanisms for a single calculated and scored separately. We do
approach because they believed that the performance category (specifically, the not have the ability to aggregate data on
scoring of only one submission quality, improvement activities, or the same measure across submission
mechanism per performance category advancing care information performance mechanisms. We would only count the
may influence which quality measures a category). Under this proposal, submission that gives the clinician the
MIPS eligible clinician chooses to report individual MIPS eligible clinicians and higher score, thereby avoiding the
given that the commenter believed only groups that have fewer than the required double count. We refer readers to
number of measures and activities section II.C.7. of this proposed rule,
a limited number of measures relevant

applicable and available under one which further outlines how we propose
1 Requires no separate data submission to CMS: submission mechanism could be to score measures and activities
Measures are calculated based on data available required to submit data on additional regardless of submission mechanism.
from MIPS eligible clinicians billings on Medicare measures and activities via one or more We believe that this flexible approach
Part B claims. NOTE: Claims differ from additional submission mechanisms, as would help individual MIPS eligible
administrative claims as they require MIPS eligible
clinicians to append certain billing codes to
necessary, provided that such measures clinicians and groups with reporting, as
denominator eligible claims to indicate the required and activities are applicable and it provides more options for the
quality action or exclusion occurred. available to them to receive the submission of data for the applicable
performance categories. For example, an advancing care information performance data must be submitted during an 8-
individual MIPS eligible clinician or categories. week period following the close of the
group submitting data on four For those MIPS eligible clinicians performance period that will begin no
applicable and available quality participating in a MIPS APM, who are earlier than January 2, and end no later
measures via EHR may not be able to on an APM Participant List on at least than March 31. For example, the CMS
receive the maximum number of points one of the three snapshot dates as Web Interface submission period could
available under the quality performance finalized in the CY 2017 Quality span an 8-week timeframe beginning
category. However, with this proposed Payment Program Final Rule (81 FR January 16 and ending March 13. The
modification, the MIPS eligible clinician 77444 through 77445), or for MIPS specific deadline during this timeframe
could meet the requirement to report six eligible clinicians participating in a full will be published on the CMS Web site.
quality measures by submitting data on TIN MIPS APM, who are on an APM We are not proposing any changes to the
two additional quality measure via Participant List on at least one of the submission deadlines in this proposed
another submission mechanism, such as four snapshot dates as discussed in rule.
claims or qualified registry. This would section II.C.6.g.(2) of this proposed rule,
the APM scoring standard applies. We b. Quality Performance Criteria
enable the MIPS eligible clinician to
receive the maximum number of points refer readers to 414.1370 and the CY (1) Background
available under the quality performance 2017 Quality Payment Program final
Sections 1848(q)(1)(A)(i) and (ii) of
category. We believe that by providing rule (81 FR 77246), which describes
the Act require the Secretary to develop
this flexibility, we would be allowing how MIPS eligible clinicians
a methodology for assessing the total
MIPS eligible clinicians the flexibility to participating in APM entities submit
performance of each MIPS eligible
choose the measures and activities that data to MIPS in the form and manner
required, including separate approaches clinician according to performance
are most meaningful to them, regardless standards and, using that methodology,
of the submission mechanism. We are to the quality and cost performance
categories applicable to MIPS APMs. We to provide for a final score for each
aware that this proposal for increased MIPS eligible clinician. Section
flexibility in data submission are not proposing any changes to how
APM entities in MIPS APMs and their 1848(q)(2)(A)(i) of the Act requires us to
mechanisms may increase complexity use the quality performance category in
and in some instances additional costs participating MIPS eligible clinicians
submit data to MIPS. determining each MIPS eligible
for clinicians, as they may need to clinicians final score, and section
establish relationships with additional (2) Submission Deadlines 1848(q)(2)(B)(i) of the Act describes the
data submission mechanism vendors in measures and activities that must be
In the CY 2017 Quality Payment
order to report additional measures and/ Program final rule (81 FR 77097), we specified under the quality performance
or activities for any given performance finalized submission deadlines by category.
category. We would like to clarify that which all associated data for all The statute does not specify the
the requirements for the performance performance categories must be number of quality measures on which a
categories remain the same, regardless submitted for the submission MIPS eligible clinician must report, nor
of the number of submission mechanisms described in this rule. does it specify the amount or type of
mechanisms used. It is also important to As specified at 414.1325(f)(1), the information that a MIPS eligible
note for the improvement activities and data submission deadline for the clinician must report on each quality
advancing care information performance qualified registry, QCDR, EHR, and measure. However, section
categories, that using multiple data attestation submission mechanisms is 1848(q)(2)(C)(i) of the Act requires the
submission mechanisms (for example, March 31 following the close of the Secretary, as feasible, to emphasize the
attestation and the qualified registry) performance period. The submission application of outcomes-based
may limit our ability to provide real- period will begin prior to January 2 measures.
time feedback. While we strive to following the close of the performance Sections 1848(q)(1)(E) of the Act
provide flexibility to individual MIPS period, if technically feasible. For requires the Secretary to encourage the
eligible clinicians and groups, we would example, for performance periods use of QCDRs, and section
like to note that our goal within the occurring in 2018, the data submission 1848(q)(5)(B)(ii)(I) of the Act requires
MIPS program is to minimize period will occur prior to January 2, the Secretary to encourage the use of
complexity and administrative burden 2019, if technically feasible, through CEHRT and QCDRs for reporting
to individual MIPS eligible clinicians March 31, 2019. If it is not technically measures under the quality performance
and groups. We request comments on feasible to allow the submission period category under the final score
this proposal. to begin prior to January 2 following the methodology, but the statute does not
As discussed in section II.C.4. of this close of the performance period, the limit the Secretarys discretion to
proposed rule, we are proposing to submission period will occur from establish other reporting mechanisms.
generally apply our previously finalized January 2 through March 31 following Section 1848(q)(2)(C)(iv) of the Act
and proposed group policies to virtual the close of the performance period. In generally requires the Secretary to give
groups. With respect to data submission any case, the final deadline will remain consideration to the circumstances of
mechanisms, we are proposing that March 31, 2019. non-patient facing MIPS eligible
virtual groups would be able to use a At 414.1325(f)(2), we specified that clinicians and allows the Secretary, to
different submission mechanism for for the Medicare Part B claims the extent feasible and appropriate, to
each performance category, and would submission mechanism, data must be apply alternative measures or activities
be able to utilize multiple submission submitted on claims with dates of to such clinicians.
mechanisms for the quality performance service during the performance period As discussed in the CY 2017 Quality
category, beginning with performance that must be processed no later than 60 Payment Program final rule (81 FR
periods occurring in 2018. However, days following the close of the 77098 through 77099), we finalized
virtual groups would be required to performance period. Lastly, for the CMS MIPS quality criteria that focus on
utilize the same submission mechanism Web Interface submission mechanism, measures that are important to
for the improvement activities and the at 414.1325(f)(3), we specified that the beneficiaries and maintain some of the
flexibility from PQRS, while addressing subject to the Secretarys authority to performance category to zero percent for
several of the comments we received in assign different scoring weights under MIPS payment year 2020 is finalized,
response to the CY 2017 Quality section 1848(q)(5)(F) of the Act. Section then we would modify 414.1330(b)(2)
Payment Program proposed rule and the 1848(q)(2)(E)(i)(I)(aa) of the Act states to provide that performance in the
MIPS and APMs RFI. that the quality performance category quality performance category will
To encourage meaningful will account for 30 percent of the final comprise 60 percent of a MIPS eligible
measurement, we finalized allowing score for MIPS. However, section clinicians final score for MIPS payment
individual MIPS eligible clinicians and 1848(q)(2)(E)(i)(I)(bb) of the Act year 2020. We refer readers to section
groups the flexibility to determine the stipulates that for the first and second II.C.6.d. for more information on the
most meaningful measures and data years for which MIPS applies to cost performance category.
submission mechanisms for their payments, the percentage of the final As also discussed in section II.C.6.d.
practice. score applicable for the quality of this proposed rule, we note that by
To simplify the reporting criteria, performance category will be increased reweighting the cost performance
we aligned the submission criteria for so that the total percentage points of the category to zero percent in performance
several of the data submission increase equals the total number of period 2018, there will be a sharp
mechanisms. percentage points by which the increase in the cost performance
To reduce administrative burden percentage applied for the cost category to a 30 percent weight in
and focus on measures that matter, we performance category is less than 30 performance period 2019. In order to
lowered the required number of the percent. Section 1848(q)(2)(E)(i)(II)(bb) assist MIPS eligible clinicians and
measures for several of the data of the Act requires that, for the groups in obtaining additional comfort
submission mechanisms, yet still transition year for which MIPS applies with measurement based on the cost
required that certain types of measures, to payments, not more than 10 percent performance category, we considered
particularly outcome measures, be of the final score shall be based on the maintaining our previously-finalized
reported. cost performance category. Furthermore, cost performance category weight of 10
To create alignment with other section 1848(q)(2)(E)(i)(II)(bb) of the Act percent for the 2018 performance
payers and reduce burden on MIPS states that, for the second year for which period. However, in our discussions
eligible clinicians, we incorporated MIPS applies to payments, not more with some MIPS eligible clinicians and
measures that align with other national than 15 percent of the final score shall clinician societies, eligible clinicians
payers. be based on the cost performance expressed their desire to down-weight
To create a more comprehensive category. the cost performance category to zero
picture of a practices performance, we In the CY 2017 Quality Payment percent for an additional year with full
also finalized the use of all-payer data Program final rule (81 FR 77100), we knowledge that the cost performance
where possible. finalized at 414.1330(b) that, for MIPS category weight is set at 30 percent
As beneficiary health is always our payment years 2019 and 2020, 60 under the statute for the 2021 MIPS
top priority, we finalized criteria to percent and 50 percent, respectively, of payment year. The clinicians we spoke
continue encouraging the reporting of the MIPS final score will be based on with preferred our proposed approach
certain measures such as outcome, the quality performance category. For and noted that they are actively
appropriate use, patient safety, the third and future years, 30 percent of preparing for full cost performance
efficiency, care coordination, or patient the MIPS final score will be based on category implementation and would be
experience measures. However, as the quality performance category. prepared for the 30 percent statutory
discussed in the CY 2017 Quality As discussed in section II.C.6.d. of weight for the cost performance category
Payment Program final rule (81 FR this proposed rule, we are proposing to for the 2021 MIPS payment year.
77098), we removed the requirement for weight the cost performance category at We intend to provide an initial
measures to span across multiple zero percent for the second MIPS opportunity for clinicians to review
domains of the NQS. We continue to payment year (2020). In accordance their performance based on the new
believe the NQS domains are extremely with section 1848(q)(5)(E)(i)(I)(bb) of the episode-based measures at some point
important, and we encourage MIPS Act, for the first 2 years, the percentage in the fall of 2017, as the measures are
eligible clinicians to continue to strive of the MIPS final score that would developed and as the information is
to provide care that focuses on: Effective otherwise be based on the quality available. We note that this feedback
clinical care, communication and care performance category (that is, 30 will be specific to the new episode-
coordination, efficiency and cost percent) must be increased by the same based measures that are developed
reduction, person and caregiver- number of percentage points by which under the process described above and
centered experience and outcomes, the percentage based on the cost may be presented in a different format
community and population health, and performance category is less than 30 than MIPS eligible clinicians
patient safety. While we do not require percent. Therefore, if our proposal to performance feedback as described in
that MIPS eligible clinicians select reweight the cost performance category section II.C.9.a. of this proposed rule.
measures across multiple domains, we for MIPS payment year 2020 is However, our intention is to align the
encourage them to do so. In addition, finalized, we would need to inversely feedback as much as possible to ensure
we believe the MIPS program overall, reweight the quality performance clinicians receive opportunities to
with the focus on the quality, cost, category for the same year. Accordingly, review their performance on potential
we are proposing to modify new episode-based measures for the cost
improvement activities, and advancing

care information performance 414.1330(b)(2) to reweight the performance category prior to the
categories, will naturally cover many percentage of the MIPS final score based proposed 2019 MIPS performance
elements in the NQS. on the quality performance category for period. We are unable to offer a list of
MIPS payment year 2020 as may be new episode-based measures on which
(2) Contribution to Final Score necessary to account for any we will provide feedback because that
For MIPS payment year 2019, the reweighting of the cost performance will be determined in our ongoing
quality performance category will category, if finalized. For example, if development work described above. We
account for 60 percent of the final score, our proposal to reweight the cost are concerned that continuing to
provide feedback on the older episode- (3) Quality Data Submission Criteria efficiency, patient experience, and care
based measures along with feedback on (a) Submission Criteria coordination measures) within the
new episode-based measures will be measure set in lieu of an outcome
confusing and a poor use of resources. (i) Submission Criteria for Quality measure. MIPS eligible clinicians may
Because we are focusing on Measures Excluding Groups Reporting choose to report measures in addition to
development of new episode-based via the CMS Web Interface and the those contained in the specialty
measures, our feedback on episode- CAHPS for MIPS Survey measure set and will not be penalized
based measures that were previously In the CY 2017 Quality Payment for doing so, provided that such MIPS
developed will discontinue after 2017 as Program final rule (81 FR 77114), we eligible clinicians follow all
these measures would no longer be finalized at 414.1335(a)(1) that requirements discussed here.
maintained or reflect changes in individual MIPS eligible clinicians In accordance with
diagnostic and procedural coding. As submitting data via claims and 414.1335(a)(1)(ii), individual MIPS
described in section II.C.9.a. of this individual MIPS eligible clinicians and eligible clinicians and groups will select
proposed rule, we intend to provide groups submitting data via all their measures from either the set of all
mechanisms (excluding the CMS Web MIPS measures listed or referenced in
feedback on these new measures as they
Interface and the CAHPS for MIPS Table A of the Appendix in this
become available in a new format
survey) are required to meet the proposed rule or one of the specialty
around summer 2018, in addition to the measure sets listed in Table B of the
following submission criteria. For the
fall 2017 feedback discussed previously. Appendix in this proposed rule. We
applicable period during the
We note that the feedback provided in note that some specialty measure sets
performance period, the individual
the summer of 2018 will go to those include measures grouped by
MIPS eligible clinician or group will
MIPS eligible clinicians for whom we report at least six measures, including at subspecialty; in these cases, the measure
are able to calculate the episode-based least one outcome measure. If an set is defined at the subspecialty level.
measures, which means it would be applicable outcome measure is not Previously finalized quality measures
possible that a clinical may not receive available, the individual MIPS eligible may be found in the CY 2017 Quality
feedback on episode-based measures in clinician or group will be required to Payment Program final rule (81 FR
both the fall of 2017 and the summer of report one other high priority measure 77558 through 77816).
2018. We believe that receiving (appropriate use, patient safety, We also finalized the definition of a
feedback on the new episode-based efficiency, patient experience, and care high priority measure at 414.1305 to
measures, along with the previously- coordination measures) in lieu of an mean an outcome, appropriate use,
finalized total per capita cost and MSPB outcome measure. If fewer than six patient safety, efficiency, patient
measures, will support clinicians in measures apply to the individual MIPS experience, or care coordination quality
their readiness for the proposed 2019 eligible clinician or group, then the measure. Except as discussed in section
MIPS performance period. individual MIPS eligible clinician or II.C.6.b.(3)(a) of this proposed rule with
group would be required to report on regard to the CMS Web Interface and the
Section 1848(q)(5)(B)(i) of the Act
each measure that is applicable. We CAHPS for MIPS survey, we are not
requires the Secretary to treat any MIPS
defined applicable to mean measures proposing any changes to the
eligible clinician who fails to report on
relevant to a particular MIPS eligible submission criteria or definitions
a required measure or activity as established for measures in this
clinicians services or care rendered. As
achieving the lowest potential score discussed in section II.C.7.a.(2)(e)., we proposed rule.
applicable to the measure or activity. will only make determinations as to In the CY 2017 Quality Payment
Specifically, under our finalized scoring whether a sufficient number of Program final rule (81 FR 77114), we
policies, an individual MIPS eligible measures are applicable for claims- solicited comments regarding adding a
clinician or group that reports on all based and registry submission requirement to our finalized policy that
required measures and activities could mechanisms; we will not make this patient-facing MIPS eligible clinicians
potentially obtain the highest score determination for EHR and QCDR would be required to report at least one
possible within the performance submission mechanisms, for example. cross-cutting measure in addition to the
category, assuming they perform well on Alternatively, the individual MIPS high priority measure requirement for
the measures and activities they report. eligible clinician or group will report further consideration for the Quality
An individual MIPS eligible clinician or one specialty measure set, or the Payment Program Year 2 and future
group who does not submit data on a measure set defined at the subspecialty years. For clarification, we consider a
required measure or activity would level, if applicable. If the measure set cross-cutting measure to be any measure
receive a zero score for the unreported contains fewer than six measures, MIPS that is broadly applicable across
items in the performance category (in eligible clinicians will be required to multiple clinical settings and individual
accordance with section 1848(q)(5)(B)(i) report all available measures within the MIPS eligible clinicians or groups
of the Act). The individual MIPS set. If the measure set contains six or within a variety of specialties. We
eligible clinician or group could still more measures, MIPS eligible clinicians specifically requested feedback on how
obtain a relatively good score by will be required to report at least six we could construct a cross-cutting
performing very well on the remaining measures within the set. Regardless of measure requirement that would be
the number of measures that are most meaningful to MIPS eligible
items, but a zero score would prevent

the individual MIPS eligible clinician or contained in the measure set, MIPS clinicians from different specialties and
eligible clinicians reporting on a that would have the greatest impact on
group from obtaining the highest
measure set will be required to report at improving the health of populations. We
possible score within the performance
least one outcome measure or, if no received conflicting feedback on adding
category.
outcome measures are available in the a future requirement for MIPS eligible
measure set, the MIPS eligible clinician clinicians to report at least one cross-
will report another high priority cutting measure in the Quality Payment
measure (appropriate use, patient safety, Program Year 2 and future years.
Many commenters agreed that cross- ProjectDescription.aspx?projectID= (ii) Submission Criteria for Quality
cutting measures are applicable across 80808. Measures for Groups Reporting via the
multiple clinical settings and that MIPS Other commenters appreciated our CMS Web Interface
eligible clinicians within a variety of decision not to finalize the requirement In the CY 2017 Quality Payment
specialties should report at least one to report a cross-cutting measure in the Program final rule (81 FR 77116), we
cross-cutting measure. Some stated that transition year and requested that we finalized at 414.1335(a)(2) the
cross-cutting measures promote shared not require cross-cutting measures in following criteria for the submission of
accountability and improve the health the future, as they believed it is data on quality measures by registered
of populations. Others recommended administratively burdensome for groups of 25 or more eligible clinicians
we continue to work with stakeholders clinicians and QCDRs and removes who want to report via the CMS Web
and specialists, including solo and Interface. For the applicable 12-month
focus and resources from quality
small practices, to develop cross-cutting performance period, the group would be
measures that are more relevant to MIPS
measures for all settings, whether they required to report on all measures
eligible clinicians scope of practice and
be patient-facing or non-patient facing included in the CMS Web Interface
important to their patients treatment
practices that are patient-centric (that is, completely, accurately, and timely by
and outcomes. They stated that PQRS populating data fields for the first 248
following the patient and not the site of
demonstrated the challenge of consecutively ranked and assigned
care) and recommended the term
patient-centered measures rather than identifying cross-cutting measures that Medicare beneficiaries in the order in
cross-cutting measures. In addition, are truly meaningful across different which they appear in the groups
some commenters stated we should specialties and that truly have an impact sample for each module or measure. If
consider measures that are on improving the health of populations. the sample of eligible assigned
multidisciplinary, foster cross- Some stated we should focus on high- beneficiaries is less than 248, then the
collaboration within virtual groups, priority measures over cross-cutting group would report on 100 percent of
improve patient outcomes, target high- measures. A few commenters did not assigned beneficiaries. A group would
cost areas, target areas with gaps in care, agree that cross-cutting measures were be required to report on at least one
and include individual patient relevant and stated they should not be measure for which there is Medicare
preferences in shared decision-making. a requirement in MIPS until all MIPS patient data. Groups reporting via the
A few commenters provided specific eligible clinicians can successfully meet CMS Web Interface are required to
measures that they recommended the current requirements. Others did not report on all of the measures in the set.
utilizing as cross-cutting measures, such agree that QCDRs should be required to Any measures not reported would be
as: Screening for Hepatitis C; submit cross-cutting measures because considered zero performance for that
Controlling High Blood Pressure; they believed that Congress did not measure in our scoring algorithm. In
Tobacco Use Cessation Counseling and intend for QCDRs to submit clinical addition, we are proposing to clarify
Treatment; Advance Care Planning; or process measures, that implementation that these criteria apply to groups of 25
Medication Reconciliation. One may be complicated by practices that or more eligible clinicians. Specifically,
commenter recommended we utilize upgrade their health IT, and vendors we propose to revise 414.1335(a)(2)(i)
have indicated it would take 12 to 18 to provide criteria applicable to groups
shared accountability measures around
months to implement system changes to of 25 or more eligible clinicians, report
surgical goals of care, shared decision
on all measures included in the CMS
making relying on some form of risk support capture of cross-cutting
Web Interface. The group must report on
estimation such as a risk calculator, measures. They also questioned the
the first 248 consecutively ranked
medication reconciliation, and a shared value of investing additional time and beneficiaries in the sample for each
plan of care across clinicians. Another resources in this effort, especially if measure or module.
commenter suggested that instead of these cross-cutting measures are In the CY 2017 Quality Payment
having a cross-cutting measure ultimately found to be topped out or Program final rule (81 FR 77116), we
requirement, we could use health IT as removed. Others believed we should finalized to continue to align the 2019
a cross-cutting requirement. delay implementation until the Quality CMS Web Interface beneficiary
Specifically, the commenter noted we Payment Program Year 3 in order to assignment methodology with the
could require that at least one measure allow MIPS eligible clinicians to focus attribution methodology for two of the
using end-to-end electronic reporting, or on implementing new CEHRT measures that were formerly in the VM:
that at least one measure be tied to an requirements and modifying their The population quality measure
improvement activity the clinician is processes to address lessons learned discussed in the CY 2017 Quality
performing. Other commenters from reporting in the first 2 years. Payment Program proposed rule (81 FR
suggested that we provide bonus points 28188) and total per capita cost for all
Except as discussed in section
to practices that elect to submit data on attributed beneficiaries discussed in the
II.C.6.b.(3)(a)(iii). of this proposed rule
cross-cutting measures and hold CY 2017 Quality Payment Program
harmless from any future cross-cutting with regard to the CAHPS for MIPS
proposed rule (81 FR 28196). When
measure requirements MIPS eligible survey, we are not proposing any
establishing MIPS, we also finalized a
clinicians who have less than 15 changes to the submission criteria for modified attribution process to update
instances in the measure denominator quality measures in this proposed rule. the definition of primary care services
during the performance period, allow We thank the commenters for their and to adapt the attribution to different
MIPS eligible clinicians to use high- feedback and will take the comments identifiers used in MIPS. These changes
priority measures in the place of a cross- into consideration in future rulemaking. are discussed in the CY 2017 Quality
cutting measure if necessary, and apply We welcome additional feedback on Payment Program proposed rule (81 FR
the guiding principles listed in NQFs meaningful ways to incorporate cross- 28196). We note that groups reporting
Attribution: Principles and cutting measurement into MIPS and the via the CMS Web Interface may also
Approaches final report which may be Quality Payment Program generally. report the CAHPS for MIPS survey and
found at http://www.qualityforum.org/ receive bonus points for submitting that
measure. We are not proposing any would end no later than February 28th conducting before finalizing this
changes to the submission criteria for following the applicable performance proposal. Specifically, we will review
quality measures for groups reporting period. In addition, we propose to the findings of the CAHPS for ACO
via the CMS Web Interface in this further specify the start and end survey pilot, which was administered
proposed rule. timeframes of the survey administration from November 2016 through February
period through our normal 2017. The CAHPS for ACO survey pilot
(iii) Performance Criteria for Quality
communication channels. utilized a survey instrument which did
Measures for Groups Electing To Report In addition, as discussed in the CY not contain the two SSMs we are
Consumer Assessment of Healthcare 2017 Quality Payment Program final proposing for removal from the CAHPS
Providers and Systems (CAHPS) for rule (81 FR 77116), we anticipated for MIPS survey. For more information
MIPS Survey exploring the possibility of updating the on the other SSMs within the CAHPS
In the CY 2017 Quality Payment CAHPS for MIPS survey under MIPS, for MIPS survey, please see the
Program final rule (81 FR 77100), we specifically not finalizing all of the explanation of the CAHPS for PQRS
finalized at 414.1335(a)(3) the proposed Summary Survey Measures survey in the CY 2016 PFS final rule
following criteria for the submission of (SSMs). The CAHPS for MIPS survey with comment period (80 FR 71142
data on the CAHPS for MIPS survey by currently consists of the core CAHPS through 71143).
registered groups via CMS-approved Clinician & Group (CGCAHPS) Survey
survey vendor: For the applicable 12- developed by the Agency for Healthcare TABLE 4PROPOSED SUMMARY SUR-
month performance period, a group that Research and Quality (AHRQ), plus VEY MEASURES (SSMS) INCLUDED
wishes to voluntarily elect to participate additional survey questions to meet IN THE CAHPS FOR MIPS SURVEY
in the CAHPS for MIPS survey measure CMSs program needs. We are proposing
must use a survey vendor that is for the Quality Payment Program Year 2 Summary survey measures (SSMs)
approved by CMS for a particular and future years to remove two SSMs,
performance period to transmit survey specifically, Helping You to Take Getting Timely Care, Appointments, and In-
measures data to CMS. The CAHPS for Medication as Directed and Between formation.
MIPS survey counts for one measure Visit Communication from the CAHPS How Well Providers Communicate.
towards the MIPS quality performance for MIPS survey. We are proposing to Patients Rating of Provider.
Access to Specialists.
category and, as a patient experience remove the SSM entitled Helping You Health Promotion and Education.
measure, also fulfills the requirement to to Take Medication as Directed due to Shared Decision-Making.
report at least one high priority measure low reliability. In 2014 and 2015, the Health Status and Functional Status.
in the absence of an applicable outcome majority of groups had very low Courteous and Helpful Office Staff.
measure. In addition, groups that elect reliability on this SSM. Furthermore, Care Coordination.
this data submission mechanism must based on analyses conducted of SSMs in Stewardship of Patient Resources.
select an additional group data an attempt to improve their reliability,
submission mechanism (that is, removing questions from this SSM did We are seeking comment on
qualified registries, QCDRs, EHR, etc.) not result in any improvements in expanding the patient experience data
in order to meet the data submission reliability. The SSM, Helping You to available for the CAHPS for MIPS
criteria for the MIPS quality Take Medication as Directed, has also survey. Currently, the CAHPS for MIPS
performance category. The CAHPS for never been a scored measure with the survey is available for groups to report
MIPS survey will count as one patient Medicare Shared Savings Program under the MIPS. The patient experience
experience measure, and the group will CAHPS for Accountable Care survey data that is available on
be required to submit at least five other Organizations (ACOs) Survey. We refer Physician Compare is highly valued by
measures through one other data readers to the CY 2014 Physician Fee patients and their caregivers as they
submission mechanism. A group may Schedule final rule for a discussion on evaluate their health care options.
report any five measures within MIPS the CAHPS for ACO survey scoring (79 However, in user testing with patients
plus the CAHPS for MIPS survey to FR 67909 through 67910) and measure and caregivers in regard to the Physician
achieve the six measures threshold. We tables (79 FR 67916 through 67917). The Compare Web site, the users regularly
are not proposing any changes to the SSM entitled Between Visit ask for more information from patients
performance criteria for quality Communication currently contains like them in their own words. Patients
measures for groups electing to report only one question. This question could regularly request that we include
the CAHPS for MIPS survey in this also be considered related to other SSMs narrative reviews of individual
proposed rule. entitled: Care Coordination or clinicians and groups on the Web site.
In the CY 2017 Quality Payment Courteous and Helpful Office Staff, AHRQ is fielding a beta version of the
Program final rule (see 81 FR 77120), we but does not directly overlap with any CAHPS Patient Narrative Elicitation
finalized retaining the CAHPS for MIPS of the questions under that SSM. Protocol (https://www.ahrq.gov/cahps/
survey administration period that was However, we are proposing to remove surveys-guidance/item-sets/elicitation/
utilized for PQRS of November to this SSM in order to maintain index.html). This includes five open-
February. However, this survey consistency with the Medicare Shared ended questions designed to be added to
administration period has become Savings Program which, utilizes the the CG CAHPS survey, after which the
operationally problematic for the CAHPS for Accountable Care CAHPS for MIPS survey is modeled.
administration of MIPS. In order to These five questions have been
Organizations (ACOs) Survey. The SSM

compute scoring, we must have the entitled Between Visit developed and tested in order to capture
CAHPS for MIPS survey data earlier Communication has never been a patient narratives in a scientifically
than the current survey administration scored measure with the Medicare grounded and rigorous way, setting it
period deadline allows. Therefore, we Shared Savings Program CAHPS for apart from other patient narratives
are proposing for the Quality Payment ACOs Survey. collected by various health systems and
Program Year 2 and future years that the In addition to public comments we patient rating sites. More scientifically
survey administration period would, at receive, we will also take into rigorous patient narrative data would
a minimum, span over 8 weeks and consideration analysis we will be not only greatly benefit patients in their
decision for healthcare, but it would measures using QCDRs, qualified completeness is applied to all MIPS
also greatly aid individual MIPS eligible registries, or via EHR must report on at eligible clinicians. We continue to
clinicians and groups as they assess least 50 percent of the individual MIPS believe it is important to incorporate
how their patients experience care. We eligible clinician or groups patients that higher data completeness thresholds in
are seeking comment on adding these meet the measures denominator future years to ensure a more accurate
five open-ended questions to the criteria, regardless of payer for the assessment of a MIPS eligible clinicians
CAHPS for MIPS survey in future performance period. In other words, for performance on quality measures and to
rulemaking. Beta testing is an ongoing these submission mechanisms, we avoid any selection bias. Therefore, we
process, and we anticipate reviewing expect to receive quality data for both propose, below, a 60 percent data
the results of that testing in Medicare and non-Medicare patients. completeness threshold for MIPS
collaboration with AHRQ before For the transition year, MIPS eligible payment year 2021. We strongly
proposing changes to the CAHPS for clinicians whose measures fall below encourage all MIPS eligible clinicians to
MIPS survey. the data completeness threshold of 50 perform the quality actions associated
We are requiring, where possible, all- percent would receive 3 points for with the quality measures on their
payer data for all reporting mechanisms, submitting the measure. patients. The data submitted for each
yet certain reporting mechanisms are Individual MIPS eligible clinicians measure is expected to be representative
limited to Medicare Part B data. submitting data on quality measures of the individual MIPS eligible
Specifically, the CAHPS for MIPS data using Medicare Part B claims, clinicians or groups overall
survey currently relies on sampling would report on at least 50 percent of performance for that measure. The data
protocols based on Medicare Part B the Medicare Part B patients seen during completeness threshold of less than 100
billing; therefore, only Medicare Part B the performance period to which the percent is intended to reduce burden
beneficiaries are sampled through that measure applies. For the transition year, and accommodate operational issues
methodology. In the CY 2017 Quality MIPS eligible clinicians whose that may arise during data collection
Payment Program proposed rule (81 FR measures fall below the data during the initial years of the program.
28189), we requested comments on completeness threshold of 50 percent We are providing this notice to MIPS
ways to modify the methodology to would receive 3 points for submitting eligible clinicians so that they can take
assign and sample patients for these the measure. the necessary steps to prepare for higher
mechanisms using data from other Groups submitting quality measures data completeness thresholds in future
payers. We received mixed feedback on data using the CMS Web Interface or a years.
the use of all-payer data overall. The full CMS-approved survey vendor to report
discussion of the comments and the the CAHPS for MIPS survey must meet Therefore, we propose to revise the
responses can be found in the CY 2017 the data submission requirements on the data completeness criteria for the
Quality Payment Program final rule (81 sample of the Medicare Part B patients quality performance category at
FR 77123 through 77125). We are CMS provides. 414.1340(a)(2) to provide that MIPS
requesting additional comments on In addition, we finalized an increased eligible clinicians and groups
ways to modify the methodology to data completeness threshold of 60 submitting quality measures data using
assign and sample patients using data percent for MIPS for performance the QCDR, qualified registry, or EHR
from other payers for reporting periods occurring in 2018 for data submission mechanism must submit
mechanisms that are currently limited submitted on quality measures using data on at least 50 percent of the
to Medicare Part B data. In particular, QCDRs, qualified registries, via EHR, or individual MIPS eligible clinicians or
we are seeking comment on the ability Medicare Part B claims. We noted that groups patients that meet the measures
of groups to provide information on the these thresholds for data submitted on denominator criteria, regardless of
patients to whom they provide care quality measures using QCDRs, payer, for MIPS payment year 2020. We
during a calendar year, whether it qualified registries, via EHR, or also propose to revise the data
would be possible to identify a list of Medicare Part B claims would increase completeness criteria for the quality
patients seen by individual clinicians in for performance periods occurring in performance category at 414.1340(b)(2)
the group, and what type of patient 2019 and onward. to provide that MIPS eligible clinicians
contact information groups would be We are proposing to modify the and groups submitting quality measures
able to provide. Further, we would like previously established data data using Medicare Part B claims, must
to seek comment on the challenges completeness criteria for MIPS payment submit data on at least 50 percent of the
groups may anticipate in trying to year 2020. Specifically, we would like applicable Medicare Part B patients seen
provide this type of information, to provide an additional year for during the performance period to which
especially for vulnerable beneficiary individual MIPS eligible clinicians and the measure applies for MIPS payment
populations, such as those lacking groups to gain experience with MIPS year 2020. We further propose at
stable housing. We are also seeking before increasing the data completeness 414.1340(a)(3), that MIPS eligible
comment on EHR vendors ability to thresholds for data submitted on quality clinicians and groups submitting quality
provide information on the patients who measures using QCDRs, qualified measures data using the QCDR,
receive care from their client groups. registries, via EHR, or Medicare Part B qualified registry, or EHR submission
claims. We are concerned about the mechanism must submit data on at least
(b) Data Completeness Criteria unintended consequences of 60 percent of the individual MIPS
In the CY 2017 Quality Payment accelerating the data completeness eligible clinician or groups patients that
Program final rule (81 FR 77125), we threshold so quickly, which may meet the measures denominator
finalized data completeness criteria for jeopardize MIPS eligible clinicians criteria, regardless of payer for MIPS
the transition year and MIPS payment ability to participate and perform well payment year 2021. We also propose at
year 2020. We finalized at 414.1340 under the MIPS, particularly those 414.1340(b)(3), that MIPS eligible
the data completeness criteria below for clinicians who are least experienced clinicians and groups submitting quality
performance periods occurring in 2017. with MIPS quality measure data measures data using Medicare Part B
Individual MIPS eligible clinicians submission. We want to ensure that an claims, must submit data on at least 60
or groups submitting data on quality appropriate yet achievable level of data percent of the applicable Medicare Part
B patients seen during the performance PQRS. In addition, those clinicians who (c) Summary of Data Submission
period to which the measure applies for utilize a QCDR, qualified registry, or Criteria
MIPS payment year 2021. We would EHR submission must contain a
like to note that we anticipate for future minimum of one quality measure for at Table 5 reflects our proposed quality
MIPS payment years we will propose to data submission criteria for MIPS
least one Medicare patient. We are not
increase the data completeness payment year 2020 via Medicare Part B
proposing any changes to these policies
threshold for data submitted using claims, QCDR, qualified registry, EHR,
in this proposed rule. As noted in the
QCDRs, qualified registries, EHR CMS Web Interface, and the CAHPS for
CY 2017 Quality Payment Program final MIPS survey. It is important to note that
submission mechanisms, or Medicare rule, those MIPS eligible clinicians who
Part B claims. As MIPS eligible while we finalized at 414.1325(d) in
fall below the data completeness the CY 2017 Quality Payment Program
clinicians gain experience with the thresholds will receive 3 points for the
MIPS, we would propose to steadily final rule that individual MIPS eligible
specific measures that fall below the clinicians and groups may only use one
increase these thresholds for future
data completeness threshold in the submission mechanism per performance
years through rulemaking. In addition,
transition year of MIPS only. For the category, in section II.C.6.a.(1) of this
we are seeking comment on what data
completeness threshold should be Quality Payment Program Year 2, we are rule, we are proposing to revise
established for future years. proposing that MIPS eligible clinicians 414.1325(d) for purposes of the 2020
In the CY 2017 Quality Payment would receive 1 point for measures that MIPS payment year and future years to
Program final rule (81 FR 77125 through fall below the data completeness allow individual MIPS eligible
77126), we finalized our approach of threshold, with an exception for small clinicians and groups to submit
including all-payer data for the QCDR, practices of 15 or fewer who would still measures and activities, as applicable,
qualified registry, and EHR submission receive 3 points for measures that fail via as many submission mechanisms as
mechanisms because we believed this data completeness. We refer readers to necessary to meet the requirements of
approach provides a more complete section II.C.6.b.(3)(b) of this proposed the quality, improvement activities, or
picture of each MIPS eligible clinicians rule for our proposed policies on advancing care information performance
scope of practice and provides more instances when MIPS eligible clinicians categories. We refer readers to section
access to data about specialties and measures fall below the data II.C.6.a.(1) of this proposed rule for
subspecialties not currently captured in completeness threshold. further discussion of this proposal.
TABLE 5SUMMARY OF PROPOSED QUALITY DATA SUBMISSION CRITERIA FOR MIPS PAYMENT YEAR 2020 VIA PART B
CLAIMS, QCDR, QUALIFIED REGISTRY, EHR, CMS WEB INTERFACE, AND THE CAHPS FOR MIPS SURVEY
Submission
Performance period Clinician type Submission criteria Data completeness
mechanism
Jan 1Dec 31 ............ Individual MIPS eligi- Part B Claims ............. Report at least six measures including one 50 percent of indi-
ble clinicians. outcome measure, or if an outcome meas- vidual MIPS eligible
ure is not available report another high pri- clinicians Medicare
ority measure; if less than six measures Part B patients for
apply then report on each measure that is the performance pe-
applicable. Individual MIPS eligible clini- riod.
cians would have to select their measures
from either the set of all MIPS measures
listed or referenced in Table A or one of
the specialty measure sets listed in Table
B of the Appendix in this proposed rule.
Jan 1Dec 31 ............ Individual MIPS eligi- QCDR, Qualified Reg- Report at least six measures including one 50 percent of indi-
ble clinicians, istry, & EHR. outcome measure, or if an outcome meas- vidual MIPS eligible
groups or virtual ure is not available report another high pri- clinicians, groups,
groups. ority measure; if less than six measures or virtual groups
apply then report on each measure that is patients across all
applicable. Individual MIPS eligible clini- payers for the per-
cians, groups, or virtual groups would formance period.
have to select their measures from either
the set of all MIPS measures listed or ref-
erenced in Table A or one of the specialty
measure sets listed in Table B of the Ap-
pendix in this proposed rule.
Jan 1Dec 31 ............ Groups or virtual CMS Web Interface ... Report on all measures included in the CMS Sampling require-
groups. Web Interface; AND populate data fields ments for the
for the first 248 consecutively ranked and groups or virtual
assigned Medicare beneficiaries in the groups Medicare
order in which they appear in the groups Part B patients.
or virtual groups sample for each module/

measure. If the pool of eligible assigned
beneficiaries is less than 248, then the
group or virtual group would report on 100
percent of assigned beneficiaries.
TABLE 5SUMMARY OF PROPOSED QUALITY DATA SUBMISSION CRITERIA FOR MIPS PAYMENT YEAR 2020 VIA PART B
CLAIMS, QCDR, QUALIFIED REGISTRY, EHR, CMS WEB INTERFACE, AND THE CAHPS FOR MIPS SURVEYContinued
Submission
Performance period Clinician type Submission criteria Data completeness
mechanism
Jan 1Dec 31 ............ Groups or virtual CAHPS for MIPS Sur- CMS-approved survey vendor would need to Sampling require-
groups. vey. be paired with another reporting mecha- ments for the
nism to ensure the minimum number of groups or virtual
measures is reported. CAHPS for MIPS groups Medicare
survey would fulfill the requirement for one Part B patients.
patient experience measure towards the
MIPS quality data submission criteria.
CAHPS for MIPS survey would only count
for one measure under the quality per-
formance category.
As discussed in section II.C.4.d. of risk adjustment, needed to be made to c. Selection of MIPS Quality Measures
this proposed rule, we are proposing to these measures prior to inclusion in for Individual MIPS Eligible Clinicians
generally apply our previously finalized MIPS. We did, however, calculate these and Groups Under the Annual List of
and proposed group policies to virtual measures at the TIN level, through the Quality Measures Available for MIPS
groups. QRURs released in September 2016, and Assessment
(4) Application of Quality Measures to this data can be used by MIPS eligible
(1) Background and Policies for the Call
Non-Patient Facing MIPS Eligible clinicians for informational purposes.
for Measures and Measure Selection
Clinicians We did finalize the all-cause hospital Process
readmissions (ACR) measure from the
In the CY 2017 Quality Payment VM Program as part of the quality Under section 1848(q)(2)(D)(i) of the
Program final rule (81 FR 77127), we measure domain for the MIPS total Act, the Secretary, through notice and
finalized at 414.1335 that non-patient
performance score. We finalized this comment rulemaking, must establish an
facing MIPS eligible clinicians would be
measure with the following annual list of MIPS quality measures
required to meet the applicable
modifications. We did not apply the from which MIPS eligible clinicians
submission criteria that apply for all
ACR measure to solo practices or small may choose for purposes of assessment
MIPS eligible clinicians for the quality
groups (groups of 15 or less). We did for a performance period. The annual
performance category. We are not
apply the ACR measure to groups of 16 list of MIPS quality measures must be
proposing any changes to this policy in
or more who meet the case volume of published in the Federal Register no
this proposed rule.
200 cases. A group was scored on the later than November 1 of the year prior
(5) Application of Facility-Based ACR measure even if it did not submit to the first day of a performance period.
Measures any quality measures, if it submitted in Updates to the annual list of MIPS
Section 1848(q)(2)(C)(ii) of the Act other performance categories. quality measures must be published in
provides that the Secretary may use Otherwise, the group was not scored on the Federal Register no later than
measures used for payment systems the readmission measure if it did not November 1 of the year prior to the first
other than for physicians, such as submit data in any of the performance day of each subsequent performance
measures used for inpatient hospitals, categories. In our transition year period. Updates may include the
for purposes of the quality and cost policies, the readmission measure alone addition of new MIPS quality measures,
performance categories. However, the would not produce a neutral to positive substantive changes to MIPS quality
Secretary may not use measures for MIPS payment adjustment since in measures, and removal of MIPS quality
hospital outpatient departments, except order to achieve a neutral to positive measures. MIPS eligible clinicians
in the case of items and services MIPS payment adjustment, an reporting on the quality performance
furnished by emergency physicians, individual MIPS eligible clinician or category are required to use the most
radiologists, and anesthesiologists. We group must submit information on one recent version of the clinical quality
refer readers to section II.C.7.a.(4) of this of the three performance categories as measure (CQM) electronic specifications
proposed rule for a full discussion of discussed in the CY 2017 Quality as indicated in the CY 2017 Quality
our proposals regarding the application Payment Program final rule (81 FR Payment Program final rule (81 FR
of facility-based measures. 77329). In addition, the ACR measure in 77291). For purposes of the 2018 MIPS
the MIPS transition year CY 2017 was performance period, the spring 2017
(6) Global and Population-Based based on the performance period version of the eCQM annual update to
Measures (January 1, 2017 through December 31, the measure specifications and any
In the CY 2017 Quality Payment 2017). However, for MIPS eligible applicable addenda are available on the
Program final rule (81 FR 77136), we clinicians who did not meet the electronic clinical quality improvement
did not finalize all of our proposals on minimum case requirements, the ACR (eCQI) Resource Center Web site at
global and population-based measures measure was not applicable. We are not https://ecqi.healthit.gov. The CMS
as part of the quality score. Specifically, proposing any changes for the global Quality Measure Development Plan
we did not finalize our proposal to use and population-based measures in this (MDP) serves as a strategic framework
the acute and chronic composite proposed rule. As discussed in section for the future of the clinician quality
measures of the AHRQ Prevention II.C.4.d. of this rule, we are proposing to measure development to support MIPS
Quality Indicators (PQIs). We agreed generally apply our previously finalized and APMs. The MDP is available on the
with commenters that additional and proposed group policies to virtual CMS Web site and highlights known
enhancements, including the addition of groups. measurement gaps and recommends
approaches to close those gaps through Measure Application Partnership (MAP) enough to assure us that sufficient
development, use, and refinement of provides an additional opportunity for variation in performance exists. We also
quality measures that address stakeholders to provide input on note that we are likely to reject
significant variation in performance whether or not they believe the measures that are not outcome-based
gaps. We encourage stakeholders to measures are applicable to clinicians as measures, unless (1) there is substantial
develop additional quality measures for well as feasible, scientifically documented and peer reviewed
MIPS that would address the gaps. acceptable, and reliable and valid at the evidence that the clinical process
Under section 1848(q)(2)(D)(ii) of the clinician level. Furthermore, we must go measured varies directly with the
Act, the Secretary must solicit a Call through notice and comment outcome of interest and (2) it is not
for Quality Measures each year. rulemaking to establish the annual list possible to measure the outcome of
Specifically, the Secretary must request of quality measures, which gives interest in a reasonable timeframe.
that eligible clinician organizations and stakeholders an additional opportunity We also note that retired measures
other relevant stakeholders identify and to review the measures and provide that were in one of CMSs previous
submit quality measures to be input on whether or not they believe the quality programs, such as the Physician
considered for selection in the annual measures are applicable to clinicians, as Quality Reporting System (PQRS)
list of MIPS quality measures, as well as well as feasible, scientifically program, will likely be rejected if
updates to the measures. Under section acceptable, and reliable and valid at the proposed for inclusion. This includes
1848(q)(2)(D)(ii) of the Act, eligible clinician level. Additionally, we are measures that were retired due to being
clinician organizations are professional required by statute to submit new topped out, as defined below. For
organizations as defined by nationally measures to an applicable specialty- example, measures may be retired due
recognized specialty boards of appropriate, peer-reviewed journal. to attaining topped out status because of
certification or equivalent certification As previously noted, we encourage high performance, or measures that are
boards. However, we do not believe the submission of potential quality retired due to a change in the evidence
there needs to be any special restrictions measures regardless of whether such supporting their use.
on the type or make-up of the measures were previously published in In the CY 2017 Quality Payment
organizations that submit measures for a proposed rule or endorsed by an entity Program final rule (81 FR 77153), we
consideration through the call for with a contract under section 1890(a) of established that we will categorize
measures. Any such restriction would the Act. However, we propose to request measures into the six NQS domains
limit the type of quality measures and that stakeholders apply the following (patient safety, person- and caregiver-
the scope and utility of the quality considerations when submitting quality centered experience and outcomes,
measures that may be considered for measures for possible inclusion in communication and care coordination,
inclusion under the MIPS. MIPS: effective clinical care, community/
As we described previously in the CY Measures that are not duplicative of population health, and efficiency and
2017 Quality Payment Program final an existing or proposed measure. cost reduction). We intend to submit
rule (81 FR 77137), we will accept Measures that are beyond the future MIPS quality measures to the
quality measures submissions at any measure concept phase of development NQF-convened Measure Application
time, but only measures submitted and have started testing, at a minimum, Partnerships (MAP), as appropriate,
during the timeframe provided by us with strong encouragement and and we intend to consider the MAPs
through the pre-rulemaking process of preference for measures that complete recommendations as part of the
each year will be considered for or are near completion of reliability and comprehensive assessment of each
inclusion in the annual list of MIPS validity testing. measure considered for inclusion under
quality measures for the performance Measures that include a data MIPS.
period beginning 2 years after the submission method beyond claims- In the CY 2017 Quality Payment
measure is submitted. This process is based data submission. Program final rule (81 FR 77155), we
consistent with the pre-rulemaking Measures that are outcome-based established that we use the Call for
process and the annual call for rather than clinical process measures. Quality Measures process as a forum to
measures, which are further described at Measures that address patient safety gather the information necessary to draft
(https://www.cms.gov/Medicare/ and adverse events. the journal articles for submission from
Quality-Initiatives-Patient-Assessment- Measures that identify appropriate measure developers, measure owners
Instruments/QualityMeasures/Pre-Rule- use of diagnosis and therapeutics. and measure stewards since we do not
Making.html). Measures that address the domain always develop measures for the quality
Submission of potential quality for care coordination. programs. The submission of this
measures, regardless of whether they Measures that address the domain information does not preclude us from
were previously published in a for patient and caregiver experience. conducting our own research using
proposed rule or endorsed by an entity Measures that address efficiency, Medicare claims data, Medicare survey
with a contract under section 1890(a) of cost, and resource use. results, and other data sources that we
the Act, which is currently the National Measures that address significant possess. We submit new measures for
Quality Forum, is encouraged. The variation in performance. publication in applicable specialty-
annual Call for Measures process allows We will apply these considerations appropriate, peer-reviewed journals
eligible clinician organizations and when considering quality measures for before including such measures in the
other relevant stakeholder organizations possible inclusion in MIPS. final annual list of quality measures.
to identify and submit quality measures In addition, we note that we are likely In the CY 2017 Quality Payment
for consideration. Presumably, to reject measures that do not provide Program final rule (81 FR 77158), we
stakeholders would not submit substantial evidence of variation in established at 414.1330(a)(2) that for
measures for consideration unless they performance; for example, if a measure purposes of assessing performance of
believe that the measure is applicable to developer submits data showing a small MIPS eligible clinicians on the quality
clinicians and can be reliably and variation in performance among a group performance category, we use quality
validly measured at the individual already composed of high performers, measures developed by QCDRs. In the
clinician level. The NQF-convened such evidence would not be substantial circumstances where a QCDR wants to
use a QCDR measure for inclusion in the MIPS under the Quality Payment The measures that would be used for
MIPS program for reporting, those Program. These recommendations were the APM scoring standard and our
measures go through a CMS approval based on the MIPS quality measures authority for waiving certain measure
process during the QCDR self- finalized in the CY 2017 Quality requirements are described in section
nomination period. We also established Payment Program final rule, and include II.C.6.g.(3)(b)(ii) and the measures that
that we post the quality measures for recommendations to add or remove the would be used to calculate a quality
use by QCDRs by no later than January current MIPS quality measures from the score for the APM scoring standard are
1 for performance periods occurring in specialty measure sets. The current proposed in Tables 14, 15, and 16.
2018 and future years. specialty measure sets can be found on We also seek comment for this rule,
Previously finalized MIPS quality the Quality Payment Program Web site on whether there are any MIPS quality
measures can be found in the CY 2017 at https://qpp.cms.gov/measures/ measures that commenters believe
Quality Payment Program final rule (81 quality. All specialty measure sets should be classified in a different NQS
FR 77558 through 77675). Updates may submitted for consideration were domain than what is being proposed, or
include the proposal to add new MIPS assessed to ensure that they met the that should be classified as a different
quality measures, including measures needs of the Quality Payment Program. measure type (for example, process vs.
selected 2 years ago during the Call for As a result, we propose to add new outcome) than what is being proposed
Measures process. The new MIPS quality measures to MIPS (Table A), in this rule.
quality measures proposed for inclusion revise the specialty measure sets in
(2) Topped Out Measures
MIPS (Table B), remove specific MIPS
in MIPS for the 2018 performance As defined in the CY 2017 Quality
quality measures only from specialty
period and future years are found in Payment Program final rule at (81 FR
sets (Table C.1), and propose to remove
Table A. The proposed new and 77136), a measure may be considered
specific MIPS quality measures from the
modified MIPS specialty sets for the topped out if measure performance is so
MIPS program for the 2018 performance
2018 performance period and future high and unvarying that meaningful
period (Table C.2). The aforementioned
years are listed in Table B, and include distinctions and improvement in
measure tables can be found in the
existing measures that are proposed performance can no longer be made.
Appendix of this proposed rule. In
with modifications, new measures, and Topped out measures could have a
addition, we are proposing to also
measures finalized in the CY 2017 disproportionate impact on the scores
remove cross cutting measures from
Quality Payment Program final rule. We most of the specialty sets. Specialty for certain MIPS eligible clinicians, and
note that the modifications made to the groups and societies reported that cross provide little room for improvement for
specialty sets may include the removal cutting measures may or may not be the majority of MIPS eligible clinicians.
of certain quality measures that were relevant to their practices, contingent on We refer readers to section II.C.7.a.(2)(c)
previously finalized. The specialty the eligible clinicians or groups. CMS of this proposed rule for additional
measure sets should be used as a guide chose to retain the cross cutting information regarding the scoring of
for eligible clinicians to choose measures in Family Practice, Internal topped out measures.
measures applicable to their specialty. Medicine and Pediatrics specialty sets We noted in the CY 2017 Quality
To clarify, some of the MIPS specialty because they are frequently used in Payment Program final rule that we
sets have further defined subspecialty these practices. The proposed 2017 anticipate removing topped out
sets, each of which is effectively a cross cutting measures, (81 FR 28447 measures over time and sought
separate specialty set. In instances through 28449), were compiled and comment on what point in time we
where an individual MIPS eligible placed in a separate table for eligible should remove topped out measures
clinician or group reports on a specialty clinicians to elect to use or not, for from MIPS (81 FR 77286). We received
or subspecialty set, if the set has less reporting. To clarify, the cross-cutting the following comments.
than six measures, that is all the measures are intended to provide Many commenters recommended that
clinician is required to report. MIPS clinicians with a list of measures that we retain topped out quality measures
eligible clinicians are not required to are broadly applicable to all clinicians for 2 or more years because commenters
report on the specialty measure sets, but regardless of the clinicians specialty. believed they serve to motivate
they are suggested measures for specific Even though it is not required to report continued high-quality care; more
specialties. Throughout measure on cross-cutting measures, it is provided clinicians may participate in MIPS
utilization, measure maintenance as a reference to clinicians who are compared to prior programs such as
should be a continuous process done by looking for additional measures to PQRS, and thus there may be more
the measure owners, to include report outside their specialty. We performance variation in MIPS showing
environmental scans of scientific continue to consider cross-cutting that the measure is not actually topped
literature about the measure. New measures to be an important part of our out; declines in performance will not be
information gathered during this quality measure programs, and seek captured if a measure is eliminated; it
ongoing review may trigger an ad hoc comment on ways to incorporate cross- will help provide stability and
review. The specialty measure sets in cutting measures into MIPS in the encourage reporting in the early years of
Table B of the Appendix, include future. The proposed Table of Cross- the MIPS program; removing topped out
existing measures that are proposed Cutting Measures can be found in Table measures could further limit the number
with modifications, new measures, and D of the Appendix. of measures available to specialists; and
measures that were previously finalized For MIPS quality measures that are providing eligible clinicians and the
in the CY 2017 Quality Payment undergoing substantive changes, we public with information about high
Program final rule. Please note that propose to identify measures including, performance is as important as
these specialty specific measure sets are but not limited to measures that have informing them about deficits.
not all inclusive of every specialty or had measure specification, measure A few commenters recommended that
subspecialty. On January 25, 2017, we title, and domain changes. MIPS quality we publish information about topped
announced that we would be accepting measures with proposed substantive out and potentially topped out measures
recommendations for potential new changes can be found at Table E of the prior to the performance period to allow
specialty measure sets for year 2 of Appendix. clinicians time to adjust their reporting
strategies, with one commenter noting topped out measures identified in year 1 the next time the measure
that improvement may be rewarded in section II.C.7.a.(2)(c) of this proposed benchmark is topped out.
addition to achievement. One rule. In section II.C.7.a.(2)(c) of this We seek comment on the above
commenter recommended pushing back proposed rule, we are also proposing to proposed timeline, specifically
the baseline performance period for the phase in special scoring for measures regarding the number of years before a
purpose of identifying topped out identified as topped out in the topped out measure is identified and
measures to 2018 because in the published benchmarks for two considered for removal, and under what
transition year it is unclear how many consecutive performance periods, circumstances we should remove
eligible clinicians will be reporting at starting with the select set of highly topped out measures once they reach
different times and for what time period topped out measures for the 2018 MIPS that point. For example, should we
they will report. performance period. An example automatically remove topped out
Finally, a few commenters illustrating the proposed timeline for measures after they are identified for the
recommended that we consider the removal and special scoring of proposed number of years or should we
specialty, case mix, and rural location topped out measures, as it would be review measures identified for removal
before determining that a measure is applied to the select set of highly and consider certain criteria before
topped out, specifically whether there is topped out measures identified in removing the measure? If so what
still room for improvement among section II.C.7.a.(2)(c), is as follows: criteria should be considered? We
certain specialist groups and to ensure Year 1: The measures are identified would like to note that if for some
that rural provider improvement is as topped out in the benchmarks reason a measure benchmark is topped
recognized. One commenter published for the 2017 MIPS out for only one submission mechanism
recommended that we determine topped performance Period. The 2017 benchmark, then we would remove that
out measures based on reporting in the benchmarks are posted on the Quality measure from the submission
Quality Payment Program rather than Payment Program Web site: https:// mechanism, but not remove the measure
PQRS or value modifier reporting qpp.cms.gov/resources/education. from other submission mechanisms
because the commenter believed using Year 2: Measures are identified as available for submitting that measure.
historical performance disadvantages topped out in the benchmarks published We also seek comment on whether
small groups. A few commenters for the 2018 MIPS performance period. topped out Summary Survey Measures
requested that the process for We refer readers to section II.C.7.a.(2)(c) (SSMs), if topped out, should be
identifying and determining the removal of this proposed rule for additional considered for removal from the
of topped out measures be transparent, information regarding the scoring of Consumer Assessment of Healthcare
evidence-based, patient-centered, and topped out measures. Providers and Systems (CAHPS) for
include feedback from all appropriate Year 3: Measures are identified as MIPS Clinician or Group Survey
stakeholders, including the medical topped out in the benchmarks published measure due to high, unvarying
community and measures owner. A few for the 2019 MIPS performance period. performance within the SSM, or
commenters specifically recommended The measures identified as topped out whether there is another alternative
that determining whether to remove a in the benchmarks published for the policy that could be applied for topped
topped out measure be part of a 2019 MIPS performance period and the out SSMs within the CAHPS for MIPS
rulemaking process while another previous two consecutive performance Clinician or Group Survey measure.
commenter suggested that we seek out periods would continue to have special In the CY 2017 Quality Payment
stakeholder input from the Measure scoring applied for the 2019 MIPS Program final rule, we state that we do
Applications Partnership (MAP) on performance period and would be not believe it would be appropriate to
whether a measure should be removed, considered, through notice-and- remove topped out measures from the
awarded lower points, or remain with comment rulemaking, for removal for CMS Web Interface for the Quality
benchmarks as a flat percentage. the 2020 MIPS performance period. Payment Program because the CMS Web
We propose a 3-year timeline for Year 4: Topped out measures that Interface measures are used in MIPS and
identifying and proposing to remove are finalized for removal are no longer in APMs, such as the Shared Savings
topped out measures. After a measure available for reporting. For example, the Program. Removing topped out
has been identified as topped out for measures in the set of highly topped out measures from the CMS Web Interface
three consecutive years, we may measures identified as topped out for would not be appropriate because we
propose to remove the measure through the 2017, 2018 and 2019 MIPS have aligned policies where possible,
comment and rulemaking for the 4th performance periods, and if with the Shared Savings Program, such
year. Therefore, in the 4th year, if subsequently finalized for removal will as using the Shared Savings Program
finalized through rulemaking, the not be available on the list of measures benchmarks for the CMS Web Interface
measure would be removed and would for the 2020 MIPS performance period measures (81 FR 77285). In the CY 2017
no longer be available for reporting and future years. Quality Payment Program final rule, we
during the performance period. This For all other measures, the timeline also finalized that MIPS eligible
proposal provides a path toward would apply starting with the clinicians reporting via the CMS Web
removing topped out measures over benchmarks for the 2018 MIPS Interface must report all measures
time, and will apply to the MIPS quality performance period. Thus, the first year included in the CMS Web Interface (81
measures. QCDR measures that any other topped out measure could be FR 77116). Thus, if a CMS Web Interface
consistently are identified as topped out proposed for removal would be in measure is topped out, the CMS Web
according to the same timeline as rulemaking for the 2021 MIPS Interface reporter cannot select other
proposed below, would not be approved performance period, based on the measures. We refer readers to section
for use in year 4 during the QCDR self- benchmarks being topped out in the II.C.7.a.(2) of this proposed rule for
nomination review process, and would 2018, 2019, and 2020 MIPS performance information on scoring policies with
not go through the comment and periods. If the measure benchmark is regards to topped out measures from the
rulemaking process described below. not topped out during one of the three CMS Web Interface for the Quality
We propose to phase in this policy MIPS performance periods, then the Payment Program. We are not proposing
starting with a select set of six highly lifecycle would stop and start again at to include CMS Web Interface measures
in our proposal on removing topped out Utilization of the CMS Blueprint Specifically, we adopted 2 measures
measures. definitions for outcome measures: that had been used in the VM: The total
https://www.cms.gov/Medicare/Quality- per capita costs for all attributed
(3) Non-Outcome Measures
Initiatives-Patient-Assessment- beneficiaries measure (referred to as the
In the CY 2017 Quality Payment Instruments/MMS/Downloads/ total per capita cost measure) and the
Program final rule, we sought comment Blueprint-130.pdf. An outcome of care MSPB measure (81 FR 77166 through
on whether we should remove non- is a health state of a patient resulting 77168). We also adopted 10 episode-
outcomes measures for which from health care. Outcome measures are based measures that had previously
performance cannot reliably be scored supported by evidence that the measure been included in the Supplemental
against a benchmark (for example, has been used to detect the impact of Quality and Resource Use Reports
measures that do not have 20 reporters one or more clinical interventions. (sQRURs) (81 FR 77171 through 77174).
with 20 cases that meet the data Clinical analysts are utilized to evaluate At 414.1325(e), we finalized that all
completeness standard) for 3 years in a the measure. measures used under the cost
row (81 FR 77288). We also note that patient-reported performance category would be derived
A few commenters recommended that outcome measures are considered from Medicare administrative claims
measures that cannot be scored against outcome measures, as they measure the data and, thus, participation would not
a benchmark should be removed from health of the patient directly resulting require additional data submission. We
the MIPS score. One commenter from the health care provided. finalized a reliability threshold of 0.4 for
recommended that non-outcome Efficiency measures are not considered measures in the cost performance
measures that are unscorable should be outcome measures, as they are category (81 FR 77170). We also
given a weight of zero or re-weighted in measuring the cost of care associated finalized a case minimum of 35 for the
the performance category. One with a specific level of care, but we do MSPB measure (81 FR 77171) and 20 for
commenter supported removing non- note that efficiency is considered a high the total per capita cost measure (81 FR
outcomes measures for which priority measure. 77170) and each of the 10 episode-based
performance cannot reliably be scored After a MIPS quality measure is measures (81 FR 77175) in the cost
against a benchmark for 3 years in a established in the program, it is performance category to ensure the
row. One commenter believed it would generally only reviewed again if there reliability threshold is met.
also be appropriate to remove outcomes are significant changes to a measure for For the transition year, we finalized a
measures under a separate more the next program year that might policy to weight the cost performance
protracted timeline because the warrant a change to the designation of category at zero percent in the final
commenter believed the reporting of outcome or not. In most cases, these score in order to give clinicians more
outcome measures is more difficult and updates are significant enough that they opportunity to understand the
expected to increase at a slower pace, are usually presented as a new measure attribution and the scoring methodology
while maintaining outcome measures from the measure owner. New measures and gain more familiarity with the
would encourage the testing and to the program will follow the criteria measures through performance feedback
availability of such measures. outlined above. QCDR measures (81 FR 77165 through 77166) so that
Based on the need for CMS to further however, are reviewed on a yearly basis clinicians may be able to act to improve
assess this issue, we are not proposing (during the fall) regardless if there is a their performance. In the CY 2017
to remove non-outcome measures in this significant change or not. We refer Quality Payment Program final rule, we
proposed rule. However, we seek readers to section II.C.10.a. for finalized a cost performance category
comment on what the best timeline for additional information on the QCDR weight of 10 percent for the 2020 MIPS
removing both non-outcome and self-nomination and measures review payment year (81 FR 77165). For the
outcome measures that cannot be and approval process. 2021 MIPS payment year and beyond,
reliably scored against a benchmark for We seek comment on the criteria and the cost performance category will have
3 years. We intend to revisit this issue process outlined above on how we a weight of 30 percent of the final score
and make proposals in future designate outcome measures. as required by section
rulemaking. Specifically are there additional criteria 1848(q)(5)(E)(i)(II)(aa) of the Act.
we should take into consideration when For descriptions of the statutory basis
(4) Quality Measures Determined To Be
we determine if a measure meets the and our existing policies for the cost
Outcome Measures
criteria of an outcome measure? Should performance category, we refer readers
Under the MIPS, individual MIPS we use different criteria for MIPS to the CY 2017 Quality Payment
eligible clinicians are generally required measures versus QCDR measures? Program final rule (81 FR 77162 through
to submit at least one outcome measure, 77177).
or, if no outcome measure is available, d. Cost Performance Category As finalized at 414.1370(g)(2), the
one high priority measure. As such, our (1) Background cost performance category is weighted at
determinations as to whether a measure zero percent for MIPS eligible clinicians
is an outcome measure is of importance (a) General Overview
scored under the MIPS APM scoring
to stakeholders. We utilize the following Measuring cost is an integral part of standard because many MIPS APM
as a basis to determine if a measure is measuring value as part of MIPS. In models incorporate cost measurement in
considered an outcome measure: implementing the cost performance other ways. For more on the APM
Measure Steward and National category for the transition year (2017
scoring standard, see II.C.6.E. of this

Quality Forum (NQF) designationFor MIPS performance period/2019 MIPS proposed rule.
most measures, we will utilize the payment year), we started with
designation as determined by the measures that had been used in (2) Weighting in the Final Score
measure steward and the measures previous programs but noted our intent We are proposing at 414.1350(b)(2)
NQF designation to determine if it is an to move towards episode-based to change the weight of the cost
outcome measure or not. If this is not measurement as soon as possible, performance category from 10 percent to
clear, we will consider the following consistent with the statute and the zero percent for the 2020 MIPS payment
step. feedback from the clinician community. year. We continue to have concerns
about the level of familiarity and category for the 2020 MIPS payment published the Episode-Based Cost
understanding of cost measures among year. Measure Development for the Quality
clinicians. We will use this additional Program (https://www.cms.gov/
(3) Cost Criteria
year in which the score in the cost Medicare/Quality-Initiatives-Patient-
performance category does not count (a) Measures Proposed for the MIPS Cost Assessment-Instruments/Value-Based-
towards the final score for outreach to Performance Category Programs/MACRA-MIPS-and-APMs/
increase understanding of the measures (i) Background Episode-Based-Cost-Measure-
so that clinicians will be more Development-for-the-Quality-Payment-
Under 414.1350(a), we specify cost Program.pdf) and requested input on a
comfortable with their role in reducing
measures for a performance period to draft list of care episode and patient
costs for their patients. In addition, we
assess the performance of MIPS eligible condition groups and codes as required
will use this additional year to develop
clinicians on the cost performance by section 1848(r)(2)(E) and (F) of the
more episode-based measures, which
category. For the 2017 MIPS Act. We additionally requested feedback
are cost measures that are focused on a
performance period, we will utilize 12 on our overall approach to cost measure
clinical conditions or procedures. We
cost measures that are derived from development, including several pages of
intend to propose in future rulemaking
Medicare administrative claims data. specific questions on the proposed
to adopt episode-based measures
Two of these measures, the MSPB approach for clinicians and stakeholders
currently in development. measure and total per capita cost
Although we believe reducing this to provide feedback on. This feedback
measure, have been used in the VM (81 will be used to modify our cost measure
weight is appropriate given the level of FR 77166 through 77168), and the
understanding of the measures and the development and ensure that our
remaining 10 are episode-based approach is continually informed by
scoring standards, we note that section measures that were included in the
1848(q)(5)(E)(i)(II)(aa) of the Act stakeholder feedback. We are currently
sQRURs in 2014 and 2015 (81 FR 77171 reviewing the feedback that was
requires the cost performance category through 77174).
be assigned a weight of 30 percent of the recently received on that posting and
Section 1848(r) of the Act specifies a will share plans to work with clinicians
MIPS final score beginning in the 2021 series of steps and activities for the
MIPS payment year. We recognize that and others on the further developments
Secretary to undertake to involve the of these episodes in the future.
assigning a zero percent weight to the physician, practitioner, and other
cost performance category for the 2020 We will be posting the operational list
stakeholder communities in enhancing of care episode and patient condition
MIPS payment year may not provide a the infrastructure for cost measurement,
smooth enough transition for integrating groups in December 2017, as required
including for purposes of MIPS. Section by section 1848(r)(2)(G) of the Act.
cost measures into MIPS and may not 1848(r)(2) of the Act requires the Section 1848(r)(2)(H) of the Act also
provide enough encouragement to development of care episode and patient requires that not later than November 1
clinicians to review their performance condition groups, and classification of each year (beginning with 2018), the
on cost measures. This policy could codes for such groups, and provides for Secretary shall, through rulemaking,
reduce understanding of the measures care episode and patient condition revise the operational list as the
when we reach the 2021 MIPS payment groups to account for a target of an Secretary determines may be
year and the cost performance category estimated one-half of expenditures appropriate.
will be used to determine 30 percent of under Parts A and B (with this target
the final score for MIPS eligible increasing over time as appropriate). (ii) Total Per Capita Cost and MSPB
clinicians, when in the two previous Section 1848(r) of the Act requires us to Measures
years it was weighted at zero. Therefore, consider several factors when For the 2018 MIPS performance
we also seek comment on keeping the establishing these groups. For care period and future performance periods,
weight of the cost performance category episode groups, we must consider the we are proposing to include in the cost
at 10 percent for the 2020 MIPS patients clinical problems at the time performance category the total per
payment year. items and services are furnished during capita cost measure and the MSPB
In our discussions with clinicians and an episode of care, such as clinical measure as finalized for the 2017 MIPS
clinician societies, clinicians expressed conditions or diagnoses, whether performance period. We refer readers to
their desire to down-weight the cost inpatient hospitalization occurs, the the description of these measures in the
performance category to zero percent for principal procedures or services CY 2017 Quality Payment Program final
an additional year with full knowledge furnished, and other factors determined rule (81 FR 77164 through 77171). We
that the cost performance category appropriate by the Secretary. For patient are proposing to include the total per
weight is set at 30 percent under the condition groups, we must consider the capita cost measure because it is a
statute for the 2021 MIPS payment year. patients clinical history at the time of global measure of all Medicare Part A
The clinicians we spoke with preferred a medical visit, such as the patients and Part B costs during the performance
a low weighting and noted that they are combination of chronic conditions, period. MIPS eligible clinicians are
actively preparing for cost performance current health status, and recent familiar with the total per capita cost
category implementation and would be significant history (such as measure because the measure has been
prepared for the 30 percent statutory hospitalization and major surgery used in the VM since the 2015 payment
weight for the cost performance category during a previous period), and other adjustment period and performance
for the 2021 MIPS payment year. We factors determined appropriate. feedback has been provided through the
intend to continue to provide education Section 1848(r)(2) of the Act requires annual QRUR since 2013 (for a subset of
to clinicians to help them prepare for us to post on the CMS Web site a draft groups that had 20 or more eligible
the upcoming 30 percent weight. list of care episode and patient professionals, based on 2014
We invite public comments on this condition groups and codes for performance) and to all groups in the
proposal of a zero percent weighting for solicitation of input from stakeholders, annual QRUR since 2014 (based on 2013
the cost performance category and the and subsequently, post on the CMS Web performance) and mid-year QRUR since
alternative option of 10 percent site an operational list of such groups 2015. We are proposing to use the MSPB
weighting for the cost performance and codes. In December 2016, we measure because many MIPS eligible
clinicians will be familiar with the additional comments after publication from a diverse array of clinicians on
measure from the VM, where it has been of that final rule with comment period identifying conditions and procedures
included since the 2016 payment about the decision to include 10 for episode groups. Moving forward, the
adjustment period and in annual QRUR episode-based measures for the 2017 Clinical Committee will recommend
since 2014 (based on 2013 performance) MIPS performance period. Although which services or claims would be
and the mid-year QRUR since 2015, or comments were generally in favor of the counted in episode costs. This will
its hospital-specified version, which has inclusion of episode-based measures in ensure that cost measures in
been a part of the Hospital VBP Program the future, there was also overwhelming development are directly informed by a
since 2015, based on 2013 performance. stakeholder interest in more clinician substantial number of clinicians and
In addition to familiarity, these two involvement in the development of members of specialty societies.
measures cover a large number of these episode-based measures as In addition, a technical expert panel
patients and provide an important required by section 1848(r)(2) of the Act. has met 3 times to provide oversight and
measurement of clinician contribution Although there was an opportunity for guidance for our development of
to the overall population that a clinician clinician involvement in the episode-based cost measures. The
encounters. development of some of the episode- technical expert panel has offered
We are not proposing any changes to based measures included for the 2017 recommendations for defining an
the methodologies for payment MIPS performance period, it was not as episode group, assigning costs to the
standardization, risk adjustment, and extensive as the process we are group, and attributing episode groups to
specialty adjustment for these measures currently using to develop episode- clinicians. This expert feedback has
and refer readers to the CY 2017 Quality based measures. We believe that the been built into the current cost measure
Payment Program final rule (81 FR new episode-based measures, which we development process.
77164 through 77171) for more intend to propose in future rulemaking As this process continues, we are
information about these methodologies. to include in the cost performance continuing to seek input from
We will continue to evaluate cost category for the 2019 MIPS performance clinicians. Earlier this year, we opened
measures that are included in MIPS on period, will be substantially improved an opportunity to submit the names of
a regular basis and anticipate that by more extensive stakeholder feedback clinicians to participate in this process.
measures could be added or removed, and involvement in the process. This process remains open to additional
subject to rulemaking under applicable Thus far, stakeholder feedback has individuals. We believe that episode-
law, as measure development continues. been sought in several ways. First, based measures will benefit from this
We will also maintain the measures that stakeholder feedback has been sought comprehensive approach to
are used in the cost performance through various public postings. In development. In addition, because it is
category by updating specifications, risk October 2015 and April 2016, pursuant possible that the new episode-based
adjustment, and attribution as to section 1848(r)(2)(B) and (C) of the measures under development could
appropriate. We anticipate including a Act, we gathered input from address similar conditions as those in
list of cost measures for a given stakeholders on the episode groups the episode-based measures finalized for
performance period in annual previously developed under section the 2017 MIPS performance period, we
rulemaking. 1848(n)(9)(A) of the Act that has been believe that it would be better to focus
We invite public comments on these used to inform the process of attention on the new episode-based
proposals. constructing the new episode-based cost measures, so that clinicians would not
measures. This feedback emphasized receive feedback or scores from two
(iii) Episode-Based Measures
several key aspects of cost measure measures for the same patient condition
Episode-based measures differ from development such as attribution, risk or procedure. Recognizing that under
the total per capita cost measure and adjustment, and alignment with quality section 1848(q)(5)(E)(i)(II)(aa) of the Act,
MSPB measure because their measurement and patient outcomes. we must assign a weight of 30 percent
specifications only include services that Stakeholders have also emphasized that to the cost performance category for the
are related to the episode of care for a feedback related to cost measures 2021 MIPS payment year, we will
clinical condition or procedure (as should be actionable and timely. In endeavor to have as many episode-based
defined by procedure and diagnosis addition, a draft list of care episode and measures available as possible for the
codes), as opposed to including all patient condition groups, along with proposed 2019 MIPS performance
services that are provided to a patient trigger codes, was posted for comment period.
over a given period of time. For the 2018 in December 2016 (https:// We plan to include episode-based
MIPS performance period, we are not www.cms.gov/Medicare/Quality- measures in the cost performance
proposing to include in the cost Initiatives-Patient-Assessment- category in future years as they are
performance category the 10 episode- Instruments/Value-Based-Programs/ developed and would propose new
based measures that we adopted for the MACRA-MIPS-and-APMs/Episode- measures in future rulemaking.
2017 MIPS performance period in the Based-Cost-Measure-Development-for- Although we are not proposing to
CY 2017 Quality Payment Program final the-Quality-Payment-Program.pdf) as include any episode-based measures in
rule (81 FR 77171 through 77174). We required by section 1848(r)(2)(E) of the calculating the cost performance
instead will work to develop new Act and comments were accepted as category score for the 2020 MIPS
episode-based measures, with required by section 1848(r)(2)(F) of the payment year, we do plan to continue
significant clinician input, for future to provide confidential performance
Act.
performance periods. This draft list of care episode and feedback to clinicians on their
We received extensive comments on patient condition groups and trigger performance on episode-based measures
our proposal to include 41 of these codes was informed by engagement with developed under the processes required
episode-based measures for the 2017 clinicians from over 50 clinician by section 1848(r)(2) of the Act as
MIPS performance period, which we specialty societies through a Clinical appropriate in order to increase
responded to in the CY 2017 Quality Committee formed to participate in cost familiarity with the concept of episode-
Payment Program final rule (81 FR measure development. The Clinical based measurement as well as the
77171 through 77174). We also received Committee work has provided input specific episodes that could be included
in determining the cost performance capita cost and MSPB measures, will performance for a measure within a
category score in the future. Because support clinicians in their readiness for clinicians attributed beneficiaries
these measures will be generated based the proposed 2019 MIPS performance (noise), and the number of
on claims data like other cost measures, period. beneficiaries attributed to the clinician.
we will not collect any additional data As previously finalized in the CY High reliability for a measure suggests
from clinicians. As we develop new 2017 Quality Payment Program final that comparisons of relative
episode-based measures, we believe it is rule (81 FR 77173), the episode-based performance among clinicians are likely
likely that they would cover similar measures that we are not proposing for to be stable over different performance
clinical topics to those that are in the the 2018 MIPS performance period will periods and that the performance of one
previously developed episode-based be used for determining the cost clinician on the measure can be
measures because of our intent to performance category score for the 2019 confidently distinguished from another.
address common clinical conditions MIPS payment year, although the cost As an example of the statistical concept
with episode-based measures. We aim to performance category score will be of reliability, a test in which the same
provide an initial opportunity for weighted at zero percent in that year. individual received very different scores
clinicians to review their performance We invite public comments on this depending on how the included
based on the new episode-based proposal. questions are framed would not be
measures at some point in the fall of (iv) Attribution reliable. Potential reliability values
2017, as the measures are developed range from 0.00 to 1.00, where 1.00
In the CY 2017 Quality Payment (highest possible reliability) signifies
and as the information is available. We Program final rule, we changed the list
note that this feedback will be specific that all variation in the measures rates
of primary care services that had been is the result of variation in differences
to the new episode-based measures that used to determine attribution for the
are developed under the process in performance across clinicians,
total per capita cost measure by adding whereas 0.0 (lowest possible reliability)
described above and may be presented transitional care management (CPT
in a different format than MIPS eligible signifies that all variation could be a
codes 99495 and 99496) codes and a result of measurement error. The 0.4
clinicians performance feedback as chronic care management code (CPT reliability threshold that we adopted for
described in section II.C.9.a. of this code 99490) (81 FR 77169). In the CY the cost performance category measures
proposed rule. However, our intention 2017 Physician Fee Schedule final rule, in MIPS means that the majority of
is to align the feedback as much as we changed the payment status for two MIPS eligible clinicians and groups who
possible to ensure clinicians receive existing CPT codes (CPT codes 99487 meet the case minimum required for
opportunities to review their and 99489) that could be used to scoring under a measure have measure
performance on potential new episode- describe care management from B reliability scores that exceed 0.4. We
based measures for the cost performance (bundled) to A (active) meaning that the generally consider reliability levels
category prior to the proposed 2019 services would be paid under the between 0.4 and 0.7 to indicate
MIPS performance period. We are Physician Fee Schedule (81 FR 80349). moderate reliability and levels above
unable to offer a list of new episode- The services described by these codes 0.7 to indicate high reliability.
based measures on which we will are substantially similar to those We addressed comments we received
provide feedback because that will be described by the chronic care on the CY 2017 Quality Payment
determined in our ongoing development management code that we added to the Program proposed rule (81 FR 77169
work described above. We are list of primary care services beginning through 77171), that expressed concern
concerned that continuing to provide with the 2017 performance period. We that our 0.4 reliability threshold was too
feedback on the older episode-based therefore propose to add CPT codes low. Many commenters recommended
measures along with feedback on new 99487 and 99489, both describing that cost measures be included only
episode-based measures will be complex chronic care management, to when they could meet the standard of
confusing and a poor use of resources. the list of primary care services used to high reliability (0.7 or above). Many
Because we are focusing on attribute patients under the total per commenters on the CY 2017 Quality
development of new episode-based capita cost measure. Payment Program final rule made
measures, our feedback on episode- We are not proposing any changes to similar comments. Commenters
based measures that were previously the attribution methods for the MSPB emphasized the importance of
developed will discontinue after 2017 as measure and refer readers to the CY reliability; however, we have also seen
these measures would no longer be 2017 Quality Payment Program final commenters incorrectly refer to
maintained or reflect changes in rule (81 FR 77168 through 77169) for measures as being 40 percent reliable.
diagnostic and procedural coding. As more information. Reliability is not a percentage but is
described in section II.C.9.a. of this We invite public comment on our instead a coefficient so a measure with
proposed rule, we intend to provide proposals. 0.4 reliability does not reflect that it is
feedback on these new measures as they only correct for 40 percent of those
become available in a new format (v) Reliability
measured. We encourage a review of our
around summer 2018. We note that the In the CY 2017 Quality Payment analysis of reliability for the total per
feedback provided in the summer of Program final rule (81 FR 77169 through capita cost measure (80 FR 71282) and
2018 will go to those MIPS eligible 77170), we finalized a reliability MSPB (81 FR 77169 through 77171).
clinicians for whom we are able to threshold of 0.4 for measures in the cost Reliability is an important evaluation
calculate the episode-based measures, performance category. Reliability is an tool for an individual measure, but it is
which means it would be possible a important evaluation for cost measures only one element of evaluation.
clinician may not receive feedback on to ensure that differences in Reliability generally increases as we
episode-based measures in both the fall performance are not the result of increase the case size but a high
of 2017 and the summer of 2018. We random variation. Statistically, reliability may also reflect low variation.
believe that receiving feedback on the reliability depends on performance A measure in which all clinicians
new episode-based measures, along variation for a measure across clinicians perform at nearly the same rate would
with the previously-finalized total per (signal), the random variation in be reliable but not valuable in a program
that attempts to recognize and reward (d) Incorporation of Cost Measures With clinicians. Accordingly, for the 2018
differential performance. A measure in ICD10 Impacts MIPS performance period, we are not
which there is very little variation In section II.C.7.a.(1)(c) of this proposing alternative cost measures for
provides little value in a program like proposed rule, we discuss our proposal non-patient facing MIPS eligible
MIPS given the devotion of resources to to assess performance on any measures clinicians or groups. This means that
developing and maintaining that impacted by ICD10 updates based only non-patient facing MIPS eligible
measure over other potential measures. on the first 9 months of the 12-month clinicians or groups are unlikely to be
Reliability must also be considered in performance period. Because the total attributed any cost measures that are
the context of a measurement system per capita cost and MSPB measures generally attributed to clinicians who
like MIPS which incorporates other include costs from all Medicare Part A have patient-facing encounters with
elements of measurement. We and B services, regardless of the specific patients. Therefore, we anticipate that,
understand and appreciate the concerns ICD10 codes that are used on claims, similar to MIPS eligible clinicians or
that have been expressed about and do not assign patients based on groups that do not meet the required
reliability of measures. Medicine, ICD10, we do not anticipate that any case minimums for any cost measures,
however, always has a certain amount of measures for the cost performance many non-patient facing MIPS eligible
category would be affected by this ICD clinicians may not have sufficient cost
variability which may affect the
10 issue during the 2018 MIPS measures applicable and available to
reliability score. We want strong
performance period. However, as we them and would not be scored on the
reliability, but not at the expense of
continue our plans to expand cost cost performance category under MIPS.
losing valuable information about We continue to consider opportunities
clinicians. We are concerned that measures to incorporate episode-based
measures, ICD10 changes could to develop alternative cost measures for
placing too much of an emphasis on non-patient facing clinicians and solicit
reliability calculations could limit the become important. Episode-based
measures may be opened (triggered) by comment on this topic to inform our
applicability of cost measures to large future rulemaking.
group practices who, by nature of their and may assign services based on ICD
size, have larger patient populations, 10 codes. Therefore, a change to ICD10 (f) Facility-Based Measurement as it
thus depriving solo clinicians and coding could have a significant effect on Relates to the Cost Performance
individual reporters from being an episode-based measure. Changes to Category
ICD10 codes will be incorporated into
rewarded for efforts to better manage In section II.C.7.a.(4) of this proposed
the measure specifications on a regular
patients. Therefore, we are not rule, we discuss our proposal to
basis through the measure maintenance
proposing any adjustments to our implement section 1848(q)(2)(C)(ii) of
process.
reliability policies, but we will continue the Act by assessing clinicians who
to evaluate reliability as we develop (e) Application of Measures to Non- meet certain requirements and elect
new measures and to ensure that our Patient Facing MIPS Eligible Clinicians participation based on the performance
measures meet an appropriate standard. We are not proposing changes to the of their associated hospital in the
policy we finalized in the CY 2017 Hospital VBP Program. We refer readers
(b) Attribution for Individuals and to that section for full details on our
Groups Quality Payment Program final rule (81
FR 77176) that we will attribute cost proposals related to facility-based
We are not proposing any changes for measures to non-patient facing MIPS measurement, including the measures
eligible clinicians who have sufficient and how the measures are scored, for
how we attribute cost measures to
case volume, in accordance with the the cost performance category.
individual and group reporters. We refer
readers to the CY 2017 Quality Payment attribution methodology. e. Improvement Activity Criteria
Program final rule for more information Section 1848(q)(2)(C)(iv) of the Act
requires the Secretary to consider the (1) Background
(81 FR 77175 through 77176).
circumstances of professional types who Section 1848(q)(2)(C)(v)(III) of the Act
(c) Incorporation of Cost Measures With typically furnish services without defines an improvement activity as an
SES or Risk Adjustment patient facing interaction (non-patient activity that relevant eligible clinician
facing) when determining the organizations and other relevant
Both measures proposed for inclusion application of measures and activities. stakeholders identify as improving
in the cost performance category for the In addition, this section allows the clinical practice or care delivery, and
2018 MIPS performance period are risk Secretary to apply alternative measures that the Secretary determines, when
adjusted at the measure level. Although or activities to non-patient facing MIPS effectively executed, is likely to result in
the risk adjustment of the 2 measures is eligible clinicians that fulfill the goals of improved outcomes. Section
not identical, in both cases it is used to a performance category. Section 1848(q)(2)(B)(iii) of the Act requires the
recognize the higher risk associated 1848(q)(5)(F) of the Act allows the Secretary to specify improvement
with demographic factors (such as age) Secretary to re-weight MIPS activities under subcategories for the
or certain clinical conditions. We performance categories if there are not performance period, which must
recognize that the risks accounted for sufficient measures and activities include at least the subcategories
with this adjustment are not the only applicable and available to each type of specified in section 1848(q)(2)(B)(iii)(I)
potential attributes that could lead to a MIPS eligible clinician involved. through (VI) of the Act, and in doing so
higher cost patient. Stakeholders have We believe that non-patient facing to give consideration to the
pointed to many other factors such as clinicians are an integral part of the care circumstances of small practices, and
income level, race, and geography that team and that their services do practices located in rural areas and
they believe contribute to increased contributed to the overall costs but at geographic health professional shortage
costs. These issues and our plans for this time we believe it better to focus on areas (HPSAs).
attempting to address them are the development of a comprehensive Section 1848(q)(2)(C)(iv) of the Act
discussed in length in section system of episode-based measures generally requires the Secretary to give
II.C.7.b.(1)(a) of this rule. which focus on the role of patient-facing consideration to the circumstances of
non-patient facing individual MIPS Table F in the Appendix of this provide that a MIPS eligible clinician or
eligible clinicians or groups and allows proposed rule, and in Table H: Finalized group in a practice that is certified or
the Secretary, to the extent feasible and Improvement Activities Inventory that recognized as a patient-centered
appropriate, to apply alternative we finalized in the CY 2017 Quality medical home or comparable specialty
measures and activities to such Payment Program final rule (81 FR practice, as determined by the Secretary,
individual MIPS eligible clinicians and 77817 through 77831). In that same final receives full credit for performance on
groups. rule, we also finalized a policy to allow the improvement activities performance
Section 1848(q)(2)(C)(v) of the Act MIPS eligible clinicians to achieve a category. For purposes of 414.1380
required the Secretary to use a request bonus in the advancing care information (b)(3)(iv), full credit means that the
for information (RFI) to solicit performance category when they use MIPS eligible clinician or group has met
recommendations from stakeholders to functions included in CEHRT to the highest potential category score of
identify improvement activities and complete eligible activities from the 40 points. A practice is certified or
specify criteria for such improvement Improvement Activities Inventory. recognized as a patient-centered
activities, and provides that the Please refer to section II.C.6.f.(2)(d) of medical home if it meets any of the
Secretary may contract with entities to this proposed rule for details on how criteria specified under
assist in identifying activities, improvement activities using CEHRT 414.1380(b)(3)(iv).
specifying criteria for the activities, and relate to the objectives and measures of In the CY 2017 Quality Payment
determining whether individual MIPS the advancing care information and Program final rule (81 FR 77198), we
eligible clinicians or groups meet the improvement activities performance requested commenters specific
criteria set. For a detailed discussion of categories. We are not proposing any suggestions for additional activities or
the feedback received from the MIPS changes to these policies for activities that may merit additional
and APMs RFI, see the CY 2017 Quality incentivizing the use of health IT in this points beyond the high level. Several
Payment Program 2017 final rule (81 FR proposed rule; however, we will commenters urged us to increase the
77177). continue to consider including emerging overall number of high-weighted
We defined improvement activities at certified health IT capabilities as part of activities in this performance category.
414.1305 as an activity that relevant activities within the Improvement Some commenters recommended
MIPS eligible clinicians, organizations Activities Inventory in future years. additional criteria for designating high-
and other relevant stakeholders identify In addition, as noted previously, we weighted activities, such as an
as improving clinical practice or care believe a key goal of the Quality improvement activitys impact on
delivery and that the Secretary Payment Program is to establish a population health, medication
determines, when effectively executed, program that allows for close alignment adherence, and shared decision-making
is likely to result in improved outcomes. of the four performance categories. tools, and encouraged us to be more
In the CY 2017 Quality Payment Although we are not proposing any transparent in our weighting decisions.
Program final rule (81 FR 77199), we specific new policies, we seek comment Several commenters recommended that
solicited comments on activities that on how we might provide flexibility for we weight registry-related activities as
would advance the usage of health IT to MIPS eligible clinicians to effectively high, and suggested that we award
support improvement activities. We demonstrate improvement through individual MIPS eligible clinicians and
received several comments in support of health IT usage while also measuring groups in APMs full credit in this
the concept to include emerging such improvement. We welcome public performance category. The commenters
certified health IT capabilities as part of comment on these considerations. also offered many recommendations for
the activities in the Improvement changing current medium-weighted
Activities Inventory and several (2) Contribution to the Final Score
activities to high and offered many
commenters supported our assessment In the CY 2017 Quality Payment specific suggestions for new high-
that using CEHRT can aid in improving Program final rule (81 FR 77179 through weighted improvement activities.
clinical practices and help healthcare 77180), we finalized at 414.1355 that In response to the comments, we are
organizations achieve success on the improvement activities performance proposing new, high-weighted activities
numerous improvement activities, as category would account for 15 percent in Table F in the Appendix of this
well as the continued integration of of the final score. We also finalized at proposed rule. As explained in the CY
improvement activities and advancing 414.1380(b)(3)(iv) criteria for 2017 Quality Payment Program final
clinical information. However, several recognition as a certified-patient rule (81 FR 77194), we believe that high
commenters expressed concern about centered medical home or comparable weighting should be used for activities
health IT-associated burdens and costs specialty practice. We are proposing to that directly address areas with the
and recommended that we also continue clarify the term certified patient- greatest impact on beneficiary care,
to offer diverse activities that do not rely centered medical home finalized at safety, health, and well-being. We are
on emerging capabilities of certified 414.1380(b)(3)(iv). It has come to our not proposing changes to this approach
health IT, as they are not universally attention that the common terminology in this proposed rule; however, we will
available or may only be offered as high utilized in the general medical take these suggested additional criteria
cost add-on capabilities. Some community for certified patient- into consideration for designating high-
commenters also requested that we be centered medical home is recognized weighted activities in future
less prescriptive in our requirements for patient-centered medical home. rulemaking. For MIPS eligible clinicians
the use of health IT. Therefore, in order to provide clarity we participating in MIPS APMs, we
In response to the comments, we will are proposing that the term finalized a policy to reduce reporting
continue to focus on incentivizing the recognized be accepted as equivalent burden through the APM scoring
use of health IT, telehealth, and to the term certified when referring to standard for this category to recognize
connection of patients to community- the requirements for a patient-centered improvement activities work performed
based services. The use of health IT is medical home to receive full credit for through participation in MIPS APMs.
an important aspect of care delivery the improvement activities performance This policy is codified at
processes described in many of the category for MIPS. Specifically, we 414.1370(g)(3), and we refer readers to
proposed new improvement activities in propose to revise 414.1380(b)(3)(iv) to the CY 2017 Quality Payment Program
final rule for further details on reporting proposing to generally apply our considering different thresholds we
and scoring this category under the previously finalized and proposed could attribute recognition as a certified
APM Scoring Standard (81 FR 77259 group policies to virtual groups. or recognized patient-centered medical
through 77260). We would like to note that while we home or comparable specialty practice
finalized at 414.1325(d) in the CY at the individual TIN/NPI level, and
(3) Improvement Activities Data 2017 Quality Payment Program final attribute this designation to the group
Submission Criteria rule that individual MIPS eligible under which they bill if they are
(a) Submission Mechanisms clinicians and groups may only use one participating in MIPS as a group or as
In the CY 2017 Quality Payment submission mechanism per performance part of a virtual group. A group or
Program final rule (81 FR 77180), we category, in section II.C.6.a.(1) of this virtual group consisting of 100 NPIs
discussed that for the transition year of proposed rule, we are proposing to could have a reporting threshold of 50
MIPS we would allow for submission of revise 414.1325(d) for purposes of the percent while a group consisting of 10
data for the improvement activities 2020 MIPS payment year and future NPIs could have a lower reporting
performance category using the years to allow individual MIPS eligible threshold of 10 percent. We are
qualified registry, EHR, QCDR, CMS clinicians and groups to submit concerned that while establishing any
Web Interface, and attestation data measures and activities, as applicable, specific threshold for the percentage of
submission mechanisms through via as many submission mechanisms as NPIs in a TIN that must participate in
attestation. Specifically, we finalized a necessary to meet the requirements of an improvement activity for credit will
the quality, improvement activities, or incentivize some groups to move closer
policy that regardless of the data
advancing care information performance to the threshold, it may have the
submission method, with the exception
categories. We refer readers to section unintended consequence of
of MIPS eligible clinicians in MIPS
II.C.6.a.(1) of this proposed rule for incentivizing groups who are exceeding
APMs, all individual MIPS eligible
further discussion of this proposal. the threshold to gravitate back toward
clinicians or groups must select We also included a designation
activities from the Improvement the threshold. Therefore, we are
column in the Improvement Activities requesting comments on how to set this
Activities Inventory. In addition, we Inventory at Table H in the Appendix of threshold while maintaining the goal of
finalized at 414.1360 that for the the CY 2017 Quality Payment Program promoting greater participation in an
transition year of MIPS, all individual final rule (81 FR 77817) that indicated improvement activity.
MIPS eligible clinicians or groups, or which activities qualified for the Additionally, we noted in the CY
third party intermediaries such as advancing care information bonus 2017 Quality Payment Program final
health IT vendors, QCDRs and qualified finalized at 414.1380. In future rule (81 FR 77197) that we intended, in
registries that submit on behalf of an updates to the Improvement Activities future years, to score the improvement
individual MIPS eligible clinician or Inventory we intend to continue to activities performance category based on
group, must designate a yes response indicate which activities qualify for the performance and improvement, rather
for activities on the Improvement advancing care information performance than simple attestation. We seek
Activities Inventory. In the case where category bonus. comment on how we could measure
an individual MIPS eligible clinician or In the CY 2017 Quality Payment performance and improvement; we are
group is using a health IT vendor, Program final rule (81 FR 77181), we especially interested in ways to measure
QCDR, or qualified registry for their data clarified that if one MIPS eligible performance without imposing
submission, the individual MIPS clinician (NPI) in a group completed an additional burden on eligible clinicians,
eligible clinician or group will certify all improvement activity, the entire group such as by using data captured in
improvement activities were performed (TIN) would receive credit for that eligible clinicians daily work.
and the health IT vendor, QCDR, or activity. In addition, we specified that
qualified registry would submit on their all MIPS eligible clinicians reporting as (b) Submission Criteria
behalf. We would like to maintain a group would receive the same score In the CY 2017 Quality Payment
stability in the Quality Payment for the improvement activities Program final rule (81 FR 77185), we
Program and continue this policy into performance category if at least one finalized at 414.1380 to set the
future years. Therefore, we are clinician within the group is performing improvement activities submission
proposing at 414.1360 that for the activity for a continuous 90 days in criteria under MIPS, to achieve the
purposes of the transition year of MIPS the performance period. As discussed in highest potential score, at two high-
and future years all individual MIPS section II.C.4.d. of this proposed rule, weighted improvement activities or four
eligible clinicians or groups, or third we are proposing to generally apply our medium-weighted improvement
party intermediaries such as health IT previously finalized and proposed activities, or some combination of high
vendors, QCDRs and qualified registries group policies to virtual groups. We are and medium-weighted improvement
that submit on behalf of an individual not proposing any changes to this policy activities. While the minimum reporting
MIPS eligible clinician or group, must in this proposed rule. However, we are period for one improvement activity is
designate a yes response for activities requesting comment on whether we 90 days, the maximum frequency with
on the Improvement Activities should establish a minimum threshold which an improvement activity may be
Inventory. In the case where an (for example, 50 percent) of the reported would be once during the 12-
individual MIPS eligible clinician or clinicians (NPIs) that must complete an month performance period. In addition,
group is using a health IT vendor, improvement activity in order for the as discussed in section II.C.4.d. of this
QCDR, or qualified registry for their data entire group (TIN) to receive credit in proposed rule, we are proposing to
submission, the MIPS eligible clinician the improvement activities performance generally apply our previously finalized
or group will certify all improvement category in future years. In addition, we and proposed group policies to virtual
activities were performed and the health are requesting comments on groups.
IT vendor, QCDR, or qualified registry recommended minimum threshold We established exceptions to the
would submit on their behalf. In percentages and whether we should above for: small practices; practices
addition, as discussed in section establish different thresholds based on located in rural areas; practices located
II.C.4.d. of this proposed rule, we are the size of the group. For example, in in geographic HPSAs; non-patient facing
individual MIPS eligible clinicians or FR 77178). We finalized at group policies to virtual groups.
groups; and individual MIPS eligible 414.1380(b)(3)(viii) that to receive full Further, we welcome suggestions on an
clinicians and groups that participate in credit as a certified patient-centered appropriate threshold for the number of
a MIPS APM or a patient-centered medical home or comparable specialty NPIs within the TIN that must be
medical home submitting in MIPS. practice, a TIN that is reporting must recognized as a certified patient-
Specifically, for individual MIPS include at least one practice that is a centered medical home or comparable
eligible clinicians and groups that are certified patient-centered medical home specialty practice to receive full credit
small practices, practices located in or comparable specialty practice. We in the improvement activities
rural areas or geographic HPSAs, or also indicated that we would continue performance category.
non-patient facing individual MIPS to have more stringent requirements in We have determined that the
eligible clinicians or groups, to achieve future years, and would lay the Comprehensive Primary Care Plus
the highest score, one high-weighted or groundwork for expansion towards (CPC+) APM design satisfies the
two medium-weighted improvement continuous improvement over time (81 requirements to be designated as a
activities are required. For these FR 77189). We received many medical home model, as defined in
individual MIPS eligible clinicians and comments on the CY 2017 Quality 414.1305, and is therefore a certified
groups, in order to achieve one-half of Payment Program final rule regarding or recognized patient-centered medical
the highest score, one medium-weighted our transition year policy that only one home for purposes of the improvement
improvement activity is required. practice site within a TIN needs to be activities performance category. The
Under the APM scoring standard, all certified as a patient-centered medical CPC+ model meets the criteria to be an
clinicians identified on the Participation Advanced APM. CPC+ eligibility criteria
home for the entire TIN to receive full
List of an APM receive at least one-half for practices include, but are not limited
credit in the improvement activities
of the highest score applicable to the to, the use of CEHRT and care delivery
performance category. While several
MIPS APM. To develop the activities such as: Assigning patients to
commenters supported our transition
improvement activities score assigned to clinician panels; providing 24/7
year policy, others disagreed and
each MIPS APM, we compare the clinician access; and supporting quality
suggested to move to a more stringent
requirements of the specific MIPS APM improvement activities. Control groups
requirement in future years while still
with the list of activities in the in CPC+ are required to meet the same
offering some flexibility. Accordingly,
Improvement Activities Inventory and eligibility criteria as those selected to be
we propose to revise 414.1380(b)(3)(x) active participants in the model. For
score those activities in the same
manner that they are otherwise scored to provide that for the 2020 MIPS Round 2 of CPC+, CMS is randomly
for MIPS eligible clinicians. If by our payment year and future years, to assigning accepted practices into the
assessment the MIPS APM does not receive full credit as a certified or intervention group or a control group.
receive the maximum improvement recognized patient-centered medical Practices accepted into CPC+ and
activities performance category score home or comparable specialty practice, randomized into the control group have
then the APM entity can submit at least 50 percent of the practice sites satisfied the requirements for
additional improvement activities. All within the TIN must be recognized as a participation in CPC+, a medical home
other individual MIPS eligible patient-centered medical home or model, and we believe that the MIPS
clinicians or groups that we identify as comparable specialty practice. This is eligible clinicians in the control group
participating in APMs that are not MIPS an increase to the requirement that only should therefore receive full credit for
APMs will need to select additional one practice site within a TIN needs to the improvement activities performance
improvement activities to achieve the be certified as a patient-centered category. In addition, the practices
improvement activities highest score. medical home, but does not require randomized to the CPC+ control group
We refer readers to section II.C.6.g. of every site be certified, which could be must sign a Participation Agreement
this proposed rule for further discussion overly restrictive given that some sites with us; the agreement will require
of the APM scoring standard. within a TIN may be in the process of practices in a control group to maintain
We also provided full credit for the being certified as patient-centered a Practitioner Roster of all MIPS eligible
improvement activities performance medical homes. In addition, we believe clinicians in the practice.
category, as required by law, for an a 50 percent threshold is achievable Accordingly, we are proposing that
individual MIPS eligible clinician or which is supported by a study of MIPS eligible clinicians in practices that
group that has received certification or physician-owned primary care groups in have been randomized to the control
accreditation as a patient-centered a recent Annals of Family Medicine group in the CPC+ APM would receive
medical home or comparable specialty article (Casalino, et al., 2016) http:// full credit as a medical home model,
practice from a national program or www.annfammed.org/content/14/1/ and therefore a certified patient-
from a regional or state program, private 16.full. For nearly all groups in this centered medical home, for the
payer or other body that administers study (sampled with variation in size improvement activities performance
patient-centered medical home and geographic area) at least 50 percent category. MIPS eligible clinicians who
accreditation and certifies 500 or more of the practice sites within the group attest that they are in practices that have
practices for patient-centered medical had a medical home designation. If the been randomized to the control group in
home accreditation or comparable group is unable to meet the 50 percent the CPC+ APM would receive full credit
specialty practice certification, or for an threshold then the individual MIPS for the improvement activities
individual MIPS eligible clinician or eligible clinician may choose to receive performance category for each
group that is a participant in a medical full credit as a certified patient-centered performance period in which they are
home model. medical home or comparable specialty on the Practitioner Roster, the official
We also noted in the CY 2017 Quality practice by reporting as an individual list of eligible clinicians participating in
Payment Program final rule that for all performance categories. In a practice in the CPC+ control group.
practices may receive this designation at addition, as discussed in section The inclusion of MIPS eligible
a practice level and that TINs may be II.C.4.d. of this proposed rule, we are clinicians in practices that have been
comprised of both undesignated proposing to generally apply our randomized into the CPC+ control group
practices and designated practices (81 previously finalized and proposed recognizes that they have met the
requirements to receive full credit for (5) Special Consideration for Small, suggesting possible new activities via a
performance in the improvement Rural, or Health Professional Shortage nomination form that was posted on the
activities performance category as a Areas Practices CMS Web site at https://www.cms.gov/
medical home model, and will help In the CY 2017 Quality Payment Medicare/Quality-Initiatives-Patient-
ensure more equitable treatment of the Program final rule (81 FR 77188), we Assessment-Instruments/MMS/
CPC+ control group by allowing finalized at 414.1380(b)(3)(vii) that one CallForMeasures.html. We are
clinicians in the control group that have high-weighted or two medium-weighted proposing new activities and changes to
met the criteria for participation in the improvement activities are required for the Improvement Activities Inventory in
CPC+ APM to receive the same individual MIPS eligible clinicians and Tables F and G of the Appendix of this
recognition as those actively groups that are small practices or proposed rule.
located in rural areas, or geographic For the Quality Payment Program
participating in the CPC+ intervention Year 3 and future years, we are
group. HPSAs, to achieve full credit. In
addition, we specified at 414.1305 that proposing to formalize an Annual Call
We request comments on these for Activities process for adding
a rural area means ZIP codes designated
proposals. as rural, using the most recent HRSA possible new activities to the
Area Health Resource File data set Improvement Activities Inventory. We
(c) Required Period of Time for believe this is a way to engage eligible
Performing an Activity available. Lastly, we finalized the
clinician organizations and other
following definitions at 414.1305: (1)
In the CY 2017 Quality Payment relevant stakeholders, including
Small practices is defined to mean
Program final rule (81 FR 77186), we beneficiaries, in the identification and
practices consisting of 15 or fewer
submission of improvement activities
specified at 414.1360 that MIPS clinicians and solo practitioners; and (2)
for consideration. We propose that
eligible clinicians or groups must Health Professional Shortage Areas
individual MIPS eligible clinicians or
perform improvement activities for at (HPSA) refers to areas as designated
groups and other relevant stakeholders
least 90 consecutive days during the under section 332(a)(1)(A) of the Public
may recommend activities for potential
performance period for improvement Health Service Act. We are not
inclusion in the Improvement Activities
activities performance category credit. proposing any changes to the special Inventory via a similar nomination form
Activities, where applicable, may be consideration for small, rural, or health utilized in the transition year of MIPS
continuing (that is, could have started professional shortage areas practices for found on the Quality Payment Program
prior to the performance period and are the improvement activities performance Web site at www.qpp.cms.gov. As part of
continuing) or be adopted in the category in this proposed rule. the process, individual MIPS eligible
performance period as long as an (6) Improvement Activities clinicians, groups, and other relevant
activity is being performed for at least Subcategories stakeholders would be able to nominate
90 days during the performance period. In the CY 2017 Quality Payment additional improvement activities that
In addition, as discussed in section Program final rule (81 FR 77190), we we may consider adding to the
II.C.4.d. of this proposed rule, we are finalized at 414.1365 that the Improvement Activities Inventory.
proposing to generally apply our improvement activities performance Individual MIPS eligible clinicians and
previously finalized and proposed category will include the subcategories groups and relevant stakeholders would
group policies to virtual groups. We are of activities provided at section be able to provide an explanation via
not proposing any changes to the 1848(q)(2)(B)(iii) of the Act. In addition, the nomination form of how the
required period of time for performing we finalized at 414.1365 the following improvement activity meets all the
an activity for the improvement additional subcategories: Achieving criteria we have identified in section
activities performance category in this Health Equity; Integrated Behavioral II.C.6.e.(7)(b) of this proposed rule. The
and Mental Health; and Emergency 2018 proposed new improvement
proposed rule.
Preparedness and Response. We are not activities and the 2018 proposed
(4) Application of Improvement proposing any changes to the improvement activities with changes
Activities to Non-Patient Facing improvement activities subcategories for can be found in Tables F and G of the
Individual MIPS Eligible Clinicians and the improvement activities performance Appendix of this proposed rule and will
Groups category in this proposed rule. be available on the CMS Web site.
We request comments on this
In the CY 2017 Quality Payment (7) Improvement Activities Inventory proposed annual Call for Activities
Program final rule (81 FR 77187), we (a) Proposed Approach on the Annual process.
specified at 414.1380(b)(3)(vii) that for Call for Activities Process for Adding (b) Criteria for Nominating New
non-patient facing individual MIPS New Activities Improvement Activities for the Annual
eligible clinicians or groups, to achieve Call for Activities
In Table H in the Appendix of the CY
the highest score one high-weighted or
2017 Quality Payment Program final We propose for the Quality Payment
two medium-weighted improvement rule (81 FR 77817), we finalized the
activities are required. For these Program Year 2 and future years that
Improvement Activities Inventory for stakeholders would apply one or more
individual MIPS eligible clinicians and MIPS. In addition, through of the following criteria when
groups, in order to achieve one-half of subregulatory guidance we provided an
submitting improvement activities in

the highest score, one medium-weighted informal process for submitting new response to the Annual Call for
improvement activity is required. We improvement activities for potential Activities:
are not proposing any changes to the inclusion in the comprehensive Relevance to an existing
application of improvement activities to Improvement Activities Inventory for improvement activities subcategory (or a
non-patient facing individual MIPS the Quality Payment Program Year 2. proposed new subcategory);
eligible clinicians and groups for the During this transition period we Importance of an activity toward
improvement activities performance received input from various MIPS achieving improved beneficiary health
category in this proposed rule. eligible clinicians and organizations outcome;
Importance of an activity that could Annual Call for Activities submissions the advancing care information
lead to improvement in practice to by March 1 before the applicable performance category measures and
reduce health care disparities; performance period, which will enable allow MIPS eligible clinicians to earn
Aligned with patient-centered us to propose the new improvement credit in the improvement activities
medical homes; activities for adoption in the same years performance category, while receiving a
Activities that may be considered rulemaking cycle for implementation in bonus in the advancing care information
for an advancing care information the following year. For example, an performance category as well. We are
bonus; improvement activity submitted prior to seeking suggestions on how a health IT
Representative of activities that March 1, 2018, would be considered for subcategory within the improvement
multiple individual MIPS eligible performance periods occurring in 2019. activities performance category could be
clinicians or groups could perform (for In addition, we propose that we will structured to afford MIPS eligible
example, primary care, specialty care); add new improvement activities to the clinicians with flexible opportunities to
Feasible to implement, recognizing inventory through notice-and-comment gain experience in using CEHRT and
importance in minimizing burden, rulemaking. In future years we other health IT to improve their
especially for small practices, practices anticipate developing a process and practice. Should the current policies
in rural areas, or in areas designated as establishing criteria for identifying where improvement activities earn
geographic HPSAs by HRSA; activities for removal from the bonus points within the advancing care
Evidence supports that an activity Improvement Activities Inventory information performance category be
has a high probability of contributing to through the Annual Call for Activities enhanced? Are there additional policies
improved beneficiary health outcomes; process. We are requesting comments on that should be explored in future
or what criteria should be used to identify rulemaking? We welcome public
CMS is able to validate the activity. improvement activities for removal from comment on this potential health IT
We note that in future rulemaking, the Improvement Activities Inventory. subcategory.
activities that overlap with other
performance categories may be included (8) Approach for Adding New (9) CMS Study on Burdens Associated
if such activities support the key goals Subcategories With Reporting Quality Measures
of the program. In the CY 2017 Quality Payment In the CY 2017 Quality Payment
We request comments on this Program final rule (81 FR 77197), we Program final rule (81 FR 77195), we
proposal. finalized the following criteria for finalized specifics regarding the CMS
(c) Submission Timeline for Nominating adding a new subcategory to the Study on Improvement Activities and
New Improvement Activities for the improvement activities performance Measurement including the study
Annual Call for Activities category: purpose, study participation credit and
The new subcategory represents an requirements, and the study procedure.
It is our intention that the nomination area that could highlight improved We are modifying the name of the study
and acceptance process will, to the best beneficiary health outcomes, patient in this proposed rule to the CMS study
extent possible, parallel the Annual Call engagement and safety based on on burdens associated with reporting
for Measures process already conducted evidence. quality measures to more accurately
for MIPS quality measures. Aligned The new subcategory has a reflect the purpose of the study. The
with this approach, we propose to designated number of activities that study assesses clinician burden and data
accept submissions for prospective meet the criteria for an improvement submission errors associated with the
improvement activities at any time activity and cannot be classified under collection and submission of clinician
during the performance period for the the existing subcategories. quality measures for MIPS, enrolling
Annual Call for Activities and create an Newly identified subcategories groups of different sizes and individuals
Improvement Activities under Review would contribute to improvement in in both rural and non-rural settings and
(IAUR) list. This list will be considered patient care practices or improvement in also different specialties. We also noted
by us and may include federal partners performance on quality measures and that study participants would receive
in collaboration with stakeholders. The cost performance categories. full credit in the improvement activities
IAUR list will be analyzed with We are not proposing any changes to performance category after successfully
consideration of the proposed criteria the approach for adding new electing, participating, and submitting
for inclusion of improvement activities subcategories for the improvement data to the study coordinators at CMS
in the Improvement Activities activities performance category in this for the full calendar year (81 FR 77196).
Inventory. In addition, we propose that proposed rule. However, we are We requested comment on the study,
for the Annual Call for Activities, only proposing that in future years of the and received generally supportive
activities submitted by March 1 would Quality Payment Program we will add feedback for the study.
be considered for inclusion in the new improvement activities We are not proposing any changes to
Improvement Activities Inventory for subcategories through notice-and- the study purpose. We are proposing
the performance periods occurring in comment rulemaking. In addition, we changes to the study participation credit
the following calendar year. This are seeking comments on new and requirements sample size, how the
proposal is slightly different than the improvement activities subcategories. study sample is categorized into groups,
Call for Measures timeline. The Annual A number of stakeholders have and the frequency of quality data
Call for Measures requires a 2-year suggested that a separate subcategory for submission, focus groups, and surveys.
implementation timeline because the improvement activities specifically In addition to performing descriptive
measures being considered for inclusion related to health IT would make it easier statistics to compare the trends in errors
in MIPS undergo the pre-rulemaking for MIPS eligible clinicians and vendors and burden between study years 2017
process with review by the Measures to understand and earn points toward and 2018, we would like to perform a
Application Partnership (MAP). We are their final score through the use of more rigorous statistical analysis with
not proposing that improvement health IT. Such a health IT subcategory the 2018 data, which will require a
activities undergo MAP review. could include only improvement larger sample size. We propose this
Therefore, our intention is to close the activities that are specifically related to increase in the sample size for 2018 to
provide the minimum sample needed to Up to 10 non-MIPS eligible of the Paperwork Reduction Act of 1995
get a significant result with adequate clinicians reporting as a group or (5 CFR 1320), the associated burden is
power for the following investigation. individual (any number of individuals exempt from application of the
Specifically, we are interested in and any group size). Paperwork Reduction Act. Specifically,
whether there are any significant In addition, we are proposing changes section 1848(s)(7) of the Act, as added
differences in quality measurement data to the study procedures. In the by section 102 of the MACRA (Pub. L.
submission errors and/or clinician transition year of MIPS, study 11410) states that Chapter 35 of title
burdens between rural clinicians participants were required to attend a 44, United States Code, shall not apply
submitting either individually or as a monthly focus group to share lessons to the collection of information for the
group, and urban clinicians submitting learned in submitting quality data along development of quality measures. Our
as an individual or as a group. A with providing survey feedback to goals for new measures are to develop
statistical power analysis was performed monitor effectiveness. However, an new high quality, low cost measures
and a total sample size of 118 will be individual MIPS eligible clinician or that are meaningful, easily
adequate for the main objective of the group who chooses to report all 6 understandable and operable, and also,
study. However, allowance will be made measures within a period of 90 days reliably and validly measure what they
to account for attrition and other may not need to be a part of all of the purport. This study shall inform us (and
additional (or secondary) analysis. focus groups and survey sessions after our contractors) on the root causes of
This analysis would be compared at their first focus group and survey clinicians performance measure data
different sizes of practices (<3 eligible following the measurement data collection and data submission burdens
clinicians, between 38 eligible submission. This is because they may and challenges that hinders accurate
clinicians, etc.). This assessment is have nothing new to contribute in terms and timely quality measurement
important since it facilitates tracing the of discussion of errors or clinician activities. In addition, this study will
root causes of measurement burdens burdens. This also applies to MIPS inform us on the characteristic attributes
and data submission errors that may be eligible clinicians that submit only three that our new measures must possess to
associated with any sub-group of MIPS measures within the performance be able to accurately capture and
clinician practice. This comparison may period, if they submitted all three measure the priorities and gaps MACRA
further break the sample down into measures within the 90-day period or at aims for, as described in the Quality
more than four categories and a much one submission. All study participants Measures Development Plan.2 This
larger sample size is a requisite for would participate in surveys and focus study, therefore, serves as the initial
significant results with adequate group meetings at least once after each stage of developing new measures and
probability of certainty. measures data submission. For those also adapting existing measures. We
The sample size for performance who elect to report data for a 90-day believe that understanding clinicians
periods occurring in 2017 consisted of period, we would make further challenges and skepticisms, and
42 MIPS groups as stated by MIPS engagement optional. Therefore, we are especially, understanding the factors
criteria from the following seven proposing that for Quality Payment that undermine the optimal functioning
categories: Program Year 2 and future years that and effectiveness of quality measures
10 urban individual or groups of <3 study participants would be required to are requisites of developing measures
eligible clinicians. attend as frequently as four monthly that are not only measuring what it
10 rural individual or groups of <3 surveys and focus group sessions purports but also that are user friendly
eligible clinicians. throughout the year, but certain study and understandable for frontline
10 groups of 38 eligible clinicians. participants would be able to attend less cliniciansour main stakeholders in
5 groups of 820 eligible clinicians. frequently. measure development. This will lead to
3 groups of 20100 eligible Further, the CY 2017 study requires the creation of practice-derived, tested
clinicians. study measurement data to be collected measures that reduces burden and
2 groups of 100 or greater eligible at baseline and at every 3 months create a culture of continuous
clinicians. (quarterly basis) afterwards for the improvement in measure development.
2 specialty groups. duration of the calendar year. It also We request comments on our study on
We are proposing to increase the calls for a minimum requirement of burdens associated with reporting
sample size for the performance periods three MIPS quality measures four times quality measures proposals regarding
occurring in 2018 to a minimum of: within the year. We believe this is sample size for the performance periods
20 urban individual or groups of <3 inconsistent with clinicians reporting a occurring in 2018, study procedures for
eligible clinicians(broken down into full years data as we believe some study the performance periods occurring in
10 individuals & 10 groups). participants may choose to submit data 2018 and future years, and data
20 rural individual or groups of <3 for all measures at one time, or submissions for the performance
eligible clinicians(broken down into alternatively, may choose to submit data periods occurring in 2018 and future
10 individuals & 10 groups). up to six times during the 1-year period. years.
10 groups of 38 eligible clinicians. We are proposing for the Quality
10 groups of 820 eligible Payment Program Year 2 and future f. Advancing Care Information
clinicians. years to offer study participants Performance Category
10 groups of 20100 eligible flexibility in their submissions so that (1) Background
they could submit once, as can occur in
clinicians.
10 groups of 100 or greater eligible the MIPS program, and participate in Section 1848(q)(2)(A) of the Act
clinicians. study surveys and focus groups while includes the meaningful use of CEHRT
6 groups of >20 eligible clinicians still earning improvement activities as a performance category under the
reporting as individuals(broken down credit. MIPS. We refer to this performance
into 3 urban & 3 rural). It must be noted that although the 2 https://www.cms.gov/Medicare/Quality-
6 specialty groups(broken down aforementioned activities constitute an Initiatives-Patient-Assessment-Instruments/Value-
into 3 reporting individually & 3 information collection request as Based-Programs/MACRA-MIPS-and-APMs/Final-
reporting as a group). defined in the implementing regulations MDP.pdf (assessed: 06/02/2017).
category as the advancing care fulfills the Immunization Registry performance score. We are not
information performance category, and Reporting Measure, the MIPS eligible proposing to change the maximum
it is reported by MIPS eligible clinicians clinician would earn 10 percentage performance score that a MIPS eligible
as part of the overall MIPS program. As points in the performance score. If a clinician can earn; it remains at 90
required by sections 1848(q)(2) and (5) MIPS eligible clinician cannot fulfill the percent.
of the Act, the four performance Immunization Registry Reporting We are inviting public comment on
categories of the MIPS shall be used in Measure, we are proposing that the these proposals.
determining the MIPS final score for MIPS eligible clinician could earn 5 (c) Bonus Score
each MIPS eligible clinician. In general, percentage points in the performance
MIPS eligible clinicians will be score for each public health agency or In the CY 2017 Quality Payment
evaluated under all four of the MIPS clinical data registry to which the Program final rule (81 FR 77220 through
performance categories, including the clinician reports for the following 77226), for the Public Health and
advancing care information performance measures, up to a maximum of 10 Clinical Data Registry Reporting
category. percentage points: Syndromic objective and the Public Health
Surveillance Reporting; Electronic Case Reporting objective, we finalized that
(2) Scoring MIPS eligible clinicians who report to
Reporting; Public Health Registry
Section 1848(q)(5)(E)(i)(IV) of the Act Reporting; and Clinical Data Registry one or more public health agencies or
states that 25 percent of the MIPS final Reporting. A MIPS eligible clinician clinical data registries beyond the
score shall be based on performance for who chooses to report to more than one Immunization Registry Reporting
the advancing care information public health agency or clinical data Measure will earn a bonus score of 5
performance category. We established at registry may receive credit in the percentage points in the advancing care
414.1380(b)(4) that the score for the performance score for the submission to information performance category. (In
advancing care information performance more than one agency or registry; section II.C.6.f.(6)(b) of this proposed
category would be comprised of a base however, the MIPS eligible clinician rule, we are proposing to allow MIPS
score, performance score, and potential would not earn more than a total of 10 eligible clinicians to report using the
bonus points for reporting on certain percentage points for such reporting. 2018 Advancing Care Information
measures and activities. For further We further propose similar flexibility Transition Objectives and Measures in
explanation of our scoring policies for for MIPS eligible clinicians who choose 2018.) Based on our proposals above to
the advancing care information to report the measures specified for the allow MIPS eligible clinicians who
performance category, we refer readers Public Health Reporting Objective of the cannot fulfill the Immunization Registry
to 81 FR 7721677227. 2018 Advancing Care Information Reporting Measure to earn additional
Transition Objective and Measure set. points in the performance score, we
(a) Base Score believe we should modify this policy so
(In section II.C.6.f.(6)(b) of this proposed
For the CY 2018 performance period, rule, we are proposing to allow MIPS that MIPS eligible clinicians cannot earn
we are not proposing any changes to the eligible clinicians to report using the points in both the performance score
base score methodology as established 2018 Advancing Care Information and bonus score for reporting to the
in the CY 2017 Quality Payment Transition Objectives and Measures in same public health agency or clinical
Program final rule (81 FR 7721777223). 2018.) We propose if a MIPS eligible data registry. We are proposing to
We established the policy that MIPS clinician fulfills the Immunization modify our policy beginning with the
eligible clinicians must report a Registry Reporting Measure, the MIPS performance period in CY 2018. We are
numerator of at least one for the eligible clinician would earn 10 proposing that a MIPS eligible clinician
numerator/denominator measures, or a percentage points in the performance may only earn the bonus score of 5
yes response for the yes/no measure score. If a MIPS eligible clinician cannot percentage points for reporting to at
in order to earn the 50 percentage points fulfill the Immunization Registry least one additional public health
in the base score. In addition, if the base Reporting Measure, we are proposing agency or clinical data registry that is
score requirements are not met, a MIPS that the MIPS eligible clinician could different from the agency/agencies or
eligible clinician would receive a score earn 5 percentage points in the registry/or registries to which the MIPS
of zero for the ACI performance performance score for each public eligible clinician reports to earn a
category. health agency or specialized registry to performance score. For example, if a
which the clinician reports for the MIPS eligible clinician reports to a
(b) Performance Score public health agency and a clinical data
following measures, up to a maximum
In the CY 2017 Quality Payment of 10 percentage points: Syndromic registry for the performance score, they
Program final rule (81 FR 77223 through Surveillance Reporting; Specialized could earn the bonus score of 5
77226), we finalized that MIPS eligible Registry Reporting. A MIPS eligible percentage points by reporting to a
clinicians can earn 10 percentage points clinician who chooses to report to more different agency or registry that the
in the performance score for meeting the than one specialized registry or public clinician did not identify for purposes
Immunization Registry Reporting health agency to submit syndromic of the performance score. A MIPS
Measure. We believe we should modify surveillance data may earn 5 percentage eligible clinician would not receive
this policy because we have learned that points in the performance score for credit under both the performance score
there are areas of the country where reporting to each one, up to a maximum and bonus score for reporting to the
immunization registries are not same agency or registry.
of 10 percentage points.
available, and we did not intend to By proposing to expand the options We are proposing that for the
disadvantage MIPS eligible clinicians for fulfilling the Public Health and Advancing Care Information Objectives
practicing in those areas. Thus, we are Clinical Data Registry Reporting and the and Measures, a bonus of 5 percentage
proposing to modify the scoring of the Public Health Reporting objectives, we points would be awarded if the MIPS
Public Health and Clinical Data Registry believe that we are adding flexibility so eligible clinician reports yes for any
Reporting objective beginning with the that additional MIPS eligible clinicians one of the following measures
performance period in CY 2018. We can successfully fulfill this objective associated with the Public Health and
propose if a MIPS eligible clinician and earn 10 percentage points in the Clinical Data Registry Reporting
objective: Syndromic Surveillance discussed the need to move toward CY 2018 performance period by
Reporting; Electronic Case Reporting; measurement of health IT use with identifying additional improvement
Public Health Registry Reporting; or respect to its contribution to effective activities in Table 6 that would be
Clinical Data Registry Reporting. We are care coordination and improving eligible for the advancing care
proposing that for the 2018 Advancing outcomes for patients. We stated that information performance category bonus
Care Information Transition Objectives this approach would allow us to more score if they are completed using
and Measures, a bonus of 5 percent directly link health IT adoption and use CEHRT functionality. The activities
would be awarded if the MIPS eligible to patient outcomes, moving MIPS eligible for the bonus score would
clinician reports yes for any one of beyond the measurement of EHR include those listed in Table 6, as well
the following measures associated with adoption and process measurement and as those listed in Table 8 in last years
the Public Health Reporting objective: into a more patient-focused health IT final rule. We refer readers to the
Syndromic Surveillance Reporting or program. Toward that end, we adopted Improvement Activities section of this
Specialized Registry Reporting. We are a policy to award a bonus score to MIPS proposed rule (section II.C.6.e. of this
proposing that to earn the bonus score, eligible clinicians who use CEHRT to proposed rule) for a discussion of the
the MIPS eligible clinician must be in complete certain activities in the proposed new improvement activities
active engagement with one or more improvement activities performance and proposed changes to the
additional public health agencies or category based on our belief that the use improvement activities for 2018.
clinical data registries that is/are of CEHRT in carrying out these Ten percentage points is the
different from the agency or registry that activities could further the outcomes of maximum bonus a MIPS eligible
they identified to earn a performance clinical practice improvement. clinician would receive if they attest to
score. We adopted a final policy to award a using CEHRT for one or more of the
We are inviting public comment on 10 percent bonus for the advancing care activities we have identified as eligible
this proposal. information performance category if a for the bonus. This bonus is intended to
MIPS eligible clinician attests to support progression toward holistic
(d) Improvement Activities Bonus Score completing at least one of the health IT use and measurement;
Under the Advancing Care Information improvement activities we have attesting to even one improvement
Performance Category specified using CEHRT (81 FR 77209). activity demonstrates that the MIPS
In the CY 2017 Quality Payment We refer readers to Table 8 in the CY eligible clinician is working toward this
Program final rule (81 FR 77202), we 2017 Quality Payment Program final holistic approach to the use of their
discussed our approach to the rule (81 FR 7720277209) for a list of CEHRT. The weight of the improvement
measurement of the use of health IT to the improvement activities eligible for activity for the improvement activities
allow MIPS eligible clinicians and the advancing care information performance category has no effect on
groups the flexibility to implement performance category bonus. In this the bonus awarded in the advancing
health IT in a way that supports their proposed rule, we are proposing to care information performance category.
clinical needs. In addition, we expand this policy beginning with the We invite comment on this proposal.
TABLE 6: Proposed New Improvement Activities Eligible for the Advancing Care
Information Performance Category Bonus Beginning with
the 2018 Performance Period
"0'-g
A MIPS eligible clinician providing unscheduled care (such
~ ;; as an emergency room, urgent care, or other unplanned Secure
(\)
.g
u
!S
~~
~ ~
(\)
~ P-l
- 1::
encounter) attests that, for greater than 75 percent of case
visits that result from a clinically significant adverse drug
Messaging
~ ...... ~ 01l (\) event, the MIPS eligible clinician transmits information, Send A
~
"0
~
~ gJ
a ~=&l
4-< .....
oOc....,
~ (\) 0
including through the use of health IT to the patient's
primary care clinician regarding both the unscheduled visit
s
.;:1
"0
Summary of
Care
l!l (\) (\)
~ ~
0
~ (\) ~ and the nature of the adverse drug event within 48 hours. A ::;s
s13-6~
Vl~
clinically significant adverse event is defined as a
1:: ~ z
medication-related harm or injury such as side-effects, Request/Accep
~ t8
(\)
-~
~ ......
.....
supratherapeutic effects, allergic reactions, laboratory t Summary of
0 c;j
u::; abnormalities, or medication errors requiring Care
urgent/emergent evaluation, treatment, or hospitalization.
A MIPS eligible clinician would attest that they are
consulting specified applicable appropriate use criteria
(\)
u
~
a a~ .s~
c;3
;.::::; "0
01l
(AUC) through a qualified clinical decision support
mechanism for all advanced diagnostic imaging services
~ u
bJ) ~ -~
b s ordered. This activity is for clinicians that are early
~ ...... ~ - u Clinical
~ cn= ~ ~ -~
"0
~
_cgJ
a u
~~~
;$
rJJ
0
adopters of the Medicare AUC program (e.g., 2018
performance year) and for clinicians that begin the program ~
01l
Decision
Support
~ ~ ~ 0
:;a "'
in future years as will be required by CFR 414.94 ::a (CEHRT
Vl~ gjli;l"C (authorized by the Protecting Access to Medicare Act of
function only)
1:: E ~ 8 2014). Qualified mechanisms will be able to provide a
(\)
~ =.;2 ~
~ .;!l
report to the ordering clinician that can be used to assess
"'
~ 0 u "0
""
patterns of image-ordering and improve upon those patterns
u~"' to ensure that patients are receiving the most appropriate
ima in for their individual condition.
Patient-
1::
a
(\)
01l
s
gjl
(\)
For at-risk outpatient Medicare beneficiaries, individual
MIPS eligible clinicians and groups must attest to
Specific
Education
implementation of systematic preventive approaches in s
~
~ -~
"'
clinical practice for at least 75 percent of medical records .;:1 Patient
::;s u ;:::; "0
:::: with documentation of screening patients for abnormal (\) Generated
0 a~ ::;s
~ (\)
u
blood glucose according to current U.S. Preventive Services Health Data or
~ "' ~ Task Force (USPSTF) and/or Americans Diabetes Data from
0..
0 ~ Association (ADA) guidelines. Non-clinical
~
Settin s
Patient-
1::
a
(\)
s
gjl For at-risk outpatient Medicare beneficiaries, individual
MIPS eligible clinicians and groups must attest to
Specific
Education
~ ~ "'(\) implementation of systematic preventive approaches in
~
(\)
::;s ~ .~ clinical practice for at least 75 percent of medical records Patient

.~ ;:::; with documentation of referring eligible patients with Generated
:::: sQ)Vl(\) (\)
::;s
.;2 prediabetes to a CDC-recognized diabetes prevention Health Data or

~ u
~ ~ program operating under the framework of the National Data from
0.. ~
0 Diabetes Prevention Program. Non-clinical
~
Settin s
EP30JN17.000</GPH>
Engaging connnunity health workers to provide a

-s a0 comprehensive link to connnunity resources through
Provide Patient
a
<l)

a
family-based services focusing on success in health,
Access
education, and self-sufficiency. This activity supports
~
i 8'Cll
C'j
<ao..:.::0:::
individual MIPS eligible clinicians or groups that coordinate
with primary care and other clinicians, engage and support
."d
Patient-
Specific
.:: a :: v Education
0
~ o..J patients, use of health infonnation teclmology, and employ
quality measurement and improvement processes. An
~
Patient-
~ <l)
0.. :-s! example of this connnunity based program is the NCQA
0 :> Generated
iJ... 8 Patient-Centered Connected Care (PCCC) Recognition
iJ... Health Data
Program or other such programs that meet these criteria.
Implementation of practices/processes to develop advance

-s
<l)
gp care planning that includes: documenting the advance care
a<l)
" plan or living will within the medical record, educating
Patient-
Generated
Cl)
~ "'
15:: clinicians about advance care planning motivating them to a Health Data
"'
~
~ address advance care planning needs of their patients, and ;:::l
;a
.:: u"' how these needs can translate into quality improvement, v
.s <l)
educating clinicians on approaches and barriers to talking to ~ Patient
g
~0.. .;"' patients about end-of-life and palliative care needs and ways
Specific
Education
0
~ to manage its documentation, as well as informing clinicians
iJ...
of the healthcare policy side of advance care planning.
Public Health
.e -s~
' CJJ
Promote use of patient-reported outcome tools
Registry
&
~
~
<l)
.8
0
Demonstrate performance of activities for employing
Reporting
~
.=: o..a0
"'
......
<l)
patient-reported outcome (PRO) tools and corresponding
Clinical Data
~
"'
<l)
::r::
0
<l)-<;::;
0 collection of PRO data (e.g., use of PQH -2 or PHQ-9 and Cl)
Registry
gp
CJJ
;:::l
,..
0 PROMIS instruments) such as patient reported Wound :E Reporting
V"d
...... <l) Quality of Life (QoL), patient reported Wound Outcome,
~
:.a a t::o0..
0
8
and patient reported Nutritional Screening.
Patient-
0
~
iJ... ~ Generated
Health Data
-s <l)
Develop pathways to neighborhood/community-based
~
<l)
resources to support patient health goals that could include
~"'
Cl)IJ...
one or more of the following: Send a
.:: t::
~ Summary of
.:: ~ ::
0
Maintain formal (referral) links to community- Care
0
~ -saCJJ based chronic disease self-management support
~ ~oc;
.:: ...... 0 programs, exercise programs and other wellness a Request/Accep
~0 ae'j~ resources with the potential for bidirectional flow
;:::l
;a t Summary of
0 v~.S v
u 6o"Ca of information; ~ Care
..... "' <l)
~ S'~ ::r:: Including through the use of tools that facilitate

u Patient-
~0 electronic connnunication between settings;
~a Generated
Screen patients for health-harming legal needs;

~~
Health Data
and/or
0
u Provide a guide to available connnunity resources.
EP30JN17.001</GPH>
.:: Send a
.9 The primary care and behavioral health practices use the Summary of
ctl Care
.:: same electronic health record system for shared patients or
~0 have an established bidirectional flow of primary care and
0 Request/Accep
u behavioral health records.
t Summary of
~ Care
u
Participation in a Perioperative Surgical Home (PSH) that

provides a patient-centered, physician-led, interdisciplinary,
and team-based system of coordinated patient care, which
coordinates care from pre-procedure assessment through the Send a
acute care episode, recovery, and post-acute care. This Summary of
activity allows for reporting of strategies and processes Care
.::0 related to care coordination of patients receiving surgical or
.::0 .p Request/Accep
.p ~ procedural care within a PSH. The clinician must perform
t Summary of
~ ~0 one or more of the following care coordination activities:
Care
~0 Coordinate with care managers/navigators in
0
u0 preoperative clinic to plan and implementation
u ~
ro
Clinical
u comprehensive post discharge plan of care;
~ Deploy perioperative clinic and care processes to
Information
u ::r::
rJl
Reconciliation
p., reduce post-operative visits to emergency rooms;
Implement evidence-informed practices and Health
standardize care across the entire spectrum of Information
surgical patients; or Exchange
Implement processes to ensure effective
communications and education of patients' post-
dischar e instructions.
EP30JN17.002</GPH>
(3) Performance Periods for the and 2018), we will accept a minimum (4) Certification Requirements
Advancing Care Information of 90 consecutive days of data and
Performance Category encourage MIPS eligible clinicians to In the CY 2017 Quality Payment
Program final rule (81 FR 77211 through
report data for the full year performance
In the CY 2017 Quality Payment 77213), we outlined the requirements
period. We are maintaining this policy
Program final rule (81 FR 77210 through for MIPS eligible clinicians using
as finalized for the performance period
77211), we established a performance CEHRT during the CY 2017 performance
in CY 2018, and will accept a minimum period for the advancing care
period for the advancing care
of 90 consecutive days of data in CY information performance category as it
information performance category to
2018. We are proposing the same policy relates to the objectives and measures
align with the overall MIPS performance
period of one full year to ensure all four for the advancing care information they select to report, and also outlined
performance categories are measured performance category for the requirements for the CY 2018
and scored based on the same period of performance period in CY 2019, Quality performance period. We additionally
time. We believe this will lower Payment Program Year 3, and would adopted a definition of CEHRT at
reporting burden, focus clinician quality accept a minimum of 90 consecutive 414.1305 for MIPS eligible clinicians
improvement efforts and align days of data in CY 2019. We refer that is based on the definition that
administrative actions so that MIPS readers to section II.C.5. in this applies in the EHR Incentive Programs
eligible clinicians can use common proposed rule for additional information under 495.4.
systems and reporting pathways. We on the MIPS performance period. For the CY 2017 performance period,
stated for the first and second we adopted a policy by which MIPS
performance periods of MIPS (CYs 2017 eligible clinicians may use EHR
EP30JN17.003</GPH>
technology certified to either the 2014 percent of eligible clinicians and 80 be ready to participate in MIPS using
or 2015 Edition certification criteria, or percent of eligible hospitals have 2015 2015 Edition certified EHR technologies
a combination of the two. For the CY Edition certified EHR technology by January 1, 2018.
2018 performance period, we previously available based on previous EHR However, subsequent to the
stated that MIPS eligible clinicians must Incentive Programs attestation data. preliminary analysis, ONC has
use EHR technology certified to the Based on these data, and as compared continued to monitor readiness and to
2015 Edition to meet the objectives and to the transition from 2011 Edition to receive feedback from stakeholders on
measures specified for the advancing 2014 Edition, it appears that the factors influencing variations in the
care information performance category. transition from the 2014 Edition to the development and implementation
We received significant comments 2015 Edition is on schedule for the CY timelines for developers supporting
and feedback from stakeholders 2018 performance period. different segments of the market, as well
requesting that we extend the use of However, the analysis also considered as the relationship between the
2014 Edition CEHRT beyond CY 2017 market trends such as consolidation and developer readiness timeline and
into CY 2018 and even CY 2019. Many the number of large and small participant readiness. This continuing
commenters noted the lack of products developers covering various groups of analysis supports a potential need for a
certified to the 2015 Edition. Others participants and the potential impact on longer implementation timeline for
stated that switching from the 2014 readiness. The eligible hospital market MIPS eligible clinicians. Stakeholder
Edition to the 2015 Edition requires a is fairly concentrated, with nearly 98 feedback suggests that while the
large amount of time and planning and percent of eligible hospital EHR estimate for known readiness remains
if it is rushed there is a potential risk to Incentive Program participants using the same, readiness among the
patient health. Some commenters noted health IT from the top ten developers remaining MIPS eligible clinicians may
the significant burden of combining (ranked by market share) with a not be on the same timeline. About one
outputs from multiple CEHRTs. A few significant majority of that coverage by quarter of eligible professional EHR
mentioned that the cost to switch to the the top five developers. For hospitals, Incentive Program participants in prior
2015 Edition is prohibitive for smaller some developers representing a smaller years used certified health IT from small
practices. market share also have certified health developers that each has an historical
Our experience with the transition IT already available and are not market share of 1 percent or less.
from EHR technology certified to the expected to have a release schedule Therefore, MIPS eligible clinicians will
2011 Edition to EHR technology much different from their larger need a significant number of smaller
certified to the 2014 Edition did make competitors. Considering market factors developers to reach the same readiness
us aware of the many issues associated and using previous EHR Incentive on the same timeline as larger
with the adoption of EHR technology Programs attestation data, ONC companies in order to support program
certified to a new Edition. These estimates that at least 85 percent of participants seeking to upgrade to the
include the time that will be necessary eligible hospitals would have EHR 2015 Edition. However, small
to effectively deploy EHR technology technology certified to the 2015 Edition developers generally offer a limited
certified to the 2015 Edition standards available for use by the end of CY 2017 number or type of products, and may
and certification criteria and to make for program participation in 2018. In the have more limited resources to dedicate
the necessary patient safety, staff FY 2018 IPPS/LTCH PPS proposed rule to upgrade development, testing and
training, and workflow investments to (82 FR 20136), we proposed to shorten certification, and implementation,
be prepared to report for the advancing the EHR reporting period to a minimum which may affect availability and
care information performance category of any continuous 90-day period within timing. In addition, the same factors
for 2018. We understand and appreciate CY 2018 for eligible hospitals and may impact the capacity of some
these concerns, and are working in CAHs, as well as EPs who attest for a developers to support participants
collaboration with our federal partners states Medicaid EHR Incentive during the process and therefore the
at the Office of the National Coordinator Program, to allow additional time for timeline for participant readiness would
for Health Information Technology successful implementation of EHR also potentially be longer. This is
(ONC) to monitor progress on the 2015 technology certified to the 2015 Edition supported by historical analysis as a
Edition upgrade. in CY 2018. smaller percentage of eligible
As noted in the FY 2018 Inpatient For MIPS eligible clinicians, the professionals used 2014 Edition
Prospective Payment Systems for Acute concern of potential impact on certified EHR technology for
Care Hospitals and the Long-Term Care participation readiness when reviewing participation in the EHR Incentive
Hospital Prospective Payment System these market factors may be more Programs during the 2014 calendar year
proposed rule (referred to as the FY significant. As noted in the FY 2018 than eligible hospitals and CAHs for the
2018 IPPS/LTCH PPS proposed rule) (82 IPPS/LTCH PPS proposed rule (82 FR same year. For this reason, we believe
FR 20136), ONC is working with health 20136), historical data indicates eligible additional flexibility for MIPS eligible
IT developers to analyze and monitor professionals were more likely to use a clinicians is essential to support
the status of developer readiness for wider range of certified health IT, successful participation in the
2015 Edition technology. As part of including those which individually advancing care information performance
these analyses, ONC also reviewed make up a smaller segment of the category.
health IT being certified to 2015 Edition overall market. Therefore, when market We continue to believe that there are
by health IT developers who have factors are taken into account, there many benefits for switching to EHR
products that were certified for the 2014 exists a larger proportion of readiness technology certified to the 2015 Edition.
Edition and were used by EHR Incentive that is unknown due to the wider range As noted in the FY 2018 IPPS/LTCH
Program participants to attest. This of certified health IT which may be used PPS proposed rule (82 FR 20136), the
analysis compared the pace of 2014 by MIPS eligible clinicians. This 2015 Edition health IT certification
Edition certification with the pace of necessitated a more conservative criteria enables health information
2015 Edition certification to date. As of approach for MIPS eligible clinician exchange through new and enhanced
the beginning of the second quarter of readiness. That estimate is that 74 certification criteria standards, and
CY 2017, ONC confirmed that at least 53 percent of MIPS eligible clinicians will through implementation specifications
for interoperability. The 2015 Edition the performance period in CY 2018 performance category. Further, section
also incorporates changes that are using only 2015 Edition CEHRT. We are 1848(q)(5)(E)(ii) of the Act, provides that
designed to spur innovation and proposing to amend in any year in which the Secretary
provide more choices to health care 414.1380(b)(4)C)(3) to reflect this estimates that the proportion of eligible
providers and patients for the exchange change. We are proposing this one-time professionals (as defined in section
of electronic health information, bonus for CY 2018 to support and 1848(o)(5) of the Act) who are
including new Application recognize MIPS eligible clinicians and meaningful EHR users (as determined
Programming Interface (API) groups that invest in implementing under section 1848(o)(2) of the Act) is
certification criteria. APIs are required certified EHR technology in their 75 percent or greater, the Secretary may
for patient engagement measures within practice. Specifically, we intend this reduce the applicable percentage weight
the advancing care information bonus to support new participants that of the advancing care information
category; however, they may also be may be adopting health IT for the first performance category in the MIPS final
enabled by a health care provider or time in CY 2018 and do not have 2014 score, but not below 15 percent, and
organization for their own use of third Edition technology available to use or increase the weightings of the other
party applications with their CEHRT, that may have no prior experience with performance categories such that the
such as for quality improvement. An meaningful use objectives and total percentage points of the increase
API can also be enabled by a health care measures. We believe this bonus will
equals the total percentage points of the
provider to give patients access to their help recognize their investment to adopt
reduction. We note that section
health information through a third-party health IT and support their participation
1848(o)(5) of the Act defines an eligible
application with more flexibility than is in the advancing care information
performance category in MIPS. In professional as a physician, as defined
often found in many current patient in section 1861(r) of the Act.
portals. From the MIPS eligible clinician addition, we believe this bonus will
perspective, an API could complement help to incentivize participants to In CY 2017 Quality Payment Program
a patient portal or could also potentially continue the process of upgrading from final rule (81 FR 7722677227), we
make one unnecessary if patients are 2014 Edition to 2015 Edition, especially established a final policy, for purposes
able to use software applications small practices where the investment in of applying section 1848(q)(5)(E)(ii) of
designed to interact with an API that updated workflows and implementation the Act, to estimate the proportion of
could support their ability to view, may present unique challenges. We physicians as defined in section 1861(r)
download, and transmit their health intend this bonus to support and of the Act who are meaningful EHR
information to a third party. In addition, recognize their efforts to engage with the users as those physician MIPS eligible
the 2015 Edition health IT transitions of advancing care information measures clinicians who earn an advancing care
care certification criterion rigorously using technology certified to the 2015 information performance category score
assesses a products ability to create and Edition, which include more robust of at least 75 percent for a performance
receive a Consolidated-Clinical measures using updated standards and period. We established that we will base
Document Architecture (CCDA) functions which support this estimation on data from the relevant
formatted documents. The ONC also interoperability. We seek comment on performance period, if we have
adopted certification criteria that both this proposed bonus. Specifically, we sufficient data available from that
support interoperability in other settings seek comment on if the percentage of period. For example, if feasible, we
and use cases, such as the Common the bonus is appropriate, or whether it would consider whether to reduce the
Clinical Data Set summary record, data should be limited to new participants in applicable percentage weight of the
segmentation for privacy, and care plan MIPS and small practices. advancing care information performance
certification criteria (80 FR 62603). This bonus is not available to MIPS category in the MIPS final score for the
eligible clinicians who use a 2019 MIPS payment year based on an
However, in light of the conservative combination of the 2014 and 2015
readiness estimates for MIPS eligible estimation using the data from the 2017
Editions. We note that with the addition performance period. We stated that we
clinicians, and in line with our of the 2015 Edition CEHRT bonus of 10
commitment to supporting small will not include in the estimation
percentage points, MIPS eligible physicians for whom the advancing care
practices, solo practitioners and clinicians would be able to earn a bonus
specialties which may be more likely to information performance category is
score of up to 25 percentage points in weighted at zero percent under section
use certified health IT offered by small CY 2018 under the advancing care
developers, we are proposing that MIPS 1848(q)(5)(F) of the Act, which we
information performance category, an
eligible clinicians may use EHR relied on in the CY 2017 Quality
increase from the 15 percentage point
technology certified to either the 2014 Payment Program final rule (81 FR
bonus score available in CY 2017.
or 2015 Edition certification criteria, or To facilitate readers in identifying the 77226 through 77227) to establish
a combination of the two for the CY requirements of CEHRT for the policies under which we would weigh
2018 performance period. We propose Advancing Care Information Objectives the advancing care information
to amend 414.1305 to reflect this and Measures, we are including Table 8 performance category at zero percent of
change. We further note, that to in section II.C.6.f.(6)(a) which lists the the final score. In addition, we are
encourage new participants to adopt 2015 Edition and 2014 Edition proposing not to include in the
certified health IT and to incentivize certification criteria required to meet the estimation physicians for whom the
participants to upgrade their technology advancing care information performance
objectives and measures.

to 2015 Edition products which better We invite comments on these category would be weighted at zero
support interoperability across the care proposals. percent under our proposal in section
continuum, we are proposing to offer a II.C.6.f.(7) of this proposed rule to
bonus of 10 percentage points under the (5) Scoring Methodology Considerations implement certain provisions of the 21st
advancing care information performance Section 1848(q)(5)(E)(i)(IV) of the Act Century Cures Act (that is, physicians
category for MIPS eligible clinicians states that 25 percent of the MIPS final who are determined hospital-based or
who report the Advancing Care score shall be based on performance for ambulatory surgical center-based, or
Information Objectives and Measures for the advancing care information who are granted an exception based on
significant hardship or decertified EHR payment year would be in mid-2018, as (6) Objectives and Measures
technology. the deadline for data submission is (a) Advancing Care Information
We are considering modifications to March 31, 2018. We are requesting Objectives and Measures Specifications
the policy we established in last years public comments on whether this
rulemaking to base our estimation of timeframe is sufficient, or whether a We are proposing to maintain for the
physicians who are meaningful EHR more extended timeframe would be CY 2018 performance period the
users for a MIPS payment year (for preferable. We are proposing to modify Advancing Care Information Objectives
example, 2019) on data from the our existing policy such that we would and Measures as finalized in the CY
relevant performance period (for base our estimation of physicians who 2017 Quality Payment Program final
example, 2017). We are concerned that rule (81 FR 77227 through 77229) with
are meaningful EHR users for a MIPS
if in future rulemaking we decide to the modifications proposed below. As
payment year on data from the
propose to change the weight of the we noted (81 FR 77227), these objectives
performance period that occurs four
advancing care information performance and measures were adapted from the
category based on our estimation, such years before the MIPS payment year. For Stage 3 objectives and measures
a change may cause confusion to MIPS example, we would use data from the finalized in the 2015 EHR Incentive
eligible clinicians who are adjusting to 2017 performance period to estimate the Programs final rule (80 FR 62829
the MIPS program and believe this proportion of physicians who are through 62871), however, we did not
performance category will make up 25 meaningful EHR users for purposes of maintain the previously established
percent of the final score for the 2019 reweighting the advancing care thresholds for MIPS. For a more detailed
MIPS payment year. The earliest we information performance category for discussion of the Stage 3 objectives and
would be able to make our estimation the 2021 MIPS payment year. measures, including explanatory
based on 2017 data and propose in We invite comments on this proposal. material and defined terms, we refer
future rulemaking to change the weight readers to the 2015 EHR Incentive
of the advancing care information Programs final rule (80 FR 62829
performance category for the 2019 MIPS through 62871).
TABLE 7: 2018 Performance Period Advancing Care Information Performance Category

Scoring Methodology
Advancing Care Information Objectives and Measures
.....
...t:eJJ=
= e~
~
0 =
Q.=
~0"'
~
Protect Patient Security Risk Analysis Required 0 Yes/No
Health Statement
Information
Electronic e-Prescribing Required 0 Numerator/
Prescribing Denominator
Patient Electronic Provide Patient Access Required Up to 10% Numerator/
Access Denominator
Patient-Specific Education Not Required Up to 10% Numerator/
Denominator
Coordination of View, Download, or Transmit Not Required Up to 10% Numerator/
Care Through (VDT) Denominator
Patient Secure Messaging Not Required Up to 10% Numerator/
Engagement Denominator
Patient-Generated Health Data Not Required Up to 10% Numerator/
Denominator
Health Send a Summary of Care Required Upto 10% Numerator/
Information Denominator
Exchange Request/Accept Summary of Required Up to 10% Numerator/
Care Denominator
Clinical Information Not Required Up to 10% Numerator/
Reconciliation Denominator
Public Health and Immunization Registry Reporting Not Required 0 or 10% Yes/No
Clinical Data Statement
Registry Syndromic Surveillance Not Required 0 or 5%* Yes/No
Reporting Reporting Statement
Electronic Case Reporting Not Required 0 or 5%* Yes/No
Statement
Public Health Registry Reporting Not Required 0 or 5%* Yes/No
Statement
Clinical Data Registry Reporting Not Required 0 or 5%* Yes/No
Statement
Bonus {up to 2~.% .. . . \ . ' . . . .. . /. . . ... .: . . ..
Report to one or more additional public health 5% bonus Yes/No
agencies or clinical data registries beyond those Statement
identified for the performance score
Report improvement activities using CEHRT 10% bonus Yes/No
Statement
Report using only 2015 Edition CEHRT 10% bonus Based upon
measures
submitted
* A MIPS eligible clinician who cannot fulfill the Immumzatwn Registry Reportmg Measure may earn 5% for each
public health agency or clinical data registry to which the clinician reports, up to a maximum of 10% under the
performance score.
EP30JN17.004</GPH>
Objective: Protect Patient Health Numerator: The number of patients used by applications chosen by the
Information. in the denominator (or patient patient and configured to the API in the
Objective: Protect electronic protected authorized representative) who are MIPS eligible clinicians CEHRT; or (3)
health information (ePHI) created or provided timely access to health a combination of (1) and (2). We are
maintained by the CEHRT through the information to view online, download, proposing this change because we
implementation of appropriate and transmit to a third party and to erroneously described the actions in the
technical, administrative, and physical access using an application of their measure (viewing, downloading or
safeguards. choice that is configured meet the transmitting; or accessing through an
Security Risk Analysis Measure: technical specifications of the API in the API) as being taken by the MIPS eligible
Conduct or review a security risk MIPS eligible clinicians CEHRT. clinician rather than the patient or the
analysis in accordance with the Definition of timelyBeginning with patient-authorized representatives. This
requirements in 45 CFR 164.308(a)(1), the 2018 performance period, we are change would align the measure
including addressing the security (to proposing to define timely as within description with the requirements of the
include encryption) of ePHI data created 4 business days of the information being numerator and denominator. We
or maintained by CEHRT in accordance available to the MIPS eligible clinician. propose this change would apply
with requirements in 45 CFR This definition of timely is the same as beginning with the performance period
164.312(a)(2)(iv) and 164.306(d)(3), we adopted under the EHR Incentive in 2017.
implement security updates as Programs (80 FR 62815). Denominator: Number of unique
necessary, and correct identified Patient-Specific Education Measure: patients seen by the MIPS eligible
security deficiencies as part of the MIPS The MIPS eligible clinician must use clinician during the performance
eligible clinicians risk management clinically relevant information from period.
process. CEHRT to identify patient-specific Numerator: The number of unique
Objective: Electronic Prescribing. educational resources and provide patients (or their authorized
Objective: Generate and transmit electronic access to those materials to at representatives) in the denominator who
permissible prescriptions electronically. least one unique patient seen by the have viewed online, downloaded, or
E-Prescribing Measure: At least one MIPS eligible clinician. transmitted to a third party the patients
permissible prescription written by the Denominator: The number of health information during the
MIPS eligible clinician is queried for a unique patients seen by the MIPS performance period and the number of
drug formulary and transmitted eligible clinician during the unique patients (or their authorized
electronically using CEHRT. performance period. representatives) in the denominator who
Denominator: Number of Numerator: The number of patients have accessed their health information
prescriptions written for drugs requiring in the denominator who were provided through the use of an API during the
a prescription to be dispensed other electronic access to patient-specific performance period.
than controlled substances during the educational resources using clinically Secure Messaging Measure: For at
performance period; or number of relevant information identified from least one unique patient seen by the
prescriptions written for drugs requiring CEHRT during the performance period. MIPS eligible clinician during the
a prescription to be dispensed during Objective: Coordination of Care performance period, a secure message
the performance period. Through Patient Engagement. was sent using the electronic messaging
Numerator: The number of Objective: Use CEHRT to engage with function of CEHRT to the patient (or the
prescriptions in the denominator patients or their authorized patient-authorized representative), or in
generated, queried for a drug formulary, representatives about the patients care. response to a secure message sent by the
and transmitted electronically using View, Download, Transmit (VDT) patient (or the patient-authorized
CEHRT. Measure: During the performance representative).
Objective: Patient Electronic Access. period, at least one unique patient (or Denominator: Number of unique
Objective: The MIPS eligible clinician patient-authorized representatives) seen patients seen by the MIPS eligible
provides patients (or patient-authorized by the MIPS eligible clinician actively clinician during the performance
representative) with timely electronic engages with the EHR made accessible period.
access to their health information and by the MIPS eligible clinician. A MIPS Numerator: The number of patients
patient-specific education. eligible clinician may meet the measure in the denominator for whom a secure
Provide Patient Access Measure: For by either (1) view, download or transmit electronic message is sent to the patient
at least one unique patient seen by the to a third party their health information; (or patient-authorized representative) or
MIPS eligible clinician: (1) The patient or (2) access their health information in response to a secure message sent by
(or the patient-authorized through the use of an API that can be the patient (or patient-authorized
representative) is provided timely used by applications chosen by the representative), during the performance
access to view online, download, and patient and configured to the API in the period.
transmit his or her health information; MIPS eligible clinicians CEHRT; or (3) Patient-Generated Health Data
and (2) The MIPS eligible clinician a combination of (1) and (2). Measure: Patient-generated health data
ensures the patients health information Proposed change to the View, or data from a non-clinical setting is
is available for the patient (or patient- Download, Transmit (VDT) Measure: incorporated into the CEHRT for at least
authorized representative) to access During the performance period, at least one unique patient seen by the MIPS
using any application of their choice one unique patient (or patient-
eligible clinician during the

that is configured to meet the technical authorized representatives) seen by the performance period.
specifications of the Application MIPS eligible clinician actively engages Denominator: Number of unique
Programing Interface (API) in the MIPS with the EHR made accessible by the patients seen by the MIPS eligible
eligible clinicians CEHRT. MIPS eligible clinician by either (1) clinician during the performance
Denominator: The number of viewing, downloading or transmitting to period.
unique patients seen by the MIPS a third party their health information; or Numerator: The number of patients
eligible clinician during the (2) accessing their health information in the denominator for whom data from
performance period. through the use of an API that can be non-clinical settings, which may
include patient-generated health data, is denominator where a summary of care health agency to submit immunization
captured through the CEHRT into the record was created using CEHRT and data and receive immunization forecasts
patient record during the performance exchanged electronically. and histories from the public health
period. Request/Accept Summary of Care immunization registry/immunization
Objective: Health Information Measure: For at least one transition of information system (IIS).
Exchange care or referral received or patient We note that the functionality to be
Objective: The MIPS eligible clinician encounter in which the MIPS eligible bi-directional is part of EHR technology
provides a summary of care record clinician has never before encountered certified to the 2015 Edition (80 FR
when transitioning or referring their the patient, the MIPS eligible clinician 62554). It means that in addition to
patient to another setting of care, receives or retrieves and incorporates sending the immunization record to the
receives or retrieves a summary of care into the patients record an electronic immunization registry, the CEHRT must
record upon the receipt of a transition summary of care document. be able to receive and display a
or referral or upon the first patient Denominator: Number of patient consolidated immunization history and
encounter with a new patient, and encounters during the performance forecast.
incorporates summary of care period for which a MIPS eligible Syndromic Surveillance Reporting
information from other health care clinician was the receiving party of a Measure: The MIPS eligible clinician is
clinician into their EHR using the transition or referral or has never before in active engagement with a public
functions of CEHRT. encountered the patient and for which health agency to submit syndromic
Proposed Change to the Objective: an electronic summary of care record is surveillance data from a non-urgent care
The MIPS eligible clinician provides a available. ambulatory setting where the
summary of care record when Numerator: Number of patient jurisdiction accepts syndromic data
transitioning or referring their patient to encounters in the denominator where an from such settings and the standards are
another setting of care, receives or electronic summary of care record clearly defined.
retrieves a summary of care record upon received is incorporated by the clinician Proposed Change to the Syndromic
the receipt of a transition or referral or into the CEHRT. Surveillance Reporting Measure: The
upon the first patient encounter with a Clinical Information Reconciliation MIPS eligible clinician is in active
new patient, and incorporates summary Measure: For at least one transition of engagement with a public health agency
of care information from other health care or referral received or patient to submit syndromic surveillance data.
care providers into their EHR using the encounter in which the MIPS eligible We are proposing this change because
functions of CEHRT. clinician has never before encountered we inadvertently finalized the measure
We inadvertently used the term the patient, the MIPS eligible clinician description that we had proposed for
health care clinician and are performs clinical information Stage 3 of the EHR Incentive Program
proposing to replace it with the more reconciliation. The MIPS eligible (80 FR 82866) and not the measure
appropriate term health care provider. clinician must implement clinical description that we finalized (80 FR
We are proposing this change would information reconciliation for the 82970). The proposed change aligns
apply beginning with the performance following three clinical information with the measure description finalized
period in 2017. sets: (1) Medication. Review of the for Stage 3.
Send a Summary of Care Measure: patients medication, including the Electronic Case Reporting Measure:
For at least one transition of care or name, dosage, frequency, and route of The MIPS eligible clinician is in active
referral, the MIPS eligible clinician that each medication; (2) Medication allergy. engagement with a public health agency
transitions or refers their patient to Review of the patients known to electronically submit case reporting
another setting of care or health care medication allergies; (3) Current of reportable conditions.
clinician (1) creates a summary of care Problem list. Review of the patients Public Health Registry Reporting
record using CEHRT; and (2) current and active diagnoses. Measure: The MIPS eligible clinician is
electronically exchanges the summary Denominator: Number of transitions in active engagement with a public
of care record. of care or referrals during the health agency to submit data to public
Proposed Change to the Send a performance period for which the MIPS health registries.
