[Federal Register Volume 82, Number 125 (Friday, June 30, 2017)]
[Proposed Rules]
[Pages 30010-30500]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2017-13010]



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Vol. 82

Friday,

No. 125

June 30, 2017

Part II

Book 2 of 3 Books

Pages 30009-30500





 Department of Health and Human Services





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 Centers for Medicare & Medicaid Services



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42 CFR Part 414



 Medicare Program; CY 2018 Updates to the Quality Payment Program; 
Proposed Rule

Federal Register / Vol. 82 , No. 125 / Friday, June 30, 2017 / 
Proposed Rules

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Part 414

[CMS-5522-P]
RIN 0938-AT13


Medicare Program; CY 2018 Updates to the Quality Payment Program

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Proposed rule.

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SUMMARY: The Medicare Access and CHIP Reauthorization Act of 2015 
(MACRA) established the Quality Payment Program for eligible 
clinicians. Under the Quality Payment Program, eligible clinicians can 
participate via one of two tracks: Advanced Alternative Payment Models 
(APMs); or the Merit-based Incentive Payment System (MIPS). We began 
implementing the Quality Payment Program through rulemaking for 
calendar year (CY) 2017. This rule provides proposed updates for the 
second and future years of the Quality Payment Program.

DATES: To be assured consideration, comments must be received at one of 
the addresses provided below, no later than 5 p.m. on August 21, 2017.

ADDRESSES: In commenting, please refer to file code CMS-5522-P. Because 
of staff and resource limitations, we cannot accept comments by 
facsimile (FAX) transmission. You may submit comments in one of four 
ways (please choose only one of the ways listed):
    1. Electronically. You may submit electronic comments on this 
regulation to http://www.regulations.gov. Follow the ``Submit a 
comment'' instructions.
    2. By regular mail. You may mail written comments to the following 
address ONLY: Centers for Medicare & Medicaid Services, Department of 
Health and Human Services, Attention: CMS-5522-P, P.O. Box 8013, 
Baltimore, MD 21244-8013.
    Please allow sufficient time for mailed comments to be received 
before the close of the comment period.
    3. By express or overnight mail. You may send written comments to 
the following address ONLY: Centers for Medicare & Medicaid Services, 
Department of Health and Human Services, Attention: CMS-5522-P, Mail 
Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
    4. By hand or courier. Alternatively, you may deliver (by hand or 
courier) your written comments ONLY to the following addresses prior to 
the close of the comment period:
    a. For delivery in Washington, DC--Centers for Medicare & Medicaid 
Services, Department of Health and Human Services, Room 445-G, Hubert 
H. Humphrey Building, 200 Independence Avenue SW., Washington, DC 
20201.
    (Because access to the interior of the Hubert H. Humphrey Building 
is not readily available to persons without Federal government 
identification, commenters are encouraged to leave their comments in 
the CMS drop slots located in the main lobby of the building. A stamp-
in clock is available for persons wishing to retain a proof of filing 
by stamping in and retaining an extra copy of the comments being 
filed.)
    b. For delivery in Baltimore, MD--Centers for Medicare & Medicaid 
Services, Department of Health and Human Services, 7500 Security 
Boulevard, Baltimore, MD 21244-1850.
    If you intend to deliver your comments to the Baltimore address, 
call telephone number (410) 786-7195 in advance to schedule your 
arrival with one of our staff members. Comments erroneously mailed to 
the addresses indicated as appropriate for hand or courier delivery may 
be delayed and received after the comment period. For information on 
viewing public comments, see the beginning of the SUPPLEMENTARY 
INFORMATION section.

FOR FURTHER INFORMATION CONTACT:
    Molly MacHarris, (410) 786-4461, for inquiries related to MIPS.
    Benjamin Chin, (410) 786-0679, for inquiries related to APMs.

SUPPLEMENTARY INFORMATION: 

Table of Contents

I. Executive Summary and Background
II. Provisions of the Proposed Regulations
    A. Introduction
    B. Definitions
    C. MIPS Program Details
    D. Overview of Incentives for Participation in Advanced 
Alternative Payment Models
III. Collection of Information Requirements
IV. Response to Comments
V. Regulatory Impact Analysis
    A. Statement of Need
    B. Overall Impact
    C. Changes in Medicare Payments
    D. Impact on Beneficiaries
    E. Regulatory Review Costs
    F. Accounting Statement

Acronyms

    Because of the many terms to which we refer by acronym in this 
rule, we are listing the acronyms used and their corresponding meanings 
in alphabetical order below:

ABCTM Achievable Benchmark of Care
ACO Accountable Care Organization
API Application Programming Interface
APM Alternative Payment Model
APRN Advanced Practice Registered Nurse
ASC Ambulatory Surgical Center
ASPE HHS' Office of the Assistant Secretary for Planning and 
Evaluation
BPCI Bundled Payments for Care Improvement
CAH Critical Access Hospital
CAHPS Consumer Assessment of Healthcare Providers and Systems
CBSA Core Based Statistical Area
CEHRT Certified EHR technology
CFR Code of Federal Regulations
CHIP Children's Health Insurance Program
CJR Comprehensive Care for Joint Replacement
COI Collection of Information
CPR Customary, Prevailing, and Reasonable
CPS Composite Performance Score
CPT Current Procedural Terminology
CQM Clinical Quality Measure
CY Calendar Year
eCQM Electronic Clinician Quality Measure
ED Emergency Department
EHR Electronic Health Record
EP Eligible Professional
ESRD End-Stage Renal Disease
FFS Fee-for-Service
FR Federal Register
FQHC Federally Qualified Health Center
GAO Government Accountability Office
HIE Health Information Exchange
HIPAA Health Insurance Portability and Accountability Act of 1996
HITECH Health Information Technology for Economic and Clinical 
Health
HPSA Health Professional Shortage Area
HHS Department of Health & Human Services
HRSA Health Resources and Services Administration
IHS Indian Health Service
IT Information Technology
LDO Large Dialysis Organization
MACRA Medicare Access and CHIP Reauthorization Act of 2015
MEI Medicare Economic Index
MIPAA Medicare Improvements for Patients and Providers Act of 2008
MIPS Merit-based Incentive Payment System
MLR Minimum Loss Rate
MSPB Medicare Spending per Beneficiary
MSR Minimum Savings Rate
MUA Medically Underserved Area
NPI National Provider Identifier
OCM Oncology Care Model
ONC Office of the National Coordinator for Health Information 
Technology
PECOS Medicare Provider Enrollment, Chain, and Ownership System
PFPMs Physician-Focused Payment Models
PFS Physician Fee Schedule
PHI Protected Health Information
PHS Public Health Service
PQRS Physician Quality Reporting System
PTAC Physician-Focused Payment Model Technical Advisory Committee
QCDR Qualified Clinical Data Registry
QP Qualifying APM Participant
QRDA Quality Reporting Document Architecture
QRUR Quality and Resource Use Reports
RBRVS Resource-Based Relative Value Scale

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RFI Request for Information
RHC Rural Health Clinic
RIA Regulatory Impact Analysis
RVU Relative Value Unit
SGR Sustainable Growth Rate
TCPI Transforming Clinical Practice Initiative
TIN Tax Identification Number
VBP Value-Based Purchasing
VM Value-Based Payment Modifier
VPS Volume Performance Standard

I. Executive Summary and Background

A. Overview

    This proposed rule would make payment and policy changes to the 
Quality Payment Program. The Medicare Access and CHIP Reauthorization 
Act of 2015 (MACRA) (Pub. L. 114-10, enacted April 16, 2015) amended 
title XVIII of the Social Security Act (the Act) to repeal the Medicare 
sustainable growth rate (SGR), to reauthorize the Children's Health 
Insurance Program, and to strengthen Medicare access by improving 
physician and other clinician payments and making other improvements.
    The MACRA advances a forward-looking, coordinated framework for 
clinicians to successfully take part in the Quality Payment Program 
that rewards value and outcomes in one of two ways:
     Advanced Alternative Payment Models (Advanced APMs).
     Merit-based Incentive Payment System (MIPS).
    These policies are collectively referred to as the Quality Payment 
Program. Recognizing that the Quality Payment Program represents a 
major milestone in the way that we bring quality measurement and 
improvement together with payment, we have taken efforts to review 
existing policies to identify how to move the program forward in the 
least burdensome manner possible. Our goal is to support patients and 
clinicians in making their own decisions about health care using data 
driven insights, increasingly aligned and meaningful quality measures, 
and technology that allows clinicians to focus on providing high 
quality healthcare for their patients. We believe our existing APMs 
alongside the proposals in this proposed rule provide opportunities 
that support state flexibility, local leadership, regulatory relief and 
innovative approaches to improve quality accessibility and 
affordability. By driving changes in how care is delivered, we believe 
the Quality Payment Program supports eligible clinicians in improving 
the health of their patients and increasing care efficiency. To 
implement this vision, the Quality Payment Program emphasizes high-
value care and patient outcomes while minimizing burden on eligible 
clinicians; the Program is also designed to be flexible, transparent, 
and structured to improve over time with input from clinicians, 
patients, and other stakeholders. We have sought and continue to seek 
feedback from the health care community through various public avenues 
such as rulemaking, listening sessions and stakeholder engagement. Last 
year, when we engaged in rulemaking to establish policies for effective 
implementation of the Quality Payment Program, we did so with the 
explicit understanding that technology, infrastructure, physician 
support systems, and clinical practices will change over the next few 
years. For more information, see the Merit-based Incentive Payment 
System (MIPS) and Alternative Payment Model (APM) Incentive under the 
Physician Fee Schedule, and Criteria for Physician-Focused Payment 
Models final rule with comment period (81 FR 77008, November 4, 2016), 
hereinafter referred to as the ``CY 2017 Quality Payment Program final 
rule.'' In addition, we are aware of the diversity among clinician 
practices in their experience with quality-based payments. As a result 
of these factors, we expect the Quality Payment Program to evolve over 
multiple years in order to achieve our national goals. To date, we have 
laid the groundwork for expansion toward an innovative, outcome-
focused, patient-centered, resource-effective health system that 
leverages health information technology to support clinicians and 
patients and builds collaboration across care settings. This proposed 
rule is the next part of a staged approach to develop policies that are 
reflective of system capabilities and grounded in our core strategies 
to drive progress and reform efforts. We commit to continue evolving 
these policies.
    CMS strives to put patients first, ensuring that they can make 
decisions about their own healthcare along with their clinicians. We 
want to ensure innovative approaches to improve quality, accessibility 
and affordability while paying particular attention to improving 
clinicians and beneficiaries experience when interacting with CMS 
programs. The Quality Payment Program aims to (1) support care 
improvement by focusing on better outcomes for patients, decreased 
clinician burden, and preservation of independent clinical practice; 
(2) promote adoption of APMs that align incentives for high-quality, 
low-cost care across healthcare stakeholders; and (3) advance existing 
delivery system reform efforts, including ensuring a smooth transition 
to a healthcare system that promotes high-value, efficient care through 
unification of CMS legacy programs.
    We previously finalized the transition year Quality Payment Program 
policies in the CY 2017 Quality Payment Program final rule. In that 
final rule, we implemented policies to improve physician and other 
clinician payments by changing the way Medicare incorporates quality 
measurement into payments and by developing new policies to address and 
incentivize participation in APMs. The final rule established the 
Quality Payment Program and its two interrelated pathways: Advanced 
APMs, and the MIPS. The final rule established incentives for 
participation in Advanced APMs, supporting the goals of transitioning 
from fee-for-service (FFS) payments to payments for quality and value, 
including approaches that focus on better care, smarter spending, and 
healthier people. The final rule included definitions and processes to 
identify Qualifying APM Participants (QPs) in Advanced APMs and 
outlined the criteria for use by the Physician-Focused Payment Model 
Technical Advisory Committee (PTAC) in making comments and 
recommendations to the Secretary on proposals for physician-focused 
payment models (PFPMs).
    The final rule also established policies to implement MIPS, a 
program for certain eligible clinicians that makes Medicare payment 
adjustments based on performance on quality, cost and other measures 
and activities, and that consolidates components of three precursor 
programs--the Physician Quality Reporting System (PQRS), the Physician 
Value-based Payment Modifier (VM), and the Medicare Electronic Health 
Record (EHR) Incentive Program for eligible professionals (EPs). As 
prescribed by MACRA, MIPS focuses on the following: quality--including 
a set of evidence-based, specialty-specific standards; cost; practice-
based improvement activities; and use of certified electronic health 
record (EHR) technology (CEHRT) to support interoperability and 
advanced quality objectives in a single, cohesive program that avoids 
redundancies.
    In this proposed rule, we are building and improving Quality 
Payment Program policies that will be familiar to stakeholders and are 
designed to integrate easily across clinical practices during the 
second and future years of implementation. We strive to continue our 
focus on priorities that can drive improvements toward better patient 
outcomes without creating undue

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burden for clinicians. In this proposed rule, we also address elements 
of MACRA that were not included in the first year of the program, 
including virtual groups, facility-based measurement, and improvement 
scoring. We also include proposals to continue implementing elements of 
MACRA that do not take effect in the first or second year of the 
Quality Payment Program, including policies related to the All-Payer 
Combination Option for identifying QPs and assessing eligible 
clinicians' participation in Other Payer Advanced APMs. To provide 
unity and consistency across the two paths of the Quality Payment 
Program, MIPS and APMs, in this proposed rule we have referred to the 
second year of the program as ``Quality Payment Program Year 2.''

B. Quality Payment Program Strategic Objectives

    As discussed in the CY 2017 Quality Payment Program final rule (81 
FR 77010), after extensive outreach with clinicians, patients and other 
stakeholders, we created six strategic objectives to drive continued 
progress and improvement. These objectives guided our final policies 
and will guide our future rulemaking in order to design, implement, and 
evolve a Quality Payment Program that aims to improve health outcomes, 
promote efficiency, minimize burden of participation, and provide 
fairness and transparency in operations. These strategic objectives are 
as follows: (1) To improve beneficiary outcomes and engage patients 
through patient-centered Advanced APM and MIPS policies; (2) to enhance 
clinician experience through flexible and transparent program design 
and interactions with easy-to-use program tools; (3) to increase the 
availability and adoption of Advanced APMs; (4) to promote program 
understanding and maximize participation through customized 
communication, education, outreach and support that meet the needs of 
the diversity of physician practices and patients, especially the 
unique needs of small practices; (5) to improve data and information 
sharing to provide accurate, timely, and actionable feedback to 
clinicians and other stakeholders; and (6) to promote IT systems 
capabilities that meet the needs of users and are seamless, efficient 
and valuable on the front and back-end. We also believe it is important 
to ensure the Quality Payment Program maintains operational excellence 
as the program develops. Therefore we are adding a seventh objective, 
specifically to ensure operational excellence in program implementation 
and ongoing development. More information on these objectives and the 
Quality Payment Program can be found at www.qpp.cms.gov.
    With these objectives, we recognize that the Quality Payment 
Program provides new opportunities to improve care delivery by 
supporting and rewarding clinicians as they find new ways to engage 
patients, families, and caregivers and to improve care coordination and 
population health management. In addition, we recognize that by 
developing a program that is flexible instead of one-size-fits-all, 
clinicians will be able to choose to participate in a way that is best 
for them, their practice, and their patients. For eligible clinicians 
interested in APMs, we believe that by setting ambitious yet achievable 
goals, eligible clinicians will move with greater certainty toward 
these new approaches of delivering care. APMs are a vital part of 
bending the Medicare cost curve by encouraging the delivery of high-
quality, low-cost care. To these ends, and to allow this program to 
work for all stakeholders, we further recognize that we must provide 
ongoing education, support, and technical assistance so that clinicians 
can understand program requirements, use available tools to enhance 
their practices, and improve quality and progress toward participation 
in APMs if that is the best choice for their practice. Finally, we 
understand that we must achieve excellence in program management, 
focusing on customer needs, promoting problem-solving, teamwork, and 
leadership to provide continuous improvements in the Quality Payment 
Program.

C. One Quality Payment Program

    Clinicians have told us that they do not separate their patient 
care into domains, and that the Quality Payment Program needs to 
reflect typical clinical workflows in order to achieve its goal of 
better patient care. Advanced APMs, the focus of one pathway of the 
Quality Payment Program, contribute to better care and smarter spending 
by allowing physicians and other clinicians to deliver coordinated, 
customized, high-value care to their patients in a streamlined and 
cost-effective manner. Within MIPS, the second pathway of the Quality 
Payment Program, we believe that integration into typical clinical 
workflows can best be accomplished by making connections across the 
four statutory pillars of the MIPS incentive structure--quality, 
clinical practice improvement activities (referred to as ``improvement 
activities''), meaningful use of CEHRT (referred to as ``advancing care 
information''), and resource use (referred to as ``cost'')--and by 
emphasizing that the Quality Payment Program is at its core about 
improving the quality of patient care.
    Although there are two separate pathways within the Quality Payment 
Program, the Advanced APM and MIPS tracks both contribute toward the 
goal of seamless integration of the Quality Payment Program into 
clinical practice workflows. Advanced APMs promote this seamless 
integration by way of payment methodology and design that incentivize 
care coordination, and the MIPS builds the capacity of eligible 
clinicians across the four pillars of MIPS to prepare them for 
participation in MIPS APMs and Advanced APMs in later years of the 
Quality Payment Program. Indeed, the bedrock of the Quality Payment 
Program is high-value, patient-centered care, informed by useful 
feedback, in a continuous cycle of improvement. The principal way that 
MIPS measures quality of care is through a set of clinical quality 
measures (CQMs) from which MIPS eligible clinicians can select. The 
CQMs are evidence-based, and the vast majority are created or supported 
by clinicians. Over time, the portfolio of quality measures will grow 
and develop, driving towards outcomes that are of the greatest 
importance to patients and clinicians and away from process, or ``check 
the box'' type measures.
    Through MIPS, we have the opportunity to measure quality, not only 
through evidence-based quality measures, but also by accounting for 
activities that clinicians themselves identify: namely, practice-driven 
quality improvement. MIPS also requires us to assess whether CEHRT is 
used meaningfully. Based on significant feedback, this area was 
simplified to support the exchange of patient information, engagement 
of patients in their own care through technology, and the way 
technology specifically supports the quality goals selected by the 
practice. The cost performance category was simplified and weighted at 
zero percent of the final score for the transition year of CY 2017 to 
allow clinicians an opportunity to ease into the Quality Payment 
Program. We further note the cost performance category requires no 
separate submissions for participation which minimizes burden on 
clinicians. The assessment of cost is a vital part of ensuring that 
clinicians are providing Medicare beneficiaries with high-value care. 
Given the primary focus on value, we indicated in the CY 2017 Quality

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Payment Program final rule our intention to align cost measures with 
quality measures over time in the scoring system (81 FR 77010). That 
is, we established special policies for the first year of the Quality 
Payment Program, which enabled a ramp-up and gradual transition with 
less financial risk for clinicians in the transition year. We called 
this approach ``pick your pace'' and allowed clinicians and groups to 
participate in MIPS through flexible means while avoiding a negative 
payment adjustment. In this proposed rule, we continue the slow ramp-up 
of the Quality Payment Program by establishing special policies for 
Program Year 2 aimed at encouraging successful participation in the 
program while reducing burden, reducing the number of clinicians 
required to participate, and preparing clinicians for the CY 2019 
performance period (CY 2021 payment year).

D. Summary of the Major Provisions

1. Quality Payment Program Year 2
    We believe the second year of the Quality Payment Program should 
build upon the foundation that has been established which provides a 
trajectory for clinicians to value-based care. This trajectory provides 
to clinicians the ability to participate in the program through two 
pathways: MIPS and Advanced APMs. As we indicated in the CY 2017 
Quality Payment Program final rule (81 FR 77011), we believed that a 
second transition period would be necessary to build upon the iterative 
learning and development period as we build towards a steady state. We 
continue to believe this to be true and have therefore crafted our 
policies to extend flexibilities into Quality Payment Program Year 2.
2. Small Practices
    The support of small, independent practices remains an important 
thematic objective for the implementation of the Quality Payment 
Program and is expected to be carried throughout future rulemaking. For 
MIPS performance periods occurring in 2017, many small practices are 
excluded from new requirements due to the low-volume threshold, which 
was set at less than or equal to $30,000 in Medicare Part B allowed 
charges or less than or equal to 100 Medicare Part B patients. We have 
heard feedback, however, from many small practices that challenges 
still exist in their ability to participate in the program. We are 
proposing additional flexibilities including: Implementing the virtual 
groups provisions; increasing the low-volume threshold to less than or 
equal to $90,000 in Medicare Part B allowed charges or less than or 
equal to 200 Medicare Part B patients; adding a significant hardship 
exception from the advancing care information performance category for 
MIPS eligible clinicians in small practices; and providing bonus points 
that are added to the final scores of MIPS eligible clinicians who are 
in small practices. We believe that these additional flexibilities and 
reduction in barriers will further enhance the ability of small 
practices to participate successfully in the Quality Payment Program.
    In keeping with the objectives to provide education about the 
Quality Payment Program and maximize participation, and as mandated by 
the statute, during a period of 5 years, $100 million in funding was 
provided for technical assistance to be available to provide guidance 
and assistance to MIPS eligible clinicians in small practices through 
contracts with regional health collaboratives, and others. Guidance and 
assistance on the MIPS performance categories or the transition to APM 
participation will be available to MIPS eligible clinicians in 
practices of 15 or fewer clinicians with priority given to practices 
located in rural areas or medically underserved areas (MUAs), and 
practices with low MIPS final scores. More information on the technical 
assistance support available to small practices can be found at https://qpp.cms.gov/docs/QPP_Support_for_Small_Practices.pdf.
    As discussed in section V.C. of this proposed rule, we have also 
performed an updated regulatory impact analysis, accounting for 
flexibilities, many of which are continuing into the Quality Payment 
Program Year 2, that have been created to ease the burden for small and 
solo practices. We estimate that at least 80 percent of clinicians in 
small practices with 1-15 clinicians will receive a positive or neutral 
MIPS payment adjustment. We refer readers to section V.C. of this 
proposed rule for details on how this estimate was developed.
3. Summary of Major Provisions for Advanced Alternative Payment Models 
(Advanced APMs)
a. Overview
    APMs represent an important step forward in our efforts to move our 
healthcare system from volume-based to value-based care. APMs that meet 
the criteria to be Advanced APMs provide the pathway through which 
eligible clinicians, who would otherwise fall under the MIPS, can 
become Qualifying APM Participants (QPs), thereby earning incentive 
payments for their Advanced APM participation. In the CY 2017 Quality 
Payment Program final rule (81 FR 77516), we estimated that 70,000 to 
120,000 eligible clinicians would be QPs for payment year 2019 based on 
Advanced APM participation in performance year 2017. With new Advanced 
APMs expected to be available for participation in 2018, including the 
Medicare ACO Track 1 Plus (1+) Model, and the reopening of the 
application process to new participants for some current Advanced APMs, 
such as the Next Generation ACO Model and Comprehensive Primary Care 
Plus Model, we anticipate higher numbers of QPs in subsequent years of 
the program. We currently estimate that approximately 180,000 to 
245,000 eligible clinicians may become QPs for payment year 2020 based 
on Advanced APM participation in performance year 2018.
b. Advanced APMs
    In the CY 2017 Quality Payment Program final rule (81 FR 77408), to 
be considered an Advanced APM, we finalized that an APM must meet all 
three of the following criteria, as required under section 
1833(z)(3)(D) of the Act: (1) The APM must require participants to use 
CEHRT; (2) The APM must provide for payment for covered professional 
services based on quality measures comparable to those in the quality 
performance category under MIPS and; (3) The APM must either require 
that participating APM Entities bear risk for monetary losses of a more 
than nominal amount under the APM, or be a Medical Home Model expanded 
under section 1115A(c) of the Act.
    We are proposing to maintain the generally applicable revenue-based 
nominal amount standard at 8 percent of the estimated average total 
Parts A and B revenue of eligible clinicians in participating APM 
Entities for QP Performance Periods 2019 and 2020.
c. Qualifying APM Participant (QP) and Partial QP Determination
    QPs are eligible clinicians in an Advanced APM who have met a 
threshold for a certain percentage of their patients or payments 
through an Advanced APM. QPs are excluded from MIPS for the year, and 
receive a 5 percent APM Incentive Payment for each year they are QPs 
beginning in 2019 through 2024. The statute sets thresholds for the 
level of participation in Advanced APMs required for an eligible 
clinician to become a QP for a year. For Advanced APMs that start or 
end during the Medicare QP Performance Period and operate

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continuously for a minimum of 60 days during the Medicare QP 
Performance Period for the year, we are proposing to make QP 
determinations using payment or patient data only for the dates that 
APM Entities were able to participate in the Advanced APM per the terms 
of the Advanced APM, not for the full Medicare QP Performance Period. 
Eligible clinicians who participate in Advanced APMs but do not meet 
the QP or Partial QP thresholds are subject to MIPS reporting 
requirements and payment adjustments.
d. All-Payer Combination Option
    The All-Payer Combination Option, which uses a calculation based on 
both the Medicare Option and the eligible clinician's participation in 
Other Payer Advanced APMs to conduct QP determinations, is applicable 
beginning in performance year 2019. To become a QP through the All-
Payer Combination Option, an eligible clinician must participate in an 
Advanced APM with CMS, as well as an Other Payer Advanced APM. We 
identify Other Payer Advanced APMs based on information submitted to us 
by eligible clinicians, APM Entities, and in some cases by payers, 
including states and Medicare Advantage Organizations. In addition, the 
eligible clinician or the APM Entity must submit information to CMS so 
that we can determine whether other payer arrangements are Other Payer 
Advanced APMs and whether the eligible clinician meets the requisite QP 
threshold of participation. To be an Other Payer Advanced APM, as set 
forth in section 1833(z)(2)(B)(ii) and (C)(ii) of the Act and 
implemented in the CY 2017 Quality Payment Program final rule, a 
payment arrangement with a payer (for example, payment arrangements 
authorized under Title XIX, Medicare Health Plan payment arrangements, 
and payment arrangements in CMS Multi-Payer Models) must meet all three 
of the following criteria: (1) CEHRT is used; (2) the payment 
arrangement must require the use of quality measures comparable to 
those in the quality performance category under MIPS and; (3) the 
payment arrangement must either require the APM Entities to bear more 
than nominal financial risk if actual aggregate expenditures exceed 
expected aggregate expenditures, or be a Medicaid Medical Home Model 
that meets criteria comparable to Medical Home Models expanded under 
section 1115A(c) of the Act.
    We are proposing modifications pertaining to the third criterion 
that the payment arrangement must either require the APM Entities to 
bear more than nominal financial risk if actual aggregate expenditures 
exceed expected aggregate expenditures; or be a Medicaid Medical Home 
Model that meets criteria comparable to Medical Home Models expanded 
under section 1115A(c) of the Act. Specifically, we are proposing to 
add a revenue-based nominal amount standard in addition to the 
benchmark-based nominal amount standard that would be applicable only 
to payment arrangements in which risk is expressly defined in terms of 
revenue.
    We are proposing modifications to our methodologies to determine 
whether eligible clinicians will meet the QP thresholds using the All-
Payer Combination Option. Specifically, we are proposing to conduct all 
QP determinations under the All-Payer Combination Option at the 
individual eligible clinician level and are seeking comment on any 
possible exceptions to this proposed policy that would be warranted, 
such as a determination based on APM Entity group performance under the 
All-Payer Combination Option for eligible clinicians participating in 
CMS Multi-Payer Models. We are also proposing to establish an All-Payer 
QP Performance Period to assess participation in Other Payer Advanced 
APMs under the All-Payer Combination Option, and to rename the QP 
Performance Period we established in rulemaking last year as the 
Medicare QP Performance Period.
    We are proposing to modify the information submission requirements 
for the All-Payer Combination Option. Specifically, we are proposing 
modifications to the information we require to make APM Entity or 
eligible clinician initiated determinations of Other Payer Advanced 
APMs after the All-Payer QP Performance Period, as well as the 
information we require to perform QP determinations under the All-Payer 
Combination Option. We are also proposing policies on the handling of 
information submitted for purposes of assessment under the All-Payer 
Combination Option.
    We are proposing a Payer Initiated Other Payer Advanced APM 
Determination Process, which would allow certain other payers, 
including payment arrangements authorized under Title XIX, Medicare 
Health Plans, and payers with payment arrangements in CMS Multi-Payer 
Models, to request that we determine whether their other payer 
arrangements are Other Payer Advanced APMs starting prior to the 2019 
All-Payer QP Performance Period and each year thereafter.
e. Physician-Focused Payment Models (PFPMs)
    The PTAC is an 11-member federal advisory committee that is an 
important avenue for the creation of innovative payment models. The 
PTAC is charged with reviewing stakeholders' proposed PFPMs, and making 
comments and recommendations to the Secretary regarding whether they 
meet the PFPM criteria established by the Secretary through rulemaking 
in the CY 2017 Quality Payment Program final rule. PTAC comments and 
recommendations will be reviewed by the CMS Innovation Center and the 
Secretary, and we will post a detailed response to them on the CMS Web 
site. We are seeking comments on broadening the definition of PFPM to 
include payment arrangements that involve Medicaid or the Children's 
Health Insurance Program (CHIP) as a payer even if Medicare is not 
included as a payer. This broadened definition might be more inclusive 
of potential PFPMs that could focus on areas not generally applicable 
to the Medicare population, and could engage more stakeholders in 
designing PFPMs. In addition, as we gain experience with public 
submission of PFPM proposals to the PTAC, we are seeking comments on 
the Secretary's criteria and stakeholders' needs in developing PFPM 
proposals aimed at meeting the criteria.
4. Summary of Major Provisions for the Merit-Based Incentive Payment 
System (MIPS)
    For Quality Payment Program Year 2 which is the second year of the 
MIPS and includes the performance periods in 2018 and the 2020 MIPS 
payment year, we are proposing the following policies:
a. Quality
    We previously finalized that the quality performance category would 
comprise 60 percent of the final score for the transition year and 50 
percent of the final score for the 2020 MIPS payment year (81 FR 
77100). For the 2020 MIPS payment year, now we are proposing to 
maintain a 60 percent weight for the quality performance category 
contingent upon our proposal to reweight the cost performance category 
to zero for the 2020 MIPS payment year as discussed in section 
II.C.6.b.(2) in this proposed rule. Quality measures are selected 
annually through a call for quality measures, and a final list of 
quality measures will be published in the Federal Register by November 
1 of each year. Except as discussed in section II.C.6.b.(3)(a)(iii) of 
this proposed rule with regard to the

[[Page 30015]]

CAHPS for MIPS survey, we are not proposing any changes to the 
submission criteria for quality measures in this proposed rule. We are 
proposing for the CAHPS for MIPS survey for the Quality Payment Program 
Year 2 and future years that the survey administration period would, at 
a minimum, span over 8 weeks and would end no later than February 28th 
following the applicable performance period. In addition, we are 
proposing for the Quality Payment Program Year 2 and future years to 
remove two Summary Survey Modules (SSM), specifically, ``Helping You to 
Take Medication as Directed'' and ``Between Visit Communication'' from 
the CAHPS for MIPS survey.
    For the 2018 MIPS performance period, we previously finalized that 
the data completeness threshold would increase to 60 percent for data 
submitted on quality measures using QCDRs, qualified registries, via 
EHR, or Medicare Part B claims. We noted that these thresholds for data 
submitted on quality measures using QCDRs, qualified registries, via 
EHR, or Medicare Part B claims would increase for performance periods 
occurring in 2019 and future years. However, as discussed in section 
II.C.6.b. of this proposed rule, we are proposing for the 2018 MIPS 
performance period to maintain the transition year data completeness 
threshold of 50 percent for data submitted on quality measures using 
QCDRs, qualified registries, EHR, or Medicare Part B claims to provide 
an additional year for individual MIPS eligible clinicians and groups 
to gain experience with the MIPS before increasing the data 
completeness threshold. However, we are proposing to increase the data 
completeness threshold for the 2021 MIPS payment year to 60 percent for 
data submitted on quality measures using QCDRs, qualified registries, 
EHR, or Medicare Part B claims. We anticipate that for performance 
periods going forward, as MIPS eligible clinicians gain experience with 
the MIPS, we would further increase these thresholds over time.
b. Improvement Activities
    Improvement activities are those that support broad aims within 
healthcare delivery, including care coordination, beneficiary 
engagement, population management, and health equity. In response to 
comments from experts and stakeholders across the healthcare system, 
improvement activities were given relative weights of high and medium. 
For the 2020 MIPS payment year, we previously finalized that the 
improvement activities performance category would comprise 15 percent 
of the final score (81 FR 77179). For performance periods occurring in 
2018, we are not proposing any changes in improvement activities 
scoring as discussed in the CY 2017 Quality Payment Program final rule 
(81 FR 77312).
    As discussed in the appendices of this proposed rule, we are 
proposing new improvement activities (Table F) and improvement 
activities with changes (Table G) for the 2018 MIPS performance period 
and future years for inclusion in the Improvement Activities Inventory. 
Activities proposed in this section would apply for the 2018 MIPS 
performance period and future performance periods unless further 
modified via notice and comment rulemaking. We refer readers to Table H 
of the CY 2017 Quality Payment Program final rule for a list of all the 
previously finalized improvement activities (81 FR 77817 through 
77831).
    As discussed in section II.C.6.e.3.(c) of this proposed rule, we 
are proposing to expand our definition of how we will recognize an 
individual MIPS eligible clinician or group as being a certified 
patient-centered medical home or comparable specialty practice. We 
finalized at Sec.  414.1380(b)(3)(iv) in the CY 2017 Quality Payment 
Program final rule that a certified patient-centered medical home 
includes practice sites with current certification from a national 
program, regional or state program, private payer or other body that 
administers patient-centered medical home accreditation. We are 
proposing in section II.C.6.e.(3)(b) of this proposed rule that 
eligible clinicians in practices that have been randomized to the 
control group in the CPC+ model would also receive full credit as a 
Medical Home Model. In addition, for group reporters, for the 2018 MIPS 
performance period and future performance periods, we are proposing to 
require that at least 50 percent of the practice sites within a TIN 
must be recognized as a certified or recognized patient-centered 
medical home or comparable specialty practice to receive full credit in 
the improvement activities performance category.
    As discussed in section II.C.6.f.(2)(d) of this proposed rule, in 
recognition of improvement activities as supporting the central mission 
of a unified Quality Payment Program, we propose to continue to 
designate activities in the Improvement Activities Inventory that will 
also qualify for the advancing care information bonus score. This is 
consistent with our desire to recognize that CEHRT is often deployed to 
improve care in ways that our programs should recognize.
c. Advancing Care Information
    For the Quality Payment Program Year 2, the advancing care 
information performance category comprises 25 percent of the final 
score. However, if a MIPS eligible clinician is participating in a MIPS 
APM the advancing care information performance category may comprise 30 
percent or 75 percent of the final score depending on the availability 
of APM quality data for reporting. Objectives and measures in the 
advancing care information performance category focus on the secure 
exchange of health information and the use CEHRT to support patient 
engagement and improved healthcare quality. While we continue to 
recommend that physicians and clinicians migrate to the implementation 
and use of EHR technology certified to the 2015 Edition so they may 
take advantage of improved functionalities, including care coordination 
and technical advancements such as application programming interfaces, 
or APIs, we recognize that some practices may have challenges in 
adopting new certified health IT. Therefore we are proposing that MIPS 
eligible clinicians may continue to use EHR technology certified to the 
2014 Edition for the performance period in CY 2018. We are proposing 
minor modifications to the advancing care information objectives and 
measures and the 2017 advancing care information transition objectives 
and measures. We are also proposing to add an exclusion for the e-
Prescribing and Health Information Exchange Objectives. We are 
proposing to modify our scoring policy for the Public Health and 
Clinical Data Registry Reporting Objectives and Measures for the 
performance score and the bonus score.
    We are also proposing to implement several provisions of the 21st 
Century Cures Act (Pub. L. 114-255, enacted on December 13, 2016) 
pertaining to hospital-based MIPS eligible clinicians, ambulatory 
surgical center-based MIPS eligible clinicians, MIPS eligible 
clinicians using decertified EHR technology, and significant hardship 
exceptions under the MIPS. We are also proposing to add a significant 
hardship exception for MIPS eligible clinicians in small practices.
d. Cost
    In this proposed rule, we are proposing to weight the cost 
performance category at zero percent of the final score for the 2020 
MIPS payment year in order to improve clinician understanding of the 
measures

