The rule for the 2021 Quality Payment Program, covering the Merit-based Incentive Payment System (MIPS) and Alternative Payment Model (APM), was released at the beginning of the year. Concerns regarding how the COVID-19 pandemic would impact the program for 2020 and 2021, lead to the release of rules for the MIPS. However, a thorough analysis of the anticipated concerns, in the form of proposed rules, revealed that COVID-related impacts are comparatively minor, and eventually, both 2020 and 2021 will need complete contribution for MIPS eligible clinicians and entities. Here are key highlights of the changes that have been proposed in various categories.

Performance Category weights

The key changes in the MIPS performance category weights for the year 2021 are: quality is reduced to 40% from 45%, and the cost is increased to 20% from 15%.

Minimum threshold and payment adjustments

Regarding minimum threshold and payment adjustments, CMS proposed to increase the minimum threshold to 50 points from 45 points in 2020, for the new performance year. It means to avoid any penalty; one must achieve at least 50 points. For exceptional performance, the additional performance threshold is the same, which is 85 points. Also, there will be no changes in the MIPS payment adjustments, remaining the same at +/-9%.

Quality performance category

For the quality performance category, making up to 40% of the total MIPS score, one must continue to report 6 measures on at least 70% of one’s eligible patients. Of the 6 measures, at least one should be an Outcome or High Priority measure. The major changes in this category are:

Measure changes:

The two new administrative claims measure added for the year 2021 are:

• Hospital-wide, 30-Day, All-cause Unplanned Readmission (HWR) Rate for MIPS Eligible Clinician Groups
• The risk-standardized complication rate following elective primary total hip arthroplasty and/or total knee arthroplasty for MIPS Eligible Clinicians

Following measures are proposed to be removed from the MIPS program for 2021:

• Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older
• Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older
• Hematology: Multiple Myeloma – Treatment with Bisphosphonates
• Radiology: Inappropriate Use of “Probably Benign” Assessment Category in Screening Mammograms
• Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse)
• Psoriasis: Tuberculosis (TB) Prevention for Patients with Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier
• Implantable Cardioverter-Defibrillator (ICD) Complications Rate
• Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options
• Opioid Therapy Follow-up Evaluation
• Documentation of Signed Opioid Treatment Agreement
• Evaluation or Interview for Risk of Opioid Misuse
• Quality of Life Assessment For Patients With Primary Headache Disorders
• Rate of Surgical Conversion from Lower Extremity Endovascular Revascularization Procedure
• All-Cause Hospital Readmission (Administrative Claims measure)

Benchmarking:

CMS proposed to use the performance period as a benchmark for scoring quality measures in the year 2021, as the clinicians may not have a representative sample of historic data for CY 2019 because of the COVID-19 pandemic.

Topped out measures:

Because of the proposed benchmark changes, the scoring policy for topped-out measures is also updated. Now, the 7 point cap is only applicable if the measure is identified as topped out on the basis of the established benchmarks for both the 2020 and 2021 performance periods.

Scoring flexibility:

CMS proposed to revise the scoring for measures during the performance year by:

• Shortening the performance period to 9 consecutive months if no concerns with potential patient harm are there, and 9 consecutive months of data is available; or
• Suppressing the measure from scoring, if consecutive months of data are not available. It means the 0 achievement points and total measure achievement points are reduced by 10 for each “impacted” measure, which is submitted.

Cost performance category

For the cost performance category, worthing 20% of total MIPS score in 2021, CMS decided to maintain the following existing measures:

• TPCC measure
• MSPB Clinician measure
• 18 existing episode-based cost measures

Additionally, CMS proposed telehealth services, which is directly applicable to episode-based cost measure and the TPCC measure.

Improvement Activities category

In this category, making 15% of the total MIPS score, significant changes are made. The two activities proposed by CMS to be modified are:

• IA_BE_4 Engagement of patient through the implementation of improvements in the patient portal
• IA_AHE_7 Comprehensive Eye Exams

Promoting Interoperability Performance category

This category continues to worth 25% of the total MIPS score. Here, CMS proposed the following changes:

• PDMP measure will remain as an optional measure with the worth of 10 bonus points.
• The name of the Support Electronic Referral Loops by Receiving and Incorporating Health Information measure is changed by replacing “incorporating” with “reconciling”.
• An optional Health Information Exchange (HIE) bidirectional exchange measure is added.
• The automatic reweighting policies for the following clinician types are preserved in 2021:
• Nurse Practitioners (NPs)
• Physician Assistants (PAs)
• Certified Registered Nurse Anesthesiologists (CRNAs)
• Clinical Nurse Specialists (CNSs)
• Physical Therapists
• Occupational Therapists
• Qualified Speech-language Pathologist
• Qualified Audiologists
• Clinical Psychologists Registered Dieticians or Nutrition Professionals

Complex patient bonus:

CMS proposed to double the complex patient bonus from 5 bonus points to 10 bonus points (for the year 2020 only) so that clinicians, groups, and entities earn up to bonus points for the additional complexity of treating their patients in the COVID-pandemic.

Elimination of Web Interface reporting

CMS decided to end the CMS Web Interface reporting option for ACOs, registered groups, and APM Entities with the beginning of the 2021 performance period. Now, groups can choose their quality measures, instead of reporting on the established, predetermined set of measures.

MIPS APM reporting options

CMS proposed that MIPS-eligible clinicians in APMs can now participate in MIPS and submit their data at the individual, group, or APM entity level.

MVPs postponed

CMS is also deciding to postpone the adoption of the MIPS value pathway (MVP) framework until the 2022 performance period or beyond.

How these changes can affect you as a practitioner?

These changes are proposed, not implemented yet, the final requirements have yet to be decided. The most significant of these changes is to meet the higher performance threshold of 50 points. Now, the development of a strong reporting plan is imperative to ensure you don’t have to pay the penalty. There is also a need to thoroughly review the measures proposed for removal as they may have some which you have historically reported. If there are such measures, you need to identify the alternative measures for which you have eligible patients, and you can report. Also, the MIPS APM participants have an option to report with a qualified registry from next year.