2018 Quality Payment ProgramExperience Report1

Table of ContentsIntroduction . 3Purpose . 4Eligibility and Participation . 5Table 1: Overall MIPS Participation . 8Table 2: Type of MIPS Participation . 8Table 3: MIPS Participation by Clinician Type . 9Table 4: MIPS Participation by Clinicians in a Small Practice or Rural Area .10Table 5: Clinicians Participating in MIPS APMs Scored Under the APM Scoring Standard10Table 6: Total Count of Qualifying APM Participants (QPs) or Partial QPs .11Table 7: QP Threshold Scores by Advanced APM .11Reporting Options and Performance Categories .12Table 8: Submission Methods, by Performance Category, for Measures/Activities thatContributed to Final Scores .15Table 9: Submission Method and Participation Type for Each Performance Category .16Table 10: Top 10 Quality Measures Contributing to a Clinician’s Quality PerformanceCategory Score Across All Submission Methods .17Table 11: Top 10 Quality Measures Contributing to a Clinician’s Quality PerformanceCategory Score Excluding CMS Web Interface Submissions .18Table 12: Top 5 Improvement Activities Reported .19Table 13: Promoting Interoperability Base Measure Reporting .20Final Score and Payment Adjustment .21Table 14: Payment Adjustment and Final Scores Attributed to MIPS Eligible Clinicians(identified by TIN/NPI) .22Table 15: Final Score and Payment Adjustment for Small Practices and Rural Practices 23Table 16: Final Scores by Participation Type.24Table 17: Final Scores for Clinicians in a Rural Area or Small Practice .24Summary.252

List of QIMIPSMSPBMSSPNPIQCDRQPPQPsTINTPCCAccountable Care OrganizationApplication Programming InterfaceAlternative Payment ModelAmbulatory Surgical CenterConsumer Assessment of Healthcare Providers and SystemsCertified EHR TechnologyComprehensive Care for Joint ReplacementCenters for Medicare & Medicaid ServicesElectronic Health RecordEnd-Stage Renal DiseaseImprovement ActivitiesIschemic Vascular DiseaseMedicare Advantage Qualifying Payment Arrangement IncentiveMerit-based Incentive Payment SystemMedicare Spending per BeneficiaryMedicare Shared Savings ProgramNational Provider IdentifierQualified Clinical Data RegistryQuality Payment ProgramQualifying APM Participant (in an Advanced APM)Taxpayer Identification NumberTotal per Capita Costs3

IntroductionIn 2017, the Centers for Medicare & Medicaid Services (CMS) launched the Quality PaymentProgram (QPP), a new program that aims to reward innovation in improving patient outcomes anddrive fundamental movement toward a value-based system of care. The program offers 2participation tracks: The Merit-based Incentive Payment System (MIPS) and Advanced AlternativePayment Models (APMs).The MIPS track streamlined 3 CMS programs (Physician Quality Reporting System (PQRS),Value-Based Payment Modifier, and the Medicare Electronic Health Record (EHR) Incentive (orMeaningful Use) Program) into a single system. Clinicians are evaluated and receive paymentadjustments based on their overall performance in 4 performance categories: Quality; Cost; Improvement Activities; and Promoting Interoperability (formerly known as Advancing Care Information).Clinicians who were eligible for MIPS in the 2018 performance period will receive a paymentadjustment during the 2020 payment year—either positive, neutral, or negative—based on theirperformance in 2018.The Advanced APM track provides an opportunity to reward clinicians for significant participationin taking on greater risk and accountability for patient outcomes. Eligible clinicians whoparticipated in an Advanced APM and achieve Qualifying APM Participant (QP) status based onthe level of their participation in 2018 will be eligible to receive a 5% APM Incentive Payment in2020.While these tracks are structured to complement each other, one of CMS’s foremost goals underthe Quality Payment Program is to encourage movement of clinicians and practices into APMsand Advanced APMs and ultimately toward a value-based system of care.PurposeFrom the start of the Quality Payment Program, we committed to being transparent with our dataand listening to your feedback. The primary goal of this report is to identify trends associated withthe clinician experience in the second year of the Quality Payment Program, while noting progressfrom program year 2017.Based on stakeholder feedback, we have drafted a concise report highlighting the data elementsthat you have indicated are important. This report is divided into 4 sections: Eligibility and Participation: Reviews eligibility requirements, identifies the number ofclinicians eligible to participate in the Quality Payment Program and provides a breakout ofparticipation rates across both MIPS and Advanced APMs. Reporting Options: Highlights various ways clinicians could and did submit performancedata, specifically for MIPS, to CMS. Performance Categories: Reviews MIPS performance category requirements andperformance periods and provides trends in measure/activity selection. Final Score and Payment Adjustments: Examines MIPS final scores and paymentadjustments across clinicians reporting as individuals, clinicians reporting as a group, andclinicians participating through a MIPS APM.4