Summary of Care Measure: For at least eligible clinician was the recipient of Clinical Data Registry Reporting
one transition of care or referral, the the transition or referral or has never Measure: The MIPS eligible clinician is
MIPS eligible clinician that transitions before encountered the patient. in active engagement to submit data to
or refers their patient to another setting Numerator: The number of a clinical data registry.
of care or health care provider (1) transitions of care or referrals in the We note that we have split the
creates a summary of care record using denominator where the following three Specialized Registry Reporting Measure
CEHRT; and (2) electronically clinical information reconciliations that we adopted under the 2017
exchanges the summary of care record. were performed: Medication list; Advancing Care Information Transition
We inadvertently used the term medication allergy list; and current Objectives and Measures into two
health care clinician and are problem list. separate measures, Public Health
proposing to replace it with the more Objective: Public Health and Clinical Registry and Clinical Data Registry
appropriate term health care provider. Data Registry Reporting. Reporting to better define the registries
We are proposing this change would Objective: The MIPS eligible clinician available for reporting. We want to
is in active engagement with a public continue to encourage those MIPS
apply beginning with the 2017

performance period. health agency or clinical data registry to eligible clinicians who have already
Denominator: Number of transitions submit electronic public health data in started down the path of reporting to a
of care and referrals during the a meaningful way using CEHRT, except specialized registry to continue to
performance period for which the MIPS where prohibited, and in accordance engage in public health and clinical data
eligible clinician was the transferring or with applicable law and practice. registry reporting. Therefore, we
referring clinician. Immunization Registry Reporting propose to allow MIPS eligible
Numerator: The number of Measure: The MIPS eligible clinician is clinicians and groups to continue to
transitions of care and referrals in the in active engagement with a public count active engagement in electronic
public health reporting with specialized engagement as described under active As noted previously, to facilitate
registries. We propose to allow these engagement option 3: production in readers in identifying the requirements
registries to be counted for purposes of the 2015 EHR Incentive Programs final of CEHRT for the Advancing Care
reporting the Public Health Registry rule with comment period (80 FR 62862 Information Objectives and Measures,
Reporting Measure or the Clinical Data through 62865), meaning the clinician we are including the following Table 8,
Registry Reporting Measure beginning has completed testing and validation of which includes the 2015 Edition and
with the 2018 performance period. A the electronic submission and is 2014 Edition certification criteria
MIPS eligible clinician may count a electronically submitting production required to meet the objectives and
specialized registry if the MIPS eligible data to the public health agency or measures.
clinician achieved the phase of active clinical data registry.
TABLE 8ADVANCING CARE INFORMATION 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.
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. cation. Resources). Resources).
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. 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.
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)
(Optional-Transitions 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).
Public Health and Clin- Immunization Registry 170.315(f)(1) (Transmission to Immunization N/A.
ical Data Registry Reporting. Registries).
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. Care Setting Only. 170.314(f)(7) (Optional-Ambulatory Set-

ting Only-Transmission 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.
TABLE 8ADVANCING CARE INFORMATION OBJECTIVES AND MEASURES AND CERTIFICATION CRITERIA FOR 2014 AND
2015 EDITIONSContinued
Objective Measure 2015 Edition 2014 Edition
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). 170.314(f)(6) (OptionalAmbulatory Set-
170.315(f)(7) (Transmission to Public Health ting OnlyTransmission to Cancer Reg-
AgenciesHealth 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.
We are inviting public comment on (b) 2017 and 2018 Advancing Care
these proposals. Information Transition Objectives and
Measures Specifications
TABLE 9ADVANCING CARE INFORMATION PERFORMANCE CATEGORY SCORING METHODOLOGY FOR 2018 ADVANCING
CARE INFORMATION TRANSITION OBJECTIVES AND MEASURES
Required/ Performance
2018 Advancing Care Information 2018 Advancing Care Information not required Reporting
Score
Transition Objective Transition Measure for 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/Denomi-
nator.
Patient Electronic Access .......................... Provide Patient Access ............................. Required ........ Up to 20 ......... Numerator/Denomi-
nator.
View, Download, or Transmit (VDT) ......... Not Required Up to 10 ......... Numerator/Denomi-
nator.
Patient-Specific Education ......................... Patient-Specific Education ........................ Not Required Up to 10 ......... Numerator/Denomi-
nator.
Secure Messaging ..................................... Secure Messaging .................................... Not Required Up to 10 ......... Numerator/Denomi-
nator.
Health Information Exchange ..................... Health Information Exchange ................... Required ........ Up to 20 ......... Numerator/Denomi-
nator.
Medication Reconciliation .......................... Medication Reconciliation ......................... Not Required Up to 10 ......... Numerator/Denomi-
nator.
Public Health Reporting ............................. Immunization Registry Reporting ............. Not Required 0 or 10 ........... Yes/No Statement.
Syndromic Surveillance Reporting ........... Not Required 0 or 5 * ........... Yes/No Statement.
Specialized Registry Reporting ................ Not Required 0 or 5 * ........... Yes/No Statement.
Bonus up to 15%
Report to one or more additional public health agencies or clinical data registries beyond those identified 5 bonus .......... Yes/No Statement.
for the performance score.
Report improvement activities using CEHRT ................................................................................................ 10 bonus ........ Yes/No Statement.
* A MIPS eligible clinician who cannot fulfill the Immunization Registry Reporting measure may earn 5% for each public health agency or clin-
ical data registry to which the clinician reports, up to a maximum of 10% under the performance score.
In the CY 2017 Quality Payment explanatory material and defined terms, period because these objectives and
Program final rule (81 FR 77229 through we refer readers to the 2015 EHR measures are for MIPS eligible
77237), we finalized the 2017 Incentive Programs final rule (80 FR clinicians using EHR technology
Advancing Care Information Transition 62793 through 62825). We are proposing certified to the 2014 Edition. Because
Objectives and Measures for MIPS to make several modifications identified we are proposing in section II.C.6.f.(4) to
eligible clinicians using EHR technology and described below to the 2017 continue to allow the use of EHR
certified to the 2014 Edition. We noted Advancing Care Information Transition technology certified to the 2014 Edition
(81 FR 77229 that these objectives and Objectives and Measures for the in the 2018 performance period, we are
measures have been adapted from the advancing care information performance also proposing to allow MIPS eligible
Modified Stage 2 objectives and category of MIPS for the 2017 and 2018 clinicians to report the Advancing Care
measures finalized in the 2015 EHR performance periods. These Information Transition Objectives and
Incentive Programs final rule (80 FR modifications would not require Measures in 2018.
62793 through 62825); however, we did changes to EHR technology that has Objective: Protect Patient Health
not maintain the previously established been certified to the 2014 Edition. Information.
thresholds for MIPS. For a more detailed We finalized the 2017 Advancing Care Objective: Protect electronic protected
discussion of the Modified Stage 2 Information Transition Objectives and health information (ePHI) created or
Objectives and Measures, including Measures only for the 2017 performance maintained by the CEHRT through the
implementation of appropriate access to view online, download, and Denominator: The number of
technical, administrative, and physical transmit to a third party their health unique patients seen by the MIPS
safeguards. information subject to the MIPS eligible eligible clinician during the
Security Risk Analysis Measure: clinicians discretion to withhold performance period.
Conduct or review a security risk certain information. Numerator: The number of patients
analysis in accordance with the Denominator: The number of in the denominator who were provided
requirements in 45 CFR 164.308(a)(1), unique patients seen by the MIPS access to patient-specific educational
including addressing the security (to eligible clinician during the resources using clinically relevant
include encryption) of ePHI data created performance period. information identified from CEHRT
or maintained by CEHRT in accordance Numerator: The number of patients during the performance period.
with requirements in 45 CFR in the denominator (or patient Objective: Secure Messaging.
164.312(a)(2)(iv) and 164.306(d)(3), and authorized representative) who are Objective: Use CEHRT to engage with
implement security updates as provided timely access to health patients or their authorized
necessary and correct identified security information to view online, download, representatives about the patients care.
deficiencies as part of the MIPS eligible and transmit to a third party. Secure Messaging Measure: For at
clinicians risk management process. View, Download, Transmit (VDT) least one patient seen by the MIPS
Objective: Electronic Prescribing. Measure: At least one patient seen by eligible clinician during the
Objective: MIPS eligible clinicians the MIPS eligible clinician during the performance period, a secure message
must generate and transmit permissible performance period (or patient- was sent using the electronic messaging
prescriptions electronically. authorized representative) views, function of CEHRT to the patient (or the
E-Prescribing Measure: At least one downloads or transmits their health patient-authorized representative), or in
permissible prescription written by the information to a third party during the response to a secure message sent by the
MIPS eligible clinician is queried for a performance period. patient (or the patient authorized
drug formulary and transmitted Denominator: Number of unique
representative) during the performance
electronically using CEHRT. patients seen by the MIPS eligible
period.
Denominator: Number of clinician during the performance
Denominator: Number of unique
prescriptions written for drugs requiring period.
Numerator: The number of unique patients seen by the MIPS eligible
a prescription to be dispensed other
patients (or their authorized clinician during the performance
than controlled substances during the
representatives) in the denominator who period.
performance period; or number of
have viewed online, downloaded, or Numerator: The number of patients
prescriptions written for drugs requiring
transmitted to a third party the patients in the denominator for whom a secure
a prescription to be dispensed during
health information during the electronic message is sent to the patient
the performance period.
Numerator: The number of performance period. (or patient-authorized representative) or
prescriptions in the denominator Objective: Patient-Specific Education. in response to a secure message sent by
generated, queried for a drug formulary, Objective: The MIPS eligible clinician the patient (or patient-authorized
and transmitted electronically using provides patients (or patient authorized representative), during the performance
CEHRT. representative) with timely electronic period.
Objective: Patient Electronic Access. access to their health information and Objective: Health Information
Objective: The MIPS eligible clinician patient-specific education. Exchange.
provides patients (or patient-authorized Proposed Change to the Objective: Objective: The MIPS eligible clinician
representative) with timely electronic The MIPS eligible clinician uses provides a summary of care record
access to their health information and clinically relevant information from when transitioning or referring their
patient-specific education. CEHRT to identify patient-specific patient to another setting of care,
Proposed Modification to the educational resources and provide those receives or retrieves a summary of care
Objective: We are proposing to modify resources to the patient. We record upon the receipt of a transition
this objective beginning with the 2017 inadvertently finalized the description or referral or upon the first patient
performance period by removing the of the Patient Electronic Access encounter with a new patient, and
word electronic from the description objective for the Patient-Specific incorporates summary of care
of timely access as it was erroneously Education Objective, so that the Patient- information from other health care
included in the final rule (81 FR 77228). Specific Education Objective had the clinicians into their EHR using the
It was our intention to align the wrong description. We are proposing to functions of CEHRT.
objective with the objectives for Patient correct this error by adopting the Proposed Change to the Objective:
Specific Education and Patient description of the Patient-Specific The MIPS eligible clinician provides a
Electronic Access adopted under Education Objective adopted under summary of care record when
modified Stage 2 in the 2015 EHR modified Stage 2 in the 2015 EHR transitioning or referring their patient to
Incentive Programs final rule (80 FR Incentive Programs final rule (80 FR another setting of care, receives or
62809 and 80 FR 62815), which do not 62809 and 80 FR 62815). We are retrieves a summary of care record upon
include the word electronic. The proposing this change would apply the receipt of a transition or referral or
word electronic was also not included beginning with the performance period upon the first patient encounter with a
in the certification specifications for the in 2017. new patient, and incorporates summary
2014 Edition, 170.314(a)(15) (Patient- Patient-Specific Education Measure: of care information from other health
specific education resources) and The MIPS eligible clinician must use care providers into their EHR using the
170.314(e)(1) (View, download, and clinically relevant information from functions of CEHRT.
transmit to third party). CEHRT to identify patient-specific We inadvertently used the term
Provide Patient Access Measure: At educational resources and provide health care clinician and are
least one patient seen by the MIPS access to those materials to at least one proposing to replace it with the more
eligible clinician during the unique patient seen by the MIPS eligible appropriate term health care provider.
performance period is provided timely clinician. We are proposing this change would
apply beginning with the performance objective adopted for Modified Stage 2 2017 Quality Payment Program final
period in 2017. at 80 FR 62811. rule (81 FR 77237 through 77238), we
Health Information Exchange Medication Reconciliation Measure: did not finalize any exclusions for the
Measure: The MIPS eligible clinician The MIPS eligible clinician performs measures specified for the advancing
that transitions or refers their patient to medication reconciliation for at least care information performance category
another setting of care or health care one transition of care in which the as we believe that the MIPS exclusion
clinician (1) uses CEHRT to create a patient is transitioned into the care of criteria and that the advancing care
summary of care record; and (2) the MIPS eligible clinician. information performance category
electronically transmits such summary Denominator: Number of transitions scoring methodology together
to a receiving health care clinician for of care or referrals during the accomplish the same end as the
at least one transition of care or referral. performance period for which the MIPS previously established exclusions for
Proposed Change to the Measure: The eligible clinician was the recipient of the majority of the advancing care
MIPS eligible clinician that transitions the transition or referral or has never information performance category
or refers their patient to another setting before encountered the patient. measures. We further noted that it was
of care or health care provider (1) uses Numerator: The number of not necessary to finalize the proposed
CEHRT to create a summary of care transitions of care or referrals in the exclusion for the Immunization Registry
record; and (2) electronically transmits denominator where the following three Reporting Measure because MIPS
such summary to a receiving health care clinical information reconciliations eligible clinicians have the flexibility to
provider for at least one transition of were performed: Medication list, choose whether to report the measure
care or referral. Medication allergy list, and current because it is part of the performance
This change reflects the change problem list. score of the advancing care information
proposed to the Health Information performance category. However, we
Exchange objective replacing health Proposed Modification to the Numerator
understand that many MIPS eligible
care clinician with health care Proposed Numerator: The number of clinicians may not achieve a base score
provider. We are proposing this change transitions of care or referrals in the because they cannot fulfill the measures
would apply beginning with the denominator where medication associated with the Health Information
performance period in 2017. reconciliation was performed. Exchange objective in the base score
Denominator: Number of transitions We are proposing to modify the because they seldom refer or transition
of care and referrals during the numerator by removing medication list, patients, and we believe that the
performance period for which the EP medication allergy list, and current implementation burden of the objective
was the transferring or referring health problem list. These three criteria were is too high to require of those with only
care clinician. adopted for Stage 3 (80 FR 62862) but a small number of referrals or
Proposed Change to the Denominator: not for Modified Stage 2 (80 FR 62811). transitions. Similarly, we understand
Number of transitions of care and We are proposing this change would that many MIPS eligible clinicians do
referrals during the performance period apply beginning with the performance not often write prescriptions in their
for which the MIPS eligible clinician period in 2017. practice or lack prescribing authority,
was the transferring or referring health Objective: Public Health Reporting. and thus could not meet the E-
care provider. This change reflects the Objective: The MIPS eligible clinician prescribing Measure and would also fail
change proposed to the Health is in active engagement with a public to earn a base score. As this was not our
Information Exchange Measure health agency or clinical data registry to intention, we are proposing to establish
replacing health care clinician with submit electronic public health data in exclusions for these measures, as
health care provider. We also a meaningful way using CEHRT, except described below.
inadvertently referred to the EP in the where prohibited, and in accordance
description and are replacing EP with with applicable law and practice. Proposed Exclusion for the E-
MIPS eligible clinician. We are Immunization Registry Reporting Prescribing Objective and Measure: In
proposing this change would apply Measure: The MIPS eligible clinician is the CY 2017 Quality Payment Program
beginning with the performance period in active engagement with a public final rule (81 FR 28237 through 28238),
in 2017. health agency to submit immunization we established a policy that MIPS
Numerator: The number of data. eligible clinicians who write fewer than
transitions of care and referrals in the Syndromic Surveillance Reporting 100 permissible prescriptions in a
denominator where a summary of care Measure: The MIPS eligible clinician is performance period may elect to report
record was created using CEHRT and in active engagement with a public their numerator and denominator (if
exchanged electronically. health agency to submit syndromic they have at least one permissible
surveillance data. prescription for the numerator), or they
Medication Reconciliation Specialized Registry Reporting may report a null value. This policy has
Objective: Medication Reconciliation. Measure: The MIPS eligible clinician is confused MIPS eligible clinicians as a
Proposed Objective: We are proposing in active engagement to submit data to null value would appear to indicate a
to add a description of the Medication a specialized registry. MIPS eligible clinician has failed the
Reconciliation Objective beginning with We invite public comments on these measure and thus not would not achieve
the CY 2017 performance period, which proposals. a base score. We are proposing to
we inadvertently omitted from the CY change this policy beginning with the
2017 Quality Payment Program (c) Exclusions CY 2017 performance period and
proposed and final rules, as follows: We are proposing to add exclusions to propose to establish an exclusion for the
Proposed Objective: The MIPS eligible the measures associated with the Health e-Prescribing Measure. MIPS eligible
clinician who receives a patient from Information Exchange and Electronic clinicians who wish to claim this
another setting of care or provider of Prescribing objectives required for the exclusion would select yes to the
care or believes an encounter is relevant base score. We propose these exclusions exclusion and submit a null value for
performs medication reconciliation. would apply beginning with the CY the measure, thereby fulfilling the
This description aligns with the 2017 performance period. In the CY requirement to report this measure as
part of the base score. It is important Measures: We are proposing to add clinician has never before encountered
that a MIPS eligible clinician actually exclusions for the measures associated the patient, the MIPS eligible clinician
claims the exclusion if they wish to with the Health Information Exchange receives or retrieves and incorporates
exclude the measure. If a MIPS eligible Objective. Stakeholders have expressed into the patients record an electronic
clinician does not claim the exclusion, concern through public comments on summary of care document.
they would fail the measure and not the CY 2017 Quality Payment Program Denominator: Number of patient
earn a base score or any score in the proposed rule and other inquiries to us encounters during the performance
advancing care information performance that some MIPS eligible clinicians are period for which a MIPS eligible
category. unable to meet the measures associated clinician was the receiving party of a
with the Health Information Exchange transition or referral or has never before
Advancing Care Information Objective encountered the patient and for which
Objective, which are required for the
and Measure. an electronic summary of care record is
base score, because they do not
Objective: Electronic Prescribing. regularly refer or transition patients in available.
Objective: Generate and transmit the normal course of their practice. As Numerator: Number of patient
permissible prescriptions electronically. we did not intend to disadvantage those encounters in the denominator where an
E-Prescribing Measure: At least one MIPS eligible clinicians and prevent electronic summary of care record
permissible prescription written by the them from earning a base score, we are received is incorporated by the clinician
MIPS eligible clinician is queried for a proposing the exclusions. into the CEHRT.
drug formulary and transmitted Proposed Exclusion: Any MIPS
electronically using CEHRT. Advancing Care Information Objective eligible clinician who receives
Denominator: Number of and Measures transitions of care or referrals or has
prescriptions written for drugs requiring Objective: Health Information patient encounters in which the MIPS
a prescription to be dispensed other Exchange. eligible clinician has never before
than controlled substances during the Objective: The MIPS eligible clinician encountered the patient fewer than 100
performance period; or number of provides a summary of care record times during the performance period.
prescriptions written for drugs requiring when transitioning or referring their
a prescription to be dispensed during 2017 and 2018 Advancing Care
patient to another setting of care,
the performance period. Information Transition Objective and
receives or retrieves a summary of care
Numerator: The number of Measures
record upon the receipt of a transition
prescriptions in the denominator or referral or upon the first patient Objective: Health Information
generated, queried for a drug formulary, encounter with a new patient, and Exchange.
and transmitted electronically using incorporates summary of care Objective: The MIPS eligible clinician
CEHRT. information from other health care provides a summary of care record
Proposed Exclusion: Any MIPS clinician into their EHR using the when transitioning or referring their
eligible clinician who writes fewer than functions of CEHRT. patient to another setting of care,
100 permissible prescriptions during the We note that we proposed above to receives or retrieves a summary of care
performance period. replace health care clinician with record upon the receipt of a transition
health care provider. or referral or upon the first patient
2017 and 2018 Advancing Care encounter with a new patient, and
Send a Summary of Care Measure:
Information Transition Objective and incorporates summary of care
For at least one transition of care or
Measure information from other health care
referral, the MIPS eligible clinician that
Objective: Electronic Prescribing. transitions or refers their patient to clinicians into their EHR using the
Objective: MIPS eligible clinicians another setting of care or health care functions of CEHRT.
must generate and transmit permissible clinician (1) creates a summary of care We note that we are proposing above
prescriptions electronically. record using CEHRT; and (2) to replace health care clinician with
E-Prescribing Measure: At least one electronically exchanges the summary health care provider.
permissible prescription written by the of care record. Health Information Exchange
MIPS eligible clinician is queried for a We note that we proposed above to Measure: The MIPS eligible clinician
drug formulary and transmitted replace health care clinician with that transitions or refers their patient to
electronically using CEHRT. health care provider. another setting of care or health care
Denominator: Number of Denominator: Number of transitions clinician (1) uses CEHRT to create a
prescriptions written for drugs requiring of care and referrals during the summary of care record; and (2)
a prescription to be dispensed other performance period for which the MIPS electronically transmits such summary
than controlled substances during the eligible clinician was the transferring or to a receiving health care clinician for
performance period; or number of referring clinician. at least one transition of care or referral.
prescriptions written for drugs requiring Numerator: The number of We note that we are proposing above
a prescription to be dispensed during transitions of care and referrals in the to replace health care clinician with
the performance period. denominator where a summary of care health care provider.
Numerator: The number of record was created using CEHRT and Denominator: Number of transitions
prescriptions in the denominator exchanged electronically. of care and referrals during the
generated, queried for a drug formulary, Proposed Exclusion: Any MIPS
performance period for which the EP

and transmitted electronically using eligible clinician who transfers a patient was the transferring or referring health
CEHRT. to another setting or refers a patient care clinician.
Proposed Exclusion: Any MIPS fewer than 100 times during the We note that we are proposing above
eligible clinician who writes fewer than performance period. to replace health care clinician with
100 permissible prescriptions during the Request/Accept Summary of Care health care provider.
performance period. Measure: For at least one transition of Numerator: The number of
Proposed Exclusion for the Health care or referral received or patient transitions of care and referrals in the
Information Exchange Objective and encounter in which the MIPS eligible denominator where a summary of care
record was created using CEHRT and similar to the manner in which such information performance category in an
exchanged electronically. provisions apply with respect to the appropriate manner which may be
Proposed Exclusion: Any MIPS meaningful use payment adjustment similar to the manner in which such
eligible clinician who transfers a patient made under section 1848(a)(7)(A) of the provisions apply with respect to the
to another setting or refers a patient Act. As a result of this legislative payment adjustment made under
fewer than 100 times during the change, we believe that the general section 1848(a)(7)(A) of the Act. We
performance period. exceptions described under sections would assign a zero percent weighting
We are inviting public comment on 1848(a)(7)(B) and (D) of the Act are to the advancing care information
these proposals. applicable under the MIPS program. We performance category in the MIPS final
include below proposals to implement score for a MIPS payment year for MIPS
(7) Additional Considerations
these provisions as applied to eligible clinicians who successfully
(a) 21st Century Cures Act assessments of MIPS eligible clinicians demonstrate a significant hardship
As we noted in the CY 2017 Quality under section 1848(q) of the Act with through the application process. We
Payment Program final rule (81 FR respect to the advancing care would use the same categories of
77238), section 101(b)(1)(A) of the information performance category. significant hardship and application
MACRA amended section 1848(a)(7)(A) process as established in the CY 2017
(i) MIPS Eligible Clinicians Facing a
of the Act to sunset the meaningful use Quality Payment Program final rule (81
Significant Hardship
payment adjustment at the end of CY FR 7724077243). We would
In the CY 2017 Quality Payment automatically reweight the advancing
2018. Section 1848(a)(7) of the Act Program final rule (81 FR 77240 through
includes certain statutory exceptions to care information performance category
77243), we recognized that there may to zero percent for a MIPS eligible
the meaningful use payment adjustment not be sufficient measures applicable
under section 1848(a)(7)(A) of the Act. clinician who lacks face-to-face patient
and available under the advancing care interaction and is classified as a non-
Specifically, section 1848(a)(7)(D) of the information performance category to patient facing MIPS eligible clinician
Act exempts hospital-based EPs from MIPS eligible clinicians facing a without requiring an application. If a
the application of the payment significant hardship, such as those who MIPS eligible clinician submits an
adjustment under section 1848(a)(7)(A) lack sufficient internet connectivity, application for a significant hardship
of the Act. In addition, section face extreme and uncontrollable exception or is classified as a non-
1848(a)(7)(B) of the Act provides that circumstances, lack control over the patient facing MIPS eligible clinician,
the Secretary may, on a case-by-case availability of CEHRT, or do not have but also reports on the measures
basis, exempt an EP from the face-to-face interactions with patients. specified for the advancing care
application of the payment adjustment We relied on section 1848(q)(5)(F) of the information performance category, they
under section 1848(a)(7)(A) of the Act if Act to establish a final policy to assign would be scored on the advancing care
the Secretary determines, subject to a zero percent weighting to the information performance category like
annual renewal, that compliance with advancing care information performance all other MIPS eligible clinicians, and
the requirement for being a meaningful category in the final score if there are the category would be given the
EHR user would result in a significant not sufficient measures and activities weighting prescribed by section
hardship, such as in the case of an EP applicable and available to MIPS 1848(q)(5)(E) of the Act regardless of the
who practices in a rural area without eligible clinicians within the categories MIPS eligible clinicians score.
sufficient internet access. The last of significant hardship noted above (81 We believe this policy would be an
sentence of section 1848(a)(7)(B) of the FR 77243). Additionally, under the final appropriate application of the
Act also provides that in no case may an policy (81 FR 77243), we did not impose provisions of section 1848(a)(7)(B) of the
exemption be granted under a limitation on the total number of MIPS Act to MIPS eligible clinicians and is
subparagraph (B) for more than 5 years. payment years for which the advancing similar to the manner in which those
The MACRA did not maintain these care information performance category provisions apply with respect to the
statutory exceptions for the advancing could be weighted at zero percent, in payment adjustment made under
care information performance category contrast with the 5-year limitation on section 1848(a)(7)(A) of the Act. Under
of the MIPS. Thus, we had previously significant hardship exceptions under the Medicare EHR Incentive Program an
stated that the provisions under sections the Medicare EHR Incentive Program as approved hardship exception exempted
1848(a)(7)(B) and (D) of the Act are required by section 1848(a)(7)(B) of the an EP from the payment adjustment. We
limited to the meaningful use payment Act. believe that weighting the advancing
adjustment under section 1848(a)(7)(A) We are not proposing substantive care information performance category
of the Act and do not apply in the changes to this policy; however, as a to zero percent is similar in effect to an
context of the MIPS. result of the changes in the law made by exemption from the requirements of that
Following the publication of the CY the 21st Century Cures Act discussed performance category.
2017 Quality Payment Program final above, we will not rely on section As required under section
rule, the 21st Century Cures Act (Pub. 1848(q)(5)(F) of the Act and instead are 1848(a)(7)(B) of the Act, eligible
L. 114255) was enacted on December proposing to use the authority in the last professionals were not granted
13, 2016. Section 4002(b)(1)(B) of the sentence of section 1848(o)(2)(D) of the significant hardship exceptions for the
21st Century Cures Act amended section Act for significant hardship exceptions payment adjustments under the
1848(o)(2)(D) of the Act to state that the under the advancing care information Medicare EHR Incentive Program for
provisions of sections 1848(a)(7)(B) and performance category under MIPS. more than 5 years. We propose not to
(D) of the Act shall apply to assessments Section 1848(o)(2)(D) of the Act, as apply the 5-year limitation under
of MIPS eligible clinicians under section amended by section 4002(b)(1)(B) of the section 1848(a)(7)(B) of the Act to
1848(q) of the Act with respect to the 21st Century Cures Act, states in part significant hardship exceptions for the
performance category described in that the provisions of section advancing care information performance
subsection (q)(2)(A)(iv) (the advancing 1848(a)(7)(B) of the Act shall apply to category under MIPS. We believe this
care information performance category) assessments of MIPS eligible clinicians proposal is an appropriate application
in an appropriate manner which may be with respect to the advancing care of the provisions of section 1848(a)(7)(B)
of the Act to MIPS eligible clinicians Program proposed rule (81 FR 28161 accordance with section 1848(a)(7)(B) of
due to our desire to reduce clinician 28586), we heard many concerns about the Act, the exception would be subject
burden, promote the greatest level of the impact of MIPS on eligible to annual renewal. Under our proposal
participation in the MIPS program, and clinicians in small practices. Some in section II.C.6.f.(7)(a), the 5-year
maintain consistency with the policies commenters stated that there was not a limitation under section 1848(a)(7)(B) of
established in last years final rule (81 meaningful exclusion for small practices the Act would not apply to this
FR 77243). In the Medicare EHR that cannot afford the upfront significant hardship exception for MIPS
Incentive Program, we received many investments (including investments in eligible clinicians in small practices.
applications for significant hardship EHR technology) (81 FR 77066). Many We believe that applying the
exceptions and approved most of them, noted there are still many small significant hardship exception in this
which we believe indicates many practices that have not adopted EHRs way would be appropriate given the
eligible professionals were unable to or due to the administrative and financial challenges small practices face as
would have struggled to satisfy the burden. Some expressed concern that described by the commenters. In
requirements of meaningful use. We small group and solo practices would be addition, we believe this application
believe that there will be a continued driven out of business because of the would be similar to the manner in
need for significant hardship exceptions potential negative payment adjustments which the exception applies with
in order to provide clinicians with the under MIPS (81 FR 77055). A few respect to the payment adjustment made
necessary flexibility to participate in the commenters were concerned about the under section 1848(a)(7)(A) of the Act
MIPS program that best matches their impact of MACRA on small practices because weighting the advancing care
available resources and circumstances, and asked CMS to remain sensitive to information performance category to
which may not change during a 5-year this concern and offer special zero percent is similar in effect to an
time period. For example, a clinician in opportunities for MIPS eligible exemption from the requirements of that
an area without internet connectivity clinicians in areas threatened by access performance category.
may continue to lack connectivity for problems (81 FR 77055). While we would be making this
more than 5 years. In addition, in the significant hardship exception available
Based on these concerns, we are to small practices in particular, we are
CY 2017 Quality Payment Program final proposing a significant hardship
rule (81 FR 77242 through 77243), we considering whether other categories or
exception for the advancing care types of clinicians might similarly
noted that we had received comments
information performance category for require an exception. We solicit
expressing appreciation that CMS
MIPS eligible clinicians who are in comment on what those categories or
moved away from the 5-year limitation
small practices, under the authority in types are, why such an exception is
to significant hardship exceptions.
We solicit comments on the proposed section 1848(o)(2)(D) of the Act, as required, and any data available to
use of the authority provided in the 21st amended by section 4002(b)(1)(B) of the support the necessity of the exception.
Century Cures Act in section 21st Century Cures Act (see discussion We note that supporting data would be
1848(o)(2)(D) of the Act as it relates to of the statutory authority for significant particularly helpful to our consideration
application of significant hardship hardship exceptions in section of whether any additional exceptions
exceptions under MIPS and the II.C.6.f.(7)(ii). We are proposing that this would be appropriate.
proposal not to apply a 5-year limit to hardship exception would be available We are seeking comments on these
such exceptions. to MIPS eligible clinicians in small proposals.
practices as defined under 414.1305
(ii) Significant Hardship Exception for (15 or fewer clinicians and solo (iii) Hospital-Based MIPS Eligible
MIPS Eligible Clinicians in Small practitioners). We are proposing in Clinicians
Practices section II.C.1.e. of this proposed rule, In the CY 2017 Quality Payment
Section 1848(q)(2)(B)(iii) of the Act that CMS would make eligibility Program final rule (81 FR 77238 through
requires the Secretary to give determinations regarding the size of 77240), we defined a hospital-based
consideration to the circumstances of small practices for performance periods MIPS eligible clinician under 414.1305
small practices (consisting of 15 or occurring in 2018 and future years. We as a MIPS eligible clinician who
fewer professionals) and practices are proposing to reweight the advancing furnishes 75 percent or more of his or
located in rural areas and geographic care information performance category her covered professional services in
HPSAs in establishing improvement to zero percent of the MIPS final score sites of service identified by the Place of
activities under MIPS. In the CY 2017 for MIPS eligible clinicians who qualify Service (POS) codes used in the HIPAA
Quality Payment Program final rule (81 for this hardship exception. We are standard transaction as an inpatient
FR 77187 through 77188), we finalized proposing this exception would be hospital (POS 21), on-campus outpatient
that for MIPS eligible clinicians and available beginning with the 2018 hospital (POS 22), or emergency room
groups that are in small practices or performance period and 2020 MIPS (POS 23) setting, based on claims for a
located in rural areas, or geographic payment year. We are proposing a MIPS period prior to the performance period
health professional shortage areas eligible clinician seeking to qualify for as specified by CMS. We intend to use
(HPSAs), to achieve full credit under the this exception would submit an claims with dates of service between
improvement activities category, one application in the form and manner September 1 of the calendar year 2 years
high-weighted or two medium-weighted specified by us by December 31st of the preceding the performance period
improvement activities are required. performance period or a later date through August 31 of the calendar year
While there is no corresponding specified by us. We are also proposing preceding the performance period, but
statutory provision for the advancing MIPS eligible clinicians seeking this in the event it is not operationally
care information performance category, exception must demonstrate in the feasible to use claims from this time
we believe that special consideration application that there are overwhelming period, we will use a 12-month period
should also be available for MIPS barriers that prevent the MIPS eligible as close as practicable to this time
eligible clinicians located in small clinician from complying with the period. We discussed our assumption
practices. Through comments received requirements for the advancing care that MIPS eligible clinicians who are
on the CY 2017 Quality Payment information performance category. In determined hospital-based do not have
sufficient advancing care information exemption from the requirements of that To align with our hospital-based
measures applicable to them, and we performance category. MIPS eligible clinician policy, we are
established a policy to reweight the We propose to amend 414.1380(c)(1) proposing to define at 414.1305 an
advancing care information performance and (2) of the regulation text to reflect ASC-based MIPS eligible clinician as a
category to zero percent of the MIPS this proposal. MIPS eligible clinician who furnishes
final score for the MIPS payment year in We request comments on the 75 percent or more of his or her covered
accordance with section 1848(q)(5)(F) of proposed use of the authority provided professional services in sites of service
the Act (81 FR 77240). in the 21st Century Cures Act in section identified by the Place of Service (POS)
We are not proposing substantive 1848(o)(2)(D) of the Act as it relates to code 24 used in the HIPAA standard
changes to this policy; however, as a hospital-based MIPS eligible clinicians. transaction based on claims for a period
result of the changes in the law made by (iv) Ambulatory Surgical Center (ASC) prior to the performance period as
the 21st Century Cures Act discussed Based MIPS Eligible Clinicians specified by us. We request comments
above, we will not rely on section on this proposal and solicit comments
1848(q)(5)(F) of the Act and instead are Section 16003 of the 21st Century as to whether other POS codes should
proposing to use the authority in the last Cures Act amended section be used to identify a MIPS eligible
sentence of section 1848(o)(2)(D) of the 1848(a)(7)(D) of the Act to provide that clinicians ASC-based status or if an
Act for exceptions for hospital-based no payment adjustment may be made alternative methodology should be used.
MIPS eligible clinicians under the under section 1848(a)(7)(A) of the Act We note that the ASC-based
advancing care information performance for 2017 and 2018 in the case of an determination will be made
category. Section 1848(o)(2)(D) of the eligible professional who furnishes independent of the hospital-based
Act, as amended by section substantially all of his or her covered determination.
4002(b)(1)(B) of the 21st Century Cures professional services in an ambulatory To determine a MIPS eligible
Act, states in part that the provisions of surgical center (ASC). Section clinicians ASC-based status, we are
section 1848(a)(7)(D) of the Act shall 1848(a)(7)(D)(iii) of the Act provides proposing to use claims with dates of
apply to assessments of MIPS eligible that determinations of whether an service between September 1 of the
clinicians with respect to the advancing eligible professional is ASC-based may calendar year 2 years preceding the
care information performance category be made based on the site of service as performance period through August 31
in an appropriate manner which may be defined by the Secretary or an of the calendar year preceding the
similar to the manner in which such attestation, but shall be made without performance period, but in the event it
provisions apply with respect to the regard to any employment or billing is not operationally feasible to use
payment adjustment made under arrangement between the eligible claims from this time period, we would
section 1848(a)(7)(A) of the Act. We professional and any other supplier or use a 12-month period as close as
would assign a zero percent weighting provider of services. Section practicable to this time period. For
to the advancing care information 1848(a)(7)(D)(iv) of the Act provides that example, for the 2018 performance
performance category in the MIPS final the ASC-based exception shall no longer period (2020 MIPS payment year), we
score for a MIPS payment year for apply as of the first year that begins would use the data available at the end
hospital-based MIPS eligible clinicians more than 3 years after the date on of October 2017 for Medicare claims
as previously defined. A hospital-based which the Secretary determines, with dates of service between
MIPS eligible clinician would have the through notice and comment September 1, 2016 through August 31,
option to report the advancing care rulemaking, that CEHRT applicable to 2017, to determine whether a MIPS
information measures for the the ASC setting is available. eligible clinician is considered ASC-
performance period for the MIPS Under section 1848(o)(2)(D) of the based under our proposed definition.
payment year for which they are Act, as amended by section We are proposing this timeline to allow
determined hospital-based. However, if 4002(b)(1)(B) of the 21st Century Cures us to notify MIPS eligible clinicians of
a MIPS eligible clinician who is Act, the ASC-based provisions of their ASC-based status prior to the start
determined hospital-based chooses to section 1848(a)(7)(D) of the Act shall of the performance period and to align
report on the advancing care apply to assessments of MIPS eligible with the hospital-based MIPS eligible
information measures, they would be clinicians under section 1848(q) of the clinician determination period. For the
scored on the advancing care Act with respect to the advancing care 2019 MIPS payment year, we would not
information performance category like information performance category in an be able to notify MIPS eligible clinicians
all other MIPS eligible clinicians, and appropriate manner which may be of their ASC-based status until after the
the category would be given the similar to the manner in which such final rule is published, which we
weighting prescribed by section provisions apply with respect to the anticipate would be later in 2017. We
1848(q)(5)(E) of the Act regardless of payment adjustment made under expect that we would provide this
their score. section 1848(a)(7)(A) of the Act. We notification through QPP.cms.gov.
We believe this policy would be an believe our proposals set forth below for For MIPS eligible clinicians who we
appropriate application of the ASC-based MIPS eligible clinicians are determine are ASC-based, we propose to
provisions of section 1848(a)(7)(D) of an appropriate application of the assign a zero percent weighting to the
the Act to MIPS eligible clinicians and provisions of section 1848(a)(7)(D) of advancing care information performance
is similar to the manner in which those the Act to MIPS eligible clinicians. category in the MIPS final score for the
provisions apply with respect to the Under the Medicare EHR Incentive MIPS payment year. However, if a MIPS
payment adjustment made under Program an approved hardship eligible clinician who is determined
section 1848(a)(7)(A) of the Act. Under exception exempted an EP from the ASC-based chooses to report on the
the Medicare EHR Incentive Program an payment adjustment. We believe that advancing care information measures
approved hardship exception exempted weighting the advancing care for the performance period for the MIPS
an EP from the payment adjustment. We information performance category to payment year for which they are
believe that weighting the advancing zero percent is similar in effect to an determined ASC-based, we propose they
care information performance category exemption from the requirements of that would be scored on the advancing care
to zero percent is similar in effect to an performance category. information performance category like
all other MIPS eligible clinicians, and performance period and the 2020 MIPS certified health IT. Prior to the EOA
the performance category would be payment year. final rule, ONC-Authorized Certification
given the weighting prescribed by We are proposing that a MIPS eligible Bodies (ONCACBs) had the only
section 1848(q)(5)(E) of the Act clinician may qualify for this exception authority to terminate or revoke
regardless of their advancing care if their CEHRT was decertified either certification of health IT under the
information performance category score. during the performance period for the program, which they used on previous
We are proposing these ASC-based MIPS payment year or during the occasions. On September 23, 2015, we
policies would apply beginning with the calendar year preceding the posted an FAQ discussing the
2017 performance period/2019 MIPS performance period for the MIPS requirements for using a decertified
payment year. payment year. We believe that this CEHRT.3
We propose to amend 414.1380(c)(1) timeframe is appropriate because the Once all administrative processes, if
and (2) of the regulation text to reflect loss of certification may prevent a MIPS any, are complete, then notice of a
these proposals. eligible clinician from reporting for the termination of certification is listed
We request comments on these advancing care information performance on the of the Certified Health IT Product
proposals. category because it will require that the List (CPHL) Web page.4 As appropriate,
(v) Exception for MIPS Eligible MIPS eligible clinician switch to an ONC will also publicize the termination
Clinicians Using Decertified EHR alternate CEHRT, a process that we of certification of health IT through
Technology believe may take up to 2 years. For other communication channels (for
example, for the 2020 MIPS payment example, ONC list serv(s)). Further,
Section 4002(b)(1)(A) of the 21st year, if the MIPS eligible clinicians when ONC terminates the certification
Century Cures Act amended section EHR technology was decertified during of a health IT product, the health IT
1848(a)(7)(B) of the Act to provide that the CY 2018 performance period or
the Secretary shall exempt an eligible developer is required to notify all
during CY 2017, the MIPS eligible potentially affected customers in a
professional from the application of the clinician may qualify for this exception.
payment adjustment under section timely manner.
In addition, we are proposing that the We further note that in comparison to
1848(a)(7)(A) of the Act with respect to MIPS eligible clinician must
a year, subject to annual renewal, if the termination actions taken by ONC and
demonstrate in their application and ONCACBs, a health IT developer may
Secretary determines that compliance through supporting documentation if
with the requirement for being a voluntarily withdraw a certification that
available that the MIPS eligible clinician is in good standing under the ONC
meaningful EHR user is not possible made a good faith effort to adopt and
because the CEHRT used by such Health IT Certification Program. A
implement another CEHRT in advance voluntary withdrawal may be the result
professional has been decertified under of the performance period. We are
ONCs Health IT Certification Program. of the health IT developer going out of
proposing a MIPS eligible clinician business, the developer no longer
Section 1848(o)(2)(D) of the Act, as seeking to qualify for this exception
amended by section 4002(b)(1)(B) of the supporting the product, or for other
would submit an application in the form reasons that are not in response to
21st Century Cures Act, states in part and manner specified by us by
that the provisions of section ONCACB surveillance, ONC direct
December 31st of the performance review, or a finding of non-conformity
1848(a)(7)(B) of the Act shall apply to period, or a later date specified by us.
assessments of MIPS eligible clinicians by ONC or an ONCACB.5 In such
We believe that applying the instances, ONC will list these products
with respect to the advancing care exception in this way is an appropriate
information performance category in an on the Inactive Certificates 6 Web
application of the provisions of section
appropriate manner which may be page of the CHPL.
1848(a)(7)(B) of the Act to MIPS eligible We propose to amend 414.1380(c)(1)
similar to the manner in which such clinicians given that weighting the
provisions apply with respect to the and (2) of the regulation text to reflect
advancing care information performance
payment adjustment made under these proposals. We are seeking
category to zero percent is similar in
section 1848(a)(7)(A) of the Act. comments on these proposals.
effect to an exemption from the
We are proposing that a MIPS eligible requirements of that performance (b) Hospital-Based MIPS Eligible
clinician may demonstrate through an category. Under the Medicare EHR Clinicians
application process that reporting on the Incentive Program an approved
measures specified for the advancing In the CY 2017 Quality Payment
hardship exception exempted an EP Program final rule (81 FR 77238 through
care information performance category from the payment adjustment. We
is not possible because the CEHRT used 77240, we defined a hospital-based
believe that weighting the advancing MIPS eligible clinician as a MIPS
by the MIPS eligible clinician has been care information performance category
decertified under ONCs Health IT eligible clinician who furnishes 75
to zero percent is similar in effect to an percent or more of his or her covered
Certification Program. We are proposing exemption from the requirements of that
that if the MIPS eligible clinicians professional services in sites of services
performance category. identified by the Place of Service (POS)
demonstration is successful and an The ONC Health IT Certification
exception is granted, we would assign a codes used in the HIPAA standard
Program: Enhanced Oversight and
zero percent weighting to the advancing transaction as an inpatient hospital
Accountability final rule (EOA final
care information performance category rule) (81 FR 72404), effective December (POS 21), on campus outpatient hospital
in the MIPS final score for the MIPS 19, 2016, created a regulatory
3 https://questions.cms.gov/faq.php?isDept=
payment year. In accordance with framework for the ONCs direct review 0&search=decertify&searchType=keyword&
section 1848(a)(7)(B) of the Act, the of health information technology (health submitSearch=1&id=5005.
exception would be subject to annual IT) certified under the ONC Health IT 4 The list is available at https://chpl.healthit.gov/
renewal, and in no case may a MIPS Certification Program, including, when #/decertifications/products.
5 For further descriptions of certification statuses,
eligible clinician be granted an necessary, requiring the correction of
please consult the CHPL Public User Guide.
exception for more than 5 years. We are non-conformities found in health IT 6 The Inactive Certificates Web page is
proposing this exception would be certified under the Program and/or available at https://chpl.healthit.gov/#/
available beginning with the CY 2018 terminating certifications issued to decertifications/inactive.
(POS 22) or emergency room (POS 23) advancing care information measures (d) Scoring for MIPS Eligible Clinicians
setting, based on claims for a period should they determine that these in Group Practices
prior to the performance period as measures are applicable and available to
specified by CMS. them; however, we noted that if they In any of the situations described in
We are proposing to modify our choose to report, they will be scored on the sections above, we would assign a
policy to include covered professional the advancing care information zero percent weighting to the advancing
services furnished by MIPS eligible performance category like all other care information performance category
clinicians in an off-campus-outpatient in the MIPS final score for the MIPS
MIPS eligible clinicians and the
hospital (POS 19) in the definition of payment year if the MIPS eligible
performance category will be given the
hospital-based MIPS eligible clinician. clinician meets certain specified
weighting prescribed by section
POS 19 was developed in 2015 in order requirements for this weighting. We
to capture the numerous physicians that 1848(q)(5)(E) of the Act regardless of
noted that these MIPS eligible clinicians
are paid for a portion of their services their advancing care information
may choose to submit advancing care
in an off campus-outpatient hospital performance category score.
information measures; however, if they
versus an on campus-outpatient We stated that this approach is choose to report, they will be scored on
hospital, (POS 22). We also believe that appropriate for the first MIPS the advancing care information
these MIPS eligible clinicians would not performance period based on the performance category like all other
typically have control of the payment consequences associated with MIPS eligible clinicians and the
development and maintenance of their reporting, the fact that many of these performance category will be given the
EHR systems, just like those who bill types of MIPS eligible clinicians may weighting prescribed by section
using POS 22. We propose to add POS lack experience with EHR use, and our 1848(q)(5)(E) of the Act regardless of
19 to our existing definition of a current uncertainty as to whether we their advancing care information
hospital-based MIPS eligible clinician have adopted sufficient measures that performance category score. This policy
beginning with the performance period includes MIPS eligible clinicians
are applicable and available to these
in 2018.
We invite comment on this proposal. types of MIPS eligible clinicians. We choosing to report as part of a group
noted that we would use the first MIPS practice or part of a virtual group.
(c) Nurse Practitioners, Physician performance period to further evaluate Group practices as defined at
Assistants, Clinical Nurse Specialists, the participation of these MIPS eligible 414.1310(e)(1) are required to
and Certified Registered Nurse clinicians in the advancing care aggregate their performance data across
Anesthetists information performance category and the TIN in order for their performance
In the CY 2017 Quality Payment would consider for subsequent years to be assessed as a group (81 FR 77058).
Program final rule (81 FR 7724377244), whether the measures specified for this Additionally, groups that elect to have
we discussed our belief that certain category are applicable and available to their performance assessed as a group
types of MIPS eligible clinicians (NPs, these MIPS eligible clinicians. At this will be assessed as a group across all
PAs, CNSs, and CRNAs) may lack time we have no additional information four MIPS performance categories. By
experience with the adoption and use of because the first MIPS performance reporting as part of a group practice,
CEHRT. Because many of these non- period is currently underway, and thus MIPS eligible clinicians are subscribing
physician clinicians are not eligible to we propose the same policy for NPs, to the data reporting and scoring
participate in the Medicare or Medicaid requirements of the group practice. We
PAs, CRNAs, and CNSs for the 2018
EHR Incentive Program, we stated that
performance period as well. We still note that the data submission criteria for
we have little evidence as to whether
intend to evaluate the participation of groups reporting advancing care
there are sufficient measures applicable
these MIPS eligible clinicians in the information performance category
and available to these types of MIPS
eligible clinicians under the advancing advancing care information performance described in the CY 2017 Quality
care information performance category. category for 2017 and expect to adopt Payment Program final rule (81 FR
We established a policy under section measures applicable and available to 77215) state that group data should be
1848(q)(5)(F) of the Act to assign a them in subsequent years. aggregated for all MIPS eligible
weight of zero to the advancing care clinicians within the group practice.
We are seeking comment on how the
information performance category in the This includes those MIPS eligible
advancing care information performance
MIPS final score if there are not clinicians who may qualify for a zero
category could be applied to NPs, PAs,
sufficient measures applicable and percent weighting of the advancing care
CRNAs, and CNSs in future years of
available to NPs, PAs, CRNAs, and information performance category due
MIPS, and the types of measures that
CNSs. We will assign a weight of zero to the circumstances as described above,
would be applicable and available to
only in the event that an NP, PA, CRNA, such as a significant hardship or other
these types of MIPS eligible clinicians.
or CNS does not submit any data for any type of exception, hospital-based or
In addition, through the Call for
of the measures specified for the ASC-based status, or certain types of
Measures Process we are seeking new
advancing care information performance non-physician practitioners (NPs, PAs,
measures that may be more broadly
category. We encouraged all NPs, PAs, CNSs, and CRNAs). If these MIPS
applicable to these additional types of
CRNAs, and CNSs to report on these eligible clinicians report as part of a
MIPS eligible clinicians in future group practice or virtual group, they
measures to the extent they are
program years. For more information on will be scored on the advancing care
applicable and available, however, we
the Call for Measures, see https:// information performance category like
understand that some NPs, PAs, CRNAs,
and CNSs may choose to accept a www.cms.gov/Medicare/Quality- all other MIPS eligible clinicians and
weight of zero for this performance Initiatives-Patient-Assessment- the performance category will be given
category if they are unable to fully Instruments/MMS/ the weighting prescribed by section
report the advancing care information CallForMeasures.html. 1848(q)(5)(E) of the Act regardless of the
measures. These MIPS eligible We are inviting public comment on group practices advancing care
clinicians may choose to submit these proposals. information performance category score.
(e) Timeline for Submission of deadline for the CY 2018 performance measures. We specified that we will
Reweighting Applications period, March 31, 2019. post the list of MIPS APMs prior to the
We request comments on these first day of the MIPS performance year
In the CY 2017 Quality Payment proposals. for each year (81 FR 77250). We
Program final rule (81 FR7724077243), finalized in the regulation at
we established the timeline for the g. APM Scoring Standard for MIPS
414.1370(b) that for a new APM to be
submission of applications to reweight Eligible Clinicians in MIPS APMs
a MIPS APM, its first performance year
the advancing care information (1) Overview must start on or before the first day of
performance category in the MIPS final the MIPS performance year. A list of
score to align with the data submission Under section 1848(q)(1)(C)(ii)(1) of
the Act, Qualifying APM Participants MIPS APMs is available at
timeline for MIPS. We established that www.qpp.cms.gov.
all applications for reweighting the (QPs) are not MIPS eligible clinicians
and are thus excluded from MIPS We established in the regulation at
advancing care information performance 414.1370(c) that the MIPS performance
category be submitted by the MIPS reporting requirements and payment
adjustments. Similarly, under section year under 414.1320 of the regulations
eligible clinician or designated group applies for the APM scoring standard.
representative in the form and manner 1848(q)(1)(c)(ii)(II) of the Act, Partial
We finalized that under section
specified by us. All applications may be Qualifying APM Participants (Partial
414.1370(f) of our regulations on the
submitted on a rolling basis, but must be QPs) are also not MIPS eligible APM scoring standard, MIPS eligible
received by us no later than the close of clinicians unless they opt to report and clinicians will be scored at the APM
the submission period for the relevant be scored under MIPS. All other eligible Entity group level and each eligible
performance period, or a later date clinicians, including those participating clinician will receive the APM Entity
specified by us. An application would in MIPS APMs, are MIPS eligible groups final score. The MIPS payment
need to be submitted annually to be clinicians and subject to MIPS reporting adjustment is applied at the TIN/NPI
considered for reweighting each year. requirements and payment adjustments level for each of the MIPS eligible
unless they are excluded on another clinicians in the APM Entity. The MIPS
The Quality Payment Program basis such as being newly enrolled in
Exception Application will be used to final score is comprised of the four
Medicare or not exceeding the low MIPS performance category scores, as
apply for the following exceptions: volume threshold.
Insufficient Internet Connectivity; described in our regulation at
In the CY 2017 Quality Payment 414.1370(g): quality, cost,
Extreme and Uncontrollable Program final rule (81 FR 7724677269,
Circumstances; Lack of Control over the improvement activities, and advancing
77543), we finalized the APM scoring care information. Both the Medicare
Availability of CEHRT; Decertification standard, which is designed to reduce
of CEHRT; and Small Practice. Shared Savings Program and Next
reporting burden for participants in Generation ACO Model are MIPS APMs
We are proposing to change the certain APMs by minimizing the need for the CY 2017 performance year. For
submission deadline for the application for them to make duplicative data these two MIPS APMs, in accordance
as we believe that aligning the data submissions for both MIPS and their with our regulation at 414.1370(h), the
submission deadline with the respective APMs. We also sought to MIPS performance category scores are
reweighting application deadline could ensure that eligible clinicians in APM weighted as follows: Quality at 50
disadvantages MIPS eligible clinicians. Entities that participate in certain types percent; cost at zero percent;
We are proposing to change the of APMs that assess their participants improvement activities at 20 percent;
submission deadline for the CY 2017 on quality and cost are assessed as and advancing care information at 30
performance period to December 31, consistently as possible across MIPS percent of the final score. For all other
2017, or a later date specified by us. We and their respective APMs. Given that MIPS APMs for the CY 2017
believe this change would help MIPS many APMs already assess their performance year, quality and cost are
eligible clinicians by allowing them to participants on cost and quality of care each weighted at zero percent,
learn whether their application is and require engagement in certain improvement activities at 25 percent,
approved prior to the data submission improvement activities, we believe that and advancing care information at 75
deadline for the CY 2017 performance without the APM scoring standard, percent of the final score.
period, March 31, 2018. We plan to have misalignments could be quite common As explained in the following
the application available in mid-2017. between the evaluation of performance sections, we propose to: Add an APM
We encourage MIPS eligible clinicians under the terms of the APM and participant assessment date for full TIN
to apply early as we expect to process evaluation of performance on measures APMs; add the CAHPS for ACOs survey
the applications on a rolling basis. We and activities under MIPS. to the Shared Savings Program and Next
note that if a MIPS eligible clinician In the CY 2017 Quality Payment Generation ACO quality measures
submits data for the advancing care Program final rule (81 FR 77249), we included for scoring under the MIPS
information category after an identified the types of APMs for which APM quality performance category;
application has been submitted, the data the APM scoring standard would apply define Other MIPS APMs; and add
would be scored, the application would as MIPS APMs. We finalized that to be scoring for quality improvement to the
be considered voided and the advancing a MIPS APM, an APM must satisfy the MIPS APM quality performance
care information performance category following criteria: (1) APM Entities category for MIPS APMs beginning in
would not be reweighted. participate in the APM under an 2018. We also propose a Quality
We further propose that the agreement with CMS or by law or Payment Program 2018 performance
submission deadline for the 2018 regulation; (2) the APM requires that year quality scoring methodology for
performance period will be December APM Entities include at least one MIPS Other MIPS APMs, and describe the
31, 2018, or a later date as specified by eligible clinician on a Participation List; scoring methodology for quality
us. We believe this would help MIPS and (3) the APM bases payment improvement for Other MIPS APMs as
eligible clinicians by allowing them to incentives on performance (either at the applicable.
learn whether their application is APM Entity or eligible clinician level) In reviewing these proposals, we
approved prior to the data submission on cost/utilization and quality remind readers that the APM scoring
standard is built upon the generally generally applicable MIPS reporting and scoring under the generally applicable
applicable MIPS scoring standard, but scoring criteria. MIPS scoring standard when they were
provides for special policies to address We will continue to use the three part of the MIPS APM for only a very
the unique circumstances of MIPS assessment dates of March 31, June 30, limited portion of the performance year.
eligible clinicians who are in APM and August 31 to identify MIPS eligible That is, for MIPS APMs that allow split
Entities participating in MIPS APMs. clinicians who are on an APM Entitys TIN participation, it would be possible
For the cost, improvement activities, Participation List and determine the for eligible clinicians to briefly join a
and advancing care information APM Entity group that is used for MIPS APM principally in order to
performance categories, unless a purposes of the APM scoring standard. benefit from the APM scoring standard,
separate policy has been established or Beginning in the 2018 performance year, despite having limited opportunity to
is being proposed for the APM scoring we propose to add a fourth assessment contribute to the APM Entitys
standard, the generally applicable MIPS date of December 31 to identify those performance in the MIPS APM. In
policies would be applicable. MIPS eligible clinicians who participate contrast, we believe MIPS eligible
Additionally, unless we include a in a full TIN APM. We propose to define clinicians would be less likely to join a
proposal to adopt a unique policy for full TIN APM at 414.1305 to mean an full TIN APM principally to avail
the APM scoring standard, we propose APM where participation is determined themselves of the APM scoring
to adopt the same generally applicable at the TIN level, and all eligible standard, since doing so would require
MIPS policies proposed elsewhere in clinicians who have assigned their either that the entire TIN join the MIPS
this proposed rule, and would treat the billing rights to a participating TIN are APM or the administratively
APM Entity group as the group for therefore participating in the APM. An burdensome act of the eligible clinician
purposes of MIPS. For the quality example of a full TIN APM is the Shared reassigning their billing rights to the
performance category, however, the Savings Program which requires all TIN of an entity participating in the full
APM scoring standard we propose is individuals and entities that have TIN APM.
presented as a separate, unique reassigned their right to receive We will continue to use only the three
standard, and therefore generally Medicare payment to the TIN of an ACO dates of March 31, June 30, and August
applicable MIPS policies would not be participant to participate in the ACO 31 to determine, based on Participation
applied to the quality performance and comply with the requirements of Lists, the MIPS eligible clinicians who
category under the APM scoring the Shared Savings Program. participate in MIPS APMs that are not
standard unless specifically stated. We If an eligible clinician elects to full TIN APMs. We seek comment on
seek comment on whether there may be reassign their billing rights to a TIN the proposed addition of the fourth date
potential conflicts or inconsistencies participating in a full TIN APM, the of December 31 to assess Participation
between the generally applicable MIPS eligible clinician is necessarily Lists to identify MIPS eligible clinicians
policies and those under the APM participating in the full TIN APM. We who participate in MIPS APMs that are
scoring standard, particularly where propose to add this fourth date of full TIN APMs for purposes of the APM
these could impact our goals to reduce December 31 only for eligible clinicians scoring standard.
duplicative and potentially incongruous in a full TIN APM, and only for
purposes of applying the APM scoring (3) Calculating MIPS APM Performance
reporting requirements and performance Category Scores
evaluations that could undermine our standard. We are not proposing to use
ability to test or evaluate MIPS APMs, this additional assessment date of In the CY 2017 Quality Payment
or whether certain generally applicable December 31 for purposes of QP Program final rule, we established a
MIPS policies should be made explicitly determinations. Therefore, we propose scoring standard for MIPS eligible
applicable to the APM scoring standard. to amend 414.1370(e) to identify the clinicians participating in MIPS APMs
four assessment dates that would be to reduce participant reporting burden
(2) Assessment Dates for Inclusion of used to identify the APM Entity group by reducing the need for eligible
MIPS Eligible Clinicians in APM Entity for purposes of the APM scoring clinicians participating in these types of
Groups Under the APM Scoring standard, and to specify that the APMs to make duplicative data
Standard December 31 date would be used only submissions for both MIPS and their
In the CY 2017 Quality Payment to identify eligible clinicians on the respective APMs (81 FR 77246 through
Program final rule, we specified in the APM Entitys Participation List for a 77271). In accordance with section
regulation at 414.1370(e) that the APM MIPS APM that is a full TIN APM in 1848(q)(1)(D)(i) of the Act, we proposed
Entity group for purposes of scoring order to add them to the APM Entity to assess the performance of a group of
under the APM scoring standard is group that is scored under the APM MIPS eligible clinicians in an APM
determined in the manner prescribed at scoring standard. Entity that participates in one or more
414.1425(b)(1), which provides that We propose to use this fourth MIPS APMs based on their collective
eligible clinicians who are on a assessment date of December 31 to performance as an APM Entity group, as
Participation List on at least one of three extend the APM scoring standard to defined at 414.1305.
dates (March 31, June 30, and August only those MIPS eligible clinicians In addition to reducing reporting
31) would be considered part of the participating in MIPS APMs that are full burden, we sought to ensure that
APM Entity group. Under these TIN APMs, ensuring that an eligible eligible clinicians in MIPS APMs are not
regulations, MIPS eligible clinicians clinician who joins the full TIN APM assessed in multiple ways on the same
who are not on a Participation List on late in the performance year would be performance activities. Depending on
one of these three assessment dates are scored under the APM scoring standard. the terms of the particular MIPS APM,
not scored under the APM scoring We considered proposing to use the we believe that misalignments could be
standard. Instead, they would need to fourth assessment date more broadly for common between the evaluation of
submit data to MIPS through one of the all MIPS APMs. However, we believe performance on quality and cost under
MIPS data submission mechanisms and that this approach would have allowed MIPS versus under the terms of the
their performance would be assessed MIPS eligible clinicians to APM. We believe requiring eligible
either as individual MIPS eligible inappropriately leverage the fourth clinicians in MIPS APMs to submit data,
clinicians or as a group according to the assessment date to avoid reporting and be scored on measures, and be subject
to payment adjustments that are not would vary based on the unique APM performance category beginning with
aligned between MIPS and an APM Entity characteristics such as which and the 2018 MIPS performance year.
could potentially undermine the how many eligible clinicians comprise We seek comment on this proposal.
validity of testing or performance an APM Entity group. We believe that
evaluation under the APM. We also with an APM Entitys finite resources (b) Quality Performance Category
believe imposition of MIPS reporting for engaging in efforts to improve (i) Web Interface Reporters: Shared
requirements would result in reporting quality and lower costs for a specified Savings Program and Next Generation
activity that provides little or no added beneficiary population, measurement of ACO Model
value to the assessment of eligible the population identified through the
clinicians, and could confuse eligible (A) Quality Measures
APM must take priority in order to
clinicians as to which CMS incentives ensure that the goals and the model We finalized in the CY 2017 Quality
should take priority over others in evaluation associated with the APM are Payment Program final rule that under
designing and implementing care as clear and free of confounding factors the APM scoring standard, participants
improvement activities. as possible. The potential for different, in the Shared Savings Program and Next
(a) Cost Performance Category conflicting results across APMs and Generation ACO Model would be
MIPS assessments may create assessed for the purposes of generating
In the CY 2017 Quality Payment uncertainty for MIPS eligible clinicians a MIPS APM quality performance
Program final rule, for MIPS eligible who are attempting to strategically category score based exclusively on
clinicians participating in MIPS APMs, transform their respective practices and quality measures submitted using the
we used our authority to waive succeed under the terms of the APM. CMS Web Interface (81 FR 77256 and
requirements under the Medicare statute We are not proposing changes to these 77261). In the CY 2017 Quality Payment
to reduce the scoring weight for the cost policies. Program final rule, we recognized that
performance category to zero (81 FR
We welcome comment on our ACOs in both the Shared Savings
77258, 77262, and 77266). We did this
proposal to continue to waive the Program and Next Generation ACO
for MIPS APMs authorized under
weighting of the cost performance Model use the CMS Web Interface to
section 1115A of the Act using our
category for the 2020 payment year submit data on quality measures, and
authority under section 1115A(d)(1) of
forward. that the measures they would report
the Act to waive the requirement under
were also MIPS measures for 2017. For
section 1848(q)(5)(E)(i)(II) of the Act that (i) Measuring Improvement in the Cost
specifies the scoring weight for the cost the Shared Savings Program and the
Performance Category Next Generation ACO Model, we
performance category. Having reduced
the cost performance category weight to In setting performance standards with finalized a policy to use quality
zero, we further used our authority respect to measures and activities in measures and data submitted by the
under section 1115A(d)(1) of the Act to each MIPS performance category, participant ACOs to the CMS Web
waive the requirements under sections section 1848(q)(3)(B) of the Act requires Interface (as required under the rules for
1848(q)(2)(B)(ii) and 1848(q)(2)(A)(ii) of us to consider, historical performance these initiatives) and MIPS benchmarks
the Act to specify and use, respectively, standards, improvement, and the for these measures to score quality for
cost measures in calculating the MIPS opportunity for continued MIPS eligible clinicians in these MIPS
final score for MIPS eligible clinicians improvement. Section 1848(q)(5)(D)(i)(I) APMs at the APM Entity level (81 FR
participating in Other MIPS APMs (81 requires us to introduce the 77256, 77261). For these MIPS APMs,
FR 77261 through 77262 and 77265 measurement of improvement into which we refer to as Web Interface
through 77266). Similarly, for MIPS performance scores in the cost reporters going forward, we established
eligible clinicians participating in the performance category for MIPS eligible that quality performance data that are
Medicare Shared Savings Program, we clinicians for the 2020 MIPS Payment not submitted to the CMS Web Interface,
used our authority under section 1899(f) Year if data sufficient to measure for example the CAHPS for ACOs
of the Act to waive the same improvement are available. Section survey and claims-based measures, will
requirements of section 1848 of the Act 1848(q)(5)(D)(i)(II) permits us to take not be included in the MIPS APM
for the MIPS cost performance category into account improvement in the case of quality performance category score for
(81 FR 77257 through 77258). We performance scores in other 2017.
finalized this policy because: (1) APM performance categories. Given that we (aa) Addition of New Measures
Entity groups are already subject to cost have in effect waivers of the scoring
and utilization performance assessment weight for the cost performance For the Shared Savings Program and
under the MIPS APMs; (2) MIPS APMs category, and of the requirement to Next Generation ACO Model, we
usually measure cost in terms of total specify and use cost measures in propose to score the CAHPS for ACOs
cost of care, which is a broader calculating the MIPS final score for survey, in addition to the CMS Web
accountability standard that inherently MIPS eligible clinicians participating in Interface measures that are used to
encompasses the purpose of the claims- MIPS APMs, and for the same reasons calculate the MIPS APM quality
based measures that have relatively that we initially waived those performance category score for the
narrow clinical scopes, and MIPS APMs requirements, we propose to use our Shared Savings Program and Next
that do not measure cost in terms of authority under section 1115A(d)(1) of Generation ACO Model, beginning in
total cost of care may depart entirely the Act for MIPS APMs authorized the 2018 performance year. The CAHPS
from MIPS measures; and (3) the under section 1115A of the Act and for ACOs survey is already required in
beneficiary attribution methodologies under section 1899(f) of the Act for the Shared Savings Program and Next
differ for measuring cost under APMs MIPS APMs under the Medicare Shared Generation ACO Model, and including
and MIPS, leading to an unpredictable Savings Program, to waive the the CAHPS for ACOs survey would
degree of overlap (for eligible clinicians requirement under section better align the measures on which
and for CMS) between the sets of 1848(q)(5)(D)(i)(I) of the Act to take participants in these MIPS APMs are
beneficiaries for which eligible improvement into account for assessed under the APM scoring
clinicians would be responsible that performance scores in the cost standard with the measures used to
assess participants quality performance the CAHPS for MIPS survey. Under our which describes the identical CAHPS
under the APM. proposal, the CAHPS for ACOs survey for MIPS survey and its scoring method
We did not initially propose to would be added to the total number of that will be used for MIPS in the 2018
include the CAHPS for ACOs survey as quality performance category measures performance year. We note that
part of the MIPS APM quality available for scoring in these MIPS although each question in the CAHPS
performance category scoring for the APMs. for ACOs survey can also be found in
Shared Savings Program and Next While the CAHPS for ACOs survey is the CAHPS for MIPS survey, the CAHPS
Generation ACO Model because we new to MIPS APM scoring, the CG for ACOs survey will have one fewer
believed that the CAHPS for ACOs CAHPS survey upon which it is based
survey question the SSM entitled
survey would not be collected and is also the basis for the CAHPS for MIPS
Between Visit Communication, which
scored in time to produce a MIPS survey, which was included on the
quality performance category score. MIPS final list for the 2017 performance has never been a scored measure with
However, operational efficiencies have year. For a further discussion of the the Medicare Shared Savings Program
recently been introduced that have CAHPS for ACOs survey, and the way CAHPS for ACOs Survey and which we
made it possible to score the CAHPS for it will be scored, we refer readers to believe to be inappropriate for use by
ACOs survey on the same timeline as II.C.6.b.(3)(a)(ii) of this proposed rule, ACOs.
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 ......... N/A ............... Patient/Caregiver Ex- Consumer Assessment of Healthcare Providers and Systems Agency for Healthcare
perience. (CAHPS) surveys for Accountable Care Organizations (ACOs) in the Research and Qual-
Medicare Shared Savings Program (SSP) and Next Generation ity (AHRQ)
ACOs 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 an 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 Providers.
Access to Specialists.
Health Promotion and Education.
Shared Decision Making.
Health Status/Functional Status.
Stewardship of Patient Resources.
(B) Calculating Quality Scores through the CMS Web Interface. (81 FR (D) Scoring Quality Improvement
77291 through 77294). We will assign
We refer readers to section Beginning in the CY 2018
two bonus points for reporting two or
II.C.7.a.(1)(h)(ii) of this proposed rule performance year, section
more outcome or patient experience
for our summary of finalized policies 1848(q)(5)(D)(i)(I) of the Act requires us
measures and one bonus point for
and proposed changes related to to score improvement for the MIPS
calculating the MIPS quality reporting any other high priority
measure, beyond the first high priority quality performance category for MIPS
performance category percent score for eligible clinicians, including those
MIPS eligible clinicians, including APM measure. We note that in addition to the
measures required by the APM to be participating in MIPS APMs, if data
Entity groups reporting through the sufficient to measure quality
CMS Web Interface. Those policies and submitted through the CMS Web
Interface, APM Entities in the Shared improvement are available. We propose
proposed changes in section to calculate the quality improvement
II.C.7.a.(1)(h)(ii) of this proposed rule Savings Program and Next Generation
score using the methodology described
would apply in the same manner under ACO Models must also report the
in section II.C.7.a.(1)(i) for scoring
the APM scoring standard except as CAHPS for ACOs survey and we
quality improvement for eligible
otherwise noted in this section of the propose that beginning for the 2020
clinicians submitting quality measures
proposed rule. However, we propose not payment year forward they may receive
via the CMS Web Interface. We believe
to subject MIPS APM Web Interface bonus points under the APM scoring
reporters to a 3 point floor because we aligning the scoring methodology used
standard for submitting that measure.
do not believe it is necessary to apply for all CMS Web Interface submissions
Participants in MIPS APMs, like all
this transition year policy to eligible will minimize confusion among MIPS
MIPS eligible clinicians, are also subject
clinicians participating in previously eligible clinicians receiving a MIPS
to the 10 percent cap on bonus points
established MIPS APMs. score, including those participating in
for reporting high priority measures.

MIPS APMs.
(C) Incentives to Report High Priority APM Entities reporting through the
Measures CMS Web Interface will only receive (E) Total Quality Performance Category
bonus points if they submit a high Score for CMS Web Interface Reporters
In the CY 2017 Quality Payment priority measure with a performance
Program final rule, we finalized that for rate that is greater than zero, provided We propose to calculate the total
CMS Web Interface reporters, we will that the measure meets the case quality percent score for MIPS eligible
apply bonus points based on the minimum requirements. clinicians using the CMS Web Interface
finalized set of measures reportable according to the methodology described
in section II.C.7.a.(1)(h)(2) of this in Other MIPS APMs, the weight for the performance data in order to generate a
proposed rule. quality performance category is zero (81 MIPS quality performance category
We seek comment on our proposed FR 77268). To avoid risking adverse score for APM Entities participating in
quality performance category scoring operational or program evaluation MIPS APMs beginning with the 2018
methodology for CMS Web Interface consequences for MIPS APMs while we performance year.
reporters. worked toward incorporating MIPS
(aa) APM Measures for MIPS
(ii) Other MIPS APMs APM quality measures into scoring for
future performance years, we used the In the CY 2017 Quality Payment
We propose to define the term Other authority provided by section Program final rule, we explained the
MIPS APM at 414.1305 as a MIPS 1115A(d)(1) of the Act to waive the concerns that led us to express our
APM that does not require reporting quality performance category weight intent to use the quality measures and
through the CMS Web Interface. We required under section 1848(q)(5)(E)(i)(I) data that apply in the MIPS APM for
propose to add this definition as we of the Act, and we indicated that with purposes of the APM scoring standard,
believe it will be useful in discussing the reduction of the quality performance including concerns about the
our policies for the APM scoring category weight to zero, it was application of multiple, potentially
standard. In the 2018 MIPS performance unnecessary to establish for MIPS APMs duplicative or inconsistent performance
period, Other MIPS APMs will include a final list of quality measures as assessments that could negatively
the Comprehensive ESRD Care Model, required under section 1848(q)(2)(D) of impact our ability to evaluate MIPS
the Comprehensive Primary Care Plus the Act or to specify and use quality APMs (81 FR 77246). Additionally, the
Model (CPC+), and the Oncology Care measures in determining the MIPS final quality and cost/utilization measures
Model. score for these MIPS eligible clinicians. that are used to calculate performance-
(A) Quality Measures As such, we further waived the based payments in MIPS APMs may
requirements under sections vary from one MIPS APM to another.
In the CY 2017 Quality Payment 1848(q)(2)(D), 1848(q)(2)(B)(i) and Factors such as the type and quantity of
Program final rule, we explained that 1848(q)(2)(A)(i) of the Act to establish a measures required, the MIPS APMs
current MIPS APMs have requirements final list of quality measures (using particular measure specifications, how
regarding the number of quality certain criteria and processes); and to frequently the measures must be
measures, measure specifications, as specify and use, respectively, quality reported, and the mechanisms used to
well as the measure reporting method(s) measures in calculating the MIPS final collect or submit the measures all add
and frequency of reporting, and have an score for the first MIPS performance to the diversity in the quality and cost/
established mechanism for submission year. utilization measures used to evaluate
of these measures to us within the In the CY 2017 Quality Payment performance among MIPS APMs. Given
structure of the specific MIPS APM. We Program final rule, we anticipated that these concerns and the differences
explained that operational beginning with the second MIPS between and among the quality
considerations and constraints performance year, the APM quality measures used to evaluate performance
interfered with our ability to use the measure data submitted to us during the within MIPS APMs as opposed to those
quality measure data from some MIPS MIPS performance year would be used used more generally under MIPS, we
APMs for the purpose of satisfying MIPS to derive a MIPS quality performance propose to use our authority under
data submission requirements for the score for APM Entities in all MIPS section 1115A(d)(1) of the Act to waive
quality performance category for the APMs. requirements under section
first performance year. We concluded We also anticipated that it may be 1848(q)(2)(D) of the Act, which requires
that there was insufficient time to necessary to propose policies and the Secretary to use certain criteria and
adequately implement changes to the waivers of requirements of the statute, processes to establish an annual MIPS
current MIPS APM quality measure data such as section 1848(q)(2)(D) of the Act, final list of quality measures from which
collection timelines and infrastructure to enable the use of non-MIPS quality all MIPS eligible clinicians may choose
in the first performance year to conduct measures in the quality performance measures for purposes of assessment,
a smooth hand-off to the MIPS system category score. We anticipated that by and instead to establish a MIPS APM
that would enable use of APM quality the second performance year we would quality measure list for purposes of the
measure data to satisfy the MIPS quality have had sufficient time to resolve APM scoring standard. The MIPS APM
performance category requirements in operational constraints related to use of quality measure list would be adopted
the first MIPS performance year (81 FR separate quality measure systems and to as the final list of MIPS quality
77264). Out of concern that subjecting adjust quality measure data submission measures under the APM scoring
MIPS eligible clinicians who participate timelines. Accordingly, we stated our standard, and would reflect the quality
in MIPS APMs to multiple, potentially intention to, in future rulemaking, use measures that are used to evaluate
duplicative or inconsistent performance our section 1115A(d)(1) waiver performance on quality within each
assessments could undermine the authority to establish that the quality MIPS APM.
validity of testing or performance measures and data that are used to The MIPS APM quality measure list
evaluation under the MIPS APMs; and evaluate performance for APM Entities we propose in Table 13, would define
that there was insufficient time to make in MIPS APMs would be used to distinct measure sets for participants in
adjustments in operationally complex calculate a MIPS quality performance each MIPS APM for purposes of the
systems and processes related to the score under the APM scoring standard. APM scoring standard, based on the
alignment, submission and collection of We have since designed the means to measures that are used by the APM, and
APM quality measures for purposes of overcome the operational constraints for which data will be collected by the
MIPS, we used our authority under that prevented us from scoring quality close of the MIPS submission period.
section 1115A(d)(1) to waive certain under the APM scoring standard in the The measure sets on the MIPS APM
requirements of section 1848(q). first performance year, and we propose measure list would represent all
We finalized that for the first MIPS to adopt quality measures for use under possible measures which may
performance year only, for MIPS eligible the APM scoring standard, and begin contribute to an APM Entitys MIPS
clinicians participating in APM Entities collecting MIPS APM quality measure score for the MIPS quality performance
category, and may include measures We believe using the Other MIPS APM nor MIPS has a benchmark
that are the same as or similar to those APMs quality measure data that have available for a reported measure, the
used by MIPS. However, measures may been submitted no later than the close APM Entity that reported that measure
ultimately not be used for scoring if a of the MIPS submission period and have would receive a null score for that
measures data becomes inappropriate been processed and made available to measures achievement points, and the
or unavailable for scoring; for example, MIPS for scoring in time to calculate a measure would be removed from both
if a measures clinical guidelines are MIPS quality performance category the numerator and the denominator of
changed or the measure is otherwise score is consistent with our intent to the quality performance category
modified by the APM during the decrease duplicative reporting for MIPS percentage.
performance year, the data collected eligible clinicians who would otherwise
(C) Calculating the Quality Performance
during that performance year would not need to report quality measures to both
Category Percent Score
be uniform, and as such may be MIPS and their APM. Going forward,
rendered unusable for purposes of the these are the measures to which we are Eligible clinicians who participate in
APM scoring standard (See Tables 14, referring when we limit scoring to Other MIPS APMs are subject to specific
15, and 16). measures that are available near the quality measure reporting requirements
close of the MIPS submission period. within these APMs. To best align with
(B) Measure Requirements for Other APM design and objectives, we propose
MIPS APMs (cc) 20 Case Minimum that the minimum number of required
Because the quality measure sets for We also believe that a 20 case measures to be reported for the APM
each Other MIPS APM are unique, we minimum, in alignment with the one scoring standard would be the
propose to calculate the MIPS quality finalized generally under MIPS in the minimum number of quality measures
performance category score using APM- CY 2017 Quality Payment Program final that are required by the MIPS APM and
specific quality measures. For purposes rule (81 FR 77288), is necessary to are collected and available in time to be
of the APM scoring standard, we will ensure the reliability of the measure included in the calculation for the APM
score only measures that: (1) Are tied to data submitted, as explained the CY Entity score under the APM scoring
payment as described under the terms of 2017 Quality Payment Program final standard. For example, if an Other MIPS
the APM, (2) are available for scoring rule. APM requires participating APM
near the close of the MIPS submission As under the general policy for MIPS, Entities to report nine of 14 quality
period, (3) have a minimum of 20 cases when an APM Entity reports a quality measures by a specific date and the
available for reporting, and (4) have an measure that includes less than 20 APM Entity misses the MIPS
available benchmark. We discuss each cases, that measure would receive a null submission deadline, then for the
of these requirements for Other MIPS score for that measures achievement purposes of calculating an APM Entity
APM quality measures below. points, and the measure would be quality performance category score, the
removed from both the numerator and APM Entity would receive a zero for
(aa) Tied to Payment the denominator of the MIPS quality those measures. An APM Entity that
For purposes of the APM scoring performance category percentage. We does not submit any APM quality
standard, we will consider a measure to propose to apply this policy under the measures by the MIPS submission
be tied to payment if an APM Entity APM scoring standard. deadline would receive a zero for its
group will receive a payment MIPS APM quality performance
adjustment or other incentive payment (dd) Available Benchmark
category percent score for the
under the terms of the APM, based on An APM Entitys score on each performance year.
the APM Entitys performance on the quality measure would be calculated in We propose that if an APM Entity
measure. part by comparing the APM Entitys submits some, but not all of the
performance on the measure with a measures required by the MIPS APM by
(bb) Available for Scoring benchmark performance score. the close of the MIPS submission
Some MIPS APM quality measure Therefore, we would need all scored period, the APM Entity would receive
results are not available until late in the measures to have a benchmark available points for the measures that were
calendar year subsequent to the MIPS by the time that the MIPS quality submitted, but would receive a score of
performance year, which would prevent performance category score is zero for each remaining measure
us from including them in the MIPS calculated, in order to make that between the number of measures
APM quality performance category score comparison. reported and the number of measures
due to the larger programmatic We propose that, for the APM scoring required by the APM that were available
timelines for providing MIPS eligible standard, the benchmark score used for for scoring.
clinician performance feedback by July a quality measure would be the For example, if an APM Entity in the
and issuing budget-neutral MIPS benchmark used in the MIPS APM for above hypothetical MIPS APM submits
payment adjustments. Consequently, we calculation of the performance based quality performance data on three of the
propose to only use the MIPS APM payments, where such a benchmark is APMs measures, instead of the required
quality measure data that are submitted available. If the APM does not produce nine, the APM Entity would receive
by the close of the MIPS submission a benchmark score for a reportable quality points in the APM scoring
period and are available for scoring in measure that is included on the APM standard quality performance category
time for inclusion to calculate a MIPS measures list, we would use the percent score for the three measures it
quality performance category score. benchmark score for the measure that is submitted, but would receive zero
Measures are to be submitted according used for the MIPS quality performance points for each of the six remaining
to requirements under the terms of the category generally (outside of the APM measures that were required under the
APM; the measure data will then be scoring standard) for that performance terms of the MIPS APM. On the other
aggregated and prepared for submission year, provided the measure hand, if an APM Entity reports on more
to MIPS for the purpose of creating a specifications for the measure are the than the minimum number of measures
MIPS quality performance category same under both the MIPS final list and required to be reported under the MIPS
score. the APM measures list. If neither the APM and the measures meet the other
criteria for scoring, only the measures for a quality measure would be the such. For example, if a model only
with the highest scores, up to the benchmark used by the MIPS APM for requires that an APM Entity must
number of measures required to be calculation of the performance based surpass a threshold and does not
reported under the MIPS APM, would payments within the APM, if possible, measure APM Entities on performance
be counted; however, any bonus points in order to best align the measure beyond surpassing a threshold, we
earned by reporting on measures beyond performance outcomes between the would not consider such a measure to
the minimum number of required APM and MIPS programs. If the MIPS measure performance on a continuum.
measures would be awarded. APM does not produce a benchmark We propose to score quality measure
If a measure is reported but fails to score for a reportable measure that will performance under the APM scoring
meet the 20 case minimum or does not be available at the close of the MIPS standard using a percentile distribution,
have a benchmark available, there submission period, the benchmark score separated by decile categories, as
would be a null score for that measure, for the measure that is used for the described in the finalized MIPS quality
and it would be removed from both the MIPS quality performance category scoring methodology (81 FR 77282
numerator and the denominator, so as generally for that performance year through 77284). For each benchmark,
not to negatively affect the APM Entitys would be used, provided the measure we will calculate the decile breaks for
quality performance category score. specifications are the same for both. If measure performance and assign points
We propose to assign bonus points for neither the APM nor MIPS has a based on the benchmark decile range
reporting high priority measures or benchmark available for a reported into which the APM Entitys measure
measures with end-to-end CEHRT measure, the APM Entity that reported performance falls.
reporting as described for general MIPS that measure will receive a null score
scoring in the CY 2017 Quality Payment for that measures achievement points, We propose to use a graduated points-
Program final rule (81 FR 77297 through and the measure will be removed from assignment approach, where a measure
77299). both the numerator and the is assigned a continuum of points out to
denominator of the quality performance one decimal place, based on its place in
(aa) Quality Measure Benchmarks category percentage. the decile. For example, a raw score of
An APM Entitys MIPS quality We are proposing that for measures 55 percent would fall within the sixth
measure score will be calculated by that are pay for reporting or which do decile of 41.0 percent to 61.9 percent
comparing the APM Entitys not measure performance on a and would receive between 6.0 and 6.9
performance on a given measure with a continuum of performance, we will points.
benchmark performance score. We consider these measures to be lacking a We seek comment on this proposed
propose that the benchmark score used benchmark and they will be treated as method.
TABLE 11BENCHMARK DECILE DISTRIBUTION

Sample quality Graduated
Sample benchmark decile measure points
(%) (with no floor)
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
(bb) Assigning Quality Measure Points clinicians under the APM scoring example, end-to-end submission)
Based on Achievement standard are required to be submitted to according to the criteria described in
the APM under the terms of section II.C.7.a.(1) of this proposed rule.
For the APM scoring standard quality participation in the APM, and the MIPS For each Other MIPS APM, we propose
performance category, we propose that eligible clinicians do not select their to identify whether any of their
each APM Entity that reports on quality APM measures, there will be no cap on available measures meets the criteria to
measures would receive between 1 and topped out measures for MIPS APM receive a bonus, and add the bonus
10 achievement points for each measure participants being scored under the points to the quality achievement
reported that can be reliably scored APM scoring standard, which differs points. Further, we propose that the
against a benchmark, up to the number from the policy for other MIPS eligible total number of awarded bonus points
of measures that are required to be clinicians proposed at section may not exceed 10 percent of the APM
reported by the APM. Because measures II.C.7.a.(2)(c) of this proposed rule. Entitys total available achievement
that lack benchmarks or 20 reported Beginning in the 2018 MIPS points for the MIPS quality performance
cases are removed from the numerator performance year, we propose that APM category score.
and denominator of the quality Entities in MIPS APMs, like other MIPS To generate the APM Entitys quality
performance category percentage, it is eligible clinicians, would be eligible to performance category percentage,
unnecessary to include a point-floor for receive bonus points for the MIPS achievement points would be added to
scoring of Other MIPS APMs. Similarly, quality performance category for any applicable bonus points, and then
because the quality measures reported reporting on high priority measures or divided by the total number of available
by the MIPS APM for MIPS eligible measures submitted via CEHRT (for achievement points, with a cap of 100
percent. For more detail on the MIPS (E) Calculating Total Quality the advancing care information
quality performance category percentage Performance Category Score performance category.
score calculation, we refer readers to We propose that the APM Entitys (i) Special Circumstances
section II.C.7.a.(1) of this proposed rule. total quality performance category score
Under the APM scoring standard for As described in the CY 2017 Quality
would be equal to [(achievement points Payment Program final rule (81 FR
Other MIPS APMs, the number of + bonus points)/total available
available achievement points would be 7723877245), under the generally
achievement points] + quality applicable MIPS scoring standard, we
the number of measures required under improvement score. The APM Entitys
the terms of the APM and available for will assign a weight of zero percent to
total quality performance category score the advancing care information
scoring multiplied by ten. If, however, may not exceed 100 percent. We request
an APM Entity reports on a required performance category in the final score
comment on the above proposed quality for MIPS eligible clinicians who meet
measure that fails the 20 case minimum scoring methodology.
requirement, or which has no available specific criteria: hospital-based MIPS
We seek comment on the proposed eligible clinicians, MIPS eligible
benchmark for that performance year, quality performance category scoring
the measure would receive a null score clinicians who are facing a significant
methodology for APM Entities hardship, and certain types of non-
and all points from that measure would participating in Other MIPS APMs. physician practitioners (NPs, PAs,
be removed from both the numerator
(c) Improvement Activities Performance CRNAs, CNSs) who are MIPS eligible
and the denominator.
Category clinicians. In section II.C.7.a.(6) of this
For example, if an APM Entity reports proposed rule, we are also proposing to
on four out of four measures required to As finalized in the CY 2017 Quality include in this weighting policy ASC-
be reported by the MIPS APM, and Payment Program final rule, for all MIPS based MIPS eligible clinicians and MIPS
receives an achievement score of five on APMs we will assign the same eligible clinicians who are using
each and no bonus points, the APM improvement activities score to each decertified EHR technology.
Entitys quality performance category APM Entity based on the activities Under the APM scoring standard, we
percentage would be [(5 points 4 involved in participation in a MIPS propose that if a MIPS eligible clinician
measures) + 0 bonus points]/(4 APM. APM Entities will receive a who qualifies for a zero percent
measures 10 max available points), or minimum of one half of the total weighting of the advancing care
50 percent. If, however, one of those possible points. This policy is in information performance category in the
measures failed the 20 case minimum accordance with section final score is part of a TIN that includes
requirement or had no benchmark 1848(q)(5)(C)(ii) of the Act. In the event one or more MIPS eligible clinicians
available, that measure would have a that the assigned score does not who do not qualify for a zero percent
null value and would be removed from represent the maximum improvement weighting, we would not apply the zero
both the numerator and denominator to activities score, the APM Entity group percent weighting to the qualifying
create a quality performance category will have the opportunity to report MIPS eligible clinician, and the TIN
percentage of [(5 points 3 measures) + additional improvement activities to would still be required to report on
0 bonus points]/(3measures 10 max add points to the APM Entity level behalf of the group, although the TIN
available points), or 50 percent. score. would not need to report data for the
If an APM Entity fails to meet the 20 (d) Advancing Care Information qualifying MIPS eligible clinician. All
case minimum on all available APM Performance Category MIPS eligible clinicians in the TIN
measures, that APM Entity would have would count towards the TINs weight
its quality performance category score In the CY 2017 Quality Payment when calculating an aggregated APM
reweighted to zero, as described below. Program final rule, we finalized our Entity score for the advancing care
We request comment on the above policy to attribute one score to each information performance category.
proposals for calculating the quality MIPS eligible clinician in an APM If, however, the MIPS eligible
category percent score. Entity group by looking for both clinician is a solo practitioner and
individual and group TIN level data qualifies for a zero percent weighting, or
(D) Quality Improvement Scoring submitted for a MIPS eligible clinician, if all MIPS eligible clinicians in a TIN
Beginning in the 2018 performance and using the highest available score (81 qualify for the zero percent weighting,
year, we propose to score improvement FR 77268). We will then use these the TIN would not be required to report
as well as achievement in the quality scores to create an APM Entitys score on the advancing care information
performance category. based on the average of the highest performance category, and if the TIN
For the APM scoring standard, we scores available for all MIPS eligible chooses not to report that TIN would be
propose that the quality improvement clinicians in the APM Entity group. If an assigned a weight of 0 when calculating
percentage points would be awarded individual or TIN did not report on the the APM Entitys advancing care
based on the following formula: advancing care information performance information performance category score.
category, they will contribute a zero to If advancing care information data are
Quality Improvement Score = (Absolute the APM Entitys aggregate score. Each reported by one or more TINs in an
Improvement/Previous Year Quality MIPS eligible clinician in an APM APM Entity, an advancing care
Performance Category Percent Score Entity group will receive one score, information performance category score
Prior to Bonus Points)/10 weighted equally with the scores of will be calculated for, and will be
For a more detailed discussion of every other MIPS eligible clinician in applicable to, all MIPS eligible
improvement scoring for the quality the APM Entity group, and we will use clinicians in the APM Entity group. If
performance category under the APM these to calculate a single APM Entity- all MIPS eligible clinicians in all TINs
scoring standard, we refer readers to the level advancing care information in an APM Entity group qualify for a
discussion on calculating improvement performance category score. zero percent weighting of have the
at the quality performance category We refer readers to section II.C.6.f.(6) advancing care information performance
level for MIPS at section II.C.7.a.(1)(i) of of this proposed rule for our summary category, or in the case of a solo
this proposed rule. of proposed changes related to scoring practitioner who comprises an entire
APM Entity and qualifies for zero performance period and subsequent for all APM Entities in Other MIPS
percent weighting, the advancing care MIPS performance periods. Because the APMs. We propose these weights to
information performance category cost performance category would be align the Other MIPS APM performance
would be weighted at zero percent of reweighted to zero that weight would category weights with those assigned to
the final score, and the advancing care need to be redistributed to other the Web Interface reporters, which we
information performance categorys performance categories. We propose to adopted as explained in the CY 2017
weight would be redistributed to the use our authority under section Quality Payment Program final rule at
quality performance category. 1115A(d)(1) to waive requirements 81 FR 77262 through 77263. We believe
(4) Calculating Total APM Entity Score under sections 1848(q)(5)(E)(i)(I)(bb), it is appropriate to align the
1848(q)(5)(E)(i)(III) and performance category weights for APM
(a) Performance Category Weighting 1848(q)(5)(E)(i)(IV) of the Act that Entities in MIPS APMs that require
As discussed in section II.C.6.g.(3)(a) prescribe the weights, respectively, for reporting through the Web Interface
of this proposed rule, we propose to the quality, improvement activities, and with those in Other MIPS APMs. By
continue to use our authority to waive ACI performance categories. We propose aligning the performance category
sections 1848(q)(2)(B)(ii) and to weight the quality performance weights among all MIPS APMs, we
1848(q)(2)(A)(ii) of the Act to specify category score to 50 percent, the would create greater scoring parity
and use, respectively, cost measures; improvement activities performance among the MIPS eligible clinicians in
and to maintain the cost performance category to 20 percent, and the MIPS APMs who are being scored under
category weight of zero under the APM advancing care information performance the APM scoring standard. These
scoring standard for the 2018 category to 30 percent of the final score proposals are summarized in Table 12.
TABLE 12APM SCORING STANDARD PERFORMANCE CATEGORY WEIGHTSBEGINNING FOR 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.
Cost ............................... The APM Entity group will not be assessed on N/A ........................................................................ 0
cost under MIPS.
Improvement Activities .. MIPS eligible clinicians do not need to report im- CMS will assign the same improvement activities 20
provement activities data; if the CMS-assigned score to each APM Entity based on the activi-
improvement activities score is below the max- ties involved in participation in the MIPS APM.
imum improvement activities score APM Enti- APM Entities will receive a minimum of one
ties will have the opportunity to submit addi- half of the total possible points. In the event
tional improvement activities to raise the APM that the assigned score does not represent the
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 We 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 clinicians will be
averaged for a single APM Entity score.
It is possible that there could be removed due to changes in clinical category to zero, in accordance with
instances where an Other MIPS APM practice guidelines. In addition, as section 1848(q)(5)(F) of the Act.
has no measures available to score for explained in section II.C.6.g.(3)(d)(i) of If the quality performance category is
the quality performance category for a this proposed rule, the MIPS eligible reweighted to zero, we propose to
MIPS performance period; for example, clinicians in an APM Entity may qualify reweight the improvement activities and
it is possible that none of the Other for a zero percent weighting for the advancing care information performance
MIPS APMs measures would be advancing care information performance categories to 25 and 75 percent,
available for calculating a quality category. In such instances, under the respectively. If the advancing care
performance category score by or shortly APM scoring standard, we propose to information performance category is
after the close of the MIPS submission reweight the affected performance reweighted to zero, the quality
period because the measures were performance category weight would be
increased to 80 percent. These proposals

are summarized in Table 13.
TABLE 13APM SCORING STANDARD PERFORMANCE CATEGORY WEIGHTS FOR OTHER MIPS APMS WITH
PERFORMANCE CATEGORIES WEIGHTED TO 0BEGINNING FOR THE 2018 PERFORMANCE PERIOD
Performance
Performance category
category
MIPS performance weight (no ad-
APM entity submission requirement Performance category score weight
category vancing care
(no quality) information)
(%) (%)
Quality ....................... The APM Entity would not be assessed CMS will assign the same quality cat- 0 80
on 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 MIPS APM. ures.
Cost ........................... The APM Entity group will not be as- N/A ............................................................ 0 0
sessed on cost under MIPS.
Improvement Activi- MIPS eligible clinicians do not need to re- CMS will assign the same improvement 25 20
ties. port improvement activities data unless activities score to each APM Entity
the CMS-assigned improvement activi- group based on the activities involved
ties scores is below the maximum im- in participation in the MIPS APM.
provement 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 We will attribute the same score to each 75 0
mation. Entity group reports advancing care in- MIPS eligible clinician in the APM Enti-
formation to MIPS through either group ty group. This score will be the highest
TIN or individual reporting. score attributable to the TIN/NPI com-
bination of each MIPS eligible clinician,
which may be derived from either
group or individual reporting. The
scores attributed to each MIPS eligible
clinicians will be averaged for a single
APM Entity score.
We seek comment on the proposed (c) Small Practice Bonus the changes we are proposing for the
reweighting for APM Entities We believe an adjustment for eligible final score methodology.
participating in MIPS APMs. clinicians in small practices (referred to (5) MIPS APM Performance Feedback
(b) Risk Factor Score herein as the small practice bonus) is
appropriate to recognize barriers faced In the CY 2017 Quality Payment
Section 1848(q)(1)(G) of the Act by small practices, such as unique Program final rule (81 FR 77270), we
requires us to consider risk factors in challenges related to financial and other finalized that all MIPS eligible
our scoring methodology. Specifically, resources, environmental factors, and clinicians scored under the APM
that section provides that the Secretary, access to health information technology, scoring standard will receive
on an ongoing basis, shall, as the and to incentivize eligible clinicians in performance feedback as specified
small practices to participate in the under section 1848(q)(12) of the Act on
Secretary determines appropriate and
Quality Payment Program and to the quality and cost performance
based on individuals health status and
overcome any performance discrepancy categories to the extent applicable,
other risk factors, assess appropriate based on data collected in the
adjustments to quality measures, cost due to practice size.
We refer readers to section II.C.7.b.(2) September 2016 QRUR, unless they did
measures, and other measures used not have data included in the September
under MIPS and assess and implement of this proposed rule for a discussion of
the small practice adjustment and its 2016 QRUR. Those eligible clinicians
appropriate adjustments to payment without data included in the September
application to APM Entities.
adjustments, final scores, scores for 2016 QRUR will not receive any
performance categories, or scores for (d) Final Score Methodology performance feedback until performance
measures or activities under the MIPS. In the CY 2017 Quality Payment data is available for feedback.
We refer readers to II.C.7.b.(1) of this Program final rule, we finalized the Beginning with the 2018 performance
proposed rule for a description of the methodology for calculating a final year, we propose that MIPS eligible
risk factor adjustment and its score of 0100 based on the four clinicians whose MIPS payment
application to APM Entities. performance categories (81 FR 77320). adjustment is based on their score under
We refer readers to section II.C.7.c. of the APM scoring standard will receive
this proposed rule for a discussion of performance feedback as specified
under section 1848(q)(12) of the Act for year would be scored under the APM used for a quality measure would be the
the quality, advancing care information, scoring standard. benchmark used in the MIPS APM for
and improvement activities performance We propose to continue to weight calculation of the performance based
categories to the extent data are the cost performance category under the payments, where such a benchmark is
available for the MIPS performance APM scoring standard for Web Interface available. If the APM does not produce
year. Further, we propose that in cases reporters at zero percent for the 2020 a benchmark score for a reportable
where performance data are not payment year forward. measure that is included on the APM
available for a MIPS APM performance Aligned with our proposal to measures list, we would use the
category because the MIPS APM weight the cost performance category at benchmark score for the measure that is
performance category has been weighted zero percent, we propose not to take used for the MIPS quality performance
to zero for that performance year, we improvement into account for category generally (outside of the APM
would not provide performance performance scores in the cost scoring standard) for that performance
feedback on that MIPS performance performance category for Web Interface year, provided the measure
category. reporters beginning with the 2020 MIPS specifications for the measure are the
We believe that with an APM Entitys Payment Year. same under both the MIPS final list and
finite resources for engaging in efforts to We propose to score the CAHPS for the APM measures list.
improve quality and lower costs for a ACOs survey, in addition to the CMS We propose that the minimum
specified beneficiary population, the Web Interface measures that are used to number of quality measures required to
incentives of the APM must take calculate the MIPS APM quality be reported for the APM scoring
priority over those offered by MIPS in performance category score for Web standard would be the minimum
order to ensure that the goals and Interface reporters including the Shared number of quality measures that are
evaluation associated with the APM are Savings Program and Next Generation required within the MIPS APM and are
as clear and free of confounding factors ACO Model), beginning in the 2018 collected and available in time to be
as possible. The potential for different, performance year. included in the calculation for the APM
conflicting messages in performance We propose that, beginning for the Entity score under the APM scoring
feedback provided by the APMs and 2018 performance year, eligible standard. We propose that if an APM
that provided by MIPS may create clinicians in MIPS APMs that are Web Entity submits some, but not all of the
uncertainty for MIPS eligible clinicians Interface reporters may receive bonus measures required by the MIPS APM by
who are attempting to strategically points under the APM scoring standard the close of the MIPS submission
transform their respective practices and for submitting the CAHPS for ACOs period, the APM Entity would receive
succeed under the terms of the APM. survey. points for the measures that were
Accordingly, under section 1115A(d)(1) We propose to calculate the quality submitted, but would receive a score of
and section 1899(f), for all performance improvement score for MIPS eligible zero for each remaining measure
years we propose to waivefor MIPS clinicians submitting quality measures between the number of measures
eligible clinicians participating in MIPS via the CMS Web Interface using the reported and the number of measures
APMsthe requirement under section methodology described in section required by the APM that were available
1848(q)(12)(A)(i)(I) of the Act to provide II.C.7.a.(1)(i). for scoring.
performance feedback for the cost We propose to calculate the total
quality percent score for MIPS eligible We propose that the benchmark
performance category.
We request comment on these clinicians using the CMS Web Interface score used for a quality measure would
proposals to waive requirements for according to the methodology described be the benchmark used by the MIPS
performance feedback on the cost in section II.C.7.a.(1)(h)(2) of this APM for calculation of the performance
performance category indefinitely, and proposed rule. based payments within the APM, if
for the other performance categories in We propose to establish a separate possible, in order to best align the
years for which the weight for those MIPS final list of quality measures for measure performance outcomes between
categories has been reweighted to zero. each Other MIPS APM that would be the two programs. We are proposing that
the quality measure list used for for measures that are pay for reporting
(6) Summary of Proposals or which do not measure performance
purposes of the APM scoring standard.
In summary, we have proposed the We propose to calculate the MIPS on a continuum of performance, we will
following in this section: quality performance category score for consider these measures to be lacking a
We propose to amend the regulation Other MIPS APMs using MIPS APM- benchmark and they will be treated as
at 414.1370(e) to identify the four specific quality measures. For purposes such.
assessment dates that would be used to of the APM scoring standard, we would We propose to score quality
identify the APM Entity group for score only measures that: (1) Are tied to measure performance under the APM
purposes of the APM scoring standard, payment as described under the terms of scoring standard using a percentile
and to specify that the December 31 date the APM, (2) are available for scoring distribution, separated by decile
will be used only to identify eligible near the close of the MIPS submission categories, as described in the finalized
clinicians on the APM Entitys period, (3) have a minimum of 20 cases MIPS quality scoring methodology. We
Participation List for a MIPS APM that available for reporting, and (4) have an propose to use a graduated points-
is a full TIN APM in order to add them available benchmark. assignment approach, where a measure
to the APM Entity group that is scored We propose to only use the MIPS is assigned a continuum of points out to
under the APM scoring standard. We APM quality measure data that are one decimal place, based on its place in
propose to use this fourth assessment submitted by the close of the MIPS the decile.
date of December 31 to extend the APM submission period and are available for We propose that each APM Entity
scoring standard to only those MIPS scoring in time for inclusion to calculate that reports on quality measures would
eligible clinicians participating in MIPS a MIPS quality performance category receive between 1 and 10 achievement
APMs that are full TIN APMs, ensuring score. points for each measure reported that
that an eligible clinician who joins the We propose that, for the APM can be reliably scored against a
full TIN APM late in the performance scoring standard, the benchmark score benchmark, up to the number of
measures that are required to be information performance category in the clinical practice guidelines. In addition,
reported by the APM. final score is part of a TIN that includes the MIPS eligible clinicians in an APM
We propose that APM Entities in one or more MIPS eligible clinicians Entity may qualify for a zero percent
MIPS APMs, like other MIPS eligible who do not qualify for a zero percent weighting for the advancing care
clinicians, would be eligible to receive weighting, we would not apply the zero information performance category. In
bonus points for the MIPS quality percent weighting to the qualifying such instances, under the APM scoring
performance category for reporting on MIPS eligible clinician, and the TIN standard, we propose to reweight the
high priority measures or measures would still be required to report on affected performance category to zero.
submitted via CEHRT. For each Other behalf of the group, although the TIN Beginning with the 2018
MIPS APM, we propose to identify would not need to report data for the
whether any of their available measures performance year, we propose that MIPS
qualifying MIPS eligible clinician. eligible clinicians whose MIPS payment
meets the criteria to receive a bonus, We propose to maintain the cost
and add the bonus points to the quality adjustment is based on their score under
performance category weight of zero for
achievement points. the APM scoring standard will receive
Other MIPS APMs under the APM
Beginning in the 2018 performance performance feedback as specified
scoring standard for the 2020 MIPS
year, we propose to score improvement under section 1848(q)(12) of the Act for
payment year and subsequent MIPS
as well as achievement in the quality the quality, advancing care information,
payment years. Because the cost
performance category. For the APM performance category would be and improvement activities performance
scoring standard, we propose that the reweighted to zero that weight would categories to the extent data are
improvement percentage points would need to be redistributed to other available for the MIPS performance
be awarded based on the following performance categories. We propose to year. Further, we propose that in cases
formula: align the Other MIPS APM performance where the MIPS APM performance
Quality Improvement Score = (Absolute category weights with those proposed category has been weighted to zero for
Improvement/Previous Year Quality for Web Interface reporters and weight that performance year, we would not
Performance Category Percent Score the quality performance category to 50 provide performance feedback on that
Prior to Bonus Points)/10. percent, the improvement activities MIPS performance category.
We propose that the APM Entitys performance category to 20 percent, and The following tables represent the
total quality performance category score the advancing care information measures being introduced for notice
would be equal to [(achievement points performance category to 30 percent of and comment, and would serve as the
+ bonus points)/total available the APM Entity final score. measure set used by participants in the
achievement points] + quality It is possible that none of the Other identified MIPS APMs in order to create
improvement score. MIPS APMs measures would be a MIPS score under the APM scoring
Under the APM scoring standard, available for calculating a quality standard, as described in section
we propose that if a MIPS eligible performance category score by or shortly II.C.6.g.(3)(b)(ii)(A) of this proposed
clinician who qualifies for a zero after the close of the MIPS submission rule. Once this list is finalized, no
percent weighting of the advancing care period, for example, due to changes in measures may be added to this list.
TABLE 14MIPS APM MEASURES LISTONCOLOGY CARE MODEL
NQF/Quality National quality strategy
Measure name number Measure description Primary measure steward
domain
(if applicable)
Risk-adjusted proportion of NA ................ Effective Clinical Care ......... Percentage of OCM-attributed FFS beneficiaries who NA
patients with all-cause were had an acute-care hospital stay during the
hospital admissions within measurement period.
the 6-month episode.
Risk-adjusted proportion of NA ................ Effective Clinical Care ......... Percentage of OCM-attributed FFS beneficiaries who
patients with all-cause ED had an ER visit that did not result in a hospital stay
visits or observation stays during the measurement period.
that did not result in a
hospital admission within
the 6-month episode.
Proportion of patients who NA ................ Effective Clinical Care ......... Percentage of OCM-attributed FFS beneficiaries who NA
died who were admitted died and spent at least 3 days in hospice during the
to hospice for 3 days or measurement time period.
more.
Oncology: Medical and Ra- 0384/143 ...... Person and Caregiver Cen- Percentage of patient visits, regardless of patient age, Physician Consortium for
diationPain Intensity tered Experience. with a diagnosis of cancer currently receiving chemo- Performance Improve-
Quantified. therapy or radiation therapy in which pain intensity is ment Foundations (PCPI).
quantified.
Oncology: Medical and Ra- 0383/144 ...... Person and Caregiver Cen- Percentage of visits for patients, regardless of age, with American Society of Clinical
diationPlan of Care for tered Experience. a diagnosis of cancer currently receiving chemo- Oncology.
Pain. therapy or radiation therapy who report having pain
with a documented plan of care to address pain.
Preventive Care and 0418/134 ...... Community/Population Percentage of patients aged 12 and older screened for Centers for Medicare &
Screening: Screening for Health. depression on the date of the encounter using an age Medicaid Services.
Depression and Follow- appropriate standardized depression screening tool
Up Plan. AND if positive, a follow-up plan is documented on the
date of the positive screen.
TABLE 14MIPS APM MEASURES LISTONCOLOGY CARE MODELContinued

domain
(if applicable)
Patient-Reported Experi- NA ................ Person and Caregiver Cen- Summary/Survey Measures may include: NA
ence of Care. tered Experience. Overall measure of patient experience ..................
Exchanging Information with Patients ...................
Access ....................................................................
Shared Decision Making ........................................
Enabling Self-Management ....................................
Affective Communication .......................................
Prostate Cancer: Adjuvant 0390/104 ...... Effective Clinical Care ......... Percentage of patients, regardless of age, with a diag- American Urological Asso-
Hormonal Therapy for nosis of prostate cancer at high or very high risk of re- ciation Education and Re-
High or Very High Risk currence receiving external beam and radiotherapy to search.
Prostate Cancer. the prostate who were prescribed adjuvant hormonal
therapy (GnRH [gonadotropin releasing hormone]
agonist or antagonist).
Adjuvant chemotherapy is 0223 ............. Communication and Care Percentage of patients under the age of 80 with AJCC Commission on Cancer,
recommended or adminis- Coordination. III (lymph node positive) colon cancer for whom adju- American College of Sur-
tered within 4 months vant chemotherapy is recommended and not received geons.
(120 days) of diagnosis to or administered within 4 months (120 days) of diag-
patients under the age of nosis.
80 with AJCC III (lymph
node positive) colon can-
cer.
Combination chemotherapy 0559 ............. Communication and Care Percentage of female patients, age >18 at diagnosis, Commission on Cancer,
is recommended or ad- Coordination. who have their first diagnosis of breast cancer American College of Sur-
ministered within 4 (epithelial malignancy), at AJCC stage T1cN0M0 geons.
months (120 days) of di- (tumor greater than 1 cm), or Stage IBIII, whose pri-
agnosis for women under mary tumor is progesterone and estrogen receptor
70 with AJCC T1cN0M0, negative recommended for multiagent chemotherapy
or Stage IBIII hormone (recommended or administered) within 4 months (120
receptor negative breast days) of diagnosis.
cancer.
Trastuzumab administered 1858/450 ...... Efficiency and Cost Reduc- Proportion of female patients (aged 18 years and older) American Society of Clinical
to patients with AJCC tion. with AJCC stage I (Tlc)Ill, human epidermal growth Oncology.
stage I (T1c)III and factor receptor 2 (HER2) positive breast cancer re-
human epidermal growth ceiving adjuvant chemotherapy.
factor receptor 2 (HER2)
positive breast cancer
who receive adjuvant
chemotherapy.
Breast Cancer: Hormonal 0387 ............. Communication and Care Percentage of female patients aged 18 years and older AMA-convened Physician
Therapy for Stage I Coordination. with Stage I (T1b) through IIIC, ER or PR positive Consortium for Perform-
(T1b)IIIC Estrogen Re- breast cancer who were prescribed tamoxifen or ance Improvement.
ceptor/Progesterone Re- aromatase inhibitor (AI) during the 12-month reporting
ceptor (ER/PR) Positive period.
Breast Cancer.
Documentation of Current 0419/130 ...... Patient Safety ...................... Percentage of visits for patients aged 18 years and older Centers for Medicare &
Medications in the Med- for which the eligible clinician attests to documenting a Medicaid Services.
ical Record. list of current medications using all immediate re-
sources available 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, fre-
quency and route of administration.
TABLE 15MIPS APM MEASURES LISTCOMPREHENSIVE ESRD CARE

domain
(if applicable)
ESCO Standardized Mor- 0101/154 ...... Patient Safety ...................... Falls: Risk Assessment: Percentage of patients aged 65 National Committee for
tality Ratio. years and older with a history of falIs who had a risk Quality Assurance.
assessment for falls completed within for Quality 12
months.
Falls: Screening, Risk As- 0101/154 ...... Communication and Coordi- Falls: Risk Assessment: Percentage of patients aged 65 National Committee for
sessment and Plan of nation. years and older with a history of falIs who had a risk Quality Assurance.
Care to Prevent Future assessment for falls completed within for Quality 12
Falls. 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

domain
(if applicable)
ICH-CAHPS: Nephrologists 0258 ............. Person and Caregiver Cen- Summary/Survey Measures may include: Agency for Healthcare Re-
Communication and Car- tered Experience and Getting timely care, appointments, and informa- search and Quality.
ing. 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 ..........................
ICH-CAHPS: ICH-CAHPS: 0258 ............. Person and Caregiver Cen- Comparison of services and quality of care that dialysis Agency for Healthcare Re-
Rating of Dialysis Center. tered Experience and facilities provide from the perspective of ESRD pa- search and Quality.
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.
ICH-CAHPS: Quality of Di- 0258 ............. ............................................. Comparison of services and quality of care that dialysis Agency for Healthcare Re-
alysis Center Care and facilities provide from the perspective of ESRD pa- search and Quality.
Operations. tients receiving in-center hemodialysis care. Patients
ICH-CAHPS: Providing In- 0258 ............. ............................................. Comparison of services and quality of care that dialysis Agency for Healthcare Re-
formation to Patients. facilities provide from the perspective of ESRD pa- search and Quality.
tients receiving in-center hemodialysis care. Patients
ICH-CAHPS: Rating of Kid- 0258 ............. ............................................. Comparison of services and quality of care that dialysis Agency for Healthcare Re-
ney Doctors. facilities provide from the perspective of ESRD pa- search and Quality.
tients receiving in-center hemodialysis care. Patients
ICH-CAHPS: Rating of Di- 0258 ............. ............................................. Comparison of services and quality of care that dialysis Agency for Healthcare Re-
alysis Center Staff. facilities provide from the perspective of ESRD pa- search and Quality.
ICH-CAHPS: Rating of Di- 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 reconciled
with the current medication list in the outpatient med-
ical 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 diabetes National Committee for
who had a retinal or dilated eye exam by an eye care Quality Assurance.
professional during the measurement period or a neg-
ative 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 diabetes National Committee for
(type 1 and type 2) who received a foot exam (visual Quality Assurance.
inspection and sensory exam with mono filament and
a pulse exam) during the previous measurement year.
Influenza Immunization for 0041/110, Community/Population Percentage of patients aged 6 months and older seen Kidney Care Quality Alli-
the ESRD Population. 0226. Health. for a visit between October 1 and March 31 who re- ance (KCQA).
ceived 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

domain
(if applicable)
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 (PCPI).
seling intervention if identified as a tobacco user.
TABLE 16MIPS APM MEASURES LISTCOMPREHENSIVE PRIMARY CARE PLUS (CPC+)

domain
(if applicable)
Depression Remission at 0710/370 ...... Effective Clinical Care ......... Patients age 18 and older with major depression or Minnesota Community
Twelve Months. dysthymia and an initial Patient Health Questionnaire Measurement
(PHQ9) score greater than nine who demonstrate re-
mission at twelve months (+/ 30 days after an index
visit) defined as a PHQ9 score less than five. This
measure applies to both patients with newly diag-
nosed and existing depression whose current PHQ9
score indicates a need for treatment.
Controlling High Blood Pres- 0018/236 ...... Effective Clinical Care ......... Percentage of patients 1885 years of age who had a National Committee for
sure. 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 diabetes National Committee for
who had a retinal or dilated eye exam by an eye care Quality Assurance
professional during the measurement period or a neg-
ative 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 diabetes National Committee for
(HbA1c) Poor Control who had hemoglobin A1c >9.0% during the measure- Quality Assurance
(>9%). ment 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- NA/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 ...................... Percentage of patients 65 years of age and older who National Committee for
Fall Risk. were screened for future fall risk at least once during Quality Assurance
the measurement period.
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 Drug new episode of alcohol and other drug (AOD) depend- Quality Assurance
Dependence Treatment. ence who received the following. Two rates are re-
ported.
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 initiation
visit.
Closing the Referral Loop: NA/374 ......... Communication and Care Percentage of Patients with referrals, regardless of age, Centers for Medicare and
Receipt of Specialist Re- 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
performed 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 ap- National Committee for
ing. propriate 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 (PCPI)
Intervention. seling intervention if identified as a tobacco user.
TABLE 16MIPS APM MEASURES LISTCOMPREHENSIVE PRIMARY CARE PLUS (CPC+)Continued

domain
(if applicable)
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
Preventive Care and 0041/110 ...... Community/Population Percentage of patients aged 6 months and older seen PCPI(R) Foundation
Screening: Influenza Im- Health. for a visit between October 1 and March 31 who re- (PCPI[R])
munization. ceived an influenza immunization OR who reported
previous receipt of an influenza immunization.
Pneumonia Vaccination Sta- 0043/111 ...... Community/Population Percentage of patients 65 years of age and older who National Committee for
tus 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 Quality
(IVD): Use of Aspirin or were diagnosed with acute myocardial infarction 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 docu-
mentation of use of aspirin or another antiplatelet dur-
ing the measurement period.
Hypertension: Improvement NA/373 ......... Effective Clinical Care ......... Percentage of patients aged 1885 years of age with a Centers for Medicare &
in Blood Pressure. diagnosis of hypertension whose blood pressure im- Medicaid Services (CMS)
proved 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 (CMS)
Depression and Follow- using an age appropriate standardized depression
Up Plan. screening tool AND if positive, a follow-up plan is doc-
umented on the date of the positive screen.
Diabetes: Foot Exam ........... 0056/163 ...... Effective Clinical Care ......... The percentage of patients 1875 years of age with dia- National Committee for
betes (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 measurement year.
Statin Therapy for the Pre- NA/438 ......... Not provided in the measure Percentage of the following patientsall considered at Quality Insights
vention and Treatment of high risk of cardiovascular eventswho were pre-
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 fast-
ing or direct low-density lipoprotein cholesterol
(LDL-C) level 190 mg/dL or were previously di-
agnosed with or currently have an active diag-
nosis of familial or pure hypercholesterolemia; OR
* Adults aged 4075 years with a diagnosis of dia-
betes with a fasting or direct LDL-C level of 70
189 mg/dL.
Inpatient Hospital Utilization NA ................ ............................................. 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- NA ................ ............................................. 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.
Preventive Care and 0421 ............. Community/Population Percentage of patients aged 18 years and older with a Centers for Medicare &
Screening: Body Mass Health. BMI documented during the current encounter or dur- Medicaid Services (CMS)
Index (BMI) Screening ing the previous six months AND with a BMI outside
and Follow-Up Plan. of normal parameters, a follow-up plan is documented
during the encounter or during the previous six
months of the current encounter. Normal Parameters:
Age 18 years and older BMI 18.5 and <25 kg/m2.
CAHPS ................................ CPC+ spe- ............................................. CG-CAHPS Survey 3.0 .................................................... AHRQ
cific; dif-
ferent than
CAHPS for
MIPS.
7. MIPS Final Score Methodology burden on MIPS eligible clinicians, MIPS scoring system has many
For the 2020 MIPS payment year, we while continuing to prepare MIPS components and numerous moving
intend to build on the scoring eligible clinicians for the performance parts.
methodology we finalized for the threshold required for the 2021 MIPS As we continue to move forward in
transition year, which allows for payment year. Our rationale for our implementing the MIPS program, we
accountability and alignment across the scoring methodology continues to be strive to balance the statutory
performance categories and minimizes grounded in the understanding that the requirements and programmatic goals
with the ease of use, stability, and APM scoring standard applies to APM and the opportunity for continued
meaningfulness for MIPS eligible Entities in MIPS APMs, and those improvement. Section 1848(q)(5)(D)(ii)
clinicians, while also emphasizing policies take precedence where of the Act also provides that
simplicity and scoring that is applicable; however, where those achievement may be weighted higher
understandable for MIPS eligible policies do not apply, scoring for MIPS than improvement.
clinicians. In this section, we propose eligible clinicians as described in this In the CY 2017 Quality Payment
refinements to the performance section II.C.7. on scoring will apply. We Program final rule, we summarized
standards, the methodology for refer readers to section II.C.6.g. of this public comments received on the
determining a score for each of the four proposed rule for additional information proposed rule regarding potential ways
performance categories (the about the APM scoring standard. to incorporate improvement into the
performance category score), and the scoring methodology moving forward,
methodology for determining a final a. Converting Measures and Activities including approaches based on
score based on the performance category Into Performance Category Scores methodologies used in the Hospital VBP
scores. (1) Policies That Apply Across Multiple Program, the Shared Savings Program,
We intend to continue the transition Performance Categories and Medicare Advantage 5-star Ratings
of MIPS by proposing the following The detailed policies and proposals Program (81 FR 77306 through 77308).
policies: We did not finalize a policy at that time
for scoring the four performance
Continuation of many transition on this topic and indicated we would
categories are described in detail in
year scoring policies in the quality take comments into account in
section II.C.7.a. of this proposed rule.
performance category, with an developing a proposal for future
However, as the four performance
adjustment to the number of rulemaking.
categories collectively create a single When considering the applicability of
achievement points available for
MIPS final score, there are several these programs to MIPS, we looked at
measures that fail to meet the data
policies that apply across categories, the approach that was used to measure
completeness criteria, to encourage
which we discuss in section II.C.7.a.(1) improvement for each of the programs
MIPS eligible clinician to meet data
of this proposed rule. and how improvement was incorporated
completeness while providing an
exception for small practices; (a) Performance Standards into the overall scoring system. An
An improvement scoring In accordance with section 1848(q)(3)
approach that focuses on measure-level
methodology that rewards MIPS eligible comparison enables a more granular
of the Act, in the CY 2017 Quality
clinicians who improve their assessment of improvement because
Payment Program final rule, we
performance in the quality and cost performance on a specific measure can
finalized performance standards for the
performance categories; be considered and compared from year
four performance categories. We refer
A new scoring option for the quality to year. All options that we considered
readers to the CY 2017 Quality Payment
and cost performance categories that last year use a standard set of measures
Program final rule for a description of
allows facility-based MIPS eligible that do not provide for choice of
the performance standards against
clinicians to be scored based on their measures to assess performance;
which measures and activities in the
facilitys performance; therefore, they are better structured to
Special considerations for MIPS four performance categories are scored compare changes in performance based
eligible clinicians in small practices or (81 FR 77271 through 77272). on the same measure from year to year.
As discussed in section
those who care for complex patients; The aforementioned programs do not
II.C.7.a.(1)(b)(i) of this proposed rule, we
and use a category-level approach; however,
Policies that allow multiple are proposing to add an improvement
we believe that a category-level
pathways for MIPS eligible clinicians to scoring standard to the quality and cost
approach would provide a broader
receive a neutral to positive MIPS performance categories starting for the
perspective, particularly in the absence
payment adjustment. 2020 MIPS payment year. of a standard set of measures, because
We believe these sets of proposed (b) Policies Related to Scoring it would allow for a more flexible
policies will help clinicians smoothly Improvement approach that enables MIPS eligible
transition from the transition year to the clinicians to select measures and data
2021 MIPS payment year, for which the (i) Background
submission mechanisms that can change
performance threshold (which In accordance with section from year to year and be more
represents the final score that would 1848(q)(5)(D)(i) of the Act, beginning appropriate to their practice in a given
earn a neutral MIPS adjustment) will be with the 2020 MIPS payment year, if year.
either the mean or median (as selected data sufficient to measure improvement We believe that both approaches are
by the Secretary) of the MIPS final are available, the final score viable options for measuring
scores for all MIPS eligible clinicians methodology shall take into account improvement. Accordingly, we believe
from a previous period specified by the improvement of the MIPS eligible that an appropriate approach for
Secretary. clinician in calculating the performance measuring improvement for the quality
Unless otherwise noted, for purposes score for the quality and cost performance category and the cost
of this section II.C.7. on scoring, the performance categories and may take performance category should consider
term MIPS eligible clinician will refer into account improvement for the the unique characteristics of each
to MIPS eligible clinicians that submit improvement activities and advancing performance category rather than
data and are scored at either the care information performance necessarily applying a uniform
individual- or group-level, including categories. In addition, section approach across both performance
virtual groups, but will not refer to 1848(q)(3)(B) of the Act provides that categories. For the quality performance
MIPS eligible clinicians who elect the Secretary, in establishing category, clinicians are offered a variety
facility-based scoring. The scoring rules performance standards for measures and of different measures which can be
for facility-based measurement are activities for the MIPS performance submitted by different mechanisms,
discussed in section II.C.7.a.(4). of this categories, shall consider: Historical rather than a standard set of measures
proposed rule. We also note that the performance standards; improvement; or a single data submission mechanism.
For the cost performance category, our ability to capture performance variety of measures available in MIPS
however, clinicians are scored on the changes at the measure level. and the flexibility clinicians have in
same set of cost measures to the extent We continue to believe that flexibility selecting different measures and
each measure is applicable and for clinicians to select meaningful submission mechanisms from year to
available to them; clinicians cannot measures is appropriate for MIPS, year could affect our ability to capture
choose which cost measures they will especially for the quality performance performance changes at the measure
be scored on. In addition, all of the cost category. The Hospital VBP Program level, particularly for the quality
measures are derived from methodology, which relies on consistent performance category. Accordingly, we
administrative claims data with no measures from year to year in order to do not believe this is an appropriate
additional submission required by the track improvement, would limit our approach for the quality performance
clinician. ability to measure improvement in category. Although this approach could
When considering the applicability of MIPS. be considered for the cost performance
these programs to MIPS, we also We also considered adopting the category, we believe that the Shared
considered how scoring improvement is Shared Savings Programs approach for Savings Program is more analogous to
incorporated into the overall scoring assessing improvement, where MIPS and that the improvement
system, including when only participants can receive bonus points methodology used in that program is
achievement or improvement is for improving on quality measures over one with which more stakeholders in
incorporated into a final score or when time. The Shared Savings Program MIPS would be familiar.
improvement and achievement are both methodology could be adopted without After taking all of this into
incorporated into a final score. an underlying change to the scoring of consideration, we are proposing two
We considered whether we could achievement in the quality and cost different approaches for scoring
adapt the Hospital VBP Programs performance categories with an improvement from year to year. As
general approach for assessing approach that considers both described in section II.C.7.a.(2)(i)(i) of
improvement to MIPS and note that achievement and improvement in its this proposed rule, we are proposing to
many commenters, in response to the overall scoring calculation and would measure improvement at the
CY 2017 Quality Payment Program align MIPS and the Shared Savings performance category level for the
proposed rule, recommended this Program. However, we believe that the quality performance category score.
methodology for MIPS because it is Shared Savings Programs improvement Because clinicians can elect the
familiar to the health care community. methodology would not be appropriate submission mechanisms and quality
However, we decided that the Hospital for the MIPS quality performance measures that are most meaningful to
VBP Programs improvement scoring category because we are again their practice, and these choices can
methodology, which compares changes concerned about the wide variety of change from year to year, we want a
in performance based on the same quality measures available in MIPS and flexible methodology that allows for
measure from year to year, is not fully the flexibility clinicians have in improvement scoring even when the
translatable to MIPS for the quality selecting measures and submission quality measures change. This is
performance category and the cost mechanisms that could affect our ability particularly important as we encourage
performance category. The scoring to capture performance changes at the MIPS eligible clinicians to move away
methodology used to assess measure level. We seek to balance a from topped out measures and toward
achievement in the Hospital VBP system that allows for meaningful more outcome measures. We do not
Program, as required by section measurement to clinicians and want the flexibility that is offered to
1886(o)(5)(B)(ii) of the Act, does not accommodates the various practice MIPS eligible clinicians in the quality
reward points for achievement in the types by allowing for a choice of performance category to limit clinicians
same method as MIPS, because measures and submission mechanisms ability to move towards outcome
hospitals that fall below the that may differ from year to year for the measures, or limit our ability to measure
achievement threshold (the median quality performance category. However, improvement. Our proposal for taking
performance during the benchmark as we discuss in section II.C.7.a.(3)(a) of improvement into account as part of the
period) are not awarded achievement this proposed rule, we do believe the quality performance category score is
points. We refer readers to the Hospital Shared Savings Program measure level addressed in detail in sections
Inpatient VBP Program Final Rule (76 methodology could be translated for II.C.7.a.(2)(i) through II.C.7.a.(2)(j) of
FR 26516 through 26525) for additional cost measures in the cost performance this proposed rule.
discussion of the Hospital VBP category. We believe that there is reason to
Programs scoring methodology. In Finally, we also considered adopting adopt a different methodology for
addition, the Hospital VBP Program the Medicare Advantage Programs 5- scoring improvement for the cost
requires the use of either the Star Rating approach for assessing performance category from that used for
achievement score or the improvement improvement, where Medicare the quality performance category. In
points, but not both, for the Programs Advantage contracts are rated on quality contrast to the quality performance
performance scoring calculation. and performance measures. Under this category, for the cost performance
Adopting the Hospital VBP Program approach, we would identify an overall category, MIPS eligible clinicians do not
method for MIPS would require improvement measure score by have a choice in measures or
significant changes to the scoring comparing the underlying numeric data submission mechanisms; rather, all
methodology used for the quality and for measures from the prior year with MIPS eligible clinicians are assessed on
cost performance categories. For the the data from measures for the all measures based on the availability
quality performance category, there are performance period. To obtain an and applicability of the measure to their
a wide variety of measures available in improvement measure score MIPS practice, and all measures are derived
MIPS, and clinicians have flexibility in eligible clinicians would need to have from administrative claims data.
selecting measures and submission data for both years in at least half of the Therefore, for the cost performance
mechanisms, with the potential for required measures for the quality category, we propose in section
clinicians to select different measures performance category (81 FR 77307). We II.C.7.a.(3)(a)(i) of this proposed rule to
from year to year, which would affect are again concerned that the wide measure improvement at the measure
level. We also note, that while we are (c) Scoring Flexibility for ICD10 changes or new products or procedures
statutorily required to measure Measure Specification Changes During reflected in ICD10 code changes; and
improvement for the cost performance the Performance Period feedback on a measure received from
category beginning with the second The quality and cost performance measure developers and stewards. We
MIPS payment year if data sufficient to categories rely on measures that use considered an approach where we
measure improvement is available, we detailed measure specifications that would consider any change in ICD10
are also proposing at II.C.6.d.(2) of this include ICD10CM/PCS (ICD10) coding to impact performance on a
proposed rule to weight the cost code sets. We annually issue new ICD measure and thus only rely on the first
performance category at zero percent for 10 coding updates, which are effective 9 months of the 12-month performance
the 2018 MIPS performance period/2020 from October 1, through September 30 period for such measures. However, we
MIPS payment year. Therefore, the (https://www.cms.gov/Medicare/Coding/ believe such an approach would be too
improvement score for the cost ICD10/ICD10Ombudsmanand broad and truncate measurement for too
performance category would not affect many measures where performance may
ICD10CoordinationCenterICC.html). As
the MIPS final score for the 2018 MIPS not be significantly affected. We believe
part of this update, codes are added as
performance period/2020 MIPS that our proposed approach ensures the
well as removed from the ICD10 code
payment year and would be for measures on which individual MIPS
set.
informational purposes only. To provide scoring flexibility for eligible clinicians and groups will have
We are not proposing to score their performance assessed are accurate
MIPS eligible clinicians and groups for
improvement in the improvement for the performance period and are
measures impacted by ICD10 coding
activities performance category or the consistent with the benchmark set for
changes in the final quarter of the
advancing care information performance the performance period.
Quality Payment Program performance
category at this time, though we may We propose to publish on the CMS
periodwhich may render the measures Web site which measures are
address improvement scoring for these
performance categories in future no longer comparable to the historical significantly impacted by ICD10
rulemaking. benchmarkwe propose at coding changes and would require the
We propose to amend 414.1380(b)(1)(xviii) and 9-month assessment. We propose to
414.1380(a)(1)(i) to add that 414.1320(c)(2) to provide that we will publish this information by October 1st
improvement scoring is available for assess performance on measures of the performance period if technically
performance in the quality performance considered significantly impacted by feasible, but by no later than the
category and for the cost performance ICD10 updates based only on the first beginning of the data submission
category at 414.1380(a)(1)(ii) beginning 9 months of the 12-month performance period, which is January 1, 2019 for the
with the 2020 MIPS payment year. period (for example, January 1, 2018 2018 performance period.
We invite public comment on our through September 30, 2018, for the We request comment on the proposal
proposals to score improvement for the 2018 MIPS performance period). We to address ICD10 measures
quality and cost performance categories believe it would be appropriate to assess specification changes during the
starting with the 2020 MIPS payment performance for significantly impacted performance period by relying on the
year. measures based on the first 9 months of first 9 months of the 12-month
the performance period, rather than the performance period. We also request
(ii) Data Sufficiency Standard To full 12 months, because the indicated
Measure Improvement comment on potential alternate
performance for the last quarter could approaches to address measures that are
Section 1848(q)(5)(D)(i) of the Act be affected by the coding changes rather significantly impacted due to ICD10
requires us to measure improvement for than actual differences in performance. changes during the performance period,
the quality and cost performance Performance on measures that are not including the factors we might use to
categories of MIPS if data sufficient to significantly impacted by changes to determine whether a measure is
measure improvement are available, ICD10 codes would continue to be significantly impacted.
which we interpret to mean that we assessed on the full 12-month
would measure improvement when we performance period (January 1 through (2) Scoring the Quality Performance
can identify data from a current December 31). Category for Data Submission via
performance period that can be Any measure that relies on an ICD10 Claims, Data Submissions via EHR,
compared to data from a prior code which is added, modified, or Third Party Data Submission Options,
performance period or data that removed, such as in the measure CMS Web Interface, and Administrative
compares performance from year to numerator, denominator, exclusions, or Claims
year. In section II.C.7.a.(2)(i)(ii) of this exceptions, could have an impact on the Many comments submitted in
proposed rule, we propose for the indicated performance on the measure, response to the CY 2017 Quality
quality performance category that we although the impact may not always be Payment Program final rule requested
would measure improvement when data significant. We propose an annual additional clarification on our finalized
are available because there is a review process to analyze the measures scoring methodology for the 2019 MIPS
performance category score for the prior that have a code impact and assess the payment year. To provide further clarity
performance period. In section subset of measures significantly to MIPS eligible clinicians about the
II.C.7.a.(3)(a)(i) of this proposed rule, we impacted by ICD10 coding changes transition year scoring policies, before
propose for the cost performance during the performance period. describing our proposed scoring policies
category that we would measure Depending on the data available, we for the 2020 MIPS payment year, we
improvement when data are available anticipate that our determination as to provide a summary of the scoring
which is when there is sufficient case whether a measure is significantly policies finalized in the CY 2017
volume to provide measurable data on impacted by ICD10 coding changes Quality Payment Program final rule
measures in subsequent years with the would include these factors: A more along with examples of how they apply
same identifier. We refer readers to the than 10 percent change in codes in the under several scenarios.
noted sections for details on these measure numerator, denominator, In the CY 2017 Quality Payment
proposals. exclusions, and exceptions; guideline Program final rule (81 FR 77286 through
77287), we finalized that the quality available measure achievement quality measures available and
performance category would be scored points = quality performance applicable will have 60 total available
by assigning achievement points to each category percent score. measure achievement points. For
submitted measure, which we refer to in In the CY 2017 Quality Payment example, as shown in Table 17, if an
this section of the proposed rule as Program final rule, we finalized that for individual MIPS eligible clinician
measure achievement points and we the quality performance category, an submits 7 measures, including one
propose to amend various paragraphs in individual MIPS eligible clinician or required outcome measure and 2
414.1380(b)(1) to use this term in place group that submits data on quality additional high priority measures, the
of achievement points. MIPS eligible measures via EHR, QCDR, qualified MIPS eligible clinician will be assigned
clinicians can also earn bonus points for registry, claims, or a CMS-approved points based on achievement for the
certain measures (81 FR 77293 through survey vendor for the CAHPS for MIPS required outcome measure and the next
77294; 81 FR 77297 through 77299), survey will be assigned measure 5 measures with the highest number of
which we refer to as measure bonus achievement points for 6 measures (1 measure achievement points. In this
points, and we propose to amend outcome or, if an outcome measure is example, the second high priority
414.1380(b)(1)(xiii) (which we propose not available, other high priority measure has the lowest number of
to redesignate as 414.1380(b)(1)(xiv) in measure and the next 5 highest scoring measure achievement points and
this proposed rule),7 measures) as available and applicable, therefore is not included in the total
414.1380(b)(1)(xiv) (which we propose and will receive applicable measure measure achievement points calculated
to redesignate as 414.1380(b)(1)(xv) in bonus points for all measures submitted (81 FR 77300), but the MIPS eligible
this proposed rule), and that meet the bonus criteria (81 FR clinician will still receive a bonus point
414.1380(b)(1)(xv) (which we propose 77282 through 77301). for submitting a high priority measure
to redesignate as 414.1380(b)(1)(xvii) In addition, for groups of 16 or more (81 FR 77291 through 77294). We note
in this proposed rule) to use this term clinicians who meet the case minimum that in the CY 2017 Quality Payment
in place of bonus points. The measure of 200, we will also automatically score Program proposed rule, we proposed
achievement points assigned to each the administrative claims-based all- that bonus points would be available for
measure would be added with any cause hospital readmission measure as a high priority measures that are not
measure bonus points and then divided scored (not included in the top 6
seventh measure (81 FR 77287). For
by the total possible points
individual MIPS eligible clinicians and measures for the quality performance
( 414.1380(b)(1)(xv) (which we propose
groups for whom the readmission category score) as long as the measure
to redesignate as 414.1380(b)(1)(xvii)).
measure does not apply, the has the required case minimum, data
In this section of the proposed rule we
denominator is generally 60 (10 completeness, and has a performance
refer to the total possible points as total
available measure achievement points rate greater than zero, because we
available measure achievement points,
multiplied by 6 available measures). For believed these qualities would allow us
and we propose to amend
groups for whom the readmission to include the measure in future
414.1380(b)(1)(xv) to use this term in
measure applies, the denominator is benchmark development (81 FR 28255).
place of total possible points. We also
generally 70 points. Although we received public comments
propose to amend these terms in
414.1380(b)(1)(xiii)(D) (which we If we determined that a MIPS eligible on this policy, responded to those
propose to redesignate as clinician has fewer than 6 measures comments, and reiterated this proposal
414.1380(b)(1)(xiv)(D) in this proposed available and applicable, we will score in the CY 2017 Quality Payment
rule), and 414.1380(b)(1)(xiv) (which only the number of measures that are Program final rule (81 FR 77292), we
we propose to redesignate as available and adjust the denominator would like to clarify that our policy to
414.1380(b)(1)(xv) in this proposed accordingly to the total available assign measure bonus points for high
rule). measure achievement points (81 FR priority measures, even if the measures
This resulting quality performance 77291). We refer readers to section achievement points are not included in
category score is a fraction from zero to II.C.7.a.(2)(e) of this proposed rule, for a the total measure achievement points
1, which can be formatted as a percent; description of the validation process to for calculating the quality performance
therefore, for this section, we will determine measure availability. category percent score, as long as the
present the quality performance For the 2019 MIPS payment year, a measure has the required case
category score as a percent and refer to MIPS eligible clinician that submits minimum, data completeness, and has a
it as quality performance category quality measure data via claims, EHR, or performance rate greater than zero,
percent score. We also propose to third party data submission options applies beginning with the transition
amend 414.1380(b)(1)(xv) (which we (that is, QCDR, qualified registry, EHR, year. We propose to amend
propose to redesignate as or CMS-approved survey vendor for the 414.1380(b)(1)(xiii)(A) (which we
414.1380(b)(1)(xvii) in this proposed CAHPS for MIPS survey), can earn propose to redesignate as
rule) to use this term in place of between 3 and 10 measure achievement 414.1380(b)(1)(xiv)(A)) to state that
quality performance category score. points for quality measures submitted measure bonus points may be included
Thus, the formula for the quality for the performance period of greater in the calculation of the quality
performance category percent score that than or equal to 90 continuous days performance category percent score
we will use in this section is as follows: during CY 2017. A MIPS eligible regardless of whether the measure is
clinician can earn measure bonus points included in the calculation of the total
(total measure achievement points +

total measure bonus points)/total (subject to a cap) if they submit measure achievement points. We also
additional high priority measures with a propose a technical correction to the
7 In section II.C.7.a.(2)(c) of this proposed rule, we performance rate that is greater than second sentence of that paragraph to
propose a new provision to be codified at zero, and that meet the case minimum state that to qualify for measure bonus
414.1380(b)(1)(xiii), and in section II.C.7.a.(2)(i) of and data completeness requirements, or points, each measure must be reported
this proposed rule, we propose a new provision to
be codified at 414.1380(b)(1)(xvi). As a result, we
submit a measure using an end-to-end with sufficient case volume to meet the
propose as well that the remaining paragraphs be electronic pathway. An individual MIPS required case minimum, meet the
redesignated in order following the new provisions. eligible clinician that has 6 or more required data completeness criteria, and
not have a zero percent performance

rate.
TABLE 17EXAMPLE CALCULATION OF THE QUALITY PERFORMANCE CATEGORY PERCENT SCORE FOR AN INDIVIDUAL FOR
THE TRANSITION YEAR
Total available
Measure achievement Measure measure Performance category
points bonus points * achievement percent score
points
Measure 1 (Outcomere- 3 ....................................... n/a 10 (measure achievement points from 6 measures +

quired). 6 ....................................... n/a 10 measure bonus points)/total available measure
Measure 2 ......................... achievement points.
Measure 3 ......................... 6 ....................................... n/a 10
Measure 4 ......................... 6 ....................................... n/a 10
Measure 5 ......................... 6 ....................................... n/a 10
Measure 6 (High priority) .. 4 ....................................... 1 10
Measure 7 (High priority) .. 3 (not included for 1 n/a
achievement).
Total ........................... 31 ..................................... 2 60 (31+2)/60 = 55%

* Assumes the measures meet the required case minimum, data completeness, and has performance greater than zero. Assumes no bonus
points for end-to-end electronic submission. This example does not apply to CMS Web Interface Reporters because individuals are not able to
submit data via that mechanism.
A group of 16 or more clinicians will illustrates an example of a group that measure achievement points for each
also be automatically scored on the submitted the 6 required quality submitted measure and the all-cause
hospital readmission measure if they measures, including an additional high readmission measure.
meet the case minimum. Table 18 priority measure, and received 3
TABLE 18EXAMPLE CALCULATION OF THE QUALITY PERFORMANCE CATEGORY PERCENT SCORE FOR A GROUP OF 16
OR MORE CLINICIANS, NON-CMS WEB INTERFACE REPORTER FOR THE TRANSITION YEAR
Total available
Measure Measure measure
achievement Performance category percent score
bonus points * achievement
points points
Measure 1 (Outcomere- 3 n/a 10 (measure achievement points from 7 measures + measure

quired). bonus points)/total available measure achievement points.
Measure 2 (High priority) ........ 3 1 10
Measure 3 ............................... 3 n/a 10
Measure 4 ............................... 3 n/a 10
Measure 5 ............................... 3 n/a 10
Measure 6 ............................... 3 n/a 10
Measure 7(readmission 3 n/a 10
measure with 200+ cases).
Total ................................. 21 1 70 (21+1)/70 = 31.4%

* Assumes the measures meet the required case minimum, data completeness, and has performance greater than zero. Assumes no bonus
points for end-to-end electronic submission.
In the CY 2017 Quality Payment submitted via multiple mechanisms, correction to paragraphs (i) and (ii) to
Program final rule, we also finalized adding a method for scoring selected clarify that measure benchmark data are
scoring policies specific to groups of 25 topped out measures, and adding a separated into decile categories based
or more that submit their quality method for scoring improvement. We on percentile distribution, and that,
performance measures using the CMS also note that in section II.C.7.a.(4) of other than using performance period
Web Interface (81 FR 77278 through this proposed rule, we are also data, performance period benchmarks
77306). proposing an additional option for are created in the same manner as
Although we are not proposing to facility-based scoring for the quality historical benchmarks using decile
change the basic scoring system that we performance category. categories based on a percentile
finalized in the CY 2017 Quality distribution and that each benchmark

(a) Quality Measure Benchmarks
Payment Program final rule for the 2020 must have a minimum of 20 individual
MIPS payment year, we are proposing We are not proposing to change the clinicians or groups who reported on
several modifications to scoring the policies on benchmarking finalized in the measure meeting the data
quality performance category, including the CY 2017 Quality Payment Program completeness requirement and case
adjusting scoring for measures that do final rule and codified at paragraphs minimum case size criteria and
not meet the data completeness criteria, (b)(1)(i) through (iii) of 414.1380; performance greater than zero. We refer
adding a method for scoring measures however, we are proposing a technical
readers to the discussion at 81 FR 77282 and because quality measures may have (b) Assigning Points Based on
for more details on that policy. characteristics that are less favorable to Achievement
We note that in section II.C.2.c. of this small groups. One commenter
proposed rule, we are proposing to recommended that we stratify by In the CY 2017 Quality Payment
increase the low-volume threshold practice size during the 5 years in which Program final rule, we finalized at
which, because we include MIPS technical assistance is available. One 414.1380(b)(1) that a MIPS quality
eligible clinicians and comparable commenter recommended that we measure must have a measure
APMs that meet our benchmark criteria develop criteria for determining when a benchmark to be scored based on
in our measure benchmarks, could have benchmark should be stratified by group performance. MIPS quality measures
an impact on our MIPS benchmarks, size, and another commenter that do not have a benchmark (for
specifically by reducing the number of recommended if we do not stratify example, because fewer than 20 MIPS
individual eligible clinicians and groups benchmarks by practice size, we adjust eligible clinicians or groups submitted
that meet the definition of a MIPS MIPS payment adjustments for practice data that met our criteria to create a
eligible clinician and contribute to our size. Several commenters recommended reliable benchmark) will not be scored
benchmarks. Therefore, we seek that we stratify benchmarks beyond based on performance (81 FR 77286).
feedback on whether we should broaden practice size and include adjustments We are not proposing any changes to
the criteria for creating our MIPS for disease severity and socioeconomic this policy, but we are proposing a
benchmarks to include PQRS and any status of patients, specialty or sub- technical correction to the regulatory
data from MIPS, including voluntary specialty, geographic region, and/or site text at 414.1380(b)(1) to delete the
reporters, that meet our benchmark of service. One commenter specifically term MIPS before quality measure
performance, case minimum and data suggested that we use peer comparison in third sentence of that paragraph and
completeness criteria when creating our groups when establishing measure to delete the term MIPS before quality
benchmarks. benchmarks. measures in the fourth sentence of that
In the CY 2017 Quality Payment After consideration of the comments
paragraph because this policy applies to
Program final rule, we did not stratify we received, we are not proposing to
benchmarks by practice characteristics, all quality measures, including the
change our policies related to stratifying
such as practice size, because we did measures finalized for the MIPS
benchmarks by practice size for the
not believe there was a compelling 2020 MIPS payment year. For many program and the quality measures
rationale for such an approach, and we measures, the benchmarks may not need submitted through a QCDR that have
believed that stratifying could have stratification as they are only been approved for MIPS.
unintended negative consequences for meaningful to certain specialties and We are also not proposing to change
the stability of the benchmarks, equity only expected to be submitted by those the policies to score quality measure
across practices, and quality of care for certain specialists. We would like to performance using a percentile
beneficiaries (81 FR 77282). However, further clarify that in the majority of distribution, separated by decile
we sought comment on any rationales instances our current benchmarking categories and assign partial points
for or against stratifying by practice size approach only compares like clinicians based on the percentile distribution
we may not have considered. We note to like clinicians. We continue to finalized in the CY 2017 Quality
that we do create separate benchmarks believe that stratifying by practice size Payment Program final rule and codified
for each of the following submission could have unintended negative at paragraphs (b)(1)(ix), (x), and (xi) of
mechanisms: EHR submission options; consequences for the stability of the 414.1380; however, we propose a
QCDR and qualified registry submission benchmarks, equity across practices, technical correction to paragraph (ix) to
options; claims submission options; and quality of care for beneficiaries. clarify that measures are scored against
CMS Web Interface submission options; However, we seek comment on methods measure benchmarks. We refer readers
CMS-approved survey vendor for by which we could stratify benchmarks, to the discussion at 81 FR 77286 for
CAHPS for MIPS submission options; while maintaining reliability and more details on those policies.
and administrative claims submission stability of the benchmarks, to use in
options (for measures derived from developing future rulemaking for future For illustration, Table 19 provides an
claims data, such as the all-cause performance and payment years. example of assigning points for
hospital readmission measure) (81 FR Specifically, we seek comment on performance based on benchmarks
77282). methods for stratifying benchmarks by using a percentile distribution,
Several commenters who responded specialty or by place of service. We also separated by decile categories. The
to our solicitation of comment in the request comment on specific criteria to example is of the benchmarks for
final rule supported stratifying measure consider for stratifying measures, such Measure 130 Documentation of Current
benchmarks by practice size because the as how we should stratify submissions Medications in the Medical Record,
commenters believed it would help by multi-specialty practices or by which is based on our 2015 benchmark
small practices, which have limited practices that operate in multiple places file for the 2017 MIPS performance
resources compared to larger practices, of service. period.
TABLE 19EXAMPLE OF ASSIGNING POINTS FOR PERFORMANCE BASED ON A BENCHMARK, SEPARATED BY DECILES
Measure ID #130 (documentation of current medications in
the medical record) *

Submission mechanism
Claims perform- EHR performance Registry/QCDR
ance benchmark benchmark benchmark
Decile 1 or 2 (3 points) .............................................................................................. <96.11 <76.59 <61.27

Decile 3 (3.03.9 points) ........................................................................................... 96.1198.73 76.5987.88 61.2782.11
Decile 4 (4.04.9 points) ........................................................................................... 98.7499.64 87.8992.73 82.1291.71
Decile 5 (5.05.9 points) ........................................................................................... 99.6599.99 92.7495.35 91.7296.86
TABLE 19EXAMPLE OF ASSIGNING POINTS FOR PERFORMANCE BASED ON A BENCHMARK, SEPARATED BY DECILES
Continued
Measure ID #130 (documentation of current medications in
the medical record) *
Submission mechanism
Claims perform- EHR performance Registry/QCDR
ance benchmark benchmark benchmark
Decile 6 (6.06.9 points) ........................................................................................... 95.36 97.08 96.8799.30

Decile 7 (7.07.9 points) ........................................................................................... 97.0998.27 99.31 99.99
Decile 8 (8.08.9 points) ........................................................................................... 98.2899.12
Decile 9 (9.09.9 points) ........................................................................................... 99.1399.75
Decile 10 (10 points) ................................................................................................. 100 >= 99.76 100
* Based on our historical benchmark file for the 2017 MIPS performance period.
In Table 19, the cells with 10 measure achievement points for Eight of those 10 SSMs have had high
represent where there is a cluster at the performance years after the first reliability for scoring in prior years, or
top of benchmark distribution. For transition year because it would help to reliability is expected to improve for the
example, for the claims benchmark, over ensure that the MIPS eligible clinicians revised version of the measure, and they
50 percent of the MIPS eligible are protected from a poor performance also represent elements of patient
clinicians submitting that measure had score that they would not be able to experience for which we can measure
a performance rate of 100 percent based anticipate (81 FR 77282; 81 FR 77287). the effect one practice has compared to
on 2015 PQRS data. Because of the For measures with benchmarks based on other practices participating in MIPS.
cluster, clinicians who are at the 6, 7, the baseline period, we stated the 3- The Health Status and Functional
8, and 9th decile all would have point floor was for the transition year Status SSM, however, assesses
performance rates of 100 percent and and that we would revisit the 3-point underlying characteristics of a groups
would all receive a score of 10 points, floor in future years (81 FR 77286 patient population characteristics and is
indicated by dashes for those deciles. through 77287). less of a reflection of patient experience
Based on this clustered distribution, For the 2018 MIPS performance of care with the group. Moreover, to the
those clinicians with performance of period, we propose to again apply a 3- extent that health and functional status
99.99 percent fall into decile 5 and point floor for each measure that can be reflects experience with the practice,
receive points in the range from 5.0 to reliably scored against a benchmark case-mix adjustment is not sufficient to
5.9 points. For this measure, the based on the baseline period, and to separate how much of the score is due
benchmark for each submission amend 414.1380(b)(1) accordingly. We to patient experience versus due to
mechanism is topped out. refer readers to section II.C.7.a.(2)(h)(ii) aspects of the underlying health of
We note that for quality measures for of this rule, for our proposal to score patients. The Access to Specialists
which baseline period data is available, measures in the CMS Web Interface for SSM has low reliability; historically it
we will publish the numerical baseline the Quality Payment Program for which has had small sample sizes, and
period benchmarks with deciles prior to performance is below the 30th therefore, the majority of groups do not
the start of the performance period (or percentile. We will revisit the 3-point achieve adequate reliability, which
as soon as possible thereafter) (81 FR floor for such measures again in future means there is limited ability to
77282). For quality measures for which rulemaking. distinguish between practices
there is no comparable data from the We invite public comment on this performance.
baseline period, we will publish the proposal to again apply this 3-point For these reasons, we propose not to
numerical performance period floor for quality measures that can be score the Health Status and Functional
benchmarks after the end of the reliably scored against a baseline Status SSM and the Access to
performance period (81 FR 77282). We benchmark in the 2018 MIPS Specialists SSM beginning with the
will also publish further explanation of performance period. 2018 MIPS performance period. Despite
how we calculate partial points at not being suitable for scoring, both
(ii) Additional Policies for the CAHPS
qpp.cms.gov. SSMs provide important information
for MIPS Measure Score
about patient care. Qualitative work
(i) Floor for Scored Quality Measures In the CY 2017 Quality Payment suggests that Access to Specialists is
For the 2017 MIPS performance Program final rule, we finalized a policy a critical issue for Medicare FFS
period, we also finalized at for the CAHPS for MIPS measure, such beneficiaries. The survey is also a useful
414.1380(b)(1) a global 3-point floor that each Summary Survey Measure tool for assessing beneficiaries self-
for each scored quality measure, as well (SSM) will have an individual reported health status and functional
as for the hospital readmission measure benchmark, that we will score each SSM status, even if this measure is not used
(if applicable), such that MIPS eligible individually and compare it against the for scoring practices care experiences.
clinicians would receive between 3 and benchmark to establish the number of Therefore, we believe that continued
10 measure achievement points for each points, and the CAHPS score will be the
collection of the data for these two

submitted measure that can be reliably average number of points across SSMs SSMs is appropriate even though we do
scored against a benchmark, which (81 FR 77284). not propose to score them.
requires meeting the case minimum and As described in section Other than these two SSMs, we
data completeness requirements (81 FR II.C.6.b.(3)(a)(iii) of this proposed rule, propose to score the remaining 8 SSMs
77286 through 77287). Likewise, for we are proposing to remove two SSMs because they have had high reliability
measures without a benchmark based on from the CAHPS for MIPS survey, for scoring in prior years, or reliability
the baseline period, we stated that we which would result in the collection of is expected to improve for the revised
would continue to assign between 3 and 10 SSMs in the CAHPS for MIPS survey. version of the measure, and they also
represent elements of patient experience participating in MIPS. Table 20 and illustrates application of our
for which we can measure the effect one summarizes the proposed SSMs proposal to score only 8 measures.
practice has compared to other practices included in the CAHPS for MIPS survey
TABLE 20PROPOSED SSM FOR CAHPS FOR MIPS SCORING

Proposed for inclusion Proposed for inclusion
Summary survey measure in the CAHPS for in CAHPS for MIPS
MIPS survey? scoring?
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.
We invite comment on our proposal clinicians; however, we believe asking In the CY 2017 Quality Payment
not to score the Health Status and clinicians to submit measures that we Program final rule, we sought comment
Functional Status and Access to have identified as topped out and on how topped out measures should be
Specialists SSMs beginning with the measures for which they already excel scored provided that it is the second
2018 MIPS performance period. is an unnecessary burden that does not year the measure has been identified as
We note that in section add value or improve beneficiary topped out (81 FR 77286). We suggested
II.C.6.g.(3)(b)(i)(A) of this proposed rule, outcomes. three possible options: (1) Score the
we are proposing to add the CAHPS for Based on 2015 historic benchmark measures using a mid-cluster approach;
ACOs survey as an available measure for data,8 approximately 45 percent of the (2) remove topped out measures; or (3)
calculating the MIPS APM score for the quality measure benchmarks currently apply a flat percentage in building the
Shared Savings Program and Next meet the definition of topped out, with benchmarks for topped out measures.
Generation ACO Model. We refer some submission mechanisms having a Flat percentages assign points based
readers participating in ACOs to section higher percent of topped out measures directly on the percentage of
II.C.6.g.(3)(b) of this proposed rule for than others. Approximately 70 percent performance rather than by a percentile
the CAHPS for ACOs scoring of claims measures are topped out, 10 distribution by decile. Flat-rate would
methodology. percent of EHR measures are topped provide high scores to virtually all
out, and 45 percent of registry/QCDR clinicians submitting the measure
(c) Identifying and Assigning Measure because performance rates tend to be
Achievement Points for Topped Out measures are topped out.
In the CY 2017 Quality Payment high. Cluster-based benchmarks for
Measures topped out measures are based on a
Program final rule, we finalized that for
Section 1848(q)(3)(B) of the Act percentile distribution, but because
the 2019 MIPS payment year, we would
requires that, in establishing many submitters are clustered at the top
score topped out quality measures in the
performance standards with respect to of performance, there can be large drops
same manner as other measures (81 FR
measures and activities, we consider, in points assigned for relatively small
77286). We finalized that we would not
among other things, the opportunity for differences in performance. The current
modify the benchmark methodology for
continued improvement. We finalized top of the cluster approach can result in
topped out measures for the first year
in the CY 2017 Quality Payment many clinicians receiving 10 points. A
that the measure has been identified as
Program final rule that we would mid-cluster approach would limit the
topped out, but that we would modify
identify topped out process measures as maximum number of points a topped
the benchmark methodology for topped
those with a median performance rate of out measure can achieve based on how
out measures beginning with the 2020
95 percent or higher (81 FR 77286). For clustered the score are, and could still
MIPS payment year, provided that it is
non-process measures we finalized a result in large drops, although less than
the second year the measure has been
topped out definition similar to the with the top of the cluster approach, in
identified as topped out. As described
definition used in the Hospital VBP points assigned for relatively small
in detail later in this section, we are
Program: Truncated Coefficient of differences in performance. We also
proposing a phased in approach to
Variation is less than 0.10 and the 75th noted in the CY 2017 Quality Payment
apply special scoring to topped out
and 90th percentiles are within 2 Program final rule that we anticipate
measures, beginning with the 2018
standard errors (81 FR 77286). When a removing topped out measures over
MIPS performance period (2020 MIPS
measure is topped out, a large majority time and sought comment on what point
payment year), rather than modifying
of clinicians submitting the measure in time we should remove topped out
the benchmark methodology for topped

performs at or very near the top of the measures from MIPS (81 FR 77286). The
out measures as indicated in the CY
distribution; therefore, there is little or comments and our proposed policy for
2017 Quality Payment Program final
no room for the majority of MIPS removing topped out measures are
rule.
eligible clinicians who submit the described in section II.C.6.c.(2) of this
measure to improve. We understand 8 The topped out determination is calculated on
proposed rule.
that every measure we have identified historic performance data and the percentage of
In response to our request for
as topped out may offer room for topped out measures may change when evaluated comment in the CY 2017 Quality
improvement for some MIPS eligible for the most applicable annual period. Payment Program final rule, a few
commenters believed that we should not We are not proposing to remove represents the spot between the bottom
score topped out measures differently topped out measures for the 2018 MIPS 5 deciles and start of the top 5 deciles.
from other measures because performance period because we We believe this proposed capped
commenters believed changing the recognize that there are currently a large scoring methodology will incentivize
scoring could reduce quality, add number of topped out measures and MIPS eligible clinicians to begin
complexity to the program, and reduce removing them may impact the ability submitting non-topped out measures
incentives to participate in MIPS. of some MIPS eligible clinicians to without performing below the median
Several commenters recommended that submit 6 measures and may impact score. This methodology also would not
if we do score topped out measures some specialties more than others. We impact scoring for those MIPS eligible
differently, we use flat percentages note, however, that as described in clinicians that do not perform near the
rather than cluster-based benchmarks, section II.C.6.c.(2) of this proposed rule, top of the measure and therefore have
with a few commenters noting that we are proposing a timeline for significant room to improve on the
using flat percentages could help ensure removing topped out measures in future measure. We may also consider
those with high performance on a years. We believe this provides MIPS lowering the cap below 6 points in
measure are not penalized as low eligible clinicians the ability to future years, especially if we remove the
performers and another noting that anticipate and plan for the removal of 3-point floor for performance in future
allowing high scorers to earn maximum specific topped out measures, while years.
or near maximum points is similar to providing measure developers time to We note that although we are
the approach in the Shared Savings develop new measures. proposing a new methodology for
Program. A few commenters We note that because we create a assigning measure achievement points
recommended that we publish separate benchmark for each submission for topped out measures, we are not
information about topped out and mechanism available for a measure, a changing the policy for awarding
potentially topped out measures prior to benchmark for one submission measure bonus points for topped out
the performance period to allow mechanism for the measure may be measures. Topped out measures will
clinicians time to adjust their reporting identified as topped out while another still be eligible for measure bonus points
strategies, with one commenter noting submission mechanisms benchmark if they meet the required criteria. We
that improvement may be rewarded in may not be topped out. The topped out refer readers to sections II.C.7.a.(2)(f)
addition to achievement. One designation and special scoring apply and II.C.7.a.(2)(g) of this proposed rule
commenter recommended pushing back only to the specific benchmark that is for more information about measure
the baseline performance period for topped out, not necessarily every bonus points.
identifying topped out measures to the benchmark for a measure. For example, We request comments on our proposal
2018 MIPS performance period because the benchmark for the claims to score topped out measures differently
in the transition year it is unclear how submission mechanism may be topped by applying a 6-point cap, provided it
many eligible clinicians will be out for a measure, but the benchmark for is the second consecutive year the
reporting at different times and for what the EHR submission mechanisms for measure is identified as topped out.
period they will report. that same measure may not be topped Specifically, we seek feedback on
As described in section II.C.6.c.(2) of out. In this case, the topped out scoring whether 6 points is the appropriate cap
this proposed rule, we are proposing a would only apply to measures or whether we should consider another
lifecycle for topped out measures by submitted via the claims submission value. We also seek comment on other
which, after a measure benchmark is mechanism, which has the topped out possible options for scoring topped out
identified as topped out in the benchmark. We also describe in section measures that would meet our policy
published benchmark for 2 years, in the II.C.6.c.(2) of this proposed rule that, goals to encourage clinicians to begin to
third consecutive year it is identified as similarly, only the submission submit measures that are not topped out
topped out it will be considered for mechanism that is topped out for the while also providing stability for MIPS
removal through notice-and-comment measure would be removed. eligible clinicians.
rulemaking or the QCDR approval We propose to cap the score of topped While we believe it is important to
process and may be removed from the out measures at 6 measure achievement score topped out measures differently
benchmark list in the fourth year, points. We are proposing a 6-point cap because they could have a
subject to the phased in approach for multiple reasons. First, we believe disproportionate impact on the scores
described in section II.C.6.c.(2) of this applying a cap to the current method of for certain MIPS eligible clinicians and
proposed rule. scoring a measure against a benchmark topped out measures provide little room
As part of the lifecycle for topped out is a simple approach that can easily be for improvement for the majority of
measures, we also propose in this predicted by clinicians. Second, the cap MIPS eligible clinicians who submit
section II.C.7.a.(2)(c) of this proposed will create incentives for clinicians to them, we also recognize that numerous
rule, a method to phase in special submit other measures for which they measure benchmarks are currently
scoring for topped out measure can improve and earn future identified as topped out and special
benchmarks starting with the 2018 MIPS improvement points. Third, considering scoring for topped out measures could
performance period, provided that is the our proposed topped out measure impact some specialties more than
second consecutive year the measure lifecycle, we believe this cap would others. Therefore, we considered ways
benchmark is identified as topped out in only be used for a few years and the to phase in special scoring for topped
the benchmarks published for the simplicity of a cap on the current out measures in a way that will begin
performance period. This special benchmarks would outweigh the to apply special scoring, but would not
scoring would not apply to measures in cluster-based options or applying a cap overwhelm any one specialty and would
the CMS Web Interface, as explained on benchmarks based on flat-percentage, also provide additional time to evaluate
later in this section. The phased-in which are more complicated. The the impact of topped out measures
approach described in this section rationale for a 6-point cap is that 6 before implementing it for all topped
represents our first step in methodically points is the median score for any out measures, while also beginning to
implementing special scoring for topped measure as it represents the start of the encourage submission of measures that
out measures. 6th decile for performance and are not topped out.