[[Page 30016]]

and continue development of episode-based measures that will be used in 
this performance category.
    For the 2018 MIPS performance period, we are proposing to adopt for 
the cost performance category the total per capita costs for all 
attributed beneficiaries measure and the Medicare Spending per 
Beneficiary (MSPB) measure that were adopted for the 2017 MIPS 
performance period. For the 2018 MIPS performance period, we are not 
proposing to use the 10 episode-based measures that were adopted for 
the 2017 MIPS performance period. Although data on the episode-based 
measures has been made available to clinicians in the past, we are in 
the process of developing new episode-based measures with significant 
clinician input and believe it would be more prudent to introduce these 
new measures over time. We will continue to offer performance feedback 
on episode-based measures prior to potential inclusion of these 
measures in MIPS to increase clinician familiarity with the concept as 
well as specific episode-based measures.
    Specifically, we intend to provide feedback on these new episode-
based cost measures in the fall of this year for informational purposes 
only. We intend to provide performance feedback on the MSPB and total 
per capita cost measures by July 1, 2018, consistent with section 
1848(q)(12) of the Act. In addition, we intend to offer feedback on 
another set of newly developed episode-based cost measures in 2018 as 
well. Therefore, clinicians would have received feedback on cost 
measures at several points prior to the cost performance category 
counting as part of the final score.
e. Submission Mechanisms
    As discussed in section II.6.a. of this proposed rule, we are 
proposing additional flexibility for submitting data. Individual MIPS 
eligible clinicians or groups would be able to submit measures and 
activities, as available and applicable, via as many mechanisms as 
necessary to meet the requirements of the quality, improvement 
activities, or advancing care information performance categories. We 
expect that this option will provide clinicians the ability to select 
the measures most meaningful to them, regardless of the submission 
mechanism.
f. Virtual Groups
    There are generally three ways to participate in MIPS: (1) As an 
individual; (2) as a group; and (3) as a virtual group. In this 
proposed rule, we are proposing to establish requirements for MIPS 
participation at the virtual group level. We propose to define a 
virtual group as a combination of two or more TINs composed of a solo 
practitioner (a MIPS eligible clinician (as defined at Sec.  414.1305) 
who bills under a TIN with no other NPIs billing under such TIN) or a 
group (as defined at Sec.  414.1305) with 10 or fewer eligible 
clinicians under the TIN that elects to form a virtual group with at 
least one other such solo practitioner or group for a performance 
period for a year.
    To provide support and reduce burden, we intend to make technical 
assistance (TA) available, to the extent feasible and appropriate, to 
support clinicians who choose to come together as a virtual group for 
the first 2 years of virtual group implementation applicable to the 
2018 and 2019 performance years. Clinicians can access the TA 
infrastructure that they may be already utilizing. For Quality Payment 
Program Year 3, we intend to provide an electronic election process if 
technically feasible. Clinicians who do not elect to contact their 
designated TA representative would still have the option of contacting 
the Quality Payment Program Service Center. We believe that our 
proposal will create an election process that is simple and 
straightforward.
g. MIPS APMs
    In the CY 2017 Quality Payment Program final rule (81 FR 77246), we 
finalized that MIPS eligible clinicians who participate in MIPS APMs 
will be scored using the APM scoring standard instead of the generally 
applicable MIPS scoring standard. For the 2018 performance period, we 
are proposing modifications to the quality performance category 
reporting requirements and scoring for MIPS eligible clinicians in most 
MIPS APMs, and other modifications to the APM scoring standard. For 
purposes of the APM scoring standard, we are proposing to add a fourth 
snapshot date that would be used only to identify APM Entity groups 
participating in those MIPS APMs that require full TIN participation. 
Along with the other APM Entity groups, these APM Entity groups would 
be used for the purposes of reporting and scoring under the APM scoring 
standard described the CY 2017 Quality Payment Program final rule (81 
FR 77246).
h. Facility-Based Measurement
    For the transition year of MIPS, we considered an option for 
facility-based MIPS eligible clinicians to elect to use their 
institution's performance rates as a proxy for the MIPS eligible 
clinician's performance in the quality and cost performance categories. 
However, we did not propose an option for the transition year of MIPS 
because there were several operational considerations that needed to be 
addressed before this option could be implemented. After consideration 
of comments received on the CY 2017 Quality Payment Program proposed 
rule (81 FR 28192) and other comments received, we have decided to 
implement facility-based measures for the 2018 MIPS performance period 
and future performance periods to add more flexibility for clinicians 
to be assessed in the context of the facilities at which they work. As 
discussed in section II.C.7.b. of this proposed rule, we are proposing 
facility-based measures policies related to applicable measures, 
applicability to facility-based measurement, group participation, and 
facility attribution.
    For clinicians whose primary professional responsibilities are in a 
healthcare facility we present a method to assess performance in the 
quality and cost performance categories of MIPS based on the 
performance of that facility in another value-based purchasing program. 
While we propose to limit that opportunity to clinicians who practice 
primarily in the hospital, we seek to expand the program to other 
value-based payment programs as appropriate in the future. We discuss 
that new method of scoring in section II.C.7.b.(4) of this proposed 
rule.
i. Scoring
    In the CY 2017 Quality Payment Program final rule, we finalized a 
unified scoring system to determine a final score across the 4 
performance categories (81 FR 77273 through 77276). For the 2018 MIPS 
performance period, we propose to build on the scoring methodology we 
finalized for the transition year, focusing on encouraging MIPS 
eligible clinicians to meet data completeness requirements.
    For quality performance category scoring, we are proposing to 
extend some of the transition year policies to the 2018 MIPS 
performance period and are also proposing several modifications to 
existing policy. For the 2018 MIPS performance period, we are proposing 
to maintain the 3 point floor for measures that can be reliably scored 
against a benchmark. We are also proposing, to maintain the policy to 
assign 3 points to measures that are submitted but do not have a 
benchmark or do not meet the case minimum, which does not apply to the 
CMS Web Interface measures and administrative claims based measures. 
For the 2018 MIPS performance period, we are also proposing to lower 
the number of points available for measures that do not meet the data 
completeness

[[Page 30017]]

criteria, except for a measure submitted by a small practice, which we 
propose to continue to assign 3 points if the measure does not meet 
data completeness. This does not apply to CMS Web Interface measures or 
administrative claims based measures.
    Beginning with the 2018 MIPS performance period, we are proposing 
to add performance standards for scoring improvement for the quality 
and cost performance categories. We are also proposing a systematic 
approach to address topped out quality measures.
    For the 2018 MIPS performance period, we are proposing that 3 
performance category scores (quality, improvement activities, and 
advancing care information) would be given weight in the final score, 
or be reweighted if a performance category score is not available. We 
are also proposing to add final score bonuses for small practices and 
for MIPS eligible clinicians that care for complex patients.
    We are also proposing that the final score will be compared against 
a MIPS performance threshold of 15 points, which can be achieved via 
multiple pathways and continues the gradual transition into MIPS.
j. Performance Feedback
    We are proposing to provide Quality Payment Program performance 
feedback to eligible clinicians and groups. Initially, we would provide 
performance feedback on an annual basis. In future years, we aim to 
provide performance feedback on a more frequent basis, which is in line 
with clinician requests for timely, actionable feedback that they can 
use to improve care.
k. Targeted Review Process
    In the CY 2017 Quality Payment Program final rule (81 FR 77353), we 
finalized a targeted review process under MIPS wherein a MIPS eligible 
clinician or group may request that we review the calculation of the 
MIPS payment adjustment factor and, as applicable, the calculation of 
the additional MIPS payment adjustment factor applicable to such MIPS 
eligible clinician or group for a year. We are not proposing any 
changes to this process for the second year of the MIPS.
l. Third Party Intermediaries
    We believe that third party intermediaries that collect or submit 
data on behalf of individual eligible clinicians and groups 
participating in MIPS and allowing for flexible reporting options, will 
provide individual MIPS eligible clinicians and groups with options to 
accommodate different practices and make measurement meaningful. In the 
CY 2017 Quality Payment Program final rule (81 FR 77362), we finalized 
that qualified registries, QCDRs, health IT vendors, and CMS-approved 
survey vendors will have the ability to act as intermediaries on behalf 
of individual MIPS eligible clinicians and groups for submission of 
data to CMS across the quality, improvement activities, and advancing 
care information performance categories. As discussed in section 
II.C.10.a.(3) of this proposed rule, we propose to eliminate the self-
nomination submission method of email and require that QCDRs and 
qualified registries submit their self-nomination applications via a 
web-based tool for future program years beginning with performance 
periods occurring in 2018. We are proposing, beginning with the 2019 
performance period, a simplified process in which existing QCDRs or 
qualified registries in good standing may continue their participation 
in MIPS by attesting that their approved data validation plan, cost, 
approved QCDR measures (applicable to QCDRs only), MIPS quality 
measures, activities, services, and performance categories offered in 
the previous year's performance period of MIPS have no changes. QCDRs 
and qualified registries in good standing, may also make substantive or 
minimal changes to their approved self-nomination application from the 
previous year of MIPS that would be submitted during the self-
nomination period for CMS review and approval. By attesting that 
certain aspects of their application will remain the same, as approved 
from the previous year, existing QCDRs in good standing and qualified 
registries will be spending less time completing the self-nomination 
application, as was previously required. This process will be conducted 
on an annual basis.
    In addition, we are proposing that the term ``QCDR measures'' 
replace the term ``non-MIPS measures,'' without proposing any changes 
to the definition, criteria, or requirements that were finalized in the 
CY 2017 Quality Payment Program final rule (81 FR 77375). We are not 
proposing any changes to the health IT vendors that obtain data from 
CEHRT requirements.
    Lastly, we are proposing for future program years, beginning with 
performance periods occurring in 2018 that we remove the April 30th 
survey vendor application deadline. We are proposing for the Quality 
Payment Program Year 2 and future years that the vendor application 
deadline be January 31st of the applicable performance year or a later 
date specified by CMS. We will notify vendors of the application 
deadline, to become a CMS-approved survey vendor through additional 
communications and postings.
m. Public Reporting
    As discussed in section II.C.11. of this proposed rule, we are 
proposing public reporting of certain eligible clinician and group 
Quality Payment Program information, including MIPS and APM data in an 
easily understandable format as required under the MACRA.
n. Eligibility and Exclusion Provisions of the MIPS Program
    In section II.C.1.f. of this proposed rule, we are proposing to 
modify the definition of a non-patient facing MIPS eligible clinician 
to apply to virtual groups. We are also proposing to specify that 
groups considered to be non-patient facing (more than 75 percent of the 
NPIs billing under the group's TIN meet the definition of a non-patient 
facing individual MIPS eligible clinician) during the non-patient 
facing determination period would automatically have their advancing 
care information performance category reweighted to zero. Additionally, 
in section II.C.3.c. of this proposed rule, we are proposing to modify 
the low-volume threshold policy established in the CY 2017 Quality 
Payment Program final rule. As discussed in section II.C.3.c of this 
proposed rule, we believe that increasing the low-volume threshold to 
less than or equal to $90,000 in Medicare Part B charges or 200 or 
fewer Part-B enrolled Medicare beneficiaries would further decrease 
burden on MIPS eligible clinicians that practice in rural areas or are 
part of a small practice or are solo practitioners.

E. Payment Adjustments

    As discussed in section V.C. of this proposed rule, for the 2020 
payment year based on Advanced APM participation in 2018 performance 
period, we estimate that approximately 180,000 to 245,000 clinicians 
will become QPs, and therefore be exempt from MIPS and qualify for lump 
sum incentive payments based on 5 percent of their Part B allowable 
charges for covered professional services. We estimate that the total 
lump sum incentive payments will be between approximately $590 and $800 
million for the 2020 Quality Payment Program payment year. This 
expected growth in QPs between the first and second year of the program 
is due in part to reopening of CPC+ and Next Generation ACO for 2018, 
and the ACO Track 1+ which is projected to have a large number of 
participants, with a large majority reaching QP status.

[[Page 30018]]

    Under the policies in this proposed rule, we estimate that 
approximately 572,000 eligible clinicians would be required to 
participate in MIPS in the 2018 MIPS performance period, although this 
number may vary depending on the number of eligible clinicians excluded 
from MIPS based on their status as QPs or Partial QPs. After 
restricting the population to eligible clinician types who are not 
newly enrolled, the proposed increase in the low-volume threshold is 
expected to exclude 585,560 clinicians who do not exceed the low-volume 
threshold. In the 2020 MIPS payment year, MIPS payment adjustments will 
be applied based on MIPS eligible clinicians' performance on specified 
measures and activities within three integrated performance categories; 
the fourth category of cost, as previously outlined, would be weighted 
to zero in the 2020 MIPS payment year. Assuming that 90 percent of 
eligible clinicians of all practice sizes participate in MIPS, we 
estimate that MIPS payment adjustments will be approximately equally 
distributed between negative MIPS payment adjustments ($173 million) 
and positive MIPS payment adjustments ($173 million) to MIPS eligible 
clinicians, as required by the statute to ensure budget neutrality. 
Positive MIPS payment adjustments will also include up to an additional 
$500 million for exceptional performance to MIPS eligible clinicians 
whose final score meets or exceeds the additional performance threshold 
of 70 points. These MIPS payment adjustments are expected to drive 
quality improvement in the provision of MIPS eligible clinicians' care 
to Medicare beneficiaries and to all patients in the health care 
system. However, the distribution will change based on the final 
population of MIPS eligible clinicians for CY 2020 and the distribution 
of scores under the program. We believe that starting with these modest 
initial MIPS payment adjustments is in the long-term best interest of 
maximizing participation and starting the Quality Payment Program off 
on the right foot, even if it limits the magnitude of MIPS positive 
adjustments during the 2018 MIPS performance period. The increased 
availability of Advanced APM opportunities, including through Medical 
Home models, also provides earlier avenues to earn APM incentive 
payments for those eligible clinicians who choose to participate.

F. Benefits and Costs of Proposed Rule

    The Quality Payment Program may result in quality improvements and 
improvements to the patients' experience of care as MIPS eligible 
clinicians respond to the incentives for high-quality care provided by 
MIPS and implement care quality improvements in their clinical 
practices.
    We also quantify several costs associated with this rule. We 
estimate that this proposed rule will result in approximately $857 
million in collection of information-related burden. We estimate that 
the incremental collection of information-related burden associated 
with this proposed rule is approximately $12.4 million relative to the 
estimated burden of continuing the policies the CY 2017 Quality Payment 
Program final rule, which is $869 million. We also estimate regulatory 
review costs of $4.8 million for this proposed rule, comparable to the 
regulatory review costs of the CY 2017 Quality Payment Program proposed 
rule. We estimate that federal expenditures will include $173 million 
in revenue neutral payment adjustments and $500 million for exceptional 
performance payments. Additional federal expenditures include 
approximately $590-$800 million in APM incentive payments to QPs.

G. Stakeholder Input

    In developing this proposed rule, we sought feedback from 
stakeholders and the public throughout the process, including in the CY 
2017 Quality Payment Program final rule with comment period, listening 
sessions, webinars, and other listening venues. We received a high 
degree of interest from a broad spectrum of stakeholders. We thank our 
many commenters and acknowledge their valued input throughout the 
rulemaking process. We discuss the substance of relevant comments in 
the appropriate sections of this proposed rule, though we were not able 
to address all comments or all issues that all commenters brought forth 
due to the volume of comments and feedback. In general, commenters 
continue to support establishment of the Quality Payment Program and 
maintain optimism as we move from pure FFS Medicare payment towards an 
enhanced focus on the quality and value of care. Public support for our 
proposed approach and policies in the proposed rule focused on the 
potential for improving the quality of care delivered to beneficiaries 
and increasing value to the public--while rewarding eligible clinicians 
for their efforts.
    We thank stakeholders again for their considered responses 
throughout our process, in various venues, including comments on the 
Request for Information Regarding Implementation of the Merit-based 
Incentive Payment System, Promotion of Alternative Payment Models, and 
Incentive Payments for Participation in Eligible Alternative Payment 
Models (herein referred to as the MIPS and APMs RFI) (80 FR 59102 
through 59113) and the CY 2017 Quality Payment Program final rule (81 
FR 77008 through 77831). We intend to continue open communication with 
stakeholders, including consultation with tribes and tribal officials, 
on an ongoing basis as we develop the Quality Payment Program in future 
years.

II. Provisions of the Proposed Regulations and Analysis of and 
Responses to Comments

A. Introduction

    The Quality Payment Program, authorized by the Medicare Access and 
CHIP Reauthorization Act of 2015 (MACRA) is a new approach for 
reforming care across the health care delivery system for eligible 
clinicians. Under the Quality Payment Program, eligible clinicians can 
participate via one of two pathways: Advanced Alternative Payment 
Models (APMs); or the Merit-based Incentive Payment System (MIPS). We 
began implementing the Quality Payment Program through rulemaking for 
calendar year (CY) 2017. This rule provides proposed updates for the 
second and future years of the Quality Payment Program.

B. Definitions

    At Sec.  414.1305, subpart O, we propose to define the following 
terms:

 All-Payer QP Performance Period.
 Ambulatory Surgical Center (ASC)-based MIPS eligible 
clinician.
 CMS Multi-Payer Model.
 Full TIN APM.
 Improvement Scoring.
 Medicare QP Performance Period.
 Other MIPS APM.
 Virtual group.

    We propose to revise the definitions of the following terms:

 Affiliated practitioner.
 APM Entity.
 Attributed beneficiary.
 Certified Electronic Health Record Technology (CEHRT).
 Final Score.
 Hospital-based MIPS eligible clinician.
 Low-volume threshold.
 Medicaid APM.
 Non-patient facing MIPS eligible clinician.
 Other Payer Advanced APM.
 Rural areas.

    We propose to remove the following terms:


[[Page 30019]]


 Advanced APM Entity.
 QP Performance Period.

    These terms and definitions are discussed in detail in relevant 
sections of this proposed rule.

C. MIPS Program Details

1. MIPS Eligible Clinicians
a. Definition of a MIPS Eligible Clinician
    In the CY 2017 Quality Payment Program final rule (81 FR77040 
through 77041), we defined at Sec.  414.1305 a MIPS eligible clinician, 
as identified by a unique billing TIN and NPI combination used to 
assess performance, as any of the following (excluding those identified 
at Sec.  414.1310(b)): A physician (as defined in section 1861(r) of 
the Act), a physician assistant, nurse practitioner, and clinical nurse 
specialist (as such terms are defined in section 1861(aa)(5) of the 
Act), a certified registered nurse anesthetist (as defined in section 
1861(bb)(2) of the Act), and a group that includes such clinicians. We 
established at Sec.  414.1310(b) and (c) that the following are 
excluded from this definition per the statutory exclusions defined in 
section 1848(q)(1)(C)(ii) and (v) of the Act: (1) QPs; (2) Partial QPs 
who choose not to report on applicable measures and activities that are 
required to be reported under MIPS for any given performance period in 
a year; (3) low-volume threshold eligible clinicians; and (4) new 
Medicare-enrolled eligible clinicians. In accordance with sections 
1848(q)(1)(A) and (q)(1)(C)(vi) of the Act, we established at Sec.  
414.1310(b)(2) that eligible clinicians (as defined at Sec.  414.1305) 
who are not MIPS eligible clinicians have the option to voluntarily 
report measures and activities for MIPS. Additionally, we established 
at Sec.  414.1310(d) that in no case will a MIPS payment adjustment 
apply to the items and services furnished during a year by eligible 
clinicians who are not MIPS eligible clinicians, as described in Sec.  
414.1310(b) and (c), including those who voluntarily report on 
applicable measures and activities specified under MIPS.
    In the CY 2017 Quality Payment Program final rule (81 FR 77340), we 
noted that the MIPS payment adjustment applies only to the amount 
otherwise paid under Part B with respect to items and services 
furnished by a MIPS eligible clinician during a year, in which we will 
apply the MIPS payment adjustment at the TIN/NPI level. We have 
received requests for additional clarifications on which specific Part 
B services are subject to the MIPS payment adjustment, as well as which 
Part B services are included for eligibility determinations. We note 
that when Part B items or services are rendered by suppliers that are 
also MIPS eligible clinicians, there may be circumstances in which it 
is not operationally feasible for us to attribute those items or 
services to a MIPS eligible clinician at an NPI level in order to 
include them for purposes of applying the MIPS payment adjustment or 
making eligibility determinations.
    To further clarify, there are circumstances that involve Part B 
prescription drugs and durable medical equipment where the supplier may 
also be a MIPS eligible clinician. In circumstances in which a MIPS 
eligible clinician furnishes a Part B covered item or service such as 
prescribing Part B drugs that are dispensed, administered, and billed 
by a supplier that is a MIPS eligible clinician, or ordering durable 
medical equipment that is administered and billed by a supplier that is 
a MIPS eligible clinician, it is not operationally feasible for us at 
this time to associate those billed allowable charges with a MIPS 
eligible clinician at an NPI level in order to include them for 
purposes of applying the MIPS payment adjustment or making eligibility 
determinations. For Part B items and services furnished by a MIPS 
eligible clinician such as purchasing and administering Part B drugs 
that are billed by the MIPS eligible clinician, such items and services 
may be subject to MIPS adjustment based on the MIPS eligible 
clinician's performance during the applicable performance period or 
included for eligibility determinations. For those billed Medicare Part 
B allowable charges relating to the purchasing and administration of 
Part B drugs that we are able to associate with a MIPS eligible 
clinician at an NPI level, such items and services furnished by the 
MIPS eligible clinician would be included for purposes of applying the 
MIPS payment adjustment or making eligibility determinations.
b. Group Practice (Group)
    As discussed in the CY 2017 Quality Payment Program final rule (81 
FR 77088 through 77831), we indicated that we will assess performance 
either for individual MIPS eligible clinicians or for groups. We 
defined a group at Sec.  414.1305 as a single Taxpayer Identification 
Number (TIN) with two or more eligible clinicians (including at least 
one MIPS eligible clinician), as identified by their individual NPI, 
who have reassigned their Medicare billing rights to the TIN. We 
recognize that MIPS eligible clinicians participating in MIPS may be 
part of a TIN that has one portion of its NPIs participating in MIPS 
according to the generally applicable scoring criteria while the 
remaining portion of its NPIs is participating in a MIPS APM or an 
Advanced APM according to the MIPS APM scoring standard. In the CY 2017 
Quality Payment Program final rule (81 FR 77058), we noted that except 
for groups containing APM participants, we are not permitting groups to 
``split'' TINs if they choose to participate in MIPS as a group. Thus, 
we would like to clarify that we consider a group to be either an 
entire single TIN or portion of a TIN that: (1) Is participating in 
MIPS according to the generally applicable scoring criteria while the 
remaining portion of the TIN is participating in a MIPS APM or an 
Advanced APM according to the MIPS APM scoring standard; and (2) 
chooses to participate in MIPS at the group level. Also, we defined an 
APM Entity group at Sec.  414.1305 as a group of eligible clinicians 
participating in an APM Entity, as identified by a combination of the 
APM identifier, APM Entity identifier, TIN, and NPI for each 
participating eligible clinician.
c. Small Practices
    In the CY 2017 Quality Payment Program final rule (81 FR 77188), we 
defined the term small practices at Sec.  414.1305 as practices 
consisting of 15 or fewer clinicians and solo practitioners. In section 
II.C.4.d. of this proposed rule, we discuss how small practice status 
would apply to virtual groups. Also, in the final rule, we noted that 
we would not make an eligibility determination regarding the size of 
small practices, but indicated that small practices would attest to the 
size of their group practice (81 FR 77057). However, we have since 
realized that our system needs to account for small practice size in 
advance of a performance period for operational purposes relating to 
assessing and scoring the improvement activities performance category, 
determining hardship exceptions for small practices as proposed in this 
proposed rule, calculating the small practice bonus for the final score 
as proposed in this proposed rule, and identifying small practices 
eligible for technical assistance. As a result, we believe it is 
critical to modify the way in which small practice size would be 
determined. To make eligibility determinations regarding the size of 
small practices for performance periods occurring in 2018 and future 
years, we propose that CMS would determine the size of small practices 
as described in this section of the proposed rule. As noted in the CY 
2017 Quality Payment

[[Page 30020]]

Program final rule, the size of a group (including a small practice) 
would be determined before exclusions are applied (81 FR 77057). We 
note that group size determinations are based on the number of NPIs 
associated with a TIN, which would include clinicians (NPIs) who may be 
excluded from MIPS participation and do not meet the definition of a 
MIPS eligible clinician.
    To make eligibility determinations regarding the size of small 
practices for performance periods occurring in 2018 and future years, 
we propose that CMS would determine the size of small practices by 
utilizing claims data. For purposes of this section, we are coining the 
term ``small practice size determination period'' to mean a 12-month 
assessment period, which consists of an analysis of claims data that 
spans from the last 4 months of a calendar year 2 years prior to the 
performance period followed by the first 8 months of the next calendar 
year and includes a 30-day claims run out. This would allow us to 
inform small practices of their status near the beginning of the 
performance period as it pertains to eligibility relating to technical 
assistance, applicable improvement activities criteria, the proposed 
hardship exception for small practices under the advancing care 
information performance category, and the proposed small practice bonus 
for the final score.
    Thus, for purposes of performance periods occurring in 2018 and the 
2020 MIPS payment year, we would identify small practices based on 12 
months of data starting from September 1, 2016 to August 31, 2017. We 
would not change an eligibility determination regarding the size of a 
small practice once the determination is made for a given performance 
period and MIPS payment year. We recognize that there may be 
circumstances in which the small practice size determinations made by 
CMS do not reflect the real-time size of such practices. We considered 
two options that could address such potential discrepancies. One option 
would include an expansion of the proposed small practice size 
determination period to 24 months with two 12-month segments of data 
analysis (before and during the performance period), in which CMS would 
conduct a second analysis of claims data during the performance period. 
Such an expanded determination period may better capture the real-time 
size of small practices, but determinations made during the performance 
period prevent our system from being able to account for the assessment 
and scoring of the improvement activities performance category and 
identification of small practices eligible for technical assistance 
prior to the performance period. Specifically, our system needs to 
capture small practice determinations in advance of the performance 
period in order for the system to reflect the applicable requirements 
for the improvement activities performance category and when a small 
practice bonus would be applied. A second option would include an 
attestation component, in which a small practice that was not 
identified as a small practice during the proposed small practice size 
determination period would be able to attest to the size of their group 
practice prior to the performance period. However, this second option 
would require us to develop several operational improvements, such as a 
manual process or system that would provide an attestation mechanism 
for small practices, and a verification process to ensure that only 
small practices are identified as eligible for technical assistance. 
Since individual MIPS eligible clinicians and groups are not required 
to register to participate in MIPS (except for groups utilizing the CMS 
Web Interface for the Quality Payment Program or administering the 
CAHPS for MIPS survey), requiring small practices to attest to the size 
of their group practice prior to the performance period could increase 
burden on individual MIPS eligible clinicians and groups that are not 
already utilizing the CMS Web Interface for the Quality Payment Program 
or administering the CAHPS for MIPS survey. We solicit public comment 
on the proposal regarding how CMS would determine small practice size.
d. Rural Area and Health Professional Shortage Area Practices
    In the CY 2017 Quality Payment Program final rule (81 FR 77188), we 
finalized at Sec.  414.1380 that for individual MIPS eligible 
clinicians and groups that are located in rural areas or geographic 
HPSAs, to achieve full credit under the improvement activities 
performance category, one high-weighted or two medium-weighted 
improvement activities are required. In addition, we defined rural 
areas at Sec.  414.1305 as clinicians in ZIP codes designated as rural, 
using the most recent Health Resources and Services Administration 
(HRSA) Area Health Resource File data set available; and Health 
Professional Shortage Areas (HPSAs) at Sec.  414.1305 as areas 
designated under section 332(a)(1)(A) of the Public Health Service Act. 
For technical accuracy purposes, we are proposing to modify the 
definition of a rural areas at Sec.  414.1305 as ZIP codes designated 
as rural, using the most recent Health Resources and Services 
Administration (HRSA) Area Health Resource File data set available. We 
recognize that there are cases in which an individual MIPS eligible 
clinician (including a solo practitioner) or a group may have multiple 
practice sites associated with its TIN and as a result, it is critical 
for us to outline the application of rural area and HPSA practice 
designations to such practices. For performance periods occurring in 
2017, we consider an individual MIPS eligible clinician or a group with 
at least one practice site under its TIN in a ZIP code designated as a 
rural area or HPSA to be a rural area or HPSA practice. For performance 
periods occurring in 2018 and future years, we believe that a higher 
threshold than one practice within a TIN is necessary to designate an 
individual MIPS eligible clinician, a group, or a virtual group as a 
rural or HPSA practice. We recognize that the establishment of a higher 
threshold starting in 2018 would more appropriately identify groups and 
virtual groups with multiple practices under a group's TIN or TINs that 
are part of a virtual group as rural or HPSA practices and ensure that 
groups and virtual groups are assessed and scored according to 
requirements that are applicable and appropriate. We note that in the 
CY 2017 Quality Payment Program final rule (81 FR 77048 through 77049), 
we defined a non-patient facing MIPS eligible clinician at Sec.  
414.1305 as including a group provided that more than 75 percent of the 
NPIs billing under the group's TIN meet the definition of a non-patient 
facing individual MIPS eligible clinician during the non-patient facing 
determination period. We refer readers to section II.C.1.e. of this 
proposed rule for our proposal to modify the definition of a non-
patient facing MIPS eligible clinician. We believe that using a similar 
threshold for applying the rural and HPSA designation to an individual 
MIPS eligible clinician, a group, or virtual group with multiple 
practices under its TIN or TINs within a virtual group will add 
consistency for such practices across the MIPS as it pertains to groups 
and virtual groups obtaining such statuses. Also, we believe that 
establishing a 75 percent threshold renders an adequate representation 
of a group or virtual group where a significant portion of a group or a 
virtual group is identified as having such status. Therefore, for 
performance periods occurring in 2018 and future

[[Page 30021]]

years, we propose that an individual MIPS eligible clinician, a group, 
or a virtual with multiple practices under its TIN or TINs within a 
virtual group would be designated as a rural or HPSA practice if more 
than 75 percent of NPIs billing under the individual MIPS eligible 
clinician or group's TIN or within a virtual group, as applicable, are 
designated in a ZIP code as a rural area or HPSA. We solicit public 
comment on these proposals.
e. Non-Patient Facing MIPS Eligible Clinicians
    Section 1848(q)(2)(C)(iv) of the Act requires the Secretary, in 
specifying measures and activities for a performance category, to give 
consideration to the circumstances of professional types (or 
subcategories of those types determined by practice characteristics) 
who typically furnish services that do not involve face-to-face 
interaction with a patient. To the extent feasible and appropriate, the 
Secretary may take those circumstances into account and apply 
alternative measures or activities that fulfill the goals of the 
applicable performance category to such non-patient facing MIPS 
eligible clinicians. In carrying out these provisions, we are required 
to consult with non-patient facing MIPS eligible clinicians.
    In addition, section 1848(q)(5)(F) of the Act allows the Secretary 
to re-weight MIPS performance categories if there are not sufficient 
measures and activities applicable and available to each type of MIPS 
eligible clinician. We assume many non-patient facing MIPS eligible 
clinicians will not have sufficient measures and activities applicable 
and available to report under the performance categories under MIPS. We 
refer readers to section II.C.6.f.(7) of this proposed rule for the 
discussion regarding how we address performance category weighting for 
MIPS eligible clinicians for whom no measures or activities are 
applicable and available in a given category.
    In the CY 2017 Quality Payment Program final rule (81 FR 77048 
through 77049), we defined a non-patient facing MIPS eligible clinician 
for MIPS at Sec.  414.1305 as an individual MIPS eligible clinician 
that bills 100 or fewer patient-facing encounters (including Medicare 
telehealth services defined in section 1834(m) of the Act) during the 
non-patient facing determination period, and a group provided that more 
than 75 percent of the NPIs billing under the group's TIN meet the 
definition of a non-patient facing individual MIPS eligible clinician 
during the non-patient facing determination period. In order to account 
for the formation of virtual groups starting in the 2018 performance 
year and how non-patient facing determinations would apply to virtual 
groups, we need to modify the definition of a non-patient facing MIPS 
eligible clinician. Therefore, for performance periods occurring in 
2018 and future years, we propose to modify the definition of a non-
patient facing MIPS eligible clinician at Sec.  414.1305 to mean an 
individual MIPS eligible clinician that bills 100 or fewer patient-
facing encounters (including Medicare telehealth services defined in 
section 1834(m) of the Act) during the non-patient facing determination 
period, and a group or virtual group provided that more than 75 percent 
of the NPIs billing under the group's TIN or within a virtual group, as 
applicable, meet the definition of a non-patient facing individual MIPS 
eligible clinician during the non-patient facing determination period.
    We considered a patient-facing encounter to be an instance in which 
the individual MIPS eligible clinician or group billed for items and 
services furnished such as general office visits, outpatient visits, 
and procedure codes under the PFS. We published the list of patient-
facing encounter codes for performance periods occurring in 2017 at 
qpp.cms.gov/resources/education. We intend to publish the list of 
patient-facing encounter codes for performance periods occurring in 
2018 at qpp.cms.gov by the end of 2017. The list of patient-facing 
encounter codes is used to determine the non-patient facing status of 
MIPS eligible clinicians.
    The list of patient-facing encounter codes include two general 
categories of codes: Evaluation and Management (E&M) codes; and 
Surgical and Procedural codes. E&M codes capture clinician-patient 
encounters that occur in a variety of care settings, including office 
or other outpatient settings, hospital inpatient settings, emergency 
departments, and nursing facilities, in which clinicians utilize 
information provided by patients regarding history, present illness, 
and symptoms to determine the type of assessments to conduct. 
Assessments are conducted on the affected body area(s) or organ 
system(s) for clinicians to make medical decisions that establish a 
diagnosis or select a management option(s).
    Surgical and Procedural codes capture clinician-patient encounters 
that involve procedures, surgeries, and other medical services 
conducted by clinicians to treat medical conditions. In the case of 
many of these services, evaluation and management work is included in 
the payment for the single code instead of separately reported. 
Patient-facing encounter codes from both of these categories describe 
direct services furnished by eligible clinicians with impact on patient 
safety, quality of care, and health outcomes.
    For purposes of the non-patient facing policies under MIPS, the 
utilization of E&M codes and Surgical and Procedural codes allows for 
accurate identification of patient-facing encounters, and thus accurate 
eligibility determinations regarding non-patient facing status. As a 
result, MIPS eligible clinicians considered non-patient facing are able 
to prepare to meet requirements applicable to non-patient facing MIPS 
eligible clinicians. We propose to continue applying these policies for 
purposes of the 2020 MIPS payment year and future years.
    As described in the CY 2017 Quality Payment Program final rule, we 
established the non-patient facing determination period for purposes of 
identifying non-patient facing MIPS eligible clinicians in advance of 
the performance period and during the performance period using 
historical and performance period claims data. This eligibility 
determination process allows us to begin identifying non-patient facing 
MIPS eligible clinicians prior to or shortly after the start of the 
performance period. The non-patient facing determination period is a 
24-month assessment period, which includes a two-segment analysis of 
claims data regarding patient-facing encounters during an initial 12-
month period prior to the performance period followed by another 12-
month period during the performance period. The initial 12-month 
segment of the non-patient facing determination period spans from the 
last 4 months of a calendar year 2 years prior to the performance 
period followed by the first 8 months of the next calendar year and 
includes a 60-day claims run out, which allows us to inform individual 
MIPS eligible clinicians and groups of their non-patient facing status 
during the month (December) prior to the start of the performance 
period. The second 12-month segment of the non-patient facing 
determination period spans from the last 4 months of a calendar year 1 
year prior to the performance period followed by the first 8 months of 
the performance period in the next calendar year and includes a 60-day 
claims run out, which will allow us to inform additional individual 
MIPS eligible clinicians and groups of their non-patient status during 
the performance period.

[[Page 30022]]

    However, based on our analysis of data from the initial segment of 
the non-patient facing determination period for performance periods 
occurring in 2017 (that is, data spanning from September 1, 2015 to 
August 31, 2016), we found that it may not be necessary to include a 
60-day claims run out since we could achieve a similar outcome for such 
eligibility determinations by utilizing a 30-day claims run out. In our 
comparison of data analysis results utilizing a 60-day claims run out 
versus a 30-day claims run out, there was a 1 percent decrease in data 
completeness (see Table 1 for data completeness regarding comparative 
analysis of a 60-day and 30-day claims run out). The small decrease in 
data completeness would not negatively impact individual MIPS eligible 
clinicians or groups regarding non-patient facing determinations. We 
believe that a 30-day claims run out would allow us to complete the 
analysis and provide such determinations in a more timely manner.

 Table 1--Percentages of Data Completeness for 60-Day and 30-Day Claims
                                 Run Out
------------------------------------------------------------------------
                                         30-day  claims   60-day  claims
             Incurred year                 run out *        run out *
------------------------------------------------------------------------
2015..................................           97.1%            98.4%
------------------------------------------------------------------------
* Note: Completion rates are estimated and averaged at aggregated
  service categories and may not be applicable to subsets of these
  totals. For example, completion rates can vary by provider due to
  claim processing practices, service mix, and post payment review
  activity. Completion rates vary from subsections of a calendar year;
  later portions of a given calendar year will be less complete than
  earlier ones. Completion rates vary due to variance in loading
  patterns due to technical, seasonal, policy, and legislative factors.
  Completion rates are a function of the incurred date used to process
  claims, and these factors will need to be updated if claims are
  processed on a claim from date or other methodology.

