Key MACRA updates for the 2018 performance year

CMS recently published the 2018 final rule for the Quality Payment Program (QPP) under the Medicare Access and Chip Reauthorization Act (MACRA). The 2018 Merit-based Incentive Payment System (MIPS) performance year contains several significant changes. We’ve outlined some of the most impactful provisions for you, but you can access a full summary of the changes on the website.

Cost category

For the 2017 performance year, the cost category accounts for 0 percent of the MIPS final composite score. It was initially expected to continue at that level and not count as a part of the final score for the 2018 performance year. However, the final rule for 2018 increases the weight of the cost category to 10 percent. This change will reduce the weight of the quality category score to 50 percent (from 60 percent in the 2017 performance year). Furthermore, for the 2019 performance year, the weight of the cost category is proposed to increase to 30 percent (decreasing the weight of the quality category score to 30 percent).

CMS will use Medicare Spending per Beneficiary (MSPB) and total per capita cost as the measures for the cost category. The data will be collected via administrative claims data, meaning there is no submission requirement for eligible clinicians. The data will be compared to the performance of eligible clinician peers in the same method as quality measures. To score the cost category, CMS will take an average of the scores between the two measures. If only one measure can be scored, that score will become the cost category score. The 10 episodes-based measures that were originally adopted in the 2017 final rule will no longer apply. (However, CMS does expect to develop new episode-based measures based on feedback from the 2018 performance year to apply to future performance years.)

Virtual groups

Solo clinicians and groups that are eligible for MIPS can now elect to participate in a virtual group in order to maximize their MIPS scoring potential. Virtual groups are comprised of a combination of TINs (tax identification numbers), regardless of specialty or geographic location, reporting MIPS measures to CMS.

Participation eligibility is determined by TIN. Solo practitioners must be billing under a TIN with no other NPI billing under the same TIN. Groups must have a TIN that has no more than 10 eligible clinicians. Solo practitioners and groups that are excluded from MIPS are not permitted to participate in a virtual group. Groups can only be members of one virtual group, and if a group TIN participates in a virtual group, all eligible clinicians reporting under that TIN are also a part of that virtual group.

CMS recommends that, before forming a virtual group, the arrangement should be outlined in a written, formal agreement between all members of the virtual group. A representative from the virtual group should be named to submit the election, which must identify each clinician (NPI) associated with each TIN participating in the virtual group.

Election for virtual group participation must be done between October 11, 2017, and December 1, 2017. If you are interested in participating in the MIPS program as a virtual group, please contact your local QPP Technical Assistance Organization to confirm eligibility.

Low-Volume threshold changes

There have been significant changes made to the low-volume threshold. Previously, the low-volume threshold was set at less than/equal to $30,000 in Medicare Part B allowed charges, or less than/equal to 100 Medicare Part B patients. With the new updates just released, the low-volume threshold will now increase to less than/equal to $90,000 in Medicare Part B allowed charges, or less than/equal to 200 Medicare Part B patients. These changes mean even fewer physicians will be subject to MIPS.

Small practice protections

CMS is making a strong effort to ease the burden of participating in MIPS by awarding bonus points to small practices and groups that treat a variety of complex patients.

Small practices (those with 15 or fewer clinicians) can earn five additional points toward their MIPS final score if they submit data on at least one performance category.
CMS will award providers up to five bonus points if their patient population is deemed particularly complex, as measured by a combination of Hierarchical Conditions Category (HCC) risk scores and the number of dually eligible patients treated

Disaster relief

CMS has adopted a policy to account for those affected by recent natural disasters and hurricanes. Providers who were in affected areas during the 2017 reporting year will be eligible to receive neutral payment adjustment (in the 2019 payment year). In fact, these providers will not be required to submit 2017 MIPS data; they can automatically avoid the 2019 penalty. However, they may choose to submit 2017 MIPS data to receive a MIPS score and MIPS payment adjustment based on category-to-category performance similar to other eligible clinicians.

Transition year components that will remain in place for 2018

CMS, specifically the QPP program, has made a conscious effort to listen to feedback and ensure that the burden is minimized. The program’s stated goals include making sure that:

  • The program’s measures and activities are meaningful
  • Clinician burden is minimized
  • Care coordination is improved
  • Clinicians have a clear way to participate in Advanced APMs

Additionally, QPP has decided to maintain many of the flexibilities from the 2017 transition year, carrying them over to 2018 in hopes that this will even better prepare clinicians for the third year (2019) of reporting.

  • Advancing Care Information may use either 2014 or 2015 Edition CEHRT for the 2017 transition year, as well as for 2018. However, a 10 percent bonus is available if you only use the 2015 Edition CEHRT.
  • The free hands-on technical assistance (TA) that is currently available to help providers participate in the QPP will continue to be offered.

Additional changes

Under the quality measures category, six measures have been classified as ‘topped-out’ and will be scored at a maximum of seven points per measure. Over the next four years, the maximum amount of points awarded for each identified measure will be reduced over a four-year period until they are phased out.

Topped-out measures aren’t the only change to the quality category. During the 2017 transition year, reported measures were still awarded three points even if they did not fulfill the data completeness criteria. The 2018 reporting year will only award one point per reported measure that does not fulfill the criteria specified for data completeness. It was previously reported that the 2018 performance year would allow for multiple submission methods in each category. However, this allowance has been delayed to the 2019 performance year. For 2018 measures, only one submission method will be allowed for each category.

Continue the dialogue

The CMS is welcoming feedback on the final rules through 5 p.m. on January 1, 2018. You can submit comments via phone, mail or email ( You can also follow the steps at to submit an electronic comment. Please visit or additional information on the QPP or to provide feedback to CMS.

Confused by all of these MACRAnyms? Give us a call. We’d be happy to discuss best practices for reporting so you can avoid penalties and be rewarded for providing better, patient-centered care.

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