We believe the best way to Measure is topped out and there is separate benchmark for each submission
accomplish this is by applying special no difference in performance between mechanism available for a measure, a
topped out scoring to a select number of decile 3 through decile 10. We applied benchmark for one submission
measures for the 2018 performance this limitation because, based on mechanism for the measure may be
period and to then apply the special historical data, there is no room for identified as topped out while another
topped out scoring to all topped out improvement for over 80 percent of submission mechanisms benchmark
measures for the 2019 performance MIPS eligible clinicians that reported on may not be topped out. For example, the
period, provided it is the second these measures. benchmark for the claims submission
consecutive year the measure is topped Process measures only because we mechanism may be topped out for a
out. We believe this approach allows us want to continue to encourage reporting measure, but the benchmark for the EHR
time to further evaluate the impact of on high priority outcome measures, and submission mechanisms for that same
topped out measures and allows for a the small subset of structure measures measure may not be topped out. We
methodical way to phase in topped out was confined to only three specialties. decided to limit our criteria to only
scoring. MIPS measures only (which does measures that were topped out for all
not include measures that can only be measures for simplicity and to avoid
We identified measures we believe reported through a QCDR) given that confusion about what scoring is applied
should be scored with the special QCDR measures go through a separate to a measure.
topped out scoring for the 2018 process for approval and because we Measure is in a specialty set with at
performance period by using the want to encourage use of QCDRs least 10 measures, because 2 measures
following set criteria, which are only required by section 1848(q)(1)(E) of the in the pathology specialty set, which
intended as a way to phase in our Act. only has 8 measures total would have
topped-out measure policy for selected Measure is topped out for all been included.
measures and are not intended to be mechanisms by which the measure can Applying these criteria results in the
criteria for use in future policies: be submitted. Because we create a 6 measures as listed in Table 21.
TABLE 21TOPPED OUT MEASURES PROPOSED 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.
ImageLocalized 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 propose to apply the special out measures, provided it is the second identified in Table 21 have special
topped out scoring method that we (or more) consecutive year the measure scoring applied, provided they are
finalize for the 2018 performance period is identified as topped out. We seek identified as topped out for the 2018
to only the 6 measures in Table 21 for comment on our proposal to apply MIPS performance period, meaning it is
the 2018 performance period, provided special topped out scoring to all topped the second consecutive year they are
they are again identified as topped out out measures, provided it is the second identified as topped out.
in the benchmarks for the 2018 (or more) consecutive year the measure
Year 3: Measure benchmarks are
performance period. If these measures is identified as topped out.
are not identified as topped out in the identified as topped out in the
We illustrate the lifecycle for scoring
benchmarks published for the 2018 benchmarks published for the 2019
and removing topped out measures
performance period, they will not be MIPS performance period. All measure
based on our proposals as follows:
scored differently because they would benchmarks identified as topped out for
Year 1: Measure benchmarks are
not be topped out for a second the second (or more) consecutive year
identified as topped out, which in this
consecutive year. have special scoring applied for the

example would be in the benchmarks
We seek comment on our proposal to 2019 MIPS performance period. In Year
published for the 2017 MIPS
apply special topped out scoring only to performance period. 3 we would also consider removal of the
select set of topped out measures
the 6 measures identified in Table 21 for Year 2: Measure benchmarks are
the 2018 performance period. identified in Table 21, through notice
identified as topped out, which in this
Starting with the 2019 performance example would be in the benchmarks and comment rulemaking, provided
period, we propose to apply the special published for the 2018 MIPS they are identified as topped out during
topped out scoring method to all topped performance period. Measures the previous two (or more) consecutive
years. In our example, Year 3 would be benchmarks identified as topped out for performance period are no longer
the 2019 performance period. a second (or more) consecutive year available for reporting.
Year 4: Measure benchmarks are continue to have special scoring An example of applying the proposed
identified as topped out in the applied. Topped out measures finalized scoring cap compared to scoring applied
benchmarks published for the 2020 for removal for the 2020 MIPS for the 2017 MIPS performance period
MIPS performance period. Measure is provided in Table 22.
TABLE 22PROPOSED SCORING 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 Cate-gory
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 achievement achievement achievement achievement achievement achievement
Scoring. points. points. points. points (did not points. points.
get max score).
Proposed Capped 6 measure 6 measure 6 measure 4 measure 10 measure 5 measure 37/60 = 61.67%.
Scoring applied. achievement achievement achievement achievement achievement achievement
points. points. points. points. points. points.
Notes .................... Topped out measures scored with 6-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 21 for the CY 2018 MIPS Performance Period. This example also excludes bonus points and
improvement scoring proposed in section II.C.7.a.(2)(i) of this proposed rule.
Together the proposed policies for whether the proposed policy to cap the not believe capping benchmarks from
phasing in capped scoring and removing score of topped out measures beginning the CMS Web Interface for the Quality
topped out measures are intended to with the 2019 performance period Payment Program is appropriate. We
provide an incentive for MIPS eligible should apply to SSMs in the CAHPS for finalized in the CY 2017 Quality
clinicians to begin to submit measures MIPS survey measure or whether there Payment Program final rule at
that are not topped out while also is another alternative policy that could 414.1380(b)(1)(ii)(A) to use
providing stability by allowing MIPS be applied for the CAHPS for MIPS benchmarks from the corresponding
eligible clinicians who have few survey measure due to high, unvarying reporting year of the Shared Savings
alternative measures to continue to performance within the SSM. We note Program. The Shared Savings Program
receive standard scoring for most that we would like to encourage groups adjusts some benchmarks to a flat
topped out measures for an additional to report the CAHPS for MIPS survey as percentage when the 60th percentile is
year, and not perform below the median it incorporates beneficiary feedback. equal to or greater than 80.00 percent for
score for those 6 measures that receive We stated in the CY 2017 Quality individual measures (78 FR 74759
special scoring. It also provides MIPS Payment Program final rule that we do through 74763), and, for other measures,
eligible clinicians the ability to not believe it would be appropriate to benchmarks are set using flat
anticipate and plan for the removal of remove topped out measures from the percentages when the 90th percentile
specific topped out measures, while CMS Web Interface for the Quality for a measure are equal to or greater
providing measure developers time to Payment Program because the CMS Web than 95.00 percent (79 FR 67925). Thus,
develop new measures. Interface measures are used in MIPS and we are not proposing to apply the
We propose to add a new paragraph in APMs such as the Shared Savings topped out measure cap to measures in
at 414.1380(b)(1)(xiii) to codify our Program and because we have aligned the CMS Web Interface for the Quality
proposal for the lifecycle for removing policies, where possible, with the Payment Program.
topped out measures. Shared Savings Program, such as using
We also propose to add at the Shared Savings Program We seek comment on this proposal
414.1380(b)(1)(xiii)(A) that for the benchmarks for the CMS Web Interface not to apply the topped out measure cap
2018 MIPS performance period, the 6 measures (81 FR 77285). In the CY 2017 to measures in the CMS Web Interface
measures identified in Table 21 will Quality Payment Program final rule, we for the Quality Payment Program.
receive a maximum of 6 measure also finalized that MIPS eligible (d) Case Minimum Requirements and
achievement points, provided that the clinicians submitting via the CMS Web Measure Reliability and Validity
measure benchmarks are identified as Interface must submit all measures
topped out again in the benchmarks included in the CMS Web Interface (81 To help ensure reliable measurement,
published for the 2018 MIPS FR 77116). Thus, if a CMS Web Interface in the CY 2017 Quality Payment
performance period. We also propose to measure is topped out, the CMS Web Program final rule (81 FR 77288), we
add at 414.1380(b)(1)(xiii)(B) that Interface submitter cannot select other finalized a 20-case minimum for all
beginning with the 2019 MIPS measures. Because of the lack of ability quality measures except the all-cause
performance period, measure to select measures, we are not proposing hospital readmission measure. For the
benchmarks, except for measures in the to apply a special scoring adjustment to all-cause hospital readmission measure,
CMS Web Interface, that are identified topped out measures for CMS Web we finalized in the CY 2017 Quality
as topped out for two 2 or more Interface for the Quality Payment Payment Program final rule a 200-case
consecutive years will receive a Program. minimum and finalized to apply the all-
maximum of 6 measure achievement Additionally, because the Shared cause hospital readmission measure
points in the second consecutive year it Savings Program incorporates a only to groups of 16 or more clinicians
is identified as topped out, and beyond. methodology for measures with high that meet the 200-case minimum
We specifically seek comment on performance into the benchmark, we do requirement (81 FR 77288).
We are not proposing any changes to To encourage complete reporting, we to fail to meet the data completeness
these policies. are proposing that in the 2020 MIPS criteria. Applying 1 point for missing
For the 2019 MIPS payment year, we payment year, measures that do not data completeness based on missing a
finalized in the CY 2017 Quality meet data completeness standards will relatively small number of cases could
Payment Program final rule that if the receive 1 point instead of the 3 points disadvantage these clinicians, who may
measure is submitted but is unable to be that were awarded in the 2019 MIPS have additional burdens for reporting in
scored because it does not meet the payment year. We propose lowering the MIPS, although we also recognize that
required case minimum, does not have point floor to 1 for measures that do not failing to report on 10 or more patients
a benchmark, or does not meet the data meet data completeness standards for is undesirable. In addition, we know
completeness requirement, the measure several reasons. First, we want to that many small practices may have less
would receive a score of 3 points (81 FR encourage complete reporting because experience with submitting quality
77288 through 77289). We identified data completeness is needed to reliably performance category data and may not
two classes of measures for the measure quality. Second, unlike case yet have systems in place to ensure they
transition year. Class 9 1 measures are minimum and availability of a can meet the data completeness criteria.
measures that can be scored based on benchmark, data completeness is within Thus, we are also proposing an
performance because they have a the direct control of the MIPS eligible exception to the proposed policy for
benchmark, meet the case minimum clinician. In the future, we intend that measures submitted by small practices,
requirement, and meet the data measures that do not meet the as defined in 414.1305. We propose
completeness standard. We finalized completeness criteria will receive zero that these clinicians would continue to
that Class 1 measures would receive 3 points; however, we believe that during receive 3 points for measures that do not
to 10 points based on performance the second year of transitioning to meet data completeness.
compared to the benchmark (81 FR MIPS, clinicians should continue to Therefore, we propose to revise Class
77289). Class 2 measures are measures receive at least 1 measure achievement 2 measures to include only measures
that cannot be scored based on point for any submitted measure, even that cannot be scored based on
performance because they do not have if the measure does not meet the data performance because they do not have
a benchmark, do not have at least 20 completeness standards. a benchmark or do not have at least 20
cases, or the submitted measure does We are concerned, however, that data cases. We also propose to create Class 3
not meet data completeness criteria. We completeness may be harder to achieve measures, which are measures that do
finalized that Class 2 measures, which for small practices. For example, small not meet the data completeness
do not include measures submitted with practices tend to have small case requirement. We propose that the
the CMS Web Interface or volume and missing one or two cases revised Class 2 measure would continue
administrative claims-based measures, could cause the MIPS eligible clinician to receive 3 points. The proposed Class
receive 3 points (81 FR 77289). to miss the data completeness standard 3 measures would receive 1 point,
as each case may represent multiple except if the measure is submitted by a
We propose to maintain the policy to percentage points for data completeness. small practice in which case the Class
assign 3 points for measures that are For example, for a small practice with 3 measure would receive 3 points.
submitted but do not meet the required only 20 cases for a measure, each case However, consistent with the policy
case minimum or does not have a is worth 5 percentage points, and if they finalized in the CY 2017 Quality
benchmark for the 2020 MIPS payment miss reporting just 11 or more cases, Payment Program final rule, these
year and amend 414.1380(b)(1)(vii) they would fail to meet the data policies for Class 2 and Class 3
accordingly. completeness threshold, whereas for a measures would not apply to measures
We also propose a change to the practice with 200 cases, each case is submitted with the CMS Web Interface
policy for scoring measures that do not worth 0.5 percentage points towards or administrative claims-based
meet the data completeness requirement data completeness and the practice measures. A summary of the proposals
for the 2020 MIPS payment year. would have to miss more than 100 cases is provided in Table 23.
TABLE 23QUALITY PERFORMANCE CATEGORY: SCORING MEASURES BASED ON PERFORMANCE

Description proposed for
Scoring rules in 2017 MIPS Proposed for 2018 MIPS
Measure type Description in transition year 2018 MIPS
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 50 percent.)
9 References to Classes of measures in this
section II.C.7.a.(2)(d) are intended only to

characterize the measures for ease of discussion.
TABLE 23QUALITY PERFORMANCE CATEGORY: SCORING MEASURES BASED ON PERFORMANCEContinued

Description proposed for
Scoring rules in 2017 MIPS Proposed for 2018 MIPS
Measure type Description in transition year 2018 MIPS
performance period performance period
performance period
Class 2 .............. Measures that cannot be 3 points ................................. Measures that were sub- 3 points
scored based on perform- * This Class 2 measure pol- mitted and meet data com- *This Class 2 measure policy
ance. Measures that were icy does not apply to CMS pleteness, but does not would not apply to CMS
submitted, but fail to meet Web Interface measures have one or both of the fol- Web Interface measures
one of the Class 1 criteria. and administrative claims lowing: and administrative claims
The measure either based measures. (1) a benchmark based measures.
(2) at least 20 cases
(1) does not have a
benchmark,
(2) does not have at
least 20 cases, or
(3) does not meet data
completeness criteria.
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.
We propose to amend Quality Payment Program final rule and implementation of a validation process
414.1380(b)(1)(vii) to assign 3 points codified at paragraph (b)(1)(viii) of for claims and registry submissions to
for measures that do not meet the case 414.1380. We refer readers to the validate whether MIPS eligible
minimum or do not have a benchmark discussion at 81 FR 77288 for more clinicians have 6 applicable and
in the 2020 MIPS payment year, and to details on that policy. available measures, whether an outcome
assign 1 point for measures that do not To clarify the exclusion of measures measure is available or whether another
meet data completeness requirements, submitted via the CMS Web Interface high priority measure is available if an
unless the measure is submitted by a and based on administrative claims outcome measure is not available (81 FR
small practice, in which case it would from the policy changes proposed to be 77290 through 77291).
receive 3 points. codified at paragraph (b)(1)(vii) We are not proposing any changes to
We invite comment on our proposal previously, we are amending paragraph apply a process to validate whether
to assign 1 point to measures that do not (b)(1)(vii) to make it subject to MIPS eligible clinicians that submit
meet data completeness criteria, with an paragraph (b)(1)(viii), which codifies the measures via claims and registry
exception for measures submitted by exclusion. submissions have measures available
small practices. and applicable. As stated in the CY 2017
We are not proposing to change the (e) Scoring for MIPS Eligible Clinician Quality Payment Program final rule (81
methodology we use to score measures That Do Not Meet Quality Performance FR 77290), we did not intend to
submitted via the CMS Web Interface Category Criteria establish a validation process for QCDRs
that do not meet the case minimum, do In the CY 2017 Quality Payment because we expect that MIPS eligible
not have a benchmark, or do not meet Program final rule, we finalized that clinicians that enroll in QCDRs will
the data completeness requirement MIPS eligible clinicians who fail to have sufficient meaningful measures to
finalized in the CY 2017 Quality submit a measure that is required to meet the quality performance category
Payment Program final rule and codified satisfy the quality performance category criteria (81 FR 77290 through 77291).
at paragraph (b)(1)(viii) of 414.1380. submission criteria would receive zero We do not propose any changes to this
However, we note that as described in points for that measure (81 FR 77291). policy.
section II.C.7.a.(2)(h)(ii) of this proposed For each required measure that is not We also stated that if a MIPS eligible
rule, we are proposing to add that CMS submitted, a MIPS eligible clinician clinician did not have 6 measures
Web Interface measures with a would receive zero points out of 10. For relevant within their EHR to meet the
benchmark that are redesignated from example, if a MIPS eligible clinician had full specialty set requirements or meet
pay for performance to pay for reporting 6 measures available and applicable but the requirement to submit 6 measures,
by the Shared Savings Program will not submitted only 4 measures, the MIPS the MIPS eligible clinician should select
be scored. We refer readers to the eligible clinician would be assigned a different submission mechanism to
discussion at 81 FR 77288 for more zero out of 10 measure achievement meet the quality performance category
details on our previously finalized requirements and should work with
points for the 2 missing measures,

policy. which would be calculated into their their EHR vendors to incorporate
We are also not proposing any performance category percent score. applicable measures as feasible (81 FR
changes to the policy to not include We are not proposing any changes to 77290 through 77291). Under our
administrative claims measures in the the policy to assign zero points for proposals in section II.C.6.a.(1) of this
quality performance category percent failing to submit a measure that is proposed rule to allow measures to be
score if the case minimum is not met or required in this proposed rule. submitted and scored via multiple
if the measure does not have a In the CY 2017 Quality Payment mechanisms within a performance
benchmark finalized in the CY 2017 Program final rule, we also finalized category, we anticipate that MIPS
eligible clinicians that submit fewer a very targeted clinical area may not the quality performance category for the
than 6 measures via EHR will have have any measures available. However, first 2 years of MIPS (81 FR 77294).
sufficient additional measures available in many cases, the clinician may be part Groups that submit via the CMS Web
via a combination of submission of a broader group or would have the Interface for the Quality Payment
mechanisms to submit the measures ability to select some of the cross- Program are also subject to the 10
required to meet the quality cutting measures that are available. percent cap on high priority measure
performance category criteria. For Given the wide array of submission bonus points. We are not proposing any
example, the MIPS eligible clinician options, including QCDRs which have changes to the cap on measure bonus
could submit 2 measures via EHR and the flexibility to develop additional points for reporting high priority
supplement that with 4 measures via measures, we believe this scenario measures, which is codified at
QCDR or registry. should be extremely rare. If we are not 414.1380(b)(1)(xiv)(D) 10, in this
Therefore, given our proposal to score able to score the quality performance proposed rule.
multiple mechanisms, if a MIPS eligible category, we may reweight their score
clinician submits any quality measures (g) Incentives to Use CEHRT To Support
according to the reweighting policies
via EHR or QCDR, we would not Quality Performance Category
described in section II.C.7.b.(3)(b) and
conduct a validation process because we Submissions
II.C.7.b.(3)(d) of this proposed rule. We
expect these MIPS eligible clinicians to note that we anticipate this will be a Section 1848(q)(5)(B)(ii) of the Act
have sufficient measures available to rare circumstance given our proposals to outlines specific scoring rules to
meet the quality performance category allow measures to be submitted and encourage the use of CEHRT under the
requirements. scored via multiple mechanisms within quality performance category. For more
Given our proposal in section a performance category and to allow of the statutory background and
II.C.7.a.(2)(h) of this proposed rule to facility-based measurement for the description of the proposed and
score measures submitted via multiple quality performance category. finalized policies, we refer readers to
mechanisms, we propose to validate the the CY 2017 Quality Payment Program
availability and applicability of (f) Incentives To Report High Priority final rule (81 FR 77294 through 77299).
measures only if a MIPS eligible Measures In the CY 2017 Quality Payment
clinician submits via claims submission In the CY 2017 Quality Payment Program final rule at
options only, registry submission Program final rule, we finalized that we 414.1380(b)(1)(xiv), we codified that 1
options only, or a combination of claims would award 2 bonus points for each bonus point is available for each quality
and registry submission options. In outcome or patient experience measure measure submitted with end-to-end
these cases, we propose that we will and 1 bonus point for each additional electronic reporting, under certain
apply the validation process to high priority measure that is reported in criteria described below (81 FR 77297).
determine if other measures are addition to the 1 high priority measure We also finalized a policy capping the
available and applicable broadly across that is already required to be reported number of bonus points available for
claims and registry submission options. under the quality performance category electronic end-to-end reporting at 10
We will not check if there are measures submission criteria, provided the percent of the denominator of the
available via EHR or QCDR submission measure has a performance rate greater quality performance category percent
options for these reporters. We note that than zero, and the measure meets the score, for the first 2 years of the program
groups cannot report via claims and case minimum and data completeness (81 FR 77297). For example, when the
therefore groups and virtual groups will requirements (81 FR 77293). High denominator is 60, the number of
only have validation applied across priority measures were defined as measure bonus points will be capped at
registries. We would validate the outcome, appropriate use, patient safety, 6 points. We also finalized that the
availability and applicability of a efficiency, patient experience and care CEHRT bonus would be available to all
measure through a clinically related coordination measures, as identified in submission mechanisms except claims
measure analysis based on patient type, Tables A and E in the Appendix of the submissions. Specifically, MIPS eligible
procedure, or clinical action associated CY 2017 Quality Payment Program final clinicians who report via qualified
with the measure specifications. For us rule (81 FR 77558 and 77686). We also registries, QCDRs, EHR submission
to recognize fewer than 6 measures, an finalized that we will apply measure mechanisms, or the CMS Web Interface
individual MIPS eligible clinician must bonus points for the CMS Web Interface for the Quality Payment Program, in a
submit exclusively using claims or for the Quality Payment Program based manner that meets the end-to-end
qualified registries or a combination of on the finalized set of measures reporting requirements, may receive 1
the two, and a group or virtual group reportable through that submission bonus point for each reported measure
must submit exclusively using qualified mechanism (81 FR 77293). We note that with a cap as described (81 FR 77297).
registries. Given our proposal in section in addition to the 14 required measures, We are not proposing changes to these
II.C.7.a.(2)(h) of this proposed rule to CMS Web Interface reporters may also policies related to bonus points for
score measures submitted via multiple report the CAHPS for MIPS survey and using CEHRT for end-to-end reporting
mechanisms, validation will be receive measure bonus points for in this proposed rule. However, we are
conducted first by applying the submitting that measure. seeking comment on the use of health IT
clinically related measure analysis for We are not proposing any changes to in quality measurement and how HHS
the individual measure and then, to the these policies for awarding measure can encourage the use of certified EHR
extent technically feasible, validation bonus points for reporting high priority technology in quality measurement as
will be applied to check for available measures in this proposed rule. established in the statute. What other
measures available via both claims and In the CY 2017 Quality Payment incentives within this category for
registries. Program final rule, we finalized a cap on reporting in an end-to-end manner
We recognize that in extremely rare high priority measure bonus points at 10 could be leveraged to incentivize more
instances there may be a MIPS eligible percent of the denominator (total clinicians to report electronically? What
clinician who may not have available possible measure achievement points format should these incentives take? For
and applicable quality measures. For the MIPS eligible clinician could receive
example, a subspecialist who focuses on in the quality performance category) of 10 Redesignated from 414.1380(b)(1)(xiii)(D).
example, should clinicians who report be able to submit measures within a multiple mechanisms if reported by the
all of their quality performance category performance category via multiple same individual MIPS eligible clinician,
data in an end-to-end manner receive submission mechanisms. In the CY 2017 group, virtual group or APM Entity, as
additional bonus points than those who Quality Payment Program final rule, we described in Table 24.
report only partial electronic data? Are also sought comment on what approach We do not propose to aggregate
there other ways that HHS should we should use to combine the scores for measure results across different
incentivize providers to report quality measures from multiple submitters to create a single score for an
electronic quality data beyond what is submission mechanisms into a single individual measure (for example, we are
currently employed? We welcome aggregate score for the quality not going to aggregate scores from
public comment on these questions. performance category (81 FR 77275). different TINs within a virtual group
(h) Calculating Total Measure Examples of possible scoring options TIN to create a single virtual group score
Achievement and Measure Bonus Points were a weighted average score on for the measures; rather, virtual groups
quality measures submitted through two must perform that aggregation across
In section II.C.7.a.(2)(i) of this or more different mechanisms or taking
proposed rule, we are proposing a new TINs prior to data submission to CMS).
the highest scores for any submitted Virtual groups are treated like other
methodology to reward improvement measure regardless of how the measure
based on achievement, from 1 year to groups and must report all of their
is submitted. A few comments received
another, which requires modifying the measures at the virtual group level, for
in response to the CY 2017 Quality
calculation of the quality performance the measures to be scored. Data
Payment Program final rule did not
category percent score. In this section completeness and all the other criteria
support developing different weights for
II.C.7.a.(2)(h) of the proposed rule, we will be evaluated at the virtual group
different submission methods. One
are summarizing the policies for level. Then the same rules apply for
commenter recommended that we take
calculating the total measure selecting which measures are used for
the highest score for any submitted
achievement points and total measure scoring. In other words, if a virtual
measure, regardless of submission
bonus points, prior to scoring group representative submits some
mechanisms, or alternatively, calculate
improvement and the final quality measures via a qualified registry and
independent scores that would each
performance category percent score. We contribute equally to the final score. other measures via EHR, but an
note that we will refer to policies After consideration of the comments individual TIN within the virtual group
finalized in the CY 2017 Quality we received, we are proposing, also submits measures, we will only use
Payment Program final rule that apply beginning with the 2018 MIPS the scores from the measures that were
to the quality performance category performance period, a method to score submitted at the virtual group level,
score, which is referred to as the quality quality measures if a MIPS eligible because the TIN submission does not
performance category percent score in use the virtual group identifier. This is
clinician submits measures via more
this proposed rule, in this section. We consistent with our other scoring
than one of the following submission
are also proposing some refinements to principles, where, for virtual groups, all
mechanisms: Claims, qualified registry,
address the ability for MIPS eligible quality measures are scored at the
EHR or QCDR submission options. We
clinicians to submit quality data via virtual group level.
believe that allowing MIPS eligible
multiple submission mechanisms.
clinicians to be scored across these data Separately, as also described in
(i) Calculating Total Measure submission mechanisms in the quality Table 24, because CMS Web Interface
Achievement and Measure Bonus Points performance category will provide and facility-based measurement each
for Non-CMS Web Interface Reporters additional options for MIPS eligible have a comprehensive set of measures
In the CY 2017 Quality Payment clinicians to report the measures that meet the proposed MIPS
Program final rule (81 FR 77300), we required to meet the quality submission requirements, we do not
finalized that if a MIPS eligible clinician performance category criteria, and propose to combine CMS Web Interface
elects to report more than the minimum encourage MIPS eligible clinicians to measures or facility-based measurement
number of measures to meet the MIPS begin using electronic submission with other group submission
quality performance category criteria, mechanisms, even if they may not have mechanisms (other than CAHPS for
then we will only include the scores for 6 measures to report via a single MIPS, which can be submitted in
the measures with the highest number electronic submission mechanism alone. conjunction with the CMS Web
of assigned points, once the first We note that we also continue to score Interface). We refer readers to section
outcome measure is scored, or if an the CMS-approved survey vendor for II.C.7.a.(2)(h)(ii) of this proposed rule
outcome measure is not available, once CAHPS for MIPS submission options in for discussion of calculating the total
another high priority measure is scored. conjunction with other submission measure achievement and measure
We are not proposing any changes to the mechanisms (81 FR 77275) as noted in bonus points for CMS Web Interface
policy to score the measures with the Table 24. reporters and to section II.C.7.a.(4) of
highest number of assigned points in We propose to score measures across this proposed rule for a description of
this proposed rule; however, we are multiple mechanisms using the our proposed policies on facility-based
proposing refinements to account for following rules: measurement. We list these submission
measures being submitted across As with the rest of MIPS, we will mechanisms in Table 24, to illustrate
multiple submission mechanisms. only score measures within a single that CMS Web Interface submissions
In the CY 2017 Quality Payment identifier. For example, as codified in and facility-based measurement cannot
Program final rule, we sought comment 414.1310(e), eligible clinicians and be combined with other submission
on whether to score measures submitted MIPS eligible clinicians within a group options, except that the CAHPS for
across multiple submission mechanisms aggregate their performance data across MIPS survey can be combined with
(81 FR 77275). As described in section the TIN in order for their performance CMS Web Interface, as described in
II.C.6.a.(1) of this proposed rule, we are to be assessed as a group. Therefore, section II.C.7.a.(2)(h)(ii) of this proposed
proposing that MIPS eligible clinicians measures can only be scored across rule.
TABLE 24SCORING ALLOWED ACROSS MULTIPLE MECHANISMS BY SUBMISSION MECHANISM

[Determined by MIPS identifier and submission mechanism]
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.
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 provide 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 anticipate that this will be a rare
for earning the bonus point. For propose 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 25
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 our
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 propose 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 25EXAMPLE 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
6 Scored
Measure achievement points measure bonus CEHRT measure
measures points bonus points
Registry
Measure A (Outcome) .......................... 7.1 ........................................................ 7.1 (Outcome (required outcome

measure with measure does
highest achieve- not receive
ment points). bonus points).
Measure B ............................................ 6.2 (points not considered because it
is lower than the 8.2 points for the
same claims measure).
Measure C (high priority patient safety 5.1 (points not considered because it ............................... 1
measure that meets requirements for is lower than the 6.0 points for the
additional bonus points). same claims measure).
Claims
Measure A (Outcome) .......................... 4.1 (points not considered because it ............................... No bonus points
is lower than the 7.1 points for the because the reg-
same measure submitted via a registry submission
istry). of the same
measure satis-
fies requirement
for outcome
measure.
Measure B ............................................ 8.2 ........................................................ 8.2
Measure C (High priority patient safety 6.0 ........................................................ 6.0 ......................... No bonus (Bonus
measure that meets requirements for applied to the
additional bonus points). registry meas-
ure).
Measure D (outcome measure <50% 1.0 ........................................................ 1.0 ......................... (no high priority
of data submitted). bonus points be-
cause below
data complete-
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 safety 3.0 ........................................................ ............................... (no high priority 1
measure that is below case min- bonus points be-
imum). cause below
case minimum).
35.6 ...................................................... 1 (below 10% 5 (below 10% cap).
cap1).
Quality Performance Category Percent .............................................................. (35.6 + 1 + 5)/60 = 69.33%

Score Prior to Improvement Scoring.
1 In this example the cap would be 6 points, which is 10 percent of the total available measure achievement points of 60.
We propose to amend mechanism, which will be the submission mechanisms. We invite

414.1380(b)(1)(xii) to add paragraph submission mechanism with the highest comments on our proposal that if the
(A) to state that if a MIPS eligible measure achievement points. Groups same measure is submitted via 2 or
clinician submits measures via claims, that submit via these submission more mechanisms, we will only take the
qualified registry, EHR, or QCDR mechanisms may also submit and be one with the highest measure
submission options, and submits more scored on CMS-approved survey vendor achievement points. We invite
than the required number of measures, for CAHPS for MIPS submission comments on our proposal to assign
they are scored on the required mechanisms. high priority measure bonus points to
measures with the highest assigned We invite comments on our proposal all measures, with performance greater
measure achievement points. MIPS to calculate the total measure than zero, that meet case minimums,
eligible clinicians that report a measure achievement points by using the and that meet data completeness
via more than 1 submission mechanism measures with the 6 highest measure requirements, regardless of submission
can be scored on only 1 submission achievement points across multiple mechanism and to assign measure
bonus points for each unique measure MIPS performance year; we make this minimum for administrative claims
submitted using end-to-end electronic proposal in order to continue to align measures will automatically be scored
reporting. We invite comments on our with the 3-point floor for other measures on the all-cause hospital readmission
proposal that if the same measure is and because the Shared Savings measure and have that measure score
submitted using 2 different Program does not publish benchmarks included in their quality category
mechanisms, the measure will receive with values below the 30th percentile. performance percent score.
measure bonus points once. We will reassess this policy again next We are not proposing any changes to
We are not proposing any changes to year through rulemaking. calculating the total measure
our policy that if a MIPS eligible We are not proposing any changes to achievement points and measure bonus
clinician does not have any scored our previously finalized policy to points for CMS Web Interface measures
measures, then a quality performance exclude from scoring CMS Web in this proposed rule, although we are
category percent score will not be Interface measures that are submitted proposing to add improvement to the
calculated as finalized in the CY 2017 but that do not meet the case minimum quality performance category percent
Quality Payment Program final rule at requirement or that lack a benchmark, score for such submissions (as well as
81 FR 77300. We refer readers to the or to our policy that measures that are other submission mechanisms) in
discussion at 81 FR 77299 through not submitted and measures submitted section II.C.7.a.(2)(j) of this proposed
77300 for more details on that policy. below the data completeness rule.
As stated in section II.C.7.a.(2)(e) of this requirements will receive a zero score
proposed rule, we anticipate that it will (82 FR 77305). However, to further (i) Scoring Improvement for the MIPS
be only in rare case that a MIPS eligible increase alignment with the Shared Quality Performance Category Percent
clinician does not have any scored Savings Program, we propose to also Score
measures and a quality performance exclude CMS Web Interface measures (i) Calculating Improvement at the
category percent score cannot be from scoring if the measure is Quality Performance Category Level
calculated. redesignated from pay for performance
to pay for reporting for all Shared
(ii) Calculating Total Measure Program final rule, we noted that we
Savings Program ACOs, although we
Achievement and Measure Bonus Points consider achievement to mean how a
will recognize the measure was
for CMS Web Interface Reporters MIPS eligible clinician performs relative
submitted. While the Shared Savings
In the CY 2017 Quality Payment to performance standards, and
Program designates measures that are
Program final rule, we finalized that pay for performance in advance of the improvement to mean how a MIPS
CMS Web Interface reporters are reporting year, the Shared Savings eligible clinician performs compared to
required to report 14 measures, 13 Program may redesignate a measure as the MIPS eligible clinicians own
individual measures, and a 2- pay for reporting under certain previous performance on measures and
component measure for diabetes (81 FR circumstances (see 42 CFR activities in the performance category
77302 through 77305). We note that for 425.502(a)(5)). Therefore, we propose to (81 FR 77274). We also solicited public
the transition year, 3 measures did not amend 414.1380(b)(1)(viii) to add that comments in the CY 2017 Quality
have a benchmark in the Shared Savings CMS Web Interface measures that have Payment Program proposed rule on
Program. Therefore, for the transition a measure benchmark but are potential ways to incorporate
year, CMS Web Interface reporters are redesignated as pay for reporting for all improvement in the scoring
scored on 11 of the total 14 required Shared Savings Program ACOs by the methodology. In section II.C.7.a.(1)(b)(i)
measures, provided that they report all Shared Savings Program will not be of this proposed rule, we explain why
14 required measures. scored, as long as the data completeness we believe that the options set forth in
In the CY 2017 Quality Payment requirement is met. the CY 2017 Quality Payment Program
Program final rule, we finalized a global We invite comment on our proposal proposed rule, including the Hospital
floor of 3 points for all CMS Web to not score CMS Web Interface VBP Program, the Shared Savings
Interface measures submitted in the measures redesignated as pay for Program, and Medicare Advantage 5-star
transition year, even with measures at reporting by the Shared Savings Ratings Program, were not fully
zero percent performance rate, provided Program. translatable to MIPS. Beginning with the
that these measures have met the data We also note that, while we did not 2018 MIPS performance period, we
completeness criteria, have a benchmark state explicitly in the CY 2017 Quality propose here to score improvement as
and meet the case minimum Payment Program final rule, groups that well as achievement in the quality
requirements (82 FR 77305). Therefore, choose to report quality measures via performance category level when data is
measures with performance below the the CMS Web Interface may, in addition sufficient. We believe that scoring
30th percentile will be assigned a value to the 14 required measures, also submit improvement at the performance
of 3 points during the transition year to the CAHPS for MIPS survey in the category level, rather than measuring
be consistent with the floor established quality performance category (81 FR improvement at the measure level, for
for other measures and because the 77094 through 77095; 81 FR 77292). If the quality performance category would
Shared Savings Program does not they do so, they can receive bonus allow improvement to be available to
publish benchmarks below the 30th points for submitting this high priority the broadest number of MIPS eligible
percentile (82 FR 77305). We stated that measure and will be scored on it as an clinicians because we are connecting
we will reassess scoring for measures additional measure. Therefore, we performance to previous MIPS quality
below the 30th percentile in future propose to amend 414.1380(b)(1)(xii) performance as a whole rather than
years. to add paragraph (B) to state that groups changes in performance for individual
We propose to continue to assign 3 that submit measures via the CMS Web measures. Just as we believe it is
points for measures with performance Interface may also submit and be scored important for a MIPS eligible clinician
below the 30th percentile, provided the on CMS-approved survey vendor for to have the flexibility to choose
measure meets data completeness, has a CAHPS for MIPS submission options. measures that are meaningful to their
benchmark, and meets the case In addition, groups of 16 or more practice, we want them to be able to
minimum requirements for the 2018 eligible clinicians that meet the case adopt new measures without concern
about losing the ability to be measured (ii) Data Sufficiency Standard To We propose to compare results from
on improvement. In addition, we are Measure Improvement for Quality an identifier when we receive
encouraging MIPS eligible clinicians to Performance Category submissions with that same identifier
select more outcome measures and to (either TIN/NPI for individual, or TIN
move away from topped out measures. Section 1848(q)(5)(D)(i) of the Act for group, APM entity, or virtual group
We do not want to remove the stipulates that beginning with the identifier) for two consecutive
second year to which the MIPS applies, performance periods. However, if we do
opportunity to score improvement from
if data sufficient to measure not have the same identifier for two
those who select different measures
improvement is available then we shall consecutive performance periods, we
between performance periods for the
measure improvement for the quality propose a methodology to create a
quality performance category; therefore, performance category. Measuring comparable performance category score
we are proposing to measure improvement requires a direct that can be used for improvement
improvement at the category level comparison of data from one Quality measurement. Just as we do not want to
which can be calculated with different Payment Program year to another. remove the opportunity to earn an
measures. Starting with the 2020 MIPS payment improvement score from those who
We propose at 414.1380(b)(1)(xvi)(E) year, we propose that a MIPS eligible elect new measures between
to define an improvement percent score clinicians data would be sufficient to performance periods for the quality
to mean the score that represents score improvement in the quality performance category, we also do not
improvement for the purposes of performance category if the MIPS want to restrict improvement for those
calculating the quality performance eligible clinician had a comparable MIPS eligible clinicians who elect to
category percent score. We also propose quality performance category participate in MIPS using a different
at 414.1380(b)(1)(xvi)(C) that an achievement percent score for the MIPS identifier.
improvement percent score would be performance period immediately prior There are times when submissions
to the current MIPS performance period; from a particular individual clinician or
assessed at the quality performance
we explain our proposal to identify how group of clinicians use different
category level and included in the
we will identify comparable quality identifiers between 2 years. For
calculation of the quality performance example, a group of 20 MIPS eligible
category percent score. When we performance category achievement
percent scores below. We believe that clinicians could choose to submit as a
evaluated different improvement group (using their TIN identifier) for the
this approach would allow
scoring options, we saw two general current performance period. If the group
improvement to be broadly available to
methods for incorporating also submitted as a group for the
MIPS eligible clinicians and encourage
improvement. One method measures continued participation in the MIPS previous years performance period, we
both achievement and improvement and program. Moreover, this approach would simply compare the group scores
takes the higher of the two scores for would encourage MIPS eligible associated with the previous
each measure that is compared. The clinicians to focus on efforts to improve performance period to the current
Hospital VBP Program incorporates the quality of care delivered. We note performance period (following the
such a methodology. The second that, by measuring improvement based methodology explained in section
method is to calculate an achievement only on the overall quality performance II.C.7.a.(2)(i)(iv) of this proposed rule).
score and then add an improvement category achievement percent score, However, if the group members had
score if improvement is measured. The some MIPS eligible clinicians and previously elected to submit to MIPS as
Shared Savings Program utilizes a groups may generate an improvement individual clinicians, we would not
similar methodology for measuring score simply by switching to measures have a group score at the TIN level from
improvement. For the quality on which they perform more highly, the previous performance period to
performance category, we are proposing rather than actually improving at the which to compare the current
same measures. We will monitor how performance period.
to calculate improvement at the category In circumstances where we do not
level and believe adding improvement frequently improvement is due to actual
have the same identifier for two
to an existing achievement percent score improvement versus potentially
consecutive performance periods, we
would be the most straight-forward and perceived improvement by switching
propose to identify a comparable score
simple way to incorporate measures and will address through
for individual submissions or calculate
improvement. For the purpose of future rulemaking, as needed. We also
a comparable score for group, virtual
improvement scoring methodology, the solicit comment on whether we should
group, and APM entity submissions. For
term quality performance category require some level of year to year
individual submissions, if we do not
achievement percent score means the consistency when scoring improvement. have a quality performance category
total measure achievement points We propose that comparability of achievement percent score for the same
divided by the total possible available quality performance category individual identifier in the immediately
measure achievement points, without achievement percent scores would be prior period, then we propose to apply
consideration of bonus points or established by looking first at the the hierarchy logic that is described in
improvement adjustments and is submitter of the data. As discussed in section II.C.8.a.(2) of this proposed rule
discussed in section II.C.7.a.(2)(i)(iv) of more detail in section II.C.7.a.(2)(i)(i) of to identify the quality performance
this proposed rule, we are comparing category achievement score associated
this proposed rule.

results at the category, rather than the with the final score that would be
Consistent with bonuses available in
performance measure level because we applied to the TIN/NPI for payment
the quality performance category, we believe that the performance category purposes. For example, if there is no
propose at 414.1380(b)(1)(xvi)(B) that score from 1 year is comparable to the historical score for the TIN/NPI, but
the improvement percent score may not performance category score from the there is a TIN score (because in the
total more than 10 percentage points. prior year, even if the measures in the previous period the TIN submitted as a
We invite public comments on these performance category have changed group), then we would use the quality
proposals. from year to year. performance category achievement
percent score associated with the TINs participates as a new TIN, or a new exclude any TIN/NPIs that did not have
prior performance. If the NPI had virtual group, or a new APM Entity a final score because they were not
changed TINs and there was no submitting data in the performance eligible for MIPS. We would include
historical score for the same TIN/NPI, period, we would not have a quality performance category
then we would take the highest prior comparable TIN, virtual group, or APM achievement percent scores of zero in
score associated with the NPI. Entity score to use for scoring the average.
When we do not have a comparable improvement. Therefore, we propose to
TIN group, virtual group, or APM Entity calculate a score by taking the average There are instances where we would
score, we propose to calculate a score of the individual quality performance not be able to measure improvement
based on the individual TIN/NPIs in the category achievement scores for the due to lack of sufficient data. For
practice for the current performance MIPS eligible clinicians that were in the example, if the MIPS eligible clinicians
period. For example, in a group of 20 group for the current performance did not participate in MIPS in the
clinicians that previously participated period. If we have more than one quality previous performance period because
in MIPS as individuals, but now want performance category achievement they were not eligible for MIPS, we
to participate as a group, we would not percent score for the same individual could not calculate improvement
have a comparable TIN score to use for identifier in the immediately prior because we would not have a previous
scoring improvement. We believe period, then we propose to apply the quality performance category
however it is still important to provide hierarchy logic that is described in achievement percent score.
to the MIPS eligible clinicians the section II.C.8.a.(2) of this proposed rule Table 26 summarizes the different
improvement points they have earned. to identify the quality performance
cases when a group or individual would
Similarly, in cases where a group of category score associated with the final
be eligible for improvement scoring
clinicians previously participated in score that would be applied to the TIN/
MIPS as individuals, but now NPI for payment purposes. We would under this proposal.
TABLE 26ELIGIBILITY FOR IMPROVEMENT SCORING EXAMPLES

Prior MIPS
Current MIPS performance Eligible for
Scenario performance period identifier improvement Data comparability
period identifier (with score greater scoring
than zero)
No change in identifier .......................... Individual (TIN A/ Individual (TIN A/ Yes ....................... Current individual score is compared
NPI 1). NPI 1). to individual score from prior per-
formance 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 se- Individual (TIN A/ Group (TIN A) ....... Yes ....................... Current individual score is compared
lects to submit as an individual NPI 1). to the group score associated with
whereas previously the group sub- the TIN/NPI from the prior perform-
mitted as a group. ance period.
Individual changes practices, but sub- Individual (TIN B/ Individual (TIN A/ Yes ....................... Current individual score is compared
mitted to MIPS previously as an indi- NPI). NPI). to the individual score from the prior
vidual. performance period.
Individual changes practices and has Individual (TIN C/ Group (TIN A/NPI); Yes ....................... Current individual score is compared
multiple scores in prior performance NPI). Individual (TIN to highest score from the prior per-
period. B/NPI). formance period.
Group does not have a previous group Group (TIN A) ....... Individual scores Yes ....................... The current group score is compared
score from prior performance period. (TIN A/NPI 1, to the average of the scores from
TIN A/NPI 2, TIN the prior performance period of indi-
A/NPI 3, etc.). viduals who comprise the current
group.
Virtual group does not have previous Virtual Group (Vir- Individuals (TIN A/ Yes ....................... The current group score is compared
group score from prior performance tual Group Iden- NPI 1, TIN A/ to the average of the scores from
period. tifier A) (Assume NPI 2, TIN B/ the prior performance period of indi-
virtual group has NPI 1, TIN B/ viduals who comprise the current
2 TINs with 2 cli- NPI 2). group.
nicians.).
Individual does not have a quality per- Individual (TIN A/ Individual was not No ......................... The individual quality performance
formance category achievement NPI 1). eligible for MIPS category score is missing for the
score for the prior performance pe- and did not vol- prior performance period and not el-
riod. untarily submit igible for improvement scoring.
any quality
measures to
MIPS.
We propose at which means when data are available previous performance period. We also
414.1380(b)(1)(xvi)(A) to state that and a MIPS eligible clinician or group propose at 414.1380(b)(1)(xvi)(A)(1)
improvement scoring is available when has a quality performance category that data must be comparable to meet
the data sufficiency standard is met, achievement percent score for the the requirement of data sufficiency,
which means that the quality required measures, including meeting would receive at least 3 of 10 possible
performance category achievement data completeness, for the quality measure achievement points for each
percent score is available for the current performance category for the current required measure. For example, if a solo
performance period and the previous performance period. For example, for practitioner submitted 6 measures and
performance period and, therefore, MIPS eligible clinicians submitting via received 3 points for each measure, then
quality performance category QCDR, full participation would the solo practitioner would have 18
achievement percent scores can be generally mean submitting 6 measures measure achievement points out of a
compared. We also propose at including 1 outcome measure if an possible 60 total possible measure
414.1380(b)(1)(xvi)(A)(2) that quality outcome measure is available or 1 high achievement points (3 measure
performance category achievement priority measure if an outcome measure achievement points 6 measures). The
percent scores are comparable when is not available, and meeting the 50 quality performance category
submissions are received from the same percent data completeness criteria for achievement percent score is 18/60
identifier for two consecutive each of the 6 measures. which equals 30 percent. For groups
performance periods. We also propose We believe that improvement is most with 16 or more clinicians that
an exception at meaningful and valid when we have a submitted 6 measures and receive 3
414.1380(b)(1)(xvi)(A)(3) that if the full set of quality measures. A measure achievement points for each
identifier is not the same for 2 comparison of data resulting from full submitted measure as well as the all-
consecutive performance periods, then participation of a MIPS eligible clinician cause hospital readmission measure,
for individual submissions, the from 1 year to another enables a more then the group would have 21 measure
comparable quality performance accurate assessment of improvement achievement points out of 70 total
category achievement percent score is because the performance being possible measure achievement points or
the quality performance category compared is based on the applicable a quality performance category
achievement percent score associated and available measures for the achievement percent score of 21/70
with the final score from the prior performance periods and not from which equals 30 percent (3 measure
performance period that will be used for changes in participation. While we are achievement points 7 measures). For
payment. For group, virtual group, and not requiring full participation for both the CMS Web Interface submission
APM entity submissions, the performance periods, requiring full option, MIPS eligible clinicians that
comparable quality performance participation for the current fully participate by submitting and
category achievement percent score is performance period means that any meeting data completeness for all
the average of the quality performance future improvement scores for a measures, would also be able to achieve
category achievement percent score clinician or group would be derived a quality performance category
associated with the final score from the solely from changes in performance and achievement percent score of at least 30
prior performance period that will be not because the clinician or group percent, as each scored measure would
used for payment for each of the submitted more measures. We propose receive 3 measure achievement points
individuals in the group. As noted at 414.1380(b)(1)(xvi)(C)(5) that the out of 10 possible measure achievement
above, these proposals are designed to quality improvement percent score is points.
offer improvement scoring to all MIPS zero if the clinician did not fully Therefore, we propose at
eligible clinicians with sufficient data in participate in the quality performance 414.1380(b)(1)(xvi)(C)(4) that if a MIPS
the prior MIPS performance period. We category for the current performance eligible clinician has a previous year
invite public comments on our period. quality performance category score less
proposals as they relate to data Because we want to award than or equal to 30 percent, we would
sufficiency for improvement scoring. improvement for net increases in compare 2018 performance to an
We also seek comment on an performance and not just improved assumed 2017 quality performance
alternative to this proposal: Whether we participation in MIPS, we want to category achievement percent score of
should restrict improvement to those measure improvement above a floor for 30 percent. In effect, for the MIPS 2018
who submit quality performance data the 2018 MIPS performance period, to performance period, improvement
using the same identifier for two account for our transition year policies. would be measured only if the
consecutive MIPS performance periods. We considered that MIPS eligible clinicians 2018 quality performance
We believe this option would be simpler clinicians who chose the test option category achievement percent score for
to apply, communicate and understand of the pick your pace approach for the the quality performance category
than our proposal is, but this alternative transition year may not have submitted exceeds 30 percent. We believe this
could have the unintended consequence all the required measures and, as a approach appropriately recognizes the
of not allowing improvement scoring for result, may have a relatively low quality participation of MIPS eligible clinicians
certain MIPS eligible clinicians, groups, performance category achievement score who participated in the transition year
virtual groups and APM entities. for the 2017 MIPS performance period. and accounts for MIPS eligible
Due to the transition year policy to clinicians who participated minimally
(iii) Additional Requirement for Full award at least 3 measure achievement
Participation To Measure Improvement and may otherwise be awarded for an
points for any submitted measure via increase in participation rather than an
for Quality Performance Category claims, EHR, QCDR, qualified registry, increase in achievement performance.
To receive a quality performance and CMS-approved survey vendor for We invite public comment on these
category improvement percent score CAHPS for MIPS, and the 3-point floor
proposals.
greater than zero, we are also proposing for the all-cause readmission measure (if
that MIPS eligible clinicians must fully the measure applies), a MIPS eligible (iv) Measuring Improvement Based on
participate, which we propose in clinician that submitted some data via Changes in Achievement
414.1380(b)(1)(xvi)(F) to mean these mechanisms on the required To calculate improvement with a
compliance with 414.1330 and number of measures would focus on quality performance, we are
414.1340, in the current performance automatically have a quality proposing to focus on improvement
year. Compliance with those referenced performance category achievement score based on achievement performance and
regulations entails the submission of all of at least 30 percent because they would not consider measure bonus
points in our improvement algorithm. excluding measure bonus points (and achievement points for each of the
Bonus points may be awarded for any improvement score) for the submitted 6 required measures in the
reasons not directly related to applicable years. We propose at current performance period, which
performance such as the use of end-to- 414.1380(b)(1)(xvi)(D) to call this equals 36 total measure achievement
end electronic reporting. We believe score, which is based on achievement points. This is compared to the previous
that improvement points should be only, the quality performance category performance period when the MIPS
awarded based on improvement related achievement percent score which is eligible clinician received only 5
to achievement. Accordingly, we are calculated using the following formula: measure achievement points per
proposing to use an individual MIPS Quality performance category measure, for 30 total measure
eligible clinicians or groups total achievement percent score = total achievement points. The quality
measure achievement points from the measure achievement points/total performance category achievement
prior MIPS performance period without available measure achievement percent score is represented in line 2.
the bonus points the individual MIPS points.
eligible clinician or group may have For improvement, performance in the
received, to calculate improvement. Table 27 illustrates how the quality current 2018 MIPS performance period
Therefore, to measure improvement at performance category achievement (60 percent) is compared to the
the quality performance category level, percent score is calculated. For performance category achievement
we will use the quality performance simplicity, we assume the MIPS eligible percent score in the 2017 MIPS
category achievement percent score clinician received 6 measure performance period (50 percent).
TABLE 27COMPARISON OF QUALITY PERFORMANCE CATEGORY ACHIEVEMENT PERCENT SCORES

Current MIPS performance period Previous MIPS performance period
(1) Total Measure Achievement Points .............. 6 measure achievement points 6 measures 5 measure achievement points 6 measures
= 36 total measure achievement points. = 30 total measure achievement points.
(2) Quality Performance Category Achievement 36/60 = 60 percent .......................................... 30/60 = 50 percent.
Percent Score (measure achievement points/
60 for this example).
The current MIPS performance period the quality performance category percent score) * 10 percent = 2
quality performance category recognizes the rate of increase in quality percentage points. Another way to
achievement percent score is compared performance category scores of MIPS explain the logic is a 20 percent rate of
to the previous performance period eligible clinicians from one performance improvement for achievement (for
quality performance category period to another performance period so example increasing the achievement
achievement percent score. If the that a higher rate of improvement percent score 10 percentage points
current score is higher, the MIPS results in a higher improvement percent which is 20 percent higher than the
eligible clinician may qualify for an score. We believe this is particularly original 50 percent achievement percent
improvement percent score to be added true for those clinicians with lower score) is worth a 2 percentage point
into the quality performance category performance who will be incentivized to increase to the quality performance
percent score for the current begin improving with the opportunity to category achievement percent score.
performance year. increase their improvement significantly We believe that this improvement
We propose to amend the regulatory and achieve a higher improvement scoring methodology provides an easily
text at 414.1380(b)(1)(xvi) to state that percent score. explained and applied approach that is
improvement scoring is available to We propose to award an consistent for all MIPS eligible
MIPS eligible clinicians and groups that improvement percent score based on clinicians. Additionally, it provides
demonstrate improvement in the following formula: additional incentives for MIPS eligible
performance in the current MIPS clinicians who are lower performers to
Improvement percent score = (increase
performance period compared to the improve performance. We believe that
in quality performance category
performance in the previous MIPS providing larger incentives for MIPS
achievement percent score from
performance period, based on eligible clinicians with lower quality
prior performance period to current
achievement. Bonus points or performance category scores to improve
performance period/prior year
improvement percent score adjustments will not only increase the quality
quality performance category
made to the category score in the prior performance category scores but also
achievement percent score) * 10
or current performance period are not will have the greatest impact on
percent.
taken into account when determining improving quality for beneficiaries.
whether an improvement has occurred Using the example from Table 27, the We also propose that the
or the size of any improvement percent quality performance category improvement percent score cannot be
score. achievement percent score for the negative (that is, lower than zero
We invite public comment on our current performance period is 60 percentage points). The improvement
proposal to award improvement based percent, and the previous performance percent score would be zero for those
on changes in the quality performance period achievement percent score is 50 who do not have sufficient data or who
category achievement percent score. percent. The increase in achievement is are not eligible under our proposal for
10 percentage points (60 percent50 improvement points. For example, as
(v) Improvement Scoring Methodology percent). Therefore, the improvement noted in section II.C.7.a.(2)(i)(ii) of this
for the Quality Performance Category percent score is 10 percent (increase in proposed rule, a MIPS eligible clinician
We believe the improvement scoring achievement)/50 percent (previous would not be eligible for improvement
methodology that we are proposing for performance period achievement if the clinician was not eligible for MIPS
in the prior performance period and did percentage points under our proposed recognition and award for the largest
not have a quality performance category formula would represent 100 percent increases in performance improvement.
achievement percent score. We are also improvementor doubling of Table 28 illustrates examples of the
proposing to cap the size of the achievement measure pointsover the proposed improvement percent scoring
improvement award at 10 percentage immediately preceding period. For the methodology, which is based on rate of
points, which we believe appropriately reasons stated, we anticipate that this
increase in quality performance category
rewards improvement and does not amount will encourage participation by
achievement percent scores.
outweigh percentage points available individual MIPS eligible clinicians and
through achievement. In effect, 10 groups and will provide an appropriate
TABLE 28IMPROVEMENT SCORING EXAMPLES BASED ON RATE OF INCREASE IN QUALITY PERFORMANCE CATEGORY
ACHIEVEMENT PERCENT SCORES
Year 2 quality
Year 1 quality performance
performance Increase in Improvement percent
category Rate of improvement
category achievement achievement score
achievement
percent score percent score
Individual Eligible Clini- 5% (Will substitute 50 20% Because the year 20%/30%= 0.67 ........... 0.67*10% = 6.7% No
cian #1 (Pick your 30% which is the 1 score is below cap needed.
Pace Test Option). lowest score a clini- 30%, we measure
cian can achieve improvement above
with complete report- 30%.
ing in year 1.).
Individual Eligible Clini- 60% ............................. 66 6% ............................... 6%/60%= 0.10 ............. 0.10*10% = 1.0% No
cian #2. cap needed.
Individual Eligible Clini- 90% ............................. 93 3% ............................... 3%/90%= 0.033 ........... 0.033*10% = 0.3% No
cian #3. cap needed.
Individual Eligible Clini- 30% ............................. 70 40% ............................. 40%/30%=1.33 ............ 1.33*10%=13.3%
cian #4. Apply cap at 10%.
We also considered an alternative to the improvement points. Under this TABLE 29BAND LEVEL AND IM-
measuring the rate of improvement. The alternative, simple improvement PROVEMENT POINTS ALLOTTED FOR
alternative would use band levels to percentage points for improvement are DETERMINING IMPROVEMENT PER-
determine the improvement points for awarded to MIPS eligible clinicians CENT SCORESContinued
MIPS eligible clinicians who qualify for whose category scores improved across
improvement points. Under the band years according to the band level, up to Transition year % Credit for each percent
level methodology, a MIPS eligible a maximum of 10 percent of the total score range increase in achievement
clinicians improvement points would score.
be determined by an improvement in In Table 29, we illustrate the band 5175 ............. 75% of increase in achieve-
the quality performance category levels we considered as part of this ment.
achievement percent score from 1 year alternative proposal. The chart depicts 75100 ........... 50% of increase in achieve-
to the next year to determine ment.
the band level and the improvement
improvement in the same manner as set points allotted for the increases in
forth in the rate of improvement improvement scores that fall within the Table 30 illustrates examples of the
methodology. However, for the band transition year score range. improvement scoring methodology
level methodology, an improvement based on band levels. Generally, this
percent score would then be assigned by TABLE 29BAND LEVEL AND IM- methodology would generate a higher
taking into account a portion (50, 75 or PROVEMENT POINTS ALLOTTED FOR improvement percent score for
100 percent) of the improvement in clinicians; however, we believe the
achievement, based on the clinicians
DETERMINING IMPROVEMENT PER-
CENT SCORES policy we proposed would provide a
performance category achievement score that better represents true
percent score for the prior year. Bands
Transition year % Credit for each percent improvement at the performance
would be set for category achievement score range increase in achievement category level, rather than comparing
percent scores, with increases from
lower category achievement scores simple increases in performance
150 ............... 100% of increase in achieve-
earning a larger portion (percentage) of ment. category scores.
TABLE 30EXAMPLES OF IMPROVEMENT SCORING METHODOLOGY BASED ON BAND LEVELS

Year 2 quality
Year 1 quality performance Band for Improvement percent
performance category category Increase in achievement improvement score (after applying the
achievement percent achievement adjustment cap)
score percent score
Individual Eligible Clini- 5% (Will substitute 30% 50% 20% Because the year 1 100% 20%*100%= 20% which
cian #1 (Pick your Pace which is the lowest score is below 30%, is capped at 10%.
Test Option). score a clinician can we measure improve-
achieve with complete ment above 30%.
reporting in year 1.)
Individual Eligible Clini- 60% ................................. 66% 6% ................................... 75% 6%*75%= 4.5% No cap
cian #2. needed
Individual Eligible Clini- 90% ................................. 93% 3% ................................... 50% 3%*50%= 1.5% No cap
cian #3. needed
In addition, we considered another We considered the Shared Savings quality performance category
alternative that would adopt the Program methodology because it would achievement percent score, and
improvement scoring methodology of promote alignment with ACOs. We multiplying by 10 percent.
the Shared Savings Program11 for CMS ultimately decided not to adopt this We invite public comments on our
Web Interface submissions in the scoring methodology because we believe proposal to calculate improvement
quality performance category, but having a single performance category scoring using a methodology that
decided to not adopt this approach. level approach for all quality awards improvement points based on
Under the Shared Savings Program performance category scores encourages the rate of improvement and,
approach, eligible clinicians and groups a uniformity in our approach to alternatively, on rewarding
that submit through the CMS Web improvement scoring and simplifies the improvement at the band level or using
Interface would have been required to scoring rules for MIPS eligible the Shared Saving Program approach for
submit on the same set of quality clinicians. It also allows us greater CMS Web Interface submissions.
measures, and we would have awarded flexibility to compare performance (j) Calculating the Quality Performance
improvement for all eligible clinicians scores across the diverse submission Category Percent Score Including
or groups who submitted complete data mechanisms, which makes Improvement
in the prior year. As Shared Savings improvement scoring more broadly
available to eligible clinicians and In the CY 2017 Quality Payment
Program and Next Generation ACOs Program final rule, we finalized at
report using the CMS Web Interface, groups that elect different ways of
participating in MIPS. 414.1380(b)(1)(xv) that the quality
using the same improvement score performance category score is the sum
We propose to add regulatory text at
approach would align MIPS with these of all points assigned for the measures
414.1380(b)(1)(xvi)(C)(3) to state that
other programs. We believed it could be required for the quality performance
an improvement percent score cannot be
beneficial to align improvement category criteria plus bonus points,
negative (that is, lower than zero
between the programs because it would divided by the sum of total possible
percentage points). We also propose to
align incentives for those who points (81 FR 77300). Using the
add regulatory text at
participate in the Shared Savings terminology proposed in section
414.1380(b)(1)(xvi)(C)(1) to state that
Program or ACOs. The Shared Savings improvement scoring is awarded based II.C.7.a.(2) of this proposed rule, this
Program approach would test each on the rate of increase in the quality formula can be represented as:
measure for statistically significant performance category achievement Quality performance category percent
improvement or statistically significant percent score of individual MIPS score = (total measure achievement
decline. We would sum the number of eligible clinicians or groups from the points + measure bonus points)/
measures with a statistically significant current MIPS performance period total available measure achievement
improvement and subtract the number compared to the score in the year points.
of measures with a statistically immediately prior to the current MIPS We propose to incorporate the
significant decline to determine the Net performance period. We also propose to improvement percent score, which is
Improvement. We would next divide the add regulatory text at proposed in section II.C.7.a.(2)(i)(i) of
Net Improvement in each domain by the 414.1380(b)(1)(xvi)(C)(2) to state that this proposed rule, into the quality
number of eligible measures in the an improvement percent score is performance category percent score. We
domain to calculate the Improvement calculated by dividing the increase in propose to amend 414.1380(b)(1)(xv)
Score. We would cap the number of the quality performance category (redesignated as 414.1380(b)(1)(xvii))
possible improvement percentage points achievement percent score of an to add the improvement percent score
at 10. individual MIPS eligible clinician or (as calculated pursuant to proposed
group, which is calculated by paragraph (b)(1)(xvi)(A) through (F)) to
11 For additional information on the Shared

comparing the quality performance the quality performance score. We also
Savings Programs scoring methodology, we refer
readers to the Quality Measurement Methodology
category achievement percent score the propose to amend 414.1380(b)(1)(xv)
and Resources, September 2016, Version 1 and the current MIPS performance period to the (redesignated as 414.1380(b)(1)(xvii))
Medicare Shared Savings Program Quality Measure quality performance category to amend the text that states the quality
Benchmarks for the 2016 and 2017 Reporting Years achievement percent score from the performance category percent score
(available at https://www.cms.gov/Medicare/
Medicare-Fee-for-Service-Payment/
MIPS performance period in the year cannot exceed the total possible points
sharedsavingsprogram/Downloads/MSSPQM- immediately prior to the current MIPS for the quality performance category to
Benchmarks-2016.pdf.) performance period, by the prior year clarify that the total possible points for
the quality performance category cannot Table 31 illustrates an example of section II.C.7.a.(2)(i) of this proposed
exceed 100 percentage points. Thus, the calculating the quality performance rule; Table 31 does not illustrate the
calculation for the proposed quality category percent score including underlying calculations for the
performance category percent score improvement for a non-CMS Web improvement percent score. To
including improvement, can be Interface reporter. In this example, an calculate the quality performance
summarized in the following formula: individual MIPS eligible clinician category percent score, the total
received measure achievement points measures achievement points would be
Quality performance category percent
for their 6 required measures, and summed with the total measure bonus
score = ([total measure achievement
received 6 measure bonus points. points and then divided by the total
points + measure bonus points]/
Because this is an individual clinician available measure achievement points.
total available measure achievement
and the administrative claims based
points) + improvement percent The improvement percent score would
measure is not applicable, the total
score, not to exceed 100 percent. be added to that calculation. The
available measure achievement points
This same formula and logic will be for this clinician is 60. The resulting quality performance category
applied for both CMS Web Interface and improvement percent score would be percent score cannot exceed 100
Non-CMS Web Interface reporters. calculated based on the proposal in percentage points.
TABLE 31EXAMPLE OF SCORING THE QUALITY PERFORMANCE CATEGORY PERCENT SCORE INCLUDING IMPROVEMENT
Total available Quality
Total measure Improvement
Total measure measure Calculation prior to performance
achievement percent score
bonus points achievement improvement category percent
points (%)
points score
Individual Eligible Clinician ......... 35.6 6 60 (35.6 + 6)/60 = 1.9 69.33% + 1.9% =
69.33%. 71.23%
Individual Eligible Clinician (did 35.6 6 60 (35.6 + 6)/60 = 0 69.33% + 0% =
not submit in Year 1). 69.33%. 69.33%
Individual Eligible Clinician (with 50 6 60 (50 + 6)/60 = 10 93.33% + 10% =
maximum improvement). 93.33%. 103.33%, which
is capped at
100%
We note that the quality performance as a group practice) or TIN/NPI and are proposing to codify it under
category percent score is then combinations (for those MIPS eligible 414.1380(b)(2)(v).
multiplied by the performance category clinicians participating in MIPS as an For more of the statutory background
weight for calculating the final score. individual) can be attributed the case and descriptions of our current policies
We invite public comment on this minimum for the measure (81 FR for the cost performance category, we
overall methodology and formula for 77309). If a benchmark is not developed, refer readers to the CY 2017 Quality
calculating the quality performance the cost measure is not scored or Payment Program final rule (81 FR
category percent score. included in the performance category 77308 through 77311).
(81 FR 77309). For each set of In section II.C.7.a.(3)(a) of this
(3) Scoring the Cost Performance proposed rule, we propose to add
benchmarks, we calculate the decile
Category improvement scoring to the cost
breaks based on cost measure
We score the cost performance performance during the performance performance category scoring
category using a methodology that is period and assign 1 to 10 achievement methodology starting with the 2020
generally consistent with the points for each measure based on which MIPS payment year. We do not propose
methodology used for the quality benchmark decile range the MIPS any changes to the methodology for
performance category. In the CY 2017 eligible clinicians performance on the scoring achievement in the cost
Quality Payment Program final rule (81 measure is between (81 FR 77309 performance category for the 2020 MIPS
FR 77309), we codified at through 77310). We also codified at payment year other than the method
414.1380(b)(2) that a MIPS eligible 414.1380(b)(2)(iii) that a MIPS eligible used for facility-based measurement
clinician receives 1 to 10 achievement clinicians cost performance category described in II.C.7.a.(4) of this proposed
points for each cost measure attributed score is the equally-weighted average of rule. We are proposing a change in
to the MIPS eligible clinician based on all scored cost measures (81 FR 77311). terminology to refer to the cost
the MIPS eligible clinicians In the CY 2017 Quality Payment performance category percent score in
performance compared to the measure Program final rule (81 FR 77311), we order to be consistent with the
benchmark. We establish a single adopted a final policy to not calculate terminology used in the quality
benchmark for each cost measure and a cost performance category score if a performance category. In section
base those benchmarks on the MIPS eligible clinician or group is not II.C.7.a.(2) of this proposed rule, we
performance period (81 FR 77309). attributed any cost measures because propose to calculate a quality
Because we base the benchmarks on the the MIPS eligible clinician or group has performance category percent score
performance period, we will not be able not met the case minimum requirements which is reflective of performance in the
to publish the actual numerical for any of the cost measures or a quality performance category based on
benchmarks in advance of the benchmark has not been created for any dividing the sum of total measure
performance period (81 FR 77309). We of the cost measures that would achievement points and bonus points by
develop a benchmark for a cost measure otherwise be attributed to the clinician the total available measure achievement
only if at least 20 groups (for those MIPS or group. We inadvertently failed to points. We propose to revise
eligible clinicians participating in MIPS include this policy in the regulation text 414.1380(b)(2)(iii) to provide that a
MIPS eligible clinicians cost practice improvement changes can drive evaluated only when there is a
performance category percent score is changes for each specific cost measure. consistent identifier.
the sum of the following, not to exceed Additionally, as discussed in section Therefore, for the cost performance
100 percent: The total number of II.C.7.a.(1)(b)(i) of this proposed rule, category, we are proposing at
achievement points earned by the MIPS other Medicare value-based purchasing 414.1380(b)(2)(iv)(B) that we would
eligible clinician divided by the total programs generally assess performance calculate a cost improvement score only
number of available achievement points improvement at the measure level. when data sufficient to measure
(which can be expressed as a Therefore, we propose at section improvement is available. We are
percentage); and the cost improvement 414.1380(b)(2)(iv)(A) to measure cost proposing that sufficient data would be
score. This terminology change to refer improvement at the measure level for available when a MIPS eligible clinician
to the score as a percentage is consistent the cost performance category. participates in MIPS using the same
with the change in section II.C.7.a.(2) for As described in section identifier in 2 consecutive performance
the quality performance category. We II.C.7.a.(1)(b)(ii) of this proposed rule, periods and is scored on the same cost
discuss our proposals for improvement we believe that we would have data measure(s) for 2 consecutive
scoring in the cost performance category sufficient to measure improvement performance periods (for example, in
in section II.C.7.b.3.(a) of this proposed when we can measure performance in the 2017 MIPS performance period and
rule. the current performance period the 2018 MIPS performance period). If
compared to the prior performance the cost improvement score cannot be
(a) Measuring Improvement calculated because sufficient data is not
period. Due to the differences in our
(i) Calculating Improvement at the Cost proposals for measuring improvement available, we are proposing to assign a
Measure Level for the quality and cost performance cost improvement score of zero
categories, such as measuring percentage points. While the total
In section II.C.7.a.(1)(b) of this available cost improvement score would
proposed rule, we propose to make improvement at the measure level
versus the performance category level, be limited at first because only 2 cost
available to MIPS eligible clinicians and measures would be included in both the
groups a method of measuring we are proposing a different data
sufficiency standard for the cost first and second performance periods of
improvement in the quality and cost the program (total per capita cost and
performance categories. In section performance category than for the
quality performance category, which is MSPB), more opportunities for
II.C.7.a.(2)(i) of this proposed rule, for improvement scoring would be
the quality performance category, we proposed in section II.C.7.a.(2)(i)(ii) of
available in the future as additional cost
propose to assess improvement on the this proposed rule. First, for data
measures, including episode-based
basis of the score at the performance sufficient to measure improvement to be
measures, are added in future
category level. For the cost performance available for the cost performance
rulemaking. MIPS eligible clinicians
category, similar to the quality category, the same cost measure(s)
would be able to review their
performance category, we propose at would need to be specified for the cost
performance feedback and make
414.1380(b)(2)(iv) that improvement performance category for 2 consecutive
improvements compared to the score in
scoring is available to MIPS eligible performance periods. For the 2020 MIPS
their previous feedback.
clinicians and groups that demonstrate payment year, only 2 cost measures, the We invite public comments on these
improvement in performance in the MSPB measure and the total per capita proposals.
current MIPS performance period cost measure, would be eligible for
compared to their performance in the improvement scoring. For a measure to (ii) Improvement Scoring Methodology
immediately preceding MIPS be scored in either performance period, In section II.C.7.a.(1)(b)(i) of this
performance period (for example, a MIPS eligible clinician would need to proposed rule, we discuss a number of
demonstrating improvement in the 2018 have a sufficient number of attributed different programs and how they
MIPS performance period over the 2017 cases to meet or exceed the case measure improvement at the category or
MIPS performance period). minimum for the measure. measure level as part of their scoring
In section II.C.7.a.(2)(i) of this In addition, a clinician would have to systems. For example, the Hospital
proposed rule, we note the various report for MIPS using the same Value-Based Purchasing (VBP) Program
challenges associated with attempting to identifier (TIN/NPI combination for awards either measure improvement or
measure improvement in the quality individuals, TIN for groups, or virtual measure achievement, but not both. In
performance category at the measure group identifiers for virtual groups) and the proposed method for the quality
level, given the many opportunities be scored on the same measure(s) for 2 performance category, we compare the
available to clinicians to select which consecutive performance periods. We overall rate of achievement on all the
measures to report. The cost wish to encourage action on the part of underlying measures in the quality
performance category is not subject to clinicians in reviewing and performance category and measure a
this same issue of measure selection. understanding their contribution to rate of overall improvement to calculate
Cost measures are calculated based on patient costs. For example, a clinician an improvement percent score. We then
Medicare administrative claims data who is shown to have lower add the improvement percent score after
maintained by CMS, without any performance on the MSPB measure taking into account measure
additional data input from or reporting could focus on the efficient use of post- achievement points and measure bonus
by clinicians, and MIPS eligible acute care and be able to see that points as described in proposed
clinicians are not given the opportunity improvement reflected in the cost 414.1380(b)(1)(xvii). In reviewing the
to select which cost measures apply to improvement score in future years. This methodologies that are specified in
them. We believe that there are review could highlight opportunities for section II.C.7.a.(1)(b)(i) of this proposed
advantages to measuring cost better stewardship of healthcare costs rule that include consideration of
improvement at the measure level. such as better recognition of improvement at the measure level, we
Principally, MIPS eligible clinicians unnecessary costs related to common noted that the methodology used in the
could see their performance on each ordering practices. For these reasons, we Shared Savings Program would best
cost measure and better understand how believe that improvement should be reward achievement and improvement
for the cost performance category rate of improvement and without measures, activities, and/or performance
because this program includes measures requiring statistical significance. We categories. When read together, we
for clinicians, the methodology is refer readers to section II.C.7.a.(2)(i) of interpret sections 1848(q)(5)(D)(ii) and
straightforward, and it only recognizes this proposed rule for our proposal 1848(q)(5)(F) of the Act to provide
significant improvement. We propose to related to measuring improvement in discretion to the Secretary to assign a
quantify improvement in the cost the quality performance category. scoring weight of zero for improvement
performance category by comparing the Section 1848(q)(5)(D)(ii) of the Act on the measures specified for the cost
number of cost measures with specifies that the Secretary may assign performance category. Under the
significant improvement in performance a higher scoring weight under improvement scoring methodology we
and the number of cost measures with subparagraph (F) with respect to the have proposed, we believe a maximum
significant declines in performance. We achievement of a MIPS eligible clinician cost improvement score of zero would
propose at 414.1380(b)(2)(iv)(C) to than with respect to any improvement be effectively the same as a scoring
determine the cost improvement score of such clinician with respect to a weight of zero. As a result of our
by subtracting the number of cost measure, activity, or category described proposal, the cost improvement score
measures with significant declines from in paragraph (2). We believe that there would not contribute to the cost
the number of cost measures with are many opportunities for clinicians to performance category percent score
significant improvement, and then actively work on improving their calculated for the 2020 MIPS payment
dividing the result by the number of performance on cost measures, through year. In other words, we would
cost measures for which the MIPS more active care management or calculate a cost improvement score, but
eligible clinician or group was scored in reductions in certain services. However, the cost improvement score would not
both performance periods, and then we recognize that most clinicians are contribute any points to the cost
multiplying the result by the maximum still learning about their opportunities performance category percent score for
cost improvement score. For the 2020 in cost measurement. We aim to the 2020 MIPS payment year.
MIPS payment year, improvement In section II.C.6.d.(2) of this proposed
continue to educate clinicians about
scoring would be possible for the total rule, we consider an alternative to make
opportunities in cost measurement and
per capita cost measure and the MSPB no changes to the previously finalized
continue to develop opportunities for
measure as those 2 measures would be weight of 10 percent for the cost
robust feedback and measures that
available for 2 consecutive performance performance category for the 2020 MIPS
better recognize the role of clinicians. payment year. If we finalize this
periods under our proposals in section Since MIPS is still in its beginning years
II.C.6.d.(3)(a). As in our proposed alternative, we believe that
and we understand that clinicians are improvement should be given weight
quality improvement methodology, we working hard to understand how we
propose at 414.1380(b)(2)(iv)(D) that towards the cost performance category
measure costs for purposes of the cost percent score, but it should still be
the cost improvement score could not be performance category, as well as how
lower than zero, and therefore, could limited. Therefore, we propose that if
we score their performance in all other we maintain a weight of 10 percent for
only be positive. aspects of the program, we believe the cost performance category for the
We propose to determine whether improvement scoring in the cost 2020 MIPS payment year, the maximum
there was a significant improvement or performance category should be limited cost improvement score available in the
decline in performance between the 2 to avoid creating additional confusion. cost performance category would be 1
performance periods by applying a Based on these considerations, we percentage point out of 100 percentage
common standard statistical test, a t- propose in section II.C.6.d.(2) of this points available for the cost
test, as is used in the Shared Savings proposed rule to weight the cost performance category percent score. If a
Program (79 FR 67930 through 67931). performance category at zero percent for clinician were measured on only one
The t-tests statistical significance and the 2020 MIPS payment year/2018 MIPS measure consistently from one
the t-tests effect size are the 2 primary performance period. With the entire cost performance period to the next and met
outputs of the t-test. Statistical performance category proposed to be the requirements for improvement, the
significance indicates whether the weighted at zero percent, we believe clinician would receive one
difference between sample averages is that the focus of clinicians should be on improvement percentage point in the
likely to represent an actual difference achievement as opposed to cost performance category percent score.
between populations and the effect size improvement, and therefore we propose If a clinician were measured on 2
indicates whether that difference is at 414.1380(b)(2)(iv)(E) that although measures consistently, improved
large enough to be practically improvement would be measured significantly on one, and did not show
meaningful. Statistical significance according to the method described significant improvement on the other (as
testing in this case assesses how above, the maximum cost improvement measured by the t-test method described
unlikely it is that differences as large as score for the 2020 MIPS payment year above), the clinician would receive 0.5
those observed would be due to chance would be zero percentage points. improvement percentage points.
when the performance is actually the Section 1848(q)(5)(D)(ii) of the Act We invite comments on these
same. The test recognizes and provides discretion for the Secretary to proposals as well as alternative ways to
appropriately adjusts measures at both assign a higher scoring weight under measure changes in statistical
high and low levels of performance for subparagraph (F), which refers to significance for the cost measure.
statistically significant levels of change. section 1848(q)(5)(F) of the Act, with
However, as an alternative, we welcome respect to achievement than with (b) Calculating the Cost Performance
public comments on whether we should respect to improvement. Section Category Percent Score With
consider instead adopting an 1848(q)(5)(F) of the Act provides if there Achievement and Improvement
improvement scoring methodology that are not sufficient measures and In section II.C.7.a.(1)(b) of this
measures improvement in the cost activities applicable and available to proposed rule, we evaluated different
performance category the same way we each type of MIPS eligible clinician, the improvement scoring options used in
propose to do in the quality Secretary shall assign different scoring other CMS programs. In those programs,
performance category; that is, using the weights (including a weight of zero) for we saw 2 general methods for
incorporating improvement. One existing category percent score. We score. With these two proposed changes,
method measures both achievement and believe this is the most straight-forward the formula would be (Cost
improvement and takes the higher of the and simple way to incorporate Achievement Points/Available Cost
2 scores for each measure that is improvement. It is also consistent with Achievement Points) + (Cost
compared. The Hospital VBP Program other Medicare programs that reward Improvement Score) = (Cost
incorporates such a methodology. The improvement. Performance Category Percent Score).
second method is to calculate an As noted in section II.7.b.(3) of this
achievement score and then add an proposed rule, we have proposed a We invite public comments on these
improvement score if improvement is change in terminology to express the proposals.
measured. The Shared Savings Program cost performance category percent score In Table 32, we provide an example
utilizes a similar methodology for as a percentage. We propose to revise of cost performance category percent
measuring improvement. For the cost 414.1380(b)(2)(iii) to provide that a scores along with the determination of
performance category, we are proposing MIPS eligible clinicians cost improvement or decline. For illustrative
to evaluate improvement at the measure performance category percent score is purposes, we are using the alternative
level, unlike the quality performance the sum of the following, not to exceed proposal of a maximum cost
category where we are proposing to 100 percent: The total number of improvement score of 1. This example
evaluate improvement at the achievement points earned by the MIPS is for group reporting where the group
performance category level. For both the eligible clinician divided by the total is measured on both the total per capita
quality performance category and the number of available achievement points cost measure and the MSPB measure for
cost performance category, we are (which can be expressed as a
2 consecutive performance periods.
proposing to add improvement to an percentage); and the cost improvement
TABLE 32EXAMPLE 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
In this example, there are 20 total other than for physicians, such as (2) possible criteria for attributing a
possible measure achievement points measures for inpatient hospitals, for facilitys performance to a MIPS eligible
and 14.6 measure achievement points purposes of the quality and cost clinician for purposes of the quality and
earned by the group, and the group performance categories. However, the cost performance categories; (3) the
improved on one measure but not the Secretary may not use measures for specific measures and settings for which
other, with both measures being scored hospital outpatient departments, except we can use the facilitys quality and cost
in each performance period. The cost in the case of items and services data as a proxy for the MIPS eligible
improvement score would be furnished by emergency physicians, clinicians quality and cost performance
determined as follows: ((1 measure with radiologists, and anesthesiologists. In categories; and (4) if attribution should
significant improvementzero the MIPS and APMs RFI (80 FR 59108), be automatic or if an individual MIPS
measures with significant decline)/2 we sought comment on how we could eligible clinician or group should elect
measures) * 1 percentage point = 0.5 best use this authority. We refer readers for it to be done and choose the facilities
percentage points. Under the proposed to the CY 2017 Quality Payment through a registration process.
revised formula, the cost performance Program final rule (81 FR 77127) for a As noted in the CY 2017 Quality
category percent score would be (14.6/ summary of these comments. Payment Program final rule (81 FR
20) + 0.5% = 73.5%. As noted in the CY 2017 Quality 77127 through 77130), the majority of
As discussed in section II.C.7.b.(2) of Payment Program proposed rule (81 FR the comments we received supported
this proposed rule, in determining the 28192), we considered an option for attributing a facilitys performance to a
MIPS final score, the cost performance facility-based MIPS eligible clinicians to MIPS eligible clinician for purposes of
category percent score is multiplied by elect to use their institutions the quality and cost performance
the cost performance category weight. performance rates as a proxy for the categories. Some commenters opposed
For the 2020 MIPS payment year, if we MIPS eligible clinicians quality score. using a facilitys quality and cost
finalize the cost performance category However, we did not propose an option performance as a proxy for MIPS
weight of zero percent, then the cost for the transition year of MIPS because eligible clinicians. Many of these
there were several operational commenters expressed the view that
performance category percent score will
considerations that we believed needed facility scores do not represent the
not contribute to the final score.
to be addressed before this option could individual MIPS eligible clinicians
(4) Facility-Based Measures Scoring be implemented. We requested performance. In addition, we received
Option for the 2020 MIPS Payment Year comments on the following issues: (1) suggestions on how we should attribute
for the Quality and Cost Performance Whether we should attribute a facilitys a facilitys performance to a MIPS
Categories performance to a MIPS eligible clinician eligible clinician, as well as comments
(a) Background for purposes of the quality and cost suggesting that attribution should be
performance categories and under what voluntary and that the facilitys
Section 1848(q)(2)(C)(ii) of the Act conditions such attribution would be measures should be relevant to the
provides that the Secretary may use appropriate and representative of the MIPS eligible clinician. A full
measures used for payment systems MIPS eligible clinicians performance; discussion of the comments we received
and our responses can be found in the just reporting. For this reason, we the FY 2019 Hospital VBP Programs
CY 2017 Quality Payment Program final believe that facility-based measurement performance period will be concluded
rule (81 FR 77127 through 77130). under MIPS should be based on pay-for- by December 31, 2017 (we refer readers
In addition, we have received ongoing performance programs rather than pay- to the finalized FY 2019 performance
feedback from various stakeholder for-reporting programs. periods in the FY 2017 Inpatient
associations and individuals regarding Many Medicare payment systems Prospective Payment System/Long-Term
facility-based measurement for MIPS include a pay-for-performance program, Care Hospital Prospective Payment
eligible clinicians, which included: such as the Hospital VBP Program, the System Final Rule, 81 FR 57002), and
Support for MIPS eligible clinicians Skilled Nursing Facility VBP Program the Hospital VBP Program scoring
being able to choose to be assessed in (SNF VBP), the End Stage Renal Disease reports (referred to as the Percentage
this manner; several groups preference Quality Incentive Program (ESRD QIP), Payment Summary Reports) will be
that value-based purchasing and quality and the Home Health Value-Based provided to participating hospitals not
reporting program measure data be used Purchasing Program (HHVBP). We later than 60 days prior to the beginning
for facility-based scoring; support for a believe that clinicians play a role in of FY 2019, pursuant to the Hospital
hybrid approach where MIPS eligible contributing to quality performance in VBP Programs statutory requirement at
clinicians could select both clinician- all of these programs. However, we section 1886(o)(8) of the Act. We further
based measures and facility-based believe that a larger and more diverse note that hospitals must meet case and
measures for purposes of MIPS scoring; group of clinicians contributes to measure minimums during the
and a suggested 2-year pilot program quality in the inpatient hospital setting performance period to receive a Total
before expanding facility-based scoring than in other settings in which we might Performance Score under that Program.
more broadly with an emphasis on no begin to implement this measurement We discuss eligibility for facility-based
negative impact on those who are option. In addition, the inpatient measurement in section II.C.7.b.(4)(c) of
measured in this fashion. We took this hospital setting has a mature value- this proposed rule, and we note that the
feedback, as well as the comments based purchasing program, first determination of the applicable hospital
discussed in the CY 2017 Quality established to adjust payment for will be made on the basis of a period
Payment Program final rule, into hospitals in FY 2013 (76 FR 26489). that overlaps with the applicable
consideration when developing Therefore, we believe it is appropriate to Hospital VBP Program performance
proposals for the application of facility- implement this scoring option in a period. Although Hospital VBP Program
based measures. limited fashion in the first year of measures have different measurement
incorporating additional facility-based periods, the FY 2019 measures all
(b) Facility-Based Measurement
measures under MIPS by focusing on overlap from January to June in 2017,
We believe that facility-based inpatient hospital measures that are
measurement is intended to reduce which also overlaps with our first 12-
used for certain pay-for-performance month period to determine MIPS
reporting burden on facility-based MIPS programs as facility-based measures.
eligible clinicians by leveraging existing eligibility.
The inpatient hospital setting
quality data sources and value-based includes three distinct pay-for- We believe that MIPS eligible
purchasing experiences and aligning performance programs: The Hospital clinicians electing the facility-based
incentives between facilities and the VBP Program, the Hospital measurement option under MIPS should
MIPS eligible clinicians who provide Readmissions Reduction Program be able to consider as much information
services there. In addition, we believe (HRRP), and the Hospital-Acquired as possible when making that decision,
that facility-based MIPS eligible Condition Reduction Program (HACRP). including how their attributed hospital
clinicians contribute substantively to We believe that the Hospital VBP performed in the Hospital VBP Program
their respective facilities performance Program is most analogous to the MIPS because an individual clinician is a part
on facility-based measures of quality program at this time because the of the clinical team in the hospital,
and cost, and that their performance Hospital VBP Program compares rather than the sole clinician
may be better reflected by their facilities on a series of different responsible for care as tracked by
facilities performance on such measures that intend to capture the quality measures. Therefore, we
measures. breadth of care provided in a facility. In concluded that we should be as
Medicare operates both pay-for- contrast, the HACRP and HRRP each transparent as possible with MIPS
reporting programs and pay-for- focus on a single type of outcome for eligible clinicians about their potential
performance programs. Pay-for- patients treated in a hospital (safety and facility-based scores before they begin
reporting programs incentivize the act of readmissions, respectively), though we data submission for the MIPS
reporting data on quality and/or other note that these outcomes are critically performance period since this policy
measures and activities, typically by important to health care improvement. option is intended to minimize
applying a downward payment The payment adjustments associated reporting burdens on clinicians that are
adjustment to facilities or clinicians, as with those 2 programs are intended to already participating in quality
applicable, that fail to submit data as provide negative adjustments for poor improvement efforts through other CMS
required by the Secretary. This type of performance but do not similarly reward programs. We expect that MIPS eligible
program does not adjust payments based high performance. In contrast, the clinicians that would consider facility-
on performance. In contrast, pay-for- Hospital VBP Program compares based scoring would generally be aware
performance programs, such as VBP performance among hospitals and of their hospitals performance on its
programs, score facilities or clinicians, rewards high performers and provides quality measures, but believe that
as applicable, on their performance on negative adjustments to poor providing this information directly to
specified quality and/or other measures performers. clinicians ensures that such clinicians
and activities and adjust payments We also considered program timing are fully aware of the implications of
based on that performance. Pay-for- when determining what Hospital VBP their scoring elections under MIPS.
performance programs, such as VBP Program year to use for facility-based However, we note that this policy could
programs, are more analogous to MIPS measurement for the 2020 MIPS conceivably place non-facility-based
given its focus on performance and not payment year. Quality measurement for MIPS eligible clinicians at a competitive
disadvantage since they would not have contribution to quality performance 75 percent or more of his or her covered
any means by which to ascertain their than others. However, we believe that professional services in sites of service
MIPS measure scores in advance. We clinicians have a broad and important identified by the POS codes used in the
view that compromise as a necessity to role as part of the healthcare team at a HIPAA standard transaction as an
maximize transparency, and we request hospital and that attempting to inpatient hospital, on-campus
comment on whether this notification in differentiate certain measures outpatient hospital, or emergency room
advance of the conclusion of the MIPS undermines the team-based approach of setting, based on claims for a period
performance period is appropriate, or if facility-based measurement. We propose prior to the performance period as
we should consider notifying facility- at 414.1380(e)(6)(i) that the quality and specified by CMS. We considered
based clinicians later in the MIPS cost measures are those adopted under whether we should simply use this
performance period or even after its the value-based purchasing program of definition to determine eligibility for
conclusion. Notification after the MIPS the facility program for the year facility-based measurement under MIPS.
performance period would prevent specified. However, we are concerned that this
facility-based clinicians from being able Therefore, we propose for the 2020 definition could include many
to compare their expected MIPS MIPS payment year to include all the clinicians that have limited or no
performance category scores under the measures adopted for the FY 2019 presence in the inpatient hospital
facility-based measurement option with Hospital VBP Program on the MIPS list setting. We have noted that hospital-
their expected scores under the options of quality measures and cost measures. based clinicians may not have control
available to all MIPS eligible clinicians Under this proposal, we consider the FY over important aspects of the certified
and pick the higher of the two. Since 2019 Hospital VBP Program measures to EHR technology that is available in the
higher performance category scores may meet the definition of additional hospital setting (81 FR 77238). In that
result in a higher final score and a system-based measures provided in regard, there is little difference between
higher MIPS payment adjustment, there section 1848(q)(2)(C)(ii) of the Act, and outpatient and inpatient hospital
is a substantial incentive for a clinician we propose at 414.1380(e)(1)(i) that settings. But we are proposing to
to undertake this comparison, a facility-based measures available for the determine a MIPS eligible clinicians
comparison unavailable to non-facility- 2018 MIPS performance period are the quality performance category score and
based peers. measures adopted for the FY 2019 cost performance category score based
The performance periods proposed in Hospital VBP Program year authorized on a hospitals Hospital VBP
section II.C.5. of this proposed rule for by section 1886(o) of the Act and performance, which is based on
the 2020 MIPS payment year occur in codified in our regulations at 412.160 inpatient services. Section
2018, with data submission for most through 412.167. Measures in the FY 1848(q)(2)(C)(ii) of the Act limits our
mechanisms starting in January 2019. 2019 Hospital VBP Program have ability to incorporate measures used for
To provide potential facility-based different performance periods as noted hospital outpatient departments. Our
scores to clinicians by the time the data in Table 33. proposal at section II.C.6.f.(7)(a)(i) of
submission period for the 2018 MIPS We request comments on these this proposed rule to expand the
performance period begins assuming proposals. We also request comments on definition of a hospital-based MIPS
that timeframe is operationally feasible), what other programs, if any, we should eligible clinician for the advancing care
we believe that the FY 2019 program consider including for purposes of information performance category to
year of the Hospital VBP Program, as facility-based measurement under MIPS include clinicians who practice
well as the corresponding performance in future program years. primarily in off-campus outpatient
periods, is the most appropriate
(c) Facility-Based Measurement hospitals could include clinicians that
program year to use for purposes of
Applicability practice many miles away from the
facility-based measurement under the
hospital in practices which are owned
quality and cost performance categories (i) General by the hospital, but do not substantially
for the 2020 MIPS payment year.
The percentage of professional time a contribute to the hospitals Hospital
However, we note also that Hospital
clinician spends working in a hospital VBP Program performance. As we
VBP performance periods can run for
varies considerably. Some clinicians discuss further in this section, the
periods as long as 36 months, and for
may provide services in the hospital measures used in the Hospital VBP
some FY 2019 Hospital VBP Program
regularly, but also treat patients Program are focused on care provided in
measures, the performance period
begins in 2014. We request comment on extensively in an outpatient office or the inpatient setting. We do not believe
whether this lengthy performance another environment. Other clinicians it is appropriate for a MIPS eligible
period duration should override our may practice exclusively within a clinician to use a hospitals Hospital
desire to include all Hospital VBP hospital. Recognizing the various levels VBP Program performance for MIPS
Program measures as discussed further of presence of different clinicians scoring if they did not provide services
below. We propose at within a hospital environment, we seek in that setting.
414.1380(e)(6)(iii) that the to limit the potential applicability of Therefore, we believe establishing a
performance period for facility-based facility-based measurement to those different definition for purposes of
measurement is the performance period MIPS eligible clinicians with a facility-based measurement is necessary
for the measures for the measures significant presence in the hospital. to implement this option. We also note
In the CY 2017 Quality Payment that, since we are seeking comments
adopted under the value-based

purchasing program of the facility of the Program final rule (81 FR 77238 through above on other programs to consider
year specified. 77240), we adopted a definition of including for purposes of facility-based
We considered whether we should hospital-based MIPS eligible clinician measurement in future years, we believe
include the entire set of Hospital VBP under 414.1305 for purposes of the establishing a separate definition that
Program measures for purposes of advancing care information performance could be expanded as needed for this
facility-based measurement under MIPS category. Section 414.1305 defines a purpose is appropriate. We propose at
or attempt to differentiate those which hospital-based MIPS eligible clinician as 414.1380(e)(2) that a MIPS eligible
may be more influenced by clinicians a MIPS eligible clinician who furnishes clinician is eligible for facility-based
measurement under MIPS if they are based through an evaluation of covered we believe that allowing facility-based
determined facility-based as an professional services between MIPS eligible clinicians the most
individual. We propose at September 1 of the calendar year 2 years flexibility possible, while still being
414.1380(e)(2)(i) that a MIPS eligible preceding the performance period able to accurately measure the value of
clinician is considered facility-based as through August 31 of the calendar year care those clinicians provide, as we
an individual if the MIPS eligible preceding the performance period with continue implementation of the Quality
clinician furnishes 75 percent or more a 30-day claims run out. For example, Payment Program is paramount in
of their covered professional services (as for the 2020 MIPS payment year, where ensuring that clinicians understand the
defined in section 1848(k)(3)(A) of the we have adopted a performance period program and its effects on the care they
Act) in sites of service identified by the of CY 2018 for the quality and cost provide.
POS codes used in the HIPAA standard performance categories, we would use We request comments on this
transaction as an inpatient hospital, as the data available at the end of October proposal.
identified by POS code 21, or an 2017 to determine whether a MIPS (ii) Facility-Based Measurement Group
emergency room, as identified by POS eligible clinician is considered facility- Participation
code 23, based on claims for a period based by our definition. At that time,
prior to the performance period as those data would include Medicare We are also proposing at
specified by CMS. We understand that claims with dates of service between 414.1380(e)(2) that a MIPS eligible
the services of some clinicians who September 1, 2016 and August 31, 2017. clinician is eligible for facility-based
practice solely in the hospital are billed In the event that it is not operationally measurement under MIPS if they are
using place of service codes such as feasible to use claims from this exact determined facility-based as part of a
time period, we would use a 12-month group. We are proposing at
code 22, reflecting an on-campus
414.1380(e)(2)(ii) that a facility-based
outpatient hospital for patients who are period as close as practicable to
group is a group in which 75 percent or
in observation status. Because there are September 1 of the calendar year 2 years
more of the MIPS eligible clinician NPIs
limits on the length of time a Medicare preceding the performance period and
billing under the groups TIN are
patient may be seen under observation August 31 of the calendar year
eligible for facility-based measurement
status, we believe that these clinicians preceding the performance period. This
as individuals as defined in
would still furnish 75 percent or more determination would allow clinicians to
414.1380(e)(2)(i). We also considered
of their covered professional services be made aware of their eligibility for
an alternative proposal in which a
using POS code 21, but seek comment facility-based measurement near the
facility-based group would be a group
on whether a lower or higher threshold beginning of the MIPS performance
where the TIN overall furnishes 75
of inpatient services would be period. We believe that this definition
percent or more of its covered
appropriate. We do not propose to allows us to identify MIPS eligible
professional services (as defined in
include POS code 22 in determining clinicians who are significant
section 1848(k)(3)(A) of the Act) in sites
whether a clinician is facility-based contributors to facilities care for
of service identified by the POS codes
because many clinicians who bill for Medicare beneficiaries and other
used in the HIPAA standard transaction
services using this POS code may work patients for purposes of facility-based
as an inpatient hospital, as identified by
on a hospital campus but in a capacity measurement.
POS code 21, or the emergency room, as
that has little to do with the inpatient We also recognize that in addition to identified by POS code 23, based on
care in the hospital. In contrast, we the variation in the percentage of time claims for a period prior to the
believe those who provide services in a clinician is present in the hospital, performance period as specified by
the emergency room or the inpatient there is also great variability in the types CMS. Groups would be determined to
hospital clearly contribute to patient of services that clinicians perform. be facility-based through an evaluation
care that is captured as part of the Some may be responsible for overall of covered professional services
Hospital VBP Program because many management of patients throughout between September 1 of the calendar
patients who are admitted are admitted their stay, others may perform a year 2 years preceding the performance
through the emergency room. We seek procedure, and others may serve a role period through August 31 of the
comments on whether POS 22 should be in supporting diagnostics. We calendar year preceding the
included in determining if a clinician is considered whether certain clinicians performance period with a 30 day
facility-based and how we might should be identified as eligible for this claims run out period (or if not
distinguish those clinicians who facility-based measurement option operationally feasible to use claims from
contribute to inpatient care from those based on characteristics in addition to this exact time period, a 12-month
who do not. We note that the inclusion their percentage of covered professional period as close as practicable to
of any POS code in our definition is services furnished in the inpatient September 1 of the calendar year 2 years
pending technical feasibility to link a hospital or emergency room setting, preceding the performance period and
clinician to a facility under the method such as by requiring a certain specialty August 31 of the calendar year
described in section II.C.7.b.(4)(d) of such as hospital medicine or by limiting preceding the performance period).
this proposed rule. eligibility to those who served in We request comments on our proposal
We note that this more limited patient-facing roles. However, we and alternative proposal.
definition would mean that a clinician believe that all MIPS eligible clinicians
who is determined to be facility-based with a significant presence in the (d) Facility Attribution for Facility-
likely would also be determined to be facility play a role in the overall Based Measurement
hospital-based for purposes of the performance of a facility, and therefore, Many MIPS eligible clinicians provide
advancing care information performance are not proposing at this time to further services at more than one hospital, so
category, because this proposed limit this option based on we must develop a method to identify
definition of facility-based is narrower characteristics other than the percentage which hospitals scores should be
than the hospital-based definition of covered professional services associated with that MIPS eligible
established for that purpose. Clinicians furnished in an inpatient hospital or clinician under this facility-based
would be determined to be facility- emergency room setting. Additionally, measurement option. We considered
whether a clinician should be required propose that those clinicians or groups considerations we described above led
to identify for us the hospital with who are eligible for and wish to elect us to conclude that FY 2019 was the
which they were affiliated, but felt that facility-based measurement would be most appropriate Hospital VBP Program
such a requirement would add required to submit their election during year for the first year of the facility-
unnecessary administrative burden in a the data submission period as based measurement option under MIPS,
process that we believe was intended to determined at 414.1325(f) through the and selecting other years would result
reduce burden. We also considered attestation submission mechanism in further divergence between the MIPS
whether we could combine scores from established for the improvement performance period and the Hospital
multiple hospitals, but believe that such activities and advancing care VBP Programs performance periods. We
a combination would reduce the information performance categories. If are also concerned that a method that
alignment between a single hospital and technically feasible, we would let the does not require active selection may
a clinician or group and could be MIPS eligible clinician know that they result in MIPS eligible clinicians being
confusing for participants. We believe were eligible for facility-based scored on measures at a facility and
we must establish a reasonable measurement prior to the submission being unaware that such scoring is
threshold for a MIPS eligible clinicians period, so that MIPS eligible clinicians taking place. We are also concerned that
participation in clinical care at a given would be informed if this option is such a method could provide an
facility to allow that MIPS eligible available to them. advantage to those facility-based
clinician to be scored using that We also considered an alternative clinicians who do not submit quality
facilitys measures. We do not believe it approach of not requiring an election measures in comparison to those who
to be appropriate to allow MIPS eligible process but instead automatically work in other environments. We also
clinicians to claim credit for facilities applying facility-based measurement to note that this option may not be
measures if the MIPS eligible clinician MIPS eligible clinicians and groups who technically feasible for us to implement
does not participate meaningfully in the are eligible for facility-based for the 2018 MIPS performance period.
care provided at a given facility. We invite comments on this proposal
measurement, if technically feasible.
Therefore, we propose at and alternate proposal.
Under this approach, we would
414.1380(e)(5) that MIPS eligible
calculate a MIPS eligible clinicians (e) Facility-Based Measures
clinicians who elect facility-based
facility-based measurement score based For the FY 2019 program year, the
measurement would receive scores
on the hospitals (as identified using the Hospital VBP Program has adopted 13
derived from the value-based
purchasing score (using the process described in section II.C.6.b. of quality and efficiency measures. The
methodology described in section this proposed rule) performance using Hospital VBP Program currently
II.B.7.b.4 of this proposed rule) for the the methodology described in section includes 4 domains: Person and
facility at which they provided services II.C.7.a.2.b. of this proposed rule, and community engagement, clinical care,
for the most Medicare beneficiaries automatically use that facility-based safety, and efficiency and cost
during the period of September 1 of the measurement score for the quality and reduction. These domains align with
calendar year 2 years preceding the cost performance category scores if the many MIPS high priority measures
performance period through August 31 facility-based measurement score is (outcome, appropriate use, patient
of the calendar year preceding the higher than the quality and cost safety, efficiency, patient experience,
performance period with a 30 day performance category scores as and care coordination measures) in the
claims run out. This mirrors our period determined based on data submitted by quality performance category and the
of determining if a clinician is eligible the MIPS eligible clinician through any efficiency and cost reduction domain
for facility-based measurement and also available reporting mechanism. This closely aligns with our cost performance
overlaps with parts of the performance facility-based measurement score would category. We believe this set of
period for the applicable Hospital VBP be calculated even if an individual measures covering 4 domains and
program measures. For the first year, the MIPS eligible clinician or group did not composed primarily of measures that
value-based purchasing score for the submit any data for the quality would be considered high priority
facility is the FY 2019 Hospital VBP performance category. This option under the MIPS quality performance
Programs Total Performance Score. In would reduce burden for MIPS eligible category capture a broad picture of
cases in which there was an equal clinicians by not requiring them to elect hospital-based care. For example, the
number of Medicare beneficiaries facility-based measurement, but is HCAHPS survey under the Hospital
treated at more than one facility, we contrary to stakeholders request for a VBP Program is a patient experience
propose to use the value-based voluntary policy. Additionally, under measure, which would make it a high-
purchasing score from the facility with this option, our considerations about priority measure under MIPS.
the highest score. Hospital VBP Program timing would be Additionally, the Hospital VBP Program
less applicable. That is, we explained has adopted several measures of clinical
(e) Election of Facility-Based our rationale for specifying the FY 2019 outcomes in the form of 30-day
Measurement Hospital VBP Program above, in part to mortality measures, and clinical
Stakeholders have expressed a strong ensure that MIPS eligible clinicians are outcomes are a high-priority topic for
preference that facility-based informed about their potential facility- MIPS. The Hospital VBP Program
measurement be a voluntary process, based scores prior to the conclusion of includes several measures in a Safety
and we agree with this preference the MIPS performance period. However, domain, which meets our definition of
considering our general goal in making under an automatic process, we could patient safety measures as high-priority.
MIPS as flexible as possible. Therefore, consider automatically using other Therefore, we propose that facility-
we propose at 414.1380(e)(3) that Hospital VBP Program years scores. For based individual MIPS eligible
individual MIPS eligible clinicians or example, we could apply FY 2020 clinicians or groups that are attributed
groups who wish to have their quality Hospital VBP Program scores instead of to a hospital would be scored on all the
and cost performance category scores FY 2019. We intend in general to align measures on which the hospital is
determined based on a facilitys Hospital VBP and MIPS performance scored for the Hospital VBP Program via
performance must elect to do so. We periods when feasible, and the timing the Hospital VBP Programs Total
Performance Score (TPS) scoring The Hospital VBP Programs FY 2019 reproduced in Table 33 (see 81 FR
methodology. measures, and their associated 56985 and 57002).
performance periods, have been
TABLE 33FY 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 0166 (0228) CY 2017
and Systems (HCAHPS) (including Care Transition
Measure).
Clinical Care Domain
MORT30AMI ................... Hospital 30-Day, All-Cause, Risk-Standardized Mortality 0230 July 1, 2014June 30, 2017
Rate (RSMR) Following Acute Myocardial Infarction
(AMI) Hospitalization.
MORT30HF ..................... Hospital 30-Day, All-Cause, Risk-Standardized Mortality 0229 July 1, 2014June 30, 2017
Rate (RSMR) Following Heart Failure (HF) Hospitaliza-
tion.
MORT30PN .................... Hospital 30-Day, All-Cause, Risk-Standardized Mortality 0468 July 1, 2014June 30, 2017
Rate (RSMR) Following Pneumonia Hospitalization.
THA/TKA ............................. Hospital-Level Risk-Standardized Complication Rate 1550 January 1, 2015June 30,
(RSCR) Following Elective Primary Total Hip Arthroplasty 2017
(THA) and/or Total Knee Arthroplasty (TKA).
Safety Domain
CAUTI ................................. National Healthcare Safety Network (NHSN) Catheter-As- 0138 CY 2017
sociated Urinary Tract Infection (CAUTI) Outcome Meas-
ure.
CLABSI ............................... National Healthcare Safety Network (NHSN) Central Line- 0139 CY 2017
Associated Bloodstream Infection (CLABSI) Outcome
Measure.
Colon and Abdominal American College of SurgeonsCenters for Disease Con- 0753 CY 2017
Hysterectomy SSI. trol and Prevention (ACSCDC) Harmonized Procedure
Specific Surgical Site Infection (SSI) Outcome Measure.
MRSA Bacteremia .............. National Healthcare Safety Network (NHSN) Facility-wide 1716 CY 2017
Inpatient Hospital-onset Methicillin-resistant Staphy-
lococcus aureus (MRSA) Bacteremia Outcome Measure.
CDI ...................................... National Healthcare Safety Network (NHSN) Facility-wide 1717 CY 2017
Inpatient Hospital-onset Clostridium difficile Infection
(CDI) Outcome Measure.
PSI90* ............................... Patient Safety for Selected Indicators (Composite Measure) 0531 July 1, 2015June 30 2017
PC01 ................................. Elective Delivery .................................................................... 0469 CY 2017
Efficiency and Cost Reduction Domain
MSPB .................................. Payment-Standardized Medicare Spending Per Beneficiary 2158 CY 2017

(MSPB).
* PSI90 has been proposed in the FY 2018 IPPS/LTCH PPS proposed rule for removal beginning with the FY 2019 program year.
We note that the Patient Safety option through attestation as proposed Care Act, requires the Secretary to
Composite Measure (PSI90) was in section II.C.7.a.(4)(e). We also refer establish a hospital value-based
proposed for removal beginning with readers to section II.C.7. of this purchasing program (the Hospital VBP
the FY 2019 measure set in the FY 2018 proposed rule for further details on how Program) under which value-based
IPPS/LTCH proposed rule (82 FR 19970) we will incorporate scoring for facility- incentive payments are made in a fiscal
due to issues with calculating the based measurements into MIPS. year to hospitals that meet performance
measure score. If the proposal to remove standards established for a performance
(f) Scoring Facility-Based Measurement
that measure from the hospital measure period for such fiscal year. These value-
set is finalized, we would remove the (i) Hospital VBP Program Scoring based incentive payments are funded
measure from the list of those adopted As we discuss above in subsection (b), through a reduction to participating
for facility-based measurement in the we believe that the Hospital VBP hospitals base-operating DRG payment
MIPS program. Program represents the most appropriate amounts, with the amount of the
We propose at 414.1380(e)(4) that value-based purchasing program with reduction specified by statute. For the
there are no data submission which to begin implementation of the FY 2019 program year, that reduction
requirements for the facility-based facility-based measurement option will be equal to 2 percent. Participating
measures used to assess performance in under MIPS. hospitals then receive value-based
the quality and cost performance Section 1886(o) of the Act, as added incentive payments depending on their
categories, other than electing the by section 3001(a)(1) of the Affordable performance on measures adopted
under the Program. For more detail on established for scoring and no bonus quality performance category and
the statutory background and history of points are available in this scoring calculate the cost performance category
the Hospital VBP Programs system. score as we do for other clinicians.
implementation, we refer readers to 81 Points awarded for measures within However, we believe that value-based
FR 56979. each domain are summed to reach the purchasing programs are generally
As noted previously, the FY 2019 unweighted domain score. We note for constructed to assess an overall picture
Hospital VBP Program will score the person and community engagement of the care provided by the facility,
participating hospitals on 13 measures domain only, the domain score consists taking into account both the costs and
covering 4 domains of care, although as of a base score and a consistency score. the quality of care provided. Given our
discussed in the FY 2018 IPPS/LTCH The base score is based on the greater
focus on alignment between quality and
proposed rule (82 FR 19970), we have of improvement or achievement points
cost, we also do not believe it is
proposed to remove the PSI 90 Patient for each of the 8 HCAHPS survey
dimensions. Consistency points are appropriate to measure quality on one
Safety Composite measure from the FY unit (a hospital) and cost on another
2019 measure set. For each of the awarded based on a hospitals lowest
HCAHPS dimension score during the (such as an individual clinician or TIN).
measures, performance standards are Therefore, we propose at 414.1380(e)
established for the applicable fiscal year performance period relative to national
hospital scores on that dimension that facility-based scoring is available
that include levels of achievement and for the quality and cost performance
improvement. For the FY 2019 program during the baseline period. The domain
scores are then weighted according to categories and that the facility-based
year, the achievement threshold and measurement scoring standard is the
domain weights specified each Program
benchmark are calculated using baseline MIPS scoring methodology applicable
year, then summed to reach the Total
period data with respect to that fiscal for those who meet facility-based
Performance Score, which is converted
year, with the achievement threshold for
to a value-based incentive payment eligibility requirements and who elect
each of these measures being the
percentage that is used to adjust facility-based measurement.
median of hospital performance on the
payments to each hospital for inpatient
measure during the baseline period and (iii) Benchmarking Facility-Based
services furnished during the applicable
the benchmark for each of these Measures
program year. For the FY 2019 program
measures being the arithmetic mean of
year, all 4 domains will be weighted Measures in the MIPS quality
the top decile of hospital performance equally. We refer readers to 81 FR 57005
during the baseline period. The performance category are benchmarked
and 81 FR 79857 through 79858 for to historical performance on the basis of
achievement threshold and benchmark additional information on the Hospital
for the MSPB measure are calculated performance during the 12-month
VBP Programs performance standards,
using the same methodology, except calendar year that is 2 years prior to the
as well as the QualityNet Web site for
that we use performance period data certain technical updates to the performance period for the MIPS
instead of baseline period data in our performance standards. payment year. If a historical benchmark
calculations. We then calculate hospital cannot be established, a benchmark is
performance on each measure during (ii) Applying Hospital VBP Program calculated during the performance
the performance period for which they Scoring to the MIPS Quality and Cost period. In the cost performance
have sufficient data and calculate a Performance Categories category, benchmarks are established
measure score based on that We considered several methods to during the performance period because
performance as compared with the incorporate facility-based measures into changes in payment policies year to year
performance standards that apply to the scoring for the 2020 MIPS payment year, can make it challenging to compare
measure. For achievement scoring, those including selecting hospitals measure performance on cost measure year to
hospitals that perform below (or above scores, domain scores, and the Hospital year. Although we propose a different
in the case of measures for which a VBP Program Total Performance Scores performance period for MIPS eligible
lower rate is better) the level of the to form the basis for the cost and quality clinicians in facility-based
achievement threshold are not awarded performance category scores for measurement, the baseline period used
any achievement points. Those that individual MIPS eligible clinicians and for creating MIPS benchmarks is
perform between the level of the groups that are eligible to participate in generally consistent with this approach.
achievement threshold and the facility-based measurement. Although We note that the Hospital VBP Program
benchmark are awarded points based on each of these approaches may have uses measures for the same fiscal year
the relative performance of the hospital, merit, we have proposed the option that even if those measures do not have the
according to formulas specified by the we believe provides the fairest
same performance period length, but the
Hospital VBP Program (see the Hospital comparison between performance in the
Inpatient VBP Program final rule, 76 FR baseline period closes well before the
2 programs and will best allow us to
26518 through 26519). Those hospitals performance period. The MSPB is
expand the opportunity to other
whose performance meets or exceeds benchmarked in a manner that is similar
programs in the future.
the benchmark are awarded 10 Unlike MIPS, the Hospital VBP to measures in the MIPS cost
achievement points for the measure. Program does not have performance performance category. The MSPB only
Hospitals are also provided the categories. There are instead four uses a historical baseline period for
opportunity to receive improvement domains of measures. We considered improvement scoring and bases its
points based on their improvement whether we should try to identify achievement threshold and benchmark
between the baseline period for the certain domains or measures that were solely on the performance period (81 FR
measure and the performance period. A more closely aligned with those 57002). We propose at
hospital is awarded between 0 and 10 identified in the quality performance 414.1380(e)(6)(ii) that the benchmarks
points for achievement and 0 and 9 category or the cost performance for facility-based measurement are those
points for improvement, and is awarded category. We also considered whether that are adopted under the value-based
the higher of the 2 scores for each we should limit the application of purchasing program of the facility for
individual measure. There are no floors facility-based measurement to the the year specified.
(iv) Assigning MIPS Performance Program Total Performance Score was improvement in the individual
Category Scores Based on Hospital VBP 35 out of 100 possible points and the measures would in turn receive a higher
Performance median quality performance category score through the Hospital VBP Program
Performance measurement in the percent score in MIPS was 75 percent methodology, so that improvement is
Hospital VBP Program and MIPS is and the median cost performance reflected in the underlying Hospital
quite different in part due to the design category score was 50 percent, then a VBP Program measurement. In addition,
and the maturity of the programs. As clinician or group that is evaluated improvement is already captured in the
noted above, the Hospital VBP Program based on a hospital that received an distribution of MIPS performance scores
only assigns achievement points to a Hospital VBP Program Total that is used to translate Hospital VBP
hospital for its performance on a Performance Score of 35 points would Total Performance Score into a MIPS
measure if the hospitals performance receive a score of 75 percent for the quality performance category score.
during the performance period meets or quality performance category and 50 Therefore, we are not proposing any
exceeds the median of hospital percent for the cost performance additional improvement scoring for
performance on that measure during the category. The percentile distribution for facility-based measurement for either
applicable baseline period, whereas both the Hospital VBP Program and the quality or cost performance
MIPS assigns achievement points to all MIPS would be based on the category.
measures that meet the required data distribution during the applicable Because we intend to allow clinicians
performance periods for each of the the flexibility to elect facility-based
completeness and case minimums. In
programs and not on a previous measurement on an annual basis, some
addition, the Hospital VBP Program has
benchmark year. clinicians may be measured through
removed many process measures and We believe this proposal offers a fairer
topped out measures since its first facility-based measurement in 1 year
comparison of the performance among and through another MIPS method in
program year (FY 2013), while both participants in MIPS and the Hospital
process and topped out measures are the next. Because the first MIPS
VBP Program compared to other options performance period in which a clinician
available in MIPS. With respect to the we considered and provides an
FY 2017 program year, for example, the could switch from facility-based
objective means to normalize measurement to another MIPS method
median Total Performance Score for a differences in measured performance
hospital in Hospital VBP was 33.88 out would be in 2019, we seek comment on
between the programs. In addition, we how to assess improvement for those
of 100 possible points. If we were to believe this method will make it simpler
simply assign the Hospital VBP Total that switch from facility-based scoring
to apply the concept of facility-based
Performance Score for a hospital to a to another MIPS method. We request
measurement to additional programs in
clinician, the performance of those comment on whether it is appropriate to
the future.
MIPS eligible clinicians electing facility- We welcome public comments on this include measurement of improvement
based measurement would likely be proposal. in the MIPS quality performance
lower than most who participated in the category for facility-based measured
MIPS program, particularly in the (v) Scoring Improvement for Facility- clinicians and groups given that the
quality performance category. Based Measurement Hospital VBP Program already takes
We believe that we should recognize The Hospital VBP Program includes a improvement into account in its scoring
relative performance in the facility methodology for recognizing methodology.
programs that reflects their different improvement on individual measures In section II.C.7.a.(3)(a) of this
designs. Therefore, we propose at which is then incorporated into the total proposed rule, we discuss our proposal
414.1380(e)(6)(iv) that the quality performance score for each participating to measure improvement in the cost
performance category score for facility- hospital. A hospitals performance on a performance category at the measure
based measurement is reached by measure is compared to a national level. We propose that clinicians under
determining the percentile performance benchmark as well as its own facility-based measurement would not
of the facility determined in the value- performance from a corresponding be eligible for a cost improvement score
based purchasing program for the baseline period. in the cost performance category. As in
specified year as described under In this proposed rule, we have the quality performance category, we
414.1380(e)(5) and awarding a score proposed to consider improvement in believe that a clinician participating in
associated with that same percentile the quality and cost performance facility-based measurement in
performance in the MIPS quality categories. In section II.C.7.a.(2)(i) of subsequent years would already have
performance category score for those this proposed rule, we propose to improvement recognized as part of the
clinicians who are not scored using measure improvement in the quality Hospital VBP Program methodology and
facility-based measurement. We also performance category based on should therefore not be given additional
propose at 414.1380(e)(6)(v) that the improved achievement for the credit. In addition, because we propose
cost performance category score for performance category percent score and to limit measurement of improvement to
facility-based measurement is award improvement even if, under those MIPS eligible clinicians that
established by determining the certain circumstances, a clinician moves participate in MIPS using the same
percentile performance of the facility from one identifier to another from 1 identifier and are scored on the same
determined in the value-based year to the next. For those who may be cost measure(s) in 2 consecutive
purchasing program for the specified measured under facility-based performance periods, those MIPS
year as described in 414.1380(e)(5) and measurement, improvement is already eligible clinicians who elect facility-
awarding the number of points captured in the scoring method used by based measurement would not be
associated with that same percentile the Hospital VBP Program, so we do not eligible for a cost improvement score in
performance in the MIPS cost believe it is appropriate to separately the cost performance category under our
performance category score for those measure improvement using the proposed methodology because they
clinicians who are not scored using proposed MIPS methodology. Although would not be scored on the same cost
facility-based measurement. For the improvement methodology is not measure(s) for 2 consecutive
example, if the median Hospital VBP identical, a hospital that demonstrated performance periods.
We invite comments on these VBP Program are routinely excluded, translated into the percentile
proposals. such as hospitals in Maryland. In such distribution described above, that would
cases, facility-based clinicians would result in a score of below 30 percent
(vi) Bonus Points for Facility-Based
know well in advance that the hospital would be reset to a score of 30 percent
Measurement
would not receive a Total Performance in the quality performance category. We
MIPS eligible clinicians that report on Score, and that they would need to believe that this adjustment is important
quality measures are eligible for bonus participate in MIPS through another to maintain consistency with our other
points for the reporting of additional method. However, we are concerned policies. There is no similar floor
outcome and high priority measures that some facility-based clinicians may established for measures in the cost
beyond the one that is required. 2 bonus provide services in hospitals which they performance category under MIPS, so
points are awarded for each additional expect will receive a Total Performance we do not propose any floor for the cost
outcome or patient experience measure, Score but do not due to various rare performance category for facility-based
and one bonus point is awarded for each circumstances such as natural disasters. measurement.
additional other high priority measure. In section II.C.7.b.(3)(c) of this proposed Some MIPS eligible clinicians who
These bonus points are intended to rule, we propose a process for select facility-based measurement could
encourage the use of measures that are requesting a reweighting assessment for have sufficient numbers of attributed
more impactful on patients and better the quality, cost and improvement patients to meet the case minimums for
reflect the overall goals of the MIPS activities performance categories due to the cost measures established under
program. Many of the measures in the extreme and uncontrollable MIPS. Although there is no additional
Hospital VBP Program meet the criteria circumstances, such as natural disasters. data reporting for cost measures, we
that we have adopted for high-priority We propose that MIPS eligible believe that, to facilitate the relationship
measures. We support measurement that clinicians who are facility-based and between cost and quality measures, they
takes clinicians focus away from affected by extreme and uncontrollable should be evaluated covering the same
clinical process measures; however, our circumstances, such as natural disasters, population as opposed to comparing a
proposed scoring method described may apply for reweighting. hospital population and a population
above is based on a percentile In addition, we note that hospitals attributed to an individual clinician or
distribution of scores within the quality may submit correction requests to their group. In addition, we believe that
and cost performance categories that Total Performance Scores calculated including additional cost measures in
already accounts for bonus points. For under the Hospital VBP Program, and the cost performance category score for
this reason, we are not proposing to may also appeal the calculations of their MIPS eligible clinicians who elect
calculate additional high priority bonus Total Performance Scores, subject to facility-based measurement would
points for facility-based measurement. Hospital VBP Program requirements reduce the alignment of incentives
We note that clinicians have an established in prior rulemaking. We between the hospital and the clinician.
additional opportunity to receive bonus intend to use the final Hospital VBP Thus, we are proposing at
points in the quality performance Total Performance Score for the facility- 414.1380(e)(6)(v)(A) that MIPS eligible
category score for using end-to-end based measurement option under MIPS. clinicians who elect facility-based
electronic submission of quality In the event that a hospital obtains a measurement would not be scored on
measures. The Hospital VBP Program successful correction or appeal of its other cost measures specified for the
does not capture whether or not Total Performance Score, we would cost performance category, even if they
measures are reported using end-to-end update MIPS eligible clinicians quality meet the case minimum for a cost
electronic reporting. In addition, our and cost performance category scores measure.
proposed facility-based scoring method accordingly, as long as the update could If a clinician or a group elects facility-
described above is based on a percentile be made prior to the application of the based measurement but also submits
distribution of scores within the quality MIPS payment adjustment for the quality data through another MIPS
and cost performance categories that relevant MIPS payment year. We mechanism, we propose to use the
already accounts for bonus points. For welcome public comments on whether higher of the two scores for the quality
this reason, we are not proposing to a different deadline should be performance category and base the score
calculate additional end-to-end considered. of the cost performance category on the
electronic reporting bonus points for Additionally, although we wish to tie same method (that is, if the facility-
facility-based measurement. the hospital and clinician performance based quality performance category
We welcome public comments on our as closely together as possible for score is higher, facility-based
approach. purposes of the facility-based scoring measurement is used for quality and
policy, we do not wish to disadvantage cost). Since this policy may result in a
(vii) Special Rules for Facility-Based those clinicians and groups that select higher final score, it may provide
Measurement this measurement method. In section facility-based clinicians with a
Some hospitals do not receive a Total II.C.7.a.(2) of this proposed rule, we substantial incentive to elect facility-
Performance Score in a given year in the propose to retain a policy equivalent to based measurement, whether or not the
Hospital VBP Program, whether due to the 3-point floor for all measures with clinician believes such measures are the
insufficient quality measure data, failure complete data in the quality most accurate or useful measures of that
to meet requirements under the Hospital performance category scored against a clinicians performance. Therefore, this
Inpatient Quality Reporting Program, or benchmark in the 2020 MIPS payment policy may create an unfair advantage
other reasons. In these cases, we would year. However, the Hospital VBP for facility-based clinicians over non-
be unable to calculate a facility-based Program does not have a corresponding facility-based clinicians, since non-
score based on the hospitals scoring floor. Therefore, we propose to facility-based clinicians would not have
performance, and facility-based adopt a floor on the Hospital VBP the opportunity to use the higher of two
clinicians would be required to Program Total Performance Score for scores. Therefore, we seek comment on
participate in MIPS via another method. purposes of facility-based measurement whether this proposal to use the higher
Most hospitals which do not receive a under MIPS so that any score in the score is the best approach to score the
Total Performance Score in the Hospital quality performance category, once performance of facility-based clinicians
in comparison to their non-facility- in the Transforming Clinical Practice activities performance category for the
based peers. Initiative (TCPI), participation in a MIPS performance period. In addition, MIPS
eligible clinicians state Medicaid eligible clinicians that are participating
(5) Scoring the Improvement Activities
program, or an activity identified as a in MIPS APMs will be assigned an
Performance Category
public health priority (such as emphasis improvement activity score, which may
Section 1848(q)(5)(C) of the Act on anticoagulation management or be higher than one half of the highest
specifies scoring rules for the utilization of prescription drug potential score. This assignment is
improvement activities performance monitoring programs) are justifiably based on the extent to which the
category. For more of the statutory weighted as high (81 FR 77311 through requirements of the specific model meet
background and description of the 77312). the list of activities in the Improvement
proposed and finalized policies, we We refer readers to Table 26 of the CY Activities Inventory. For a further
refer readers to the CY 2017 Quality 2017 Quality Payment Program final description of improvement activities
Payment Program final rule (81 FR rule for a summary of the previously and the APM scoring standard for MIPS,
77311 through 77319). We have also finalized improvement activities that are we refer readers to the CY 2017 Quality
codified certain requirements for the weighted as high (81 FR 77312 through Payment Program final rule (81 FR
improvement activities performance 77313), and we refer readers to Table H 77246). For all other individual MIPS
category at 414.1380(b)(3). Based on of the same final rule, for a list of all the eligible clinicians or groups, we refer
these criteria, we finalized at previously finalized improvement readers to the scoring requirements for
414.1380(b)(3) in the CY 2017 Quality activities, both medium- and high- individual MIPS eligible clinicians and
Payment Program final rule the scoring weighted (81 FR 77817 through 77831). groups in the CY 2017 Quality Payment
methodology for this category, which Please refer to Table F and Table G in Program final rule (81 FR 77270). An
assigns points based on certified the appendices of this proposed rule for individual MIPS eligible clinician or
patient-centered medical home proposed additions and changes to the group is not required to perform
participation or comparable specialty Improvement Activities Inventory for activities in each improvement activities
practice participation, APM the 2020 MIPS payment year and future subcategory or participate in an APM to
participation, and the improvement years. Activities included in these achieve the highest potential score in
activities reported by the MIPS eligible proposed tables would apply for the accordance with section
clinician (81 FR 77312). A MIPS eligible 2020 MIPS payment year and future 1848(q)(5)(C)(iii) of the Act (81 FR
clinicians performance will be years unless further modified via notice 77178).
evaluated by comparing the reported and comment rulemaking. Consistent In the CY 2017 Quality Payment
improvement activities to the highest with our unified scoring system Program final rule, we also finalized
possible score (40 points). We are not principles, we finalized in the CY 2017 that individual MIPS eligible clinicians
proposing any changes to the scoring of Quality Payment Program final rule that and groups that successfully participate
the improvement activities performance MIPS eligible clinicians will know in and submit data to fulfill the
category in this proposed rule. advance how many potential points requirements for the CMS Study on
(a) Assigning Points to Reported they could receive for each Improvement Activities and
Improvement Activities improvement activity (81 FR 77311 Measurement will receive the highest
through 77319). score for the improvement activities
We will assign points for each performance category (81 FR 77315). We
reported improvement activity within 2 (b) Improvement Activities Performance
refer readers to section II.C.6.e.(7) of this
categories: Medium-weighted and high- Category Highest Potential Score
proposed rule for further detail on this
weighted activities. Each medium- At 414.1380(b)(3), we finalized that study.
weighted activity is worth 10 points we will require a total of 40 points to
toward the total category score of 40 receive the highest score for the (c) Points for Certified Patient-Centered
points, and each high-weighted activity improvement activities performance Medical Home or Comparable Specialty
is worth 20 points toward the total category (81 FR 77315). For more of the Practice
category score of 40 points. These points statutory background and description of Section 1848(q)(5)(C)(i) of the Act
are doubled for small practices, the proposed and finalized policies, we specifies that a MIPS eligible clinician
practices in rural areas, or practices refer readers to the CY 2017 Quality who is in a practice that is certified as
located in geographic HPSAs, and non- Payment Program final rule (81 FR a patient-centered medical home or
patient facing MIPS eligible clinicians. 77314 through 77315). comparable specialty practice for a
We refer readers to 414.1380(b)(3) and For small practices, practices in rural performance period, as determined by
the CY 2017 Quality Payment Program areas and geographic HPSA practices the Secretary, must be given the highest
final rule (81 FR 78312) for further and non-patient facing MIPS eligible potential score for the improvement
detail on improvement activities clinicians, the weight for any activity activities performance category for the
scoring. selected is doubled so that these performance period. Accordingly, at
Activities will be weighted as high practices and eligible clinicians only 414.1380(b)(3)(iv), we specify that a
based on the extent to which they align need to select one high- or two medium- MIPS eligible clinician who is in a
with activities that support the certified weighted activities to achieve the practice that is certified as a patient-
patient-centered medical home, since highest score of 40 points (81 FR 77312). centered medical home, including a
that is consistent with the standard In accordance with section Medicaid Medical Home, Medical Home
under section 1848(q)(5)(C)(i) of the Act 1848(q)(5)(C)(ii) of the Act, we codified Model, or comparable specialty practice,
for achieving the highest potential score at 414.1380(b)(3)(ix) that individual will receive the highest potential score
for the improvement activities MIPS eligible clinicians or groups who for the improvement activities
performance category, as well as with are participating in an APM (as defined performance category (81 FR 77196
our priorities for transforming clinical in section 1833(z)(3)(C) of the Act) for through 77180).
practice (81 FR 77311). Additionally, a performance period will automatically We are not proposing any changes to
activities that require performance of earn at least one half of the highest the scoring of the patient-centered
multiple actions, such as participation potential score for the improvement medical home or comparable specialty
practice; although we are proposing a a practice located in a rural area, or a (e) Self-Identification Policy for MIPS
change to how groups qualify for this practice in a geographic HPSA: Eligible Clinicians
activity. We refer readers to section Reporting of one medium-weighted We also noted in the CY 2017 Quality
II.C.6.e. of this proposed rule for a activity will result in 10 points which Payment Program final rule (81 FR
discussion of the requirements for is one-fourth of the highest score. 77319), that individual MIPS eligible
certified patient-centered medical home Reporting of two medium-weighted clinicians or groups participating in
practices or comparable specialty activities will result in 20 points which APMs would not be required to self-
practices. is one-half of the highest score. identify as participating in an APM, but
(d) Calculating the Improvement Reporting of three medium- that all MIPS eligible clinicians would
Activities Performance Category Score weighted activities will result in 30 be required to self-identify if they were
In the CY 2017 Quality Payment points which is three-fourths of the part of a certified patient-centered
Program final rule (81 FR 77318), we highest score. medical home or comparable specialty
finalized that individual MIPS eligible Reporting of four medium-weighted practice, a non-patient facing MIPS
clinicians and groups must earn a total activities will result in 40 points which eligible clinician, a small practice, a
of 40 points to receive the highest score is the highest score. practice located in a rural area, or a
for the improvement activities Reporting of one high-weighted practice in a geographic HPSA or any
performance category. To determine the activity will result in 20 points which combination thereof, and that we would
improvement activities performance is one-half of the highest score. validate these self-identifications as
appropriate. However, beginning with
category score, we sum the points for all Reporting of two high-weighted
of a MIPS eligible clinicians reported the 2018 MIPS performance period, we
activities will result in 40 points which
activities and divide by the are proposing to no longer require these
is the highest score.
improvement activities performance self-identifications for a non-patient
Reporting of a combination of facing MIPS eligible clinician, a small
category highest potential score of 40. A medium-weighted and high-weighted
perfect score will be 40 points divided practice, a practice located in a rural
activities where the total number of area, or a practice in a geographic HPSA
by 40 possible points, which equals 100 points achieved are calculated based on
percent. If MIPS eligible clinicians have or any combination thereof because it is
the number of activities selected and the technically feasible for us to identify
more than 40 improvement activities weighting assigned to that activity
points we will cap the resulting these MIPS eligible clinicians during
(number of medium-weighted activities attestation to the performance of
improvement activities performance selected 10 points + number of high-
category score at 100 percent. improvement activities following the
weighted activities selected 20 points) performance period. We define these
Section 1848(q)(2)(B)(iii) of the Act (81 FR 78318).
requires the Secretary to give MIPS eligible clinicians in the CY 2017
consideration to the circumstances of We also finalized in the CY 2017 Quality Payment Program final rule (81
small practices and practices located in Quality Payment Program final rule that FR 77540), and they are discussed in
rural areas and in geographic HPSAs (as certain activities in the improvement this proposed rule in section II.C.1. of
designated under section 332(a)(1)(A) of activities performance category will also this proposed rule. However, MIPS
the PHS Act) in defining activities. qualify for a bonus under the advancing eligible clinicians that are part of a
Section 1848(q)(2)(C)(iv) of the Act also care information performance category certified patient-centered medical home
requires the Secretary to give (81 FR 78318). This bonus will be or comparable specialty practice are still
consideration to non-patient facing calculated under the advancing care required to self-identify for the 2018
MIPS eligible clinicians. Further, information performance category and MIPS performance period, and we will
section 1848(q)(5)(F) of the Act allows not under the improvement activities validate these self-identifications as
the Secretary to assign different scoring performance category. We refer readers appropriate. We refer readers to section
weights for measures, activities, and to section II.C.6.f.5.(d) of this proposed II.C.6.e.3.(c) of this proposed rule for the
performance categories, if there are not rule for further details. For more criteria for recognition as a certified
sufficient measures and activities information about our finalized patient-centered medical home or
applicable and available to each type of improvement activities scoring policies comparable specialty practice.
eligible clinician. and for several sample scoring charts,
we refer readers to the CY 2017 Quality (6) Scoring the Advancing Care
Accordingly, we finalized that the Information Performance Category
following scoring applies to MIPS Payment Program final rule (81 FR
eligible clinicians who are a non-patient 78319). Finally, in that same final rule, We refer readers to section II.C.6.f. of
facing MIPS eligible clinician, a small we codified at 414.1380(b)(3)(ix) that this proposed rule with comment
practice (consisting of 15 or fewer MIPS eligible clinicians participating in period, where we discuss scoring the
professionals), a practice located in a APMs that are not certified patient- advancing care information performance
rural area, or practice in a geographic centered medical homes will category.
HPSA or any combination thereof: automatically earn a minimum score of
one-half of the highest potential score b. Calculating the Final Score
Reporting of one medium-weighted
activity will result in 20 points or one- for the performance category, as For a description of the statutory basis
half of the highest score. required by section 1848(q)(5)(C)(ii) of and our policies for calculating the final
Reporting of two medium-weighted the Act. For any other MIPS eligible score for MIPS eligible clinicians, we
activities will result in 40 points or the clinician who does not report at least refer readers to the discussion in the CY
highest score. one activity, including a MIPS eligible 2017 Quality Payment Program final
Reporting of one high-weighted clinician who does not identify to us rule (81 FR 77319 through 77329) and
activity will result in 40 points or the that they are participating in a certified 414.1380. In this proposed rule, we
highest score. patient-centered medical home or propose to add a complex patient
The following scoring applies to MIPS comparable specialty practice, we will scoring bonus and add a small practice
eligible clinicians who are not a non- calculate a score of zero points (81 FR bonus to the final score. In addition, we
patient facing clinician, a small practice, 77319). review the final score calculation for the
2020 MIPS payment year and propose the issue in these programs. On input on this topic previously, we
refinements to the reweighting policies. December 21, 2016, ASPE submitted the continue to seek public comment on
first of several Reports to Congress on a whether we should account for social
(1) Accounting for Risk Factors
study it was required to conduct under risk factors in the MIPS, and if so, what
Section 1848(q)(1)(G) of the Act section 2(d) of the IMPACT Act of 2014. method or combination of methods
requires us to consider risk factors in The first study analyzed the effects of would be most appropriate for
our scoring methodology. Specifically, certain social risk factors in Medicare accounting for social risk factors in the
that section provides that the Secretary, beneficiaries on quality measures and MIPS. Examples of methods include:
on an ongoing basis, shall, as the measures of resource use used in one or Adjustment of MIPS eligible clinician
Secretary determines appropriate and more of nine Medicare value-based scores (for example, stratifying the
based on individuals health status and purchasing programs.12 The report also scores of MIPS eligible clinicians based
other risk factors, assess appropriate included considerations for strategies to on the proportion of their patients who
adjustments to quality measures, cost account for social risk factors in these are dual eligible); confidential reporting
measures, and other measures used programs. A second report due October of stratified measure rates to MIPS
under MIPS and assess and implement 2019 will expand on these initial eligible clinicians; public reporting of
appropriate adjustments to payment analyses, supplemented with non- stratified measure results; risk
adjustments, final scores, scores for Medicare datasets to measure social risk adjustment of a particular measure as
performance categories, or scores for factors. In a January 10, 2017 report appropriate based on data and evidence;
measures or activities under the MIPS. released by the National Academies of and redesigning payment incentives (for
In doing this, the Secretary is required Sciences, Engineering, and Medicine, instance, rewarding improvement for
to take into account the relevant studies that body provided various potential clinicians caring for patients with social
conducted under section 2(d) of the methods for accounting for social risk risk factors or incentivizing clinicians to
Improving Medicare Post-Acute Care factors, including stratified public achieve health equity). We are seeking
Transformation (IMPACT) Act of 2014 reporting.13 comments on whether any of these
and, as appropriate, other information, As noted in the FY 2017 IPPS/LTCH methods should be considered, and if
including information collected before PPS final rule (81 FR 56974), the NQF so, which of these methods or
completion of such studies and has undertaken a 2-year trial period in combination of methods would best
recommendations. We refer readers to which certain new measures and account for social risk factors in MIPS,
our discussion of risk factors for the measures undergoing maintenance, and if any.
transition year of MIPS (81 FR 77320 measures endorsed with the condition In addition, we are seeking public
through 77321). that they enter the trial period can be comment on which social risk factors
In this section, we summarize our assessed to determine whether risk might be most appropriate for stratifying
efforts related to social risk and the adjustment for selected social risk measure scores and/or potential risk
relevant studies conducted under factors is appropriate for these adjustment of a particular measure.
section 2(d) of the IMPACT Act of 2014. measures. This trial entails temporarily Examples of social risk factors include,
We also propose some short-term allowing inclusion of social risk factors but are not limited to the following:
adjustments to address patient in the risk-adjustment approach for Dual eligibility/low-income subsidy;
complexity. these measures. At the conclusion of the race and ethnicity; and geographic area
(a) Considerations for Social Risk trial, NQF will issue recommendations of residence. We are seeking comment
on the future inclusion of social risk on which of these factors, including
We understand that social risk factors factors in risk adjustment for these current data sources where this
such as income, education, race and quality measures, and we will closely information would be available, could
ethnicity, employment, disability, review its findings. be used alone or in combination, and
community resources, and social As we continue to consider the whether other data should be collected
support (certain factors of which are analyses and recommendations from to better capture the effects of social
also sometimes referred to as these and any future reports, and await risk. We will take commenters input
socioeconomic status (SES) factors or the results of the NQF trial on risk into consideration as we continue to
socio-demographic status (SDS) factors) adjustment for quality measures, we are assess the appropriateness and
play a major role in health. One of our continuing in this proposed rule to work feasibility of accounting for social risk
core objectives is to improve beneficiary with stakeholders in this process. As we factors in MIPS. We note that any such
outcomes, including reducing health have previously communicated, we are changes would be proposed through
disparities, and we want to ensure that concerned about holding providers to future notice and comment rulemaking.
all beneficiaries, including those with different standards for the outcomes of We look forward to working with
social risk factors, receive high quality their patients with social risk factors stakeholders as we consider the issue of
care. In addition, we seek to ensure that because we do not want to mask accounting for social risk factors and
the quality of care furnished by potential disparities or minimize reducing health disparities in CMS
providers and suppliers is assessed as incentives to improve the outcomes for programs. Of note, implementing any of
fairly as possible under our programs disadvantaged populations. Keeping the above methods would be taken into
while ensuring that beneficiaries have this concern in mind, while we sought consideration in the context of how this
adequate access to excellent care. and other CMS programs operate (for
We have been reviewing reports example, data submission methods,
12 Office of the Assistant Secretary for Planning
prepared by the Office of the Assistant and Evaluation. 2016. Report to Congress: Social availability of data, statistical
Risk Factors and Performance Under Medicares
Secretary for Planning and Evaluation Value-Based Purchasing Programs. Available at considerations relating to reliability of
(ASPE) and the National Academies of https://aspe.hhs.gov/pdf-report/report-congress- data calculations, among others), we
Sciences, Engineering, and Medicine on social-risk-factors-and-performance-under- also welcome comment on operational
the issue of accounting for social risk medicares-value-based-purchasing-programs. considerations. CMS is committed to
13 National Academies of Sciences, Engineering,
factors in CMS value-based purchasing and Medicine. 2017. Accounting for social risk
ensuring that its beneficiaries have
and quality reporting programs, and factors in Medicare payment. Washington, DC: The access to and receive excellent care, and
considering options on how to address National Academies Press. that the quality of care furnished by
providers and suppliers is assessed are common indicators of patient beneficiary risk scores (77 FR 69325
fairly in CMS programs. complexity in the Medicare program through 69326). CMS proposes and
and the data is readily available. As announces changes to the HCC risk
(b) Complex Patient Bonus
discussed below, both of these adjustment model as part of the
While we work with stakeholders on indicators have been used in Medicare announcement of payment policies for
these issues as we have described, we programs to account for risk and both Medicare Advantage plans under
are proposing, under the authority data elements are already publicly section 1853 of the Act; the proposals
within section 1848(q)(1)(G) of the Act, available for individual NPIs in the and announcements are posted at
which allows us to assess and Medicare Physician and Other Supplier https://www.cms.gov/Medicare/Health-
implement appropriate adjustments to Public Use File (referred to as the Plans/MedicareAdvtgSpecRateStats/
payment adjustments, MIPS final scores, Physician and Other Supplier PUF) Announcements-and-Documents.html.
scores for performance categories, or (https://www.cms.gov/research- A mean HCC risk score for a MIPS
scores for measures or activities under statistics-data-and-systems/statistics- eligible clinician can be calculated by
MIPS, to implement a short-term trends-and-reports/medicare-provider- averaging the HCC risk scores for the
strategy for the Quality Payment charge-data/physician-and-other- beneficiaries cared for by the clinician.
Program to address the impact patient supplier.html). While we recognize that In considering options for a complex
complexity may have on final scores. these indicators are interrelated (as dual patient bonus, we explored the use of
The overall goal when considering a eligible status is one of the factors average HCC risk scores while
bonus for complex patients is two-fold: included in calculation of HCC risk recognizing that complexity is one of
(1) To protect access to care for complex scores), we intend for the sake of several drivers of that metric. We
patients and provide them with simplicity to implement one of these believe that using the HCC risk score as
excellent care; and (2) to avoid placing indicators for the 2020 MIPS payment a proxy for patient complexity is a
MIPS eligible clinicians who care for year. helpful starting point, and will explore
complex patients at a potential We believe that average HCC risk methods for further distinguishing
disadvantage while we review the scores are a valid proxy for medical complexity from other reasons a
completed studies and research to complexity that have been used by other clinician could receive a high average
address the underlying issues. We used CMS programs. The HCC model was HCC risk score.
the term patient complexity to take developed by CMS as a risk-adjustment In addition to medical complexity,
into account a multitude of factors that model that uses hierarchical condition patient complexity includes social risk
describe and have an impact on patient categories to assign risk scores to factors, and we considered identifying
health outcomes; such factors include Medicare beneficiaries. Those scores patients dually eligible for Medicare and
the health status and medical conditions estimate how Medicare beneficiaries Medicaid, which we believe is a proxy
of patients, as well as social risk factors. FFS spending will compare to the for social risk factors. A ratio of
We believe that as the number and overall average for the entire Medicare beneficiaries seen by a MIPS eligible
intensity of these factors increase for a population. According to the Physician clinician who are dual eligible can be
single patient, the patient may require and Other Supplier PUF methodological calculated using claims data based on
more services, more clinician focus, and overview, published in January of the proportion of unique patients who
more resources in order to achieve 2017,14 the average risk score is set at are dually eligible for Medicare and full-
health outcomes that are similar to those 1.08; beneficiaries with scores greater
who have fewer factors. In developing and partial-benefit Medicaid (referred to
than that are expected to have above-
the policy for the complex patient herein as dual eligible status) seen by
average spending, and vice versa. Risk
bonus, we assessed whether there was a the MIPS eligible clinician during the
scores are based on a beneficiarys age
MIPS performance discrepancy by performance year among all unique
and sex; whether the beneficiary is
patient complexity using two well- Medicare beneficiaries seen during the
eligible for Medicaid, first qualified for
established indicators in the Medicare performance year. Dual eligible
Medicare on the basis of disability, or
program. Our proposal is intended to Medicare beneficiaries are qualified to
lives in an institution (usually a nursing
address any discrepancy, without receive Medicare and Medicaid benefits.
home); and the beneficiarys diagnoses
masking performance. Because this In the Physician and Other Supplier
from the previous year. The HCC model
bonus is intended to be a short-term PUF, beneficiaries are classified as
was designed for risk adjustment on
strategy, we are proposing the bonus larger populations, such as the enrollees Medicare and Medicaid entitlement if in
only for the 2018 MIPS performance in an MA plan, and generates more any month in the given calendar year
period (2020 MIPS payment year) and accurate results when used to compare they were receiving full or partial
will assess on an annual basis whether groups of beneficiaries rather than Medicaid benefits.15 Dual eligibility has
to continue the bonus and how the individuals. For more information on been used in the Medicare Advantage 5-
bonus should be structured. the HCC risk score, see: https:// star methodology 16 and stratification by
When considering approaches for a www.cms.gov/Medicare/Health-Plans/ proportion of dual eligibility status is
complex patient bonus, we reviewed MedicareAdvtgSpecRateStats/Risk- proposed for the Hospital Readmissions
evidence to identify how indicators of Adjustors.html. Reduction Program (82 FR 19959
patient complexity have an impact on HCC risk scores have been used in the through 19961).
performance under MIPS as well as VM to apply an additional upward
availability of data to implement the payment adjustment of +1.0x for 15 https://www.cms.gov/Research-Statistics-Data-
bonus. Specifically, we identified two and-Systems/Statistics-Trends-and-Reports/

clinicians whose attributed patient Medicare-Provider-Charge-Data/Downloads/
potential indicators for complexity: population has an average risk score Medicare-Physician-and-Other-Supplier-PUF-
Medical complexity as measured that is in the top 25 percent of all Methodology.pdf.
through Hierarchical Condition 16 Centers for Medicare & Medicaid Services.
Category (HCC) risk scores, and social 14 https://www.cms.gov/Research-Statistics-Data- Medicare 2017 Part C & D Star Rating Technical
and-Systems/Statistics-Trends-and-Reports/ Notes. Available at https://www.cms.gov/Medicare/
risk as measured through the proportion Medicare-Provider-Charge-Data/Downloads/ Prescription-Drug-Coverage/PrescriptionDrug
of patients with dual eligible status. We Medicare-Physician-and-Other-Supplier-PUF- CovGenIn/Downloads/2017-Part-C-and-D-Medicare-
identified these indicators because they Methodology.pdf. Star-Ratings-Data-v04-04-2017-.zip.
We evaluated both indicators (average who reported no measures or who and from 82.36 (fourth HCC quartile,
HCC risk score and proportion dual reported less than 6 measures). We highest risk) to 86.39 (first HCC quartile,
eligible status) using the 2015 Physician restricted our analysis to individuals lowest risk) for individual reporters who
and Other Supplier PUF. We who reported 6 or more measures reported 6 or more measures (see Table
incorporated these factors into our because we wanted to look at 34). When reviewing average HCC risk
scoring model that uses historical PQRS differences in performance for those scores by practice size, we found that
data to simulate scores for MIPS eligible who reported the required 6 measures, MIPS eligible clinicians in larger
clinicians including estimates for the rather than differences in scores due to practices had slightly higher risk scores
quality, advancing care information, and incomplete reporting. than those in small practices (average
improvement activities performance We observed modest correlation HCC risk score of 1.82 for practices with
categories, and the small practice bonus between these two indicators. Using the 100 or more clinicians, compared with
that is proposed in section II.C.7.b.(1)(c) Physician and Other Supplier PUF (after 1.61 for practices with 115 clinicians)
of this proposed rule. The scoring model restricting to those clinicians that we (see Table 35) and that the average HCC
is described in more detail in the estimate to be MIPS eligible in our risk score varied by specialty, with
regulatory impact analysis in section scoring model described in section V.C nephrology having the highest average
V.C. of this proposed rule. For HCC, we of this proposed rule), the correlation HCC risk score (3.05) and dermatology
merged the average HCC risk score by coefficient for these two factors is 0.487 having the lowest (1.24). The average
NPI with each TIN/NPI in our (some correlation is expected due to the HCC risk score for family medicine was
population. We calculated a dual inclusion of dual eligible status in the 1.58 (see Table 36).
eligible ratio by taking a proportion of HCC risk model). The correlation We also ranked MIPS eligible
dual eligible beneficiaries and divided between average HCC risk scores and clinicians by proportion of patients with
by total beneficiaries for each NPI. We proportion of patients with dual eligible dual eligibility (see Table 34).
created group level scores by taking an status indicates that while there is Performance for MIPS eligible clinicians
average of NPI scores weighted by the overlap between these two indicators, ranged from 82.35 in the fourth dual
number of beneficiaries. We divided they cannot be used interchangeably. quartile (highest proportion dual
clinicians and groups into quartiles We also assessed the correlation of eligible patients) to 89.49 in the second
based on average HCC risk score and these indicators with MIPS final scores dual quartile (second lowest proportion
percent of duals. To assess whether based on performance and the small dual eligible patients) for group
there was a difference in MIPS practice bonus for MIPS eligible reporters. Performance for MIPS eligible
simulated scores by these two variables, clinicians, as well as variations by clinicians reporting individually who
we analyzed the effect of average HCC practice size, submission mechanism, reported 6 or more measures ranged
risk score and dual eligible ratio and specialty. Average MIPS simulated from 83.08 in the fourth dual quartile
separately for groups and individuals. scores (prior to any complex patient (highest proportion dual eligible
When looking at individuals, we bonus) varied from 82.73 (fourth HCC patients) to 86.80 in the first dual
focused on individuals that reported 6 quartile, highest risk) to 87.14 (first HCC quartile (lowest proportion dual eligible
or more measures (removing individuals quartile, lowest risk) for group reporters, patients).
TABLE 34MIPS SIMULATED SCORE * BY HCC RISK QUARTILE AND DUAL ELIGIBLE RATIO QUARTILE
Individuals
with 6+ Group
measures **
HCC Quartile
Quartile 1Lowest Average HCC Risk Score ................................................................................................. 86.39 87.14
Quartile 2 .......................................................................................................................................................... 84.89 88.41
Quartile 3 .......................................................................................................................................................... 83.31 86.76
Quartile 4Highest Average HCC Risk Score ................................................................................................ 82.36 82.73
Dual Eligible Ratio
Quartile 1Lowest Proportion of Dual Status ................................................................................................. 86.80 88.03
Quartile 2 .......................................................................................................................................................... 83.76 89.49
Quartile 3 .......................................................................................................................................................... 82.63 85.39
Quartile 4Highest Proportion of Dual Status ................................................................................................ 83.08 82.35
* The simulated score includes estimated quality, advancing care information, and improvement activities performance categories without com-
plex patient bonus. Simulated score does include small practice bonus proposed in II.C.7.b.(1)(c) of this proposed rule.
** We restricted this column to individuals who reported 6 or more measures to assess differences in performance for those who reported the
required 6 measures and to not consider changes due to incomplete reporting.
TABLE 35AVERAGE HCC RISK SCORE AND DUAL ELIGIBLE RATIO BY PRACTICE SIZE
Dual eligible
Average HCC
Practice size ratio
risk score (%)
115 clinicians ......................................................................................................................................................... 1.61 24.90

1624 clinicians ....................................................................................................................................................... 1.70 26.20
2599 clinicians ....................................................................................................................................................... 1.72 27.50
100 or more clinicians ............................................................................................................................................. 1.82 26.90
Total .................................................................................................................................................................. 1.75 26.60
TABLE 36AVERAGE HCC RISK SCORE AND DUAL ELIGIBLE RATIO BY SPECIALTY
Average Dual eligible
Specialty * HCC risk ratio
score (%)
Total ......................................................................................................................................................................... 1.75 26.60

Addiction Medicine ................................................................................................................................................... 1.77 37.00
Allergy/Immunology ................................................................................................................................................. 1.38 19.70
Anesthesiology ......................................................................................................................................................... 1.78 26.00
Anesthesiology Assistant ......................................................................................................................................... 1.94 26.50
Cardiac Electrophysiology ....................................................................................................................................... 1.85 23.20
Cardiac Surgery ....................................................................................................................................................... 1.93 25.10
Cardiovascular Disease (Cardiology) ...................................................................................................................... 1.85 25.30
Certified Clinical Nurse Specialist ........................................................................................................................... 1.78 31.20
Certified Registered Nurse Anesthetist (CRNA) ..................................................................................................... 1.77 25.50
Chiropractic .............................................................................................................................................................. 1.27 19.10
Clinic or Group Practice .......................................................................................................................................... 1.57 30.60
Colorectal Surgery (Proctology) .............................................................................................................................. 1.70 22.10
Critical Care (Intensivists) ........................................................................................................................................ 2.06 28.50
Dermatology ............................................................................................................................................................. 1.24 11.90
Diagnostic Radiology ............................................................................................................................................... 1.78 26.50
Emergency Medicine ............................................................................................................................................... 1.94 34.10
Endocrinology .......................................................................................................................................................... 1.78 24.70
Family Medicine * ..................................................................................................................................................... 1.58 25.80
Gastroenterology ..................................................................................................................................................... 1.70 24.20
General Practice ...................................................................................................................................................... 1.60 35.80
General Surgery ...................................................................................................................................................... 1.83 27.10
Geriatric Medicine .................................................................................................................................................... 1.93 29.60
Geriatric Psychiatry .................................................................................................................................................. 1.92 39.30
Gynecological Oncology .......................................................................................................................................... 1.76 24.20
Hand Surgery ........................................................................................................................................................... 1.39 17.80
Hematology .............................................................................................................................................................. 1.95 25.80
Hematology-Oncology ............................................................................................................................................. 1.92 24.90
Hospice and Palliative Care .................................................................................................................................... 1.93 26.90
Infectious Disease ................................................................................................................................................... 2.35 31.60
Internal Medicine ..................................................................................................................................................... 1.84 28.10
Interventional Cardiology ......................................................................................................................................... 1.79 22.90
Interventional Pain Management ............................................................................................................................. 1.50 26.90
Interventional Radiology .......................................................................................................................................... 2.18 28.80
Maxillofacial Surgery ................................................................................................................................................ 1.90 30.20
Medical Oncology .................................................................................................................................................... 1.94 23.50
Nephrology ............................................................................................................................................................... 3.05 33.00
Neurology ................................................................................................................................................................. 1.79 27.40
Neuropsychiatry ....................................................................................................................................................... 1.76 30.30
Neurosurgery ........................................................................................................................................................... 1.68 24.70
Nuclear Medicine ..................................................................................................................................................... 1.91 26.10
Nurse Practitioner .................................................................................................................................................... 1.78 28.60
Obstetrics & Gynecology ......................................................................................................................................... 1.63 26.20
Ophthalmology ......................................................................................................................................................... 1.37 18.70
Optometry ................................................................................................................................................................ 1.33 24.80
Oral Surgery (Dentist only) ...................................................................................................................................... 1.82 29.20
Orthopedic Surgery .................................................................................................................................................. 1.44 20.50
Osteopathic Manipulative Medicine ......................................................................................................................... 1.62 29.70
Otolaryngology ......................................................................................................................................................... 1.50 21.10
Pain Management .................................................................................................................................................... 1.57 29.50
Pathology ................................................................................................................................................................. 1.71 23.70
Pediatric Medicine ................................................................................................................................................... 1.95 31.10
Peripheral Vascular Disease ................................................................................................................................... 1.83 23.10
Physical Medicine and Rehabilitation ...................................................................................................................... 1.76 27.00
Physician Assistant .................................................................................................................................................. 1.69 26.40
Physician, Sleep Medicine ....................................................................................................................................... 1.70 23.20
Plastic and Reconstructive Surgery ........................................................................................................................ 1.74 23.60
Podiatry .................................................................................................................................................................... 1.72 27.70
Preventive Medicine ................................................................................................................................................ 1.80 27.60
Psychiatry ................................................................................................................................................................ 1.80 39.50
Pulmonary Disease .................................................................................................................................................. 2.00 27.20
Radiation Oncology ................................................................................................................................................. 1.79 22.20

Rheumatology .......................................................................................................................................................... 1.65 23.40
Sports Medicine ....................................................................................................................................................... 1.54 22.70
Surgical Oncology .................................................................................................................................................... 1.92 25.10
Thoracic Surgery ..................................................................................................................................................... 1.94 26.30
Urology ..................................................................................................................................................................... 1.56 20.30
Vascular Surgery ..................................................................................................................................................... 2.22 26.80
* Specialty descriptions as self-reported on Part B claims. Note that all categories are mutually exclusive, including General Practice and Fam-
ily Practice. Family Medicine is used here for physicians listed as Family Practice in Part B claims.
