The Quality Payment Program: What You Need to Know for 2018

Beth Hickerson, Quality Improvement Advisor, Medical Advantage Group

Almost a year ago, Congress established the Quality Payment Program (QPP) under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). While designed to improve patient health outcomes, encourage practices to spend wisely, minimize the burden of practice participation, and be fair and transparent, the program has been difficult for many medical practices to implement.

The government recently announced 2018 changes to this program. But don’t be dismayed. Many of these changes add flexibility and higher exemption requirements—welcome news to medical practices.

Medical practices will be most affected by changes made by the Centers for Medicare and Medicaid Services (CMS) to the Merit-Based Incentive Payment System (MIPS), one of two QPP tracks. Some of the major changes to MIPS that practices should be aware of are:

1. Category weights have changed, even though the four reporting categories and requirements remain the same:

  • Quality: 50 percent
  • Advancing Care Information: 25 percent
  • Improvement Activities: 15 percent
  • Cost: 10 percent 

2. Important general MIPS changes/updates include:

  • Performance threshold to avoid penalties increased from 3 points to 15 points. This can be achieved solely by maxing out points in the Improvement Activities category.
  • Virtual groups participation option offered. Virtual groups are composed of solo practitioners and groups of 10 or fewer eligible clinicians (eligible to participate in MIPS) who come together “virtually” with at least one other such solo practitioner or group to participate in MIPS for a performance period of 12 months.
  • Low-volume threshold increased. More small practices and eligible clinicians in rural and Health Professional Shortage Areas (HPSAs) are exempt from MIPS participation.
    2017 threshold: </= to $30,000 or 100 patients
    2018 threshold: </= to $90,000 or 200 patients
  • Five bonus points added to the final score of clinicians in small practices. These points will be added automatically for providers in practices with 15 or fewer clinicians.
  • Up to five points added to the MIPS final score for providers caring for complex patients. CMS will use a combination of Hierarchical Condition Categories and counts of dually eligible patients (Medicare and Medicaid) to assign a complex patient bonus to the MIPS final score for applicable providers.
  • Extreme and Uncontrollable Circumstances provision added for providers impacted by natural disasters. In 2017, providers in identified areas (e.g., hurricanes Harvey, Irma, and Maria) will automatically avoid a penalty for payment year 2019 without submitting any performance data. Beginning in 2018, providers must submit a hardship exception application to qualify.

3. MIPS Quality category changes have taken place:

  • Quality reporting period increased to 12 months. Providers must be ready to start tracking quality measure data on January 1, 2018, to fully report in the Quality category in 2018.
  • MIPS performance improvement incorporated in scoring quality performance. Up to 10 points will be added to the Quality category score for statistically significant performance improvement at the category level between 2017 and 2018.
  • Data completeness standards increased to 60 percent. Providers submitting quality measures via claims must report on at least 60 percent of their Medicare Part B patients. Providers submitting via registry, QCDR, or Electronic Health Record (EHR) must report on at least 60 percent of all denominator eligible patients, regardless of payer. No changes for CMS web interface and Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS submission methods.
  • Minimum scoring on measures that do not meet case minimum standards reduced to one point for large practices (16 or more providers).
  • Caps on scoring limits on “topped-out” measures have changed. Six “topped-out” measures have been given a cap of seven performance points, rather than 10.

4. MIPS Advancing Care Information category changes have occurred:

  • Incentives added to encourage the use of 2015 edition Certified Electronic Health Record Technology (CEHRT). Providers have been given a full year extension on the use of 2014 CEHRT and can continue to report the 2017 Advancing Care Information Transition Objectives and Measures. However, providers who elect to use 2015 edition CEHRT in 2018 will earn bonus points.
  • Exclusions added for the E-prescribing and Health Information Exchange base measures. Individuals or groups with fewer than 100 patients in the denominator for these measures may claim an exclusion and not report them. These new exclusions are retroactive to the 2017 reporting year.
  • New Advancing Care Information hardship exception added for clinicians in small practices. Practices with 15 or fewer eligible clinicians can apply to have their Advancing Care Information category score re-weighted to the Quality category.
  • New Advancing Care Information hardship exception option added for clinicians whose EHR was decertified.
  • Automatic re-weighting of the Advancing Care Information performance category score to Quality added for ambulatory surgical center (ASC)-based MIPS eligible clinicians. This change will be retroactive to the 2017 performance year.

5. MIPS Improvement Activities category changes have been made:

  • Total number of approved Improvement Activities increased from 92 in 2017 to 112 in 2018.
  • Additional CEHRT-related Improvement Activities made available. This increases options for earning Advancing Care Information bonus points.
  • Patient-Centered Medical Home (PCMH) certification threshold changed for full Improvement Activities credit. Tax Identification Numbers (TINs) must have 50 percent of their practice sites certified as PCMHs to receive automatic full credit in the Improvement Activities category.

6. MIPS Cost category changes have occurred:

  • Episode-based measures eliminated from the Cost category score calculation. Only Total Per Capita Cost and Medicare Spending per Beneficiary (MSPB) measures will be used to calculate the Cost score.
  • Automatic re-weighting of Cost score to Quality added for clinicians who do not meet minimum case standards requirements. Individuals and groups who do not receive a Cost score because they do not have enough attributed patients for either Cost measure will automatically have their 10 percent Cost points re-weighted to Quality.
  • Improvement scoring added for Cost. Individuals or groups who demonstrate statistically significant Cost improvement between 2017 and 2018 will receive up to 1 percent added to their Cost category score.

Practices that find these changes overwhelming may want to reach out for expert help with industry-leading best practices to maximize Medicare payments—visit for more information. For resources on MACRA and being successful in optimizing reimbursement, go to

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.


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