    For performance periods occurring in 2018 and future years, we 
propose a modification to the non-patient facing determination period, 
in which the initial 12-month segment of the non-patient facing 
determination period would span from the last 4 months of a calendar 
year 2 years prior to the performance period followed by the first 8 
months of the next calendar year and include a 30-day claims run out; 
and the second 12-month segment of the non-patient facing determination 
period would span from the last 4 months of a calendar year 1 year 
prior to the performance period followed by the first 8 months of the 
performance period in the next calendar year and include a 30-day 
claims run out. This proposal would only change the duration of the 
claims run out, not the 12-month timeframes used for the first and 
second segments of data analysis.
    For purposes of the 2020 MIPS payment year, we would initially 
identify individual MIPS eligible clinicians and groups who are 
considered non-patient facing MIPS eligible clinicians based on 12 
months of data starting from September 1, 2016, to August 31, 2017. To 
account for the identification of additional individual MIPS eligible 
clinicians and groups that may qualify as non-patient facing during 
performance periods occurring in 2018, we would conduct another 
eligibility determination analysis based on 12 months of data starting 
from September 1, 2017, to August 31, 2018.
    Similarly, for future years, we would conduct an initial 
eligibility determination analysis based on 12 months of data 
(consisting of the last 4 months of the calendar year 2 years prior to 
the performance period and the first 8 months of the calendar year 
prior to the performance period) to determine the non-patient facing 
status of individual MIPS eligible clinicians and groups, and conduct 
another eligibility determination analysis based on 12 months of data 
(consisting of the last 4 months of the calendar year prior to the 
performance period and the first 8 months of the performance period) to 
determine the non-patient facing status of additional individual MIPS 
eligible clinicians and groups. We would not change the non-patient 
facing status of any individual MIPS eligible clinician or group 
identified as non-patient facing during the first eligibility 
determination analysis based on the second eligibility determination 
analysis. Thus, an individual MIPS eligible clinician or group that is 
identified as non-patient facing during the first eligibility 
determination analysis would continue to be considered non-patient 
facing for the duration of the performance period and MIPS payment year 
regardless of the results of the second eligibility determination 
analysis. We would conduct the second eligibility determination 
analysis to account for the identification of additional, previously 
unidentified individual MIPS eligible clinicians and groups that are 
considered non-patient facing.
    Additionally, in the CY 2017 Quality Payment Program final rule (81 
FR 77241), we established a policy regarding the re-weighting of the 
advancing care information performance category for non-patient facing 
MIPS eligible clinicians. Specifically, MIPS eligible clinicians who 
are considered to be non-patient facing will have their advancing care 
information performance category automatically reweighted to zero (81 
FR 77241). For groups that are considered to be non-patient facing 
(that is, more than 75 percent of the NPIs billing under the group's 
TIN meet the definition of a non-patient facing individual MIPS 
eligible clinician) during the non-patient facing determination period, 
we are proposing in section II.C.7.b.(3) of this proposed rule to 
automatically reweight their advancing care information performance 
category to zero.
    We propose to continue applying these policies for purposes of the 
2020 MIPS payment year and future years. We solicit public comment on 
these proposals.
f. MIPS Eligible Clinicians Who Practice in Critical Access Hospitals 
Billing Under Method II (Method II CAHs)
    In the CY 2017 Quality Payment Program final rule (81 FR 77049), we 
noted that MIPS eligible clinicians who practice in CAHs that bill 
under Method I (Method I CAHs), the MIPS payment adjustment would apply 
to payments made for items and services billed by MIPS eligible 
clinicians, but it would not apply to the facility payment to the CAH 
itself. For MIPS eligible clinicians who practice in Method II CAHs and 
have not assigned their billing rights to the CAH, the MIPS payment 
adjustment would apply in the same manner as for MIPS eligible 
clinicians who bill for items and services in Method I CAHs. As 
established in the CY 2017 Quality Payment Program final rule (81 FR 
77051), the MIPS payment adjustment will apply to Method II CAH 
payments under section 1834(g)(2)(B) of the Act when MIPS eligible 
clinicians who practice in Method II CAHs have assigned their billing 
rights to the CAH.
    We refer readers to the CY 2017 Quality Payment Program final rule 
(81 FR 77049 through 77051) for our discussion of MIPS eligible 
clinicians who practice in Method II CAHs.
g. MIPS Eligible Clinicians Who Practice in Rural Health Clinics (RHCs) 
or Federally Qualified Health Centers (FQHCs)
    As established in the CY 2017 Quality Payment Program final rule 
(81 FR 77051 through 77053), services rendered by an eligible clinician 
under the RHC or FQHC methodology, will not be subject to the MIPS 
payments adjustments. As noted, these eligible clinicians have the 
option to voluntarily report on applicable measures and activities for 
MIPS, in which the data received will not be used to assess their

[[Page 30023]]

performance for the purpose of the MIPS payment adjustment.
    We refer readers to the CY 2017 Quality Payment Program final rule 
(81 FR 77051 through 77053) for our discussion of MIPS eligible 
clinicians who practice in RHCs or FQHCs.
h. MIPS Eligible Clinicians Who Practice in Ambulatory Surgical Centers 
(ASCs), Home Health Agencies (HHAs), Hospice, and Hospital Outpatient 
Departments (HOPDs)
    Section 1848(q)(6)(E) of the Act provides that the MIPS payment 
adjustment is applied to the amount otherwise paid under Part B with 
respect to the items and services furnished by a MIPS eligible 
clinician during a year. Some eligible clinicians may not receive MIPS 
payment adjustments due to their billing methodologies. If a MIPS 
eligible clinician furnishes items and services in an ASC, HHA, 
Hospice, and/or HOPD and the facility bills for those items and 
services (including prescription drugs) under the facility's all-
inclusive payment methodology or prospective payment system 
methodology, the MIPS adjustment would not apply to the facility 
payment itself. However, if a MIPS eligible clinician furnishes other 
items and services in an ASC, HHA, Hospice, and/or HOPD and bills for 
those items and services separately, such as under the PFS, the MIPS 
adjustment would apply to payments made for such items and services. 
Such items and services would also be considered for purposes of 
applying the low-volume threshold. Therefore, we propose that services 
rendered by an eligible clinician that are payable under the ASC, HHA, 
Hospice, or HOPD methodology would not be subject to the MIPS payments 
adjustments. However, these eligible clinicians have the option to 
voluntarily report on applicable measures and activities for MIPS, in 
which the data received would not be used to assess their performance 
for the purpose of the MIPS payment adjustment. We note that eligible 
clinicians who bill under both the PFS and one of these other billing 
methodologies (ASC, HHA, Hospice, and/or HOPD) may be required to 
participate in MIPS if they exceed the low-volume threshold and are 
otherwise eligible clinicians; in such case, data reported would be 
used to determine their MIPS payment adjustment. We solicit public 
comments on this proposal.
i. MIPS Eligible Clinician Identifier
    As described in the CY 2017 Quality Payment Program final rule (81 
FR 77057), we established that the use of multiple identifiers that 
allow MIPS eligible clinicians to be measured as an individual or 
collectively through a group's performance and that the same identifier 
be used for all four performance categories. While we have multiple 
identifiers for participation and performance, we established the use 
of a single identifier, TIN/NPI, for applying the MIPS payment 
adjustment, regardless of how the MIPS eligible clinician is assessed.
(1) Individual Identifiers
    As established in the CY 2017 Quality Payment Program final rule 
(81 FR 77058), we define a MIPS eligible clinician at Sec.  414.1305 to 
mean the use of a combination of unique billing TIN and NPI combination 
as the identifier to assess performance of an individual MIPS eligible 
clinician. Each unique TIN/NPI combination is considered a different 
MIPS eligible clinician, and MIPS performance is assessed separately 
for each TIN under which an individual bills.
(2) Group Identifiers for Performance
    As established in the CY 2017 Quality Payment Program final rule 
(81 FR 77059), we codified the definition of a group at Sec.  414.1305 
to mean a group that consists of a single TIN with two or more eligible 
clinicians (including at least one MIPS eligible clinician), as 
identified by their individual NPI, who have reassigned their billing 
rights to the TIN.
(3) APM Entity Group Identifier for Performance
    As described in the CY 2017 Quality Payment Program final rule (81 
FR 77060), we established that each eligible clinician who is a 
participant of an APM Entity is identified by a unique APM participant 
identifier. The unique APM participant identifier is a combination of 
four identifiers: (1) APM Identifier (established by CMS; for example, 
XXXXXX); (2) APM Entity identifier (established under the APM by CMS; 
for example, AA00001111); (3) TIN(s) (9 numeric characters; for 
example, XXXXXXXXX); (4) EP NPI (10 numeric characters; for example, 
1111111111). We codified the definition of an APM Entity group at Sec.  
414.1305 to mean a group of eligible clinicians participating in an APM 
Entity, as identified by a combination of the APM identifier, APM 
Entity identifier, TIN, and NPI for each participating eligible 
clinician.
2. Exclusions
a. New Medicare-Enrolled Eligible Clinician
    As established in the CY 2017 Quality Payment Program final rule 
(81 FR 77061 through 77062), we defined a new Medicare-enrolled 
eligible clinician at Sec.  414.1305 as a professional who first 
becomes a Medicare-enrolled eligible clinician within the PECOS during 
the performance period for a year and had not previously submitted 
claims under Medicare such as an individual, an entity, or a part of a 
physician group or under a different billing number or tax identifier. 
Additionally, we established at Sec.  414.1310(c) that these eligible 
clinicians will not be treated as a MIPS eligible clinician until the 
subsequent year and the performance period for such subsequent year. We 
established at Sec.  414.1310(d) that in no case would a MIPS payment 
adjustment apply to the items and services furnished during a year by 
new Medicare-enrolled eligible clinicians for the applicable 
performance period.
    We used the term ``new Medicare-enrolled eligible clinician 
determination period'' to refer to the 12 months of a calendar year 
applicable to the performance period. During the new Medicare-enrolled 
eligible clinician determination period, we conduct eligibility 
determinations on a quarterly basis to the extent that is technically 
feasible to identify new Medicare-enrolled eligible clinicians that 
would be excluded from the requirement to participate in MIPS for the 
applicable performance period.
b. Qualifying APM Participant (QP) and Partial Qualifying APM 
Participant (Partial QP)
    In the CY 2017 Quality Payment Program final rule (81 FR 77062), we 
established at Sec.  414.1305 that a QP (as defined at Sec.  414.1305) 
is not a MIPS eligible clinician, and is therefore excluded from MIPS. 
Also, we established that a Partial QP (as defined, at Sec.  414.1305) 
who does not report on applicable measures and activities that are 
required to be reported under MIPS for any given performance period in 
a year is not a MIPS eligible clinician.
c. Low-Volume Threshold
    Section 1848(q)(1)(C)(ii)(III) of the Act provides that the 
definition of a MIPS eligible clinician does not include MIPS eligible 
clinicians who are below the low-volume threshold selected by the 
Secretary under section 1848(q)(1)(C)(iv) of the Act for a given year. 
Section 1848(q)(1)(C)(iv) of the Act requires the Secretary to select a 
low-volume

[[Page 30024]]

threshold to apply for the purposes of this exclusion which may include 
one or more of the following: (1) The minimum number, as determined by 
the Secretary, of Part B-enrolled individuals who are treated by the 
MIPS eligible clinician for a particular performance period; (2) the 
minimum number, as determined by the Secretary, of items and services 
furnished to Part B-enrolled individuals by the MIPS eligible clinician 
for a particular performance period; and (3) the minimum amount, as 
determined by the Secretary, of allowed charges billed by the MIPS 
eligible clinician for a particular performance period.
    In the CY 2017 Quality Payment Program final rule (81 FR 77069 
through 77070), we defined individual MIPS eligible clinicians or 
groups who do not exceed the low-volume threshold at Sec.  414.1305 as 
an individual MIPS eligible clinician or group who, during the low-
volume threshold determination period, has Medicare Part B allowed 
charges less than or equal to $30,000 or provides care for 100 or fewer 
Part B-enrolled Medicare beneficiaries. We established at Sec.  
414.1310(b) that for a year, MIPS eligible clinicians who do not exceed 
the low-volume threshold (as defined at Sec.  414.1305) are excluded 
from MIPS for the performance period for a given calendar year.
    In the CY 2017 Quality Payment Program final rule (81 FR 77069 
through 77070), we defined the low-volume threshold determination 
period to mean a 24-month assessment period, which includes a two-
segment analysis of claims data during an initial 12-month period prior 
to the performance period followed by another 12-month period during 
the performance period. The initial 12-month segment of the low-volume 
threshold determination period spans from the last 4 months of a 
calendar year 2 years prior to the performance period followed by the 
first 8 months of the next calendar year and includes a 60-day claims 
run out, which allows us to inform eligible clinicians and groups of 
their low-volume status during the month (December) prior to the start 
of the performance period. The second 12-month segment of the low-
volume threshold determination period spans from the last 4 months of a 
calendar year 1 year prior to the performance period followed by the 
first 8 months of the performance period in the next calendar year and 
includes a 60-day claims run out, which allows us to inform additional 
eligible clinicians and groups of their low-volume status during the 
performance period.
    We recognize that individual MIPS eligible clinicians and groups 
that are small practices or practicing in designated rural areas face 
unique dynamics and challenges such as fiscal limitations and workforce 
shortages, but serve as a critical access point for care and provide a 
safety net for vulnerable populations. Claims data shows that 
approximately 15 percent of individual MIPS eligible clinicians (TIN/
NPIs) are considered to be practicing in rural areas after applying all 
exclusions. Also, we have heard from stakeholders that MIPS eligible 
clinicians practicing in small practices and designated rural areas 
tend to have a patient population with a higher proportion of older 
adults, as well as higher rates of poor health outcomes, co-
morbidities, chronic conditions, and other social risk factors, which 
can result in the costs of providing care and services being 
significantly higher compared to non-rural areas. We also have heard 
from many solo practitioners and small practices who still face 
challenges and additional resource burden in participating in the MIPS.
    In the CY 2017 Quality Payment Program final rule, we did not 
establish an adjustment for social risk factors in assessing and 
scoring performance. In response to the CY 2017 Quality Payment Program 
final rule, we received public comments indicating that individual MIPS 
eligible clinicians and groups practicing in designated rural areas 
would be negatively impacted and at a disadvantage if assessment and 
scoring methodology did not adjust for social risk factors. 
Additionally, commenters expressed concern that such individual MIPS 
eligible clinicians and groups may be disproportionately more 
susceptible to lower performance scores across all performance 
categories and negative MIPS payments adjustments, and as a result, 
such outcomes may further strain already limited fiscal resources and 
workforce shortages, and negatively impact access to care (reduction 
and/or elimination of available services).
    After the consideration of stakeholder feedback provided during 
informal listening sessions since the publication of the CY 2017 
Quality Payment Program final rule, we are proposing to modify the low-
volume threshold policy established in the CY 2017 Quality Payment 
Program final rule. We believe that increasing the dollar amount and 
beneficiary count of the low-volume threshold would further reduce the 
number of eligible clinicians that are required to participate in the 
MIPS, which would reduce the burden on individual MIPS eligible 
clinicians and groups practicing in small practices and designated 
rural areas. Based on our analysis of claims data, we found that 
increasing the low-volume threshold to to exclude individual eligible 
clinicians or groups that have Medicare Part B allowed charges less 
than or equal to $90,000 or that provide care for 200 or fewer Part B-
enrolled Medicare beneficiaries will exclude approximately 134,000 
additional clinicians from MIPS from the approximately 700,000 
clinicians that would have been eligible based on the low-volume 
threshold that was finalized in the CY 2017 Quality Payment Program 
final rule. Almost half of the additionally excluded clinicians are in 
small practices and approximately 17 percent are clinicians from 
practices in designated rural areas. Applying this criterion decreases 
the percent of the MIPS eligible clinicians that come from small 
practices. For example, prior to any exclusions, clinicians in small 
practices represent 35 percent of all clinicians billing Part B 
services. After applying the eligibility criteria for the CY 2017 
Quality Payment Program final rule, MIPS eligible clinicians in small 
practices represent approximately 27 percent of the clinicians eligible 
for MIPS; however, with the increased low-volume threshold, 
approximately 22 percent of the clinicians eligible for MIPS are from 
small practices. In our analysis, the proposed changes to the low-
volume threshold showed little impact on MIPS eligible clinicians from 
practices in designated rural areas. MIPS eligible clinicians from 
practices in designated rural areas account for 15 to 16 percent of the 
total MIPS eligible population. We note that, due to data limitations, 
we assessed rural status based on the status of individual TIN/NPI and 
did not model any group definition for practices in designated rural 
areas.
    We believe that increasing the number of such individual eligible 
clinicians and groups excluded from MIPS participation would reduce 
burden and mitigate, to the extent feasible, the issue surrounding 
confounding variables impacting performance under the MIPS. Therefore, 
beginning with the 2018 MIPS performance period, we are proposing to 
increase the low-volume threshold. Specifically, at Sec.  414.1305, we 
are proposing to define an individual MIPS eligible clinician or group 
who does not exceed the low-volume threshold as an individual MIPS 
eligible clinician or group who, during the low-volume threshold 
determination period, has Medicare Part B allowed charges less than or 
equal to $90,000 or provides care for 200 or fewer Part B-enrolled 
Medicare beneficiaries. This

[[Page 30025]]

would mean that 37 percent of individual MIPS eligible clinicians and 
groups would be in MIPS based on the low-volume threshold exclusion 
(and the other exclusions). However, 65 percent of Medicare payments 
would still be captured under MIPS compared to 72.2 percent of Medicare 
payments under the CY 2017 Quality Payment Program final rule.
    We recognize that increasing the dollar amount and beneficiary 
count of the low-volume threshold would increase the number of 
individual MIPS eligible clinicians and groups excluded from MIPS. We 
assessed various levels of increases and found that $90,000 as the 
dollar amount and 200 as the beneficiary count balances the need to 
account for individual MIPS eligible clinicians and groups who face 
additional participation burden while not excluding a significant 
portion of the clinician population.
    MIPS eligible clinicians who do not exceed the low-volume threshold 
(as defined at Sec.  414.1305) are excluded from MIPS for the 
performance period with respect to a year. The low-volume threshold 
also applies to MIPS eligible clinicians who practice in APMs under the 
APM scoring standard at the APM Entity level, in which APM Entities do 
not exceed the low-volume threshold. In such cases, the MIPS eligible 
clinicians participating in the MIPS APM Entity would be excluded from 
the MIPS requirements for the applicable performance period and not 
subject to a MIPS payment adjustment for the applicable year. Such an 
exclusion would not affect an APM Entity's QP determination if the APM 
Entity is an Advanced APM.
    In the CY 2017 Quality Payment Program final rule, we established 
the low-volume threshold determination period to refer to the timeframe 
used to assess claims data for making eligibility determinations for 
the low-volume threshold exclusion (81 FR 77069 through 77070). We 
defined the low-volume threshold determination period to mean a 24-
month assessment period, which includes a two-segment analysis of 
claims data during an initial 12-month period prior to the performance 
period followed by another 12-month period during the performance 
period. Based on our analysis of data from the initial segment of the 
low-volume threshold determination period for performance periods 
occurring in 2017 (that is, data spanning from September 1, 2015 to 
August 31, 2016), we found that it may not be necessary to include a 
60-day claims run out since we could achieve a similar outcome for such 
eligibility determinations by utilizing a 30-day claims run out.
    In our comparison of data analysis results utilizing a 60-day 
claims run out versus a 30-day claims run out, there was a 1 percent 
decrease in data completeness. The small decrease in data completeness 
would not substantially impact individual MIPS eligible clinicians or 
groups regarding low-volume threshold determinations. We believe that a 
30-day claims run out would allow us to complete the analysis and 
provide such determinations in a more timely manner. For performance 
periods occurring in 2018 and future years, we propose a modification 
to the low-volume threshold determination period, in which the initial 
12-month segment of the low-volume threshold determination period would 
span from the last 4 months of a calendar year 2 years prior to the 
performance period followed by the first 8 months of the next calendar 
year and include a 30-day claims run out; and the second 12-month 
segment of the low-volume threshold determination period would span 
from the last 4 months of a calendar year 1 year prior to the 
performance period followed by the first 8 months of the performance 
period in the next calendar year and include a 30-day claims run out. 
This proposal would only change the duration of the claims run out, not 
the 12-month timeframes used for the first and second segments of data 
analysis.
    For purposes of the 2020 MIPS payment year, we would initially 
identify individual eligible clinicians and groups that do not exceed 
the low-volume threshold based on 12 months of data starting from 
September 1, 2016 to August 31, 2017. To account for the identification 
of additional individual eligible clinicians and groups that do not 
exceed the low-volume threshold during performance periods occurring in 
2018, we would conduct another eligibility determination analysis based 
on 12 months of data starting from September 1, 2017 to August 31, 
2018. We would not change the low-volume status of any individual 
eligible clinician or group identified as not exceeding the low-volume 
threshold during the first eligibility determination analysis based on 
the second eligibility determination analysis. Thus, an individual 
eligible clinician or group that is identified as not exceeding the 
low-volume threshold during the first eligibility determination 
analysis would continue to be excluded from MIPS for the duration of 
the performance period regardless of the results of the second 
eligibility determination analysis. We established our policy to 
include two eligibility determination analyses in order to prevent any 
potential confusion for an individual eligible clinician or group to 
know whether or not participate in MIPS; also, such policy makes it 
clear from the onset as to which individual eligible clinicians and 
groups would be required to participate in MIPS. We would conduct the 
second eligibility determination analysis to account for the 
identification of additional, previously unidentified individual 
eligible clinicians and groups who do not exceed the low-volume 
threshold. We note that low-volume threshold determinations are made at 
the individual and group level, and not at the virtual group level.
    We note that section 1848(q)(1)(C)(iv) of the Act requires the 
Secretary to select a low-volume threshold to apply for the purposes of 
this exclusion which may include one or more of the following: (1) The 
minimum number, as determined by the Secretary, of Part B-enrolled 
individuals who are treated by the MIPS eligible clinician for a 
particular performance period; (2) the minimum number, as determined by 
the Secretary, of items and services furnished to Part B-enrolled 
individuals by the MIPS eligible clinician for a particular performance 
period; and (3) the minimum amount, as determined by the Secretary, of 
allowed charges billed by the MIPS eligible clinician for a particular 
performance period. We have established a low-volume threshold that 
accounts for the minimum number of Part-B enrolled individuals who are 
treated by a MIPS eligible clinician and that accounts for the minimum 
amount of allowed charges billed by a MIPS eligible clinician. We have 
not made proposals specific to a minimum number of items and service 
furnished to Part-B enrolled individuals by a MIPS eligible clinician.
    In order to expand the ways in which claims data could be analyzed 
for purposes of determining a more comprehensive assessment of the low-
volume threshold, we have assessed the option of establishing a low-
volume threshold for items and services furnished to Part-B enrolled 
individuals by a MIPS eligible clinician. We have considered defining 
items and services by using the number of patient encounters or 
procedures associated with a clinician. Defining items and services by 
patient encounters would assess each patient per visit or encounter 
with the MIPS eligible clinician. We believe that defining items and 
services by using the number of patient encounters or procedures is a 
simple and straightforward approach for stakeholders to understand. 
However,

[[Page 30026]]

we are concerned that using this unit of analysis could incentivize 
clinicians to focus on volume of services rather than the value of 
services provided to patients. Defining items and services by procedure 
would tie a specific clinical procedure rendered to a patient to a 
clinician. We solicit public comment on the methods of defining items 
and services furnished by clinicians described above and alternate 
methods of defining items and services.
    For the individual MIPS eligible clinicians and groups that would 
be excluded from MIPS participation as a result of an increased low-
volume threshold, we believe that in future years it would be 
beneficial to provide, to the extent feasible, such individual MIPS 
eligible clinicians and groups with the option to opt-in to MIPS 
participation if they might otherwise be excluded under the low-volume 
threshold such as where they only meet one of the threshold 
determinations (including a third determination based on Part B items 
and services, if established). For example, if a clinician meets the 
low-volume threshold of $90,000 in allowed charges, but does not meet 
the threshold of 200 patients or, if established, the threshold 
pertaining to Part B items and services, we believe the clinician 
should, to the extent feasible, have the opportunity to choose whether 
or not to participate in the MIPS and be subject to MIPS payment 
adjustments. We recognize that this choice would present additional 
complexity to clinicians in understanding all of their available 
options and may impose additional burden on clinicians by requiring 
them to notify CMS of their decision. Because of these concerns and our 
desire to establish options in a way that is a low-burden and user-
focused experience for all MIPS eligible clinicians, we would not be 
able to offer this additional flexibility until performance periods 
occurring in 2019. Therefore, as a means of expanding options for 
clinicians and offering them the ability to participate in MIPS if they 
otherwise would not be included, for the purposes of the 2021 MIPS 
payment year, we propose to provide clinicians the ability to opt-in to 
the MIPS if they meet or exceed one, but not all, of the low-volume 
threshold determinations, including as defined by dollar amount, 
beneficiary count or, if established, items and services. We request 
public comment on this proposal.
    We note that there may be additional considerations we should 
address for scenarios in which an individual eligible clinician or a 
group does not exceed the low-volume threshold and opts-in to 
participate in MIPS. We therefore seek comment on any additional 
considerations we should address when establishing this opt-in policy. 
Such as, should we establish parameters for individual clinicians or 
groups who elect to opt-in to participate in MIPS such as required 
length of participation? Additionally, we note that there is the 
potential with this opt-in policy for there to be an impact on our 
ability to create quality benchmarks that meet our sample size 
requirements. For example, if particularly small practices or solo 
practitioners with low Part B beneficiary volumes opt-in, such 
clinician's may lack sufficient sample size to be scored on many 
quality measures, especially measures that do not apply to all of a 
MIPS eligible clinician's patients. We therefore seek comment on how to 
address any potential impact on our ability to create quality 
benchmarks that meet our sample size requirements.
    We solicit public comments on these proposals.
3. Group Reporting
a. Background
    As described in the CY 2017 Quality Payment Program final rule, we 
established the following requirements for groups (81 FR 77072):
     Individual eligible clinicians and individual MIPS 
eligible clinicians will have their performance assessed as a group as 
part of a single TIN associated with two or more eligible clinicians 
(including at least one MIPS eligible clinician), as identified by a 
NPI, who have reassigned their Medicare billing rights to the TIN (at 
Sec.  414.1310(e)(1)).
     A group must meet the definition of a group at all times 
during the performance period for the MIPS payment year in order to 
have its performance assessed as a group (at Sec.  414.1310(e)(2)).
     Individual eligible clinicians and individual MIPS 
eligible clinicians within a group must aggregate their performance 
data across the TIN to have their performance assessed as a group (at 
Sec.  414.1310(e)(3)).
     A group that elects to have its performance assessed as a 
group will be assessed as a group across all four MIPS performance 
categories (at Sec.  414.1310(e)(4)).
    As noted in the CY 2017 Quality Payment Program final rule, we 
would not make an eligibility determination regarding group size, but 
indicated that groups would attest to their group size for purpose of 
using the CMS Web Interface or a group identifying as a small practice 
(81 FR 77057). In section II.C.1.d. of this proposed rule, we are 
proposing to modify the way in which size would be determined for small 
practices by establishing a process under which CMS would utilize 
claims data to make small practice size determinations. Also, in 
section II.C.4.e. of this proposed rule, we are proposing to establish 
a policy under which CMS would utilize claims data to determine group 
size for groups of 10 or fewer eligible clinicians seeking to form or 
join a virtual group.
    As noted in the CY 2017 Quality Payment Program final rule, a group 
size would be determined before exclusions are applied (81 FR 77057). 
We note that group size determinations are based on the number of NPIs 
associated with a TIN, which would include clinicians (NPIs) who may be 
excluded from MIPS participation and do not meet the definition of a 
MIPS eligible clinician.
b. Registration
    As described in the CY 2017 Quality Payment Program final rule (81 
FR 77072 through 77073), we established, the following policies:
     A group must adhere to an election process established and 
required by CMS (Sec.  414.1310(e)(5)), which includes:
    ++ Groups will not be required to register to have their 
performance assessed as a group except for groups submitting data on 
performance measures via participation in the CMS Web Interface or 
groups electing to report the CAHPS for MIPS survey for the quality 
performance category. For all other data submission mechanisms, groups 
must work with appropriate third party intermediaries as necessary to 
ensure the data submitted clearly indicates that the data represent a 
group submission rather than an individual submission.
    ++ In order for groups to elect participation via the CMS Web 
Interface or administration of the CAHPS for MIPS survey, such groups 
must register by June 30 of the applicable performance period (that is, 
June 30, 2018, for performance periods occurring in 2018). We note that 
groups participating in APMs that require APM Entities to report using 
the CMS Web Interface are not required to register for the CMS Web 
Interface or administer the CAHPS for MIPS survey separate from the 
APM.
    When groups submit data utilizing third party intermediaries, such 
as a qualified registry, QCDR, or EHR, we are able to obtain group 
information from the third party intermediary and discern whether the 
data submitted represents group submission or individual submission 
once the data are submitted.

[[Page 30027]]

    In the CY 2017 Quality Payment Program final rule (81 FR 77072 
through 77073), we discussed the implementation of a voluntary 
registration process if technically feasible. Since the publication of 
the CY 2017 Quality Payment Program final rule, we have determined that 
it is not technically feasible to develop and build a voluntary 
registration process. Until further notice, we are not implementing a 
voluntary registration process.
    Also, in the CY 2017 Quality Payment Program final rule (81 FR 
77075), we expressed our commitment to pursue the active engagement of 
stakeholders throughout the process of establishing and implementing 
virtual groups. We received public comments in response to the CY 2017 
Quality Payment Program final rule and additional stakeholder feedback 
by hosting several virtual group listening sessions and convening user 
groups. Many stakeholders requested that CMS provide an option that 
would permit a portion of a group to participate in MIPS outside the 
group by reporting as a separate subgroup or forming a virtual group. 
Stakeholders indicated that the option would measure performance more 
effectively, enable groups to identify areas for improvement at a 
granular level that would further improve quality of care and health 
outcomes, and increase coordination of care.
    We recognize that groups, including multi-specialty groups, have 
requested over the years that we make an option available to them that 
would allow a portion of a group to report as a separate subgroup on 
measures and activities that are more applicable to the subgroup and be 
assessed and scored accordingly based on the performance of the 
subgroup. In future rulemaking, we intend to explore the feasibility of 
establishing group-related policies that would permit participation in 
MIPS at a subgroup level and create such functionality through a new 
identifier. We solicit public comment on the ways in which 
participation in MIPS at the subgroup level could be established.
4. Virtual Groups
a. Background
    There are generally three ways to participate in MIPS: (1) 
Individual-level reporting; (2) group-level reporting; and (3) virtual 
group-level reporting. We refer readers to sections II.C.1., II.C.3., 
and II.C.5. of this proposed rule for a discussion of the previously 
established requirements for individual- and group-level participation 
and our proposed policies for performance periods occurring in 2018 and 
future years. In this rule, we are proposing to establish requirements 
for MIPS participation at the virtual group level.
    Section 1848(q)(5)(I) of the Act provides for the use of voluntary 
virtual groups for certain assessment purposes, including the election 
of practices to be a virtual group and the requirements for the 
election process. Section 1848(q)(5)(I)(i) of the Act provides that 
MIPS eligible clinicians electing to be a virtual group must: (1) Have 
their performance assessed for the quality and cost performance 
categories in a manner that applies the combined performance of all the 
MIPS eligible clinicians in the virtual group to each MIPS eligible 
clinician in the virtual group for the applicable performance period; 
and (2) be scored for the quality and cost performance categories based 
on such assessment. Section 1848(q)(5)(I)(ii) of the Act requires, in 
accordance with section 1848(q)(5)(I)(iii) of the Act, the 
establishment and implementation of a process that allows an individual 
MIPS eligible clinician or a group consisting of not more than 10 MIPS 
eligible clinicians to elect, for a given performance period, to be a 
virtual group with at least one other such individual MIPS eligible 
clinician or group. The virtual group may be based on appropriate 
classifications of providers, such as by geographic areas or by 
provider specialties defined by nationally recognized specialty boards 
of certification or equivalent certification boards.
    Section 1848(q)(5)(I)(iii) of the Act provides that the virtual 
group election process must include the following requirements: (1) An 
individual MIPS eligible clinician or group electing to be in a virtual 
group must make their election prior to the start of the applicable 
performance period and cannot change their election during the 
performance period; (2) an individual MIPS eligible clinician or group 
may elect to be in no more than one virtual group for a performance 
period, and, in the case of a group, the election applies to all MIPS 
eligible clinicians in the group; (3) a virtual group is a combination 
of TINs; (4) the requirements must provide for formal written 
agreements among individual MIPS eligible clinicians and groups 
electing to be a virtual group; and (5) such other requirements as the 
Secretary determines appropriate.
b. Definition of a Virtual Group
    As noted above, section 1848(q)(5)(I)(ii) of the Act requires, in 
accordance with section 1848(q)(5)(I)(iii) of the Act, the 
establishment and implementation of a process that allows an individual 
MIPS eligible clinician or group consisting of not more than 10 MIPS 
eligible clinicians to elect, for a given performance period, to be a 
virtual group with at least one other such individual MIPS eligible 
clinician or group. Given that section 1848(q)(5)(I)(iii)(V) of the Act 
provides that a virtual group is a combination of TINs, we interpret 
the references to an ``individual'' MIPS eligible clinician in section 
1848(q)(5)(I)(ii) of the Act to mean a solo practitioner, which, for 
purposes of section 1848(q)(5)(I) of the Act, we propose to define as a 
MIPS eligible clinician (as defined at Sec.  414.1305) who bills under 
a TIN with no other NPIs billing under such TIN.
    Also, we recognize that a group (TIN) may include not only NPIs who 
meet the definition of a MIPS eligible clinician, but also NPIs who do 
not meet the definition of a MIPS eligible clinician at Sec.  414.1305 
and who are excluded from MIPS under Sec.  414.1310(b) or (c) based on 
one of four exclusions (new Medicare-enrolled eligible clinician; QP; 
Partial QP who chooses not to report on measures and activities under 
MIPS; and eligible clinicians that do not exceed the low-volume 
threshold). Thus, we interpret the references to a group ``consisting 
of not more than 10'' MIPS eligible clinicians in section 
1848(q)(5)(I)(ii) of the Act to mean that a group with 10 or fewer 
eligible clinicians (as defined at Sec.  414.1305) would be eligible to 
form or join a virtual group. For purposes of the MIPS payment 
adjustment, the adjustment would apply only to NPIs in the virtual 
group who meet the definition of a MIPS eligible clinician at Sec.  
414.1305 and who are not excluded from MIPS under Sec.  414.1310(b) or 
(c). We note that such groups, as defined at Sec.  414.1305, would need 
to include at least one MIPS eligible clinician in order to be eligible 
to join or form a virtual group. We refer readers to section II.C.4.g. 
of this proposed rule for discussion regarding the assessment and 
scoring of groups participating in MIPS as a virtual group.
    We propose to define a virtual group at Sec.  414.1305 as a 
combination of two or more TINs composed of a solo practitioner (a MIPS 
eligible clinician (as defined at Sec.  414.1305) who bills under a TIN 
with no other NPIs billing under such TIN), or a group (as defined at 
Sec.  414.1305) with 10 or fewer eligible clinicians under the TIN that 
elects to form a virtual group with at least one

[[Page 30028]]

other such solo practitioner or group for a performance period for a 
year.
    Lastly, we note that qualifications as a virtual group for purposes 
of MIPS do not change the application of the physician self-referral 
law to a financial relationship between a physician and an entity 
furnishing designated health services, nor does it change the need for 
such a financial relationship to comply with the physician self-
referral law.
    We note that while entire TINs participate in a virtual group, 
including each NPI under a TIN, and are assessed and scored 
collectively as a virtual group, only NPIs that meet the definition of 
a MIPS eligible clinician would be subject to a MIPS payment 
adjustment. However, we note that, as discussed in section II.C.4.h. of 
this proposed rule, any MIPS eligible clinician who is part of a TIN 
participating in a virtual group and participating in a MIPS APM or 
Advanced APM under the MIPS APM scoring standard would not receive a 
MIPS payment adjustment based on the virtual group's final score, but 
would receive a payment adjustment based on the MIPS APM scoring 
standard.
    Additionally, we recognize that there are circumstances in which a 
TIN may have one portion of its NPIs participating under the generally 
applicable MIPS scoring criteria while the remaining portion of NPIs 
under the TIN is participating in a MIPS APM or an Advanced APM under 
the MIPS APM scoring standard. In the CY 2017 Quality Payment Program 
final rule (81 FR 77058), we noted that except for groups containing 
APM participants, we are not permitting groups to ``split'' TINs if 
they choose to participate in MIPS as a group (81 FR 77058). Thus, we 
consider a group to mean an entire single TIN that elects to 
participate in MIPS at the group or virtual group level, including 
groups that have a portion of its NPIs participating in a MIPS APM or 
an Advanced APM. We note that such groups would participate in MIPS 
similar to other groups.
    To clarify, for all groups, including groups containing 
participants in a MIPS APM or an Advanced APM, the group's performance 
assessment consists of the entire TIN regardless of whether the group 
participates in MIPS as part of a virtual group. Generally, for groups 
other than groups containing participants in a MIPS APM or an Advanced 
APM, each MIPS eligible clinician under the TIN (TIN/NPI) receives a 
MIPS adjustment based on the entire group's performance assessment 
(entire TIN). For groups containing participants in a MIPS APM or an 
Advanced APM, only the portion of the TIN that is being scored for MIPS 
according to the generally applicable scoring criteria (TIN/NPI) 
receives a MIPS adjustment based on the entire group's performance 
assessment (entire TIN). The remaining portion of the TIN that is being 
scored according to the APM scoring standard (TIN/NPI) receives a MIPS 
adjustment based on that standard, or may be exempt from MIPS if they 
achieve QP or Partial QP status.
    We propose to apply a similar policy to groups, including groups 
containing participants in a MIPS APM or an Advanced APM, that are 
participating in MIPS as part of a virtual group. Specifically, for 
groups other than groups containing participants in a MIPS APM or an 
Advanced APM, each MIPS eligible clinician (TIN/NPI) would receive a 
MIPS adjustment based on the virtual group's combined performance 
assessment (combination of TINs). For groups containing participants in 
a MIPS APM or an Advanced APM, only the portion of the TIN that is 
being scored for MIPS according to the generally applicable scoring 
criteria (TIN/NPI) would receive a MIPS adjustment based on the virtual 
group's combined performance assessment (combination of TINs). As 
discussed in section II.C.4.h. of this proposed rule, we are proposing 
to use waiver authority to ensure that any participants in the group 
who are participating in a MIPS APM receive their payment adjustment 
based on their score under the APM scoring standard (TIN/NPI). Such 
participants may be exempt from MIPS if they achieve QP or Partial QP 
status.
    We refer readers to section II.C.4.e. of this proposed rule for a 
discussion of the proposed virtual group election process and section 
II.C.4.g. of this proposed rule for discussion of our proposals 
regarding the assessment and scoring of virtual groups.
    We recognize that virtual groups would each have unique 
characteristics and varying patient populations. As noted in section 
II.C.4.a. of this proposed rule, the statute provides the Secretary 
with discretion to establish appropriate classifications regarding the 
composition of virtual groups such as by geographic area or specialty. 
However, we believe it is important for virtual groups to have the 
flexibility to determine their own composition at this time, and, as a 
result, we are not proposing to establish any such classifications 
regarding virtual group composition. We further note that the statute 
does not limit the number of TINs that may form a virtual group, and we 
are not proposing to establish such a limit at this time. We did 
consider however proposing to establish such a limit, such as 50 or 100 
participants. In particular, we are concerned that virtual groups of 
too substantial a size (for example, 10 percent of all MIPS eligible 
clinicians in a given specialty or sub-specialty) may make it difficult 
to compare performance between and among clinicians. We believe that 
limiting the number of virtual group participants could eventually 
assist virtual groups as they aggregate their performance data across 
the virtual group. However, we believe that as we initially implement 
virtual groups, it is important for virtual groups to have the 
flexibility to determine their own size, and thus, a better approach is 
to not place such a limit on virtual group size. We will, however, 
monitor the ways in which solo practitioners and groups with 10 or 
fewer eligible clinicians form virtual groups and may propose to 
establish appropriate classifications regarding virtual group 
composition or a limit on the number of TINs that may form a virtual 
group in future rulemaking as necessary. We solicit public comment on 
these proposals, as well as our approach of not establishing 
appropriate classifications (such as classification by geographic area 
or specialty) regarding virtual group composition or a limit on the 
number of TINs that may form a virtual group at this time.
    In the CY 2017 Quality Payment Program final rule (81 FR 77073 
through 77077), we expressed our commitment to pursue the active 
engagement of stakeholders throughout the process of establishing and 
implementing virtual groups. We received public comments in response to 
the CY 2017 Quality Payment Program final rule and additional 
stakeholder feedback by hosting several virtual group listening 
sessions and convening user groups. Many stakeholders requested that 
CMS provide an option that would permit a portion of a group to 
participate in MIPS outside the group by reporting separately or 
forming a virtual group. We refer readers to section II.C.b.3. of this 
proposed rule for discussion regarding a potential option for 
addressing such issue.
c. MIPS Virtual Group Identifier for Performance
    To ensure that we have accurately captured all of the MIPS eligible 
clinicians participating in a virtual group, we propose that each MIPS 
eligible clinician who is part of a virtual group would be identified 
by a unique virtual group participant identifier. The unique virtual 
group participant