Based on our assessment of these two period) as described in section II.C.3.c. average HCC risk scores was
indicators, we generally see high of this proposed rule. We propose the approximately 4 points for individuals
average simulated scores 17 that are second 12-month segment of the and approximately 5 points for groups.
above 80 points for each quartile based eligibility period to align with other We considered whether we should
on average HCC risk score or proportion MIPS policies and to ensure we have apply a set number of points to those in
of dual status patients (see Table 34). As sufficient time to determine the a specific quartile (for example, for the
discussed in II.C.8.d. of this proposed necessary calculations. The second highest risk quartile only), but did not
rule, 70 points is the proposed period 12-month segment overlaps 8- want to restrict the bonus to only certain
additional performance threshold at months with the MIPS performance MIPS eligible clinicians. Rather than
which MIPS eligible clinicians can period which means that many of the assign points based on quartile, we
receive the additional adjustment factor patients in our complex patient bonus believed that adding the average HCC
for exceptional performance. However, would have been cared for by the risk score directly to the final score
even though the simulated scores are clinician, group, virtual group or APM would achieve our goal of accounting
high, we also generally see a very Entity during the MIPS performance for patient complexity without masking
modest decrease in simulated scores of period. low performance and does provide a
4.0 points (for individuals who report 6 HCC risk scores for beneficiaries modest effect on the final score. The
or more measures) and 4.4 points (for would be calculated based on the 95th percentile of HCC values for
groups) from the top quartile to the calendar year immediately prior to the individual clinicians was 2.91 which we
bottom quartile for the average patient performance period. For the 2018 MIPS rounded to 3 for simplicity. We believe
HCC risk score and from 3.7 (for performance period, the HCC risk scores applying this bonus to the final score is
individuals who report 6 or more would be calculated based on appropriate because caring for complex
measures) and 5.7 points (for groups) beneficiary services from the 2017 and vulnerable patients can affect all
from the top quartile to the bottom calendar year. We chose this approach aspects of a practice and not just
quartile for dual eligible ratio. While we because CMS uses prior year diagnoses specific performance categories. It may
are transitioning into MIPS and evolving to set Medicare Advantage rates also create a small incentive to provide
our scoring policies, we want to ensure prospectively every year and has access to complex patients.
safeguards and access for these employed this approach in the VM (77 Finally, we propose that the MIPS
vulnerable patients; therefore, we are FR 693178). Additionally, this eligible clinician, group, virtual group
proposing to apply a small complex approach mitigates the risk of or APM Entity must submit data on at
patient bonus to final scores used for the upcoding to get higher expected costs, least one measure or activity in a
2020 MIPS payment year. As we stated which could happen if concurrent risk performance category during the
earlier, we intend to start with one adjustments were incorporated. We performance period to receive the
dimension of patient complexity for realize using the 2017 calendar year to complex patient bonus. Under this
simplicity. For the 2020 MIPS payment assess beneficiary HCC risk scores proposal, MIPS eligible clinicians
year, we are proposing a complex overlaps by 4-months with the 12- would not need to meet submissions
patient bonus based on the average HCC month data period to identify requirements for the quality
risk score because this is the indicator beneficiaries (which is September 1, performance category in order to receive
that clinicians are familiar with from the 2017 to August 31, 2018 for the 2018 the bonus (they could instead submit
VM. MIPS performance period); however, we improvement activities or advancing
We propose at 414.1380(c)(3) to add annually calculate the beneficiary HCC care information measures only or
a complex patient bonus to the final risk score and use it for multiple submit fewer than the required number
score for the 2020 MIPS payment year purposes (like the Physician and Other of measures for the quality performance
for MIPS eligible clinicians that submit Supplier PUF). category).
data (as explained below) for at least For MIPS APMs and virtual groups, Based on our data analysis, we
one performance category. We propose we propose at 414.1380(c)(3)(ii) to use estimate that this bonus on average
at 414.1380(c)(3)(i) to calculate an the beneficiary weighted average HCC would range from 1.16 points in the first
average HCC risk score, using the model risk score for all MIPS eligible quartile based on HCC risk scores to
adopted under section 1853 of the Act clinicians, and if technically feasible, 2.49 points in the fourth quartile for
for Medicare Advantage risk adjustment TINs for models and virtual groups individual reporters submitting 6 or
purposes, for each MIPS eligible which rely on complete TIN more measures, and 1.26 points in the
clinician or group, and to use that participation, within the APM Entity or first quartile to 2.23 points in the fourth
average HCC risk score as the complex virtual group, respectively, as the quartile for group reporters. For
patient bonus. We would calculate the complex patient bonus. We would example, a MIPS eligible clinician with
average HCC risk score for a MIPS calculate the weighted average by taking a final score of 55.11 with an average
eligible clinician or group by averaging the sum of the individual clinicians (or HCC risk score of 2.01 would receive a
HCC risk scores for beneficiaries cared TINs as appropriate) average HCC risk final score of 57.12. We propose in
for by the MIPS eligible clinician or score multiplied by the number of section II.C.7.b.(2) of this proposed rule
clinicians in the group during the unique beneficiaries cared for by the that if the result of the calculation is
second 12-month segment of the clinician and then divide by the sum of greater than 100 points, then the final
eligibility period, which spans from the the beneficiaries cared for by each score would be capped at 100 points.
individual clinician (or TIN as We also seek comment on an
last 4 months of a calendar year 1 year

prior to the performance period appropriate) in the APM Entity or alternative complex patient bonus
followed by the first 8 months of the virtual group. methodology, similarly for the 2020
performance period in the next calendar We propose at 414.1380(c)(3)(iii) MIPS payment year only. Under the
year (September 1, 2017 to August 31, that the complex patient bonus cannot alternative, we would apply a complex
2018 for the 2018 MIPS performance exceed 3 points. This value was selected patient bonus based on a ratio of
because the differences in performance patients who are dual eligible, because
17 Scores are simulated prior to any complex we observed between simulated scores we believe that dual eligible status is a
patient bonus. between the first and fourth quartiles of common indicator of social risk for
which we currently have data available. in section II.C.3.c. of this proposed rule, (c) Small Practice Bonus for the 2020
We believe the advantage of this option to identify MIPS eligible clinicians for MIPS Payment Year
is its relative simplicity and that it calculation of the complex patient Eligible clinicians and groups who
creates a direct incentive to care for dual bonus. This date range aligns with the work in small practices are a crucial
eligible patients, who are often second low-volume threshold part of the health care system. The
medically complex and have concurrent determination and also represents care Quality Payment Program provides
social risk factors. In addition, whereas provided during the performance options designed to make it easier for
the HCC risk scores rely on the period. these MIPS eligible clinicians and
diagnoses a beneficiary receives which We would propose to multiply the groups to report on performance and
could be impacted by variations in dual eligible ratio by 5 points to quality and participate in advanced
coding practices among clinicians, the calculate a complex patient bonus for alternative payment models for
dual eligibility ratio is not impacted by each MIPS eligible clinician. For incentives. We have heard directly from
variations in coding practices. For this example, a MIPS eligible clinician who clinicians in small practices that they
alternative option, we would calculate a sees 400 patients with dual eligible face unique challenges related to
dual eligible ratio (including both full status out of 1000 total Medicare financial and other resources,
and partial Medicaid beneficiaries) for patients seen during the second 12- environmental factors, and access to
each MIPS eligible clinician based on month segment of the eligibility period health information technology. We
the proportion of unique patients who would have a complex patient ratio of heard from many commenters that the
have dual eligible status seen by the 0.4, which would be multiplied by 5 Quality Payment Program advantages
MIPS eligible clinician among all points for a complex patient bonus of 2 large organizations because such
unique patients seen during the second points toward the final score. We organizations have more resources
12-month segment of the eligibility believe this approach is simple to invested in the infrastructure required
period, which spans from the last 4 explain and would be available to all to track and report measures to MIPS.
months of a calendar year 1 year prior clinicians who care for dual eligible Based on our scoring model, which is
to the performance period followed by beneficiaries. We also believe a complex described in the regulatory impact
the first 8 months of the performance patient bonus ranging from 1 to 5 points analysis in section V.C. of this proposed
period.
(with most MIPS eligible clinicians rule, practices with more than 100
For MIPS APMs and virtual groups,
receiving a bonus between 1 and 3 clinicians may perform better in the
we would use the average dual eligible
patient ratio for all MIPS eligible points) is appropriate because, in our Quality Payment Program, on average
clinicians, and if technically feasible, analysis, we estimated differences in compared to smaller practices. We
TINs for models and virtual groups performance between the 1st and 4th believe this trend is due primarily to
which rely on complete TIN quartiles of dual eligible ratios to be two factors: Participation rates and
participation, within the APM entity or approximately 3 points for individuals submission mechanism. Based on the
virtual group, respectively. and approximately 6 points for groups. most recent PQRS data available,
Under this alternative option, we A bonus of less than 5 points would practices with 100 or more MIPS
would identify dual eligible status help to mitigate the impact of caring for eligible clinicians have participated in
(numerator of the ratio) using data on patients with social risk factors while the PQRS at a higher rate than small
dual-eligibility status sourced from the not masking poor performance. Using practices (99.4 percent compared to 69.7
state Medicare Modernization Act this approach, we estimate that the percent, respectively). As we indicate in
(MMA) files, which are files each state bonus would range from 0.45 (first dual our regulatory impact analysis in
submits to CMS with monthly Medicaid quartile) to 2.42 (fourth dual quartile) section V.C. of this proposed rule, we
eligibility information. We would use for individual reporters, and from 0.63 believe participation rates based only on
dual-eligibility status data from the state (first dual quartile) to 2.19 (fourth dual historic 2015 quality data submitted
MMA files because it is the best quartile) for group reporters. Under this under PQRS significantly underestimate
available data for identifying dual alternative option, we would also the expected participation in MIPS
eligible beneficiaries. Under this include the complex patient bonus in particularly for small practices.
alternative option, an individual would the calculation of the final score. Again, Therefore, we have modeled the
be counted as a full-benefit or partial- we propose in section II.C.7.b.(2) of this regulatory impact analysis using
benefit dual patient if the beneficiary proposed rule that if the result of the minimum participation assumptions of
was identified as a full-benefit or calculation is greater than 100 points, 80 percent and 90 percent participation
partial-benefit dual in the state MMA then the final score would be capped at for each practice size category (115
files at the conclusion of the second 12- 100 points. We seek comments on our clinicians, 1624 clinicians, 2599
month segment of the eligibility proposed bonus for complex patients clinicians, and 100 or more clinicians).
determination period. based on average HCC risk scores, and However, even with these enhanced
We would define the proportion of our alternative option using a ratio of participation assumptions, MIPS
full benefit or partial dual eligible dual eligible patients in lieu of average eligible clinicians in small practices
beneficiaries as the proportion of dual HCC risk scores. We reiterate that the would have lower participation than
eligible patients among all unique complex patient bonus is intended to be MIPS eligible clinicians in larger
Medicare patients seen by the MIPS a short-term solution, which we plan to practices as 80 or 90 percent
eligible clinician or group during the revisit on an annual basis, to incentivize participation is still much lower than
second 12-month segment of the clinicians to care for patients with the 99.4 percent participation for MIPS
eligibility period which spans from the medical complexity. We may consider eligible clinicians in practices with 100
last 4 months of a calendar year prior to alternate adjustments in future years or more clinicians.
the performance period followed by the after methods that more fully account In addition, practices with 100 or
first 8 months of the performance period for patient complexity in MIPS have more MIPS eligible clinicians are more
in the next calendar year (September 1, been developed. We also seek comments likely to report as a group, rather than
2017 to August 31, 2018 for the 2018 on alternative methods to construct a individually, which reduces burden to
MIPS performance period) as described complex patient bonus. individuals within those practices due
to the unified nature of group reporting. are in small practices or virtual groups not. Therefore, we are not proposing to
Specifically, 63.1 percent of practices or APM entities with 15 or fewer extend the final score bonus to those
with 100 or more MIPS eligible clinicians (the entire virtual group or who practice in a rural area, but plan to
clinicians are reporting via CMS Web APM entity combined must include 15 continue to monitor the Quality
Interface (either through the Shared or fewer clinicians to qualify for the Payment Programs impacts on the
Savings Program or as a group practice) bonus). We believe a bonus of 5 points performance of those who practice in
compared to 20.5 percent of small is appropriate to acknowledge the rural areas. We also seek comment on
practices (the CMS Web Interface challenges small practices face in the application of a rural bonus in the
reporting mechanism is only available participating in MIPS, and to help them future, including available evidence
to small practices participating in the achieve the performance threshold demonstrating differences in clinician
Shared Saving Program or Next proposed at section II.C.8.c. of this performance based on rural status. If we
Generation ACO Model.) 18 proposed rule at 15 points for the 2020 implement a bonus for practices located
These two factors have financial MIPS payment year, as this bonus in rural areas, we would use the
implications based on the MIPS scoring represents one-third of the total points definition for rural specified in section
model described in section V.C. of this needed to meet or exceed the II.C.1. of this proposed rule for
proposed rule. Looking at the combined performance threshold and receive a individuals and groups (including
impact performance, we see consistent neutral to positive payment adjustment. virtual groups).
trends for small practices in various With a small practice bonus of 5 points,
scenarios. A combined impact of (2) Final Score Calculation
small practices could achieve this
performance measurement looks at the performance threshold by reporting 2 With the proposed addition of the
aggregate net percent change (the quality measures or 1 quality measure complex patient and small practice
combined impact of MIPS negative and and 1 improvement activity.19 We bonuses, we propose to use the formula
positive adjustments in the final score). believe that a higher bonus (for at 414.1380(c) to calculate the final
In analyzing the combined impact example, a bonus that would meet or score for all MIPS eligible clinicians,
performance, we see MIPS eligible exceed the performance threshold) is
clinicians in small practices groups, virtual groups, and MIPS APMs
not ideal because it might discourage starting with the 2020 MIPS payment
consistently have a lower combined small practices from actively
impact performance than larger year.
participating in MIPS or could mask
practices based on actual historical data poor performance. We propose in We propose to revise the final score
and after we apply the 80 and 90 section II.C.7.b.(2) of this proposed rule calculation at 414.1380(c) to reflect
percent participation assumptions. that if the result of the calculation is this updated formula. We also propose
Due to these challenges, we believe an greater than 100 points, then the final to revise the policy finalized in the CY
adjustment to the final score for MIPS 2017 Quality Payment Program final
score would be capped at 100 points.
eligible clinicians in small practices This bonus is intended to be a short- rule to assign MIPS eligible clinicians
(referred to herein as the small practice term strategy to help small practices with only 1 scored performance
bonus) is appropriate to recognize transition to MIPS, therefore, we are category a final score that is equal to the
these barriers and to incentivize MIPS proposing the bonus only for the 2018 performance threshold (81 FR 77326
eligible clinicians in small practices to MIPS performance period (2020 MIPS through 77328) (we note that we
participate in the Quality Payment payment year) and will assess on an inadvertently failed to codify this policy
Program and to overcome any annual basis whether to continue the in 414.1380(c)). We are proposing this
performance discrepancy due to bonus and how the bonus should be revision to the policy to account for our
practice size. To receive the small structured. proposal in section II.C.7.b.(3)(c) of this
practice bonus, we propose that the We are inviting public comment on proposed rule for extreme and
MIPS eligible clinician must participate our proposal to apply a small practice uncontrollable circumstances which, if
in the program by submitting data on at bonus for the 2020 MIPS payment year. finalized, could result in a scenario
least one performance category in the We also considered applying a bonus where a MIPS eligible clinician is not
2018 MIPS performance period. for MIPS eligible clinicians that practice scored on any performance categories.
Therefore, MIPS eligible clinicians in either a small practice or a rural area. To reflect this proposal, we propose to
would not need to meet submission However, on average, we saw less than add to 414.1380(c) that a MIPS eligible
requirements for the quality a one point difference between scores clinician with fewer than 2 performance
performance category in order to receive for MIPS eligible clinicians who category scores would receive a final
the bonus (they could instead submit practice in rural areas and those who do score equal to the performance
improvement activities or advancing threshold.
care information measures only or 19 Assuming the small practice did not submit
With the proposed addition of the
submit fewer than the required number advancing care information and applied for the complex patient and small practice
of measures for the quality performance hardship exception and had the advancing care
bonuses, we also propose to strike the
category). Additionally, we propose that information performance category weight
redistributed to quality, the small practice would following phrase from the final score
group practices, virtual groups, or APM have a final score with 85 percent weight from the definition at 414.1305: The final
Entities that consist of a total of 15 or quality performance category score and 15 percent score is the sum of each of the products
fewer clinicians may receive the small from improvement activities. With the proposed
of each performance category score and
practice bonus. scoring for small practices, submitting one measure

one time would provide at least 3 measure each performance categorys assigned
We propose at 414.1380(c)(4) to add achievement points out of 60 total available weight, multiplied by 100. We believe
a small practice bonus of five points to measure points. With 85 percent quality this portion of the definition would be
the final score for MIPS eligible performance category weight, each quality measure
incorrect and redundant of the proposed
clinicians who participate in MIPS for would be worth at least 4.25 point towards the final
score. ((3/60) 85% 100= 4.25 points). For revised regulation at 414.1380(c).
the 2018 MIPS performance period and improvement activities, each medium weighted
activity is worth 20 out of 40 possible points which
We invite public comment on the
18 Groups must have at least 25 clinicians to translates to 7.5 points to the file score. (20/40) proposed final score methodology and
participate in Web Interface. 15% 100 = 7.5 points). associated revisions to regulation text.
(3) Final Score Performance Category minus the weight specified for the cost the Secretary estimates that the
Weights performance category for the year. proportion of eligible professionals (as
In the CY 2017 Quality Payment defined in section 1848(o)(5) of the Act)
(a) General Weights Program final rule, we established the who are meaningful EHR users (as
Section 1848(q)(5)(E)(i) of the Act weights of the cost performance determined in section 1848(o)(2) of the
specifies weights for the performance category as 10 percent of the final score Act) is 75 percent or greater, the
categories included in the MIPS final (81 FR 77166) and the quality Secretary may reduce the applicable
score: In general, 30 percent for the performance category as 50 percent of percentage weight of the advancing care
the final score (81 FR 77100) for the information performance category in the
quality performance category, 30
2020 MIPS payment year. However, we final score, but not below 15 percent.
percent for the cost performance
are proposing in section II.C.6.d. of this For more on our policies concerning
category, 25 percent for the advancing
proposed rule to change the weight of section 1848(q)(5)(E)(ii) of the Act and
care information performance category, the cost performance category to zero
and 15 percent for the improvement a review of our proposal for reweighting
percent and in section II.C.6.b. of this the advancing care information
activities performance category. proposed rule to change the weight of
However, that section also specifies performance category in the event that
the quality performance category to 60 the proportion of MIPS eligible
different weightings for the quality and percent for the 2020 MIPS payment
cost performance categories for the first clinicians who are meaningful EHR
year. We refer readers to sections users is 75 percent or greater starting
and second years for which the MIPS II.C.6.b. and II.C.6.d. of this proposed
applies to payments. Section with the 2019 MIPS performance
rule for further information on the period, we refer readers to section
1848(q)(5)(E)(i)(II)(bb) of the Act policies related to the weight of the
specifies that for the transition year, not II.C.6.f.(5) of this proposed rule.
quality and cost performance categories,
more than 10 percent of the final score including our rationale for our proposed Table 37 summarizes the weights
will be based on the cost performance weighting for each category. specified for each performance category
category, and for the 2020 MIPS As specified in section 1848(q)(5)(E)(i) under section 1848(q)(5)(E)(i) of the Act
payment year, not more than 15 percent of the Act, the weights for the other and in accordance with our policies in
will be based on the cost performance performance categories are 25 percent the CY 2017 Quality Payment Program
category. Under section for the advancing care information final rule as codified at
1848(q)(5)(E)(i)(I)(bb) of the Act, the performance category and 15 percent for 414.1380(c)(1), 414.1330(b),
weight of the quality performance the improvement activities performance 414.1350(b), 414.1355(b), and
category for each of the first 2 years will category. Section 1848(q)(5)(E)(ii) of the 414.1375(a), and with our proposals in
increase by the difference of 30 percent Act provides that in any year in which section II.C.6. of this proposed rule.
TABLE 37FINALIZED AND PROPOSED WEIGHTS BY MIPS PERFORMANCE CATEGORY *

2021 MIPS
2020 MIPS
Transition year payment year
payment year
Performance category (final) and beyond
(proposed)
(%) (final)
(%) (%)
Quality .................................................................................................................. 60 60 30
Cost ...................................................................................................................... 0 0 30
Improvement Activities ......................................................................................... 15 15 15
Advancing Care Information** ............................................................................. 25 25 25
* In sections II.C.6.b. and II.C.6.c., we propose to maintain the same weights from the transition year for the 2020 MIPS payment year for qual-
ity and cost (60 percent and zero percent, respectively).
**As described in section II.C.6.f. of this proposed rule, the weight for advancing care information could decrease (not below 15 percent) start-
ing 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 and redistribute its weight to the other one quality measure applicable and
Performance Categories performance categories in the following available to every MIPS eligible
scenarios. clinician, if we receive no quality
Under section 1848(q)(5)(F) of the For the quality performance category, performance category submission from a
Act, if there are not sufficient measures we propose that having sufficient MIPS eligible clinician, the MIPS
and activities applicable and available measures applicable and available eligible clinician generally will receive
to each type of MIPS eligible clinician means that we can calculate a quality a performance category score of zero (or
involved, the Secretary shall assign performance category percent score for slightly above zero if the all-cause
different scoring weights (including a the MIPS eligible clinician because at hospital readmission measure applies
weight of zero) for each performance least one quality measure is applicable because the clinician submits data for a
category based on the extent to which and available to the MIPS eligible
performance category other than the

the category is applicable and for each clinician. Based on the volume of quality performance category).20
measure and activity based on the measures available to MIPS eligible
extent to which the measure or activity clinicians via the multiple submission 20 As discussed in the CY 2017 Quality Payment
is applicable and available to the type mechanisms, we generally believe there Program final rule (81 FR 77300), groups of 16 or
of MIPS eligible clinician involved. For will be at least one quality measure more eligible clinicians that meet the applicable
case minimum requirement are automatically
the 2020 MIPS payment year, we applicable and available to every MIPS scored on the all-cause readmission measure, even
propose to assign a scoring weight of eligible clinician. Given that we if they do not submit any other data under the
zero percent to a performance category generally believe there will be at least Continued
However, as described in section be scored for that clinician (81 FR considered for reweighting of the
II.C.7.a.(2)(e) of this proposed rule, there 77323). If we do not score any cost advancing care information performance
may be rare instances that we believe measures for a MIPS eligible clinician in category under section 1848(q)(5)(F) of
could affect only a very limited subset accordance with this policy, then the the Act. Although we are proposing in
of MIPS eligible clinicians (as well as clinician would not receive a cost section II.C.6.f. of this proposed rule to
groups and virtual groups) that may performance category percent score. use the authority in the last sentence of
have no quality measures available and Because we have proposed in section section 1848(o)(2)(D) of the Act, as
applicable and for whom we receive no II.C.6.d. of this proposed rule to set the amended by section 4002(b)(1)(B) of the
quality performance category weight of the cost performance category 21st Century Cures Act, as the authority
submission (and for whom the all-cause to zero percent of the final score for the for this policy, rather than section
hospital readmission measure does not 2020 MIPS payment year, we are not 1848(q)(5)(F) of the Act, we continue to
apply). In those instances, we would not proposing to redistribute the weight of believe that extreme and uncontrollable
be able to calculate a quality the cost performance category to any circumstances could affect the
performance category percent score. other performance categories for the availability of a MIPS eligible clinicians
The proposed quality performance 2020 MIPS payment year. In the event CEHRT and the measures specified for
category scoring policies for the 2020 we do not finalize this proposal, we are the advancing care information
MIPS payment year continue many of proposing to redistribute the weight of performance category.
the special scoring policies from the the cost performance category as While we did not propose or finalize
transition year which would enable us described in section II.C.7.b.(3)(d) of a similar reweighting policy for other
to determine a quality performance this proposed rule. performance categories in the transition
category percent score whenever a MIPS For the improvement activities
year, we believe a similar reweighting
eligible clinician has submitted at least performance category, we believe that
policy may be appropriate for the
1 quality measure. In addition, MIPS all MIPS eligible clinicians will have
quality, cost, and improvement
eligible clinicians that do not submit sufficient activities applicable and
activities performance categories
quality measures when they have them available; however, as discussed in
beginning with the 2020 MIPS payment
available and applicable would receive section II.C.7.b.(3)(c) of this proposed
year. For these performance categories,
a quality performance category percent rule, we believe there are limited
we propose to define extreme and
score of zero percent. It is only in the extreme and uncontrollable
uncontrollable circumstances as rare
rare scenarios when we determine that circumstances, such as natural disasters,
a MIPS eligible clinician does not have where a clinician is unable to report (that is, highly unlikely to occur in a
any relevant quality measures available improvement activities. Barring these given year) events entirely outside the
to report or the MIPS eligible clinician circumstances, we are not proposing control of the clinician and of the
is approved for reweighting the quality any changes that would affect our facility in which the clinician practices
performance category based on extreme ability to calculate an improvement that cause the MIPS eligible clinician to
and uncontrollable circumstances as activities performance category score. not be able to collect information that
proposed in section II.C.7.b.(3)(c) of this We refer readers to section II.C.6.f. of the clinician would submit for a
proposed rule, that we would reweight this proposed rule for a detailed performance category or to submit
the quality performance category. discussion of our proposals and policies information that would be used to score
Therefore, we continue to believe that under which we would not score the a performance category for an extended
we will not be able to calculate a score advancing care information performance period of time (for example, 3 months
for the quality performance category category and would assign a weight of could be considered an extended period
only in the rare scenarios when a MIPS zero percent to that category for a MIPS of time with regard to information a
eligible clinician does not have any eligible clinician. clinician would collect for the quality
relevant quality measures available to We invite public comment on our performance category). For example, a
report. interpretation of sufficient measures tornado or fire destroying the only
For the cost performance category, we available and applicable in the facility in which a clinician practices
continue to believe that having performance categories. likely would be considered an extreme
sufficient measures applicable and and uncontrollable circumstance;
(c) Extreme and Uncontrollable however, neither the inability to renew
available means that we can reliably
Circumstances a leaseeven a long or extended lease
calculate a score for the cost measures
that adequately captures and reflects the In the CY 2017 Quality Payment nor a facility being found not compliant
performance of a MIPS eligible Program final rule (81 FR 77241 through with federal, state, or local building
clinician, and that MIPS eligible 77243), we discussed our belief that codes or other requirements would be
clinicians who are not attributed enough extreme and uncontrollable considered extreme and uncontrollable
cases to be reliably measured should not circumstances, such as a natural disaster circumstances. We propose that we
be scored for the cost performance in which an EHR or practice location is would review both the circumstances
category (81 FR 77322 through 77323). destroyed, can happen at any time and and the timing independently to assess
We established a policy that if a MIPS are outside a MIPS eligible clinicians the availability and applicability of
eligible clinician is not attributed a control. We stated that if a MIPS eligible measures and activities independently
sufficient number of cases for a measure clinicians CEHRT is unavailable as a for each performance category. For
(in other words, has not met the result of such circumstances, then the example, in 2018 the performance
required case minimum for the measures specified for the advancing period for improvement activities is
measure), or if a measure does not have care information performance category only 90 days, whereas it is 12 months
a benchmark, then the measure will not may not be available for the MIPS for the quality performance category, so
eligible clinician to report. We an issue lasting 3 months may have
quality performance category, provided that they established a policy allowing a MIPS more impact on the availability of
submit data under one of the other performance eligible clinician affected by extreme measures for the quality performance
categories. If such groups do not submit data under
any performance category, the readmission measure and uncontrollable circumstances to category than for the improvement
is not scored. submit an application to us to be activities performance category, because
the MIPS eligible clinician, conceivably, the quality measures they submit. same deadline (December 31, 2018 for
could participate in improvement However, we established a policy not to the 2018 MIPS performance period) for
activities for a different 90-day period. score a cost measure unless a MIPS submission of a reweighting assessment
We believe that extreme and eligible clinician has met the required (see section II.C.6.f. of this proposed
uncontrollable circumstances, such as case minimum for the measure (81 FR rule), and we would encourage the
natural disasters, may affect a clinicians 77323), and not to score administrative requests to be submitted on a rolling
ability to access or submit quality claims measures, such as the all-cause basis. We propose the reweighting
measures via all submission hospital readmission measure, if they assessment must include the nature of
mechanisms (effectively rendering the cannot be reliably scored against a the extreme and uncontrollable
measures unavailable to the clinician) as benchmark (81 FR 77288 through circumstance, including the type of
well as the availability of numerous 77289). Even if the required case event, date of the event, and length of
improvement activities. In addition, minimums have been met and we are time over which the event took place,
damage to a facility where care is able to reliably calculate scores for the performance categories impacted, and
provided due to a natural disaster, such measures that are derived from claims, other pertinent details that impacted the
as a hurricane, could result in practice we believe a MIPS eligible clinicians ability to report on measures or
management and clinical systems that performance on those measures could activities to be considered for
are used for the collection or submission be adversely impacted by a natural reweighting of the quality, cost, or
of data to be down, thus impacting a disaster or other extraordinary improvement activities performance
clinicians ability to submit necessary circumstance, similar to the issues we categories (for example, information
information via Qualified Registry, identified for the Hospital VBP Program. detailing how exactly the event
QCDR, CMS Web Interface, or claims. For example, the claims data used to impacted availability and applicability
This policy would not include issues calculate the cost measures or the all- of measures). If we finalize the policy to
that third party intermediaries, such as cause hospital readmission measure allow reweighting based on extreme and
EHRs, Qualified Registries, or QCDRs, could be significantly affected if a uncontrollable circumstances beginning
might have submitting information to natural disaster caused wide-spread with the 2020 MIPS payment year, we
MIPS on behalf of a MIPS eligible injury or health problems for the would specify the form and manner in
clinician. Instead, this policy is geared community, which could not have been which these reweighting applications
towards events, such as natural prevented by high-value healthcare. In must be submitted outside of the
disasters, that affect the MIPS eligible such cases, we believe that the measures rulemaking process after the final rule is
clinicians ability to submit data to the are available to the clinician, but are published.
third party intermediary, which in turn, likely not applicable, because the For virtual groups, we propose to ask
could affect the ability of the clinician extreme and uncontrollable the virtual group to submit a
(or the third party intermediary acting circumstance has disrupted practice and reweighting assessment for extreme and
on their behalf) to successfully submit measurement processes. Therefore, we uncontrollable circumstances similar to
measures and activities to MIPS. believe an approach similar to Hospital groups, and we would evaluate whether
We also propose to use this policy for sufficient measures and activities are
VBP Program is warranted under MIPS,
measures which we derive from claims applicable and available to the majority
and we are proposing that we would
data, such as the all-cause hospital of TINs in the virtual group. We are
exempt a MIPS eligible clinician from
readmission measure and the cost proposing that a majority of TINs in the
all quality and cost measures calculated
measures. Other programs, such as the virtual group would need to be
from administrative claims data if the
Hospital VBP Program, allow hospitals impacted before we grant an exception.
clinician is granted an exception for the
to submit exception applications when We still find it important to measure the
a hospital is able to continue to report respective performance categories based
performance of virtual group members
data on measures . . . but can on extreme and uncontrollable
unaffected by an extreme and
demonstrate that its Hospital VBP circumstances.
uncontrollable circumstance even if
Program measure rates are negatively Beginning with the 2020 MIPS some of the virtual groups TINs are
impacted as a result of a natural disaster payment year, we propose that we affected.
or other extraordinary circumstance would reweight the quality, cost, and/or We also seek comment on what
and, as a result, the hospital receives a improvement activities performance additional factors we should consider
lower value-based incentive payment categories if a MIPS eligible clinician, for virtual groups. This reweighting
(78 FR 50705). For the Hospital VBP group, or virtual groups request for a assessment due to extreme and
Program, we interpret[ed] the reweighting assessment based on uncontrollable circumstances for the
minimum numbers of cases and extreme and uncontrollable quality, cost, and improvement
measures requirement in the Act to circumstances is granted. We propose activities would not be available to APM
enable us to not score . . . all applicable that MIPS eligible clinicians could Entities in the APM scoring standard for
quality measure data from a request a reweighting assessment if they the following reasons. First, all MIPS
performance period and, thus, exclude believe extreme and uncontrollable eligible clinicians scored under the
the hospital from the Hospital VBP circumstances affect the availability and APM scoring standard will
Program for a fiscal year during which applicability of measures for the quality, automatically receive an improvement
the hospital has experienced a disaster cost, and improvement activities activities category score based on the
or other extraordinary circumstance performance categories. To the extent terms of their participation in a MIPS
(78 FR 50705). Hospitals that request possible, we would seek to align the APM and need not report anything for
and are granted an exception are requirements for submitting a this performance category. Second, the
exempted from the Program entirely for reweighting assessment for extreme and cost performance category has no weight
the applicable year. uncontrollable circumstances with the under the APM scoring standard.
For the 2020 MIPS payment year, we requirements for requesting a significant Finally, for the quality performance
would score quality measures and hardship exception for the advancing category, each MIPS APM has its own
assign points even for those clinicians care information performance category. rules related to quality measures and we
who do not meet the case minimums for For example, we propose to adopt the believe any decisions related to
availability and applicability of Payment Program final rule for a unlikely scenario where a MIPS eligible
measures should reside within the description of our policies for clinician qualifies for reweighting of the
model. As noted in II.C.6.g.(2)(d) of this redistributing the weights of the quality performance category percent
proposed rule, MIPS APM entities performance categories (81 FR 77325 score (because there are not sufficient
would be able to request reweighting of through 77329). For the 2020 MIPS quality measures applicable and
the advancing care information payment year, we propose to available to the clinician or the clinician
performance category. redistribute the weights of the is facing extreme and uncontrollable
If we finalize these proposals for performance categories in a manner that circumstances) and the MIPS eligible
reweighting the quality, cost, and is similar to the transition year. clinician is eligible to have the
improvement activities performance However, we are also proposing new advancing care information performance
categories based on extreme and scoring policies to incorporate our category reweighted to zero and the
uncontrollable circumstances, then it proposals for extreme and MIPS eligible clinician has sufficient
would be possible that one or more of uncontrollable circumstances. cost measures applicable and available
these performance categories would not In section II.C.6.f. of this proposed to have a cost performance category
be scored and would be weighted at rule, we are proposing to use the percent score that is not reweighted,
zero percent of the final score for a authority in the last sentence of section then we would redistribute the weight
MIPS eligible clinician. We propose to 1848(o)(2)(D) of the Act, as amended by of the quality and advancing care
assign a final score equal to the section 4002(b)(1)(B) of the 21st Century information performance categories to
performance threshold if fewer than two Cures Act, as the authority for certain the improvement activities performance
performance categories are scored for a policies under which we would assign category and would not redistribute the
MIPS eligible clinician. This is a scoring weight of zero percent for the weight to the cost performance category.
consistent with our policy finalized in advancing care information performance If we finalize the cost performance
the CY 2017 Quality Payment Program category, and to amend 414.1380(c)(2) category weight at zero percent for the
final rule that because the final score is to reflect our proposals. We are not, 2020 MIPS payment year, then we
a composite score, we believe the however, proposing substantive changes would set the final score at the
intention of section 1848(q)(5) of the Act to the policy established in the CY 2017 performance threshold because the final
is for MIPS eligible clinicians to be Quality Payment Program final rule to score would be based on improvement
scored based on multiple performance redistribute the weight of the advancing activities which would not be a
categories (81 FR 77326 through 77328). care information performance category composite of two or more performance
We request comment on our extreme to the other performance categories for category scores.
and uncontrollable circumstances the transition year (81 FR 77325 through For the 2020 MIPS payment year, if
proposals. We also seek comment on the 77329). we do not finalize the proposal to set
types of the extreme and uncontrollable For the 2020 MIPS payment year, if the cost performance category a zero
circumstances we should consider for we assign a weight of zero percent for percent weight, and if a MIPS eligible
this policy given the general parameters the advancing care information clinician does not receive a cost
we describe in this section. performance category for a MIPS eligible performance category percent score
clinician, we propose to continue our because there are not sufficient cost
(d) Redistributing Performance Category
policy from the transition year and measures applicable and available to the
Weights
redistribute the weight of the advancing clinician or the clinician is facing
In the CY 2017 Quality Payment care information performance category extreme and uncontrollable
Program final rule, we codified at to the quality performance category circumstances, we propose to
414.1380(c)(2) that we will assign (assuming the quality performance redistribute the weight of the cost
different scoring weights for the category does not qualify for performance category to the quality
performance categories if we determine reweighting). We believe redistributing performance category. In the rare
there are not sufficient measures and the weight of the advancing care scenarios where a MIPS eligible
activities applicable and available to information performance category to the clinician does not receive a quality
MIPS eligible clinicians (81 FR 77327). quality performance category (rather performance category percent score
We also finalized a policy to assign than redistributing to both the quality because there are not sufficient quality
MIPS eligible clinicians with only one and improvement activities performance measures applicable and available to the
scored performance category a final categories) is appropriate because MIPS clinician or the clinician is facing
score that is equal to the performance eligible clinicians have more experience extreme and uncontrollable
threshold, which means the clinician reporting quality measures through the circumstances, we propose to
would receive a MIPS payment PQRS program, and measurement in redistribute the weight of the cost
adjustment factor of zero percent for the this performance category is more performance category equally to the
year (81 FR 77326 through 77328). We mature. remaining performance categories that
are proposing in section II.C.7.b.(2) of If we do not finalize our proposal at are not reweighted.
this proposed rule to refine this policy section II.C.6.d. of this proposed rule to In the rare event a MIPS eligible
such that a MIPS eligible clinician with weight the cost performance category at clinician is not scored on at least one
fewer than 2 performance category zero percent (which means the weight of measure in the quality performance
scores would receive a final score equal the cost performance category is greater category because there are not sufficient
to the performance threshold. This than zero percent), then we propose to measures applicable and available or the
refinement is to account for our not redistribute the weight of any other clinician is facing extreme and
proposal in section II.C.7.b.(3)(c) of this performance categories to the cost uncontrollable circumstances, we
proposed rule for extreme and performance category. We believe this is propose for the 2020 MIPS payment
uncontrollable circumstances which, if consistent with our policy of year to continue our policy from the
finalized, could result in a scenario introducing cost measurement in a transition year and redistribute the 60
where a MIPS eligible clinician is not deliberate fashion and recognition that percent weight of the quality
scored on any performance categories. clinicians are more familiar with other performance category so that the
We refer readers to the CY 2017 Quality elements of MIPS. In the rare and performance category weights are 50
percent for the advancing care category is reweighted to zero percent, performance categories would not also
information performance category and then we would redistribute the weight qualify for reweighting, we propose to
50 percent for the improvement of the quality performance category to redistribute the improvement activities
activities performance category the remaining performance category that performance category weight to the
(assuming these performance categories is not weighted at zero percent. We quality performance category consistent
do not qualify for reweighting). While would not redistribute the weight to the with the redistribution policies for the
clinicians have more experience cost performance category. cost and advancing care information
reporting advancing care information We believe that all MIPS eligible performance categories. Should the cost
measures, we believe equal weighting to clinicians will have sufficient
performance category have available
both the improvement activities and improvement activities applicable and
and applicable measures and the cost
advancing care information is available. It is possible that a MIPS
eligible clinician might face extreme performance category weight is not
appropriate for simplicity. Additionally,
in the absence of quality measures, we and uncontrollable circumstances that finalized at zero percent, and the quality
believe increasing the relative weight of render the improvement activities not performance category is reweighted to
the improvement activities performance applicable or available to the clinician; zero percent, then we would
category is appropriate because both however, in that scenario, we believe it redistribute the weight of the
improvement activities and advancing is likely that the measures specified for improvement activities performance
care information have elements of the other performance categories also category to the advancing care
quality and care improvement which are would not be applicable or available to information performance category.
important to emphasize. Should the cost the clinician based on the Table 38 summarizes the potential
performance category have available circumstances. In the rare event that the reweighting scenarios based on our
and applicable measures and the cost improvement activities performance proposals for the 2020 MIPS payment
performance category weight is not zero, category would qualify for reweighting year should the cost performance
but either the improvement activities or based on extreme and uncontrollable category be weighted at zero percent.
advancing care information performance circumstances, and the other
TABLE 38PROPOSED PERFORMANCE CATEGORY REDISTRIBUTION POLICIES FOR THE 2020 MIPS PAYMENT YEAR IF THE
COST PERFORMANCE CATEGORY WEIGHT IS ZERO PERCENT
Reweight Reweight
scenario if no Reweight
Weighting scenario if no
advancing scenario if no
for the improvement
care quality
Performance category 2020 MIPS activities
information performance
payment year performance
performance category
(%) category score
category score percent score (%)
(%)
Quality .............................................................................................................. 60 85 0 75
Cost .................................................................................................................. 0 0 0 0
Improvement Activities ..................................................................................... 15 15 50 0
Advancing Care Information ............................................................................ 25 0 50 25
In response to our final policy to expressed the belief that specialties with on the comments we received, we
redistribute the advancing care few quality measures available to them considered an alternative approach for
information performance category will be unfairly impacted by this the 2020 MIPS payment year to
weight solely to the quality performance reweighting policy, by putting a redistribute the weight of the advancing
category in the CY 2017 Quality disproportionate weight on just a few care information performance category
Payment Program final rule (81 FR quality measures. Commenters to the quality and improvement
77327), we received some comments suggested we redistribute the weight of activities performance categories, to
expressing concern that this would the advancing care information minimize the impact of the quality
place undue emphasis on the quality performance category to the performance category on the final score.
performance category. Commenters improvement activities performance For this approach, we would
expressed the belief that this policy category because the improvement redistribute 15 percent to the quality
would particularly affect non-patient activities performance category allows performance category (60 percent + 15
facing MIPS eligible clinicians who for the most flexibility. One commenter percent = 75 percent) and 10 percent to
have limited available measures, and recommended redistributing the weight the improvement activities performance
would limit the ability to fairly compare of the advancing care information category (15 percent + 10 percent = 25
different specialties that are reweighted performance category to both the quality percent). We considered redistributing
differently. One reason for the and improvement activities performance the weight of the advancing care
discrepancy is that MIPS eligible categories. information performance category
clinicians that submit data to the We continue to have concerns about equally to the quality and improvement
advancing care information performance increasing the weight of the activities performance categories.
category can readily achieve a base improvement activities performance However, for simplicity, we wanted to
score of 50 percent if they meet the category, given that this performance redistribute the weights in increments of
requirements for the base score category is based on attestation only and 5 points. Because MIPS eligible
measures, whereas the quality is not connected to a predecessor CMS clinicians have more experience
performance category does not start at program like the other MIPS reporting quality measures and because
the same base. Commenters also performance categories. However, based these measures are more mature, under
this alternative option, we would category weight is not finalized at zero improvement activities performance
redistribute slightly more to the quality percent and the quality performance category. This alternative approach,
performance category (15 percent vs. 10 category is reweighted to zero percent, assuming the cost performance category
percent). Should the cost performance then we would redistribute the weight weight is zero percent is detailed in
category have available and applicable of the advancing care information Table 39.
measures and the cost performance performance category to the
TABLE 39ALTERNATIVE OPTION FOR REWEIGHTING THE ADVANCING CARE INFORMATION PERFORMANCE CATEGORY FOR
THE 2020 MIPS PAYMENT YEAR IF THE COST PERFORMANCE CATEGORY WEIGHT IS ZERO PERCENT
Reweight
scenario if no
Weighting for advancing care
Performance the 2020 MIPS information
category payment year performance
(%) category score
(%)
Quality .................................................................................................................................................................. 60 75
Cost ...................................................................................................................................................................... 0 0
Improvement Activities ......................................................................................................................................... 15 25
Advancing Care Information ................................................................................................................................ 25 0
We invite comments on our proposal to do so. Thus, we clarify that the In some cases, a TIN/NPI could have
for weighting the performance following final policies apply beginning more than one final score associated
categories for the 2020 MIPS payment with the transition year. For groups with it from the performance period, if
year and our alternative option for submitting data using the TIN identifier, the MIPS eligible clinician submitted
reweighting the advancing care we will apply the group final score to duplicative data sets. In this situation,
information performance category. all the TIN/NPI combinations that bill the MIPS eligible clinician has not
under that TIN during the performance changed practices; rather, for example, a
8. MIPS Payment Adjustments
period. For individual MIPS eligible MIPS eligible clinician has a final score
a. Payment Adjustment Identifier and clinicians submitting data using TIN/ for an APM Entity and a final score for
Final Score Used in Payment NPI, we will use the final score a group TIN. If a MIPS eligible clinician
Adjustment Calculation associated with the TIN/NPI that is used has multiple final scores, the following
(1) Payment Adjustment Identifier during the performance period. For hierarchy will apply. If a MIPS eligible
eligible clinicians in MIPS APMs, we clinician is a participant in MIPS APM,
For purposes of applying the MIPS then the APM Entity final score would
will assign the APM Entity groups final
payment adjustment under section be used instead of any other final score.
score to all the APM Entity Participant
1848(q)(6)(E) of the Act, we finalized a If a MIPS eligible clinician has more
Identifiers that are associated with the
policy in the CY 2017 Quality Payment than one APM Entity final score, we
APM Entity. For eligible clinicians that
Program final rule to use a single will apply the highest APM Entity final
participate in APMs for which the APM
identifier, TIN/NPI, for all MIPS eligible score to the MIPS eligible clinician. If a
scoring standard does not apply, we will
clinicians, regardless of whether the MIPS eligible clinician reports as a
assign a final score using either the
TIN/NPI was measured as an individual, group and as an individual and not as
individual or group data submission
group or APM Entity group (81 FR an APM Entity, we will calculate a final
assignments.
77329 through 77330). In other words, score for the group and individual
a TIN/NPI may receive a final score In the case where a MIPS eligible identifier and use the highest final score
based on individual, group, or APM clinician starts working in a new for the TIN/NPI (81 FR 77332).
Entity group performance, but the MIPS practice or otherwise establishes a new For a further description of our
payment adjustment would be applied TIN that did not exist during the policies, we refer readers to the CY 2017
at the TIN/NPI level. performance period, there would be no Quality Payment Program final rule (81
We are not proposing any changes to corresponding historical performance FR 77330 through 77332).
the MIPS payment adjustment information or final score for the new In addition to the above policies from
identifier. TIN/NPI. In cases where there is no final the CY 2017 Quality Payment Program
score associated with a TIN/NPI from final rule, beginning with the 2020
(2) Final Score Used in Payment the performance period, we will use the MIPS payment year, we are proposing to
Adjustment Calculation NPIs performance for the TIN(s) the NPI modify the policies to address the
In CY 2017 Quality Payment Program was billing under during the addition of virtual groups. Section
final rule (81 FR 77330 through 77332), performance period. If the MIPS eligible 1848(q)(5)(I)(i) of the Act provides that
we finalized a policy to use a TIN/NPIs clinician has only one final score MIPS eligible clinicians electing to be a
historical performance from the associated with the NPI from the virtual group must: (1) Have their
performance period associated with the performance period, then we will use performance assessed for the quality
MIPS payment adjustment. We also that final score. In the event that an NPI and cost performance categories in a
proposed the following policies, and, bills under multiple TINs in the manner that applies the combined
although we received public comments performance period and bills under a performance of all the MIPS eligible
on them and responded to those new TIN in the MIPS payment year, we clinicians in the virtual group to each
comments, we inadvertently failed to finalized a policy of taking the highest MIPS eligible clinician in the virtual
state that we were finalizing these final score associated with that NPI in group for the applicable performance
policies, although it was our intention the performance period (81 FR 77332). period; and (2) be scored for the quality
and cost performance categories based 1115A(d)(1) of the Act and the Shared clinician is not in an APM Entity and is
on such assessment. Therefore, when Savings Program waiver authority under in a virtual group, the MIPS eligible
identifying a final score for payment section 1899(f) of the Act to waive clinician would receive the virtual
adjustments, we must prioritize a virtual section 1848(q)(5)(I)(i)(I) and (II) of the group final score over any other final
group final score over other final scores Act. As discussed in section II.C.4.h. of score. Our policies remain unchanged
such as individual and group scores. this proposed rule, the use of waiver for TIN/NPIs who are not in an APM
Because we also wish to encourage authority is to avoid creating competing Entity or virtual group.
movement towards APMs, we will incentives between MIPS and the APM.
prioritize using the APM Entity final We invite public comment on our
We want MIPS eligible clinicians to
score over any other score for a TIN/ proposals.
focus on the requirements of the APM
NPI, including a TIN/NPI that is in a to ensure that the models produce valid Table 40 illustrates the previously
virtual group. If a TIN/NPI is in both a results that are not confounded by the finalized and newly proposed policies
virtual group and a MIPS APM, we incentives created by MIPS. for determining which final score to use
propose to use the waiver authority for We also propose to modify our when more than one final score is
Innovation Center models under section hierarchy to state that if a MIPS eligible associated with a TIN/NPI.
TABLE 40HIERARCHY 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 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 41 illustrates the previously from the performance period, such as working in a new practice or otherwise
finalized policies that apply if there is when a MIPS eligible clinician starts establishes a new TIN.
no final score associated with a TIN/NPI
TABLE 41NO FINAL SCORE ASSOCIATED WITH A TIN/NPI

MIPS eligible TIN/NPI billing in MIPS payment year Final score used to determine payment
clinician Performance period final score (yes/no) adjustments
(NPI 1)
TIN A/NPI 1 ......... 90 ........................................................... Yes (NPI 1 is still billing under TIN A in 90 (Final score for TIN A/NPI 1 from
the MIPS payment year). the performance period).
TIN B/NPI 1 ......... 70 ........................................................... No (NPI 1 has left TIN B and no longer n/a (no claims are billed under TIN B/
bills under TIN B in the MIPS pay- NPI 1).
ment year).
TIN C/NPI 1 ........ n/a (NPI 1 was not part of TIN C during Yes (NPI 1 has joined TIN C and is bill- 90 (No final score for TIN C/NPI 1, so
the performance period). ing under TIN C in the MIPS pay- use the highest final score associ-
ment year). ated with NPI 1 from the perform-
ance period).
b. MIPS Payment Adjustment Factors 1848(q)(6)(A) of the Act for a year. The section 1848(q)(6)(C) of the Act, each of
performance threshold for a year must which shall be based on a period prior
For a description of the statutory
be either the mean or median (as to the performance period and take into
background and further description of
our policies, we refer readers to the CY selected by the Secretary, and which account data available for performance
2017 Quality Payment Program final may be reassessed every 3 years) of the on measures and activities that may be
rule (81 FR 77332 through 77333). final scores for all MIPS eligible used under the performance categories
We are not proposing any changes to clinicians for a prior period specified by and other factors determined
these policies. the Secretary. Section 1848(q)(6)(D)(iii) appropriate by the Secretary. We
of the Act outlines a special rule for the codified the term performance threshold
c. Establishing the Performance initial 2 years of MIPS, which requires at 414.1305 as the numerical threshold
Threshold the Secretary, prior to the performance for a MIPS payment year against which
Under section 1848(q)(6)(D)(i) of the period for such years, to establish a the final scores of MIPS eligible
Act, for each year of the MIPS, the performance threshold for purposes of clinicians are compared to determine
Secretary shall compute a performance determining the MIPS payment the MIPS payment adjustment factors.
threshold with respect to which the adjustment factors under section We codified at 414.1405(b) that a
final scores of MIPS eligible clinicians 1848(q)(6)(A) of the Act and an performance threshold will be specified
are compared for purposes of additional performance threshold for for each MIPS payment year. We refer
determining the MIPS payment purposes of determining the additional readers to the CY 2017 Quality Payment
adjustment factors under section MIPS payment adjustment factors under Program final rule for further discussion
of the performance threshold (81 FR all MIPS eligible clinicians from a prior care information performance category
77333 through 77338). In accordance period. We want to encourage continued weight 100 equals 15 points towards
with the special rule set forth in section participation and the collection of the final score). We refer readers to
1848(q)(6)(D)(iii) of the Act, we meaningful data by MIPS eligible section II.C.8.g.(2) of this proposed rule
finalized a performance threshold of 3 clinicians. A higher performance for complete examples of how MIPS
points for the transition year (81 FR threshold would help MIPS eligible eligible clinician could exceed the
77334 through 77338). clinicians strive to achieve more performance threshold. We believe the
Our goal was to encourage complete reporting and better proposed performance threshold would
participation and provide an performance and prepare MIPS eligible mitigate concerns from MIPS eligible
opportunity for MIPS eligible clinicians clinicians for the 2021 MIPS payment clinicians about participating in the
to become familiar with the MIPS year. However, a performance threshold program for the second year. However,
Program. We determined that it would set too high could also create a we remain concerned that moving from
have been inappropriate to set a performance barrier, particularly for a performance threshold of 15 points for
performance threshold that would result MIPS eligible clinicians who did not the 2020 MIPS payment year to a
in downward adjustments to payments previously participate in PQRS or the performance threshold of the mean or
for many clinicians who may not have EHR Incentive Programs. We have heard median of the final scores for all MIPS
had time to prepare adequately to from stakeholders requesting that we eligible clinicians for a prior period for
succeed under MIPS. By providing a continue a low performance threshold the 2021 MIPS payment year may be a
pathway for many clinicians to succeed and from stakeholders requesting that steep jump.
under MIPS, we believed that we would we ramp up the performance threshold By the 2021 MIPS payment year,
encourage early participation in the to help MIPS eligible clinicians prepare MIPS eligible clinicians would likely
program, which may enable more robust for the 2021 MIPS payment year and to need to submit most of the required
and thorough engagement with the meaningfully incentivize higher information and perform well on the
program over time. We set the performance. Given our desire to measures and activities to receive a
performance threshold at a low number provide a meaningful ramp between the positive MIPS payment adjustment.
to provide MIPS eligible clinicians an transition years 3-point performance Therefore, we also seek comment on
opportunity to achieve a minimum level threshold and the 2021 MIPS payment setting the performance threshold either
of success under the program, while year performance threshold using the lower or higher than the proposed 15
gaining experience with reporting on mean or median of the final scores for points for the 2020 MIPS payment year.
the measures and activities and all MIPS eligible clinicians for a prior A performance threshold lower than the
becoming familiar with other program period, we are proposing to set the proposed 15 points for the 2020 MIPS
policies and requirements. We believed performance threshold at 15 points for payment year presents the potential for
if we set the threshold too high, using the 2020 MIPS payment year. a significant increase in the final score
a new formula that is unfamiliar and We propose a performance threshold a MIPS eligible clinician must earn to
confusing to clinicians, many could be of 15 points because it represents a meet the performance threshold in the
discouraged from participating in the meaningful increase in performance 2021 MIPS payment year, as well as
first year of the program, which may threshold, compared to 3 points in the providing for a potentially smaller total
lead to lower participation rates in transition year, while maintaining amount of negative MIPS payment
future years. Additionally, we believed flexibility for MIPS eligible clinicians in adjustments upon which the total
this flexibility is particularly important the pathways available to achieve this amount of the positive MIPS payment
to reduce the burden for MIPS eligible performance threshold. For example, adjustments would depend due to the
clinicians in small or solo practices. We submitting the maximum number of budget neutrality requirement under
believed that active participation of improvement activities could qualify for section 1848(q)(6)(F)(ii) of the Act. A
MIPS eligible clinicians in MIPS will a score for 15 points (40 out 40 possible performance threshold higher than the
improve the overall quality, cost, and points for the improvement activity proposed 15 points would increase the
care coordination of services provided which is worth 15 percent of the final final score required to receive a neutral
to Medicare beneficiaries. In accordance score). The performance threshold could MIPS payment adjustment, which may
with section 1848(q)(6)(D)(iii) of the also be met by full participation in the be particularly challenging for small
Act, we took into account available data quality performance category: By practices, even with the proposed
regarding performance on measures and submitting all required measures with addition of the small practice bonus. A
activities, as well as other factors we the necessary data completeness, MIPS higher performance threshold would
determined appropriate. We refer eligible clinicians would earn at least a also allow for potentially higher positive
readers to 81 FR 77333 through 77338 quality performance category percent MIPS payment adjustments for those
for details on our analysis. We also score of 30 percent (which is 3 measure who exceed the performance threshold.
stated our intent to increase the achievement points out of 10 measure We considered an alternative of
performance threshold in the 2020 MIPS points for each required measure). setting a performance threshold of 6
payment year, and that, beginning in the If the quality performance category is points, which could be met by
2021 MIPS payment year, we will use weighted at 60 percent, then the quality submitting two quality measures with
the mean or median final score from a performance category would be 30 required data completeness or one high-
prior period as required by section percent 60 percent 100 which equals weighted improvement activity. While
18 points toward the final score and this lower performance threshold may
1848(q)(6)(D)(i) of the Act (81 FR

77338). exceeds the performance threshold. provide a sharp increase to the required
For the 2020 MIPS payment year, we Finally, a MIPS eligible clinician could performance threshold in MIPS
again want to use the flexibility achieve a final score of 15 points payment year 2021 (the mean or median
provided in section 1848(q)(6)(D)(iii) to through an advancing care information of the final scores for all MIPS eligible
help transition MIPS eligible clinicians performance category score of 60 clinicians for a prior period), it would
to the 2021 MIPS payment year, when percent or higher (60 percent advancing continue to reward clinicians for
the performance threshold will be the care information performance category participation in MIPS as they transition
mean or median of the final scores for score 25 percent for the advancing into the program.
We also considered an alternative of impact analysis in section V.C. of this threshold as the numerical threshold for
setting the performance threshold at 33 proposed rule for a detailed description a MIPS payment year against which the
points, which would require full of our scoring model and data sources. final scores of MIPS eligible clinicians
participation both in improvement Using 2015 PQRS data, we are compared to determine the
activities and in the quality performance determined which of these MIPS additional MIPS payment adjustment
category (either for a small group or for eligible clinicians participated in PQRS factors for exceptional performance. We
a large group that meets data and estimated participation rates for the also codified at 414.1405(d) that an
completeness standards) to meet the MIPS quality performance category additional performance threshold will
performance threshold. Such a based on PQRS participation, which is be specified for each of the MIPS
threshold would make the step to the the performance category that accounts payment years 2019 through 2024. We
required mean or median performance for the largest share (a minimum of 60 refer readers to the CY 2017 Quality
threshold in MIPS payment year 2021 percent) of the 2020 MIPS payment year Payment Program final rule for further
less steep, but could present further final score. We noted that 92.4 percent discussion of the additional
challenges to clinicians who have not of the estimated MIPS eligible clinicians performance threshold (81 FR 77338
previously participated in legacy quality submitted data to PQRS, but the through 77339).
reporting programs. participation rate was lower for MIPS Based on the special rule for the
As required by section eligible clinicians in small practices at initial 2 years of MIPS in section
1848(q)(6)(D)(iii) of the Act, for the 69.7 percent. While we believe many of 1848(q)(6)(D)(iii) of the Act, for the
purposes of determining the the policies in this proposed rule and transition year, we decoupled the
performance threshold, we considered the technical assistance for small additional performance threshold from
data available for performance on practices would help increase the performance threshold and
measures and activities that may be participation, we believe it is important established the additional performance
used under the MIPS performance to keep the performance threshold low threshold at 70 points. We selected a 70-
categories. Specifically, we updated our so that these small practices can learn point numerical value for the additional
scoring model using 2019 MIPS to participate and perform well in MIPS performance threshold, in part, because
payment year eligibility data from the for future years without excessive it would require a MIPS eligible
initial 12-month period to identify financial risk. clinician to submit data for and perform
potential MIPS eligible clinicians who We invite public comments on the well on more than one performance
are physicians (doctors of medicine, proposal to set the performance category (except in the event the
doctors of osteopathy, chiropractors, threshold at 15 points, and also seek advancing care information performance
dentists, optometrists, and podiatrists), comment on setting the performance category is reweighted to zero percent
nurse practitioners, physician assistants, threshold at the alternative of 6 points and the weight is redistributed to the
certified registered nurse anesthetists, or at 33 points for the 2020 MIPS quality performance category making
and clinical nurse specialists, and who payment year. the quality performance category worth
exceeded the low-volume threshold. We We also seek public comments on 85 percent of the final score). Under
estimated newly enrolled Medicare principles and considerations for setting section 1848(q)(6)(C) of the Act, a MIPS
clinicians who would be excluded from the performance threshold beginning eligible clinician with a final score at or
MIPS by using clinicians (identified by with the 2021 MIPS payment year, above the additional performance
NPI) that have Part B charges in the which will be the mean or median of the threshold will receive an additional
eligibility file, but no Part B charges in final scores for all MIPS eligible MIPS payment adjustment factor and
2015. To exclude QPs from our scoring clinicians from a prior period. may share in the $500,000,000 available
model, we used a preliminary version of d. Additional Performance Threshold for the year under section
the file used for the predictive 1848(q)(6)(F)(iv) of the Act. We believed
for Exceptional Performance
qualifying Alternative Payment Model these additional incentives should only
participants analysis made available on Section 1848(q)(6)(D)(ii) of the Act be available to those clinicians with
qpp.cms.gov on June 2, 2017 and requires the Secretary to compute, for very high performance on the MIPS
prepared using claims for services each year of the MIPS, an additional measures and activities. We took into
between January 1, 2016 through August performance threshold for purposes of account the data available and the
31, 2016. We assumed that all partial determining the additional MIPS modeling described in section
QPs would participate in MIPS and payment adjustment factors for II.E.7.c.(1) of the CY 2017 Quality
included them in our scoring model. exceptional performance under Payment Program final rule in selecting
We used 2014 and 2015 PQRS and paragraph (C). For each such year, the the additional performance threshold
2015 VM data to estimate scores for the Secretary shall apply either of the for the transition year (81 FR 77338
quality performance category, using the following methods for computing the through 77339).
published benchmarks for the 2017 additional performance threshold: (1) As we discussed in section II.C.8.c. of
MIPS performance period. We used The threshold shall be the score that is this proposed rule, we are relying on the
2015 and 2016 Medicare and Medicaid equal to the 25th percentile of the range special rule under section
EHR Incentive files to estimate of possible final scores above the 1848(q)(6)(D)(iii) of the Act to establish
advancing care information performance performance threshold determined the performance threshold at 15 points
category scores. We also modeled an under section 1848(q)(6)(D)(i) of the Act; for 2020 MIPS payment year. We are
improvement activities performance or (2) the threshold shall be the score proposing to again decouple the
category score using assumptions based that is equal to the 25th percentile of the additional performance threshold from
on prior PQRS and EHR Incentive actual final scores for MIPS eligible the performance threshold. Because we
Program participation. We did not clinicians with final scores at or above do not have actual MIPS final scores for
model any cost measures as we the performance threshold for the prior a prior performance period, if we do not
proposed in section II.C.6.d.(2) of this period described in section decouple the additional performance
proposed rule to weight the cost 1848(q)(6)(D)(i) of the Act. threshold from the performance
performance category at zero percent. We codified at 414.1305 the threshold, then we would have to set
We refer readers to the regulatory definition of additional performance the additional performance threshold at
the 25th percentile of possible final payment year which helps to simplify We are not proposing any changes to
scores above the performance threshold. the overall MIPS framework. the scaling and budget neutrality
With a performance threshold set at 15 We invite public comment on these requirements as they are applied to
points, the range of total possible points proposals. We also seek feedback on MIPS payment adjustment factors in
above the performance threshold is 16 whether we should raise the additional this proposed rule.
to 100 points. The 25th percentile of performance threshold to a higher
number which would in many instances f. Additional Adjustment Factors
that range is 36.25 points, which is
barely more than one third of the require the use of an EHR for those to We refer readers to the CY 2017
possible 100 points in the MIPS final whom the advancing care information Quality Payment Program final rule for
score. We do not believe it would be performance category requirements further discussion of the additional
appropriate to lower the additional would apply. In addition, a higher MIPS payment adjustment factor (81 FR
performance threshold to 36.25 points, additional performance threshold would 77339 through 77340). We are not
as we do not believe a final score of incentivize better performance and proposing any changes to determine the
would also allow MIPS eligible additional MIPS payment adjustment
36.25 points demonstrates exceptional
clinicians to receive a higher additional factors.
performance by a MIPS eligible
MIPS payment adjustment.
clinician. We believe these additional We also seek public comment on g. Application of the MIPS Payment
incentives should only be available to which method we should use to Adjustment Factors
those clinicians with very high compute the additional performance (1) Application to the Medicare Paid
performance on the MIPS measures and threshold beginning with the 2021 MIPS Amount
activities. Therefore, we are relying on payment year. Section 1848(q)(6)(D)(ii)
the special rule under section Section 1848(q)(6)(E) of the Act
of the Act requires the additional
1848(q)(6)(D)(iii) of the Act to set the performance threshold to be the score provides that for items and services
additional performance threshold at 70 that is equal to the 25th percentile of the furnished by a MIPS eligible clinician
points for the 2020 MIPS payment year, range of possible final scores above the during a year (beginning with 2019), the
which is higher than the 25th percentile performance threshold for the year, or amount otherwise paid under Part B for
of the range of the possible final scores the score that is equal to the 25th such items and services and MIPS
above the performance threshold. percentile of the actual final scores for eligible clinician for such year, shall be
MIPS eligible clinicians with final multiplied by 1 plus the sum of the
We took into account the data MIPS payment adjustment factor
available and the modeling described in scores at or above the performance
threshold for the prior period described determined under section 1848(q)(6)(A)
section II.C.8.c. of this proposed rule to of the Act divided by 100, and as
estimate final scores for the 2020 MIPS in section 1848(q)(6)(D)(i) of the Act.
For example, should we use the lower applicable, the additional MIPS
payment year. We believe 70 points is payment adjustment factor determined
appropriate because it requires a MIPS of the two options, which would result
in more MIPS eligible clinicians under section 1848(q)(6)(C) of the Act
eligible clinician to submit data for and divided by 100.
perform well on more than one receiving an additional MIPS payment
adjustment for exceptional We codified at 414.1405(e) the
performance category (except in the application of the MIPS payment
event the advancing care information performance? Or should we use the
higher of the options, which would adjustment factors. For each MIPS
measures are not applicable and payment year, the MIPS payment
restrict the additional MIPS payment
available to a MIPS eligible clinician). adjustment factor, and if applicable the
adjustment for exceptional performance
Generally, a MIPS eligible clinician additional MIPS payment adjustment
to those with the higher final scores?
could receive a maximum score of 60 factor, are applied to Medicare Part B
Since a fixed amount is available for a
points for the quality performance payments for items and services
year under section 1848(q)(6)(F)(iv) of
category, which is below the 70-point furnished by the MIPS eligible clinician
the Act to fund the additional MIPS
additional performance threshold. In payment adjustments, the more during the year.
addition, 70 points is at a high enough clinicians that receive an additional We are proposing to apply the MIPS
level that MIPS eligible clinicians must MIPS payment adjustment, the lower payment adjustment factor, and if
submit data for the quality performance the average clinicians additional MIPS applicable, the additional MIPS
category to achieve this target. For payment adjustment will be. payment adjustment factor, to the
example, if a MIPS eligible clinician Medicare paid amount for items and
gets a perfect score for the improvement e. Scaling/Budget Neutrality services paid under Part B and
activities and advancing care We codified at 414.1405(b)(3) that a furnished by the MIPS eligible clinician
information performance categories, but scaling factor not to exceed 3.0 may be during the year. This proposal is
does not submit quality measures data, applied to positive MIPS payment consistent with the approach taken for
then the MIPS eligible clinician would adjustment factors to ensure budget the value-based payment modifier (77
only receive 40 points (0 points for neutrality such that the estimated FR 69308 through 69310) and would
quality + 15 points for improvement increase in aggregate allowed charges mean that beneficiary cost-sharing and
activities + 25 points for advancing care resulting from the application of the coinsurance amounts would not be
information), which is below the positive MIPS payment adjustment affected by the application of the MIPS
additional performance threshold. We factors for the MIPS payment year payment adjustment factor and the
believe the additional performance equals the estimated decrease in additional MIPS payment adjustment
threshold at 70 points maintains the aggregate allowed charges resulting from factor. The MIPS payment adjustment
incentive for excellent performance the application of negative MIPS applies only to the amount otherwise
while keeping the focus on quality payment adjustment factors for the paid under Part B for items and services
performance. Finally, we believe MIPS payment year. We refer readers to furnished by a MIPS eligible clinician
keeping the additional performance the CY 2017 Quality Payment Program during a year. Please refer to the CY
threshold at 70 points maintains final rule for further discussion of 2017 Quality Payment Program final
consistency with the 2019 MIPS budget neutrality (81 FR 77339). rule at 81 FR 77340 and section II.C.3.c.
of this proposed rule for further negative applicable percentage (negative adjustment factor is 0.22, which is much
discussion and our proposals regarding 5 percent for the 2020 MIPS payment lower than 1.0. In this example, MIPS
which Part B covered items and services year). Second, the linear sliding scale eligible clinicians with a final score
would be subject to the MIPS payment line for the positive MIPS adjustment equal to 100 would have an adjustment
adjustment. factor is adjusted by the scaling factor factor of 1.10 percent (5 percent 0.22).
(2) Example of Adjustment Factors (as discussed in section II.C.8.e. of this The additional performance threshold
proposed rule). If the scaling factor is is 70 points. An additional adjustment
Figure A provides an example of how greater than zero and less than or equal
various final scores would be converted factor of 0.5 percent starts at the
to 1.0, then the adjustment factor for a additional performance threshold and
to an adjustment factor, and potentially final score of 100 would be less than or
an additional adjustment factor, using increases on a linear sliding scale up to
equal to 5 percent. If the scaling factor 10 percent times a scaling factor that is
the statutory formula and based on is above 1.0, but less than or equal to
proposed policies. In Figure A, the greater than zero and less than or equal
3.0, then the adjustment factor for a to 1.0. The scaling factor will be
performance threshold is 15 points. The final score of 100 would be higher than
applicable percentage is 5 percent for determined so that the estimated
5 percent. Only those MIPS eligible aggregate increase in payments
2020. The adjustment factor is
clinicians with a final score equal to 15 associated with the application of the
determined on a linear sliding scale
points (which is the performance additional adjustment factors is equal to
from zero to 100, with zero being the
threshold in this example) would $500,000,000. In Figure A of this
lowest negative applicable percentage
receive a neutral MIPS payment proposed rule, the example scaling
(negative 5 percent for the 2020 MIPS
payment year), and 100 being the adjustment. Because our proposed factor for the additional adjustment
highest positive applicable percentage. policies have set the performance factor is 0.183. Therefore, MIPS eligible
However, there are two modifications to threshold at 15 points, we anticipate clinicians with a final score of 100
this linear sliding scale. First, there is an that the scaling factor would be less would have an additional adjustment
exception for a final score between zero than 1.0 and the payment adjustment for factor of 1.83 percent (10 percent
and one-fourth of the performance MIPS eligible clinicians with a final 0.183). The total adjustment for a MIPS
threshold (zero and 3.75 points based on score of 100 points would be less than eligible clinician with a final score
the proposed performance threshold for 5 percent. equal to 100 would be 1 + 0.0110 +
the 2020 MIPS payment year). All MIPS Figure A of this proposed rule 0.0183 = 1.0293, for a total positive
eligible clinicians with a final score in illustrates an example slope. In this MIPS payment adjustment of 2.93
this range would receive the lowest example, the scaling factor for the percent.
The final MIPS payment adjustments adjustment. More MIPS eligible Table 42 illustrates the changes in
would be determined by the distribution clinicians below the performance payment adjustments from the
of final scores across MIPS eligible threshold means the scaling factors transition year to the 2020 MIPS
clinicians and the performance would increase because more MIPS payment year based on the proposals in
threshold. More MIPS eligible clinicians eligible clinicians would have negative this proposed rule as well as the
above the performance threshold means MIPS payment adjustments and statutorily-required increase in the
the scaling factors would decrease relatively fewer MIPS eligible clinicians applicable percent as required by
because more MIPS eligible clinicians receive positive MIPS payment section 1848(q)(6)(B) of the Act.
receive a positive MIPS payment adjustments.
TABLE 42ILLUSTRATION 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.

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 multiplied by a percent on a linear sliding scale multiplied by a
scaling factor to preserve budget neutrality. scaling factor to preserve budget neutrality.
The linear sliding scale ranges from greater than 0 ........................ The linear sliding scale ranges from greater than 0
EP30JN17.005</GPH>
to 4 percent for scores from 3.01 to 100.00. to 5 percent for scores from 15.01 to 100.00.
TABLE 42ILLUSTRATION 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
70.00100 ........... Positive MIPS payment adjustment on a linear slid- 70.00100 Positive MIPS payment adjustment on a linear slid-
ing scale multiplied by a scaling factor to preserve ing scale multiplied by a scaling factor to preserve
budget neutrality AND additional MIPS payment budget neutrality AND additional MIPS payment
adjustment for exceptional performance. (Addi- adjustment for exceptional performance. (Addi-
tional MIPS payment adjustment starting at 0.5 tional MIPS payment adjustment starting at 0.5
percent and increasing on a linear sliding scale to percent and increasing on a linear sliding scale to
10 percent multiplied by a scaling factor.) 10 percent multiplied by a scaling factor.)
The linear sliding scale ranges from greater than 0 ........................ The linear sliding scale ranges from greater than 0
to 4 percent for scores from 3.01 to 100.00. to 5 percent for scores from 15.01 to 100.00.
We have provided the following not contribute to the final score. Finally, measure points + zero improvement
examples for the 2020 MIPS payment we assume the average HCC score for percent score which is 5 percent.
year to demonstrate scenarios in which the beneficiaries seen by the MIPS The advancing care information
MIPS eligible clinicians can achieve a eligible clinician is 1.5. performance category weight is
final score at or above the performance There are several special scoring rules redistributed to quality so that the
threshold of 15 points. which affect MIPS eligible clinicians in quality performance category percent
a small practice: score is worth 85 percent of the final
Example 1: MIPS Eligible Clinician in 3 measure achievement points for
Small Practice Submits 1 Quality score. We refer you to section
each quality measure even if the II.C.7.b.(3)(d) of this proposed rule for a
Measure and 1 Improvement Activity measure does not meet data discussion of this proposed policy.
In the example illustrated in Table 43, completeness standards. We refer
a MIPS eligible clinician in a small readers to section II.C.7.a.(2)(d) of this MIPS eligible clinicians in small
practice reporting individually meets proposed rule for discussion of this practices qualify for special scoring for
the performance threshold by reporting policy. Therefore, a quality measure improvement activities so a medium
one measure one time via claims and submitted one time would receive 3 weighted activity is worth 20 points out
one medium-weight improvement points. Because the measure is of a total 40 possible points for the
activity. The practice does not submit submitted via claims, it does not qualify improvement activities performance
data for the advancing care information for the end-to-end electronic reporting category. We refer you to section
performance category, but does submit a bonus, nor would it qualify for the high- II.C.6.e.(5) of this proposed rule for a
significant hardship exception priority bonus because it is the only discussion of this proposed policy.
application which is approved; measure submitted. However, because MIPS eligible clinicians in small
therefore, the weight for the advancing the MIPS eligible clinician does not practices qualify for the 5 point small
care information performance category meet full participation requirements, the practice bonus which is applied to the
is reweighted to the quality performance MIPS eligible clinician does not qualify final score. We refer you to section
category due to proposed reweighting for improvement scoring. We refer you II.C.7.b.(1)(c) of this proposed rule for a
policies discussed in section II.C.7.b,(3) to section II.C.7.a.(2)(i)(iii) of this discussion of this proposed policy.
of this proposed rule. We also assume proposed rule for a discussion on full This MIPS eligible clinician exceeds
the small practice has a cost participation requirements. Therefore, the performance threshold of 15 points
performance category percent score of the quality performance category is (3 (but does not exceed the additional
50 percent, although the cost measure achievement points + zero performance threshold). This score is
performance category percent score will measure bonus points)/60 total available summarized in Table 43.
TABLE 43SCORING EXAMPLE 1, MIPS ELIGIBLE CLINICIAN IN A SMALL PRACTICE

Performance Category Earned points
Performance category score weight ([B]*[C]*100)
[A] [B] [C] [D]
Quality ......................................................................................................... 5% .................................. 85% ................................ 4.25

Cost ............................................................................................................. 50% ................................ 0% .................................. 0
Improvement Activities ................................................................................ 20 out of 40 points 15% ................................ 7.5
50%.
Advancing Care Information ....................................................................... Missing ........................... 0% (reweighted to qual- 0

ity).
Subtotal (Before Bonuses) .................................................................. ........................................ ........................................ 11.75
Complex Patient Bonus .............................................................................. ........................................ ........................................ 1.5

Small Practice Bonus ................................................................................. ........................................ ........................................ 5
Final Score (not to exceed 100) .......................................................... ........................................ ........................................ 18.25
Example 2: Group Submission Not in a care information and improvement performance threshold are exceeded.
Small Group activities performance categories. There Again, for simplicity, we assume the
are many paths for a practice to receive average HCC score for the group is 1.5.
In the example illustrated in Table 44, a 75 percent score in the quality In this example, the group practice does
a MIPS eligible clinician in a medium performance category, so for simplicity not qualify for any special scoring, yet
size practice participating in MIPS as a we are assuming the score has been is able to exceed the additional
group meets 75 percent of the quality calculated. Both the performance performance threshold and achieve the
score and 100 percent for the advancing threshold and the additional additional adjustment factor.
TABLE 44SCORING EXAMPLE 2, MIPS ELIGIBLE CLINICIAN IN A MEDIUM PRACTICE
[A] [B] [C] [D]
Quality ......................................................................................................................... 75% ................................ 60% 45

Cost ............................................................................................................................. 50% ................................ 0% 0
Improvement Activities ................................................................................................ 40 out of 40 points 15% 15
100%.
Advancing Care Information ........................................................................................ 100% .............................. 25% 25
Subtotal (Before Bonuses) ................................................................................... ........................................ ........................ 85
Complex Patient Bonus ............................................................................................... ........................................ ........................ 1.5

Small Practice Bonus .................................................................................................. ........................................ ........................ 0
Final Score (not to exceed 100) .......................................................................... ........................................ ........................ 86.5
Example 3: Non-Patient Facing MIPS in the quality performance category, so advancing care information performance
Eligible Clinician for simplicity we are assuming the score category to quality. The non-patient
has been calculated. Because the MIPS facing MIPS eligible clinician has an
In the example illustrated in Table 45, eligible clinician is non-patient facing, average HCC score of 1.5, but as the
an individual MIPS eligible clinician they qualify for special scoring for MIPS eligible clinician is not in a small
that is non-patient facing and not in a improvement activities, they receive 20 practice, the MIPS eligible clinician
small practice meets 50 percent of the points (out of 40 possible points) for the does not qualify for the small practice
quality score and 50 percent for 1 medium weighted activity. Also, this bonus.
medium-weighted for improvement individual did not submit advancing In this example, the performance
activity. Again, there are many paths for care information measures and qualifies threshold is exceeded while the
a practice to receive a 50 percent score for the automatic reweighting of the additional performance threshold is not.
TABLE 45SCORING EXAMPLE 2, NON-PATIENT FACING MIPS ELIGIBLE CLINICIAN

[A] [B] [C] [D]
Quality ......................................................................................................................... 50% ................................ 60% 30

Cost ............................................................................................................................. 50% ................................ 0% 0
Improvement Activities ................................................................................................ 20 out of 40 points for 1 15% 7.5
medium weight activ-
ity50%.
Advancing Care Information ........................................................................................ 0% .................................. 25% 0
Subtotal (Before Bonuses) ................................................................................... ........................................ ........................ 37.5
Complex Patient Bonus ............................................................................................... ........................................ ........................ 1.5

Small Practice Bonus .................................................................................................. ........................................ ........................ 0
Final Score (not to exceed 100) .......................................................................... ........................................ ........................ 39

We note that these examples are not 9. Review and Correction of MIPS Final rule (81 FR 77345), we will continue to
intended to be exhaustive of the types Score engage in user research with front-line
of participants nor the opportunities for a. Feedback and Information To clinicians to ensure we are providing
reaching and exceeding the performance Improve Performance the performance feedback data in a user-
threshold. friendly format, and that we are
(1) Performance Feedback including the data most relevant to
As we have stated previously in the clinicians. Any suggestions from user
CY 2017 Quality Payment Program final research would be considered as we
develop the systems needed for Beginning July 1, 2018, we are for additional information related to this
performance feedback, which would proposing to provide performance proposal.
occur outside of the rulemaking process. feedback to MIPS eligible clinicians and
(c) Voluntary Clinician and Group
Over the past year, we have groups for the quality and cost
Reporting
conducted numerous user research performance categories for the 2017
sessions to determine what the performance period, and if technically As noted in the CY 2017 Quality
community most needs in performance feasible, for the improvement activities Payment Program final rule (81 FR
feedback. In summary we have found and advancing care information 77071), eligible clinicians who are not
the users want the following: performance categories. We propose to included in the definition of a MIPS
(1) To know as soon as possible how provide this performance feedback at eligible clinician during the first 2 years
I am performing based on my submitted least annually, and as, technically of MIPS (or any subsequent year) may
data so that I have confidence that I feasible, we would provide it more voluntarily report on measures and
performed the way I thought I would. frequently, such as quarterly. If we are activities under MIPS, but will not be
(2) To be able to quickly understand able to provide it more frequently, we subject to the payment adjustment. In
how and why my payments will be would communicate the expected the final rule (81 FR 77346), we
adjusted so that I can understand how frequency to our stakeholders via our summarized public comments
my business will be impacted. education and outreach communication requesting that eligible clinicians who
(3) To be able to quickly understand channels. are not required, but who voluntarily
how I can improve my performance so report on measures and activities under
Based on public comments
that I can increase my payment in future MIPS, should receive the same access to
summarized and responded to in the CY
program years. performance feedback as MIPS eligible
2017 Quality Payment Program final
(4) To know how I am performing clinicians, and indicated that we would
rule (81 FR 77347), we also propose that
over time so I can improve the care I am take the comments into consideration in
the measures and activities specified for
providing patients in my practice. the future development of performance
(5) To know how my performance the CY 2017 performance period (for all
feedback. We propose to furnish
compares to my peers. four MIPS performance categories),
performance feedback to eligible
Based on that research, we have along with the final score, would be
clinicians and groups that do not meet
already begun development of real-time included in the performance feedback
the definition of a MIPS eligible
feedback on data submission and provided on or about July 1, 2018. We clinician but voluntarily report on
scoring where technically feasible (some request comment on these proposals. measures and activities under MIPS. We
scoring requires all clinician data be For cost measures, since we can propose that this would begin with data
submitted, and therefore, cannot occur measure performance using any 12- collected in performance period 2017,
until the end of the submission period). month period of prior claims data, we and would be available beginning July
By real-time feedback, we mean request comment on whether it would 1, 2018. Based on user and market
instantaneous feedback; for example, be helpful to provide more frequent research, we believe that making this
when a clinician submits their data via feedback on the cost performance information available would provide
our Web site or a third party submits category using rolling 12-month periods value in numerous ways. First, it would
data via our Application Program or quarterly snapshots of the most help clinicians who are excluded from
Interface (API), they will know recent 12-month period; how frequent MIPS in the 2017 performance period,
immediately if their submission was that feedback should be; and the format but who may be considered MIPS
successful. in which we should make it available to eligible clinicians in future years, to
We will continue to provide clinicians and groups. In addition, as prepare for participation in the Quality
information for stakeholders who wish described in sections II.C.6.b. and Payment Program when there are
to participate in user research via our II.C.6.d. of this proposed rule, we intend payment consequences associated with
education and communication to provide cost performance feedback in participation. Second, it would give all
channels. Suggestions can also be sent the fall of 2017 and the summer of 2018 clinicians equal access to the CMS
via the Contact Us information on on new episode-based cost measures claims and benchmarking data available
qpp.cms.gov. However, we note that that are currently under development by in performance feedback. And third, it
suggestions provided through this CMS. With regard to the format of would allow clinicians who may be
channel will not be considered feedback on cost measures, we are interested in participating in an APM to
comments on this proposed rule. To considering utilizing the parts of the make a more informed decision.
submit comments on this proposed rule, Quality and Resource Use Reports We request comments on this
please see the explanation of how to (QRURs) that user testing has revealed proposal.
submit such comments and relevant beneficial while making the overall look
and feel usable to clinicians. We request (2) Mechanisms
deadlines explained at the beginning of
this proposed rule. comment whether that format is Under section 1848(q)(12)(A)(ii) of the
appropriate or if other formats or Act, the Secretary may use one or more
(a) MIPS Eligible Clinicians revisions to that format should be used mechanisms to make performance
Under section 1848(q)(12)(A)(i) of the to provide performance feedback on cost feedback available, which may include
Act, we are at a minimum required to measures. use of a web-based portal or other
provide MIPS eligible clinicians with mechanisms determined appropriate by
(b) MIPS APMs

timely (such as quarterly) confidential the Secretary. For the quality
feedback on their performance under We are proposing that MIPS eligible performance category, described in
the quality and cost performance clinicians who participate in MIPS section 1848(q)(2)(A)(i) of the Act, the
categories beginning July 1, 2017, and APMs would receive performance feedback shall, to the extent an eligible
we have discretion to provide such feedback in 2018 and future years of the clinician chooses to participate in a data
feedback regarding the improvement Quality Payment Program, as registry for purposes of MIPS (including
activities and advancing care technically feasible. Please refer to registries under sections 1848(k) and
information performance categories. section II.C.6.g.(5) of this proposed rule (m) of the Act), be provided based on
performance on quality measures 77367 through 77386) we finalized that (3) Receipt of Information
reported through the use of such at least 4 times per year, qualified
registries. For any other performance registries and QCDRs will provide Section 1848(q)(12)(A)(v) of the Act,
category (that is, cost, improvement feedback on all of the MIPS performance states that the Secretary may use the
activities, or advancing care categories that the qualified registry or mechanisms established under section
information), the Secretary shall QCDR reports to us (improvement 1848(q)(12)(A)(ii) of the Act to receive
encourage provision of feedback activities, advancing care information, information from professionals. This
through qualified clinical data registries and/or quality performance category). allows for expanded use of the feedback
(QCDRs) as described in section The feedback should be given to the mechanism to not only provide
1848(m)(3)(E) of the Act. individual MIPS eligible clinician or feedback on performance to MIPS
As previously stated in the CY 2017 group (if participating as a group) at the eligible clinicians, but to also receive
Quality Payment Program final rule (81 individual participant level or group information from professionals.
FR 77347 through 77349), we will use level, as applicable, for which the In the CY 2017 Quality Payment
a CMS-designated system as the qualified registry or QCDR reports. The Program final rule (81 FR 77350), we
mechanism for making performance qualified registry or QCDR is only discussed that we intended to explore
feedback available, which we expect required to provide feedback based on the possibility of adding this feature to
will be a web-based application. We the MIPS eligible clinicians data that is the CMS-designated system, such as a
expect to use a new and improved available at the time the performance portal, in future years under MIPS.
format for the next performance feedback is generated. In regard to third Although we are not making any
feedback, anticipated to be released party intermediaries, we also noted we specific proposals at this time, we are
around July 1, 2018. It will be provided would look to propose real time again seeking comment on the features
via the Quality Payment Program Web feedback as soon as it is technically that could be developed for the
site (qpp.cms.gov), and we intend to feasible. expanded use of the feedback
leverage additional mechanisms, such Per the policies finalized in the CY mechanism. This could be a feature
as health IT vendors, registries, and 2017 Quality Payment Program final where eligible clinicians and groups can
QCDRs to help disseminate data and rule (81 FR 77367 through 77386), we send their feedback (for example, if they
information contained in the continue to require qualified registries are experiencing issues accessing their
performance feedback to eligible and QCDRs, as well as encourage other data, technical questions about their
clinicians, where applicable. third party intermediaries (such as data, etc.) to us through the Quality
We are also seeking comment on how health IT vendors that submit data to us Payment Program Service Center or the
health IT, either in the form of an EHR on behalf of a MIPS eligible clinician or Quality Payment Program Web site. We
or as a supplemental module, could group), to provide performance feedback appreciate that eligible clinicians and
better support the feedback related to to individual MIPS eligible clinicians groups may have questions regarding
participation in the Quality Payment and groups via the third party the Quality Payment Program
Program and quality improvement in intermediary with which they are information contained in their
general. Specifically already working. We also understand performance feedback. To assist eligible
Are there specific health IT that performance feedback is valuable to clinicians and groups, we intend to
functionalities that could contribute individual clinicians and groups, and utilize existing resources, such as a
significantly to quality improvement? seek feedback from third party helpdesk or offer technical assistance, to
Are there specific health IT intermediaries on when real-time
help address questions with the goal of
functionalities that could be part of a feedback could be provided.
linking these resource features to the
certified EHR technology or made Additionally, we plan to continue to
work with third party intermediaries as Quality Payment Program Web site and
available as optional health IT modules
we continue to develop the mechanisms Service Center.
in order to support the feedback loop
related to Quality Payment Program for performance feedback, to see where (4) Additional InformationType of
participation or participation in other we may be able to develop and Information
HHS reporting programs? implement efficiencies for the Quality
In what other ways can health IT Payment Program. We are exploring Section 1848(q)(12)(B)(i) of the Act
support clinicians seeking to leverage options with an API, which could allow states that beginning July 1, 2018, the
quality data reports to inform clinical authenticated third party intermediaries Secretary shall make available to MIPS
improvement efforts? For example, are to access the same data that we use to eligible clinicians information about the
there existing or emerging tools or provide confidential feedback to the items and services for which payment is
resources that could leverage an API to individual clinicians and groups on made under Title 18 that are furnished
provide timely feedback on quality whose behalf the third party to individuals who are patients of MIPS
improvement activities? intermediary reports for purposes of eligible clinicians by other suppliers
Are there opportunities to expand MIPS, in accordance with applicable and providers of services. This
existing tracking and reporting for use law, including, but not limited to, the information may be made available
by clinicians, for example expanding HIPAA Privacy and Security Rules. Our through mechanisms determined
the feedback loop for patient goal is to enable individual clinicians appropriate by the Secretary, such as the
engagement tools to support remote and groups to more easily access their CMS-designated system that would also
feedback via the mechanisms and provide performance feedback. Section
monitoring of patient status and access

to education materials? relationships they already have 1848(q)(12)(B)(ii) of the Act specifies
We welcome public comment on established. We are seeking comments that the type of information provided
these questions. on this approach as we continue to may include the name of such
We intend to continue to leverage develop performance feedback providers, the types of items and
third party intermediaries as a mechanisms. We refer readers to section services furnished, and the dates that
mechanism to provider performance II.C.10. of this proposed rule for items and services were furnished.
feedback. In the CY 2017 Quality additional information on Third Party Historical data regarding the total, and
Payment Program final rule (81 FR Data Submission. components of, allowed charges (and
other figures as determined appropriate performance feedback, including the or without the assistance of a third party
by the Secretary) may also be provided. data on items and services furnished, as intermediary; or
We propose, beginning with the discussed above. Additionally, we The MIPS eligible clinician or
performance feedback provided around understand the term performance group believes that there are certain
July 1, 2018, to make available to MIPS feedback may not be meaningful to errors made by us, such as performance
eligible clinicians and eligible clinicians clinicians or groups to clearly denote category scores were wrongly assigned
information about the items and what this data might imply. Therefore, to the MIPS eligible clinician or group
services for which payment is made we seek comment on what to term (for example, the MIPS eligible clinician
under Title 18 that are furnished to performance feedback. User testing to or group should have been subject to the
individuals who are patients of MIPS date has provided some considerations low-volume threshold exclusion and
eligible clinicians and eligible clinicians for a name in the Quality Payment should not have received a performance
by other suppliers and providers of Program, such as Progress Notes, category score).
services. We propose to include as Reports, Feedback, Performance (3) The MIPS eligible clinician or
much of the following data elements as Feedback, or Performance Reports. group may include additional
technically feasible: The name of such Any suggestions on the template to be information in support of their request
suppliers and providers of services; the used for performance feedback or what for targeted review at the time the
types of items and services furnished to call performance feedback can be request is submitted. If we request
and received; the dollar amount of submitted to the Quality Payment additional information from the MIPS
services provided and received; and the Program Web site at qpp.cms.gov. eligible clinician or group, it must be
dates that items and services were provided and received by us within 30
furnished. We propose that the b. Targeted Review days of the request. Non-responsiveness
additional information would include In the CY 2017 Quality Payment to the request for additional information
historical data regarding the total, and Program final rule (81 FR 77546), we may result in the closure of the targeted
components of, allowed charges (and finalized at 414.1385 that MIPS review request, although the MIPS
other figures as determined eligible clinicians or groups may request eligible clinician or group may submit
appropriate). We propose that this a targeted review of the calculation of another request for targeted review
information be provided on the the MIPS payment adjustment factor before the deadline.
aggregate level; with the exception of under section 1848(q)(6)(A) of the Act (4) Decisions based on the targeted
data on items and services, as we could and, as applicable, the calculation of the review are final, and there is no further
consider providing this data at the additional MIPS payment adjustment review or appeal.
patient level, if clinicians find that level factor under section 1848(q)(6)(C) of the c. Data Validation and Auditing
of data to be useful, although we note Act applicable to such MIPS eligible
it may contain personally identifiable In the CY 2017 Quality Payment
clinician or group for a year. We note Program final rule (81 FR 77546 through
information and protected health MIPS eligible clinicians who are scored
information. We propose the date range 77547), we finalized at 414.1390(a)
under the APM scoring standard that we will selectively audit MIPS
for making this information available described in section II.C.6.g. of this
would be based on what is most helpful eligible clinicians and groups on a
proposed rule may request this targeted yearly basis. If a MIPS eligible clinician
to clinicians, such as the most recent
review. Although we are not proposing or group is selected for audit, the MIPS
data we have available, which as
any changes to the targeted review eligible clinician or group will be
technically feasible would be provided
process, we are providing information required to do the following in
from a 3 to 12-month period. We
on the process that was finalized in the accordance with applicable law and
propose to make this information
CY 2017 Quality Payment Program final timelines we establish:
available via the Quality Payment
rule (81 FR 77353 through 77358). (1) Comply with data sharing
Program Web site, and as technically
feasible, as part of the performance (1) MIPS eligible clinicians and requests, providing all data as requested
feedback. Finally, because data on items groups have a 60-day period to submit by us or our designated entity. All data
and services furnished is generally kept a request for targeted review, which must be shared with us or our
confidential, we propose that access begins on the day we make available the designated entity within 45 days of the
would be provided only after secure MIPS payment adjustment factor, and if data sharing request, or an alternate
credentials are obtained. We request applicable the additional MIPS payment timeframe that is agreed to by us and the
comment on these proposals. adjustment factor, for the MIPS payment MIPS eligible clinician or group. Data
year and ends on September 30 of the will be submitted via email, facsimile,
(5) Performance Feedback Template year prior to the MIPS payment year or or an electronic method via a secure
As we have previously indicated (81 a later date specified by us. Web site maintained by us.
FR 77352), we intend to do as much as (2) We will respond to each request (2) Provide substantive, primary
we can of the development of the for targeted review timely submitted source documents as requested. These
template for performance feedback by and determine whether a targeted documents may include: Copies of
working with the stakeholder review is warranted. Examples under claims, medical records for applicable
community in a transparent manner. We which a MIPS eligible clinician or group patients, or other resources used in the
believe this will encourage stakeholder may wish to request a targeted review data calculations for MIPS measures,
commentary and make sure the result is include, but are not limited to: objectives, and activities. Primary
the best possible format(s) for feedback. The MIPS eligible clinician or source documentation also may include
To continue with our collaborative group believes that measures or verification of records for Medicare and
goal of working with the stakeholder activities submitted to us during the non-Medicare beneficiaries where
community, we seek comment on the submission period and used in the applicable. We are not proposing any
structure, format, content (for example, calculations of the final score and changes to the requirements in section
detailed goals, data fields, and elements) determination of the adjustment factors 414.1390(a).
that would be useful for MIPS eligible have calculation errors or data quality We indicated in the CY 2017 Quality
clinicians and groups to include in issues. These submissions could be with Payment Program final rule that all
MIPS eligible clinicians and groups that such data and information for a period II.C.4. of this rule for more information
submit data to us electronically must of 10 years from the end the MIPS related to virtual groups.
attest to the best of their knowledge that Performance Period. Additionally, we believe it is
the data submitted to us is accurate and Finally, we indicated in the CY 2017 important that the MIPS data submitted
complete (81 FR 77362). We also Quality Payment Program final rule, by third party intermediaries is true,
indicated in the final rule that that, in addition to recouping any accurate, and complete. To that end, we
attestation requirements would be part incorrect payments, we intend to use are proposing to add a requirement at
of the submission process (81 FR data validation and audits as an 414.1400(a)(5) stating that all data
77360). We neglected to codify this educational opportunity for MIPS submitted to CMS by a third party
requirement in regulation text of the CY eligible clinicians and groups and we intermediary on behalf of a MIPS
2017 Quality Payment Program final note that this process will continue to eligible clinician, group or virtual group
rule. Additionally, after further include education and support for MIPS must be certified by the third party
consideration since the final rule, the eligible clinicians and groups selected intermediary to the best of its
requirement is more in the nature of a for an audit. knowledge as true, accurate, and
certification, rather than an attestation. complete. We also propose that this
Thus, we are proposing to revise 10. Third Party Data Submission certification occur at the time of the
414.1390 to add a new paragraph (b) In developing MIPS, our goal is to submission and accompany the
that requires all MIPS eligible clinicians develop a program that is meaningful, submission. We solicit comments on
and groups that submit data and understandable, and flexible for this proposal.
information to CMS for purposes of participating MIPS eligible clinicians. As more clinicians participate in
MIPS to certify to the best of their Flexible reporting options will provide value based payment arrangements with
knowledge that the data submitted to eligible clinicians with options to multiple payers, we believe third-party
CMS is true, accurate, and complete. We accommodate different practices and intermediaries will play an important
also propose that the certification by the make measurement meaningful. We role in calculating quality measures,
MIPS eligible clinician or group must believe that allowing eligible clinicians reporting once to all payers, and sharing
accompany the submission. actionable feedback to clinicians. A
to participate in MIPS through the use
We also indicated in the CY 2017 robust ecosystem of third-party
of third party intermediaries that will
Quality Payment Program final rule that intermediaries would more reliably
collect or submit data on their behalf,
if a MIPS eligible clinician or group is calculate measures using data across
will help us accomplish our goal of
found to have submitted inaccurate data clinical practices caring for the same
implementing a flexible program. We
for MIPS, we would reopen and revise patients and reduce burden by
strongly encourage all third party
the determination in accordance with streamlining reporting to all payers and
intermediaries to work with their MIPS
the rules set forth at 405.980 through offering timely feedback to clinicians
eligible clinicians to ensure the data
405.984 (81 FR 77362). We neglected to that is easier to act on in addressing
submitted are representative of the
codify this policy in regulation text of gaps in care. Third-party intermediaries
individual MIPS eligible clinicians or can also take the burden off clinical
the CY 2017 Quality Payment Program
groups overall performance for that practices by integrating various types of
final rule and further, we did not
measure or activity. health care data, including
include 405.986, which is also an
applicable rule in our reopening policy. For purposes of this section, we use administrative data from payers, other
We also finalized our approach to the term third party to refer to a utilization data, cost data, and clinical
recoup incorrect payments from the qualified registry, QCDR, a health IT data derived from health IT systems, to
MIPS eligible clinician by the amount of vendor or other third party that obtains provide front-line clinicians and others
any debts owed to us by the MIPS data from a MIPS eligible clinicians with a comprehensive view of the cost
eligible clinician and likewise, we Certified Electronic Health Record and quality of the care they are
would recoup any payments from the Technology, or a CMS approved survey delivering.
group by the amount of any debts owed vendor. In the CY 2017 Quality Payment We are continuing to explore how we
to us by the group. Thus, we are Program final rule (81 FR 77363), we can further encourage those third-party
proposing to revise 414.1390 to add a finalized at 414.1400(a)(1) that MIPS intermediaries that provide
new paragraph (c) that states we may data may be submitted by third party comprehensive data services to support
reopen and revise a MIPS payment intermediaries on behalf of a MIPS eligible clinicians participating in both
determination in accordance with the eligible clinician or group by: (1) A MIPS and APMs. For instance, should
rules set forth at 405.980 through qualified registry; (2) a QCDR; (3) a we consider implementing additional
405.986. health IT vendor; or (4) a CMS approved incentives for eligible clinicians to use
In the CY 2017 Quality Payment survey vendor. Additionally, we a third-party intermediary which has
Program, we also indicated that MIPS finalized at 414.1400(a)(3) that third demonstrated substantial participation
eligible clinicians and groups should party intermediaries must meet all the from additional payers and/or other
retain copies of medical records, charts, criteria designated by us as a condition clinical data sources across practices
reports and any electronic data utilized of their qualification or approval to caring for a cohort of Medicare
for reporting under MIPS for up to 10 participate in MIPS as a third party beneficiaries within a given geographic
years after the conclusion of the intermediary. Lastly, as finalized at area? Should these incentives also
performance period (81 FR 77360). We 414.1400(a)(3)(ii), all submitted data include expectations that structured,
neglected to codify this policy in must be submitted in the form and standardized data be shared with third
regulation text of the CY 2017 Quality manner specified by us. party intermediaries? Should there be
Payment Program final rule. Thus, we We are proposing to revise additional refinements to the approach
are proposing to revise 414.1390 to 414.1400(a)(1) to state that MIPS data to qualifying third party intermediaries
add a new paragraph (d) that states that may be submitted by third party which evaluate the degree to which
all MIPS eligible clinicians or groups intermediaries on behalf of an these intermediaries can deliver
that submit data and information to individual MIPS eligible clinician, longitudinal information on a patient to
CMS for purposes of MIPS must retain group, or virtual group. See section participating clinicians, for example, a
virtual care team of primary and noted below. Finally, QCDRs may want data submissions and to make
specialty physicians? Should there be a to update or change the measures or determinations on the standing of the
special designation for registries that services or performance categories they QCDRs. We note that substantive
would convey the availability of intend to provide. We believe an annual changes to existing QCDR measure
longitudinal clinical data for robust self-nomination process is the best specifications or any new QCDR
measurement and feedback? We seek process to ensure accurate information measures would have to be submitted
comment on these and other ideas is conveyed to MIPS eligible clinicians for CMS review and approval by the
which can further advance the role of and accurate data is submitted to MIPS. close of the self-nomination period. This
intermediaries and reduce clinician However, we do understand that some proposed process will allow existing
burden by enabling a streamlined QCDRs have no changes to the measure QCDRs in good standing to avoid
reporting and feedback system. and/or activity inventory they offer to completing the entire application
their clients and intend to participate in annually, as is required in the existing
a. Qualified Clinical Data Registries
the MIPS for many years. Because of process, and in alignment with the
(QCDRs)
this, we are proposing, beginning with existing timeline. We request comments
In the CY 2017 Quality Payment on this proposal. In the development of
the 2019 performance period, a
Program final rule (81 FR 77364), we this proposal, we had reviewed the
simplified process in which existing
finalized the definition and capabilities possibility of offering a multi-year
QCDRs in good standing may continue
of a QCDR. We are not proposing any approval, where QCDRs would be
their participation in MIPS, by attesting
changes to the definition or the approved for a 2-year increment of time.
capabilities of a QCDR in this proposed that the QCDRs approved data
validation plan, cost, measures, We are concerned that utilizing a multi-
rule, and refer readers to the CY 2017 year approval process in which QCDRs
Quality Payment Program final rule for activities, services, and performance
categories offered in the previous years would be approved for 2 continuous
a detailed discussion of the definition years using the same fixed services they
and capabilities of a QCDR. performance period of MIPS have
minimal or no changes and will be used had for the first year, would not provide
(1) Establishment of an Entity Seeking for the upcoming performance period. the QCDR with the flexibility to add or
To Qualify as a QCDR remove services and/or measures or
Specifically, existing QCDRs in good
activities based on their QCDR
In the CY 2017 Quality Payment standing may attest during the self-
capabilities for the upcoming program
Program final rule (81 FR 77365), we nomination period that they have no
year. Furthermore, another concern with
finalized the criteria to establish an changes to their approved self-
a multi-year approval process is the
entity seeking to qualify as a QCDR. We nomination application from the
concern for those QCDRs who perform
are not proposing any changes to the previous year of MIPS. In addition, the
poorly during the first year, and who
criteria in this proposed rule, and refer existing QCDRs may decide to make
should be placed on probation or
readers to the CY 2017 Quality Payment minimal changes to their approved self-
disqualified (as described below). We
Program final rule for the criteria to nomination application from the
request comments on this alternative.
qualify as a QCDR. previous year, which would be We finalized to require other
submitted by the QCDR for CMS review information (described below) of QCDRs
(2) Self-Nomination Period and approval by the close of the self- at the time of self-nomination. If an
In the CY 2017 Quality Payment nomination period. Minimal changes entity becomes qualified as a QCDR,
Program final rule (81 FR 77365 through may include limited changes to their they will need to sign a statement
77366), we finalized the self-nomination performance categories, adding or confirming this information is correct
period for the 2018 performance period removing MIPS quality measures, and prior to listing it on their Web site. Once
and for future years of the program to adding or updating existing services we post the QCDR on our Web site,
be from September 1 of the year prior and/or cost information. Existing including the services offered by the
to the applicable performance period QCDRs in good standing, may also QCDR, we will require the QCDR to
until November 1 of the same year. As submit for CMS review and approval, support these services or measures for
an example, the self-nomination period substantive changes to measure its clients as a condition of the entitys
for the 2018 performance period will specifications for existing QCDR qualification as a QCDR for purposes of
begin on September 1, 2017, and will measures that were approved the MIPS. Failure to do so will preclude the
end on November 1, 2017. Entities that previous year, or submit new QCDR QCDR from participation in MIPS in the
desire to qualify as a QCDR for the measures for CMS review and approval subsequent year.
purposes of MIPS for a given without having to complete the entire For future years, beginning with the
performance period will need to self- self-nomination application process, 2018 performance period, we are
nominate for that year and provide all which is required to be completed by a proposing that self-nomination
information requested by us at the time new QCDR. By attesting that certain information must be submitted via a
of self-nomination. Having qualified as aspects of their approved application web-based tool, and to eliminate the
a QCDR in a prior year does not from the previous year have not submission method of email. We will
automatically qualify the entity to changed, existing QCDRs in good provide further information on the web-
participate in MIPS as a QCDR in standing would be spending less time based tool at www.qpp.cms.gov. We
subsequent performance periods. completing the entire self-nomination request comments on this proposal.
Furthermore, prior performance of the form, as was previously required on a
QCDR (when applicable) will be taken yearly basis. We are proposing such a (3) Information Required at the Time of
into consideration in approval of their simplified process to reduce the burden Self-Nomination
self-nomination. For example, a QCDR of self-nomination for those existing In the CY 2017 Quality Payment
may choose not to continue QCDRs who have previously Program final rule (81 FR 77366 through
participation in the program in future participated in MIPS, and are in good 77367), we finalized the information a
years, or the QCDR may be precluded standing (not on probation or QCDR must provide to us at the time of
from participation in a future year due disqualified, as described below) and to self-nomination. We are proposing to
to multiple data or submission errors as allow for sufficient time for us to review replace the term non-MIPS measures
with QCDR measures for future program intermediaries and performance programs, such as the Physician Quality
years, beginning with the 2018 feedback. Reporting System (PQRS) program, if
performance period. We note that For purposes of distributing proposed as QCDR measures. This
although we are proposing a change in performance feedback to MIPS eligible includes measures that were retired due
the term referring to such measures, we clinicians, we encourage QCDRs to to being topped out (as defined in
are not proposing any other changes to assist MIPS eligible clinicians in the section II.C.6.c.(2) of this proposed rule)
the information a QCDR must provide to update of their email addresses in CMS due to high-performance or measures
us at the time of self-nomination systemsincluding PECOS and the retired due to a change in the evidence
finalized in the CY 2017 Quality Identity and Access Systemso that supporting the use of the measure.
Payment Program final rule. We refer they have access to feedback as it We seek comment for future
readers to the CY 2017 Quality Payment becomes available on www.qpp.cms.gov rulemaking, on requiring QCDRs that
Program final rule for specific and have documentation from the MIPS develop and report on QCDR measures,
information requirements. eligible clinician authorizing the release must fully develop and test (that is,
of his or her email address. conduct reliability and validity testing)
(4) QCDR Criteria for Data Submission As noted in the CY 2017 Quality their QCDR measures, by the time of
In the CY 2017 Quality Payment Payment Program final rule (81 FR submission of the new measure during
Program final rule (81 FR 77367 through 77370), we will on a case-by-case basis the self-nomination process.
77374), we finalized that a QCDR must allow QCDRs and qualified registries to Beginning with the 2018 performance
perform specific functions to meet the request review and approval for period and for future program years, we
criteria for data submission. While we additional MIPS measures throughout propose that QCDR vendors may seek
are not proposing any changes to the the performance period. We would like permission from another QCDR to use
criteria for data submission in this to explain that this flexibility would an existing measure that is owned by
proposed rule, we would like to note the only apply for MIPS measures; QCDRs the other QCDR. If a QCDR would like
following as clarifications to existing will not be able to request additions of report on an existing QCDR measure
criteria. Specifically, a QCDR any new QCDR measures throughout the that is owned by another QCDR, they
Must have in place mechanisms for performance period. QCDRs will not be must have permission from the QCDR
the transparency of data elements and able to retire any measures they are that owns the measure that they can use
specifications, risk models, and approved for during the performance the measure for the performance period.
measures. That is, we expect that the period. Should a QCDR encounter an Permission must be granted at the time
QCDR measures, and their data issue regarding the safety or change in of self-nomination, so that the QCDR
elements (that is, specifications) evidence for a measure during the that is using the measure can include
comprising these measures be listed on performance period, they must inform the proof of permission for CMS review
the QCDRs Web site unless the measure CMS of said issue and indicate whether and approval for the measure to be used
is a MIPS measure, in which case the they will or will not be reporting on the in the performance period. The QCDR
specifications will be posted by us. measure, and we will review measure measure owner (QCDR vendor) would
QCDR measure specifications should be issues on a case-by-case basis. Any still own and maintain the QCDR
provided at a level of detail that is measures QCDRs wish to retire would measure, but would allow other
comparable to what is posted by us on need to be retained until the next approved QCDRs to utilize their QCDR
the CMS Web site for MIPS quality annual self-nomination process and measure with proper notification. This
measures specifications. applicable performance period. proposal will help to harmonize
Approved QCDRs may post the clinically similar measures and limit the
MIPS quality measure specifications on (5) QCDR Measure Specifications
Criteria use of measures that only slightly differ
their Web site, if they so choose. If the from another. We invite comments on
MIPS quality measure specifications are In the CY 2017 Quality Payment this proposal.
posted by the QCDRs, they must Program final rule (81 FR 77374 through We would like to clarify from the CY
replicate exactly the same as the MIPS 77375), we specified at 414.1400(f) 2017 Quality Payment Program final
quality measure specifications posted that the QCDR must provide specific rule (81 FR 77375) that the QCDR must
on the CMS Web site. QCDR measures specifications criteria. publicly post the measure specifications
Enter into and maintain with its We generally intend to apply a process no later than 15 calendar days following
participating MIPS eligible clinicians an similar to the one used for MIPS our approval of these measures
appropriate Business Associate measures to QCDR measures that have specifications for each QCDR measure it
agreement that complies with the been identified as topped out. We are intends to submit for MIPS.
HIPAA Privacy and Security Rules. not proposing any changes to the QCDR We refer readers to the CY 2017
Ensure that the Business Associate measure specifications criteria as Quality Payment Program final rule for
agreement provides for the QCDRs finalized in the CY2017 Quality the QCDR measure specifications
receipt of patient-specific data from an Payment Program final rule. We would criteria.
individual MIPS eligible clinician or like to note that for QCDR quality
group, as well as the QCDRs disclosure measures, we encourage alignment with (6) Identifying QCDR Quality Measures
of quality measure results and our measures development plan, but In the CY 2017 Quality Payment
numerator and denominator data or will consider all QCDR measures Program final rule (81 FR 77375 through
patient specific data on Medicare and submitted by the QCDR. For MIPS 77377), we finalized the definition and
non-Medicare beneficiaries on behalf of measures, we would also like to note types of QCDR quality measures for
MIPS eligible clinicians and groups. that CMS expects that a QCDR reporting purposes of QCDRs submitting data for
Must provide timely feedback at on MIPS measures retain and use the the MIPS quality performance category.
least 4 times a year, on all of the MIPS MIPS specifications as they exist for the We are not proposing any changes to the
performance categories that the QCDR performance period. criteria on how to identify QCDR quality
will report to us. We refer readers to We would like to clarify that we will measures in this proposed rule. We
section II.C.9.a. of this proposed rule for likely not approve retired measures that would like to clarify that QCDRs are not
additional information on third party were previously in one of CMSs quality limited to reporting on QCDR measures,
and may also report on MIPS measures Certification Program (Program), (80 FR performance period will need to provide
as indicated above in the QCDR data 62604), a health IT developer all requested information to us at the
submission criteria section. constitutes a vendor, self-developer, or time of self-nomination and would need
other entity that presents health IT for to self-nominate for that performance
(7) Collaboration of Entities To Become
certification or has health IT certified period. Having previously qualified as a
a QCDR
under the Program. The use of health qualified registry does not automatically
In the CY 2017 Quality Payment IT developer is consistent with the use qualify the entity to participate in
Program final rule (81 FR 77377), we of the term health IT in place of subsequent MIPS performance periods.
finalized policy on the collaboration of EHR or EHR technology under the Furthermore, prior performance of the
entities to become a QCDR. We are not Program (see 80 FR 62604; and section qualified registry (when applicable) will
proposing any changes to this policy in II.C.6.f. of this proposed rule). be taken into consideration in approval
this proposed rule, and would refer Throughout this proposed rule, we use of their self-nomination. For example, a
readers to the CY 2017 Quality Payment the term health IT vendor to refer to qualified registry may choose not to
Program final rule for the criteria. entities that support the health IT continue participation in the program in
In response to the CY 2017 Quality requirements of a clinician participating future years, or the qualified registry
Payment Program final rule, in the Quality Payment Program. may be precluded from participation in
commenters recommended that we We are not proposing any changes to a future year, due to multiple data or
work with QCDRs to determine a more this policy in this proposed rule, and submission errors as noted below. As
reasonable cycle for self-nomination, would refer readers to the CY 2017 such, we believe an annual self-
measure selection, and reporting Quality Payment Program final rule for nomination process is the best process
because the current process is the criteria. However we seek comment to ensure accurate information is
burdensome. Commenters also for future rulemaking regarding the conveyed to MIPS eligible clinicians
recommended that we not disqualify potential shift to seeking alternatives and accurate data is submitted to MIPS.
QCDRs that do not have the capability which might fully replace the QRDA III
to allow MIPS eligible clinicians to However, we do understand that some
format in the Quality Payment Program qualified registries have no changes to
report across all performance categories in future program years.
using only one submission mechanism, the measures and/or activity inventory
and noted that the ability for QCDRs to c. Qualified Registries they offer to their clients and intend to
report their own measures allows MIPS In the CY 2017 Quality Payment participate in MIPS for many years.
eligible clinicians the ability to Program final rule (81 FR 77382 through Because of this, we are proposing,
implement measures that are more 77386), we finalized the definition and beginning with the 2019 performance
clinically meaningful and up-to-date capability of qualified registries. We are period, a simplified process in which
than those measures that may be not proposing any changes to the existing qualified registries in good
available in the MIPS measure set. We definition or the capabilities of qualified standing may continue their
would like to note that we are proposing registries in this final rule, and refer participation in MIPS by attesting that
above, a simplified self-nomination and readers to the CY 2017 Quality Payment the qualified registrys approved data
measure selection process available to Program final rule for the detailed validation plan, cost, approved MIPS
existing QCDRs that are in good definition and capabilities of a qualified quality measures, services, and
standing, beginning in the third year of registry. performance categories offered in the
the Quality Payment Program. We previous years performance period of
would also like to explain that QCDRs (1) Establishment of an Entity Seeking MIPS have minimal or no changes and
are not required to report on all To Qualify as a Registry will be used for the upcoming
performance categories across the MIPS In the CY 2017 Quality Payment performance period. Specifically,
program, and would not be disqualified Program final rule (81 FR 77383), we existing qualified registries in good
for not being able to report data across finalized the requirements for the standing may attest during the self-
on performance categories only using establishment of an entity seeking to nomination period that they have no
one mechanism. We thank the qualify as a registry. We are not changes to their approved self-
commenters for their support with proposing any changes to the criteria nomination application from the
regards to allowing QCDRs to nominate regarding the establishment of an entity previous year of MIPS. In addition, the
and report on QCDR measures that may seeking to qualify as a registry criteria existing qualified registry may decide to
be specialty related. We thank the in this proposed rule, and refer readers make minimal changes to their self-
commenters for their feedback and will to the final rule for the criteria for nomination application from the
take their comments into consideration establishing an entity seeking to qualify previous year, which would be
in future rule making. as a registry. submitted by the qualified registry for
CMS review and approval by the close
b. Health IT Vendors That Obtain Data (2) Self-Nomination Period of the self-nomination period. Minimal
From MIPS Eligible Clinicians Certified For the 2018 performance period, and changes may include limited changes to
EHR Technology (CEHRT) for future years of the program, we their performance categories, adding or
In the CY 2017 Quality Payment finalized at 414.1400(g) a self- removing MIPS quality measures, and
Program final rule 81 FR 77382, we nomination period from September 1 of adding or updating existing services
finalized definitions and criteria around the year prior to the applicable and/or cost information. By attesting
health IT vendors that obtain data from performance period, until November 1 that certain aspects of their approved
MIPS eligible clinicians CEHRT. We of the same year. For example, for the application from the previous year have
note that, for this proposed rule, a 2018 performance period, the self- not changed, existing qualified registries
health IT vendor that serves as a third nomination period would begin on will be spending less time completing
party intermediary to collect or submit September 1, 2017, and end on the entire self-nomination form, as was
data on behalf MIPS eligible clinicians November 1, 2017. Entities that desire to previously required on a yearly basis.
may or may not also be a health IT qualify as a qualified registry for We are proposing such a simplified
developer. Under the ONC Health IT purposes of MIPS for a given process to reduce the burden of self-
nomination for those existing qualified we post the qualified registry on our additional information on third party
registries who have previously Web site, including the services offered intermediaries and performance
participated in MIPS, and are in good by the qualified registry, we would feedback.
standing (not on probation or require the qualified registry to support We had received comments in
disqualified, as described below) and to these services/measures for its clients as response to the CY 2017 Quality
allow for sufficient time for us to review a condition of the entitys qualification Payment Program final rule from
data submissions and to make as a qualified registry for purposes of commenters who expressed concern
determinations on the standing of MIPS. Failure to do so will preclude the that the 3 percent acceptable error rate
qualified registries. This proposed qualified registry from participation in for qualified registries is too low.
process will allow existing qualified MIPS in the subsequent performance Commenters recommended we analyze
registries in good standing to avoid year. reporting for the transition year and
completing the entire application For the 2018 performance period and increase the error rate to 5 percent at the
annually, as is required in the existing beyond, we are proposing that self- minimum because qualified registries
process, and in alignment with the nomination information must be may make a small number of errors
existing timeline. We request comments submitted via a web-based tool, and to given that 2017 is the first year of MIPS
on this proposal. In the development of eliminate the submission method of and that removing qualified registries
this proposal, we had reviewed the email. We will provide further due to a low error threshold could hurt
possibility of offering a multi-year information on the web-based tool at clinicians. We thank the commenters for
approval, where qualified registries www.qpp.cms.gov. We request their feedback and will take the
would be approved for a 2-year comments on this proposal. comments into consideration in future
increment of time. We are concerned rulemaking.
(3) Information Required at the Time of As indicated in the CY 2017 Quality
that utilizing a multi-year approval Self-Nomination
process in which qualified registries Payment Program final rule (81 FR
would be approved for 2 continuous We finalized in the CY 2017 Quality 77370), we will on a case-by-case basis
program years using the same fixed Payment Program final rule (81 FR allow qualified registries to request
services they had for the first year, 77384) that a qualified registry must review and approval for additional
would not provide the qualified registry provide specific information to us at the MIPS measures throughout the
with the flexibility to add or remove time of self-nomination. We are not performance period. Any new measures
services and or measures based on their proposing any changes to the that are approved by us will be added
capabilities for the upcoming program information required at the time of self- to the information related to the
nomination in this proposed rule, and qualified registry on the CMS Web site,
year. Furthermore, another concern with
refer readers to the final rule for specific as technically feasible. We anticipate
a multi-year approval process is the
information requirements. only being able to update this
concern for those qualified registries
information on the Web site on a
who perform poorly during the first (4) Qualified Registry Criteria for Data
quarterly basis, as technically feasible.
year, who should be placed on Submission
probation or disqualified (as described In the CY 2017 Quality Payment d. CMS-Approved Survey Vendors
below). We are proposing that this Program final rule (81 FR 77386), we In the CY 2017 Quality Payment
process be conducted on a yearly basis, finalized the criteria for qualified Program final rule (81 FR 77386), we
from September 1 of the year prior to registry data submission. We are not finalized the definition, criteria,
the applicable performance period until proposing any changes to the data required forms, and vendor business
November 1 of the same year, starting in submission criteria in this proposed requirements needed to participate in
2018, aligning with the annual self- rule, and refer readers to the final rule MIPS as a survey vendor. We refer
nomination period in order to ensure for specific criteria regarding qualified readers to the CY 2017 Quality Payment
that only those qualified registries who registry data submission. We would like Program final rule for specific details on
are in good standing utilize this process. to note two clarifications to the existing requirements. We have heard from some
We believe that this annual process will criteria: groups that it would be useful to have
provide qualified registries with the Enter into and maintain with its a final list of CMS-approved survey
flexibility to make minor changes to participating MIPS eligible clinicians an vendors to inform their decision on
their services should they wish to do so. appropriate Business Associate whether or not to participate in the
We request comments on this proposal. agreement that complies with the CAHPS for MIPS survey. Therefore,
We also seek comment to potentially HIPAA Privacy and Security Rules. beginning with the 2018 performance
allow for qualified registries to utilize a Ensure that the Business Associate period and for future program years, we
multi-year approval process, in which agreement provides for the Qualified propose to remove the April 30th survey
they would be approved for a Registrys receipt of patient-specific data vendor application deadline because
continuous 2-year increment since from an individual MIPS eligible this deadline is within the timeframe of
qualified registries can only make minor clinician or group, as well as the when groups can elect to participate in
changes (for example, including a Qualified Registrys disclosure of the CAHPS for MIPS survey. In order to
performance category, or a MIPS quality quality measure results and numerator provide a final list of CMS-approved
measure, all of which are already and denominator data or patient specific survey vendors earlier in the timeframe
considered a part of the MIPS program). data on Medicare and non-Medicare during which groups can elect to
We finalized to require further beneficiaries on behalf of individual participate in the CAHPS for MIPS
information of qualified registries at the MIPS eligible clinicians and groups. survey, an earlier vendor application
time of self-nomination. If an entity We had finalized that timely deadline would be necessary. This
becomes qualified as a qualified feedback be provided at least four times could be accomplished by having a
registry, they would need to sign a a year, on all of the MIPS performance rolling application period, where
statement confirming this information is categories that the qualified registry will vendors would be able to submit an
correct prior to us listing their report to us. We refer readers to section application by the end of the first
qualifications on their Web site. Once II.C.9.a. of this proposed rule for quarter. However, in addition to
submitting a vendor application, In addition, we finalized that if the place with the vendor at the time of
vendors must also complete vendor third party intermediary has data their withdrawal from the marketplace.
training and submit a Quality Assurance inaccuracies including (but not limited We are not proposing any changes to the
Plan and we need to allow sufficient to) TIN/NPI mismatches, formatting process of probation and
time for these requirements as well. issues, calculation errors, data audit disqualification of a third party
Therefore, we propose for the Quality discrepancies affecting in excess of 3 intermediary in this proposed rule.
Payment Program Year 2 and future percent (but less than 5 percent) of the Commenters on the final rule
years that the vendor application total number of MIPS eligible clinicians requested that we provide opportunities
deadline would be January 31st of the or groups submitted by the third party for MIPS eligible clinicians and groups
applicable performance year or a later intermediary, we would annotate the that discover an issue with their third
date specified by CMS. This proposal listing of qualified third party party intermediary to change reporting
would allow us to adjust the application intermediaries on the CMS Web site, methods and/or third party
deadline beyond January 31st on a year noting that the third party intermediary intermediaries without restriction on
to year basis, based on program needs. furnished data of poor quality and the eligible clinicians. We thank the
We will notify vendors of the would place the entity on probation for commenters for their feedback and will
application deadline to become a CMS- the subsequent performance period. take the comments into consideration in
approved survey vendor through Further, we finalized if the third party future rulemaking.
additional communications and intermediary does not reduce their data
error rate below 3 percent for the f. Auditing of Third Party Intermediaries
postings. We request comments on this Submitting MIPS Data
proposal and other alternatives that subsequent performance period, the
would allow us to provide a final list of third party intermediary would In the CY 2017 Quality Payment
CMS-approved survey vendors early in continue to be on probation and have Program final rule (81 FR 77389), we
the timeframe during which groups can their listing on the CMS Web site finalized at 414.1400(j) that any third
elect to participate in the CAHPS for continue to note the poor quality of the party intermediary (that is, a QCDR,
MIPS survey. data they are submitting for MIPS for health IT vendor, qualified registry, or
one additional performance period. CMS-approved survey vendor) must
e. Probation and Disqualification of a After 2 years on probation, the third comply with the following procedures
Third Party Intermediary party intermediary would be as a condition of their qualification and
At 414.1400(k), we finalized the disqualified for the subsequent approval to participate in MIPS as a
process for placing third party performance period. Data errors third party intermediary:
intermediaries on probation and for affecting in excess of 5 percent of the (1) The entity must make available to
disqualifying such entities for failure to MIPS eligible clinicians or groups us the contact information of each MIPS
meet certain standards established by us submitted by the third party eligible clinician or group on behalf of
(81 FR 77386). Specifically, we intermediary may lead to the whom it submits data. The contact
proposed that if at any time we disqualification of the third party information will include, at a minimum,
determine that a third party intermediary from participation for the the MIPS eligible clinician or groups
intermediary (that is, a QCDR, health IT following performance period. In practice phone number, address, and if
vendor, qualified registry, or CMS- placing the third party intermediary on available, email;
probation; we would notify the third (2) The entity must retain all data
approved survey vendor) has not met all
party intermediary of the identified submitted to us for MIPS for a minimum
of the applicable criteria for
issues, at the time of discovery of such of 10 years; and
qualification, we may place the third
issues. (3) For the purposes of auditing, we
party intermediary on probation for the In addition, we finalized that if the may request any records or data retained
current performance period or the third party intermediary does not for the purposes of MIPS for up to 6
following performance period, as submit an acceptable corrective action years and 3 months.
applicable. plan within 14 days of notification of We are proposing to change
In addition, we finalized that we the deficiencies and correct the 414.1400(j)(2) to clarify that the entity
require a corrective action plan from the deficiencies within 30 days or before the must retain all data submitted to us for
third party intermediary to address any submission deadlinewhichever is purposes of MIPS for a minimum of 10
deficiencies or issues and prevent them sooner, we may disqualify the third years from the end of the MIPS
from recurring. We finalized that the party intermediary from participating in performance period.
corrective action plan must be received MIPS for the current performance
and accepted by us within 14 days of period or the following performance 11. Public Reporting on Physician
the CMS notification to the third party period, as applicable. Compare
intermediary of the deficiencies or We note that MIPS eligible clinicians This section contains the approach for
probation. Failure to comply with these are ultimately responsible for the data public reporting on Physician Compare
corrective action plan requirements that are submitted by their third party for the CY 2018 Quality Payment
would lead to disqualification from intermediaries and expect that MIPS Program final rule, including MIPS,
MIPS for the subsequent performance eligible clinicians and groups should APMs, and other information as
period. ultimately hold their third party required by the MACRA and building
We finalized for probation to mean intermediaries accountable for accurate on the MACRA public reporting policies
that, for the applicable performance reporting. We will consider cases of previously finalized (81 FR 77390
period, the third party intermediary vendors leaving the marketplace during through 77399).
must meet all applicable criteria for the performance period on a case by Physician Compare draws its
qualification and approval and also case basis, but would note that we will operating authority from section
must submit a corrective action plan for not consider cases prior to the 10331(a)(1) of the Affordable Care Act.
remediation or correction of any performance period. We would As required by section 10331(a)(1) of the
deficiencies identified by CMS that however, need proof that the MIPS Affordable Care Act, by January 1, 2011,
resulted in the probation (81 FR 77548). eligible clinician had an agreement in we developed a Physician Compare
Internet Web site with information on assessment of efficiency, patient health Initial plans to publicly report this
physicians enrolled in the Medicare outcomes, and patient experience, as performance information on Physician
program under section 1866(j) of the specified. The first set of quality Compare were finalized in the CY 2017
Act, as well as information on other EPs measures were publicly reported on Quality Payment Program final rule (81
who participate in the PQRS under Physician Compare in February 2014. FR 77390). The proposals related to
section 1848 of the Act. More Currently, Physician Compare publicly each of these requirements for year 2 of
information about Physician Compare reports 91 group-level measures the Quality Payment Program are
can be accessed on the Physician collected through either the Web addressed below in this section.
Compare Initiative Web site at https:// Interface or registry for groups Section 1848(q)(9)(B) of the Act also
www.cms.gov/medicare/quality- participating in 2015 under the PQRS, requires that this information indicate,
initiatives-patient-assessment- 19 quality measures for ACOs where appropriate, that publicized
instruments/physician-compare- participating in the 2015 Shared Savings information may not be representative
initiative/. Program or Pioneer ACO program, and of the eligible clinicians entire patient
The first phase of Physician Compare 90 individual clinician-level measures population, the variety of services
was launched on December 30, 2010 collected either through claims or furnished by the eligible clinician, or
(http://www.medicare.gov/ registry for individual EPs participating the health conditions of individuals
physiciancompare). Since the initial in 2015 under the PQRS. In addition, 31 treated. The information mandated for
launch, Physician Compare has been total individual clinician-level Qualified Physician Compare under section
continually improved and more Clinical Data Registry (QCDR) non- 1848(q)(9) of the Act will generally be
information has been added. In PQRS measures are publicly available publicly reported consistent with
December 2016, the site underwent a either through Physician Compare sections 10331(a)(2) and 10331(b) of the
complete user-informed, evidenced- profile pages or 2015 QCDR Web sites. Affordable Care Act, and like all
based redesign to further enhance A complete history of public reporting measure data included on Physician
usability and functionality on both on Physician Compare is detailed in the Compare, will be comparable. In
desktop computers and mobile devices CY 2016 PFS final rule (80 FR 71117 addition, section 10331(b) of the
and to begin to prepare the site for the through 71122). Affordable Care Act requires that we
inclusion of more data as required by As finalized in the CY 2015 and CY include, to the extent practicable,
the MACRA. 2016 PFS final rules (79 FR 67547 and processes to ensure that data made
Currently, Web site users can view 80 FR 70885, respectively), Physician public are statistically valid, reliable,
information about approved Medicare Compare will continue to expand public and accurate, including risk adjustment
clinicians, such as: Name; Medicare reporting. This expansion includes mechanisms used by the Secretary. In
primary and secondary specialties; publicly reporting both individual addition to the public reporting
practice locations; group affiliations; eligible professional (now referred to as standards identified in the Affordable
hospital affiliations that link to the eligible clinician) and group-level QCDR Care Actstatistically valid and reliable
hospitals profile on Hospital Compare measures starting with 2016 data data that are accurate and comparable
as available; Medicare assignment available for public reporting in late we have established a policy that, as
status; education; residency; and, 2017, as well as the inclusion of a determined through user testing, the
American Board of Medical Specialties benchmark and 5-star rating in late 2017 data we disclose generally should
(ABMS), American Osteopathic based on 2016 data (80 FR 71125 and resonate with and be accurately
Association (AOA), and American 71129), among other additions. interpreted by Web site users to be
Board of Optometry (ABO) board This expansion will continue under included on Physician Compare profile
certification information. For groups, the MACRA. Sections 1848(q)(9)(A) and pages. Together, we refer to these
users can view group names, specialties, (D) of the Act facilitate the continuation conditions as the Physician Compare
practice locations, Medicare assignment of our phased approach to public public reporting standards (80 FR 71118
status, and affiliated clinicians. In reporting by requiring the Secretary to through 71120). Section 10331(d) of the
December 2016, we also added make available on the Physician Affordable Care Act also requires us to
indicators on the results page to show Compare Web site, in an easily consider input from multi-stakeholder
those clinicians and groups that had understandable format, individual MIPS groups, consistent with sections
performance scores available to view. eligible clinician and group 1890(b)(7) and 1890A of the Act. We
We also included an indicator on profile performance information, including: continue to receive general input from
pages to show those Medicare clinicians The MIPS eligible clinicians final stakeholders on Physician Compare
and groups that satisfactorily or score; through a variety of means, including
successfully participated in a CMS The MIPS eligible clinicians rulemaking and different forms of
quality program to indicate their performance under each MIPS stakeholder outreach (for example,
commitment to quality. performance category (quality, cost, Town Hall meetings, Open Door
Consistent with section 10331(a)(2) of improvement activities, and advancing Forums, webinars, education and
the Affordable Care Act, Physician care information); outreach, Technical Expert Panels, etc.).
Compare phased in public reporting of Names of eligible clinicians in In addition, section 1848(q)(9)(C) of
performance scores that provide Advanced APMs and, to the extent the Act requires the Secretary to provide
comparable information on quality and feasible, the names of such Advanced an opportunity for MIPS eligible
patient experience measures for APMs and the performance of such clinicians to review the information that
reporting periods beginning January 1, models; and, will be publicly reported prior to such
2012. To the extent that scientifically Aggregate information on the MIPS, information being made public. This is
sound measures are developed and are posted periodically, including the range generally consistent with section
available, Physician Compare is of final scores for all MIPS eligible 10331(a)(2) of the Affordable Care Act,
required to include, to the extent clinicians and the range of the under which we have established a 30-
practicable, the following types of performance of all MIPS eligible day preview period for all measurement
measures for public reporting: Measures clinicians for each performance performance data that allows physicians
collected under PQRS and an category. and other eligible clinicians to view
their data as it will appear on the Web is available to the public, such as an year, we rely on the established public
site in advance of publication on NPI. reporting standards to guide the
Physician Compare (80 FR 77392). The information is further required to information available for inclusion on
Section 1848(q)(9)(C) of the Act also be made searchable by at least specialty Physician Compare. The public
requires that MIPS eligible clinicians be or type of physician or other eligible reporting standards require data
able to submit corrections for the clinician; characteristics of the services included on Physician Compare to be
information to be made public. We furnished (such as, volume or groupings statistically valid, reliable, and accurate;
finalized a policy to extend the current of services); and the location of the be comparable across reporting
Physician Compare 30-day preview physician or other eligible clinician. mechanisms; and, meet the reliability
period for MIPS eligible clinicians In accordance with section 104(e) of threshold. And, to be included on the
starting with data from the 2017 MIPS the MACRA, we finalized a policy in the public facing profile pages, the data
performance period, which is available CY 2016 PFS final rule (80 FR 71130) must also resonate with Web site users,
for public reporting in late 2018. to add utilization data to the Physician as determined by CMS. At proposed
Therefore, we finalized a 30-day Compare downloadable database. 414.1395(c), we propose to codify our
preview period in advance of the Utilization data is currently available at policy regarding first year measures:
publication of data on Physician http://www.cms.gov/Research-Statistics- For each program year, CMS does not
Compare (81 FR 77392). Data-and-Systems/Statistics-Trends- publicly report any first year measure,
We will coordinate data review and and-Reports/Medicare-Provider-Charge- meaning any measure in its first year of
any relevant data resubmission or Data/Physician-and-Other- use in the quality and cost performance
correction between Physician Compare Supplier.html. This information is categories. After the first year, CMS
and the four performance categories of integrated on the Physician Compare reevaluates measures to determine when
MIPS. All data available for public Web site via the downloadable database and if they are suitable for public
reportingmeasure rates, scores, and each year using the most current data, reporting. At proposed 414.1395(d),
attestations, etc.are available for starting with the 2016 data, targeted for we propose to specify the 30-day
review and correction during the initial release in late 2017 (80 FR preview period rule: For each program
targeted review process, which will 71130). Not all available data will be year, CMS provides a 30-day preview
begin at least 30 days in advance of the included. The specific HCPCS codes period for any clinician or group with
publication of new data. Data under included are to be determined based on Quality Payment Program data before
review is not publicly reported until the analysis of the available data, focusing the data are publicly reported on
review is complete. All corrected on the most used codes. Additional Physician Compare.
measure rates, scores, and attestations details about the specific HCPCS codes We believe section 10331 of the
submitted as part of this process are that are included in the downloadable Affordable Care Act supports the
available for public reporting. The database will be provided to overarching goals of the MACRA by
technical details of the process are stakeholders in advance of data providing the public with quality
communicated directly to affected MIPS publication. All data available for public information that will help them make
eligible clinicians and groups and reportingon the public-facing Web site informed decisions about their health
detailed outside of rulemaking with pages or in the downloadable care, while encouraging clinicians to
specifics made public on the Physician databaseare available for review improve the quality of care they provide
Compare Initiative page on during the 30-day preview period. to their patients. In accordance with
www.cms.gov and communicated We propose to revise the public section 10331 of the Affordable Care
through Physician Compare and other reporting regulation at 414.1395(a), to Act, section 1848(q)(9) of the Act, and
CMS listservs (81 FR 77391). more completely and accurately section 104(e) of the MACRA, we plan
In addition, section 1848(q)(9)(D) of reference the data available for public to continue to publicly report
the Act requires that aggregate reporting on Physician Compare. We performance information on Physician
information on the MIPS be periodically propose to modify 414.1395(a) to Compare. As such, we propose the
posted on the Physician Compare Web remove from the heading and text inclusion of the following information
site, including the range of final scores references to MIPS and public Web on Physician Compare.
for all MIPS eligible clinicians and the site and instead reference Quality
Payment Program and Physician a. Final Score, Performance Categories,
range of performance for all MIPS and Aggregate Information
eligible clinicians for each performance Compare. Specifically, proposed
category. 414.1395(a) reads as follows: Public Sections 1848(q)(9)(A) and (D) of the
Lastly, section 104(e) of the MACRA reporting of eligible clinician and group Act require that we publicly report on
requires the Secretary to make publicly Quality Payment Program information. Physician Compare the final score for
available, on an annual basis, in an For each program year, CMS posts on each MIPS eligible clinician,
easily understandable format, Physician Compare, in an easily performance of each MIPS eligible
information for physicians and, as understandable format, information clinician for each performance category,
appropriate, other eligible clinicians regarding the performance of eligible and periodically post aggregate
related to items and services furnished clinicians or groups under the Quality information on the MIPS, including the
to people with Medicare, and to Payment Program. We also propose to range of final scores for all MIPS eligible
include, at a minimum: add paragraphs (b), (c), and (d) at clinicians and the range of performance
Information on the number of 414.1395, to capture previously of all the MIPS eligible clinicians for
services furnished under Part B, which established policies for Physician each performance category. We finalized
may include information on the most Compare relating to the public reporting such data for public reporting on
frequent services furnished or groupings standards, first year measures, and the Physician Compare for the transition
of services; 30-day preview period. Specifically, at year (81 FR 77393), and we are now
Information on submitted charges proposed 414.1395(b), we propose proposing to add these data each year to
and payments for Part B services; and, that, with the exception of data that Physician Compare for each MIPS
A unique identifier for the must be mandatorily reported on eligible clinician or group, either on the
physician or other eligible clinician that Physician Compare, for each program profile pages or in the downloadable
database, as technically feasible. of not publicly reporting first year relates to scoring of cost measures see
Statistical testing and user testing, as measures, meaning new measures that section II.C.7.a.(3) of this proposed rule.
well as consultation of the Physician have been in use for less than 1 year, In the CY 2017 Quality Payment
Compare Technical Expert Panel, will regardless of submission method used, Program final rule, we established that
determine how and where these data are for this MIPS quality performance we will include the total number of
best reported on Physician Compare. As category. After a measures first year in patients reported on each measure in
the MACRA requires that this use, we will evaluate the measure to see the downloadable database to facilitate
information be available for public if and when the measure is suitable for transparency and more accurate
reporting on Physician Compare, we are public reporting (81 FR 77395). understanding and use of the data (81
proposing to include it each year Currently, there is a minimum sample FR 77395). We will begin publishing the
moving forward, as technically feasible. size requirement of 20 patients for total number of patients reported on
We request comment on this proposal to performance data to be included on each measure in the downloadable
publicly report on Physician Compare Physician Compare. We previously database with 2017 data available for
the final score for each MIPS eligible sought comment on moving away from public reporting in late 2018 and for
clinician or group, performance of each this requirement and moving to a each year moving forward.
MIPS eligible clinician or group for each reliability threshold for public Understanding that we will continue
performance category, and periodically reporting. In general, commenters our policies to not publicly report first
post aggregate information on the MIPS, supported a minimum reliability year quality measures, that we will only
including the range of final scores for threshold. As a result, we finalized report those measures that meet the
and the range of performance of all the instituting a minimum reliability reliability threshold and meet the public
MIPS eligible clinicians or groups for threshold for public reporting data on reporting standards, and include the
each performance category, as Physician Compare starting with 2017 total number of patients reported on for
technically feasible. data available for public report in late each measure in the downloadable
A detailed discussion of proposals 2018 and each year moving forward (81 database, we are again proposing to
related to each performance category of FR 77395). make all measures under the MIPS
MIPS data follows. The reliability of a measure refers to quality performance category available
the extent to which the variation in the for public reporting on Physician
b. Quality performance rate is due to variation in Compare, as technically feasible. This
As detailed in the CY 2017 Quality quality of care as opposed to random would include all available measures
Payment Program final rule (81 FR variation due to sampling. Statistically, reported via all available submission
77395), and consistent with the existing reliability depends on performance methods for both MIPS eligible
policy that makes all current PQRS variation for a measure across entities, clinicians and groups, for 2018 data
measures available for public reporting, the random variation in performance for available for public reporting in late
we finalized a decision to make all a measure within an entitys panel of 2019, and for each year moving forward,
measures under the MIPS quality attributed patients, and the number of these data are required by the MACRA
performance category available for patients attributed to the entity. High to be available for public reporting on
public reporting on Physician Compare reliability for a measure suggests that Physician Compare, continuing to
in the transition year of the Quality comparisons of relative performance publicly report these data ensures
Payment Program, as technically across entities, such as eligible continued transparency and provides
feasible. This included all available clinicians or groups, are likely to be people with Medicare and their
measures reported via all available stable and consistent, and that the caregivers valuable information they can
submission methods, and applied to performance of one entity on the quality use to make informed health care
both MIPS eligible clinicians and measure can confidently be decisions. We request comment on this
groups. distinguished from another. We will proposal.
Also consistent with current policy, conduct analyses to determine the In addition, we seek comment on
although all measures will be available reliability of the data collected and use expanding the patient experience data
for public reporting, not all measures this to calculate the minimum reliability available for public reporting on
will be made available on the public- threshold for the data. Once an Physician Compare. Currently, the
facing Web site profile pages. As appropriate minimum reliability Consumer Assessment of Healthcare
explained in the CY 2017 Quality threshold is determined, we will only Providers and Systems (CAHPS) for
Payment Program final rule (81 FR publicly report those performance rates MIPS survey is available for groups to
77394), providing too much information for any given measure that meet the report under the MIPS. This patient
can overwhelm Web site users and lead minimum reliability threshold. We note experience survey data is highly valued
to poor decision making. Therefore, that reliability standards for public by patients and their caregivers as they
consistent with section reporting and reliability for scoring need evaluate their health care options.
1848(q)(9)(A)(i)(II) of the Act, all not align; reliability for public reporting However, in testing with patient and
measures in the quality performance is unique because, for example, public caregivers, they regularly ask for more
category that meet the statistical public reporting requires ensuring additional information from patients like them in
reporting standards will be included in protections to maintain confidentiality. their own words. Patients regularly
the downloadable database, as In addition, because publicly reported request we include narrative reviews of
technically feasible. We also finalized a measures can be compared across clinicians and groups on the Web site.
policy that a subset of these measures clinicians and across groups, it is The Agency for Healthcare Research and
will be publicly reported on the Web particularly important for the most Quality (AHRQ) is fielding a beta
sites profile pages, as technically stringent reliability standards to be in version of the CAHPS Patient Narrative
feasible, based on Web site user testing. place to ensure differences in Elicitation Protocol (https://
Statistical testing and user testing will performance scores reflect true www.ahrq.gov/cahps/surveys-guidance/
determine how and where measures are differences in quality of care to promote item-sets/elicitation/index.html). This
reported on Physician Compare. In accurate comparisons by the public. For includes five open-ended questions
addition, we adopted our existing policy further information on reliability as it designed to be added to the Clinician &
Groups CAHPS survey, which CAHPS reporting standards would be included any improvement activities in their first
for MIPS is molded after. These five in the downloadable database. year of use. Starting with year 2 (2018
questions have been developed and Statistical testing and Web site user data available for public reporting in
tested to work to capture patient testing would determine how and where late 2019), we propose publicly
narratives in a scientifically grounded measures are reported on Physician reporting first year activities if all other
and rigorous way, setting it apart from Compare to minimize passing the reporting criteria are satisfied. This
other patient narratives collected by complexity of these measures on to evolution in our Quality Payment
various health systems and patient patients and to ensure those measures Program public reporting plan provides
rating sites. More scientifically rigorous included are accurately understood and an opportunity to make more valuable
patient narrative data would not only correctly interpreted. Under this information public given that
greatly benefit patients, but it would proposal, we note that the policies we completion of or participation in
also greatly aid clinicians and groups as previously mentioned regarding first activities the first year they are available
they work to assess how their patients year measures, the minimum reliability is different from reporting first year
experience care. We are seeking threshold, and all public reporting quality or cost measures. Clinicians and
comment on potentially public standards would apply. This proposal groups can learn from the first year of
reporting these five open-ended applies to all available measures quality and cost data, understand why
questions for the CAHPS for MIPS reported via all available submission their performance rate is what it is, and
survey on Physician Compare as a methods, and applies to both MIPS take time to improve. A waiting period
consideration in future rulemaking. We eligible clinicians and groups. We for indicating completion or
direct readers to the Quality request comment on this proposal. participation in an improvement
Performance Criteria in section activity is unlikely to produce the same
d. Improvement Activities
II.C.6.b.(3)(a) of this proposed rule for benefit. We request comments on these
additional information related to Consistent with section proposals.
seeking comment on adding these 1848(q)(9)(A)(i)(II) of the Act, we
finalized a decision to make all e. Advancing Care Information
questions to the CAHPS for MIPS
survey. activities under the MIPS improvement Since the beginning of the EHR
activities performance category Incentive Programs in 2011, participant
c. Cost available for public reporting on performance data has been publicly
Consistent with section Physician Compare (81 FR 77396). This available in the form of public use files
1848(q)(9)(A)(i)(II) of the Act, we included all available improvement on the CMS Web site. In the 2015 EHR
finalized in the CY 2017 Quality activities reported via all available Incentive Programs final rule (80 FR
Payment Program final rule a decision submission methods, and applied to 62901), we addressed comments
to make all measures under the MIPS both MIPS eligible clinicians and requesting that we not only continue
cost performance category available for groups. this practice but also include a wider
public reporting on Physician Compare Consistent with the policy finalized range of information on participation
(81 FR 77396). This included all for the transition year, we are again and performance. In that rule, we stated
available measures reported via all proposing to include a subset of our intent to publish the performance
available submission methods, and improvement activities data on and participation data on Stage 3
applied to both MIPS eligible clinicians Physician Compare that meet the public objectives and measures of meaningful
and groups. However, as noted in the reporting standards, either on the profile use in alignment with quality programs
final rule, we may not have data pages or in the downloadable database, which utilize publicly available
available for public reporting in the if technically feasible, for 2018 data performance data such as Physician
transition year of the Quality Payment available for public reporting in late Compare. At this time there is only an
Program for the cost performance 2019, and for each year moving forward. indicator on Physician Compare profile
category (2017 data available for public This again includes all available pages to show that an eligible clinician
reporting in late 2018). activities reported via all available successfully participated in the current
As discussed in the final rule (81 FR submission methods, and applies to Medicare EHR Incentive Program.
77395), cost data are difficult for both MIPS eligible clinicians and As MIPS will include advancing care
patients to understand and, as a result, groups. For those eligible clinicians or information as one of the four MIPS
publicly reporting these measures could groups that successfully meet the performance categories, we decided,
lead to significant misinterpretation and improvement activities performance consistent with section 1848(q)(9)(i)(II)
misunderstanding. For this reason, we category requirements this information of the Act, to include more information
are again proposing to include on may be posted on Physician Compare as on an eligible clinicians or groups
Physician Compare a sub-set of cost an indicator. This information is performance on the objectives and
measures that meet the public reporting required by the MACRA to be available measures of meaningful use on
standards, either on profile pages or in for public reporting on Physician Physician Compare for the transition
the downloadable database, if Compare, but the improvement year (81 FR 77387). An important
technically feasible, for 2018 data activities performance category is a new consideration was that to meet the
available for public reporting in late field of data for Physician Compare so public reporting standards, the data
2019, and for each year moving forward. concept and Web site user testing is still added to Physician Compare must
These data are required by the MACRA needed to ensure these data are resonate with Medicare patients and
to be available for public reporting on understood by stakeholders. Therefore, their caregivers. Testing to date has
Physician Compare, but we want to we again propose that statistical testing shown that people with Medicare value
ensure we only share those cost and user testing would determine how the use of certified EHR technology and
measures that can help patients and and where improvement activities are see EHR use as something that if used
caregivers make informed health care reported on Physician Compare. well can improve the quality of their
decisions on profile pages. For For the transition year, we proposed care. In addition, we believe the
transparency purposes, the cost to exclude first year activities from inclusion of indicators for clinicians
measures that meet all other public public reporting. First year activities are and groups who achieve high
performance in key care coordination and between clinicians. In an effort to number by the total number of patients
and patient engagement activities find the best possible methodology for that were measured by the top
provide significant value for patients Physician Compare, we embarked on a performing doctors. This would produce
and their caregivers as they make health year-long information gathering and a benchmark that represents the best
care decisions. stakeholder outreach effort in advance care provided to the top 10 percent of
Consistent with our transition year of the CY 2016 PFS rule process. We patients by measure, by reporting
final policy, and understanding the reached out to stakeholders, including mechanism.
value of this information to Web site specialty societies, consumer advocacy An Example: A clinician reports on
users, we are again proposing to include groups, physicians and other clinicians, how many patients with diabetes she
an indicator on Physician Compare for measure experts, and quality measure has given foot exams. There are four
any eligible clinician or group who specialists, as well as other CMS Quality steps to establishing the benchmark for
successfully meets the advancing care Programs. Based on this outreach and this measure.
information performance category, as the recommendation of our Technical (1) We look at the total number of
technically feasible. Also, as technically Expert Panel, we proposed and patients with diabetes for all clinicians
feasible, we propose to include ultimately finalized (80 FR 71129) a who reported this diabetes measure.
additional indicators, including but not decision to publicly report on Physician (2) We rank clinicians that reported
limited to, objectives, activities, or Compare an item, or measure-level, this diabetes measure from highest
measures specified in section II.C.6.f. of benchmark using the Achievable performance score to lowest
this proposed rule, such as, identifying Benchmark of Care (ABCTM) 21 performance score to identify the set of
if the eligible clinician or group scores methodology annually based on the top clinicians who treated at least 10
high performance in patient access, care PQRS performance rates most recently percent of the total number of patients
coordination and patient engagement, or available by reporting mechanism. As a with diabetes.
health information exchange. These result, in late 2017, we expect to (3) We count how many of the
proposals would apply to 2018 data publicly report a benchmark based on patients with diabetes who were treated
available for public reporting in late the 2016 PQRS performance rates for by the top clinicians also got a foot
2019, and for each year moving forward, each measure by each available exam.
as this information is required by the reporting mechanism. The specific (4) This number is divided by the
MACRA to be available for public measures the benchmark will be total number of patients with diabetes
reporting on Physician Compare. We calculated for will be determined once who were treated by the top clinicians,
also propose that any advancing care the data are available and analyzed. As producing the ABCTM benchmark.
information objectives, activities, or with all data, the benchmark will only To account for low denominators,
measures would need to meet the public be applied to those measures deemed to ABCTM suggests the calculation of an
reporting standards applicable to data meet the established public reporting adjusted performance fraction (AFP)
posted on Physician Compare, either on standards. using a Bayesian Estimator or use of
the profile pages or in the downloadable We believe ABCTM is a well-tested, another statistical methodology. After
database. This would include all data-driven methodology that allows us analysis, we have determined that the
available objectives, activities, or to account for all of the data collected use of a beta binomial model adjustment
measures reported via all available for a quality measure, evaluate who the is most appropriate for the type of data
submission methods, and would apply top performers are, and then use that to we are working with. The beta binomial
to both MIPS eligible clinicians and set a point of comparison for all of those method moves extreme values toward
groups. Statistical testing and Web site groups or clinicians who report the the average for a given measure, while
user testing would determine how and measure. the Bayesian Estimator moves extreme
where objectives and measures are ABCTM starts with the pared-mean, values toward 50 percent. Using the beta
reported on Physician Compare. As with which is the mean of the best binomial method is a more
improvement activities, we are also performers on a given measure for at methodologically sophisticated
proposing to allow first year advancing least 10 percent of the patient approach to address the issue of extreme
care information objectives, activities, populationnot the population of values based on small sample sizes.
and measures to be available for public reporters. To find the pared-mean, we This ensures that all clinicians are
reporting starting in year 2 (2018 data will rank order physicians or groups (as accounted for and appropriately figured
available for public reporting in late appropriate per the measure being in to the benchmark.
2019). Again, especially if we are evaluated) in order from highest to The benchmarks for Physician
including an indicator over a lowest performance score. We will then Compare developed using the ABCTM
performance rate, the benefits of waiting subset the list by taking the best methodology will be based on the
1 year are not the same and thus, we performers moving down from best to current years data, so the benchmark
believe it is more important to make worst until we have selected enough will be appropriate regardless of the
more information available for public reporters to represent 10 percent of all unique circumstances of data collection
reporting as the Quality Payment patients in the denominator across all or the measures available in a given
Program matures. We request comment reporters for that measure. reporting year. We also finalized (80 FR
on these proposals. We finalized that the benchmark 71129) a decision to use the ABCTM
would be derived by calculating the methodology to generate a benchmark
f. Achievable Benchmark of Care total number of patients in the highest which will be used to systematically
(ABCTM) scoring subset receiving the intervention assign stars for the Physician Compare
Benchmarks are important to ensuring or the desired level of care, or achieving 5-star rating. The details of how the
that the quality data published on the desired outcome, and dividing this benchmark will be specifically used to
Physician Compare are accurately determine the 5-star categories for all
understood. A benchmark allows Web 21 Kiefe CI, Weissman NW., Allison JJ, Farmer R,
applicable measures is being
Weaver M, Williams OD. Identifying achievable
site users to more easily evaluate the benchmarks of care: concepts and methodology.
determined in close collaboration with
information published by providing a International Journal of Quality Health Care. 1998 stakeholders, CMS programs, measure
point of comparison between groups Oct; 10(5):4437. experts, and the Physician Compare
Technical Expert Panel. We expect to support this methodology received in Payment Program (2018 data available
publicly report the benchmark and 5- previous rulemaking and throughout for public reporting in 2019) and for
star rating for the first time on Physician our outreach process to date, we are each year moving forward, to make
Compare in late 2017 using the 2016 again proposing to use the ABCTM available for public reporting all data
PQRS performance scores for both methodology to determine a benchmark submitted voluntarily across all MIPS
clinicians and groups. for the quality, cost, improvement performance categories, regardless of
As a result of stakeholder feedback activities, and advancing care submission method, by clinician and
asking that we consider one consistent information data, as feasible and groups not subject to the MIPS payment
approach for benchmarking and parsing appropriate, by measure and by adjustments, as technically feasible.
the data based on the benchmark across reporting mechanism for each year of If a clinician or group chooses to
the Quality Payment Program, we did the Quality Payment Program, starting submit quality, cost, improvement
consider an alternative approach. We with the transition year data (2017 data activity, or advancing care information,
reviewed the benchmark and decile available for public reporting in late these data would become available for
breaks being used to assign points and 2018). We are also proposing to use this public reporting. However, because
determine payment under MIPS (see benchmark to determine a 5-star rating these data would be submitted
II.C.7.a.(2)(b) of this proposed rule). for each MIPS measure, as feasible and voluntarily, we propose that during the
This approach was not considered ideal appropriate. As previously finalized, 30-day preview period these clinicians
for public reporting for several reasons. only those measures that meet the and groups would have the option to
A primary concern was that the decile public reporting standards would be opt out of having their data publicly
approach when used for public considered and the benchmark would reported on Physician Compare. If
reporting would force a star rating be based on the most recently available clinicians and groups do not actively
distribution inconsistent with the raw data. The details of how the benchmark opt out at this time, their data would be
distribution of scores on a given will translate to the 5-star rating will be available for inclusion on Physician
measure. If applied to star ratings, there determined in consultation with Compare if the data meet all previously
would need to be an equal distribution stakeholders. stated public reporting standards and
of clinicians in each of the star rating We believe that displaying the the minimum reliability threshold. As
categories. appropriate and relevant MIPS data in clinicians and groups not required to
Using the ABCTM methodology for the this user-friendly format provides more report under MIPS, particularly in the
benchmark sets the 5-star rating at the opportunities to present these data to first years of the Quality Payment
performance rate that is the best people with Medicare in a way that is Program, are taking additional steps to
achievable rate in the current clinical most likely to be accurately understood show their commitment to quality care,
climate based on the current set of and interpreted. We request comment we want to ensure they have the
measures and the current universe of on these proposals. opportunity to report their data and
reporters. The star ratings are then have it included on Physician Compare.
g. Voluntary Reporting We request comment on this proposal.
derived from there consistent with the
raw score distribution. In this way, if In CY 2017 Quality Payment Program
h. APM Data
the majority of clinicians performed proposed rule (81 FR 28291), we
well on a measure, the majority would solicited comment on the advisability Section 1848(q)(9)(A)(ii) of the Act
receive a high star rating. If we used the and technical feasibility of including on requires us to publicly report names of
decile approach some clinicians would Physician Compare data voluntarily eligible clinicians in Advanced APMs
be reported as having a low star rating reported by eligible clinicians and and, to the extent feasible, the names
despite their relative performance on groups that are not subject to MIPS and performance of Advanced APMs.
the measure. payment adjustments, such as exempt We see this as an opportunity to
It is not always ideal to use the same clinician types and those clinicians continue to build on the ACO reporting
methodology across the program as practicing through Rural Health Centers we are now doing on Physician
scoring for payment purposes may be (RHCs), Federally Qualified Health Compare. At this time, if a clinician or
designed in a somewhat different way Centers (FQHCs), etc., to be addressed group submitted quality data as part of
that may incorporate factors that are not through separate notice-and-comment an ACO, there is an indicator on the
necessarily as applicable for public rulemaking. clinicians or groups profile page
reporting, while the key consideration Overall, comments received were indicating this. In this way, it is known
for public reporting is that the favorable. Stakeholders generally which clinicians and groups took part in
methodology used best helps patients support clinicians and groups being an ACO. Also, currently, all ACOs have
and caregivers easily interpret the data permitted to have data available for a dedicated page on the Physician
accurately. Testing with Web site users public reporting when submitting these Compare Web site to showcase their
has shown that the star rating based on data voluntarily under MIPS. As a data. For the transition year of the
the ABCTM benchmark helps patients result, we are now proposing that Quality Payment Program, we decided
and caregivers interpret the data starting with year 2 of the Quality to use this model as a guide as we add
accurately. APM data to Physician Compare.
ABCTM has been historically well benchmarks of care: concepts and methodology. Specifically, we finalized a policy to
received by the clinicians and entities it International Journal of Quality Health Care. 1998 indicate on eligible clinician and group
Oct; 10(5):4437. profile pages of Physician Compare
is measuring because the benchmark 23 Kiefe CI, Allison JJ, Williams O, Person SD,
represents quality while being both when the eligible clinician or group is
Weaver MT, Weissman NW. Improving Quality
realistic and achievable; it encourages Improvement Using Achievable Benchmarks For participating in an APM (81 FR 77398).
continuous quality improvement; and, it Physician Feedback: A Randomized Controlled We also finalized a decision to link
is shown to lead to improved quality of Trial. JAMA. 2001;285(22):28712879. eligible clinicians and groups to their
24 Wessell AM, Liszka HA, Nietert PJ, Jenkins RG,
care.22 23 24 Appreciating this and the APMs data, as technically feasible,
Nemeth LS, Ornstein S. Achievable benchmarks of
care for primary care quality indicators in a
through Physician Compare. The
22 Kiefe CI, Weissman NW., Allison JJ, Farmer R, practice-based research network. American Journal finalized policy provides the
Weaver M, Williams OD. Identifying achievable of Medical Quality 2008 JanFeb;23(1):3946. opportunity to publicly report data for
both Advanced APMs and APMs that on December 21, 2016, and analyzed the represent clinicians and specialties
are not considered Advanced APMs for effects of social risk factors of people represented on the Web site. Such board
the transition year, as technically with Medicare on clinician performance certification information is of interest to
feasible. under nine Medicare value-based users as it provides additional
At the outset, APMs will be very new purchasing programs. A second report information to use to evaluate and
concepts for Medicare patients and their due October 2019 will expand on these distinguish between clinicians on the
caregivers. In these early years, initial analyses, supplemented with Web site, which can help in making an
indicating who participated in APMs non-Medicare datasets to measure social informed health care decision. The more
and testing language to accurately risk factors. The National Academies of data of immediate interest that is
explain that to Web site users provides Sciences, Engineers, and Medicine included on Physician Compare, the
useful and valuable information as we released its fifth and final report on more users will come to the Web site
continue to evolve Physician Compare. January 10, 2017, and provided various and find quality data that can help them
As we come to understand how to best potential methods for accounting for make informed decisions. Please note
explain this concept to patients and social risk factors, including stratified we are not endorsing any particular
their caregivers, we can continue to public reporting, as well as boards.
assess how to most fully integrate these recommended next steps.26 Another board, the American Board of
data on the Web site. Understanding As we continue to consider the Wound Medicine and Surgery
this and understanding the value of analyses and recommendations from (ABWMS), has shown interest in being
adding APM data to Physician Compare, these and any future reports, we look added to Physician Compare and have
we are again proposing to publicly forward to working with stakeholders in demonstrated that they have the data to
report names of eligible clinicians in this process. Therefore, we seek facilitate inclusion of this information
Advanced APMs and the names and comment only on accounting for social on the Web site. We believe this board
performance of Advanced APMs and risk factors through public reporting on fills a gap for a specialty that is not
APMs that are not considered Advanced Physician Compare. Specifically, we currently covered by the ABMS, so we
APMs related to the Quality Payment seek comment on stratified public propose to add ABWMS Board
Program starting with year 2 (2018 data reporting by risk factors and ask for Certification information to Physician
available for public reporting in late feedback on which social risk factors or Compare.
2019), and for each year moving indicators should be used and from Additionally, for all years moving
forward, as technically feasible. In what sources. Examples of social risk forward, for any board that would like
addition, we again propose to continue factor indicators include but are not to be considered to be added to the
to find ways to more clearly link limited to dual eligibility/low-income Physician Compare Web site, we
clinicians and groups and the APMs subsidy, race and ethnicity, social propose to establish a process for
they participate in on Physician support, and geographic area of reviewing interest from these boards as
Compare, as technically feasible. We residence. We also seek comment on the it is brought to our attention on a case-
request comment on these proposals. process for accessing or receiving the by-case basis, and selecting boards as
i. Stratification by Social Risk Factors necessary data to facilitate stratified possible sources of additional board
reporting. Finally, we seek comment on certification information for Physician
We understand that social risk factors
whether strategies such as confidential Compare. We further propose that, for
such as income, education, race and
reporting of stratified rates using social purposes of CMSs selection, the board
ethnicity, employment, disability,
risk factor indicators should be would need to demonstrate that it: Fills
community resources, and social
considered in the initial years of the a gap in currently available board
support play a major role in health. One
Quality Payment Program in lieu of certification information listed on
of our core objectives is to improve the
publicly reporting stratified Physician Compare, can make the
outcomes of people with Medicare, and
performance rates for quality and cost necessary data available, and if
we want to ensure that complex
measures under the MIPS on Physician appropriate, can make arrangements and
patients, as well as those with social
risk factors receive excellent care. In Compare. We seek comment only on enter into agreements to share the
addition, we seek to ensure that all these items for possible consideration in needed information for inclusion on
clinicians are treated as fairly as future rulemaking. Physician Compare. We propose that
possible within all CMS programs. In boards contact the Physician Compare
j. Board Certification support team at PhysicianCompare@
the CY 2017 Quality Payment Program
final rule (81 FR 77395), we noted that Finally, we propose adding additional Westat.com to indicate interest and
we would review the first of several Board Certification information to the initiate the review and discussion
reports by the Office of the Assistant Physician Compare Web site. Board process. Once decisions are made, they
Secretary for Planning and Evaluation Certification is the process of reviewing will be communicated via the CMS.gov
(ASPE).25 In addition, we have been and certifying the qualifications of a Physician Compare initiative Web page
reviewing the report of the National physician or clinician by a board of and via the Physician Compare listserv.