Looking for More Information?We will also release a Public Use File (PUF) in the summer of 2020 that will allow you to drilldown into details behind the data in the tables presented in this report. Once released, it will beavailable at believe that this report, along with the Public Use File, will provide the data needed toillustrate the successes and challenges in 2018, and opportunities for future program years.QPP follows numerous strategic objectives that helped guide policy and product development in2018.1 At a high level, these include: Improve patient population healthImprove care received by Medicare patientsLower costs to the Medicare program through improvement of care and healthAdvance use of healthcare information between allied providers and patientsEducate, engage, and empower patients as members of their care teamMaximize QPP participation through a flexible and transparent design, and easy-to-useprogram toolsMaximize QPP participation through education, outreach and support tailored to the needs ofpractices, especially those that are small, rural, and in underserved areasExpand Alternative Payment Model participationProvide accurate, timely, and actionable performance data to clinicians, patients, and otherstakeholdersContinuously improve QPP based on participant feedback and collaborationWe believe these strategic objectives are dynamic and should reflect current needs and valuesof participating clinicians. Therefore, we anticipate the continual refinement of these strategicobjectives as we work closely with clinician and stakeholder communities to improve and evolvethe Quality Payment Program.Eligibility and ParticipationThe primary starting point for clinicians within the Quality Payment Program is determining theireligibility and how they intend to report, if required to participate. As previously mentioned, theQuality Payment Program has 2 participation tracks – the Merit-based Incentive PaymentSystem (MIPS) and Advanced Alternative Payment Models (APMs).Advanced APMsEligible clinicians have an opportunity to become QPs and earn a 5% APM incentive paymentby sufficiently participating in an Advanced APM during a given performance year. Eligibleclinicians who become QPs also are excluded from MIPS reporting, scoring, and paymentadjustments. To become a QP, eligible clinicians must meet or exceed specific thresholds forpayment amount or patient count based on their participation in the Advanced APM. QPdeterminations are made at 3 specific dates—March 31, June 30, and August 31 (also referredto as “Snapshots”).1Additional details on the program’s Strategic Objectives are found on the Quality Payment Program website.5

In 2018, if an eligible clinician participated in an Advanced APM and at least 25% of theirpayments or 20% of their patients were through an Advanced APM, they became a QP. Thereare instances where a clinician who participated in an Advanced APM may not have met the QPpayment amount or patient count thresholds. In such cases, an eligible clinician could become aPartial QP if the Partial QP payment amount threshold (20% of their payments) or patient countthreshold (10% of their patients) were met. Partial QPs do not receive the 5% APM incentivepayment, but within the performance year they had the option to elect to participate in MIPS andreceive a MIPS payment adjustment. Tables 5, 6, and 7 summarize 2018 APM and AdvancedAPM participation.MIPSUnder the MIPS track, clinicians are included and required to participate if they: (1) are a MIPSeligible clinician type; (2) exceed the low volume threshold; and (3) are not otherwiseexcluded (for example, by becoming QPs). MIPS eligible clinicians are both physicians and nonphysician clinicians who are eligible to participate in MIPS. Through rulemaking, CMS definesthe MIPS eligible clinician types for a specific performance year. MIPS eligible clinicians in 2018include certain physicians and non-physician clinicians as described in the graphic below.The low-volume threshold is the second step in determining whether a clinician is included inMIPS for a specific performance period. It’s used to determine if a MIPS eligible clinician sawenough patients and provided enough services to meaningfully participate in MIPS. In 2018, thelow-volume threshold was based on the amount of allowed charges for covered professionalservices under Medicare Physician Fee Schedule (PFS) and the number of Medicare Part Bpatients who were furnished covered professional services under the PFS during 2 distinctdetermination periods: September 1, 2016 – August 31, 2017 (initial determination period basedon historic claims) and September 1, 2017 – August 31, 2018 (second determination based onperformance period claims). MIPS eligible clinicians were required to participate in MIPS in2018 if they billed more than 90,000 in Medicare Part B covered professional services and sawmore than 200 Medicare Part B beneficiaries in both determination periods. Note that thesethresholds have increased from 2017 levels of 30,000 in Part B charges and 100 Part Bpatients.6

There are several exclusions available to MIPS eligible clinicians. In 2018, clinicians wereexcluded from MIPS if they met any 1 of the following conditions: Not a MIPS eligible clinician typeEnrolled in Medicare for the first time in 2018Participated in the Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI)Did not exceed the low-volume threshold in at least 1 determination period.Participated in an Advanced APM sufficiently to either become a QP or become a Partial QPand then elected not to participate in MIPSIn 2018, MIPS eligible clinicians required to participate in MIPS either could report data as anindividual,2 a group, a virtual group, or through an APM. Certain APMs, called MIPS APMs,include MIPS eligible clinicians as participants and hold them accountable for the cost andquality of care provided to Medicare patients. MIPS eligible clinicians participating in a MIPSAPM receive special MIPS scoring to help account for the activities already required by themodel.We also employ “special status” designations for certain MIPS eligible clinicians. Thesedesignations determine whether special rules will affect the number of total measures, activities,or entire performance categories that an individual clinician, group, or virtual group must report.In 2018, “special status” designations included: small practice, rural practice, non-patient facing,health professional shortage area (HPSA), hospital-based, and ambulatory surgical centerbased (ASC). Note that the data in this report focuses on small and rural practices. The PublicUse File will include breakouts for clinicians with other special statuses.Data TablesTables 1 – 7 provide high-level eligibility and participation information for the 2018 performanceperiod. Note that we generally define participation in terms of data submission. “Eligibleparticipants” are MIPS eligible clinicians who submitted any amount of MIPS data as anindividual or group or who were excepted from data submission in 2018 under the automaticextreme and uncontrollable circumstances policy.2An individual is defined as a single clinician, identified by their Individu