[[Page 30029]]

identifier would be a combination of three identifiers: (1) Virtual 
group identifier (established by CMS; for example, XXXXXX); (2) TIN (9 
numeric characters; for example, XXXXXXXXX); and (3) NPI (10 numeric 
characters; for example, 1111111111). For example, a virtual 
participant identifier could be VG-XXXXXX, TIN-XXXXXXXXX, NPI-
11111111111. We solicit public comment on this proposal.
d. Application of MIPS Group Policies to Virtual Groups
    In the CY 2017 Quality Payment Program final rule (81 FR 77070 
through 77072), we finalized various requirements for groups under MIPS 
at Sec.  414.1310(e), under which groups electing to report at the 
group level are assessed and scored across the TIN for all four 
performance categories. We propose to apply our previously finalized 
and proposed group policies to virtual groups, unless otherwise 
specified. We recognize that there are instances in which we may need 
to clarify or modify the application of certain previously finalized or 
proposed group-related policies to virtual groups, such as the 
definition of a non-patient facing MIPS eligible clinician; small 
practice, rural area and HPSA designations; and groups that have a 
portion of its NPIs participating in a MIPS APM or an Advanced APM (see 
section II.C.4.b. of this proposed rule). More generally, such policies 
may include those that require a calculation of the number of NPIs 
across a TIN (given that a virtual group is a combination of TINs), the 
application of any virtual group participant's status or designation to 
the entire virtual group, and the applicability and availability of 
certain measures and activities to any virtual group participant and to 
the entire virtual group.
    With regard to the applicability of the non-patient facing policies 
to virtual groups, in the CY 2017 Quality Payment Program final rule 
(81 FR 77048 through 77049), we defined the term non-patient facing 
MIPS eligible clinician at Sec.  414.1305 as an individual MIPS 
eligible clinician that bills 100 or fewer patient facing encounters 
(including Medicare telehealth services defined in section 1834(m) of 
the Act) during the non-patient facing determination period, and a 
group provided that more than 75 percent of the NPIs billing under the 
group's TIN meet the definition of a non-patient facing individual MIPS 
eligible clinician during the non-patient facing determination period. 
We are proposing to modify the definition of a non-patient facing MIPS 
eligible clinician to include clinicians in a virtual group provided 
that more than 75 percent of the NPIs billing under the virtual group's 
TINs meet the definition of a non-patient facing individual MIPS 
eligible clinician during the non-patient facing determination period. 
We refer readers to section II.C.4.f. of this rule for the proposed 
modification. We note that other policies previously established and 
proposed in this proposed rule for non-patient facing groups would 
apply to virtual groups. For example, as discussed in section II.C.1.e. 
of this proposed rule, virtual groups determined to be non-patient 
facing would have their advancing care information performance category 
automatically reweighted to zero.
    In regard to the application of small practice status to virtual 
groups, we are proposing that a virtual group would be identified as 
having a small practice status if the virtual group does not have 16 or 
more members of a virtual group (NPIs). We refer readers to section 
II.C.4.d. of this proposed rule for discussion regarding how small 
practice status would apply to virtual groups for scoring under MIPS. 
In the CY 2017 Quality Payment Program final rule (81 FR 77188), we 
defined the term small practices at Sec.  414.1305 as practices 
consisting of 15 or fewer clinicians and solo practitioners. In section 
II.C.1.c. of this proposed rule, we are proposing for performance 
periods occurring in 2018 and future years to identify small practices 
by utilizing claims data. For performance periods occurring in 2018, we 
would identify small practices based on 12 months of data starting from 
September 1, 2016 to August 31, 2017.
    In section II.C.1.e. of this rule, we propose to determine rural 
area and HPSA practice designations for groups participating in MIPS at 
the group level. We note that in section II.C.7.b we describe our 
scoring proposals for practices that are in a rural area or HPSA 
practice. For performance periods occurring in 2018 and future years, 
we are proposing that a group with 75 percent or more of the TIN's 
practice sites designated as rural areas or HPSA practices would be 
designated as a rural area or HPSA at the group level. We are proposing 
that a virtual group with 75 percent or more of the virtual group's 
TINs designated as rural areas or HPSA practices would be designated as 
a rural area or HPSA practice at the virtual group level. We note that 
other policies previously established and proposed in this proposed 
rule for rural area and HPSA groups would apply to virtual groups.
    We recognize that the measures and activities available to groups 
would also be available to virtual groups. Virtual groups would be 
required to meet the reporting requirements for each measure and 
activity, and the virtual group would be responsible for ensuring that 
their measures and activities are aggregated across the virtual group 
(for example, across their TINs). We note that other previously 
established group-related policies and proposed policies in this 
proposed rule pertaining to the four performance categories would apply 
to virtual groups.
    Therefore, we propose to apply MIPS group policies to virtual 
groups except as otherwise specified. We solicit public comment on this 
proposal. We are also interested on receiving feedback on how such 
group-related policies previously established and proposed in this 
proposed rule either would or would not apply to virtual groups. In 
addition, we request public comment on any other policies that may need 
to be clarified or modified with respect to virtual groups, such as 
those that require a calculation of the number of NPIs across a TIN 
(given that a virtual group is a combination of TINs), the application 
of any virtual group participant's status or designation to the entire 
virtual group, the application of the group reporting requirements for 
the individual performance categories to virtual groups, and the 
applicability and availability of certain measures and activities to 
any virtual group participant and to the entire virtual group.
e. Election Process
    As noted above, section 1848(q)(5)(I)(iii)(I) and (II) of the Act 
provides that the virtual group election process must include certain 
requirements, including that: (1) An individual MIPS eligible clinician 
or group electing to be in a virtual group must make their election 
prior to the start of the applicable performance period and cannot 
change their election during the performance period; and (2) an 
individual MIPS eligible clinician or group may elect to be in no more 
than one virtual group for a performance period, and, in the case of a 
group, the election applies to all MIPS eligible clinicians in the 
group. We propose to codify at Sec.  414.1315(a) that a solo 
practitioner or a group of 10 or fewer eligible clinicians must make 
their election prior to the start of the applicable performance period 
and cannot change their election during the performance period. Virtual 
group participants may elect to be in no more than one virtual group 
for a performance period and, in the case of a group, the election 
applies to all MIPS eligible

[[Page 30030]]

clinicians in the group. For the 2018 performance year and future 
years, we are proposing to establish an election period.
    We propose to codify at Sec.  414.1315(b) that, beginning with 
performance periods occurring in 2018, a solo practitioner, or group of 
10 or fewer eligible clinicians electing to be in a virtual group must 
make their election by December 1 of the calendar year preceding the 
applicable performance period. For example, a solo practitioner or 
group would need to make their election by December 1, 2017 to 
participate in MIPS as a virtual group during the 2018 performance 
period. Prior to the election deadline, a virtual group representative 
would have the opportunity to make an election, on behalf of the 
members of a virtual group, regarding the formation of a virtual group 
for an applicable performance period. We intend to publish the 
beginning date of the virtual group election period applicable to the 
2018 performance period and future years in subregulatory guidance.
    In order to provide support and reduce burden, we intend to make 
technical assistance (TA) available, to the extent feasible and 
appropriate, to support clinicians who choose to come together as a 
virtual group. Clinicians can access TA infrastructure and resources 
that they may already be utilizing). For Quality Payment Program year 
3, we intend to provide an electronic election process if technically 
feasible. We propose that clinicians who do not elect to contact their 
designated TA representative would still have the option of contacting 
the Quality Payment Program Service Center.
    We propose to codify at Sec.  414.1315(c) a two-stage virtual group 
election process, stage 1 of which is optional, for the applicable 2018 
and 2019 performance periods. Stage 1 pertains to virtual group 
eligibility determinations. In stage 1, solo practitioners and groups 
with 10 or fewer eligible clinicians interested in forming or joining a 
virtual group would have the option to contact their designated TA 
representative or the Quality Payment Program Service Center in order 
to obtain information pertaining to virtual groups and/or determine 
whether or not they are eligible, as it relates to the practice size 
requirement of a solo practitioner or a group of 10 or fewer eligible 
clinicians, to participate in MIPS as a virtual group (Sec.  
414.1315(a)(1)(i)). We note that activity involved in stage 1 is not 
required, but a resource available to solo practitioners and groups 
with 10 or fewer eligible clinicians; otherwise, solo practitioners or 
groups with 10 or fewer eligible clinicians that do not engage in any 
activity during stage 1, they would begin the election process at stage 
2. For solo practitioners and groups who engage in stage 1 and were 
determined eligible for virtual group participation, they would proceed 
to stage 2. Engaging in stage 1 would provide solo practitioners and 
groups with the option to confirm whether or not they are eligible to 
join or form a virtual group before going to the lengths of executing 
formal written agreements, submitting a formal election registration, 
allocating resources for virtual group implementation, and other 
related activities; whereas, engaging directly in stage 2 as an initial 
step, solo practitioners and groups may have conducted all such efforts 
to only have their election registration be rejected with no recourse 
or remaining time to amend and resubmit.
    During stage 1 of the virtual group election process, we would 
determine whether or not a TIN is eligible to form or join a virtual 
group. In order for a solo practitioner to be eligible to form or join 
a virtual group, the solo practitioner would need to be considered a 
MIPS eligible clinician (defined at Sec.  414.1305) who bills under a 
TIN with no other NPIs billing under such TIN, and not excluded from 
MIPS under Sec.  414.1310(b) and (c). In order for a group to be 
eligible to form or join a virtual group, a group would need to have a 
TIN size that does not exceed 10 eligible clinicians and not excluded 
from MIPS based on the low-volume threshold exclusion at the group 
level. For purposes of determining TIN size for virtual group 
participation eligibility, we coin the term ``virtual group eligibility 
determination period'' and define it to mean an analysis of claims data 
during an assessment period of up to five months that would begin on 
July 1 and end as late as November 30 of a calendar year prior to the 
performance year and includes a 30-day claims run out.
    To capture a real-time representation of TIN size, we propose to 
analyze up to five months of claims data on a rolling basis, in which 
virtual group eligibility determinations for each TIN would be updated 
and made available monthly. We note that an eligibility determination 
regarding TIN size is based on a relative point in time within the 
five-month virtual group eligibility determination period, and not an 
eligibility determination made at the end of such five-month 
determination period. If at any time a TIN is determined to be eligible 
to participate in MIPS as part of a virtual group, the TIN would retain 
that status for the duration of the election period and the applicable 
performance period. TINs could determine their status by contacting 
their designated TA representative or the Quality Payment Program 
Service Center; otherwise, the TIN's status would be determined at the 
time that the TIN's virtual group election is submitted. For example, 
if a group contacted their designated TA representative or the Quality 
Payment Program Service Center on October 20, 2017, the claims data 
analysis would include the months of July through September of 2017, 
and if determined not to exceed 10 eligible clinicians, such TIN's size 
status would be identified at such time and would be retained for the 
duration of the election period and the 2018 performance period. If 
another group contacted their designated TA representative or the 
Quality Payment Program Service Center on November 20, 2017, the claims 
data analysis would include the months of July through October of 2017, 
and if determined not to exceed 10 eligible clinicians, such TIN's size 
status would be identified at such time and would be retained for the 
duration of the election period and the 2018 performance period.
    We believe such a virtual group determination period process 
provides a relative representation of real-time group size for purposes 
of virtual group eligibility and allows groups to know their real-time 
size status immediately and plan accordingly for virtual group 
implementation. It is anticipated that starting in September of each 
calendar year prior to the applicable performance year beginning in 
2018, groups would be able to contact their designated TA 
representative or the Quality Payment Program Service Center and 
inquire about virtual group participation eligibility. We note that TIN 
size determinations are based on the number of NPIs associated with a 
TIN, which would include clinicians (NPIs) excluded from MIPS 
participation and who do not meet the definition of a MIPS eligible 
clinician.
    For groups that do not choose to participate in stage 1 of the 
election process (that is, the group does not request an eligibility 
determination), we will make an eligibility determination during stage 
2 of the election process. If a group began the election process at 
stage 2 and if its TIN size is determined not to exceed 10 eligible 
clinicians and not excluded based on the low-volume threshold exclusion 
at the group level, the group is determined eligible to participate in 
MIPS as part of a virtual group, and such virtual group eligibility 
determination status would be retained

[[Page 30031]]

for the duration of the election period and applicable performance 
period.
    Stage 2 pertains to virtual group formation. For stage two, we 
propose the following:
     TINs comprising a virtual group must establish a written 
formal agreement between each member of a virtual group prior to an 
election (Sec.  414.1315(c)(2)(i)).
     On behalf of a virtual group, the official designated 
virtual group representative must submit an election by December 1 of 
the calendar year prior to the start of the applicable performance 
period. (Sec.  414.1315(c)(2)(ii)). We anticipate this election will 
occur via email to the Quality Payment Program Service Center using the 
following email address: [email protected].
     The submission of a virtual group election must include, 
at a minimum, information pertaining to each TIN and NPI associated 
with the virtual group and contact information for the virtual group 
representative (Sec.  414.1315(c)(2)(iii). A virtual group 
representative would submit the following type of information: each TIN 
associated with the virtual group; each NPI associated with a TIN that 
is part of the virtual group; name of the virtual group representative; 
affiliation of the virtual group representative to the virtual group; 
contact information for the virtual group representative; and confirm 
through acknowledgment that a written formal agreement has been 
established between each member of the virtual group prior to election 
and each member of the virtual group is aware of participating in MIPS 
as a virtual group for an applicable performance period. Each member of 
the virtual group must retain a copy of the virtual group's written 
agreement. We note that the virtual group agreement is subject to the 
MIPS data validation and auditing requirements as described in section 
II.C.9.c. of this rule.
     Once an election is made, the virtual group representative 
must contact their designated CMS contact to update any election 
information that changed during an applicable performance period one 
time prior to the start of an applicable submission period (Sec.  
414.1315(c)(2)(iv)). We anticipate that virtual groups will use the 
Quality Payment Program Service Center as their designated CMS contact; 
however, we will define this further in subregulatory guidance.
    For stage 2 of the election process, we would review all submitted 
election information; confirm whether or not each TIN within a virtual 
group is eligible to participate in MIPS as part of a virtual group; 
identify the NPIs within each TIN participating in a virtual group that 
are excluded from MIPS in order to ensure that such NPIs would not 
receive a MIPS payment adjustment or, when applicable and when 
information is available, would receive a payment adjustment based on a 
MIPS APM scoring standard; calculate the low-volume threshold at the 
individual and group levels in order to determine whether or not a solo 
practitioner or group is eligible to participate in MIPS as part of a 
virtual group; and notify virtual groups as to whether or not they are 
considered official virtual groups for the applicable performance 
period. For virtual groups that are determined to have met the virtual 
group formation criteria and identified as an official virtual group 
participating in MIPS for an applicable performance period, we would 
contact the official designated virtual group representative via email 
notifying the virtual group of its official virtual group status and 
issuing a virtual group identifier for performance (as described in 
section II.C.4.c. of this proposed rule) that would accompany the 
virtual group's submission of performance data during the submission 
period.
    In regard to virtual group determinations pertaining to the low-
volume threshold, we recognize that such determinations are made at the 
individual and group level, but not at the virtual group level. The 
low-volume threshold determinations are applicable to the way in which 
individual eligible clinicians and groups participate in MIPS as 
individual MIPS eligible clinicians (solo practitioners) or groups. For 
example, if an individual MIPS eligible clinician is part of a practice 
that is participating in MIPS at the individual level (reporting at the 
individual level), then the low-volume threshold determination is made 
at the individual level. Whereas, if an individual MIPS eligible 
clinician is part of a practice that is participating in MIPS at the 
group level (reporting at the group level), then the low-volume 
threshold determination at the group level would be applicable to such 
MIPS eligible clinician regardless of the low-volume threshold 
determination made at the individual level because such individual MIPS 
eligible clinician is part of a group reporting at the group level and 
the low-volume threshold determinations for groups applies to the group 
as a whole. Similarly, if a solo practitioner or a group with 10 or 
fewer eligible clinicians seeks to participate in MIPS at the virtual 
group level (reporting at the virtual group level), then the low-volume 
threshold determination at the individual or group level would be 
applicable to such solo practitioner or group with 10 or fewer eligible 
clinicians. Thus, solo practitioners (individual MIPS eligible 
clinicians) or groups with 10 or fewer eligible clinicians that are 
determined not to exceed the low-volume threshold at the individual or 
group level would not be eligible to participate in MIPS as an 
individual, group, or virtual group.
    As we engaged in various discussions with stakeholders during the 
rulemaking process through listening sessions and user groups, 
stakeholders indicated that many solo practitioners and small groups 
have limited resources and technical capacities, which may make it 
difficult for the entities to form virtual groups without sufficient 
time and technical assistance. Depending on the resources and technical 
capacities of the entities, stakeholders conveyed that it may take 
entities 3 to 18 months to prepare to participate in MIPS as a virtual 
group. The majority of stakeholders indicated that virtual groups would 
need at least 6 to 12 months prior to the start of the 2018 performance 
period to form virtual groups, prepare health IT systems, and train 
staff to be ready for the implementation of virtual group related 
activities by January 1, 2018.
    We recognize that for the first year of virtual group formation and 
implementation prior to the start of the 2018 performance period, the 
timeframe for virtual groups to make an election by registering would 
be relatively short, particularly from the date we issue the 
publication of a final rule toward the end of the 2017 calendar year. 
To provide solo practitioners and groups with 10 or fewer eligible 
clinicians with additional time to assemble and coordinate resources, 
and form a virtual group prior to the start of the 2018 performance 
period, we are providing virtual groups with an opportunity to make an 
election prior to the publication of our final rule. We intend for the 
virtual group election process to be available as early as mid-
September of 2017; we will publicize the specific opening date via 
subregulatory guidance. Virtual groups would have from mid-September to 
December 1, 2017 to make an election for the 2018 performance year. In 
regard to our proposed policies pertaining to virtual group 
implementation (for example, definition of a virtual group and election 
process requirements), we intend to closely align with the statutory 
requirements in order to establish clear expectations for solo 
practitioners and

[[Page 30032]]

small groups, and have an opportunity to begin the preparation of 
forming virtual groups in advance of the publication of our final rule. 
However, any MIPS eligible clinicians applying to be a virtual group 
that does not meet all finalized virtual group requirements would not 
be permitted to participate in MIPS as a virtual group.
    As previously noted, groups participating in a virtual group would 
have the size of their TIN determined for eligibility purposes. The 
virtual group size would be determined one time for each performance 
period. We recognize that the size of a group may fluctuate during a 
performance period with eligible clinicians and/or MIPS eligible 
clinicians joining or leaving a group. For groups within a virtual 
group that are determined to have a group size of 10 eligible 
clinicians or less based on the one time determination per applicable 
performance year, any new eligible clinicians or MIPS eligible 
clinicians that join the group during the performance period would 
participate in MIPS as part of the virtual group. In such cases, we 
recognize that a group may exceed 10 eligible clinicians associated 
with its TIN during an applicable performance period, but at the time 
of election, such group would have been determined eligible to form or 
join a virtual group given that the TIN did not have more than 10 
eligible clinicians associated with its TIN. As previously noted, the 
virtual group representative would need to contact the Quality Payment 
Program Service Center to update the virtual group's information that 
was provided during the election period if any information changed 
during an applicable performance period one time prior to the start of 
an applicable submission period (for example, include new NPIs who 
joined a TIN that is part of a virtual group). Virtual groups must re-
register before each performance period.
    The statute provides that a solo practitioner (TIN/NPI) and a group 
with 10 or fewer eligible clinicians may elect to be in no more than 
one virtual group for a performance period. We note that such a solo 
practitioner or a group that is part of a virtual group may not elect 
to be in more than one virtual group for a performance period. Also, 
the statute determines that a virtual group election by the group for 
an applicable performance period applies to all MIPS eligible 
clinicians in the group. In the case of a TIN within a virtual group 
being acquired or merged with another TIN, or no longer operating as a 
TIN (for example, a group practice closes) during a performance period, 
such solo practitioner or group's performance data would continue to be 
attributed to the virtual group. The remaining members of a virtual 
group would continue to be part of the virtual group even if only one 
solo practitioner or group remains. We consider a TIN that is acquired 
or merged with another TIN, or no longer operating as a TIN (e.g., a 
group practice closes) to mean a TIN that no longer exists or operates 
under the auspices of such TIN during a performance year.
    As outlined in section 1848(q)(5)(I)(iii) of the Act and previously 
noted, a virtual group is a combination of TINs, which would include at 
least two separate TINs associated with a solo practitioner (TIN/NPI), 
or a group with 10 or fewer eligible clinicians and another such solo 
practitioner, or group. However, given that a virtual group must be a 
combination of TINs, we recognize that the composition of a virtual 
group could include, for example, one solo practitioner (NPI) who is 
practicing under multiple TINs, in which the solo practitioner would be 
able to form a virtual group with his or her own self based on each TIN 
assigned to the solo practitioner. For the number of TINs able to form 
a virtual group, we note that there is not a limit to the number of 
TINs able to comprise a virtual group.
f. Virtual Group Agreements
    The statute provides for formal written agreements among the MIPS 
eligible clinicians electing to form a virtual group. We propose that 
each virtual group member would be required to execute formal written 
agreements with each other virtual group member to ensure that 
requirements and expectations of participation in MIPS are clearly 
articulated, understood, and agreed upon. We note that a virtual group 
may not include a solo practitioner or group as part of the virtual 
group unless an authorized person of the TIN has executed a formal 
written agreement. During the election process and submission of a 
virtual group election, a designated virtual group representative would 
be required to confirm through acknowledgement that an agreement is in 
place between each member of the virtual group. An agreement would be 
executed for at least one performance period. If a NPI joins or leaves 
a TIN, or a change is made to a TIN that impacts the agreement itself, 
such as a legal business name change, during the applicable performance 
year, a virtual group would be required to update the agreement to 
reflect such changes and submit changes to CMS via the Quality Payment 
Program Service Center.
    We propose, at Sec.  414.1315(c)(3), that a formal written 
agreement between each member of a virtual group must include the 
following elements:
     Expressly state the only parties to the agreement are the 
TINs and NPIs of the virtual group (at Sec.  414.1315(c)(3)(i)). For 
example, the agreement may not be between a virtual group and another 
entity, such as an independent practice association (IPA) or management 
company that in turn has an agreement with one or more TINs within the 
virtual group. Similarly, virtual groups should not use existing 
contracts between TINs that include third parties.
     Be executed on behalf of the TINs and the NPIs by 
individuals who are authorized to bind the TINs and the NPIs, 
respectively at Sec.  414.1315(c)(3)(ii)).
     Expressly require each member of the virtual group 
(including each NPI under each TIN) to agree to participate in MIPS as 
a virtual group and comply with the requirements of the MIPS and all 
other applicable laws and regulations (including, but not limited to, 
federal criminal law, False Claims Act, anti-kickback statute, civil 
monetary penalties law, Health Insurance Portability and Accountability 
Act, and physician self-referral law) at Sec.  414.1315(c)(3)(iii)).
     Require each TIN within a virtual group to notify all NPIs 
associated with the TIN of their participation in the MIPS as a virtual 
group at Sec.  414.1315(c)(3)(iv)).
     Set forth the NPI's rights and obligations in, and 
representation by, the virtual group, including without limitation, the 
reporting requirements and how participation in MIPS as a virtual group 
affects the ability of the NPI to participate in the MIPS outside of 
the virtual group at Sec.  414.1315(c)(3)(v)).
     Describe how the opportunity to receive payment 
adjustments will encourage each member of the virtual group (including 
each NPI under each TIN) to adhere to quality assurance and improvement 
at Sec.  414.1315(c)(3)(vi)).
     Require each member of the virtual group to update its 
Medicare enrollment information, including the addition and deletion of 
NPIs billing through a TIN that is part of a virtual group, on a timely 
basis in accordance with Medicare program requirements and to notify 
the virtual group of any such changes within 30 days after the change 
at Sec.  414.1315(c)(3)(vii)).
     Be for a term of at least one performance period as 
specified in the formal written agreement at Sec.  
414.1315(c)(3)(viii)).

[[Page 30033]]

     Require completion of a close-out process upon termination 
or expiration of the agreement that requires the TIN (group part of the 
virtual group) or NPI (solo practitioner part of the virtual group) to 
furnish all data necessary in order for the virtual group to aggregate 
its data across the virtual group at Sec.  414.1315(c)(3)(ix)).
    As part of the virtual group election ICR, we filed a 60-day notice 
on June 14, 2017 (82 FR 27257), which includes an agreement template 
that could be used by virtual groups and will be made available via 
subregulatory guidance. The agreement template is not required, but 
serves as a model agreement that could be utilized by virtual groups. 
The agreement template includes all necessary elements required for 
such an agreement.
    We solicit public comment on these proposals.
    Through the formal written agreements, we want to ensure that all 
members of a virtual group are aware of their participation in a 
virtual group. As noted above, formal written agreements must include a 
provision that requires each TIN within a virtual group to notify all 
NPIs associated with the TIN regarding their participation in the MIPS 
as a virtual group in order to ensure that each member of a virtual 
group is aware of their participation in the MIPS as a virtual group. 
We want to implement an approach that considers a balance between the 
need to ensure that all members of a virtual group are aware of their 
participation in a virtual group and the minimization of administration 
burden. We solicit public comment on approaches for virtual groups to 
ensure that all members of a virtual group are aware of their 
participation in the virtual group.
g. Reporting Requirements
    As we noted in this proposed rule, we believe virtual groups should 
generally be treated under the MIPS as groups. Therefore, for MIPS 
eligible clinicians participating at the virtual group level, we 
propose the following requirements:
     Individual eligible clinicians and individual MIPS 
eligible clinicians who are part of a TIN participating in MIPS at the 
virtual group level would have their performance assessed as a virtual 
group at Sec.  414.1315(d)(1).
     Individual eligible clinicians and individual MIPS 
eligible clinicians who are part of a TIN participating in MIPS at the 
virtual group level would need to meet the definition of a virtual 
group at all times during the performance period for the MIPS payment 
year (at Sec.  414. 1315(d)(2)).
     Individual eligible clinicians and individual MIPS 
eligible clinicians who are part of a TIN participating in MIPS at the 
virtual group level must aggregate their performance data across 
multiple TINs in order for their performance to be assessed as a 
virtual group (at Sec.  414.1315(d)(3)).
     MIPS eligible clinicians that elect to participate in MIPS 
at the virtual group level would have their performance assessed at the 
virtual group level across all four MIPS performance categories (at 
Sec.  414.1315(d)(4)).
     Virtual groups would need to adhere to an election process 
established and required by CMS (at Sec.  414.1315(d)(5)).
    We solicit public comment on these proposals.
h. Assessment and Scoring for the MIPS Performance Categories
    As noted above, section 1848(q)(5)(I)(i) of the Act provides that 
eligible clinicians electing to be a virtual group will: (1) Have their 
performance assessed for the quality and cost performance categories in 
a manner that applies the combined performance of all eligible 
clinicians in the virtual group to each MIPS eligible clinician (except 
for those participating in a MIPS APM or an Advanced APM under the MIPS 
APM scoring standard) in the virtual group for a performance period of 
a year; and (2) be scored based on the assessment of the combined 
performance described above regarding the quality and cost performance 
categories for a performance period. We believe it is critical for 
virtual groups to be assessed and scored at the virtual group level for 
all performance categories; it eliminates the burden of virtual group 
members having to report as a virtual group and separately outside of a 
virtual group. Additionally, we believe that the assessment and scoring 
at the virtual group level provides for a comprehensive measurement of 
performance, shared responsibility, and an opportunity to effectively 
and efficiently coordinate resources to also achieve performance under 
the improvement activities and the advancing care information 
performance categories. We propose at Sec.  414.1315 that virtual 
groups would be assessed and scored across all four MIPS performance 
categories at the virtual group level for a performance period of a 
year.
    In the CY 2017 Quality Payment Program final rule (81 FR 77319 
through 77329), we established the MIPS final score methodology, which 
will apply to virtual groups. We refer readers to sections II.C.7.b. 
and II.C.8. of this proposed rule for scoring policies that would apply 
to virtual groups.
    As previously noted, we propose to allow solo practitioners and 
groups with 10 or fewer eligible clinicians that have elected to be 
part of a virtual group to have their performance measured and 
aggregated at the virtual group level across all four performance 
categories; however, we would apply payment adjustments at the 
individual TIN/NPI level. Each TIN/NPI would receive a final score 
based on the virtual group performance, but the payment adjustment 
would still be applied at the TIN/NPI level. We would assign the 
virtual group score to all TIN/NPIs billing under a TIN in the virtual 
group during the performance period.
    During the performance year, we recognize that NPIs in a TIN that 
has joined a virtual group may also be participants in an APM. The TIN, 
as part of the virtual group, must submit performance data for all 
eligible clinicians associated with the TIN, including those 
participating in APMs, to ensure that all eligible clinicians 
associated with the TIN are being measured under MIPS.
    For participants in MIPS APMs, we propose to use our authority 
under section 1115A(d)(1) for MIPS APM authorized under section 1115A 
of the Act, and under section 1899(f) for the Shared Savings Program, 
to waive the requirement under section 1848 (q)(2)(5)(I)(i)(II) of the 
Act that requires performance category scores from virtual group 
reporting must be used to generate the composite score upon which the 
MIPS payment adjustment is based for all TIN/NPIs in the virtual group. 
Instead, we would use the score assigned to the MIPS eligible clinician 
based on the applicable APM Entity score to determine MIPS payment 
adjustments for all MIPS eligible clinicians that are part of an APM 
Entity participating in a MIPS APM, in accordance with Sec.  414.1370, 
instead of determining MIPS payment adjustments for these MIPS eligible 
clinicians using the composite score of their virtual group.
    APMs seek to deliver better care at lower cost and to test new ways 
of paying for care and measuring and assessing performance. In the CY 
2017 Quality Payment Program final rule, we established policies to the 
address concerns we have expressed in regard to the application of 
certain MIPS policies to MIPS eligible clinicians in MIPS APMs (81 FR 
77246 through 77269). In section II.C.6.g. of this proposed rule, we 
reiterate those concerns and propose additional policies for the APM 
scoring standard. We believe it is important to

[[Page 30034]]

consistently apply the APM scoring standard under MIPS for eligible 
clinicians participating in MIPS APMs in order to avoid potential 
misalignments between the evaluation of performance under the terms of 
the MIPS APM and evaluation of performance on measures and activities 
under MIPS, and to preserve the integrity of the initiatives we are 
testing. Therefore, we believe it is necessary to waive the requirement 
to only use the virtual group scores under section 1848(q)(5)(I)(i)(II) 
of the Act, and instead to apply the score under the APM scoring 
standard for eligible clinicians in virtual groups who are also in an 
APM Entity participating in an APM.
    We note that MIPS eligible clinicians who are participants in both 
a virtual group and a MIPS APM would be assessed under MIPS as part of 
the virtual group and under the APM scoring standard as part of an APM 
Entity group, but would receive their payment adjustment based only on 
the APM Entity score. In the case of an eligible clinician 
participating in both a virtual group and an Advanced APM who has 
achieved QP status, the clinician would be assessed under MIPS as part 
of the virtual group, but would still be excluded from the MIPS payment 
adjustment as a result of his or her QP status. We refer readers to 
section II.C.6.g.(2) of this proposed rule for further discussion 
regarding the waiver and the CY 2017 Quality Payment Program final rule 
(81 FR 77013) for discussion regarding the timeframe used for 
determining QP status.
5. MIPS Performance Period
    In the CY 2017 Quality Payment Program final rule (81 FR 77085), we 
finalized at Sec.  414.1320(b)(1) that for purposes of the MIPS payment 
year 2020, the performance period for the quality and cost performance 
categories is CY 2018 (January 1, 2018 through December 31, 2018). For 
the improvement activities and advancing care information performance 
categories, we finalized at Sec.  414.1320(b)(2) that for purposes of 
the MIPS payment year 2020, the performance period for the improvement 
activities and advancing care information performance categories is a 
minimum of a continuous 90-day period within CY 2018, up to and 
including the full CY 2018 (January 1, 2018, through December 31, 
2018). We are not proposing any changes to these policies.
    We also finalized at Sec.  414.1325(f)(2) to use claims with dates 
of service during the performance period that must be processed no 
later than 60 days following the close of the performance period for 
purposes of assessing performance and computing the MIPS payment 
adjustment. Lastly, we finalized that individual MIPS eligible 
clinicians or groups who report less than 12 months of data (due to 
family leave, etc.) would be required to report all performance data 
available from the applicable performance period (for example, CY 2018 
or a minimum of a continuous 90-day period within CY 2018).
    We are proposing at Sec.  414.1320(c) and (c)(1) that for purposes 
of the MIPS payment year 2021 and future years, for the quality and 
cost performance categories, the performance period under MIPS would be 
the full calendar year (January 1 through December 31) that occurs 2 
years prior to the applicable payment year. For example, for the MIPS 
payment year 2021, the performance period would be CY 2019 (January 1, 
2019 through December 31, 2019), and for the MIPS payment year 2022 the 
performance period would be CY 2020 (January 1, 2020 through December 
31, 2020).
    We are proposing at Sec.  414.1320(d) and (d)(1) that for purposes 
of the MIPS payment year 2021, the performance period for the 
improvement activities and advancing care information performance 
categories would be a minimum of a continuous 90-day period within the 
calendar year that occurs 2 years prior to the applicable payment year, 
up to and including the full CY 2019 (January 1, 2019 through December 
31, 2019).
    We request comments on our proposals for the performance period for 
MIPS payment year 2021 and future years.
6. MIPS Performance Category Measures and Activities
a. Performance Category Measures and Reporting
(1) Submission Mechanisms
    We finalized in the CY 2017 Quality Payment Program final rule (81 
FR 77094) at Sec.  414.1325(a) that individual MIPS eligible clinicians 
and groups must submit measures and activities, as applicable, for the 
quality, improvement activities, and advancing care information 
performance categories. For the cost performance category, we finalized 
that each individual MIPS eligible clinician's and group's cost 
performance would be calculated using administrative claims data. As a 
result, individual MIPS eligible clinicians and groups are not required 
to submit any additional information for the cost performance category. 
For individual eligible clinicians and groups that are not MIPS 
eligible clinicians, such as physical therapists, but elect to report 
to MIPS, we will calculate administrative claims-based cost measures 
and quality measures, if data are available. We finalized in the CY 
2017 Quality Payment Program final rule (81 FR 77094 through 77095) 
multiple data submission mechanisms for MIPS, which provide individual 
MIPS eligible clinicians and groups with the flexibility to submit 
their MIPS measures and activities in a manner that best accommodates 
the characteristics of their practice, as indicated in Tables 2 and 3. 
Table 2 summarizes the data submission mechanisms for individual MIPS 
eligible clinicians that we finalized at Sec.  414.1325(b) and (e). 
Table 3 summarizes the data submission mechanisms for groups that are 
not reporting through an APM that we finalized at Sec.  414.1325(c) and 
(e).