Academies of Sciences, Engineering, specialists in the relevant field. We We request comments on these
and Medicine on the issue of accounting currently include ABMS, AOA, and proposals.
for social risk factors in CMS programs. ABO data as part of clinician profiles on
D. Overview of the APM Incentive
ASPEs first report, as required by the Physician Compare. We appreciate that
Improving Medicare Post-Acute Care there are additional, well respected 1. Overview
Treatment (IMPACT) Act, was released boards that are not included in the Section 1833(z) of the Act requires
ABMS, AOA, and ABO data currently that an incentive payment be made to
25 ASPE, Report to Congress: Social Risk Factors available on Physician Compare that QPs for participation in Advanced
and Performance Under Medicares Value-Based APMs. In the CY 2017 Quality Payment
Purchasing Programs. 21 Dec 2016. Available at 26 National Academies of Sciences, Engineering,
https://aspe.hhs.gov/pdf-report/report-congress- and Medicine. 2017. Accounting for social risk

Program final rule (81 FR 77399 through
social-risk-factors-and-performance-under- factors in Medicare payment. Washington, DC: The 77491), we finalized policies relating to
medicares-value-based-purchasing-programs. National Academies Press. the following topics:
Beginning in 2019, if an eligible occurs in our regulations and replace it and to replace Advanced APM Entity
clinician participated sufficiently in an with either All-Payer QP Performance where it appears throughout the
Advanced APM during the QP Period or Medicare QP Performance regulations with APM Entity. We also
Performance Period, that eligible Period as relevant. As we discuss in propose to make this substitution in the
clinician may become a QP for the year. section II.D.6.d.(3)(a) of this proposed definitions of Affiliated Practitioner and
Eligible clinicians who are QPs are rule, we propose to make QP Attributed Beneficiary in 414.1305.
excluded from the MIPS reporting determinations under the All-Payer Similarly, we propose to replace
requirements in the performance year Combination Option at the eligible Advanced APM Entity group with
and payment adjustment for the clincian level only. In connection with APM Entity group where it appears
payment year. our proposals to calculate Threshold throughout our regulations. We note
For years from 2019 through 2024, Scores for QP determinations under the that these proposed changes are
QPs receive a lump sum incentive All-Payer Combination Option, we do technical, and would not have a
payment equal to 5 percent of their prior not anticipate having or receiving substantive effect on our policies.
years payments for Part B covered information about attributed We propose technical changes to
professional services. Beginning in beneficiaries as we do under the correct the references in the first
2026, QPs receive a higher update under Medicare Option. This is because, under sentence of the regulation at 414.1415
the PFS for the year than non-QPs. the All-Payer Combination Option, APM to refer to the financial risk standard
For 2019 and 2020, eligible Entities or eligible clinicians would under paragraph (c)(1) or (2) and the
clinicians may become QPs only only submit aggregate payment and nominal amount standard under
through participation in Advanced patient data. We would not have paragraph (c)(3) or (4). Due to
APMs. anything similar to a Participation List typographical errors, the current
For 2021 and later, eligible or an Affiliated Practitioner List for regulation refers to paragraphs (d)(1)
clinicians may become QPs through a Other Payer Advanced APMs. through (4), and there is no paragraph
combination of participation in Therefore, we are proposing to change (d) in this section. We also propose to
Advanced APMs and Other Payer the definition of attributed beneficiary correct typographical errors in
Advanced APMs (which we refer to as so that it only applies to Advanced 414.1420(a)(3)(i), (ii), (d) and (d)(1). In
the All-Payer Combination Option). APMs, not to Other Payer Advanced 414.1420(d), we propose to correct the
In this proposed rule, we discuss reference to the nominal risk standard
APMs. We seek comment on these
proposals for clarifications and to instead refer to the nominal amount
proposals.
modifications to some of the policies standard. We propose technical, non-
We seek comment on these terms,
that we previously finalized, and substantive clarifications in
including how we have defined the
provide additional details and proposals 414.1425(a)(1) through (3),
terms, the relationship between terms,
regarding the All-Payer Combination 414.1425(b)(2), and 414.1435(d). We
any additional terms that we should
Option. also propose to correct a typographical
formally define to clarify the
2. Terms and Definitions explanation and implementation of this error in 414.1460(b) to refer to
program, and potential conflicts with participation during a Medicare QP
As we continue to develop the Performance Period instead of during
Quality Payment Program, we have other terms we use in similar contexts.
We also seek comment on the naming of the QP Performance Periods.
identified the need to propose
additions, deletions, and changes to the terms and whether there are ways to b. Changes to 414.1460
some of the previously finalized name or describe their relationships to We propose to reorganize and revise
definitions. A list of these definitions is one another that make the definitions the monitoring and program integrity
available in the CY 2017 Quality more distinct and easier to understand. provisions at 414.1460. We propose
Payment Program final rule (81 FR For instance, we would consider changes to paragraphs (a), (b), and (d) in
77537 through 77540). options for a framework of definitions this section of the proposed rule as
As we discuss in section II.D.6.d.(2)(a) that might more intuitively distinguish these policies apply to both the
of this proposed rule, we propose to between APMs and Other Payer Medicare Option and the All-Payer
change the timeframe of the QP Advanced APMs and between APMs Combination Option. We discuss
Performance Period under the All-Payer and Advanced APMs. proposed changes to paragraph (c) of
Combination Option so that it would 3. Regulation Text Changes 414.1460 in sections II.D.6.c.(7) and
begin on January 1 and end on June 30 II.D.6.d.(4) of this proposed rule, and
of the calendar year that is 2 years prior a. Clarifications and Corrections changes to paragraph (e) of 414.1460
to the payment year. We propose to add We propose to revise the definition of in sections II.D.6.c.(7)(b) and
the definition of All-Payer QP APM Entity in the regulation at II.D.6.d.(4)(c), as the policies in these
Performance Period using this 414.1305 to clarify that a payment paragraphs only apply to the All-Payer
timeframe. We also propose to add the arrangement with a non-Medicare Combination Option.
definition of Medicare QP Performance payer is an other payer arrangement as We finalized in the CY 2017 Quality
Period, which would begin on January defined in 414.1305. We propose to Payment Program final rule at
1 and end on August 31 of the calendar make technical changes to the definition 414.1460(d) that for any QPs who are
year that is 2 years prior to the payment of Medicaid APM in 414.1305 to terminated from an Advanced APM or
year. We would replace the definition clarify that these arrangements must found to be in violation of any federal,
we established in the CY 2017 Quality meet the Other Payer Advanced APM state, or tribal statute, regulation, or
Payment Program final rule for QP criteria set forth in 414.1420, and not binding guidance during the QP
Performance Period with the definitions just the criteria under 414.1420(a) as Performance Period or Incentive
of All-Payer QP Performance Period and provided under the current definition. Payment Base Period or terminated after
Medicare QP Performance Period. To To consolidate our regulations and these periods as a result of a violation
update the regulation to incorporate this avoid unnecessarily defining a term, we occurring during either period we may
proposal, we also propose to remove propose to remove the defined term for rescind such eligible clinicians QP
QP Performance Period each time it Advanced APM Entity in 414.1305 determinations and, if necessary, recoup
part or all of any such eligible paragraph (d) to discuss when CMS may and have lower Medicare revenues
clinicians APM Incentive Payment or reduce or deny an APM Incentive relative to total Medicare spending than
deduct such amount from future Payment to an eligible clinician. We other APM Entities, which affects their
payments to such individuals. We also solicit comment on these proposals. ability to bear substantial risk,
finalized that we may reopen and especially in relation to total cost of
4. Advanced APMs care. We believe that the meaning of
recoup any payments that were made in
error (81 FR 77555). We recognize that a. Overview nominal financial risk varies according
rescinding QP determinations and In the CY 2017 Quality Payment to context, and that smaller practices
reopening and recouping APM Incentive Program final rule (81 FR 77408), we participating in Medical Home Models,
Payments are separate policies and for finalized the criteria that define an as a category, experience risk differently
this reason, we propose to reorganize Advanced APM based on the than much larger, multispecialty
414.1460 so that paragraph (b) sets requirements set forth in sections focused organizations do. Historically,
forth our policy on rescinding QP 1833(z)(3)(C) and (D) of the Act. An Medical Home Model participants have
determinations and paragraph (d) sets Advanced APM is an APM that: not been required to bear financial risk,
forth our policy on reopening and Requires its participants to use which means the assumption of any
recouping APM Incentive Payments. We new financial risk presents a new
certified EHR technology (CEHRT) (See
propose to revise 414.1460(b) to challenge for these entities (81 FR
81 FR 7740944414);
provide when we may rescind a QP 7742077421). For these reasons, we
Provides for payment for covered
determination. In addition, we propose finalized special standards for Medical
professional services based on quality
to remove the last sentence of Home Models that are exceptions to the
measures comparable to measures under
414.1460(d), which provides that an generally applicable financial risk and
the quality performance category under
APM Incentive Payment will be nominal amount standards.
MIPS (See 81 FR 7741477418); and
recouped if an audit reveals a lack of Either requires its participating (1) Medical Home Model Eligible
support for attested statements provided APM Entities to bear financial risk for Clinician Limit
by eligible clinicians and APM Entitles. monetary losses that are in excess of a
We believe that this provision is In the CY 2017 Quality Payment
nominal amount, or the APM is a Program final rule, we finalized that
duplicative of the immediately Medical Home Model expanded under
preceding sentence, which permits us to beginning in the 2018 Medicare QP
section 1115A(c) of the Act (See 81 FR Performance Period, the Medical Home
reopen and recoup any erroneous 7741877431). Model financial risk standard would
payments in accordance with existing APMs may offer multiple options or only apply to APM Entities that
procedures set forth at 405.980 tracks with variations in CEHRT use participate in Medical Home Models
through 405.986 and 405.370 through requirements, quality-based payments, and that have fewer than 50 eligible
405.379. We propose to codify our and the level of financial risk; or clinicians in the organization through
recoupment policy at 414.1460(d)(2), multiple tracks designed for different which the APM Entity is owned and
which provides that we may reopen, types of participant organizations, and operated (81 FR 77430). Under this
revise, and recoup an APM Incentive we finalized in the CY 2017 Quality policy, in a Medical Home Model that
Payment that was made in error in Payment Program final rule (81 FR otherwise meets the criteria to be an
accordance with procedures similar to 77406) that we will consider different Advanced APM, the Medical Home
those set forth at 405.980 through tracks or options within an APM Model financial risk standard would be
405.986 and 405.370 through 405.379 or separately for purposes of making applicable only for those APM Entities
as established under the relevant APM. Advanced APM determinations. owned and operated by organizations
In the CY 2017 Quality Payment with fewer than 50 eligible clinicians.
Program final rule, we indicated at b. Bearing Financial Risk for Monetary
Losses We note this policy does not apply to
414.1460(b) that CMS may reduce or Medical Home Models expanded under
deny an APM Incentive Payment to In the CY 2017 Quality Payment section 1115A of the Act.
eligible clinicians who are terminated Program final rule (81 FR 77418), we We are proposing to exempt from this
by APMs or whose APM Entities are divided the discussion of this criterion requirement any APM Entities enrolled
terminated by APMs for non- into two main elements: (1) What it in Round 1 of the Comprehensive
compliance with all Medicare means for an APM Entity to bear Primary Care Plus Model (CPC+).
conditions of participation or the terms financial risk for monetary losses under We finalized the Medical Home
of the relevant Advanced APMs in an APM); and (2) what levels of risk we Model eligible clinician limit after
which they participate during the QP would consider to be in excess of a practices applied and signed agreements
Performance Period. We also finalized at nominal amount. For each of these with CMS to participate in CPC+ Round
414.1460(a) that for QPs who CMS elements, we established a generally 1. As such, practices applying to
determines are not in compliance with applicable standard and a Medical participate in CPC+ Round 1 were not
all Medicare conditions of participation Home Model standard. necessarily aware of the eligible
and the terms of the relevant Advanced As we discussed in the CY 2017 clinician limit policy and will have
APMs in which they participate during Quality Payment Program final rule, we already participated in CPC+ for one
the QP Performance Period, there may believe that it is important to maintain year without this requirement applying
be a reduction or denial of the APM the distinction between Medical Home to them by the beginning of CY 2018.
Incentive Payment. We propose to Models and other APMs because we Thus, to permit continued and
consolidate our policy on reducing and believe that Medical Home Models are uninterrupted testing of CPC+ in
denying APM Incentive Payments and categorically different than other types existing regions, we believe it is
redesignate it to 414.1460(d)(1). Thus, of APMs, as supported by specific necessary to exempt practices
we propose to remove provisions provisions in the statute enabling participating in CPC+ Round 1 from this
regarding reducing and denying APM unique treatment of Medical Home requirement. Additionally, since in
Incentive Payments from paragraphs (a) Models. Also, Medical Home Model future all APM Entities would know
and (b) of 414.1460, and revise participants tend to be smaller in size about this requirement prior to their
enrollment and in order to ensure that standard in terms of average estimated predictability for eligible clinicians
large APM entities that are able to bear total Medicare Parts A and B revenue of participating in certain APMs. Other
more risk enroll in such higher risk participating APM Entities. We commenters noted that increasing the
models, we are also proposing that recognize that this language may be revenue-based nominal amount
CPC+ participants who enroll in the ambiguous as to whether it is intended standard may reduce or discourage
future (for example, in CPC+ Round 2) to include payments to all providers and eligible clinicians from participating in
will not be exempt from this suppliers in an APM Entity or only Advanced APMs and that the added
requirement. While this creates a small payments directly to the APM Entity complexity of requiring that a 10
difference between the incentives for itself. To eliminate this potential percent revenue-based standard also be
large APM Entities in different cohorts ambiguity, we propose to amend equivalent to at least 1.5 percent of
to participate in CPC+, we believe an 414.1415(c)(3)(i)(A) and (c)(4)(i)(A) expected expenditures would be
APM Entity should seek to enroll in an through (D) to more clearly define the confusing for participants and other
APM, including an Advanced APM, generally applicable revenue-based stakeholders. A few commenters
primarily based on the framework of nominal amount standard and the suggested that we only consider
that APM itself, rather than the Medical Home Model revenue-based increasing the revenue-based nominal
possibility of other associated payments nominal amount standard as a amount standard after we review how
such as the Advanced APM incentive percentage of the average estimated total the finalized standard affects
payment. Additionally, we note that any Medicare Parts A and B revenue of participation in Advanced APMs.
eligible clinicians in APM Entities providers and suppliers in participating We agree that maintaining the
participating in CPC+ that do not APM Entities. Under this proposed revenue-based nominal amount
achieve QP status for the year would be policy, when assessing whether an APM standard at 8 percent of the average
scored under MIPS using the APM meets the generally applicable revenue- estimated total Medicare Parts A and B
scoring standard, meaning minimal based nominal amount standard, where revenue of providers and suppliers in
additional burden would be required for total risk under the model is not participating APM Entities would
such MIPS eligible clinicians. expressly defined in terms of revenue, provide stability and clarity for eligible
We seek comment on these proposals. we would calculate the estimated total clinicians and APM Entities. We also
Medicare Parts A and B revenue of continue to believe that 8 percent of the
(2) Nominal Amount of Risk providers and suppliers at risk for each average estimated total Medicare Parts A
We finalized in the CY 2017 Quality APM Entity. We would then calculate and B revenue of providers and
Payment Program final rule (81 FR an average of all the estimated total suppliers in participating APM Entities
77427) that an APM would meet the Medicare Parts A and B revenue of represents a reasonable standard to
generally applicable nominal amount providers and suppliers at risk for each determine what constitutes a more than
standard if, under the terms of the APM, APM Entity, and if that average nominal amount of financial risk. We
the total annual amount that an APM estimated total Medicare Parts A and B believe that the continued testing and
Entity potentially owes us or foregoes is revenue at risk for all APM Entities was evaluation of APMs with two-sided risk
equal to at least: equal to or greater than 8 percent, the will yield critical information about the
For QP Performance Periods in APM would satisfy the generally best way to structure financial
2017 and 2018, 8 percent of the average applicable revenue-based nominal incentives and financial risk, and this
estimated total Medicare Parts A and B amount standard. information may have bearing on what
revenue of participating APM Entities We request comment on this proposal. constitutes a more than nominal amount
(the revenue-based standard); or of risk. Therefore, we will continue to
(a) Generally Applicable Revenue-Based
For all QP Performance Periods, 3 Nominal Amount Standard
evaluate the revenue-based nominal
percent of the expected expenditures for amount standard in light of
which an APM Entity is responsible In the CY 2017 Quality Payment participation in Advanced APMs before
under the APM (the benchmark-based Program final rule we finalized the considering any increase in later years.
standard). amount of the generally applicable After considering public comments
We also finalized in the CY 2017 revenue-based nominal amount submitted on the potential options for
Quality Payment Program final rule (81 standard for the first two QP increasing the revenue-based nominal
FR 77428) that to be an Advanced APM, Performance Periods only, and we amount standard for Medicare QP
a Medical Home Model must require sought comment on what the revenue- Performance Periods 2019 and later, we
that the total annual amount that an based nominal amount standard should propose to maintain the current
Advanced APM potentially owes us or be for the third and subsequent QP revenue-based nominal amount
foregoes under the Medical Home Performance Periods. Specifically, we standard at 8 percent of the average
Model be at least the following amounts sought comment on: (1) Setting the estimated total Medicare Parts A and B
in a given performance year: revenue-based standard for 2019 and revenue of all providers and suppliers
In 2017, 2.5 percent of the APM later at up to 15 percent of revenue; or in participating APM Entities for the
Entitys total Medicare Parts A and B (2) setting the revenue-based standard at 2019 and 2020 Medicare QP
revenue. 10 percent so long as risk is at least Performance Periods, and to address the
In 2018, 3 percent of the APM equal to 1.5 percent of expected standard for Medicare QP Performance
Entitys total Medicare Parts A and B expenditures for which an APM Entity Periods after 2020 through subsequent
is responsible under an APM (81 FR rulemaking. We seek comment on
revenue.
In 2019, 4 percent of APM Entitys 77427). whether we should consider either a
total Medicare Parts A and B revenue. Many commenters requested that we lower or higher revenue-based nominal
In 2020 and later, 5 percent of the not raise the revenue-based nominal amount standard for the 2019 and 2020
APM Entitys total Medicare Parts A and amount standard for 2019 and beyond. Medicare QP Performance Periods, and
B revenue. Some commenters stated that on the amount and structure of the
Both the generally applicable and maintaining the 8 percent revenue- revenue-based nominal amount
Medical Home Model revenue-based based nominal amount standard for standard for Medicare QP Performance
nominal amount standards state the 2019 would allow for stability and Periods 2021 and later.
We also seek comment on whether we Models have had experience with Therefore, we are proposing that to be
should consider a different, potentially financial risk, and that many would be an Advanced APM, a Medical Home
lower, revenue-based nominal amount financially challenged to provide Model must require that the total annual
standard only for small practices and sufficient care or even remain a viable amount that an APM Entity potentially
those in rural areas that are not business if they were faced with the owes us or foregoes under the Medical
participating in a Medical Home Model kinds of substantial disruptions in Home Model be at least the following:
for the 2019 and 2020 Medicare QP revenue that can accompany financial For Medicare QP Performance
Performance Periods. For the purposes risk arrangements. Some commenters Period 2018, 2 percent of the average
of the Quality Payment Program, we use indicated that taking on the level of risk estimated total Medicare Parts A and B
the definition of small practices and required under our finalized policy revenue of all providers and suppliers
rural areas in 414.1305. Specifically, would still represent an increase in total in participating APM Entities.
we seek comment on whether such a risk that is too great in magnitude and For Medicare QP Performance
standard should apply only to small premature for the many APM Entities in Period 2019, 3 percent of the average
and, or rural practices that are Medical Home Models that have little estimated total Medicare Parts A and B
participants in an APM, or also small experience with financial risk. revenue of all providers and suppliers
and, or rural practices that join larger We recognize these concerns, in participating APM Entities.
APM Entities in order to participate in however, we still believe that a final For Medicare QP Performance
APMs. We also seek comment on how Medical Home Model nominal amount Period 2020, 4 percent of the average
we should decide where a practice is standard of 5 percent is the appropriate estimated total Medicare Parts A and B
located in order to determine whether it target for the standard, and that revenue of all providers and suppliers
is operating in a rural area as rural area ultimately setting the standard at 5 in participating APM Entities.
is defined in 414.1305 of our percent of Parts A and B revenue of For Medicare QP Performance
regulations. We believe that a different, providers and suppliers in participating Periods 2021 and later, 5 percent of the
potentially lower, revenue-based APM Entities would strike the average estimated total Medicare Parts A
nominal amount standard for the 2019 appropriate balance to reflect the and B revenue of all providers and
and 2020 Medicare QP Performance meaning of nominal in the Medical suppliers in participating APM Entities.
Periods specifically for small practices Home Model context. We continue to We seek comment on this proposal.
and those in rural areas that are not believe that the meaning of the term c. Summary of Proposals
participating in a Medical Home Model nominal depends on the situation in
may allow for their increased which it is applied, so it is appropriate In summary, we are making the
participation in Advanced APMs, which to consider the characteristics of following proposals in this section:
may help increase the quality and Medical Home Models and their We are proposing to amend our
coordination of care beneficiaries participating APM Entities in setting the regulation at 414.1415(c)(3)(i)(A) and
receive as a result. We believe such a nominal amount standard for Medical (c)(4)(i)(A) through (D) to more clearly
standard should not apply to small and, Home Models. define the generally applicable revenue-
or rural practices participating in a We have reconsidered the incremental based nominal amount standard and the
Medical Home Model because annual increases in the nominal amount Medical Home Model revenue-based
participants in Medical Home Models standard that we finalized to occur over nominal amount standard as a
with fewer than 50 eligible clinicians in several years from 2.5 percent to 5 percentage of the average estimated total
their parent organization benefit from percent. We recognize that establishing Medicare Parts A and B revenue of all
the lower Medical Home Model nominal an even more gradual increase in risk providers and suppliers in participating
amount standard. We also note that for Medical Home Models with a lower APM Entities.
such a standard may have certain risk floor for the 2018 Medicare QP We are proposing to amend our
disadvantages, including reducing the Performance Period may be better suited regulation at 414.1415(c)(2) to any
likelihood that potential Advanced to the circumstances of many APM APM Entities enrolled in an Advanced
APMs will ultimately result in Entities in Medical Home Models that APM qualifying under the Medical
reductions in the growth of Medicare have little experience with risk. We also Home Model standard as of January 1,
expenditures and increasing the reiterate, as we note for the generally 2017, to exempt Round 1 of the CPC+
complexity of the generally applicable applicable nominal amount standard, Model from the requirement that
nominal amount standard. that the terms and conditions in the beginning in the 2018 Medicare QP
particular APM govern the actual risk Performance Period, the Medical Home
(b) Medical Home Model Nominal that participants experience; the Model financial risk standard applies
Amount Standard nominal amount standard merely sets a only to an APM Entity that is
In the CY 2017 Quality Payment floor on the level of risk required for the participating in a Medical Home Model
Program final rule, we finalized that if APM to be considered an Advanced if it has fewer than 50 eligible clinicians
the financial risk arrangement under the APM. To that end, we believe a small in its parent organization.
Medical Home Model is not based on reduction of risk in the Medical Home We are proposing to amend our
revenue (for example, it is based on total Model nominal amount standard regulation at 414.1415(c)(3)(i)(A) to
cost of care or a per beneficiary per beginning in the 2018 Medicare QP provide that the generally applicable
month dollar amount), we will make a Performance Period, along with a more revenue-based nominal amount
determination for the APM based on the gradual progression toward the 5 standard remain at 8 percent of the
risk under the Medical Home Model percent nominal amount standard, average estimated total Medicare Parts A
compared to the average estimated total would allow for greater flexibility at the and B revenue of providers and
Parts A and B revenue of its APM level in setting financial risk suppliers in participating APM Entities
participating APM Entities using the thresholds that would encourage more for the 2019 and 2020 Medicare QP
most recently available data (81 FR participation in Medical Home Models Performance Periods, and to address the
77428). and be more sustainable for the type of standard for Medicare QP Performance
We received comments suggesting APM Entities that would potentially Periods after 2020 through subsequent
that few APM Entities in Medical Home participate in Medical Home Models. rulemaking.
We are proposing to amend our An Advanced APM is in active testing determination date for the year. This
regulation at 414.1415(c)(4)(i)(A) if APM Entities are furnishing services outcome would be a direct result of our
through (D) to provide that, to be an to beneficiaries and those services will operational decisions to begin the
Advanced APM, a Medical Home Model count toward the APM Entitys performance period for the Advanced
must require that the total annual performance in the Advanced APM. APM on May 1, which is outside of the
amount that an APM Entity potentially Active testing does not include, for control of both the participating APM
owes us or foregoes under the Medical example, the period of time after an Entities and eligible clinicians. As such,
Home Model be at least the following APM Entity has stopped furnishing participants in Advanced APMs that
amounts: services to beneficiaries under the terms start or end during the Medicare QP
++ For Medicare QP Performance of the Advanced APM but is waiting for Performance Period for the year could
Period 2018, 2 percent of the average calculation or receipt of a performance- be disadvantaged for purposes of QP
estimated total Medicare Parts A and B based payment. We note that we tie this determinations. This is because the
revenue of all providers and suppliers policy to the timeframe during which numerator of the Threshold Score
in participating APM Entities. APM Entities, rather than eligible calculation would include payment
++ For Medicare QP Performance clinicians, participate in an Advanced amounts or patient counts from only the
Period 2019, 3 percent of the average APM. To the extent the participation of period before the QP determination date
estimated total Medicare Parts A and B APM Entities and eligible clinicians is during which the Advanced APM was
revenue of all providers and suppliers not the same, we believe it is more actively tested, while the denominator
in participating APM Entities. appropriate and consistent with other would include payment amounts or
++ For Medicare QP Performance policies relating to the APM incentive, patient counts for the entire Medicare
Period 2020, 4 percent of the average and to APMs in general, to base the QP performance period up to the QP
estimated total Medicare Parts A and B active testing period for an APM on the determination date.
revenue of all providers and suppliers activities of the APM Entities because We propose to modify our policies
in participating APM Entities. they are the participants directly subject regarding the timeframe(s) for which
++ For Medicare QP Performance to the terms of the Advanced APM, payment amount and patient count data
Periods 2021 and later, 5 percent of the including the specified performance are included in the QP payment amount
average estimated total Medicare Parts A period for the Advanced APM. For and patient count threshold calculations
and B revenue of all providers and example, in a model like CJR, where we for Advanced APMs that start after
suppliers in participating APM Entities. identify eligible clinicians for QP January 1 or end before August 31 in a
determinations based on the Affiliated given Medicare QP Performance Period.
5. Qualifying APM Participant (QP) and
Practitioner List, it would be possible In these situations, we would calculate
Partial QP Determination QP Threshold Scores using only data in
for APM Entities to be participating in
We finalized policies relating to QP the numerator and denominator for the
active testing of the Advanced APM
and Partial QP determinations in the CY dates that APM Entities were able to
without any Affiliated Practitioners for
2017 Quality Payment Program final participate in active testing of the
a period of time. In that case, we would
rule (See 81 FR 77433 through 77450). Advanced APM, per the terms of the
We finalized that the QP Performance consider the dates the APM Entities
were able to be in active testing for CJR, Advanced APM, so long as APM
Period will run from January 1 through Entities were able to participate in the
August 31 of the calendar year that is 2 as opposed to the dates when eligible
Advanced APM for 60 or more
years prior to the payment year (81 FR clinicians began participating as
continuous days during the Medicare
77446). As we discuss in section Affiliated Practitioners. If a specific
QP Performance Period. We propose to
II.D.6.(d)(2)(a)of this proposed rule, we APM Entity joins an Advanced APM
add this policy at 414.1425(c)(6) of our
propose to refer to this time period for after the January 1 start and before the
regulations. The QP Threshold Score
the Medicare Option as the Medicare QP August 31 end of a Medicare QP
would be calculated at the APM Entity
Performance Period. Performance Period, but other APM
level or the Affiliated Practitioner level
Entities participate during the entire
a. Advanced APMs Starting or Ending as set forth in 414.1425(b); this change
Medicare QP Performance Period (from
During a Medicare QP Performance would not affect our established policy
January 1 through August 31), then we
Period as to which list of eligible clinicians, the
would consider the Advanced APM to Participation List or Affiliated
We acknowledge that there may be be in active testing for the entire Practitioner List, would be used.
Advanced APMs that start after January Medicare QP Performance Period. This proposed change would not
1 of the Medicare QP Performance For example, the performance period affect how we make QP and Partial QP
Period for a year. There may also be for an Advanced APM may start on May determinations for eligible clinicians
Advanced APMs that end prior to the 1, which is after the first QP who participate in multiple Advanced
August 31 end of the Medicare QP determination date (March 31) and APMs as set forth by 414.1425(c)(4)
Performance Period for a year. By before the second QP determination and 414.1425(d)(2). We propose to make
start and end, in this context, we date (June 30) during the Medicare QP those calculations using the full
mean that the period of active testing of Performance Period. If we were to Medicare QP Performance Period even if
the model starts or ends such that there calculate Threshold Scores in such an the eligible clinician participates in one
is no opportunity for any APM Entity to Advanced APM using data in the or more Advanced APMs that start or
participate in the Advanced APM before denominator for all attribution-eligible end during the Medicare QP
it starts, or to participate in it after it beneficiaries from January through June Performance Period. We believe that
ends. We consider the active testing 30, which would include data for the this policy appropriately reflects the
period to mean the dates within the period before the Advanced APM is participation of the individual eligible
performance period specific to the actively tested, the APM Entities, or, as clinician in multiple Advanced APMs
model, which is also the time period for applicable, individual eligible clinicians and is consistent with our general
which we consider payment amounts or in that Advanced APM, are less likely framework for making QP
patient counts through the Advanced to achieve a QP threshold on either the determinations. For these QP
APM when we make QP determinations. June 30 or the final August 31 determinations, we would include
patients or payments through all snapshot date because this would be the that requests two-sided risk to take
Advanced APMs the eligible clinician first snapshot where the Advanced APM effect beginning on July 1, 2018, would
participates in for a Medicare QP was active for 60 or more continuous be considered a participant in and
Performance Period, including any days. The QP determination would be Advanced APM as of July 1, but would
Advanced APMs that are in active made based on payment amounts or be subject to a QP determination based
testing for less than 60 continuous days. patient counts from the June 1 start date on payment and patient count data for
This policy accounts for the eligible to August 31 in both the numerator and the full Medicare QP Performance
clinicians flexibility in participating in the denominator. For an Advanced APM Period because that APM Entity had the
Advanced APMs while combining that that starts on or before January 1 and opportunity to elect two-sided risk
participation to potentially meet the QP ends active testing on June 1, we would beginning on January 1, 2018. In this
threshold. make QP determinations on each scenario, the APM Entity has control
With the exception of QP snapshot date, but those determinations over its participation in an Advanced
determinations for individual eligible would be made based only on payment APM, and could choose to be in the
clinicians who participate in multiple amounts or patient counts from January Advanced APM for the full Medicare QP
Advanced APMs, we believe it is 1 to June 1. Although the Advanced Performance Period.
appropriate to require that an Advanced APM would not be actively tested We clarify that this proposed policy
APM must be actively tested for a between June 30 and August 31, we for Advanced APMs that start or end
minimum of 60 continuous days during would still make another QP Threshold during the Medicare QP Performance
the Medicare QP Performance Period in Score calculation for APM Entities or Period does not apply to the CEHRT
order for the payment amount or patient eligible clinicians who had not met the Track (Track 1) of the Comprehensive
count data to be considered for purposes QP Threshold in case the additional Care for Joint Replacement Model (CJR)
of QP determinations for the year time for claims run out would give us because we have determined that Track
because it is important that the QP more accurate information. For an 1 of CJR is an Advanced APM for the
determination be based on a measure of Advanced APM that started on August 2017 QP Performance Period. Therefore,
meaningful participation in an 30 of a year, we would not make a QP we will include episodes ending on or
Advanced APM. For example, if an determination for that year because the after January 1, 2017 in QP
Advanced APM started on August 30, APM would not be actively tested for 60 determinations as set forth in our
we do not believe a QP determination continuous days during the Medicare regulations at 414.1425.
made based on only 2 days of payment QP Performance Period. b. Participation in Multiple Advanced
amount or patient count data in the We believe that this proposal allows
APMs
numerator and denominator would us to properly measure performance in
reflect a meaningful assessment of Advanced APMs without penalizing We propose to edit 414.1425(c)(4)
participation in an Advanced APM. We APM Entities or eligible clinicians for and (d)(4) to better reflect our intended
have chosen a minimum of 60 start or end dates that are wholly policy for QP determinations and Partial
continuous days because it is the outside of their control. We believe this QP determinations for eligible clinicians
shortest amount of time between two policy is needed to match the data used who are included in more than one
snapshot dates: June 30 and August 31. to assess Advanced APM participation APM Entity group and none of the APM
We believe this amount of time is for purposes of the APM incentive Entity groups in which the eligible
sufficient for purposes of measuring payment with the timeframe during clinician is included meets the
participation in an Advanced APM. We which the Advanced APM is actively corresponding QP or Partial QP
seek comment on whether it would be tested and to accurately reflect the threshold, or who are Affiliated
more appropriate to require that the participation of APM Entities and Practitioners. As we explained in the CY
Advanced APM be in active testing for eligible clinicians. This proposed policy 2017 Quality Payment Program final
at least 90 days, since 90 days is the would not apply to Other Payer rule (81 FR 774467), eligible clinicians
shortest possible length of time we Advanced APMs because eligible may become QPs through any of the
would use to make a QP determination clinicians have more control over the assessments conducted for the three
(if the QP determination is based on start and end dates of payment snapshot dates: March 31, June 30, and
January 1 through March 31). arrangements with Other Payers, such as August 31. If the APM Entity group
Under this proposal, we would make through contract negotiations, than they meets the QP threshold under this first
QP determinations for all QP do over our start and end dates, which assessment, then all eligible clinicians
determination snapshot dates that fall we exclusively determine. in the APM Entity group will be QPs
after the Advanced APM meets the This proposed policy would not apply unless the APM Entitys participation in
minimum time requirement of 60 to APM Entities that had the the Advanced APM is voluntarily or
continuous days, whether the Advanced opportunity to participate in the involuntarily terminated before the end
APM starts or ends during the Medicare Advanced APM track of an APM during of the Medicare QP Performance Period,
QP Performance Period. We would not the entire Medicare QP Performance or in the event of eligible clinician or
make a QP or Partial QP determination Period, but did not do so until partway APM Entity program integrity violation.
for participants in Advanced APMs that through the Medicare QP Performance We stated these same procedures apply
are not actively tested for a period of at Period. For example, Oncology Care to the QP determination made for
least 60 continuous days during the Model (OCM), has two risk tracks: One- individual eligible clinicians on an
Medicare QP Performance Period. For sided and two-sided risk. Only the two- APM Entitys Affiliated Practitioner List
example, for an Advanced APM that sided risk track is an Advanced APM. or individual eligible clinicians in
starts its performance period on June 1, APM Entities participating in OCM now multiple Advanced APMs whose APM
we would not make any QP Threshold have the opportunity to change their Entity groups did not meet the QP
Score calculations for the June 30 risk track from one-sided to two-sided threshold.
snapshot date because the Advanced risk, to take effect on either January 1 or We propose to amend our regulation
APM would not yet have been actively July 1 of the applicable calendar year. to make clear that under
tested for 60 consecutive days. We Applying this proposed policy to OCM, 414.1425(c)(4), if an eligible clinician
would wait until the August 31 an APM Entity participating in OCM is a determined to be a QP based on
participation in multiple Advanced the terms of the Advanced APM, not the All-Payer Combination Option does not
APMs, but any of the APM Entities in full Medicare QP Performance Period. replace or supersede the Medicare
which the eligible clinician participates We propose to make QP Option; instead, it would allow eligible
voluntarily or involuntarily terminates determinations under 414.1425(c)(4), clinicians to become QPs by meeting the
from the Advanced APM before the end for eligible clinicians participating in QP thresholds through a pair of
of the Medicare QP Performance Period, multiple Advanced APMs using the full calculations that assess Medicare Part B
the eligible clinician is not a QP. We Medicare QP Performance Period even if covered professional services furnished
propose to make the same clarification the eligible clinician participates in one through Advanced APMs, and a
for Partial QP determinations under or more Advanced APMs that start or combination of both Medicare Part B
414.1425(d)(4). These clarifying edits end during the Medicare QP covered professional services furnished
specify that this policy applies within Performance Period. through Advanced APMs and services
the context of QP and Partial QP We propose to amend our furnished through Other Payer
determinations based on participation regulation to make clear that under Advanced APMs. We finalized that
in multiple Advanced APMs, not all QP 414.1425(c)(4), if an eligible clinician beginning in payment year 2021, we
determinations. Accordingly, for is determined to be a QP based on will conduct QP determinations
example, if an eligible clinician is a QP participation in multiple Advanced sequentially so that the Medicare
through participation in both of two APMs, but any of the APM Entities in Option is applied before the All-Payer
Advanced APMs under 414.1425(b)(1), which the eligible clinician participates Combination Option (81 FR 77438). An
and one APM Entity voluntarily or voluntarily or involuntarily terminates eligible clinician only needs to be a QP
involuntarily terminates from one of from the Advanced APM before the end under either the Medicare Option or the
those Advanced APMs, the eligible of the Medicare QP Performance Period, All-Payer Combination Option to be a
clinician is still a QP. However, if the the eligible clinician is not a QP. QP for the payment year. The All-Payer
eligible clinician is a QP through Combination Option encourages eligible
participation in multiple Advanced 6. All-Payer Combination Option
clinicians to participate in payment
APMs under 414.1425(c)(4), and any a. Overview arrangements with payers other than
APM Entity that eligible clinician Medicare that have payment designs
participates in that counts towards the Section 1833(z)(2)(B)(ii) of the Act
requires that beginning in payment year that satisfy the Other Payer Advanced
QP determination voluntarily or APM criteria. It also encourages
involuntarily terminates, the eligible 2021, in addition to the Medicare
Option, eligible clinicians may become sustained participation in Advanced
clinician is no longer a QP. We seek APMs across multiple payers.
comment on these proposals. QPs through the Combination All-Payer
and Medicare Payment Threshold We finalized that the QP
c. Summary of Proposals Option, which we refer to as the All- determinations under the All-Payer
In summary, we are making the Payer Combination Option. In the CY Combination Option are based on
following proposals in this section: 2017 Quality Payment Program final payment amounts or patient counts as
We propose to calculate QP rule (81 FR 77459), we finalized our illustrated in Tables 46, 47, and Figures
Threshold Scores for Advanced APMs overall approach to the All-Payer K1 and K2 (See 81 FR 77460 through
that are actively tested continuously for Combination Option. The Medicare 77461). We also finalized that, in
a minimum of 60 days during the Option focuses on participation in making QP determinations, we will use
Medicare QP Performance Period and Advanced APMs, and we make the Threshold Score that is most
start or end during the Medicare QP determinations under this option based advantageous to the eligible clinician
Performance Period using only the dates on Medicare Part B covered professional toward achieving QP status for the year,
that APM Entities were able to services attributable to services or if QP status is not achieved, Partial
participate in the Advanced APM per furnished through an APM Entity. The QP status for the year (81 FR 77475).
TABLE 46: QP Payment Amount Thresholds- All-Payer Combination Option
All-Payer Combination Option- Payment Amount Method

Payment Year 2019 2020 2021 2022 2023 2024 and later
QPPayment N/A N/A 50% 25% 50% 25% 75% 25% 75% 25%
Amount
Threshold
Partial QP N/A N/A 40% 20% 40% 20% 50% 20% 50% 20%
Payment Amount
Threshold
>--3
0 ~~
..... >--3
0 ~~
..... >--3
0 ~~
..... >--3
0 ~~
.....
g. ~
(])
g. ~
(])
g. ~
(])
g. ~
(])
.: .., .: .., .: .., .: ..,

s (il s (il s (il s (il
TABLE 47: QP Patient Count Thresholds- All-Payer Combination Option
All-Payer Combination Option- Patient Count Method

Payment Year 2019 2020 2021 2022 2023 2024 and later
QP Patient Count N/A N/A 35% 20% 35% 20% 50% 20% 50% 20%
Threshold
Partial QP Patient N/A N/A 25% 10% 25% 10% 35% 10% 35% 10%
Count Threshold
>--3
0 ~~
.....(])
>--3
0 ~~
.....
(])
>--3
0 ~~
.....
(])
>--3
0 ~~
.....
(])
....... ....... ....... .......
e:.. ~
.: e;
e:.. ~
.: e;
e:.. ~
.: e;
e:.. ~
.: e;
s (]) s (]) s (]) s (])
EP30JN17.006</GPH>
Unlike the Medicare Option, where a QP without receiving the required The eligible clinician meets the
we have access to all of the information information from an external source. relevant QP thresholds by having
necessary to determine whether an APM We finalized the process that eligible sufficient payments or patients
meets the criteria to be an Advanced clinicians can use to seek a QP attributed to a combination of
APM, we cannot identify whether an determination under the All-Payer participation in Other Payer Advanced
other payer arrangement meets the Combination Option (81 FR 77478 APMs and Advanced APMs.
criteria to be an Other Payer Advanced through 77480):
We address the following topics in

APM without receiving the required The eligible clinician submits to this section of the proposed rule: (1)
information from an external source. CMS sufficient information on all Other Payer Advanced APM Criteria; (2)
Similarly, we do not have the necessary relevant payment arrangements with Determination of Other Payer Advanced
payment amount and patient count other payers; APMs; and (3) Calculation of All-Payer
information to determine under the All- Based upon that information CMS Combination Option Threshold Scores
Payer Combination Option whether an determines that at least one of those and QP Determinations.
eligible clinician meets the payment payment arrangements is an Other Payer
amount or patient count threshold to be Advanced APM; and
EP30JN17.007</GPH>
b. Other Payer Advanced APM Criteria We recognize that there may be amount standards, which could be
(1) In General medical homes that are operated by different from the generally applicable
other payers that may be appropriately Other Payer Advanced APM standards
Our goal is to align the Advanced considered medical home models under and would be identical to the Medicaid
APM criteria under the Medicare Option the All-Payer Combination Option. Medical Home Model financial risk and
and the Other Payer Advanced APM Examples of these arrangements may nominal amount standards.
criteria under the All-Payer include those aligned with the We are particularly interested in, and
Combination Option as permitted by Comprehensive Primary Care Plus seek comment on, whether there are
statute and as feasible and appropriate. (CPC+) model. Therefore, we seek payment arrangements that currently
We believe this alignment will help comment on whether we should define exist that would meet this definition.
simplify the Quality Payment Program the term Other Payer Medical Home We encourage commenters to note
and encourage participation in Other Model as an other payer arrangement whether such payment arrangements
Payer Advanced APMs. that is determined by CMS to have the would meet the existing generally
In the CY 2017 Quality Payment following characteristics: applicable Other Payer Advanced APM
Program final rule, we finalized that, in The other payer arrangement has a financial risk and nominal amount
general, an other payer arrangement primary care focus with participants standards. We also request comments on
with any payer other than traditional that primarily include primary care any special considerations that might be
Medicare, including Medicare Health practices or multispecialty practices that relevant when establishing a definition
Plans, which include Medicare include primary care physicians and for a medical home model standard for
Advantage, Medicaid-Medicaid Plans, practitioners and offer primary care payers with payment arrangements that
1876 and 1833 Cost Plans, and Programs services. For the purposes of this would not fit under the Medical Home
of All Inclusive Care for the Elderly provision, primary care focus means the Model or Medicaid Medical Home
(PACE) plans, will be an Other Payer inclusion of specific design elements Model definitions, including how the 50
Advanced APM if it meets all three of related to eligible clinicians practicing clinician cap discussed in section
the following criteria: under one more of the following II.D.4.b.(1) of this proposed rule for the
The other payer arrangement Physician Specialty Codes: 01 General Medical Home Model nominal amount
requires at least 50 percent of Practice; 08 Family Medicine; 11 standard would apply.
participating eligible clinicians in each Internal Medicine; 16 Obstetrics and
APM Entity (or each hospital if Gynecology; 37 Pediatric Medicine; 38 (3) Financial Risk for Monetary Losses
hospitals are the APM participants) to Geriatric Medicine; 50 Nurse In the CY 2017 Quality Payment
use Certified EHR Technology (CEHRT) Practitioner; 89 Clinical Nurse Program final rule we finalized policies
to document and communicate clinical Specialist; and 97 Physician Assistant; to assess whether an other payer
care (81 FR 77464 through 77465); Empanelment of each patient to a arrangement requires participating APM
The other payer arrangement primary clinician; and Entities to bear more than nominal
requires that quality measures At least four of the following: financial risk if aggregate expenditures
comparable to measures under the MIPS ++ Planned coordination of chronic exceed expected aggregated
quality performance category apply, and preventive care. expenditures (more than nominal
which means measures that are ++ Patient access and continuity of financial risk for monetary losses). This
evidence-based, reliable and valid; and, care. Other Payer Advanced APM criterion
if available, at least one measure must ++ Risk-stratified care management. has two components: A financial risk
be an outcome measure (81 FR 77466); ++ Coordination of care across the
standard and a nominal amount
and medical neighborhood.
The other payer arrangement either: ++ Patient and caregiver engagement. standard. The financial risk standard
(1) Requires APM Entities to bear more ++ Shared decision-making. defines what it means for an APM Entity
than nominal financial risk if actual ++ Payment arrangements in addition to bear financial risk if actual aggregate
aggregate expenditures exceed expected to, or substituting for, fee-for-service expenditures exceed expected aggregate
aggregate expenditures (under either the payments (for example, shared savings expenditures under an other payer
generally applicable or Medicaid or population-based payments). arrangement. We finalized a generally
Medical Home Model standards for Similar to Medical Home Models and applicable financial risk standard and a
nominal amount of financial risk, as Medicaid Medical Home Models, we Medicaid Medical Home Model
applicable); or (2) is a Medicaid Medical believe that Other Payer Medical Home financial risk standard for Other Payer
Home Model that meets criteria Models could be considered unique Advanced APMs. (See 81 FR 77466
comparable to Medical Home Models types of other payer arrangements for through 77474).
expanded under section 1115A(c) of the purposes of the Quality Payment We finalized that for an other payer
Act (81 FR 77466 through 77467). Program. We anticipate that participants arrangement to meet the generally
in these arrangements may generally be applicable financial risk standard for
(2) Other Payer Medical Home Models more limited in their ability to bear Other Payer Advanced APMs, if an APM
In the CY 2017 Quality Payment financial risk than other entities because Entitys actual aggregate expenditures
Program final rule we finalized they may be smaller and predominantly exceed expected aggregate expenditures
definitions of Medical Home Model and include primary care practitioners, during a specified performance period,
Medicaid Medical Home Model at whose revenues are a smaller fraction of the payer must:
414.1305. The statute does not define the patients total cost of care than those Withhold payment of services to the
medical homes, but sections of other eligible clinicians. Because of APM Entity and/or the APM Entitys
1848(q)(5)(C)(i), these factors, we believe it may be eligible clinicians;
1833(z)(2)(B)(iii)(II)(cc)(BB), appropriate to determine whether an Reduce payment rates to APM
1833(z)(2)(C)(iii)(II)(cc)(BB), and Other Payer Medical Home Model Entity and/or the APM Entitys eligible
1833(z)(3)(D)(ii)(II) of the Act make satisfies the financial risk criterion by clinicians; or
medical homes an instrumental piece of using special Other Payer Medical Require direct payments by the
the Quality Payment Program. Home Model financial risk and nominal APM Entity to the payer (81 FR 77467).
We also finalized that for a Medicaid standard for Advanced APMs in two future Advanced APMs would meet the
Medical Home Model to be an Other ways. three measures of risk as well.
Payer Advanced APM, if the APM First, the finalized generally Therefore, we do not expect the
Entitys actual aggregate expenditures applicable Advanced APM nominal application of the different criteria
exceed expected aggregate expenditures amount standard only requires an APM between Advanced APMs and Other
during a specified performance period, to meet one measure of risktotal risk Payer Advanced APMs to produce
the Medicaid Medical Home Model (81 FR 77424). The finalized generally meaningfully different results in terms
must: applicable Other Payer Advanced APM of actual risk faced by participants.
Withhold payment of services to the nominal amount standard involves Second, the finalized generally
APM Entity and/or the APM Entitys assessment of the following three applicable Advanced APM nominal
eligible clinicians; measures of risk: amount standard allows for total risk to
Reduce payment rates to APM Marginal riskthe percentage of the be defined in one of two ways, based on
Entity and/or the APM Entitys eligible amount by which actual expenditures expected expenditures (the benchmark-
clinicians; exceed expected expenditures for which based standard) or based on revenue
Require direct payments by the an APM Entity would be liable under (the revenue-based standard) (81 FR
APM Entity to the payer; or the payment arrangement. 77427). In contrast, the finalized Other
Require the APM Entity to lose the Minimum loss ratea percentage Payer Advanced APM generally
right to all or part of an otherwise by which actual expenditures may applicable nominal amount standard is
guaranteed payment or payments (81 FR exceed expected expenditures without only based on expected expenditures
77468 through 77469). triggering financial risk. (81 FR 77471).
(a) Generally Applicable Nominal Total riskthe maximum potential In the CY 2017 Quality Payment
Amount Standard payment for which an APM Entity could program final rule, we sought comments
be liable under a payment arrangement. on using the expected expenditures
(i) Marginal Risk and Minimum Loss We note that as described in the CY approach for the generally applicable
Rate 2017 Quality Payment Program final Other Payer Advanced APM nominal
The generally applicable nominal rule (81 FR 77426), although we did not amount standard.
amount standard that we finalized in formally adopt marginal risk or Table 48 lists the requirements of the
the CY 2017 Quality Payment Program minimum loss rate criteria for Advanced generally applicable nominal amount
final rule (81 FR 77471) for Other Payer APMs, we pointed out that all current standards as finalized in the CY 2017
Advanced APMs differs from the Advanced APMs would meet these Quality Payment Program final rule (81
generally applicable nominal amount standards, and that we intend that all FR 77427 and 77471).
TABLE 48GENERALLY APPLICABLE NOMINAL AMOUNT STANDARDS FOR ADVANCED APMS AND OTHER PAYER
ADVANCED APMS FINALIZED IN THE CY 2017 QUALITY PAYMENT PROGRAM FINAL RULE
Advanced APMs Other Payer Advanced APMs
Generally Applicable Nominal Amount Standard For 2017 and 2018, nominal amount of risk Nominal amount of risk must be:
must be at least equal to either: Marginal Risk of at least 30 percent;
8 percent of average estimated total of Minimum Loss Rate of no more than 4
Medicare Part A and Part B revenues percent; and
of all providers and suppliers in partici- Total Risk of at least 3 percent of the
pating APM Entities; or. expected expenditures for which the
3 percent of expected expenditures for APM Entity is responsible.
which the APM entity is responsible.
We do not propose to modify the assurance that Other Payer Advanced APMs that is parallel to the revenue-
marginal risk and minimum loss rate APMs will involve true financial risk in based nominal amount standard for
requirements as we finalized in the CY accordance with statutory requirements. Advanced APMs. Specifically, we
2017 Quality Payment Program final Including marginal risk and a minimal propose that an other payer arrangement
rule as part of the generally applicable loss rate as components of the nominal would meet the revenue-based nominal
nominal amount standard for Other amount standard assures that the amount standard we are proposing if,
Payer Advanced APMs. We continue to payment arrangements that we could under the terms of the other payer
believe that using these measures of risk determine are Other Payer Advanced arrangement, the total amount that an
will ensure that payment arrangements APMs and could contribute to the APM Entity potentially owes the payer
involving other payers and APM attainment of QP status are similarly or foregoes is equal to at least: For the
Entities or eligible clinicians cannot be rigorous to Advanced APMs. We request 2019 and 2020 All-Payer QP
engineered in such a way as to provide additional comments on this approach, Performance Periods, 8 percent of the
eligible clinicians an avenue to QP and on whether there are potential total combined revenues from the payer
status through an Other Payer Advanced alternative approaches to achieving of providers and suppliers in
APM that technically meets the these goals. participating APM Entities. We would
financial risk criterion but carries a very use this standard for other payer
(ii) Revenue-Based Generally Applicable
low risk of losses based on performance. arrangements where financial risk is
Nominal Amount Standard
Because we do not have direct control expressly defined in terms of revenue in
over the design of Other Payer We propose to add a revenue-based the payment arrangement. We seek
Advanced APMs, we believe the use of nominal amount standard to the comment on this proposal.
a multi-factor nominal amount standard generally applicable nominal amount For Advanced APMs, we may
to assess financial risk provides greater standard for Other Payer Advanced determine that an APM still meets the
revenue-based generally applicable arrangements to meet the generally beneficiaries receive as a result.
nominal amount standard, even if risk is applicable nominal amount standard, Specifically, we seek comment on
not explicitly defined in terms of and would allow closer alignment whether such a standard should apply
revenue, by comparing model downside between Medicare and other payers as only to small and, or, rural practices
risk to the estimated average Medicare new payment arrangements are that are participants in an APM, or also
revenue of model participants. Because introduced and evolve. As with the to small and/or rural practices that join
we have direct access to Medicare revenue-based nominal amount larger APM Entities to participate in
claims data, we can estimate such an standard for Advanced APMs, which we APMs. We also seek comment on how
average. For other payers, we do not discuss in section II.D.4.b.(2)(a) of this we should decide where a practice is
have similar direct access to claims proposed rule, we seek comment on located to determine whether it is
data. As such, there are significant whether we should consider either a operating in a rural area is defined in
operational challenges to identifying lower or higher revenue-based nominal 414.1305.
whether an other payer arrangement amount standard for the 2019 and 2020
would satisfy the revenue-based All-Payer QP Performance Periods, and (b) Medicaid Medical Home Model
nominal amount standard when the on the amount and structure of the Nominal Amount Standard
other payer arrangement does not define revenue-based nominal amount
risk explicitly in terms of revenue. We standard for All-Payer QP Performance In the CY 2017 Quality Payment
do not have direct access to other payer Periods 2021 and later. Program final rule (81 FR 77472), in
revenue data, so we could not do this We also seek comment on whether we addition to the financial risk standard
calculation without significant should consider a different, potentially for Medicaid Medical Home Models, we
assistance from the relevant payer. For lower, revenue-based nominal amount finalized that to be an Other Payer
this reason, we propose that the standard only for small practices and Advanced APM, a Medicaid Medical
revenue-based standard would only be those in rural areas that are not Home Model must require that the total
applied to other payer arrangements in participating in a Medicaid Medical annual amount that an APM Entity
which risk is explicitly defined in terms Home Model for the 2019 and 2020 All- potentially owes or foregoes be at least
of revenue, as specified in an agreement Payer QP Performance Periods. For the the following amounts in a given
covering the other payer arrangement. purposes of the Quality Payment performance year:
We propose that under the generally Program, we use the definition of small In 2019, 4 percent of the APM
applicable nominal amount standard for practices and rural areas in 414.1305. Entitys total revenues under the payer.
Other Payer Advanced APMs, an other We believe that a different, potentially
payer arrangement would need to meet lower, revenue-based nominal amount In 2020 and later, 5 percent of the
either the benchmark-based nominal standard for the 2019 and 2020 All- APM Entitys total revenues under the
amount standard or the revenue-based Payer QP Performance Periods payer.
nominal amount standard, and need not specifically for small and rural Table 49 lists the requirements of the
meet both. We believe this proposed organizations may allow for their Medicaid Medical Home Model nominal
approach to the nominal amount increased participation in Advanced amount standards as finalized in the CY
standard would expand the APMs, which may help increase the 2017 Quality Payment Program final
opportunities for other payer quality and coordination of care rule (81 FR 77428 and 77472).
TABLE 49MEDICAID MEDICAL HOME MODEL NOMINAL AMOUNT STANDARDS FOR ADVANCED APMS AND OTHER PAYER
ADVANCED APMS FINALIZED IN THE CY 2017 QUALITY PAYMENT PROGRAM FINAL RULE
Medical Home Model Medicaid Medical Home Model
Nominal Amount Standard ................................. Nominal amount of risk must be: Nominal amount of risk must be:
In 2017, 2.5 percent .............................. In 2019, 4 percent.
In 2018, 3 percent ................................. In 2020 and later, 5 percent.
In 2019, 4 percent
In 2020 and later, 5 percent
As we have discussed in section is appropriate and that setting the Medicaid Medical Home Models that
II.D.4.b.(2)(b) of this proposed rule standard at 5 percent of the APM have little experience with risk. To that
regarding APM Entities in Medical Entitys total revenue under the payer end, we believe a small reduction of risk
Home Models, we have also received appropriately reflects the meaning of in the Medicaid Medical Home Model
comments that few APM Entities in nominal in the Medicaid Medical Home nominal amount standard beginning in
Medical Home Models and Medicaid Model context. the 2019 All-Payer QP Performance
Medical Home Models have had We have reconsidered the incremental Period may allow for greater flexibility
experience with financial risk, and that annual increases in the standard over in setting financial risk thresholds that
many would be financially challenged several years. Our policy finalized in the would encourage more participation in
to provide sufficient care or even remain CY 2017 Quality Payment Program final Medicaid Medical Home Models and be
a viable business in the event of rule set forth what we envisioned was more sustainable for the type of APM
substantial disruptions in revenue. We a gradually increasing but achievable Entities that would potentially
understand these concerns that the amount of risk that would apply over participate in Medicaid Medical Home
gradual increase in risk over time may time. In general, we still believe this to Models.
be unmanageable for some APM be true, but recognize that establishing Therefore, we are proposing that, to
Entities; however, we still believe that a an even more gradual increase in risk be an Other Payer Advanced APM, a
final Medicaid Medical Home Model for Medicaid Medical Home Models Medicaid Medical Home Model must
nominal amount standard of 5 percent may better suit many APM Entities in require that the total annual amount that
an APM Entity potentially owes or CY 2017 Quality Payment Program final Programs of All Inclusive Care for the
foregoes under the Medicaid Medical rule and the beginning of the first QP Elderly (PACE) Plans.
Home Model must be at least: Performance Period because we already If a payer requests that we determine
For All-Payer QP Performance possessed all of the information whether a payment arrangement
Period 2019, 3 percent of the APM necessary. authorized under Title XIX, a Medicare
Entitys total revenue under the payer. For other payer arrangements, we Health Plan payment arrangement, or a
For All-Payer QP Performance specified that an APM Entity or eligible payment arrangement in a CMS Multi-
Period 2020, 4 percent of the APM clinician must submit, by a date and in Payer Model is an Other Payer
Entitys total revenue under the payer. a manner determined by us, information Advanced APM, and the payer uses the
For All-Payer QP Performance necessary to identify whether a given same other payer arrangement in other
Period 2021 and later, 5 percent of the payment arrangement satisfies the Other commercial lines of business, we
APM Entitys total revenue under the Payer Advanced APM criteria (81 FR propose to allow the payer to
payer. 77480). We finalized that we will concurrently request that we determine
We seek comment on this proposal. identify Medicaid APMs and Medicaid whether those other payer arrangements
Medical Home Models that meet the are Other Payer Advanced APMs as
(4) Summary of Proposals Other Payer Advanced APM criteria well. We will make Other Payer
In summary, we are proposing the before the beginning of the QP Advanced APM determinations for each
following: Performance Period (81 FR 77478 individual payment arrangement.
We propose that an other payer through 77480). We also sought We propose that these Other Payer
arrangement would meet the revenue- comment on the overall process for Advanced APM determinations would
based nominal amount standard we are reviewing payment arrangements to be in effect for only one year at a time.
proposing if, under the terms of the determine whether they are Other Payer Payers would need to submit payment
other payer arrangement, the total Advanced APMs, and we also sought arrangement information each year in
amount that an APM Entity potentially comment on whether we should create order for us to make an Other Payer
owes the payer or foregoes is equal to a separate pathway to identify whether Advanced APM determination in each
at least: for the 2019 and 2020 All-Payer other payer arrangements with Medicaid year. We believe this approach is
QP Performance Periods, 8 percent of as a payer meet the Other Payer appropriate since payment
the total combined revenues from the Advanced APM criteria (81 FR 77463). arrangements can change from year to
payer of providers and suppliers in year, and also since we may modify
(a) Payer Initiated Other Payer aspects of the Other Payer Advanced
participating APM Entities. Advanced APM Determination Process
We are proposing that to be an APM criteria from one year to the next.
(Payer Initiated Process) We seek comment on this approach, and
Other Payer Advanced APM, a Medicaid
We propose to allow certain other we are exploring ways to streamline this
Medical Home Model must require that
payers, including payers with payment process over time.
the total annual amount that an APM
arrangements authorized under Title We propose to allow remaining other
Entity potentially owes or foregoes
XIX, Medicare Health Plan payment payers, including commercial and other
under the Medicaid Medical Home
arrangements, and payers with payment private payers, to request that we
Model must be at least:
arrangements in CMS Multi-Payer determine whether other payer
++ For All-Payer QP Performance
Models to request that we determine arrangements are Other Payer Advanced
Period 2019, 3 percent of the APM
whether their other payer arrangements APMs starting in 2019 prior to the 2020
Entitys total revenue under the payer.
are Other Payer Advanced APMs All-Payer QP Performance Period and
++ For All-Payer QP Performance starting prior to the 2019 All-Payer QP annually each year thereafter. We
Period 2020, 4 percent of the APM Performance Period and each year believe that phasing in the Payer
Entitys total revenue under the payer. thereafter. We propose to generally refer Initiated Process would allow us to gain
++ For All-Payer QP Performance to this process as the Payer Initiated experience with the determination
Period 2021 and later, 5 percent of the Other Payer Advanced APM process on a limited basis with payers
APM Entitys total revenue under the Determination Process (Payer Initiated where we have the strongest
payer. Process). We believe that establishing relationships and existing processes that
c. Determination of Other Payer this Payer Initiated Process would be we believe can help facilitate submitting
Advanced APMs beneficial to APM Entities and eligible this information. We anticipate making
clinicians because it would help reduce improvements and refinements to this
(1) Overview
their reporting burden, and it would process, which we believe will help us
In the CY 2017 Quality Payment provide us with the most complete facilitate receiving this information from
Program final rule, we established a information on payment arrangements. the remaining other payers.
prospective Advanced APM In addition, we believe the Other Payer We propose that the Payer Initiated
determination process (81 FR 77408). Advanced APM determinations made Process would be voluntary for all
This prospective approach was via the Payer Initiated Process could be payers. We propose that the Payer
implemented to ensure that APM completed prior to the All-Payer QP Initiated Process would generally
Entities and eligible clinicians were Performance Period, and we could involve the same steps for each payer
aware of which APMs met the therefore provide APM Entities and type as listed below for each All-Payer
Advanced APM criteria prior to the first eligible clinicians with information that QP Performance Period, and we
QP Performance Period, and because we may help them plan their participation elaborate on details within this
have a general goal of providing notice, in Other Payer Advanced APMs. framework that are specific to payer
when possible, of which models are When referring to Medicare Health type in the following subsections:
Advanced APMs prior to the beginning Plans in the context of the Payer Guidance and Submission Form: We
of the Medicare QP Performance Period. Initiated Process, we include in the term intend to make guidance available
We were able to perform Advanced Medicare Advantage and certain types regarding the Payer Initiated Process for
APM determinations within the time of plans including Medicare-Medicaid each payer type prior to the first
period between the effective date of the Plans, 1876 and 1833 Cost Plans, and Submission Period, which would occur
during 2018. We intend to develop a not submit sufficient information, we (b) APM Entity or Eligible Clinician
submission form (which we refer to as would not make a determination in Initiated Other Payer Advanced APM
the Payer Initiated Submission Form) response to that request submitted via Determination Process (Eligible
that would be used by payers to request the Payer Initiated Submission Form. As Clinician Initiated Process)
Other Payer Advanced APM a result, the other payer arrangement In the CY 2017 Quality Payment
determinations, and we intend to make would not be considered an Other Payer Program final rule, we finalized that
this Payer Initiated Submission Form Advanced APM for the year. These APM Entities and eligible clinicians in
available to payers prior to the first determinations are final and not subject payment arrangements with other
Submission Period. We propose that to reconsideration. payers would have an opportunity to
payers would be required to use the CMS Notification: We intend to notify request determinations of whether an
Payer Initiated Submission Form to payers of our determinations for each other payer arrangement(s) is an Other
request that we make an Other Payer request as soon as practicable after the Payer Advanced APM after the QP
Advanced APM determination. We relevant Submission Deadline. APM Performance Period (81 FR 77480). At
intend for the Payer Initiated Entities or eligible clinicians may that time, APM Entities and eligible
Submission Form to include questions submit information regarding an other clinicians would know which payment
that are applicable to all payment payer arrangement for a subsequent All- arrangements they participated in
arrangements and some that are specific Payer QP Performance Period even if we during the preceding QP Performance
to a particular type of payment have determined that the other payer Period. We clarify that both APM
arrangements, and we intend for it to arrangement is not an Other Payer Entities and eligible clinicians may
include a way for payers to attach Advanced APM for a prior year. request Other Payer Advanced APM
supporting documentation. We propose CMS Posting of Other Payer Advanced determinations through this process,
that payers may submit requests for APMs: We intend to post on the CMS and we refer to this process as the
review of multiple other payer Web site a list (which we refer to as the
arrangements through the Payer Eligible Clinician Initiated Process.
Other Payer Advanced APM List) of all We propose that through the Eligible
Initiated Process, though we would other payer arrangements that we Clinician Initiated Process, APM
make separate determinations as to each determine to be Other Payer Advanced Entities and eligible clinicians
other payer arrangement and a payer APMs. Prior to the start of the relevant participating in other payer
would be required to use a separate All-Payer QP Performance Period, we arrangements would have an
Payer Initiated Submission Form for intend to post the Other Payer opportunity to request that we
each other payer arrangement. Payers Advanced APMs that we determine
may submit other payer arrangements determine for the year whether those
through the Payer Initiated Process and other payer arrangements are Other
with different tracks within that Other Payer Advanced APMs under
arrangement as one request along with Payer Advanced APMs. The Eligible
Title XIX that we determine through the Clinician Initiated Process could also be
information specific to each track. Eligible Clinician Initiated Process.
Submission Period: We propose that used to request determinations before
After the All-Payer QP Performance the beginning of an All-Payer QP
the Submission Period opening date and
Period, we would update this list to Performance Period for other payer
Submission Deadline would vary by
include Other Payer Advanced APMs arrangements authorized under Title
payer type to align with existing CMS
that we determine based on other XIX, as we discuss in section
processes for payment arrangements
authorized under Title XIX, Medicare requests through the Eligible Clinician II.D.6.(c)(2)(b) of this proposed rule. The
Health Plan payment arrangements, and Initiated Process. Eligible Clinician Initiated Process
payers with payment arrangements in We believe that this proposed Payer would not be necessary for, or
CMS Multi-Payer Models to the extent Initiated Process would encourage applicable to, other payer arrangements
possible and appropriate. We are greater participation in Other Payer that are already determined to be Other
proposing these dates based on Advanced APMs, particularly because it Payer Advanced APMs through the
operational timelines that take into would allow us to post a list of at least Payer Initiated Process.
account the time necessary to review some of the Other Payer Advanced Guidance and Submission Form: We
submitted information, to align with APMs before the start of the All-Payer intend to make guidance available
other relevant deadlines in the Quality QP Performance Period as discussed in regarding the Eligible Clinician Initiated
Payment Program to the extent possible, section II.D.6.d.(2)(a) of this proposed Process for each payer type prior to the
and to provide payers with as much rule. We also believe that payers are first Submission Period, which would
notice of what is required in the Payer well positioned to compile and submit occur during 2018. We intend to
Initiated Process and as much time to to us the information we require to develop a submission form (which we
complete any Payer Initiated make Other Payer Advanced APM refer to as the Eligible Clinician Initiated
Submission Form as possible. determinations because they develop Submission Form) that would be used
CMS Determination: Upon the timely other payer arrangements. We seek by APM Entities or eligible clinicians to
receipt of a Payer Initiated Submission comment on these proposals. request Other Payer Advanced APM
Form, we would use the information We note that we will seek OMB determinations, and we intend to make
submitted to determine whether the approval for the proposed Payer this Eligible Clinician Initiated
other payer arrangement meets the Initiated Submission Form separately Submission Form available to APM
Other Payer Advanced APM criteria. We from this rulemaking process. In Entities and eligible clinicians prior to
propose that if we determine that the accordance with the Paperwork the first Submission Period. We propose
payer has submitted incomplete or Reduction Act (PRA), we will publish that APM Entities and eligible clinicians
inadequate information, we would the required 60-day public notice and would be required to use the Eligible
inform the payer and allow the payer to 30-day public notice. In addition, the Clinician Initiated Submission Form to
submit additional information no later entire information collection request request that we make an Other Payer
than 10 business days from the date we and all associated forms will be made Advanced APM determination. We
inform the payer. For each other payer available for public review prior to OMB intend for the Eligible Clinician
arrangement for which the payer does submission. Initiated Submission Form to include
questions that are applicable to all other CMS Notification: We propose to (2) Medicaid APMs and Medicaid
payer arrangements and some that are notify APM Entities and eligible Medical Home Models
specific to a particular type of other clinicians of our determinations for each In this section, we discuss how
payer arrangements, and we intend for other payer arrangement for which a payers, APM Entities, and eligible
it to include a way for APM Entities or determination was requested as soon as clinicians may request that we
eligible clinicians to attach supporting practicable after the Submission determine whether payment
documentation. We propose that APM Deadline. arrangements authorized under Title
Entities or eligible clinicians may We note that APM Entities and XIX of the Act are Medicaid APMs or
submit requests for review of multiple eligible clinicians who submit complete Medicaid Medical Home Models that
other payer arrangements through the Eligible Clinician Initiated Submission meet the Other Payer Advanced APM
Eligible Clinician Initiated Process, Forms by September 1 of the calendar criteria. There are some differences
though we would make separate year of the relevant All-Payer QP between the determination process for
determinations as to each other payer Performance Period may allow for us to other payer arrangements where
arrangement, and an APM Entity or make Other Payer Advanced APM Medicaid is the payer and the process
eligible clinician would be required to determinations and inform APM for other payer arrangements with other
use a separate Eligible Clinician Entities or eligible clinicians of those types of payers. These differences stem
Initiated Submission Form for each determinations prior to the December 1 in part from the requirements specified
other payer arrangement. APM Entities QP Determination Submission Deadline. in sections 1833(z)(2)(B)(ii)(bb) and
or eligible clinicians may submit other If we determine that an other payer 1833(z)(2)(C)(ii)(bb) of the Act for the
payer arrangements with different tracks arrangement is not an Other Payer All-Payer Combination Option for QP
within that arrangement as one request Advanced APM, notifying APM Entities determinations. We interpret those
along with information specific to each or eligible clinicians of such a statutory provisions to direct us, when
track. determination may help them avoid the
Submission Period: In general, we making QP determinations under the
burden of submitting payment amount All-Payer Combination Option, to
propose that APM Entities or eligible and patient count information for that
clinicians may request Other Payer exclude from the calculation of all
payment arrangement. We intend to other payments any payments made (or
Advanced APM determinations make these early notifications to the
beginning on August 1 of the same year patients under the patient count
extent possible. We propose that APM method) under Title XIX in a state in
as the relevant All-Payer QP Entities or eligible clinicians may
Performance Period. We discuss our which there is no available Medicaid
submit information regarding an other APM (which by definition at 414.1305
proposal to establish the All-Payer QP payer arrangement for a subsequent All-
Performance Period in section meets the Other Payer Advanced APM
Payer QP Performance Period even if we criteria) or Medicaid Medical Home
II.D.6.d.(2)(a) of this proposed rule. We have determined that the other payer
propose that the Submission Deadline Model that meets the Other Payer
arrangement is not an Other Payer Advanced APM criteria. We believe that
for requesting Other Payer Advanced
Advanced APM for a prior year. our interpretation of the statute to
APM determinations, as well as to
CMS Posting of Other Payer Advanced exclude, when appropriate as discussed
request QP determinations under the
APMs: We intend to post on the CMS in section II.D.6.(d)(3)(c) of this
All-Payer Combination Option, is
Web site a list (which we refer to as the proposed rule, Medicaid APMs or
December 1 of the same year as the
relevant All-Payer QP Performance Other Payer Advanced APM List) of all Medicaid Medical Home Models that
Period. of the other payer arrangements that we meet the Other Payer Advanced APM
CMS Determination: Upon timely determine to be Other Payer Advanced criteria, is appropriate to carry out the
receipt of an Eligible Clinician Initiated APMs. Prior to the start of the relevant terms of the statute while avoiding
Submission Form, we would use the All-Payer QP Performance Period, we circumstances that could unfairly
information submitted to determine intend to post the Other Payer impact the ability of eligible clinicians
whether the other payer arrangement Advanced APMs that we determine to plan ahead and position themselves
meets the Other Payer Advanced APM through the Payer Initiated Process and to attain QP status. Our interpretation
criteria. We propose that, if we Other Payer Advanced APMs under leads us to exclude Title XIX payments
determine that the APM Entity or Title XIX that we determine through the or patients from the denominator of QP
eligible clinician has submitted Eligible Clinician Initiated Process. calculations when eligible clinicians
incomplete or inadequate information, After the All-Payer QP Performance had no opportunity to participate in a
we would inform the APM Entity or Period, we would update this list to Medicaid APM or Medicaid Medical
eligible clinician and allow the APM include Other Payer Advanced APMs Home Model that meets the Other Payer
Entity or eligible clinician to submit that we determine based on other Advanced APM criteria.
additional information no later than 10 requests through the Eligible Clinician To implement this requirement, we
business days from the date we inform Initiated Process. need to determine which states have no
the APM Entity or eligible clinician. For We seek comment on these proposals. available Medicaid APMs or Medicaid
each other payer arrangement for which We note that we will seek OMB Medical Home Models that meet the
the APM Entity or eligible clinician approval for the proposed Eligible Other Payer Advanced APM criteria
does not submit sufficient information, Clinician Initiated Submission Form during a given All-Payer QP
we would not make a determination in separately from this rulemaking process. Performance Period as described in
response to that request submitted via In accordance with the Paperwork section II.D.6.c.(2)(b) of the proposed
the Eligible Clinician Initiated Reduction Act (PRA), we will publish rule. We believe that it is important for
Submission Form. As a result, the other the required 60-day public notice and us to make this determination prior to
payer arrangement would not be 30-day public notice. In addition, the the All-Payer QP Performance Period,
considered an Other Payer Advanced entire information collection request and to announce the Medicaid APMs
APM for the year. These determinations and all associated forms will be made and Medicaid Medical Home Models
are final and not subject to available for public review prior to OMB that meet the Other Payer Advanced
reconsideration. submission. APM criteria and the locations where
they are available, so that eligible regarding the Payer Initiated Process for submissions is April 1 of the year prior
clinicians can assess whether their Title each payer type prior to the first to the All-Payer QP Performance Period
XIX payments and patients would be Submission Period, which would occur for which we would make the
excluded under the All-Payer during 2018. We intend to develop a determination. As we discuss in section
Combination Option for that particular submission form (which we refer to as II.D.6.c.(2) of this proposed rule, we
performance year. If, for a given state, the Payer Initiated Submission Form) need to determine Medicaid APMs and
we receive no requests to make that would be used by payers to request Medicaid Medical Home Models that
determinations for other payer Other Payer Advanced APM are Other Payer Advanced APMs prior
arrangements that could be Medicaid determinations, and we intend to send to the start of the All-Payer QP
APMs or Medicaid Medical Home this Payer Initiated Submission Form to Performance Period in order to apply
Models that are Other Payer Advanced states prior to the first Submission the Title XIX exclusions where
APMs for the year through either the Period. We propose that payers would appropriate. We propose these dates for
Payer Initiated Process or the Eligible be required to use the Payer Initiated this reason, as well as to provide time
Clinician Initiated Process, we would Submission Form to request that we for APM Entities and eligible clinicians
assume that there are no Medicaid make an Other Payer Advanced APM to review the Medicaid APMs and
APMs or Medicaid Medical Home determination. We intend for the Payer Medicaid Medical Home Models that
Models that meet the Other Payer Initiated Submission Form to include are Other Payer Advanced APMs on the
Advanced APM criteria in that state for questions that are applicable to all other Other Payer Advanced APM list.
the relevant All-Payer QP Performance payer arrangements and some that are CMS Determination: Upon the timely
Period. Accordingly, we would exclude specific to payment arrangements receipt of a Payer Initiated Submission
Title XIX payments and patients from authorized under Title XIX, and we Form, we would use the information
the All-Payer Combination Option intend for it to include a way for payers submitted to determine whether the
calculations for eligible clinicians in to attach supporting documentation. We other payer arrangement meets the
that state. propose that payers may submit Other Payer Advanced APM criteria. We
requests for review of multiple other propose that, if we determine that the
(a) Payer Initiated Process state has submitted incomplete or
payer arrangements through the Payer
We propose that any states and Initiated Process, though we would inadequate information, we would
territories (which we refer to as states) make separate determinations as to each inform the state and allow the state to
that have in place a state plan under other payer arrangement, and a payer submit additional information no later
Title XIX may request that we determine would be required to use a separate than 10 business days from the date we
prior to the All-Payer QP Performance Payer Initiated Submission Form for inform the state. For each other payer
Period whether other payer each other payer arrangement. Payers arrangement for which the state does
arrangements authorized under Title may submit other payer arrangements not submit sufficient information, we
XIX are Medicaid APMs or Medicaid with different tracks within that would not make a determination in
Medical Home Models that meet the arrangement as one request along with response to that request submitted via
Other Payer Advanced APM criteria, in information specific to each track. the Payer Initiated Submission Form. As
other words, are Other Payer Advanced We intend to work with states as they a result, the other payer arrangement
APMs, under the Payer Initiated prepare and submit Payer Initiated would not be considered an Other Payer
Process. States include the 50 states, the Submission Forms for our review. In Advanced APM for the year. These
District of Columbia, the completing the Payer Initiated determinations are final and not subject
Commonwealth of Puerto Rico, the Submission Form, states could refer to to reconsideration.
Virgin Islands, Guam, American Samoa, information we already possess on their CMS Notification: We propose to
and the Northern Mariana Islands. payment arrangements to support their notify states of our determinations for
We propose to allow states to request request for a determination. This each request as soon as practicable after
determinations for both Medicaid fee- information could include, for example, the relevant Submission Deadline. We
for-service and Medicaid managed care submissions that states typically make propose that states may submit
plan payment arrangements. States often to us to obtain authorization to modify information regarding an other payer
use managed care plan contracts to their Medicaid payment arrangements, arrangement for a subsequent All-Payer
implement payment arrangements, and such as a State Plan Amendment or an QP Performance Period even if we have
a substantial portion of the Medicaid 1115 demonstrations waiver determined that the other payer
beneficiary population receives their application, Special Terms and arrangement is not an Other Payer
health care services through Medicaid Conditions document, implementation Advanced APM for a prior year.
managed care plans. We expect that protocol document, or other document CMS Posting of Other Payer Advanced
states would work closely with their describing the 1115 demonstration APMs: We intend to post on the CMS
managed care plans to identify and arrangements approved by CMS. Web site a list (which we refer to as the
collect relevant information. However, Submission Period: We propose that Other Payer Advanced APM List) of all
we propose to accept requests regarding the Submission Period for the Payer other payer arrangements that we
payment arrangements authorized under Initiated Process for use by states to determine to be Other Payer Advanced
Title XIX under the Payer Initiated request Other Payer Advanced APM APMs. Prior to the start of the relevant
Process only from the state, not from a determinations for other payer All-Payer QP Performance Period, we
Medicaid managed care plan, as states arrangements authorized under Title intend to post the Other Payer
are responsible ultimately for the XIX will open on January 1 of the Advanced APMs that we determine
administration of their Medicaid calendar year prior to the relevant All- through the Payer Initiated Process and
programs. Details specific to the Payer Payer QP Performance Period for which Other Payer Advanced APMs under
Initiated Process for payment we would make the determination for a Title XIX that we determine through the
arrangements authorized under Title Medicaid APM or a Medicaid Medical Eligible Clinician Initiated Process.
XIX are explained below. Home Model that is an Other Payer After the All-Payer QP Performance
Guidance and Submission Form: We Advanced APM. We propose that the Period, we would update this list to
intend to make guidance available Submission Deadline for these include Other Payer Advanced APMs
that we determine based on other Guidance and Submission Form: We criteria. We propose that if we
requests through the Eligible Clinician intend to make guidance available determine that the APM Entity or
Initiated Process. regarding the Eligible Clinician Initiated eligible clinician has submitted
We intend to implement ongoing Process for payment arrangements incomplete or inadequate information,
assistance through existing authorized under Title XIX prior to the we would inform the APM Entity or
conversations or negotiations as states first Submission Period, which would eligible clinician and allow the APM
design and develop new payment occur during 2018. We intend to Entity or eligible clinician to submit
arrangements that may be identified as develop a submission form (which we additional information no later than 10
Other Payer Advanced APMs. As states refer to as the Eligible Clinician Initiated business days from the date we inform
begin discussions with us regarding the Submission Form) that would be used the APM Entity or eligible clinician. For
development of other payer by APM Entities or eligible clinicians to each other payer arrangement for which
arrangements through the different legal request Other Payer Advanced APM the APM Entity or eligible clinician
authorities available under Title XIX or determinations, and we intend to make does not submit sufficient information,
this Eligible Clinician Initiated we would not make a determination in
Title XI of the Act, we would help states
Submission Form available to APM response to that request submitted via
consider and address the Other Payer
Entities and eligible clinicians prior to the Eligible Clinician Initiated
Advanced APM criteria.
the first Submission Period. We propose Submission Form. As a result, the other
(b) Eligible Clinician Initiated Process that APM Entities and eligible clinicians payer arrangement would not be
would be required to use the Eligible considered an Other Payer Advanced
We believe that, to appropriately Clinician Initiated Submission Form to APM for the year. These determinations
implement the Title XIX exclusions, it request that we make an Other Payer are final and not subject to
is not feasible to allow APM Entities Advanced APM determination. We reconsideration.
and eligible clinicians to request intend for the Eligible Clinician CMS Notification: We propose to
determinations for Title XIX payment Initiated Submission Form to include notify APM Entities and eligible
arrangements after the conclusion of the questions that are applicable to all other clinicians of our determinations for each
All-Payer QP Performance Period for the payer arrangements and some that are other payer arrangement for which a
year, as we are allowing APM Entities specific to payment arrangements made determination was requested as soon as
and eligible clinicians to do for other under Title XIX, and we intend for it to practicable after the relevant
payers. To do so would mean that a include a way for APM Entities or Submission Deadline. We propose that
single clinician requesting a eligible clinicians to attach supporting APM Entities or eligible clinicians may
determination for a previously unknown documentation. We propose that APM submit information regarding an other
Medicaid APM or Medicaid Medical Entities or eligible clinicians may payer arrangement for a subsequent All-
Home Model that meets the Other Payer submit requests for review of multiple Payer QP Performance Period even if we
Advanced APM criteria could other payer arrangements through the have determined that the other payer
unexpectedly affect QP threshold Eligible Clinician Initiated Process, arrangement is not an Other Payer
calculations for every other clinician in though we would make separate Advanced APM for a prior year.
that state (or county) as described in determinations as to each other payer CMS Posting of Other Payer Advanced
section II.D.6.d.(3) of this proposed rule. arrangement and an APM Entity or APMs: We intend to post on the CMS
Thus, we would be unable to provide eligible clinician would be required to Web site a list (which we refer to as the
timely notice of the presence of a use a separate Eligible Clinician Other Payer Advanced APM List) of all
Medicaid APM or Medicaid Medical Initiated Submission Form for each of the other payer arrangements that we
Home Model that meets the Other Payer other payer arrangement. APM Entities determine to be Other Payer Advanced
Advanced APM criteria to all other or eligible clinicians may submit other APMs. Prior to the start of the relevant
eligible clinicians in the state whose QP payer arrangements with different tracks All-Payer QP Performance Period, we
determinations under the All-Payer within that arrangement as one request intend to post the Other Payer
Combination Option could be affected. along with information specific to each Advanced APMs that we determine
To avoid this scenario, we propose to track. through the Payer Initiated Process and
require that APM Entities and eligible Submission Period: We propose that Other Payer Advanced APMs under
clinicians may request determinations APM Entities or eligible clinicians may Title XIX that we determine through the
for any Medicaid payment arrangements submit Eligible Clinician Initiated Eligible Clinician Initiated Process.
in which they are participating at an Forms for payment arrangements After the All-Payer QP Performance
earlier point, prior to the All-Payer QP authorized under Title XIX beginning Period, we would update this list to
Performance Period. This would allow on September 1 of the calendar year include Other Payer Advanced APMs
all clinicians in a given state or county prior to the All-Payer QP Performance that we determine based on other
to know before the beginning of the Period. We also propose that the requests through the Eligible Clinician
performance period whether their Title Submission Deadline is November 1 of Initiated Process.
XIX payments and patients would be the calendar year prior to the All-Payer
excluded from the all-payer calculations QP Performance Period. (c) Summary
that are used for QP determinations for CMS Determination: Upon the timely The proposed timeline for both the
the year under the All-Payer receipt of an Eligible Clinician Initiated Payer Initiated and Eligible Clinician
Combination Option. Details specific to Submission Form, we would use the Initiated Other Payer Advanced APM
the Eligible Clinician Initiated Process information submitted to determine Determination Processes for payment
for payment arrangements authorized whether the other payer arrangement arrangements authorized under Title
under Title XIX are explained below. meets the Other Payer Advanced APM XIX are summarized in Table 50.
TABLE 50OTHER PAYER ADVANCED APM DETERMINATION PROCESS FOR PAYMENT ARRANGEMENTS AUTHORIZED
UNDER TITLE XIX FOR ALL-PAYER 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 ECsSub- Sept. 2018.
Period Opens. mission 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 under Title XIX and Medicare Health 30 of the calendar year prior to the
Plan payment arrangements discussed relevant All-Payer QP Performance
For purposes of carrying out the
in sections II.D.6.c.(2) and II.D.6.c.(4) of Period.
Quality Payment Program, we propose
this proposed rule. CMS Determination: Upon the timely
to define the term CMS-Multi Payer
Model at 414.1305 of our regulations (a) Payer Initiated Process receipt of a Payer Initiated Submission
as an Advanced APM that CMS Form, we would use the information
Details specific to the Payer Initiated submitted to determine whether the
determines, per the terms of the Process for payment arrangements in
Advanced APM, has at least one other other payer arrangement meets the
CMS Multi-Payer Models are explained Other Payer Advanced APM criteria. We
payer arrangement that is designed to below.
align with the terms of that Advanced propose that if we determine that the
Guidance and Submission Form: We
APM. Examples of CMS Multi-Payer payer has submitted incomplete or
intend to make guidance available
Models include the Comprehensive inadequate information, we would
regarding the Payer Initiated Process for
Primary Care Plus (CPC+) Model, the inform the payer and allow the payer to
other payer arrangements in CMS Multi-
Oncology Care Model (OCM) (2-sided submit additional information no later
Payer Models prior to the first
risk arrangement), and the Vermont All- than 10 business days from the date we
Submission Period, which would occur
Payer ACO Model. inform the payer. For each other payer
during 2018. We intend to develop a
Other payer arrangements that are in arrangement for which the payer does
submission form (which we refer to as
a CMS Multi-Payer Model, by not submit sufficient information, we
the Payer Initiated Submission Form)
definition, are not APMs and thus would not make a determination in
that would be used by payers to request
cannot be Advanced APMs under the response to that request submitted via
Other Payer Advanced APM
Medicare Option. We recognize, though, the Payer Initiated Submission Form. As
determinations, and we intend to make
that these other payer arrangements a result, the other payer arrangement
this Payer Initiated Submission Form
could be Other Payer Advanced APMs. would not be considered an Other Payer
available to payers prior to the first
We therefore propose that beginning in Advanced APM for the year. These
Submission Period. We propose that
the first All-Payer QP Performance determinations are final and not subject
payers would be required to use the
Period, payers with other payer to reconsideration.
Payer Initiated Submission Form to
arrangements in a CMS Multi-Payer request that we make an Other Payer CMS Notification: We propose to
Model may request that we determine Advanced APM determination. We notify payers of our determinations for
whether those aligned other payer intend for the Payer Initiated each request as soon as practicable after
arrangements are Other Payer Advanced Submission Form to include questions the relevant Submission Deadline. We
APMs. that are applicable to all other payer propose that payers may submit
Because there may be differences arrangements and some that are specific information regarding an other payer
among the other payer arrangements to other payer arrangements in CMS arrangement for a subsequent All-Payer
that are aligned with an Advanced APM Multi-Payer Models, and we intend for QP Performance Period even if we have
in a CMS Multi-Payer Model, we it to include a way for payers to attach determined that the other payer
propose to make separate supporting documentation. We propose arrangement is not an Other Payer
determinations about each of those that payers may submit requests for Advanced APM for a prior year.
other payer arrangements on an review of multiple other payer CMS Posting of Other Payer Advanced
individual basis. In other words, an arrangements through the Payer APMs: We intend to post on the CMS
other payer arrangement aligned with an Initiated Process, though we would Web site a list (which we refer to as the
Advanced APM in a CMS Multi-Payer make separate determinations as to each Other Payer Advanced APM List) of all
Model is not automatically an Other other payer arrangement and a payer other payer arrangements that we
Payer Advanced APM by virtue of its would be required to use a separate determine to be Other Payer Advanced
alignment. Payer Initiated Submission Form for APMs. Prior to the start of the relevant
We acknowledge that there can be each other payer arrangement. Payers All-Payer QP Performance Period, we
payment arrangements authorized under may submit other payer arrangements intend to post the Other Payer
Title XIX or Medicare Health Plan with different tracks within that Advanced APMs that we determine
payment arrangements that are aligned arrangement as one request along with through the Payer Initiated Process and
with a CMS Multi-Payer Model. We information specific to each track. Other Payer Advanced APMs under
propose that payers, APM Entities, or Submission Period: We propose that Title XIX that we determine through the
eligible clinicians who want to request the submission period would open on Eligible Clinician Initiated Process.
that we determine whether those January 1 of the calendar year prior to After the All-Payer QP Performance
arrangements are Other Payer Advanced the relevant All-Payer QP Performance Period, we would update this list to
APMs would use the processes specified Period. We also propose that the include Other Payer Advanced APMs
for payment arrangements authorized submission period would close on June that we determine based on other
requests through the Eligible Clinician Deadline for requesting Other Payer arrangement for a subsequent All-Payer
Initiated Process. Advanced APM determinations, as well QP Performance Period even if we have
as to request QP determinations under determined that the other payer
(b) Eligible Clinician Initiated Process
the All-Payer Combination Option, is arrangement is not an Other Payer
Details specific to the Eligible December 1 of the same year as the Advanced APM for a prior year.
Clinician Initiated Process for payment relevant All-Payer QP Performance CMS Posting of Other Payer Advanced
arrangements in CMS Multi-Payer Period. APMs: We intend to post on the CMS
Models are explained below. CMS Determination: Upon the timely Web site a list (which we refer to as the
Guidance and Submission Form: We receipt of an Eligible Clinician Initiated Other Payer Advanced APM List) of all
intend to make guidance available Submission Form, we would use the of the other payer arrangements that we
regarding the Eligible Clinician Initiated information submitted to determine determine to be Other Payer Advanced
Process for payment arrangements in whether the other payer arrangement APMs. Prior to the start of the relevant
CMS Multi-Payer Models prior to the meets the Other Payer Advanced APM All-Payer QP Performance Period, we
first Submission Period, which would criteria. We propose that if we intend to post the Other Payer
occur during 2019. We intend to determine that the APM Entity or Advanced APMs that we determine
develop a submission form (which we eligible clinician has submitted through the Payer Initiated Process and
refer to as the Eligible Clinician Initiated incomplete or inadequate information, Other Payer Advanced APMs under
Submission Form) that would be used we would inform the APM Entity or Title XIX that we determine through the
by APM Entities or eligible clinicians to eligible clinician and allow the APM Eligible Clinician Initiated Process.
request Other Payer Advanced APM Entity or eligible clinician to submit After the All-Payer QP Performance
determinations, and we intend to make additional information no later than 10 Period, we would update this list to
this Eligible Clinician Initiated business days from the date we inform include Other Payer Advanced APMs
Submission Form available to APM the APM Entity or eligible clinician. For that we determine based on other
Entities and eligible clinicians prior to each other payer arrangement for which requests through the Eligible Clinician
the first Submission Period. We propose the APM Entity or eligible clinician Initiated Process.
that APM Entities and eligible clinicians does not submit sufficient information,
would be required to use the Eligible we would not make a determination in (c) State All-Payer Models
Clinician Initiated Submission Form to response to that request submitted via Some CMS Multi-Payer Models
request that we make an Other Payer the Eligible Clinician Initiated involve an agreement with a state to test
Advanced APM determination. We Submission Form. As a result, the other an APM and one or more associated
intend for the Eligible Clinician payer arrangement would not be other payer arrangements in that state
Initiated Submission Form to include considered an Other Payer Advanced where the state prescribes uniform
questions that are applicable to all other APM for the year. These determinations payment arrangements across state-
payer arrangements and some that are are final and not subject to based payers. As such, we believe it
specific to other payer arrangements in reconsideration. may be appropriate and efficient for
CMS Multi-Payer Models, and we CMS Notification: We propose to states, rather than any other payer, to
intend for it to include a way for APM notify APM Entities and eligible submit information to us on these
Entities or eligible clinicians to attach clinicians of our determinations for each payment arrangements for purposes of
supporting documentation. We propose other payer arrangement for which a an Other Payer Advanced APM
that APM Entities or eligible clinicians determination was requested as soon as determination.
may submit requests for review of practicable after the relevant We propose that, in CMS Multi-Payer
multiple other payer arrangements Submission Deadline. We note that Models where a state prescribes uniform
through the Eligible Clinician Initiated APM Entities and eligible clinicians payment arrangements across all payers
Process, though we would make who submit complete Eligible Clinician statewide, the state would submit on
separate determinations as to each other Initiated Submission Forms by behalf of payers in the Payer Initiated
payer arrangement. An APM Entity or September 1 of the calendar year of the Process for Other Payer Advanced
eligible clinician would be required to relevant All-Payer QP Performance APMs; we would seek information for
use a separate Eligible Clinician Period may allow for us to make Other the determination from the state, rather
Initiated Submission Form for each Payer Advanced APM determinations than individual payers. The same Payer
other payer arrangement. APM Entities and inform APM Entities or eligible Initiated Process and timeline described
or eligible clinicians may submit other clinicians of those determinations prior above for CMS Multi-Payer Models
payer arrangements with different tracks to the December 1 QP Determination would apply. We seek comment on this
within that arrangement as one request Submission Deadline. If we determine proposal. Additionally, we seek
along with information specific to each that an other payer arrangement is not comment regarding the effectiveness of
track. an Other Payer Advanced APM, taking a similar approach in cases where
Submission Period: We propose that notifying APM Entities or eligible the state does not require uniform
APM Entities or eligible clinicians may clinicians of such a determination may payment arrangements across payers.
request Other Payer Advanced APM help them avoid the burden of
determinations beginning on August 1 submitting payment amount and patient (d) Summary
of the same year as the relevant All- count information for that payment The proposed timelines for both the
Payer QP Performance Period. We arrangement. We intend to make these Payer Initiated and Eligible Clinician
discuss our proposal to establish the early notifications to the extent possible. Initiated Other Payer Advanced APM
All-Payer QP Performance Period in We propose that APM Entities or Determination Processes for payment
section II.D.6.(d)(2)(a) of this proposed eligible clinicians may submit arrangements in CMS Multi-Payer
rule. We propose that the Submission information regarding an other payer Models are summarized in Table 51.
TABLE 51OTHER PAYER ADVANCED APM DETERMINATION PROCESS FOR CMS MULTI-PAYER MODELS FOR ALL-PAYER
QP PERFORMANCE PERIOD 2019
Eligible Clinician (EC)
Payer Initiated Process Date Date
initiated process *
CMS Multi- Guidance made available to payersSub- Jan. 2018 ......... Guidance made available to ECsSub- Aug. 2019.
Payer 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 Plan and an eligible clinician is relevant Submission Form to include questions
The Medicare Option for QP when determining whether a payment that are applicable to all other payer
determinations under sections arrangement is an Other Payer arrangements and some that are specific
1833(z)(2)(A), (2)(B)(i), and (2)(C)(i) of Advanced APM. to Medicare Health Plan payment
the Act, is based only on the percentage arrangements, and we intend for it to
(a) Payer Initiated Process
of Part B payments for covered include a way for payers to attach
professional services, or patients, that is We propose that Medicare Health supporting documentation. We propose
attributable to payments through an Plans may request that we determine that payers may submit requests for
Advanced APM. As such, payment whether their payment arrangements are review of multiple other payer
amounts or patient counts under Other Payer Advanced APMs prior to arrangements through the Payer
Medicare Health Plans, including the All-Payer QP Performance Period, Initiated Process, though we would
Medicare Advantage, Medicare- by submitting information make separate determinations as to each
Medicaid Plans, 1876 and 1833 Cost contemporaneously with the annual other payer arrangement and a payer
Plans, and Programs of All Inclusive bidding process for Medicare Advantage would be required to use a separate
Care for the Elderly (PACE) plans, contracts (that is., submitted by the first Payer Initiated Submission Form for
cannot be included in the QP Monday in June of the year prior to the each other payer arrangement. Payers
determination calculations under the payment and coverage year). Because may submit other payer arrangements
Medicare Option. (See 81 FR 77473 this is a process in which many with different tracks within that
through 77474). Instead, eligible Medicare Health Plans currently arrangement as one request along with
clinicians who participate in Other participate, we believe it will be the information specific to each track.
Payer Advanced APMs, including those least burdensome approach for
Medicare Health Plans. Submission Period: We propose that
with Medicare Advantage as a payer, the Submission Period would begin and
could begin receiving credit for that Details specific to the Payer Initiated
Process for Medicare Health Plan end at the same time as the annual bid
participation through the All-Payer timeframe. We propose the Submission
Combination Option in 2021 based on payment arrangements are explained
below. Period would begin when the bid
the performance in the 2019 All-Payer packages are sent out to plans in April
QP Performance Period. Guidance and Submission Form: We
intend to make guidance available of the year prior to the relevant All-
In light of these statutory limitations, Payer QP Performance Period. We also
we have received feedback in support of regarding the Payer Initiated Process for
Medicare Health Plan payment propose that the Submission Deadline
creating a way for those participating or
arrangements prior to the first would be the annual bid deadline,
who could participate in Advanced
Submission Period, which would occur which would be the first Monday in
APMs that include Medicare Advantage
during 2018. We intend to make June in the year prior to the relevant
to receive credit for that participation in
guidance available on or around the All-Payer QP Performance Period.
QP determinations under the Medicare
Option. We are considering time of release of the Part C and D CMS Determination: Upon the timely
opportunities to address this issue. We Advance Notice and Draft Call Letter the receipt of a Payer Initiated Submission
seek comment on such opportunities, year prior to the relevant All-Payer QP Form, we would use the information
including potential models and uses of Performance Period. We intend to submitted to determine whether the
our waiver and demonstration develop a submission form (which we other payer arrangement meets the
authorities. refer to as the Payer Initiated Other Payer Advanced APM criteria. We
Under the All-Payer Combination Submission Form) that would be used propose that if we determine that the
Option, eligible clinicians can become by payers to request Other Payer payer has submitted incomplete or
QPs based in part on payment amounts Advanced APM determinations, and we inadequate information, we would
or patient counts associated with payer intend to make this Payer Initiated inform the payer and allow the payer to
arrangements through Medicare Health Submission Form available to payers submit additional information no later
Plans, provided that such arrangements prior to the first Submission Period. than 10 business days from the date we
meet the criteria to be Other Payer This form would be built into the Health inform the payer. For each other payer
Advanced APMs. We note that the Plan Management System (HPMS), arrangement for which the payer does
financial relationship between the which payers currently use for the not submit sufficient information, we
Medicare Health Plan and CMS is not annual bidding process. We propose would not make a determination in
relevant to the Other Payer Advanced that payers would be required to use the response to that request submitted via
APM determination. Rather, because QP Payer Initiated Submission Form to the Payer Initiated Submission Form. As
determinations are made for eligible request that we make an Other Payer a result, the other payer arrangement
clinicians, only the payment Advanced APM determination. We would not be considered an Other Payer
arrangement between a Medicare Health intend for the Payer Initiated Advanced APM for the year. These
determinations are final and not subject payment arrangements, and we intend CMS Notification: We propose to
to reconsideration. for it to include a way for APM Entities notify APM Entities and eligible
CMS Notification: We propose to or eligible clinicians to attach clinicians of our determinations for each
notify payers of our determinations for supporting documentation. We propose other payer arrangement for which a
each request as soon as practicable after that APM Entities or eligible clinicians determination was requested as soon as
the relevant Submission Deadline. We may submit requests for review of practicable after the relevant
propose that payers may submit multiple other payer arrangements Submission Deadline. We note that
information regarding an other payer through the Eligible Clinician Initiated APM Entities and eligible clinicians
arrangement for a subsequent All-Payer Process, though we would make who submit complete Eligible Clinician
QP Performance Period even if we have separate determinations as to each other Initiated Submission Forms by
determined that the other payer payer arrangement and an APM Entity September 1 of the calendar year of the
arrangement is not an Other Payer or eligible clinician would be required relevant All-Payer QP Performance
Advanced APM for a prior year. to use a separate Eligible Clinician
CMS Posting of Other Payer Advanced Period may allow for us to make Other
Initiated Submission Form for each Payer Advanced APM determinations
APMs: We intend to post on the CMS other payer arrangement. APM Entities
Web site a list (which we refer to as the and inform APM Entities or eligible
or eligible clinicians may submit other clinicians of those determinations prior
Other Payer Advanced APM List) of all payer arrangements with different tracks
other payer arrangements that we to the December 1 QP Determination
within that arrangement as one request
determine to be Other Payer Advanced Submission Deadline. If we determine
along with information specific to each
APMs. Prior to the start of the relevant that an other payer arrangement is not
track.
All-Payer QP Performance Period, we Submission Period: We propose that an Other Payer Advanced APM,
intend to post the Other Payer APM Entities or eligible clinicians may notifying APM Entities or eligible
Advanced APMs that we determine request Other Payer Advanced APM clinicians of such a determination may
through the Payer Initiated Process and determinations beginning on August 1 help them avoid the burden of
Other Payer Advanced APMs under of the same year as the relevant All- submitting payment amount and patient
Title XIX that we determine through the Payer QP Performance Period. We count information for that payment
Eligible Clinician Initiated Process. discuss our proposal to establish the arrangement. We intend to make these
After the All-Payer QP Performance All-Payer QP Performance Period in early notifications to the extent possible.
Period, we would update this list to section II.D.6.(d)(2)(a) of this proposed We propose that APM Entities or
include Other Payer Advanced APMs rule. We propose that the Submission eligible clinicians may submit
that we determine based on other Deadline for requesting Other Payer information regarding an other payer
requests through the Eligible Clinician Advanced APM determinations, as well arrangement for a subsequent All-Payer
Initiated Process. QP Performance Period even if we have
as to request QP determinations under
(b) Eligible Clinician Initiated Process the All-Payer Combination Option, is determined that the other payer
December 1 of the same year as the arrangement is not an Other Payer
Details specific to the Payer Initiated
Process for Medicare Health Plan relevant All-Payer QP Performance Advanced APM for a prior year.
payment arrangements are explained Period. CMS Posting of Other Payer Advanced
below. CMS Determination: Upon the timely APMs: We intend to post on the CMS
Guidance and Submission Form: We receipt of an Eligible Clinician Initiated Web site a list (which we refer to as the
intend to make guidance available Submission Form, we would use the Other Payer Advanced APM List) of all
regarding the Eligible Clinician Initiated information submitted to determine of the other payer arrangements that we
Process for Medicare Health Plan whether the other payer arrangement determine to be Other Payer Advanced
payment arrangements prior to the first meets the Other Payer Advanced APM APMs. Prior to the start of the relevant
Submission Period, which would occur criteria. We propose that if we All-Payer QP Performance Period, we
during 2019. We intend to develop a determine that the APM Entity or intend to post the Other Payer
submission form (which we refer to as eligible clinician has submitted Advanced APMs that we determine
the Eligible Clinician Initiated incomplete or inadequate information, through the Payer Initiated Process and
Submission Form) that would be used we would inform the APM Entity or Other Payer Advanced APMs under
by APM Entities or eligible clinicians to eligible clinician and allow the APM Title XIX that we determine through the
request Other Payer Advanced APM Entity or eligible clinician to submit
Eligible Clinician Initiated Process.
determinations, and we intend to make additional information no later than 10
After the All-Payer QP Performance
this Eligible Clinician Initiated business days from the date we inform
Period, we would update this list to
Submission Form available to APM the APM Entity or eligible clinician. For
include Other Payer Advanced APMs
Entities and eligible clinicians prior to each other payer arrangement for which
that we determine based on other
the first Submission Period. We propose the APM Entity or eligible clinician
does not submit sufficient information, requests through the Eligible Clinician
that APM Entities and eligible clinicians
we would not make a determination in Initiated Process.
would be required to use the Eligible
Clinician Initiated Submission Form to response to that request submitted via (c) Summary
request that we make an Other Payer the Eligible Clinician Initiated
Advanced APM determination. We Submission Form. As a result, the other The proposed timeline for both the
intend for the Eligible Clinician payer arrangement would not be Payer Initiated and Eligible Clinician
Initiated Submission Form to include considered an Other Payer Advanced Initiated Other Payer Advanced APM
questions that are applicable to all other APM for the year. These determinations Determination Processes for Medicare
payer arrangements and some that are are final and not subject to Health Plan payment arrangements are
specific to Medicare Health Plan reconsideration. summarized in Table 52.
TABLE 52OTHER PAYER ADVANCED APM DETERMINATION PROCESS FOR MEDICARE HEALTH PLAN PAYMENT
ARRANGEMENTS FOR ALL-PAYER QP PERFORMANCE PERIOD 2019
Payer Initiated Process Date Eligible Clinician (EC) initiated process * Date
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 payer arrangements and some that are the APM Entity or eligible clinician
(a) Payer Initiated Process specific to remaining other payer does not submit sufficient information,
arrangements, and we intend for it to we would not make a determination in
We propose to allow the remaining include a way for APM Entities or response to that request submitted via
other payers not specifically addressed eligible clinicians to attach supporting the Eligible Clinician Initiated
in proposals above, including documentation. We propose that APM Submission Form. As a result, the other
commercial and other private payers Entities or eligible clinicians may payer arrangement would not be
that are not states, Medicare Health submit requests for review of multiple considered an Other Payer Advanced
Plans or payers with arrangements that other payer arrangements through the APM for the year. These determinations
are aligned with a CMS Multi-Payer Eligible Clinician Initiated Process, are final and not subject to
Model, to request that we determine though we would make separate reconsideration.
whether other payer arrangements are determinations as to each other payer CMS Notification: We propose to
Other Payer Advanced APMs starting arrangement and an APM Entity or notify APM Entities and eligible
prior to the 2020 All-Payer QP eligible clinician would be required to clinicians of our determinations for each
Performance Period and each year use a separate Eligible Clinician other payer arrangement for which a
thereafter. We seek comment on this Initiated Submission Form for each determination was requested as soon as
proposal, and we also seek comment on other payer arrangement. APM Entities practicable after the relevant
potential challenges to these other or eligible clinicians may submit other Submission Deadline. We note that
payers submitting information to us for payer arrangements with different tracks APM Entities and eligible clinicians
Other Payer Advanced APM within that arrangement as one request who submit complete Eligible Clinician
determinations. We intend to discuss along with information specific to each Initiated Submission Forms by
this process in more detail in future track. September 1 of the calendar year of the
rulemaking. Submission Period: We propose that relevant All-Payer QP Performance
APM Entities or eligible clinicians may Period may allow for us to make Other
(b) Eligible Clinician Initiated Process request Other Payer Advanced APM Payer Advanced APM determinations
We propose that APM Entities and determinations beginning on August 1 and inform APM Entities or eligible
eligible clinicians may request that we of the same year as the relevant All- clinicians of those determinations prior
determine whether an other payer Payer QP Performance Period. We to the December 1 QP Determination
arrangement with one of these other discuss our proposal to establish the Submission Deadline. If we determine
payers is an Other Payer Advanced All-Payer QP Performance Period in that an other payer arrangement is not
APM beginning 2019 All-Payer QP section II.D.6.(d)(2)(a) of this proposed an Other Payer Advanced APM,
Performance Period as explained below. rule. We propose that the Submission notifying APM Entities or eligible
Guidance and Submission Form: We Deadline for requesting Other Payer clinicians of such a determination may
intend to make guidance available Advanced APM determinations, as well help them avoid the burden of
regarding the Eligible Clinician Initiated as to request QP determinations under submitting payment amount and patient
Process for remaining other payer the All-Payer Combination Option, is count information for that payment
arrangements prior to the first December 1 of the same year as the arrangement. We intend to make these
Submission Period, which would occur relevant All-Payer QP Performance early notifications to the extent possible.
during 2019. We intend to develop a Period. We propose that APM Entities or
submission form (which we refer to as CMS Determination: Upon the timely eligible clinicians may submit
the Payer Initiated Submission Form) receipt of an Eligible Clinician Initiated information regarding an other payer
that would be used by APM Entities or Submission Form, we would use the arrangement for a subsequent All-Payer
eligible clinicians to request Other Payer information submitted to determine QP Performance Period even if we have
Advanced APM determinations, and we whether the other payer arrangement determined that the other payer
intend to make this Eligible Clinician meets the Other Payer Advanced APM arrangement is not an Other Payer
Initiated Submission Form available to criteria. We propose that if we Advanced APM for a prior year.
APM Entities and eligible clinicians determine that the APM Entity or CMS Posting of Other Payer Advanced
prior to the first Submission Period. We eligible clinician has submitted APMs: We intend to post on the CMS
propose that APM Entities and eligible incomplete or inadequate information, Web site a list (which we refer to as the
clinicians would be required to use the we would inform the APM Entity or Other Payer Advanced APM List) of all
Eligible Clinician Initiated Submission eligible clinician and allow the APM of the other payer arrangements that we
Form to request that we make an Other Entity or eligible clinician to submit determine to be Other Payer Advanced
Payer Advanced APM determination. additional information no later than 10 APMs. Prior to the start of the relevant
We intend for the Eligible Clinician business days from the date we inform All-Payer QP Performance Period, we
Initiated Submission Form to include the APM Entity or eligible clinician. For intend to post the Other Payer
questions that are applicable to all other each other payer arrangement for which Advanced APMs that we determine
through the Payer Initiated Process and that we determine based on other (c) Summary
Other Payer Advanced APMs under requests through the Eligible Clinician The proposed timeline for both the
Title XIX that we determine through the Initiated Process. Payer Initiated and Eligible Clinician
Eligible Clinician Initiated Process. We seek comments on these Initiated Other Payer Advanced APM
After the All-Payer QP Performance proposals. Determination Processes for payment
Period, we would update this list to arrangements for remaining other payers
include Other Payer Advanced APMs are summarized in Table 53.
TABLE 53OTHER PAYER ADVANCED APM DETERMINATION PROCESS FOR REMAINING OTHER PAYER PAYMENT
ARRANGEMENTS FOR ALL-PAYER 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) Timeline for the Proposed Other Clinician Initiated Other Payer
Payer Advanced APM Determination Advanced APM Determination
Processes Processes for all payer types is
The proposed timeline for both the presented in Table 54.
proposed Payer Initiated and Eligible
TABLE 54TIMELINE FOR OTHER PAYER ADVANCED APM DETERMINATION PROCESS FOR THE 2019 QP PERFORMANCE
PERIOD BY PAYER TYPE *
Payment arrangements Payment arrangements in CMS Medicare Health Plan Remaining other payer
Year Date authorized under Multi-Payer Models payment arrangements payment arrangements
Title XIX
2018 ... January ............... Guidance sent to Guidance made available to ..............................................
statesSubmis- payersSubmission Pe-
sion Period Opens. riod Opens.
April ..................... Submission Period .............................................. Guidance sent to Medicare
Closes for states. Health PlansSubmission
Period Opens.
June .................... Guidance made Submission Period Closes Submission Period Closes
available to ECs for Payers. for Medicare Health Plans.
Submission Period
Opens for ECs.
JulyAugust ......... CMS makes Other CMS makes Other Payer CMS makes Other Payer
Payer Advanced Advanced APM Deter- Advanced APM Deter-
APM Determina- minations for payers. minations for Medicare
tions for states. Health Plans.
September ........... CMS posts Other CMS posts Other Payer Ad- CMS posts Other Payer Ad-
Payer Advanced vanced APM List. vanced APM List.
APM List.
November ............ Submission Period .............................................. ..............................................
Closes for ECs.
December ............ CMS posts Other .............................................. ..............................................
Payer Advanced
APM List.
2019 ... August ................. Submission Period Submission Period Opens Submission Period Opens Submission Period Opens
Opens for ECs. for ECs. for ECs. for ECs.
September ........... ................................. Latest time where ECs can Latest time where ECs can Latest time where ECs can
request Other Payer Ad- request Other Payer Ad- request Other Payer Ad-
vanced APM determina- vanced APM determina- vanced APM determina-
tions to get notification tions to get notification tions to get notification
prior to close of data sub- prior to close of data sub- prior to close of data sub-
mission period. mission period. mission period.
Submission Period for QP Submission Period for QP Submission Period for QP
determination data opens. determination data opens. determination data opens.
TABLE 54TIMELINE FOR OTHER PAYER ADVANCED APM DETERMINATION PROCESS FOR THE 2019 QP PERFORMANCE
PERIOD BY PAYER TYPE *Continued
Payment arrangements Payment arrangements in CMS Medicare Health Plan Remaining other payer
Year Date authorized under Multi-Payer Models payment arrangements payment arrangements
Title XIX
December ............ ................................. Submission Period Closes Submission Period Closes Submission Period Closes
for EC requests for Other for EC requests for Other for EC requests for Other
Payer Advanced APM de- Payer Advanced APM de- Payer Advanced APM de-
terminations and QP determinations and QP determinations and QP de-
termination data. termination data. termination data.
CMS makes Other Payer CMS makes Other Payer CMS makes Other Payer
Advanced APM Deter- Advanced APM Deter- Advanced APM Deter-
minations for ECs. minations for ECs. minations for ECs.
CMS posts Other Payer Ad- CMS posts Other Payer Ad- CMS posts Other Payer Ad-
vanced APM List. vanced APM List. vanced APM List.
* The process repeats beginning in 2019 for the 2020 QP Performance Period.
(7) Submission of Information for Other Evidence that the CEHRT criterion some other documents that detail and
Payer Advanced APM Determinations set forth in 414.1420(b) is satisfied; govern the payment arrangement.
In the CY 2017 Quality Payment Evidence that the quality measure (ii) Eligible Clinician Initiated Process
Program final rule, we finalized that to criterion set forth in 414.1420(c) is
satisfied; including an outcome We intend to create an Eligible
be assessed under the All-Payer Clinician Initiated Submission Form
Combination Option, APM Entities or measure;
that would allow for APM Entities or
eligible clinicians must submit, in a Evidence that the financial risk eligible clinicians to submit the
manner and by a date that we specify, criterion set forth in 414.1420(d) is information necessary for us to
payment arrangement information satisfied; and determine whether a payment
necessary to assess whether the other Other documentation as may be arrangement is an Other Payer
payer arrangement meets the Other necessary for us to determine that the Advanced APM. We propose that, for
Payer Advanced APM criteria (81 FR other payer arrangement is an Other each other payer arrangement an APM
77480). Payer Advanced APM. Entity or eligible clinician requests us to
(a) Required Information We propose that the Payer Initiated determine whether it is an Other Payer
Submission Form would allow payers to Advanced APM, the APM Entity or
As we discuss in sections II.D.6.c.(1)
include descriptive language for each of eligible clinician must use, complete,
through II.D.6.c.(5) of this proposed
the required information elements. We and submit the Eligible Clinician
rule, we propose to allow for certain
are proposing to require the name and Initiated Submission Form by the
types of payers as well as APM Entities
description of the arrangement, nature relevant deadline.
or eligible clinicians to request that we
of the arrangement, term of the For us to make these determinations,
determine whether certain other payer
arrangement, eligibility criteria, and we propose to require that the APM
arrangements are Other Payer Advanced
location(s) where the arrangement will Entity or eligible clinician submit the
APMs.
be available so that we can verify following information for each other
(i) Payer Initiated Process whether eligible clinicians who may tell payer arrangement:
us that they participate in such Arrangement name;
We intend to create a Payer Initiated Brief description of the nature of
Submission Form that would allow arrangements are eligible to do so. We
require evidence that all of the Other the arrangement;
payers to submit the information Term of the arrangement
necessary for us to determine whether a Payer Advanced APM criteria are met in
order for us to determine whether the (anticipated start and end dates);
payment arrangement is an Other Payer Locations (nationwide, state, or
Advanced APM. We propose that, for arrangement is an Other Payer
Advanced APM. We propose that a county) where this other payer
each other payer arrangement a payer arrangement will be available;
submission for an Other Payer
requests us to determine whether it is an Evidence that the CEHRT criterion
Other Payer Advanced APM, the payer Advanced APM determination
set forth in 414.1420(b) is satisfied;
must use, complete, and submit the submitted by the payer is complete only Evidence that the quality measure
Payer Initiated Submission Form by the if all of these information elements are criterion set forth in 414.1420(c) is
relevant deadline. submitted to us. satisfied, including an outcome
For us to make these determinations, We propose to require that payers measure;
we propose to require that payers submit documentation that supports the Evidence that the financial risk
submit the following information for information they provided in the Payer criterion set forth in 414.1420(d) is
each other payer arrangement: Initiated Submission Form and that is satisfied; and
Arrangement name; sufficient to enable us to determine Other documentation as may be
Brief description of the nature of whether the other payer arrangement is necessary for us to determine whether
the arrangement; an Other Payer Advanced APM. the other payer arrangement is an Other
Term of the arrangement Examples of such documentation would Payer Advanced APM.
(anticipated start and end dates); include contracts and other relevant We propose that the Eligible Clinician
Participant eligibility criteria; documents that govern the other payer Initiated Submission Form would allow
Locations (nationwide, state, or arrangement that verify each required APM Entities and eligible clinicians to
county) where this other payer information element, copies of their full include descriptive language for each of
arrangement will be available; contracts governing the arrangement, or the required information elements. We
are proposing to require the name and through the Payer Initiated Process is section II.D.6.c.(7)(b)(i) of this rule, we
description of the arrangement, nature true, accurate, and complete. To that are proposing that payers must certify
of the arrangement, term of the end, we propose to add a new only the information they submit
arrangement, eligibility criteria, and, in requirement at 414.1445(d) stating that directly to us.
the case of Title XIX arrangements only, a payer that submits information In the CY 2017 Quality Payment
location(s) where the arrangement will pursuant to 414.1445(c) must certify to Program final rule, we finalized a
be available. We require evidence that the best of its knowledge that the requirement at 414.1460(c) that
all of the Other Payer Advanced APM information it submitted to us through eligible clinicians and APM Entities
criteria are met in order for us to the Payer Initiated Process is true, must attest to the accuracy and
determine that the arrangement is an accurate, and complete. Additionally, completeness of data submitted to meet
Other Payer Advanced APM. We we propose that this certification must the requirements under the All-Payer
propose that a submission for an Other accompany the Payer Initiated Combination Option. We believe this
Payer Advanced APM determination Submission Form and any supporting requirement would be more
submitted by the APM Entity or eligible documentation that payers submit to us appropriately placed in the regulatory
clinician is complete only if all of these through this process. provisions that discuss the submission
information elements are submitted to We propose to revise and clarify the of information related to requests for
us. monitoring and program integrity Other Payer Advanced APM
We propose to require that APM provisions at 414.1460. First, we determinations. Accordingly, we are
Entities or eligible clinicians submit propose to modify 414.1460(c) to proposing to remove this requirement at
documentation that supports the specify that information submitted by 414.1460(c) and proposing at
information they provided in the payers for purposes of the All-Payer 414.1445(d) that an APM Entity or
Eligible Clinician Initiated Submission Combination Option may be subject to eligible clinician that submits
Form and that is sufficient to enable us audit by us. We anticipate that the information pursuant to 414.1445(c)
to determine whether the other payer purpose of any such audit would be to must certify to the best of its knowledge
arrangement is an Other Payer verify the accuracy of an Other Payer that the information it submitted to us
Advanced APM. Examples of such Advanced APM determination. We seek is true, accurate, and complete. In the
documentation would include contracts comment on how this might be done case of information submitted by the
and other relevant documents that with minimal burden to payers. Second, APM Entity, we propose that the
govern the other payer arrangement that we propose at 414.1460(e)(1) to require certification be made by a person with
verify each required information payers who choose to submit the authority to bind the APM Entity.
element, copies of their full contracts information through the Payer Initiated We also propose that this certification
governing the arrangement, or some Process to such books, contracts, accompany the Eligible Clinician
other documents that detail and govern records, documents, and other evidence Initiated Submission Form and any
the payment arrangement. In addition to as necessary to audit an Other Payer supporting documentation that eligible
requesting that we determine whether Advanced APM determination. We clinicians submit to us through this
one or more other payer arrangements propose that such information must be process. We note that under
are Other Payer Advanced APMs for the maintained for 10 years after 414.1460(c), APM Entities or eligible
year, APM Entities or eligible clinicians submission. We also propose at clinicians may be subject to audit of the
may also inform us that they are 414.1460(e)(3) that such information information and supporting
participating in an other payer and supporting documentation must be documentation provided under the
arrangement that we determine to be an provided to us upon request. We request certification. In section II.D.6.c.(7)(b) of
Other Payer Advanced APM for the comments on this proposal, including this rule, we discuss our proposal to add
comment on the length of time payers a similar certification requirement at
year. To do so, we propose that an APM
typically maintain such information. We 414.1440(f)(2) for QP determinations.
Entity or eligible clinician would
also seek comment on how this might be We note that we propose to remove the
indicate, upon submission of Other
done with minimal burden to payers. last sentence of 414.1460(c) regarding
Payer Advanced APM participation data
record retention and address the record
for purposes of QP determination, (ii) Eligible Clinician Initiated Process
retention issue only in the maintenance
which Other Payer Advanced APMs In the CY 2017 Quality Payment of records provision at 414.1460(e).
they participated in during the All- Program final rule, we finalized a Finally, we are proposing to clarify
Payer QP Performance Period, and requirement at 414.1445(b)(3) that the nature of the information subject to
include copies of participation payers must attest to the accuracy of the record retention requirements at
agreements or similar contracts (or information submitted by eligible 414.1460(e). Specifically, we propose
relevant portions of them) to document clinicians (81 FR 77480). After that an APM Entity or eligible clinician
their participation in those payment publication of the final rule, we must maintain such books, contracts,
arrangements. received comments from stakeholders records, documents, and other evidence
We acknowledge that there is some opposing this requirement. Commenters as necessary to enable the audit of an
burden associated with requesting Other noted that payers may not have any Other Payer Advanced APM
Payer Advanced APM determinations. existing relationship with us, that determination, QP determination, and
We seek comment on ways to reduce payers do not have any direct stake in the accuracy of an APM Incentive
burden on states, payers, APM Entities, the QP status of eligible clinicians, and
Payment.
and eligible clinicians while still that there may be operational and legal
allowing us to receive the information barriers to payers attesting to this (iii) Outcome Measure
necessary to make such determinations. information. In consideration of these For both Advanced APMs and Other
(b) Certification and Program Integrity comments, we propose to eliminate the Payer Advanced APMs, we want to
requirement at 414.1445(b)(3) that encourage the use of outcome measures
(i) Payer Initiated Process payers attest that the information for quality performance assessment. We
We believe that it is important that submitted by eligible clinicians is also recognize there is a lack of
the information submitted by payers accurate. Instead, as discussed in appropriate outcome measures for use
by certain specialties and take that into the extent permitted by federal law, we (8) Summary of Proposals
consideration when interpreting the would maintain confidentiality of In summary, we are proposing the
requirement that an Other Payer certain information that APM Entities or following:
Advanced APM is one under which eligible clinicians submit for purposes
MIPS-comparable quality measures of Other Payer Advanced APM Payer Initiated Process
apply. Therefore, in the CY 2017 determinations to avoid dissemination We propose to allow certain other
Quality Payment Program final rule, we of potentially sensitive contractual payers, including payers with payment
finalized at 414.1420(c)(3) that to meet information or trade secrets (81 FR arrangements authorized under Title
the quality measure use criterion to be 77478 through 77480). XIX, Medicare Health Plan payment
an Other Payer Advanced APM, the We propose that, with the exception arrangements, and payers with payment
other payer arrangement must use an of the specific information we propose arrangements in CMS Multi-Payer
outcome measure if there is an to make publicly available as stated Models to request that we determine
applicable outcome measure on the above, the information a payer submits whether their other payer arrangements
MIPS quality measure list; but if there to us through the Payer Initiated Process
are Other Payer Advanced APMs
is no outcome measure available for use and the information an APM Entity or
starting prior to the 2019 All-Payer QP
in the other payer arrangement, the eligible clinician submits to us through
Performance Period and each year
APM Entity must attest that there is no the Eligible Clinician Initiated Process
thereafter. We propose to allow
applicable measure on the MIPS quality would be kept confidential to the extent
remaining other payers, including
measure list. While we are not permitted by federal law, in order to
commercial and other private payers, to
proposing substantive changes to this avoid dissemination of potentially
request that we determine whether other
policy, we are making technical sensitive contractual information or
payer arrangements are Other Payer
revisions to our regulations to codify trade secrets.
We seek comment on this proposal. Advanced APMs starting in 2019 prior
this policy at 414.1445(c)(3) and we
to the 2020 All-Payer QP Performance
clarify that a payer, APM entity, or (d) Use of Certified EHR Technology Period, and annually each year
eligible clinician must certify that there (CEHRT) thereafter. We propose to generally refer
is no applicable measure on the MIPS
In the CY 2017 Quality Payment to this process as the Payer Initiated
quality measure list if the payment
Program final rule, we finalized that to Other Payer Advanced APM
arrangement does not use an outcome
be an Other Payer Advanced APM, the Determination Process (Payer Initiated
measure.
other payer arrangement must require at Process), and we propose that the Payer
(c) Use of Information Submitted least 50 percent of participating eligible Initiated Process would generally
We intend to post, on a CMS Web site, clinicians in each APM Entity to use involve the same steps for each payer
only the following information about Certified EHR Technology (CEHRT) to type for each All-Payer QP Performance
other payer arrangements that we document and communicate clinical Period. If a payer uses the same other
determine are Other Payer Advanced care (81 FR 77465). payer arrangement in other commercial
APMs: The names of payers with Other We believe that some other payer lines of business, we propose to allow
Payer Advanced APMs as specified in arrangements, particularly those for the payer to concurrently request that
either the Payer Initiated or Eligible which eligible clinicians may request we determine whether those other payer
Clinician Initiated Submission Form, determinations as Other Payer arrangements are Other Payer Advanced
the location(s) in which the Other Payer Advanced APMs, may only require APMs as well.
Advanced APMs are available whether CEHRT use at the individual eligible We propose that these Other Payer
at the nationwide, state, or county level, clinician level in the contract the Advanced APM determinations would
and the names of the specific Other eligible clinician has with the payer. We be in effect for only one year at a time.
Payer Advanced APMs. also believe that it may be challenging We propose that the Payer Initiated
We believe that making this for eligible clinicians to submit Process would be voluntary for all
information publicly available is information sufficient for us to payers.
particularly important for Medicaid determine that at least 50 percent of We propose that payers would be
APMs and Medicaid Medical Home eligible clinicians under the other payer required to use the Payer Initiated
Models so that eligible clinicians can arrangement are required to use CEHRT Submission Form to request that we
assess whether their Medicaid payments to document and communicate clinical make an Other Payer Advanced APM
and patients would be excluded in care. determination. We propose that the
calculations under the All-Payer To address this issue, we propose that Submission Period opening date and
Combination Option. More generally, we would presume that an other payer Submission Deadline would vary by
we believe that making this information arrangement would satisfy the 50 payer type to align with existing CMS
publicly available would help eligible percent CEHRT use criterion if we processes for payment arrangements
clinicians to identify which of their receive information and documentation authorized under Title XIX, Medicare
other payer arrangements are Other from the eligible clinician through the Health Plan payment arrangements, and
Payer Advanced APMs so they can Eligible Clinician Initiated Process payers with payment arrangements in
include information on those Other showing that the other payer CMS Multi-Payer Models to the extent
Payer Advanced APMs in their requests arrangement requires the requesting possible and appropriate.
for QP determinations; and to learn eligible clinician(s) to use CEHRT to We propose that if we determine
about, and potentially join, Other Payer document and communicate clinician that the payer has submitted incomplete
Advanced APMs that may be available information. We seek comment on this or inadequate information, we would
to them. We seek comment on whether proposal. We also seek comment on inform the payer and allow the payer to
posting this information would be what kind of requirements for CEHRT submit additional information no later
helpful to APM Entities or eligible currently exist in other payer than 10 business days from the date we
clinicians. arrangements, particularly if they are inform the payer. For each other payer
In the CY 2017 Quality Payment written to apply at the eligible clinician arrangement for which the payer does
Program final rule, we finalized that, to level. not submit sufficient information, we
would not make a determination in The same Payer Initiated Process and Title XIX (Medicaid): We propose
response to that request submitted via timeline described above for CMS that for the first All-Payer QP
the Payer Initiated Submission Form. Multi-Payer Models would apply. Performance Period, APM Entities and
Title XIX (Medicaid): We propose Medicare Health Plans: We propose eligible clinicians may submit
that any states and territories (states) that the Submission Period would begin information on payment arrangements
that have in place a state plan under and end at the same time as the annual authorized under Title XIX to request
Title XIX may request that we determine bid timeframe. We propose the that we determine whether those
prior to the All-Payer QP Performance Submission Period would begin when arrangements are Medicaid APMs or
Period whether other payer the bid packages are sent out to plans Medicaid Medical Home Models that
arrangements authorized under Title in April of the year prior to the relevant meet the Other Payer Advanced APM
XIX are Other Payer Advanced APMs All-Payer QP Performance Period. We criteria prior to the All-Payer QP
under the Payer Initiated Process. We also propose that the Submission Performance Period. We propose that
propose to allow states to request Deadline would be the annual bid APM Entities or eligible clinicians may
determinations for both Medicaid fee- deadline, which would be the first submit Eligible Clinician Initiated
for-service and Medicaid managed care Monday in June in the year prior to the Forms for payment arrangements
plan payment arrangements. We relevant All-Payer QP Performance authorized under Title XIX beginning
propose that the Submission Period for Period. on September 1 of the calendar year
the Payer Initiated Process for use by Remaining Other Payers: We prior to the All-Payer QP Performance
states to request Other Payer Advanced propose to allow the remaining other Period. We also propose that the
APM determinations for other payer payers not specifically addressed in Submission Deadline is November 1 of
arrangements authorized under Title proposals above, including commercial the calendar year prior to the All-Payer
XIX will open on January 1 of the and other private payers that are not QP Performance Period.
calendar year prior to the relevant All- states, Medicare Health Plans, or payers CMS Multi-Payer Models: We
Payer QP Performance Period for which with arrangements that are aligned with propose that through the Eligible
we would make the determination for a a CMS Multi-Payer Model, to request Clinician Initiated Process, APM
Medicaid APM or a Medicaid Medical that we determine whether their other Entities and eligible clinicians
Home Model that is an Other Payer participating in other payer
payer arrangements are Other Payer
Advanced APM. We propose that the arrangements in CMS Multi-Payer
Advanced APMs starting prior to the
Submission Deadline for these Models may request that we determine
2020 All-Payer QP Performance Period
submissions is April 1 of the year prior whether those other payer arrangements
and each year thereafter.
to the All-Payer QP Performance Period are Other Payer Advanced APMs. We
for which we would make the Eligible Clinician Initiated Process propose that APM Entities or eligible
determination. clinicians may request Other Payer
We propose that through the
CMS Multi-Payer Models: We Advanced APM determinations
propose that payers with other payer Eligible Clinician Initiated Process,
beginning on August 1 of the same year
arrangements aligned with a CMS Multi- APM Entities and eligible clinicians
as the relevant All-Payer QP
Payer Model may request that we participating in other payer
Performance Period. We propose that
determine whether their aligned other arrangements would have an
the Submission Deadline for requesting
payer arrangements are Other Payer opportunity to request that we
Other Payer Advanced APM
Advanced APMs. We propose that determine for the year whether those
determinations, as well as to request QP
payers with other payer arrangements in other payer arrangements are Other determinations under the All-Payer
a CMS Multi-Payer Model may request Payer Advanced APMs. The Eligible Combination Option, is December 1 of
that we determine prior to the All-Payer Clinician Initiated Process could also be the same year as the relevant All-Payer
QP Performance Period whether those used to request determinations before QP Performance Period.
other payer arrangements are Other the beginning of an All-Payer Payer QP Medicare Health Plans: We propose
Payer Advanced APMs. We propose that Performance Period for other payer that through the Eligible Clinician
payers that want to request that we arrangements authorized under Title Initiated Process, APM Entities and
determine whether those arrangements XIX. eligible clinicians participating in other
are Other Payer Advanced APMs would We propose that APM Entities or payer arrangements in Medicare Health
use the processes specified for payment eligible clinicians would be required to Plans would have an opportunity to
arrangements authorized under Title use the Eligible Clinician Initiated request that we determine whether
XIX and Medicare Health Plan payment Submission Form to request that we those other payer arrangements that are
arrangements. We propose that the make an Other Payer Advanced APM not already determined to be Other
submission period would open on determination. Payer Advanced APMs through the
January 1 of the calendar year prior to We propose that if we determine Payer Initiated Process are Other Payer
the relevant All-Payer QP Performance that the APM Entity or eligible clinician Advanced APMs. We propose that APM
Period. We also propose that the has submitted incomplete or inadequate Entities or eligible clinicians may
submission period would close on June information, we would inform the payer request Other Payer Advanced APM
30 of the calendar year prior to the and allow the payer to submit determinations beginning on August 1
relevant All-Payer QP Performance additional information no later than 10 of the same year as the relevant All-
Period. We propose that, in CMS Multi- business days from the date we inform Payer QP Performance Period. We
Payer Models where a state prescribes the APM Entity or eligible clinician. For propose that the Submission Deadline
uniform payment arrangements across each other payer arrangement for which for requesting Other Payer Advanced
all payers statewide, the state would the APM Entity or eligible clinician APM determinations, as well as to
submit on behalf of payers in the Payer does not submit sufficient information, request QP determinations under the
Initiated Process for Other Payer we would not make a determination in All-Payer Combination Option, is
Advanced APMs; we would seek response to that request submitted via December 1 of the same year as the
information for the determination from the Eligible Clinician Initiated relevant All-Payer QP Performance
the state, rather than individual payers. Submission Form. Period.
Remaining Other Payers: We whether eligible clinicians who may tell information pursuant to 414.1445(c)
propose that through the Eligible us that they participate in such must certify to the best of its knowledge
Clinician Initiated Process APM Entities arrangements are eligible to do so. We that the information it submitted to us
and eligible clinicians participating in propose to require that APM Entities or is true, accurate, and complete. We also
other payer arrangements through one of eligible clinicians submit propose that this certification must
these other payers is an Other Payer documentation that supports the accompany the submission.
Advanced APM. We propose that APM information they provided in the We propose to remove the record
Entities or eligible clinicians may Eligible Clinician Initiated Submission retention requirement at 414.1445(c)
request Other Payer Advanced APM Form and that is sufficient to enable us and only address the record retention
determinations beginning on August 1 to determine whether the other payer issue at 414.1445(e) stating that APM
of the same year as the relevant All- arrangement is an Other Payer Entities and eligible clinicians must
Payer QP Performance Period. We Advanced APM. maintain such books, contracts, records,
propose that the Submission Deadline We propose that, for each other documents, and other evidence as
for requesting Other Payer Advanced payer arrangement a payer requests us necessary to enable the audit of an
APM determinations, as well as to to determine whether it is an Other Other Payer Advanced APM
request QP determinations under the Payer Advanced APM, the payer must determination, QP determination, and
All-Payer Combination Option, is complete and submit the Payer Initiated the accuracy of an APM Incentive
December 1 of the same year as the Submission Form by the relevant Payment.
relevant All-Payer QP Performance deadline. We propose that, with the exception
Period. We propose that, for each other of the specific information we propose
payer arrangement an APM Entity or to make publicly available as stated
Submission of Information for Other eligible clinician requests us to
Payer Advanced APM Determinations above, the information a payer submits
determine whether it is an Other Payer to us through the Payer Initiated Process
We propose that, for each other Advanced APM, the APM Entity or and the information an APM Entity or
payer arrangement a payer requests us eligible clinician must complete and eligible clinician submits to us through
to determine whether it is an Other submit the Eligible Clinician Initiated the Eligible Clinician Initiated Process
Payer Advanced APM, all payers must Submission Form by the relevant would be kept confidential to the extent
complete and submit the Payer Initiated deadline. permitted by federal law, in order to
Submission Form by the relevant We propose to add a new avoid dissemination of potentially
Submission Deadline. We propose that requirement at 414.1445(d) stating that
sensitive contractual information or
the Payer Initiated Submission Form a payer that submits information
trade secrets.
would allow payers to include pursuant to 414.1445(c) must certify to
We propose that we would initially
descriptive language for each of the the best of its knowledge that the
presume that an other payer
required information elements. We are information submitted to us through the
arrangement would satisfy the 50
proposing to require the name and Payer Initiated Process is true, accurate,
percent CEHRT use criterion if we
description of the arrangement, nature and complete. Additionally, we propose
receive information and documentation
of the arrangement, term of the that this certification must accompany
from the APM Entity or eligible
arrangement, eligibility criteria, and the Payer Initiated Submission Form
clinician through the Eligible Clinician
location(s) where the arrangement will and any supporting documentation that
Initiated Process showing that the other
be available so that we can verify payers submit to us through this
payer arrangement requires the
whether eligible clinicians who may tell process.
We also propose to revise the requesting eligible clinician(s) to use
us that they participate in such
monitoring and program integrity CEHRT to document and communicate
arrangements are eligible to do so. We
provisions at 414.1460 to ensure the clinical information.
propose to require that payers submit
documentation that supports the integrity of the Payer Initiated Process. d. Calculation of All-Payer Combination
information they provided in the Payer Specifically, we are proposing to require Option Threshold Scores and QP
Initiated Submission Form and that is payers that choose to submit Determinations
sufficient to enable us to determine information through the Payer Initiated
Process to maintain such books, (1) Overview
whether the other payer arrangement is
an Other Payer Advanced APM. contracts, records, documents, and other In the CY 2017 Quality Payment
We propose that, for each other evidence as necessary to audit an Other Program final rule, we finalized our
payer arrangement an APM Entity or Payer Advanced APM determination overall approach to the All-Payer
eligible clinician requests us to and that such information and Combination Option (81 FR 77463).
determine whether it is an Other Payer supporting documentation must be Beginning in 2021, in addition to the
Advanced APM, all payers must maintained for 10 years after submission Medicare Option, an eligible clinician
complete and submit the Eligible and must be provided to CMS upon may alternatively become a QP through
Clinician Initiated Submission Form by request. We also propose to specify that the All-Payer Combination Option, and
the relevant deadline. We propose that information submitted by payers for an eligible clinician need only meet the
the Eligible Clinician Initiated purposes of the All-Payer Combination QP threshold under one of the two
Submission Form would allow APM Option may be subject to audit by CMS. options to be a QP for the payment year
Entities or eligible clinicians to include We are proposing to remove the (81 FR 77459). We finalized that we will
descriptive language for each of the requirement at 414.1445(b)(3) that conduct the QP determination
required information elements. We are payers must attest to the accuracy of sequentially so that the Medicare
proposing to require the name and information submitted by eligible Option is applied before the All-Payer
description of the arrangement, nature clinicians. We are also proposing to Combination Option (81 FR 77439).
of the arrangement, term of the remove the attestation requirement at We finalized that we will calculate
arrangement, eligibility criteria, and 414.1460(c) and add a requirement at Threshold Scores under the Medicare
location(s) where the arrangement will 414.1445(d) that an APM Entity or Option through both the payment
be available so that we can verify eligible clinician that submits amount and patient count methods,
compare each Threshold Score to the Payer QP Performance Period. The QP that is 2 years prior to the payment year.
relevant QP and Partial QP thresholds, Performance Period for the Medicare We believe this option would provide
and use the most advantageous score to Option will remain the same as the most ample time possible for eligible
make QP determinations (81 FR 77457). previously finalized, so it would begin clinicians to prepare and submit
We finalized the same approach for the on January 1 and end on August 31 of information to enable us to make a QP
All-Payer Combination Option (81 FR the calendar year that is 2 years to the determination under the All-Payer
77475). payment year. We propose to define this Combination Option. In the CY 2017
Sections 1833(z)(2)(B)(ii)(I) and term in 414.1305 as the Medicare QP Quality Payment Program final rule, we
(C)(ii)(I) of the Act specify that the all Performance Period. finalized a snapshot approach that
payer portion of the Threshold Score We are proposing to establish the All- allows an eligible clinician to attain QP
calculations under the All-Payer Payer QP Performance Period because, status based on Advanced APM
Combination Option is based on the to make QP determinations under the participation from January 1 through
sum of payments for Medicare Part B All-Payer Combination Option, we first March 31 under the Medicare Option.
covered professional services furnished need to collect information on eligible Since QP determinations under the
by the eligible clinician and, with clinicians payments and patients with Medicare Option can be based on
certain exceptions, all other payments all other payers. In order to provide participation information for January 1
regardless of payer. We finalized that we eligible clinicians with timely QP through March 31 of a year, we believe
would include such payments in the determination that would enable them this alternative performance period
numerator and denominator, and we to make their own timely decisions for under the All-Payer Combination
would exclude the following excepted purposes of MIPS based on their QP Option would not be inconsistent with
categories of payments made to the status for the year, we need to collect the policy that we finalized last year,
eligible clinician and associated patients this information by December 1 of the and seek comment on this alternative
from the calculations: QP performance year. We are concerned approach. We seek comments on the
By the Secretary of Defense; that eligible clinicians would not be establishment of a January 1 through
By the Secretary of Veterans Affairs; able to submit the necessary payment March 31 All-Payer QP Performance
and and patient information from all of their Period and whether additional
Under Title XIX in a state in which other payers for the period from January requirements may be needed to ensure
no Medicaid Medical Home Model or 1 through August 31 before the the appropriate inplementation of this
APM is available under the state plan. December 1 Information Submission proposal.
We finalized this exclusion of Deadline. For the Medicare Option, we We seek comment on the proposed
payments under Title XIX to mean that allow for a 90 day claims run out period All-Payer QP Peformance Period from
Medicaid payments and patients should before gathering the necessary payment January 1 through June 30 of the year
be excluded from the all-payer amount and patient count information. that is 2 years prior to the payment year,
calculation under the All-Payer We believe the same claims run out and a possible alternative All-Payer QP
Combination Option, unless: timeframe should be adopted for other Performance Period that would be from
++ A state has in operation at least payers. If we were to maintain the January 1 through March 31. If we do
one Medicaid APM or Medicaid current QP Performance Period through not finalize the proposed or alternative
Medical Home Model that is determined August 31 eligible clinicians would be All-Payer QP Performance Period, we
to be an Other Payer Advanced APM; required to submit their other payer would retain the QP Performance Period
and payment and patient information to us that we finalized in the CY 2017 Quality
++ The relevant APM Entity is on or very near the end of the 90 day Payment Program final rule, which is
eligible to participate in at least one of claims run out period leaving them with from January 1 through August 31 of the
such Other Payer Advanced APMs little or no time to prepare the calendar year that is 2 years prior to the
during the QP Performance Period, submission. We also believe that an payment year. We are particularly
regardless of whether the APM Entity additional 60 days after the claims run concerned about the potential delay or
actually participates in such Other out is a reasonable amount of time for run out from other payers that may
Payer Advanced APMs. the eligible clinician to collect and affect the ability of APM entities or
submit the payment and patient data. eligible clinicians to gather and submit
(2) Timing of QP Determinations Under We seek comment on this proposal, the necessary payment amount and
the All-Payer Combination Option specifically as to an appropriate claims patient count information for the
In the CY 2017 Quality Payment run out standard for other payers. applicable All-Payer QP Performance
Program final rule, we finalized that the If we retained the current QP Period by the December 1 All-Payer QP
QP Performance Period for both the Performance Period and instead delayed Determination Submission Deadline. At
Medicare Option and the All-Payer the submission deadline to allow the same time, we recognize the need to
Combination Option would begin on eligible clinicians time comparable to balance this concern with the benefit of
January 1 and end on August 31 of the the time provided under the Medicare collecting Other Payer Advanced APM
calendar year that is 2 years prior to the Option to fully collect and submit this participation information over a
payment year (81 FR 7744677447). information, QP determinations under meaningful period of time. We seek
the All-Payer Combination Option comment on the feasibility or difficulty
(a) All-Payer QP Performance Period would likely not be complete before the in gathering and submitting this
and Medicare QP Performance Period end of the MIPS reporting period, which
information for each of the potential

Upon further consideration, we would undermine our goal of giving performance period time frames.
propose to establish a separate QP eligible clinicians information about
Performance Period for the All-Payer their QP status prior to the end of the (b) Alignment of Time Periods Assessed
Combination Option, which would MIPS reporting period. Under the Medicare Option and the All-
begin on January 1 and end on June 30 Alternatively, we are considering Payer Combination Option
of the calendar year that is 2 years prior whether to establish the All-Payer QP In the CY 2017 Quality Payment
to the payment year. We propose to Performance Period from January 1 Program final rule, we finalized that we
define this term in 414.1305 as the All- through March 31 of the calendar year will make QP determinations under the
Medicare Option using three snapshot rule. We therefore propose to inform may participate in Other Payer
dates during the QP Performance Period eligible clinicians of their QP status Advanced APMs at different rates
on March 31, June 30, and August 31 under the All-Payer Combination within an APM Entity group (or not at
(81 FR 77446 through 77447). Option as soon as practicable after the all).
Consistent with our proposal to make proposed All-Payer Information Eligible clinicians may participate in
the All-Payer QP Performance Period Submission Deadline. Other Payer Advanced APMs whose
from January 1 through June 30 of the participants do not completely overlap,
calendar year that is 2 years prior to the (3) QP Determinations Under the All- or do not overlap at all, with the APM
payment year, we propose to make QP Payer Combination Option Entity the eligible clinician is part of.
determinations based on eligible In the CY 2017 Quality Payment Therefore, we believe that looking at
clinicians participation in Advanced Program final rule, we finalized that, participation in Other Payer Advanced
APMs and Other Payer Advanced APMs similar to the Medicare Option, we will APMs at the individual eligible
between January 1 through March 31 calculate the Threshold Scores used to clinician level may be a more
and January 1 through June 30 under the make QP determinations under the All- meaningful way to assess their
All-Payer Combination Option. Payer Combination Option at the APM participation across multiple payers. In
We also propose that an eligible Entity group level unless certain addition, those risks and rewards
clinician would need to meet the exceptions apply (81 FR 77478). associated with participation in Other
relevant QP or Partial QP Threshold Payer Advanced APMs may vary
(a) QP Determinations at the Individual
under the All-Payer Combination significantly among eligible clinicians
Eligible Clinician Level
Option, and we would use data for the depending on the Other Payer
same time periods for Medicare Upon further consideration, we Advanced APMs in which they
payments or patients and that of other propose to make QP determinations participate. Specifically, we are
payers. For example, we would not under the All-Payer Combination concerned that if we were to make All-
assess an eligible clinician under the Option at the individual eligible Payer Combination Option QP
All-Payer Combination Option using clinician level only. We believe that determinations at the APM Entity level,
their Advanced APM payment amount there will likely be significant the denominator in QP threshold
and patient count information from challenges associated with making QP calculations could include all other
January 1 through March 31 and their determinations under the All-Payer payments and patients from eligible
Other Payer Advanced APM payment Combination Option at the APM Entity clinicians who had no, or limited, Other
amount and patient count information group level as we finalized through Payer Advanced APM participation,
from January 1 through June 30. We are rulemaking last year. thereby disadvantaging those eligible
proposing to align the time period As we explained in the CY 2017 clinicians who did have significant
assessed for the for the Medicare and Quality Payment Program final rule, an Other Payer Advanced APM
other payer portions of the calculations APM Entity faces the risks and rewards participation. By contrast, this scenario
under the All-Payer Combination of participation in an Advanced APM as is unlikely to occur when making QP
Option because we believe that would a single unit and is responsible for determinations at the APM Entity level
support the principle that QP performance metrics that are aggregated under the Medicare Option because all
determinations should be based on an to the APM Entity group level as eligible clinicians in the APM Entity
eligible clinicians performance over a determined by the Advanced APM group would be contributing to the APM
single period of time, and that lack of unless that APM Entity falls under the Entitys performance under the
alignment, comingling participation exception specified in 414.1425(b)(1) Advanced APM. For these reasons, we
information from multiple time periods for eligible clinicians on Affiliated believe it would be most appropriate to
for the purposes of making QP Practitioner Lists. Because of this, we make all QP determinations under the
determinations, would not believe it is generally preferable to make All-Payer Combination Option at the
appropriately reflect the structure of QP QP determinations at the APM Entity individual eligible clinician level.
assessment using the All-Payer level unless we are making QP We seek comment on this proposal,
Combination Option. We seek comment determinations for eligible clinicians specifically on the possible extent to
on this proposal. identified on Affiliated Practitioner which APM Entity groups in Advanced
Lists as specified at 414.1425(b)(1); or APMs could agree to be assessed
(c) Notification of QP Determinations we are making QP determinations for collectively for performance in Other
Under the All-Payer Combination eligible clinicians participating in Payer Advanced APMs. We also seek
Option multiple APM Entities, none of which comment on whether there is variation,
Our goal, under both the Medicare reach the QP Threshold as a group as and the extent of that variation, among
Option and the All-Payer Combination specified at 414.1425(c)(4) (81 FR eligible clinicians within an APM Entity
Option, is to notify eligible clinicians of 77439). However, under the All-Payer group in their participation in other
their QP status at a time that gives any Combination Option, we believe in payer arrangements that we may
Partial QPs time to decide whether to many instances that the eligible determine to be Other Payer Advanced
report to MIPS and gives those eligible clinicians in the APM Entity group we APMs We seek comment on whether
clinicians who are not QPs or Partial would identify and use to make QP there are circumstances in which QP
QPs sufficient notice of the need to determinations under the Medicare determinations should be made at a
report to MIPS. For the All-Payer Option would likely have little, if any, group level under the All-Payer
Combination Option, we also believe it common group-level participation in Combination Option.

is important to provide eligible Other Payer Advanced APMs. The If we were to establish a mechanism
clinicians as much information as eligible clinicians in the same APM for making QP determinations at the
possible about their QP status under the Entity group would not necessarily have APM Entity group level, we anticipate
Medicare Option prior to the proposed agreed to share risks and rewards for that there could be significant
All-Payer Information Submission Other Payer Advanced APM challenges in obtaining the information
Deadline, as subsequently discussed in participation as an APM Entity group, necessary at the APM Entity group level
section II.D.6.d.(4)(b) of this proposed particularly when eligible clinicians under the All-Payer Combination
Option. When we make QP clinicians who meet the criteria to be APMs relative to their activities in
determinations at the APM Entity group assessed individually under the Advanced APMs when calculating
level under the Medicare Option, we Medicare Option. Threshold Scores under the All-Payer
can do so more easily because we Combination Option. We do not believe
(b) Use of Individual or APM Entity
receive Participation Lists and we also that this underweighting would be
Group Information for Medicare
have the claims data necessary to Payment Amounts and Patient Count consistent with sections 1833(z)(2)(B)(ii)
identify the payment or patient data that Calculations Under the All-Payer and (c)(11) of the Act.
belong in the numerator and Combination Option We recognize that in many cases an
denominator of the Threshold Score individual eligible clinicians Medicare
calculations for QP Determinations. Because we are proposing to make QP Threshold Scores would likely differ
To make QP determinations at the determinations at the individual eligible from Threshold Scores calculated at the
APM Entity group level under the All- clinician level only, we are proposing to APM Entity group level, which would
Payer Combination Option, we would use the individual eligible clinician benefit those eligible clinicians whose
payment amounts and patient counts for individual Threshold Scores would be
need to collect for each APM Entity
the Medicare calculations in the All- higher than the group Threshold Scores
group all of the payment amount and
Payer Combination Option. We believe and disadvantage those eligible
patient count information for all eligible
that matching the information we use at clinicians whose individual Threshold
clinicians as discussed in section
the same level for all payment amounts Scores are equal to or lower than the
II.D.6.d.(4)(a) of this proposed rule. We
and patient counts for both the group Threshold Scores. In situations
anticipate also needing Participation
Medicare and all-payer calculations
Lists or similar documentation to where eligible clinicians are assessed
under the All-Payer Combination
identify eligible clinicians within each under the Medicare Option as an APM
Option is most consistent with sections
APM Entity group that participate in an Entity group, and receive a Medicare
1833(z)(2)(B)(ii) and (C)(ii) of the Act
Other Payer Advanced APM. We seek Threshold Score at the group level, we
because these provisions require
comment on whether APM Entities in believe that the Medicare portion of
calculations that add together the
Other Payer Advanced APMs could their All-Payer Combination Option
payments or patients from Medicare and
report this information at the APM should not be lower than the Medicare
all other payers (except those excluded).
Entity group level to facilitate our Threshold Score that they received by
We note however that we would use the
ability to make QP determinations at the participating in an APM Entity group.
APM Entity group level payment
group level. amounts and patient counts for all To accomplish this outcome, we
We note that when an Affiliated Medicare Option Threshold Scores, propose a modified methodology. When
Practitioner List defines the eligible unless we are making QP the eligible clinicians Medicare
clinicians to be assessed for QP determinations for Affiliated Threshold Score calculated at the
determination in the Advanced APM, Practitioner Lists as specified at individual level would be a lower
we make QP determinations under the 414.1425(b)(1) or we are making QP percentage than the one that is
Medicare Option at the individual level determinations for eligible clinicians calculated at the APM Entity group level
only. To promote consistency with the participating in multiple APM Entities, we would apply a weighted
Medicare Option where possible, if in none of which reach the QP Threshold methodology. This methodology would
response to comments on this proposed as a group as specified at allow us to apply the APM Entity group
rule we adopt a mechanism to make QP 414.1425(c)(4) (81 FR 77439). level Medicare Threshold Score (if
determinations under the All-Payer If we were to use the APM Entity higher than the individual eligible
Combination Option at the APM Entity group level payment amounts and clinician level Medicare Threshold
group level, we propose that eligible patient counts for Medicare and Score), to the eligible clinician, under
clinicians who meet the criteria to be individual eligible clinician payment either the payment amount or patient
assessed individually under the amounts and patient counts for other count method, but weighted to reflect
Medicare Option would still be assessed payers, we would combine APM Entity the individual eligible clinicians
at the individual level only under the group level Medicare information with Medicare volume.
All-Payer Combination Option. We seek individual eligible clinician level other We would multiply the eligible
comment on whether there are payer information. In most instances clinicians APM Entity group Medicare
alternative approaches to making QP this would disproportionately Threshold Score by the total Medicare
determinations under the All-Payer underweight the eligible clinicians payments or patients made to that
Combination Option for eligible activities in Other Payer Advanced 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 55WEIGHTING METHODOLOGY EXAMPLEPAYMENT AMOUNT METHOD

MedicareAdvanced MedicareTotal Other PayerAdvanced Other PayerTotal
APM Payments Payments APM Payments Payments
Clinician A ........................................ $150 $200 $0 $500

Clinician B ........................................ 150 800 760 1,200
EP30JN17.250</GPH>
TABLE 55WEIGHTING METHODOLOGY EXAMPLEPAYMENT AMOUNT METHODContinued

MedicareAdvanced MedicareTotal Other PayerAdvanced Other PayerTotal
APM Payments Payments APM Payments Payments
APM Entity ....................................... 300 1,000 ........................................ ........................................
In this example, the APM Entity denominator for the QP determination an Other Payer Advanced APM was
group Medicare Threshold Score is unless: available. We would require eligible
$300/$1000, or 30 percent. Eligible (1) A state has in operation at least clinicians to identify and certify the
Clinicians A and B would not be QPs one Medicaid APM or Medicaid county where they saw the most
under the Medicare Option, but Medical Home Model that is determined patients during the relevant All-Payer
Clinician B could request that we make to be an Other Payer Advanced APM; QP Performance Period. If this county is
a QP determination under the All-Payer and not in a county where a Medicaid APM
Combination Option since the APM (2) The relevant APM Entity is eligible or Medicaid Medical Home Model was
Entity group exceeded the 25 percent to participate in at least one of such available during the All-Payer QP
minimum Medicare payment amount Other Payer Advanced APMs during the Performance Period, then Title XIX
threshold under that option. QP Performance Period, regardless of payments would be excluded from the
If we calculate Clinician Bs payments whether the APM Entity actually eligible clinicians QP calculations. We
individually as proposed, we would participates in such Other Payer are proposing this approach to ensure
calculate the Threshold Score as Advanced APMs (81 FR 77475). that, before including Title XIX payment
For purposes of the discussion below or patient count information in
follows:
on the exclusion of Title XIX payments calculating QP determinations, eligible
and patients in QP determinations, clinicians have a meaningful
when we refer to Medicaid APMs or opportunity to participate in a Medicaid
Medicaid Medical Home Models, we APM or Medicaid Medical Home Model
Because Clinician Bs Threshold mean to refer to those that are Other determined to be an Other Payer
Score is less than the 50 percent QP Payer Advanced APMs. We also Advanced APM in a manner that would
Payment Amount Threshold, Clinician discussed that if a state operates such an allow for both positive and negative
B would not be a QP based on this Other Payer Advanced APM at a sub- contributions to their QP threshold
result. However, if we apply the state level such that eligible clinicians score under the All-Payer Combination
weighting methodology, we would who do not practice in the area are not Option. We seek comments on this
calculate the Threshold Score as eligible to participate, Medicaid proposal.
follows: payments or patients should not be As we discuss in section II.D.6.c.(3) of
included in those eligible clinicians QP this proposed rule, we need to
calculations because no Medicaid determine whether there are Medicaid
Medical Home Model or Medicaid APM APMs and Medicaid Medical Home
was available for their participation (81 Models available in each state prior to
FR 77475). end of the All-Payer QP Performance
Based upon this Threshold Score, We propose that we will use the Period in order to properly implement
Clinician B would be a QP under the county level to determine whether a the statutory exclusion of Title XIX
All-Payer Combination Option. state operates a Medicaid APM or a payments and patients, which is why
We would calculate the eligible Medicaid Medical Home Model at a sub- we finalized in the CY 2017 Quality
clinicians Threshold Scores both state level. We believe that the county Payment Program final rule that we will
individually and with this weighted level is appropriate as in our identify Medicaid APMs and Medicaid
methodology, and then use the most experience, the county level is the most Medical Home Models that are Other
advantageous score when making a QP common geographic unit used by states Payer Advanced APMs prior to the QP
determination. We believe that this when creating payment arrangements Performance Period (81 FR 77478).
approach promotes consistency between under Title XIX at the sub-state level. In addition to excluding payments
the Medicare Option and the All-Payer We believe that applying this exclusion based on county-level geography, we
Combination Option to the extent at the county level would allow us to propose to exclude Title XIX payments
possible. We seek comment on this carry out this exclusion in accordance and patients from the QP determination
approach. with the statute in a way that would not calculation when the only Medicaid
penalize eligible clinicians who have no APMs and Medicaid Medical Home
(c) Title XIX Excluded Payments and
Medicaid APMs or Medicaid Medical Models available in a given county are
Patients
Home Models available to them. We not available to the eligible clinician in
Sections 1833(z)(2)(B)(ii)(I)(bb) and seek comment on this proposal. question based on their specialty. We
1833(z)(2)(C)(ii)(I)(bb) of the Act direct We propose that, in states where a believe that this proposal is consistent
us to exclude payments made under Medicaid APM or Medicaid Medical with the statutory requirement to
Title XIX in a state where no Medicaid Home Model only exists in certain exclude Title XIX data from the
Medical Home Model or Medicaid APM counties, we would exclude Title XIX calculations when no Medicaid APM or
is available under that state program. To data from an eligible clinicians QP Medicaid Medical Home Model is
carry out this exclusion, in the CY 2017 calculations unless the county where available. In cases where participation
EP30JN17.009</GPH>
Quality Payment Final Rule, we the eligible clinician saw the most in such a model is limited to eligible
finalized that for both the payment patients during the relevant All-Payer clinicians in certain specialties, we do
amount and patient count methods, QP Performance Period was a county not believe the Medicaid APM or
Title XIX payments or patients will be where a Medicaid APM or Medicaid Medicaid Medical Home Model would
excluded from the numerator and Medical Home Model determined to be effectively be available to eligible
EP30JN17.008</GPH>
clinicians who are not in those clinicians in an APM Entity using the would be the number of unique patients
specialties. We therefore believe it payment amount method (81 FR 77476 to whom eligible clinicians in the APM
would be inappropriate and inequitable through 77477). We finalized that the Entity furnish services that are included
to include Title XIX payments and numerator will be the aggregate of all in the aggregate expenditures used
patients in such eligible clinicians QP payments from all payers, except those under the terms of all their Other Payer
determination calculations. We propose excluded, to the APM Entitys eligible Advanced APMs during the QP
to identify Medicaid APM or Medicaid clinicians, or the eligible clinician in the Performance Period plus the patient
Medical Home Models that are only event of an individual eligible clinician count numerator for Advanced APMs
open to certain specialties through assessment, under the terms of all Other (81 FR 77477 through 77478). We
questions asked of states in the Payer Payer Advanced APMs during the QP finalized that the denominator would be
Initiated Process and of APM Entities Performance Period. We finalized that the number of unique patients to whom
and eligible clinicians in the Eligible the denominator will be the aggregate of eligible clinicians in the APM Entity
Clinician Initiated Process. We would all payments from all payers, except furnish services under all payers, except
exclude Title XIX data from an eligible excluded payments, to the APM Entitys those excluded (81 FR 77477 through
clinicians QP calculations unless the eligible clinicians, or the eligible 77478). We finalized that we will
eligible clinician practiced under one of clinician in the event of an individual calculate the Threshold Score by
the specialty codes eligible to eligible clinician assessment during the dividing the numerator value by the
participate in a Medicaid APM or QP Performance Period. denominator value, which will result in
Medicaid Medical Home Model that was We finalized that we will calculate a percent value Threshold Score (81 FR
available in the county where the the Threshold Score by dividing the 77477 through 77478). We will compare
eligible clinician saw the most patients. numerator value by the denominator that Threshold Score to the finalized QP
We would use the method generally value, which will result in a percent Patient Count Threshold and the Partial
used in the Quality Payment Program to value Threshold Score. We will QP Patient Count Threshold and
identify an eligible clinicians specialty compare that Threshold Score to the determine the QP status of the eligible
or specialties. We seek comment on this finalized QP Payment Amount clinicians for the payment year (81 FR
proposal. Threshold and the Partial QP Payment 77477 through 77478). We finalized that
We also wish to clarify that payment Amount Threshold and determine the we would count each unique patient
arrangements offered by Medicare- QP status of the eligible clinicians for one time in the numerator and one time
Medicaid Plans, operating under the the payment year (81 FR 77475). in the denominator (81 FR 77477
Financial Alignment Initiative for We propose to maintain the policies through 77478).
