Pandemic Puts Hold on Major Changes to Medicare Quality Payment Program

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In recognition of the global public health crisis caused by COVID-19, the federal government is offering few major changes to the Medicare Quality Payment Program in the proposed rule for the 2021 Medicare Physician Fee Schedule released in August.

However, the Centers for Medicare and Medicaid (CMS) is proposing to increase the weight assigned to the cost category and decrease the weight assigned to the quality category within its formula for incentive payments in the Medicare Quality Payment Program. That means that high-cost services provided by participating physicians will weigh more heavily in whether they receive an incentive payment.

The proposed rule encompasses recommendations regarding physician payment—including proposed changes to the 2021 conversion factor for determining reimbursement for evaluation/management (E/M) office visit services, and telehealth. Those proposals should result in an increase in the overall payment to clinicians designated as “psychiatrists” (see Psychiatric News).

The proposed rule also includes updates to regulations governing the Medicare Quality Payment Program, which encompasses the Merit-based Incentive Payment System (MIPS). That system, implemented in 2017, seeks to reward high-value, high-quality Medicare clinicians with payment increases while reducing payments to those clinicians who aren’t meeting performance standards.

In MIPS, performance is measured through the data clinicians report in four areas: quality, improvement activities, promoting interoperability (formerly known as “advancing care information”), and cost.

Importantly, CMS is proposing to raise the percentage weight given in formulating incentive payments to cost to 20% (it is now weighted at 15%) and lower the weight given to quality to 40% (it is now weighted at 45%).

The categories of promoting interoperability and improvement activities would remain at 25% and 15% of the MIPS final score, respectively.

Only one episode-based cost measure—the Medicare spending per beneficiary measure—applies to psychiatrists. That measure looks at Medicare Part A and Part B claims submitted for services from three days prior to 30 days after an inpatient hospitalization.

The minimum number of patients needed for the measure to be calculated is 35 patients with inpatient charges. (For those who are under the minimum number of patients to report on this measure, the cost category would have no weight, and quality would be weighted at 60%.)

The proposed rule would not add any new “quality” measures specific to mental or behavioral health for the 2021 performance period.

For reporting purposes, CMS is invoking an “Extreme and Uncontrollable Circumstances” policy to allow clinicians to request to have one or more MIPS performance categories re-weighted due to the COVID-19 pandemic public health emergency.

Additionally, CMS is proposing to adjust its approach to establishing benchmarks for rewards and penalties. Usually, a historic benchmark is used—that is, performance thresholds for penalties and rewards are based on data about overall physician performance from a previous year. However, due to concern that the COVID-19 emergency could skew results, benchmarks for 2021 performance will instead be set using data from the 2021 period itself.

Also related to COVID-19, CMS proposes a more gradual increase in the performance threshold needed to avoid a penalty in 2021: the 2019 final rule would have increased the threshold from 45 points to 60 points, but CMS proposes to hold the increase to 50. CMS also proposes to maintain the exceptional performance threshold at 85 points in 2021, the same threshold as in 2020.

Finally, CMS is delaying implementation of a new MIPS program, the MIPS Value Pathway initiative, originally planned for 2021. That initiative intends to establish specialty-specific sets of performance measures that better assess the “value” of clinician activity across the four domains. ■