The QPP: Small Practice Relief in 2018?

Happy New Year, blog readers! Did you make any resolutions this year? Do they remain intact? Was MIPS part of one of those resolutions? If Med-PAC has its way, MIPS will ride off into the sunset just as you are getting used to it—but I would not bet on that happening anytime soon. The arrival of 2018 marks the start of year 2 of the CMS Quality Payment Program (QPP). I am certain blog readers have not forgotten about the new payment program birthed a few years back by MACRA. Today we are going to focus on the MIPS side of the house, turning our attention to “small” practices.

A short history of small practices and MIPS

Small practices have received a lot of attention from the folks who have constructed the QPP framework. Early in the process there was a concern that small practices would be disadvantaged by the new program. Much of that concern centered around a perceived lack of resources within small practices, which could limit their ability to adopt the workflows necessary to participate—a troubling development given the fact that all eligible clinics, regardless of practice size, are competing for a finite number of MIPS dollars. In an effort to level the playing field (or at least try to do so), several perks have been extended to small practices.

What’s small?

Before we get to the specific perks, let’s start at the beginning. How does the QPP define a small practice? The short answer is that any practice with 15 or fewer providers is a small practice in the eyes of the QPP. I find this to be a very interesting number as the vast majority of nephrology practices have fewer than 15 providers. For 2018, CMS has firmed up the way they count. They have established a new phrase “small practice size determination period” (really, I couldn’t make this stuff up if I tried). This is basically a 12-month period that includes the last 4 months of the year that’s 2 years prior to the performance period and the first 8 months of the following year. Enough to make your head spin right? It’s easier for me to understand a real life example. For the 2018 performance period (which dictates your 2020 fee schedule), practice size will be determined based on a review of claims data between September 1, 2016, and August 31, 2017. If CMS sees 15 or fewer NPI numbers associated with your TIN during that period of time, you practice in a small practice. Glad we got that out of the way!

Improvement Activities

If you are in a small practice, what sort of MIPS relief can you expect this year? Well, as in 2017, you get a substantial break in the new MIPS category. Recall there are 4 categories in MIPS and 3 of them we have seen before. Improvement Activities is the new kid on the block. As a doc in a small practice, you basically receive “double points” for Improvement Activities, which means you will do half the work a large practice will do in order to receive the maximum number of MIPS points available in this category. That’s a pretty good deal.

Small practice bonus

But wait, there’s more! By simply practicing in a small group, after your MIPS score is tallied, CMS will add 5 points to your score. Now this may not sound like much, but it’s actually a pretty big deal. Remember there are only 100 MIPS points available and since this is a budget neutral program, you are competing with every other doc in the country, regardless of specialty and regardless of practice size. Those 5 points are basically a head start in the race against the rest of the crowd. And don’t forget, your final MIPS score will dictate your fee schedule in a couple of years—almost like CMS is handing you money. (They aren’t.)

Low volume threshold

Last year, providers who had encounters with fewer than 100 unique beneficiaries or those who had a Part B allowable of less than $30,000 during the year were excluded from MIPS. For 2018, the low volume threshold hurdles changed significantly. The new figures are 200 unique beneficiaries or $90,000 in Part B allowable during the year. Come in under either of these and you get a pass from MIPS for the year. This one has received a lot of fanfare, but in my experience this will provide little relief for nephrologists in small practices. Your advanced practioners may avoid MIPS, but ultimately this creates a more competitive MIPS landscape for nephrology practices. How is that possible? According the final rule, raising the low volume threshold in 2018 will remove about 134,000 eligible clinicians from the 700,000 or so that would be required to participate under the 2017 rule. How many nephrologists do you suppose are among those 134,000? My bet is not many. So those of us who remain in the MIPS pool find ourselves competing with a higher percentage of large practices. Though touted by CMS as small practice relief, not the case for nephrology.

Completeness in quality

A few other points are worth calling out. What’s known as the “completeness” rate for quality measures rises to 60% in 2018. This means if you pick a quality measure but don’t report enough data for that measure you can’t collect the possible 10 points. If this happens to you and you’re in a small practice, you will receive 3 points for your troubles, unlike the docs in larger practices who receive a single point. Sounds like small change, but for 2018, you only need 15 MIPS points to avoid the 5% haircut in 2020. Out of the gate you have the 5 small-practice bonus points mentioned above, pick 6 quality measures and report 1 patient for each? Sounds like another 15 MIPS points to me and you are free and clear of the 2020 penalty!

New ACI hardship

Last but not least, if you are in a small practice, you have the opportunity to request a hardship exception for advancing care information (ACI). Remember, ACI is the new meaningful use, only easier. In fact it’s so much easier, I find it hard to believe anyone with a certified EHR will go down this path. But those of you in a small practice still using paper charts or an EHR that is not certified can request this hardship. In the likely event it is granted, ACI is reweighted to zero and those 25 potential MIPS points move over to the Quality category. Note this makes Quality worth 75% of your MIPS score, substantially magnifying Quality’s impact on your 2020 fee schedule.

The upside of small

All in all this should be welcome news for the vast majority of nephrology practices facing MIPS this year. The only strike against us in my view is the impact raising the low volume threshold may have on small nephrology practices because it shrinks the pool of “competitors”, likely by removing other small practices. Having said that, putting 5 MIPS points in your pocket before the race begins, doing half the work of the other guy within the Improvement Activities category, and the generous handout for not achieving “completeness” among your quality measures should put most nephrology practices in a good place. CMS has also provided additional support for small practices. Check out this website to see what else is available to those of you in a small practice. Couple these small-practice benefits with the “complex” patient bonus many nephrologists will capture, and MIPS may not require much of a resolution in 2018 after all.

Are you in a small practice? Drop us a note and let us know what you think about the 2018 QPP relief for small practices.

Terry Ketchersid, MD, MBA, practiced nephrology for 15 years before spending the past seven years at Acumen focused on the Health IT needs of nephrologists. He currently holds the position of Chief Medical Officer for the Integrated Care Group at Fresenius Medical Care North America where he leverages his passion for Health IT to problem solve the coordination of care for the complex patient population served by the enterprise.

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