Medicare-Medicaid Enrollees, will not we finalized for the payment amount We intend to carry out QP
be considered to be either Medicaid method as finalized, with some determinations using the patient count
APMs or Medicaid Medical Home proposed modifications. We propose method as finalized with some proposed
Models, and that the presence of such these changes to facilitate the modifications. We propose these
payment arrangements in a state will implementation of the payment amount changes to facilitate the implementation
not preclude the exclusion of Title XIX method while providing eligible of the patient count method while
payment and patients in the All-Payer clinicians with some flexibility in providing eligible clinicians with some
Combination Option calculations for choosing the timeframe for making QP flexibility in choosing the timeframe for
eligible clinicians in that state if no determinations. To carry out our making QP determinations. To carry out
Medicaid APM or Medicaid Medical proposal to make QP determinations at our proposal to make QP determinations
Home Model is otherwise in operation the eligible clinician level only, we at the eligible clinician level only, we
in the state. Medicare-Medicaid Plans propose that the numerator would be propose to count each unique patient
are limited to certain Medicare- the aggregate of all payments from all one time in the numerator and one time
Medicaid enrollees, and enter into payers, except those excluded, in the denominator across all payers to
payment arrangements that do not attributable to the eligible clinician align with our finalized policy for
uniformly segregate Title XVIII and Title only, under the terms of all Advanced patient counts at the eligible clinician
XIX funds. As such, payments to APMs and Other Payer Advanced APMs level. We propose that the numerator
eligible clinicians in Medicare-Medicaid from either January 1 through March 31 would be the number of unique patients
plans cannot consistently be attributed or January 1 through June 30 of the All- the eligible clinician furnishes services
to funding under either Title XVIII or Payer QP Performance Period. We also to under the terms of all of their
XIX. Additionally, given that Medicare propose that the denominator would be Advanced APMs or Other Payer
is generally the primary payer for the aggregate of all payments from all Advanced APMs from either January 1
services furnished by eligible clinicians payers, except excluded payments, to through March 31, or January 1 through
to dual Medicare-Medicaid enrollees, the eligible clinician from either January June 30 of the All-Payer QP Performance
any possible segregable Title XIX 1 through March 31, or January 1 Period. We propose that the
funding for professional services through June 30 of the All-Payer QP denominator would be the number of
through these payment arrangements Performance Period. We seek comment unique patients the eligible clinician
would be de minimus. We do not on this approach. furnishes services to under all payers,
believe it would be appropriate to except those excluded from either
(e) Patient Count Method
consider these payment arrangements January 1 through March 31, or January
We finalized that the Threshold Score
exclusively focused on this population 1 through June 30 of the All-Payer QP

as Medicaid APMs or Medicaid Medical calculation for the patient count method Performance Period. We seek comment
Home Models. would include patients for whom the on this approach.
eligible clinicians in an APM Entity
(d) Payment Amount Method furnish services and receive payment (4) Submission of Information for QP
In the CY 2017 Quality Payment under the terms of an Other Payer Determinations Under the All-Payer
Program final rule, we finalized that we Advanced APM, except for those that Combination Option
will calculate an All-Payer Combination are excluded (81 FR 77477 through In the CY 2017 Quality Payment
Option Threshold Score for eligible 77478). We finalized that the numerator Program final rule, we finalized that
either APM Entities or individual patient count information from January approach, particularly because we have
eligible clinicians must submit by a date 1 through June 30 of the calendar year finalized that we will use the more
and in a manner determined by us: (1) 2 years prior to the payment year. We advantageous of the Threshold Scores to
Payment arrangement information will need this payment amount and make QP determinations (81 FR 77475).
necessary to assess whether each other patient count information submitted in We clarify that APM Entities or eligible
payer arrangement is an Other Payer a way that allows us to distinguish clinicians can submit information to
Advanced APM, including information information from January 1 through allow us to use both the payment
on financial risk arrangements, use of March 31 and from January 1 through amount and patient count methods.
CEHRT, and payment tied to quality June 30 so that we can make QP To facilitate and ease burden for
measures; (2) for each payment determinations based on the two information submissions, we also
arrangement, the amounts of payments snapshot dates as discussed above. propose to create a form that APM
for services furnished through the To meet the need for information in Entities or eligible clinicians would be
arrangement, the total payments from a way that we believe minimizes able to use to submit this payment
the payer, the numbers of patients reporting burden, we propose to collect amount and patient count information.
furnished any service through the this payment amount and patient count APM Entities and eligible clinicians
arrangement (that is, patients for whom information aggregated for the two would be required to use this form for
the eligible clinician is at risk if actual proposed snapshot time frames: From submitting the payment and patient
expenditures exceed expected January 1 through March 31 and from information.
expenditures), and (3) the total number January 1 through June 30. We seek We seek comment on these proposals.
of patients furnished any service comment on this approach, particularly
as to the feasibility of submitting (b) QP Determination Submission
through the arrangement (81 FR 77480).
information in this way and suggestions Deadline
We also finalized that if we do not
receive sufficient information to on how to further minimize reporting We propose that APM Entities or
complete our evaluation of an other burden. Alternatively, if we finalize an eligible clinicians must submit all of the
payer arrangement and to make QP All-Payer QP Performance Period of required information about the Other
determinations, we would not assess the January 1 through March 31, we would Payer Advanced APMs in which they
eligible clinicians under the All-Payer need payment amount and patient count participate, including those for which
Combination Option (81 FR 77480). information only from January 1 there is a pending request for an Other
through March 31. If we retain the Payer Advanced APM determination, as
(a) Required Information current finalized QP Performance well as the payment amount and patient
In order for us to make QP Period, we would need information count information sufficient for us to
determinations for an eligible clinician aggregated for three snapshot make QP determinations by December 1
under the All-Payer Combination timeframes: From January 1 through of the calendar year that is 2 years to
Option, we need information for all of March 31, January 1 through June 30, prior to the payment year, which we
the Other Payer Advanced APMs in and January 1 through August 31. refer to as the QP Determination
which an eligible clinician participated As we discuss in section II.D.6.d.(3)(a) Submission Deadline.
during the All-Payer QP Performance of this proposed rule, we are proposing We believe that December 1 is the
Period. Eligible clinicians can to make QP determinations under the latest date in the year that we could
participate in other payer arrangements All-Payer Combination Option only at receive information, and be able to
that we determine are Other Payer the eligible clinician level. As a result, complete QP determinations and notify
Advanced APMs through the Payer we propose that all of this payment and eligible clinicians of their QP status in
Initiated Process, through the Eligible patient information must be submitted time for them to report to MIPS as
Clinician Initiated Process, or both. We at the eligible clinician level, and not at needed. We also proposed this date for
discuss the submission of information the APM Entity group level as we the QP Determination Submission
that pertains to Other Payer Advanced finalized in rulemaking last year. Deadline to provide eligible clinicians
APM determinations in section To minimize reporting burden on requesting QP determinations under the
II.D.6.c.(7)(a) of this proposed rule. individual eligible clinicians and to All-Payer Combination Option as much
In order for us to make QP allow eligible clinicians to submit time as possible to gather and submit
determinations under the All-Payer information to us as efficiently as information.
Combination Option using either the possible, we propose to allow eligible In the CY 2017 Quality Payment
payment amount or patient count clinicians to have APM Entities submit Program final rule, we finalized that
method, we would need to receive all of this information on behalf of any of the without sufficient information we will
the payment amount and patient count eligible clinicians in the APM Entity not make QP determinations under the
information: (1) Attributable to the group at the individual eligible clinician All-Payer Combination Option (81 FR
eligible clinician through every Other level. We seek comments on these 77480). As such, we will not make QP
Payer Advanced APM; and (2) for all proposals, particularly regarding the determinations for an eligible clinician
other payments or patients, except from feasibility of APM Entities reporting this under the All-Payer Combination
excluded payers, made or attributed to information for some or all of the Option if we do not receive information
the eligible clinician during the All- eligible clinicians in the APM Entity sufficient to make a QP determination
Payer QP Performance Period. We group. under either the payment amount or
clarify that eligible clinicians will not Additionally, we propose that if an
patient count method by the QP

need to submit Medicare payment or APM Entity or eligible clinician submits Determination Submission Deadline.
patient information for QP sufficient information only for the We seek comment on these proposals.
determinations under the All-Payer payment amount or patient count
Combination Option. method, but not for both, we will make (c) Certification and Program Integrity
To make calculations for the snapshot a QP determination based on the one We propose that a new requirement
dates as proposed in section method for which we receive sufficient be added at 414.1440(f)(2) stating that
II.D.6.d.(4)(b) of this proposed rule, we information. We believe that this the APM Entity or eligible clinician that
will need this payment amount and proposal is consistent with our overall submits information to request a QP
determination under the All-Payer propose to revise 414.1460(e) to apply (5) Example
Combination Option must certify to the to information submitted to us under
best of its knowledge that the 414.1440 for QP determinations. We In Tables 56 and 57, we provide
information that they submitted to us is also propose to add paragraph (3) to examples where an eligible clinician is
true, accurate, and complete. In the case 414.1460(e) stating that an APM Entity in a Medicare ACO Model that we have
of information submitted by the APM or eligible clinician who submits determined to be an Advanced APM, a
Entity, we propose that the certification information to us under 414.1445 or commercial ACO arrangement, and a
must be made by an individual with the 414.1440 must provide such Medicaid APM from January 1 through
authority to legally bind the APM information and supporting June 30, 2019. We would use the
Entity. This certification would documentation to us upon request. We information below to determine that
accompany the Eligible Clinician seek comments on these proposals. eligible clinicians QP status for
Initiated Submission Form, which both payment year 2021.
(d) Use of Information
eligible clinicians and APM Entities use
In the CY 2017 Quality Payment We would calculate the Threshold
for the Eligible Clinician Initiated
Process. We seek comment on these Program final rule, we finalized that, to Scores for the APM Entity group in the
proposals. the extent permitted by federal law, we Advanced APM under the Medicare
We propose to revise the monitoring will maintain confidentiality of the Option. For the payment amount
and program integrity provisions at information and data that APM Entities method, as shown in Table 56, the APM
414.1460 to further promote the and eligible clinicians submit to support Entity group would not attain QP status
integrity of the All-Payer Combination Other Payer Advanced APM under the Medicare Option, which for
Option. In the CY 2017 Quality Payment determinations in order to avoid payment year 2021 requires a QP
Program final rule, we finalized at dissemination of potentially sensitive payment amount Threshold Score of 50
414.1460(e) that an APM Entity or contractual information or trade secrets percent. The APM Entity group would
eligible clinician that submits (81 FR 77479 through 77480). also fail to attain Partial QP status under
information to us under 414.1445 for We believe that it is similarly the Medicare Option, which for
assessment under the All-Payer appropriate for us to maintain the payment year 2021 requires a Partial QP
Combination Option must maintain confidentiality of information submitted payment amount Threshold Score of 40
such books contracts records, to us for the purposes of QP percent. For the patient count method,
documents, and other evidence for a determinations to the extent permitted as shown in Table 57, the APM Entity
period of 10 years from the final date of by federal law. Therefore, we propose group would not attain QP status under
the QP Performance Period or from the that, to the extent permitted by federal
the Medicare Option, which for
date of completion of any audit, law, we will maintain confidentiality of
payment year 2021 requires a QP patient
evaluation, or inspection, whichever is the information that APM Entities or
later (81 FR 77555). We also finalized at eligible clinicians submit to us for count Threshold Score of 35 percent.
414.1460(c) that eligible clinicians and purposes of QP determinations under The APM Entity group would not attain
APM Entities must maintain copies of the All-Payer Combination Option, in Partial QP status under the Medicare
any supporting documentation related order to avoid dissemination of Option, which for payment year 2021
to the All-Payer Combination Option for potentially sensitive contractual requires a Partial QP patient count
at least 10 years (81 FR 77555). We information or trade secrets. Threshold Score of 25 percent.
TABLE 56ALL-PAYER COMBINATION OPTION EXAMPLEPAYMENT AMOUNT METHOD

Payments to Total
group/eligible payments to Threshold
Payer Level clinician group/eligible score
by payer clinician by payer (percentage)
(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 57ALL-PAYER COMBINATION OPTION EXAMPLEPATIENT COUNT METHOD

Total
Patients of patients of Threshold
group/eligible
Payer Level group/eligible score
clinician clinician (percentage)
by payer by payer
Medicare Option
Advanced APM (Medicare) .......................................................... APM Entity Group ..... 2,200 10,000 22
TABLE 57ALL-PAYER COMBINATION OPTION EXAMPLEPATIENT COUNT METHODContinued

Total
Patients of patients of Threshold
group/eligible
Payer Level group/eligible score
clinician clinician (percentage)
by payer by payer
All-Payer Combination Option
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 notified of this as we share information Partial QP patient count Threshold
QP or Partial QP status under either the on a regular basis on their QP status under the All-Payer Combination
payment amount or patient count under each snapshot. For payment year Option, which for payment year 2021 is
method under the Medicare Option. 2021, the eligible clinicians in this APM 40 percent. We would use the more
However, because under both methods Entity group would submit their advantageous score, so the eligible
of calculation, the APM Entity group payment amount or patient count data clinician would be a QP for payment
meets or exceeds the required Medicare from all payers to calculate their year 2021.
threshold for the year under the All- Threshold Score under the All-Payer
Payer Combination Option of 25 percent Combination Option. Alternatively, if we were to use the
and 20 percent, respectively, eligible In this example, the eligible clinician APM Entity weighted methodology for
clinicians within the APM Entity group score exceeds the QP payment amount calculation of a Threshold Score using
would be eligible to obtain QP status Threshold under the All-Payer the payment amount method as
through the All-Payer Combination Combination Option, which for described in section II.D.6.d.(3)(d) of
Option. The eligible clinicians in the payment year 2021 is 50 percent, but the this proposed rule, we would apply the
APM Entity group would have been eligible clinician only exceeds the weighting methodology as follows:
The eligible clinician would obtain a adjustments (81 FR 77449). To promote 1 through March 31 and between
Threshold Score of 58 percent. This alignment with the Medicare Option January 1 through June 30 of the All-
would be slightly below the Threshold and to simplify requirements when Payer QP Performance Period under the
Score obtained from the individual possible, we propose that eligible All-Payer Combination Option. We
eligible clinician payment count clinicians who are Partial QPs for the propose to use data for the same time
calculation, but it would still exceed the year under the All-Payer Combination periods for Medicare payments or
QP payment amount Threshold of 50 Option would make the election patients and that of other payers. We
percent under the All-Payer whether to report to MIPS and then be also propose the eligible clinicians must
Combination Option. Based upon this subject to MIPS reporting requirements request QP determinations under the
Threshold Score, the eligible clinician and payment adjustments. We seek All-Payer Combination Option and must
would be a QP under the All-Payer comment on this approach. submit to CMS payment amount and
Combination Option. patient count data from other payers to
(7) Summary Proposals
support the determination.
(6) Partial QP Election To Report to To summarize, we are proposing the We propose to notify eligible
MIPS following: clinicians of their QP status under the
In the 2017 Quality Payment Program We propose to establish the All- All-Payer Combination Option as soon
final rule, we finalized under the Payer QP Performance Period, which as practicable after the proposed QP
Medicare Option that, in the cases would begin on January 1 and end on Determination Submission Deadline.
where the QP determination is made at June 30 of the calendar year that is 2 We propose to make QP
the individual eligible clinician level, if years prior to the payment year. determinations under the All-Payer
the eligible clinician is determined to be We propose to make QP Combination Option at the individual
a Partial QP, the eligible clinician will determinations based on eligible eligible clinician level only.
make the election whether to report to clinicians participation in Advanced We propose to use the individual
MIPS and then be subject to MIPS APMs and Other Payer Advanced APMs eligible clinician payment amounts and
reporting requirements and payment for two time periods: Between January patient counts for Medicare in the All-
EP30JN17.010</GPH>
Payer Combination Option. We propose aggregate of all payments from all submitted by the APM Entity, we
that when the eligible clinicians payers, except those excluded, that are propose that the certification be made
Medicare Threshold Score calculated at made or attributable to the eligible by an executive of the APM Entity. We
the individual level would be a lower clinician, under the terms of all also propose that this certification must
percentage than the one that is Advanced APMs and Other Payer accompany the form that APM Entities
calculated at the APM Entity group Advanced APMs. We also propose that or eligible clinicians submit to us when
level, we would apply a weighted the denominator would be the aggregate requesting that we make QP
methodology. of all payments from all payers, except determinations under the All-Payer
We propose that we will determine those excluded, that are made or Combination Option.
whether a state operates a Medicaid attributed to the eligible clinician. We propose that APM Entities and
APM or a Medicaid Medical Home For the patient count method under eligible clinicians that submit
Model that has been determined to be the All-Payer Combination Option, we information to CMS under 414.1445
an Other Payer Advanced APM at a sub- propose to count each unique patient for assessment under the All-Payer
state level. We propose that we will use one time in the numerator and one time Combination Option or 414.1440 for
the county level to determine whether a in the denominator across all payers to QP determinations must maintain such
state operates a Medicaid APM or a align with our finalized policy for books, contracts, records, documents,
Medicaid Medical Home Model an patient counts at the eligible clinician and other evidence as necessary to
Other Payer Advanced APM at a sub- level. We propose that the numerator enable the audit of an Other Payer
state level. would be the number of unique patients Advanced APM determination, QP
We propose that in a state where we the eligible clinician furnishes services determinations, and the accuracy of
determine there are one or more to under the terms of all of their APM Incentive Payments for a period of
Medicaid APMs or Medicaid Medical Advanced APMs or Other Payer 10 years from the end of the All-Payer
Home Models that are Other Payer Advanced APMs. We propose that the QP Performance Period or from the date
Advanced APMs in operation, but only denominator would be the number of of completion of any audit, evaluation,
in certain counties, or only for eligible unique patients the eligible clinician or inspection, whichever is later.
clinicians in certain specialties, we furnishes services to under all payers, We propose that APM Entities and
would further evaluate whether those except those excluded. eligible clinicians that submit
Medicaid APMs or Medicaid Medical We propose to collect the necessary information to us under 414.1445 or
Home Models were available to each payment amount and patient count 414.1440 must provide such
eligible clinician for whom we make a information for QP determinations information and supporting
QP determination under the All-Payer under the All-Payer Combination documentation to us upon request.
Combination Option. We would identify Option aggregated for the two proposed We propose that, to the extent
the county in which the eligible snapshot timeframes: From January 1 permitted by federal law, we will
clinician practices by having the eligible through March 31 and from January 1 maintain confidentiality of the
clinician submit that information to through June 30. We propose that APM information that an APM Entity or
identify the county where they saw the Entities may submit this information on eligible clinician submits to us for
most patients during the relevant All- behalf of any of the eligible clinicians in purposes of QP determinations under
Payer QP Performance Period when they the APM Entity group at the individual the All-Payer Combination Option, to
request a QP determination. We also eligible clinician level. avoid dissemination of potentially
propose that if the eligible clinicians We propose that if an APM Entity sensitive contractual information or
practice is in a county, or in a specialty, or eligible clinician submits sufficient trade secrets.
in which there is no Medicaid APM or information for either the payment We propose that eligible clinicians
Medicaid Medical Home Model in amount or patient count method, but who are Partial QPs for the year under
operation, all of that eligible clinicians not for both, we will make a QP the All-Payer Combination Option
Medicaid payments and patients would determination based on the one method would make the election whether to
be excluded from the numerator and for which we receive sufficient report to MIPS and then be subject to
denominator of the calculations under information. MIPS reporting requirements and
the payment amount or patient count We propose that APM Entities or payment adjustments.
method, respectively. We also propose eligible clinicians must submit all of the We seek comment on these proposals.
to identify Medicaid APM or Medicaid required information about the Other 7. Physician-Focused Payment Models
Medical Home Models that are only Payer Advanced APMs in which they (PFPMs)
open to certain specialties through participate, including those for which
questions asked of states in the Payer there is a pending request for an Other a. Overview
Initiated Process and of eligible Payer Advanced APM determination, as Section 1868(c) of the Act established
clinicians in the Eligible Clinician well as the payment amount and patient an innovative process for individuals
Initiated Process. We would use the count information sufficient for us to and stakeholder entities (stakeholders)
method generally used in the Quality make QP determinations by December 1 to propose physician-focused payment
Payment Program to identify an eligible of the calendar year that is 2 years to models (PFPMs) to the Physician-
clinicians specialty or specialties. prior to the payment year, which we Focused Payment Model Technical
For the payment amount method refer to as the QP Determination Advisory Committee (PTAC). The
we would first make a calculation under Submission Deadline. PTAC, established under section
the Medicare Option using all Medicare We propose that an APM Entity or 1868(c)(1)(A) of the Act, is a federal
payments for the APM Entity. If the eligible clinician who submits advisory committee comprised of 11
minimum threshold score for the information to request a QP members that provides advice to the
Medicare Option were met, we would determination under the All-Payer Secretary. A copy of the PTACs charter,
make calculations under the All-Payer Combination Option must certify to the established on January 5, 2016, is
Combination Option. We propose that best of its knowledge that the available at https://aspe.hhs.gov/
under the All-Payer Combination information submitted is true, accurate charter-physician-focused-payment-
Option the numerator would be the and complete. In the case of information model-technical-advisory-committee.
Section 1868(c)(2)(C) of the Act be required to follow all applicable is defined under section 1833(z)(3)(C) of
requires the PTAC to review regulations and requirements relevant to the Act as any of the following: (1) A
stakeholders proposed PFPMs, prepare the approach they propose except those model under section 1115A of the Act
comments and recommendations for which waivers are expressly (other than a health care innovation
regarding whether such proposed provided under the terms of the PFPM award); (2) the Shared Savings Program
PFPMs meet the PFPM criteria in the event, and at the time, that the under section 1899 of the Act; (3) a
established by the Secretary, and submit PFPM is implemented. demonstration under section 1866C of
those comments and recommendations We believe broadening the definition the Act; or (4) a demonstration required
to the Secretary. Section 1868(c)(2)(D) of of PFPM to include payment by federal law. If a payment
the Act requires the Secretary to review arrangements with Medicaid and CHIP, arrangement is a PFPM it must also be
the PTACs comments and even if Medicare is not included in the an APM. Under our current regulation,
recommendations on proposed PFPMs payment arrangement, may complement a model that does not meet the
and to post a detailed response to the policies we are proposing within definition of APM is not a PFPM.
those comments and recommendations this rule for the All-Payer Combination However, a payment arrangement with
on the CMS Web site. Option. Broadening the definition of Medicaid or CHIP as the payer, but not
PFPM could potentially provide an Medicare, would not necessarily meet
b. Definition of PFPM opportunity for stakeholders to propose the definition of APM. Therefore, we
(1) Definition of PFPM PFPMs to the PTAC that could be Other seek comment on whether we should, in
Payer Advanced APMs, and tandem with potentially broadening the
participation in such Other Payer scope of PFPMs to include payment
Program final rule (81 FR 77555), we
Advanced APMs would contribute to an arrangements with Medicaid and CHIP,
defined PFPM at 414.1465 as an
eligible clinicians ability to become a require that a PFPM be an APM or a
Alternative Payment Model in which: QP through the All-Payer Combination payment arrangement operated under
Medicare is a payer; eligible clinicians Option. legal authority for Medicaid or CHIP
that are eligible professionals as defined The PTACs charge is to review payment arrangements.
in section 1848(k)(3)(B) of the Act are submitted proposals and provide In the CY 2017 Quality Payment
participants and play a core role in comments and recommendations to the Program final rule (81 FR 77494), we
implementing the APMs payment Secretary regarding whether the stated that we anticipate PFPMs that are
methodology; and the APM targets the proposals meet the PFPM criteria recommended by the PTAC and tested
quality and costs of services that eligible established by the Secretary. The by CMS will be tested using section
clinicians participating in the Secretary is then charged with 1115A authority, although a model or
Alternative Payment Model provide, reviewing and posting on the CMS Web payment arrangement does not need to
order, or can significantly influence. site a detailed response to the PTACs be tested under section 1115A of the Act
In the CY 2017 Quality Payment comments and recommendations. to be a PFPM. APMs tested under
Program final rule (81 FR 77496) we Because the Secretary does not have sections 1115A or 1866C of the Act, or
finalized the requirement that PFPMs be authority to direct the design or demonstrations required by federal law,
tested as APMs with Medicare as a development of payment arrangements may include Medicaid or CHIP, but not
payer. We stated that a PFPM could that might be tested with private payers, necessarily Medicare, as a payer. We
include other payers in addition to we seek comment on, if we were to believe that because Medicaid and CHIP
Medicare, but that other payer broaden the definition of PFPM, payment arrangements may be operated
arrangements and Other Payer including in the scope of PFPMs only under other legal authorities than those
Advanced APMs are not PFPMs. payment arrangements or models for included in the definition of APM, such
Therefore, PFPM proposals would need which the Secretary and CMS could as section 1115(a) waivers, section
to include Medicare as a payer. take subsequent action following the 1915(b) and (c) waivers, and state plan
In this proposed rule, we seek statutory PTAC review process. amendments, we may need to consider
comment on whether to broaden the We seek comment on whether broadening the PFPM definition beyond
definition of PFPM to include payment broadening the definition of PFPMs APMs to correspond with potentially
arrangements that involve Medicaid or would be inclusive of potential PFPMs including Medicaid or CHIP as the only
the Childrens Health Insurance that could focus on areas not generally payer. We note that were our policy to
Program (CHIP) as a payer, even if applicable to the Medicare population, change, PFPMs that are Medicaid or
Medicare is not included as a payer. A such as pediatric issues or maternal CHIP payment arrangements that fall
PFPM would then include Medicaid, health and whether changing the outside the definition of APM would
CHIP, or Medicare (or some definition of PFPM may engage more need to follow the processes and meet
combination of these) as a payer. A stakeholders in designing PFPMs that the requirements associated with the
PFPM might still include other payers include more populations beyond legal authorities on which they are
in addition to Medicaid, CHIP, or Medicare FFS beneficiaries. We seek based.
Medicare; however, an other payer comment on how the PFPM criteria We believe it is important for PFPMs
arrangement or Other Payer Advanced could be applied to these payment to include innovative payment
APM that includes only private payers, arrangements. We seek comment on methodologies. For that reason, we
including a Medicare Advantage plan, whether including more issues and continue to believe that the definition of
would not be a PFPM. Medicare populations fits within the PTACs PFPM, as well as the PFPM criteria we
Advantage and other private plans paid charge and whether stakeholders are established through rulemaking should
to act as insurers on the Medicare interested in the opportunity to allow apply exclusively to payment
programs behalf are considered to be the PTAC to apply its expertise to a arrangements, and not to arrangements
private payers. The inclusion of broader range of proposals for PFPMs. focused on care delivery reform without
Medicaid or CHIP as a payer would not The current definition of PFPM a payment reform component. We
imply the waiver of any requirements specifies that a PFPM is an APM. In the believe there are various statutory
under Title XIX or Title XXI; PFPMs CY 2017 Quality Payment Program final authorities outside of those specified in
with Medicaid or CHIP as a payer would rule (81 FR 77406), we noted that APM the definition of APM that might allow
Medicaid and CHIP payment acknowledge that any PFPMs with We believe that proposed PFPMs that
arrangements to be structured to address Medicaid or CHIP as a payer, as we are include Medicare as a payer and that
payment reform. We seek comment on seeking comment on, could not be meet all of the PFPM criteria and are
whether states and stakeholders see tested without significant coordination recommended by the PTAC may need
value in having the definition of PFPM and cooperation with the state(s) less time to go through the development
broadened to include payment involved. We could not ensure the process; however, we cannot guarantee
arrangements with Medicaid or CHIP agreement of the state(s) for which a that the development process would be
but not Medicare as a payer, and PFPM is proposed with Medicaid or shortened, or estimate by how much it
whether they see value in having CHIP as a payer, and therefore, similar would be shortened. These processes
proposals for PFPMs with Medicaid or to models with Medicare as the payer, depend on the nature of the PFPMs
CHIP but not Medicare as a payer go we could not commit to testing these design, and any attempt to impose a
through the PTACs review process. proposed payment arrangements. The deadline on them would not benefit
Secretary and CMS must retain the
(2) Relationship Between PFPMs and stakeholders because it would not allow
ability to make final decisions on which
Advanced APMs us to tailor the review and development
PFPMs, whether they include Medicare
Section 1868(c) of the Act does not process to the needs of the proposed
as a payer or only include Medicaid or
require PFPMs to meet the criteria to be CHIP, are tested using section 1115A or PFPM. We could not speak to the length
an Advanced APM for purposes of the section 1866C authority, and if so, when of time it would take a state to
incentives for participation in Advanced they are tested. Proposed PFPMs that implement a PFPM with Medicaid or
APMs under section 1833(z) of the Act, the PTAC recommends to the Secretary CHIP as a payer, or whether it would be
and we did not define PFPMs solely as but that are not immediately tested by shorter than the normal process. This
Advanced APMs. Stakeholders may us may be considered for testing at a would be true for Medicaid or CHIP
therefore propose as PFPMs either later time. payment arrangements tested using any
Advanced APMs or Medical Home We also could not speak to the length legal authorities.
Models, or other APMs. If we were to of time it would take a state to d. PFPM Criteria
broaden the definition to include implement a PFPM with Medicaid or
payment arrangements with Medicaid or CHIP as a payer, or whether it would be In the CY 2017 Quality Payment
CHIP but not Medicare as a payer, shorter than the normal process for Program final rule (81 FR 77496), we
stakeholders could propose as PFPMs implementing a payment arrangement finalized the Secretarys criteria for
Medicaid APMs, Medicaid Medical using Title XIX, Title XXI, or any other PFPMs as required by section
Home Models, or other payer relevant legal authority. 1868(c)(2)(A) of the Act. The PFPM
arrangements involving Medicaid or The decision to test a model criteria are for the PTACs use in
CHIP as a payer. We recognize that both recommended by the PTAC that discharging its duties under section
stakeholders and the PTAC may want to includes Medicare, Medicaid, or CHIP
1868(c)(2)(C) of the Act to make
discuss whether a proposed PFPM as a payer and is tested under section
comments and recommendations to the
would be an Advanced APM in their 1115A authority would not require
Secretary on proposed PFPMs.
proposals, comments, and submission of a second proposal to us;
recommendations. we would review the proposal We seek comment on the Secretarys
submitted to the PTAC along with criteria, including, but not limited to,
c. PTAC Review Process of PFPM whether the criteria are appropriate for
comments from the PTAC and the
Proposals With Medicaid or CHIP as a evaluating PFPM proposals and are
Secretary, and any other resources we
Payer
believe would be useful. In order to clearly articulated. In addition, we seek
In the CY 2017 Quality Payment further evaluate or proceed to test a comment on stakeholders needs in
Program final rule (81 FR 77491 through proposed PFPM based on a developing PFPM proposals that meet
77492), we described the roles of the recommendation from the PTAC under the Secretarys criteria. In particular, we
Secretary, the PTAC, and CMS as they section 1115A authority, we may seek to want to know whether stakeholders
relate to PFPMs and the PTACs review obtain additional information based on believe there is sufficient guidance
process. We believe that expanding the the contents of the proposal. After a available on what constitutes a PFPM,
definition of PFPM to include Medicaid PFPM proposal has been recommended the relationship between PFPMs, APMs,
or CHIP as a payer, even when Medicare by the PTAC, if it is selected for further and Advanced APMs; and on how to
is not involved, might encourage evaluation or testing under section access data, or how to gather supporting
innovation in additional areas and that 1115A authority, we may work with the evidence for a PFPM proposal.
stakeholders and states may benefit individual stakeholders who submitted
from the PTACs review process. their proposals to consider design e. Summary
We intend to continue to give serious elements for testing the PFPM and make
consideration to proposed PFPMs changes as necessary, to the extent that In summary, we seek comment on
recommended by the PTAC. Section we are involved in the design and changing the definition of PFPM to
1868(c) of the Act does not require us testing or operation of the PFPM. We include payment arrangements with
to test proposals that are recommended note that if a PFPM we select for testing Medicare, Medicaid or CHIP, or any
by the PTAC. In the CY 2017 Quality under section 1115A authority requires combination of these, as a payer; and we
Payment Program final rule (81 FR those interested to apply in order to seek comment on revising the definition
77491), we explained that without being participate, the stakeholder who to require that a PFPM be an APM or a
able to predict the volume, quality, or submitted the proposal for a model to be payment arrangement operated under
appropriateness of the proposed PFPMs established would still have to apply in legal authority for Medicaid or CHIP
on which the PTAC will make order to participate in that model. payment arrangements. We also seek
comments and recommendations, we PFPMs with Medicaid or CHIP as a comments on the Secretarys criteria
are not in a position to commit to test payer operated under legal authority more broadly and stakeholders needs in
all such models. We continue to believe other than 1115A would need to meet developing PFPM proposals that meet
this is the case. In addition, we the requirements for that legal authority. the Secretarys criteria.
III. Collection of Information In the CY 2017 Quality Payment that will become QPs for the 2018
Requirements Program final rule, we estimated a performance period compared to
Under the Paperwork Reduction Act reduction in burden hours of 1,066,658 110,159 eligible clinicians that are
of 1995 (PRA), we are required to and reduction of burden costs of $7.4 estimated to become QPs during the
publish a 60-day notice in the Federal million relative to the legacy programs 2017 performance period, an increase of
Register and solicit public comment it replaced (81 FR 77513). The total between 69,841 and 134,841. This
existing burden for the previously expected growth is due in part to
before a collection of information
approved information collections reopening of CPC+ and Next Generation
requirement is submitted to the Office of
related to the CY 2017 Quality Payment ACO for 2018, and the ACO Track 1+ in
Management and Budget (OMB) for
Program final rule was approximately response to public comments. These
review and approval. To fairly evaluate
11 million hours and a total labor cost models are projected to have a large
whether an information collection
of reporting of $1.311 million. The number of participants, the majority of
should be approved by OMB, section
streamlining and simplification of data whom are expected to reach QP status.
3506(c)(2)(A) of the PRA requires that
submission structures in the transition Additional enrollees in currently active
we solicit comment on the following
year resulted in a reduction in burden and new Advanced APMs are both
issues:
relative to the approved information considered in the growth estimate.
The need for the information Our estimates assume clinicians who
collection and its usefulness in carrying collections for the legacy programs
(PQRS and EHR Incentive Program for participated in the 2015 PQRS and who
out the proper functions of our agency. are not QPs in Advanced APMs in the
The accuracy of our burden Eligible Professionals), which
represented approximately 12 million 2017 Quality Payment Program
estimates. performance period will continue to
The quality, utility, and clarity of hours for a total labor cost of reporting
of $1.318 million. We estimate that the submit quality data as either MIPS
the information to be collected. eligible clinicians or voluntary reporters
Our effort to minimize the policies proposed in this rule would
result in further reduction of 132,620 in the 2018 Quality Payment Program
information collection burden on the performance period. Our participation
affected public, including the use of burden hours and a further reduction in
burden cost of $12.4 million relative to estimates are reflected in Table 65 for
automated collection techniques. the quality performance category, Table
We are soliciting public comment on a baseline of continuing the policies in
the CY 2017 Quality Payment Program 76 for the advancing information
each of the required issues under performance category, and Table 78 for
section 3506(c)(2)(A) of the PRA for the final rule. The Quality Payment Program
Year 2 reduction in burden based on the improvement activities performance
following information collection category. We estimate that 36 percent of
requirements (ICRs). this rule reflects several proposed
policies, including our proposal for the 975,723 ineligible or excluded
Summary and Overview significant hardship or other type of clinicians are expected to report
exception, including a new significant voluntarily because they reported under
The Quality Payment Program aims to PQRS. We expect them to continue to
do the following: (1) Support care hardship exception for small practices
for the advancing care information submit because (a) the collection and
improvement by focusing on better submission of quality data has been
outcomes for patients, decreased performance category; our proposal to
use a shorter version of the CAHPS for integrated into their clinician practice;
clinician burden, and preservation of and (b) the clinician types that were
independent clinical practice; (2) MIPS survey; our proposal to allow
ineligible from MIPS in years 1 and 2
promote adoption of alternative election of facility-based measurement
may potentially become eligible in the
payment models that align incentives for applicable MIPS eligible clinicians,
future.
across healthcare stakeholders; and (3) thereby eliminating the need for We also assume that previous PQRS
advance existing delivery system reform additional quality data submission participants who are not QPs will also
efforts, including ensuring a smooth processes; and our proposal to allow submit under the improvement
transition to a healthcare system that MIPS eligible clinicians to form virtual activities performance category, and
promotes high-value, efficient care groups which would create efficiencies will submit under the advancing care
through unification of CMS legacy in data submission. information performance category
programs. In addition to the decline in burden unless they receive a significant
The CY 2017 Quality Payment due to the policies proposed in this rule, hardship or other type of exception,
Program final rule established policies we anticipate further reduction in including a new significant hardship
to implement MIPS, a program for burden as a result of policies set forth exception for small practices or are
certain eligible clinicians that makes in the CY 2017 Quality Payment automatically assigned a weighting of
Medicare payment adjustments based Program final rule, including greater zero percent for the advancing care
on performance on quality, cost and clinician familiarity with the measures information performance category. We
other measures and activities, and that and data submission methods set in are excluding the 110,159 QPs
consolidates components of three their second year of participation, identified using a preliminary version of
precursor programsthe PQRS, the VM, operational improvements streamlining the file used for predictive qualifying
and the Medicare EHR Incentive registration and data submission, and Alternative Payment Model participants
Program for eligible professionals. As continued growth in the number of QPs analysis made available on qpp.cms.gov
prescribed by MACRA, MIPS focuses on that are excluded from MIPS. This on June 2, 2017 and prepared using
the following: Qualityincluding a set expected growth is due in part to claims for services between January 1,
of evidence-based, specialty-specific reopening of CPC+ and Next Generation 2016 through August 31, 2016. Because
standards; cost; practice-based ACO for 2018, and the ACO Track 1+ we do not have an estimated
improvement activities; and use of which is projected to have a large participation status by TIN/NPI for
CEHRT to support interoperability and number of participants, with a large clinicians who join Advanced APMs in
advanced quality objectives in a single, majority reaching QP status. We 2017 and 2018, we cannot model the
cohesive program that avoids estimate that there will be between exclusion of the additional estimated
redundancies. 180,000 and 245,000 eligible clinicians 69,841 to 134,841 QPs clinicians that
will become QPs for the 2018 below (except for CAHPS for MIPS and significantly from employer to
performance period. Hence, these virtual groups election) were submitted employer, and because methods of
burden estimates may overstate the total as a request for revision of OMB control estimating these costs vary widely from
burden for data submission under the number 09381314. The CAHPS for study to study. Nonetheless, there is no
quality, advancing care information, and MIPS ICR was submitted as a request for practical alternative, and we believe that
improvement activities performance revision of OMB control number 0938 doubling the hourly wage to estimate
categories. 1222. The virtual groups ICR has a 60 total cost is a reasonably accurate
Our burden estimates assume that 36 data day Federal Register notice (82 FR estimation method. We have selected
percent of clinicians who do not exceed 27257) published on June 14, 2017. ICR- the occupations in Table 58 based on a
the low- volume threshold or are not comments related to virtual group study (Casalino et al., 2016) that
eligible clinician types will voluntarily election are due on or before August 14, collected data on the staff in physicians
submit quality data under MIPS because 2017. offices involved in the quality data
they submitted quality data under the submission process.27
PQRS. Hence, the proposed changes in A. Wage Estimates
low-volume threshold will increase our To derive wage estimates, we used In addition, to calculate time costs for
estimate of the proportion of clinicians data from the U.S. Bureau of Labor beneficiaries who elect to complete the
who will submit data voluntarily, but Statistics (BLS) May 2016 National CAHPS for MIPS survey, we have used
will not affect the estimated number of Occupational Employment and Wage wage estimates for Civilian, All
respondents. Section II.C.2.c. of this rule Estimates for all salary estimates (http:// Occupations, using the same BLS data
proposes a low-volume threshold of less www.bls.gov/oes/current/oes_nat.htm). discussed in this section of the
than or equal to $90,000 in allowed Table 58 in this proposed rule presents proposed rule. We have not adjusted
Medicare Part B charges or less than or the mean hourly wage (calculated at 100 these costs for fringe benefits and
equal to 200 Medicare patients. The CY percent of salary), the cost of fringe overhead because direct wage costs
2017 Quality Payment Program final benefits and overhead, and the adjusted represent the opportunity cost to
rule established a low-volume threshold hourly wage. beneficiaries themselves for time spent
of less than or equal to $30,000 in As indicated, we are adjusting our completing the survey. To calculate
allowed Medicare Part B charges or less employee hourly wage estimates by a time costs for virtual groups to prepare
than or equal to 100 Medicare patients. factor of 100 percent. This is necessarily their written formal agreements, we
The revised MIPS requirements and a rough adjustment, both because fringe have used wage estimates for Legal
burden estimates for all ICRs listed benefits and overhead costs vary Support Workers, All Others.
TABLE 58ADJUSTED HOURLY WAGES USED IN BURDEN ESTIMATES

Mean hourly Fringe benefits Adjusted
Occupational
Occupation title wage and overhead hourly wage
code ($/hr.) ($/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 as individuals, groups, or virtual groups For the advancing care information
Burden of MIPS Data Submission to the quality, advancing care performance category, billing TINs will
information, and improvement activities submit data on behalf of participants
Because of the wide range of performance categories. For MIPS who are MIPS eligible clinicians. For
information collection requirements APMs, the organizations submitting data the improvement activities performance
under MIPS, Table 59 presents a on behalf of participating MIPS eligible category, we will assume no reporting
framework for understanding how the clinicians will vary across categories of burden for MIPS APM participants
organizations permitted or required to because we will assign the improvement
data, and in some instances across
submit data on behalf of clinicians activities performance category score at
APMs. For the 2018 MIPS performance
varies across the types of data, and the MIPS APM level and all APM Entity
period, the quality data submitted by
whether the clinician is a MIPS eligible groups in the same MIPS APM will
Shared Savings Program ACOs, Next
clinician, MIPS APM participant, or an receive the same score. Advanced APM
Generation ACOs, and Other MIPS
Advanced APM participant. As shown participants who are determined to be
APMs on behalf of their participant
in the first row of Table 59, MIPS Partial QPs may incur additional burden
eligible clinicians that are not in MIPS eligible clinicians will fulfill any MIPS
if they elect to participate in MIPS,
APMs and other clinicians voluntarily submission requirements for the quality which is discussed in more detail in
submitting data will submit data either performance category. section II.D.5. of this proposed rule.
27 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 59CLINICIANS OR ORGANIZATIONS SUBMITTING MIPS DATA ON BEHALF OF CLINICIANS, BY TYPE OF DATA AND
CATEGORY OF CLINICIAN
Type of data submitted
Category of clinician Advancing care Other data submitted on

Quality performance Improvement activities
information performance behalf of MIPS eligible
category performance category
category clinician
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. a hospital, ambulatory CAHPS must register.
surgical center based Groups electing to submit
clinicians, non-patient via CMS Web Interface
facing clinicians, PAs, for the first time must
NPs, CNSs and CRNAs register.
are automatically eligible Virtual groups must reg-
for a zero percent ister via email.
weighting for the ad-
vancing care information
performance category.
Clinicians approved for
significant hardship ex-
ceptions are also eligible
for a zero percent
weighting.
Facility-based clinicians Clinicians and groups Facility-based clinicians As groups, virtual groups, Facility-based clinicians
and groups that elect fa- electing facility-based may be eligible for a or individual clinicians. that elect facility-based
cility-based measure- measurement will re- zero percent weighting measurement make the
ment. ceive a quality score for the advancing care election online.
based on their facilitys information category.
Hospital VBP data sub-
mission. The burden has
been previously counted
under the Hospital VBP
rule, and is not included
in burden estimates here.
Eligible Clinicians partici- ACOs submit to the CMS Each group TIN in the CMS will assign the same Advanced APM Entities
pating in the Shared Web Interface on behalf APM Entity reports ad- improvement activities will make election for
Savings Program or of their participating vancing care information performance category participating MIPS eligi-
Next Generation ACO MIPS eligible clinicians. to MIPS.29 score to each APM Enti- ble clinicians.
Model (both MIPS [Not included in burden ty group based on the
APMs). estimate because quality activities involved in par-
data submission to fulfill ticipation in the Shared
requirements of the Savings Program.30
Shared Savings Pro- [The burden estimates
gram and Next Genera- assume no improvement
tion ACO models are not activity reporting burden
subject to the Paperwork for APM participants.]
Reduction Act.] 28
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 Paper- activities performance
work Reduction Act.]. category reporting bur-
den for APM partici-
pants.]
29 For MIPS APMs other than the Shared Savings The policies finalized in the CY 2017
Program, both group TIN and individual clinician Quality Payment Program final rule and
advancing care information data will be accepted.
If both group TIN and individual scores are proposed in this rule create some
28 Sections and 3021 and 3022 of the Affordable
submitted for the same MIPS APM Entity, CMS additional data collection requirements
Care Act state the Shared Savings Program and would take the higher score for each TIN/NPI. The
testing, evaluation, and expansion of Innovation TIN/NPI scores are then aggregated for the APM
Center models are not subject to the Paperwork Entity score. unless the CMS-assigned improvement activities
Reduction Act (42 U.S.C. 1395jjj and 42 U.S.C. 30 APM Entities participating in MIPS APMs do scores is below the maximum improvement
1315a(d)(3), respectively). not need to submit improvement activities data activities score.
not listed in Table 59. These additional virtual group election must include, at due to being a QP using a version of the
data collections, some of which were a minimum, detailed information file used for the predictive qualifying
previously approved by OMB under pertaining to each TIN and NPI Alternative Payment Model participants
control numbers 09381314 and 0938 associated with the virtual group and (QP) analysis made available on
1222 are as follows: detailed information for the virtual qpp.cms.gov on June 2, 2017 and
Self-nomination of new and group representative, as well as prepared using claims for services
returning QCDRs and registries (0938 confirmation of a written formal between January 1, 2016 through August
1314). agreement between members of the 31, 2016. We assume an average of 5
CAHPS for MIPS survey completion virtual group. TINs per virtual group with an average
by beneficiaries (09381222). We assume that virtual group of 9.5 clinicians in each TINs across
Approval process for new and participation will be relatively low in each virtual group or approximately 48
returning CAHPS for MIPS survey the first year because we have heard eligible clinicians per virtual group (5
vendors. from stakeholders that they need at least TINs 9.5 clinicians per TIN). For
Call for new improvement 36 months to form groups and purposes of this burden estimate for the
activities. establish agreements before signing up. 2018 MIPS performance period, we
Other Payer Advanced APM We are not able to give them that much assumed that approximately one percent
identification: other payer initiated time in the first year, rather closer to 60 of eligible clinicians will participate in
process. days. Because of this we expect the approximately 16 virtual groups
Opt out of performance data display number of virtual groups will be very consisting of approximately 5 TINs per
on Physician Compare for voluntary small in the first year of virtual group virtual group will be formed (765 MIPS
reporters under MIPS. implementation. Our assumptions for
eligible clinicians 48 eligible
participation in a virtual group are
C. ICR Regarding Burden for Virtual clinicians per virtual group) or 80 TINs
shown in Table 60. We assume that only
Group Election ( 414.1315) total that will participate in virtual
those eligible clinicians that reported
groups (16 virtual groups 5 MIPS
As described in section II.C.4.b. of historically will participate in virtual
groups in the first year because of the eligible clinicians per TIN).
this proposed rule, virtual groups are
defined by a combination of two or limited lead time to create processes. We assume that the virtual election
more TINs and must report as a virtual Also, while virtual groups may use the process will require 10 hours per virtual
group on measures in all quality, same submission mechanisms as group, similar to the burden of the
improvement activities, and advancing groups, we are estimating based on QCDR or registry self-nomination
care information performance categories stakeholder feedback that the 16 virtual process finalized in 414.1400. We
as virtual groups. Virtual groups may groups reflected in Table 60 will report assume that 8 hours of the 10 burden
submit data through any of the by registry. Table 60 also shows that we hours per virtual group will be
mechanisms available to groups. We estimate that approximately 765 MIPS computer systems analysts time or the
refer to section II.C.4. on additional eligible clinicians will decide to join 16 equivalent with an average labor cost of
requirements for virtual groups. virtual groups for the 2018 MIPS $88.10/hour, and an estimated cost of
We propose an optional 2-stage performance period. The virtual groups $704.80 per virtual group ($88.10/hour
process for enrollment. In stage 1, MIPS could range in size from a few clinicians 8 hours). We also assume that 2 hours
eligible clinicians have the option to to hundreds of clinicians, as long as of the 10 burden hours per virtual group
request a determination of their each participant is a solo practice or TIN will be legal support services
eligibility to form a virtual group before with 10 or fewer eligible clinicians. In professionals assisting in formulating
they form a group and begin the stage order to estimate the number of the written virtual agreement with an
2 submission of an election to clinicians available to participate in average labor cost of $63.62/hour, with
participate in a virtual group. For virtual groups, we used the data a cost of $127.24 per virtual group
clinicians or groups that do not choose prepared to support the 2017 ($63.62/hour 2 hours). Therefore, the
to participate in stage 1 of the election performance period initial total burden cost per virtual group
process, we will make an eligibility determination of clinician eligibility associated with the election process is
determination during stage 2 of the (available via the NPI lookup on $832.04 ($704.80 + $127.24). We also
election process. We refer readers to qpp.cms.gov) using a date range of assume that 16 new virtual groups will
section II.C.4.e. of this proposed rule for September 1, 2015August 31, 2016. We go through the election process leading
a discussion of the proposed virtual also used the initial small practice to a total burden of $13,313 ($832.04
group election process. determinations made on the same date 16 virtual groups). We estimate that the
As proposed in II.C.4.e. of this range. We estimated the number of total annual burden hours will be 160
proposed rule, the submission of a clinicians who would not participate (16 virtual groups 10 hours).
TABLE 60ESTIMATED 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 Number 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 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
Estimate 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
TABLE 60ESTIMATED BURDEN FOR VIRTUAL GROUP ELECTION PROCESSContinued

Burden
estimate
Estimated Total Annual Burden Cost (k) = (c) * (j) ...................................................................................................................... $13,313
While the formation of virtual groups D. ICR Regarding Burden for Election of 77069 and 77070.31 We estimate 18,207
will result in a burden for virtual group Facility-Based Measurement respondents (17,943 MIPS eligible
registration, we also estimate that the ( 414.1345) clinicians who practice primarily in the
formation of virtual groups will result in In section II.C.7.a.(4) of this proposed hospital electing as individuals and 264
a decline in burden from other forms of rule, we propose that for the 2020 MIPS groups with 75 percent or more of their
data submission. Because we assume payment year (2018 MIPS performance clinicians qualifying as clinicians who
burden is the same for each organization period), we would allow facility-based practice primarily in the hospital) will
(group, virtual group, or eligible MIPS eligible clinicians to be given a elect facility-based measurement in the
clinician) submitting quality, MIPS score in the quality and cost 2018 MIPS performance period. We
improvement activities or advancing performance categories that is based on estimate that the 17,943 individual
care information performance category the performance of the facility in which clinicians electing facility-based scoring
data, virtual groups will reduce burden they provide services. We propose at are comprised of 20 percent (10,353) of
by reducing the time needed to prepare 414.1380(e)(2)(i) that a MIPS eligible a total of the approximately 51,767 of
data for submission, review measure clinician is eligible for facility-based clinicians who practice primarily in the
specifications, register or elect to submit measurement under MIPS if they hospital that previously submitted as
data via a mechanism such as QCDR, furnish 75 percent or more of their individuals in the 2017 MIPS
registry, CMS Web Interface, or EHR. covered professional services (as performance period; 80 percent (7,590)
This reduction in burden is described in defined in section 1848(k)(3)(A) of the of a total of 9,488 clinicians who
each of the quality, improvement Act) in sites of service identified by the practice primarily in the hospital that
activities, and advancing care place of service codes used in the we estimate will not have submitted in
information performance category HIPAA standard transaction as an the 2017 MIPS performance period. We
sections below. inpatient hospital, as identified by place believe that the 80 percent (7,590) of the
of service code 21, and the emergency total 9,488 would not have submitted in
As stated earlier, the information room, as identified by place of service
collection request for the virtual group the 2017 MIPS performance period
code 23, based on claims for a period
election process will be submitted for because of the additional effort required
prior to the performance period as
OMB review and approval separately to report MIPS measures in addition to
specified by CMS.
from this rulemaking process. Please These MIPS eligible clinicians may measures required for the Hospital
note that the 60-day Federal Register elect to participate in facility-based Value-Based Purchasing program. We
notice already published on June 14, measurement during the performance have heard this from hospitalists and
2017 (82 FR 27257) and the related period. For the 2020 MIPS payment year other clinicians and we believe that the
comment period ends August 14, 2017. (2018 MIPS performance period), we inclusion of this opportunity within
When the 30-day Federal Register will base our assumptions for these MACRA was in response to this
notice publishes, it will not only eligible clinicians on the Hospital VBP concern. We estimate that 20 percent (or
announce that we are formally Program. 264) of groups that would have
submitting the information collection In Table 61, we estimate participation previously submitted on behalf of
request to OMB but it will also inform in facility-based measurement, based on clinicians in the 2017 MIPS
the public on its additional opportunity 2015 data from the PQRS and the first performance period will elect facility-
to review the information collection 2019 payment year MIPS eligibility and based measurement on behalf of their
request and submit comments. special status file as described in 81 FR 12,125 clinicians.
TABLE 61ESTIMATED NUMBER OF INDIVIDUAL CLINICIANS AND GROUPS WHO PRACTICE PRIMARILY IN THE HOSPITAL TO
ELECT FACILITY-BASED MEASUREMENT
Counts
Estimated number of clinicians who practice primarily in the hospital that previously submitted as individuals under the 2017
MIPS performance period to elect facility-based measurement in the 2018 MIPS performance period (a) .................................. 10,353
Estimated number of clinicians who practice primarily in the hospital that did not submit under the 2017 MIPS performance pe-
riod to elect facility-based measurement as individuals in the 2018 MIPS performance period (b) .............................................. 7,590
Estimated number of clinicians who practice primarily in the hospital to elect facility-based measurement as individuals in the
2017 MIPS performance period (c) = (a) + (b) ................................................................................................................................ 17,943
Estimated number of clinicians who practice primarily in the hospital that previously submitted as groups under the 2017 MIPS
performance period to elect facility-based measurement in the 2018 MIPS performance period (d) ............................................ 12,125
Estimated number of groups who practice primarily in the hospital that previously submitted on behalf of clinicians as groups
under the 2017 MIPS performance period to elect facility-based measurement in the 2018 MIPS performance period (e) ........ 264
Estimated number of respondents that elect facility-based measurements (including individual clinicians who practice primarily in
the hospital electing facility-based measurement and groups electing facility-based measurement) (f) = (c) + (e) ...................... 18,207
31 The data used for our estimates defined service in sites of service identified by place service more of their covered professional service in sites
hospital-based clinicians as those who furnish 75 codes 21, 22, or 23. The proposal defines facility- of service identified by place service codes 21 and
percent or more of their covered professional based clinicians as those who furnish 75 percent or 23.
Although the election of facility-based below. We assume that there will be no hour. Therefore, assuming the total
measurement generates burden, it will reduction in burden related to the burden hours per group or individual
also result in the reduction of burden in advancing care information performance clinician associated with the election
the quality performance category category because MIPS eligible process is 1 hour, the total annual
because certain clinicians and groups clinicians who practice primarily in the burden hours are 18,207 (18,207 groups
will no longer be required to submit hospital are not required to submit data or individual clinicians 1 hour). We
data for this category. Hence, our for this performance category. estimate that the total cost to groups and
burden estimates for the quality As shown in Table 62, we estimate individual clinicians associated with
that the election to participate via
performance category consider the the election process will be
facility-based measurement will take 1
reduction in burden for clinicians who approximately $36.12 ($36.12 per hour
hour of staff time, comparable to the
practice primarily in the hospital that CMS Web Interface registration process. 1 hour per group or eligible clinician).
previously submitted data for this We assume that the staff involved in the We also assume that 18,207 individual
performance category and elected to use election process to participate via clinicians or groups will go through the
facility-based measurement. The facility-based measurement will mainly election process leading to a total
reduction in burden is described in the be billing clerks or their equivalent, who burden of $657,637 ($36.12 18,207
quality performance category section have an average labor cost of $36.12/ clinicians).
TABLE 62ESTIMATED BURDEN FOR ELECTION TO PARTICIPATE IN FACILITY-BASED MEASUREMENT

Burden
estimate
Estimated number of respondents to elect facility-based measurements (including individual clinicians who practice primarily in
the hospital electing facility-based measurement and groups electing facility-based measurement) (a) ....................................... 18,207
Estimated number of Burden Hours Per Group or Eligible Clinician to Elect Facility-based Measurement (b) ................................ 1
Estimated Total Annual Burden Hours (c) = (a) * (b) .................................................................................................................. 18,207
Estimated Cost Per Clinician or Group Practice to Elect Facility-Based Measurement (@billing clerks labor rate of $36.12/hr.)
(d) ..................................................................................................................................................................................................... $36.12
Estimated Total Annual Burden Cost (e) = (c) * (d) .................................................................................................................... $657,637
E. ICRs Regarding Burden for Third MIPS eligible clinicians will be able to meeting with CMS officials when
Party Reporting ( 414.1400) use the qualified registry and QCDR for additional information is needed. In
Under MIPS, quality, advancing care all MIPS submission (not just for quality addition, QCDRs calculate their measure
information, and improvement activities submission) and (2) QCDRs will be able results. QCDRs must possess
performance category data may be to provide innovative measures that benchmarking capability (for non-MIPS
submitted via relevant third party address practice needs. Qualified quality measures) that compares the
intermediaries, such as qualified registries or QCDRs interested in quality of care a MIPS eligible clinician
registries, QCDRs and health IT vendors. submitting quality measures results and provides with other MIPS eligible
The CAHPS for MIPS survey data, numerator and denominator data on clinicians performing the same quality
which counts as one quality quality measures to us on their measures. For non-MIPS measures the
performance category measure, can be participants behalf will need to QCDR must provide to us, if available,
submitted via CMS-approved survey complete a self-nomination process to data from years prior (for example, 2016
vendors. The burdens associated with be considered qualified to submit on data for the 2018 MIPS performance
qualified registry and QCDR self- behalf of MIPS eligible clinicians or period) before the start of the
nomination and the CAHPS for MIPS groups, unless the qualified registry or performance period. In addition, the
survey vendor applications are QCDR was qualified to submit on behalf QCDR must provide to us, if available,
discussed below. of MIPS eligible clinicians or groups for the entire distribution of the measures
prior program years and did so performance broken down by deciles.
1. Burden for Qualified Registry and successfully. As an alternative to supplying this
QCDR Self-Nomination 32 information to us, the QCDR may post
We estimate that the self-nomination
For the 2017 MIPS performance process for qualifying additional this information on their Web site prior
period, 120 qualified registries and 113 qualified registries or QCDRs to submit to the start of the performance period,
QCDRs were qualified to report quality on behalf of MIPS eligible clinicians or to the extent permitted by applicable
measures data for purposes of the PQRS, groups for MIPS will involve privacy laws. The time it takes to
an increase from 114 qualified registries approximately 1 hour per qualified perform these functions may vary
and 69 QCDRs in CY 2016.33 Under registry or QCDR to complete the online depending on the sophistication of the
MIPS, we believe that the number of self-nomination process. The self- entity, but we estimate that a qualified
QCDRs and qualified registries will nomination form is submitted registry or QCDR will spend an
continue to increase because: (1) Many electronically using a web-based tool. additional 9 hours performing various
We are proposing to eliminate the other functions related to being a MIPS

32 We do not anticipate any changes in the
option of submitting the self-nomination qualified registry or QCDR.
CEHRT process for health IT vendors as we
transition to MIPS. Hence, health IT vendors are not form via email that was available in the As shown in Table 63, we estimate
included in the burden estimates for MIPS. transition year. that the staff involved in the qualified
33 The full list of qualified registries for 2017 is
In addition to completing a self- registry or QCDR self-nomination
available at https://qpp.cms.gov/docs/QPP_MIPS_
2017_Qualified_Registries.pdf and the full list of
nomination statement, qualified process will mainly be computer
QCDRs is available at https://qpp.cms.gov/docs/ registries and QCDRs will need to systems analysts or their equivalent,
QPP_2017_CMS_Approved_QCDRs.pdf. perform various other functions, such as who have an average labor cost of
$88.10/hour. Therefore, assuming the requirements in MIPS will be the time registries and QCDRs already perform
total burden hours per qualified registry and effort associated with calculating many of these activities for their
or QCDR associated with the self- quality measure results from the data participants. We believe the estimate
nomination process is 10 hours, the submitted to the qualified registry or noted in this section represents the
annual burden hours is 2,330 (233 (113 QCDR by its participants and submitting upper bound of QCDR burden, with the
+ 120) QCDRs or qualified registries these results, the numerator and potential for less additional MIPS
10 hours). We estimate that the total denominator data on quality measures, burden if the QCDR already provides
cost to a qualified registry or QCDR the advancing care information similar data submission services.
associated with the self-nomination performance category, and improvement
process will be approximately $881.00 activities data to us on behalf of their Based on the assumptions previously
($88.10 per hour 10 hours per participants. We expect that the time discussed, we provide an estimate of
qualified registry). We also estimate that needed for a qualified registry to total annual burden hours and total
233 qualified registries or QCDRs will accomplish these tasks will vary along annual cost burden associated with a
go through the self-nomination process with the number of MIPS eligible qualified registry or QCDR self-
leading to a total burden of $205,273 clinicians submitting data to the nominating to be considered qualified
($881.00 233). qualified registry or QCDR and the to submit quality measures results and
The burden associated with the number of applicable measures. numerator and denominator data on
qualified registry and QCDR submission However, we believe that qualified MIPS eligible clinicians.
TABLE 63ESTIMATED BURDEN FOR QCDR AND REGISTRY SELF-NOMINATION

Burden
estimate
Estimated number 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
2. Burden for CAHPS for MIPS Survey criteria for a CMS-approved survey labor cost of $88.10/hour. Therefore,
Vendors vendor for the CAHPS for MIPS survey. assuming the total burden hours per
We estimate that it will take a survey CAHPS associated with the application
In the CY 2017 Quality Payment vendor 10 hours to submit the process is 10 hours, the annual burden
Program final rule (81 FR 77386), we information required for the CMS- hours is 150 (15 CAHPS vendors 10
finalized the definition, criteria, approval process, including the hours). We estimate that the total cost to
required forms, and vendor business completion of the Vendor Participation each CAHPS vendor associated with the
requirements needed to participate in Form and compiling documentation, application process will be
MIPS as a survey vendor. For purposes including the quality assurance approximately $881.00 ($88.10 per hour
of MIPS, we defined a CMS-approved plan,that demonstrates that they comply 10 hours per CAHPS vendor). We
survey vendor at 414.1305 as a survey with Minimum Survey Vendor Business estimate that 15 CAHPS vendors will go
vendor that is approved by us for a Requirements. This is comparable to the through the process leading to a total
particular performance period to burden of the QCDR and qualified burden of $13,215 ($881.00 15 CAHPS
administer the CAHPS for MIPS survey registry self-nomination process. As vendors).
and transmit survey measures data to shown in Table 64, we assume that the Based on the assumptions previously
us. At 414.1400(i), we require that survey vendor staff involved in discussed, we provide an estimated
vendors undergo the CMS-approval collecting and submitting the number of total annual burden hours
process each year in which the survey information required for the CAHPS for and total annual cost burden associated
vendor seeks to transmit survey MIPS certification will be computer with the survey vendor approval
measures data to us. We finalized the systems analysts, who have an average process in Table 64.
TABLE 64ESTIMATED BURDEN FOR CAHPS SURVEY VENDOR APPLICATION

Burden
estimate
Estimated number of New CAHPS Vendors Applying (a) .................................................................................................................. 15

Estimated number 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 CAHPS Vendor Application Process (e) = (a) * (c) .................................................... $13,215
F. ICRs Regarding the Quality submit as MIPS eligible clinicians, and Historically, the PQRS has never
Performance Category ( 414.1330 and other clinicians who opt to submit data experienced 100 percent participation;
414.1335) voluntarily but will not be subject to the participation rate for 2015 was 69
Two groups of clinicians will submit MIPS payment adjustments. percent. For purposes of these analyses,
quality data under MIPS: those who we assume that clinicians who
participated in the 2015 PQRS and who the rate of voluntary quality data Reduction Act (42 U.S.C. 1395jjj and 42
are not QPs in Advanced APMs in the submission among clinicians excluded U.S.C. 1315a(d)(3), respectively).36
2017 Quality Payment Program from or ineligible for MIPS relative to Tables 65, 66, and 67 explain our
performance period will continue to our estimated voluntary reporting rate of revised estimates of the number of
submit quality data as either MIPS 45 percent in the CY 2017 Quality organizations (including groups, virtual
eligible clinicians or voluntary reporters Payment Program final rule. groups, and individual MIPS eligible
in the 2018 MIPS performance period. Historically, clinicians who are clinicians) submitting data on behalf of
In addition, as shown in Table 62, expected to be QPs in 2018 MIPS clinicians via each of the quality
regarding our burden estimates for performance period were much more submission mechanisms. The proposed
election of facility-based measurement, likely to have submitted quality data policies related to both virtual groups
we assume that approximately 18,207 under the 2015 PQRS than other and facility-based measurement are
individual clinicians or groups will clinicians excluded from or ineligible reflected, as is the proposed policy to
elect to participate in facility-based from MIPS. Due to data limitations, our score quality measures submitted via
measurement for the 2018 MIPS assumptions about quality performance multiple submission mechanisms.
performance period and will not be category participation for the purposes Table 65 provides our estimated
required to submit any additional of our burden estimates differs from our counts of clinicians that will submit
quality performance category data under assumptions about quality performance quality performance category data as
MIPS. Based on 2015 data from the category participation in the impact MIPS individual clinicians, groups, or
PQRS, the data prepared to support the analysis.35 virtual groups in the 2018 MIPS
2017 performance period initial Our burden estimates for data performance period. The first step was
determination of clinician and special submission combine the burden for to estimate the number of clinicians to
status eligibility (available via the NPI MIPS eligible clinicians and other submit as an individual clinician or
lookup on qpp.cms.gov) using a date clinicians submitting data voluntarily. group via each mechanism during the
range of September 1, 2015August 31, Apart from clinicians who practice 2017 MIPS performance period using
2016, and a version of the file used for primarily in the hospital electing 2015 PQRS data on individuals and
the predictive qualifying Alternative facility-based measurement and groups submitting through various
Payment Model participants analysis clinicians that became QPs in the first mechanisms and excluding clinicians
made available on qpp.cms.gov on June QP performance period, we assume that identified as QPs in a preliminary
2, 2017 and prepared using claims for clinicians will continue to submit version of the file used for the
services between January 1, 2016 quality data under the same submission predictive qualifying APM participants
through August 31, 2016. We estimate mechanisms that they used under the analysis made available on qpp.cms.gov
that at least 92 percent of MIPS eligible 2015 PQRS. As discussed in more detail on June 2, 2017 and prepared using
clinicians not participating in MIPS in the section of this proposed rule claims for services between January 1,
APMs will submit quality performance describing the burden for facility-based 2016 through August 31, 2016. The
category data including those measurement (III.D.), we assume that second step was to subtract out the
participating as individual clinicians, some eligible clinicians who practice estimated number of clinicians who
groups, or virtual groups. We assume primarily in the hospital will elect practice primarily in the hospital to
that 100 percent of MIPS APM Entities facility-based measurement, rather than elect facility-based scoring as groups or
will submit quality data to CMS as submit quality data via other individuals in the 2018 MIPS
required under their models.34 We mechanisms. Further, as discussed in performance period. Further detail on
anticipate that the professionals more detail in the section of this our methods to estimate the number of
submitting data voluntarily will include proposed rule describing the burden for clinicians who practice primarily in the
clinicians that are ineligible for the the virtual group application process hospital to elect facility-based scoring as
Quality Payment Program, clinicians (III.C.), we assume that the individual clinicians or groups is
that do not exceed the low-volume approximately 80 TINs that elect to form provided on the burden for the election
threshold, and newly enrolled Medicare the approximately 16 virtual groups will of facility-based measurement (section
clinicians. Based on those assumptions, continue to use the same submission III.D. of this proposed rule).
using data from the 2015 PQRS, the data mechanism as under the 2015 PQRS, Based on these methods, Table 65
prepared to support the 2017 but the submission will be at the virtual shows that in the 2018 MIPS
performance period initial group, rather than group level. Our performance period, an estimated
determination of clinician and special burden estimates for the quality 364,002 clinicians will submit as
status eligibility (available via the NPI performance category do not include the individuals via claims submission
lookup on qpp.cms.gov), and a burden for the quality data that MIPS mechanisms; 225,569 clinicians will
preliminary version of the file used for APM Entities submit to fulfill the submit as individuals, or as part of
the predictive QP analysis made requirements of their models. Sections groups or virtual groups via qualified
available on qpp.cms.gov on June 2, 3021 and 3022 of the Affordable Care registry or QCDR submission
2017, we estimate that an additional Act state the Shared Savings Program mechanisms; 115,241 clinicians will
292,351 clinicians, or 36 percent of and the testing, evaluation, and submit as individuals, or as part of
clinicians excluded from or ineligible expansion of Innovation Center models groups or virtual groups via EHR
from MIPS, will submit MIPS quality are not subject to the Paperwork submission mechanisms; and 101,939
data voluntarily. Because in the

clinicians will submit as part of groups
projected growth in the number of QPs 35 As noted, the COI section of this rule uses the
via the CMS Web Interface.
over time, we are predicting a decline in actual overall average participation rate of 92 Our estimated numbers of clinicians
percent in quality data submission based on 2015
34 We estimate that 110,159 clinicians that PQRS data. The RIA section of this rule uses the to submit as individual clinicians,
participated in the 2015 PQRS will be QPs who will actual participation rate for practices with more
not be not required to submit MIPS quality than 15 clinicians and assumes a minimum 90 36 Our estimates do reflect the burden that MIPS
performance category data under MIPS, and are not percent participation (standard assumption or 80 APM participants of submitting advancing care
included in the numerator or denominator of our percent participation (alternative assumption) for information data, which is outside the requirements
participation rate. practices with 115 clinicians. of their models.
groups, or virtual groups via each can be scored on data submitted via submission mechanisms are not
submission mechanism account for the multiple submission mechanisms. mutually exclusive, and reflect the
policy proposed under section Hence, the estimated numbers of occurrence of individual clinicians or
II.C.6.a.(1) of this rule that individual individual clinicians, groups, and groups that submitted data via multiple
clinicians, groups, and virtual groups virtual groups to submit via the various mechanism under the 2015 PQRS.
TABLE 65ESTIMATED 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) (a) ............................................................................................ 371,987 236,908 118,395 101,939
Subtract out: Estimated number of clinicians to submit via mechanism (as
individual clinicians, groups or virtual groups) in Quality Payment Pro-
gram Year 1 that will opt for facility-based scoring in Quality Payment
Program Year 2 (b) ...................................................................................... 7,985 11,339 3,154 0
Estimated number of clinicians to submit via mechanism (as individual clini-
cians or groups) in Quality Payment Program Year 2 (excludes QPs and
facility-based measurement) (c) = (a)(b) .................................................. 364,002 225,569 115,241 101,939
Table 65 provides estimates of the individuals or part of groups or virtual qualified registry or QCDR submission
number of clinicians to submit quality groups. mechanisms; and approximately 60,253
measures via each mechanism, Table 66 uses methods similar to clinicians will submit as individuals via
regardless of whether they decide to those described for Table 65 to estimate EHR submission mechanisms.
submit as individual clinicians or as the number of clinicians to submit as Individual clinicians cannot elect to
part of groups or virtual groups. Because individual clinicians via each submit via CMS Web Interface.
our burden estimates for quality data mechanism in Quality Payment Program Consistent with the proposed policy to
submission assume that burden is Year 2. We estimate that approximately allow individual clinicians to be scored
reduced when clinicians elect to submit 364,002 clinicians will submit as on quality measures submitted via
as part of a group or virtual group, we individuals via claims submission multiple mechanisms, our columns in
also separately estimate the expected mechanisms; approximately 86,046
Table 66 are not mutually exclusive.
number of clinicians to submit as clinicians will submit as individuals via
TABLE 66ESTIMATED 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) ................................................... 371,987 88,078 60,589 0
Subtract out: Estimated number of clinicians to submit via mechanism as in-
dividuals in Quality Payment Program Year 1 that will opt for facility-
based scoring in Quality Payment Program Year 2 (b) ............................... 7,985 2,032 336 0
Estimated number of clinicians to submit via mechanism as individuals in
Quality Payment Program Year 2 (excludes QPs and facility-based meas-
urement) (c) = (a)(b) ................................................................................. 364,002 86,046 60,253 0
Table 67 provides our estimated performance period was to estimate the number of groups who practice
counts of groups or virtual groups to number of groups to submit on behalf of primarily in the hospital to elect
submit quality data on behalf of clinicians via each mechanism in the facility-based scoring on behalf of
clinicians via each mechanism in the 2017 MIPS performance period. We clinicians is provided in section III.D. of
2018 MIPS performance period and used 2015 PQRS data on groups this proposed rule, on the burden for the
reflects our assumption that the submitting on behalf of clinicians via election of facility-based measurement.
formation of virtual groups will reduce various mechanisms and excluded The third and fourth steps in Table 67
burden. Except for groups who practice groups comprised entirely of QPs in a reflect our assumption that virtual
primarily in the hospital electing preliminary version of the file used for groups will reduce the burden for
facility-based measurement and groups the predictive qualifying Alternative quality data submission by reducing the
comprised entirely of QPs, we assume Payment Model participants analysis number of organizations to submit
that groups that submitted quality data made available on qpp.cms.gov on June quality data on behalf of clinicians. We
as groups under the 2015 PQRS will 2, 2017 and prepared using claims for assume that 40 groups that previously
continue to submit quality data either as services between January 1, 2016 submitted on behalf of clinicians via
groups or virtual groups via the same through August 31, 2016. The second QCDR or qualified registry submission
submission mechanisms in the 2018 step was to subtract out the estimated mechanisms will elect to form 8 virtual
MIPS performance period. The first step number of groups who practice groups that will submit via QCDR and
in estimating the numbers of groups or primarily in the hospital that will elect qualified registry submission
virtual groups to submit via each facility-based measurement. Further mechanisms. We assume that another 40
mechanism in the 2018 MIPS detail on our methods to estimate the groups that previously submitted on
behalf of clinicians via EHR submission in Table 67 is to add in the estimated clinicians; 817 groups and virtual
mechanisms will elect to form another number of virtual groups that will groups will submit via EHR submission
8 virtual groups via EHR submission submit on behalf of clinicians via each mechanisms on behalf of 56,772 eligible
mechanisms. Hence, the third step in submission mechanism. clinicians; and 298 groups will submit
Table 67 is to subtract out the estimated Specifically, we assumed that 2,455 data via the CMS Web Interface on
number of groups under each groups and virtual groups will submit behalf of 102,914 clinicians. Groups
submission mechanism that will elect to data via QCDR/registry submission cannot elect to submit via claims
form virtual groups, and the fourth step mechanisms on behalf of 146,676 submission mechanism.
TABLE 67ESTIMATED 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 2,672 928 298
Subtract out: Estimated number groups to submit via mechanism on behalf
of clinicians in Quality Payment Program Year 1 that will opt for facility-
based scoring in Quality Payment Program Year 2 (b) ............................... 0 185 79 0
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 (c) .......................................... 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 (d) ........................... 0 8 8 0
Estimated number groups to submit via mechanism on behalf of clinicians
in Quality Payment Program Year 2 (e) = (a)(b)(c) + (d) ..................... 0 2,455 817 298
These burden estimates have some the applicable measures or specialty mechanisms. (We have also reduced our
limitations. We believe it is difficult to measure sets for which they can report burden estimate for CMS Web Interface
quantify the burden accurately because the necessary information, review the to reflect the new CMS API in a separate
clinicians and groups may have measure specifications for the selected section below.).38
different processes for integrating measures or measures group, and For the claims submission
quality data submission into their incorporate submission of the selected mechanism, we estimate that the start-
practices work flows. Moreover, the measures or specialty measure sets into up cost for a MIPS eligible clinicians
time needed for a clinician to review the office work flows. Building on data practice to review measure
quality measures and other information, in a recent article, Casalino et al. (2016), specifications is $596.80, including 3
select measures applicable to their we assume that a range of expertise is hours of a practice administrators time
patients and the services they furnish, needed to review quality measures: 2 (3 hours $105.16=$315.48), 1 hour of
and incorporate the use of quality data hours of an office administrators time, a clinicians time (1 hour $202.08/
codes into the office workflows is 1 hour of a clinicians time, 1 hour of hour=$202.08), 1 hour of an LPN/
expected to vary along with the number an LPN/medical assistants time, 1 hour medical assistants time (1 hour
of measures that are potentially of a computer systems analysts time, $43.12), and 1 hour of a billing clerks
applicable to a given clinicians and 1 hour of a billing clerks time.37 In time (1 hour $36.12/hour = $36.12).
practice. Further, these burden the CY 2017 Quality Payment Program These start-up costs pertain to the
estimates are based on historical rates of final rule we estimated 3 hours for an specific quality submission methods
participation in the PQRS program, and administrators time for data below, and hence appear in the burden
the rate of participation in MIPS are submission. Because the new CMS estimate tables.
expected to differ. Application Programming Interface For the purposes of our burden
We believe the burden associated (API) will be available for EHR, registry estimates for the claims, qualified
with submitting the quality measures and QCDR, and CMS Web Interface registry and QCDR, and EHR submission
will vary depending on the submission submission mechanisms, we have mechanisms, we also assume that, on
method selected by the clinician, group, reduced our estimate to 2 hours of an average, each clinician, group, or virtual
or virtual group. As such, we break office administrators time for data group will submit 6 quality measures.
down the burden estimates by submission. This CMS API will Our estimated number of respondents
clinicians, groups, and virtual groups by streamline the process of reviewing for the claims and EHR submission
the submission method used. measure specifications and submitting mechanisms increased relative to the
We anticipate that clinicians and measures for third party submission estimates in the CY 2017 Quality
groups using QCDR, qualified registry, Payment Program final rule because our
and EHR submission mechanisms will 37 Our burden estimates are based on prorated estimates now reflect the proposed
have the same start-up costs related to policy to allow individual clinicians
versions of the estimates for reviewing measure

reviewing measure specifications. As specifications in Lawrence P. Casalino et al., US and groups to be scored on quality
Physician Practices Spend More than $15.4 Billion measures submitted via multiple
such, we estimate for clinicians, groups, Annually to Report Quality Measures, Health
and virtual groups using any of these Affairs, 35, no. 3 (2016): 401406. The estimates
mechanisms. Our estimated number of
three submission mechanisms a total of were annualized to 50 weeks per year, and then respondents for the QCDRs and
7 staff hours needed to review the prorated to reflect that Medicare revenue is 30
percent of all revenue paid by insurers, and then 38 CMS: New API Will Automate MACRA Quality
quality measures list, review the various adjusted to reflect that the decrease from 9 required Measure Data Sharing. http://healthitanalytics.com/
submission options, select the most quality measures under PQRS to 6 required news/cms-new-api-will-automate-macra-quality-
appropriate submission option, identify measures under MIPS. measure-data-sharing.
qualified registries submission 2016 through August 31, 2016, we burden will involve becoming familiar
mechanisms has declined relative to the assume that 364,002 individual with MIPS data submission
CY 2017 Quality Payment final rule clinicians will submit quality data via requirements. As noted in Table 68, we
because our estimates now reflect the claims. We anticipate the claims believe that the start-up cost for a
proposed policies allowing certain submission process for MIPS will be clinicians practice to review measure
eligible clinicians who practice operationally similar to the way the specifications totals 7 hours, which
primarily in the hospital to elect claims submission process functioned includes 3 hours of a practice
facility-based measurement, as well as under the PQRS. Specifically, clinicians administrators time (3 hours $105.16
the proposed policy to allow practices will need to gather the required = $315.48), 1 hour of a clinicians time
of 10 or fewer eligible clinicians to information, select the appropriate (1 hour $202.08/hour = $202.08), 1
participate as part of a virtual group. quality data codes (QDCs), and include hour of an LPN/medical assistants time
The number of respondents for CMS the appropriate QDCs on the claims they (1 hour $43.12 = $43.12), 1 hour of a
Web Interface has declined relative to submit for payment. Clinicians will computer systems analysts time (1 hour
the estimates in the CY 2017 Quality collect QDCs as additional (optional) $88.10 = $88.10), and 1 hour of a
Payment Program final rule because our line items on the CMS1500 claim form billing clerks time (1 hour $36.12/
estimates now exclude the CMS Web or the electronic equivalent HIPAA hour = $36.12).
Interface data submitted by Shared transaction 837P, approved by OMB Considering both data submission and
Savings Program and Pioneer ACOs to under control number 09381197. start-up costs, the total estimated
fulfill the requirement of their models. burden hours per clinician ranges from
As noted in this section of the proposed The total estimated burden of claims-
based submission will vary along with a minimum of 7.22 hours (0.22 + 3 + 1
rule, information collections associated + 1 + 1 + 1) to a maximum of 17.8 hours
with the Shared Savings Program and the volume of claims on which the
submission is based. Based on our (10.8 + 3 + 1 + 1 + 1 + 1). The total
the testing, evaluation, and expansion of estimated annual cost per clinician
CMS Innovation Center models are not experience with the PQRS, we estimate
that the burden for submission of ranges from the minimum estimate of
subject to the Paperwork Reduction Act.
quality data will range from 0.22 hours $704.28 ($19.38 + $315.48 + $88.10 +
1. Burden for Quality Data Submission to 10.8 hours per clinician. The wide $43.12 + $36.12 + $202.08) to a
by Clinicians: Claims-Based Submission range of estimates for the time required maximum estimate of $1,636.38
As noted in Table 65, based on 2015 for a clinician to submit quality ($951.48 + $315.48 + $88.10 + $43.12 +
PQRS data, the data prepared to support measures via claims reflects the wide $36.12 + $202.08). Therefore, total
the 2017 performance period initial variation in complexity of submission annual burden cost is estimated to range
determination of clinician and special across different clinician quality from a minimum burden estimate of
status eligibility (available via the NPI measures. As shown in Table 68, we $256,359,329 (364,002 $704.28) to a
lookup on qpp.cms.gov) using a date also estimate that the cost of quality maximum burden estimate of
range of September 1, 2015August 31, data submission using claims will range $595,645,593 (364,002 $1,636.38).
2016, and a preliminary version of the from $19.38 (0.22 hours $88.10) to Based on the assumptions discussed
file used for the predictive qualifying $951.48 (10.8 hours $88.10). The total in this section of the proposed rule,
Alternative Payment Model participants estimated annual cost per clinician Table 68 summarizes the range of total
analysis made available on qpp.cms.gov ranges from the minimum burden annual burden associated with
on June 2, 2017, and prepared using estimate of $704.28 to a maximum clinicians using the claims submission
claims for services between January 1, burden estimate of $1,636.38. The mechanism.
TABLE 68BURDEN ESTIMATE FOR QUALITY PERFORMANCE CATEGORY: CLINICIANS USING THE CLAIMS SUBMISSION
MECHANISM
Maximum
Minimum Median burden
burden burden estimate
Estimated number of Clinicians (a) ............................................................................................. 364,002 364,002 364,002

Burden Hours Per Clinician to Submit Quality Data (b) .............................................................. 0.22 1.58 10.8
Estimated number of Hours Office Administrator Review Measure Specifications (c) ............... 3 3 3
Estimated number of Hours Computer Systems Analyst Review Measure Specifications (d) ... 1 1 1
Estimated number of Hours LPN Review Measure Specifications (e) ....................................... 1 1 1
Estimated number of Hours Billing Clerk Review Measure Specifications (f) ............................ 1 1 1
Estimated number 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) ........................................................... 2,628,094 3,123,137 6,479,236
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
TABLE 68BURDEN ESTIMATE FOR QUALITY PERFORMANCE CATEGORY: CLINICIANS USING THE CLAIMS SUBMISSION
MECHANISMContinued
Maximum
Minimum Median burden
burden burden estimate
Estimated Total Annual Burden Cost (q) = (a) * (p) ............................................................ $256,359,329 $299,974,048 $595,645,593
2. Burden for Quality Data Submission same for each respondent submitting $88.10), 1 hour of an LPN/medical
by Individuals, Groups, and Virtual data via qualified registry or QCDR, assistants time, (1 hour $43.12/hour
Groups Using Qualified Registry and whether the clinician is participating in = $43.12), and 1 hour of a billing clerks
QCDR Submissions MIPS as an individual, group or virtual time (1 hour $36.12/hour = $36.12).
group. Clinicians, groups, and virtual groups
As noted in Table 65 and based on We estimate that burdens associated will need to authorize or instruct the
2015 PQRS data, the data prepared to with QCDR submissions are similar to qualified registry or QCDR to submit
support the 2017 performance period the burdens associated with qualified quality measures results and numerator
initial determination of clinician and registry submissions. Therefore, we and denominator data on quality
special status eligibility (available via discuss the burden for both data
the NPI lookup on qpp.cms.gov) using a measures to us on their behalf. We
submissions together below. For
date range of September 1, 2015August estimate that the time and effort
qualified registry and QCDR
31, 2016, a preliminary version of the associated with authorizing or
submissions, we estimate an additional
file used for the predictive qualifying time burden for respondents (individual instructing the quality registry or QCDR
Alternative Payment Model participants clinicians, groups, and virtual groups) to to submit this data will be
analysis made available on qpp.cms.gov become familiar with MIPS submission approximately 5 minutes (0.083 hours)
on June 2, 2017, and prepared using requirements and, in some cases, per clinician or group (respondent) for
claims for services between January 1, specialty measure sets and QCDR a total burden cost of $7.31, at a
2016 through August 31, 2016, we measures. Therefore, we believe that the computer systems analysts labor rate
assume that 225,569 clinicians will start-up cost for an individual clinician (.083 hours $88.10/hour). Hence, we
submit quality data as individuals, or group to review measure estimate 9.083 burden hours per
groups, or virtual groups via qualified specifications and submit quality data to respondent, with annual total burden
registry or QCDR submissions. Of these, total $851.35. For review costs, this total hours of 803,855 (9.083 burden hours
we expect 86,046 clinicians, as shown includes 3 hours per respondent to 88,501 respondents). The total estimated
in Table 66, to submit as individuals submit quality data (3 hours $88.10/ annual cost per respondent is estimated
and 2,455 groups, as shown in Table 67, hour = $264.00), 3 hours of a practice to be approximately $851.05. Therefore,
are expected to submit on behalf of the administrators time (2 hours $105.16/ total annual burden cost is estimated to
remaining 139,523 clinicians. Given that hour = $210.32), 1 hour of a clinicians be $75,318,776 (88,501 $851.05).
the number of measures required is the time (1 hours $202.08/hour = Based on these assumptions, we have
same for clinicians, groups, and virtual $202.08), 1 hour of a computer systems estimated the burden for these
groups, we expect the burden to be the analysts time (1 hour $88.10/hour = submissions.
TABLE 69BURDEN 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
Number of clinicians submitting as individuals (a) .............................................................................................................................. 86,046

Number of groups or virtual groups submitting via QCDR or registry on behalf of individual clinicians (b) ...................................... 2,455
Number of Respondents (groups and virtual groups plus clinicians submitting as individuals) (c) = (a) + (b) ................................. 88,501
Estimated Burden Hours Per Respondent to Report Quality Data (d) ............................................................................................... 3
Estimated number of Hours Office Administrator Review Measure Specifications (e) ...................................................................... 2
Estimated number of Hours Computer Systems Analyst Review Measure Specifications (f) ........................................................... 1
Estimated number of Hours LPN Review Measure Specifications (g) ............................................................................................... 1
Estimated number of Hours Billing Clerk Review Measure Specifications (h) ................................................................................... 1
Estimated number of Hours Clinician Review Measure Specifications (i) .......................................................................................... 1
Estimated number 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) ................................................................................................................... 803,855
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
TABLE 69BURDEN ESTIMATE FOR QUALITY PERFORMANCE CATEGORY: CLINICIANS (PARTICIPATING INDIVIDUALLY OR AS
PART OF A GROUP OR VIRTUAL GROUP) USING THE QUALIFIED REGISTRY/QCDR SUBMISSIONContinued
Burden
estimate
Estimated Total Annual Burden Cost (u) = (c) * (t) ..................................................................................................................... $75,318,776
3. Burden for Quality Data Submission To prepare for the EHR submission require 1 hour per respondent for a cost
by Clinicians, Groups, and Virtual mechanism, the clinician or group must of $88.10 (1 hour $88.10/hour). For
Groups: EHR Submission review the quality measures on which submitting the actual data file, we
we will be accepting MIPS data believe that this will take clinicians or
As noted in Tables 65, 66 and 67, extracted from EHRs, select the groups no more than 2 hours per
based on our analysis of 2015 PQRS appropriate quality measures, extract respondent for a cost of submission of
data, data prepared to support the 2017 the necessary clinical data from their $176.20 (2 hours $88.10/hour). The
performance period initial EHR, and submit the necessary data to burden will involve becoming familiar
determination of clinician and special the CMS-designated clinical data with MIPS submission. We believe that
status eligibility (available via the NPI warehouse or use a health IT vendor to the start-up cost for a clinician or group
lookup on qpp.cms.gov) using a date submit the data on behalf of the to submit the test data file and review
range of September 1, 2015August 31, clinician or group. We assume the measure specifications is a total 7 hours,
2016, and a preliminary version of the burden for submission of quality 1 hour for the test data submission and
file used for the predictive qualifying measures data via EHR is similar for 6 hours for reviewing measuring which
Alternative Payment Model participants clinicians, groups, and virtual groups includes 2 hours of a practice
QP analysis made available on who submit their data directly to us administrators time (2 hours $105.16/
qpp.cms.gov on June 2, 2017 and from their CEHRT and clinicians, hour = $210.32), 1 hour of a clinicians
prepared using claims for services groups, and virtual groups who use an time (1 hour $202.08/hour = $202.08),
between the date range January 1, 2016 EHR data submission vendor to submit 1 hour of a computer systems analysts
through August 31, 2016, we assume the data on their behalf. To submit data time (1 hour $88.10/hour = $88.10), 1
that 115,241 clinicians will submit to us directly from their CEHRT, hour of an LPN/medical assistants time
quality data as individuals or groups via clinicians, groups, and virtual groups (1 hour $43.12/hour = $43.12), and 1
EHR submissions; 60,253 clinicians are must have access to a CMS-specified hour of a billing clerks time (1 hour
expected to submit as individuals; and identity management system which we $36.12/hour = $36.12). Hence, we
817 groups are expected to submit on believe takes less than 1 hour to obtain. estimated 10 total burden hours per
behalf of 56,772 clinicians. We expect Once a clinician or group has an respondent with annual total burden
the burden to be the same for each account for this CMS-specified identity hours of 610,700 (10 burden hours
respondent submitting data via qualified management system, they will need to 61,070 respondents). The total estimated
registry or QCDR, whether the clinician extract the necessary clinical data from annual cost per respondent is estimated
is participating in MIPS as an individual their EHR, and submit the necessary to be $932.14. Therefore, total annual
or group. data to the CMS-designated clinical data burden cost is estimated to be
Under the EHR submission warehouse. $56,925,790 = (61,070 respondents
mechanism, the individual clinician or We estimate that obtaining an account $932.14).
group may either submit the quality on a CMS-specified identity Based on the assumptions discussed
measures data directly to us from their management system will require 1 hour in this section of the proposed rule, we
EHR or utilize an EHR data submission per respondent for a cost of $88.10 (1 have estimated the burden for the
vendor to submit the data to us on the hour $88.10/hour), and that quality data submission using EHR
clinicians or groups behalf. submitting a test data file to us will also submission mechanism below.
TABLE 70BURDEN ESTIMATE FOR QUALITY PERFORMANCE CATEGORY: CLINICIANS (SUBMITTING INDIVIDUALLY OR AS
PART OF A GROUP OR VIRTUAL GROUP) USING THE EHR SUBMISSION MECHANISM
Burden
estimate
Number of clinicians submitting as individuals (a) .............................................................................................................................. 60,253

Number of Groups and Virtual Groups submitting via EHR on behalf of individual clinicians (b) ..................................................... 817
Number of Respondents (Groups and Virtual Groups plus clinicians submitting as individuals) (c) = (a) + (b) ............................... 61,070
Estimated Burden Hours Per Respondent to Obtain Account in CMS-Specified Identity Management System (d) ......................... 1
Estimated Burden Hours Per Respondents to Submit Test Data File to CMS (e) ............................................................................. 1
Estimated Burden Hours Per Respondent to Submit MIPS Quality Data File to CMS (f) ................................................................. 2
Estimated number of Hours Office Administrator Review Measure Specifications (g) ...................................................................... 2
Estimated number of Hours Computer Systems Analyst Review Measure Specifications (h) .......................................................... 1
Estimated number of Hours LPN Review Measure Specifications (i) ................................................................................................ 1
Estimated number of Hours Billing Clerk Review Measure Specifications (j) .................................................................................... 1
Estimated number of Hours Clinicians Review Measure Specifications (k) ....................................................................................... 1
Estimated Annual Burden Hours Per Respondent (l) = (d) + (e) + (f) + (g) + (h) + (i) + (j) + (k) .............................................. 10
Estimated Total Annual Burden Hours (m) = (c) * (l) .................................................................................................................. 610,700
TABLE 70BURDEN 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 Per Respondent to Obtain Account in CMS-specified identity management system (@computer systems ana-
lysts labor rate of $88.10/hr.) (n) .................................................................................................................................................... $88.10
Estimated Cost Per Respondent to Submit Test Data File to CMS (@computer systems analysts labor rate of $88.10/hr.) (o) ... 88.10
Estimated Cost Per Respondent to Submit Quality Data (@computer systems analysts labor rate of $88.10/hr.) (p) .................... 176.20
Estimated Cost to Review Measure Specifications (@practice administrators labor rate of $105.16/hr.) (q) .................................. 210.32
Estimated Cost to Review Measure Specifications (@computer systems analysts labor rate of $88.10/hr.) (r) .............................. 88.10
Estimated Cost to Review Measure Specifications (@LPNs labor rate of $43.12/hr.) (s) ................................................................ 43.12
Estimated Cost to Review Measure Specifications (@clerks labor rate of $36.12/hr.) (t) ................................................................ 36.12
Estimated Cost to D21Review Measure Specifications (@physicians labor rate of $202.08/hr.) (u) ............................................... 202.08
Estimated Total Annual Cost Per Respondent (v) = (n) + (o) + (p) + (q) + (r) + (s) + (t) + (u) .................................................. 932.14
Estimated Total Annual Burden Cost (w) = (c) * (v) .................................................................................................................... 56,925,790
4. Burden for Quality Data Submission measures data via the CMS Web 2017 Quality Payment Program final
via CMS Web Interface Interface at a cost of $88.10 per hour, for rule to 74 hours. Because each group
a total cost of $6,519 (74 hours $88.10/ must provide data on 248 eligible
Based on 2015 PQRS data and as hour). Our estimate of 74 hours for assigned Medicare beneficiaries (or all
shown in Table 67, we assume that 298 submission includes the time needed for eligible assigned Medicare beneficiaries
groups will submit quality data via the each group to populate data fields in the if the pool of eligible assigned
CMS Web Interface in the 2018 MIPS web interface with information on beneficiaries is less than 248), we
performance period. We anticipate that approximately 248 eligible assigned assume that entering or uploading data
approximately 252,808 clinicians will Medicare beneficiaries and then submit for one Medicare beneficiary requires
be represented. the data (we will partially pre-populate approximately 18 minutes of a computer
The burden associated with the group the CMS Web Interface with claims data systems analysts time (74 hours 248
submission requirements under the from their Medicare Part A and B patients).
CMS Web Interface is the time and effort beneficiaries). The patient data either The total annual burden hours are
associated with submitting data on a can be manually entered or uploaded estimated to be 22,052 (298 groups 74
sample of the organizations into the CMS Web Interface via a annual hours), and the total annual
beneficiaries that is prepopulated in the standard file format, which can be burden cost is estimated to be
CMS Web Interface. Based on populated by CEHRT. Because the CMS $1,942,662 (298 groups $6,519).
experience with PQRS GPRO Web API will streamline the measure Based on the assumptions discussed
Interface submission mechanism, we submission process for many groups, we in this section of the proposed rule, we
estimate that, on average, it will take have reduced our estimate of the have calculated the following burden
each group 74 hours of a computer computer systems analyst time needed estimate for groups submitting to MIPS
systems analysts time to submit quality for submission from 79 hours in the CY with the CMS Web Interface.
TABLE 71BURDEN ESTIMATE FOR QUALITY DATA SUBMISSION VIA THE CMS WEB INTERFACE
Burden
estimate
Estimated number of Eligible Group Practices (a) .............................................................................................................................. 298

Estimated Total Annual Burden Hours Per Group to Submit (b) ........................................................................................................ 74
Estimated Cost Per Group to Report (@computer systems analysts labor rate of $88.10/hr.) (d) ................................................... $88.10
Estimated Total Annual Cost Per Group (e) = (b) * (d) ............................................................................................................... $6,519
Estimated Total Annual Burden Cost (f) = (a) * (e) ..................................................................................................................... $1,942,662
By eligible
clinician or
group
Estimated number of Participating Eligible Professionals (g) ............................................................................................................. 252,808

Average Burden Hours Per Eligible Professional (h) = (c) (g) ........................................................................................................ 0.09
Estimated Cost Per Eligible Professional to Report Quality Data (i) = (f) (g) ................................................................................. $7.68
5. Burden for Beneficiary Responses to CMS-approved survey vendor and use the CAHPS for MIPS survey will
CAHPS for MIPS Survey the CAHPS for MIPS survey as one of experience burden.
their six required quality measures. The usual practice in estimating the
Under MIPS, groups of two or more Beneficiaries that choose to respond to
clinicians can elect to contract with a burden on public respondents to
surveys such as CAHPS is to assume CAHPS for PQRS survey respondents, estimate reflects the length of the
that respondent time is valued, on we assume that an average of 287 English survey. Our proposal would
average, at civilian wage rates. As beneficiaries will respond per group. reduce beneficiary burden compared to
previously explained, the BLS data Therefore, the CAHPS for MIPS survey the transition year; we estimate that the
show the average hourly wage for will be administered to approximately 81-item survey requires an average
civilians in all occupations to be $23.86. 132,307 beneficiaries per year (461 administration time of 18 minutes in
Although most Medicare beneficiaries groups an average of 287 beneficiaries English and 21.6 minutes in Spanish.
are retired, we believe that their time per group responding). Compared to the survey for reporting
value is unlikely to depart significantly We are proposing to use a shorter year 2016, this is a reduction of 5.1
from prior earnings expense, and we version of the CAHPS for MIPS survey minutes (18 minutes12.9 minutes) in
have used the average hourly wage to with 58 items, as compared to 81 items administration time for the English
compute the dollar cost estimate for for the version that will be used in the version and a reduction of 6.1 (21.6
these burden hours. transition year. The proposed shorter minutes15.5 minutes) minutes in
Under the 2018 MIPS performance survey is estimated to require an average administration time for the Spanish
period, we assume that 461 groups will administration time of 12.9 minutes (or version.
elect to report on the CAHPS for MIPS 0.22 hours) in English (at a pace of 4.5 Given that we expect approximately
survey, which is equal to the number of items per minute). We assume the 132,307 respondents per year, the
groups reporting via CAHPS for the Spanish survey would require 15.5 annual total burden hours are estimated
PQRS for reporting period 2015.39 Table minutes (assuming 20 percent more to be 29,108 hours (132,307 respondents
72 shows the estimated annualized words in the Spanish translation). 0.22 burden hours per respondent).
burden for beneficiaries to participate in Because less than 1 percent of surveys The estimated total burden annual
the CAHPS for MIPS Survey. Based on were administered in Spanish for burden cost is $694,612 (132,307
historical information on the numbers of reporting year 2016, our burden $5.25).
TABLE 72BURDEN ESTIMATE FOR BENEFICIARY PARTICIPATION IN CAHPS FOR MIPS SURVEY
Burden
estimate
Estimated number of Eligible Group Practices Administering CAHPS for Physician Quality Reporting Survey (a) .......................... 461
Estimated number of Beneficiaries Per Group Responding to Survey (b) ......................................................................................... 287
Estimated number of Total Beneficiary Respondents (c) = (a) * (b) .................................................................................................. 132,307
Estimated number 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
6. Burden for Group Registration for MIPS involves approximately 1 hour of process to be approximately $88.10
CMS Web Interface administrative staff time per group. We ($88.10 per hour 1 hour per group).
assume that a billing clerk will be We assume that approximately 10
Groups interested in participating in responsible for registering the group and groups will elect to use the CMS Web
MIPS using the CMS Web Interface for that, therefore, this process has an Interface submission mechanism in the
the first time must complete an on-line average computer systems analyst labor 2018 MIPS performance period. The
registration process. After first time cost of $88.10 per hour. Therefore, total annual burden hours are estimated
registration, groups will only need to assuming the total burden hours per to be 10 (10 groups 1 annual hour),
opt out if they are not going to continue group associated with the group and the total annual burden cost is
to submit via the CMS Web Interface. In registration process is 1 hour, we
estimated to be $881.00 (10 groups
Table 73 we estimate that the estimate the total cost to a group
$88.10).
registration process for groups under associated with the group registration
TABLE 73TOTAL 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
39 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.
7. Burden for Group Registration for the survey on their behalf. In the 2018 total burden hours per registration is 1
CAHPS for MIPS Survey MIPS performance period, we assume hour and 0.5 hours to select the CAHPS
Under MIPS, the CAHPS for MIPS that 461 groups will enroll in the MIPS for MIPS Survey vendor that will be
survey counts for one measure towards for CAHPS survey. used and electronically notify CMS of
the MIPS quality performance category As shown in Table 74, we assume that their selection, the total burden hours
and, as a patient experience measure, the staff involved in the group for CAHPS for MIPS registration is 1.5.
also fulfills the requirement to submit at registration for CAHPS for MIPS Survey We estimate the total annual burden
least one high priority measure in the will mainly be computer systems hours as 692 (461 groups 1.5 hours).
absence of an applicable outcome analysts or their equivalent, who have We estimate the cost per group for
measure. Groups that wish to administer an average labor cost of $88.10/hour. We CAHPS for MIPS Survey registration is
the CAHPS for MIPS survey must assume the CAHPS for MIPS Survey $132.15 ($88.10 1.5 hours). We
register by June of the applicable 12- registration burden estimate includes estimate that the total cost associated
month performance period, and the time to register for the survey as with the registration process is $60,921
electronically notify CMS of which well as select the CAHPS for MIPS ($132.15 per hour 461 hours per
vendor they have selected to administer Survey vendor. Therefore, assuming the group).
TABLE 74BURDEN ESTIMATE FOR GROUP REGISTRATION FOR CAHPS FOR MIPS SURVEY
Burden
estimate
Estimated number 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
G. ICRs Regarding Burden Estimate for 1. Burden for Advancing Care apply for a reweighting to zero of their
Advancing Care Information Data Information Application advancing care information performance
( 414.1375) As stated in the CY 2017 Quality category due to a significant hardship
Payment Program final rule, some MIPS exception or as a result of a
During the 2018 MIPS performance decertification of an EHR, as well as an
eligible clinicians may not have
period, clinicians, groups, and virtual application for significant hardship by
sufficient measures applicable and
groups can submit advancing care available to them for the advancing care small practices. Based on 2016 data
information data through qualified information performance category, and from the Medicare EHR Incentive
registry, QCDR, EHR, CMS Web as such, they may apply to have the Program and the first 2019 payment year
Interface, and attestation data advancing care information category re- MIPS eligibility and special status file,
submission methods. We have worked weighted to zero in the following we assume 50,689 respondents (eligible
to further align the advancing care circumstances: insufficient internet clinicians, groups, or virtual groups)
information performance category with connectivity, extreme and will submit a request for reweighting to
other MIPS performance categories. We uncontrollable circumstances, lack of zero of their advancing care information
anticipate that most organizations will control over the availability of CEHRT category due to a significant hardship
use the same data submission (81 FR 77240 through 77243). As exception, decertification of an EHR or
mechanism for the advancing care described in section II.C.6.f.(7)(a) of this significant hardship for small practices
information and quality performance proposed rule, we are proposing to through the Quality Payment Program.
categories, and that the clinicians, allow MIPS eligible clinicians to apply We estimate that 6,699 respondents
practice managers, and computer to have their advancing care information (eligible clinicians, groups, or virtual
systems analysts involved in supporting performance category re-weighted to groups) will submit a request for a
the quality data submission will also zero through the Quality Payment reweighting to zero for the advancing
support the advancing care information Program due to a significant hardship care information performance category
data submission process. Hence, the exception or exception for decertified due to extreme and uncontrollable
burden estimate for the submission of EHR technology. We are also proposing circumstances or as a result of a
advancing care information data below that MIPS eligible clinicians who are in decertification of an EHR, and 43,990
small practices (15 or fewer clinicians) respondents will submit a request for a
shows only incremental hours required
may, beginning with the 2018 reweighting to zero for the advancing
above and beyond the time already
performance period and 2020 MIPS care information performance category
accounted for in the quality data as a small practice. The application to
payment year, request a reweighting to
submission process. While this analysis request a reweighting to zero for the
zero for the advancing care information

assesses burden by performance category due to a significant hardship. advancing care information performance
category and submission mechanism, We are proposing to rely on section category due to significant hardship is a
we emphasize that MIPS is a 1848(o)(2)(D) of the Act, as amended by short online form that requires
consolidated program and submission section 4002(b)(1)(B) of the 21st Century identifying which type of hardship or if
analysis and decisions are expected to Cures Act, as our authority for the decertification of an EHR applies and a
be made for the program as a whole. significant hardship exceptions. description of how the circumstances
Table 75 shows the estimated impair the ability to submit the
annualized burden for clinicians to advancing care information data, as well
as some proof of circumstances beyond that we expect 50,689 applications per respondent). The estimated total annual
the submitters control. The estimate to year, the annual total burden hours are burden is $2,232,850 (50,689 $44.05).
submit this application is 0.5 hours of estimated to be 25,345 hours (50,689
a computer system analysts time. Given respondents 0.5 burden hours per
TABLE 75BURDEN ESTIMATE FOR APPLICATION FOR ADVANCING CARE INFORMATION REWEIGHTING
Burden
estimate
Number of Eligible Clinicians, Groups, or Virtual Groups Applying Due to Significant Hardship and Other Exceptions (a) ............. 6,699
Number of Eligible Clinicians, Groups, or Virtual Groups Applying Due to Significant Hardship as Small Practice (b) ................... 43,990
Total respondents Due to Hardships, Other Exceptions and Hardships for Small Practices (c) ....................................................... 50,689
Estimated Burden Hours Per Applicant for Advancing Care Information (d) ..................................................................................... 0.5
Estimated Total Annual Burden Hours (e) = (a) * (c) .................................................................................................................. 25,345
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) ..................................................................................................................... $2,232,850
2. Number of Organizations Submitting Program and the data prepared to scoring weight of zero percent for the
Advancing Care Information Data on support the 2017 performance period advancing care information performance
Behalf of Eligible Clinicians initial determination of clinician category for MIPS eligible clinicians
eligibility and special status who are determined to be based in
A variety of organizations will submit determination (available via the NPI ambulatory surgical centers (ASCs).
advancing care information data on lookup on qpp.cms.gov) using a date
behalf of clinicians. Clinicians not Further, we anticipate that the 480
range of September 1, 2015August 31, Shared Savings Program ACOs will
participating in a MIPS APM can submit 2016, we estimate that 265,895
as individuals or as part of a group or submit data at the ACO participant
individual MIPS eligible clinicians and
virtual group. Group TINs may submit group TIN-level, for a total of 15,945
301 groups or virtual groups,
advancing care information data on group TINs. We anticipate that the three
representing 106,406 MIPS eligible
behalf of clinicians in MIPS APMs, or, APM Entities electing the one-sided
clinicians, will submit advancing care
except for participants in the Shared track in the CEC model will submit data
information data. These estimates reflect
Savings Program, clinicians in MIPS that under the policies finalized in CY at the group TIN-level, for an estimated
APMs may submit advancing care 2017 Quality Payment Program final total of 100 group TINs submitting data.
information performance category data rule, certain MIPS eligible clinicians We anticipate that the 195 APM Entities
individually. Because group TINs in will be eligible for automatic in the OCM (one-sided risk
APM Entities will be submitting reweighting of their advancing care arrangement) will submit data at APM
advancing care information data to information performance category score Entity level, for an estimated total of
fulfill the requirements of submitting to to zero, including MIPS eligible 6,478 group TINs. Based on a
MIPS, we have included MIPS APMs in clinicians that practice primarily in the preliminary version of the file used for
our burden estimate for the advancing hospital, physician assistants, nurse the predictive qualifying Alternative
care information performance category. practitioners, clinician nurse specialists, Payment Model participants analysis
Consistent with the list of APMs that are certified registered nurse anesthetists, made available on qpp.cms.gov on June
MIPS APMs on the QPP Web site,40 we and non-patient facing clinicians. These 2, 2017, and prepared using claims for
assume that 5 MIPS APMs that do not estimates also account for the significant services between January 1, 2016
also qualify as Advanced APMs will hardships finalized in the CY 2017 through August 31, 2016, we estimate 2
operate in the 2018 MIPS performance Quality Payment Program final rule and APM Entities in the CPC+ model will
period: Track 1 of the Shared Savings our proposed policies for significant submit at the group TIN-level, for an
Program, CEC (one-sided risk hardship exceptions, including for MIPS estimated total of 2 group TINs
arrangement), OCM (one-sided risk eligible clinicians in small practices, as submitting data. Based on preliminary
arrangement), and the Comprehensive well as exceptions due to decertification data, we assume that 1 CPC+ APM
Primary Care Plus Model (CPC+). of an EHR. Due to data limitations, our entity will submit data because one or
Further, we assume that group TINs will estimate of the number of clinicians to more of its participants is a partial QP,
submit advancing care information data submit advancing care information data and that 1 CPC+ APM Entity will submit
on behalf of partial QPs that elect to does not account for our proposal to rely data because some of its participants
participate in MIPS. on section 1848(o)(2)(D) of the Act, as qualify as either as QPs or partial QPs.
As shown in Table 76, based on 2015 amended by section 4002(b)(1)(B) of the The total estimated number of
data from the Medicare EHR Incentive 21st Century Cures Act, to assign a respondents is estimated at 288,721.
40 https://qpp.cms.gov/docs/QPP_Advanced_
APMs_in_2017.pdf.
TABLE 76ESTIMATED 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) ............................................................. 265,895 ........................
Number of groups or virtual groups to submit advancing care information (b) ...................................................... 301 ........................
Shared Savings Program ACO Group TINs (c) ...................................................................................................... 15,945 480
CEC one-sided risk track participants 41 (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) ........................................................................................................ 288,721 680
3. Burden for Submission of Advancing quality data would also submit under category data. We anticipate that the
Care Information Data advancing care information. For this year-over-year consistency of data
proposed rule, MIPS special status submission processes, measures, and
In Table 76, we estimate that up to eligibility data were available to model activities and the further alignment of
approximately 288,721 respondents will exceptions. The majority (214,302) of
be submitting data under the advancing the advancing care information
the difference in our estimated number performance category with other
care information performance category, of respondents is due to the availability
265,895 clinicians, 301 groups or virtual performance categories will reduce the
of MIPS special status data to identify clinician time needed under this
groups, 15,945 group TINs within the clinicians and groups that would also
Shared Savings Program ACOs, 100 performance category in the 2018 MIPS
not need to report advancing care performance period. Further, for some
group TINs within the APM Entity information data under transition year
participating in CECs in the one-sided practices the staff mix requirements in
policies, including hospital-based the 2018 MIPS performance period may
risk track, and 6,478 group TINs within eligible clinicians, clinician types
the OCM (one-sided risk arrangement), be driven more by transition to 2015
eligible for automatic reweighting of
and 2 CPC+ group TINs. We estimate CEHRT. Therefore, as shown in Table
their advancing care information
this is a significant reduction in performance category score, non-patient 77, the total burden hours for an
respondents from the 2017 MIPS facing clinicians, and clinicians facing a organization to submit data on the
performance period as a result of our significant hardship. The remaining specified Advancing Care Information
proposed policy to provide significant decline in respondents is due to policies Objectives and Measures is estimated to
hardship exceptions, including for MIPS proposed in this rule, including 25,881 be 3 incremental hours of a computer
eligible clinicians in small practices, as respondents who would be excluded analysts time above and beyond the
well as for situations due to under the new proposed significant clinician, practice manager, and
decertification of an EHR, and our hardship exception for small practices. computer systems analyst time required
proposed policy to allow eligible Our burden estimates in the CY 2017 to submit quality data. The total
clinicians to participate as part of a Quality Payment Program final rule estimated burden hours are 866,163
virtual group. assumed that during the transition year, (288,721 respondents 3 hours). At a
In the CY 2017 Quality Payment 3 hours of clinician time would be computer systems analysts hourly rate,
Program final rule, our burden estimates required to collect and submit the total burden cost is $76,308,960
assumed all clinicians who submitted advancing care information performance (288,721 $264.30/hour).
TABLE 77ESTIMATED BURDEN FOR ADVANCING CARE INFORMATION PERFORMANCE CATEGORY DATA SUBMISSION
Burden
estimate
Number of respondents submitting advancing care information data on behalf of clinicians (a) ....................................................... 288,721
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) .................................................................................................................... $76,308,960
H. ICR Regarding Burden for the legacy programs replaced by MIPS, improvement activity performance
Improvement Activities Submission and we do not have historical data category data. For clinicians who are not
( 414.1355) which is directly relevant. A variety of part of APMs, we assume that clinicians
Requirements for submitting organizations and in some cases, submitting quality data as part of a
improvement activities did not exist in individual clinicians, will submit group or virtual group through the
41 The 3 CEC APM Entities reflected in the burden
estimate are the non-large dialysis organizations

participating in the one-sided risk track.
QCDR and registry, EHR, and CMS Web to submit improvement activities data 16 virtual groups to submit
Interface submission mechanisms will unless the CMS-assigned improvement improvement activities, resulting in
also submit improvement activities data. activities score is below the maximum 524,488 total respondents. The burden
Further, we assume that clinicians and improvement activities score. As estimates assume there will be no
groups that practice primarily in the represented in Table 78, we estimate improvement activities burden for MIPS
hospital that elect facility-based 520,654 clinicians will submit APM participants. We will assign the
measurement for the quality improvement activities as individuals improvement activities performance
performance category will also submit during the 2018 MIPS performance category score at the APM level; each
improvement activities data. As noted period, an estimated 3,818 groups to APM Entity within the same MIPS APM
in section II.C.6.g.(3)(c) of the proposed submit improvement activities on behalf
will be assigned the same score.
rule, MIPS eligible clinicians of clinicians during the 2018 MIPS
participating in MIPS APMs do not need performance period, and an additional
TABLE 78ESTIMATED NUMBERS OF ORGANIZATIONS SUBMITTING IMPROVEMENT ACTIVITIES PERFORMANCE CATEGORY

DATA ON BEHALF OF CLINICIANS
Count
Estimated number of clinicians to participate in Improvement Activities data submission as individuals during the 2018 MIPS
performance period (a) .................................................................................................................................................................... 520,654
Estimated number of Groups to submit improvement activities on behalf of clinicians during the 2018 MIPS performance period
(b) ..................................................................................................................................................................................................... 3,818
Estimated number of Virtual Groups to submit improvement activities on behalf of clinicians during the 2018 MIPS performance
period (c) .......................................................................................................................................................................................... 16
Total number 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) ............................................................... 524,488
In Table 79, we estimate that been revised to assume that the total Additionally, the same improvement
approximately 524,488 respondents will burden hours to submit data on the activity may be reported across multiple
be submitting data under the specified improvement activities will be performance periods so many MIPS
improvement activities performance 1 hour of computer system analyst time eligible clinicians will not have any
category. Our burden estimates in the in addition to time spent on other additional information to develop for
CY 2017 Quality Payment Program final performance categories. Our revised the 2018 MIPS performance period. The
rule assumed that during the transition estimate is based on feedback from total estimated burden hours are
year, 2 hours of clinician time would be stakeholders that these are activities 524,488 (524,488 responses 1 hour).
required to submit data on the specified they have already been doing and At a computer systems analysts hourly
improvement activities. For this tracking so there is no additional rate, the total burden cost is $46,207,393
proposed rule, our burden estimate has development of material needed. (524,488 $88.10/hour).
TABLE 79ESTIMATED BURDEN FOR IMPROVEMENT ACTIVITIES SUBMISSION

Burden
estimate
Total number of Respondents (Groups, Virtual Groups, and Individual Clinicians) to submit improvement activities data on be-
half of clinicians during the 2018 MIPS performance period (a) ..................................................................................................... 524,488
Estimated Total Annual Burden Hours Per Respondent (b) ............................................................................................................... 1
Estimated Total Annual Burden Hours (c) ................................................................................................................................... 524,488

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) .................................................................................................................... $46,207,393
I. ICR Regarding Burden for Nomination new improvement activities to us via including an estimated 0.3 hours per
of Improvement Activities 414.1360) email. As shown in Table 80, based on practice for a practice administrator to
response to an informal call for new identify and submit an activity to us via
For the 2018 MIPS performance proposed improvement activities during email at a rate of $105.16/hour for a
period, we are also proposing to allow the transition year, we estimate that total of $31.55 per activity and clinician
clinicians, groups, and other relevant approximately 150 organizations review time of 0.2 hours at a rate of
stakeholders to nominate new (clinicians, groups or other relevant $202.08/hour for a total of $40.42 per
improvement activities using a stakeholders) will nominate new activity. We estimate that the total
nomination form provided on the improvement activities. We estimate it annual burden cost is $10,796 (150
Quality Payment Program Web site at will take an estimated 0.5 hours per $71.96).
qpp.cms.gov, and to send their proposed organization to submit an activity to us,
TABLE 80ESTIMATED BURDEN FOR NOMINATION OF IMPROVEMENT ACTIVITIES

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

Estimated Number of Hours Per Practice Administrator to Identify and Propose Activity (b) ............................................................ 0.30
Estimated Number 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
J. ICRs Regarding Burden for Cost K. ICR Regarding Partial QP Elections the predictive qualifying Alternative
( 414.1350) ( 414.1430) Payment Model participants analysis
made available on qpp.cms.gov on June
The cost performance category relies APM Entities may face a data 2, 2017, and prepared using claims for
on administrative claims data. The submission burden under MIPS related services between January 1, 2016
Medicare Parts A and B claims to Partial QP elections. Advanced APM through August 31, 2016, we assume
submission process is used to collect participants will be notified about their that approximately 17 APM Entities will
data on cost measures from MIPS QP or Partial QP status before the end face the data submission requirement in
eligible clinicians. MIPS eligible of the performance period. For the 2018 performance period.
clinicians are not asked to provide any Advanced APMs the burden of partial As shown in Table 81, we assume that
documentation by CD or hardcopy. QP election would be incurred by a 17 APM Entities will make the election
Therefore, under the cost performance representative of the participating APM to participate as a partial QP in MIPS.
category, we do not anticipate any new Entity. For the purposes of this burden We estimate it will take the APM Entity
estimate, we assume that all MIPS representative 15 minutes to make this
or additional submission requirements
eligible clinicians determined to be election. Using a computer systems
for MIPS eligible clinicians.
Partial QPs will participate in MIPS. analysts hourly labor cost, we estimate
Based on our analyses of a a total burden cost of just $375 (17
preliminary version of the file used for participant $22.03).
TABLE 81ESTIMATED BURDEN FOR PARTIAL QP ELECTION

Burden
estimate
Number of APM Entities Electing Partial QP Status on behalf of their Participants (a) ..................................................................... 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
L. ICRs Regarding Other Payer Advanced APMs in their QP threshold in CY 2018, and determinations would
Advanced APM Identification: Payer- score, we will need to determine if be applicable for the Quality Payment
Initiated Process ( 414.1440) certain payment arrangements with Program Year 3.
other payers meet the criteria to be As shown in Table 82, we estimate
Beginning in Quality Payment Other Payer Advanced APMs. To that 300 other payer arrangements will
Program Year 3, the All-Payer provide eligible clinicians with be submitted (50 Medicaid payers, 150
Combination Option will be an available advanced notice prior to the start of the MA Organizations, and 100 Multi-
pathway to QP status for eligible 2019 QP performance period, and to payers) for identification as Other Payer
clinicians participating sufficiently in allow other payers to be involved Advanced APMs. The estimated burden
Advanced APMs and Other Payer prospectively in the process, we have to apply is 10 hours per payment
Advanced APMs. The All-Payer outlined in section II.D.6.a. of this arrangement, for a total annual burden
Combination Option allows for eligible proposed rule a payer-initiated hours of 3,000 (300 100). We estimate
clinicians to achieve QP status through identification process for identifying a total cost per payer of $881.00 using
their participation in both Advanced payment arrangements that qualify as a computer system analysts rate of
APMs and Other Payer Advanced Other Payer Advanced APMs. This $88.10/hour (10 81.10). The total
APMs. In order to include an eligible payer-initiated identification process of annual burden cost for all other payers
clinicians participation in Other Payer Other Payer Advanced APMs will begin is $264,300 (300 $881.00).
TABLE 82BURDEN FOR PROSPECTIVE IDENTIFICATION OF OTHER PAYER ADVANCED APMS

Burden
estimate
Estimated Number of other payer payment arrangements (50 Medicaid, 150 MA 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 Identifying Other Payer Advanced APMs (e) = (a) * (d) ............................................ $264,300
M. ICRs Regarding Burden for Voluntary in MIPS but will also elect not to labor rate of $88.10. The total annual
Participants to Elect Opt Out of participate in public reporting. Table 83 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 83BURDEN FOR VOLUNTARY PARTICIPANTS TO ELECT OPT OUT OF PERFORMANCE DATA DISPLAY ON PHYSICIAN
COMPARE
Burden
estimate
Estimated Number 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
N. Summary of Annual Burden rule 42 because we anticipate greater burden based on proposals in this rule
Estimates respondent familiarity with the reflects several proposed policies,
Table 84 includes the total estimated measures and data submission methods including our proposal for significant
burden of recordkeeping and data in their second year of participation and hardship or other type of exception,
submission of the proposed rule because the number of QPs that are including a new significant hardship
9,391,175 hours with total labor cost of excluded from MIPS is expected to exception for small practices for the
$856,996,819. In order to understand continue to grow. Further, our estimated advancing care information performance
the burden implications of the proposals baseline burden estimates reflect the category. Our burden estimates also
in this rule, we have also estimated a recent availability of data sources to reflect the proposed reduction in the
baseline burden of continuing the more accurately reflect the number of length of the CAHPS survey; our
policies and information collections set the organizations exempt from the proposal to allow clinicians that
forth in the CY 2017 Quality Payment advancing care information performance practice primarily in the hospital to
Program final rule into the 2018 category. elect to use facility-based
performance period. This estimated We estimate that the proposed rule measurements, thereby eliminating the
baseline burden of 9,523,975 hours and will reduce burden by 132,620 hours need for additional quality data
a total labor cost of $869,369,094 is and $12,372,275 in labor costs relative submission processes; and our proposal
lower than the burden approved for to the estimated baseline of continued to allow MIPS eligible clinicians to form
information collection related to the CY transition year policies. The Quality virtual groups, which would create
2017 Quality Payment Program final Payment Program Year 2 reduction in efficiencies in data submission.
TABLE 84PROPOSED ANNUAL RECORDKEEPING AND SUBMISSION REQUIREMENTS
Respondents/ Hours per Total annual Total annual
Labor cost of submission
responses response burden hours burden cost
Registration for Virtual Groups ............................................................ 16 10.0 160 Varies (See Table 60) .... $13,313
Election of Facility-Based Measurement ............................................. 18,207 1.0 18,207 36.12 ............................... 657,637
QCDR and Registries self-nomination ................................................. 233 10.0 2,330 88.10 ............................... 205,273
CAHPS Survey Vendor Application ..................................................... 15 10.0 150 88.10 ............................... 13,215
(Quality Performance Category) Claims Submission Mechanism ....... 364,002 17.8 6,479,236 Varies (See Table 68) .... 595,645,593
(Quality Performance Category) Qualified Registry or QCDR Sub- 88,501 9.1 803,855 Varies (See Table 69) .... 75,318,776
mission Mechanisms.
(Quality Performance Category) EHR-Submission Mechanism .......... 61,070 10.0 610,700 Varies (See Table 70) .... 56,925,790
42 The burden estimate for the CY 2017 Quality

comparability for the burden estimate in this Quality Payment Program final rule has been
Payment Program final rule was 10,940,417 hours proposed rule, the burden estimate for the CY 2017 updated using 2016 wages.
for a total labor cost of $1,349,763,999. For
TABLE 84PROPOSED ANNUAL RECORDKEEPING AND SUBMISSION REQUIREMENTSContinued

Respondents/ Hours per Total annual Total annual
Labor cost of submission
responses response burden hours burden cost
(Quality Performance Category) CMS Web Interface Submission 298 74.0 22,052 88.10 ............................... 1,942,662
Mechanism.
(Quality Performance Category) Registration and Enrollment for 10 1.0 10 88.10 ............................... 881
CMS Web Interface.
(CAHPS for MIPS Survey) Beneficiary Participation ........................... 132,307 0.22 29,108 23.86 ............................... 694,612
(CAHPS for MIPS Survey) Group Registration ................................... 461 1.5 692 88.10 ............................... 60,921
414.1375 (Advancing Care Information) Performance Category 50,689 0.5 25,345 88.10 ............................... 2,232,850
Significant Hardships, including for small practices and decertifica-
tion of EHRs.
(Advancing Care Information Performance Category) Data Submis- 288,721 3.0 866,163 88.10 ............................... 76,308,960
sion.
(Improvement Activities Performance Category) Data Submission .... 524,488 1.00 524,488 88.10 ............................... 46,207,393
(Improvement Activities Performance Category) Call for Activities ..... 150 0.5 75 Varies (See Table 80) .... 10,796
(Partial Qualifying APM Participant (QP) Election) .............................. 17 0.3 4 88.10 ............................... 375
Other Payer Advanced APM Identification: Other Payer Initiated 300 10.0 3,000 88.10 ............................... 264,300
Process.
(Physician Compare) Opt Out for Voluntary Participants .................... 22,400 0.3 5,600 88.10 ............................... 493,472
Total .............................................................................................. 1,551,885 ........................ 9,391,175 ......................................... 856,996,819
O. Submission of PRA-Related Federal Register documents, we are not reflects this feedback and includes
Comments able to acknowledge or respond to them several proposals that extend transition
We have submitted a copy of this individually. We will consider all year policies finalized in the CY 2017
proposed rule to OMB for its review of comments we receive by the date and Quality Payment Program final rule
the rules information collection and time specified in the DATES section of with comment period; however, we also
recordkeeping requirements. These this preamble, and, when we proceed include policies to begin ramping up to
requirements are not effective until they with a subsequent document, we will full implementation, since the
have been approved by the OMB. respond to the comments in the performance threshold must be based on
To obtain copies of the supporting preamble to that document. the mean or median of prior year
statement and any related forms for the performance under statute starting in
V. Regulatory Impact Analysis the 2019 MIPS performance period
proposed collections discussed in this
section of the proposed rule, please visit A. Statement of Need (MIPS payment year 2021).
our Web site at www.cms.hhs.gov/ Additionally, we address elements of
This proposed rule is necessary to MACRA that were not included in the
PaperworkReductionActof1995, or call make statutorily required policy
the Reports Clearance Office at 410 first year of the program, including
changes and other policy updates to the virtual groups, facility-based
7861326. Merit-based Incentive Payment System
We invite public comments on these measurement, and improvement
(MIPS) established under MACRA as scoring. We also include proposals to
potential information collection
well as the policies related to the continue implementing elements of
requirements. If you wish to comment,
Advanced APM provisions of MACRA, MACRA that do not take effect in the
please submit your comments
which together are referred to as the first or second year of the Quality
electronically as specified in the
Quality Payment Program. As required Payment Program, including policies
ADDRESSES section of this proposed rule
by MACRA, MIPS consolidates several related to the All-Payer Combination
and identify the rule (CMS5522P), the
quality programs, including components Option for the APM incentive.
ICRs CFR citation, CMS ID number, and
OMB control number (09381222 for of the Medicare Electronic Health
Record Incentive Program, the Physician B. Overall Impact
CAHPS for MIPS and 09381314 for all
other ICRs). ICR-related comments are Quality Reporting System (PQRS), and We have examined the impact of this
due August 21, 2017. the Physician Value-Based Payment proposed rule as required by Executive
We have invited public comments on Modifier (VM) and Physician Feedback Order 12866 on Regulatory Planning
the virtual group election process under Program. The MACRA effectively ends and Review (September 30, 1993),
a separate Federal Register Notice (82 these programs after CY 2018 and Executive Order 13563 on Improving
FR 27257) published on June 14, 2017. authorizes MIPS operation beginning in Regulation and Regulatory Review
ICR-comments related to virtual group CY 2019. (February 2, 2013), the Regulatory
election are due on or before August 14, The Quality Payment Program is Flexibility Act (Pub. L. 96354 enacted
2017. Because of the statutory structured to improve care quality over September 19, 1980) (RFA), section
requirement for the virtual group time with input from clinicians, 1102(b) of the Act, section 202 of the
election process to take place prior to patients, and other stakeholders. We Unfunded Mandates Reform Act of 1995
the start of the 2018 MIPS performance have sought and continue to seek (Pub. L. 1404 enacted March 22, 1995),
feedback from the health care Executive Order 13132 on Federalism
period, we have an earlier deadline for

public comments on the virtual group community through various public (August 4, 1999), the Congressional
election process to allow for earlier avenues such as listening sessions, Review Act (5 U.S.C. 804(2)), and
approval date for that information request for information and rulemaking Executive Order 13771 on Reducing
collection. where we have received feedback that Regulation and Controlling Regulatory
many clinical practices are still working Costs (January 30, 2017).
IV. Response to Comments towards implementing the Quality Executive Orders 12866 and 13563
Because of the large number of public Payment Program. This proposed rule direct agencies to assess all costs and
comments we normally receive on for Quality Payment Program Year 2 benefits of available regulatory
alternatives and, if regulation is The SBA standard for a small business requirements for an IRFA. We note that
necessary, to select regulatory is $11 million in average receipts for an whether or not a particular MIPS
approaches that maximize net benefits office of clinicians and $7.5 million in eligible clinician or other eligible
(including potential economic, average annual receipts for an office of clinician is adversely affected would
environmental, public health and safety other health practitioners. (For details, depend in large part on the performance
effects, distributive impacts, and see the SBAs Web site at http:// of that MIPS eligible clinician or other
equity). A regulatory impact analysis www.sba.gov/content/table- eligible clinician, and that CMS will
(RIA) must be prepared for major rules smallbusiness-size-standards (refer to offer significant technical assistance to
with economically significant effects the 620000 series)). MIPS eligible clinicians and other
($100 million or more in any 1 year). We Approximately 95 percent of eligible clinicians in meeting the new
estimate, as discussed below in this practitioners, other providers, and standards.
section, that the Medicare Part B suppliers are considered to be small For the 2018 MIPS performance
provisions included in this proposed entities either by nonprofit status or by period, this proposed rule has several
rule will redistribute more than $173 having annual revenues that qualify for key proposals that will provide
million in budget neutral payments in small business status under the SBA regulatory relief for clinicians and
the second performance year. In standards. There are over 1 million practices and help increase ways for
addition, this proposed rule will physicians, other practitioners, and successful participation. These include
increase government outlays for the medical suppliers that receive Medicare implementing virtual groups, raising the
exceptional performance payment payment under the PFS. Because many low volume threshold, continuing to
adjustments under MIPS ($500 million), of the affected entities are small entities, allow the use of 2014 Edition CEHRT
and incentive payments to QPs the analysis and discussion provided in (Certified Electronic Health Record
(approximately $590$800 million). this Regulatory Impact Analysis section Technology), and adding a new
Overall, this rule will transfer more than as well as elsewhere in this proposed significant hardship exception for the
$1 billion in payment adjustments for rule is intended to comply with the advancing care information performance
MIPS eligible clinicians and incentive requirement for an Initial Regulatory category for MIPS eligible clinicians
payments to QPs. Therefore, we Flexibility Analysis (IRFA). who are in small practices, as
estimate that this rulemaking is As discussed below, approximately summarized in section I.D.4.c. of this
economically significant as measured 572,000 MIPS eligible clinicians will be proposed rule.
by the $100 million threshold, and required to submit data under MIPS. As In addition, section 1102(b) of the Act
hence also a major rule under the shown later in this analysis, however, requires us to prepare an RIA if a rule
Congressional Review Act. Accordingly, potential reductions in Medicare Part B may have a significant impact on the
we have prepared a RIA that, to the best payment for MIPS eligible clinicians operations of a substantial number of
of our ability, presents the costs and under the MIPS are a small percentage small hospitals located in rural areas.
benefits of the rulemaking. of their total Medicare Part B paid This analysis must conform to the
Executive Order 13771, titled charges5 percent in the 2020 payment provisions of section 603 of the RFA.
Reducing Regulation and Controlling yearthough rising to as high as 9 For purposes of section 1102(b) of the
Regulatory Costs, was issued on January percent in subsequent years. On Act, we define a small hospital located
30, 2017. As shown in the discussion of average, clinicians Medicare billings in a rural area as a hospital that is
Table 84 in the Collection of are only approximately 23 percent of located outside of a Metropolitan
Information section of this proposed their total revenue,43 so even those Statistical Area for Medicare payment
rule, we estimate that this proposed rule MIPS eligible clinicians that receive a regulations and has fewer than 100
would reduce the ICR burden by negative MIPS payment adjustment beds. We are not preparing an analysis
132,620 hours and would result in a under MIPS would rarely face losses in for section 1102(b) of the Act because
further reduction in burden costs of excess of 3 percent of their total we have determined, and the Secretary
$12.4 million in the Quality Payment revenues, the HHS standard for certifies, that this proposed rule would
Program Year 2 relative to Quality determining whether an economic effect not have a significant impact on the
Payment Program Year 1. As shown in is significant. (In order to determine operations of a substantial number of
the discussion of Regulatory Review whether a rule meets the RFA threshold small hospitals located in rural areas.
Costs in section V.E. of this proposed of significant impact, HHS has, for Section 202 of the Unfunded
rule, we estimate that total regulatory many years, used as a standard adverse Mandates Reform Act of 1995 (UMRA)
review costs associated with the Quality effects that exceed 3 percent of either also requires that agencies assess
Payment Program would be revenues or costs.) However, because anticipated costs and benefits on state,
approximately $4.8 million. there are so many affected MIPS eligible local, or tribal governments or on the
The Regulatory Flexibility Act (RFA) clinicians, even if only a small private sector before issuing any rule
requires agencies to prepare an Initial proportion is significantly adversely whose mandates require spending in
Regulatory Flexibility Analysis to affected, the number could be any 1 year of $100 million in 1995
describe and analyze the impact of the substantial. Therefore, we are unable dollars, updated annually for inflation.
final rule on small entities unless the to conclude that an Initial Regulatory In 2017, that threshold is approximately
Secretary can certify that the regulation Flexibility Analysis (IRFA) is not $148 million. This proposed rule would
will not have a significant impact on a required. Accordingly, the analysis and impose no mandates on state, local, or
substantial number of small entities. discussion provided in this section, as tribal governments or on the private
The RFA requires agencies to analyze well as elsewhere in this final rule with sector because participation in Medicare
options for regulatory relief of small comment period, together meet the is voluntary and because physicians and
entities. Note that Small Business other clinicians have multiple options
Administration (SBA) standards for 43 Based on National Health Expenditure Data, as to how they will participate under
small entities differ than the definition Physicians and Clinical Services Expenditures, MIPS and discretion over their
https://www.cms.gov/Research-Statistics-Data-and-
of a small practice under MIPS finalized Systems/Statistics-Trends-and-Reports/
performance. Moreover, HHS interprets
in the CY 2017 Quality Payment NationalHealthExpendData/NationalHealth UMRA as applying only to unfunded
Program final rule under 414.1305. AccountsProjected.html. mandates. We do not interpret Medicare
payment rules as being unfunded C. Changes in Medicare Payments Eligible clinicians who do not become
mandates, but simply as conditions for Section 101 of the MACRA, (1) QPs, but meet a slightly lower threshold
the receipt of payments from the federal repeals the Sustainable Growth Rate to become Partial QPs for the year, may
government for providing services that (SGR) formula for physician payment elect to report to MIPS and would then
meet federal standards. This updates in Medicare, and (2) requires be scored under MIPS and receive a
interpretation applies whether the that we establish MIPS for eligible MIPS payment adjustment, but do not
facilities or providers are private, state, clinicians under which the Secretary receive the APM Incentive Payment. For
local, or tribal. the 2018 Medicare QP Performance
must use a MIPS eligible clinicians
Period, we define Partial QPs to be
Executive Order 13132 establishes final score to determine and apply a
eligible clinicians in Advanced APMs
certain requirements that an agency MIPS payment adjustment factor to the
who have at least 20 percent, but less
must meet when it issues a proposed clinicians Medicare Part B payments for
than 25 percent, of their payments for
rule (and subsequent final rule) that a year.
Part B covered professional services
imposes substantial direct effects on The largest component of the MACRA
through an Advanced APM Entity, or
state and local governments, preempts costs is its replacement of scheduled
furnish Part B covered professional
state law, or otherwise has Federalism reductions in physician payments with
services to at least 10 percent, but less
implications. We have outlined in payment rates first frozen at 2015 levels
than 20 percent, of their Medicare
section II.D.6.(a) of this proposed rule a and then increasing at a rate of 0.5
beneficiaries through an Advanced APM
payer-initiated identification process for percent a year during CYs 2016 through
Entity. If the Partial QP elects to be
identifying which payment 2019. The estimates in this RIA take scored under MIPS, they would be
arrangements qualify as Other Payer those legislated rates as the baseline for subject to all MIPS requirements and
Advanced APMs. State Medicaid the estimates we make as to the costs, would receive a MIPS payment
programs may elect to participate in the benefits, and transfer effects of this adjustment. This adjustment may be
payer-initiated identification process. proposed regulation, with some positive or negative. If an eligible
We do not believe any of these policies proposed data submission provisions for clinician does not meet either the QP or
impose a substantial direct effect on the the 2018 MIPS performance period Partial QP standards, the eligible
Medicaid program as participation in taking effect in 2018 and 2019, and the clinician would be subject to MIPS,
the Payer Initiated Determination corresponding positive and negative would report to MIPS, and would
Process is voluntary and use of the payment adjustments taking effect in the receive the corresponding MIPS
Eligible Clinician Initiated 2020 MIPS payment year. payment adjustment.
Determination Process is also voluntary. As required by the MACRA, overall Beginning in 2026, payment rates for
payment rates for services for which services furnished by clinicians who
We have prepared the following payment is made under the PFS would
analysis, which together with the achieve QP status for a year would be
remain at the 2019 level through 2025, increased each year by 0.75 percent for
information provided in the rest of this but starting in 2019, the amounts paid
proposed rule, meets all assessment the year, while payment rates for
to individual MIPS eligible clinicians services furnished by clinicians who do
requirements. The analysis explains the and other eligible clinicians would be
rationale for and purposes of this not achieve QP status for the year would
subject to adjustment through one of be increased by 0.25 percent. In
proposed rule; details the costs and two mechanisms, depending on whether addition, MIPS eligible clinicians would
benefits of the rule; analyzes the clinician achieves the threshold for receive positive, neutral, or negative
alternatives; and presents the measures participation in Advanced APMs to be MIPS payment adjustments to their Part
we would use to minimize the burden considered a Qualifying APM B payments in a payment year based on
on small entities. As indicated Participant (QP) or Partial QP, or is performance during a prior performance
elsewhere in this proposed rule, we are instead evaluated under the MIPS. period. Although the MACRA
implementing a variety of changes to amendments established overall
our regulations, payments, or payment 1. Estimated Incentive Payments to QPs
in Advanced APMs payment rate and procedure parameters
policies to implement statutory until 2026 and beyond, this impact
provisions. We provide information for From 2019 through 2024, eligible analysis covers only the second
each of the policy changes in the clinicians receiving a sufficient portion payment year (2020) of the Quality
relevant sections of this proposed rule. of Medicare Part B payments for covered Payment Program in detail. After 2020,
We note that many of the MIPS policies professional services or seeing a while overall payment levels will be
from the CY 2017 Quality Payment sufficient number of Medicare patients partially bounded, we have also
Program final rule were only defined for through Advanced APMs as required to acknowledged in the preamble that the
the 2017 MIPS performance period and become QPs would receive a lump-sum Department will likely revise its quality
2019 MIPS payment year (including the APM Incentive Payment equal to 5 and other payment measures and overall
performance threshold, the performance percent of their estimated aggregate payment thresholds and other
category reweighting policies, and many payment amounts for Medicare covered parameters as clinicians behavior
scoring policies for the quality professional services in the preceding changes.
performance category) which precludes year, as discussed in section II.D. of this We estimate that between 180,000 and
us from developing a baseline for the proposed rule. 245,000 eligible clinicians will become
2018 MIPS performance period and The APM Incentive Payment is QPs, therefore be exempt from MIPS,
2020 MIPS payment year if there were separate from, and in addition to, the and qualify for lump sum incentive
no new regulatory action. We are payment for covered professional payment based on 5 percent of their Part
unaware of any relevant federal rules services furnished by an eligible B allowable charges for covered
that duplicate, overlap, or conflict with clinician during that year. Eligible professional services, which are
this proposed rule. The relevant clinicians who become QPs for a year estimated to be between approximately
sections of this proposed rule contain a would not need to report to MIPS and $11,820 million and $15,770 million in
description of significant alternatives if would not receive a MIPS payment the 2018 Quality Payment Program
applicable. adjustment to their Part B payments. performance year. We estimate that the
aggregate total of the APM incentive Advanced APMs would be QPs based model does not reflect the proposed
payment of 5 percent of Part B allowed on the preliminary version of this file. policies for scoring virtual groups.
charges for QPs would be between We estimated the number of newly
2. Estimated Numbers of Clinicians enrolled Medicare clinicians to be
approximately $590 and $800 million Eligible for MIPS
for the 2020 Quality Payment Program excluded from MIPS by assuming
payment year. These estimates reflect Certain clinicians may not be eligible clinicians (NPIs) are newly enrolled if
longstanding HHS policy not to attempt to participate or may be excluded from they have Part B charges in the
to predict the effects of future participation in MIPS for various eligibility file, but no Part B charges in
rulemaking in order to maximize future reasons. For example, the MACRA 2015. Because of data limitations, this
Secretarial discretion over whether, and requires us to limit eligibility for the newly enrolled modeling methodology
2019 and 2020 MIPS payment years to is different than the one that will be
if so how, payment or other rules would
specified clinician types. Additionally, used under the policies finalized under
be changed.
we exclude eligible clinicians with 414.1310 and 414.1315.
We project the number of eligible billings that do not exceed the low To exclude QPs from our scoring
clinicians that will be excluded from volume threshold as proposed in section model, we used a preliminary version of
MIPS as QPs using several sources of II.C.2.c. of this proposed rule: Those the file used for the predictive
information. First, the projections are with $90,000 or less in Part B allowed qualifying Alternative Payment Model
anchored in the most recently available charges or 200 or fewer Medicare Part B participants analysis made available on
public information on Advanced APMs. patients as measured at the TIN/NPI qpp.cms.gov on June 2, 2017, and
The projections reflect APMs that will level for individual reporting, the TIN prepared using claims for services
be operating in 2018. This proposed rule level for group reporting, the APM between January 1, 2016 through August
indicates which APMs would be Entity level for reporting under the APM 31, 2016 for the first Medicare QP
Advanced APMs under proposed scoring standard. We also exclude those Performance Period for 2017 that
policies, including the Next Generation who are newly enrolled to Medicare and included clinicians participating in
ACO Model, Comprehensive Primary those eligible clinicians who are QPs. Advanced APMs active as of mid-March
Care Plus (CPC+) Model, To estimate the number of clinicians 2017. We assumed that all partial QPs
Comprehensive ESRD Care (CEC) that are not in MIPS due to an ineligible would participate in MIPS and included
Model, Episode Payment Models (EPM), clinician type for CY 2018, our scoring them in our scoring model. Because of
Vermont All-Payer ACO Model,44 model used the first 2019 Payment Year the expected growth in Advanced APM
Comprehensive Care for Joint MIPS eligibility file as described in 81 participation, the estimated number of
Replacement Payment Model (CEHRT FR 77069 and 77070. The data file QPs excluded from our model based on
Track), Oncology Care Model (Two- included 1.5 million clinicians who had data from the 2017 Quality Payment
Sided Risk Arrangement), ACO Track 1+ Medicare Part B claims from September Program performance period (74,920) is
Model, the Shared Savings Program 1, 2015 to August 31, 2016 and included lower than the summary level projection
Tracks 2 and 3. We also project a 60-day claim run-out. We limited our for the 2018 Quality Payment Program
Advanced APM participation based on analysis to those clinicians identified as performance period based on the
applicant counts and estimated MIPS eligible clinician types for the expected growth in APM participation
acceptance rates to Advanced APMs 2020 MIPS payment year: Doctors of (180,000245,000). This expected
that had open application periods as of medicine, doctors of osteopathy, growth is due in part to reopening of
early 2017. We use a preliminary chiropractors, dentists, optometrists, CPC+ and Next Generation ACO for
version of the file used for the podiatrists, nurse practitioners, 2018, and the ACO Track 1+ which is
physician assistants, certified registered projected to have a large number of
predictive qualifying Alternative
nurse anesthetists, and clinical nurse participants, with a large majority
Payment Model participants analysis
specialists. reaching QP status. Hence, our model
made available on qpp.cms.gov on June We estimated the number of may overestimate the fraction of
2, 2017 and prepared using claims for clinicians excluded for low volume by clinicians and allowed Medicare Part B
services between January 1, 2016 comparing the allowed Medicare Part B charges that will remain subject to MIPS
through August 31, 2016, for the first charges in the first 2019 MIPS payment after the exclusions.
Medicare QP Performance Period for year eligibility file to the proposed low We have estimated the cumulative
2017. We examine the extent to which volume threshold. We used 2015 PQRS effects of these exclusions in Table 85.
Advanced APM participants would reporting data to determine whether We estimate that 65 percent of
meet the QP thresholds of having at clinicians have historically reported as clinicians $124,029 million in allowed
least 25 percent of their Part B covered a group and whether to make the low- Medicare Part B charges will be
professional services or at least 20 volume determination at the individual included in MIPS. Further, we estimate
percent of their Medicare beneficiaries (TIN/NPI) or group (TIN) level. We that approximately 37 percent of
furnished Part B covered professional assumed all Shared Savings Program or 1,548,022 Medicare clinicians billing to
services through the Advanced APM Pioneer ACO participants would exceed Part B will be included in MIPS.
Entity. The preliminary version of this the low volume threshold because the Table 85 also shows the number of
file followed the methodologies for ACOs have a requirement for a eligible clinicians remaining in the
group (APM Entity level) determination minimum number of assigned scoring model used for this regulatory
of QP status outlined in the CY 2017 beneficiaries. impact analysis (554,846) is lower than
Quality Payment Program final rule Because of the lack of available data the estimated number of eligible
with comment period. We also assumed on which eligible clinicians would elect clinicians remaining after exclusions
that during the first Medicare QP to participate as part of a virtual group (572,299). The discrepancy is due to our
Performance Period, the majority of under the policies proposed in section scoring model excluding clinicians that
eligible clinicians participating in II.C.4 of this proposed rule, the scoring submitted via measures groups under
44 Vermont ACOs will be participating in an version of the Next Generation ACO Model. The Vermont Medicare ACO Initiative will be an
Advanced APM during 2018 through a modified Advanced APM beginningin 2019.
the 2015 PQRS, since that data submission mechanism was eliminated
under MIPS.
TABLE 85PROJECTED NUMBER OF CLINICIANS INELIGIBLE FOR OR EXCLUDED FROM MIPS IN CY 2018, BY REASON *
Count of Medicare Count of
Part B allowed Part B allowed
clinicians Medicare
charges remaining charges
Reason for exclusion (TIN/NPIs) clinicians
after exclusion excluded
remaining after (TIN/NPIs)
($ in millions) ($ in millions)
exclusion excluded
All Medicare clinicians billing Part B ....................................... 1,548,022 $124,029 .............................. ..............................
Subset to clinician types that are eligible for 2020 MIPS pay-
ment year ** .......................................................................... 1,314,733 $101,733 233,289 $22,296
Exclude newly enrolled clinicians *** ....................................... 1,232,779 $101,243 81,954 $490
Additionally, exclude low volume clinicians **** ....................... 647,219 $87,147 585,560 $14,096
Additionally, exclude qualifying APM participants (QPs) ***** 572,299 $80,658 74,920 $6,489
Total remaining in MIPS after exclusion ................................. 572,299 $80,658 .............................. ..............................
Percent eligible clinicians remaining in MIPS after exclusions 37% 65% .............................. ..............................
Additional Exclusions for Scoring Model
Exclude clinicians who previously submitted measures

groups under 2015 PQRS ................................................... 554,846 $71,930 17,453 $8,728
Percent eligible clinicans remaining in scoring model after
exclusions ............................................................................. 36% 58% .............................. ..............................
* Allowed Medicare Part B charges for covered services of the clinician under Part B from September 1, 2015 to August 31, 2016 data. Pay-
ments estimated using 2015 or 2016 dollars.
** Section 1848(q)(1)(C) of the Act defines a MIPS eligible clinician for payment years 1 and 2 as a physician, physicians assistant, nurse
practitioner, or clinical nurse anesthetist, or a group that includes such clinicians.
*** Newly enrolled Medicare clinicians in our scoring model had positive Part B charges between September 1, 2015 and August 31, 2016 but
had no Part B charges for CY2015.
**** Low-volume clinicians have less than or equal to $90,000 in allowed Medicare Part B charges or less than or equal to 200 Medicare pa-
tients.
**** QPs have at least 25 percent of their Medicare Part B covered professional services or least 20 percent of their Medicare beneficiaries fur-
nished part B covered professional services through an Advanced APM.
3. Estimated Impacts on Payments to affected by MIPS payment adjustment measures submitted via the claims,
MIPS Eligible Clinicians factors. EHR, qualified registry, QCDR, and
To estimate the impact of MIPS on CMS-approved survey vendor
Our scoring model includes eligible clinicians required to report, we used submission mechanisms, we applied the
clinicians who will be required to the most recently available data, published benchmarks developed for
submit MIPS data to us in year 1.45 They including 2014 and 2015 PQRS data, the 2017 MIPS performance period. For
are eligible clinicians who (a) are not 2014 and 2015 CAHPS for PQRS data, quality measures submitted via Web
QPs participating in Advanced APMs, 2014 and 2015 VM data, 2015 and 2016 Interface, we applied the published
(b) exceeded the low volume threshold, Medicare and Medicaid EHR Incentive benchmarks developed for the 2017
and (c) enrolled as Medicare clinicians Program data, the data prepared to Shared Savings Program where
prior to the current performance year. support the 2017 performance period available, and did not calculate scores
Payment impacts in this proposed initial determination of clinician and for measures for which Shared Savings
special status eligibility (available via Program benchmarks did not exist. For
rule reflect averages by specialty and
the NPI lookup on qpp.cms.gov), the all-cause hospital readmission
practice size based on Medicare
preliminary version of the file used for measure we used the 2015 VM analytic
utilization. The payment impact for a
the predictive qualifying Alternative file, which was the most recent data
MIPS eligible clinician could vary from Payment Model participants analysis available, and calculated our own
the average and would depend on the made available on qpp.cms.gov on June benchmarks based on 2015 data since
mix of services that the MIPS eligible 2, 2017, and prepared using claims for published benchmarks were not yet
clinician furnishes. The average services between January 1, 2016 available. In order to estimate the
percentage change in total revenues through August 31, 2016 for the first impact of improvement for the quality
would be less than the impact displayed Medicare QP Performance Period for performance category, we estimated a
here because MIPS eligible clinicians 2017, the 2017 MIPS published measure quality performance category percent
generally furnish services to both benchmarks, and other available data to score using 2014 PQRS data, 2014
Medicare and non-Medicare patients. In model the scoring provisions described CAHPS for PQRS data, and 2014 VM
addition, MIPS eligible clinicians may in this regulation. First, we data. Because we lack detailed
receive substantial Medicare revenues arithmetically calculated a hypothetical information on which MIPS eligible
for services under other Medicare final score for each MIPS eligible clinicians would elect to submit as part
payment systems that would not be clinician based on quality, advancing of a virtual group and which MIPS
care information, and improvement eligible clinicians based primarily in
45 Due to data limitations, our scoring model
activities performance categories. inpatient hospital settings or in
excluded the 17.453 MIPS eligible clinicians who We estimated the quality performance emergency departments would elect
submitted quality via the measures groups
mechanism under the 2015 PQRS. The measures
category score using measures facility-based measurement, the
group submission mechanism is not available in submitted to PQRS for the 2015 proposed policies regarding virtual
MIPS. performance period. For quality groups and facility-based measurement
are not reflected in our scoring model. would translate into an advancing care all the MIPS quality submission criteria
Our model applied the MIPS APM information performance score of 85 (for example, submitting 6 measures
scoring standards proposed in section percent. Generally, we see that with data completeness, including one
II.C.6.g. of this proposed rule to quality clinicians have performance greater outcome or high priority measures) and
data from MIPS eligible clinicians that than the minimum requirements, which had an estimated advancing care
participated in the Shared Savings is the reason we estimated an advancing information performance category score
Program model in 2015. care information performance category of 100 percent (if advancing care
We propose in section II.C.6.d.(2) of score of 100 percent. information is applicable to them) are
this proposed rule, for the cost For those clinicians who did not attest assigned an improvement activities
performance category to have a zero in either the 2015 Medicare or Medicaid performance category score of 100
percent weight and to not contribute to EHR Incentive Program, we evaluated percent. MIPS eligible clinicians who
the 2020 MIPS payment year final score. whether the MIPS eligible clinician did not participate in 2015 PQRS or the
Therefore, we did not include cost could have their advancing care 2015 Medicare or Medicaid EHR
measures in this scoring model. information performance category score Incentive Program (if it was applicable),
For the advancing care information reweighted. The advancing care earned an improvement activity
performance category score, we used information performance category performance category score of zero
data from the 2015 Medicare and weight is set equal to zero percent, and percent, with the rationale that these
Medicaid EHR Incentive Programs. the weight is redistributed to quality for clinicians may be less likely to
Because the EHR Incentive Programs are non-patient facing clinicians, hospital- participate in MIPS if they have not
based on attestation at the NPI level, the based clinicians, ASC-based clinicians, previously participated in other
advancing care information performance NPs, PAs, CRNAs, or CNSs, or those programs.
category scores are assigned to who request and are approved for a
clinicians by their individual national For the remaining MIPS eligible
significant hardship or other type of
provider identifier (NPI), regardless of clinicians not assigned an improvement
exception, including a new significant
whether the clinician was part of a activities performance category score of
hardship exception for small practices,
group submission for PQRS. We 0 or 100 percent in our model, we
or clinicians who are granted an
assigned a score of 100 percent to MIPS assigned a score that corresponds to
exception based on decertified EHR
eligible clinicians who attested in the submitting one medium-weighted
technology. We used the non-patient
2015 Medicare EHR Incentive Program improvement activity. The MIPS eligible
facing and hospital-based indicators and
or received a 2015 incentive payment specialty and small practice indicators clinicians assigned an improvement
from the Medicaid EHR Incentive as calculated in the initial MIPS activity performance category score
Program (after excluding incentive eligibility run. Due to data limitations, corresponding to a medium-weighted
payments to adopt, implement, and we were not able to reweight the activity include (a) those who submitted
upgrade). While we had attestation advancing care information performance some quality measures under the 2015
information for the Medicare EHR category scores of ASC-based clinicians PQRS but did not meet the MIPS quality
Incentive Program, we did not have in our scoring model. For significant submission criteria or (b) those who did
detailed attestation information for the hardship exceptions, we used the 2016 not submit any quality data under the
Medicaid EHR Incentive Program. final approved significant hardship file. 2015 PQRS who attested under the
Therefore, we used incentive payments If a MIPS eligible clinician did not attest Medicare EHR Incentive program or
(excluding the adopt implement and and did not qualify for a reweighting of received an incentive payment
upgrade incentive payments) as a proxy their advancing care information (excluding adopt implement and
for attestation in the Medicaid EHR performance category, the advancing upgrade payments) from the Medicaid
Incentive Program. Our rationale for care information performance category EHR Incentive Program. We assumed
selecting a 100 percent performance score was set equal to zero percent. that these clinicians may be likely to
score is that the requirements to achieve We modeled the improvement partially, but not fully participate, in the
a base score of 50 percent in MIPS are activities performance category score improvement activities category. For
lower than the EHR Incentive Program based on 2015 APM participation and non-patient facing clinicians, clinicians
requirements to attest for meaningful historic participation in 2015 PQRS and in a small practice (consisting of 15 or
use (which determined whether 2015 Medicare and Medicaid EHR fewer professionals), clinicians in
program requirements were met on an Incentive Programs. Our model practices located in a rural area,
all or nothing basis). We anticipate identified the 2015 Shared Savings clinicians in a geographic healthcare
clinicians who met EHR Incentive Program participants and assigned them professional shortage area (HPSA)
Program requirements for meaningful an improvement activity score of 100 practice or any combination thereof, the
use will be able to achieve an advancing percent, consistent with our policy to medium weighted improvement activity
care information performance category assign a 100 percent improvement was assigned one-half of the total
score of 100 percent. Because the activities performance category score to possible improvement activities
minimum requirements for meaningful Shared Savings Program participants in performance category score (20 out of a
use did not allow partial scoring, we Quality Payment Program Payment Year 40 possible points or 50 percent) The
believe the clinicians who met the 2019. Due to limitations in 2015 data, remaining MIPS eligible clinicians not
minimum requirements would be able our model did not include 2015 assigned an improvement activities
to achieve an advancing care participants in APMs other than the performance category score of 0, 50, or
information performance category score Shared Savings Program. 100 points were assigned a score
of 100 percent. For example, the Clinicians and groups not corresponding to one medium-weighted
minimum requirements to attest to participating in a MIPS APM were activity (10 out of 40 possible points or
Modified Stage 2 objectives and assigned an improvement activities 25 percent). Due to lack of available
measures for the 2017 Medicare EHR score based on their performance in the data, we were not able to identify MIPS
Incentive Program (assuming no quality and advancing care information eligible clinicians in patient-centered
measure exceptions and an performance categories. MIPS eligible medical homes or comparable specialty
immunization registry is available) clinicians whose 2015 PQRS data meets societies in our scoring model. The
policy finalized under 414.1380(b)(3) With the extensive changes to policy assumptions to the improvement
indicates that MIPS eligible clinicians in and the flexibility that is allowed under activities performance category.
a patient centered medical home or a MIPS, estimating impacts of this To simulate the impact of the
comparable specialty societies would proposed rule using only historic 2015 standard model assumption, we
qualify for improvement activities participation assumptions would randomly select a subset of non-
performance category score of 100 significantly overestimate the impact on participants and substitute the quality
percent. clinicians, particularly on clinicians in and improvement activity scores of
Our model assigns a final score for practices with 115 clinicians, which randomly selected participants. For
each TIN/NPI by multiplying each have traditionally had lower example, for a previously non-
performance category score by the participation rates. To assess the participating clinician, we substitute the
corresponding performance category sensitivity of the impact to the scores of a randomly selected MIPS
weight, adding the products together, participation rate, we have prepared two eligible clinician with a quality score of
and multiplying the sum by 100 points. sets of analyses. 73 percent. The improvement activities
For MIPS eligible clinicians that had performance category score is then
The first analysis, which we label as computed using this alternative quality
their advancing care information standard participation assumptions,
performance category score reweighted score. We did not apply the same
relies on the assumption that a participation assumptions to the
due to a significant hardship exception minimum 90 percent of MIPS eligible
or automatic reweighting, the weight for advancing care information performance
clinicians will participate in submitting category because the category applies
the advancing care information quality performance category data to
performance category was assigned to only to a subset of MIPS eligible
MIPS, regardless of practice size. clinicians, and, as noted above, would
the quality performance category. Therefore, we assumed that, on average,
The scoring model reflects the be weighted at zero percent for non-
the categories of practices with 115 patient facing clinicians, hospital-based
proposed bonuses for complex patients clinicians would have 90 percent
and small practices in sections clinicians, ASC-based clinicians, NPs,
participation in the quality performance PAs, CRNAs, or CNSs, and those who
II.C.7.b.(1)(b) and II.C.7.b.(1)(c) of this category. This assumption is an increase request and are approved for a
proposed rule. Consistent with the from existing historical data. PQRS significant hardship or other type of
proposal to define complex patients as participation rates have increased exception, including those in small
those with high medical risk, our steadily since the program began; the practices. Further, we took into account
scoring model adds the average 2015 PQRS Experience Report showed that advancing care information
Hierarchical Condition Category (HCC)
an increase in the participation rate performance category participation may
score across all the MIPS eligible
from 15 percent in 2007 to 69 percent be affected by the cost and time it may
clinicians patients (with a cap of three
in 2015.46 In 2015, among those eligible take to acquire and implement certified
points) to the final score. We used the
for MIPS, 88.7 percent participated in EHR technology needed to perform in
average HCC risk score calculated for
the PQRS. In 2015, MIPS eligible that performance category.
each NPI in the 2015 Physician and The second analysis, which we label
practices of less than 115 clinicians
Other Supplier Public Use File. We also as alternative participation
participated in the PQRS at a rate of
generated a group average HCC risk assumptions, assumes a minimum
69.7 percent. Because practices of 1624
score by weighing the scores for participation rate in the quality and
have a 91.7 percent participation rate
individual clinicians in each group by improvement activities performance
the number of beneficiaries they have based on historical data, and 2599
clinicians have a 96.2 percent categories of 80 percent. Because the
seen. Our scoring model also adds 5 2015 PQRS participation rates for
points to the final score for small participation rate and practices of 100+
clinicians have a 99.4 percent practices of more than 15 clinicians are
practices that had a final score greater greater than 80 percent, this analysis
than 0 points. After adding any participation rate, we assumed the
average participation rates of those assumes increased participation for
applicable bonus for complex patients practices of 115 clinicians only.
and small practices, we set any final categories of clinicians would be the
same as under the 2015 PQRS. Our Practices of more than 15 clinicians are
scores that exceeded 100 points to 100. included in the model at their historic
assumption of 90 percent average
We then implemented an exchange participation rates.
participation for the categories of
function based on the provisions of this Table 86 summarizes the impact on
practices with 115 clinicians reflects
proposed rule to estimate the positive or Part B services of MIPS eligible
our belief that small and solo practices
negative MIPS payment adjustment clinicians by specialty for the standard
will respond to the finalized policies
based on the estimated final score and participation assumptions.
and this proposed rules flexibility,
the estimated Medicare Part B paid Table 87 summarizes the impact on
reduced data submission burden,
charges. Due to data limitations, we Part B services of MIPS eligible
financial incentives, and the support
assumed that the paid amount was 80 clinicians by specialty under the
they will receive through technical
percent of Medicare Part B allowed alternative participation assumptions.
assistance by participating at a rate close
charges. We iteratively modified the Tables 89 and 90 summarize the
to that of other practice sizes, enhancing
parameters of the exchange function impact on Part B services of MIPS
the existing upward trend in quality
distributions of MIPS payment eligible clinicians by practice size for
data submission rates. Therefore, we
adjustments that meet statutory the standard participation assumptions
assume that the quality scores assigned

requirements related to the linear (Table 88) and the alternative
to new participants reflect the
sliding scale, budget neutrality and participation assumptions (Table 89).
distribution of MIPS quality scores. We
aggregate exceptional performance Tables 87 and 89 show that under our
also applied behavioral participation
payment adjustment amounts (as standard participation assumptions, the
finalized under 414.1405). Our model 46 2015 PQRS Experience Report, available at
vast majority (96.1 percent) of MIPS
used a 15-point performance threshold https://www.cms.gov/Medicare/Quality-Initiatives-
eligible clinicians are anticipated to
and a 70-point additional performance Patient-Assessment-Instruments/PQRS/Downloads/ receive positive or neutral payment
threshold. 2015_PQRS_Experience_Report.pdf. adjustments for the 2020 MIPS payment
year, with only 3.9 percent receiving clinicians are expected to receive of MIPS eligible clinicians for the
negative MIPS payment adjustments. positive or neutral payment Quality Payment Program Performance
Using the alternative participation adjustments. Year 2, which continues the ramp to
assumptions, Tables 88 and 90 show The projected distribution of funds more robust participation in future
that 94.3 percent of MIPS eligible reflects this proposed rules emphasis MIPS performance years.
on increasing more complete reporting
TABLE 86MIPS ESTIMATED PAYMENT YEAR 2020 IMPACT ON ESTIMATED PAID AMOUNT BY SPECIALTY, STANDARD
PARTICIPATION ASSUMPTIONS *
Combined
impact of
negative
Percent Percent and positive
Percent Percent Aggregate
Estimated paid eligible eligible adjustments
eligible eligible Aggregate impact
Number of amount (mil) clinicians clinicians and
clinicians clinicians impact positive negative
Provider type, specialty MIPS eligible (80% of with positive with exceptional
engaging with negative adjustment payment
clinicians allowed or neutral exceptional performance
with quality payment (mil) ** adjustment
charges) ** payment payment ad- payment as
reporting adjustment (mil) **
adjustment justment percent of
estimated
paid amount
(%)
Overall ............................................... 554,846 $57,544 96.6 96.1 76.8 3.9 673.3 173.3 0.9
Addiction Medicine ............................ 71 3 95.8 95.8 82.4 4.2 0.0 0.0 0.2
Allergy/Immunology ........................... 1,692 162 94.9 94.9 80.0 5.1 1.8 0.8 0.6
Anesthesiology .................................. 14,105 789 97.8 95.7 74.5 4.3 7.8 3.0 0.6
Anesthesiology Assistant .................. 588 7 100.0 99.8 88.4 0.2 0.1 0.0 1.7
Cardiac Electrophysiology ................. 1,970 341 97.5 98.4 81.5 1.6 4.7 0.4 1.3
Cardiac Surgery ................................ 1,181 182 98.6 98.3 85.2 1.7 2.7 0.2 1.4
Cardiovascular Disease (Cardiology) 20,025 3,600 96.5 96.8 80.9 3.2 47.2 8.5 1.1
Certified Clinical Nurse Specialist ..... 896 22 97.0 96.4 86.2 3.6 0.3 0.2 0.4
Certified Registered Nurse Anes-
thetist (CRNA) ............................... 16,600 259 99.3 98.0 84.7 2.0 3.1 0.7 0.9
Chiropractic ....................................... 581 31 92.9 92.6 52.4 7.4 0.2 0.2 0.1
Clinic or Group Practice .................... 393 51 97.7 97.2 96.9 2.8 0.9 0.4 1.0
Colorectal Surgery (Proctology) ........ 1,046 97 95.7 96.2 75.6 3.8 1.2 0.3 0.9
Critical Care (Intensivists) ................. 2,730 201 97.0 96.6 82.9 3.4 2.5 0.7 0.9
Dermatology ...................................... 9,506 2,510 91.8 91.8 69.6 8.2 27.2 10.7 0.7
Diagnostic Radiology ........................ 27,990 3,317 97.0 95.7 58.8 4.3 26.3 6.8 0.6
Emergency Medicine ......................... 31,503 1,728 99.1 97.4 56.2 2.6 12.8 2.2 0.6
Endocrinology .................................... 4,376 336 97.3 97.2 80.1 2.8 4.3 1.0 1.0
Family Medicine *** ........................... 54,171 3,667 97.0 96.9 80.7 3.1 48.1 11.1 1.0
Gastroenterology ............................... 10,910 1,204 96.0 96.5 79.2 3.5 15.6 2.8 1.1
General Practice ............................... 2,210 214 91.3 90.7 74.7 9.3 1.9 1.7 0.1
General Surgery ................................ 14,135 1,143 96.6 96.6 79.4 3.4 13.9 3.5 0.9
Geriatric Medicine ............................. 1,394 121 96.4 95.9 77.0 4.1 1.4 0.5 0.8
Geriatric Psychiatry ........................... 119 9 91.6 89.9 76.6 10.1 0.1 0.1 0.7
Gynecological Oncology ................... 807 80 98.4 98.3 79.4 1.7 1.0 0.1 1.0
Hand Surgery .................................... 1,037 131 92.8 92.3 67.8 7.7 1.3 0.5 0.6
Hematology ....................................... 648 109 98.6 98.9 83.5 1.1 1.5 0.0 1.4
Hematology-Oncology ....................... 6,463 2,929 97.5 97.2 77.3 2.8 32.4 4.5 1.0
Hospice and Palliative Care .............. 645 23 99.5 99.1 88.1 0.9 0.3 0.0 1.3
Infectious Disease ............................. 4,571 497 94.2 94.1 78.9 5.9 5.6 2.7 0.6
Internal Medicine ............................... 72,692 6,917 95.9 95.3 80.0 4.7 86.1 24.7 0.9
Interventional Cardiology .................. 2,716 491 97.5 98.5 83.8 1.5 7.1 0.4 1.3
Interventional Pain Management ...... 1,255 333 90.0 89.0 62.8 11.0 3.2 1.9 0.4
Interventional Radiology .................... 1,181 232 97.0 96.1 67.9 3.9 1.8 0.5 0.6
Maxillofacial Surgery ......................... 194 5 99.0 99.0 85.4 1.0 0.1 0.0 1.0
Medical Oncology .............................. 2,530 870 98.5 98.4 78.2 1.6 9.3 0.8 1.0
Nephrology ........................................ 5,707 1,073 95.1 95.2 78.2 4.8 12.9 3.0 0.9
Neurology .......................................... 11,588 1,141 95.3 95.7 77.8 4.3 12.9 5.4 0.7
Neuropsychiatry ................................ 67 6 91.0 91.0 72.1 9.0 0.0 0.1 0.2
Neurosurgery ..................................... 3,850 505 95.3 95.2 72.9 4.8 5.5 1.8 0.7
Nuclear Medicine .............................. 466 66 97.0 97.2 81.2 2.8 0.7 0.3 0.7
Nurse Practitioner ............................. 50,649 1,313 98.0 97.8 87.3 2.2 16.7 7.0 0.7
Obstetrics & Gynecology .................. 15,587 237 99.0 99.1 88.3 0.9 3.0 0.6 1.0
Ophthalmology .................................. 14,779 6,451 96.8 96.6 73.6 3.4 99.0 5.9 1.4
Optometry .......................................... 4,621 439 94.5 94.3 69.2 5.7 5.0 1.5 0.8
Oral Surgery (Dentist only) ............... 282 7 97.5 97.9 89.1 2.1 0.1 0.1 0.4
Orthopedic Surgery ........................... 17,504 2,586 93.4 93.3 66.8 6.7 25.2 9.9 0.6
Osteopathic Manipulative Medicine .. 297 22 96.0 94.9 79.1 5.1 0.2 0.1 0.7
Otolaryngology .................................. 6,854 777 93.7 92.5 68.5 7.5 7.5 3.6 0.5
Pain Management ............................. 1,475 291 88.1 86.6 63.4 13.4 2.6 2.0 0.2
Pathology .......................................... 7,924 770 96.6 95.5 65.0 4.5 6.1 4.2 0.2
Pediatric Medicine ............................. 4,007 43 99.6 99.6 90.2 0.4 0.5 0.1 1.1
Peripheral Vascular Disease ............. 57 7 98.2 96.5 90.9 3.5 0.1 0.0 1.0
Physical Medicine and Rehabilitation 5,237 734 91.3 90.5 68.4 9.5 6.4 5.0 0.2
Physician Assistant ........................... 38,378 875 98.7 98.4 84.1 1.6 11.2 3.0 0.9
Physician, Sleep Medicine ................ 256 18 96.5 97.7 80.8 2.3 0.2 0.0 0.9
Plastic and Reconstructive Surgery .. 1,986 170 94.7 94.7 77.5 5.3 1.8 1.0 0.4
Podiatry ............................................. 9,558 1,231 87.3 87.0 59.2 13.0 10.0 9.1 0.1
Preventive Medicine .......................... 221 11 98.2 97.7 83.8 2.3 0.1 0.0 0.8
Psychiatry .......................................... 10,590 487 93.9 93.7 75.2 6.3 4.2 4.8 0.1
Pulmonary Disease ........................... 8,756 1,111 96.2 96.2 80.0 3.8 13.8 3.4 0.9
Radiation Oncology ........................... 3,049 810 97.9 97.3 80.8 2.7 9.0 1.6 0.9
Rheumatology ................................... 3,340 1,126 97.2 97.2 80.5 2.8 15.0 2.0 1.2
Sports Medicine ................................ 792 61 97.0 96.8 78.7 3.2 0.7 0.1 0.9
Surgical Oncology ............................. 713 52 98.6 98.9 82.7 1.1 0.7 0.1 1.2
Thoracic Surgery ............................... 1,738 203 97.8 98.1 82.9 1.9 2.8 0.3 1.2
Other ................................................. 272 34 94.9 95.6 84.6 4.4 0.4 0.1 0.9
Urology .............................................. 8,590 1,596 95.4 96.1 72.4 3.9 17.9 3.4 0.9
Vascular Surgery ............................... 2,725 683 95.8 96.0 73.9 4.0 7.5 2.1 0.8
Notes:
* Standard scoring model assumes that a minimum of 90 percent of clinicians within each practice size category would participate in quality data submission.
