Impact Insights

2022 PFS Proposed Rule Part 1: Traditional MIPS Program Proposals

This month, CMS released the 2022 Physician Fee Schedule (PFS) Proposed Rule, which also governs the Quality Payment Program (QPP) for healthcare providers. Check out our high-level overview here, read on for Part 1 covering Traditional MIPS Program Proposals, and watch for subsequent blogs diving into individual sections of the rule.

Traditional MIPS Program Proposals

New MIPS Eligible Clinicians (EC)

Two new EC categories will be added, beginning in PY 2022:

▪ Clinical social workers
▪ Certified nurse midwives

Note that Promoting Interoperability (PI) will be automatically reweighted for small practices (15 or fewer clinicians) and for clinical social workers (reweighted to 0%), although certified nurse midwives would not be reweighted.

This is likely to represent a significant challenge for these new EC types in 2022, as they’ll need to quickly get up to speed with MIPS and potentially have to incorporate workflow changes in order to optimize scoring.

Changes to Performance Thresholds

MIPS Performance Threshold

For the 2022 PY, the MIPS performance threshold will be set to the mean final score from the 2017 performance year (2019 payment year), which would result in a performance threshold of 75 points. This represents an increase of 15 points from the previous year’s threshold.

Additional Performance Threshold

An additional performance threshold would be established at 89 points. This is the 25th percentile of actual 2017 final scores above 75 points.

Note that the statute requires that an additional performance threshold be set at (1) the 25th percentile of the range of possible final scores above the performance threshold or (2) the 25th percentile of the actual final scores for MIPS eligible clinicians with final scores at or above the performance threshold with respect to a prior period (42 USC 1395w–4).

Exceptional Performance Bonus

The exceptional performance threshold concludes with the 2022 performance year (2024 payment year), making this the last year for the exceptional performance bonus.

As mentioned in our previous blog post, the transition to mean/median scoring represents a fundament shift in the metrics associated with MIPS in order to ensure budget neutrality for the program. What this means is that incentive dollars must be offset by (and funded from) penalties, with the result that providers are now essentially in direct competition with each other – if you’re not “better than average” you may find yourself penalized in order to help incentivize higher-scoring providers. Consequently, more providers may find themselves on the “wrong side” of the MIPS Performance Threshold.

For more on Budget Neutrality, please visit our blog post where we discuss this “Competition Curve” in more detail and its potential impacts on providers.

Performance Category Weights

As discussed earlier, the MIPS scoring Cost Component will be set to 30%, with a corresponding adjustment to the MIPS Quality component of 30% for the 2022 performance year (2024 payment year).

Note that the 2022 performance category weights are specified in statute and are not able to be modified without changing the original legislation.

Additional MIPS Scoring Category Weights for other programs include:

Note that these weights are proposed to have the same weights as last year (2021).

While there may be sound programmatic reasons for providing different scoring weights for the various programs, this does seem to add complexity for providers, as well as requiring additional costs for compliance for health systems in general.

Performance Category Proposals

Promoting Interoperability (PI) Performance Category

▪ Apply automatic reweighting to clinical social workers and small practices.
▪ Revise reporting requirements for the Public Health and Clinical Data Exchange objective to support public health agencies (PHAs) in future health threats as well as a long-term COVID-19 recovery.
– MIPS eligible clinicians must now report:
• Immunization Registry Reporting
• Electronic Case Reporting
▪ Add a requirement in the Provide Patients Electronic Access to Their Health Information measure that patients have access to their health information indefinitely for encounters on or after January 1, 2016.
Require MIPS eligible clinicians to attest to conducting an annual assessment of the SAFER Guides (the High-Priority Guide of the Safety Assurance Factors for EHR Resilience Guides) beginning with the CY 2022 performance period.
Modify the Prevention of Information Blocking attestation statements to distinguish this from separate information blocking policies under the Office of the National Coordinator for Health Information Technology (ONC) requirements established in the 21st Century Cures Act final rule.

