On November 2, 2017, CMS issued the final rule with comment for the second year (2018) of the Quality Payment Program as well as an interim final rule. Continuing with its theme of a CMS that is “listening to feedback,” CMS continued many of its flexibilities from the transition year (2017). For example, clinicians will be able to continue using 2014 or 2015 Certified Electronic Health Record Technology in 2018. CMS also indicated that year three (2019) will be more “robust” with enhancements such as the addition of virtual groups. All of this highlights CMS’ continued efforts to reduce burdens on clinicians and provide a roadmap for increased participation in Advanced Alternative Payment Models (APMs).

One of the chief complaints from clinicians in this era of transition from volume to value-based reimbursement is the increased burden of administrative tasks that reduce their time with patients. The final rule recognizes CMS’ recent “Payment over Paperwork” initiative and includes as part of that initiative options for virtual groups. It also permits clinicians to qualify for incentive payments by participating in Advanced APMs that begin or end during a calendar year. CMS also increased the threshold for excluding eligible MIPS clinicians/groups to less than or equal to i) $90,000 in Part B allowed charges or ii) 200 Part B beneficiaries.

Virtual groups reflect CMS’ efforts to support small and solo practitioners. Many in the industry predicted that the transition to value-based reimbursement would spell the end of the solo/small practice model. Beginning in 2019, CMS will permit the combination of two or more taxpayer identification numbers (TINs) made up of solo practitioners and groups of ten or fewer eligible clinicians who come together virtually regardless of their geographic location to participate in the Merit-based Incentive Payment System (MIPS). Whether this option will preserve small groups and solo practitioners remains to be seen, but the virtual group model presents interesting options for practitioners to leverage “virtual” magnitude without geographic barriers to share resources and collaborate, ideally to increase MIPS performance. It will be interesting to see how these groups form and develop and whether rural and urban practices will team up and scale practice efficiencies across markets.

In terms of increasing Advanced APM participation, CMS noted the steps it is taking to make it easier for clinicians to participate and have an opportunity to qualify for incentive payouts. For example, CMS extended the 8% generally applicable revenue-based nominal amount standard that allows non-Medicare payment arrangements to meet the financial risk criterion to qualify as an Other Payor Advanced APM through 2020 (i.e., an additional two years). Commercial ACOs have been met with success while the move to downside risk in the Medicare ACO space has been slower with many ACOs exiting downside risk models. Adding commercial risk arrangements to an ACO’s mix of risk programs supports clinicians’ focus on the entire patient population and developing clinical efficiencies across the spectrum of the care continuum. Aligning quality measures across payors, and minimizing burdens in terms of data entry and reporting while taking a patient population-wide approach to improving the patient experience of care and patient engagement, can strengthen providers’ efforts to shift to and ultimately succeed in value-based reimbursement models.

The move to value-based reimbursement continues, and CMS had signaled its willingness to listen to and partner with the clinician community to help them succeed. While there is no magic “one-size-fits-all” solution to the right structure to succeed in a value-based reimbursement world, making it easier for clinicians to participate and slowing the pace of change will strengthen the chances of success by having more engaged clinicians. Just as patient engagement is a key to improving population health, clinician engagement is a key to success in the value-based reimbursement world.