** 2014, 2015 and 2016 data used to estimate 2018 payment adjustments. Payments estimated using 2015 and 2016 dollars.
*** Specialty descriptions as self-reported on Part B claims. Note that all categories are mutually exclusive, including General Practice and Family Practice. Family Medicine is used here for
physicians listed as Family Practice in Part B claims.
TABLE 87MIPS ESTIMATED PAYMENT YEAR 2020 IMPACT ON ESTIMATED PAID AMOUNT BY SPECIALTY, ALTERNATIVE
Combined
impact of
negative
Percent Percent Percent and positive
Percent
Estimated paid eligible eligible eligible Aggregate adjustments
eligible Aggregate
Number of amount (mil) clinicians clinicians clinicians impact nega- and
clinicians impact positive
Clinician specialty/type MIPS eligible (80% of with positive with with tive payment exceptional
engaging with adjustment
clinicians allowed or neutral exceptional negative adjustment performance
quality (mil) **
charges) ** payment payment payment (mil) ** payment as
reporting adjustment adjustment adjustment percent of
estimated
paid amount
(%)
Overall ............................................... 554,846 $57,544 94.5 94.3 77.1 5.7 782.9 282.9 0.9
Addiction Medicine ............................ 71 3 94.4 94.4 83.6 5.6 0.0 0.0 0.2
Allergy/Immunology ........................... 1,692 162 89.4 90.0 80.5 10.0 2.0 1.5 0.3
Anesthesiology .................................. 14,105 789 96.8 94.8 74.5 5.2 9.0 4.5 0.6
Anesthesiology Assistant .................. 588 7 100.0 99.8 88.4 0.2 0.1 0.0 2.0
Cardiac Electrophysiology ................. 1,970 341 96.9 98.0 81.6 2.0 5.6 0.5 1.5
Cardiac Surgery ................................ 1,181 182 97.5 97.3 85.6 2.7 3.2 0.4 1.6
Cardiovascular Disease (Cardiology) 20,025 3,600 94.1 94.9 81.2 5.1 54.8 15.4 1.1
Certified Clinical Nurse Specialist ..... 896 22 96.0 95.4 86.3 4.6 0.3 0.2 0.3
Certified Registered Nurse Anes-
thetist (CRNA) ............................... 16,600 259 98.9 97.6 84.8 2.4 3.6 1.1 1.0
Chiropractic ....................................... 581 31 85.0 86.1 51.2 13.9 0.1 0.4 0.8
Clinic or Group Practice .................... 393 51 97.2 96.7 96.8 3.3 1.0 0.4 1.2
Colorectal Surgery (Proctology) ........ 1,046 97 92.9 94.3 75.4 5.7 1.4 0.4 0.9
Critical Care (Intensivists) ................. 2,730 201 95.9 95.7 83.2 4.3 3.0 0.9 1.0
Dermatology ...................................... 9,506 2,510 85.3 85.9 69.9 14.1 31.0 17.9 0.5
Diagnostic Radiology ........................ 27,990 3,317 96.2 94.9 58.8 5.1 32.0 9.3 0.7
Emergency Medicine ......................... 31,503 1,728 98.8 97.2 56.2 2.8 15.6 2.9 0.7
Endocrinology .................................... 4,376 336 94.8 95.1 80.6 4.9 5.0 1.9 0.9
Family Medicine *** ........................... 54,171 3,667 95.2 95.3 80.9 4.7 55.7 18.3 1.0
Gastroenterology ............................... 10,910 1,204 93.5 94.4 79.5 5.6 18.2 4.8 1.1
General Practice ............................... 2,210 214 83.6 83.9 75.9 16.1 1.8 3.4 0.7
General Surgery ................................ 14,135 1,143 94.3 94.4 79.7 5.6 16.1 5.9 0.9
Geriatric Medicine ............................. 1,394 121 94.3 94.0 77.3 6.0 1.6 0.8 0.7
Geriatric Psychiatry ........................... 119 9 87.4 86.6 76.7 13.4 0.1 0.1 0.8
Gynecological Oncology ................... 807 80 98.0 97.9 79.5 2.1 1.2 0.2 1.3
Hand Surgery .................................... 1,037 131 89.9 90.0 67.7 10.0 1.5 0.7 0.7
Hematology ....................................... 648 109 98.0 98.3 83.7 1.7 1.8 0.2 1.5
Hematology-Oncology ....................... 6,463 2,929 96.3 96.3 77.3 3.7 38.6 6.0 1.1
Hospice and Palliative Care .............. 645 23 99.4 98.9 88.1 1.1 0.4 0.0 1.6
Infectious Disease ............................. 4,571 497 89.8 90.1 79.3 9.9 6.2 4.9 0.3
Internal Medicine ............................... 72,692 6,917 93.5 93.1 80.3 6.9 99.0 40.6 0.8
Interventional Cardiology .................. 2,716 491 97.0 98.2 83.8 1.8 8.4 0.6 1.6
Interventional Pain Management ...... 1,255 333 83.3 83.2 61.9 16.8 3.6 3.1 0.1
Interventional Radiology .................... 1,181 232 95.9 94.9 68.2 5.1 2.3 0.8 0.6
Maxillofacial Surgery ......................... 194 5 98.5 98.5 85.9 1.5 0.1 0.0 1.1
Medical Oncology .............................. 2,530 870 98.0 97.8 78.3 2.2 11.2 1.1 1.2
Nephrology ........................................ 5,707 1,073 91.7 92.3 78.5 7.7 14.9 5.6 0.9
Neurology .......................................... 11,588 1,141 92.1 92.9 78.0 7.1 14.5 9.0 0.5
Neuropsychiatry ................................ 67 6 91.0 91.0 72.1 9.0 0.1 0.1 0.0
Neurosurgery ..................................... 3,850 505 92.7 92.8 73.2 7.2 6.4 2.8 0.7
Nuclear Medicine .............................. 466 66 94.0 94.4 81.6 5.6 0.8 0.5 0.5
Nurse Practitioner ............................. 50,649 1,313 97.2 97.1 87.5 2.9 19.3 9.8 0.7
Obstetrics & Gynecology .................. 15,587 237 98.6 98.8 88.4 1.2 3.6 1.0 1.1
Ophthalmology .................................. 14,779 6,451 94.0 94.0 73.9 6.0 117.0 11.1 1.6
Optometry .......................................... 4,621 439 90.8 91.0 69.6 9.0 5.8 2.6 0.7
Oral Surgery (Dentist only) ............... 282 7 96.5 96.8 89.4 3.2 0.1 0.1 0.8
Orthopedic Surgery ........................... 17,504 2,586 90.1 90.4 66.7 9.6 29.3 15.2 0.5
Osteopathic Manipulative Medicine .. 297 22 93.9 93.6 79.1 6.4 0.3 0.1 0.7
Otolaryngology .................................. 6,854 777 88.8 88.3 68.5 11.7 8.4 6.3 0.3
Pain Management ............................. 1,475 291 82.2 81.6 62.9 18.4 2.8 3.2 0.1
Pathology .......................................... 7,924 770 95.1 94.0 65.2 6.0 7.1 5.4 0.2
Pediatric Medicine ............................. 4,007 43 99.5 99.5 90.2 0.5 0.6 0.1 1.2
Peripheral Vascular Disease ............. 57 7 94.7 94.7 90.7 5.3 0.1 0.0 0.9
Physical Medicine and Rehabilitation 5,237 734 86.0 85.7 68.5 14.3 7.0 8.0 0.1
Physician Assistant ........................... 38,378 875 98.2 97.9 84.2 2.1 13.2 4.3 1.0
Physician, Sleep Medicine ................ 256 18 95.7 96.9 81.0 3.1 0.3 0.1 1.1
Plastic and Reconstructive Surgery .. 1,986 170 90.9 91.5 77.6 8.5 1.9 1.6 0.2
Podiatry ............................................. 9,558 1,231 76.1 77.0 58.4 23.0 10.1 16.9 0.5
Preventive Medicine .......................... 221 11 95.9 95.5 84.8 4.5 0.1 0.1 0.6
Psychiatry .......................................... 10,590 487 90.1 90.3 75.8 9.7 4.3 7.9 0.7
Pulmonary Disease ........................... 8,756 1,111 93.4 93.8 80.3 6.2 15.9 5.9 0.9
Radiation Oncology ........................... 3,049 810 96.9 96.4 80.9 3.6 10.8 2.2 1.1
Rheumatology ................................... 3,340 1,126 95.0 95.5 80.5 4.5 17.6 3.5 1.3
Sports Medicine ................................ 792 61 96.5 96.3 78.9 3.7 0.8 0.2 1.1
Surgical Oncology ............................. 713 52 98.2 98.5 82.6 1.5 0.8 0.1 1.4
Thoracic Surgery ............................... 1,738 203 96.4 97.0 83.0 3.0 3.3 0.6 1.3
Other ................................................. 272 34 93.8 94.5 84.4 5.5 0.5 0.2 1.0
Urology .............................................. 8,590 1,596 92.9 93.9 72.5 6.1 21.2 5.7 1.0
Vascular Surgery ............................... 2,725 683 93.1 93.8 73.8 6.2 8.6 3.6 0.7
* Alternative scoring model assumes that a minimum of 80 percent of clinicians within each practice size category would participate in quality data submission.
*** Specialty descriptions as self-reported on Part B claims. Note that all categories are mutually exclusive, including General Practice and Family Practice. Family Medicine is used here for
physicians listed as Family Practice in Part B claims.
TABLE 88MIPS ESTIMATED PAYMENT YEAR 2020 IMPACT ON TOTAL ESTIMATED PAID AMOUNT BY PRACTICE SIZE,
STANDARD PARTICIPATION ASSUMPTIONS *
Combined
impact of
negative and
Percent Percent positive
Percent Percent
Estimated paid eligible eligible Aggregate adjustments
eligible eligible Aggregate
Number of amount (mil) clinicians clinicians impact nega- and
clinicians clinicians impact positive
Practice size MIPS eligible (80% of al- with positive with tive payment exceptional
engaging with with negative adjustment
clinicians lowed or neutral exceptional adjustment performance
quality payment (mil) **
charges) ** payment payment ad- (mil) ** payment as
reporting adjustment
adjustment justment percent of
estimated
paid amount
(%)
All practice sizes ............................... 554,846 $57,544 96.6 96.1 76.8 3.9 673.3 173.3 0.9
115 clinicians ................................... 114,424 26,091 90.0 90.0 64.2 10.0 288.2 115.1 0.7
1624 clinicians ................................. 22,296 3,840 91.7 89.1 52.7 10.9 32.7 17.9 0.4
2599 clinicians ................................. 99,285 9,814 96.2 94.9 63.7 5.1 94.3 29.9 0.7
100 or more clinicians ....................... 318,841 17,799 99.4 99.2 86.4 0.8 258.1 10.4 1.4
Practice size is the total number of TIN/NPIs in a TIN.
* Standard scoring model assumes that a minimum of 90 percent of clinicians within each practice size category would participate in quality data submission.
TABLE 89MIPS ESTIMATED PAYMENT YEAR 2020 IMPACT ON ESTIMATED PAID AMOUNT BY PRACTICE SIZE, ALTERNATE
Combined
impact of
negative and
Percent Percent positive
Percent Percent
Estimated paid eligible eligible Aggregate adjustments
eligible eligible Aggregate
Number of amount (mil) clinicians clinicians impact nega- and
clinicians clinicians impact positive
Practice size MIPS eligible (80% of with positive with tive payment exceptional
engaging with with negative adjustment
clinicians allowed or neutral exceptional adjustment performance
quality payment (mil) **
charges) payment payment (mil) ** payment as
reporting adjustment
adjustment adjustment percent of
estimated
paid amount
(%)
All practice sizes ............................... 554,846 $57,544 94.5 94.3 77.1 5.7 782.9 282.9 0.9
115 clinicians ................................... 114,424 26,091 80.0 81.2 64.1 18.8 317.4 224.7 0.4
1624 clinicians ................................. 22,296 3,840 91.7 89.1 52.7 10.9 40.3 17.9 0.6
2599 clinicians ................................. 99,285 9,814 96.2 94.9 63.7 5.1 115.2 29.9 0.9
100 or more clinicians ....................... 318,841 17,799 99.4 99.2 86.4 0.8 310.0 10.4 1.7
Practice size is the total number of TIN/NPIs in a TIN.
* Alternative scoring model assumes that a minimum of 80 percent of clinicians within each practice size category would participate in quality data submission.
4. Potential Costs of Advancing Care EHR Incentive Program such as rule, and are proposing an exception for
Information and Improvement Activities hospital-based clinicians, non-patient MIPS eligible clinicians whose CEHRT
for Eligible Clinicians facing clinicians, PAs, NPs, CNs and has been decertified under ONCs
We believe that most MIPS eligible CRNAs. Further, as described in section Health IT Certification Program as
clinicians who can report the advancing II.6.f.(7)(a)(iv) of this proposed rule, we discussed in section II.6.f.7.(a)(v) of this
care information performance category are proposing to rely on section proposed rule. Additionally, we believe
of MIPS have already adopted an EHR 1848(o)(2)(D) of the Act, as amended by most MIPS eligible clinicians who can
during Stage 1 and 2 of the Medicare or section 4002(b)(1)(B) of the 21st Century report the advancing care information
Medicaid EHR Incentive Programs, and Cures Act, to assign a scoring weight of performance category of MIPS have
will have limited additional operational zero percent for the advancing care already adopted an EHR during Stage 1
expenses related to compliance with the information performance category for and 2 of the Medicare EHR Incentive
advancing care information performance MIPS eligible clinicians who are Program. As we have stated with respect
category requirements. determined to be based in ambulatory to the Medicare EHR Incentive Program,
MIPS eligible clinicians who did not surgical centers (ASCs). As described in we believe that future retrospective
participate in the Medicare and section II.6.f.(7)(a)(i) of this proposed studies on the costs to implement an
Medicaid EHR Incentive Programs could rule, we are proposing to rely on section EHR and the return on investment (ROI)
potentially face additional operational 1848(o)(2)(D) of the Act, as amended by will demonstrate efficiency
expenses for implementation and section 4002(b)(1)(B) of the 21st Century improvements that offset the actual
compliance with the advancing care Cures Act, to allow MIPS eligible costs incurred by MIPS eligible
information performance category clinicians to apply for a significant clinicians participating in MIPS and
requirements. hardship exception and subsequently specifically in the advancing care
For some MIPS eligible clinicians, the have their advancing care information information performance category, but
advancing care information performance performance category reweighted to zero we are unable to quantify those costs
category will be weighted at zero when they are faced with a significant and benefits at this time. At present,
percent of the final score. We will hardship. Relying on this same evidence on EHR benefits in either
continue our policy that was finalized authority, we are also proposing a improving quality of care or reducing
in 414.1375(a) to reweight the significant hardship exception for the health care costs is mixed. This is not
advancing care information performance advancing care information performance surprising since the adoption of EHR as
category scores for certain MIPS eligible category for MIPS eligible clinicians a fully functioning part of medical
clinicians, including those who may who are in small practices, as discussed practice is progressing, with numerous
have been exempt from the Medicare in section II.6.f.7.(a)(ii) of this proposed areas of adoption, use, and
sophistication demonstrating need for Similarly, the costs for design that incentivize such care
improvement. Even physicians and implementation and complying with the coordination. The policies that are being
hospitals that can meet Medicare EHR improvement activities performance proposed regarding the All-Payer
Incentive Program standards have not category requirements could potentially Combination Option and identification
necessarily fully implemented all the lead to higher expenses for MIPS of Other Payer Advanced APMs will
functionality of their systems or fully eligible clinicians. Costs per full-time help facilitate both the development and
exploited the diagnostic, prescribing, equivalent primary care clinician for participation in alternative payment
and coordination of care capabilities improvement activities will vary across arrangements in the private and public
that these systems promise. Moreover, practices, including for some activities sectors. Clinicians can focus their efforts
many of the most important benefits of or certified patient-centered medical around the care transformation in either
EHR depend on interoperability among home practices, in incremental costs per Advanced APM or MIPS APM models
systems and this functionality is still encounter, and in estimated costs per and know that those efforts will be
lacking in many EHR systems. member per month. aligned with the Quality Payment
A recent RAND report prepared for Costs may vary based on panel size Program, either through incentive
the ONC reviewed 236 recent studies and location of practice among other payments for QPs or through MIPS
that related the use of health IT to variables. For example, Magill (2015) scores calculated based on performance
quality, safety, and efficacy in conducted a study of certified patient- within the APM assessed at the APM
ambulatory and non-ambulatory care centered medical home practices in two Entity level.
settings and found that states.49 That study found that costs Several Advanced APMs and MIPS
associated with a full-time equivalent APMS have shown evidence of
A majority of studies that evaluated
primary care clinician, who were improving the quality of care provided
the effects of health IT on healthcare
associated with certified patient- to beneficiaries and beneficiaries
quality, safety, and efficiency reported
centered medical home practices, varied experience of care. For example, the
findings that were at least partially
across practices. Specifically, the study various shared savings initiatives
positive. These studies evaluated
found an average cost of $7,691 per already operating have demonstrated
several forms of health IT: Metric of
month in Utah practices, and an average the potential for quality programs to
satisfaction, care process, and cost and
of $9,658 in Colorado practices. delivers better quality healthcare,
health outcomes across many different
Consequently, certified patient-centered smarter spending, and to put beneficiary
care settings. Our findings agree with experience at the center. For example,
previous [research] suggesting that medical home practices incremental
costs per encounter were $32.71 in Utah in August of 2015, we issued 2014
health IT, particularly those quality and financial performance
functionalities included in the Medicare and $36.68 in Colorado (Magill, 2015).
The study also found that the average results showing that ACOs continue to
EHR Incentive Program regulation, can improve the quality of care for Medicare
improve healthcare quality and safety. estimated cost per member, per month,
for an assumed panel of 2,000 patients beneficiaries while generating net
The relationship between health IT and savings to the Medicare trust fund, if
[health care] efficiency is complex and was $3.85 in Utah and $4.83 in
Colorado. However, given the lack of shared savings paid out to these ACOs
remains poorly documented or are not included.50 In 2014, the 20
understood, particularly in terms of comprehensive historical data for
improvement activities, we are unable ACOs in the Pioneer ACO Model and
healthcare costs, which are highly 333 Shared Shavings Program ACOs
dependent upon the care delivery and to quantify those costs in detail at this
time. We request comments that provide generated more than $411 million in
financial context in which the total savings, which includes all ACOs
technology is implemented. 47 Other information that would enable us to
quantify the costs, costs savings, and savings and losses but does not include
recent studies have not found definitive shared savings payments to ACOs.
quantitative evidence of benefits.48 benefits associated implementation of
improvement activities. Additionally, in their first years of
Health IT vendors may face additional implementation, both Pioneer and
costs in Quality Payment Program Year D. Impact on Beneficiaries Shared Savings Program ACOs had
2 if they choose to develop additional There are a number of changes in this higher quality care than Medicare FFS
capabilities in their systems to submit proposed rule that would have an effect providers on measures for which
advancing care information and on beneficiaries. In general, we believe comparable data were available. Shared
improvement activities performance that the changes may have a positive Savings Program patients with multiple
category data on behalf of MIPS eligible impact and improve the quality and chronic conditions and with high
clinicians. We request comments that value of care provided to Medicare predicted Medicare spending received
provide information that would enable beneficiaries. More broadly, we expect better quality care than comparable FFS
us to quantify the costs, costs savings, that over time clinician engagement in patients.51 Between the first and fourth
and benefits associated with the Quality Payment Program may result performance periods, Pioneer ACOs
implementation and compliance with in improved quality of patient care, improved their average quality score
the requirements of the advancing care resulting in lower morbidity and from 71 percent to 92 percent. The
information performance category. mortality. We believe the policies Shared Savings Program ACOs yielded
finalized in the CY 2017 Quality $465 million in savings to the Medicare
47 Paul G. Shekelle, et al. Health Information
Payment Program final rule, as well as Trust Funds in 2014, not including
Technology: An Updated Systematic Review with a
Focus on Meaningful Use Functionalities. RAND policies in this rule will lead to shared savings payments paid out to
Corporation. 2014. additional growth in the participation of
50 https://www.cms.gov/Newsroom/
48 See, for example, Saurabh Rahurkar, et al.,
both MIPS APMS and Advanced APMs.
Despite the Spread of Health Information MediaReleaseDatabase/Fact-sheets/2015-
APMs promote seamless integration by Factsheets-items/2015-08-25.html.
Exchange, There Is Little Information of Its Impact
On Cost, Use, And Quality of Care, Health Affairs, way of their payment methodology and 51 J.M. McWilliams et al., Changes in Patients
March 2015; and Hemant K. Bharga and Abhay Experiences in Medicare Accountable Care
Nath Mishra, Electronic Medical Records and 49 Magill et al. The Cost of Sustaining a Patient- Organizations. New England Journal of Medicine
Physician Productivity: Evidence from Panel Data Centered Medical Home: Experience from 2 States. 2014; 371:17151724, DOI: 10.1056/
Analysis, Management Science, July 2014. Annals of Family Medicine, 2015; 13:429435. NEJMsa1406552.
ACOs.52 The Shared Savings Program PY4 were accountable for 461,442 a higher proportion of the practice
ACOs generated total program savings beneficiaries, representing a nearly 24 revenue is de-linked from FFS payment
(inclusive of all savings and losses percent increase in average aligned and there is thus more flexibility for
relative to financial benchmarks, though beneficiaries per ACO (up to 38,454) practices to deliver care without a face-
not including shared savings payments) from PY3. PY4 was the first option year to-face encounter and instead in the
of $429 million for performance year in the Pioneer ACO Model, where modality that best meets patients health
2015 (PY15).53 Of participating ACOs, Pioneer ACOs were operating under a care needs (that is, office visit, virtual
119 Shared Savings Program ACOs new financial benchmarking visit, phone call, etc.).63 We anticipate
earned shared savings by holding methodology. While the cohort of that CPC+ will allow practices to get off
spending far enough below their Pioneer ACOs decreased by nearly a the FFS Treadmill 64 and achieve
financial benchmarks and meeting third between PY3 and PY4 with several incentive neutrality (the incentive to
quality standards. No Track 2 ACOs Pioneer ACOs transitioning to either the bring a patient to the office is balanced
owed CMS losses. The financial results Shared Savings Program or the Next with the incentive to provide the
were that for (PY15), 83 ACOs had Generation ACO model Pioneer ACOs needed care outside of an office
expenditures lower than their still generated total model savings visit).65 66
benchmark, but did not qualify for (inclusive of all Pioneer ACO savings While maintaining coverage of
shared savings, as they did not meet the and losses relative to financial Original Medicare services and
minimum savings rate (MSR), and an benchmarks) of over $37 million. Of the beneficiary freedom to choose
increasing proportion of ACOs have eight Pioneer ACOs that generated providers, ACOs could potentially
generated savings above their MSR each savings, six generated savings outside a enhance care management of the
year. For PY15, 31 percent of ACOs (120 minimum savings rate and earned chronically ill aligned population
of 392) generated savings above their shared savings, and of the four Pioneer through the adoption of leading-edge
MSR compared to 28 percent (92 of 333) ACOs that generated losses, one technologies, care coordination
in PY14 and 26 percent (58 of 220) in generated losses outside a minimum techniques, and evidence-based benefit
PY13.54 loss rate and owed shared losses.56 enhancements that motivate providers
For Pioneer ACOs, the financial and The results from the third program and beneficiaries to optimize care. The
quality results continue to be positive, year (January through December 2015) evidence discussed here focuses on the
with several Pioneer ACOs generating of the original CPC Initiative indicate Next Generation Model elements of
greater savings in the model that the from 2013 to 2015 CPC telehealth, home health care, and
performance year 4 (PY4) (2015) and practices transformed their care delivery reduced cost sharing.
one ACO generating savings for the first with the biggest improvements in The transition from the inpatient
time. While the cohort of Pioneer ACOs risk-stratified care management, setting to home is a critical period for
decreased between PY3 (2014) and PY4, expanded access to care, and continuity patients, particularly elderly
they still generated total model savings of care. The CPC also improved patient populations. Studies have examined a
of over $37 million. It is important to experience slightly. Over the first 3 variety of interventions to help smooth
note that going into PY4, the years, ED visits increased by 2 percent care transitions. Interventions found in
benchmarks for the Pioneer ACOs were less for Medicare FFS beneficiaries in the literature include advance practice
re-based, and the Model as a whole CPC practices relative to those in nurse-led comprehensive discharge
introduced new financial benchmarking comparison practices.57 58 planning and home visit follow-up
methodologies. Re-basing refers to using As the early findings from the original protocols 67 68 69 and patient coaching
a newer set of baseline years to compute CPC initiative and literature from other
financial benchmarks; the new medical home models supported by Associations with patient satisfaction, quality of
benchmarks are therefore based on payment suggest, we expect to see care, staff burnout, and hospital and emergency
ACOs spending during their initial improvement in quality and patient
department use. JAMA Intern Med, 174(8), 1350
years of participation in the Pioneer 1358.
experience of care.59 60 61 62 Under CPC+, 62 DeVries, A., Li, C.H.W., Sridhar, G., Hummel,
ACO Model.55 J.R., Breidbart, S., & Barron, J.J. (2012). Impact of
Quality performance improved 56 Id. medical homes on quality, Healthcare utilization,
considerably from PY3 to PY4 and 57 Peikes, D., Taylor, E., Dale, S., et al. and costs. AJMC, 18(9), 534544.
across all 4 years of the Pioneer ACO Evaluation of the Comprehensive Primary Care 63 Mechanic, R.E., Santos, P., Landon, B.E., &
Model. Overall quality scores for nine of Initiative: Second Annual Report. Princeton, NJ: Chernew, M.E. (2011). Medical group responses to
Mathematica Policy Research, April 13, 2016, global payment: early lessons from the Alternative
the 12 Pioneer ACOs were above 90 available at https://innovation.cms.gov/files/ Quality Contract in Massachusetts. Health Aff
percent in PY4. All 12 Pioneers reports/cpci-evalrpt2.pdf. (Millwood), 30(9), 173442.
improved their quality scores from PY1 58 For more detail see Peikes, D., Anglin, G., 64 Bitton, A., Schwartz, G.R., Stewart, E.E.,
(2012) to PY4 by over 21 percentage Taylor, E., et al. Evaluation of the Comprehensive Henderson, D.E., Keohane, C.A., Bates, D.W., &
Primary Care Initiative: Third Annual Report. Schiff, G.D. (2012). Off the hamster wheel?
points. The financial results were that Qualitative evaluation of a payment-linked patient-
Princeton, NJ: Mathematica Policy Research,
the 12 Pioneer ACOs participating in December 2016, available at https:// centered medical home (PCMH) pilot. Milbank Q,
innovation.cms.gov/Files/reports/cpci-evalrpt3.pdf. 90(3), 484515.
52 ??? 59 Reid, R.J., Fishman, P.A., Yu, O., Ross, T.R., 65 Ash, A.S., & Ellis, R.P. (2012). Risk-adjusted
53 CMS, Medicare Accountable Care Tufano, J.T., Soman, M.P, & Larson, E.B. (2009). payment and performance assessment for primary
Organizations 2015 Performance Year Quality and Patient-centered medical home demonstration: A care. Med Care, 50(8), 64353.
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25.html. J.N., Dermes, N.B., Tomcavage, J., et al. (2012). 9.
54 CMS, Medicare Accountable Care Reducing long-term cost by transforming primary 67 Naylor MD, Brooten D, Campbell R, et al.
Organizations 2015 Performance Year Quality and care: Evidence from Geisingers Medical Home Comprehensive Discharge Planning and Home
Financial Results, https://www.cms.gov/Newsroom/ Model. AJMC, 18(3), 149155. Follow-up of Hospitalized Elders: A Randomized
MediaReleaseDatabase/Fact-sheets/2016-Fact- 61 Nelson, K.M., Helfrich, C., Sun, H., Hebert, Clinical Trial. JAMA. 1999;281(7):613620.
sheets-items/2016-08-25.html (last accessed April P.L., Liu, C.F., Dolan, E., et al. (2014). 68 Naylor, M. D., Brooten, D. A., Campbell, R. L.,
14, 2016). Implementation of the patient-centered medical Maislin, G., McCauley, K. M. and Schwartz, J. S.
55 Id. home in the Veterans Health Administration: (2004), Transitional Care of Older Adults
accompanied by post-discharge home access to the most appropriate care for the Quality Payment Program in its
visits.70 While the intensity and content ACO beneficiaries. second year on encouraging more
of these interventions vary, the use of a complete data submission and
1. Impact on Other Health Care
post-discharge home visit shortly after educating clinicians. The proposed
Programs and Providers
leaving the hospital appears to be policies will continue a glide path,
effective in engaging and monitoring We estimate that the Quality Payment which began in the transition year, to
patients to decrease readmissions or Program Year 2 will not have a more robust participation and
emergency room visits. MedPAC has significant economic effect on eligible performance in future years. The
also noted that there may be a role for clinicians and groups and believe that proposed policy changes are reflected in
home health services in models that MIPS policies, along with increasing the RIA estimates, which show that the
focus on chronic care needs and care participation in APMs over time may risk for negative MIPS payment
coordination.71 The Next Generation succeed in improving quality and adjustment is minimal for MIPS eligible
reducing costs. This may in turn result clinicians, including small and solo
ACO Model seeks to encourage ACOs to
in beneficial effects on both patients and practices that meet the proposed data
engage in post-discharge home visits to
some clinicians, and we intend to completeness requirements.
improve ACO patient outcomes by
continue focusing on clinician-driven,
allowing ACOs to perform and bill for 2. Alternatives Considered
patient-centered care.
types of services not currently available We propose several policies for the This proposed rule contains a range of
under Original Medicare. Quality Payment Program Year 2 to policies, including many provisions
The study of the potential value and reduce burden. These include raising related to specific statutory provisions.
efficacy of telehealth and remote patient the low volume threshold so that fewer The preceding preamble provides
monitoring has become more prevalent clinicians in small practices are descriptions of the statutory provisions
in recent years as technology has required to participate in the MIPS that are addressed, identifies those
enabled greater utilization of these starting with the 2018 performance policies where discretion has been
services.72 Studies and case studies period; including bonus points for exercised, presents our rationale for our
from health systems have shown value clinicians in small practices; adding a proposed policies and, where relevant,
in using telehealth platforms for new significant hardship exception for analyzes alternatives that we
activities such as e-visits 73 74 and the advancing care information considered. Comment is sought in
remote patient monitoring,75 as well as performance category for MIPS eligible section II.C.8.c. of this proposed rule on
for higher intensity care through real- clinicians in small practices; policies closely related to this
time videoconferencing,76 particularly implementing virtual groups; allowing Regulatory Impact Analysis, including
to enable older adults to receive care MIPS eligible clinicians and groups to the performance threshold. We view the
more rapidly from their homes and with submit measures and activities using as performance threshold as one of the
minimal burden. The Next Generation many submission mechanisms as most important factors affecting the
Model seeks to allow ACOs flexibility in necessary to meet the requirements of distribution of payment adjustments
utilizing telehealth services to improve the quality, improvement activities, or under the Program, and the alternatives
advancing care information performance that we considered focus on that policy.
Hospitalized with Heart Failure: A Randomized,
categories; implementing a voluntary For example, we discuss above that
Controlled Trial. Journal of the American Geriatrics facility-based scoring mechanism for the we modeled the effects of the proposed
Society, 52: 675684. 2018 performance period that aligns rules policies using a 15-point
69 Stauffer BD, Fullerton C, Fleming N, et al.
with the Hospital Value Based performance threshold and a 70-point
Effectiveness and Cost of a Transitional Care Purchasing (VBP) Program, and additional performance threshold.
Program for Heart Failure: A Prospective Study
with Concurrent Controls. Arch Intern Med.
extending the ability of MIPS eligible Additionally, we assumed a minimum
2011;171(14):12381243. clinicians and groups to use 2014 90 percent participation rate in each
70 Voss R, Gardner R, Baier R, Butterfield K, Edition CEHRT while providing bonus category of eligible clinicians. We
Lehrman S, Gravenstein S. The Care Transitions points for the use of the 2015 Edition of displayed the results of that modeling in
Intervention: Translating From Efficacy to CEHRT. Additionally, for vendors, we
Effectiveness. Arch Intern Med. 2011;171(14):1232
Table 86 along with subsequent tables.
1237. believe the flexibility to use EHR We tested two additional models
71 Report to the Congress: Medicare and the technology certified to either the 2014 using a performance threshold of 6
Health Care Delivery System. March 2013. Edition or the 2015 Edition for the points and a performance threshold of
72 Joseph Kvedar, Molly Joel Coye and Wendy
Quality Payment Program Year 2 is 33 points. In both of these cases, we
Everett, Connected Health: A Review Of beneficial as vendors will have again modeled a 70-point additional
Technologies and Strategies to Improve Patient Care
with Telemedicine and Telehealth, Health Affairs, additional time to deploy the updated performance threshold and a minimum
33, no.2 (2014):194199. software to their customers, which are 90 percent participation rate in each
73 Patrick T. Courneya, Kevin J. Palattao and Jason the clinicians and other providers. category of eligible clinicians in order to
M. Gallagher. HealthPartners Online Clinic For Clinicians will likewise have additional focus the results on the differing
Simple Conditions Delivers Savings Of $88 Per
Episode And High Patient Approval. Health Affairs,
time to upgrade and implement the new performance thresholds.
32, no.2 (2013):385392. functionalities. Under the 6-point performance
74 Mehrotra A, Paone S, Martich G, Albert SM, In summary, the Quality Payment threshold alternative, we estimated that
Shevchik GJ. A Comparison of Care at E-visits and Program policies are designed to we would make approximately $663.5
Physician Office Visits for Sinusitis and Urinary promote the delivery of high-value care million in positive payment adjustments
Tract Infection. JAMA Intern Med. 2013;173(1):72

74.
for individuals in all practices and areas (including $500 million in exceptional
75 UVA Health System, Tech Firm Collaborate to with a particular focus on clinicians in performance payments), and conversely,
Reduce Hospital Readmission Rates. VHQC News. small and solo practices. We believe would make approximately $163.5
June 2014. each of these proposals will further million in negative payment
76 Shah MN, Gillespie SM, et al. High-Intensity
reduce burdens on clinicians and adjustments. These results represent a
Telemedicine-Enhanced Acute Care for Older
Adults: An Innovative Healthcare Delivery Model.
practices and help increase successful roughly $10 million reduction in the
Journal of the American Geriatrics Society. 2003; participation. Further, the policies aggregate positive adjustments and a
61(11):20002007. throughout this proposed rule will focus roughly $10 million reduction in
aggregate negative payment adjustments The scoring model does not reflect the rule is $105.16 per hour, including
compared to the results displayed above growth in Advanced APM participation overhead and fringe benefits, which we
in Table 86. Under the 6-point between 2017 and 2018. After applying assume are 100 percent of the hourly
performance threshold, we also the other MIPS exclusions, the scoring wage (https://www.bls.gov/oes/2016/
estimated that slightly fewer eligible model excluded approximately 74,920 may/naics4_621100.htm). Assuming an
clinicians would receive negative QPs using preliminary QP data for average reading speed, we estimate that
payment adjustments than in the 15- Quality Payment Program Year 2017, it would take approximately 11.5 hours
point model described further above significantly lower than CMS summary for the staff to review half of this
approximately 3.1 percent in this level projected QP counts for Quality proposed rule. For each commenter that
alternative compared to approximately Payment Program Year 2018 (180,000 reviews this proposed rule, the
3.9 percent in the 15-point model. 245,000). The methods for the summary estimated cost is $1209.34 (11.5 hours
Under the 33-point performance level estimates reflect the several new $105.16). Therefore, we estimate that
threshold alternative, we estimated that APMs that we anticipate will be the total cost of reviewing this proposed
we would make approximately $743.7 Advanced APMs in CY 2018, and that rule is $4,873,360 ($1209.34 4,000
million in positive payment adjustments some eligible clinicians will join the reviewers). We estimate that the
(including $500 million in exceptional successors of APMs already active in incremental costs of reviewing this
performance payments), and conversely, early 2017. proposed rule are the same as the CY
would make approximately $243.7 There are additional limitations to our 2017 Quality Payment Program final
million in negative payment estimates. To the extent that there are rule.
adjustments. These results represent a year-to-year changes in the data
roughly $70 million increase in submission, volume and mix of services F. Accounting Statement
aggregate positive payment adjustments provided by MIPS eligible clinicians, As required by OMB Circular A4
and a roughly $70 million increase in the actual impact on total Medicare (available at http://
aggregate negative payment adjustments revenues will be different from those www.whitehouse.gov/omb/circulars/
compared to the results displayed above shown in Tables 86 through 90. Due the a004/a-4.pdf), in Table 90 (Accounting
in Table 86. Additionally, under the 33- limitations above, there is considerable Statement), we have prepared an
point performance threshold alternative, uncertainty around our estimates that is accounting statement.
we estimated that approximately 9.1 difficult to quantify in detail. We have not attempted to quantify the
percent of eligible clinicians would benefits of this proposed rule because of
E. Regulatory Review Costs the many uncertainties as to both
receive a negative payment adjustment,
compared to the approximately 3.9 If regulations impose administrative clinician behaviors and resulting effects
percent that we estimated in the 15- costs on private entities, such as the on patient health and cost reductions.
point model. time needed to read and interpret this For example, the applicable percentage
proposed rule, we should estimate the for MIPS payment adjustments changes
3. Assumptions and Limitations cost associated with regulatory review. over time, increasing from 4 percent in
We would like to note several Due to the uncertainty involved with 2019 to 9 percent in 2022 and
limitations to the analyses that accurately quantifying the number of subsequent years, and we are unable to
estimated MIPS eligible clinicians entities that will review this proposed estimate precisely how physicians will
eligibility, negative MIPS payment rule, we assume that the total number of respond to the increasing payment
adjustments, and positive payment commenters on last years proposed rule adjustments. As noted above, in CY
adjustments for the 2020 MIPS payment will be the number of reviewers of this 2020, we estimate that we will
year based on the data prepared to proposed rule. We acknowledge that distribute approximately $173 million
support the 2017 performance period this assumption may understate or in payment adjustments on a budget-
initial determination of clinician and overstate the costs of reviewing this neutral basis, which represents the
special status eligibility (available via rule. It is possible that not all applicable percent for 2020 required
the NPI lookup on qpp.cms.gov), the commenters reviewed last years rule in under section 1848(q)(6)(B)(i) of the Act
preliminary version of the file used for detail, and it is also possible that some and excludes $500 million in additional
the predictive qualifying APM reviewers chose not to comment on the MIPS payment adjustments for
participants analysis made available on proposed rule. For these reasons, we exceptional performance.
qpp.cms.gov on June 2, 2017 and believe that the number of past Further, the addition of new
prepared using claims for services commenters would be a fair estimate of Advanced APMs and growth in
between January 1, 2016 through August the number of reviewers of this Advanced APM participation over time
31, 2016 and 2014 and 2015 data from proposed rule. We welcome any public will affect the pool of MIPS eligible
legacy programs, including the PQRS, comments on the approach in clinicians, and for those that are MIPS
CAHPS for PQRS, and the VM. estimating the number of entities that eligible clinicians, may change their
The scoring model cannot fully reflect will review this proposed rule. relative performance. The $500 million
MIPS eligible clinicians behavioral We also recognize that different types available for exceptional performance
responses to MIPS. The scoring model of entities are in many cases affected by and the 5 percent APM Incentive
assumes higher participation in MIPS mutually exclusive sections of this Payment for QPs are only available from
quality reporting than under the PQRS. proposed rule. Therefore, for the 2019 through 2024. Beginning in 2026,
Other potential behavioral responses are purposes of our estimate, we assume Medicare PFS payment rates for services
not addressed in our scoring model. The that each reviewer reads approximately furnished by QPs will receive a higher
scoring model assumes that quality 50 percent of the proposed rule. We are update than for services furnished by
measures submitted and the distribution seeking public comments on this non-QPs. However, we are unable to
of scores on those measures would be assumption. estimate the number of QPs in those
similar under Quality Payment Program Using the wage information from the years, as we cannot project the number
Payment in the 2020 MIPS payment BLS for medical and health service or types of Advanced APMs that will be
year as they were under the 2015 PQRS managers (Code 119111), we estimate made available in those years through
program. that the cost of reviewing this proposed future CMS initiatives proposed and
implemented in those years, nor the implementing MIPS and as MIPS Table 90 includes our estimate for
number of QPs for those future eligible clinicians accumulate MIPS payment adjustments ($173
Advanced APMs. experience with the new system. million), the exceptional performance
The percentage of the final score Moreover, there are interactions payment adjustments under MIPS ($500
attributable to each performance between the MIPS and APM incentive million), and incentive payments to QPs
category will change over time and we programs and other shared savings and (using the range described in the
will continue to refine our scoring rules. incentive programs that we cannot preceding analysis, approximately
The improvement activities category model or project. Nonetheless, even if $590$800 million). However, of these
represents a new category for measuring ultimate savings and health benefits three elements, only the negative MIPS
MIPS eligible clinicians performance. represent only low fractions of current payment adjustments are shown as
We may also propose policy changes in experience, benefits are likely to be
estimated decreases.
future years as we continue substantial in overall magnitude.
TABLE 90ACCOUNTING STATEMENT: TRANSFERS

Category Transfers
CY 2020 Annualized Monetized Transfers .............................................. Estimated increase of between $1,263 and $1,473 million in payments
for higher performance under MIPS and to QPs.77
From Whom to Whom? ............................................................................ Increased Federal Government payments to physicians, other practi-
tioners and suppliers who receive payment under the Medicare Phy-
sician Fee Schedule.
CY 2020 Annualized Monetized Transfers .............................................. Estimated decrease of $173 million for lower performance under MIPS.
From Whom to Whom? ............................................................................ Reduced Federal Government payments to physicians, other practi-
tioners and suppliers who receive payment under the Medicare Phy-
sician Fee Schedule.
Note: These estimates are identical under both a 7 percent and 3 percent discount rate.
Based on National Health Expenditure this proposed rule, and the collection of approximately $857 million in
data,78 total Medicare expenditures for information burden costs calculated in collection of information-related
physician and clinical services in 2015 section III.N. of this proposed rule. burden. However, we estimate that the
reached $144.3 billion. Expenditures for As noted above, we estimate the incremental collection of information-
physician and clinical services from all regulatory review costs of $4.8 million related burden associated with this
sources reached $634.9 billion. Table 90 for this proposed rule. In Table 91, we proposed rule is an approximately $12.4
shows that the aggregate negative MIPS have prepared our analysis of collection million reduction relative to the
payment adjustment for all MIPS of information burden costs to be baseline burden of continuing the
eligible clinicians under MIPS is consistent with guidance in accordance policies and information collections set
estimated at $173 million, which with OMBs April 2017 guidance on forth in the CY 2017 Quality Program
represents less than 0.2 percent of EO13771. The Orders guidance directs final rule into CY 2018. Our burden
Medicare payments for physician and agencies to measure certain costs, estimates reflect several proposed that
clinical services and less than 0.1 including costs associated with would reduce burden, including the
percent of payments for physician and Medicare quality performance proposed reduction in the length of the
clinician services from all sources. tracking, using the estimates in the CY CAHPS survey; our proposal to allow
Table 90 also shows that the aggregate 2017 Quality Payment Program final certain hospital-based clinicians to elect
positive payment adjustment for MIPS rule as a baseline. The Order notes that use facility-based measurements,
eligible clinicians under MIPS is regular updates to certain Medicare thereby eliminating the need for
estimated at $673 million (including regulations make assessments of the additional quality data submission
additional MIPS payment adjustments incremental changes related to processes; and our proposal to allow
for exceptional performance), which performance tracking included in a MIPS eligible clinicians to form virtual
represents less than 1 percent of proposed regulation much more useful groups, which would create efficiencies
Medicare expenditures for physician than a comparison against hypotheticals in data submission; and our proposal for
and clinician services and 0.2 percent of (such as a programs hypothetical significant hardship or other type of
Medicare expenditures from all sources discontinuation). exception, including a new significant
for physician and clinical services. As shown in section III.N. of this hardship exception for small practices
Table 91 summarizes the regulatory proposed rule, we estimate that this for the advancing care information
review costs discussed in section V.E. of proposed rule will result in performance category.
TABLE 91ADDITIONAL COSTS AND BENEFITS

Category of cost or benefits Costs/benefits
Regulatory Review Costs ......................................................................... $4.8 million.

Incremental Collection of Information/Paperwork Reduction Act Burden $12.4 million.
Estimates.
77 A range of estimates is provided due to 78 Physicians and Clinical Services Expenditures, NationalHealthExpendData/NationalHealth
uncertainty about the number of Advanced APM https://www.cms.gov/Research-Statistics-Data-and- AccountsHistorical.html.
participants that will meet the QP threshold in Systems/Statistics-Trends-and-Reports/
2016.
TABLE 91ADDITIONAL COSTS AND BENEFITSContinued

Category of cost or benefits Costs/benefits
Benefits of Expanded Advanced and MIPS APM Participation ............... Improvements in quality, patient experience of care, readmission rates,
access to appropriate care, and total cost of care.
Benefits of MIPS ....................................................................................... Improvements in quality, patient experience of care, and readmission
rates.
Note: These estimates are identical under both a 7 percent and 3 percent discount rate. Incremental information collection costs are total infor-
mation collection costs associated with this proposed rule minus costs associated with CY 2017 Quality Payment Program final rule.
Table 91 also shows the expected (CEHRT) by revising paragraphs (1) MIPS eligible clinician who furnishes
benefits associated with this proposed introductory text, (1)(iii), and (2) 75 percent or more of his or her covered
rule. We note that these expected introductory text; professional services in sites of service
benefits are qualitative in nature. We f. Adding the definition of CMS identified by the Place of Service (POS)
expect that the Quality Payment Multi-Payer Model; codes used in the HIPAA standard
Program will result in quality g. Revising the definition of Final transaction as an ambulatory surgical
improvements and improvements to the Score; center setting based on claims for a
patients experience of care as MIPS h. Adding the definitions of Full TIN period prior to the performance period
eligible clinicians respond to the APM; as specified by CMS.
incentives for high-quality care i. Revising the definition of Hospital-
* * * * *
provided by the Program and implement based MIPS eligible clinician;
APM Entity means an entity that
j. Adding the definitions of
care quality improvements in their participates in an APM or other payer
clinical practices. While we cannot Improvement scoring;
k. Revising the definitions of Low-
arrangement through a direct agreement
quantify these effects specifically at this with CMS or the payer or through
volume threshold, and Medicaid
time because we cannot project eligible Federal or State law or regulation.
APM;
clinicians behavioral responses to the * * * * *
l. Adding the definitions of Medicare
incentives offered under the Quality Attributed beneficiary means a
QP Performance Period;
Payment Program, we nevertheless m. Revising the definition of Non- beneficiary attributed to the APM Entity
believe that changes to clinical care will patient facing MIPS eligible clinician; under the terms of the Advanced APM
result in care quality improvements for n. Adding the definition or Other as indicated on the most recent
Medicare beneficiaries and other MIPS APM; available list of attributed beneficiaries
patients treated by eligible clinicians. o. Revising the definition of Other at the time of a QP determination.
List of Subjects Payer Advanced APM; * * * * *
p. Removing the definition of QP Certified Electronic Health Record
42 CFR Part 414 Performance Period; Technology (CEHRT) * * *
Administrative practice and q. Revising the definition of Rural (1) For any calendar year before 2019,
procedure, Biologics, Drugs, Health areas; and EHR technology (which could include
facilities, Health professions, Diseases, r. Adding the definitions of Virtual multiple technologies) certified under
Medicare, Reporting and recordkeeping group. the ONC Health IT Certification Program
requirements. The revisions and additions read as that meets one of the following:
follows:
For the reasons set forth in the * * * * *
preamble, the Centers for Medicare & 414.1305 Definitions. (iii) The definition for 2019 and
Medicaid Services proposes to amend * * * * * subsequent years specified in paragraph
42 CFR chapter IV as set forth below: Affiliated practitioner means an (2) of this definition.
eligible clinician identified by a unique (2) For 2019 and subsequent years,
PART 414PAYMENT FOR PART B APM participant identifier on a CMS- EHR technology (which could include
MEDICAL AND OTHER HEALTH maintained list who has a contractual multiple technologies) certified under
SERVICES relationship with the APM Entity for the the ONC Health IT Certification Program
purposes of supporting the APM that meets the 2015 Edition Base EHR
1. The authority citation for part 414 definition (as defined at 45 CFR
continues to read as follows: Entitys quality or cost goals under the
Advanced APM. 170.102) and has been certified to the
Authority: Secs. 1102, 1871, and 1881(b)(l) All-Payer QP Performance Period 2015 Edition health IT certification
of the Social Security Act (42 U.S.C. 1302, criteria
means the time period that CMS will
1395hh, and 1395rr(b)(l)).
2. Section 414.1305 is amended by use to assess the level of participation * * * * *
a. Removing the definition of by an eligible clinician in Advanced CMS Multi-Payer Model means an
Advanced APM Entity; APMs and Other Payer Advanced APMs Advanced APM that CMS determines,
b. Revising the definition of under the All-Payer Combination per the terms of the Advanced APM, has
Option for purposes of making a QP at least one other payer arrangement
Affiliated practitioner;
c. Adding the definitions of All- determination for the year as specified that is designed to align with the terms
Payer QP Performance Period and in 414.1440. The All-Payer QP of that Advanced APM.
Ambulatory Surgical Center (ASC)- Performance Period begins on January 1 * * * * *
based MIPS eligible clinician; and ends on June 30 of the calendar year Final score means a composite
d. Revising the definitions of APM that is 2 years prior to the payment year. assessment (using a scoring scale of 0 to
Entity and Attributed beneficiary; * * * * * 100) for each MIPS eligible clinician for
e. Amending the definition Certified Ambulatory Surgical Center (ASC)- a performance period determined using
Electronic Health Record Technology based MIPS eligible clinician means a the methodology for assessing the total
performance of a MIPS eligible clinician period, and a group or virtual group representative or the Quality Payment
according to performance standards for provided that more than 75 percent of Program Service Center, as applicable,
applicable measures and activities for the NPIs billing under the groups TIN in order to obtain information
each performance category. or within a virtual group, as applicable, pertaining to virtual groups and/or
* * * * * meet the definition of a non-patient determine whether or not they are
Full TIN APM means an APM where facing individual MIPS eligible clinician eligible, as it relates to the practice size
participation is determined at the TIN during the non-patient facing requirement of a solo practitioner or a
level, and all eligible clinicians who determination period. group of 10 or fewer eligible clinicians,
have assigned their billing rights to a * * * * * to participate in MIPS as a virtual group.
participating TIN are therefore Other MIPS APM means a MIPS APM (ii) [Reserved]
participating in the APM. that does not require reporting through (2) Stage 2: Virtual group formation.
the CMS Web Interface. (i) TINs comprising a virtual group
* * * * * must establish a written formal
Hospital-based MIPS eligible clinician Other Payer Advanced APM means an
other payer arrangement that meets the agreement between each member of a
means a MIPS eligible clinician who virtual group prior to an election.
furnishes 75 percent or more of his or Other Payer Advanced APM criteria set
forth in 414.1420. (ii) On behalf of a virtual group, the
her covered professional services in official designated virtual group
sites of service identified by the place of * * * * * representative must submit an election
service codes used in the HIPAA Rural areas means ZIP codes by December 1 of the calendar year prior
standard transaction as an inpatient designated as rural, using the most to the start of the applicable
hospital, on-campus outpatient hospital, recent Health Resources and Services performance period.
off campus-outpatient hospital, or Administration (HRSA) Area Health (iii) The submission of a virtual group
emergency room setting based on claims Resource File data set available. election must include, at a minimum,
for a period prior to the performance * * * * * information pertaining to each TIN and
period as specified by CMS. Virtual group means a combination of NPI associated with the virtual group
* * * * * two or more TINs composed of a solo and contact information for the virtual
Improvement scoring means an practitioner (a MIPS eligible clinician group representative.
assessment measuring improvement for (as defined at 414.1305) who bills (iv) Once an election is made, the
each MIPS eligible clinician or group for under a TIN with no other NPIs billing virtual group representative must
a performance period using a under such TIN) or a group (as defined contact their designated CMS contact to
methodology that compares at 414.1305) with 10 or fewer eligible update any election information that
improvement from one performance clinicians under the TIN that elects to changed during a performance period
period to another performance period. form a virtual group with at least one one time prior to the start of an
* * * * * other such solo practitioner or group for applicable submission period.
Low-volume threshold means an a performance period of a year. (3) Agreement. Virtual groups must
individual MIPS eligible clinician or 3. Section 414.1315 is added to read execute a written formal and contractual
group who, during the low-volume as follows: agreement between each member of a
threshold determination period, has virtual group that includes the following
414.1315 Virtual Groups.
Medicare Part B allowed charges less elements:
than or equal to $90,000 or provides (a) Eligibility. A solo practitioner or a (i) Expressly state the only parties to
care for 200 or fewer Part B-enrolled group of 10 or fewer eligible clinicians the agreement are the TINs and NPIs of
Medicare beneficiaries. must make their election prior to the the virtual group.
start of the applicable performance (ii) Be executed on behalf of the TINs
* * * * * period and cannot change their election and the NPIs by individuals who are
Medicaid APM means a payment during the performance period. Virtual authorized to bind the TINs and the
arrangement authorized by a State group participants may elect to be in no NPIs, respectively.
Medicaid program that meets the Other more than one virtual group for a (iii) Expressly require each member of
Payer Advanced APM criteria set forth performance period and, in the case of the virtual group (including each NPI
in 414.1420. a group, the election applies to all MIPS under each TIN) to agree to participate
* * * * * eligible clinicians in the group. in the MIPS as a virtual group and
Medicare QP Performance Period (b) Election Deadline. A virtual group comply with the requirements of the
means the time period that CMS will representative must make an election, MIPS and all other applicable laws and
use to assess the level of participation on behalf of the members of a virtual regulations (including, but not limited
by an eligible clinician in Advanced group, regarding the formation of a to, federal criminal law, False Claims
APMs under the Medicare Option for virtual group for an applicable Act, anti-kickback statute, civil
purposes of making a QP determination performance period, by December 1 of monetary penalties law, Health
for the year as specified in 414.1425. the calendar year preceding the Insurance Portability and
The Medicare QP Performance Period applicable performance year. Accountability Act, and physician self-
begins on January 1 and ends on August (c) Election Process. The two-stage referral law).
31 of the calendar year that is 2 years virtual group election process for the (iv) Require each TIN within a virtual
prior to the payment year. 2018 and 2019 performance years is as group to notify all NPIs associated with
* * * * * follows: the TIN regarding their participation in

Non-patient facing MIPS eligible (1) Stage 1: Virtual group eligibility the MIPS as a virtual group.
clinician means an individual MIPS determination. (v) Set forth the NPIs rights and
eligible clinician who bills 100 or fewer (i) Solo practitioners and groups with obligations in, and representation by,
patient-facing encounters (including 10 or fewer eligible clinicians interested the virtual group, including without
Medicare telehealth services defined in in forming or joining a virtual group limitation, the reporting requirements
section 1834(m) of the Act) during the have the option to contact their and how participation in the MIPS as a
non-patient facing determination designated technical assistance virtual group affects the ability of the
NPI to participate in the MIPS outside (c) For purposes of the 2021 MIPS Interface. The group must report on the
of the virtual group. payment year and future years, the first 248 consecutively ranked
(vi) Describe how the opportunity to performance period for: beneficiaries in the sample for each
receive payment adjustments will (1) The quality and cost performance measure or module.
encourage each member of the virtual categories is the full calendar year * * * * *
group (including each NPI under each (January 1 through December 31) that 8. Section 414.1340 is amended by
TIN) to adhere to quality assurance and occurs 2 years prior to the applicable revising paragraphs (a)(2) and (b)(2) and
improvement. MIPS payment year. adding paragraphs (a)(3) and (b)(3) to
(vii) Require each member of the (2) [Reserved] read as follows:
virtual group to update its Medicare (d) For purposes of the 2021 MIPS
payment year, the performance period 414.1340 Data completeness criteria for
enrollment information, including the the quality performance category.
addition and deletion of NPIs billing for:
(1) The advancing care information (a) * * *
through a TIN that is part of a virtual
and improvement activities performance (2) At least 50 percent of the MIPS
group, on a timely basis in accordance
categories is a minimum of a continuous eligible clinician or groups patients that
with Medicare program requirements
90-day period within CY 2019, up to meet the measures denominator
and to notify the virtual group of any
and including the full CY 2019 (January criteria, regardless of payer for the MIPS
such changes within 30 days after the
1, 2019 through December 31, 2019). payment year 2020.
change.
(2) [Reserved] (3) At least 60 percent of the MIPS
(viii) Be for a term of at least one 5. Section 414.1325 is amended by eligible clinician or groups patients that
performance period as specified in the revising paragraphs (c)(6) and (d) to read meet the measures denominator
formal written agreement. as follows: criteria, regardless of payer for MIPS
(ix) Require completion of a close-out payment year 2021.
process upon termination or expiration 414.1325 Data submission requirements. (b) * * *
of the agreement that requires the TIN * * * * * (2) At least 50 percent of the
(group part of the virtual group) or NPI (c) * * * applicable Medicare Part B patients seen
(solo practitioner part of the virtual (6) A CMS-approved survey vendor during the performance period to which
group) to furnish all data necessary in for groups that elect to include the the measure applies for MIPS payment
order for the virtual group to aggregate CAHPS for MIPS survey as a quality year 2020.
its data across the virtual group. measure. Groups that elect to include (3) At least 60 percent of the
(d) Virtual Group Reporting the CAHPS for MIPS survey as a quality applicable Medicare Part B patients seen
Requirements: For TINs participating in measure must select from the above data during the performance period to which
MIPS at the virtual group level submission mechanisms to submit their the measure applies for MIPS payment
(1) Individual eligible clinicians and other quality information. year 2021.
individual MIPS eligible clinicians who (d) Report measures and activities, as * * * * *
are part of a TIN participating in MIPS applicable, via as many submission 9. Section 414.1350 is amended by
at the virtual group level would have mechanisms as necessary to meet the revising paragraph (b)(2) to read as
their performance assessed as a virtual requirements of the quality, follows:
group. improvement activities, or advancing
care information performance 414.1350 Cost performance category.
(2) Individual eligible clinicians and
individual MIPS eligible clinicians who categories. MIPS eligible clinicians and * * * * *
are part of a TIN participating in MIPS groups may elect to submit measures (b) * * *
at the virtual group level would need to and activities, as available and (2) 0 percent of a MIPS eligible
meet the definition of a virtual group at applicable via multiple mechanisms; clinicians final score for MIPS payment
all times during the performance period however, they must use the same year 2020.
for the MIPS payment year. identifier for all performance categories. * * * * *
* * * * * 10. Section 414.1360 is amended by
(3) Individual eligible clinicians and
individual MIPS eligible clinicians who 6. Section 414.1330 is amended by revising paragraph (a) introductory text
are part of a TIN participating in MIPS revising paragraph (b)(2) to read as to read as follows:
at the virtual group level must aggregate follows:
414.1360 Data submission criteria for the
their performance data across multiple 414.1330 Quality performance category. improvement activities performance
TINs in order for their performance to * * * * * category.
be assessed as a virtual group. (b) * * * (a) For purposes of the transition year
(4) MIPS eligible clinicians that elect (2) 60 percent of a MIPS eligible of MIPS and future years MIPS eligible
to participate in MIPS at the virtual clinicians final score for MIPS payment clinicians must submit data on MIPS
group level would have their year 2020. improvement activities in one of the
performance assessed at the virtual following manners:
* * * * *
group level across all four MIPS 7. Section 414.1335 is amended by * * * * *
performance categories. revising paragraph (a)(2)(i) to read as 11. Section 414.1370 is amended by
(5) Virtual groups would need to
follows: a. Revising paragraphs (b)(4)(i); (e)

adhere to an election process and (f);
established and required by CMS. 414.1335 Data submission criteria for the b. Adding paragraphs (g)(1)(i)(A)
4. Section 414.1320 is amended by quality performance category. through (D), and (g)(1)(ii);
adding paragraphs (c) and (d) to read as (a) * * * c. Revising paragraphs (g)(2), (g)(3)(i),
follows: (2) * * * (g)(4)(i) and (ii) introductory text, (h)
(i) Criteria applicable to groups of 25 introductory text, (h)(1), (h)(3), (h)(4);
414.1320 MIPS performance period. or more eligible clinicians, report on all and
* * * * * measures included in the CMS Web d. Adding paragraph (h)(5).
The revisions and additions read as for which we calculated a Total Quality activities score, an APM Entity may
follows: Performance category score for the report additional activities.
previous APM scoring standard * * * * *
414.1370 APM scoring standard under performance period, CMS calculates a
MIPS.
(4) * * *
Quality Improvement Score for the APM (i) Each Shared Savings Program ACO
* * * * * Entity group as specified in participant TIN must report data on the
(b) * * * 414.1380(b)(1)(xvi). Advancing Care Information (ACI)
(4) * * * (C) Total Quality Performance Performance category separately from
(i) New APMs. An APM for which the Category Score. Beginning in 2018, the the ACO, as specified in
first performance year begins after the Total Quality Performance category 414.1375(b)(2). The ACO participant
first day of the APM scoring standard score is the sum of the Quality TIN scores are weighted according to
performance period for the year. Performance Category Score and the the number of MIPS eligible clinicians
* * * * * Quality Improvement Score. in each TIN as a proportion of the total
(e) APM Entity group determination. (D) If a Shared Savings Program ACO number of MIPS eligible clinicians in
Except as provided in paragraph (e)(1) does not report on quality measures on the APM Entity group, and then
of this section, the APM Entity group is behalf of its participating eligible aggregated to determine an APM Entity
determined in the manner prescribed in clinicians as required by the Shared score for the ACI Performance category.
414.1425(b)(1). Savings Program under 425.508 of this (ii) For APM Entities in MIPS APMs
(1) Full TIN APM. The APM Entity chapter, the ACO participant TINs may other than the Shared Savings Program,
group includes an eligible clinician who report data for the MIPS quality CMS uses one score for each MIPS
is on a Participation List in a Full TIN performance category according to the eligible clinician in the APM Entity
APM on December 31 of the APM MIPS submission and reporting group to derive a single average APM
scoring standard performance period. requirements. Entity score for the ACI Performance
(2) [Reserved] (ii) Other MIPS APMs. category. The score for each MIPS
(f) APM Entity group scoring under (A) Quality Performance Category eligible clinician is the higher of either:
the APM scoring standard. The MIPS Score. The MIPS Quality Performance
final score calculated for the APM * * * * *
category score for an APM scoring (h) APM scoring standard
Entity is applied to each MIPS eligible standard performance period is performance category weights. The
clinician in the APM Entity group. The calculated for the APM Entity using the performance category weights used to
MIPS payment adjustment is applied at data submitted by the APM Entity based calculate the MIPS final score for an
the TIN/NPI level for each of the MIPS on measures that we specify through APM Entity group for the APM scoring
eligible clinicians in the APM Entity notice and comment rulemaking for standard performance period are:
group. each MIPS APM from among those used (1) Quality.
(1) If a Shared Savings Program ACO under the terms of the MIPS APM, and (i) For MIPS APMs that require use of
does not report data on quality measures that are: the CMS Web Interface: 50 percent.
as required by the Shared Savings (1) Tied to payment; (ii) For Other MIPS APMs, 0 percent
Program under 425.508 of this chapter, (2) Available for scoring; for 2017, 50 percent beginning in 2018.
each ACO participant TIN will be (3) Have a minimum of 20 cases * * * * *
treated as a unique APM Entity for available for reporting; and (3) Improvement activities.
purposes of the APM scoring standard. (4) Have an available benchmark. (i) For MIPS APMs that require use of
(2) Virtual groups. MIPS eligible (B) Quality Improvement Score. the CMS Web Interface: 20 percent.
clinicians who have elected to Beginning in 2019, for an APM Entity (ii) For Other MIPS APMs, 25 percent
participate in a virtual group and who for which we calculated a Total Quality for 2017, 20 percent beginning in 2018.
are also on a MIPS APM Participation Performance category score for the (4) Advancing care information.
List will be included in the assessment previous APM scoring standard (i) For MIPS APMs that require use of
under MIPS for purposes of producing performance period, CMS calculates a the CMS Web Interface: 30 percent.
a virtual group score and under the Quality Improvement Score for the APM (ii) For Other MIPS APMs, 25 percent
APM scoring standard for purposes of Entity group, as specified in for 2017, 30 percent beginning in 2018.
producing an APM Entity score. The 414.1380(b)(1)(xvi). (5) Reweighting the MIPS Performance
MIPS payment adjustment for these (C) Total Quality Performance categories for the APM scoring standard.
eligible clinicians is based solely on Category Score. Beginning in 2018, the If CMS determines there are not
their APM Entity score. Total Quality Performance category sufficient measures or activities
(g) * * * score is the sum of the Quality applicable and available to MIPS
(1) * * * Performance category score and the eligible clinicians, CMS will assign
(i) * * * Quality Improvement Score. weights as follows:
(A) Quality Performance Category (2) Cost. The cost performance (i) If CMS reweights the Quality
Score. The MIPS Quality Performance category weight is zero percent for APM Performance category to 0 percent, the
category score for an APM scoring Entities in MIPS APMs. Improvement Activities Performance
standard performance period is (3) * * * category is reweighted to 25 percent and
calculated for the APM Entity using the (i) CMS assigns an improvement the Advancing Care Information
data submitted by the APM Entity activities score for each MIPS APM for
Performance category is reweighted to

through the CMS Web Interface an APM scoring standard performance 75 percent.
according to the terms of the MIPS period based on the requirements of the (ii) If CMS reweights the Advancing
APM, including data on measures MIPS APM. The assigned improvement Care Information Performance category
submitted through the CMS Web activities score applies to each APM to 0 percent, the Quality Performance
Interface and other measures specified Entity group for the APM scoring category is reweighted to 80 percent.
by CMS for the APM scoring standard. standard performance period. In the 12. Section 414.1375 is amended by
(B) Quality Improvement Score. event that the assigned score does not revising paragraphs (a) and (b)(2)(ii) to
Beginning in 2018, for an APM Entity represent the maximum improvement read as follows:
414.1375 Advancing care information (1) Quality performance category. For (v) As an exception, the minimum
performance category. the 2017 and 2018 performance periods. case requirements for the all-cause
* * * * * MIPS eligible clinicians receive three to hospital readmission measure is 200
(a) Final score. The advancing care ten measure achievement points for cases.
information performance category each scored quality measure in the (vi) MIPS eligible clinicians failing to
comprises 25 percent of a MIPS eligible quality performance category based on report a measure required under this
clinicians final score for the 2019 MIPS the MIPS eligible clinicians category receive zero points for that
payment year and each MIPS payment performance compared to measure measure.
year thereafter, unless a different benchmarks. A quality measure must (vii) Subject to paragraph (b)(1)(viii)
scoring weight is assigned by CMS. have a measure benchmark to be scored of this section, MIPS eligible clinicians
(b) * * * based on performance. Quality measures do not receive zero points if the
(2) * * * that do not have a benchmark will not expected measure is submitted but is
(ii) May claim an exclusion for each be scored based on performance. unable to be scored because it does not
measure that includes an option for an Instead, these measures will receive 3 meet the required case minimum or if
exclusion. points for the 2017 MIPS performance the measure does not have a measure
period and either 1 or 3 points for the benchmark for MIPS payment years
* * * * * 2019 and 2020. Instead, these measures
13. Section 414.1380 is revised to read 2018 MIPS performance period in
accordance with paragraph (b)(1)(vii) of receive a score of 3 points in MIPS
as follows: payment years 2019 and 2020. MIPS
this section.
414.1380 Scoring. (i) Measure benchmarks are based on eligible clinicians do not receive zero
historical performance for the measure points if the expected measure is
(a) General. MIPS eligible clinicians
based on a baseline period. Each submitted but is unable to be scored
are scored under MIPS based on their
benchmark must have a minimum of 20 because it is below the data
performance on measures and activities
individual clinicians or groups who completeness requirement. Instead,
in four performance categories. MIPS
reported the measure meeting the data these measures receive a score of 3
eligible clinicians are scored against
completeness requirement and points in the 2019 MIPS payment year
performance standards for each
minimum case size criteria and and a score of 1 point in the 2020 MIPS
performance category and receive a final
performance greater than zero. payment year, except if the measure is
score, composed of their scores on submitted by a small practice. Measures
individual measures and activities, and Benchmark data are separated into
decile categories based on a percentile below the data completeness
calculated according to the final score requirement submitted by a small
methodology. distribution. We will restrict the
benchmarks to data from MIPS eligible practice receive a score of 3 points in
(1) Measures and activities in the four the 2020 MIPS payment year.
performance categories are scored clinicians and comparable APM data,
(viii) As an exception, the
against performance standards. (i) For including data from QPs and Partial
administrative claims-based measures
the quality performance category, QPs.
(ii) As an exception, if there is no and CMS Web Interface measures will
measures are scored between zero and not be scored if these measures do not
10 points. Performance is measured comparable data from the baseline
period, CMS would use information meet the required case minimum. For
against benchmarks. Bonus points are CMS Web Interface measures, we will
available for both submitting specific from the performance period to create
measure benchmarks, as described in recognize the measure was submitted
types of measures and submitting but exclude the measure from being
measures using end-to-end electronic paragraph (b)(1)(i) of this section, which
would not be published until after the scored. For CMS Web Interface
reporting. Starting with the 2020 MIPS measures: Measures that do not have a
payment year, improvement scoring is performance period. For the 2017
performance period, CMS would use measure benchmark and measures that
available in the quality performance have a measure benchmark but are
category. information from CY 2017 during which
MIPS eligible clinicians may report for redesignated as pay for reporting for all
(ii) For the cost performance category, Shared Savings Program accountable
measures are scored between 1 and 10 a minimum of any continuous 90-day
period. care organizations by the Shared
points. Performance is measured against Savings Program, CMS will recognize
a benchmark. Starting with the 2020 (A) CMS Web Interface submission
uses benchmarks from the the measure was submitted but exclude
MIPS payment year, improvement the measure from being scored as long
scoring is available in the cost corresponding reporting year of the
Shared Savings Program. as the data completeness requirement is
performance category. met. CMS Web Interface measures that
(B) [Reserved]
(iii) For the improvement activities are below the data completeness
(iii) Separate benchmarks are used for
performance category, each requirement will be scored and receive
the following submission mechanisms:
improvement activity is worth a certain (A) EHR submission options; 0 points.
number of points. The points for each (B) QCDR and qualified registry (ix) Measures submitted by MIPS
reported activity are summed and submission options; eligible clinicians are scored against
scored against a total potential (C) Claims submission options; measure benchmarks using a percentile
performance category score of 40 points. (D) CMS Web Interface submission distribution, separated by decile
(iv) For the advancing care
options; categories.
information performance category, the (E) CMS-approved survey vendor for (x) For each set of benchmarks, CMS
performance category score is the sum CAHPS for MIPS submission options; calculates the decile breaks for measure
of a base score, performance score, and and performance and assigns points based
bonus score. (F) Administrative claims submission on which benchmark decile range the
(2) [Reserved] options. MIPS eligible clinicians measure rate is
(b) Performance categories. MIPS (iv) Minimum case requirements for between.
eligible clinicians are scored under quality measures are 20 cases, unless a (xi) CMS assigns partial points based
MIPS in four performance categories. measure is subject to an exception. on the percentile distribution.
(xii) MIPS eligible clinicians are points, each measure must be reported (3) If the identifier is not the same for
required to submit measures consistent with sufficient case volume to meet the 2 consecutive performance periods, then
with 414.1335. required case minimum, meet the for individual submissions, the
(A) MIPS eligible clinicians that required data completeness criteria, and comparable quality performance
submit measures via claims, qualified not have a zero percent performance category achievement percent score is
registry, EHR, or QCDR submission rate. Measure bonus points may be the quality performance category
mechanisms, and submit more than the included in the calculation of the achievement percent score associated
required number of measures are scored quality performance category percent with the final score from the prior
on the required measures with the score regardless of whether the measure performance period that will be used for
highest measure achievement points. is included in the calculation of the payment. For group, virtual group, and
MIPS eligible clinicians that report a total measure achievement points. APM Entity submissions, the
measure via more than one submission (B) Outcome and patient experience comparable quality performance
mechanism can be scored on only one measures receive two measure bonus category achievement percent score is
submission mechanism, which will be points. the average of the quality performance
the submission mechanism with the (C) Other high priority measures category achievement percent score
highest measure achievement points. receive one measure bonus point. associated with the final score from the
Groups that submit via these submission (D) Measure bonus points for high prior performance period that will be
options may also submit and be scored priority measures cannot exceed 10 used for payment for each of the
on CMS-approved survey vendor for percent of the total available measure individuals in the group.
CAHPS for MIPS submission achievement points for the 2019 and (B) The improvement percent score
mechanisms. 2020 MIPS payment years. may not total more than 10 percentage
(B) Groups that submit measures via (E) If the same high priority measure points.
the CMS Web Interface may also submit (C) The improvement percent score is
is submitted via two or more submission
and be scored on CMS-approved survey assessed at the performance category
mechanisms, the measure will receive
vendor for CAHPS for MIPS submission level for the quality performance
high priority measure bonus points only
mechanisms. category and included in the calculation
(xiii) Topped out quality measures once for the measure.
(xv) One measure bonus point is also of the quality performance category
will be identified on an annual basis percent score as described in paragraph
and may be removed from the measure available for each measure submitted
with end-to-end electronic reporting for (b)(1)(xvii) of this section.
set for a submission mechanism after (1) The improvement percent score is
the third consecutive year that a given a quality measure under certain criteria
awarded based on the rate of increase in
measure has been identified as topped determined by the Secretary. Bonus
the quality performance category
out in connection with that submission points cannot exceed 10 percent of the
achievement percent score of eligible
mechanism. CMS will identify topped total available measure achievement
clinicians from the current MIPS
out measures in the benchmarks points for the 2019 and 2020 MIPS
performance period compared to the
published for each Quality Payment payment years. If the same measure is
year immediately prior to the current
Program year. Topped out measures that submitted via 2 or more submission
MIPS performance period.
have been removed pursuant to this mechanisms, the measure will receive (2) An improvement percent score is
policy will not be available for reporting measure bonus points only once for the calculated by dividing the increase in
after removal. measure. the quality performance category
(A) For the 2018 MIPS performance (xvi) Improvement scoring is available achievement percent score from the
period (2020 MIPS payment year), to MIPS eligible clinicians that prior performance period to the current
selected topped out measures identified demonstrate improvement in performance period by the prior year
by CMS will receive no more than 6 performance in the current MIPS quality performance category
measure achievement points, provided performance period compared to achievement percent score multiplied
that the measure benchmarks for all performance in the year immediately by 10 percent.
submission mechanisms are identified prior to the current MIPS performance (3) An improvement percent score
as topped out in the benchmarks period based on achievement. cannot be lower than zero percentage
published for the 2018 MIPS (A) Improvement scoring is available points.
performance period. when the data sufficiency standard is (4) For the 2018 MIPS performance
(B) Beginning with the 2019 MIPS met, which means when data are period, if a MIPS eligible clinician has
performance period (2021 MIPS available and a MIPS eligible clinician a previous year quality performance
payment year), a measure, except for has a quality performance category category achievement percent score less
measures in the CMS Web Interface, achievement percent score for the than or equal to 30 percent, then the
whose benchmark is identified as previous performance period. 2018 performance will be compared to
topped out for 2 or more consecutive (1) Data must be comparable to meet an assumed 2017 quality performance
years will receive no more than 6 the requirement of data sufficiency category achievement percent score of
measure achievement points in the which means that the quality 30 percent.
second consecutive year it is identified performance category achievement (5) The improvement percent score is
as topped out, and beyond. percent score is available for the current zero if the MIPS eligible clinician did
(xiv) Measure bonus points are performance period and the previous not fully participate in the quality
available for measures determined to be performance period and quality performance category for the current
high priority measures when two or performance category achievement performance period.
more high priority measures are percent scores can be compared. (D) For the purpose of improvement
reported. (2) Quality performance category scoring methodology, the term quality
(A) Measure bonus points are not achievement percent scores are performance category achievement
available for the first reported high comparable when submissions are percent score means the total measure
priority measure which is required to be received from the same identifier for achievement points divided by the total
reported. To qualify for measure bonus two consecutive performance periods. available measure achievement points,
without consideration of measure bonus (A) The total number of achievement MIPS eligible clinician in comparison to
points or improvement percent score. points earned by the MIPS eligible the highest potential score (40 points)
(E) For the purpose of improvement clinician divided by the total number of for a given MIPS year. For purposes of
scoring methodology, the term available achievement points; and this paragraph, full credit means that
improvement percent score means the (B) The cost improvement score, as the MIPS eligible clinician or group has
score that represents improvement for determined under paragraph (iv). met the highest potential score for the
the purposes of calculating the quality (iv) Cost improvement scoring is improvement activities performance
performance category percent score as available to MIPS eligible clinicians that category.
described in paragraph (b)(1)(xvii) of demonstrate improvement in (i) CMS assigns credit for the total
this section. performance in the current MIPS possible category score for each reported
(F) For the purpose of improvement performance period compared to their improvement activity based on two
scoring methodology, the term fully performance in the immediately weights: Medium-weighted and high-
participate means the MIPS eligible preceding MIPS performance period. weighted activities.
clinician met all requirements in (A) The cost improvement score is (ii) Improvement activities with a
414.1330 and 414.1340. determined at the measure level for the high weighting receive credit for 20
(xvii) A MIPS eligible clinicians cost performance category. points, toward the total possible
quality performance category percent (B) The cost improvement score is category score.
score is the sum of all the measure calculated only when data sufficient to (iii) Improvement activities with a
achievement points assigned for the measure improvement is available. medium weighting receive credit for 10
measures required for the quality Sufficient data is available when a MIPS points toward the total possible category
performance category criteria plus the eligible clinician or group participates score.
measure bonus points in paragraph in MIPS using the same identifier in 2 (iv) A MIPS eligible clinician or group
(b)(1)(xiv) of this section and measure consecutive performance periods and is in a practice that is certified or
bonus points in paragraph (b)(1)(xv) of scored on the same cost measure(s) for recognized as a patient-centered
this section. The sum is divided by the 2 consecutive performance periods. If medical home or comparable specialty
sum of total available measure the cost improvement score cannot be practice, as determined by the Secretary,
achievement points. The improvement calculated because sufficient data is not receives full credit for performance on
percent score in paragraph (b)(1)(xvi) of available, then the cost improvement the improvement activities performance
this section is added to that result. The score is zero. category. A practice is certified or
quality performance category percent (C) The cost improvement score is recognized as a patient-centered
score cannot exceed 100 percentage determined by comparing the number of medical home if it meets any of the
points. measures with a statistically significant following criteria:
(xviii) Beginning with the 2018 MIPS change (improvement or decline) in (A) The practice has received
performance period, measures performance; a change is determined to accreditation from one of four
significantly impacted by ICD10 be significant based on application of a accreditation organizations that are
updates, as determined by CMS, will be t-test. The number of cost measures with nationally recognized;
assessed based only on the first 9 a significant decline is subtracted from (1) The Accreditation Association for
months of the 12-month performance the number of cost measures with a Ambulatory Health Care;
period. For purposes of this paragraph, significant improvement, with the result (2) The National Committee for
CMS will make a determination as to divided by the number of cost measures Quality Assurance (NCQA);
whether a measure is significantly for which the MIPS eligible clinician or (3) The Joint Commission; or
impacted by ICD10 coding changes group was scored for two consecutive (4) The Utilization Review
during the performance period. CMS performance periods. The resulting Accreditation Commission (URAC).
will publish on the CMS Web site which fraction is then multiplied by the (B) The practice is participating in a
measures require a 9-month assessment maximum improvement score. Medicaid Medical Home Model or
process by October 1st of the (D) The cost improvement score Medical Home Model.
performance period if technically cannot be lower than zero percentage (C) The practice is a comparable
feasible, but by no later than the points. specialty practice that has received the
beginning of the data submission period (E) The maximum cost improvement NCQA Patient-Centered Specialty
at 414.1325(f)(1). score for the 2020 MIPS payment year Recognition.
(2) Cost performance category. A is zero percentage points. (D) The practice is a participant or in
MIPS eligible clinician receives one to (v) A cost performance category a control group in the CPC+ model.
ten achievement points for each cost percent score is not calculated if a MIPS (E) The practice has received
measure attributed to the MIPS eligible eligible clinician is not attributed any accreditation from other certifying
clinician based on the MIPS eligible cost measures because the clinician or bodies that have certified a large
clinicians performance compared to the group has not met the case minimum number of medical organizations and
measure benchmark. requirements for any of the cost meet national guidelines, as determined
(i) Cost measure benchmarks are measures or a benchmark has not been by the Secretary. The Secretary must
based on the performance period. Cost created for any of the cost measures that determine that these certifying bodies
measures must have a benchmark to be would otherwise be attributed to the must have 500 or more certified member
clinician or group.
scored. practices, and require practices to

(ii) A MIPS eligible clinician must (3) Improvement activities include the following:
meet the minimum case volume performance category. MIPS eligible (1) Have a personal physician/
specified by CMS to be scored on a cost clinicians and groups receive points for clinician in a team-based practice.
measure. improvement activities based on (2) Have a whole-person orientation.
(iii) A MIPS eligible clinician cost patient-centered medical home or (3) Provide coordination or integrated
performance category percent score is comparable specialty practice care.
the sum of the following, not to exceed participation, APM participation, and (4) Focus on quality and safety.
100 percent: improvement activities reported by the (5) Provide enhanced access.
(v) CMS compares the points certain measures specified by CMS. (i) CMS determines there are not
associated with the reported activities MIPS eligible clinicians may earn up to sufficient measures and activities
against the highest potential category 10 or 20 percentage points as specified applicable and available to MIPS
score of 40 points. by CMS for each measure reported for eligible clinicians pursuant to section
(vi) A MIPS eligible clinician or the performance score. 1848(q)(5)(F) of the Act.
groups improvement activities category (C) A MIPS eligible clinician may earn (ii) CMS estimates that the proportion
score is the sum of points for all of their the following bonus scores: of eligible professionals who are
reported activities, which is capped at (1) A bonus score of 5 percentage meaningful EHR users is 75 percent or
40 points, divided by the highest points for reporting to one or more greater pursuant to section
potential category score of 40 points. additional public health agencies or 1848(q)(5)(E)(ii) of the Act.
(vii) Non-patient facing MIPS eligible clinical data registries. (iii) A significant hardship exception
clinicians and groups, small practices, (2) A bonus score of 10 percentage or other type of exception is granted to
and practices located in rural areas and points for attesting to completing one or a MIPS eligible clinician for the
geographic HPSAs receive full credit for more improvement activities specified advancing care information performance
improvement activities by selecting one by CMS using CEHRT. category pursuant to section
high-weighted improvement activity or (3) For the 2020 MIPS payment year, 1848(o)(2)(D) of the Act.
two medium-weighted improvement a bonus score of 10 percentage points (3) Complex patient bonus. Provided
activities. Non-patient facing MIPS for submitting data for the measures for that the MIPS eligible clinician, group,
eligible clinicians and groups, small the base score and the performance virtual group or APM entity submits
practices, and practices located in rural score generated solely from 2015 data for at least one MIPS performance
areas and geographic HPSAs receive Edition CEHRT. category during the applicable
half credit for improvement activities by (c) Final score calculation. Each MIPS performance period, a complex patient
selecting one medium-weighted eligible clinician receives a final score bonus will be added to the final score
improvement activity. of 0 to 100 points for a performance for the 2020 MIPS payment year, as
(viii) For the transition year, to follows:
period for a MIPS payment year
receive full credit as a certified or (i) For MIPS eligible clinicians and
calculated per the following formula. If
recognized patient-centered medical groups, the complex patient bonus is
a MIPS eligible clinician is scored on
home or comparable specialty a TIN that equal to the average HCC risk score
fewer than 2 performance categories, he
is reporting must include at least one assigned to beneficiaries (pursuant to
or she receives a final score equal to the
practice site which is a certified patient- the HCC risk adjustment model
performance threshold.
centered medical home or comparable established by CMS pursuant to section
Final score = [(quality performance
specialty practice. 1853(a)(1) of the Act) seen by the MIPS
(ix) MIPS eligible clinicians category percent score quality
performance category weight) + (cost eligible clinician or seen by clinicians in
participating in APMs that are not a group.
patient-centered medical homes for a performance category percent score
(ii) For MIPS APMs and virtual
performance period shall earn a cost performance category weight) +
groups, the complex patient bonus is
minimum score of one-half of the (improvement activities performance
equal to the beneficiary weighted
highest potential score for the category score improvement activities
average HCC risk score for all MIPS
improvement activities performance performance category weight) +
eligible clinicians and TINs for models
category. (advancing care information
and virtual groups which rely on
(x) For the 2018 MIPS performance performance category score advancing
complete TIN participation within the
period and future periods, to receive full care information performance category
APM entity or virtual group,
credit as a certified or recognized weight)] 100 + [the complex patient
respectively.
patient-centered medical home or bonus + the small practice bonus], not (iii) The complex patient bonus
comparable specialty practice, CMS to exceed 100 points. cannot exceed 3.0.
requires that at least 50 percent of the (1) Performance category weights. The (4) Small practice bonus. A small
practice sites within the TIN must be weights of the performance categories in practice bonus of 5 points will be added
recognized as a patient-centered the final score are as follows, unless a to the final score for the 2020 MIPS
medical home or comparable specialty different scoring weight is assigned payment year for MIPS eligible
practice. under paragraph (c)(2) of this section: clinicians, and for groups, virtual
(4) Advancing care information (i) Quality performance category groups, and APM Entities that consist of
performance category. (i) A MIPS weight is defined under 414.1330(b). 15 or fewer clinicians, that participate
eligible clinicians advancing care (ii) Cost performance category weight in the program by submitting data on at
information performance category score is defined under 414.1350(b). least one performance category in the
equals the sum of the base score, (iii) Improvement activities 2018 MIPS performance period.
performance score, and any applicable performance category weight is defined (d) Scoring for APM Entities. MIPS
bonus scores. A MIPS eligible clinician under 414.1355(b). eligible clinicians in APM Entities that
cannot earn the performance score or (iv) Advancing care information are subject to the APM scoring standard
base score until they have fulfilled the performance category weight is defined are scored using the methodology under
base score. The advancing care under 414.1375(a). 414.1370.
(2) Reweighting the performance (e) Scoring for Facility-Based
information performance category score

will not exceed 100 percentage points. categories. A scoring weight different Measurement. MIPS eligible clinicians
(A) A MIPS eligible clinician earns a from the weights specified in paragraph may elect to be scored under the quality
base score by reporting the numerator (c)(1) of this section, will be assigned to and cost performance categories using
(of at least one) and denominator or a a performance category, and its weight facility-based measures under the
yes/no statement or an exclusion; as as specified in paragraph (c)(1) of this methodology described in this
applicable, for each required measure. section, will be redistributed to another paragraph.
(B) A MIPS eligible clinician earns a performance category or categories, in (1) General. The facility-based
performance score by reporting on the following circumstances: measurement scoring standard is the
MIPS scoring methodology applicable (6) MIPS performance category (d) Record Retention. All MIPS
for MIPS eligible clinicians identified as scoring under the facility-based eligible clinicians or groups that submit
meeting the requirements in paragraph measurement scoring standard. data and information to CMS for
(e)(2) and (3) of this section. (i) Measures. The quality and cost purposes of MIPS must retain such data
(i) For the 2018 MIPS performance measures are those adopted under the and information for a period of 10 years
period, the facility-based measures value-based purchasing program of the from the end the MIPS Performance
available are the measures adopted for facility for the year specified. Period.
the FY 2019 Hospital Value-Based (ii) Benchmarks. The benchmarks are 15. Section 414.1395 is revised to read
Purchasing Program as authorized by those adopted under the value-based as follows:
section 1886(o) of the Act and codified purchasing program of the facility
in our regulations at 412.160 through 414.1395 Public reporting.
program for the year specified.
412.167. (iii) Performance Period. The (a) Public reporting of eligible
(ii) For the 2020 MIPS payment year, performance period for facility-based clinician and group Quality Payment
the scoring methodology applicable for measurement is the performance period Program information. For each program
MIPS eligible clinicians electing facility- for the measures adopted under the year, CMS posts on Physician Compare,
based measurement is the Total value-based purchasing program of the in an easily understandable format,
Performance Score methodology facility program for the year specified. information regarding the performance
adopted for the Hospital Value-Based of eligible clinicians or groups under the
(iv) Quality. The quality performance
Purchasing Program. Quality Payment Program.
(2) Eligibility for facility-based category percent score is established by
(b) Maintain existing public reporting
measurement. MIPS eligible clinicians determining the percentile performance
standards. With the exception of data
are eligible for facility-based of the facility in the value-based
that must be mandatorily reported on
measurement for a MIPS payment year purchasing program for the specified
Physician Compare, for each program
if they are determined facility-based as year as described in paragraph (e)(5) of
year, CMS relies on established public
an individual clinician or as part of a this section and awarding a score
reporting standards to guide the
group, as follows: associated with that same percentile
information available for inclusion on
(i) Facility-based individual performance in the MIPS quality
Physician Compare. The public
determination. A MIPS eligible clinician performance category percent score [for
reporting standards require data
furnishes 75 percent or more of his or those clinicians who are not scored
included on Physician Compare to be
her covered professional services in using facility-based measurement] for
statistically valid, reliable, and accurate;
sites of service identified by the place of the MIPS payment year.
comparable across reporting
service codes used in the HIPAA (v) Cost. The cost performance
mechanisms; and meet the reliability
standard transaction as an inpatient category percent score is established by
threshold. And, to be included on the
hospital or emergency room setting determining the percentile performance
public facing profile pages, the data
based on claims for a period prior to the of the facility in the value-based
must also resonate with Web site users,
performance period as specified by purchasing program for the specified
as determined by CMS.
CMS. year as described in paragraph (e)(5) of (c) First year measures. For each
(ii) Facility-based group this section and awarding a score program year, CMS does not publicly
determination. A facility-based group is associated with that same percentile report any first year measure, meaning
a group in which 75 percent or more of performance in the MIPS cost any measure in its first year of use in the
its MIPS eligible clinicians meet the performance category percent score for quality and cost performance categories.
requirements under paragraph (e)(2)(i) those clinicians who are not scored After the first year, CMS reevaluates
of this section. using facility-based measurement for the measures to determine when and if they
(3) Election of facility-based MIPS payment year. are suitable for public reporting.
measurement. MIPS eligible clinicians (A) Other Cost Measures. MIPS (d) 30-day preview period. For each
that meet the criteria described under eligible clinicians who elect facility- program year, CMS provides a 30-day
paragraph (e)(2) of this section must based measurement are not scored on preview period for any clinician or
elect participation in facility-based cost measures described in paragraph group with Quality Payment Program
measurement through attestation. (b)(2) of this section. data before the data are publicly
(4) Data submission for facility-based (B) [Reserved] reported on Physician Compare.
measurement. There are no data 14. Section 414.1390 is amended by 16. Section 414.1400 is amended by
submission requirements for facility- adding paragraphs (b) through (d) to a. Revising paragraph (a)(1)
based measurement other than electing read as follows: introductory text;
the option through attestation as b. Adding paragraph (a)(5);
described in paragraph (e)(3) of this 414.1390 Data validation and auditing.
c. Revising paragraphs (b), (e)
section. * * * * * introductory text, (e)(3), (f) introductory
(5) Determination of applicable (b) Certification. All MIPS eligible text, (f)(1), (f)(2), (g), (i) and (j)(2).
facility score. A facility-based clinician clinicians and groups that submit data The revisions and additions read as
or group receives a score under the and information to CMS for purposes of follows:
facility-based measurement scoring MIPS must certify to the best of their
standard derived from the value-based knowledge that the data submitted to 414.1400 Third party data submission.
purchasing score for the facility at CMS is true, accurate, and complete. (a) * * *
which the clinician or group provided Such certification must accompany the (1) MIPS data may be submitted by
services to the most Medicare submission. third party intermediaries on behalf of
beneficiaries. If there is an equal (c) Reopening. CMS may reopen and a MIPS eligible clinician, group or
number of Medicare beneficiaries revise a MIPS payment determination in virtual group by:
treated at more than one facility, the accordance with the rules set forth at * * * * *
value-based purchasing score for the 405.980 through 405.986 of this (5) All data submitted to CMS by a
highest scoring facility is used. chapter. third party intermediary on behalf of a
MIPS eligible clinician, group or virtual advancing care information) data for a minimum of 10 years from the end
group must be certified by the third starting with the 2018 performance of the MIPS Performance Period.
party intermediary to the best of its period and in future program years. * * * * *
knowledge as true, accurate, and (1) For QCDR quality measures, the 17. Section 414.1410 is amended by
complete. Such certification must quality measure specifications must revising paragraph (b) to read as follows:
accompany the submission. include the following for each measure:
(b) QCDR self-nomination criteria. For name/title of measures, NQF number (if 414.1410 Advanced APM determination.
the 2018 performance period and future NQF-endorsed), descriptions of the * * * * *
years of the program, QCDRs must self- denominator, numerator, and when (b) Advanced APM determination
nominate from September 1 of the prior applicable, denominator exceptions, process. CMS determines Advanced
year until November 1 of the prior year. denominator exclusions, risk APMs in the following manner:
Entities that desire to qualify as a QCDR adjustment variables, and risk (1) CMS updates the Advanced APM
for the purposes of MIPS for a given adjustment algorithms. The narrative list on its Web site at intervals no less
performance period will need to self- specifications provided must be similar than annually.
nominate for that performance period to the narrative specifications we (2) CMS will include notice of
and provide all information requested provide in our measures list. whether a new APM is an Advanced
by CMS at the time of self-nomination. (2) For MIPS quality measures, the APM in the first public notice of the
Having qualified as a QCDR does not QCDR only needs to submit the MIPS new APM.
18. Section 414.1415 is amended by
automatically qualify the entity to measure numbers or specialty-specific
revising paragraphs (c) introductory
participate in subsequent MIPS measure sets (if applicable). CMS
text, (c)(2) introductory text, (c)(3)(i)(A)
performance periods. Beginning with expects that QCDRs reporting on MIPS
and (c)(4) to read as follows:
the 2019 performance period existing measures, retain and use the MIPS
QCDRs that are in good standing may measure specifications as they exist 414.1415 Advanced APM criteria.
attest that certain aspects of their under the program year. * * * * *
previous years approved self- * * * * * (c) Financial risk. To be an Advanced
nomination have not changed and will (g) Qualified registry self-nomination APM, an APM must either meet the
be used for the upcoming performance criteria. For the 2018 performance financial risk standard under paragraphs
period. CMS may allow existing QCDRs period and future years of the program, (c)(1) or (2) of this section and the
in good standing to submit minimal or the qualified registry must self-nominate nominal amount standard under
substantial changes to their previously from September 1 of the prior year until paragraphs (c)(3) or (4) of this section or
approved self-nomination form, from November 1 of the prior year. Entities be an expanded Medical Home Model
the previous year, during the annual that desire to qualify as a qualified under Section 1115A(c) of the Act.
self-nomination period, for CMS review registry for a given performance period * * * * *
and approval without having to must self-nominate and provide all (2) Medical Home Model financial
complete the entire QCDR self- information requested by CMS at the risk standard. The following standard
nomination application process. time of self-nomination. Having applies only for APM Entities that are
* * * * * qualified as a qualified registry does not participating in Medical Home Models
(e) Identifying QCDR quality automatically qualify the entity to starting in the 2018 Medicare QP
measures. For purposes of QCDRs participate in subsequent MIPS Performance Period, except for APM
submitting data for the MIPS quality performance periods. Beginning with Entities participating in Round 1 of the
performance category, CMS considers the 2019 performance period, existing Comprehensive Primary Care Plus
the following types of quality measures qualified registries that are in good (CPC+) Model. This standard applies for
to be QCDR quality measures: standing may attest that certain aspects APM Entities that are owned and
* * * * * of their previous years approved self- operated by an organization with fewer
(3) CAHPS for MIPS survey. Although nomination have not changed and will than 50 eligible clinicians whose
the CAHPS for MIPS survey is included be used for the upcoming performance Medicare billing rights have been
in the MIPS measure set, we consider period. CMS may allow existing reassigned to the TIN(s) of the
the changes that need to be made to the qualified registries in good standing to organization(s) or any of the
CAHPS for MIPS survey for reporting by submit minimal or substantive changes organizations subsidiary entities. APM
individual MIPS eligible clinicians (and to their previously approved self- Entities under this standard participate
not as a part of a group) significant nomination form from the previous in a Medical Home Model that, based on
enough as to treat the CAHPS for MIPS year, during the annual self-nomination the APM Entitys failure to meet or
survey as a QCDR quality measure for period, for CMS review and approval exceed one or more specified
purposes of individual MIPS eligible without having to complete the entire performance standards, which may
clinicians reporting the CAHPS for qualified registry self-nomination include expected expenditures, does
MIPS survey via a QCDR. application process. one or more of the following:
(f) QCDR measure specifications * * * * * * * * * *
criteria. A QCDR must provide (i) CMS-approved survey vendor (3) * * *
specifications for each measure, activity, application criteria. Vendors are (i) * * *
or objective the QCDR intends to submit required to undergo the CMS approval (A) For Medicare QP Performance
to CMS. The QCDR must provide CMS process for each year in which the Periods 2017, 2018, 2019, and 2020, 8
descriptions and narrative specifications survey vendor seeks to transmit survey percent of the average estimated total
for each measure, activity, or objective measures data to CMS. Applicants must Medicare Parts A and B revenue of all
no later than November 1 of the adhere to any deadlines specified by providers and suppliers in participating
applicable performance period for CMS. APM Entities; or
which the QCDR wishes to submit (j) * * * * * * * *
quality measures or other performance (2) The entity must retain all data (4) Medical Home Model nominal
category (improvement activities and submitted to CMS for purposes of MIPS amount standard. (i) For a Medical
Home Model to be an Advanced APM, meet at least one of the following 20. Section 414.1425 is amended by
the total annual amount that an APM criteria: a. Revising paragraphs (a), (b), (c)(3),
Entity potentially owes CMS or foregoes * * * and (c)(4)(i) and (c)(4)(ii);
must be at least the following amounts: (3) To meet the quality measure use b. Redesignating paragraph (c)(6) as
(A) For Medicare QP Performance criterion, a payment arrangement must paragraph (c)(4)(iii);
Period 2017, 2.5 percent of the average use an outcome measure if there is an c. Revising newly redesignated
estimated total Medicare Parts A and B applicable outcome measure on the paragraph (c)(4)(iii);
revenue of all providers and suppliers MIPS quality measure list. d. Adding a new paragraph (c)(6);
in participating APM Entities. (d) Financial risk. To be an Other e. Revising paragraphs (d)(1) and (2);
(B) For Medicare QP Performance Payer Advanced APM, a payment and
Period 2018, 2 percent of the average arrangement must meet either the f. Removing paragraph (d)(4).
estimated total Medicare Parts A and B financial risk standard under paragraphs The revisions and addition read as
revenue of all providers and suppliers (d)(1) or (2) of this section and the follows:
in participating APM Entities; nominal amount standard under 414.1425 Qualifying APM participant
(C) For Medicare QP Performance paragraphs (d)(3) or (4) of this section, determination: In general.
Period 2019, 3 percent of the average make payment using a full capitation * * * * *
estimated total Medicare Parts A and B arrangement under paragraph (d)(6) of (a) List used for QP determination. (1)
revenue of all providers and suppliers this section, or be a Medicaid Medical For Advanced APMs in which all APM
in participating APM Entities. Home Model with criteria comparable to Entities may include eligible clinicians
(D) For Medicare QP Performance an expanded Medical Home Model on a Participation List, the Participation
Period 2020, 4 percent of the average under section 1115A(c) of the Act. List is used to identify the APM Entity
estimated total Medicare Parts A and B (1) Generally applicable financial risk group for purposes of QP
revenue of all providers and suppliers standard. Except for APM Entities to determinations, regardless of whether
in participating APM Entities. which paragraph (d)(2) of this section the APM Entity also has eligible
(E) For Medicare QP Performance applies, to be an Other Payer Advanced clinicians on an Affiliated Practitioner
Periods 2021 and later, 5 percent of the APM, an APM Entity must, based on List.
average estimated total Medicare Parts A whether an APM Entitys actual (2) For Advanced APMs in which
and B revenue of all providers and expenditures for which the APM Entity APM Entities do not include eligible
suppliers in participating APM Entities. is responsible under the APM exceed clinicians on a Participation List but do
(ii) [Reserved] expected expenditures during a include eligible clinicians on an
* * * * * specified period of performance do one Affiliated Practitioner List, the
19. Section 414.1420 is amended by or more of the following: Affiliated Practitioner List is used to
revising the section heading and * * * * * identify the eligible clinicians for
paragraphs (a) introductory text, (a)(3)(i) (3) Generally applicable nominal purposes of QP determinations.
and (ii), (c) introductory heading, (c)(2) amount standard. Except for payment (3) For Advanced APMs in which
introductory text, (c)(3), (d) introductory arrangements described in paragraph some APM Entities may include eligible
text, (d)(1) introductory text, (d)(3), and (d)(2) of this section, the total amount clinicians on a Participation List and
(4) to read as follows: an APM Entity potentially owes or other APM Entities may only include
foregoes under a payment arrangement eligible clinicians on an Affiliated
414.1420 Other payer advanced APM
criteria.
must be at least: Practitioner List depending on the type
(i) 8 percent of the total revenue from of APM Entity, paragraph (a)(1) of this
(a) Other Payer Advanced APM the payer of providers and suppliers section applies to APM Entities that
criteria. A payment arrangement with a participating in each APM Entity in the may include eligible clinicians on a
payer other than Medicare is an Other payment arrangement if financial risk is Participation List, and paragraph (a)(2)
Payer Advanced APM for an All-Payer expressly defined in terms of revenue; of this section applies to APM Entities
QP Performance Period if CMS or that only include eligible clinicians on
determines that the arrangement meets (ii) At least 3 percent of the expected an Affiliated Practitioner List.
the following criteria during an All- expenditures for which an APM Entity (b) Group or individual determination
Payer QP Performance Period: is responsible under the payment under the Medicare Option. (1) APM
* * * * * arrangement. Entity group determination. Except for
(3) * * * (4) Medicaid Medical Home Model paragraphs (b)(2) and (3) of this section,
(i) Requires APM Entities to bear more nominal amount standard. For a for purposes of the QP determinations
than nominal financial risk if actual Medicaid Medical Home Model to be an for a year, eligible clinicians are
aggregate expenditures exceed expected Other Payer Advanced APM, the total grouped and assessed through their
aggregate expenditures as described in annual amount that an APM Entity collective participation in an APM
paragraph (d) of this section; or potentially owes or foregoes must be at Entity group that is in an Advanced
(ii) Is a Medicaid Medical Home least the following amounts: APM. To be included in the APM Entity
Model that meets criteria comparable to (i) For All-Payer QP Performance group for purposes of the QP
Medical Home Models expanded under Period 2019, 3 percent of the APM determination, an eligible clinicians
section 1115A(c) of the Act as described Entitys total revenue under the payer. APM participant identifier must be
in paragraph (d) of this section. (ii) For All-Payer QP Performance present on a Participation List of an
* * * * * Period 2020, 4 percent of the APM APM Entity group on one of the dates:
(c) Use of quality measures. Entitys total revenue under the payer. March 31, June 30, or August 31 of the
* * * * * (iii) For All-Payer QP Performance Medicare QP Performance Period. An
(2) At least one of the quality Periods 2021 and later, 5 percent of the eligible clinician included on a
measures used in the payment APM Entitys total revenue under the Participation List on any one of these
arrangement must have an evidence- payer. dates is included in the APM Entity
based focus, be reliable and valid, and * * * * * group even if that eligible clinician is
not included on that Participation List (4) * * * determinations are made using claims
at one of the prior or later listed dates. (i) The eligible clinician is included data for the full Medicare QP
CMS performs QP determinations for in more than one APM Entity group and Performance Period even if the eligible
the eligible clinicians in an APM entity none of the APM Entity groups in which clinician participates in one or more
group three times during the Medicare the eligible clinician is included meets Advanced APMs that start or end during
QP Performance Period using claims the QP payment amount threshold or the Medicare QP Performance Period.
data for services furnished from January the QP patient count threshold, or the (d) * * *
1 through each of the respective QP eligible clinician is an Affiliated (1) An eligible clinician is a Partial QP
determination dates: March 31, June 30, Practitioner; and for a year under the Medicare Option if
and August 31. An eligible clinician can (ii) CMS determines that the eligible the eligible clinician is in an APM
only be determined to be a QP if the clinician individually achieves a Entity group that achieves Threshold
eligible clinician appears on the Threshold Score that meets or exceeds Score that meets or exceeds the
Participation List on a date (March 31, the QP payment amount threshold or corresponding Partial QP payment
June 30, or August 31) CMS uses to the QP patient count threshold; unless amount threshold or Partial QP patient
determine the APM Entity group and to (iii) Any of the APM Entities in which count threshold for that Medicare QP
make QP determinations collectively for the eligible clinician participates Performance Period as described in
the APM Entity group based on voluntarily or involuntarily terminates 414.1430(a)(2) and (4). An eligible
participation in the Advanced APM. from the Advanced APM before the end clinician is a Partial QP for the year
(2) Affiliated practitioner individual of the Medicare QP Performance Period. under the All-Payer Combination
determination under the Medicare Option if the individual eligible
* * * * *
Option. For Advanced APMs described clinician achieves a Threshold Score
(6) Advanced APMs that Start or End
in paragraph (a)(2) of this section, QP that meets or exceeds the corresponding
During the Medicare QP Performance
determinations are made individually Partial QP payment amount threshold or
Period. (i) Notwithstanding paragraph
for each eligible clinician. To be Partial QP patient count threshold for
(a) of this section and 414.1435 and
assessed as an Affiliated Practitioner, an that All-Payer QP Performance Period as
414.1440, and except as provided in
eligible clinician must be identified on described in 414.1430(b)(2) and (4).
paragraph (c)(6)(ii) of this section, CMS
an Affiliated Practitioner List on one of (2) Notwithstanding paragraph (d)(1)
makes QP determinations and Partial
the dates: March 31, June 30, or August of this section, an eligible clinician is a
QP determinations for the APM Entity
31 of the Medicare QP Performance Partial QP for a year if:
Period. An eligible clinician included group or individual eligible clinician
(i) The eligible clinician is included
on an Affiliated Practitioner List on any under 414.1425(b) for Advanced APMs
in more than one APM Entity group and
one of these dates is assessed as an that start or end during the Medicare QP
none of the APM Entity groups in which
Affiliated Practitioner even if that Performance Period and that are actively
the eligible clinician is included meets
eligible clinician is not included on the tested for 60 or more continuous days
the corresponding QP or Partial QP
Affiliated Practitioner List at one of the during the Medicare QP Performance
threshold, or the eligible clinician is an
prior or later listed dates. For such Period using claims data for services
Affiliated Practitioner; and
eligible clinicians, CMS performs QP furnished during those dates on which (ii) CMS determines that the eligible
determinations during the Medicare QP the Advanced APM is actively tested. clinician individually achieves a
Performance Period using claims data For Advanced APMs that start active Threshold Score that meets or exceeds
for services furnished from January 1 testing during the Medicare QP the corresponding Partial QP Threshold;
through each of the respective QP Performance Period, CMS performs QP unless
determination dates that the eligible and Partial QP determinations during (iii) Any of the APM Entities in which
clinician is on the Affiliated Practitioner the Medicare QP Performance Period the eligible clinician participates
List: March 31, June 30, and August 31. using claims data for services furnished voluntarily or involuntarily terminates
(3) Individual eligible clinician from the start of active testing of the from the Advanced APM before the end
determination under the All-Payer Advanced APM through each of the QP of the Medicare QP Performance Period.
Combination Option. Eligible clinicians determination dates that occur on or
after the Advanced APM has been * * * * *
are assessed under the All-Payer 21. Section 414.1435 is amended by
Combination Option as set forth in actively tested for 60 or more
revising paragraphs (a) introductory
414.1440. continuous days: March 31, June 30,
text, (a)(1), (2), (b)(1) through (4), (c)(3),
(c) * * * and August 31. For Advanced APMs
and (d) to read as follows:
(3) An eligible clinician is a QP for a that end active testing during the
year under the Medicare Option if the Medicare QP Performance Period, CMS 414.1435 Qualifying APM participant
eligible clinician is in an APM Entity performs QP and Partial QP determination: Medicare option.
group that achieves a Threshold Score determinations using claims data for (a) Payment amount method. The
that meets or exceeds the corresponding services furnished from January 1 or the Threshold Score for an APM Entity or
QP payment amount threshold or QP start of active testing, whichever occurs eligible clinician is calculated as a
patient count threshold for that later, through the final day of active percent by dividing the value described
Medicare QP Performance Period as testing of the Advanced APM for each under paragraph (a)(1) of this section by
described in 414.1430(a)(1) and (3). An of the QP determination dates that occur the value described under paragraph
eligible clinician is a QP for the year on or after the Advanced APM has been
(a)(2) of this section.

under the All-Payer Combination actively tested for 60 or more (1) Numerator. The aggregate of
Option if the individual eligible continuous days during that Medicare payments for Medicare Part B covered
clinician achieves a Threshold Score QP Performance Period: March 31, June professional services furnished by the
that meets or exceeds the corresponding 30, and August 31. APM Entity group to attributed
QP payment amount threshold or QP (ii) For QP determinations specified beneficiaries during the Medicare QP
patient count threshold for that All- under paragraph (c)(4) of this section Performance Period.
Payer QP Performance Period as and Partial QP determinations under (2) Denominator. The aggregate of
described in 414.1430(b)(1) and (3). paragraph (d)(2) of this section, QP payments for Medicare Part B covered
professional services furnished by the paragraphs (b)(2) and (3) of this section eligible clinicians for January 1 through
APM Entity group to all attribution- for an eligible clinician if CMS March 31 and January 1 through June
eligible beneficiaries during the determines that there is at least one 30.
Medicare QP Performance Period. Medicaid APM or Medicaid Medical (2) If the Medicare Threshold Score
* * * * * Home Model that is an Other Payer for an eligible clinician is higher when
(b) * * * Advanced APM available in the county calculated for the APM Entity group
(1) Numerator. The number of where the eligible clinician sees the than when calculated for the individual
attributed beneficiaries to whom the most patients during the All-Payer QP eligible clinician, CMS makes the QP
APM Entity group furnishes Medicare Performance Period, and that the determination under the All-Payer
Part B covered professional services or eligible clinician is eligible to Combination Option using a weighted
is furnished services by a Rural Health participate in the Other Payer Advanced Medicare Threshold Score that will be
Clinic (RHC) or Federally-Qualified APM based on their specialty. factored into an All-Payer Combination
Health Center (FQHC) during the (b) Payment amount method. (1) In Option Threshold Score calculated at
Medicare QP Performance Period. general. The Threshold Score for an the individual eligible clinician level.
(2) Denominator. The number of eligible clinician will be calculated by (e) Information used to calculate
attribution-eligible beneficiaries to dividing the value described under the Threshold Scores under the All-Payer
whom the APM Entity group or eligible numerator by the value described under Combination Option. (1) To request a
clinician furnishes Medicare Part B the denominator as specified in QP determination under the All-Payer
covered professional services or is paragraphs (b)(2) and (3) of this section. Combination Option, an APM Entity or
furnished services by a Rural Health (2) Numerator. The aggregate amount eligible clinician may request that we
Clinic (RHC) or Federally-Qualified of all payments from all payers, except evaluate whether a payment
Health Center (FQHC) during the those excluded under paragraph (a) of arrangement meets the Other Payer
Medicare QP Performance Period. this section, attributable to the eligible Advanced APM criteria as set forth in
(3) Unique beneficiaries. For each clinician under the terms of Advanced 414.1445(b)(2) and may demonstrate
APM Entity group, a unique Medicare APMs and Other Payer Advanced APMs participation in an Other Payer
beneficiary is counted no more than one during the All-Payer QP Performance Advanced APM determined as a result
time for the numerator and no more Period. CMS calculates Medicare Part B of requests made in 414.1445(a) and
than one time for the denominator. covered professional services under the (b)(1) in a form and manner specified by
(4) Beneficiaries count multiple times. All-Payer Combination Option at the CMS.
Based on attribution under the terms of eligible clinician level. (2) To request a QP determination
an Advanced APM, a single Medicare (3) Denominator. The aggregate under the All-Payer Combination
beneficiary may be counted in the amount of all payments from all payers, Option, for each payment arrangement
numerator or denominator for multiple except those excluded under paragraph submitted as set forth in paragraph
different APM Entity groups. (a) of this section, made to the eligible (e)(1), the APM Entity or eligible
(c) * * * clinician during the All-Payer QP clinician must include the amount of
(3) When it is not operationally Performance Period. CMS calculates revenue for services furnished through
feasible to use the final attributed Medicare Part B covered professional the payment arrangement, the total
beneficiary list, the attributed services under the All-Payer revenue received from the all payers
beneficiary list will be taken from the Combination Option at the eligible except those excluded as provided in
Advanced APMs most recently clinician level. paragraph (a)(2) of this section, the
available attributed beneficiary list at (c) Patient count method. (1) In number of patients furnished any
the end of the Medicare QP Performance general. The Threshold Score for an service through the arrangement, and
Period. eligible clinician is calculated by the total number of patients furnished
(d) Use of methods. CMS calculates dividing the value described under the any services, except those excluded as
Threshold Scores for an APM Entity or numerator by the value described under provided in paragraph (a)(2) of this
eligible clinician as provided by the denominator as specified in section, during the All-Payer QP
414.1425(b) under both the payment paragraphs (c)(2) and (3) of this section. Performance Period.
(2) Numerator. The number of unique (f) Requirement to submit sufficient
amount and patient count methods for
patients to whom the eligible clinician information. (1) CMS makes a QP
each Medicare QP Performance Period.
furnishes services that are included in determination with respect to the
CMS then assigns to the eligible
the measures of aggregate expenditures eligible clinician under the All-Payer
clinicians included in the APM Entity
used under the terms of all Advanced Combination Option only if the APM
group or to the eligible clinician the
APMs and Other Payer Advanced APMs Entity or eligible clinician submits the
score that results in the greater QP
during the All-Payer QP Performance information required under paragraphs
status. QP status is greater than Partial
Period. (e)(1) and (2) of this section sufficient
QP status, and Partial QP status is
(3) Denominator. The number of for CMS to assess the eligible clinician
greater than no QP status.
22. Section 414.1440 is amended by
unique patients to whom the eligible under either the payment amount or
revising paragraphs (a)(2), (b), (c), and clinician furnishes services under all patient count as described in paragraphs
(d) and adding paragraphs (e), (f), and non-excluded payers during the All- (b) and (c) of this section.
Payer QP Performance Period. (2) Certification. The APM Entity or
(g) to read as follows:
(d) QP Determinations under the All- eligible clinician who submits
414.1440 Qualifying APM participant Payer Combination Option. (1) Eligible information to request a QP
determination: All-payer combination clinicians are assessed under the All- determination under the All-Payer
option. Payer Combination Option at the Combination Option must certify that
(a) * * * individual level only. CMS performs QP the information submitted to CMS is
(2) Payments and associated patient determinations following the All-Payer true, accurate, and complete. Such
counts under paragraph (a)(1) of this QP Performance Period using payment certification must accompany the
section, are included in the numerator amount and patient count information submission. In the case of information
and denominator as specified in submitted to CMS by APM Entities or submitted by an APM Entity, the
certification must be made by an submits all of the information required (1) Any of the information CMS relied
individual with the authority to bind under this section or does not on in making the QP determination was
the APM Entity. supplement information if the need to inaccurate or misleading.
(g) Notification of QP determination. do so as identified by CMS, then CMS (2) The QP is terminated from an
CMS notifies eligible clinicians will not determine whether the payment Advanced APM or Other Payer
determined to be QPs or Partial QPs for arrangement is an Other Payer Advanced APM during the Medicare QP
a year as soon as practicable after QP Advanced APM. Performance Period, All-Payer QP
calculations are conducted. (2) If an eligible clinician submits Performance Period or Incentive
23. Section 414.1445 is revised to read information showing that a payment Payment Base Period; or
as follows: arrangement requires that the eligible (3) The QP is found to be in violation
clinician must use CEHRT as defined in of the terms of the relevant Advanced
414.1445 Determination of other payer APM or any Federal, State, or tribal
advanced APMs.
414.1305 to document and
communicate clinical care, CMS will statute or regulation during the
(a) Determination of Medicaid APMs. presume that CEHRT criterion in Medicare QP Performance Period, All-
Beginning in 2018, at a time determined 414.1420(b) is satisfied for that Payer Performance Period or Incentive
by CMS, a state, APM Entity, or eligible payment arrangement. Payment Base Period.
clinician may request, in a form and (3) If a payment arrangement has no (c) Information submitted for All-
manner specified by CMS, that CMS outcome measure, the payer, APM Payer Combination Option. Information
determine whether a payer arrangement Entity, or eligible clinician submitting submitted by payers, APM Entities, or
authorized under Title XIX is either a payment arrangement information to eligible clinicians for purposes of the
Medicaid APM or a Medicaid Medical request a determination of whether a All-Payer Combination Option may be
Home Model that meets the Other Payer payment arrangement meets the Other subject to audit by CMS.
Advanced APM criteria prior to the All- Payer Advanced APM criteria must (d) Reducing, Denying, and Recouping
Payer QP Performance Period. certify that there is no available or of APM Incentive Payments.
(b) Determination of Other Payer applicable outcome measure on the (1) CMS may reduce or deny an APM
Advanced APMs. (1) Determination MIPS list of quality measures. Incentive Payment to an eligible
prior to the All-Payer QP Performance (d) Certification. A payer, APM Entity, clinician
Period. Beginning in 2018, a payer with or eligible clinician that submits (i) Who CMS determines is not in
a Medicare Health Plan payment information pursuant to paragraph (c) of compliance with all Medicare
arrangement or a payment arrangement this section must certify that the conditions of participation and the
in a CMS Multi-Payer Model may information it submitted to CMS is true, terms of the relevant Advanced APM in
request, in a form and manner specified accurate, and complete. Such which they participate during the
by CMS, that CMS determine whether a certification must accompany the Medicare QP Performance Period, All-
payment arrangement meets the Other submission. In case of information Payer QP Performance Period, or
Payer Advanced APM criteria under submitted by an APM Entity, the Incentive Payment Base Period;
414.1420 prior to the All-Payer QP certification must be made by an (ii) Who is terminated by an APM or
Performance Period. individual with the authority to bind Advanced APM during the Medicare QP
(2) Determination following the All- the APM Entity. Performance Period, All-Payer QP
Payer QP Performance Period. (e) Timing of Other Payer Advanced Performance Period, or Incentive
Beginning in 2019, an APM Entity or APM determinations. CMS makes Other Payment Base Period; or
eligible clinician may request, in a form Payer Advanced APM determinations (iii) Whose APM Entity is terminated
and manner specified by CMS, that CMS prior to making QP determinations by an APM or Advanced APM for non-
determine whether a payment under 414.1440. compliance with any Medicare
arrangement meets the Other Payer (f) Notification of Other Payer condition of participation or the terms
Advanced APM criteria under Advanced APM determinations. CMS of the relevant Advanced APM in which
414.1420 following the All-Payer QP makes final Other Payer Advanced APM they participate during the Medicare QP
Performance Period. determinations and notifies the Performance Period, All-Payer QP
(i) CMS will not determine that a requesting payer, APM Entity, or Performance Period, or Incentive
payment arrangement is a Medicaid eligible clinician of such determinations Payment Base Period.
APM or a Medicaid Medical Home as soon as practicable following the (2) CMS may reopen, revise, and
Model that meets the Other Payer relevant submission deadline. recoup an APM Incentive Payment that
Advanced APM criteria after the end of 24. Section 414.1460 is amended by was made in error in accordance with
the All-Payer QP Performance Period. revising paragraphs (a) through (e) to procedures similar to those set forth at
(ii) [Reserved] read as follows: 405.980 through 405.986 and
(c) Information Required for 405.370 through 405.379 of this
Determination. (1) For a payer, APM 414.1460 Monitoring and program chapter or as established under the
Entity, or eligible clinician to request integrity. relevant APM.
that CMS determine whether a payment (a) Vetting eligible clinicians. Prior to (e) Maintenance of records. (1) A
arrangement is an Other Payer payment of the APM Incentive Payment, payer that submits information to CMS
Advanced APM, Medicaid APM, or CMS determines if eligible clinicians under 414.1445 for assessment under
Medicaid Medical Home Model that were in compliance with all Medicare the All-Payer Combination Option must
meets the Other Payer Advanced APM conditions of participation and the maintain such books, contracts, records,
criteria, a payer, APM Entity, or eligible terms of the relevant Advanced APMs in documents, and other evidence as
clinician must submit payment which they participated during the necessary to enable the audit of an
arrangement information necessary to Medicare QP Performance Period. A Other Payer Advanced APM
assess the payment arrangement on the determination under this provision is determination. Such information and
Other Payer Advanced APM criteria not binding for other purposes. supporting documentation must be
under 414.1420. If the payer, APM (b) Rescinding QP Determinations. maintained for a period of 10 years after
Entity, or eligible clinician fails to CMS may rescind a QP determination if: submission.
(2) An APM Entity or eligible (ii) There has been a termination, Dated: June 7, 2017.
clinician that submits information to dispute, or allegation of fraud or similar Seema Verma,
CMS under 414.1445 for assessment fault against the APM Entity or eligible Administrator, Centers for Medicare &
under the All-Payer Combination clinician, in which case the APM Entity Medicaid Services.
Option or 414.1440 for QP or eligible clinician must retain records Dated: June 13, 2017.
determinations must maintain such for an additional 6 years from the date Thomas E. Price,
books, contracts, records, documents, of any resulting final resolution of the Secretary, Department of Health and Human
and other evidence as necessary to termination, dispute, or allegation of Services.
enable the audit of an Other Payer fraud or similar fault.
Advanced APM determination, QP Appendix
determinations, and the accuracy of (3) A payer, APM Entity or eligible
clinician that submits information to Note: For previously finalized MIPS
APM Incentive Payments for a period of quality measures, we refer readers to Table A
10 years from the end of the All-Payer CMS under 414.1440 or 414.1445 in the Appendix of the CY 2017 Quality
QP Performance Period or from the date must provide such information and Payment Program final rule (81 FR 77558).
of completion of any audit, evaluation, supporting documentation to CMS upon For previously finalized MIPS specialty
or inspection, whichever is later, unless: request. measure sets, we refer readers to Table E in
(i) CMS determines there is a special the Appendix of the CY 2017 Quality
* * * * *
Payment Program final rule (81 FR 77686).
need to retain a particular record or Except as otherwise proposed below,
group of records for a longer period and previously finalized measures and specialty
notifies the APM Entity or eligible measure sets would continue to apply for the
clinician at least 30 days before the Quality Payment Program year 2 and future
formal disposition date; or years.
TABLE Group A: New Quality Measures Proposed for Inclusion in MIPS for the 2018
Performance Period
.. verage Ch angem. Back P am

AlA . t o11 owmg L urn b ar D.1scect omy /L ammo t omy
Category Description
NQF#: Not Applicable (NA)
Quality#: To Be Determined (TBD)
The average change (preoperative to three months postoperative) in back pain for
Description:
patients 18 years of age or older who had lumbar discectomy I laminotomy procedure.
Measure
MN Community Measurement
Steward:
This measure is not a proportion or rate, and as such, does not have a numerator and
denominator, but has an eligible population with a calculated result. The calculated
Numerator:
result is: The average change (preoperative to three months postoperative) in back pain
for all eligible patients.
Patients 18 years of age or older as of January 1 of the measurement period who had a
lumbar discectomy I laminotomy procedure for a diagnosis of disc herniation performed
Denominator: by an eligible provider in an eligible specialty during the measurement period and
whose back pain was measured by the Visual Analog Scale (VAS) within three months
preoperatively AND at three months (6 to 20 weeks) postoperatively.
Patient who has had any additional spine procedures performed on the same date as the
Exclusions:
lumbar discectomy I laminotomy.
Measure Type: Outcome
Measure
Person and Caregiver-Centered Experience and Outcomes
Domain:
High priority
Yes (Patient Experience)
measure:
Data
Submission Qualified Registry
Method:
CMS proposes to include this measure because it is outcomes focused and provides
measurements related to the variations in improvement after spine surgery. This
measure is useful for patients in evaluating what outcomes can be expected from
Rationale: surgery and clinicians who can conduct comparisons across results. The MAP has made
a recommendation of conditional support, with the conditions of submission to NQF for
endorsement and verification that testing supports implementation at the individual
clinician level (https:/lwww.qualityforum.orglmapl)
EP30JN17.011</GPH>
.. verage Ch angem
A2A . Bac k Pam. f o11 owmg Lurn b ar F US IOn
The average change (preoperative to one year postoperative) in back pain for patients 18
Description:
years of age or older who had lumbar spine fusion surgery.
Measure
Steward:
This measure is not a proportion or rate, and as such, does not have a numerator and
denominator, but has an eligible population with a calculated result.
Numerator:
The calculated result is: The average change (preoperative to one year postoperative) in
back pain for all eligible patients.
lumbar spine fusion surgery performed by an eligible provider in an eligible specialty
Denominator: during the measurement period and whose back pain was measured by the Visual
Analog Scale (VAS) within three months preoperatively AND at one year(+/- 3
months) postoperatively.
Exclusions: None
Measure Type: Outcome
Measure
Domain:
High priority
measure:
Data
Method:
measurements related to the variations in improvement after spine surgery in patients.
This measure is an example of quality measurement as the results can be used in
Rationale: evaluating whether the patient's pain was reduced as a result of the lumbar fusion. The
MAP has made a recommendation of conditional support, with the conditions of
submission to NQF for endorsement and verification that testing supports
implementation at the individual clinician level.(https://www.qualityfomm.org/map/)
EP30JN17.012</GPH>
A3A.. verage Ch angem L eg prn

am o owmg L urn b ar D.1scect omy /L ammo t omy
The average change (preoperative to three months postoperative) in leg pain for patients
Description: 18 years of age or older who had lumbar discectomy I laminotomy procedure.
Measure
Steward:
The average change (preoperative to three months postoperative) in leg pain for all
Numerator:
eligible patients.
lumbar discectomy and/or laminotomy procedure for a diagnosis of disc herniation
performed by an eligible provider in an eligible specialty during the measurement
Denominator:
period and whose leg pain was measured by the Visual Analog Scale (VAS) within
three months preoperatively AND at three months (6 to 20 weeks) postoperatively.
Patient had any additional spine procedures performed on the same date as the lumbar
Exclusions:
discectomyI laminotomy.
Measure
Outcome
Type:
Measure
Domain:
High priority
measure:
Data
Method:
measurements related to the variations in improvement after spine surgery. This
measure is useful for clinicians who can conduct comparisons across results. The MAP
Rationale:
has made a recommendation of conditional support, with the conditions of submission
to NQF for endorsement and verification that testing supports implementation at the
individual clinician level.(https://www.qualityforum.org/map/)
EP30JN17.013</GPH>
A.4. Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen
Depnva. f wn Th erapy
Patients determined as having prostate cancer who are currently starting or undergoing
androgen deprivation therapy (ADT), for an anticipated period of 12 months or greater
Description:
and who receive an initial bone density evaluation. The bone density evaluation must be
prior to the start of ADT or within 3 months of the start of ADT.
Measure Oregon Urology Institute
Steward:
Patients with a bone density evaluation within the two years prior to the start of or less
Numerator:
than three months after the start of ADT treatment.
Patients determined as having prostate cancer who are currently starting or undergoing
Denominator:
androgen deprivation therapy (ADT), for an anticipated period of 12 months or greater.
Exclusions: None
Measure Type: Process
Measure
Effective Clinical Care
Domain:
High priority
No
measure:
Data
Submission EHR
Method:
CMS proposes to include this measure as there are no quality measures that currently
address patients with prostate cancer and a diagnosis of osteoporosis. This measure will
Rationale: result in better care, reduced fractures, and reduced bone density loss. The MAP has
made a recommendation of conditional support, with the condition for the completion of
N QF endorsement. (https://www .qualityfomm.org/map/)
EP30JN17.014</GPH>
"f (POV) - C om b.maf IOn Th erapy (P e d"1at ncs

ASP reven f IOn ofP os t - 0peraf 1ve V Omimg . )
Percentage of patients aged 3 through 17 years, who undergo a procedure under general
anesthesia in which an inhalational anesthetic is used for maintenance AND who have
Description: two or more risk factors for post-operative vomiting (POV), who receive combination
therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of
different classes preoperatively and/or intraoperatively.
Measure
American Society of Anesthesiologists
Steward:
Patients who receive combination therapy consisting of at least two prophylactic
Numerator: pharmacologic anti-emetic agents of different classes preoperatively and/or
intraoperatively.
All patients, aged 3 through 17 years, who undergo a procedure under general anesthesia
Denominator: in which an inhalational anesthetic is used for maintenance AND who have two or more
risk factors for POV.
Cases in which an inhalational anesthetic is used only for induction.
Exclusions:
Organ Donors as designated by ASA Physical Status 6
Measure
Effective Clinical Care
Domain:
High priority
No
measure:
Data
Method:
CMS proposes to include this measure because it recognizes the difference in therapy
required for the pediatric population with regards to the prevention of post-operative
vomiting; furthermore, the American Society of Anesthesiologists have verified that
Rationale: testing supports the implementation of the measure at the individual clinician level. The
MAP has made a recommendation of conditional support, with the conditions of
submission to NQF for endorsement and verification that testing supports implementation
at the individual clinician level.(https://www.qualityfomm.org/map/)
EP30JN17.015</GPH>
A ..
6 OffI IS M e d"Ia WI"th EffUSIOn
. (OME) : S,yst ernie . b"1aI s- A vm"d ance ofi nappropna
. A nf Imicro . te use
NQF#: 657
Percentage of patients aged 2 months through 12 years with a diagnosis ofOME who
Description:
were not prescribed systemic antimicrobials.
Measure American Academy of Otolaryngology- Head and Neck Surgery Foundation
Steward: (AAOHNSF)
Numerator: Patients who were not prescribed systemic antimicrobials.
Denominator: All patients aged 2 months through 12 years with a diagnosis of OME.
Exclusions: Documentation ofmedical reason(s) for prescribing systemic antimicrobials.
Measure
Patient Safety, Efficiency and Cost Reduction
Domain:
High priority
Yes (Appropriate Use)
measure:
Data
Method:
CMS proposes to include this measure as it promotes the practice of appropriate
prescription and usage of medications in the care of all beneficiaries to facilitate health
and promote well-being. The MAP has made a recommendation of support for this NQF
Rationale:
endorsed measure. (https ://www .qualityfomm.org/map/)
EP30JN17.016</GPH>
A.7. Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and

Interrogation of Ovarian Arteries
Documentation of angiographic endpoints of embolization AND the documentation of
Description:
embolization strategies in the presence of unilateral or bilateral absent uterine arteries.
Measure
Society of Interventional Radiology
Steward:
Number of patients undergoing uterine artery embolization for symptomatic leiomyomas
and/or adenomyosis in whom embolization endpoints are documented separately for each
embolized vessel AND ovarian artery angiography or embolization performed in the
presence of variant uterine artery anatomy.
Embolization endpoints: Complete stasis (static contrast column for at least 5 heartbeats)
Numerator:
I Near-stasis (not static, but contrast visible for at least 5 heartbeats) I Slowed flow
(contrast visible for fewer than 5 heartbeats) I Normal velocity flow with pruning of
distal vasculature I Other [specify] I Not documented
Embolization strategy options for variant uterine artery anatomy: Ovarian artery
angiography, Ovarian artery embolization, Abdominal Aortic angiography, None
All patients undergoing uterine artery embolization for symptomatic leiomyomas and/or
Denominator:
adenomyosis.
SIR Guidance: Any patients that should be excluded from reporting either in the eligible
population (denominator) or from both numerator and denominator (if patient
Exclusions:
experiences outcome then exclude from denominator and numerator; if not then include
in denominator). Method to risk adjust measure.
Measure
Patient Safety
Domain:
High priority
Yes (Patient Safety)
measure:
Data
Method:
The MAP has made a recommendation of refine and resubmit based on lack of test data.
CMS proposes to include this measure, as field testing has been completed and there are
Rationale:
currently no applicable uterine artery embolization technique measures in CMS quality
programs. (https://www.qualityfomm.org/map/)
EP30JN17.017</GPH>
A.S. Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life
NQF#: 1516
The percentage of children 3-6 years of age who had one or more well-child visits with a
Description:
PCP during the measurement year.
Measure
National Committee for Quality Assurance
Steward:
Children who received at least one well-child visit with a PCP during the measurement
year. The measurement year (12 month period).
Numerator:
Children 3-6 years of age during the measurement year.

Denominator:
Numerator Exclusions:
Do not include services rendered during an inpatient or ED visit.

Exclusions:
Preventive services may be rendered on visits other than well-child visits. Well-child
preventive services count toward the measure, regardless of the primary intent of the
visit, but services that are specific to an acute or chronic condition do not count toward
the measure.
Measure
Community/Population Health
Domain:
High priority
No
measure:
Data
Method:
This pediatric measure fulfills an important measurement gap for pediatric patients in the
Rationale: 3 through 6 year olds age range; therefore, CMS is proposing its inclusion in the Pediatric
specialty measure set.
EP30JN17.018</GPH>
A.9. Developmental Screening in the First Three Years of Life
NQF#: 1448
The percentage of children screened for risk of developmental, behavioral and social
delays using a standardized screening tool in the first three years of life. This is a measure
Description: of screening in the first three years of life that includes three, age-specific indicators
assessing whether children are screened by 12 months of age, by 24 months of age and by
36 months of age.
Measure
Oregon Health & Science University
Steward:
The numerator identifies children who were screened for risk of developmental,
behavioral and social delays using a standardized tool. National recommendations call for
children to be screened at the 9, 18, and 24- OR 30-month well visits to ensure periodic
screening in the first, second, and third years of life. The measure is based on three, age-
specific indicators.
Numerator 1: Children in Denominator 1 who had screening for risk of developmental,

behavioral and social delays using a standardized screening tool that was documented by
their first birthday.
Numerator: Numerator 2: Children in Denominator 2 who had screening for risk of developmental,
their second birthday.

their third birthday.

their first, second or third birthday.
Children who meet the following eligibility requirement:
Age: Children who tum 1, 2 or 3 years of age between January 1 and December 31 of the
measurement year.
Continuous Enrollment: Children who are enrolled continuously for 12 months prior to
Denominator: child's 1st, 2nd or 3rd birthday.
Allowable Gap: No more than one gap in enrollment of up to 45 days during the
measurement year. To determine continuous enrollment for a Medicaid beneficiary for
whom enrollment is verified monthly, the beneficiary may not have more than a 1-month
gap in coverage (i.e., a beneficiary whose coverage lapses for 2 months (60 days) is not
considered continuously enrolled.
Exclusions: None

Measure
Community/Population Health
Domain:
EP30JN17.019</GPH>
High priority
No
measure:
Data
Method:
This pediatric measure fulfills an important measurement gap related to developmental
Rationale: screening for pediatric patients in the 1 through 3 year olds age range; therefore, CMS is
proposing its inclusion in the Pediatric specialty measure set.
EP30JN17.020</GPH>
TABLE Group B: Proposed New and Modified MIPS Specialty Measure Sets for
the 2018 Performance Period
Note: CMS has proposed to modify the specialty measure sets below based upon review of updates made to existing
quality measure specifications, the proposal of adding new measures for inclusion in MIPS, and the feedback
provided by specialty societies. Existing measures with proposed substantive changes are noted with an asterisk (*),
core measures as agreed upon by Core Quality Measure Collaborative (CQMC) are noted with the symbol (), high
priority measures are noted with an exclamation point(!), and high priority measures that are appropriate use
measures are noted with a double exclamation point(!!) in the colunm.
B 1 All ergy1/1 mmuno ogy

. .
-Data National
CMSE- Measure
NQF Quality Quality Measure Title Measure
Indicator Measure Submission Type
# # Strategy And Description Steward
ID Method .
Domain
Preventive Care and Screening:
Influenza Immunization: Physician
Claims,
Percentage of patients aged 6 Consortirun
Web
Community/ months and older seen for a visit or
110 147v7 Interface, Process
* 0041
Registry,
Population between October 1 and March 31 Performance
Health who received an influenza mprovement
EHR
inununization OR who reported PCPI)
previous receipt of an influenza
inununization.
Claims, National
Pneumonia Vaccination Status for
Web Committee
Community/ Older Adults:
111 127v6 Interface, or
0043 Process Population Percentage of patients 65 years of
Registry, Quality
Health age and older who have ever
EHR Assurance
received a pnerunococcal vaccine.
Documentation of Current
Medications in the Medical
Record:
Percentage of visits for patients
aged 18 years and older for which
the eligible professional attests to
documenting a list of current
Centers for
Claims, medications using all immediate
Patient Medicare &
0419 130 68v7 Registry, Process resources available on the date of
Safety Medicaid
EHR the encounter. This list must include
Services
ALL known prescriptions, over-the-
counters, herbals, and
vitamin/mineral/dietary (nutritional)
supplements AND must contain the
medications' name, dosage,
frequency and route of
administration.
HIV/AIDS: Pneumocystis Jiroveci
National
Pneumonia (PCP) Prophylaxis:
Committee
Percentage of patients aged 6 weeks
160 52v6 EHR Effective or
0405 Process and older with a diagnosis of
Clinical Care Quality
HIV/AIDS who were prescribed
Assurance
Pneumocystis Jiroveci Pneumonia
(PCP) prophylaxis.
EP30JN17.021</GPH>
B 1 All en :y1/1 mmuno ogy ( con f mue d)

National
CMS.~ Data Measure
# # Strategy and Description Steward
ID Method
Domain
Preventive Care and
Screening: Tobacco Use:
Screening and Cessation
Intervention:
a. Percentage of patients aged 18
years and older who were
screened for tobacco use one
or more times within 24
months Physician
Claims, b. Percentage of patients aged ~onsortium
Registry, 18 years and older who were or
* 0028 226 138v6 EHR, Process
Community/Po
screened for tobacco use and Performance
pulation Health
Web identified as a tobacco user mprovement
Interface who received tobacco foundation
cessation intervention PCPI)
c. Percentage of patients aged 18
screened for tobacco use one
or more times within 24
months AND who received
cessation counseling
intervention if identified as a
tobacco user.
Use of High-Risk Medications
in the Elderly:
Percentage of patients 65 years
of age and older who were
ordered high-risk medications. National
Registry, Two rates are reported. f=ommittee for
* 0022 238 156v6 Process Patient Safety
EHR a. Percentage of patients who puality
were ordered at least one high- f"\ssurance
risk medication.
b. Percentage of patients who
were ordered at least two of the
same high-risk medications.
Preventive Care and
Screening: Screening for High
Blood Pressure and Follow-Up
Documented:
Claims, Percentage of patients aged 18 f=enters for
Community /Po
Registry, years and older seen during the ~edicare &
N/A 317 22v6 Process pulation Health
EHR reporting period who were ~edicaid
screened for high blood pressure ~ervices
AND a recommended follow-up
plan is documented based on the
current blood pressure (BP)
reading as indicated.
EP30JN17.022</GPH>
B.l. Allergy/lmmuno ogy (continued)

. .
CMS:Ji:- Data Measure National
Quality Type Quality .Measure Title Measure
Indicator
NQF #
.Measure Submission
Strategy and Descripti()n Steward
# ID Method
Domain
lllV Viral Load
Suppression:
The percentage of patients,
Effective regardless of age, with a Health Resource

2082 338 N/A Registry putcome Clinical diagnosis ofHlV with a HlV and Services
!
Care viral load less than 200 Administration
copies/mL at last HlV viral
load test during the
measurement year.
lllV Medical Visit
Frequency: Percentage of
patients, regardless of age with
Health
Efficiency a diagnosis ofHlV who had at
Resources and
2079 340 N/A Registry Process and Cost least one medical visit in each 6
Services
Reduction month period of the 24 month
Administration
measurement period, with a
minimum of 60 days between
medical visits.
Closing the Referral Loop:
Receipt of Specialist Report:
Communi
Percentage of patients with Centers for
cation and
* N/A 374 50v6
Registry,
Process Care
referrals, regardless of age, for Medicare &
EHR which the referring provider Medicaid
Coordinati
receives a report from the Services
on
provider to whom the patient
was referred.
Tobacco Use and Help with
Quitting Among
Adolescents:
The percentage of adolescents
Communit National
12 to 20 years of age with a
y/ Committee for
N/A 402 N/A Registry Process primary care visit during the
Population Quality
measurement year for whom
Health Assurance
tobacco use status was
documented and received help
with quitting if identified as a
tobacco user.
EP30JN17.023</GPH>
B2 A nes th esw
. I og)
National
CMSE- Data Measure
Quality Quality Measure Xitle Measure
NQF Measure Submis~iun Type
Indicator # Strategy and Description Steward
# ID Method
. Domain .
Coronary Artery Bypass Graft
(CABG): Preoperative Beta-
Blocker in Patients with Isolated Centers for
Effective CABG Surgery: Percentage of Medicare
0236 044 N/A Registry Process Clinical isolated Coronary Artery Bypass &
Care Graft (CABG) surgeries for Medicaid
patients aged 18 years and older Services
who received a beta-blocker within
24 hours prior to surgical incision.
EP30JN17.024</GPH>
. I og: ( confmue d)
B2Anes th esw
CMSE- Data Measure ..
Quality National Quality Measure Title Measure
NQF Measure Submission Type
Indicator # Strategy Domain and Description steward
# ID Method .
Prevention of Central
Venous Catheter
(CVC)-Related
Bloodstream
Infections:
Percentage of patients,
regardless of age, who
undergo central venous
American
Claims, catheter (CVC)
! N/A 076 N/A Process Patient Safety Society of
Registry insertion for whom
Anesthesiologists
eve was inserted with
all elements of maximal
sterile barrier technique,
hand hygiene, skin
preparation and, if
ultrasound is used,
sterile ultrasound
techniques followed.
Preventive Care and
Screening: Tobacco
Use: Screening and
Cessation
Intervention:
a. Percentage of patients
aged 1g years and
older who were
screened for tobacco
use one or more
times within 24
months
b. Percentage of patients
aged 18 years and
Physician
older who were
Claims, Web Consortium for
* 0028 226 138v6
Interface,
Process
Community/
use and identified as
Performance
Registry, Population Health Improvement
a tobacco user who
EHR Foundation
received tobacco
(PCPI)
cessation
intervention
c. Percentage of patients
aged 18 years and
older who were
use one or more
times within 24
months AND who
received cessation
counseling
intervention if
identified as a
tobacco user.
EP30JN17.025</GPH>
. I ogy ( con fmue d)

B2 A nes th esw
MeasUFe National
NQF CMSE Data Submission Type Quality Measure Title Measure
Indicator Quality#
# MeasureiD Method Strategy and Description Steward
Domain .
Preventive Care and
Screening: Screening
for High Blood
Pressure and Follow-
Up Documented:
Percentage of patients
aged 18 years and
Centers for
Community/ older seen during the
Claims, Registry, Medicare &
N/A 317 22v6 Process Population reporting period who
EHR Medicaid
Health were screened for
Services
high blood pressure
AND a recommended
follow-up plan is
documented based on
the current blood
pressure (BP) reading
as indicated.
Tobacco Use and
Help with Quitting
Among Adolescents:
The percentage of
adolescents 12 to 20
years of age with a
National
ComnllmityI primary care visit
Conunittee
N/A 402 N/A Registry Process Population during the
for Quality
Health measurement year for
Assurance
whom tobacco use
status was
documented and
received help with
quitting if identified
as a tobacco user.
Anesthesiology
Smoking
Abstinence: The
American
Intermed percentage of current
Effective Society of
! N/A 404 N/A Registry iate smokers who abstain
Clinical Care Anesthesiolo
Outcome from cigarettes prior
gists
to anesthesia on the
day of elective
surgery or procedure.
EP30JN17.026</GPH>
. I ogy con mue d)

B2 A nes th esw
I National
CMSE- Data Measure
Quality Quality Measure Title Measure
Indicator . # Strategy and Description Steward
# ID Method
Domain
.
Perioperative Temperature
Management: Percentage of patients,
regardless of age, who undergo
surgical or therapeutic procedures
under general or neuraxial anesthesia
American
of 60 minutes duration or longer for
Patient Society of
! 2681 424 N/A Registry Outcome whom at least one body temperature
Safety Anesthesiolo
greater than or equal to 35.5 degrees
gists
Celsius (or 95.9 degrees Fahrenheit)
was recorded within the 30 minutes
immediately before or the 15 minutes
immediately after anesthesia end
time.
Post-Anesthetic Transfer of Care
Measure: Procedure Room to a
Post Anesthesia Care Unit (PACU):
Percentage of patients, regardless of
American
Communicat age, who are under the care of an
Society of
! N/A 426 N/A Registry Process ion and Care anesthesia practitioner and are
Anesthesiolo
Coordination admitted to a PACU in which a post-
gists
anesthetic fonnal transfer of care
protocol or checklist which includes
the key transfer of care elements is
utilized.
EP30JN17.027</GPH>
. I ogy ( con fmue d)

B2 A nes th esw
National
CMSE~. Data Measure
ID Method
.. ' Domain
Post-Anesthetic Transfer of
Care: Use of Checklist or
Protocol for Direct Transfer of
Care from Procedure Room to
Intensive Care Unit (ICU):
Percentage of patients,
regardless of age, who undergo
a procedure under anesthesia
Conununication American
and are admitted to an Intensive
! N/A 427 N/A Registry Process and Care Society of
Care Unit (ICU) directly from
Coordination Anesthesiologists
the anesthetizing location, who
have a documented use of a
checklist or protocol for the
transfer of care from the
responsible anesthesia
practitioner to the responsible
ICU team or team member.
Prevention of Post-Operative
Nausea and Vomiting
(PONV) - Combination
Therapy:
Percentage of patients, aged 18
years and older, who undergo a
procedure under an inhalational
general anesthetic, AND who American
! N/A 430 N/A Registry Process Patient Safety have three or more risk factors Society of
for post-operative nausea and Anesthesiologists
vomiting (PONV), who receive
combination therapy consisting
of at least two prophylactic
pharmacologic antiemetic agents
of different classes
preoperatively or
inlraoperali vely.
Prevention of Post-Operative
Vomiting (POV) -
Combination Therapy
(Pediatrics):
Percentage of patients aged 3
through 17 years of age, who
undergo a procedure under
general anesthesia in which an
American
inhalational anesthetic is used
Effective Society of
N/A TBD N/A Registry Process for maintenance AND who
Clinical Care Anesthesiologists
have two or more risk factors
for post-operative vomiting
(POV), who receive
combination therapy consisting
of at least two prophylactic
pharmacologic anti-emetic
agents of different classes
preoperatively and/or
intraoperatively.
EP30JN17.028</GPH>
.B 3 C ar d"National
10 I ogy
CMSR- Data Measure

NQF Quality Quality Measure title Measure
1D Method
Domain .
Heart Failure (HF): Angiotensin-
Converting Enzyme (ACE)
Inhibitor or Angiotensin Receptor
Blocker (ARB) Therapy for Left
Ventricular Systolic Dysfunction
Physician
(LVSD):
Consortitun tor
Effective Percentage of patients aged 18 years
Registry, Performance
0081 005 135v6 Process Clinical and older with a diagnosis of heart
EHR Improvement
Care failure (HF) with a current or prior
Foundation
left ventricular ejection fraction
(PCPI)
(L VEF) < 40% who were prescribed
ACE inhibitor or ARB therapy either
within a 12-month period when seen
in the outpatient setting OR at each
hospital discharge.
Chronic Stable Coronary Artery
Disease: Antiplatelet Therapy:
American Heart
0067 006 N/A Registry Process Clinical and older with a diagnosis of
Association
Care coronary artery disease (CAD) seen
within a 12-month period who were
prescribed aspirin or clopidogreL
Coronary Artery Disease (CAD):
Beta-Blocker Therapy-Prior
Myocardial Infarction (MI) or Left
Ventricular Systolic Dysfunction Physician
(LVEF<40%): Consortitun for
Effective
Registry, Percentage of patients aged 18 years Performance
0070 007 145v6 Process Clinical
EHR and older with a diagnosis of Improvement
Care
coronary artery disease seen within a Foundation
12-month period who also have prior (PCPI)
MI OR a current or prior L VEF <
40% who were prescribed beta-
blocker therapy.
Heart Failure (HF): Beta-Blocker
Therapy for Left Ventricular
Systolic Dysfunction (LVSD):
Percentage of patients aged 18 years Physician
and older with a diagnosis of heart Consortitun for
Effective
Registry, failure (HF) with a current or prior Performance
EHR left ventricular ejection fraction Improvement
Care
(L VEF) < 40% who were prescribed Foundation
beta-blocker therapy either within a (PCPI)
12-month period when seen in the
outpatient setting OR at each hospital
discharge.
EP30JN17.029</GPH>
B 3 Cardiology (continued)
National
CMSE- Data Measure
NQF Quality Type Quality Measure Title Measure
Indicator Measure Submission
1D Method
Domain .
Care Plan:
years and older who have an
advance care plan or surrogate
National
Communication decision maker documented in
Claims, Committee for
0326 047 N/A Process and Care the medical record that an
Registry Quality
Coordination advance care plan was discussed
Assurance
but the patient did not wish or
was not able to name a surrogate
decision maker or provide an
advance care plan.
Chronic Stable Coronary
Artery Disease: ACE Inhibitor
or ARB Therapy--Diabetes or
Left Ventricular Systolic
Dysfunction (LVEF <40%):
American
Effective years and older with a diagnosis
0066 118 N/A Registry Process Heart
Clinical Care of coronary artery disease seen
Association
within a 12-month period who
also have diabetes OR a current
or prior Left Ventricular Ejection
fraction (L YEP) < 40% who
were prescribed ACE inhibitor or
ARB therapy.
EP30JN17.030</GPH>
B 3 C ar d"10I ogy (con fmue d)

Data Mea sur .
CMSE- Measur
Indicato NQ Qualit Submissio e National Quality Measure title .
Measur .. e
r F.# y# n Type Strategy Domain and Description
Steward
eiD
Method
Preventive Care and
Screening: Body
Mass Index (BMI)
Screening and
Follow-Up Plan:
aged 18 years and
older with a BMI
documented during
Centers
the current encounter
for
Claims, or during the previous
Medicar
* Registry, Community /Populatio twelve months AND
0421 128 69v6 Process e&
EHR, Web n Health with a BMI outside of
Medicai
Interface normal parameters, a
d
follow-up plan is
Services
documented during
the encounter or
during the previous
twelve months of the
current encounter.
Normal Parameters:
Age 18 years and
olderBMI => 18.5
and< 25 kg/m2.
Documentation of
Current Medications
in the Medical
Record: Percentage
of visits for patients
aged 18 years and
older for which the
eligible clinician
attests to documenting
a list of current
Centers
medications using all
for
immediate resources
Claims, Medicar
available on the date
! 0419 130 68v7 Registry, Process Patient Safety e&
of the encounter. This
EHR Medicai
list must include ALL
d
known prescriptions,
Services
over-the-counters,
herbals, and
vitaminlmineral/dietar
y (nutritional)
supplements AND
must contain the
medications' name,
dosage, frequency and
route of
administration.