Quality Performance Category

Point Floor and Bonus Point Changes (for 2023 performance year)
For new measures, establish a 5-point floor for the first 2 performance periods
For measures WITH a benchmark, remove the 3-point floor [doesn’t apply to new measures in the first 2 performance periods]
For measures WITHOUT a benchmark, remove the 3-point floor [doesn’t apply to small practices, which would continue to earn 3 points, doesn’t apply to new measures in the first 2 performance periods]
For measures that don’t meet the case minimum, remove the 3-point floor [doesn’t apply to small practices, which would continue to earn 3 points, doesn’t apply to new measures in the first 2 performance periods, doesn’t apply to administrative claims measures (measures calculated from administrative claims are excluded from scoring if the case minimum is not met)]
High-Priority Bonus Points are removed for reporting additional outcome and high priority measures, beyond the 1 required.
End-to-End Electronic Reporting Bonus Points are removed
▪ For scoring quality measures in the 2022 performance period, use performance period benchmarks from the 2022 performance period, or a different baseline period (such as 2019), pending analysis of the 2020 performance period data.
Extend the CMS Web Interface as a quality reporting option for the 2022 performance period for:
– Registered groups
– Virtual groups
– Other APM Entities
▪ Updates to the quality measure inventory, resulting in a total of 195 quality measures proposed for the 2022 performance period.
Increase the data completeness requirement to 80% beginning with the 2023 performance period (maintaining the current completeness requirement at 70% for 2022).

Improvement Activities (IA) Performance Category

Addition of seven new improvement activities, 3 of which are related to promoting health equity.
Modification of 15 current improvement activities, 11 of which address health equity (and in some cases, specifically add requirements to address racial equity).
Removal of six previously adopted improvement activities.

In addition, CMS has specified eight criteria (two proposed, six existing) along with proposing six “optional factors” to be considered for nominating future new Improvement Activities.

Note that CMS is also implementing a mechanism to immediately suspend Improvement Activities if needed (for example if there are patient safety concerns).

Cost Performance Category

▪ Addition of five new episode-based cost measures:
1) Melanoma Resection [procedural measure] – 10 minimum episodes
2) Colon and Rectal Resection [procedural measure] – 20 minimum episodes
3) Sepsis [acute inpatient measure] – 20 minimum episodes
4) Diabetes [chronic condition measure] – 20 minimum episodes
5) Asthma/Chronic Obstructive Pulmonary Disease (COPD) [chronic condition measure] – 20 minimum episodes
The Cost performance category will be reweighted to 0% for the 2020 performance year (CY 2022 payment year) due to complications of the COVID-19 pandemic.

Note that CMS is also requesting input on the process for future cost measure development.

Final Scoring

CMS is proposing to continue doubling the complex patient bonus for the 2021 MIPS performance year (capped at 10 points that would be added to the final score) because of the concerns of the direct and indirect effects of the COVID-19 Public Health Emergency (PHE).

In addition, CMS is proposing additional scoring adjustments:
▪ Revisions to the complex patient bonus scoring calculations
▪ Revisions to facility-based measurement (for clinicians and groups)
▪ Updates to the redistribution policies (reweighting) for small practices:
– If PI is reweighted, then: Quality = 40%; Cost = 30%; IA = 30%
– If both PI and Cost are reweighted, then: Quality = 50%; IA = 50%
▪ As noted earlier above, beginning with the 2022 performance year, the performance threshold must be either the mean or median of the final scores for all MIPS eligible clinicians for a prior period.
– The performance threshold for 2022 is set to 75 points.
– The additional performance threshold for 2022 is set to 89 points for exceptional performance.
The final year for the MIPS adjustment for exceptional performance will be the 2022 performance year.

Care Compare (Public Reporting)

CMS is proposing to add affiliations for the following facility types on Care Compare:
1) Long-Term Care Hospitals
2) Inpatient Rehabilitation Facilities
3) Inpatient Psychiatric Facilities
4) Skilled Nursing Facilities
5) Home Health Agencies
6) Hospice
7) End-Stage Renal Disease (ESRD) Facilities

Note that CMS is soliciting feedback on various components of Care Compare, including procedure volume, conditions treated, utilization data, HCPCS and diagnosis codes, data aggregation, peer comparisons, claim lookback timeframe, and other metrics to help patients categorize and understand data in a more meaningful way.

Additionally, CMS is proposing that subgroup scores be publicly reported separately from group scores (beginning with the 2024 performance year).

Up Next: 2022 PFS Proposed Rule Part 2: MIPS Value Pathways (MVPs) Proposals

Helpful Links

CMS PFS Homepage:

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched

CMS Proposed Rule Page:

https://www.cms.gov/medicaremedicare-fee-service-paymentphysicianfeeschedpfs-federal-regulation-notices/cms-1751-p

PDF of Proposed Rule (1,747 pages):

https://public-inspection.federalregister.gov/2021-14973.pdf

Federal Register Proposed Rule Page:

https://www.federalregister.gov/public-inspection/2021-14973/medicare-program-cy-2022-payment-policies-under-the-physician-fee-schedule-and-other-changes-to-part

CMS Fact Sheet:

https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2022-medicare-physician-fee-schedule-proposed-rule