    Table 2--Data Submission Mechanisms for MIPS Eligible Clinicians
                         Reporting Individually
                                [TIN/NPI]
------------------------------------------------------------------------
  Performance category/submission   Individual reporting data submission
      combinations  accepted                     mechanisms
------------------------------------------------------------------------
Quality...........................  Claims.
                                    QCDR.
                                    Qualified registry.
                                    EHR.
Cost..............................  Administrative claims.\1\

[[Page 30035]]

 
Advancing Care Information........  Attestation.
                                    QCDR.
                                    Qualified registry.
                                    EHR.
Improvement Activities............  Attestation.
                                    QCDR.
                                    Qualified registry.
                                    EHR.
------------------------------------------------------------------------


    Table 3--Data Submission Mechanisms for MIPS Eligible Clinicians
                        Reporting as Groups (TIN)
------------------------------------------------------------------------
  Performance category/submission      Group reporting data submission
       combinations accepted                     mechanisms
------------------------------------------------------------------------
Quality...........................  QCDR.
                                    Qualified registry.
                                    EHR.
                                    CMS Web Interface (groups of 25 or
                                     more).
                                    CMS-approved survey vendor for CAHPS
                                     for MIPS (must be reported in
                                     conjunction with another data
                                     submission mechanism).
                                    and
                                    Administrative claims (for all-cause
                                     hospital readmission measure; no
                                     submission required).
Cost..............................  Administrative claims.\1\
Advancing Care Information........  Attestation.
                                    QCDR.
                                    Qualified registry.
                                    EHR.
                                    CMS Web Interface (groups of 25 or
                                     more).
Improvement Activities............  Attestation.
                                    QCDR.
                                    Qualified registry.
                                    EHR.
                                    CMS Web Interface (groups of 25 or
                                     more).
------------------------------------------------------------------------

    We finalized at Sec.  414.1325(d) that individual MIPS eligible 
clinicians and groups may elect to submit information via multiple 
mechanisms; however, they must use the same identifier for all 
performance categories, and they may only use one submission mechanism 
per performance category. In response to the CY 2017 Quality Payment 
Program final rule (81 FR 77089), we received comments supportive of 
the use of multiple submission mechanisms for a single performance 
category due to the flexibility it would provide clinicians. Another 
commenter supported such an approach because they believed that the 
scoring of only one submission mechanism per performance category may 
influence which quality measures a MIPS eligible clinician chooses to 
report given that the commenter believed only a limited number of 
measures relevant to one's practice might be available through a 
particular submission mechanism. The commenter also believed that such 
flexibility would encourage continued participation in MIPS.
---------------------------------------------------------------------------

    \1\ Requires no separate data submission to CMS: Measures are 
calculated based on data available from MIPS eligible clinicians' 
billings on Medicare Part B claims. Note: Claims differ from 
administrative claims as they require MIPS eligible clinicians to 
append certain billing codes to denominator eligible claims to 
indicate the required quality action or exclusion occurred.
---------------------------------------------------------------------------

    We are proposing to revise Sec.  414.1325(d) for purposes of the 
2020 MIPS payment year and future years, beginning with performance 
periods occurring in 2018, to allow individual MIPS eligible clinicians 
and groups to submit data on measures and activities, as applicable, 
via multiple data submission mechanisms for a single performance 
category (specifically, the quality, improvement activities, or 
advancing care information performance category). Under this proposal, 
individual MIPS eligible clinicians and groups that have fewer than the 
required number of measures and activities applicable and available 
under one submission mechanism could be required to submit data on 
additional measures and activities via one or more additional 
submission mechanisms, as necessary, provided that such measures and 
activities are applicable and available to them to receive the maximum 
number of points under a performance category. We considered an 
approach that would require MIPS eligible clinicians to first submit 
data on as many required measures and activities as possible via one 
submission mechanism before submitting data via an additional 
submission mechanism, but we believe that such an approach would limit 
flexibility.
    If an individual MIPS eligible clinician or group submits the same 
measure through two different mechanisms, each submission would be 
calculated and scored separately. We do not have the ability to 
aggregate data on the same measure across submission mechanisms. We 
would only count the submission that gives the clinician the higher 
score, thereby avoiding the double count. We refer readers to section 
II.C.7. of this proposed rule, which further outlines how we propose to 
score measures and activities regardless of submission mechanism.
    We believe that this flexible approach would help individual MIPS 
eligible clinicians and groups with reporting, as it provides more 
options for the submission of data for the applicable

[[Page 30036]]

performance categories. For example, an individual MIPS eligible 
clinician or group submitting data on four applicable and available 
quality measures via EHR may not be able to receive the maximum number 
of points available under the quality performance category. However, 
with this proposed modification, the MIPS eligible clinician could meet 
the requirement to report six quality measures by submitting data on 
two additional quality measure via another submission mechanism, such 
as claims or qualified registry. This would enable the MIPS eligible 
clinician to receive the maximum number of points available under the 
quality performance category. We believe that by providing this 
flexibility, we would be allowing MIPS eligible clinicians the 
flexibility to choose the measures and activities that are most 
meaningful to them, regardless of the submission mechanism. We are 
aware that this proposal for increased flexibility in data submission 
mechanisms may increase complexity and in some instances additional 
costs for clinicians, as they may need to establish relationships with 
additional data submission mechanism vendors in order to report 
additional measures and/or activities for any given performance 
category. We would like to clarify that the requirements for the 
performance categories remain the same, regardless of the number of 
submission mechanisms used. It is also important to note for the 
improvement activities and advancing care information performance 
categories, that using multiple data submission mechanisms (for 
example, attestation and the qualified registry) may limit our ability 
to provide real-time feedback. While we strive to provide flexibility 
to individual MIPS eligible clinicians and groups, we would like to 
note that our goal within the MIPS program is to minimize complexity 
and administrative burden to individual MIPS eligible clinicians and 
groups. We request comments on this proposal.
    As discussed in section II.C.4. of this proposed rule, we are 
proposing to generally apply our previously finalized and proposed 
group policies to virtual groups. With respect to data submission 
mechanisms, we are proposing that virtual groups would be able to use a 
different submission mechanism for each performance category, and would 
be able to utilize multiple submission mechanisms for the quality 
performance category, beginning with performance periods occurring in 
2018. However, virtual groups would be required to utilize the same 
submission mechanism for the improvement activities and the advancing 
care information performance categories.
    For those MIPS eligible clinicians participating in a MIPS APM, who 
are on an APM Participant List on at least one of the three snapshot 
dates as finalized in the CY 2017 Quality Payment Program Final Rule 
(81 FR 77444 through 77445), or for MIPS eligible clinicians 
participating in a full TIN MIPS APM, who are on an APM Participant 
List on at least one of the four snapshot dates as discussed in section 
II.C.6.g.(2) of this proposed rule, the APM scoring standard applies. 
We refer readers to Sec.  414.1370 and the CY 2017 Quality Payment 
Program final rule (81 FR 77246), which describes how MIPS eligible 
clinicians participating in APM entities submit data to MIPS in the 
form and manner required, including separate approaches to the quality 
and cost performance categories applicable to MIPS APMs. We are not 
proposing any changes to how APM entities in MIPS APMs and their 
participating MIPS eligible clinicians submit data to MIPS.
(2) Submission Deadlines
    In the CY 2017 Quality Payment Program final rule (81 FR 77097), we 
finalized submission deadlines by which all associated data for all 
performance categories must be submitted for the submission mechanisms 
described in this rule.
    As specified at Sec.  414.1325(f)(1), the data submission deadline 
for the qualified registry, QCDR, EHR, and attestation submission 
mechanisms is March 31 following the close of the performance period. 
The submission period will begin prior to January 2 following the close 
of the performance period, if technically feasible. For example, for 
performance periods occurring in 2018, the data submission period will 
occur prior to January 2, 2019, if technically feasible, through March 
31, 2019. If it is not technically feasible to allow the submission 
period to begin prior to January 2 following the close of the 
performance period, the submission period will occur from January 2 
through March 31 following the close of the performance period. In any 
case, the final deadline will remain March 31, 2019.
    At Sec.  414.1325(f)(2), we specified that for the Medicare Part B 
claims submission mechanism, data must be submitted on claims with 
dates of service during the performance period that must be processed 
no later than 60 days following the close of the performance period. 
Lastly, for the CMS Web Interface submission mechanism, at Sec.  
414.1325(f)(3), we specified that the data must be submitted during an 
8-week period following the close of the performance period that will 
begin no earlier than January 2, and end no later than March 31. For 
example, the CMS Web Interface submission period could span an 8-week 
timeframe beginning January 16 and ending March 13. The specific 
deadline during this timeframe will be published on the CMS Web site. 
We are not proposing any changes to the submission deadlines in this 
proposed rule.
b. Quality Performance Criteria
(1) Background
    Sections 1848(q)(1)(A)(i) and (ii) of the Act require the Secretary 
to develop a methodology for assessing the total performance of each 
MIPS eligible clinician according to performance standards and, using 
that methodology, to provide for a final score for each MIPS eligible 
clinician. Section 1848(q)(2)(A)(i) of the Act requires us to use the 
quality performance category in determining each MIPS eligible 
clinician's final score, and section 1848(q)(2)(B)(i) of the Act 
describes the measures and activities that must be specified under the 
quality performance category.
    The statute does not specify the number of quality measures on 
which a MIPS eligible clinician must report, nor does it specify the 
amount or type of information that a MIPS eligible clinician must 
report on each quality measure. However, section 1848(q)(2)(C)(i) of 
the Act requires the Secretary, as feasible, to emphasize the 
application of outcomes-based measures.
    Sections 1848(q)(1)(E) of the Act requires the Secretary to 
encourage the use of QCDRs, and section 1848(q)(5)(B)(ii)(I) of the Act 
requires the Secretary to encourage the use of CEHRT and QCDRs for 
reporting measures under the quality performance category under the 
final score methodology, but the statute does not limit the Secretary's 
discretion to establish other reporting mechanisms.
    Section 1848(q)(2)(C)(iv) of the Act generally requires the 
Secretary to give consideration to the circumstances of non-patient 
facing MIPS eligible clinicians and allows the Secretary, to the extent 
feasible and appropriate, to apply alternative measures or activities 
to such clinicians.
    As discussed in the CY 2017 Quality Payment Program final rule (81 
FR 77098 through 77099), we finalized MIPS quality criteria that focus 
on measures that are important to beneficiaries and maintain some of 
the

[[Page 30037]]

flexibility from PQRS, while addressing several of the comments we 
received in response to the CY 2017 Quality Payment Program proposed 
rule and the MIPS and APMs RFI.
     To encourage meaningful measurement, we finalized allowing 
individual MIPS eligible clinicians and groups the flexibility to 
determine the most meaningful measures and data submission mechanisms 
for their practice.
     To simplify the reporting criteria, we aligned the 
submission criteria for several of the data submission mechanisms.
     To reduce administrative burden and focus on measures that 
matter, we lowered the required number of the measures for several of 
the data submission mechanisms, yet still required that certain types 
of measures, particularly outcome measures, be reported.
     To create alignment with other payers and reduce burden on 
MIPS eligible clinicians, we incorporated measures that align with 
other national payers.
     To create a more comprehensive picture of a practice's 
performance, we also finalized the use of all-payer data where 
possible.
    As beneficiary health is always our top priority, we finalized 
criteria to continue encouraging the reporting of certain measures such 
as outcome, appropriate use, patient safety, efficiency, care 
coordination, or patient experience measures. However, as discussed in 
the CY 2017 Quality Payment Program final rule (81 FR 77098), we 
removed the requirement for measures to span across multiple domains of 
the NQS. We continue to believe the NQS domains are extremely 
important, and we encourage MIPS eligible clinicians to continue to 
strive to provide care that focuses on: Effective clinical care, 
communication and care coordination, efficiency and cost reduction, 
person and caregiver-centered experience and outcomes, community and 
population health, and patient safety. While we do not require that 
MIPS eligible clinicians select measures across multiple domains, we 
encourage them to do so. In addition, we believe the MIPS program 
overall, with the focus on the quality, cost, improvement activities, 
and advancing care information performance categories, will naturally 
cover many elements in the NQS.
(2) Contribution to Final Score
    For MIPS payment year 2019, the quality performance category will 
account for 60 percent of the final score, subject to the Secretary's 
authority to assign different scoring weights under section 
1848(q)(5)(F) of the Act. Section 1848(q)(2)(E)(i)(I)(aa) of the Act 
states that the quality performance category will account for 30 
percent of the final score for MIPS. However, section 
1848(q)(2)(E)(i)(I)(bb) of the Act stipulates that for the first and 
second years for which MIPS applies to payments, the percentage of the 
final score applicable for the quality performance category will be 
increased so that the total percentage points of the increase equals 
the total number of percentage points by which the percentage applied 
for the cost performance category is less than 30 percent. Section 
1848(q)(2)(E)(i)(II)(bb) of the Act requires that, for the transition 
year for which MIPS applies to payments, not more than 10 percent of 
the final score shall be based on the cost performance category. 
Furthermore, section 1848(q)(2)(E)(i)(II)(bb) of the Act states that, 
for the second year for which MIPS applies to payments, not more than 
15 percent of the final score shall be based on the cost performance 
category.
    In the CY 2017 Quality Payment Program final rule (81 FR 77100), we 
finalized at Sec.  414.1330(b) that, for MIPS payment years 2019 and 
2020, 60 percent and 50 percent, respectively, of the MIPS final score 
will be based on the quality performance category. For the third and 
future years, 30 percent of the MIPS final score will be based on the 
quality performance category.
    As discussed in section II.C.6.d. of this proposed rule, we are 
proposing to weight the cost performance category at zero percent for 
the second MIPS payment year (2020). In accordance with section 
1848(q)(5)(E)(i)(I)(bb) of the Act, for the first 2 years, the 
percentage of the MIPS final score that would otherwise be based on the 
quality performance category (that is, 30 percent) must be increased by 
the same number of percentage points by which the percentage based on 
the cost performance category is less than 30 percent. Therefore, if 
our proposal to reweight the cost performance category for MIPS payment 
year 2020 is finalized, we would need to inversely reweight the quality 
performance category for the same year. Accordingly, we are proposing 
to modify Sec.  414.1330(b)(2) to reweight the percentage of the MIPS 
final score based on the quality performance category for MIPS payment 
year 2020 as may be necessary to account for any reweighting of the 
cost performance category, if finalized. For example, if our proposal 
to reweight the cost performance category to zero percent for MIPS 
payment year 2020 is finalized, then we would modify Sec.  
414.1330(b)(2) to provide that performance in the quality performance 
category will comprise 60 percent of a MIPS eligible clinician's final 
score for MIPS payment year 2020. We refer readers to section II.C.6.d. 
for more information on the cost performance category.
    As also discussed in section II.C.6.d. of this proposed rule, we 
note that by reweighting the cost performance category to zero percent 
in performance period 2018, there will be a sharp increase in the cost 
performance category to a 30 percent weight in performance period 2019. 
In order to assist MIPS eligible clinicians and groups in obtaining 
additional comfort with measurement based on the cost performance 
category, we considered maintaining our previously-finalized cost 
performance category weight of 10 percent for the 2018 performance 
period. However, in our discussions with some MIPS eligible clinicians 
and clinician societies, eligible clinicians expressed their desire to 
down-weight the cost performance category to zero percent for an 
additional year with full knowledge that the cost performance category 
weight is set at 30 percent under the statute for the 2021 MIPS payment 
year. The clinicians we spoke with preferred our proposed approach and 
noted that they are actively preparing for full cost performance 
category implementation and would be prepared for the 30 percent 
statutory weight for the cost performance category for the 2021 MIPS 
payment year.
    We intend to provide an initial opportunity for clinicians to 
review their performance based on the new episode-based measures at 
some point in the fall of 2017, as the measures are developed and as 
the information is available. We note that this feedback will be 
specific to the new episode-based measures that are developed under the 
process described above and may be presented in a different format than 
MIPS eligible clinicians' performance feedback as described in section 
II.C.9.a. of this proposed rule. However, our intention is to align the 
feedback as much as possible to ensure clinicians receive opportunities 
to review their performance on potential new episode-based measures for 
the cost performance category prior to the proposed 2019 MIPS 
performance period. We are unable to offer a list of new episode-based 
measures on which we will provide feedback because that will be 
determined in our ongoing development work described above. We are 
concerned that continuing to

[[Page 30038]]

provide feedback on the older episode-based measures along with 
feedback on new episode-based measures will be confusing and a poor use 
of resources. Because we are focusing on development of new episode-
based measures, our feedback on episode-based measures that were 
previously developed will discontinue after 2017 as these measures 
would no longer be maintained or reflect changes in diagnostic and 
procedural coding. As described in section II.C.9.a. of this proposed 
rule, we intend to provide feedback on these new measures as they 
become available in a new format around summer 2018, in addition to the 
fall 2017 feedback discussed previously. We note that the feedback 
provided in the summer of 2018 will go to those MIPS eligible 
clinicians for whom we are able to calculate the episode-based 
measures, which means it would be possible that a clinical may not 
receive feedback on episode-based measures in both the fall of 2017 and 
the summer of 2018. We believe that receiving feedback on the new 
episode-based measures, along with the previously-finalized total per 
capita cost and MSPB measures, will support clinicians in their 
readiness for the proposed 2019 MIPS performance period.
    Section 1848(q)(5)(B)(i) of the Act requires the Secretary to treat 
any MIPS eligible clinician who fails to report on a required measure 
or activity as achieving the lowest potential score applicable to the 
measure or activity. Specifically, under our finalized scoring 
policies, an individual MIPS eligible clinician or group that reports 
on all required measures and activities could potentially obtain the 
highest score possible within the performance category, assuming they 
perform well on the measures and activities they report. An individual 
MIPS eligible clinician or group who does not submit data on a required 
measure or activity would receive a zero score for the unreported items 
in the performance category (in accordance with section 
1848(q)(5)(B)(i) of the Act). The individual MIPS eligible clinician or 
group could still obtain a relatively good score by performing very 
well on the remaining items, but a zero score would prevent the 
individual MIPS eligible clinician or group from obtaining the highest 
possible score within the performance category.
(3) Quality Data Submission Criteria
(a) Submission Criteria
(i) Submission Criteria for Quality Measures Excluding Groups Reporting 
via the CMS Web Interface and the CAHPS for MIPS Survey
    In the CY 2017 Quality Payment Program final rule (81 FR 77114), we 
finalized at Sec.  414.1335(a)(1) that individual MIPS eligible 
clinicians submitting data via claims and individual MIPS eligible 
clinicians and groups submitting data via all mechanisms (excluding the 
CMS Web Interface and the CAHPS for MIPS survey) are required to meet 
the following submission criteria. For the applicable period during the 
performance period, the individual MIPS eligible clinician or group 
will report at least six measures, including at least one outcome 
measure. If an applicable outcome measure is not available, the 
individual MIPS eligible clinician or group will be required to report 
one other high priority measure (appropriate use, patient safety, 
efficiency, patient experience, and care coordination measures) in lieu 
of an outcome measure. If fewer than six measures apply to the 
individual MIPS eligible clinician or group, then the individual MIPS 
eligible clinician or group would be required to report on each measure 
that is applicable. We defined ``applicable'' to mean measures relevant 
to a particular MIPS eligible clinician's services or care rendered. As 
discussed in section II.C.7.a.(2)(e)., we will only make determinations 
as to whether a sufficient number of measures are applicable for 
claims-based and registry submission mechanisms; we will not make this 
determination for EHR and QCDR submission mechanisms, for example.
    Alternatively, the individual MIPS eligible clinician or group will 
report one specialty measure set, or the measure set defined at the 
subspecialty level, if applicable. If the measure set contains fewer 
than six measures, MIPS eligible clinicians will be required to report 
all available measures within the set. If the measure set contains six 
or more measures, MIPS eligible clinicians will be required to report 
at least six measures within the set. Regardless of the number of 
measures that are contained in the measure set, MIPS eligible 
clinicians reporting on a measure set will be required to report at 
least one outcome measure or, if no outcome measures are available in 
the measure set, the MIPS eligible clinician will report another high 
priority measure (appropriate use, patient safety, efficiency, patient 
experience, and care coordination measures) within the measure set in 
lieu of an outcome measure. MIPS eligible clinicians may choose to 
report measures in addition to those contained in the specialty measure 
set and will not be penalized for doing so, provided that such MIPS 
eligible clinicians follow all requirements discussed here.
    In accordance with Sec.  414.1335(a)(1)(ii), individual MIPS 
eligible clinicians and groups will select their measures from either 
the set of all MIPS measures listed or referenced in Table A of the 
Appendix in this proposed rule or one of the specialty measure sets 
listed in Table B of the Appendix in this proposed rule. We note that 
some specialty measure sets include measures grouped by subspecialty; 
in these cases, the measure set is defined at the subspecialty level. 
Previously finalized quality measures may be found in the CY 2017 
Quality Payment Program final rule (81 FR 77558 through 77816).
    We also finalized the definition of a high priority measure at 
Sec.  414.1305 to mean an outcome, appropriate use, patient safety, 
efficiency, patient experience, or care coordination quality measure. 
Except as discussed in section II.C.6.b.(3)(a) of this proposed rule 
with regard to the CMS Web Interface and the CAHPS for MIPS survey, we 
are not proposing any changes to the submission criteria or definitions 
established for measures in this proposed rule.
    In the CY 2017 Quality Payment Program final rule (81 FR 77114), we 
solicited comments regarding adding a requirement to our finalized 
policy that patient-facing MIPS eligible clinicians would be required 
to report at least one cross-cutting measure in addition to the high 
priority measure requirement for further consideration for the Quality 
Payment Program Year 2 and future years. For clarification, we consider 
a cross-cutting measure to be any measure that is broadly applicable 
across multiple clinical settings and individual MIPS eligible 
clinicians or groups within a variety of specialties. We specifically 
requested feedback on how we could construct a cross-cutting measure 
requirement that would be most meaningful to MIPS eligible clinicians 
from different specialties and that would have the greatest impact on 
improving the health of populations. We received conflicting feedback 
on adding a future requirement for MIPS eligible clinicians to report 
at least one cross-cutting measure in the Quality Payment Program Year 
2 and future years.

[[Page 30039]]

    Many commenters agreed that cross-cutting measures are applicable 
across multiple clinical settings and that MIPS eligible clinicians 
within a variety of specialties should report at least one cross-
cutting measure. Some stated that cross-cutting measures promote shared 
accountability and improve the health of populations. Others 
recommended we continue to work with stakeholders and specialists, 
including solo and small practices, to develop cross-cutting measures 
for all settings, whether they be patient-facing or non-patient facing 
practices that are patient-centric (that is, following the patient and 
not the site of care) and recommended the term ``patient-centered 
measures'' rather than ``cross-cutting measures.'' In addition, some 
commenters stated we should consider measures that are 
multidisciplinary, foster cross-collaboration within virtual groups, 
improve patient outcomes, target high-cost areas, target areas with 
gaps in care, and include individual patient preferences in shared 
decision-making. A few commenters provided specific measures that they 
recommended utilizing as cross-cutting measures, such as: Screening for 
Hepatitis C; Controlling High Blood Pressure; Tobacco Use Cessation 
Counseling and Treatment; Advance Care Planning; or Medication 
Reconciliation. One commenter recommended we utilize shared 
accountability measures around surgical goals of care, shared decision 
making relying on some form of risk estimation such as a risk 
calculator, medication reconciliation, and a shared plan of care across 
clinicians. Another commenter suggested that instead of having a cross-
cutting measure requirement, we could use health IT as a cross-cutting 
requirement. Specifically, the commenter noted we could require that at 
least one measure using end-to-end electronic reporting, or that at 
least one measure be tied to an improvement activity the clinician is 
performing. Other commenters suggested that we provide bonus points to 
practices that elect to submit data on cross-cutting measures and hold 
harmless from any future cross-cutting measure requirements MIPS 
eligible clinicians who have less than 15 instances in the measure 
denominator during the performance period, allow MIPS eligible 
clinicians to use high-priority measures in the place of a cross-
cutting measure if necessary, and apply the guiding principles listed 
in NQF's ``Attribution: Principles and Approaches'' final report which 
may be found at http://www.qualityforum.org/ProjectDescription.aspx?projectID=80808.
    Other commenters appreciated our decision not to finalize the 
requirement to report a cross-cutting measure in the transition year 
and requested that we not require cross-cutting measures in the future, 
as they believed it is administratively burdensome for clinicians and 
QCDRs and removes focus and resources from quality measures that are 
more relevant to MIPS eligible clinicians' scope of practice and 
important to their patients' treatment and outcomes. They stated that 
PQRS demonstrated the challenge of identifying cross-cutting measures 
that are truly meaningful across different specialties and that truly 
have an impact on improving the health of populations. Some stated we 
should focus on high-priority measures over cross-cutting measures. A 
few commenters did not agree that cross-cutting measures were relevant 
and stated they should not be a requirement in MIPS until all MIPS 
eligible clinicians can successfully meet the current requirements. 
Others did not agree that QCDRs should be required to submit cross-
cutting measures because they believed that Congress did not intend for 
QCDRs to submit clinical process measures, that implementation may be 
complicated by practices that upgrade their health IT, and vendors have 
indicated it would take 12 to 18 months to implement system changes to 
support capture of cross-cutting measures. They also questioned the 
value of investing additional time and resources in this effort, 
especially if these cross-cutting measures are ultimately found to be 
topped out or removed. Others believed we should delay implementation 
until the Quality Payment Program Year 3 in order to allow MIPS 
eligible clinicians to focus on implementing new CEHRT requirements and 
modifying their processes to address lessons learned from reporting in 
the first 2 years.
    Except as discussed in section II.C.6.b.(3)(a)(iii). of this 
proposed rule with regard to the CAHPS for MIPS survey, we are not 
proposing any changes to the submission criteria for quality measures 
in this proposed rule. We thank the commenters for their feedback and 
will take the comments into consideration in future rulemaking. We 
welcome additional feedback on meaningful ways to incorporate cross-
cutting measurement into MIPS and the Quality Payment Program 
generally.
(ii) Submission Criteria for Quality Measures for Groups Reporting via 
the CMS Web Interface
    In the CY 2017 Quality Payment Program final rule (81 FR 77116), we 
finalized at Sec.  414.1335(a)(2) the following criteria for the 
submission of data on quality measures by registered groups of 25 or 
more eligible clinicians who want to report via the CMS Web Interface. 
For the applicable 12-month performance period, the group would be 
required to report on all measures included in the CMS Web Interface 
completely, accurately, and timely by populating data fields for the 
first 248 consecutively ranked and assigned Medicare beneficiaries in 
the order in which they appear in the group's sample for each module or 
measure. If the sample of eligible assigned beneficiaries is less than 
248, then the group would report on 100 percent of assigned 
beneficiaries. A group would be required to report on at least one 
measure for which there is Medicare patient data. Groups reporting via 
the CMS Web Interface are required to report on all of the measures in 
the set. Any measures not reported would be considered zero performance 
for that measure in our scoring algorithm. In addition, we are 
proposing to clarify that these criteria apply to groups of 25 or more 
eligible clinicians. Specifically, we propose to revise Sec.  
414.1335(a)(2)(i) to provide criteria applicable to groups of 25 or 
more eligible clinicians, report on all measures included in the CMS 
Web Interface. The group must report on the first 248 consecutively 
ranked beneficiaries in the sample for each measure or module.
    In the CY 2017 Quality Payment Program final rule (81 FR 77116), we 
finalized to continue to align the 2019 CMS Web Interface beneficiary 
assignment methodology with the attribution methodology for two of the 
measures that were formerly in the VM: The population quality measure 
discussed in the CY 2017 Quality Payment Program proposed rule (81 FR 
28188) and total per capita cost for all attributed beneficiaries 
discussed in the CY 2017 Quality Payment Program proposed rule (81 FR 
28196). When establishing MIPS, we also finalized a modified 
attribution process to update the definition of primary care services 
and to adapt the attribution to different identifiers used in MIPS. 
These changes are discussed in the CY 2017 Quality Payment Program 
proposed rule (81 FR 28196). We note that groups reporting via the CMS 
Web Interface may also report the CAHPS for MIPS survey and receive 
bonus points for submitting that

[[Page 30040]]

measure. We are not proposing any changes to the submission criteria 
for quality measures for groups reporting via the CMS Web Interface in 
this proposed rule.
(iii) Performance Criteria for Quality Measures for Groups Electing To 
Report Consumer Assessment of Healthcare Providers and Systems (CAHPS) 
for MIPS Survey
    In the CY 2017 Quality Payment Program final rule (81 FR 77100), we 
finalized at Sec.  414.1335(a)(3) the following criteria for the 
submission of data on the CAHPS for MIPS survey by registered groups 
via CMS-approved survey vendor: For the applicable 12-month performance 
period, a group that wishes to voluntarily elect to participate in the 
CAHPS for MIPS survey measure must use a survey vendor that is approved 
by CMS for a particular performance period to transmit survey measures 
data to CMS. The CAHPS for MIPS survey counts for one measure towards 
the MIPS quality performance category and, as a patient experience 
measure, also fulfills the requirement to report at least one high 
priority measure in the absence of an applicable outcome measure. In 
addition, groups that elect this data submission mechanism must select 
an additional group data submission mechanism (that is, qualified 
registries, QCDRs, EHR, etc.) in order to meet the data submission 
criteria for the MIPS quality performance category. The CAHPS for MIPS 
survey will count as one patient experience measure, and the group will 
be required to submit at least five other measures through one other 
data submission mechanism. A group may report any five measures within 
MIPS plus the CAHPS for MIPS survey to achieve the six measures 
threshold. We are not proposing any changes to the performance criteria 
for quality measures for groups electing to report the CAHPS for MIPS 
survey in this proposed rule.
    In the CY 2017 Quality Payment Program final rule (see 81 FR 
77120), we finalized retaining the CAHPS for MIPS survey administration 
period that was utilized for PQRS of November to February. However, 
this survey administration period has become operationally problematic 
for the administration of MIPS. In order to compute scoring, we must 
have the CAHPS for MIPS survey data earlier than the current survey 
administration period deadline allows. Therefore, we are proposing for 
the Quality Payment Program Year 2 and future years that the survey 
administration period would, at a minimum, span over 8 weeks and would 
end no later than February 28th following the applicable performance 
period. In addition, we propose to further specify the start and end 
timeframes of the survey administration period through our normal 
communication channels.
    In addition, as discussed in the CY 2017 Quality Payment Program 
final rule (81 FR 77116), we anticipated exploring the possibility of 
updating the CAHPS for MIPS survey under MIPS, specifically not 
finalizing all of the proposed Summary Survey Measures (SSMs). The 
CAHPS for MIPS survey currently consists of the core CAHPS Clinician & 
Group (CG-CAHPS) Survey developed by the Agency for Healthcare Research 
and Quality (AHRQ), plus additional survey questions to meet CMS's 
program needs. We are proposing for the Quality Payment Program Year 2 
and future years to remove two SSMs, specifically, ``Helping You to 
Take Medication as Directed'' and ``Between Visit Communication'' from 
the CAHPS for MIPS survey. We are proposing to remove the SSM entitled 
``Helping You to Take Medication as Directed'' due to low reliability. 
In 2014 and 2015, the majority of groups had very low reliability on 
this SSM. Furthermore, based on analyses conducted of SSMs in an 
attempt to improve their reliability, removing questions from this SSM 
did not result in any improvements in reliability. The SSM, ``Helping 
You to Take Medication as Directed,'' has also never been a scored 
measure with the Medicare Shared Savings Program CAHPS for Accountable 
Care Organizations (ACOs) Survey. We refer readers to the CY 2014 
Physician Fee Schedule final rule for a discussion on the CAHPS for ACO 
survey scoring (79 FR 67909 through 67910) and measure tables (79 FR 
67916 through 67917). The SSM entitled ``Between Visit Communication'' 
currently contains only one question. This question could also be 
considered related to other SSMs entitled: ``Care Coordination'' or 
``Courteous and Helpful Office Staff,'' but does not directly overlap 
with any of the questions under that SSM. However, we are proposing to 
remove this SSM in order to maintain consistency with the Medicare 
Shared Savings Program which, utilizes the CAHPS for Accountable Care 
Organizations (ACOs) Survey. The SSM entitled ``Between Visit 
Communication'' has never been a scored measure with the Medicare 
Shared Savings Program CAHPS for ACOs Survey.
    In addition to public comments we receive, we will also take into 
consideration analysis we will be conducting before finalizing this 
proposal. Specifically, we will review the findings of the CAHPS for 
ACO survey pilot, which was administered from November 2016 through 
February 2017. The CAHPS for ACO survey pilot utilized a survey 
instrument which did not contain the two SSMs we are proposing for 
removal from the CAHPS for MIPS survey. For more information on the 
other SSMs within the CAHPS for MIPS survey, please see the explanation 
of the CAHPS for PQRS survey in the CY 2016 PFS final rule with comment 
period (80 FR 71142 through 71143).

 Table 4--Proposed Summary Survey Measures (SSMs) Included in the CAHPS
                             for MIPS Survey
------------------------------------------------------------------------
                     Summary survey measures (SSMs)
-------------------------------------------------------------------------
Getting Timely Care, Appointments, and Information.
How Well Providers Communicate.
Patient's Rating of Provider.
Access to Specialists.
Health Promotion and Education.
Shared Decision-Making.
Health Status and Functional Status.
Courteous and Helpful Office Staff.
Care Coordination.
Stewardship of Patient Resources.
------------------------------------------------------------------------

    We are seeking comment on expanding the patient experience data 
available for the CAHPS for MIPS survey. Currently, the CAHPS for MIPS 
survey is available for groups to report under the MIPS. The patient 
experience survey data that is available on Physician Compare is highly 
valued by patients and their caregivers as they evaluate their health 
care options. However, in user testing with patients and caregivers in 
regard to the Physician Compare Web site, the users regularly ask for 
more information from patients like them in their own words. Patients 
regularly request that we include narrative reviews of individual 
clinicians and groups on the Web site. AHRQ is fielding a beta version 
of the CAHPS Patient Narrative Elicitation Protocol (https://www.ahrq.gov/cahps/surveys-guidance/item-sets/elicitation/index.html). 
This includes five open-ended questions designed to be added to the CG 
CAHPS survey, after which the CAHPS for MIPS survey is modeled. These 
five questions have been developed and tested in order to capture 
patient narratives in a scientifically grounded and rigorous way, 
setting it apart from other patient narratives collected by various 
health systems and patient rating sites. More scientifically rigorous 
patient narrative data would not only greatly benefit patients in their

[[Page 30041]]

decision for healthcare, but it would also greatly aid individual MIPS 
eligible clinicians and groups as they assess how their patients 
experience care. We are seeking comment on adding these five open-ended 
questions to the CAHPS for MIPS survey in future rulemaking. Beta 
testing is an ongoing process, and we anticipate reviewing the results 
of that testing in collaboration with AHRQ before proposing changes to 
the CAHPS for MIPS survey.
    We are requiring, where possible, all-payer data for all reporting 
mechanisms, yet certain reporting mechanisms are limited to Medicare 
Part B data. Specifically, the CAHPS for MIPS survey currently relies 
on sampling protocols based on Medicare Part B billing; therefore, only 
Medicare Part B beneficiaries are sampled through that methodology. In 
the CY 2017 Quality Payment Program proposed rule (81 FR 28189), we 
requested comments on ways to modify the methodology to assign and 
sample patients for these mechanisms using data from other payers. We 
received mixed feedback on the use of all-payer data overall. The full 
discussion of the comments and the responses can be found in the CY 
2017 Quality Payment Program final rule (81 FR 77123 through 77125). We 
are requesting additional comments on ways to modify the methodology to 
assign and sample patients using data from other payers for reporting 
mechanisms that are currently limited to Medicare Part B data. In 
particular, we are seeking comment on the ability of groups to provide 
information on the patients to whom they provide care during a calendar 
year, whether it would be possible to identify a list of patients seen 
by individual clinicians in the group, and what type of patient contact 
information groups would be able to provide. Further, we would like to 
seek comment on the challenges groups may anticipate in trying to 
provide this type of information, especially for vulnerable beneficiary 
populations, such as those lacking stable housing. We are also seeking 
comment on EHR vendors' ability to provide information on the patients 
who receive care from their client groups.
(b) Data Completeness Criteria
    In the CY 2017 Quality Payment Program final rule (81 FR 77125), we 
finalized data completeness criteria for the transition year and MIPS 
payment year 2020. We finalized at Sec.  414.1340 the data completeness 
criteria below for performance periods occurring in 2017.
     Individual MIPS eligible clinicians or groups submitting 
data on quality measures using QCDRs, qualified registries, or via EHR 
must report on at least 50 percent of the individual MIPS eligible 
clinician or group's patients that meet the measure's denominator 
criteria, regardless of payer for the performance period. In other 
words, for these submission mechanisms, we expect to receive quality 
data for both Medicare and non-Medicare patients. For the transition 
year, MIPS eligible clinicians whose measures fall below the data 
completeness threshold of 50 percent would receive 3 points for 
submitting the measure.
     Individual MIPS eligible clinicians submitting data on 
quality measures data using Medicare Part B claims, would report on at 
least 50 percent of the Medicare Part B patients seen during the 
performance period to which the measure applies. For the transition 
year, MIPS eligible clinicians whose measures fall below the data 
completeness threshold of 50 percent would receive 3 points for 
submitting the measure.
     Groups submitting quality measures data using the CMS Web 
Interface or a CMS-approved survey vendor to report the CAHPS for MIPS 
survey must meet the data submission requirements on the sample of the 
Medicare Part B patients CMS provides.
    In addition, we finalized an increased data completeness threshold 
of 60 percent for MIPS for performance periods occurring in 2018 for 
data submitted on quality measures using QCDRs, qualified registries, 
via EHR, or Medicare Part B claims. We noted that these thresholds for 
data submitted on quality measures using QCDRs, qualified registries, 
via EHR, or Medicare Part B claims would increase for performance 
periods occurring in 2019 and onward.
    We are proposing to modify the previously established data 
completeness criteria for MIPS payment year 2020. Specifically, we 
would like to provide an additional year for individual MIPS eligible 
clinicians and groups to gain experience with MIPS before increasing 
the data completeness thresholds for data submitted on quality measures 
using QCDRs, qualified registries, via EHR, or Medicare Part B claims. 
We are concerned about the unintended consequences of accelerating the 
data completeness threshold so quickly, which may jeopardize MIPS 
eligible clinicians' ability to participate and perform well under the 
MIPS, particularly those clinicians who are least experienced with MIPS 
quality measure data submission. We want to ensure that an appropriate 
yet achievable level of data completeness is applied to all MIPS 
eligible clinicians. We continue to believe it is important to 
incorporate higher data completeness thresholds in future years to 
ensure a more accurate assessment of a MIPS eligible clinician's 
performance on quality measures and to avoid any selection bias. 
Therefore, we propose, below, a 60 percent data completeness threshold 
for MIPS payment year 2021. We strongly encourage all MIPS eligible 
clinicians to perform the quality actions associated with the quality 
measures on their patients. The data submitted for each measure is 
expected to be representative of the individual MIPS eligible 
clinician's or group's overall performance for that measure. The data 
completeness threshold of less than 100 percent is intended to reduce 
burden and accommodate operational issues that may arise during data 
collection during the initial years of the program. We are providing 
this notice to MIPS eligible clinicians so that they can take the 
necessary steps to prepare for higher data completeness thresholds in 
future years.
    Therefore, we propose to revise the data completeness criteria for 
the quality performance category at Sec.  414.1340(a)(2) to provide 
that MIPS eligible clinicians and groups submitting quality measures 
data using the QCDR, qualified registry, or EHR submission mechanism 
must submit data on at least 50 percent of the individual MIPS eligible 
clinician's or group's patients that meet the measure's denominator 
criteria, regardless of payer, for MIPS payment year 2020. We also 
propose to revise the data completeness criteria for the quality 
performance category at Sec.  414.1340(b)(2) to provide that MIPS 
eligible clinicians and groups submitting quality measures data using 
Medicare Part B claims, must submit data on at least 50 percent of the 
applicable Medicare Part B patients seen during the performance period 
to which the measure applies for MIPS payment year 2020. We further 
propose at Sec.  414.1340(a)(3), that MIPS eligible clinicians and 
groups submitting quality measures data using the QCDR, qualified 
registry, or EHR submission mechanism must submit data on at least 60 
percent of the individual MIPS eligible clinician or group's patients 
that meet the measure's denominator criteria, regardless of payer for 
MIPS payment year 2021. We also propose at Sec.  414.1340(b)(3), that 
MIPS eligible clinicians and groups submitting quality measures data 
using Medicare Part B claims, must submit data on at least 60 percent 
of the applicable Medicare Part

[[Page 30042]]

B patients seen during the performance period to which the measure 
applies for MIPS payment year 2021. We would like to note that we 
anticipate for future MIPS payment years we will propose to increase 
the data completeness threshold for data submitted using QCDRs, 
qualified registries, EHR submission mechanisms, or Medicare Part B 
claims. As MIPS eligible clinicians gain experience with the MIPS, we 
would propose to steadily increase these thresholds for future years 
through rulemaking. In addition, we are seeking comment on what data 
completeness threshold should be established for future years.
    In the CY 2017 Quality Payment Program final rule (81 FR 77125 
through 77126), we finalized our approach of including all-payer data 
for the QCDR, qualified registry, and EHR submission mechanisms because 
we believed this approach provides a more complete picture of each MIPS 
eligible clinician's scope of practice and provides more access to data 
about specialties and subspecialties not currently captured in PQRS. In 
addition, those clinicians who utilize a QCDR, qualified registry, or 
EHR submission must contain a minimum of one quality measure for at 
least one Medicare patient. We are not proposing any changes to these 
policies in this proposed rule. As noted in the CY 2017 Quality Payment 
Program final rule, those MIPS eligible clinicians who fall below the 
data completeness thresholds will receive 3 points for the specific 
measures that fall below the data completeness threshold in the 
transition year of MIPS only. For the Quality Payment Program Year 2, 
we are proposing that MIPS eligible clinicians would receive 1 point 
for measures that fall below the data completeness threshold, with an 
exception for small practices of 15 or fewer who would still receive 3 
points for measures that fail data completeness. We refer readers to 
section II.C.6.b.(3)(b) of this proposed rule for our proposed policies 
on instances when MIPS eligible clinicians' measures fall below the 
data completeness threshold.
(c) Summary of Data Submission Criteria
    Table 5 reflects our proposed quality data submission criteria for 
MIPS payment year 2020 via Medicare Part B claims, QCDR, qualified 
registry, EHR, CMS Web Interface, and the CAHPS for MIPS survey. It is 
important to note that while we finalized at Sec.  414.1325(d) in the 
CY 2017 Quality Payment Program final rule that individual MIPS 
eligible clinicians and groups may only use one submission mechanism 
per performance category, in section II.C.6.a.(1) of this rule, we are 
proposing to revise Sec.  414.1325(d) for purposes of the 2020 MIPS 
payment year and future years to allow individual MIPS eligible 
clinicians and groups to submit measures and activities, as applicable, 
via as many submission mechanisms as necessary to meet the requirements 
of the quality, improvement activities, or advancing care information 
performance categories. We refer readers to section II.C.6.a.(1) of 
this proposed rule for further discussion of this proposal.