EP30JN17.031</GPH>
B 3 C ar d'100
I ~Y ( con mue d)
National
CMSE- Data Measure
# # Strategy and D~scription Steward
ID Method
Domain
Ischemic Vascular Disease (IVD):
Use of Aspirin or Another
Antiplatelet:
Percentage of patients 18 years of
age and older who were diagnosed
with acute myocardial infarction
Claims,
(AMI), coronary artery bypass graft National
Web Effective
(CABG) or percutaneous coronary Connnittee for
0068 204 164v6 Interface, Process Clinical
interventions (PCI) in the 12 months Quality
Registry, Care
prior to the measurement period, or Assurance
EHR
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.
Tobacco Use: Screening and
Cessation Intervention:
years and older who were screened
for tobacco use one or more times
within 24 months
Physician
b. Percentage of patients aged 18
Claims, Consortium for
Community years and older who were screened
* 0028 226 l38v6
Registry,
Process /Population for tobacco use and identified as a
Performance
EHR, Web Improvement
Health tobacco user who received tobacco
Interface Foundation
cessation intervention
(PCPI)
within 24 months AND who
received cessation counseling
tobacco user.
Controlling High Blood Pressure:
Percentage of patients 18-85 years of
Claims, National
Inter- Effective age who had a diagnosis of
Registry, Committee for
0018 236 165v6 mediate Clinical hypertension and whose blood
EHR, Web Quality
Outcome Care pressure was adequately controlled
Interface Assurance
(<140/90 mmHg) during the
measurement period.
EP30JN17.032</GPH>
B 3 Cardiology (continued)
CMSE- Data Measure
NQF Quality National Quality Measure Title Measure
# #
ID Method
Strategy Domain and Des~;ription Steward
Use of High-Risk Medications

in the Elderly:
Percentage of patients 65 years
of age and older who were
ordered high-risk medications. National
Registry, Two rates are reported. Committee for
* 0022 238 156v6 Process Patient Safety
EHR a. Percentage of patients who Quality
were ordered at least one high- Assurance
risk medication.
were ordered at least two of the
same high-risk medications.
Cardiac Rehabilitation
Patient Referral from an
Outpatient Setting:
Percentage of patients evaluated
in an outpatient setting who
within the previous 12 months
have experienced an acute
myocardial infarction (MI),
coronary artery bypass graft
(CABG) surgery, a
American
Communication percutaneous coronary
College of
0643 243 N/A Registry Process and Care intervention (PC I), cardiac
Cardiology
Coordination valve surgery, or cardiac
Foundation
transplantation, or who have
chronic stable angina (CSA)
and have not already
participated in an early
outpatient cardiac
rehabilitation/secondary
prevention (CR) program for
the qualifying event/diagnosis
who were referred to a CR
program.
EP30JN17.033</GPH>
B 3 C ar d"10I og, (con fmue d)

Data
Quality . CMSE- Measure National Quality Measure Title Measure
Ind.icator NQF# Submissio.n
# MeasureiD Type Strategy Domain and Description Steward
Method
.
Preventive Care and
Screening:
Screening for High
Blood Pressure and
Follow-Up
Documented:
Centers for
Claims, aged 18 years and
Community/Popu Medicare &
N/A 317 22v6 Registry, Process older seen during the
lation Health Medicaid
EHR reporting period who
Services
were screened for
high blood pressure
AND a recommended
follow-up plan is
documented based on
the current blood
pressure (BP).
Cardiac Stress
Imaging Not
Meeting
Appropriate Use
Criteria:
Preoperative
Evaluation in Low-
Risk Surgery
Patients:
Percentage of stress
single-photon
emission computed
tomography (SPECT)
myocardial perfusion American
Efficiency and
!! N/A 322 N/A Registry Efficiency imaging (MPI), stress College of
Cost Reduction
echocardiogram Cardiology
(ECHO), cardiac
computed
tomography
angiography (CCTA),
or cardiac magnetic
resonance (CMR)
performed in low risk
surgery patients 18
years or older for
preoperative
evaluation during the
12-month reporting
period.
EP30JN17.034</GPH>
B 3 C ar d'100
I ~Y ( con mue d)
..
NatiQnal
CMSE Data
NQF Quality Measure Quality Measure Title Measure
# # Type Strategy and Description Steward
ID Method
Domain
Cardiac Stress Imaging Not
Meeting Appropriate Use
Criteria: Routine Testing After
Percutaneous Coronary
Intetvention (PCI):
Percentage of all stress single-
photon emission computed
tomography (SPECT) myocardial
Efficiency American
perfusion imaging (MPI), stress
!! N/A 323 N/A Registry Efficiency and Cost College of
echocardiogram (ECHO), cardiac
Reduction Cardiology
computed tomography angiography
(CCTA), and cardiovascular
magnetic resonance (CMR)
performed in patients aged 18 years
and older routinely after
percutaneous coronary intervention
(PCI), with reference to timing of
test after PCI and symptom status.
Cardiac Stress Imaging Not
Meeting Appropriate Use
Criteria: Testing in
Asymptomatic, Low-Risk
Patients: Percentage of all stress
single-photon emission computed
tomography (SPECT) myocardial
Efficiency perfusion imaging (MPI), stress American
!! N/A 324 N/A Registry Efficiency and Cost echocardiogram (ECHO), cardiac College of
Reduction computed tomography angiography Cardiology
(CCTA), ami cardiovascular
magnetic resonance (CMR)
performed in asymptomatic, low
coronary heart disease (CHD) risk
patients 18 years and older for
initial detection and risk
assessment
Chronic Anticoagulation
Therapy: Percentage of patients
aged 18 years and older with a
diagnosis of nonvalvular atrial
fibrillation (AF) or atrial flutter
whose assessment of the specified
thromboembolic risk factors American
N/A Claims, Effective
1525 326 Process indicate one or more high-risk College of
Registry Clinical Care
factors or more than one moderate Cardiology
risk factor, as determined by
CHADS2 risk stratification, who
are prescribed warfarin OR another
oral anticoagulant drug that is FDA
approved for the prevention of
thromboembolism.
EP30JN17.035</GPH>
B 3 C ar d'100
I ~Y ( con mue d)
National
CMSE- Data
ID Method
.. Domain
Rate of Carotid Artery Stenting
(CAS) for Asymptomatic Patients,
Without Major Complications
Effective (Discharged to Home by Post- Society for
! N/A 344 N/A Registry Outcome Clinical Operative Day #2): Vascular
Care Percent of asymptomatic patients Surgeons
undergoing CAS who are discharged
to home no later than post-operative
day #2.
Rate of Postoperative Stroke or
Death in Asymptomatic Patients
Undergoing Carotid Artery
Effective Society for
Stenting (CAS):
! N/A 345 N/A Registry Outcome Clinical Vascular
Percent of asymptomatic patients
Care Surgeons
undergoing CAS who experience
stroke or death following surgery
while in the hospitaL
Hypertension: Improvement in
Blood Pressure:
Centers for
Intermed Effective Percentage of patients aged 18-85
Medicare &
N/A 373 ~5v7 EHR iate Clinical years of age with a diagnosis of
Medicaid
Outcome Care hypertension whose blood pressure
Services
improved during the measurement
period.

Communica Receipt of Specialist Report:
Centers for
tion and Percentage of patients with referrals,
* N/A 374 50v6
Registry,
Process Care regardless of age, for which the
Medicare &
! EHR Medicaid
Coordinatio referring provider receives a report
Services
n from the provider to whom the
patient was referred.
Quitting Among Adolescents:
The percentage of adolescents 12 to
National
Community 20 years of age with a primary care
Committee for
N/A 402 N/A Registry Process /Population visit during the measurement year
Quality
IIealth for whom tobacco use status was
Assurance
documented and received help with
quitting if identified as a tobacco
user.
Unhealthy Alcohol Use: Screening
& Brief Counseling:
Physician
Percentage of patients aged 18 years
Consortium for
and older who were screened for
Population/ Performance
2152 431 N/A Registry Process unhealthy alcohol use using a
Community Improvement
systematic screening method at least
Foundation
once within the last 24 months AND
(PCPI)
who received brief counseling if
identified as an unhealthy alcohol
user.
EP30JN17.036</GPH>

... National
CMSE- Data
NQF Quality Measure Quality Measure Title . Measure
ln<licator Measure Submission
ID Method .
Domain
Statin Therapy for the
Prevention and
Treatment of
Cardiovascular
Disease:
Percentage of the
following patients-all
considered at high risk
of cardiovascular
events-who were
prescribed or were on
statin therapy during
the measurement
period:
o Adults aged 2: 21 Centers for
Web
Effective years who were Medicare
Interface,
* N/A 438 347vl
Registry,
Process Clinical previously diagnosed &
Care with or currently have Medicaid
EHR
an active diagnosis of Services
clinical atherosclerotic
cardiovascular disease
(ASCVD); OR
o Adults aged 2:21 years
who have ever had a

fasting or direct low-
density lipoprotein
cholesterol (LDL-C)
level2: 190 mg/dL; OR
o Adults aged 40-75
years with a diagnosis

of diabetes with a
fasting or direct LDL-C
level of70-189 mg/dL
EP30JN17.037</GPH>

...
CMSE- . Data .
NQF Measure National Quality Measure Title Measure
IJidicator Q\lality# Measure Submission
# Type Strategy Domain and Description Steward
.
ID .. MethOd
Ischemic Vascular
Disease All or None
Outcome Measure
(Optimal Control): The
IVD All-or-None Measure
is one outcome measure
(optimal control). The
measure contains four
goals. All four goals
within a measure must be
reached in order to meet
that measure. The
numerator for the all-or-
none measure should be
collected from the Wisconsin
organization's total IVD Collaborativ
Intermed denominator.
Effective Clinical e for
N/A 441 N/A Registry iate All-or-None Outcome
! Care Healthcare
Outcome Measure (Optimal Quality
Control) (WCHQ)
Using the IVD
denominator optimal
results include: Most
recent blood pressure
(BP) measurement is
less than 140/90 mm Hg
And Most recent
tobacco status is
Tobacco Free
And Daily Aspirin or
Other Antiplatelet
Unless Contraindicated
And
Statin Use.
Persistent Beta Blocker
Treatment After a Heart
Attack:
The percentage of patients
18 years of age and older
during the measurement
year who were
hospitalized and
National
discharged from July 1 of
Registry Process Effective Clinical Committee
0071 442 N/A the year prior to the
Care for Quality
measurement year to June
Assurance
30 of the measurement
year with a diagnosis of
acute myocardial
infarction (AMI) and who
received were prescribed
persistent beta-blocker
treatment for six months
after discharge.
EP30JN17.038</GPH>
B.3a. Electrophysiology Cardiac Specialist (Subspecialty Set of B.3 Cardiology)

Note: Each subspecialty set is effectively a separate specialty set. In instances where an Individual MIPS
eligible clinician or group reports on specialty or subspecialty set, if the set has less than six measures that
is all the clinician is required to report.
National
CMSE~ Data
NQF Quality Measun:: Quality Measure Title Measure
# # type Strategy and Description Steward
ID Method
Domain
HRS-3: Implantable
Cardioverter-Defibrillator
(JCD) Complications Rate:
The Heart
Patients with physician-specific
! N/A 348 N/A Registry Outcome Patient Safety Rhythm
risk-standardized rates of
Society
procedural complications
following the first time
implantation of an ICD.
HRS-12: Cardiac Tamponade
and/or Pericardiocentesis
Following Atrial Fibrillation
Ablation: Rate of cardiac
tamponade and/or
pericardiocentesis following atrial
fibrillation ablation
The Heart
This measure is reported as four
! 2474 392 N/A Registry Outcome Patient Safety Rhythm
rates stratified by age and gender:
Society
o Reporting Age Criteria 1:
Females less than 65 years of age

o Reporting Age Criteria 2: Males
less than 65 years of age

o Reporting Age Criteria 3:
Females 65 years of age and older

o Reporting Age Criteria 4: Males
65 years of age and older.

HRS-9: Infection within 180
Days of Cardiac Implantable
Electronic Device (CIED) The Heart
! N/A 393 N/A Registry Outcome Patient Safety Implantation, Replacement, or Rhythm
Revision: Infection rate following Society
CIED device implantation,
replacement, or revision.
EP30JN17.039</GPH>
.. Gastroentero ogy
B4
National
CMSE- Data
Indicator Measure Sqbmission
# # Type Strategy and Description . Steward
1D Method
Domain
Care Plan:
National
Communication decision maker documented in
Claims, Cmmnittee
0326 047 N/A Process and Care the medical record that an
Registry for Quality
Coordination advance care plan was
Assurance
discussed but the patient did not
wish or was not able to name a
surrogate decision maker or
Preventive Care and
Screening: Body Mass Index
(BMI) Screening and Follow-
Up Plan:
years and older with a BMl
documented during the current
Claims, encounter or during the Centers for
* 0421 128 69v6
Registry,
Process
Community /Pop previous twelve months AND Medicare &
EHR, Web ulation Health with a BMI outside of normal Medicaid
Interface parameters, a follow-up plan is Services
documented during the
encounter or during the
previous twelve months of the
current encounter.
Normal Parameters:
Age 18 years and older BMI =>
18.5 and< 25 kg/m2.
Record: Percentage of visits
for patients aged 18 years and
older for which the eligible
clinician attests to documenting
a list of current medications
using all innnediate resources Centers for
Claims,
available on the date of the Medicare &
! 0419 130 68v7 Registry, Process Patient Safety
encounter. This list must Medicaid
EHR
include ALL known Services
prescriptions, over-the-
vitamin/mineral/dietary
(nutritional) supplements AND
must contain the medications'
name, dosage, frequency and
route of administration.
EP30JN17.040</GPH>
B4 Gas t roen t ero ogy ( con fmue d)

National
CMSE- Data
Indicator
NQF Quality
Measure Submission
Measure Quality Measure Title Measure
ID Method
Domain
Gastroenterol
Colonoscopy Interval for Patients
ogical
with a History of Adenomatous
Association/
Polyps- Avoidance of
American
Inappropriate Use: Percentage of
Society for
Communicat patients aged 18 years and older
Claims, Gastro-
!! 0659 185 N/A Process ion and Care receiving a surveillance
Registry intestinal
Coordination colonoscopy, with a history of a
Endoscopy/
prior adenomatous polyp(s) in
American
previous colonoscopy findings, who
College of
had an interval of 3 or more years
Gastro-
since their last colonoscopy.
enterology
within 24 months Physician
b. Percentage of patients aged 18 Consortium
Claims,
Community/ years and older who were screened for
* 0028 226 138v6
Registry,
Process Population for tobacco use and identified as a Performance
EHR, Web
Health tobacco user who received tobacco Improvement
Interface
cessation intervention Foundation
c. Percentage of patients aged 18 (PCPI)
tobacco user.
Inflammatory Bowel Disease
(IBD): Preventive Care:
Corticosteroid Related Iatrogenic
Injury- Bone Loss Assessment:
and older with an inflammatory
American
bowel disease encounter who were
Effective Gastro-
N/A 271 N/A Registry Process prescribed prednisone equivalents
Clinical Care enterologial
greater than or equal to 10 mg/day
Association
for 60 or greater consecutive days or
a single prescription equating to
600mg prednisone or greater for all
fills and were documented for risk of
bone loss once during the reporting
year or the previous calendar year.
EP30JN17.041</GPH>

National
CMSE- Data .Measure
Indicator NQF Measure Submission Type
# Strategy and Description .. Steward
# ID Method
Domain
Inflammatory Bowel Disease
(IBD): Assessment of Hepatitis B
Virus (HBV) Status Before
Initiating Anti-TNF (Tumor
Necrosis Factor) Therapy:
American
Effective Gastro-
N/A 275 N/A Registry Process years and older with a diagnosis of
Clinical Care enterological
inflammatory bowel disease (IBD)
Association
who had Hepatitis B Virus (HBV)
status assessed and results
interpreted within one year prior to
receiving a first course of anti-TNF
(tumor necrosis factor) therapy.
Screening for High Blood
Pressure and Follow-Up
Documented:
Community Percentage of patients aged 18 Centers for
Claims,
Process /Population years and older seen during the Medicare &
N/A 317 22v6 Registry,
Health reporting period who were screened Medicaid
EHR
for high blood pressure AND a Services
recommended follow-up plan is
documented based on the current
blood pressure (BP) reading as
indicated.
American
Appropriate Follow-Up Interval Gastroenterol
for Normal Colonoscopy in ogical
Average Risk Patients: Percentage Association/
of patients aged 50 to 75 years of American
Communicat age receiVmg a screerung Society for
Claims,
0658 320 N/A Process ion and Care colonoscopy without biopsy or Gastro-
!! Registry
Coordination polypectomy who had a intestinal
recommended follow-up interval of Endoscopy/
at least I 0 years for repeat American
colonoscopy documented in their College of
colonoscopy report. Gastro-
enteroloQ;y
Screening Colonoscopy Adenoma
Detection Rate Measure: The
American
percentage of patients age 50 years
Effective College of
N/A 343 N/A Registry Outcome or older with at least one
! Clinical Care Gastru-
conventional adenoma or colorectal
enterology
cancer detected during screening
colonoscopy.

Centers for
Communicat Percentage of patients with
* N/A 374 50v6
Registry,
Process ion and Care referrals, regardless of age, for
Medicare &
! EHR Medicaid
Coordination which the referring provider
Services
receives a report from the provider
to whom the patient was referred.
EP30JN17.042</GPH>

National
CMSE- Data
Quality Measure Quality Measure Title Measure
llldicator NQF Measure Submissiop
# Type Strategy a.nd Description Steward
# ID Method
Domain ..
Hepatitis C: Discussion and
Shared Decision Making
Surrounding Treatment Options:
years and older with a diagnosis of
hepatitis C with whom a physician
or other qualified healthcare
professional reviewed the range of American
treatment options appropriate to Gastro-
Person and their genotype and demonstrated a enterological
Caregiver- shared decision making approach Association/
! N/A 390 N/A Registry Process Centered with the patient Physician
Experience To meet the measure, there must be Consortium
and Outcomes documentation in the patient record for
of a discussion between the Performance
physician or other qualified Improvement
healthcare professional and the
patient that includes all of the
following: treatment choices
appropriate to genotype, risks and
benefits, evidence of effectiveness,
and patient preferences toward
treatment
Hepatitis C: Screening for
Hepatocellular Carcinoma
American
(HCC) in Patients with Cirrhosis:
Gastro-
enterological
Association/
Effective chronic hepatitis C cirrhosis who
N/A 401 N/A Registry Process Physician
Clinical Care underwent imaging with either
Consortium
ultrasound, contrast enhanced CT
for
or MRI for hepatocellular
Performance
c<:Jn.:inoma (HCC) alleasl once
Improvement
within the 12 month reporting
period.
EP30JN17.043</GPH>

National
CMSE- Data
NQF Quality Measure Quality Measure. Title Measure
m Method
Domain
National
Connmmity 20 years of age with a primary care
Commillee
N/A 402 N/A Registry Process I Population visit during the measurement year for
for Quality
Health whom tobacco use status was
Assurance
user.
Photodocumentation of Cecal
Intubation:
f'\merican
Effective The rate of screening and surveillance
Claims, Society for
N/A 425 N/A Process Clinical colonoscopies for which photo
Registry pastrointestinal
Care documentation of landmarks of cecal
~ndoscopy
intubation is performed to establish a
complete examination.
& Brief Counseling: Physician
Percentage of patients aged 18 years Consortium for
Connnunity and older who were screened for Performance
2152 431 N/A Registry Process I Population unhealthy alcohol use using a Improvement
Health systematic screening method at least Foundation
once within the last 24 months AND (PCPI)
user.
American
Gastro-
enterological
Association/
Age Appropriate Screening
American
Colonoscopy: The percentage of
Efficiency Society for
Efficienc patients greater than 85 years of age
N/A 439 N/A Registry and Cost Gastro-
!! y who received a screening
Reduction intestinal
colonoscopy from January 1 to
Endoscopy/
December 31.
American
College of
Gastro-
enteroloQ;y
EP30JN17.044</GPH>
B5 Dermato ogy
National
CMS.E- Data
lndicator Measure Submission
.
ID Method
Domain
Medications in the Medical Record:
Percentage of visits for patients aged
18 years and older for which the
eligible clinician attests to
docmnenting a list of current
medications using all inunediate Centers for
Claims,
Patient resources available on the date of the Medicare &
! 0419 130 68v7 Registry, Process
Safety encounter. This list must include ALL Medicaid
EHR
known prescriptions, over-the- Services
administration.
Melanoma: Continuity of Care-
Recall System: Percentage of
patients, regardless of age, with a
current diagnosis of melanoma or a
history of melanoma whose
information was entered, at least once
Communicat within a 12-month period, into a American
! 0650 137 N/A Registry Structure ion and Care recall system that includes: Academy of
Coordination o A target date for the next complete Dermatology
physical skin exam, AND
o A process to follow up with patients
who either did not make an

appointment within the specified
timeframe or who missed a scheduled
appointment
Melanoma: Coordination of Care:
Percentage of patients visits,
regardless of age, with a new
Communicat American
occmrence of melanoma, who have a
! N/A 138 N/A Registry Process ion and Care Academy of
treatment plan documented in the
Coordination Dermatology
chart that was communicated to the
physician(s) providing continuing
care within one month of diagnosis.
Melanoma: Overutilization of
Imaging Studies in Melanoma:
age, with a current diagnosis of stage
0 through IIC melanoma or a history
Efficiency American
of melanoma of any stage, without
!! 0562 224 N/A Registry Process and Cost Academy of
signs or symptoms suggesting
Reduction Dermatology
systemic spread, seen for an office
visit during the one-year
measurement period, for whom no
diagnostic imaging studies were
ordered.
EP30JN17.045</GPH>
B5 D ermat oI ogy con fmue d)

National
CMSE- Data
# # '}'ype Strategy and Description Steward
ID Method
Domain
Claims,
Community years and older who were screened for
* 0028 226 138v6
Registry,
Process /Population for tobacco use and identified as a Performance
EHR, Web
Interface
tobacco user.
Biopsy Follow-Up:
Communica
Percentage of new patients whose
tionand American
biopsy results have been reviewed
! N/A 265 N/A Registry Process Care Academy of
and communicated to the primary
Coordinatio Dermatology
care/reterring physician and patient
n
by the performing physician.
Screening for High Blood Pressure
and Follow-Up Documented:
Community Percentage of patients aged 18 years Centers for
Claims,
Process /Population and older seen during the reporting Medicare &
Health period who were screened for high Medicaid
EHR
blood pressure AND a recommended Services
follow-up plan is documented based
on the curTent blood pressure (BP)
Tuberculosis (TB) Prevention for
Psoriasis, Psoriatic Arthritis and
Rheumatoid Arthritis Patients on a
Biological Immune Response
Modifier:
Effective Percentage of patients whose American
N/A 337 N/A Registry Process Clinical providers are ensuring active Academy of
Care tuberculosis prevention either through Dermatology
yearly negative standard tuberculosis
screening tests or are reviewing the
patient's history to detem1ine if they
have had appropriate management for
a recent or prior positive test
EP30JN17.046</GPH>
B5 D ermat oI ogy con fmue d)

National
CMSE- Data
ID Method
Domain
Centers for
Connnunicat Percentage of patients with refenals,
* N/A 374 50v6
Registry,
Process ion and Care regardless of age, for which the
Medicare &
! EHR Medicaid
Coordination refening provider receives a report
Services
from the provider to whom the
patient was refened.
National
Commlmity/ 20 years of age with a primary care
Committee
N/A 402 N/A Registry Process Population visit during the measurement year
for Quality
Health for whom tobacco usc status was
Assurance
user.
Psoriasis: Clinical Response to
Oral Systemic or Biologic
Medications :
Percentage of psoriasis patients
receiving oral systemic or biologic
Person and
therapy who meet minimal
Caregiver
physician- or patient-reported American
Centered
! N/A 410 N/A Registry Outcome disease activity levels. It is implied Academy of
Experience
that establishment and maintenance Dermatology
and
of an established minimum level of
Outcomes
disease control as measured by
physician- and/or patient-reported
outcomes will increase patient
satisfaction with and adherence to
treatment
Basal Cell Carcinoma
(BCC)/Squamous Cell
Carcinoma: Biopsy Reporting
Time- Pathologist to Clinician:
Percentage of biopsies with a
Communicat American
diagnosis of cutaneous Basal Cell
N/A 440 N/A Registry Process ion and Care Academy of
Carcinoma (BCC) and Squamous
Coordination Dermatology
Cell Carcinoma (SCC) (including in
situ disease) in which the
pathologist communicates results to
the clinician within 7 days of biopsy
date.
EP30JN17.047</GPH>
B6 Emergency M e d".
ICllle
National
CMSE- Data
lD Method
Domain
Appropriate Testing for Children
with Pharyngitis:
National
Efficiency Percentage of children 3-18 years of
Registry, Committee
!! N/A 066 146v6 Process and Cost age who were diagnosed with
EHR for Quality
Reduction pharyngitis, ordered an antibiotic and
Assurance
received a group A streptococcus
(strep) test for the episode.
Acute Otitis Extema (AOE):

American
Topical Therapy:
Effective Academy of
Claims, Percentage of patients aged 2 years
!! 0653 091 N/A Process Clinical Ololaryngolo
Registry and older with a diagnosis of AOE
Care gy-Headand
who were prescribed topical
Neck Surgery
preparations.

Systemic Antimicrobial Therapy- American
Efficiency Avoidance of Inappropriate Use: Academy of
Claims,
!! 0654 093 N/A Process and Cost Percentage of patients aged 2 years Otolaryngolo
Registry
Reduction and older with a diagnosis of AOE gy-Headand
who were not prescribed systemic Neck Surgery
antimicrobial therapy.
Adult Major Depressive Disorder
(MDD): Suicide Risk Assessment: Physician
Percentage of patients aged 18 years Consortium
Effective and older with a diagnosis of major for
0104 107 161v6 EHR Process Clinical depressive disorder (MDD) with a Performance
Care suicide risk assessment completed Improvement
during the visit in which a new Foundation
diagnosis or recurrent episode was (PCPI)
identified.
Avoidance of Antibiotic Treatment

in Adults with Acute Bronchitis: National
Efficiency
Percentage of adults 18-64 years of Committee
0058 116 N/A Registry Process and Cost
!! age with a diagnosis of acute for Quality
Reduction
bronchitis who were not dispensed an Assurance
antibiotic prescription.
Stroke and Stroke Rehabilitation:

Thrombolytic Therapy:
Effective and older with a diagnosis of acute American
N/A 187 N/A Registry Process Clinical ischemic stroke who arrive at the Heart
Care hospital within two hours of time last Association
known well and for whom IV t-PA
was initiated within three hours of
time last known well.
EP30JN17.048</GPH>
.. mergency Me dICllle
B6E .. conf mue d)
National
CMSE- Data
ID Method
Domain
Ultrasound Determination of
Pregnancy Location for Pregnant
Patients with Abdominal Pain:
Percentage of pregnant female
American
Effective patients aged 14 to 50 who present to
Claims, College of
0651 254 N/A Process Clinical the emergency department (ED) with
Registry Emergency
Care a chief complaint of abdominal pain
Physicians
or vaginal bleeding who receive a
trans-abdominal or trans-vaginal
ultrasound to determine pregnancy
location.
Rh Immunoglobulin (Rhogam) for
Rh-Negative Pregnant Women at
Risk of Fetal Blood Exposure: American
Effective
Claims, Percentage ofRh-negative pregnant College of
N/A 255 N/A Process Clinical
Registry women aged 14-50 years at risk of Emergency
Care
fetal blood exposure who receive Rh- Physicians
Immunoglobulin (Rhogam) in the
emergency department (ED).
Claims, Community Percentage of patients aged 18 years Centers for
Registry, /Population and older seen during the reporting Medicare &
N/A 317 22v6 Process
EHR Health period who were screened for high Medicaid
on the current blood pressure (BP)
Adult Sinusitis: Antibiotic
Prescribed for Acute Sinusitis
~merican
(Overuse):
Efficiency ~cademy of
Percentage of patients, aged 18 years
!! N/A 331 N/A Registry Process and Cost ptolaryngology-
and older, with a diagnosis of acute
Reduction ~ead and Neck
sinusitis who were prescribed an
Surgery
antibiotic within 10 days after onset
of svmptoms.
Adult Sinusitis: Appropriate
Choice of Antibiotic: Amoxicillin
With or Without Clavulanate
Prescribed for Patients with Acute
~merican
Efficiency Bacterial Sinusitis (Appropriate
~cademy of
and Cost Use):
!! N/A 332 N/A Registry Process ptolaryngology-
Reduction Percentage of patients aged 18 years
~ead and Neck
and older with a diagnosis of acute
Surgery
bacterial sinusitis that were
prest.:ribecl amuxit.:illin, with or
without clavulante, as a first line
antibiotic at the time of diagnosis.
EP30JN17.049</GPH>
B.6. Emergency Medicine continued)

National
CMSE:- Data
Indicator Measu~ Submission
ID Method
Domain
Adult Sinusitis: Computerized
Tomography (CT) for Acute
Sinusitis (Overuse):
American
Efficiency Academy of
Efficienc and older with a diagnosis of acute
!! N/A 333 N/A Registry and Cost Otolaryngology
y sinusitis who had a computerized
Reduction -Head and
tomography (CT) st.:an of the
Neck Surgery
paranasal sinuses ordered at the time
of diagnosis or received within 28
days after date of diagnosis.
Emergency Medicine: Emergency
Department Utilization of CT for
Minor Blunt Head Trauma for
Patients Aged 18 Years and Older:
Percentage of emergency department
American
Et1iciency visits for patients aged 18 years and
Claims, Efficienc College of
N/A 415 N/A and Cost older who presented within 24 hours
Registry y Emergency
Reduction of a minor blunt head trauma with a
Physicians
Glasgow Coma Scale (GCS) score of
15 and who had a head CT for trauma
ordered by an emergency care
provider who have an indication for a
head CT.
Emergency Medicine: Emergency
Department Utilization of CT for
Minor Blunt Head Trauma for
Patients Aged 2 through 17 Years:
Percentage of emergency department
visits for patients aged 2 through 17
years who presented within 24 hours American
Efficiency
Claims, Efficienc of a minor blunt head trauma with a College of
!! N/A 416 N/A and Cost
Registry y Glasgow Coma Scale (GCS) score of Emergency
Reduction
15 and who had a head CT for trauma Physicians
ordered by an emergency care
provider who are classified as low
risk according to the Pediatric
Emergent.:y Care Applied Researt.:h
Network(PECARN) prediction rules
for traumatic brain injury.
EP30JN17.050</GPH>
B ..
7 F amuv
1 M e dICllle
. .
National
CMSE- Data
Quality Measure Quality Measure Title Measure.
Indicator N.QF Measure SQbmission
# Type Strategy and Description Steward
# ID Metlwd
Domain
Diabetes: Hemoglobin Ale

Claims,
(HbAlc) Poor Control (>9%): National
Weh Tntennedi
Effective Percentage of patients 18-75 years Connnittee for
0059 001 122v6 Interface, ate
! Clinical Care of age with diabetes who had Quality
Registry, Outcome
hemoglobinAlc > 9.0% during the Assurance
EHR measurement period.
EP30JN17.051</GPH>
"I M e d".
B7F amuy ICllle ( con fmue d)
National
CMSE- Data
NQF Quality Measure Quality Measure Title Meas~Jre
Indicator Measqre Submission
ID Method
Domain
Physician
(LVSD):
Consortium for
Registry, Effective Performance
0081 005 135v6 Process and older with a diagnosis of heart
EHR Clinical Care Improvement
failure (HF) with a current or prior
Foundation
left ventricular ejection fraction
(PCPI)
(L VEF) < 40% who were prescribed
ACE inhibitor or ARB therapy
either within a 12-month period
when seen in the outpatient setting
OR at each hospital discharge.
Disease: Antiplatelet Therapy:
Percentage of patients aged 18 years American
Effective
0067 006 N/A Registry Process and older with a diagnosis of Heart
Clinical Care
coronary artery disease (CAD) seen Association
within a 12-month period who were
prescribed aspirin or clopidogrel.
Myocardial Infarction (MI) or
Left Ventricular Systolic Physician
Dysfunction (LVEF <40%): Consortium for
Registry, Effective Percentage of patients aged 18 years Performance
0070 007 145v6 Process
EHR Clinical Care and older with a diagnosis of Improvement
coronary artery disease seen within a Foundation
12-month period who also have (PCPI)
prior MI OR a current or prior
L VEF < 40% who were prescribed
beta-blocker therapy.
and older with a diagnosis of heart Consortium for
Registry, Effective failure (HF) with a current or prior Performance
0083 008 144v6 Process
EHR Clinical Care left ventricular ejection fraction Improvement
(L VEF) < 40% who were prescribed Foundation
beta-blocker therapy either within a (PCPI)
outpatient setting OR at each
hospital discharge.
EP30JN17.052</GPH>
"I M e d".
National
CMSE- Data
ID Method
Domain
Anti-Depressant Medication
Management:
age and older who were treated with
antidepressant medication, had a
diagnosis of major depression, and
who remained on antidepressant
National
Effective medication treatment.
Committee for
105 009 128v6 EHR Process Clinical Care Two rates are reported
Quality
a. Percentage of patients who
Assurance
remained on an antidepressant
medication for at least 84 days (12
weeks)
months).
Communication with the
Physician or Other Clinician
Managing On-going Care Post-
Fracture for Men and Women
Aged 50 Years and Older:
and older treated for a tracture with
documentation of communication,
National
Communicat between the physician treating the
Claims, Cmmnittee for
! 0045 024 N/A Process ion and Care fracture and the physician or other
Registry Quality
Coordination clinician managing the patient's on-
Assurance
going care, that a fracture occurred
and that the patient was or should be
considered for osteoporosis
treatment or testing. This measure is
reported by the physician who treats
the fracture and who therefore is
held accountable for the
communication.
Screening for Osteoporosis for
Women Aged 65-85 Years of Age:
National
Percentage of female patients aged
Claims, Effective Cmmnittee for
0046 039 N/A Process 65-85 years of age who ever had a
Registry Clinical Care Quality
central dual-energy X-ray
Assurance
absorptiometry (DXA) to check for
osteoporosis.
Care Plan:
and older who have an advance care
plan or surrogate decision maker
National
Communicat documented in the medical record or
0326 047 N/A Process ion and Care documentation in the medical record
Registry Quality
Coordination that an advance care plan was
Assurance
surrogate decision maker or provide

an advance care plan.
EP30JN17.053</GPH>
"I M e d".
National
CMSE~ Data
NQF Quality Measure Quality Measure Title Meas:ure
# # Type Strategy .and Description Steward
ID Method
D6main
Urinary Incontinence: Assessment
of Presence or Absence of Urinary
Incontinence in Women Aged 65 National
Effective
Claims, Years and Older: Committee for
N/A 048 N/A Process Clinical
Registry Percentage of female patients aged 65 Quality
Care
years and older who were assessed Assurance
for the presence or absence of urinary
incontinence within 12 months.
Urinary Incontinence: Plan of Care
Person for Urinary Incontinence in
and Women Aged 65 Years and Older:
National
Caregiver- Percentage of female patients aged 65
! N/A 050 N/A Process Centered years and older with a diagnosis of
Registry Quality
Experienc urinary incontinence with a
Assurance
e and documented plan of care for urinary
Outcomes incontinence at least once within 12
months.
Appropriate Treatment for
Children with Upper Respiratory
Infection (URI):
National
Efficiency Percentage of children 3 months
!! 0069 065 154v6 Process and Cost through 18 years of age who were
EHR Quality
Reduction diagnosed with upper respiratory
Assurance
infection (URI) and were not
dispensed an antibiotic prescription
on or three davs after the episode.
with Pharyngitis:
National
Efficiency Percentage of children 3-18 years of
!! N/A 066 146v6 Process and Cost age who were diagnosed with
EHR Quality
Reduction pharyngitis, ordered an antibiotic and
Assurance
received a group A streptococcus
(strep) test for the episode.
Acute Otitis Extema (AOE): American

Effective Topical Therapy: Percentage of Academy of
Claims,
!! 0653 091 N/A Process Clinical patients aged 2 years and older with a Otolaryngology
Registry
Care diagnosis of AOE who were -Head and
prescribed topical preparations. Neck Surgery

Efficiency
Avoidance of Inappropriate Use: Academy of
Claims, and Cost
!! 0654 093 N/A Process Percentage of patients aged 2 years Otolaryngology
Registry Reduction
and older with a diagnosis of AOE -Head and
who were not prescribed systemic Neck Surgery
antimicrobial therapy.
EP30JN17.054</GPH>
"I M e d".
..
National
CMSE- Data
NQF Quality Measure Quality Memmre Title Measure
ID Method
Domain ..
(MDD): Suicide Risk Assessment:
Physician
Consortium for
Effective and older with a diagnosis of major
Performance
0104 107 16lv6 EHR Process Clinical depressive disorder (MDD) with a
Improvement
Care suicide risk assessment completed
Foundation
during the visit in which a new
(PCPI)
diagnosis or recurrent episode was
identified.
Osteoarthritis (OA): Function and
Person and
Pain Assessment:
Caregiver American
Percentage of patient visits for
Claims, Centered Academy of
! NIA 109 NIA Registry
Process
Experience
patients aged 21 years and older with
Orthopedic
a diagnosis of osteoarthritis (OA)
and Surgeons
with assessment for function and
Outcomes
pam.
Claims,
Percentage of patients aged 6 months Consortium for
Web Community
147v7 and older seen for a visit between Performance
* 0041 110 Interface, Process I Population October 1 and March 31 who Improvement
Registry, Health
received an influenza immunization Foundation
EHR
OR who reported previous receipt of (PCPI)
an influenza immunization.
Claims, Pneumonia Vaccination Status for
National
Web Community Older Adults:
Committee for
0043 111 127v6 Interface, Process I Population Percentage of patients 65 years of age
Quality
Registry, Health and older who have ever received a
Assurance
EHR pneumococcal vaccine.
Claims,
Breast Cancer Screening: National
Web Effective
Percentage of women 50 -74 years of Committee for
age who had a mammogram to screen Quality
Registry, Care
for breast cancer. Assurance
EHR
Claims,
Web Colo rectal Cancer Screening: National
Effective
* 0034 113 130v6
Interface,
Process Clinical
Percentage of patients 50- 75 years Committee for
Registry, of age who had appropriate screening Quality
Care
EHR for colorectal cancer. Assurance
EHREHR
Avoidance of Antibiotic Treatment
in Adults with Acute Bronchitis: National
Efficiency
Percentage of adults 18-64 years of Committee for
!!
0058 116 NIA Registry Process and Cost
age with a diagnosis of acute Quality
Reduction
bronchitis who were not dispensed an Assurance
antibiotic prescription.
EP30JN17.055</GPH>
"I M e d".
..
National
CMSE- Data
Quality M:easure Quality M:easure Title M:easure
Indicator NQF M:easure Submission
# ID M:ethod
Domain
Diabetes: Eye Exam:
Percentage of patients 18 - 75 years
Claims, of age with diabetes who had a
National
Web retinal or dilated eye exam by an eye
Effective Committee for
0055 117 13lv6 Interface, Process care professional during the
Registry, measurement period or a negative
Assurance
EHR retinal exam (no evidence of
retinopathy) in the 12 months prior
to the measurement period.
Diabetes: Medical Attention for
Nephropathy: The percentage of
National
Registry, patients 18-75 years of age with
Effective Cmmnittee for
0062 119 134v4 EHR Process diabetes who had a nephropathy
screening test or evidence of
Assurance
nephropathy during the
measurement period.
Diabetes Mellitus: Diabetic Foot
and Ankle Care, Peripheral
Neuropathy -Neurological
American
Evaluation: Percentage of patients
Effective Podiatric
0417 126 N/A Registry Process aged 18 years and older with a
Clinical Care Medical
diagnosis of diabetes mellitus who
Association
had a neurological examination of
their lower extremities within 12
months.
EP30JN17.056</GPH>
"I M e d".
...
CMSE- Data
Quality Measure National Quality Measure Title Measure
Indicator NQF# Measure Submission
# Type Strategy Domain and Description Steward
ID Method
Preventive Care and

Screening: Body Mass
Judex (BMI) Screening
and Follow-Up Plan:
Percentage of patients aged
18 years and older with a
BMI documented during the
current encounter or during Centers
Claims, the previous 12 months for
* Registry, Community /Popul AND with a BMI outside of Medicare
0421 128 69v6 Process
EHR, Web ation Health normal parameters, a &
Interface follow-up plan is Medicaid
documented during the Services
encounter or during the
previous twelve months of
the current encounter.
Normal Parameters:
Age 18 years and older
BMI => 18.5 and< 25
kg/m2.
Medications in the
Medical Record:
Percentage of visits for
patients aged 18 years and
professional attests to
documenting a list of
Centers
current medications using
for
Claims, all inunediate resources
Medicare
0419 130 68v7 Registry, Process Patient Safety available on the date of the
&
EHR encounter. This list must
Medicaid
include ALL known
Services
prescriptions, over-the-
(nutritional) supplements
AND must contain the
administration.
EP30JN17.057</GPH>
"I M e d".
National
CMSE- Data
ID Method
Domain
Preventive Care and

Screening: Screening for
Depression and Follow-Up
Plan:
Claims, Percentage of patients aged 12
Centers for
Web Connnunity/ years and older screened for
Medicare &
0418 134 2v77 Interface, Process Population depression on the date of the
Medicaid
Registry, Health encounter using an age
Services
EHR appropriate standardized
depression screening tool AND
if positive, a follow-up plan is
documented on the date of the
positive screen.
Falls: Risk Assessment:
Percentage of patients aged 65 National
Claims, years and older with a history Committee for
! 0101 154 N/A Process Patient Safety
Registry of falls who had a risk Quality
assessment for falls completed Assurance
within 12 months.
Falls: Plan of Care:
Connnunication
Claims, years and older with a history Committee for
! 0101 155 N/A Process and Care
Registry of falls who had a plan of care Quality
Coordination
for falls documented within 12 Assurance
months.
EP30JN17.058</GPH>
"I M e d".
CMSE- Data
NQF Quality Measure National Quality Measure Title Measure
# # Type Strategy Domain and Description Steward
m Method
Comprehensive
Diabetes Care: Foot
Exam:
The percentage of
patients 18-75 years of
National
age with diabetes (type
Effective Clinical Connnittee
0056 163 123v6 EHR Process 1 and type 2) who
Care for Quality
received a foot exam
Assurance
(visual inspection and
sensory exam with
mono filament and a
pulse exam) during the
measurement year.
Elder Maltreatment
Screen and Follow-
Up Plan:
aged 65 years and
older with a
documented elder Centers for
Claims, maltreatment screen Medicare &
! NA 181 N/A Process Patient Safety
Registry using an Elder Medicaid
Maltreatment Services
Screening Tool on the
date of encounter
AND a documented
follow-up plan on the
date of the positive
screen.
Ischemic Vascular
Disease (IVD): Use of
Aspirin or Another
Antiplatelet:
18 years of age and
older who were
diagnosed with acute
myocardial infarction
(AMI), coronary artery
bypass graft (CABG)
Claims, Web or percutaneous National
Interface, Effective Clinical coronary interventions Connnittee
0068 204 164v6 Process
Registry, Care (PCI) in the 12 months for Quality
EHR prior to the Assurance
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.
EP30JN17.059</GPH>
"I M e d".
..
National
CMSE- Data
ID Method
Domain
screened for tobacco use one or
more times within 24 months
b. Percentage of patients aged 18 Physician
Claims, years and older who were Consortium for
Community/
* 0028 226 138v6
Registry,
Process Population
EHR, Web identified as a tobacco user who Improvement
Health
Interface received tobacco cessation Foundation
intervention (PCPI)
AND who received cessation
counseling intervention if
identified as a tobacco user.
Use of High-Risk Medications in
the Elderly:
age and older who were ordered
high-risk medications. Two rates are National
Registry, Patient reported. Committee for
* 0022 238 156v6 Process
EHR Safety a. Percentage of patients who were Quality
ordered at least one high-risk Assurance
medication.
b. Percentage of patients who were
ordered at least two of the same
high-risk medications.
Cardiac Rehabilitation Patient
Referral from an Outpatient
Setting:
Percentage of patients evaluated in
an outpatient setting who within the
previous 12 months have
experienced an acute myocardial
infarction (MI), coronary artery
American
Communicat bypass graft (CABG) surgery, a
College of
0643 243 N/A Registry Process ion and Care percutaneous coronary intervention
Cardiology
Coordination (PCI), cardiac valve surgery, or
Foundation
cardiac transplantation, or who have
chronic stable angina (CSA) and
have not already participated in an
early outpatient cardiac
rehabilitation/secondary prevention
(CR) program for the qualifying
event/diagnosis who were referred
to a CR program.
EP30JN17.060</GPH>
B.7. Family Medicine (continued)

National
CMSE" .Data
Indicator Measure Submisgion
ID Method
Domain
Initiation and Engagement of
Alcohol and Other Drug
Dependence Treatment:
Percentage of patients 13 years of age
and older with a new episode of
alcohol and other drug (AOD)
dependence who received the National
Effective
following. Two rates are reported. Committee for
0004 305 l37v6 EHR Process Clinical
a. Percentage of patients who initiated Quality
Care
treatment within 14 days of the Assurance
diagnosis.
initiated treatment and who had two
or more additional services with an
AOD diagnosis within 30 days of the
initiation visit
Cervical Cancer Screening:
Percentage of women 21-64 years of
age who were screened for cervical
cancer using either of the following
National
Effective criteria:
Conunittee for
0032 309 124v6 EHR Process Clinical o Women age 21-64 who had cervical
Quality
Care cytology performed every 3 years
Assurance
o Women age 30-64 who had cervical
cytology!human papillomavirus
(HPV) co-testing performed every 5
years.
Community Percentage of patients aged 18 years Centers for
Claims,
Process /Population and older seen during the reporting Medicare &
Health period who were screened for high Medicaid
EHR
EP30JN17.061</GPH>
"I M e d".
. CMSE- National
Data
NQF Quality Measure Quality Measure 'fitle Measure
ID Method
Domain
CAHPS for MIPS
Clinician/Group Smvey:
Summa!}' Survey Measures may
include:
o Getting Timely Care,
Appointments, and Information;

Person and
o How well Providers Communicate; Agency for
CMS- Patient Caregiver-
o Patient's Rating of Provider;
* 0005
approved Engagem Centered
Healthcare
& 321 N/A o Access to Specialists; Research&
Survev ent!Exper Experience
! 0006 o Health Promotion and Education; Quality
Vendor 1ence and
o Shared Decision-Making; (AHRQ)
Outcomes
o Health Status and Functional
Status;
o Courteous and Helpful Office
Staff;
o Care Coordination;
o Stewardship of Patient Resources.
Atrial Fibrillation and Atrial

Flutter: Chronic Anticoagulation
Therapy:
and older with a diagnosis of
nonvalvular atrial fibrillation (AF)
or atrial flutter whose assessment of
Effective American
Claims, the specified thromboembolic risk
1525 326 N/A Process Clinical College of
Registry factors indicate one or more high-
Care Cardiology
risk factors or more than one
moderate risk factor, as determined
by CHADS2 risk stratification, who
are prescribed warfarin OR another
oral anticoagulant drug that is FDA
thromboembolism
American
(Overuse):
Percentage of patients, aged 18
!! N/A 331 N/A Registry Process and Cost Otolaryngology
years and older, with a diagnosis of
Reduction -Head and
acute sinusitis who were prescribed
Neck Surgery
an antibiotic within 10 days after
onset of symptoms.
Adult Sinusitis: Appropriate
Choice of Antibiotic: Amoxicillin
With or Without Clavulanate
Prescribed for Patients with Acute
American
Bacterial Sinusitis (Appropriate
Use):
!! N/A 332 N/A Registry Process and Cost Otolaryngology
Reduction -Head and
Neck Surgery
bacterial sinusitis that were
prescribed amoxicillin, with or
without clavulante, as a first line
antibiotic at the time of diagnosis.
EP30JN17.062</GPH>
"I M e d".
..
National
CMSE- Data
ID Method
Domain
American
!! N/A 333 N/A Registry Efficiency and Cost Otolaryngology
sinusitis who had a computerized
Reduction -Head and
tomography (CT) scan of the
Neck Surgery
days after dale of diagnosis.
Adult Sinusitis: More than One
Computerized Tomography (CT)
Scan Within 90 Days for Chronic
American
Reduction -Head and
chronic sinusitis who had more than
Neck Surgery
one CT scan of the paranasal sinuses
ordered or received within 90 days
after the date of diagnosis.
Rheumatoid Arthritis Patients on
a Biological Immune Response
Modifier:
Percentage of patients whose
American
Effective providers are ensuring active
N/A 337 N/A Registry Process Academy of
Clinical Care tuberculosis prevention either
Dermatology
through yearly negative standard
tuberculosis screening tests or are
reviewing the patient's history to
determine if they have had
appropriate management for a recent
or prior positive test
lllV Viral Load Suppression:
Health
regardless of age, with a diagnosis
Effective Resources and
2082 338 N/A Registry Outcome ofHIV with a HIV viral load less
! Clinical Care Services
than 200 copies/mL at last HTV viral
Administration
load test during the measurement
year.
Pain Brought Under Control
Within 48 Hours:
Person and
Patients aged 18 and older who
Caregiver- National
report being uncomfortable because
Centered Hospice and
! N/A 342 N/A Registry Outcome of pain at the initial assessment
Experience Palliative Care
(after admission to palliative care
and Organization
services) who report pain was
Outcomes
brought to a comfortable level
within 48 hours.
EP30JN17.063</GPH>
"I M e d".
..
Natiomtl
CMSE- Data
Quality M;easure Quality M:easure Title M:easure
Indicator NQF M:easute Submission
# ID M:ethod
I Domain
Depression Remission at
Twelve Months:
Patients age 18 and older with
major depression or dysthymia
and an initial Patient Health
Questionnaire (PHQ-9) score
Web greater than nine who
MN
Interface, Outcome Effective demonstrate remission at twelve
0710 370 159v6 Community
! Registry, Clinical Care months(+/- 30 days after an
Measurement
EHR index visit) defined as a PHQ-9
score less than five. This
measure applies to both patients
with newly diagnosed and
existing depression whose
current PHQ-9 score indicates a
need for treatment
Depression Utilization of the
PHQ-9 Tool:
the diagnosis of major
MN
Process Effective depression or dysthymia who
0712 371 160v6 EHR Community
Clinical Care have a Patient Health
Measurement
Questionnaire (PHQ-9) tool
administered at least once during
a 4-month period in which there
was a qualifying visit
Hypertension: Improvement in
Blood Pressure:
Centers for
Intermed Percentage of patients aged 18-
Effet.:Live Medicare &
N/A 373 65v7 EHR iate 85 years of age with a diagnosis
Clinical Care Medicaid
Outcome of hypertension whose blood
Services
pressure improved during the
measurement period.
Collllllunication
* Registry, referrals, regardless of age, for Medicare &
N/A 374 50v6 Process and Care
! EHR which the referring provider Medicaid
Coordination
was referred.
Functional Status Assessments
for Congestive Heart Failure:
Person and
Percentage of patients 65 years Centers for
Caregiver-
of age and older with congestive Medicare &
N/A 377 90v7 EHR Process Centered
heart failure who completed Medicaid
Experience and
initial and follow-up patient- Services
Outcomes
reported functional status
assessments.
EP30JN17.064</GPH>
"I M e d".
National
CMSE- Data
NQF Quality Measure Quality Measure Title MeasU:re
ID Method
Domain
Adherence to Antipsychotic
Medications for Individuals with
Schizophrenia:
Percentage of individuals at least 18
years of age as of the beginning of the
National
measurement period with
Intermed Committee
Patient schizophrenia or schizoaffective
! 1879 383 N/A Registry iate for Quality
Safety disorder who had at least two
Outcome Assurance
prescriptions filled for any
antipsychotic medication and who
had a Proportion of Days Covered
(PDC) of at least 0.8 for antipsychotic
medications during the measurement
period (12 consecutive months).
Annual Hepatitis C Virus (HCV)
Screening for Patients who are Physician
Active Injection Drug Users: Consortium for
Effective
Percentage of patients regardless of Performance
N/A 387 N/A Registry Process Clinical
age who are active injection drug Improvement
Care
users who received screening for Foundation
HCV infection within the 12 month (PCPI)
reporting period
Immunizations for Adolescents:
National
Community The percentage of adolescents 13
Committee for
1407 394 N/A Registry Process I Population years of age who had the
Quality
Health recommended immunizations by their
Assurance
13th birthday.
Optimal Asthma Control:
Composite measure of the percentage
Effective of pediatric and adult patients whose MN
! N/A 398 N/A Registry Outcome Clinical asthma is well-controlled as Community
Care demonstrated by one of three age Measurement
appropriate patient reported outcome
tools.
One-Time Screening for Hepatitis
C Virus (HCV) for Patients at
Risk:
and older with one or more of the Consortium for
Effective
following: a history of injection drug Performance
N/A 400 N/A Registry Process Clinical
use, receipt of a blood transfusion Improvement
Care
prior to 1992, receiving maintenance Foundation
hemodialysis OR birthdate in the (PCPI)
years 1945-1965 who received one-
time screening for hepatitis C virus
(HCV) infection.
EP30JN17.065</GPH>
"I M e d".
National
CMSE- Data
NQF Quality Measure Quality Measure Title MeasU:rc
ID MetJtod
Domain
American
Hepatitis C: Screening for Gastroenterolo
Hepatocellular Carcinoma (HCC) gical
in Patients with Cirrhosis: Association/
Effective and older with a diagnosis of chronic Society for
N/A 401 N/A Registry Process Clinical hepatitis C cirrhosis who underwent Gastro-
Care imaging with either ultrasound, intestinal
contrast enhanced CT or MRI for Endoscopy/
hepatocellular carcinoma (HCC) at American
least once within the 12 month College of
reporting period. Gastro-
enterology
National
Commlmity 20 years of age with a primary care
Committee for
N/A 402 N/A Registry Process I Population visit during the measurement year for
Quality
Health whom tobacco usc status was
Assurance
user.
Opioid Therapy Follow-up
Evaluation:
All patients 18 and older prescribed
Effective American
opiates for longer than six weeks
N/A 408 N/A Registry Process Clinical Academy of
duration who had a follow-up
Care Neurology
evaluation conducted at least every
three months during Opioid Therapy
documented in the medical record.
Documentation of Signed Opioid
Treatment Agreement:
Effective American
duration who signed an opioid
Care Neurology
treatment agreement at least once
during Opioid Therapy documented
in the medical record.
Evaluation or Interview for Risk of
Opiuid Misuse:
Effective duration evaluated for risk of opioid American
N/A 414 N/A Registry Process Clinical misuse using a brief validated Academy of
Care instrument (e.g. Opioid Risk Tool, Neurology
SOAPPSOAPP-R) or patient
interview documented at least once
during Opioid Therapy in the medical
record.
EP30JN17.066</GPH>
"I M e d".
National
CMSE- Data
ID Metltod
Domain
Osteoporosis Management in
Women Who Had a Fracture:
The percentage of women age 50-85 National
Effective
Claims, who suffered a fracture and who Committee for
0053 418 N/A Process Clinical
Registry either had a bone mineral density test Quality
Care
or received a prescription for a drug Assurance
to treat osteoporosis in the six months
after the fracture.
& Brief Counseling: Physician
Community and older who were screened for Performance
2152 431 N/A Registry Process I Population unhealthy alcohol use using a Improvement
Health systematic screening method at least Foundation
once within the last 24 months AND (PCPl)
user.
Statin Therapy for the Prevention
and Treatment of Cardiovascular
Disease:
Percentage ofthe following
patients-all considered at high risk
of cardiovascular events-who were
prescribed or were on statin therapy
during the measurement period:
Web Adults aged C: 21 years who were Centers for
Effective
Interface, previously diagnosed with or Medicare &
* N/A 438 347vl
Registry,
Process Clinical
currently have an active diagnosis of Medicaid
Care
EHR clinical atherosclerotic cardiovascular Services
disease (ASCVD); OR
Adults aged C:21 years who have
ever had a fasting or direct low-
density lipoprotein cholesterol (LDL-
C) level C: 190 mg/dL; OR
Adults aged 40-75 years with a
diagnosis of diabetes with a fasting or
direct LDL-C level of70-189 mg/dL
EP30JN17.067</GPH>
"I M e d".
National
CMSE- Data
ID Met}lod
Domain
Ischemic Vascular Disease All or
None Outcome Measure (Optimal
Control): The TVD All-or-None
Measure is one outcome measure
(optimal control). The measure
contains four goals. All four goals
within a measure must be reached in
order to meet that measure. The
numerator for the all-or-none
measure should he collected from
the organization's total IVD Wisconsin
Effective denominator. Collaborative
Intermediate All-or-None Outcome Measure
! N/A 441 N/A Registry Clinical for Healthcare
Outcome (Optimal Control)
Care Quality
Using the IVD denominator (WCHQ)
optimal results include: Most
recent blood pressure (BP)
measurement is less than 140/90
mmiig
And Most recent tobacco status is
Tobacco Free
And Daily Aspirin or Other
Antiplatelet Unless
Contraindicated
And Statin Use.
Treatment After a Heart Attack:
The percentage of patients 18 years
of age and older during the
measurement year who were
hospitalized and discharged from National
Effective
Registry Process July 1 of the year prior to the Committee for
0071 442 N/A Clinical
measurement year to June 30 of the Quality
Care
measurement year with a diagnosis Assurance
of acute myocardial infarction
(AMI) and who received were
prescribed persistent beta-blocker
treatment for six months after
discharge.
Non-Recommended Cervical
Cancer Screening in Adolescent National
Patient Females: Cmmnittee for
N/A 443 N/A Registry Process
!! Safety The percentage of adolescent Quality
females 16-20 years of age screened Assurance
mmecessarily for cervical cancer.
Medication Management for
People with Asthma (MMA):
Efficienc The percentage of patients 5-64
National
y and years of age during the measurement
Cmmnittee for
1799 444 N/A Registry Process Cost year who were identified as having
! Quality
Reductio persistent asthma and were
Assurance
n dispensed appropriate medications
that they remained on for at least
75% oftheir treatment period.

EP30JN17.068</GPH>
"I M e d".
National
CMSE:- Data
.Indicator Measu~ Submission
# # Type Strategy a:nd Description Steward
ID Method
Domain
Chlamydia Screening and
Follow-up: The percentage of National
Community/
female adolescents 16 years of age Cmmnittee for
N/A 447 N/A Registry Process Population
who had a chlamydia screening test Quality
Health
with proper follow-up during the Assurance
measurement period.
Otitis Media with Effusion
American
(OME): Systemic
Patient Academy of
Antimicrobials- Avoidance of
Safety, Otolaryngology
Inappropriate Use:
0657 TBD N/A Registry Process Efliciency -Head and
and Cost Neck Surgery
months tluough 12 years vvitl1 a
Reduction Foundation
diagnosis of OME who were not
(AAOHNSF)
prescribed systemic antimicrobials.
EP30JN17.069</GPH>
B.S. Internal Medicine

National
CMSE- Data
ID Method
Domain
Claims,
Effective (HbAlc) Poor Control (>9%): National
Web IntermediE
Clinical Percentage of patients 18-75 years Committee for
! 0059 001 122v6 Interface, te
Care of age with diabetes who had Quality
Registry, Outcome
hemoglobin Ale> 9.0% during the Assurance
EHR
measurement period.
(LVSD): Physician
Registry, Effective and older with a diagnosis of heart Performance
0081 005 135v6 Process
EHR Clinical Care failure (HF) with a current or prior Improvement
left ventricular ejection fraction Foundation
(L VEF) < 40% who were (PCPI)
prescribed ACE inhibitor or ARB
therapy either within a 12-month
period when seen in the outpatient
setting OR at each hospital
discharge.
Disease (CAD): Antiplatelet
Therapy: Percentage of patients
Registry Effective aged 18 years and older with a American Heart
0067 006 N/A Process
Clinical Care diagnosis of coronary artery disease Association
(CAD) seen within a 12-month
period who were prescribed aspirin
or clopidogrel.
Myocardial Infarction (MI) or
Left Ventricular Systolic Physician
Dysfunction (LVEF <40%): Consortium for
Registry, Effective Percentage of patients aged 18 years Performance
0070 007 145v6 Process
EHR Clinical Care and older with a diagnosis of Improvement
coronary artery disease seen within Foundation
a 12-month period who also have (PCPI)
prior MI OR a cunent or prior
L VEF < 40% who were prescribed
beta-blocker therapy.
EP30JN17.070</GPH>
B.S. Internal Medicine (continued)

National
CMSE- Data
Indicator NQF Measure Submission
# Method
Type Strategy and Description Steward
. # ID
Domain
and older with a diagnosis of heart Consortium
Effective
Registry, failure (HF) with a current or prior For
EHR lett ventricular ejection traction Performance
Care
(L VEF) < 40% who were prescribed Improvement
beta-blocker therapy either within a
outpatient setting OR at each hospital
discharge.
Management:
National
Effective medication treatment
Committee for
0105 009 128v6 EHR Process Clinical Two rates are reported
Quality
Care a. Percentage of patients who
Assurance
weeks)
months).
Communication with the Physician
or Other Clinician Managing On-
going Care Post-Fracture for Men
and Women Aged 50 Years and
Older:
and older treated for a fracture with
Communic
documentation of communication, National
ation
Claims, between the physician treating the Conm1ittee for
Registry fracture and the physician or other Quality
Coordinatio
clinician managing the patient's on- Assurance
n
considered for osteoporosis treatment
or testing. This measure is reported
by the physician who treats the
fracture and who therefore is held
accountable for the communication.
EP30JN17.071</GPH>

National
CMSE- Data
ID Method
Domain
Women Aged 65-85 Years of
Age: National
Claims, Effective Percentage of female patients Cmmnittee for
Registry Clinical Care aged 65-85 years of age who Quality
ever had a central dual-energy Assurance
X-ray absorptiometry (DXA) to
check for osteoporosis.
Care Plan:
decision maker documented in National
Communication
Claims, the medical record or Cmmnittee for
0326 047 N/A Process and Care
Registry documentation in the medical Quality
Coordination
record that an advance care plan Assurance
was discussed but the patient did
not wish or was not able to name
a surrogate decision maker or
Urinary Incontinence:
Assessment of Presence or
Absence of Urinary
Incontinence in Women Aged National
Claims, Effective 65 Years and Older: Committee for
N/A 048 N/A Process
Registry Clinical Care Percentage of female patients Quality
aged 65 years and older who Assurance
were assessed for the presence or
absence of urinary incontinence
within 12 months.
Urinary Incontinence: Plan of
Care for Urinary Incontinence
in Women Aged 65 Years and
Person and Older:
National
Caregiver Percentage of female patients
! N/A 050 N/A Process Centered aged 65 years and older with a
Registry Quality
Experience and diagnosis of urinary
Assurance
Outcomes incontinence with a documented
plan of care for urinary
incontinence at least once within
12 months.
EP30JN17.072</GPH>

.
Data
NQF Quality CMSE~ Measure National Quality Measure Title Measure
Indicator Submission
# # Measure ID Type Stra,tegy Domain and. Description Steward
Method
. \
Acute Otitis Extema

(AOE): Topical
American
Therapy: Percentage of
Academy of
Claims, Effective Clinical patients aged 2 years
!! 0653 091 N/A Process Otolaryngology
Registry Care and older with a
-Head and Neck
diagnosis of AOE who
Surgery
were prescribed topical
preparations.
Acute Otitis Extema
(AOE): Systemic
Antimicrobial
Therapy- Avoidance American
oflnappropriate Use: Academy of
Claims, Etliciency and
!! 0654 093 N/A Process Percentage of patients Otolaryngology
Registry Cost Reduction
aged 2 years and older -Head and Neck
with a diagnosis of Surgery
AOE who were not
prescribed systemic
antimicrobial therapv.
Diabetes: Eye Exam:
18 - 75 years of age
with diabetes who had a
retinal or dilated eye
Claims, Web National
exam by an eye care
Interface, Effective Clinical Committee for
0055 117 131v6 Process professional during the
Registry, Care Quality
measurement period or
EHR Assurance
a negative retinal exam
(no evidence of
retinopathy) in the 12
months prior to the
measurement period.
Diabetes: Medical
Attention for
Nephropathy:
The percentage of
National
patients 18-75 years of
Registry, Effective Clinical Committee for
0062 119 134v6 Process age with diabetes who
EHR Care Quality
had a nephropathy
Assurance
screening test or
evidence of
nephropathy during the
measurement period.
EP30JN17.073</GPH>

... ...
CMSE- Data
NQF Measure National Quality Measure Title Measure
Indicator Quality# Measure Submission
# Type Strategy Domain aJtd Description Steward
ID Method
.. ..
Diabetes Mellitus: Diabetic
Foot and Ankle Care,
Peripheral Neuropathy-
Neurological Evaluation: American
Effective Clinical Percentage of patients aged Podiatric
0417 126 N/A Registry Process
Care 1R years and older with a Medical
diagnosis of diabetes mellitus Association
who had a neurological
examination of their lower
extremities within 12 months.
Preventive Care and
Screening: Body Mass
Index (BMI) Screening and
Follow-Up Plan:
Percentage of patients aged
18 years and older with a
BMI documented during the
Claims, current encounter or during Centers for
* 0421 128 69v6
Registry,
Process
Community/ the previous twelve months Medicare &
EHR, Web Population Health AND with a BMI outside of Medicaid
Interface normal parameters, a follow- Services
up plan is documented during
the encounter or during the
previous twelve months of the
current encounter.
Normal Paran1eters:
Age 18 years and older BMI
=> 18.5 and< 25 kg/m2.
Record:
Percentage of visits for
patients aged 18 years and
professional attests to
medications using all Centers for
Claims,
inmlediate resources available Medicare &
0419 130 68v7 Registry, Process Patient Safety
on the date of the encounter. Medicaid
EHR
This list must include ALL Services
known prescriptions, over-
the-counters, herbals, and
(nutritional) supplements
AND must contain the
administration.
EP30JN17.074</GPH>

National
Data
Quality CMSE~ Measure Quality Measure Title Measure
Indicator NQF# Submission
# MeasureiD Type Strategy and Description Steward
Method I
Domain
Preventive Care
and Screening:
Screening for
Depression and
Follow-Up Plan:
Percentage of
patients aged 12
years and older
Claims, screened for Centers for
Web Connnunity depression on the Medicare
0418 134 2v7 Interface, Process I Population date of the &
Registry, Health encounter using an Medicaid
EHR age appropriate Services
standardized
depression
screening tool AND
if positive, a follow-
up plan is
documented on the
date of the positive
screen.
Falls: Risk
Assessment:
Percentage of
patients aged 65 National
Claims, Patient years and older with Connnittee
! 0101 154 N/A Process
Registry Safety a history of falls for Quality
who had a risk Assurance
assessment for falls
completed within 12
months.
Falls: Plan of
Care:
Percentage of
Connnunic
patients aged 65 National
ation and
Claims, years and older with Connnittee
! 0101 155 N/A Process Care
Registry a history of falls for Quality
Coordinatio
who had a plan of Assurance
n
care for falls
documented within
12 months.
EP30JN17.075</GPH>

... National
CMSE- Data .
ID Method
Domain ..
Comprehensive
Diabetes Care:
Foot Exam:
The percentage of
patients 18-75 years
of age with diabetes
National
(type 1 and type 2)
Effective Committee
0056 163 123v6 EHR Process who received a foot
Clinical Care for Quality
exam (visual
Assurance
inspection and
sensory exam with
mono filament and a
pulse exam) during
the measurement
year.
Elder
Maltreatment
Screen and Follow-
Up Plan:
Percentage of
patients aged 65
years and older with
Centers for
a documented elder
Claims, Medicare &
! N/A 181 N/A Process Patient Safety maltreatment screen
Registry Medicaid
using an Elder
Services
Maltreatment
Screening Tool on
the date of encounter
AND a documented
follow-up plan on
the date of the
positive screen.
EP30JN17.076</GPH>
B 8 Interna I Medicine (continued)

.
National
CMSE., Data
# # Type Strategy . and Des~ription Steward
ID Method
Domain
Ischemic Vascular
Disease (IVD): Use
of Aspirin or
Another
Antiplatelet:
Percentage of
patients 18 years of
age and older who
were diagnosed with
acute myocardial
infarction (AMI),
coronary artery
bypass graft
(CABG) or
Claims,
percutaneous National
Web
Effective coronary Committee
0068 204 164v6 Interface, Process
Clinical Care interventions (PCI) for Quality
Registry,
in the 12 months Assurance
EHR
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.
EP30JN17.077</GPH>

National
CMSE- Data
# ID Metlwd
Domain
Community/ screened for tobacco use and
* 0028 226 138v6
Registry,
Process Population
Performance
Health received tobacco cessation
intervention (PCPI)
tobacco user.
Use of High-Risk Medications in
the Elderly:
age and older who were ordered
high-risk medications. Two rates are National
EHR, Patient reported. Committee for
* 0022 238 156v6
Registry
Process
Safety a. Percentage of patients who were Quality
ordered at least one high-risk Assurance
medication.
b. Percentage of patients who were
ordered at least two of the same
high-risk medications.
Cardiac Rehabilitation Patient
Referral from an Outpatient
Setting:
Percentage of patients evaluated in
an outpatient setting who within the
previous 12 months have
experienced an acute myocardial
infarction (MI), coronary artery
American
Communicat bypass graft (CABG) surgery, a
College of
0643 243 N/A Registry Process ion and Care percutaneous coronary intervention
Cardiology
Coordination (PCI), cardiac valve surgery, or
Foundation
cardiac transplantation, or who have
chronic stable angina (CSA) and
have not already participated in an
early outpatient cardiac
rehabilitation/secondary prevention
(CR) program for the qualifying
event/diagnosis who were referred
to a CR program.
EP30JN17.078</GPH>

National
CMSE:- Data
Indicator Measu~ Submission
# # Type Strategy a:nd Description Steward
ID Method
Domain
age and older with a new episode
of alcohol and other drug (AOD)
Effective
following. Two rates are reported. Committee for
0004 305 137vG EHR Process Clinical
a. Percentage of patients who Quality
Care
initiated treatment within 14 days Assurance
of the diagnosis.
initiated treatment and who had
two or more additional services
with an AOD diagnosis within 30
days of the initiation visit.
Percentage of women 21--64 years
of age who were screened for
cervical cancer using either of the
following criteria: National
Effective
o Women age 21--64 who had Committee for
0032 309 124v6 EHR Process Clinical
cervical cytology performed every Quality
Care
3 years Assurance
o Women age 30--64 who had
cervical cytology/human
papillomavirus (HPV) co-testing
performed every 5 years.
Documented:
Community/ Percentage of patients aged 18 Centers for
Claims,
Process Population years and older seen during the Medicare &
Health reporting period who were Medicaid
EHR
screened for high blood pressure Services
EP30JN17.079</GPH>

National
CMSE- Data
# #
ID Method
Type. Strategy and Description Steward
Domain
CAHPS for MIPS
Clinician/Group Smvey:
Summaa Survey Measures may
include:
o Getting Timely Care,
Appointments, and Information;

o How well Providers
Person and
Communicate; Agency for
CMS- Patient Caregiver-
* 0005 o Patient's Rating of Provider; Healthcare
approved Engagem Centered
& 321 N/A o Access to Specialists; Research&
Survey ent!Exper Experience
! 0006 o Health Promotion and Education; Quality
Vendor 1ence and
o Shared Decision-Making; (AHRQ)
Outcomes
o Health Status and Functional
Status;
o Courteous and Helpful Office
Staff;
o Care Coordination;
o Stewardship of Patient
Resources.
Atrial Fibrillation and Atrial
Flutter: Chronic
Anticoagulation Therapy:
nonvalvular atrial fibrillation (AF)
or atrial flutter whose assessment
ofthe specified thromboembolic American
Claims, Effective
1525 326 N/A Process risk factors indicate one or more College of
high-risk factors or more than one Cardiology
moderate risk factor, as
determined by CHADS2 risk
stratification, who are prescribed
warfarin OR another oral
anticoagulant drug that is FDA
thromboembolism.
EP30JN17.080</GPH>

...
Data
NQF Quality CMSE Measure National Quality Measure Title Measure
# # MeasureiD Type Strategy Domain and Description Steward
Method
Adult Sinusitis:
Antibiotic
Prescribed for
Acute Sinusitis
(Overuse):
American
Percentage of
Academy of
Efficiency and patients, aged 18
!! N/A 331 N/A Registry Process Otolaryngolog
Cost Reduction years and older, with
y-Headand
a diagnosis of acute
Neck Surgery
sinusitis who were
prescribed an
antibiotic within 10
days after onset of
symptoms.
Adult Sinusitis:
Appropriate Choice
of Antibiotic:
Amoxicillin With or
Without
Clavulanate
Prescribed for
Patients with Acute
Bacterial Sinusitis American
(Appropriate Usc): Academy of
Efficiency and
!! N/A 332 N/A Registry Process Percentage of Otolaryngolog
Cost Reduction
patients aged 18 y-Headand
years and older with Neck Surgery
a diagnosis of acute
bacterial sinusitis that
were prescribed
amoxicillin, with or
without clavulante, as
a first line antibiotic
at the time of
diagnosis.
EP30JN17.081</GPH>

National
NQF Quality
Cl\1SE- Data
ID Method
Domain
American
sinusitis who had a computerized
Reduction -Head and
tomography (CT) scan of the
Neck Surgery
days after date of diagnosis.
Computerized Tomography (CT)
Scan Within 90 Days for Chronic
American
Reduction -Head and
chronic sinusitis who had more than
Neck Surgery
one CT scan of the paranasal sinuses
ordered or received within 90 days
after the date of diagnosis.
Rheumatoid Arthritis Patients on
a Biological Immune Response
Modifier:
Percentage of patients whose
Effective American
providers are ensuring active
tuberculosis prevention either
Care Dermatology
through yearly negative standard
tuberculosis screening tests or are
reviewing the patient's history to
determine if they have had
appropriate management for a recent
or prior positive test.
lllV Viral Load Suppression:
Health
Effective regardless of age, with a diagnosis
Resources and
2082 338 N/A Registry Outcome Clinical ofHlV with a HlV viral load less
! Services
Care than 200 copies/mL at last HTV viral
Administration
load test during the measurement
year.
Pain Brought Under Control
Within 48 Hours:
Person and
Patients aged 18 and older who
Caregiver- National
report being uncomfortable because
Centered Hospice and
! N/A 342 N/A Registry Outcome of pain at the initial assessment
Experience Palliative Care
(after admission to palliative care
and Organization
services) who report pain was
Outcomes
brought to a comfortable level
within 48 hours.
EP30JN17.082</GPH>

National
CMSE ... Data Measure
Measure Title Measure
NQF Quality Quality
# # Strategy and J)escription Steward
ID Method
Domain
Depression Remission at
Twelve Months:
major depression or dysthymia
and an initial Patient Health
Questionnaire (PHQ-9) score
Web greater than nine who
MN
Interface, Effective demonstrate remission at twelve
0710 370 159v6 Outcome Community
! Registry, Clinical Care months (+/- 30 days after an
Measurement
EHR index visit) defined as a PHQ-9
score less than five. This
measure applies to both patients
with newly diagnosed and
existing depression whose
current PHQ-9 score indicates a
need for treatment
Depression Utilization of the
PHQ-9 Tool:
the diagnosis of major
depression or dysthymia who MN
Process Effective
0712 371 lGOvG EHR have a Patient Health Community
Clinical Care
Questionnaire (PHQ-9) tool Measurement
administered at least once
during a 4-month period in
which there was a qualifying
visit
Hypertension: Improvement
in Blood Pressure:
Centers for
Intermed Percentage of patients aged 18-
Effective Medicare &
N/A 373 65v7 EHR iate 85 years of age with a diagnosis
Clinical Care Medicaid
Outcome of hypertension whose blood
Services
pressure improved during the
measurement period.
Cmurnunication
! EHR which the referring provider Medicaid
Coordination
was referred.
Functional Status Assessments
for Congestive Heart Failure:
Person and
Percentage of patients 65 years Centers for
Caregiver-
of age and older with congestive Medicare &
N/A 377 90v7 EHR Process Centered
heart failure who completed Medicaid
Experience and
initial and follow-up patient- Services
Outcomes
reported functional status
assessments.
EP30JN17.083</GPH>

National
CMSE- Data
Qualily Measure Quality Measure Title Measure
Indicator NQF #
Measure Submission
# m Method
Domain
.
Adherence to Antipsychotic
Medications for Individuals with
Schizophrenia:
Percentage of individuals at least 18
years of age as of the beginning of the
National
measurement period with
Intermed Committee
Patient schizophrenia or schizoaffective
! 1879 383 N/A Registry iate for Quality
Safety disorder who had at least two
Outcome Assurance
prescriptions filled for any
antipsychotic medication and who
had a Proportion of Days Covered
(PDC) of at least 0.8 for antipsychotic
medications during the measurement
period (12 consecutive months).
Annual Hepatitis C Virus (HCV)
Physician
Screening for Patients who are
Consortium
Active Injection Drug Users:
Effective for
Percentage of patients regardless of
N/A 387 N/A Registry Process Clinical Performance
age who are active injection drug
Care Improvement
users who received screening for
Foundation
HCV infection within the 12 month
(PCPI)
reporting period.
Composite measure ofthe
Effective percentage of pediatric and adult Milmesota
! N/A 398 N/A Registry Outcome Clinical patients whose asthma is well- Community
Care controlled as demonstrated by one Measurement
of three age appropriate patient
reported outcome tools.
One-Time Screening for Hepatitis
C Virus (HCV) for Patients at
Risk:
Physician
Consortium
and older with one or more of the
Effective for
following: a history of injection drug
N/A 400 N/A Registry Process Clinical Performance
use, receipt of a blood transfusion
Care Improvement
prior to 1992, receiving maintenance
Foundation
hemodialysis OR birthdate in the
(PCPI)
years 1945-1965 who received one-
tilne screening for hepatitis C virus
(HCV) infection.
American
Hepatitis C: Screening for Gastro-
Hepatocellular Carcinoma (HCC) enterological
in Patients with Cirrhosis: Association/
Effective and older with a diagnosis of chronic Society for
N/A 401 N/A Registry Process Clinical hepatitis C cirrhosis who underwent Gastro-
Care ilnaging with either ultrasound, intestinal
contrast enhanced CT or MRI for Endoscopy/
hepatocellular carcinoma (HCC) at American
least once within the 12 month College of
reporting period. Gastro-
enterology
EP30JN17.084</GPH>

National
CMS!.- Data
# Type Strategy and Description . Steward
# .. ID Method
Domain
The percentage of adolescents 12
National
Community/ to 20 years of age with a primary
402 Committee
N/A N/A Registry Process Population care visit during the measurement
for Quality
Health year for whom tobacco use status
Assurance
was documented and received help
tobacco user.
Evaluation:
All patients 18 and older
Effective prescribed opiates for longer than American
N/A 408 N/A Registry Process Clinical six weeks duration who had a Academy of
Care follow-up evaluation conducted at Neurology
least every three months during
Opioid Therapy documented in the
medical record.
All patients 18 and older
Effective American
prescribed opiates for longer than
six weeks duration who signed an
Care Neurology
opioid treatment agreement at least
once during Opioid Therapy
EP30JN17.085</GPH>

... National
CMSE- Data
ln<licator Measure Submission
ID Method . Domain
Evaluation or
Interview for Risk
of Opioid Misuse:
All patients 18 and
older prescribed
opiates for longer
than six weeks
duration evaluated American
Effective for risk of opioid Academy of
N/A 414 N/A Registry Process Neurology
Clinical Care misuse using a brief
validated instrument
(e.g. Opioid Risk
Tool, SOAAP-R) or
patient interview
documented at least
once during Opioid
Therapy in the
medical record.
Osteoporosis
Management in
Women Who Had
a Fracture:
The percentage of
women age 50-85
who suffered a National
Claims, Effective fracture and who Committee
Registry Clinical Care either had a bone for Quality
mineral density test Assurance
or received a
prescription for a
drug to treat
osteoporosis in the
six months after the
fracture.
Preventive Care
and Screening:
Unhealthy Alcohol
Use: Screening &
Brief Counseling:
Percentage of
patients aged 18 Physician
years and older who Consortium
were screened for for
Community/ Performance
unhealthy alcohol
2152 431 N/A Registry Process Population Improvement
useusmg a
Health Foundation
systematic screening
method at least once (PCPI)
within the last 24
months AND who
received brief
counseling if
identified as an
unhealthy alcohol
user.
EP30JN17.086</GPH>
B.8 Internal Medicine (continued)

. CMSE- National
Data
# ID Method
\ . Domain
Statin Therapy for the Prevention
and Treatment of Cardiovascular
Disease:
Percentage of the following patients:
all considered at high risk of
cardiovascular events who were
prescribed or were on statin therapy
during the measurement period:
o Adults aged 2: 21 years who were
Web Centers for
previously diagnosed with or
Interface, Effective Medicare &
* N/A 438 347vl Process currently have an active diagnosis of
Registry, Clinical Care Medicaid
clinical athero-sclerotic
EHR Services
cardiovascular disease(ASCVD);
OR
o Adults aged 2:21 years who have
ever had a fasting or direct low-

density lipoprotein cholesterol
(LDL-C) level2: 190 mg/dL; OR
o Adults aged 40-75 years with a
~iagnosis of diabetes with a fasting or

~irect LDL-C level of70-189 mg/dL
~schemic Vascular Disease All or
~one Outcome Measure (Optimal
Control): The IVD All-or- None
~easure is one outcome measure
optimal control). The measure
ontains four goals. All four goals
~ithin a measure must be reached in
prder to meet that measure. The
~mmerator for the ali-or-none measure
should be collected from the Wisconsin
Intermed prganization's total IVD denominator. Collaborative
Effective
! N/A 441 N/A Registry iate for Healthcare
Clinical Care P,.l!-or-None Outcome Measure
Outcome Optimal Control) Quality
(WCHQ)
Using the IVD denominator optimal
results include: Most recent blood
pressure (BP) measurement is less
than 140/90 mm Hg
And Most recent tobacco status is
Tobacco Free
And Daily Aspirin or Other
Antiplatelet Unless Contraindicated
And Statin Use.
Treatment After a Heart Attack:
!The percentage of patients 18 years of
~ge and older during the measurement
~ear who were hospitalized and National
Registry Process Effective ~ischarged from July 1 of the year prior Cmmnittee
0071 442 N/A
Clinical Care o the measurement year to June 30 of for Quality
~e measurement year with a diagnosis Assurance
pf acute myocardial infarction (AMI)
~nd who received were prescribed
persistent beta-blocker treatment for six

~onths after discharge.
EP30JN17.087</GPH>
B.8 Internal Medicine (continued)

National
I CMSE~ Data Measure ..
# ID Method
Domain
Non-Recommended Cervical Cancer
National
Screening in Adolescent Females:
Patient Committee
N/A 443 N/A Registry Process The percentage of adolescent females
!! Safety for Quality
16-20 years of age screened
Assurance
llllllecessarily for cervical cancer.
T11e percentage of patients 5-64 years
National
Efficiency of age during the measurement year
C OJ1llllittee
1799 444 NA Registry Process and Cost who were identified as having
! for Quality
Reduction persistent asthma and were dispensed
Assurance
appropriate medications that they
remained on for at least 75% of their
treatment period.
Chlamydia Screening and Follow-
Community up: The percentage of female National
I adolescents 16 years of age who had a Cm=ittee
Population chlamydia screening test with proper for Quality
Health follow-up during the measurement Assurance
period.
EP30JN17.088</GPH>
B 9 Ob st et ncs
. /G~vneco ogy
National ..
I CMSE- Data Measure
# ID Method
Domain
Care Plan:
decision maker documented in National
Conununication
Claims, the medical record or Committee
Registry documentation in the medical for Quality
Coordination
record that an advance care plan Assurance
was discussed but the patient did
not wish or was not able to name
a surrogate decision maker or
Urinary Incontinence:
Assessment of Presence or
Absence of Urinary
Incontinence in Women Aged National
Claims, Effective 65 Y cars and Older: Committee
N/A 048 N/A Process
Registry Clinical Care Percentage of female patients for Quality
aged 65 years and older who Assurance
were assessed for the presence or
absence of urinary incontinence
within 12 months.
Urinary Incontinence: Plan of
Care for Urinary Incontinence
in Women Aged 65 Years and
Person and Older:
National
Caregiver- Percentage of female patients
Claims, Conm1ittee
! N/A 050 N/A Process Centered aged 65 years and older with a
Experience and diagnosis of urinary
Assurance
Outcomes incontinence with a documented
plan of care for urinary
incontinence at least once within
12 months.
EP30JN17.089</GPH>
B 9 Ob stet ncs
. /G~yneco ogy ( con f mue d)
National
CMSE- Data
# ID Method
Domain
Physician
Influenza Immunization:
Claims, Consortium
Percentage of patients aged 6 months
Web Conununity for
and older seen for a visit between
* 0041 110 147v7 Interface, Process I Population
October 1 and March 31 who
Performance
Registry, Health Improvement
received an influenza inununization
EHR Foundation
OR who reported previous receipt of
(PCPI)
an influenza inununization.
Claims,
Web Effective
Percentage of women 50- 74 years of Committee
age who had a mannnogram to screen for Quality
Registry, Care
for breast cancer. Assurance
EHR
Body Mass Index (BMI) Screening
and Follow-Up Plan:
Percentage of patients aged 1R years
and older with a BMI documented
Claims,
during the current encounter or
Registry, Centers for
Conununity during the previous twelve months
* 0421 128 69v6
EHR, Web
Process I Population AND with a BMI outside of normal
Medicare &
Interface Medicaid
Health parameters, a follow-up plan is
Services
documented during the encounter or
during the previous twelve months of
the current encounter.
Normal Parameters:
Age 18 years and older BMI => 18.5
and< 25 kglm2.
eligible professional attests to
medications using all inunediate Centers for
Claims,
Patient resources available on the date of the Medicare &
0419 130 68v7 Registry, Process
Safety encounter. This list must include ALL Medicaid
EHR,
known prescriptions, over-the- Services
administration.
EP30JN17.090</GPH>
B 9 Ob stet ncs
National
CMSE- Data
.Indicator Measure Submission
ID Method
Domain
Claims,
~ommunity/ years and older who were screened for
* 0028 226 138v6
Registry,
EHR, Web
~ealth tobacco user who received tobacco Improvement
Interface
tobacco user.
Controlling High Blood Pressure:
Claims, Percentage of patients 18-85 years of
National
Web age who had a diagnosis of
Intcrmcd ~ffcctivc Committee
0018 236 165v6 Interface, hypertension and whose blood
! iate ~linical Care for Quality
Registry, pressure was adequately controlled
Outcome Assurance
EHR (<140/90mmHg) during the
measurement period.
Biopsy Follow Up: Percentage of
new patients whose biopsy results
~ommunicat American
have been reviewed and
! N/A 265 N/A Registry Process on and Care Academy of
communicated to the primary
~oordination Dermatology
care/referring physician and patient
by the performing physician.
Percentage of women 21-64 years of
age who were screened for cervical
cancer using either of the following
National
Effective criteria:
Committee
0032 309 124v6 EHR Process Clinical o Women age 21-64 who had cervical
for Quality
Care cytology performed every 3 years
Assurance
o Women age 30-64 who had cervical
cytology /human papillomavirus

(HPV) co-testing pertormed every 5
years.
Chlamydia Screening for Women:
Community Percentage of women 16-24 years of National
I age who were identified as sexually Committee
0033 310 153v6 EHR Process
Population active and who had at least one test for Quality
Health for chlamydia during the Assurance
measurement period.
EP30JN17.091</GPH>
B 9 Ob stet ncs
National
CMSE- Data
Indicator NQF #
Measure Submission
Type .. Strategy and Description Steward
# ID Method
. Domain
Documented: Percentage of
Community Centers for
Claims, patients aged 18 years and older
I Medicare &
NIA 317 22v6 Registry, Process seen during the reporting period
Population Medicaid
EHR who were screened for high blood
Health Services
pressure AND a recommended
Pregnant women that had HBsAg
Effective testing:
NIA 369 158v6 EHR Process Clinical This measure identifies pregnant Optumlnsight
Care women who had a HBsAg (hepatitis
B) test during their pregnancy.
Communic Receipt of Specialist Report:
Centers for
ation and Percentage of patients with referrals,
* Registry, Medicare &
NIA 374 50v6 Process Care regardless of age, for which the
! EHR Medicaid
Coordinatio referring provider receives a report
Services
n from the provider to whom the
Community National
20 years of age with a primary care
I Committee
NIA 402 NIA Registry Process visit during the measurement year
Population for Quality
for whom tobacco use status was
Health Assurance
user.
Effective
Claims, who suffered a fracture and who Cmmnittee
0053 418 NIA Process Clinical
Registry either had a bone mineral density for Quality
Care
test or received a prescription for a Assurance
drug to treat osteoporosis in the six
months after the fracture.
Performing Cystoscopy at the
Time of Hysterectomy for Pelvic
Organ Prolapse to Detect Lower
Urinary Tract Injury: American
Claims, Patient
2063 422 NIA Process Percentage of patients who lmdergo Urogynecolog
Registry Safety
cystoscopy to evaluate for lower ical Society
urinary tract injury at the time of
hysterectomy for pelvic organ
prolapse.
EP30JN17.092</GPH>
B 9 Ob stet ncs
. /G""'neco ogy con mue d)
National
NQF Quali,ty
CMSE- . Data
Measure Quality Measure Title
Indicator Measure Submission Measure Steward
# # Typt: Strategy 1 and De~cription
ID Method
Domain
Pelvic Organ Prolapse:
Preoperative Assessment of
Occult Stress Urinary
Effective Incontinence:
American
Clinical Percentage of patients undergoing
N/A 428 N/A Registry Process Urogynecologic
Care appropriate preoperative
Society
evaluation of stress urinmy
incontinence prior to pelvic organ
prolapse surgery per
ACOG/AUGS/AUA guidelines.
Pelvic Organ Prolapse:
Preoperative Screening for
Uterine Malignancy:
American
Claims, Patient Percentage of patients who are
N/A 429 N/A Process Urogynecologic
Registry Safety screened for uterine malignancy
Society
prior to vaginal closure or
obliterative surgery for pelvic
organ prolapse.
Unhealthy Akuhul Use:
Screening & Brief Counseling: Physician
Percentage of patients aged 18 Consortium for
Communit
years and older who were Perfom1ance
y/
2152 431 N/A Registry Process screened for unhealthy alcohol use Improvement
Population
using a systematic screening Foundation
Health
method at least once within the (PC PI)
last 24 months AND who received
brief counseling if identified as an
unhealthy alcohol user.
EP30JN17.093</GPH>
B 9 Ob stet ncs
. /G neco ogy con f mue d)
.
CMSE" Data National Quality

NQF Quality Measure Measu.re Title Measure
Indicator Measure Submission Strategy
# # Type and Description Steward
ID Method Domain
Proportion of Patients
Sustaining a Bladder
Injury at the Time of
any Pelvic Organ
Prolapse Repair:
Percentage of patients American
N/A 432 N/A Registry Outcome Patient Safety undergoing any surgery to Urogynecolo
repair pelvic organ gic Society
prolapse who sustains an
injury to the bladder
recognized either during
or within I month after
surgery.
Sustaining a Bowel
any Pelvic Organ
Prolapse Repair:
American
undergoing surgical repair
! N/A 433 N/A Registry Outcome Patient Safety Urogynecolo
of pelvic organ prolapse
gic Society
that is complicated by a
bowel injury at the time of
index surgery that is
recognized
intraoperatively or within
I month after surgery.
Sustaining A Ureter
any Pelvic Organ
Prolapse Repair:
American
! N/A 434 N/A Registry Outcome Patient Safety Urogynecolo
undergoing pelvic organ
gic Society
prolapse repairs who
sustain an injury to the
ureter recognized either
during or within 1 month
after surgery.
EP30JN17.094</GPH>
B 9 Ob stet ncs
National
CMSE~ Data Measure
Quality Qqality Measure Title Measure
# lD Method
Domain ..
Non-Recommended Cervical
Cancer Screening in Adolescent National
Patient Females: Conmrittee
!! Safety The percentage of adolescent for Quality
females 16-20 years of age screened Assurance
urmecessarily for cervical cancer.
up:
National
Community/ The percentage of female
Comnrittee
N/A 447 N/A Registry Process Population adolescents 16 years of age who had
for Quality
Health a chlamydia screening test with
Assurance
proper follow-up during the
measurement period.
Appropriate Work Up Prior to
Endometrial Ablation:
Percentage of women, aged 18 years
Health
Registry Patient and older, who undergo endometrial
0567 448 N/A Process Benchmarks-
! Safety sampling or hysteroscopy with
IMS Health
biopsy and results documented
before undergoing an endometrial
ablation.
EP30JN17.095</GPH>
B 10 0'Plhth aI mo ogy
.
National
CMSE~ Data
#. Type Strategy and Description Steward
# ID .MethOd
1 Domain
.
Primary Open-Angle Glaucoma

Physician
(POAG): Optic Nerve Evaluation:
Consortium
Claims, Effective for
and older with a diagnosis of primary
0086 012 143v6 Registry, Process Clinical Pertormance
open-angle glaucoma (POAG) who
EHR Care Improvement
have an optic nerve head evaluation
Foundation
during one or more office visits
(PCPI)
within 12 months.
Age-Related Macular
Degeneration (AMD): Dilated
Macular Examination:
and older with a diagnosis of age-
related macular degeneration (AMD) American
Effective
Claims, who had a dilated macular Academy of
0087 014 N/A Process Clinical
Registry examination performed which Ophthahuolog
Care
included documentation of the y
presence or absence of macular
thickening or hemorrhage AND the
level of macular degeneration severity
within 12 months.
EP30JN17.096</GPH>
B 10 0 'PIhth aImo ogy ( con fmue d)
I National
.CMSE- Data
ID Metho11
Domain
.
Diabetic Retinopathy:
Documentation of Presence or
Absence of Macular Edema and
Level of Severity of Retinopathy: Physician
Percentage of patients aged 18 years Consortium
EtTective and older with a diagnosis of diabetic for
0088 018 167v6 EHR Process Clinical retinopathy who had a dilated macular Performance
Care or fundus exam performed which Improvement
included documentation of the level Foundation
of severity of retinopathy and the (PCPI)
presence or absence of macular edema
within 12 months.
Diabetic Retinopathy:
Communication with the Physician
Managing Ongoing Diabetes Care:
Communi and older with a diagnosis of diabetic Consortium
Claims, cation and retinopathy who had a dilated macular for
019
! 0089 142v6 Registry, Process Care or fundus exam performed with Performance
EHR Coordinati documented communication to the Improvement
on physician who manages the ongoing Foundation
care of the patient with diabetes (PCPI)
mellitus regarding the findings of the
macular or fundus exam at least once
within 12 months.
Diabetes: Eye Exam:
Percentage of patients 18- 75 years of
Claims, age with diabetes who had a retinal or
National
Web EtTective dilated eye exam by an eye care
Cmmnittee
0055 117 13lv6 Interface, Process Clinical professional during the measurement
for Quality
Registry, Care period or a negative retinal exam (no
Assurance
EHR evidence of retinopathy) in the 12
months prior to the measurement
period.
Centers for
Patient Medicare &
0419 130 68v7 Registry, Process resources available on the date of the
Safety Medicaid
EHR, encounter. This list must include ALL
Services
known prescriptions, over-the-
medications' name, dosage, frequency
and route of administration.
EP30JN17.097</GPH>

I .. National
CMSE- Data
NQF Quality Measure. Quality Measure Title Measure
ID Method
Domain
.
Age-Related Macular Degeneration
(AMD): Counseling on Antioxidant
Supplement:
Percentage of patients aged 50 years and
American
older with a diagnosis of age-related
Claims, Effective Academy of
0566 140 N/A Process macular degeneration (AMD) or their
Registry Clinical Care Ophthalmol
caregiver(s) who were counseled within
ogy
12 months on the benefits and/or risks of
the Age-Related Eye Disease Study
(AREDS) formulation for preventing
progression of AMD.
Primary Open-Angle Glaucoma
(POAG): Reduction oflntraocular
Pressure (lOP) by 15% OR
Documentation of a Plan of Care:
and older with a diagnosis of primary American
Communicat
Claims, open-angle glaucoma (POAG) whose Academy of
! 0563 141 N/A Outcome ion and Care
Registry glaucoma treatment has not failed (the Ophthalmol
Coordination
most recent lOP was reduced by at least ogy
15% from the pre- intervention level)
OR if the most recent lOP was not
reduced by at least 15% from the pre-
intervention level, a plan of care was
documented within 12 months.
Cataracts: 20/40 or Better Visual
Acuity within 90 Days Following Physician
Cataract Surgery: Consortium
Percentage of patients aged 18 years and for
older with a diagnosis of uncomplicated Performanc
Registry, Effective
! 0565 191 133v6 Outcome cataract who had cataract surgery and no e
EIIR Clinical Care
significant ocular conditions impacting lmproveme
the visual outcome of surgery and had nt
best-corrected visual acuity of20/40 or Foundation
better (distance or near) achieved within (PCPl<ID
90 days following the cataract surgery.
Cataracts: Complications within 30
Days Following Cataract Surgery
Requiring Additional Surgical
Procedures: Physician
Percentage of patients aged 18 years and Consortium
older with a diagnosis of uncomplicated for
cataract who had cataract surgery and Performanc
Registry, Patient
! 0564 192 132v6 Outcome had any of a specified list of surgical e
EHR Safety
procedures in the 30 days following lmproveme
cataract surgery which would indicate the nt
occurrence of any of the following major Foundation
complications: retained nuclear (PCPl<ID)
fragments, endophthahnitis, dislocated or
wrong power lOL, retinal detachment, or
wound dehiscence.
EP30JN17.098</GPH>
B.lO. Ophthalmology (continued)

National
Quality. CMSE- Data
NQF Measure Quality Measure Title Measure
ID Method
Domain
more times within 24 months Physician
Claims,
Community/ years and older who were screened for
* 0028 226 138v6
Registry,
EHR, Web
Interface
c. Percentage of patients aged 18 (PCPT)
tobacco user.
Cataracts: Improvement in
Patient's Visual Function within 90
Person Days Following Cataract Surgery:
Caregiver- Percentage of patients aged 18 years American
Centered and older who had cataract surgery Academy of
! 1536 303 N/A Registry Outcome
Experience and had improvement in visual Ophthalmolog
and function achieved within 90 days y
Outcomes following the cataract surgery, based
on completing a pre-operative and
post-operative visual function survey.
Closing the Referral Loop: Receipt
of Specialist Report:
Centers for
Communicat Percentage of patients with referrals,
* Registry, Medicare &
N/A 374 50v6 Process ion and Care regardless of age, for which the
! EHR Medicaid
Coordination referring provider receives a report
Services
from the provider to whom the patient
was referred.
Adult Primary Rhegmatogenous
Retinal Detachment Surgery: No
Return to the Operating Room
Within 90 Days of Surgery: American
Effective Patients aged 18 years and older who Academy of
! N/A 384 N/A Registry Outcome
Clinical Care had surgery for primary Ophthalmolog
rhegmatogenous retinal detachment y
who did not require a return to the
operating room within 90 days of
surgery.
EP30JN17.099</GPH>

National
CMS.E- Data
.Indicator Measure Submission
ID Method I
Domain
Adult Primary Rhegmatogenous
Retinal Detachment Surgery:
Visual Acuity Improvement Within
90 Days of Surgery:
American
EtTective Patients aged 18 years and older who
Academy of
! N/A 385 N/A Registry Outcome Clinical had surgery for primary
Ophthalmolog
Care rhegmatogenous retinal detachment
y
and achieved an improvement in their
visual acuity, from their preoperative
level, within 90 days of surgery in the
operative eye.
Cataract Surgery with Intra-
Operative Complications
(Unplanned Rupture of Posterior
Capsule Requiring Unplanned American
Patient Vitrectomy: Academy of
! N/A 388 N/A Registry Outcome
Safety Percentage of patients aged 18 years Ophthalmolog
and older who had cataract surgery y
performed and had an unplanned
rupture of the posterior capsule
requiring vitrectomy.
Cataract Surgery: Difference
Between Planned and Final
Refraction: American
EtTective
Percentage of patients aged 18 years Academy of
! N/A 389 N/A Registry Outcome Clinical
and older who had cataract surgery Ophthalmolog
Care
performed and who achieved a final y
refraction within+/- 0.5 diopters of
their planned (target) refraction.
Comrnunit National
20 years of age with a primary care
y/ Committee
N/A 402 N/A Registry Process visit during the measurement year for
Population for Quality
whom tobacco use status was
Health Assurance
user.
EP30JN17.100</GPH>
B 11 0 rth ope d"IC surgery

National
CMSE- Data
Indica Quality Measure Quality Measure Title Measure
NQF Measure Submission:
tor # ID
# Method
Domajn
! 0045 024 N/A Claims, Process Communicati Communication with the Physician National
Registry on and Care or Other Clinician Managing On- Committee
Coordination going Care Post-Fracture for Men for Quality
and Women Aged 50 Years and Assurance
Older:
and older treated for a fracture with
documentation of communication,
between the physician treating the
fracture and the physician or other
clinician managing the patient's on-
considered for osteoporosis treatment
or testing. This measure is reported
by the physician who treats the
fracture and who therefore is held
accountable for the communication.
Perioperative Care: Selection of
Prophylactic Antibiotic- First OR
Second Generation Cephalosporin:
Percentage of surgical patients aged
American
18 years and older undergoing
Claims, Society of
!! 0268 021 N/A Process Patient Safety procedures with the indications for a
Registry Plastic
first OR second generation
Surgeons
cephalosporin prophylactic antibiotic,
who had an order for a first OR
second generation cephalosporin for
antimicrobial prophylaxis.
Perioperative Care: Venous
Thromboembolism (VTE)
Prophylaxis (When Indicated in
ALL Patients):
Percentage of surgical patients aged 18
years and older undergoing procedures
for which venous thromboembolism American
Claims, (VTE) prophylaxis is indicated in all Society of
! 0239 023 N/A Process Patient Safety
Registry patients, who had an order tor Low Plastic
Molecular Weight Heparin (LMWH), Surgeons
Low-Dose Unfractionated Heparin
(LDUH), adjusted-dose warfarin,
fondaparinux or mechanical prophy laxi
to be given within 24 hours prior to
incision time or within 24 hours after
surgery end time.
EP30JN17.101</GPH>
B 11 0 rth ope d"IC surgery con fmue d)

CMS National
Data Measure
llldka ~QF Quality E~ Quality Measure Title Measure
Submission Type
tor # .. # Measure Strategy and Description Steward
Method
ID Domain
Medication Reconciliation Post~
Discharge: The percentage of
discharges from any inpatient facility
(e.g. hospital, skilled nursing facility,
or rehabilitation facility) for patients
18 years and older of age seen within
30 days following discharge in the
office by the physician, prescribing
practitioner, registered nurse, or
clinical pharmacist providing on- National
Claims, Web Connnunicat
going care for whom the discharge Committee
0097 046 N/A Interface, Process ion and Care
! medication list was reconciled with for Quality
Registry Coordination
the current medication list in the Assurance
outpatient medical record.
This measure is reported as three
rates stratified by age group:
o Reporting Criteria 1: 18-64 years of
age
o Reporting Criteria 2: 65 years and
older
o Total Rate: All patients 18 years of
age and older.

Care Plan:
plan or surrogate decision maker National
Connnunicat
Claims, documented in the medical record Committee
0326 047 N/A Process ion and Care
Registry that an advance care plan was for Quality
Coordination
discussed but the patient did not wish Assurance
or was not able to name a surrogate
decision maker or provide an advance
care plan.
EP30JN17.102</GPH>
B 11 0 rth ope d"IC surgery ( con fmue d)

..
CMS National
Data
Indica NQF Quality E-: Submission
tor # # Measur Type Strategy and Description Steward
Method
eiD. Domain
Person and Osteoarthritis (OA): Function and American
Caregiver- Pain Assessment: Academy of
Claims, Centered Percentage of patient visits for patients Orthopedic
! N/A 109 N/A Process
Registry Experience aged 21 years and older with a Surgeons
and diagnosis of osteoarthritis (OA) with
Outcomes assessment for function and pain.
and Follow-Up Plan:
during the current encounter or during Centers for
Claims, Web Community/
* 0421 128 69v6 Interface, Process Population
the previous twelve months AND with Medicare &
a BMI outside of normal parameters, a Medicaid
Registry, EHR Health
follow-up plan is documented during Services
the encounter or during the previous
twelve months of the current
encounter.
Nonnal Parameters: Age 18 years and
older BMI => 18.5 and< 25 kg/m2.
EP30JN17.103</GPH>

National
CMSE- Data
# .# Type Strategy and Description Steward
ID Method
Domain
Record:
aged 18 years and older for which
the eligible professional attests to
Centers for
Medicare&
! 0419 130 68v7 Registry, Process Patient Safety resources available on the date of
Medicaid
EHR the encounter. This list must
Services
include ALL known prescriptions,
over-the-counters, herbals, and
(nutritional) supplements AND
must contain the medications'
name, dosage, frequency and route
of administration.
Pain Assessment and Follow-Up:
aged 18 years and older with Centers for
Claims, Communication
documentation of a pain Medicare&
! 0420 131 N/A Registry Process and Care
assessment using a standardized Medicaid
Coordination
tool(s) on each visit AND Services
documentation of a follow-up plan
when pain is present.
Screening for Depression and
Follow-Up Plan:
Claims, Percentage of patients aged 12
Centers for
Web Community/ years and older screened for
Medicare&
0418 134 2v7 Interface, Process Population depression on the date of the
Medicaid
Registry, Health encounter using an age appropriate
Services
EHR standardized depression screening
tool AND if positive, a follow-up
plan is documented on the date of
the positive screen.
National
Claims, Committee
! 0101 154 N/A Process Patient Safety years and older with a history of
falls who had a risk assessment for
Assurance
falls completed within 12 months.
Communication
Claims, years and older with a history of Committee
Registry falls who had a plan of care for for Quality
Coordination
falls documented within 12 Assurance
months.
Rheumatoid Arthritis (RA):
Functional Status Assessment:
American
Effective College of
N/A 178 N/A Registry Process Clinical Care Rheumatol
rheumatoid arthritis (RA) for
ogy
whom a functional status
assessment was performed at least

once within 12 months.
EP30JN17.104</GPH>
B 11 0 rth oped"IC surgery ( con fmued)

National
CMSE~ Data
N:QF Quality Measure Quality Measure Title Measure
ID Method
Domain
Assessment and Classification of
Disease Prognosis: American
Effective
Percentage of patients aged 18 years College of
Clinical
NIA 179 NIA Registry Process and older with a diagnosis of Rheumatolog
Care
rheumatoid arthritis (RA) who have an y
assessment and classification of disease
prognosis at least once within 12
months.
Glucocorticoid Management
rheumatoid arthritis (RA) who have American
Effective
been assessed for glucocorticoid use College of
NIA 180 NIA Registry Process Clinical
and, for those on prolonged doses of Rheumatolo
Care
prednisone 2: 10 mg daily (or gy
equivalent) with improvement or no
change in disease activity,
documentation of glucocorticoid
management plan within 12 months.
a. Percentage of patients aged 18 years
tobacco use one or more times within
Physician
24 months
Claims, Consortium
b. Percentage of patients aged 18 years
Web ConmmnityI for
Performance
tobacco use and identified as a
Registry, Health Improvemen
tobacco user who received tobacco
EHR t Foundation
(PCPI)
tobacco use one or more times within
24 months AND who received
cessation counseling intervention if
Percentage of patients aged 18 years Centers for
Claims, ConmmnityI
and older seen during the reporting Medicare&
NIA 317 22v6 Registry, Process Population
period who were screened for high Medicaid
EHR Health
follow-up plan is documented based on
the current blood pressure (BP) reading
as indicated.
Falls: Screening for Future Fall
Risk: National
EHR, Web Patient Percentage of patients 65 years of age Committee
0101 318 139v6 Process
Intertace Safety and older who were screened for future for Quality
fall risk during the measurement Assurance

period.
EP30JN17.105</GPH>

National
CMSE- Data
# # '}'ype Strategy and. Description Steward
ID Method
Domain
Total Knee Replacement: Shared
Decision-Making: Trial of
Conservative (Non-surgical)
Therapy: American
rommunication Percentage of patients regardless of age Associatio
~nd Care undergoing a total knee replacement with n of Hip
I N/A 350 N/A Registry Process
roordination documented shared decision-making with and Knee
discussion of conservative (non-surgical) Surgeons
therapy (e.g. nonsteroidal anti-
inflammatory dmgs (NSAIDs),
analgesics, weight loss, exercise,
injections) prior to the procedure.
Total Knee Replacement: Venous
Thromboembolic and Cardiovascular
Risk Evaluation:
Percentage of patients regardless of age American
undergoing a total knee replacement who Associatio
Patient
are evaluated for the presence or absence nofHip
! N/A 351 N/A Registry Process Safety
of venous Urromboembolic and audKnee
cardiovascular risk factors within 30 days Surgeons
prior to the procedure (e.g. history of
Deep Vein Thrombosis (DVT),
Pulmonary Embolism (PE), Myocardial
Infarction (Ml), Arrhythmia and Stroke).
Total Knee Replacement: Preoperative
Antibiotic Infusion with Proximal American
Tourniquet: Associatio
Patient Percentage of patients regardless of age n of Hip
! N/A 352 N/A Registry Process
Safety undergoing a total knee replacement who and Knee
had the prophylactic antibiotic Surgeons
completely infused prior to the inflation
of the proximal tourniquet
Total Knee Replacement:
Identification of Implanted Prosthesis
in Operative Report:
American
Percentage of patients regardless of age
Associatio
undergoing a total knee replacement
Patient nofHip
! N/A 353 N/A Registry Process whose operative report identifies the
Safety and Knee
prosthetic implant specifications
Surgeons
including the prosthetic implant
manufacturer, the brand name ofthe
prosthetic implant and the size of each
prosthetic implant.
Patient-Centered Surgical Risk
Assessment and Communication:
Person and Percentage of patients who underwent a
American
Caregiver- non-emergency surgery who had their
Associatio
Centered personalized risks of postoperative
n of Hip
! N/A 358 N/A Registry Process Experience complications assessed by their surgical
and Knee
and team prior to surgery using a clinical
Surgeons
Outcomes data-based, patient-specific risk
calculator and who received personal
discussion of those risks with the
surgeon.
EP30JN17.106</GPH>

National
CMSE- Data
# Type Strategy and Descriptian Steward
# m Method
Domain
Centers
for
Connmmication Percentage of patients with referrals,
* N/A 374 50v6
Registry,
Process and Care regardless of age, for which the
Medicare
! EHR &
Coordination referring provider receives a report
Medicaid
from the provider to whom the
Services
Functional Status Assessment for
Total Knee Replacement:
Changes to the measure description:
Person and Percentage of patients 18 years of Centers
Caregiver- age and older who received an for
* N/A 375 66v6 EIIR Process
Centered elective primary total knee Medicare
! Experience and arthroplasty (TKA) who completed &
Outcomes baseline and follow-up patient- Medicaid
reported and completed a functional Services
status assessment within 90 days
prior to the surgery and in the 270-
365 days after the surgery.
Functional Status Assessment for
Total Hip Replacement:
Person and Centers
age and older with who received an
Caregiver- for
elective primary total hip
Centered Medicare
! N/A 376 56v6 EHR Process arthroplasty (THA) who completed
Experience and &
baseline and follow-up patient-
Outcomes Medicaid
reported and completed a functional
Services
status assessment within 90 days
prior to the surgery and in the 270-
365 days after the surgery.
The percentage of adolescents 12 to National
Community/ 20 years of age with a primary care Committe
N/A 402 N/A Registry Process Population visit during the measurement year for e for
Health whom tobacco use status was Quality
documented and received help with Assurance
user.
Evaluation:
All patients 18 and older prescribed American
Effective opiates for longer than six weeks Academy
Clinical Care duration who had a follow-up of
evaluation conducted at least every Neurology
Clinical Care duration who signed an opioid of
treatment agreement at least once Neurology

in the medical record.
EP30JN17.107</GPH>

National ..
CMSE- Data Measure
Quality Quality Mca~urc Title Measure
NQF' Measure Submission Type
# m Method
Domain
Opioid Misuse:
Effective American
duration evaluated for risk of opioid
NIA 414 NIA Registry Process Clinical Academy of
misuse using a brief validated
Care Neurology
instrument (e.g. Opioid Risk Tool,
SOAAP-R) or patient interview
documented at least once during
Opioid Therapy in the medical record
Effective
Claims, who suffered a fracture and who Committee
0053 418 NIA Process Clinical
Registry either had a bone mineral density test for Quality
Care
or received a prescription for a drug Assurance
to treat osteoporosis in the six months
after the fracture
Average Change in Back Pain
Person and Following Lumbar Discectomy I
Caregiver- Laminotomy:
MN
Centered The average change (preoperative to
NIA TBD NIA Registry Outcome Community
Experience three months postoperative) in back
Measurement
and pain for patients 18 years of age or
Outcomes older who had lumbar discectomy
/laminotomy procedure
Person and Average Change in Back Pain
Caregiver- Following Lumbar Fusion:
MN
Experience one year postoperative) in back pain
Measurement
and for patients 18 years of age or older
Outcomes who had lumbar spine fusion surgery
Average Change in Leg Pain
Person and Following Lumbar Discectomy I
Caregiver- Laminotomy:
MN
Experience three months postoperative) in leg pain
Measurement
and for patients 18 years of age or older
Outcomes who had lumbar discectomy I
laminotomy procedure
EP30JN17.108</GPH>
B 12 Ot oIaryng o ogy ( con fmue d)

National
CMSE- Data
# TD Method
Domain
American
Claims, Patient Society of
!! 0268 021 N/A Process procedures with the indications for a
Registry Safety Plastic
Surgeons
antimicrobial prophy !axis
Periuperative Care: Venous
ALL Patients):
procedures for which venous
American
thromboembolism (VTE) prophylaxis
! 0239 023 N/A Process is indicated in all patients, who had
an order for Low Molecular Weight
Surgeons
Heparin (LMWH), Low-Dose
Unfractionated Heparin (LDUH),
adjusted-dose warfarin, fondaparinux
or mechanical prophy !axis to be
given within 24 hours prior to
surgery end time
Care Plan:
Communica
plan or surrogate decision maker National
tionand
Claims, documented in the medical record that Committee
0326 047 N/A Process Care
Registry an advance care plan was discussed for Quality
Coordinatio
but the patient did not wish or was not Assurance
n
able to name a surrogate decision
maker or provide an advance care
plan.
Infection (URI):
National
Registry, Cmmnittee
EHR for Quality
Assurance
on or three days after the episode
EP30JN17.109</GPH>
B 12 Ot o Iarym o ogy ( con fmue d)

I. . National
CMSE~ Data
Indicator NQF' Measure Submission
# ID Method
Domain
Acute Otitis Externa (AOE): Topical American
Effective Therapy: Academy of
Claims,
!! 0653 091 NIA Process Clinical Percentage of patients aged 2 years and Otolaryngology
Registry
Care older with a diagnosis of AOE who Head and Neck
were prescribed topical preparations Surgery
Acute Otitis Externa (AOE):
Efficiency Avoidance of Inappropriate Use: Academy of
Claims,
!! 0654 093 NIA Process and Cost Percentage of patients aged 2 years and Otolaryngology
Registry
Reduction older with a diagnosis of AOE who Head and Neck
were not prescribed systemic Surgery
antimicrobial therapy
Claims,
Percentage of patients aged 6 months Consorti1m1 for
Web Community
147v7 and older seen for a visit between Performance
* 0041 110 Intertace, Process I Population
October 1 and March 31 who received Improvement
Registry, Health
an influenza immunization OR who Foundation
EHR
reported previous receipt of an (PC PilE)
influenza immunization
Claims, Pneumonia Vaccination Status for
National
Web Conmmnity Older Adults:
Committee for
0043 111 127v6 Intertace, Process I Population Percentage of patients 65 years of age
Quality
Assurance
EHR pneumococcal vaccine
and Follow-Up Plan:
during the current encounter or during
Claims, Centers for
Conmmnity the previous twelve months AND with
* 0421 128 69v6
Registry,
Process /Population a BMI outside of normal parameters, a
Medicare &
EHR, Web Medicaid
Health follow-up plan is documented during
Intertace Services
the encounter or during the previous
twelve months of the current
encounter.
Normal Parameters:
and< 25 kglm2
eligible clinician attests to
Centers for
Patient Medicare &
! 0419 130 68v7 Registry, Process resources available on the date of the
Safety Medicaid
EHR encounter. This list must include ALL
Services
known prescriptions, over-the-

EP30JN17.110</GPH>

National
CMSE- Data
# Type Strategy and Description Stewttrd
# ID Method
Domain
National
Claims, Patient Committee for
! 0101 154 N/A Process and older with a history of falls who
Registry Safety Quality
had a risk assessment for falls
Assurance
completed within 12 months
Communica Falls: Plan of Care:
National
tion and Percentage of patients aged 65 years
! 0101 155 N/A Process Care and older with a history of falls who
Registry Quality
Coordinatio had a plan of care for falls
Assurance
n documented within 12 months
within 24 months
Physician
Claims, Consortium for
Community years and older who were screened
* 0028 226 138v6
Registry,
Process /Population for tobacco use and identified as a
Performance
EHR,Web Improvement
Health tobacco user who received tobacco
(PCPI)
tobacco user.
Biopsy Follow Up:
Communica
Percentage of new patients whose
tion and American
biopsy results have been reviewed
! N/A 265 N/A Registry Process Care Academy of
and communicated to the primary
Coordinatio Dermatology
care/referring physician and patient
n
by the performing physician
Sleep Apnea: Assessment of Sleep
Symptoms:
Effective 18 years and older with a diagnosis of American
N/A 276 N/A Registry Process Clinical obstructive sleep apnea that includes Academy of
Care documentation of an assessment of Sleep Medicine
sleep symptoms, including presence
or absence of snoring and daytime
sleepiness
EP30JN17.111</GPH>
B 12 0 to ar ngo ogy contmue d)

National
CMSE- Data
NQF Quality M~a~ure Quality Measure Title
Indicator Measure Submission Measure Steward
# # Type Strategy and Description
1D Method ..
Domain
Sleep Apnea: Severity Assessment
at Initial Diagnosis:
Effective and older with a diagnosis of
American Academy
N/A 277 N/A Registry Process Clinical obstmctive sleep apnea who had an
of Sleep Medicine
Care apnea hypopnea index (AHI) or a
respiratmy disturbance index (RDI)
measured at the time of initial
diaQ,nosis
Sleep Apnea: Positive Airway
Pressure Therapy Prescribed:
Effective Percentage of palienls aged 18 years
American Academy
N/A 278 N/A Registry Process Clinical and older with a diagnosis of
of Sleep Medicine
Care moderate or severe obstmctive sleep
apnea who were prescribed positive
airwav pressure therapy
Sleep Apnea: Assessment of
Adherence to Positive Airway
Pressure Therapy:
Effective 18 years and older with a diagnosis
American Academy
N/A 279 N/A Registry Process Clinical of obstr1.rctive sleep apnea who were
of Sleep Medicine
Care prescribed positive airway pressure
therapy who had documentation that
adherence to positive airway
pressure therapy was objectively
measured
Documented:
Cmmnunity Percentage of patients aged 18 years
Process /Population and older seen during the reporting Centers for Medicare
N/A 317 22v6 Registry
IIealth period who were screened for high & Medicaid Services
blood pressure AND a
recommended tallow-up plan is
blood pressure (BP) reading as
indicated.
(Overuse): American Academy
Efficiency
Percentage of patients, aged 18 of
!! N/A 331 N/A Registry Process and Cost
years and older, with a diagnosis of Otolaryngology-Head
Reduction
acute sinusitis who were prescribed and Neck Surgery
an antibiotic within 10 days after
onset of svmptoms
EP30JN17.112</GPH>
B 12 0 to I aryn [!0 ogy contmue d)

,'
National
CMS:E~ Data
Quallty Measure Quality Measure Title
Indi~;ator NQF Measure Submission Meas\]re Steward
# Type Strategy and Description
# ID Method
' Domain
Adult Sinusitis: Appropriate Choice of
Antibiotic: Amoxicillin With or
Without Clavulanate Prescribed for
Efficienc Patients with Acute Bacterial Sinusitis American
y and (Appropriate Use): Academy of
II NIA 332 NIA Registry Process Cost Percentage of patients aged 18 years and Otolaryngology-
Reductio older with a diagnosis of acute bacterial Head and Neck
n sinusitis that were prescribed Surgery
amoxicillin, with or without clavulante,
as a first line antibiotic at the time of
diagnosis
Tomography (CT) for Acute Sinusitis
(Overuse): American
Etlicienc
Percentage of patients aged 18 years and Academy
y and
older with a diagnosis of acute sinusitis of
!I N/A 333 NIA Registry Efficiency Cost
who had a computerized tomography Otolaryngology-
Reductio
(CT) scan of the paranasal sinuses IIead and Neck
n
ordered at the time of diagnosis or Surgery
received within 28 days after date of
diagnosis
Computerized Tomography (CT) Scan
Efficicnc Within 90 Days for Chronic Sinusitis American
y and (Overuse): Percentage of patients aged 18 Academy of
!I N/A 334 NIA Registry Efficiency Cost years and older with a diagnosis of chronic Otolaryngology-
Reductio sinusitis who had more than one CT scan Head and Neck
n of the paranasal sinuses ordered or Surgery
received within 90 days after the date of
diagnosis
Surgical Site Infection (SSI):
Effective American College
Percentage of patients aged 18 years and
! N/A 357 NIA Registry Outcome Clinical
older who had a surgical site infection
of Surgeons
Care
(SSI)
Person Assessment and Communication:
and Percentage of patients who underwent a
Caregiver non-emergency surgery who had lheir
N/A -Centered personalized risks of postoperative American College
! N/A 358 Registry Process
Experien complications assessed by their surgical of Surgeons
ce and team prior to surgery using a clinical data-
Outcome based, patient-specific risk calculator and
s who received personal discussion of those
risks with the surgeon
EP30JN17.113</GPH>

National
CMSE- Data
# Type Strategy arid Description Stewttrd
# lD Method
Domain
Cormmmication
* N/A 374 50v6
Registry,
Process and Care
referrals, regardless of age, for Medicare &
! EIIR which the referring provider Medicaid
Coordination
provider to whom the patient was
referred.
Composite measure of the
percentage of pediatric and adult Milmesota
Effective
! N/A 398 N/A Registry Outcome patients whose asthma is well- Connnunity
Clinical Care
controlled as demonstrated by Measurement
one of three age appropriate
patient reported outcome tools
12 to 20 years of age with a National
Community/
prilnary care visit during the Cmmnittee
measurement year for whom for Quality
Health
tobacco use status was Assurance
tobacco user
Preventive Care and
Screening: Unhealthy Alcohol
Use: Screening & Brief
Physician
Counseling:
Consortium
for
Community/ years and older who were
Performance
2152 431 N/A Registry Process Population screened for unhealthy alcohol
Improvement
Health use using a systematic screening
Foundation
method at least once within the
(PCPI)
last 24 months AND who
received brief cmmseling if
identified as an unhealthy
alcohol user.
Otitis Media with Effusion
(OME): Systemic American
Antimicrobials- Avoidance of Academy of
Patient Safety, Inappropriate Use: Otolaryngology
0657 TBD N/A Registry Process Efficiency and Percentage of patients aged 2 -Head and
Cost Reduction months through 12 years with a Neck Surgery
diagnosis of OME who were not Foundation
prescribed systemic (AAOHNSF)
antimicrobials.
EP30JN17.114</GPH>
B13P athi
o ogy
National '
ClVIS,E- Data
Quality Measure Quality, Measure Title Measure
# Type Strategy and Descrip,tion Steward
# ID Method
Domain
Breast Cancer Resection
Pathology Reporting: pT
Category (Primary Tumor) and
pN Category (Regional Lymph
College of
Claims, Effective Nodes) with Histologic Grade:
0391 099 N/A Process American
Registry Clinical Care Percentage of breast cancer resection
Pathologists
pathology reports that include the pT
category (primary tumor), the pN
category (regional lymph nodes),
and the histologic grade
Colo rectal Cancer Resection
Pathology Reporting: pT
Category (Primary Tumor) and
pN Category (Regional Lymph
Nodes) with Histologic Grade: College of
Claims, Effective
0392 100 N/A Process Percentage of colon and rectum American
cancer resection pathology reports Pathologists
that include the pT category
(primary tumor), the pN category
(regional lymph nodes) and the
histologic grade
Barrett's Esophagus:
Percentage of esophageal biopsy College of
Claims, Effective
lg54 249 N/A Process reports that document the presence American
of Barrett's mucosa that also include Pathologists
a statement about dysplasia
Radical Prostatectomy Pathology
Reporting:
Percentage of radical prostatectomy College of
Claims, Effective
1853 250 N/A Process pathology reports that include the American
pT category, the pN category, the Pathologists
Gleason score and a statement about
margin status
Quantitative
Immunohistochemical (IHC)
Evaluation of Human Epidermal
Growth Factor Receptor 2 Testing
(HER2) for Breast Cancer
Patients:
This is a measure based on whether College of
Claims, Effective
1855 251 N/A Structure quantitative evaluation of Human American
Epidermal Growth Factor Receptor Pathologists
2 Testing (HER2) by
immunohistochemistry (IHC) uses
the system recommended in the
current ASCO/CAP Guidelines for
Human Epidermal Growth Factor
Receptor 2 Testing in breast cancer
EP30JN17.115</GPH>
I gy ( con mue d)
B 13 P ath 00
National
CMSE- Data
# ID Method
Domain
Lung Cancer Reporting (Biopsy/
Cytology Specimens):
Pathology reports based on biopsy
Commllllicat and/or cytology specimens with a College of
Claims,
! N/A 395 N/A Process ion and Care diagnosis of primary nonsmall cell American
Registry
Coordination lllllg cancer classified into specific Pathologists
histologic type or classified as
NSCLC-NOS with an explanation
included in the pathology report
Lung Cancer Reporting
(Resection Specimens):
Pathology reports based on resection
Commllllicat College of
Claims, specimens with a diagnosis of
! N/A 396 N/A Process ion and Care American
Registry primary lung carcinoma that include
Coordination Pathologists
the pT category, pN category and for
non-small cell lung cancer,
histologic type
Melanoma Reporting:
Pathology reports for primary
Commllllicat College of
Claims, malignant cutaneous melanoma that
! N/A 397 N/A Process ion and Care American
Registry include the pT category and a
Coordination Pathologists
statement on thickness and
ulceration and for pTl, mitotic rate
EP30JN17.116</GPH>
B.14. Pediatrics
National
CMSE- Data
# ID Method
Domain
Infection (URI):
National
Registry, Committee
EHR for Quality
Assurance
on or three days after the episode.
with Pharyngitis:
Percentage of children 3-18 years of National
Efficiency
Registry, age who were diagnosed with Committee
!! N/A 066 146v6 Process and Cost
EHR pharyngitis, ordered an antibiotic for Quality
Reduction
and received a group A Assurance
streptococcus (strep) test for the
episode.
Acute Otitis External (AOE):
American
Topical Therapy:
Academy of
Claims, Effective Percentage of patients aged 2 years
!! 0653 091 N/A Process Otolaryngology
Registry Clinical Care and older with a diagnosis of AOE
-Head and
who were prescribed topical
Neck Surgery
preparations
EP30JN17.117</GPH>
B.14. Pediatrics (continued)

National
CMSE- Data
NQF Measure Submission
Indicator # Type Strategy and Description Steward
# ID Method
Domain
Systemic Antimicrobial Therapy-
American
Efficiency Avoidance of Inappropriate Use:
Claims, Academy of
!! 0654 093 NIA Process and Cost Percentage of patients aged 2 years
Registry Otolaryngolo
Reduction and older with a diagnosis of AOE
gy-Headand
who were not prescribed systemic
Neck Surgery
antilnicrobial therapy
Physician
Claims, Consortium
Web Community for
147v7 and older seen for a visit between
* 0041 110 Interface, Process I Population Performance
October 1 and March 31 who
Registry, Health Improvement
received an influenza innnunization
EHR Foundation
OR who reported previous receipt of
(PCPI)
an influenza immunization
Screening for Depression and
Follow-Up Plan:
Claims,
Web Community
and older screened for depression on Medicare &
0418 134 2v7 Interface, Process I Population
the date of the encounter using an age Medicaid
Registry, Health
appropriate standardized depression Services
EHR
screening tool AND if positive, a
follow-up plan is documented on the
date of the positive screen
IITVIAIDS: Pneumocystis Jiroveci
Pneumonia (PCP) Prophylaxis:
National
Effective Percentage of patients aged 6 weeks
Committee
9 0405 160 52v6 EHR Process Clinical and older with a diagnosis of
for Quality
Care HIVIAIDS who were prescribed
Assurance
Pneumocystis Jiroveci Pneumonia
(PCP) prophylaxis
IITVIAIDS: Sexually Transmitted
Disease Screening for Chlamydia,
Gonorrhea, and Syphilis:
National
Committee
0409 205 NIA Registry Process Clinical and older with a diagnosis of
for Quality
Care HIVIAIDS for whom chlamydia,
Assurance
gonorrhea and syphilis screenil1gs
were performed at least once since
the diagnosis ofHIV infection
EP30JN17.118</GPH>
B 14 Pediatrics (continued)
National
CMSE- Data
# TD Method
Doml!in
Weight Assessment and
Counseling for Nutrition and
Physical Activity for Children and
Adolescents:
Percentage of patients 3-17 years of
age who had an outpatient visit with
a Primary Care Physician (PCP) or
Obstetrician/Gynecologist
(OBIGYN) and who had evidence of National
Community
EHR the following dming the Committee
0024 239 155v6 Process I Population
measurement period. Three rates are for Quality
Health
reported. Assurance
Percentage of patients with height,
weight, and body mass index
(BMI) percentile documentation
Percentage of patients with
counseling for nutrition
Percentage of patients with
counseling for physical activity
Childhood Immunization Status:
Percentage of children 2 years of
age who had four diphtheria, tetanus
and acellular pertussis (DTaP); three
polio (IPV), one measles, mumps
National
Community and rubella (MMR); three H
117v6 Committee
0038 240 EHR Process I Population influenza type B (HiB); three
for Quality
Health hepatitis B (Hep B); one chicken
Assurance
pox (VZV); four pneumococcal
conjugate (PCV); one hepatitis A
(Hep A); two or three rotavirus
(RV); and two influenza (ilu)
vaccines by their second birthday
age and older with a new episode of
alcohol and other drug (AOD)
Effective
following. Two rates are reported. Committee
a. Percentage of patients who for Quality
Care
initiated treatment within 14 days of Assurance
the diagnosis.
initiated treatment and who had two
or more additional services with an
AOD diagnosis within 30 days of
the initiation visit
Chlamydia Screening for Women:

Percentage of women 16-24 years of National
Community
age who were identified as sexually Committee
0033 310 153v6 EHR Process I Population
active and who had at least one test for Quality
Health
for chlamydia during the Assurance

measurement period
EP30JN17.119</GPH>

Data National
CMSE-
Qua}ity Submissi Measure Quality Measure Title Measure
Indicator NQF Measure
# on Type Strategy and Description Steward
# ID Method Domain
ADHD: Follow-Up Care for
Children Prescribed Attention-
Deficit/Hyperactivity Disorder
(ADHD) Medication:
Percentage of children 6-12 years of
age and newly dispensed a
medication for attention-
deficit/hyperactivity disorder
(ADHD) who had appropriate follow-
up care. Two rates are reported. National
Effective
a. Percentage of children who had one Committee
follow-up visit with a practitioner for Quality
Care
with prescribing authority during the Assurance
30-Day Initiation Phase.
b. Percentage of children who
remained on ADHD medication for at
least 210 days and who, in addition to
the visit in the Initiation Phase, had at
least two additional follow-up visits
with a practitioner within 270 days (9
months) after the Initiation Phase
ended
Primary Caries Prevention
Intervention as Offered by Primary
Centers for
Effective Care Providers, including Dentists:
Medicare &
N/A 379 74v7 EHR Process Clinical Percentage of children, age 0-20
Medicaid
Care years, who received a fluoride varnish
Services
application during the measurement
period
Child and Adolescent Major
Physician
Depressive Disorder (MDD):
Consortium
Suicide Risk Assessment:
for
Patient Percentage of patient visits for those
! 1365 382 177v6 EHR Process Performance
Safety patients aged 6 through 17 years with
Improvement
a diagnosis of major depressive
Foundation
disorder with an assessment for
(PCPI)
suicide risk
EP30JN17.120</GPH>

National
CMS:E- Data
NQF Qua)jty :Measure Quality Measure Title Measure
lndicato:r Measure Submission
ID Method .
I Domain
Follow-up After Hospitalization
for Mental lllness (FUH):
The percentage of discharges for
patients 6 years of age and older who
were hospitalized for treatment of
selected mental illness diagnoses and
who had an outpatient visit, an National
Commtmicat intensive outpatient encounter or Committee
! 0576 391 N/A Registry Process ion/Care partial hospitalization with a mental for Quality
Coordination health practitioner. Two rates arc Assurance
reported:
which the patient received follow-
up within 30 days of discharge
which the patient received follow-
up within 7 days of discharge
Immunizations for Adolescents:
National
Community/ The percentage of adolescents 13
Committee
1407 394 N/A Registry Process Population years of age who had the
for Quality
Health recommended immunizations by their
Assurance
13th birthday
Composite measure ofthe
percentage of pediatric and adult MN
Effective
! N/A 398 N/A Registry Outcome patients whose asthma is well- Community
Clinical Care
controlled as demonstrated by one of Measurement
three age appropriate patient
reported outcome tools
National
Community/ 20 years of age with a primary care
Committee
N/A 402 NA Registry Process Population visit during the measurement year
for Quality
Health for whom tobacco use status was
Assurance
user
The percentage of patients 5-64
National
Efficiency years of age during the measurement
Commillee
1799 444 N/A Registry Process and Cost year who were identified as having
! for Quality
Reduction persistent astlnna and were
Assurance
dispensed appropriate medications
that they remained on for at least
75% of their treatment period.
up: The percentage of female National
Community/
adolescents 16 years of age who had Committee
~ N/A 447 N/A Registry Process Population
a chlamydia screening test with for Quality
Health
proper follow-up during the Assurance
measurement period
EP30JN17.121</GPH>

1\ National
CMSE- Data Measure
# ID Method
Domain
...
Otitis Media with Effusion (OME): American

Patient Systemic Antimicrobials- Academy of
Safely, Avoidance of Inappropriate Use: Otolaryngology
0657 TBD N/A Registry Process Efficiency Percentage of patients aged 2 months -Head and
and Cost through 12 years with a diagnosis of Neck Surgery
Reduction OME who were not prescribed Foundation
systemic antimicrobials. (AAOHNSF)
Well-Child Visits in the Third,

Fourth, Fifth, and Sixth Years of
National
Communit Life:
Conunittee
1516 TBD N/A Registry Process y/Populati The percentage of children 3-6 years
for Quality
on Health of age who had one or more well-
Assurance
child visits with a PCP during the
measurement year.
Developmental Screening in the

First Three Years of Life:
The percentage of children screened
for risk of developmental, behavioral
and social delays using a standardized
Oregon
Communit screening tool in the first three years
Health&
1448 TBD N/A Registry Process y/Populati of life. This is a measure of screening
Science
on Health in the first three years of life that
University
includes three, age-specific indicators
assessing whether children are
screened by 12 months of age, by 24
months of age and by 36 months of
age.
EP30JN17.122</GPH>
B 15 PhtySICaIMe d".
ICllle
National
CMSE Data .
NQF Quality Mea~ure Quality Measure title Measure
ID Method
Domai:n
Care Plan:
plan or surrogate decision maker
National
Communicat documented in the medical record or
Claims, Committee
0326 047 N/A Process ion and Care documentation in the medical record
Coordination that an advance care plan was
Assurance
surrogate decision maker or provide
an advance care plan.
Person and
Pain Assessment: American
Caregiver-
Percentage of patient visits for Academy of
I
Claims, Centered
N/A 109 N/A Process patients aged 21 years and older Orthopedic
Registry Experience
with a diagnosis of osteoarthritis Surgeons
and
(OA) with assessment for function
Outcomes
and pain
and Follow-Up Plan:
Claims, Centers for
Community/ during the previous twelve months
* 0421 128 69v6
Registry,
Process Population AND with a BMI outside of normal
Medicare &
EHR, Web Medicaid
Interface Services
during the previous twelve months
of the current encounter.
Nonnal Parameters:
and< 25 kg/m2
EP30JN17.123</GPH>
B 15 PhtySICaIM ed".
ICllle ( con fmue d)
National
CMSE- Data
lndicato:r Measure Submission
# # Type Strategy and Desc.ription Steward
ID Method
Domain
Record:
Centers
for
Medicare
0419 130 68v7 Registry, Process Patient Safety resources available on the date of the
&
EHR encounter. T11is list must include
Medicaid
ALL known prescriptions, over-the-
Services
administration.
Pain Assessment and Follow-Up:
Centers
for
Claims, Communication 18 years and older with
Medicare
! 0420 131 N/A Registry Process and Care documentation of a pain assessment
&
Coordination using a standardized tool(s) on each
Medicaid
visit AND documentation of a
Services
follow-up plan when pain is present
Falls: Risk Assessment: National
Percentage of patients aged 65 years Committe
Claims,
! 0101 154 N/A Process Patient Safety and older with a history of falls who e for
Registry
had a risk assessment for falls Quality
completed within 12 months Assurance
EP30JN17.124</GPH>
B 15 PhlySICaIMe d".
ICllle (con fmue d)
.
Natiomll
CMSE- Data
IndicatOr Masure Submission
# # ID Method
Domain
Communicati
Claims, years and older with a history of Committee
! 0101 155 N/A Process on and Care
Registry falls who had a plan of care for for Quality
Coordination
falls documented within 12 Assurance
months
Functional Outcome
Assessment:
aged 18 years and older with
docmnentation of a current Centers for
Communicati functional outcome assessment Medicare
Claims,
! 2624 182 N/A Process on and Care using a standardized functional &
Registry
Coordination outcome assessment tool on the Medicaid
date of encounter AND Services
docmnentation of a care plan
based on identified functional
outcome deficiencies on the date
of the identified deficiencies
years and older who were Consortium
Claims,
Community/ screened for tobacco use and for
* 0028 226 138v6
Registry,
Process Population Performance
EHR, Web identified as a tobacco user who
Health received tobacco cessation Improvement
Interface
intervention Foundation
(PCPI)
EP30JN17.125</GPH>
B.15. Physical Medicine (continued)

'
... . . ' .. ..
Cl\fSE- Data ..Mea:sure Nationa.l .
.Mea;sur~ tltle
''

NQF Quality Quality Measure.
r
.Jndicator
#

#
. . Measure
ID . .

Sn\unission
~etliod
Type. Str~ttegy.
;J>otitain .
~!lld Description
... . . .Steward ,
. '
Centers for
Community Percentage of patients aged 18 years
Claims, MediL:are
Process /Population and older seen during the reporting
N/A 317 22v6 Registry, &
Health period who were screened for high
EHR Medicaid
blood pressure AND a recommended
Services
follow-up plan is documented based on
the current blood pressure (BP)
Closing the Referral Loop: Receipt
of Specialist Report: Centers for
Communicati Percentage of patients with referrals, Medicare
* N/A 374 50v6
Registry,
Process on and Care regardless of age, for which the &
! EHR
Coordination referring provider receives a report Medicaid
from the provider to whom the patient Services
was referred.
Tobacco Usc and Help with Quitting
Among Adolescents:
The percentage of adolescents 12 to 20 National
Community/
years of age with a primary care visit Committee
during the measurement year for for Quality
Health
whom tobacco use status was Assurance
quitting if identified as a tobacco user
Evaluation:
Clinical Care duration who had a follow-up of
evaluation conducted at least every Neurology
documented in the medical record
Clinical Care duration who signed an opioid of
treatment agreement at least once Neurology
during Opioid Therapy documented in
the medical record
Opioid Misuse:
opiates for longer than six weeks American
Effective duration evaluated for risk of opioid Academy
Clinical Care misuse using a brief validated of
instrument (e.g. Opioid Risk Tool, Neurology
EP30JN17.126</GPH>
B 15 PhtySICaIM ed".
ICllle ( con fmue d)
... . .... ;
; ;
National . .. ;
.
NQF Q;ua.lity
CMSE-. Data
MeRsure ~u~!lty Meil'sme Title .; Measure
Ilulicator Measure Submission
..
#' # .. J;D ... Met)lod
Type Strategy . and J)escl'ip~ol1 . .
Steward
Domain .. ..
Unhealthy Alcohol Use:
Screening & Brief Counseling: Physician
Community years and older who were screened Performance
2152 431 N/A Registry Process I Population for unhealthy alcohol use using a Improvement
Health systematic screening method at Foundation
least once within the last 24 (PCPI)
months AND who received brief
counseling if identified as an
unhealthy alcohol user.
EP30JN17.127</GPH>
B 16 PI as fIC Surgery
National
CMSE- Data
ID Method
Domain
American
!! 0268 021 N/A Process procedures with the indications for a
Surgeons
antimicrobial prophylaxis
Perioperative Care: Venom
ALL Patients):
procedures for which venous
American
thromboembolism (VTE) prophylaxis
! 0239 023 N/A Process is indicated in all patients, who had
an order for Low Molecular Weight
Surgeons
Heparin (LMWH), Low-Dose
Unfractionated Heparin (LDUH),
adjusted-dose warfarin, fondaparinux
or mechanical prophylaxis to be
given within 24 hours prior lo
surgery end time
EP30JN17.128</GPH>
B 16 PI as f IC S ur ery ( con fmue d)

National
CMSE- Data
m Method
Domain ..
.
Record: Percentage of visits for
patients aged 18 years and older for
which the eligible clinician attests to
medications using all innnediate Centers for
Claims,
Patient resources available on the date of Medicare &
! 0419 130 68v7 Registry, Process
Safety the encounter. This list must include Medicaid
EHR
ALL known prescriptions, over-the- Services
administration.
Connnunity
* 0028 226 l38v6
Registry,
Process /Population
Health
Interface received tobacco cessation Foundation
intervention (PCPI)
screened for tobacco usc one or
Pressure and Fulluw-Up
Documented:
Centers for
Claims, Connnunity Percentage of patients aged 18 years
Medicare &
N/A 317 22v6 Registry, Process /Population and older seen during the reporting
Medicaid
EHR Health period who were screened for high
Services
blood pressure AND a
reconnnended follow-up plan is
blood pressure (BP)
Unplanned Reoperation within
the 30 Day Postoperative Period:
American
Patient Percentage of patients aged 18 years
! N/A 355 N/A Registry Outcome College of
Safety and older who had any unplmmed
Surgeons
reoperation within the 30 day
postoperative period
EP30JN17.129</GPH>
B 16 PI as f IC S urgery ( con f mue d)

National
Quality
CMSE- Data Measure
Quality Measure Title Measu.re
Indi<:ator # Strategy and Description Steward
# ID Method
. Domain ..
Unplanned Hospital Readmission
within 30 Days of Principal
Effective Procedure: American
! N/A 356 N/A Registry Outcome Clinical Percentage of patients aged 18 years College of
Care and older who had an unplanned Surgeons
hospital readmission within 30 days
of principal procedure
Surgical Site Infection (SSI):
Effective American
! N/A 357 N/A Registry Outcome Clinical College of
and older who had a surgical site
Care Surgeons
infection (SSI)
Assessment and Communication:
Percentage of patients who underwent
Person and
a non-emergency surgery who had
Caregiver-
their personalized risks of American
Centered
! N/A 358 N/A Registry Process postoperative complications assessed College of
Experience
by their surgical team prior to surgery Surgeons
and
using a clinical data-based, patient-
Outcomes
specific risk calculator and who
received personal discussion of those
risks with the surgeon
EP30JN17.130</GPH>
B.17. Preventive Medicine

National
CMSE- Data
# ID Method
Domain
Claims,
(HbAlc) Poor Control (> 9%): National
Web Effective
Intermediate Percentage of patients 18-75 years Committee for
0059 001 122v6 Interface, Clinical
! Outcome of age with diabetes who had Quality
Registry, Care
hemoglobinAlc > 9.0% during the Assurance
EHR
measurement period
Communication with the
Physician or Other Clinician
Managing On-going Care Post-
Fracture for Men and Women
Aged 50 Years and Older:
and older treated for a tracture with
Commun documentation of communication,
National
ication between the physician treating the
! 0045 024 N/A Process and Care fracture and the physician or other
Registry Quality
Coordina clinician managing the patient's on-
Assurance
tion going care, that a fracture occurred
considered for osteoporosis
treatment or testing. This measure is
reported by the physician who treats
the fracture and who therefore is
held accountable for the
communication
EP30JN17.131</GPH>
B.17. Preventive Medicine (continued)

National
CMSE- Data
Qualily Measure Quality Measm:e Title Measure
Indicator NQF #
Measure Submission
# m Method
Domain
.
Women Aged 65-85 Years of Age: National
Claims, Effective Percentage of female patients aged 65- Committee
Registry Clinical Care 85 years of age who ever had a central for Quality
dual-energy X-ray absorptiometry Assurance
(DXA) to check for osteoporosis
Care Plan:
National
Communicati plan or surrogate decision maker
Claims, Committee
0326 047 N/A Process on and Care documented in the medical record that
Coordination an advance care plan was discussed but
Assurance
the patient did not wish or was not able
to name a surrogate decision maker or
Urinary Incontinence: Assessment of
Presence or Absence of Urinary
Incontinence in Women Aged 65 National
Claims, Effective Years and Older: Committee
N/A 048 N/A Process
Registry Clinical Care Percentage of female patients aged 65 for Quality
years and older who were assessed for Assurance
the presence or absence of urinary
incontinence within 12 months
Person and
Pain Assessment: American
Caregiver-
Claims, Percentage of patient visits for patients Academy of
! N/A 109 N/A Process Centered
Registry aged 21 years and older with a Orthopedic
Experience
diagnosis of osteoarthritis (OA) with Surgeons
and Outcomes
assessment for function and pain
Physician
Consortium
Claims, for
Web Community/ Performanc
147v7 and older seen for a visit between
* 0041 110 Interface, Process Population e
October 1 and March 31 who received
Registry, Health Improveme
an influenza inununization OR who
EHR nt
reported previous receipt of an
Foundation
inl1uenza immunization
(PCPI)
Claims, Pneumonia Vaccination Status fur
National
Web Community/ Older Adults:
Committee
0043 111 127v6 Interface, Process Population Percentage of patients 65 years of age
for Quality
Assurance
EHR pneumococcal vaccine
Claims,
Web
Effective Percentage of women 50- 74 years of Committee
2372 112 125v6 Interface, Process
Clinical Care age who had a mammogram to screen for Quality
Registry,
for breast cancer Assurance
EHR
Claims,
Co1orecta1 Cancer Screening: National
Web
* 0034 113 130vGG Interface, Process
Effective Percentage of patients 50-75 years of Committee
Clinical Care age who had appropriate screening for for Quality
Registry,
colorectal cancer. Assurance
EHR
EP30JN17.132</GPH>

National
CMSE- Data
Indicator NQF #
Measure Submission
# ID Method
Domain
.
Avoidance of Antibiotic
Treatment in Adults with Acute National
Efficiency
9 Bronchitis: Percentage of adults 18- Committee for
0058 116 N/A Registry Process and Cost
!! 64 years of age with a diagnosis of Quality
Reduction
acute bronchitis who were not Assurance
Diabetes: Medical Attention for
Nephropathy:
National
The percentage of patients 18-75
Registry, Effective Cmurnittee for
0062 119 134v6 Process years of age with diabetes who had a
EHR Clinical Care Quality
nephropathy screening test or
Assurance
evidence of nephropathy during the
measurement period
Diabetes Mellitus: Diabetic Foot
and Ankle Care, Peripheral
Neuropathy -Neurological
American
Evaluation: Percentage of patients
Registry Effective Podiatric
0417 126 N/A Process aged 18 years and older with a
Clinical Care Medical
diagnosis of diabetes mellitus who
Association
had a neurological examination of
their lower extremities within 12
months.
and Follow-Up Plan:
Claims,
Registry, Centers for
Community/ during the previous twelve months
* EHR, Web Medicare &
0421 128 69v6 Process Population AND with a BMI outside of normal
Interface Medicaid
Services
during the previous twelve months
of the current encounter.
Normal Parameters:
and< 25 kg/rn2
medications using all immediate Centers for
Claims,
Patient resources available on the date of Medicare &
0419 130 68v7 Registry, Process
Safety the encounter. This list must include Medicaid
EHR
ALL known prescriptions, over-the- Services
administration.
EP30JN17.133</GPH>

Nation~}
CMSE- Data
ID Method
Domain ..
Screening for Clinical Depression
and Follow-Up Plan:
Claims, Percentage of patients aged 12 years
Communi Centers for
Web and older screened for clinical
ty/ Medicare &
041R 134 2v7 Interface, Process depression on the date of the encounter
Populatio Medicaid
Registry, using an age appropriate standardized
nHealth Services
EHR depression screening tool AND if
positive, a follow-up plan is
documented on the date of the positive
screen
National
! 0101 154 N/A Process and older with a history of falls who
Assurance
Communi Falls: Plan of Care:
National
cation Percentage of patients aged 65 years
Claims, Commillee for
! 0101 155 N/A Process and Care and older with a history of falls who
Registry Quality
Coordinat had a plan of care for falls
Assurance
lOll documented within 12 months
within 24 months
Physician
Claims, Communi Consortium for
* 0028 226 138v6
Registry,
Process
ty/
for tobacco use and identified as a
Performance
EHR, Web Populatio Improvement
tobacco user who received tobacco
Interface nHealth Foundation
(PCPI)
tobacco user.
Commun
Claims, ity/
Process and older seen during the reporting Medicare &
N/A 317 22v6 Registry, Populatio
period who were screened for high Medicaid
EHR nHealth
EP30JN17.134</GPH>

National
CMSE- Data
NQF Quality Measure Quality .Measure Title Measure
JD Method.
Domain
Cormmmication
! EHR Coordination
which the referring provider Medicaid
was referred.
12 to 20 years of age with a National
Community/
primary care visit during the Committee for
N/A 402 NA Registry Process Population
measurement year for whom Quality
Health
tobacco use status was Assurance
tobacco user
Preventive Care and
Screening: Unhealthy Alcohol
Use: Screening & Brief
Counseling: Physician
Community/ years and older who were Performance
2152 431 NA Registry Process Population screened for unhealthy alcohol Improvement
Health use using a systematic screening Foundation
method at least once within the (PCPI)
last 24 months AND who
received brief counseling if
identified as an unhealthy
alcohol user.
Statin Therapy for the
Prevention and Treatment of
Cardiovascular Disease:
Percentage of the following
patients-all considered at high
risk of cardiovascular events-
who were prescribed or were on
statin therapy during the
measurement period:
o Adults aged 2:21 years who
Web were previously diagnosed with Centers for

Interface, Effective or currently have an active Medicare &
* N/A 438 347vl Process
Registry, Clinical Care diagnosis of clinical Medicaid
EHR atherosclerotic cardiovascular Services
disease (ASCVD); OR
o Adults aged 2:21 years who
have ever had a fasting or direct

low-density lipoprotein
cholesterol (LDL-C) level2: 190
mg/dL; OR
o Adults aged 40-75 years with a
diagnosis of diabetes with a

fasting or direct LDL-C level of

70-189 mg/dL.
EP30JN17.135</GPH>
B 18 N euro ogy
National
CMSE- Data
Indicator
NQJi' Quality
M~asure Submission
# # Type Strategy .and Description Steward
ID Method
. Domain
Care Plan:
Communica plan or surrogate decision maker National
tion and documented in the medical record or Committee for
Claims,
! 0326 047 N/A Process Care documentation in the medical record Quality
Registry
Coordinatio that an advance care plan was Assurance
n discussed but the patient did not wish
or was not able to name a surrogate
decision maker or provide an advance
care plan.
! 0419 130 68v7 Claims, Process Patient Documentation of Current Centers for
Registry, Safety Medications in the Medical Record: Medicare &
EHR Percentage of visits for patients aged Medicaid
18 years and older for which the Services
medications using all immediate
resources available on the date of the
encounter. This list must include ALL
lmown prescriptions, over-the-
EP30JN17.136</GPH>
B 18 Neuro ogy (continued)

. CMS .
National
J)ata
NQF Quality E- Measure Quality Measure Title Measure
# # Measur Type Strategy and Description Steward
Method
eiD .. Domain
National
0101 154 N/A Process and older with a history of falls who
Assurance

National
Collllll Lffiicat Percentage of patients aged 65 years
0101 155 N/A Process ion and Care and older with a history of falls who
Registry Quality
Coordination had a plan of care for falls
Assurance
documented within 12 months
Claims,
years and older who were Consortium for
Web CollllllunityI
identified as a tobacco user who Improvement
Registry, Health
received tobacco cessation Foundation
EHR intervention (PCPI)
Epilepsy: Counseling for Women
of Childbearing Potential with
Epilepsy:
All female patients of childbearing
American
Claims, Effective potential (12- 44 years old)
1814 268 N/A Process Academy of
Registry Clinical Care diagnosed with epilepsy who were
Neurology
cmmseled or referred for counseling
for how epilepsy and its treatment
may affect contraception OR
pregnancy at least once a year
EP30JN17.137</GPH>
B 18Neuro ogy ( con mue d)

National
CMSE- Data
ID Method
Domain
Physician
Dementia: Cognitive Assessment:
Consortium
Effective for
age, with a diagnosis of dementia for
* NIA 281 149v6 EHR Process Clinical Pertormance
whom an assessment of cognition is
Care Improvement
perfom1ed and the results reviewed at
Foundation
least once within a 12-month period
(PCPI)
Dementia: Functional Status
Assessment:
Effective American
age, with a diagnosis of dementia for
whom an assessment of functional
Care Neurology
status is performed and the results
reviewed at least once within a 12-
month period
Dementia: Neuro-psychiatric
Symptom Assessment:
Effective American
age, with a diagnosis of dementia and
for whom an assessment of
Care Neurology
neuropsychiatric symptoms is
pertom1ed and results reviewed at least
once in a 12-month period
! N/A 286 N/A Registry Process Patient Safety Concern Screening and American
Safety Follow-Up for Patients with Academy of
Dementia: Neurology
Percentage of patients with dementia or
their caregiver(s) for whom there was a
documented safety screening * in two
domains of risk: dangerousness to self
or others and environmental risks; and if
screening was positive in the last 12
months, there was documentation of
mitigation recommendations, including
but not limited to referral to other
resources.
! N/A 288 N/A Registry Process Communi Dementia: Caregiver Education and American
cation and Support: Academy of
Care Percentage of patients, regardless of Neurology
Coordinati age, with a diagnosis of dementia whose
on caregiver(s) were provided with
education on dementia disease
management and health behavior
changes AND referred lo additional
sources for support within a 12-month
period
EP30JN17.138</GPH>
B 18 Neuro ogy ( con fmue d)

Data . National
Measure Quality
Quality CMSE- Submissio Measure Title Measure
Indicator NQF Type
# MeasureiD n Strategy and Description Steward
#
Method Domain
Parkinson's Disease:
Psychiatric Symptoms
Assessment for Patients with
All patients with a diagnosis of American
Effective
N/A 290 N/A Registry Process Parkinson's disease who were Academy of
Clinical Care
assessed for psychiatric Neurology
symptoms (e.g., psychosis,
depression, anxiety disorder,
apathy, or impulse control
disorder) in the last 12 months
Parkinson's Disease: Cognitive
Impairment or Dysfunction
Assessment:
American
Effective All patients with a diagnosis of
Clinical Care Parkinson's disease who were
Neurology
assessed for cognitive impairment
or dysfunction in the last 12
months
Rehabilitative Therapy
Options:
All patients with a diagnosis of
Communicat American
Parkinson's disease (or
! N/A 293 N/A Registry Process ion and Care Academy of
caregiver(s), as appropriate) who
Coordination Neurology
had rehabilitative therapy options
(e.g., physical, occupational, or
speech therapy) discussed in the
last 12 months
Documented:
Claims, Community/ Percentage of patients aged 18 Centers for
Registry, Population years and older seen during the Medicare &
N/A 317 22v6 Process
EHR Health reporting period who were Medicaid
screened for high blood pressure Services
EP30JN17.139</GPH>

National
CMSE. Data Measure
Indicator NQF Quality Measure Submission
Quality Measure Title Measure
# # ID Type Strategy and Description Steward
Method
Domain
Centers for
Cormmmication Percentage of patients with
* N/A 374 50v6
Registry,
Process and Care referrals, regardless of age, for
Medicare&
EHR Coordination which the referring provider
Medicaid
Services
receives a report from the provider
to whom the patient was referred.
Amyotrophic Lateral Sclerosis
(ALS) Patient Care Preferences:
Person and Percentage of patients diagnosed
Caregiver- with Amyotrophic Lateral Sclerosis American
N/A
386 N/A Registry Process Centered (ALS) who were offered assistance Academy of
Experience and in planning for end of life issues Neurology
Outcomes (e.g. advance directives, invasive
ventilation, hospice) at least once
armually
National
Community/ 20 years of age with a primary care
Committee
N/A 402 N/A Registry Process Population visit during the measurement year
for Quality
Health for whom tobacco use status was
Assurance
user
Evaluation:
American
Effective opiates for longer than six weeks
Clinical Care duration who had a follow-up
Neurology
evaluation conducted at least every
documented in the medical record
American
Effective opiates for longer than six weeks
Clinical Care duration who signed an opioid
Neurology
treatment agreement at least once
in the medical record
Evaluation or Interview for Risk
of Opioid Misuse:
American
Effective duration evaluated for risk of opioid
Clinical Care misuse using a brief validated
Neurology
instrument (e.g. Opioid Risk Tool,
EP30JN17.140</GPH>

National
CMSE- Data
NQ:F Q:uality Measure Quality Measure Title Measure
ID Method
Domain
Overuse OfNeuroimaging For
Patients With Primary Headache
And A Normal Neurological
Efficiency American
Claims, Efficienc Examination:
!! N/A 419 N/A and Cost Academy of
Registry y Percentage of patients with a
Reduction Neurology
diagnosis of primary headache
disorder whom advanced brain
imaging was not ordered
& Brief Counseling:
Physician
Consortium for
Population! Performance
2152 431 N/A Registry Process unhealthy alcohol use using a
Community Improvement
systematic screening method at least
Foundation
once within the last 24 months AND
(PCPI)
user.
Quality Of Life Assessment For
Patients With Primary Headache
Disorders:
Percentage of patients with a
diagnosis of primary headache
American
Claims, Effective disorder whose health related quality
N/A 435 N/A Outcome Academy of
Registry Clinical Care of life (HRQoL) was assessed with a
Neurology
tool( s) during at least two visits
during the 12 month measurement
period AND whose health related
quality oflife score stayed the same
or improved
Safety Concern Screening and
Follow-Up for Patients with
Dementia:
Percentage of patients with dementia
or their L:aregiver(s) for whom there
was a documented safety screening
American
N/A TBD N/A Registry Process
Patient * in two domains of risk: Academy of
Safety dangerousness to self or others and
Neurology
environmental risks; and if
screening was positive in the last 12
months, there was documentation of
mitigation recommendations,
including but not limited to referral
to other resources.
EP30JN17.141</GPH>
B.19. Mental/Behavioral Health

National
CMSE- Data
# ID Metlwd
Domain
Management:
National
medication treatment.
Effective Committee for
105 009 128v6 EHR Process Two rates are reported:
a. Percentage of patients who
Assurance
weeks)
months)
(MDD): Suicide Risk Assessment:
Physician
and older with a diagnosis of major
Effective Consortium for
0104 107 161v6 EHR Process depressive disorder (MDD) with a
Clinical Care Performance
suicide risk assessment completed
Improvement
during the visit in which a new
diagnosis or recurrent episode was
identified.
and Follow-Up Plan:

MACRA Year 2 Proposed Rule

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MACRA Year 2 Proposed Rule

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30010 Federal Register / Vol. 82, No.

125 / Friday, June 30, 2017 / Proposed Rules

Medicare & Medicaid Services, PTAC Physician-Focused Payment Model

f. Virtual Groups h. Facility-Based Measurement have a benchmark or do not meet the

including through Medical Home

eligible clinicians; in such case, data characters; for example, 1111111111).

dollar amount, beneficiary count or, if

written agreements among individual

Performance category/submission combinations Individual reporting data submission mechanisms

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

Performance category/submission combinations Individual reporting data submission mechanisms

Advancing Care Information ................................ Attestation.

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

a limited number of measures relevant

improvement activities, and advancing

items, but a zero score would prevent

Organizations (ACOs) Survey. The SSM

or virtual groups sample for each module/

scoring standard, see II.C.6.E. of this

submitting improvement activities in

::;s ~ .~ clinical practice for at least 75 percent of medical records Patient

.;2 prediabetes to a CDC-recognized diabetes prevention Health Data or

Engaging connnunity health workers to provide a

Implementation of practices/processes to develop advance

~ S'~ ::r:: Including through the use of tools that facilitate

Screen patients for health-harming legal needs;

Participation in a Perioperative Surgical Home (PSH) that

objectives and measures.

TABLE 7: 2018 Performance Period Advancing Care Information Performance Category

eligible clinician during the

apply beginning with the 2017

Reporting. Care Setting Only. 170.314(f)(7) (Optional-Ambulatory Set-

performance period for which the EP

for reporting high priority measures.

TABLE 11BENCHMARK DECILE DISTRIBUTION

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

increased to 80 percent. These proposals

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+)

performed every 3 years.

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

(total measure achievement points +

not have a zero percent performance

Measure 1 (Outcomere- 3 ....................................... n/a 10 (measure achievement points from 6 measures +

Total ........................... 31 ..................................... 2 60 (31+2)/60 = 55%

Measure 1 (Outcomere- 3 n/a 10 (measure achievement points from 7 measures + measure

Total ................................. 21 1 70 (21+1)/70 = 31.4%

finalized in the CY 2017 Quality distribution and that each benchmark

the medical record) *

Decile 1 or 2 (3 points) .............................................................................................. <96.11 <76.59 <61.27

Decile 6 (6.06.9 points) ........................................................................................... 95.36 97.08 96.8799.30

collection of the data for these two

TABLE 20PROPOSED SSM FOR CAHPS FOR MIPS SCORING

the benchmark methodology for topped

consecutive year. have special scoring applied for the

TABLE 23QUALITY PERFORMANCE CATEGORY: SCORING MEASURES BASED ON PERFORMANCE

(3) Meets the data com-

9 References to Classes of measures in this

section II.C.7.a.(2)(d) are intended only to

TABLE 23QUALITY PERFORMANCE CATEGORY: SCORING MEASURES BASED ON PERFORMANCEContinued

points for the 2 missing measures,