A physician who did not report performance on quality measures to the Physician Quality Reporting System (PQRS) for 2015 now faces a 6% penalty on all Medicare Part B payments.  The same penalty will apply in 2018 for physicians who do not report performance for 2016.

In addition to PQRS penalties, a 3% penalty now is assessed against physicians who did not attest to meaningful use (MU) of an electronic health record (EHR) for 2015.   Again, the 3% MU penalty will apply in 2018 for physicians who did not attest for 2016.

For 2017, new reporting requirements under the Merit-Based Incentive Payment System (MIPS) will take the place of PQRS reporting and MU attestation.  If a physician elects not to report any data under MIPS for 2017, he or she will be subject to a 4% penalty on all Medicare Part B payments in 2019.

For a physician who will be subject to the maximum 9% penalty in 2018 for failure to both report performance to PQRS and attest to MU for 2016, MIPS will mean a 5% increase in Medicare Part B payments in 2019, assuming the physician does not report under MIPS for 2017.

By submitting only a minimum amount of 2017 performance data to CMS, however, a physician can avoid the 4% MIPS penalty in 2019.  To assist physicians in transitioning to MIPS, the Centers for Medicare & Medicaid Services (CMS) created the “Pick Your Pace” program for 2017.  A physician (either individually or as part of a group) can avoid the 4% penalty in 2019 simply by submitting data relating to a single quality measure or attesting to performing a single clinical practice improvement activity.

Option 1:  Report on One Quality Measure

To successfully report on a quality measure for 2017, a physician must report data for a continuous 90-day period for a minimum of 20 patients that must comprise at least 50% of the denominator-eligible patients.  For example, if a physician were to elect to report on the quality measure for controlling high blood pressure, he or she would report the percentage of patients, age 18-85 with a diagnosis of hypertension, whose blood pressure is controlled during the measurement period.

Specifically, the denominator would include patients, 18-85 years of age with a diagnosis of hypertension, seen by the physician (or, in the case of group reporting, by the group as a whole) within the selected 90-day performance period.  The numerator would be those patients whose systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg at the most recent visit during that period.  Again, to be reportable, the denominator must include at least 20 patients representing at least one-half of the hypertensive adults seen during the performance period.

A complete list of the 271 approved MIPS quality measures, (including the definition of the denominator and numerator for each measure), is available on the Quality Payment Program website.  The QPP website also provides information about the different ways in which a physician or group can report on the measures (e.g., claims, EHR, registry) and the applicable benchmarks for each measure. 

Option 2:  Report on One Clinical Practice Improvement Activity

A physician seeking to avoid the 4% penalty in 2019 may elect to report on a clinical practice improvement activity instead of a quality measure.  In that case, the physician (either individually or as part of a group) would attest to having engaged in one approved activity for at least 90 continuous days during 2017.  The activity does not have to be “new;” a physician can take credit for established programs.

The complete list of the 92 activities approved for 2017 also is available on the Quality Payment Program website.  The listed activities cover a broad spectrum, from implementing an antibiotic stewardship program to providing ambulatory care management services.  The website also provides information on reporting mechanisms.

Another Option:  Report on Advancing Care Information Base Score Measures

The third option for a physician seeking to avoid the 4% penalty is successfully reporting on all of the measures included in the base score for the advancing care information (ACI) component, which replaces the MU program for physicians.  For 2017, the base score measures include: (1) conducting a security risk analysis; (2) e-prescribing; (3) providing patient electronic access; (4) sending a summary of care; (5) requesting and accepting a summary of care.  The first measure requires a “yes” response, while the other four are reported with a denominator and a numerator of at least one.  Because reporting a single quality measure or a single clinical practice improvement activity involves less tracking and compilation of data, we anticipate few physicians will use the ACI route for avoiding the 2019 penalty.

Pursuing Bonus Payments

If a physician has successfully reported performance to PQRS and/or attested to MU in prior years, he or she may be ready to “pick up the pace” by pursuing MIPS bonus payments (as opposed to merely avoiding penalties).  To be eligible for bonus payments, a physician must (1) report on six MIPS quality measures (unless reporting through the GPRO web interface or a qualified clinical data registry), (2) attest to having engaged in four clinical practice improvement activities (or only two activities, if certain conditions are satisfied), and (3) report on both the ACI base score and performance score measures.

If a physician participates in an accountable care organization enrolled in Track 1 of the Medicare Shared Savings Program (MSSP), his or her MIPS reporting requirements are reduced significantly.  These physicians only report on the ACI base score and performance score measures; the balance of the MIPS score is based on MSSP performance.

Physicians who elect to report individually using Part B claims will need to include specified codes on those claims at the time of submission for at least a 90-day period during 2017; one cannot add this information to claims at a later time.  Groups with 25 or more practitioners that elect to report through the GPRO web interface must register by the end of June 2017.  Otherwise, physicians will report on 2017 performance during the first quarter of 2018.  Now is the time, however, to develop your MIPS game plan, including “pick your pace,” measures selection, and process improvement to improve performance on selected measures.

For assistance in developing your MIPS game plan, contact Martie Ross (mross@pyapc.com) or Lori Foley (lfoley@pyapc.com).  Both can be reached at (800) 270-9629.