5 Top Takeaways from the CMS 2018 Proposed MACRA QPP Rule

By Moshe Starkman, nThrive Senior Value-Based Reimbursement Consultant | Posted: 07/11/2017

The Centers for Medicare and Medicaid Services (CMS) recently issued its 2018 Quality Payment Program (QPP) Proposed Rule (CMS-552-P), causing considerable buzz in the health care industry. The big news is that it has the potential to impact almost a million U.S. clinicians, however it also signals hesitation on CMS’ part to fully implement the program in 2018.

Perhaps even bigger news is that the proposed rule, should it be passed, all but eliminates any positive adjustment incentive for MIPS participation. Here’s how it looks when you run the numbers. Whereas the 2017 proposed rule put eligibility at $10,000 in Medicare Part B fee-for-service (FFS) charges or 100 eligible patients, the 2017 final rule set the bar at $30,000 in charges and more than 100 eligible patients. The proposed rule for 2018 further raises the minimum threshold to $90,000 AND 200 eligible patients.

At these significantly higher thresholds only 36 percent of clinicians are eligible for MIPS participation in 2018 resulting in fewer participants at risk of a negative adjustment and, in turn, fewer payers to fund the incentives. However, it is important to note that these 36 percent care for approximately 65 percent of all Medicare patients and are presumably concentrated in large physician practices and/or employed by hospital providers and integrated delivery networks (IDNs).

For this top tier, the risk of a negative adjustment for non-participation – as much as a negative five percent in 2020 – is still quite real and not to be taken lightly.

Of course, the other caveat is that this newly proposed ruling is just that… proposed. Whether or not it goes into effect in 2018 remains to be seen. And, because it does not apply to 2017, currently eligible clinicians are advised to continue their efforts to meet basic reporting requirements today in anticipation of more a competitive requirement in the future.

Ultimately, it is important that clinicians continue to prepare for value-based care and population health management. Should health care reform laws change radically, reducing the insured population and putting caps on Medicaid at the State level, it could be the health care industry’s best viable option to continue providing high quality care with significantly lower dollars.

Below are the top five takeaways from the proposed MACRA rule:

1. Modified “Pick Your Pace” Will Continue in 2018

The 2017 “pick your pace” participation allows clinicians the option to report on a minimum amount of data to avoid MIPS penalties. By and large, 2018 will have the same look and feel of 2017 with limited implementation differences and continued flexibility. To note, CMS refers to 2018 as “Quality Payment Program Year Two,” rather than “pick your pace.”  So, if you see the acronym QPPY2 or some variation of that, it’s merely referring to 2018.

2. Expansion of Low-Volume Threshold 

The proposed rule allows for greater flexibility for clinician program participation, as it significantly raises the low-volume threshold to more than $90,000 in Medicare Part B charges and more than 200 Medicare Part B beneficiaries annually. In 2017, clinicians who bill $30,000 or less to Medicare or serve 100 or fewer Medicare patients are exempt from the program.

In 2017, it was estimated 700,000 clinicians would be exempted from MACRA’s MIPS due to low patient volume, new enrollment, APM participant exclusions or ineligible clinician type. However, for 2018, an estimated 134,000 clinicians will be added to the exemption list raising the total to 834,000 ineligible clinicians.

As shown on Table 85 on page 721 of the CMS 2018 proposed rule, only 36 percent of clinicians will be eligible for MIPS after all exclusions, but they make up 58 percent of Medicare Part B charges.

MIPS Eligible Clinicians Percentage

3. Increased Data Submission Flexibility

For 2018, CMS will allow multiple submission methods within the Advancing Care Information, Quality, and Improvement Activities categories. This differs from the 2017 performance period in which MIPS-eligible clinicians can only utilize one submission method for each performance category. To learn more about MIPS data submission methods, join us for our upcoming MACRA educational webinar where we will be discussing what to consider when establishing a MIPS reporting method that best meets your organizations MIPS strategy. 

4. Additional Options for Clinician Participation

MIPS-eligible clinicians would be able to participate in MIPS as individuals, groups or virtual groups in 2018. The virtual group reporting option is new to MIPS. As a virtual group, small clinician groups of 10 or fewer can partner with other groups, regardless of location or specialty, to participate in MIPS and share administrative costs. This may provide the needed relief of which small groups have been yearning. To participate in a virtual group, clinicians must elect to participate prior to the start of the 2018 performance year. 

5. Performance Measure Requirements Revised


The quality category will continue to account for 60 percent of the overall score in 2018. The scoring range for the Quality category would remain between three and 10 points, whereas the overall MIPS performance threshold would increase to 15 from three with a maximum of 100 points. Additionally, the Quality category may require 12 months of reporting data in 2018, as opposed to only 90 days in 2017. 

Advancing Care Information (ACI)

For 2018, MIPS-eligible clinicians will again be able to report ACI category data through either 2014 or 2015 Edition certified EHRs (CEHRT) for MIPS’ Advancing Care Information (ACI) category in 2018.  As an incentive, clinicians who utilize the 2015 edition would receive a 10 percent ACI bonus.

In addition, CMS also proposed a 90-day reporting period for ACI in 2018 and 2019. To comply with the 90-day reporting period, providers would be able to delay the 2015 edition implementation until October 2019 and still maintain compliance.

Practices with 15 or fewer clinicians may apply for a new hardship exception. Practices for which “there are overwhelming barriers that prevent the MIPS-eligible clinician from complying with the requirements” can be eligible for this exception category. Approved clinician groups ACI performance category score would be reweighted the ACI performance category to zero and shift the ACI scoring weight of 25 percent to the Quality category.  

Improvement Activities

CMS is proposing more activities and is planning to change a few existing activities.  Outside of that, the scoring is not changing and small practices and practices in rural areas will continue to need no more than two medium or one high-weighted activity to reach the highest score.  Also, this category will continue to be scored by attestation in 2018.


Cost will stay at zero percent of the overall MIPS score in 2018. However, the cost category will account for 30 percent of the overall MIPS composite performance score in 2019. Therefore, MIPS eligible clinicians should continue to develop strategic initiatives to improve performance in the cost category.

Will the proposed 2018 flexibility reduce the burden?

On the whole, clinician feedback concerning the MACRA 2018 Quality Payment Program Proposed Rule has been largely positive. Most believe the proposed rule is consistent with the CMS’s goal of easing regulatory burdens for clinicians and continuing the transition to value-based reimbursement.

It will be interesting to see what occurs in future months as feedback is reviewed and the final rule is issued.

If you are interested in keeping up with all things MACRA, continue in the MACRA conversation with us.