   Table 5--Summary of Proposed Quality Data Submission Criteria for MIPS Payment Year 2020 via Part B Claims,
                 QCDR, Qualified Registry, EHR, CMS Web Interface, and the CAHPS for MIPS Survey
----------------------------------------------------------------------------------------------------------------
                                                          Submission          Submission
       Performance period           Clinician type         mechanism           criteria        Data completeness
----------------------------------------------------------------------------------------------------------------
Jan 1-Dec 31....................  Individual MIPS     Part B Claims.....  Report at least     50 percent of
                                   eligible                                six measures        individual MIPS
                                   clinicians.                             including one       eligible
                                                                           outcome measure,    clinician's
                                                                           or if an outcome    Medicare Part B
                                                                           measure is not      patients for the
                                                                           available report    performance
                                                                           another high        period.
                                                                           priority measure;
                                                                           if less than six
                                                                           measures apply
                                                                           then report on
                                                                           each measure that
                                                                           is applicable.
                                                                           Individual MIPS
                                                                           eligible
                                                                           clinicians would
                                                                           have to select
                                                                           their measures
                                                                           from either the
                                                                           set of all MIPS
                                                                           measures listed
                                                                           or referenced in
                                                                           Table A or one of
                                                                           the specialty
                                                                           measure sets
                                                                           listed in Table B
                                                                           of the Appendix
                                                                           in this proposed
                                                                           rule.
Jan 1-Dec 31....................  Individual MIPS     QCDR, Qualified     Report at least     50 percent of
                                   eligible            Registry, & EHR.    six measures        individual MIPS
                                   clinicians,                             including one       eligible
                                   groups or virtual                       outcome measure,    clinician's,
                                   groups.                                 or if an outcome    group's, or
                                                                           measure is not      virtual group's
                                                                           available report    patients across
                                                                           another high        all payers for
                                                                           priority measure;   the performance
                                                                           if less than six    period.
                                                                           measures apply
                                                                           then report on
                                                                           each measure that
                                                                           is applicable.
                                                                           Individual MIPS
                                                                           eligible
                                                                           clinicians,
                                                                           groups, or
                                                                           virtual groups
                                                                           would have to
                                                                           select their
                                                                           measures from
                                                                           either the set of
                                                                           all MIPS measures
                                                                           listed or
                                                                           referenced in
                                                                           Table A or one of
                                                                           the specialty
                                                                           measure sets
                                                                           listed in Table B
                                                                           of the Appendix
                                                                           in this proposed
                                                                           rule.
Jan 1-Dec 31....................  Groups or virtual   CMS Web Interface.  Report on all       Sampling
                                   groups.                                 measures included   requirements for
                                                                           in the CMS Web      the group's or
                                                                           Interface; AND      virtual group's
                                                                           populate data       Medicare Part B
                                                                           fields for the      patients.
                                                                           first 248
                                                                           consecutively
                                                                           ranked and
                                                                           assigned Medicare
                                                                           beneficiaries in
                                                                           the order in
                                                                           which they appear
                                                                           in the group's or
                                                                           virtual group's
                                                                           sample for each
                                                                           module/measure.
                                                                           If the pool of
                                                                           eligible assigned
                                                                           beneficiaries is
                                                                           less than 248,
                                                                           then the group or
                                                                           virtual group
                                                                           would report on
                                                                           100 percent of
                                                                           assigned
                                                                           beneficiaries.

[[Page 30043]]

 
Jan 1-Dec 31....................  Groups or virtual   CAHPS for MIPS      CMS-approved        Sampling
                                   groups.             Survey.             survey vendor       requirements for
                                                                           would need to be    the group's or
                                                                           paired with         virtual group's
                                                                           another reporting   Medicare Part B
                                                                           mechanism to        patients.
                                                                           ensure the
                                                                           minimum number of
                                                                           measures is
                                                                           reported. CAHPS
                                                                           for MIPS survey
                                                                           would fulfill the
                                                                           requirement for
                                                                           one patient
                                                                           experience
                                                                           measure towards
                                                                           the MIPS quality
                                                                           data submission
                                                                           criteria. CAHPS
                                                                           for MIPS survey
                                                                           would only count
                                                                           for one measure
                                                                           under the quality
                                                                           performance
                                                                           category.
----------------------------------------------------------------------------------------------------------------

    As discussed in section II.C.4.d. of this proposed rule, we are 
proposing to generally apply our previously finalized and proposed 
group policies to virtual groups.
(4) Application of Quality Measures to Non-Patient Facing MIPS Eligible 
Clinicians
    In the CY 2017 Quality Payment Program final rule (81 FR 77127), we 
finalized at Sec.  414.1335 that non-patient facing MIPS eligible 
clinicians would be required to meet the applicable submission criteria 
that apply for all MIPS eligible clinicians for the quality performance 
category. We are not proposing any changes to this policy in this 
proposed rule.
(5) Application of Facility-Based Measures
    Section 1848(q)(2)(C)(ii) of the Act provides that the Secretary 
may use measures used for payment systems other than for physicians, 
such as measures used for inpatient hospitals, for purposes of the 
quality and cost performance categories. However, the Secretary may not 
use measures for hospital outpatient departments, except in the case of 
items and services furnished by emergency physicians, radiologists, and 
anesthesiologists. We refer readers to section II.C.7.a.(4) of this 
proposed rule for a full discussion of our proposals regarding the 
application of facility-based measures.
(6) Global and Population-Based Measures
    In the CY 2017 Quality Payment Program final rule (81 FR 77136), we 
did not finalize all of our proposals on global and population-based 
measures as part of the quality score. Specifically, we did not 
finalize our proposal to use the acute and chronic composite measures 
of the AHRQ Prevention Quality Indicators (PQIs). We agreed with 
commenters that additional enhancements, including the addition of risk 
adjustment, needed to be made to these measures prior to inclusion in 
MIPS. We did, however, calculate these measures at the TIN level, 
through the QRURs released in September 2016, and this data can be used 
by MIPS eligible clinicians for informational purposes.
    We did finalize the all-cause hospital readmissions (ACR) measure 
from the VM Program as part of the quality measure domain for the MIPS 
total performance score. We finalized this measure with the following 
modifications. We did not apply the ACR measure to solo practices or 
small groups (groups of 15 or less). We did apply the ACR measure to 
groups of 16 or more who meet the case volume of 200 cases. A group was 
scored on the ACR measure even if it did not submit any quality 
measures, if it submitted in other performance categories. Otherwise, 
the group was not scored on the readmission measure if it did not 
submit data in any of the performance categories. In our transition 
year policies, the readmission measure alone would not produce a 
neutral to positive MIPS payment adjustment since in order to achieve a 
neutral to positive MIPS payment adjustment, an individual MIPS 
eligible clinician or group must submit information on one of the three 
performance categories as discussed in the CY 2017 Quality Payment 
Program final rule (81 FR 77329). In addition, the ACR measure in the 
MIPS transition year CY 2017 was based on the performance period 
(January 1, 2017 through December 31, 2017). However, for MIPS eligible 
clinicians who did not meet the minimum case requirements, the ACR 
measure was not applicable. We are not proposing any changes for the 
global and population-based measures in this proposed rule. As 
discussed in section II.C.4.d. of this rule, we are proposing to 
generally apply our previously finalized and proposed group policies to 
virtual groups.
c. Selection of MIPS Quality Measures for Individual MIPS Eligible 
Clinicians and Groups Under the Annual List of Quality Measures 
Available for MIPS Assessment
(1) Background and Policies for the Call for Measures and Measure 
Selection Process
    Under section 1848(q)(2)(D)(i) of the Act, the Secretary, through 
notice and comment rulemaking, must establish an annual list of MIPS 
quality measures from which MIPS eligible clinicians may choose for 
purposes of assessment for a performance period. The annual list of 
MIPS quality measures must be published in the Federal Register no 
later than November 1 of the year prior to the first day of a 
performance period. Updates to the annual list of MIPS quality measures 
must be published in the Federal Register no later than November 1 of 
the year prior to the first day of each subsequent performance period. 
Updates may include the addition of new MIPS quality measures, 
substantive changes to MIPS quality measures, and removal of MIPS 
quality measures. MIPS eligible clinicians reporting on the quality 
performance category are required to use the most recent version of the 
clinical quality measure (CQM) electronic specifications as indicated 
in the CY 2017 Quality Payment Program final rule (81 FR 77291). For 
purposes of the 2018 MIPS performance period, the spring 2017 version 
of the eCQM annual update to the measure specifications and any 
applicable addenda are available on the electronic clinical quality 
improvement (eCQI) Resource Center Web site at https://ecqi.healthit.gov. The CMS Quality Measure Development Plan (MDP) 
serves as a strategic framework for the future of the clinician quality 
measure development to support MIPS and APMs. The MDP is available on 
the CMS Web site and highlights known measurement gaps and recommends

[[Page 30044]]

approaches to close those gaps through development, use, and refinement 
of quality measures that address significant variation in performance 
gaps. We encourage stakeholders to develop additional quality measures 
for MIPS that would address the gaps.
    Under section 1848(q)(2)(D)(ii) of the Act, the Secretary must 
solicit a ``Call for Quality Measures'' each year. Specifically, the 
Secretary must request that eligible clinician organizations and other 
relevant stakeholders identify and submit quality measures to be 
considered for selection in the annual list of MIPS quality measures, 
as well as updates to the measures. Under section 1848(q)(2)(D)(ii) of 
the Act, eligible clinician organizations are professional 
organizations as defined by nationally recognized specialty boards of 
certification or equivalent certification boards. However, we do not 
believe there needs to be any special restrictions on the type or make-
up of the organizations that submit measures for consideration through 
the call for measures. Any such restriction would limit the type of 
quality measures and the scope and utility of the quality measures that 
may be considered for inclusion under the MIPS.
    As we described previously in the CY 2017 Quality Payment Program 
final rule (81 FR 77137), we will accept quality measures submissions 
at any time, but only measures submitted during the timeframe provided 
by us through the pre-rulemaking process of each year will be 
considered for inclusion in the annual list of MIPS quality measures 
for the performance period beginning 2 years after the measure is 
submitted. This process is consistent with the pre-rulemaking process 
and the annual call for measures, which are further described at 
(https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Pre-Rule-Making.html).
    Submission of potential quality measures, regardless of whether 
they were previously published in a proposed rule or endorsed by an 
entity with a contract under section 1890(a) of the Act, which is 
currently the National Quality Forum, is encouraged. The annual Call 
for Measures process allows eligible clinician organizations and other 
relevant stakeholder organizations to identify and submit quality 
measures for consideration. Presumably, stakeholders would not submit 
measures for consideration unless they believe that the measure is 
applicable to clinicians and can be reliably and validly measured at 
the individual clinician level. The NQF-convened Measure Application 
Partnership (MAP) provides an additional opportunity for stakeholders 
to provide input on whether or not they believe the measures are 
applicable to clinicians as well as feasible, scientifically 
acceptable, and reliable and valid at the clinician level. Furthermore, 
we must go through notice and comment rulemaking to establish the 
annual list of quality measures, which gives stakeholders an additional 
opportunity to review the measures and provide input on whether or not 
they believe the measures are applicable to clinicians, as well as 
feasible, scientifically acceptable, and reliable and valid at the 
clinician level. Additionally, we are required by statute to submit new 
measures to an applicable specialty-appropriate, peer-reviewed journal.
    As previously noted, we encourage the submission of potential 
quality measures regardless of whether such measures were previously 
published in a proposed rule or endorsed by an entity with a contract 
under section 1890(a) of the Act. However, we propose to request that 
stakeholders apply the following considerations when submitting quality 
measures for possible inclusion in MIPS:
     Measures that are not duplicative of an existing or 
proposed measure.
     Measures that are beyond the measure concept phase of 
development and have started testing, at a minimum, with strong 
encouragement and preference for measures that complete or are near 
completion of reliability and validity testing.
     Measures that include a data submission method beyond 
claims-based data submission.
     Measures that are outcome-based rather than clinical 
process measures.
     Measures that address patient safety and adverse events.
     Measures that identify appropriate use of diagnosis and 
therapeutics.
     Measures that address the domain for care coordination.
     Measures that address the domain for patient and caregiver 
experience.
     Measures that address efficiency, cost, and resource use.
     Measures that address significant variation in 
performance.
    We will apply these considerations when considering quality 
measures for possible inclusion in MIPS.
    In addition, we note that we are likely to reject measures that do 
not provide substantial evidence of variation in performance; for 
example, if a measure developer submits data showing a small variation 
in performance among a group already composed of high performers, such 
evidence would not be substantial enough to assure us that sufficient 
variation in performance exists. We also note that we are likely to 
reject measures that are not outcome-based measures, unless (1) there 
is substantial documented and peer reviewed evidence that the clinical 
process measured varies directly with the outcome of interest and (2) 
it is not possible to measure the outcome of interest in a reasonable 
timeframe.
    We also note that retired measures that were in one of CMS's 
previous quality programs, such as the Physician Quality Reporting 
System (PQRS) program, will likely be rejected if proposed for 
inclusion. This includes measures that were retired due to being topped 
out, as defined below. For example, measures may be retired due to 
attaining topped out status because of high performance, or measures 
that are retired due to a change in the evidence supporting their use.
    In the CY 2017 Quality Payment Program final rule (81 FR 77153), we 
established that we will categorize measures into the six NQS domains 
(patient safety, person- and caregiver-centered experience and 
outcomes, communication and care coordination, effective clinical care, 
community/population health, and efficiency and cost reduction). We 
intend to submit future MIPS quality measures to the NQF-convened 
Measure Application Partnership's (MAP), as appropriate, and we intend 
to consider the MAP's recommendations as part of the comprehensive 
assessment of each measure considered for inclusion under MIPS.
    In the CY 2017 Quality Payment Program final rule (81 FR 77155), we 
established that we use the Call for Quality Measures process as a 
forum to gather the information necessary to draft the journal articles 
for submission from measure developers, measure owners and measure 
stewards since we do not always develop measures for the quality 
programs. The submission of this information does not preclude us from 
conducting our own research using Medicare claims data, Medicare survey 
results, and other data sources that we possess. We submit new measures 
for publication in applicable specialty-appropriate, peer-reviewed 
journals before including such measures in the final annual list of 
quality measures.
    In the CY 2017 Quality Payment Program final rule (81 FR 77158), we 
established at Sec.  414.1330(a)(2) that for purposes of assessing 
performance of MIPS eligible clinicians on the quality performance 
category, we use quality measures developed by QCDRs. In the 
circumstances where a QCDR wants to

[[Page 30045]]

use a QCDR measure for inclusion in the MIPS program for reporting, 
those measures go through a CMS approval process during the QCDR self-
nomination period. We also established that we post the quality 
measures for use by QCDRs by no later than January 1 for performance 
periods occurring in 2018 and future years.
    Previously finalized MIPS quality measures can be found in the CY 
2017 Quality Payment Program final rule (81 FR 77558 through 77675). 
Updates may include the proposal to add new MIPS quality measures, 
including measures selected 2 years ago during the Call for Measures 
process. The new MIPS quality measures proposed for inclusion in MIPS 
for the 2018 performance period and future years are found in Table A. 
The proposed new and modified MIPS specialty sets for the 2018 
performance period and future years are listed in Table B, and include 
existing measures that are proposed with modifications, new measures, 
and measures finalized in the CY 2017 Quality Payment Program final 
rule. We note that the modifications made to the specialty sets may 
include the removal of certain quality measures that were previously 
finalized. The specialty measure sets should be used as a guide for 
eligible clinicians to choose measures applicable to their specialty. 
To clarify, some of the MIPS specialty sets have further defined 
subspecialty sets, each of which is effectively a separate specialty 
set. In instances where an individual MIPS eligible clinician or group 
reports on a specialty or subspecialty set, if the set has less than 
six measures, that is all the clinician is required to report. MIPS 
eligible clinicians are not required to report on the specialty measure 
sets, but they are suggested measures for specific specialties. 
Throughout measure utilization, measure maintenance should be a 
continuous process done by the measure owners, to include environmental 
scans of scientific literature about the measure. New information 
gathered during this ongoing review may trigger an ad hoc review. The 
specialty measure sets in Table B of the Appendix, include existing 
measures that are proposed with modifications, new measures, and 
measures that were previously finalized in the CY 2017 Quality Payment 
Program final rule. Please note that these specialty specific measure 
sets are not all inclusive of every specialty or subspecialty. On 
January 25, 2017, we announced that we would be accepting 
recommendations for potential new specialty measure sets for year 2 of 
MIPS under the Quality Payment Program. These recommendations were 
based on the MIPS quality measures finalized in the CY 2017 Quality 
Payment Program final rule, and include recommendations to add or 
remove the current MIPS quality measures from the specialty measure 
sets. The current specialty measure sets can be found on the Quality 
Payment Program Web site at https://qpp.cms.gov/measures/quality. All 
specialty measure sets submitted for consideration were assessed to 
ensure that they met the needs of the Quality Payment Program.
    As a result, we propose to add new quality measures to MIPS (Table 
A), revise the specialty measure sets in MIPS (Table B), remove 
specific MIPS quality measures only from specialty sets (Table C.1), 
and propose to remove specific MIPS quality measures from the MIPS 
program for the 2018 performance period (Table C.2). The aforementioned 
measure tables can be found in the Appendix of this proposed rule. In 
addition, we are proposing to also remove cross cutting measures from 
most of the specialty sets. Specialty groups and societies reported 
that cross cutting measures may or may not be relevant to their 
practices, contingent on the eligible clinicians or groups. CMS chose 
to retain the cross cutting measures in Family Practice, Internal 
Medicine and Pediatrics specialty sets because they are frequently used 
in these practices. The proposed 2017 cross cutting measures, (81 FR 
28447 through 28449), were compiled and placed in a separate table for 
eligible clinicians to elect to use or not, for reporting. To clarify, 
the cross-cutting measures are intended to provide clinicians with a 
list of measures that are broadly applicable to all clinicians 
regardless of the clinician's specialty. Even though it is not required 
to report on cross-cutting measures, it is provided as a reference to 
clinicians who are looking for additional measures to report outside 
their specialty. We continue to consider cross-cutting measures to be 
an important part of our quality measure programs, and seek comment on 
ways to incorporate cross-cutting measures into MIPS in the future. The 
proposed Table of Cross-Cutting Measures can be found in Table D of the 
Appendix.
    For MIPS quality measures that are undergoing substantive changes, 
we propose to identify measures including, but not limited to measures 
that have had measure specification, measure title, and domain changes. 
MIPS quality measures with proposed substantive changes can be found at 
Table E of the Appendix.
    The measures that would be used for the APM scoring standard and 
our authority for waiving certain measure requirements are described in 
section II.C.6.g.(3)(b)(ii) and the measures that would be used to 
calculate a quality score for the APM scoring standard are proposed in 
Tables 14, 15, and 16.
    We also seek comment for this rule, on whether there are any MIPS 
quality measures that commenters believe should be classified in a 
different NQS domain than what is being proposed, or that should be 
classified as a different measure type (for example, process vs. 
outcome) than what is being proposed in this rule.
(2) Topped Out Measures
    As defined in the CY 2017 Quality Payment Program final rule at (81 
FR 77136), a measure may be considered topped out if measure 
performance is so high and unvarying that meaningful distinctions and 
improvement in performance can no longer be made. Topped out measures 
could have a disproportionate impact on the scores for certain MIPS 
eligible clinicians, and provide little room for improvement for the 
majority of MIPS eligible clinicians. We refer readers to section 
II.C.7.a.(2)(c) of this proposed rule for additional information 
regarding the scoring of topped out measures.
    We noted in the CY 2017 Quality Payment Program final rule that we 
anticipate removing topped out measures over time and sought comment on 
what point in time we should remove topped out measures from MIPS (81 
FR 77286). We received the following comments.
    Many commenters recommended that we retain topped out quality 
measures for 2 or more years because commenters believed they serve to 
motivate continued high-quality care; more clinicians may participate 
in MIPS compared to prior programs such as PQRS, and thus there may be 
more performance variation in MIPS showing that the measure is not 
actually topped out; declines in performance will not be captured if a 
measure is eliminated; it will help provide stability and encourage 
reporting in the early years of the MIPS program; removing topped out 
measures could further limit the number of measures available to 
specialists; and providing eligible clinicians and the public with 
information about high performance is as important as informing them 
about deficits.
    A few commenters recommended that we publish information about 
topped out and potentially topped out measures prior to the performance 
period to allow clinicians time to adjust their reporting

[[Page 30046]]

strategies, with one commenter noting that improvement may be rewarded 
in addition to achievement. One commenter recommended pushing back the 
baseline performance period for the purpose of identifying topped out 
measures to 2018 because in the transition year it is unclear how many 
eligible clinicians will be reporting at different times and for what 
time period they will report.
    Finally, a few commenters recommended that we consider specialty, 
case mix, and rural location before determining that a measure is 
topped out, specifically whether there is still room for improvement 
among certain specialist groups and to ensure that rural provider 
improvement is recognized. One commenter recommended that we determine 
topped out measures based on reporting in the Quality Payment Program 
rather than PQRS or value modifier reporting because the commenter 
believed using historical performance disadvantages small groups. A few 
commenters requested that the process for identifying and determining 
the removal of topped out measures be transparent, evidence-based, 
patient-centered, and include feedback from all appropriate 
stakeholders, including the medical community and measures owner. A few 
commenters specifically recommended that determining whether to remove 
a topped out measure be part of a rulemaking process while another 
commenter suggested that we seek out stakeholder input from the Measure 
Applications Partnership (MAP) on whether a measure should be removed, 
awarded lower points, or remain with benchmarks as a flat percentage.
    We propose a 3-year timeline for identifying and proposing to 
remove topped out measures. After a measure has been identified as 
topped out for three consecutive years, we may propose to remove the 
measure through comment and rulemaking for the 4th year. Therefore, in 
the 4th year, if finalized through rulemaking, the measure would be 
removed and would no longer be available for reporting during the 
performance period. This proposal provides a path toward removing 
topped out measures over time, and will apply to the MIPS quality 
measures. QCDR measures that consistently are identified as topped out 
according to the same timeline as proposed below, would not be approved 
for use in year 4 during the QCDR self-nomination review process, and 
would not go through the comment and rulemaking process described 
below.
    We propose to phase in this policy starting with a select set of 
six highly topped out measures identified in section II.C.7.a.(2)(c) of 
this proposed rule. In section II.C.7.a.(2)(c) of this proposed rule, 
we are also proposing to phase in special scoring for measures 
identified as topped out in the published benchmarks for two 
consecutive performance periods, starting with the select set of highly 
topped out measures for the 2018 MIPS performance period. An example 
illustrating the proposed timeline for the removal and special scoring 
of topped out measures, as it would be applied to the select set of 
highly topped out measures identified in section II.C.7.a.(2)(c), is as 
follows:
     Year 1: The measures are identified as topped out in the 
benchmarks published for the 2017 MIPS performance Period. The 2017 
benchmarks are posted on the Quality Payment Program Web site: https://qpp.cms.gov/resources/education.
     Year 2: Measures are identified as topped out in the 
benchmarks published for the 2018 MIPS performance period. We refer 
readers to section II.C.7.a.(2)(c) of this proposed rule for additional 
information regarding the scoring of topped out measures.
     Year 3: Measures are identified as topped out in the 
benchmarks published for the 2019 MIPS performance period. The measures 
identified as topped out in the benchmarks published for the 2019 MIPS 
performance period and the previous two consecutive performance periods 
would continue to have special scoring applied for the 2019 MIPS 
performance period and would be considered, through notice-and-comment 
rulemaking, for removal for the 2020 MIPS performance period.
     Year 4: Topped out measures that are finalized for removal 
are no longer available for reporting. For example, the measures in the 
set of highly topped out measures identified as topped out for the 
2017, 2018 and 2019 MIPS performance periods, and if subsequently 
finalized for removal will not be available on the list of measures for 
the 2020 MIPS performance period and future years.
    For all other measures, the timeline would apply starting with the 
benchmarks for the 2018 MIPS performance period. Thus, the first year 
any other topped out measure could be proposed for removal would be in 
rulemaking for the 2021 MIPS performance period, based on the 
benchmarks being topped out in the 2018, 2019, and 2020 MIPS 
performance periods. If the measure benchmark is not topped out during 
one of the three MIPS performance periods, then the lifecycle would 
stop and start again at year 1 the next time the measure benchmark is 
topped out.
    We seek comment on the above proposed timeline, specifically 
regarding the number of years before a topped out measure is identified 
and considered for removal, and under what circumstances we should 
remove topped out measures once they reach that point. For example, 
should we automatically remove topped out measures after they are 
identified for the proposed number of years or should we review 
measures identified for removal and consider certain criteria before 
removing the measure? If so what criteria should be considered? We 
would like to note that if for some reason a measure benchmark is 
topped out for only one submission mechanism benchmark, then we would 
remove that measure from the submission mechanism, but not remove the 
measure from other submission mechanisms available for submitting that 
measure.
    We also seek comment on whether topped out Summary Survey Measures 
(SSMs), if topped out, should be considered for removal from the 
Consumer Assessment of Healthcare Providers and Systems (CAHPS) for 
MIPS Clinician or Group Survey measure due to high, unvarying 
performance within the SSM, or whether there is another alternative 
policy that could be applied for topped out SSMs within the CAHPS for 
MIPS Clinician or Group Survey measure.
    In the CY 2017 Quality Payment Program final rule, we state that we 
do not believe it would be appropriate to remove topped out measures 
from the CMS Web Interface for the Quality Payment Program because the 
CMS Web Interface measures are used in MIPS and in APMs, such as the 
Shared Savings Program. Removing topped out measures from the CMS Web 
Interface would not be appropriate because we have aligned policies 
where possible, with the Shared Savings Program, such as using the 
Shared Savings Program benchmarks for the CMS Web Interface measures 
(81 FR 77285). In the CY 2017 Quality Payment Program final rule, we 
also finalized that MIPS eligible clinicians reporting via the CMS Web 
Interface must report all measures included in the CMS Web Interface 
(81 FR 77116). Thus, if a CMS Web Interface measure is topped out, the 
CMS Web Interface reporter cannot select other measures. We refer 
readers to section II.C.7.a.(2) of this proposed rule for information 
on scoring policies with regards to topped out measures from the CMS 
Web Interface for the Quality Payment Program. We are not proposing to 
include CMS Web Interface measures

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in our proposal on removing topped out measures.
(3) Non-Outcome Measures
    In the CY 2017 Quality Payment Program final rule, we sought 
comment on whether we should remove non-outcomes measures for which 
performance cannot reliably be scored against a benchmark (for example, 
measures that do not have 20 reporters with 20 cases that meet the data 
completeness standard) for 3 years in a row (81 FR 77288).
    A few commenters recommended that measures that cannot be scored 
against a benchmark should be removed from the MIPS score. One 
commenter recommended that non-outcome measures that are unscorable 
should be given a weight of zero or re-weighted in the performance 
category. One commenter supported removing non-outcomes measures for 
which performance cannot reliably be scored against a benchmark for 3 
years in a row. One commenter believed it would also be appropriate to 
remove outcomes measures under a separate more protracted timeline 
because the commenter believed the reporting of outcome measures is 
more difficult and expected to increase at a slower pace, while 
maintaining outcome measures would encourage the testing and 
availability of such measures.
    Based on the need for CMS to further assess this issue, we are not 
proposing to remove non-outcome measures in this proposed rule. 
However, we seek comment on what the best timeline for removing both 
non-outcome and outcome measures that cannot be reliably scored against 
a benchmark for 3 years. We intend to revisit this issue and make 
proposals in future rulemaking.
(4) Quality Measures Determined To Be Outcome Measures
    Under the MIPS, individual MIPS eligible clinicians are generally 
required to submit at least one outcome measure, or, if no outcome 
measure is available, one high priority measure. As such, our 
determinations as to whether a measure is an outcome measure is of 
importance to stakeholders. We utilize the following as a basis to 
determine if a measure is considered an outcome measure:
     Measure Steward and National Quality Forum (NQF) 
designation--For most measures, we will utilize the designation as 
determined by the measure steward and the measure's NQF designation to 
determine if it is an outcome measure or not. If this is not clear, we 
will consider the following step.
     Utilization of the CMS Blueprint definitions for outcome 
measures: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/Blueprint-130.pdf. An outcome of 
care is a health state of a patient resulting from health care. Outcome 
measures are supported by evidence that the measure has been used to 
detect the impact of one or more clinical interventions. Clinical 
analysts are utilized to evaluate the measure.
    We also note that patient-reported outcome measures are considered 
outcome measures, as they measure the health of the patient directly 
resulting from the health care provided. Efficiency measures are not 
considered outcome measures, as they are measuring the cost of care 
associated with a specific level of care, but we do note that 
efficiency is considered a high priority measure.
    After a MIPS quality measure is established in the program, it is 
generally only reviewed again if there are significant changes to a 
measure for the next program year that might warrant a change to the 
designation of outcome or not. In most cases, these updates are 
significant enough that they are usually presented as a new measure 
from the measure owner. New measures to the program will follow the 
criteria outlined above. QCDR measures however, are reviewed on a 
yearly basis (during the fall) regardless if there is a significant 
change or not. We refer readers to section II.C.10.a. for additional 
information on the QCDR self-nomination and measures review and 
approval process.
    We seek comment on the criteria and process outlined above on how 
we designate outcome measures. Specifically are there additional 
criteria we should take into consideration when we determine if a 
measure meets the criteria of an outcome measure? Should we use 
different criteria for MIPS measures versus QCDR measures?
d. Cost Performance Category
(1) Background
(a) General Overview
    Measuring cost is an integral part of measuring value as part of 
MIPS. In implementing the cost performance category for the transition 
year (2017 MIPS performance period/2019 MIPS payment year), we started 
with measures that had been used in previous programs but noted our 
intent to move towards episode-based measurement as soon as possible, 
consistent with the statute and the feedback from the clinician 
community. Specifically, we adopted 2 measures that had been used in 
the VM: The total per capita costs for all attributed beneficiaries 
measure (referred to as the total per capita cost measure) and the MSPB 
measure (81 FR 77166 through 77168). We also adopted 10 episode-based 
measures that had previously been included in the Supplemental Quality 
and Resource Use Reports (sQRURs) (81 FR 77171 through 77174).
    At Sec.  414.1325(e), we finalized that all measures used under the 
cost performance category would be derived from Medicare administrative 
claims data and, thus, participation would not require additional data 
submission. We finalized a reliability threshold of 0.4 for measures in 
the cost performance category (81 FR 77170). We also finalized a case 
minimum of 35 for the MSPB measure (81 FR 77171) and 20 for the total 
per capita cost measure (81 FR 77170) and each of the 10 episode-based 
measures (81 FR 77175) in the cost performance category to ensure the 
reliability threshold is met.
    For the transition year, we finalized a policy to weight the cost 
performance category at zero percent in the final score in order to 
give clinicians more opportunity to understand the attribution and the 
scoring methodology and gain more familiarity with the measures through 
performance feedback (81 FR 77165 through 77166) so that clinicians may 
be able to act to improve their performance. In the CY 2017 Quality 
Payment Program final rule, we finalized a cost performance category 
weight of 10 percent for the 2020 MIPS payment year (81 FR 77165). For 
the 2021 MIPS payment year and beyond, the cost performance category 
will have a weight of 30 percent of the final score as required by 
section 1848(q)(5)(E)(i)(II)(aa) of the Act.
    For descriptions of the statutory basis and our existing policies 
for the cost performance category, we refer readers to the CY 2017 
Quality Payment Program final rule (81 FR 77162 through 77177).
    As finalized at Sec.  414.1370(g)(2), the cost performance category 
is weighted at zero percent for MIPS eligible clinicians scored under 
the MIPS APM scoring standard because many MIPS APM models incorporate 
cost measurement in other ways. For more on the APM scoring standard, 
see II.C.6.E. of this proposed rule.
(2) Weighting in the Final Score
    We are proposing at Sec.  414.1350(b)(2) to change the weight of 
the cost performance category from 10 percent to zero percent for the 
2020 MIPS payment year. We continue to have concerns

[[Page 30048]]

about the level of familiarity and understanding of cost measures among 
clinicians. We will use this additional year in which the score in the 
cost performance category does not count towards the final score for 
outreach to increase understanding of the measures so that clinicians 
will be more comfortable with their role in reducing costs for their 
patients. In addition, we will use this additional year to develop more 
episode-based measures, which are cost measures that are focused on a 
clinical conditions or procedures. We intend to propose in future 
rulemaking to adopt episode-based measures currently in development.
    Although we believe reducing this weight is appropriate given the 
level of understanding of the measures and the scoring standards, we 
note that section 1848(q)(5)(E)(i)(II)(aa) of the Act requires the cost 
performance category be assigned a weight of 30 percent of the MIPS 
final score beginning in the 2021 MIPS payment year. We recognize that 
assigning a zero percent weight to the cost performance category for 
the 2020 MIPS payment year may not provide a smooth enough transition 
for integrating cost measures into MIPS and may not provide enough 
encouragement to clinicians to review their performance on cost 
measures. This policy could reduce understanding of the measures when 
we reach the 2021 MIPS payment year and the cost performance category 
will be used to determine 30 percent of the final score for MIPS 
eligible clinicians, when in the two previous years it was weighted at 
zero. Therefore, we also seek comment on keeping the weight of the cost 
performance category at 10 percent for the 2020 MIPS payment year.
    In our discussions with clinicians and clinician societies, 
clinicians expressed their desire to down-weight the cost performance 
category to zero percent for an additional year with full knowledge 
that the cost performance category weight is set at 30 percent under 
the statute for the 2021 MIPS payment year. The clinicians we spoke 
with preferred a low weighting and noted that they are actively 
preparing for cost performance category implementation and would be 
prepared for the 30 percent statutory weight for the cost performance 
category for the 2021 MIPS payment year. We intend to continue to 
provide education to clinicians to help them prepare for the upcoming 
30 percent weight.
    We invite public comments on this proposal of a zero percent 
weighting for the cost performance category and the alternative option 
of 10 percent weighting for the cost performance category for the 2020 
MIPS payment year.
(3) Cost Criteria
(a) Measures Proposed for the MIPS Cost Performance Category
(i) Background
    Under Sec.  414.1350(a), we specify cost measures for a performance 
period to assess the performance of MIPS eligible clinicians on the 
cost performance category. For the 2017 MIPS performance period, we 
will utilize 12 cost measures that are derived from Medicare 
administrative claims data. Two of these measures, the MSPB measure and 
total per capita cost measure, have been used in the VM (81 FR 77166 
through 77168), and the remaining 10 are episode-based measures that 
were included in the sQRURs in 2014 and 2015 (81 FR 77171 through 
77174).
    Section 1848(r) of the Act specifies a series of steps and 
activities for the Secretary to undertake to involve the physician, 
practitioner, and other stakeholder communities in enhancing the 
infrastructure for cost measurement, including for purposes of MIPS. 
Section 1848(r)(2) of the Act requires the development of care episode 
and patient condition groups, and classification codes for such groups, 
and provides for care episode and patient condition groups to account 
for a target of an estimated one-half of expenditures under Parts A and 
B (with this target increasing over time as appropriate). Section 
1848(r) of the Act requires us to consider several factors when 
establishing these groups. For care episode groups, we must consider 
the patient's clinical problems at the time items and services are 
furnished during an episode of care, such as clinical conditions or 
diagnoses, whether inpatient hospitalization occurs, the principal 
procedures or services furnished, and other factors determined 
appropriate by the Secretary. For patient condition groups, we must 
consider the patient's clinical history at the time of a medical visit, 
such as the patient's combination of chronic conditions, current health 
status, and recent significant history (such as hospitalization and 
major surgery during a previous period), and other factors determined 
appropriate.
    Section 1848(r)(2) of the Act requires us to post on the CMS Web 
site a draft list of care episode and patient condition groups and 
codes for solicitation of input from stakeholders, and subsequently, 
post on the CMS Web site an operational list of such groups and codes. 
In December 2016, we published the Episode-Based Cost Measure 
Development for the Quality Program (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Episode-Based-Cost-Measure-Development-for-the-Quality-Payment-Program.pdf) and requested input on a draft 
list of care episode and patient condition groups and codes as required 
by section 1848(r)(2)(E) and (F) of the Act. We additionally requested 
feedback on our overall approach to cost measure development, including 
several pages of specific questions on the proposed approach for 
clinicians and stakeholders to provide feedback on. This feedback will 
be used to modify our cost measure development and ensure that our 
approach is continually informed by stakeholder feedback. We are 
currently reviewing the feedback that was recently received on that 
posting and will share plans to work with clinicians and others on the 
further developments of these episodes in the future.
    We will be posting the operational list of care episode and patient 
condition groups in December 2017, as required by section 1848(r)(2)(G) 
of the Act. Section 1848(r)(2)(H) of the Act also requires that not 
later than November 1 of each year (beginning with 2018), the Secretary 
shall, through rulemaking, revise the operational list as the Secretary 
determines may be appropriate.
(ii) Total Per Capita Cost and MSPB Measures
    For the 2018 MIPS performance period and future performance 
periods, we are proposing to include in the cost performance category 
the total per capita cost measure and the MSPB measure as finalized for 
the 2017 MIPS performance period. We refer readers to the description 
of these measures in the CY 2017 Quality Payment Program final rule (81 
FR 77164 through 77171). We are proposing to include the total per 
capita cost measure because it is a global measure of all Medicare Part 
A and Part B costs during the performance period. MIPS eligible 
clinicians are familiar with the total per capita cost measure because 
the measure has been used in the VM since the 2015 payment adjustment 
period and performance feedback has been provided through the annual 
QRUR since 2013 (for a subset of groups that had 20 or more eligible 
professionals, based on 2014 performance) and to all groups in the 
annual QRUR since 2014 (based on 2013 performance) and mid-year QRUR 
since 2015. We are proposing to use the MSPB measure because many MIPS 
eligible

[[Page 30049]]

clinicians will be familiar with the measure from the VM, where it has 
been included since the 2016 payment adjustment period and in annual 
QRUR since 2014 (based on 2013 performance) and the mid-year QRUR since 
2015, or its hospital-specified version, which has been a part of the 
Hospital VBP Program since 2015, based on 2013 performance. In addition 
to familiarity, these two measures cover a large number of patients and 
provide an important measurement of clinician contribution to the 
overall population that a clinician encounters.
    We are not proposing any changes to the methodologies for payment 
standardization, risk adjustment, and specialty adjustment for these 
measures and refer readers to the CY 2017 Quality Payment Program final 
rule (81 FR 77164 through 77171) for more information about these 
methodologies.
    We will continue to evaluate cost measures that are included in 
MIPS on a regular basis and anticipate that measures could be added or 
removed, subject to rulemaking under applicable law, as measure 
development continues. We will also maintain the measures that are used 
in the cost performance category by updating specifications, risk 
adjustment, and attribution as appropriate. We anticipate including a 
list of cost measures for a given performance period in annual 
rulemaking.
    We invite public comments on these proposals.
(iii) Episode-Based Measures
    Episode-based measures differ from the total per capita cost 
measure and MSPB measure because their specifications only include 
services that are related to the episode of care for a clinical 
condition or procedure (as defined by procedure and diagnosis codes), 
as opposed to including all services that are provided to a patient 
over a given period of time. For the 2018 MIPS performance period, we 
are not proposing to include in the cost performance category the 10 
episode-based measures that we adopted for the 2017 MIPS performance 
period in the CY 2017 Quality Payment Program final rule (81 FR 77171 
through 77174). We instead will work to develop new episode-based 
measures, with significant clinician input, for future performance 
periods.
    We received extensive comments on our proposal to include 41 of 
these episode-based measures for the 2017 MIPS performance period, 
which we responded to in the CY 2017 Quality Payment Program final rule 
(81 FR 77171 through 77174). We also received additional comments after 
publication of that final rule with comment period about the decision 
to include 10 episode-based measures for the 2017 MIPS performance 
period. Although comments were generally in favor of the inclusion of 
episode-based measures in the future, there was also overwhelming 
stakeholder interest in more clinician involvement in the development 
of these episode-based measures as required by section 1848(r)(2) of 
the Act. Although there was an opportunity for clinician involvement in 
the development of some of the episode-based measures included for the 
2017 MIPS performance period, it was not as extensive as the process we 
are currently using to develop episode-based measures. We believe that 
the new episode-based measures, which we intend to propose in future 
rulemaking to include in the cost performance category for the 2019 
MIPS performance period, will be substantially improved by more 
extensive stakeholder feedback and involvement in the process.
    Thus far, stakeholder feedback has been sought in several ways. 
First, stakeholder feedback has been sought through various public 
postings. In October 2015 and April 2016, pursuant to section 
1848(r)(2)(B) and (C) of the Act, we gathered input from stakeholders 
on the episode groups previously developed under section 1848(n)(9)(A) 
of the Act that has been used to inform the process of constructing the 
new episode-based cost measures. This feedback emphasized several key 
aspects of cost measure development such as attribution, risk 
adjustment, and alignment with quality measurement and patient 
outcomes. Stakeholders have also emphasized that feedback related to 
cost measures should be actionable and timely. In addition, a draft 
list of care episode and patient condition groups, along with trigger 
codes, was posted for comment in December 2016 (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Episode-Based-Cost-Measure-Development-for-the-Quality-Payment-Program.pdf) as required by section 
1848(r)(2)(E) of the Act and comments were accepted as required by 
section 1848(r)(2)(F) of the Act.
    This draft list of care episode and patient condition groups and 
trigger codes was informed by engagement with clinicians from over 50 
clinician specialty societies through a Clinical Committee formed to 
participate in cost measure development. The Clinical Committee work 
has provided input from a diverse array of clinicians on identifying 
conditions and procedures for episode groups. Moving forward, the 
Clinical Committee will recommend which services or claims would be 
counted in episode costs. This will ensure that cost measures in 
development are directly informed by a substantial number of clinicians 
and members of specialty societies.
    In addition, a technical expert panel has met 3 times to provide 
oversight and guidance for our development of episode-based cost 
measures. The technical expert panel has offered recommendations for 
defining an episode group, assigning costs to the group, and 
attributing episode groups to clinicians. This expert feedback has been 
built into the current cost measure development process.
    As this process continues, we are continuing to seek input from 
clinicians. Earlier this year, we opened an opportunity to submit the 
names of clinicians to participate in this process. This process 
remains open to additional individuals. We believe that episode-based 
measures will benefit from this comprehensive approach to development. 
In addition, because it is possible that the new episode-based measures 
under development could address similar conditions as those in the 
episode-based measures finalized for the 2017 MIPS performance period, 
we believe that it would be better to focus attention on the new 
episode-based measures, so that clinicians would not receive feedback 
or scores from two measures for the same patient condition or 
procedure. Recognizing that under section 1848(q)(5)(E)(i)(II)(aa) of 
the Act, we must assign a weight of 30 percent to the cost performance 
category for the 2021 MIPS payment year, we will endeavor to have as 
many episode-based measures available as possible for the proposed 2019 
MIPS performance period.
    We plan to include episode-based measures in the cost performance 
category in future years as they are developed and would propose new 
measures in future rulemaking.
    Although we are not proposing to include any episode-based measures 
in calculating the cost performance category score for the 2020 MIPS 
payment year, we do plan to continue to provide confidential 
performance feedback to clinicians on their performance on episode-
based measures developed under the processes required by section 
1848(r)(2) of the Act as appropriate in order to increase familiarity 
with the concept of episode-based measurement as well as the specific 
episodes that could be included

[[Page 30050]]

in determining the cost performance category score in the future. 
Because these measures will be generated based on claims data like 
other cost measures, we will not collect any additional data from 
clinicians. As we develop new episode-based measures, we believe it is 
likely that they would cover similar clinical topics to those that are 
in the previously developed episode-based measures because of our 
intent to address common clinical conditions with episode-based 
measures. We aim to provide an initial opportunity for clinicians to 
review their performance based on the new episode-based measures at 
some point in the fall of 2017, as the measures are developed and as 
the information is available. We note that this feedback will be 
specific to the new episode-based measures that are developed under the 
process described above and may be presented in a different format than 
MIPS eligible clinicians' performance feedback as described in section 
II.C.9.a. of this proposed rule. However, our intention is to align the 
feedback as much as possible to ensure clinicians receive opportunities 
to review their performance on potential new episode-based measures for 
the cost performance category prior to the proposed 2019 MIPS 
performance period. We are unable to offer a list of new episode-based 
measures on which we will provide feedback because that will be 
determined in our ongoing development work described above. We are 
concerned that continuing to provide feedback on the older episode-
based measures along with feedback on new episode-based measures will 
be confusing and a poor use of resources. Because we are focusing on 
development of new episode-based measures, our feedback on episode-
based measures that were previously developed will discontinue after 
2017 as these measures would no longer be maintained or reflect changes 
in diagnostic and procedural coding. As described in section II.C.9.a. 
of this proposed rule, we intend to provide feedback on these new 
measures as they become available in a new format around summer 2018. 
We note that the feedback provided in the summer of 2018 will go to 
those MIPS eligible clinicians for whom we are able to calculate the 
episode-based measures, which means it would be possible a clinician 
may not receive feedback on episode-based measures in both the fall of 
2017 and the summer of 2018. We believe that receiving feedback on the 
new episode-based measures, along with the previously-finalized total 
per capita cost and MSPB measures, will support clinicians in their 
readiness for the proposed 2019 MIPS performance period.
    As previously finalized in the CY 2017 Quality Payment Program 
final rule (81 FR 77173), the episode-based measures that we are not 
proposing for the 2018 MIPS performance period will be used for 
determining the cost performance category score for the 2019 MIPS 
payment year, although the cost performance category score will be 
weighted at zero percent in that year.
    We invite public comments on this proposal.
(iv) Attribution
    In the CY 2017 Quality Payment Program final rule, we changed the 
list of primary care services that had been used to determine 
attribution for the total per capita cost measure by adding 
transitional care management (CPT codes 99495 and 99496) codes and a 
chronic care management code (CPT code 99490) (81 FR 77169). In the CY 
2017 Physician Fee Schedule final rule, we changed the payment status 
for two existing CPT codes (CPT codes 99487 and 99489) that could be 
used to describe care management from B (bundled) to A (active) meaning 
that the services would be paid under the Physician Fee Schedule (81 FR 
80349). The services described by these codes are substantially similar 
to those described by the chronic care management code that we added to 
the list of primary care services beginning with the 2017 performance 
period. We therefore propose to add CPT codes 99487 and 99489, both 
describing complex chronic care management, to the list of primary care 
services used to attribute patients under the total per capita cost 
measure.
    We are not proposing any changes to the attribution methods for the 
MSPB measure and refer readers to the CY 2017 Quality Payment Program 
final rule (81 FR 77168 through 77169) for more information.
    We invite public comment on our proposals.
(v) Reliability
    In the CY 2017 Quality Payment Program final rule (81 FR 77169 
through 77170), we finalized a reliability threshold of 0.4 for 
measures in the cost performance category. Reliability is an important 
evaluation for cost measures to ensure that differences in performance 
are not the result of random variation. Statistically, reliability 
depends on performance variation for a measure across clinicians 
(``signal''), the random variation in performance for a measure within 
a clinician's attributed beneficiaries (``noise''), and the number of 
beneficiaries attributed to the clinician. High reliability for a 
measure suggests that comparisons of relative performance among 
clinicians are likely to be stable over different performance periods 
and that the performance of one clinician on the measure can be 
confidently distinguished from another. As an example of the 
statistical concept of reliability, a test in which the same individual 
received very different scores depending on how the included questions 
are framed would not be reliable. Potential reliability values range 
from 0.00 to 1.00, where 1.00 (highest possible reliability) signifies 
that all variation in the measure's rates is the result of variation in 
differences in performance across clinicians, whereas 0.0 (lowest 
possible reliability) signifies that all variation could be a result of 
measurement error. The 0.4 reliability threshold that we adopted for 
the cost performance category measures in MIPS means that the majority 
of MIPS eligible clinicians and groups who meet the case minimum 
required for scoring under a measure have measure reliability scores 
that exceed 0.4. We generally consider reliability levels between 0.4 
and 0.7 to indicate ``moderate'' reliability and levels above 0.7 to 
indicate ``high'' reliability.
    We addressed comments we received on the CY 2017 Quality Payment 
Program proposed rule (81 FR 77169 through 77171), that expressed 
concern that our 0.4 reliability threshold was too low. Many commenters 
recommended that cost measures be included only when they could meet 
the standard of ``high'' reliability (0.7 or above). Many commenters on 
the CY 2017 Quality Payment Program final rule made similar comments. 
Commenters emphasized the importance of reliability; however, we have 
also seen commenters incorrectly refer to measures as being 40 percent 
reliable. Reliability is not a percentage but is instead a coefficient 
so a measure with 0.4 reliability does not reflect that it is only 
correct for 40 percent of those measured. We encourage a review of our 
analysis of reliability for the total per capita cost measure (80 FR 
71282) and MSPB (81 FR 77169 through 77171).
    Reliability is an important evaluation tool for an individual 
measure, but it is only one element of evaluation. Reliability 
generally increases as we increase the case size but a high reliability 
may also reflect low variation. A measure in which all clinicians 
perform at nearly the same rate would be reliable but not valuable in a 
program

[[Page 30051]]

that attempts to recognize and reward differential performance. A 
measure in which there is very little variation provides little value 
in a program like MIPS given the devotion of resources to developing 
and maintaining that measure over other potential measures. Reliability 
must also be considered in the context of a measurement system like 
MIPS which incorporates other elements of measurement. We understand 
and appreciate the concerns that have been expressed about reliability 
of measures. Medicine, however, always has a certain amount of 
variability which may affect the reliability score. We want strong 
reliability, but not at the expense of losing valuable information 
about clinicians. We are concerned that placing too much of an emphasis 
on reliability calculations could limit the applicability of cost 
measures to large group practices who, by nature of their size, have 
larger patient populations, thus depriving solo clinicians and 
individual reporters from being rewarded for efforts to better manage 
patients. Therefore, we are not proposing any adjustments to our 
reliability policies, but we will continue to evaluate reliability as 
we develop new measures and to ensure that our measures meet an 
appropriate standard.
(b) Attribution for Individuals and Groups
    We are not proposing any changes for how we attribute cost measures 
to individual and group reporters. We refer readers to the CY 2017 
Quality Payment Program final rule for more information (81 FR 77175 
through 77176).
(c) Incorporation of Cost Measures With SES or Risk Adjustment
    Both measures proposed for inclusion in the cost performance 
category for the 2018 MIPS performance period are risk adjusted at the 
measure level. Although the risk adjustment of the 2 measures is not 
identical, in both cases it is used to recognize the higher risk 
associated with demographic factors (such as age) or certain clinical 
conditions. We recognize that the risks accounted for with this 
adjustment are not the only potential attributes that could lead to a 
higher cost patient. Stakeholders have pointed to many other factors 
such as income level, race, and geography that they believe contribute 
to increased costs. These issues and our plans for attempting to 
address them are discussed in length in section II.C.7.b.(1)(a) of this 
rule.
(d) Incorporation of Cost Measures With ICD-10 Impacts
    In section II.C.7.a.(1)(c) of this proposed rule, we discuss our 
proposal to assess performance on any measures impacted by ICD-10 
updates based only on the first 9 months of the 12-month performance 
period. Because the total per capita cost and MSPB measures include 
costs from all Medicare Part A and B services, regardless of the 
specific ICD-10 codes that are used on claims, and do not assign 
patients based on ICD-10, we do not anticipate that any measures for 
the cost performance category would be affected by this ICD-10 issue 
during the 2018 MIPS performance period. However, as we continue our 
plans to expand cost measures to incorporate episode-based measures, 
ICD-10 changes could become important. Episode-based measures may be 
opened (triggered) by and may assign services based on ICD-10 codes. 
Therefore, a change to ICD-10 coding could have a significant effect on 
an episode-based measure. Changes to ICD-10 codes will be incorporated 
into the measure specifications on a regular basis through the measure 
maintenance process.
(e) Application of Measures to Non-Patient Facing MIPS Eligible 
Clinicians
    We are not proposing changes to the policy we finalized in the CY 
2017 Quality Payment Program final rule (81 FR 77176) that we will 
attribute cost measures to non-patient facing MIPS eligible clinicians 
who have sufficient case volume, in accordance with the attribution 
methodology.
    Section 1848(q)(2)(C)(iv) of the Act requires the Secretary to 
consider the circumstances of professional types who typically furnish 
services without patient facing interaction (non-patient facing) when 
determining the application of measures and activities. In addition, 
this section allows the Secretary to apply alternative measures or 
activities to non-patient facing MIPS eligible clinicians that fulfill 
the goals of a performance category. Section 1848(q)(5)(F) of the Act 
allows the Secretary to re-weight MIPS performance categories if there 
are not sufficient measures and activities applicable and available to 
each type of MIPS eligible clinician involved.
    We believe that non-patient facing clinicians are an integral part 
of the care team and that their services do contributed to the overall 
costs but at this time we believe it better to focus on the development 
of a comprehensive system of episode-based measures which focus on the 
role of patient-facing clinicians. Accordingly, for the 2018 MIPS 
performance period, we are not proposing alternative cost measures for 
non-patient facing MIPS eligible clinicians or groups. This means that 
non-patient facing MIPS eligible clinicians or groups are unlikely to 
be attributed any cost measures that are generally attributed to 
clinicians who have patient-facing encounters with patients. Therefore, 
we anticipate that, similar to MIPS eligible clinicians or groups that 
do not meet the required case minimums for any cost measures, many non-
patient facing MIPS eligible clinicians may not have sufficient cost 
measures applicable and available to them and would not be scored on 
the cost performance category under MIPS. We continue to consider 
opportunities to develop alternative cost measures for non-patient 
facing clinicians and solicit comment on this topic to inform our 
future rulemaking.
(f) Facility-Based Measurement as it Relates to the Cost Performance 
Category
    In section II.C.7.a.(4) of this proposed rule, we discuss our 
proposal to implement section 1848(q)(2)(C)(ii) of the Act by assessing 
clinicians who meet certain requirements and elect participation based 
on the performance of their associated hospital in the Hospital VBP 
Program. We refer readers to that section for full details on our 
proposals related to facility-based measurement, including the measures 
and how the measures are scored, for the cost performance category.
e. Improvement Activity Criteria
(1) Background
    Section 1848(q)(2)(C)(v)(III) of the Act defines an improvement 
activity as an activity that relevant eligible clinician organizations 
and other relevant stakeholders identify as improving clinical practice 
or care delivery, and that the Secretary determines, when effectively 
executed, is likely to result in improved outcomes. Section 
1848(q)(2)(B)(iii) of the Act requires the Secretary to specify 
improvement activities under subcategories for the performance period, 
which must include at least the subcategories specified in section 
1848(q)(2)(B)(iii)(I) through (VI) of the Act, and in doing so to give 
consideration to the circumstances of small practices, and practices 
located in rural areas and geographic health professional shortage 
areas (HPSAs).
    Section 1848(q)(2)(C)(iv) of the Act generally requires the 
Secretary to give consideration to the circumstances of

[[Page 30052]]

non-patient facing individual MIPS eligible clinicians or groups and 
allows the Secretary, to the extent feasible and appropriate, to apply 
alternative measures and activities to such individual MIPS eligible 
clinicians and groups.
    Section 1848(q)(2)(C)(v) of the Act required the Secretary to use a 
request for information (RFI) to solicit recommendations from 
stakeholders to identify improvement activities and specify criteria 
for such improvement activities, and provides that the Secretary may 
contract with entities to assist in identifying activities, specifying 
criteria for the activities, and determining whether individual MIPS 
eligible clinicians or groups meet the criteria set. For a detailed 
discussion of the feedback received from the MIPS and APMs RFI, see the 
CY 2017 Quality Payment Program 2017 final rule (81 FR 77177).
    We defined improvement activities at Sec.  414.1305 as an activity 
that relevant MIPS eligible clinicians, organizations and other 
relevant stakeholders identify as improving clinical practice or care 
delivery and that the Secretary determines, when effectively executed, 
is likely to result in improved outcomes.
    In the CY 2017 Quality Payment Program final rule (81 FR 77199), we 
solicited comments on activities that would advance the usage of health 
IT to support improvement activities. We received several comments in 
support of the concept to include emerging certified health IT 
capabilities as part of the activities in the Improvement Activities 
Inventory and several commenters supported our assessment that using 
CEHRT can aid in improving clinical practices and help healthcare 
organizations achieve success on numerous improvement activities, as 
well as the continued integration of improvement activities and 
advancing clinical information. However, several commenters expressed 
concern about health IT-associated burdens and costs and recommended 
that we also continue to offer diverse activities that do not rely on 
emerging capabilities of certified health IT, as they are not 
universally available or may only be offered as high cost add-on 
capabilities. Some commenters also requested that we be less 
prescriptive in our requirements for the use of health IT.
    In response to the comments, we will continue to focus on 
incentivizing the use of health IT, telehealth, and connection of 
patients to community-based services. The use of health IT is an 
important aspect of care delivery processes described in many of the 
proposed new improvement activities in Table F in the Appendix of this 
proposed rule, and in Table H: Finalized Improvement Activities 
Inventory that we finalized in the CY 2017 Quality Payment Program 
final rule (81 FR 77817 through 77831). In that same final rule, we 
also finalized a policy to allow MIPS eligible clinicians to achieve a 
bonus in the advancing care information performance category when they 
use functions included in CEHRT to complete eligible activities from 
the Improvement Activities Inventory. Please refer to section 
II.C.6.f.(2)(d) of this proposed rule for details on how improvement 
activities using CEHRT relate to the objectives and measures of the 
advancing care information and improvement activities performance 
categories. We are not proposing any changes to these policies for 
incentivizing the use of health IT in this proposed rule; however, we 
will continue to consider including emerging certified health IT 
capabilities as part of activities within the Improvement Activities 
Inventory in future years.
    In addition, as noted previously, we believe a key goal of the 
Quality Payment Program is to establish a program that allows for close 
alignment of the four performance categories. Although we are not 
proposing any specific new policies, we seek comment on how we might 
provide flexibility for MIPS eligible clinicians to effectively 
demonstrate improvement through health IT usage while also measuring 
such improvement. We welcome public comment on these considerations.
(2) Contribution to the Final Score
    In the CY 2017 Quality Payment Program final rule (81 FR 77179 
through 77180), we finalized at Sec.  414.1355 that the improvement 
activities performance category would account for 15 percent of the 
final score. We also finalized at Sec.  414.1380(b)(3)(iv) criteria for 
recognition as a certified-patient centered medical home or comparable 
specialty practice. We are proposing to clarify the term ``certified'' 
patient-centered medical home finalized at Sec.  414.1380(b)(3)(iv). It 
has come to our attention that the common terminology utilized in the 
general medical community for ``certified'' patient-centered medical 
home is ``recognized'' patient-centered medical home. Therefore, in 
order to provide clarity we are proposing that the term ``recognized'' 
be accepted as equivalent to the term ``certified'' when referring to 
the requirements for a patient-centered medical home to receive full 
credit for the improvement activities performance category for MIPS. 
Specifically, we propose to revise Sec.  414.1380(b)(3)(iv) to provide 
that a MIPS eligible clinician or group in a practice that is certified 
or recognized as a patient-centered medical home or comparable 
specialty practice, as determined by the Secretary, receives full 
credit for performance on the improvement activities performance 
category. For purposes of Sec.  414.1380 (b)(3)(iv), ``full credit'' 
means that the MIPS eligible clinician or group has met the highest 
potential category score of 40 points. A practice is certified or 
recognized as a patient-centered medical home if it meets any of the 
criteria specified under Sec.  414.1380(b)(3)(iv).
    In the CY 2017 Quality Payment Program final rule (81 FR 77198), we 
requested commenters' specific suggestions for additional activities or 
activities that may merit additional points beyond the ``high'' level. 
Several commenters urged us to increase the overall number of high-
weighted activities in this performance category. Some commenters 
recommended additional criteria for designating high-weighted 
activities, such as an improvement activity's impact on population 
health, medication adherence, and shared decision-making tools, and 
encouraged us to be more transparent in our weighting decisions. 
Several commenters recommended that we weight registry-related 
activities as high, and suggested that we award individual MIPS 
eligible clinicians and groups in APMs full credit in this performance 
category. The commenters also offered many recommendations for changing 
current medium-weighted activities to high and offered many specific 
suggestions for new high-weighted improvement activities.
    In response to the comments, we are proposing new, high-weighted 
activities in Table F in the Appendix of this proposed rule. As 
explained in the CY 2017 Quality Payment Program final rule (81 FR 
77194), we believe that high weighting should be used for activities 
that directly address areas with the greatest impact on beneficiary 
care, safety, health, and well-being. We are not proposing changes to 
this approach in this proposed rule; however, we will take these 
suggested additional criteria into consideration for designating high-
weighted activities in future rulemaking. For MIPS eligible clinicians 
participating in MIPS APMs, we finalized a policy to reduce reporting 
burden through the APM scoring standard for this category to recognize 
improvement activities work performed through participation in MIPS 
APMs. This policy is codified at Sec.  414.1370(g)(3), and we refer 
readers to the CY 2017 Quality Payment Program

[[Page 30053]]

final rule for further details on reporting and scoring this category 
under the APM Scoring Standard (81 FR 77259 through 77260).
(3) Improvement Activities Data Submission Criteria
(a) Submission Mechanisms
    In the CY 2017 Quality Payment Program final rule (81 FR 77180), we 
discussed that for the transition year of MIPS we would allow for 
submission of data for the improvement activities performance category 
using the qualified registry, EHR, QCDR, CMS Web Interface, and 
attestation data submission mechanisms through attestation. 
Specifically, we finalized a policy that regardless of the data 
submission method, with the exception of MIPS eligible clinicians in 
MIPS APMs, all individual MIPS eligible clinicians or groups must 
select activities from the Improvement Activities Inventory. In 
addition, we finalized at Sec.  414.1360 that for the transition year 
of MIPS, all individual MIPS eligible clinicians or groups, or third 
party intermediaries such as health IT vendors, QCDRs and qualified 
registries that submit on behalf of an individual MIPS eligible 
clinician or group, must designate a ``yes'' response for activities on 
the Improvement Activities Inventory. In the case where an individual 
MIPS eligible clinician or group is using a health IT vendor, QCDR, or 
qualified registry for their data submission, the individual MIPS 
eligible clinician or group will certify all improvement activities 
were performed and the health IT vendor, QCDR, or qualified registry 
would submit on their behalf. We would like to maintain stability in 
the Quality Payment Program and continue this policy into future years. 
Therefore, we are proposing at Sec.  414.1360 that for purposes of the 
transition year of MIPS and future years all individual MIPS eligible 
clinicians or groups, or third party intermediaries such as health IT 
vendors, QCDRs and qualified registries that submit on behalf of an 
individual MIPS eligible clinician or group, must designate a ``yes'' 
response for activities on the Improvement Activities Inventory. In the 
case where an individual MIPS eligible clinician or group is using a 
health IT vendor, QCDR, or qualified registry for their data 
submission, the MIPS eligible clinician or group will certify all 
improvement activities were performed and the health IT vendor, QCDR, 
or qualified registry would submit on their behalf. In addition, as 
discussed in section II.C.4.d. of this proposed rule, we are proposing 
to generally apply our previously finalized and proposed group policies 
to virtual groups.
    We would like to note that while we finalized at Sec.  414.1325(d) 
in the CY 2017 Quality Payment Program final rule that individual MIPS 
eligible clinicians and groups may only use one submission mechanism 
per performance category, in section II.C.6.a.(1) of this proposed 
rule, we are proposing to revise Sec.  414.1325(d) for purposes of the 
2020 MIPS payment year and future years to allow individual MIPS 
eligible clinicians and groups to submit measures and activities, as 
applicable, via as many submission mechanisms as necessary to meet the 
requirements of the quality, improvement activities, or advancing care 
information performance categories. We refer readers to section 
II.C.6.a.(1) of this proposed rule for further discussion of this 
proposal.
    We also included a designation column in the Improvement Activities 
Inventory at Table H in the Appendix of the CY 2017 Quality Payment 
Program final rule (81 FR 77817) that indicated which activities 
qualified for the advancing care information bonus finalized at Sec.  
414.1380. In future updates to the Improvement Activities Inventory we 
intend to continue to indicate which activities qualify for the 
advancing care information performance category bonus.
    In the CY 2017 Quality Payment Program final rule (81 FR 77181), we 
clarified that if one MIPS eligible clinician (NPI) in a group 
completed an improvement activity, the entire group (TIN) would receive 
credit for that activity. In addition, we specified that all MIPS 
eligible clinicians reporting as a group would receive the same score 
for the improvement activities performance category if at least one 
clinician within the group is performing the activity for a continuous 
90 days in the performance period. As discussed in section II.C.4.d. of 
this proposed rule, we are proposing to generally apply our previously 
finalized and proposed group policies to virtual groups. We are not 
proposing any changes to this policy in this proposed rule. However, we 
are requesting comment on whether we should establish a minimum 
threshold (for example, 50 percent) of the clinicians (NPIs) that must 
complete an improvement activity in order for the entire group (TIN) to 
receive credit in the improvement activities performance category in 
future years. In addition, we are requesting comments on recommended 
minimum threshold percentages and whether we should establish different 
thresholds based on the size of the group. For example, in considering 
different thresholds we could attribute recognition as a certified or 
recognized patient-centered medical home or comparable specialty 
practice at the individual TIN/NPI level, and attribute this 
designation to the group under which they bill if they are 
participating in MIPS as a group or as part of a virtual group. A group 
or virtual group consisting of 100 NPIs could have a reporting 
threshold of 50 percent while a group consisting of 10 NPIs could have 
a lower reporting threshold of 10 percent. We are concerned that while 
establishing any specific threshold for the percentage of NPIs in a TIN 
that must participate in an improvement activity for credit will 
incentivize some groups to move closer to the threshold, it may have 
the unintended consequence of incentivizing groups who are exceeding 
the threshold to gravitate back toward the threshold. Therefore, we are 
requesting comments on how to set this threshold while maintaining the 
goal of promoting greater participation in an improvement activity.
    Additionally, we noted in the CY 2017 Quality Payment Program final 
rule (81 FR 77197) that we intended, in future years, to score the 
improvement activities performance category based on performance and 
improvement, rather than simple attestation. We seek comment on how we 
could measure performance and improvement; we are especially interested 
in ways to measure performance without imposing additional burden on 
eligible clinicians, such as by using data captured in eligible 
clinicians' daily work.
(b) Submission Criteria
    In the CY 2017 Quality Payment Program final rule (81 FR 77185), we 
finalized at Sec.  414.1380 to set the improvement activities 
submission criteria under MIPS, to achieve the highest potential score, 
at two high-weighted improvement activities or four medium-weighted 
improvement activities, or some combination of high and medium-weighted 
improvement activities. While the minimum reporting period for one 
improvement activity is 90 days, the maximum frequency with which an 
improvement activity may be reported would be once during the 12-month 
performance period. In addition, as discussed in section II.C.4.d. of 
this proposed rule, we are proposing to generally apply our previously 
finalized and proposed group policies to virtual groups.
    We established exceptions to the above for: small practices; 
practices located in rural areas; practices located in geographic 
HPSAs; non-patient facing

[[Page 30054]]

individual MIPS eligible clinicians or groups; and individual MIPS 
eligible clinicians and groups that participate in a MIPS APM or a 
patient-centered medical home submitting in MIPS. Specifically, for 
individual MIPS eligible clinicians and groups that are small 
practices, practices located in rural areas or geographic HPSAs, or 
non-patient facing individual MIPS eligible clinicians or groups, to 
achieve the highest score, one high-weighted or two medium-weighted 
improvement activities are required. For these individual MIPS eligible 
clinicians and groups, in order to achieve one-half of the highest 
score, one medium-weighted improvement activity is required.
    Under the APM scoring standard, all clinicians identified on the 
Participation List of an APM receive at least one-half of the highest 
score applicable to the MIPS APM. To develop the improvement activities 
score assigned to each MIPS APM, we compare the requirements of the 
specific MIPS APM with the list of activities in the Improvement 
Activities Inventory and score those activities in the same manner that 
they are otherwise scored for MIPS eligible clinicians. If by our 
assessment the MIPS APM does not receive the maximum improvement 
activities performance category score then the APM entity can submit 
additional improvement activities. All other individual MIPS eligible 
clinicians or groups that we identify as participating in APMs that are 
not MIPS APMs will need to select additional improvement activities to 
achieve the improvement activities highest score. We refer readers to 
section II.C.6.g. of this proposed rule for further discussion of the 
APM scoring standard.
    We also provided full credit for the improvement activities 
performance category, as required by law, for an individual MIPS 
eligible clinician or group that has received certification or 
accreditation as a patient-centered medical home or comparable 
specialty practice from a national program or from a regional or state 
program, private payer or other body that administers patient-centered 
medical home accreditation and certifies 500 or more practices for 
patient-centered medical home accreditation or comparable specialty 
practice certification, or for an individual MIPS eligible clinician or 
group that is a participant in a medical home model.
    We also noted in the CY 2017 Quality Payment Program final rule 
that practices may receive this designation at a practice level and 
that TINs may be comprised of both undesignated practices and 
designated practices (81 FR 77178). We finalized at Sec.  
414.1380(b)(3)(viii) that to receive full credit as a certified 
patient-centered medical home or comparable specialty practice, a TIN 
that is reporting must include at least one practice that is a 
certified patient-centered medical home or comparable specialty 
practice. We also indicated that we would continue to have more 
stringent requirements in future years, and would lay the groundwork 
for expansion towards continuous improvement over time (81 FR 77189). 
We received many comments on the CY 2017 Quality Payment Program final 
rule regarding our transition year policy that only one practice site 
within a TIN needs to be certified as a patient-centered medical home 
for the entire TIN to receive full credit in the improvement activities 
performance category. While several commenters supported our transition 
year policy, others disagreed and suggested to move to a more stringent 
requirement in future years while still offering some flexibility. 
Accordingly, we propose to revise Sec.  414.1380(b)(3)(x) to provide 
that for the 2020 MIPS payment year and future years, to receive full 
credit as a certified or recognized patient-centered medical home or 
comparable specialty practice, at least 50 percent of the practice 
sites within the TIN must be recognized as a patient-centered medical 
home or comparable specialty practice. This is an increase to the 
requirement that only one practice site within a TIN needs to be 
certified as a patient-centered medical home, but does not require 
every site be certified, which could be overly restrictive given that 
some sites within a TIN may be in the process of being certified as 
patient-centered medical homes. In addition, we believe a 50 percent 
threshold is achievable which is supported by a study of physician-
owned primary care groups in a recent Annals of Family Medicine article 
(Casalino, et al., 2016) http://www.annfammed.org/content/14/1/16.full. 
For nearly all groups in this study (sampled with variation in size and 
geographic area) at least 50 percent of the practice sites within the 
group had a medical home designation. If the group is unable to meet 
the 50 percent threshold then the individual MIPS eligible clinician 
may choose to receive full credit as a certified patient-centered 
medical home or comparable specialty practice by reporting as an 
individual for all performance categories. In addition, as discussed in 
section II.C.4.d. of this proposed rule, we are proposing to generally 
apply our previously finalized and proposed group policies to virtual 
groups. Further, we welcome suggestions on an appropriate threshold for 
the number of NPIs within the TIN that must be recognized as a 
certified patient-centered medical home or comparable specialty 
practice to receive full credit in the improvement activities 
performance category.
    We have determined that the Comprehensive Primary Care Plus (CPC+) 
APM design satisfies the requirements to be designated as a medical 
home model, as defined in Sec.  414.1305, and is therefore a certified 
or recognized patient-centered medical home for purposes of the 
improvement activities performance category. The CPC+ model meets the 
criteria to be an Advanced APM. CPC+ eligibility criteria for practices 
include, but are not limited to, the use of CEHRT and care delivery 
activities such as: Assigning patients to clinician panels; providing 
24/7 clinician access; and supporting quality improvement activities. 
Control groups in CPC+ are required to meet the same eligibility 
criteria as those selected to be active participants in the model. For 
Round 2 of CPC+, CMS is randomly assigning accepted practices into the 
intervention group or a control group. Practices accepted into CPC+ and 
randomized into the control group have satisfied the requirements for 
participation in CPC+, a medical home model, and we believe that the 
MIPS eligible clinicians in the control group should therefore receive 
full credit for the improvement activities performance category. In 
addition, the practices randomized to the CPC+ control group must sign 
a Participation Agreement with us; the agreement will require practices 
in a control group to maintain a Practitioner Roster of all MIPS 
eligible clinicians in the practice.
    Accordingly, we are proposing that MIPS eligible clinicians in 
practices that have been randomized to the control group in the CPC+ 
APM would receive full credit as a medical home model, and therefore a 
certified patient-centered medical home, for the improvement activities 
performance category. MIPS eligible clinicians who attest that they are 
in practices that have been randomized to the control group in the CPC+ 
APM would receive full credit for the improvement activities 
performance category for each performance period in which they are on 
the Practitioner Roster, the official list of eligible clinicians 
participating in a practice in the CPC+ control group. The inclusion of 
MIPS eligible clinicians in practices that have been randomized into 
the CPC+ control group recognizes that they have met the

[[Page 30055]]

requirements to receive full credit for performance in the improvement 
activities performance category as a medical home model, and will help 
ensure more equitable treatment of the CPC+ control group by allowing 
clinicians in the control group that have met the criteria for 
participation in the CPC+ APM to receive the same recognition as those 
actively participating in the CPC+ intervention group.
    We request comments on these proposals.
(c) Required Period of Time for Performing an Activity
    In the CY 2017 Quality Payment Program final rule (81 FR 77186), we 
specified at Sec.  414.1360 that MIPS eligible clinicians or groups 
must perform improvement activities for at least 90 consecutive days 
during the performance period for improvement activities performance 
category credit. Activities, where applicable, may be continuing (that 
is, could have started prior to the performance period and are 
continuing) or be adopted in the performance period as long as an 
activity is being performed for at least 90 days during the performance 
period. In addition, as discussed in section II.C.4.d. of this proposed 
rule, we are proposing to generally apply our previously finalized and 
proposed group policies to virtual groups. We are not proposing any 
changes to the required period of time for performing an activity for 
the improvement activities performance category in this proposed rule.
(4) Application of Improvement Activities to Non-Patient Facing 
Individual MIPS Eligible Clinicians and Groups
    In the CY 2017 Quality Payment Program final rule (81 FR 77187), we 
specified at Sec.  414.1380(b)(3)(vii) that for non-patient facing 
individual MIPS eligible clinicians or groups, to achieve the highest 
score one high-weighted or two medium-weighted improvement activities 
are required. For these individual MIPS eligible clinicians and groups, 
in order to achieve one-half of the highest score, one medium-weighted 
improvement activity is required. We are not proposing any changes to 
the application of improvement activities to non-patient facing 
individual MIPS eligible clinicians and groups for the improvement 
activities performance category in this proposed rule.
(5) Special Consideration for Small, Rural, or Health Professional 
Shortage Areas Practices
    In the CY 2017 Quality Payment Program final rule (81 FR 77188), we 
finalized at Sec.  414.1380(b)(3)(vii) that one high-weighted or two 
medium-weighted improvement activities are required for individual MIPS 
eligible clinicians and groups that are small practices or located in 
rural areas, or geographic HPSAs, to achieve full credit. In addition, 
we specified at Sec.  414.1305 that a rural area means ZIP codes 
designated as rural, using the most recent HRSA Area Health Resource 
File data set available. Lastly, we finalized the following definitions 
at Sec.  414.1305: (1) Small practices is defined to mean practices 
consisting of 15 or fewer clinicians and solo practitioners; and (2) 
Health Professional Shortage Areas (HPSA) refers to areas as designated 
under section 332(a)(1)(A) of the Public Health Service Act. We are not 
proposing any changes to the special consideration for small, rural, or 
health professional shortage areas practices for the improvement 
activities performance category in this proposed rule.
(6) Improvement Activities Subcategories
    In the CY 2017 Quality Payment Program final rule (81 FR 77190), we 
finalized at Sec.  414.1365 that the improvement activities performance 
category will include the subcategories of activities provided at 
section 1848(q)(2)(B)(iii) of the Act. In addition, we finalized at 
Sec.  414.1365 the following additional subcategories: Achieving Health 
Equity; Integrated Behavioral and Mental Health; and Emergency 
Preparedness and Response. We are not proposing any changes to the 
improvement activities subcategories for the improvement activities 
performance category in this proposed rule.
(7) Improvement Activities Inventory
(a) Proposed Approach on the Annual Call for Activities Process for 
Adding New Activities
    In Table H in the Appendix of the CY 2017 Quality Payment Program 
final rule (81 FR 77817), we finalized the Improvement Activities 
Inventory for MIPS. In addition, through subregulatory guidance we 
provided an informal process for submitting new improvement activities 
for potential inclusion in the comprehensive Improvement Activities 
Inventory for the Quality Payment Program Year 2. During this 
transition period we received input from various MIPS eligible 
clinicians and organizations suggesting possible new activities via a 
nomination form that was posted on the CMS Web site at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/CallForMeasures.html. We are proposing new activities 
and changes to the Improvement Activities Inventory in Tables F and G 
of the Appendix of this proposed rule.
    For the Quality Payment Program Year 3 and future years, we are 
proposing to formalize an Annual Call for Activities process for adding 
possible new activities to the Improvement Activities Inventory. We 
believe this is a way to engage eligible clinician organizations and 
other relevant stakeholders, including beneficiaries, in the 
identification and submission of improvement activities for 
consideration. We propose that individual MIPS eligible clinicians or 
groups and other relevant stakeholders may recommend activities for 
potential inclusion in the Improvement Activities Inventory via a 
similar nomination form utilized in the transition year of MIPS found 
on the Quality Payment Program Web site at www.qpp.cms.gov. As part of 
the process, individual MIPS eligible clinicians, groups, and other 
relevant stakeholders would be able to nominate additional improvement 
activities that we may consider adding to the Improvement Activities 
Inventory. Individual MIPS eligible clinicians and groups and relevant 
stakeholders would be able to provide an explanation via the nomination 
form of how the improvement activity meets all the criteria we have 
identified in section II.C.6.e.(7)(b) of this proposed rule. The 2018 
proposed new improvement activities and the 2018 proposed improvement 
activities with changes can be found in Tables F and G of the Appendix 
of this proposed rule and will be available on the CMS Web site.
    We request comments on this proposed annual Call for Activities 
process.
(b) Criteria for Nominating New Improvement Activities for the Annual 
Call for Activities
    We propose for the Quality Payment Program Year 2 and future years 
that stakeholders would apply one or more of the following criteria 
when submitting improvement activities in response to the Annual Call 
for Activities:
     Relevance to an existing improvement activities 
subcategory (or a proposed new subcategory);
     Importance of an activity toward achieving improved 
beneficiary health outcome;

[[Page 30056]]

     Importance of an activity that could lead to improvement 
in practice to reduce health care disparities;
     Aligned with patient-centered medical homes;
     Activities that may be considered for an advancing care 
information bonus;
     Representative of activities that multiple individual MIPS 
eligible clinicians or groups could perform (for example, primary care, 
specialty care);
     Feasible to implement, recognizing importance in 
minimizing burden, especially for small practices, practices in rural 
areas, or in areas designated as geographic HPSAs by HRSA;
     Evidence supports that an activity has a high probability 
of contributing to improved beneficiary health outcomes; or
     CMS is able to validate the activity.
    We note that in future rulemaking, activities that overlap with 
other performance categories may be included if such activities support 
the key goals of the program.
    We request comments on this proposal.
(c) Submission Timeline for Nominating New Improvement Activities for 
the Annual Call for Activities
    It is our intention that the nomination and acceptance process 
will, to the best extent possible, parallel the Annual Call for 
Measures process already conducted for MIPS quality measures. Aligned 
with this approach, we propose to accept submissions for prospective 
improvement activities at any time during the performance period for 
the Annual Call for Activities and create an Improvement Activities 
under Review (IAUR) list. This list will be considered by us and may 
include federal partners in collaboration with stakeholders. The IAUR 
list will be analyzed with consideration of the proposed criteria for 
inclusion of improvement activities in the Improvement Activities 
Inventory. In addition, we propose that for the Annual Call for 
Activities, only activities submitted by March 1 would be considered 
for inclusion in the Improvement Activities Inventory for the 
performance periods occurring in the following calendar year. This 
proposal is slightly different than the Call for Measures timeline. The 
Annual Call for Measures requires a 2-year implementation timeline 
because the measures being considered for inclusion in MIPS undergo the 
pre-rulemaking process with review by the Measures Application 
Partnership (MAP). We are not proposing that improvement activities 
undergo MAP review. Therefore, our intention is to close the Annual 
Call for Activities submissions by March 1 before the applicable 
performance period, which will enable us to propose the new improvement 
activities for adoption in the same year's rulemaking cycle for 
implementation in the following year. For example, an improvement 
activity submitted prior to March 1, 2018, would be considered for 
performance periods occurring in 2019. In addition, we propose that we 
will add new improvement activities to the inventory through notice-
and-comment rulemaking. In future years we anticipate developing a 
process and establishing criteria for identifying activities for 
removal from the Improvement Activities Inventory through the Annual 
Call for Activities process. We are requesting comments on what 
criteria should be used to identify improvement activities for removal 
from the Improvement Activities Inventory.
(8) Approach for Adding New Subcategories
    In the CY 2017 Quality Payment Program final rule (81 FR 77197), we 
finalized the following criteria for adding a new subcategory to the 
improvement activities performance category:
     The new subcategory represents an area that could 
highlight improved beneficiary health outcomes, patient engagement and 
safety based on evidence.
     The new subcategory has a designated number of activities 
that meet the criteria for an improvement activity and cannot be 
classified under the existing subcategories.
     Newly identified subcategories would contribute to 
improvement in patient care practices or improvement in performance on 
quality measures and cost performance categories.
    We are not proposing any changes to the approach for adding new 
subcategories for the improvement activities performance category in 
this proposed rule. However, we are proposing that in future years of 
the Quality Payment Program we will add new improvement activities 
subcategories through notice-and-comment rulemaking. In addition, we 
are seeking comments on new improvement activities subcategories.
    A number of stakeholders have suggested that a separate subcategory 
for improvement activities specifically related to health IT would make 
it easier for MIPS eligible clinicians and vendors to understand and 
earn points toward their final score through the use of health IT. Such 
a health IT subcategory could include only improvement activities that 
are specifically related to the advancing care information performance 
category measures and allow MIPS eligible clinicians to earn credit in 
the improvement activities performance category, while receiving a 
bonus in the advancing care information performance category as well. 
We are seeking suggestions on how a health IT subcategory within the 
improvement activities performance category could be structured to 
afford MIPS eligible clinicians with flexible opportunities to gain 
experience in using CEHRT and other health IT to improve their 
practice. Should the current policies where improvement activities earn 
bonus points within the advancing care information performance category 
be enhanced? Are there additional policies that should be explored in 
future rulemaking? We welcome public comment on this potential health 
IT subcategory.
(9) CMS Study on Burdens Associated With Reporting Quality Measures
    In the CY 2017 Quality Payment Program final rule (81 FR 77195), we 
finalized specifics regarding the CMS Study on Improvement Activities 
and Measurement including the study purpose, study participation credit 
and requirements, and the study procedure. We are modifying the name of 
the study in this proposed rule to the ``CMS study on burdens 
associated with reporting quality measures'' to more accurately reflect 
the purpose of the study. The study assesses clinician burden and data 
submission errors associated with the collection and submission of 
clinician quality measures for MIPS, enrolling groups of different 
sizes and individuals in both rural and non-rural settings and also 
different specialties. We also noted that study participants would 
receive full credit in the improvement activities performance category 
after successfully electing, participating, and submitting data to the 
study coordinators at CMS for the full calendar year (81 FR 77196). We 
requested comment on the study, and received generally supportive 
feedback for the study.
    We are not proposing any changes to the study purpose. We are 
proposing changes to the study participation credit and requirements 
sample size, how the study sample is categorized into groups, and the 
frequency of quality data submission, focus groups, and surveys. In 
addition to performing descriptive statistics to compare the trends in 
errors and burden between study years 2017 and 2018, we would like to 
perform a more rigorous statistical analysis with the 2018 data, which 
will require a larger sample size. We propose this increase in the 
sample size for 2018 to

[[Page 30057]]

provide the minimum sample needed to get a significant result with 
adequate power for the following investigation.
    Specifically, we are interested in whether there are any 
significant differences in quality measurement data submission errors 
and/or clinician burdens between rural clinicians submitting either 
individually or as a group, and urban clinicians submitting as an 
individual or as a group. A statistical power analysis was performed 
and a total sample size of 118 will be adequate for the main objective 
of the study. However, allowance will be made to account for attrition 
and other additional (or secondary) analysis.
    This analysis would be compared at different sizes of practices (<3 
eligible clinicians, between 3-8 eligible clinicians, etc.). This 
assessment is important since it facilitates tracing the root causes of 
measurement burdens and data submission errors that may be associated 
with any sub-group of clinician practice. This comparison may further 
break the sample down into more than four categories and a much larger 
sample size is a requisite for significant results with adequate 
probability of certainty.
    The sample size for performance periods occurring in 2017 consisted 
of 42 MIPS groups as stated by MIPS criteria from the following seven 
categories:
     10 urban individual or groups of <3 eligible clinicians.
     10 rural individual or groups of <3 eligible clinicians.
     10 groups of 3-8 eligible clinicians.
     5 groups of 8-20 eligible clinicians.
     3 groups of 20-100 eligible clinicians.
     2 groups of 100 or greater eligible clinicians.
     2 specialty groups.
    We are proposing to increase the sample size for the performance 
periods occurring in 2018 to a minimum of:
     20 urban individual or groups of <3 eligible clinicians--
(broken down into 10 individuals & 10 groups).
     20 rural individual or groups of <3 eligible clinicians--
(broken down into 10 individuals & 10 groups).
     10 groups of 3-8 eligible clinicians.
     10 groups of 8-20 eligible clinicians.
     10 groups of 20-100 eligible clinicians.
     10 groups of 100 or greater eligible clinicians.
     6 groups of >20 eligible clinicians reporting as 
individuals--(broken down into 3 urban & 3 rural).
     6 specialty groups--(broken down into 3 reporting 
individually & 3 reporting as a group).
     Up to 10 non-MIPS eligible clinicians reporting as a group 
or individual (any number of individuals and any group size).
    In addition, we are proposing changes to the study procedures. In 
the transition year of MIPS, study participants were required to attend 
a monthly focus group to share lessons learned in submitting quality 
data along with providing survey feedback to monitor effectiveness. 
However, an individual MIPS eligible clinician or group who chooses to 
report all 6 measures within a period of 90 days may not need to be a 
part of all of the focus groups and survey sessions after their first 
focus group and survey following the measurement data submission. This 
is because they may have nothing new to contribute in terms of 
discussion of errors or clinician burdens. This also applies to MIPS 
eligible clinicians that submit only three MIPS measures within the 
performance period, if they submitted all three measures within the 90-
day period or at one submission. All study participants would 
participate in surveys and focus group meetings at least once after 
each measures data submission. For those who elect to report data for a 
90-day period, we would make further engagement optional. Therefore, we 
are proposing that for Quality Payment Program Year 2 and future years 
that study participants would be required to attend as frequently as 
four monthly surveys and focus group sessions throughout the year, but 
certain study participants would be able to attend less frequently.
    Further, the CY 2017 study requires study measurement data to be 
collected at baseline and at every 3 months (quarterly basis) 
afterwards for the duration of the calendar year. It also calls for a 
minimum requirement of three MIPS quality measures four times within 
the year. We believe this is inconsistent with clinicians reporting a 
full year's data as we believe some study participants may choose to 
submit data for all measures at one time, or alternatively, may choose 
to submit data up to six times during the 1-year period. We are 
proposing for the Quality Payment Program Year 2 and future years to 
offer study participants flexibility in their submissions so that they 
could submit once, as can occur in the MIPS program, and participate in 
study surveys and focus groups while still earning improvement 
activities credit.
    It must be noted that although the aforementioned activities 
constitute an information collection request as defined in the 
implementing regulations of the Paperwork Reduction Act of 1995 (5 CFR 
1320), the associated burden is exempt from application of the 
Paperwork Reduction Act. Specifically, section 1848(s)(7) of the Act, 
as added by section 102 of the MACRA (Pub. L. 114-10) states that 
Chapter 35 of title 44, United States Code, shall not apply to the 
collection of information for the development of quality measures. Our 
goals for new measures are to develop new high quality, low cost 
measures that are meaningful, easily understandable and operable, and 
also, reliably and validly measure what they purport. This study shall 
inform us (and our contractors) on the root causes of clinicians' 
performance measure data collection and data submission burdens and 
challenges that hinders accurate and timely quality measurement 
activities. In addition, this study will inform us on the 
characteristic attributes that our new measures must possess to be able 
to accurately capture and measure the priorities and gaps MACRA aims 
for, as described in the Quality Measures Development Plan.\2\ This 
study, therefore, serves as the initial stage of developing new 
measures and also adapting existing measures. We believe that 
understanding clinician's challenges and skepticisms, and especially, 
understanding the factors that undermine the optimal functioning and 
effectiveness of quality measures are requisites of developing measures 
that are not only measuring what it purports but also that are user 
friendly and understandable for frontline clinicians--our main 
stakeholders in measure development. This will lead to the creation of 
practice-derived, tested measures that reduces burden and create a 
culture of continuous improvement in measure development.
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    \2\ https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Final-MDP.pdf (assessed: 06/02/2017).
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    We request comments on our study on burdens associated with 
reporting quality measures proposals regarding sample size for the 
performance periods occurring in 2018, study procedures for the 
performance periods occurring in 2018 and future years, and data 
submissions for the performance periods occurring in 2018 and future 
years.
f. Advancing Care Information Performance Category
(1) Background
    Section 1848(q)(2)(A) of the Act includes the meaningful use of 
CEHRT as a performance category under the MIPS. We refer to this 
performance

[[Page 30058]]

category as the advancing care information performance category, and it 
is reported by MIPS eligible clinicians as part of the overall MIPS 
program. As required by sections 1848(q)(2) and (5) of the Act, the 
four performance categories of the MIPS shall be used in determining 
the MIPS final score for each MIPS eligible clinician. In general, MIPS 
eligible clinicians will be evaluated under all four of the MIPS 
performance categories, including the advancing care information 
performance category.
(2) Scoring
    Section 1848(q)(5)(E)(i)(IV) of the Act states that 25 percent of 
the MIPS final score shall be based on performance for the advancing 
care information performance category. We established at Sec.  
414.1380(b)(4) that the score for the advancing care information 
performance category would be comprised of a base score, performance 
score, and potential bonus points for reporting on certain measures and 
activities. For further explanation of our scoring policies for the 
advancing care information performance category, we refer readers to 81 
FR 77216-77227.
(a) Base Score
    For the CY 2018 performance period, we are not proposing any 
changes to the base score methodology as established in the CY 2017 
Quality Payment Program final rule (81 FR 77217-77223). We established 
the policy that MIPS eligible clinicians must report a numerator of at 
least one for the numerator/denominator measures, or a ``yes'' response 
for the yes/no measure in order to earn the 50 percentage points in the 
base score. In addition, if the base score requirements are not met, a 
MIPS eligible clinician would receive a score of zero for the ACI 
performance category.
(b) Performance Score
    In the CY 2017 Quality Payment Program final rule (81 FR 77223 
through 77226), we finalized that MIPS eligible clinicians can earn 10 
percentage points in the performance score for meeting the Immunization 
Registry Reporting Measure. We believe we should modify this policy 
because we have learned that there are areas of the country where 
immunization registries are not available, and we did not intend to 
disadvantage MIPS eligible clinicians practicing in those areas. Thus, 
we are proposing to modify the scoring of the Public Health and 
Clinical Data Registry Reporting objective beginning with the 
performance period in CY 2018. We propose if a MIPS eligible clinician 
fulfills the Immunization Registry Reporting Measure, the MIPS eligible 
clinician would earn 10 percentage points in the performance score. If 
a MIPS eligible clinician cannot fulfill the Immunization Registry 
Reporting Measure, we are proposing that the MIPS eligible clinician 
could earn 5 percentage points in the performance score for each public 
health agency or clinical data registry to which the clinician reports 
for the following measures, up to a maximum of 10 percentage points: 
Syndromic Surveillance Reporting; Electronic Case Reporting; Public 
Health Registry Reporting; and Clinical Data Registry Reporting. A MIPS 
eligible clinician who chooses to report to more than one public health 
agency or clinical data registry may receive credit in the performance 
score for the submission to more than one agency or registry; however, 
the MIPS eligible clinician would not earn more than a total of 10 
percentage points for such reporting.
    We further propose similar flexibility for MIPS eligible clinicians 
who choose to report the measures specified for the Public Health 
Reporting Objective of the 2018 Advancing Care Information Transition 
Objective and Measure set. (In section II.C.6.f.(6)(b) of this proposed 
rule, we are proposing to allow MIPS eligible clinicians to report 
using the 2018 Advancing Care Information Transition Objectives and 
Measures in 2018.) We propose if a MIPS eligible clinician fulfills the 
Immunization Registry Reporting Measure, the MIPS eligible clinician 
would earn 10 percentage points in the performance score. If a MIPS 
eligible clinician cannot fulfill the Immunization Registry Reporting 
Measure, we are proposing that the MIPS eligible clinician could earn 5 
percentage points in the performance score for each public health 
agency or specialized registry to which the clinician reports for the 
following measures, up to a maximum of 10 percentage points: Syndromic 
Surveillance Reporting; Specialized Registry Reporting. A MIPS eligible 
clinician who chooses to report to more than one specialized registry 
or public health agency to submit syndromic surveillance data may earn 
5 percentage points in the performance score for reporting to each one, 
up to a maximum of 10 percentage points.
    By proposing to expand the options for fulfilling the Public Health 
and Clinical Data Registry Reporting and the Public Health Reporting 
objectives, we believe that we are adding flexibility so that 
additional MIPS eligible clinicians can successfully fulfill this 
objective and earn 10 percentage points in the performance score. We 
are not proposing to change the maximum performance score that a MIPS 
eligible clinician can earn; it remains at 90 percent.
    We are inviting public comment on these proposals.
(c) Bonus Score
    In the CY 2017 Quality Payment Program final rule (81 FR 77220 
through 77226), for the Public Health and Clinical Data Registry 
Reporting objective and the Public Health Reporting objective, we 
finalized that MIPS eligible clinicians who report to one or more 
public health agencies or clinical data registries beyond the 
Immunization Registry Reporting Measure will earn a bonus score of 5 
percentage points in the advancing care information performance 
category. (In section II.C.6.f.(6)(b) of this proposed rule, we are 
proposing to allow MIPS eligible clinicians to report using the 2018 
Advancing Care Information Transition Objectives and Measures in 2018.) 
Based on our proposals above to allow MIPS eligible clinicians who 
cannot fulfill the Immunization Registry Reporting Measure to earn 
additional points in the performance score, we believe we should modify 
this policy so that MIPS eligible clinicians cannot earn points in both 
the performance score and bonus score for reporting to the same public 
health agency or clinical data registry. We are proposing to modify our 
policy beginning with the performance period in CY 2018. We are 
proposing that a MIPS eligible clinician may only earn the bonus score 
of 5 percentage points for reporting to at least one additional public 
health agency or clinical data registry that is different from the 
agency/agencies or registry/or registries to which the MIPS eligible 
clinician reports to earn a performance score. For example, if a MIPS 
eligible clinician reports to a public health agency and a clinical 
data registry for the performance score, they could earn the bonus 
score of 5 percentage points by reporting to a different agency or 
registry that the clinician did not identify for purposes of the 
performance score. A MIPS eligible clinician would not receive credit 
under both the performance score and bonus score for reporting to the 
same agency or registry.
    We are proposing that for the Advancing Care Information Objectives 
and Measures, a bonus of 5 percentage points would be awarded if the 
MIPS eligible clinician reports ``yes'' for any one of the following 
measures associated with the Public Health and Clinical Data Registry 
Reporting

[[Page 30059]]

objective: Syndromic Surveillance Reporting; Electronic Case Reporting; 
Public Health Registry Reporting; or Clinical Data Registry Reporting. 
We are proposing that for the 2018 Advancing Care Information 
Transition Objectives and Measures, a bonus of 5 percent would be 
awarded if the MIPS eligible clinician reports ``yes'' for any one of 
the following measures associated with the Public Health Reporting 
objective: Syndromic Surveillance Reporting or Specialized Registry 
Reporting. We are proposing that to earn the bonus score, the MIPS 
eligible clinician must be in active engagement with one or more 
additional public health agencies or clinical data registries that is/
are different from the agency or registry that they identified to earn 
a performance score.
    We are inviting public comment on this proposal.
(d) Improvement Activities Bonus Score Under the Advancing Care 
Information Performance Category
    In the CY 2017 Quality Payment Program final rule (81 FR 77202), we 
discussed our approach to the measurement of the use of health IT to 
allow MIPS eligible clinicians and groups the flexibility to implement 
health IT in a way that supports their clinical needs. In addition, we 
discussed the need to move toward measurement of health IT use with 
respect to its contribution to effective care coordination and 
improving outcomes for patients. We stated that this approach would 
allow us to more directly link health IT adoption and use to patient 
outcomes, moving MIPS beyond the measurement of EHR adoption and 
process measurement and into a more patient-focused health IT program. 
Toward that end, we adopted a policy to award a bonus score to MIPS 
eligible clinicians who use CEHRT to complete certain activities in the 
improvement activities performance category based on our belief that 
the use of CEHRT in carrying out these activities could further the 
outcomes of clinical practice improvement.
    We adopted a final policy to award a 10 percent bonus for the 
advancing care information performance category if a MIPS eligible 
clinician attests to completing at least one of the improvement 
activities we have specified using CEHRT (81 FR 77209). We refer 
readers to Table 8 in the CY 2017 Quality Payment Program final rule 
(81 FR 77202-77209) for a list of the improvement activities eligible 
for the advancing care information performance category bonus. In this 
proposed rule, we are proposing to expand this policy beginning with 
the CY 2018 performance period by identifying additional improvement 
activities in Table 6 that would be eligible for the advancing care 
information performance category bonus score if they are completed 
using CEHRT functionality. The activities eligible for the bonus score 
would include those listed in Table 6, as well as those listed in Table 
8 in last year's final rule. We refer readers to the Improvement 
Activities section of this proposed rule (section II.C.6.e. of this 
proposed rule) for a discussion of the proposed new improvement 
activities and proposed changes to the improvement activities for 2018.
    Ten percentage points is the maximum bonus a MIPS eligible 
clinician would receive if they attest to using CEHRT for one or more 
of the activities we have identified as eligible for the bonus. This 
bonus is intended to support progression toward holistic health IT use 
and measurement; attesting to even one improvement activity 
demonstrates that the MIPS eligible clinician is working toward this 
holistic approach to the use of their CEHRT. The weight of the 
improvement activity for the improvement activities performance 
category has no effect on the bonus awarded in the advancing care 
information performance category.
    We invite comment on this proposal.

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(3) Performance Periods for the Advancing Care Information Performance 
Category
    In the CY 2017 Quality Payment Program final rule (81 FR 77210 
through 77211), we established a performance period for the advancing 
care information performance category to align with the overall MIPS 
performance period of one full year to ensure all four performance 
categories are measured and scored based on the same period of time. We 
believe this will lower reporting burden, focus clinician quality 
improvement efforts and align administrative actions so that MIPS 
eligible clinicians can use common systems and reporting pathways. We 
stated for the first and second performance periods of MIPS (CYs 2017 
and 2018), we will accept a minimum of 90 consecutive days of data and 
encourage MIPS eligible clinicians to report data for the full year 
performance period. We are maintaining this policy as finalized for the 
performance period in CY 2018, and will accept a minimum of 90 
consecutive days of data in CY 2018. We are proposing the same policy 
for the advancing care information performance category for the 
performance period in CY 2019, Quality Payment Program Year 3, and 
would accept a minimum of 90 consecutive days of data in CY 2019. We 
refer readers to section II.C.5. in this proposed rule for additional 
information on the MIPS performance period.
(4) Certification Requirements
    In the CY 2017 Quality Payment Program final rule (81 FR 77211 
through 77213), we outlined the requirements for MIPS eligible 
clinicians using CEHRT during the CY 2017 performance period for the 
advancing care information performance category as it relates to the 
objectives and measures they select to report, and also outlined 
requirements for the CY 2018 performance period. We additionally 
adopted a definition of CEHRT at Sec.  414.1305 for MIPS eligible 
clinicians that is based on the definition that applies in the EHR 
Incentive Programs under Sec.  495.4.
    For the CY 2017 performance period, we adopted a policy by which 
MIPS eligible clinicians may use EHR

[[Page 30064]]

technology certified to either the 2014 or 2015 Edition certification 
criteria, or a combination of the two. For the CY 2018 performance 
period, we previously stated that MIPS eligible clinicians must use EHR 
technology certified to the 2015 Edition to meet the objectives and 
measures specified for the advancing care information performance 
category.
    We received significant comments and feedback from stakeholders 
requesting that we extend the use of 2014 Edition CEHRT beyond CY 2017 
into CY 2018 and even CY 2019. Many commenters noted the lack of 
products certified to the 2015 Edition. Others stated that switching 
from the 2014 Edition to the 2015 Edition requires a large amount of 
time and planning and if it is rushed there is a potential risk to 
patient health. Some commenters noted the significant burden of 
combining outputs from multiple CEHRTs. A few mentioned that the cost 
to switch to the 2015 Edition is prohibitive for smaller practices.
    Our experience with the transition from EHR technology certified to 
the 2011 Edition to EHR technology certified to the 2014 Edition did 
make us aware of the many issues associated with the adoption of EHR 
technology certified to a new Edition. These include the time that will 
be necessary to effectively deploy EHR technology certified to the 2015 
Edition standards and certification criteria and to make the necessary 
patient safety, staff training, and workflow investments to be prepared 
to report for the advancing care information performance category for 
2018. We understand and appreciate these concerns, and are working in 
collaboration with our federal partners at the Office of the National 
Coordinator for Health Information Technology (ONC) to monitor progress 
on the 2015 Edition upgrade.
    As noted in the FY 2018 Inpatient Prospective Payment Systems for 
Acute Care Hospitals and the Long-Term Care Hospital Prospective 
Payment System proposed rule (referred to as the FY 2018 IPPS/LTCH PPS 
proposed rule) (82 FR 20136), ONC is working with health IT developers 
to analyze and monitor the status of developer readiness for 2015 
Edition technology. As part of these analyses, ONC also reviewed health 
IT being certified to 2015 Edition by health IT developers who have 
products that were certified for the 2014 Edition and were used by EHR 
Incentive Program participants to attest. This analysis compared the 
pace of 2014 Edition certification with the pace of 2015 Edition 
certification to date. As of the beginning of the second quarter of CY 
2017, ONC confirmed that at least 53 percent of eligible clinicians and 
80 percent of eligible hospitals have 2015 Edition certified EHR 
technology available based on previous EHR Incentive Programs 
attestation data. Based on these data, and as compared to the 
transition from 2011 Edition to 2014 Edition, it appears that the 
transition from the 2014 Edition to the 2015 Edition is on schedule for 
the CY 2018 performance period.
    However, the analysis also considered market trends such as 
consolidation and the number of large and small developers covering 
various groups of participants and the potential impact on readiness. 
The eligible hospital market is fairly concentrated, with nearly 98 
percent of eligible hospital EHR Incentive Program participants using 
health IT from the top ten developers (ranked by market share) with a 
significant majority of that coverage by the top five developers. For 
hospitals, some developers representing a smaller market share also 
have certified health IT already available and are not expected to have 
a release schedule much different from their larger competitors. 
Considering market factors and using previous EHR Incentive Programs 
attestation data, ONC estimates that at least 85 percent of eligible 
hospitals would have EHR technology certified to the 2015 Edition 
available for use by the end of CY 2017 for program participation in 
2018. In the FY 2018 IPPS/LTCH PPS proposed rule (82 FR 20136), we 
proposed to shorten the EHR reporting period to a minimum of any 
continuous 90-day period within CY 2018 for eligible hospitals and 
CAHs, as well as EPs who attest for a state's Medicaid EHR Incentive 
Program, to allow additional time for successful implementation of EHR 
technology certified to the 2015 Edition in CY 2018.
    For MIPS eligible clinicians, the concern of potential impact on 
participation readiness when reviewing these market factors may be more 
significant. As noted in the FY 2018 IPPS/LTCH PPS proposed rule (82 FR 
20136), historical data indicates eligible professionals were more 
likely to use a wider range of certified health IT, including those 
which individually make up a smaller segment of the overall market. 
Therefore, when market factors are taken into account, there exists a 
larger proportion of readiness that is unknown due to the wider range 
of certified health IT which may be used by MIPS eligible clinicians. 
This necessitated a more conservative approach for MIPS eligible 
clinician readiness. That estimate is that 74 percent of MIPS eligible 
clinicians will be ready to participate in MIPS using 2015 Edition 
certified EHR technologies by January 1, 2018.
    However, subsequent to the preliminary analysis, ONC has continued 
to monitor readiness and to receive feedback from stakeholders on 
factors influencing variations in the development and implementation 
timelines for developers supporting different segments of the market, 
as well as the relationship between the developer readiness timeline 
and participant readiness. This continuing analysis supports a 
potential need for a longer implementation timeline for MIPS eligible 
clinicians. Stakeholder feedback suggests that while the estimate for 
known readiness remains the same, readiness among the remaining MIPS 
eligible clinicians may not be on the same timeline. About one quarter 
of eligible professional EHR Incentive Program participants in prior 
years used certified health IT from small developers that each has an 
historical market share of 1 percent or less. Therefore, MIPS eligible 
clinicians will need a significant number of smaller developers to 
reach the same readiness on the same timeline as larger companies in 
order to support program participants seeking to upgrade to the 2015 
Edition. However, small developers generally offer a limited number or 
type of products, and may have more limited resources to dedicate to 
upgrade development, testing and certification, and implementation, 
which may affect availability and timing. In addition, the same factors 
may impact the capacity of some developers to support participants 
during the process and therefore the timeline for participant readiness 
would also potentially be longer. This is supported by historical 
analysis as a smaller percentage of eligible professionals used 2014 
Edition certified EHR technology for participation in the EHR Incentive 
Programs during the 2014 calendar year than eligible hospitals and CAHs 
for the same year. For this reason, we believe additional flexibility 
for MIPS eligible clinicians is essential to support successful 
participation in the advancing care information performance category.
    We continue to believe that there are many benefits for switching 
to EHR technology certified to the 2015 Edition. As noted in the FY 
2018 IPPS/LTCH PPS proposed rule (82 FR 20136), the 2015 Edition health 
IT certification criteria enables health information exchange through 
new and enhanced certification criteria standards, and through 
implementation specifications

[[Page 30065]]

for interoperability. The 2015 Edition also incorporates changes that 
are designed to spur innovation and provide more choices to health care 
providers and patients for the exchange of electronic health 
information, including new Application Programming Interface (API) 
certification criteria. APIs are required for patient engagement 
measures within the advancing care information category; however, they 
may also be enabled by a health care provider or organization for their 
own use of third party applications with their CEHRT, such as for 
quality improvement. An API can also be enabled by a health care 
provider to give patients access to their health information through a 
third-party application with more flexibility than is often found in 
many current patient portals. From the MIPS eligible clinician 
perspective, an API could complement a patient portal or could also 
potentially make one unnecessary if patients are able to use software 
applications designed to interact with an API that could support their 
ability to view, download, and transmit their health information to a 
third party. In addition, the 2015 Edition health IT transitions of 
care certification criterion rigorously assesses a product's ability to 
create and receive a Consolidated-Clinical Document Architecture (C-
CDA) formatted documents. The ONC also adopted certification criteria 
that both support interoperability in other settings and use cases, 
such as the Common Clinical Data Set summary record, data segmentation 
for privacy, and care plan certification criteria (80 FR 62603).
    However, in light of the conservative readiness estimates for MIPS 
eligible clinicians, and in line with our commitment to supporting 
small practices, solo practitioners and specialties which may be more 
likely to use certified health IT offered by small developers, we are 
proposing that MIPS eligible clinicians may use EHR technology 
certified to either the 2014 or 2015 Edition certification criteria, or 
a combination of the two for the CY 2018 performance period. We propose 
to amend Sec.  414.1305 to reflect this change. We further note, that 
to encourage new participants to adopt certified health IT and to 
incentivize participants to upgrade their technology to 2015 Edition 
products which better support interoperability across the care 
continuum, we are proposing to offer a bonus of 10 percentage points 
under the advancing care information performance category for MIPS 
eligible clinicians who report the Advancing Care Information 
Objectives and Measures for the performance period in CY 2018 using 
only 2015 Edition CEHRT. We are proposing to amend Sec.  
414.1380(b)(4)C)(3) to reflect this change. We are proposing this one-
time bonus for CY 2018 to support and recognize MIPS eligible 
clinicians and groups that invest in implementing certified EHR 
technology in their practice. Specifically, we intend this bonus to 
support new participants that may be adopting health IT for the first 
time in CY 2018 and do not have 2014 Edition technology available to 
use or that may have no prior experience with meaningful use objectives 
and measures. We believe this bonus will help recognize their 
investment to adopt health IT and support their participation in the 
advancing care information performance category in MIPS. In addition, 
we believe this bonus will help to incentivize participants to continue 
the process of upgrading from 2014 Edition to 2015 Edition, especially 
small practices where the investment in updated workflows and 
implementation may present unique challenges. We intend this bonus to 
support and recognize their efforts to engage with the advancing care 
information measures using technology certified to the 2015 Edition, 
which include more robust measures using updated standards and 
functions which support interoperability. We seek comment on this 
proposed bonus. Specifically, we seek comment on if the percentage of 
the bonus is appropriate, or whether it should be limited to new 
participants in MIPS and small practices.
    This bonus is not available to MIPS eligible clinicians who use a 
combination of the 2014 and 2015 Editions. We note that with the 
addition of the 2015 Edition CEHRT bonus of 10 percentage points, MIPS 
eligible clinicians would be able to earn a bonus score of up to 25 
percentage points in CY 2018 under the advancing care information 
performance category, an increase from the 15 percentage point bonus 
score available in CY 2017.
    To facilitate readers in identifying the requirements of CEHRT for 
the Advancing Care Information Objectives and Measures, we are 
including Table 8 in section II.C.6.f.(6)(a) which lists the 2015 
Edition and 2014 Edition certification criteria required to meet the 
objectives and measures.
    We invite comments on these proposals.
(5) Scoring Methodology Considerations
    Section 1848(q)(5)(E)(i)(IV) of the Act states that 25 percent of 
the MIPS final score shall be based on performance for the advancing 
care information performance category. Further, section 
1848(q)(5)(E)(ii) of the Act, provides that in any year in which the 
Secretary estimates that the proportion of eligible professionals (as 
defined in section 1848(o)(5) of the Act) who are meaningful EHR users 
(as determined under section 1848(o)(2) of the Act) is 75 percent or 
greater, the Secretary may reduce the applicable percentage weight of 
the advancing care information performance category in the MIPS final 
score, but not below 15 percent, and increase the weightings of the 
other performance categories such that the total percentage points of 
the increase equals the total percentage points of the reduction. We 
note that section 1848(o)(5) of the Act defines an eligible 
professional as a physician, as defined in section 1861(r) of the Act.
    In CY 2017 Quality Payment Program final rule (81 FR 77226-77227), 
we established a final policy, for purposes of applying section 
1848(q)(5)(E)(ii) of the Act, to estimate the proportion of physicians 
as defined in section 1861(r) of the Act who are meaningful EHR users 
as those physician MIPS eligible clinicians who earn an advancing care 
information performance category score of at least 75 percent for a 
performance period. We established that we will base this estimation on 
data from the relevant performance period, if we have sufficient data 
available from that period. For example, if feasible, we would consider 
whether to reduce the applicable percentage weight of the advancing 
care information performance category in the MIPS final score for the 
2019 MIPS payment year based on an estimation using the data from the 
2017 performance period. We stated that we will not include in the 
estimation physicians for whom the advancing care information 
performance category is weighted at zero percent under section 
1848(q)(5)(F) of the Act, which we relied on in the CY 2017 Quality 
Payment Program final rule (81 FR 77226 through 77227) to establish 
policies under which we would weigh the advancing care information 
performance category at zero percent of the final score. In addition, 
we are proposing not to include in the estimation physicians for whom 
the advancing care information performance category would be weighted 
at zero percent under our proposal in section II.C.6.f.(7) of this 
proposed rule to implement certain provisions of the 21st Century Cures 
Act (that is, physicians who are determined hospital-based or 
ambulatory surgical center-based, or who are granted an exception based 
on

[[Page 30066]]

significant hardship or decertified EHR technology.
    We are considering modifications to the policy we established in 
last year's rulemaking to base our estimation of physicians who are 
meaningful EHR users for a MIPS payment year (for example, 2019) on 
data from the relevant performance period (for example, 2017). We are 
concerned that if in future rulemaking we decide to propose to change 
the weight of the advancing care information performance category based 
on our estimation, such a change may cause confusion to MIPS eligible 
clinicians who are adjusting to the MIPS program and believe this 
performance category will make up 25 percent of the final score for the 
2019 MIPS payment year. The earliest we would be able to make our 
estimation based on 2017 data and propose in future rulemaking to 
change the weight of the advancing care information performance 
category for the 2019 MIPS payment year would be in mid-2018, as the 
deadline for data submission is March 31, 2018. We are requesting 
public comments on whether this timeframe is sufficient, or whether a 
more extended timeframe would be preferable. We are proposing to modify 
our existing policy such that we would base our estimation of 
physicians who are meaningful EHR users for a MIPS payment year on data 
from the performance period that occurs four years before the MIPS 
payment year. For example, we would use data from the 2017 performance 
period to estimate the proportion of physicians who are meaningful EHR 
users for purposes of reweighting the advancing care information 
performance category for the 2021 MIPS payment year.
    We invite comments on this proposal.
(6) Objectives and Measures
(a) Advancing Care Information Objectives and Measures Specifications
    We are proposing to maintain for the CY 2018 performance period the 
Advancing Care Information Objectives and Measures as finalized in the 
CY 2017 Quality Payment Program final rule (81 FR 77227 through 77229) 
with the modifications proposed below. As we noted (81 FR 77227), these 
objectives and measures were adapted from the Stage 3 objectives and 
measures finalized in the 2015 EHR Incentive Programs final rule (80 FR 
62829 through 62871), however, we did not maintain the previously 
established thresholds for MIPS. For a more detailed discussion of the 
Stage 3 objectives and measures, including explanatory material and 
defined terms, we refer readers to the 2015 EHR Incentive Programs 
final rule (80 FR 62829 through 62871).

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    Objective: Protect Patient Health Information.
    Objective: Protect electronic protected health information (ePHI) 
created or maintained by the CEHRT through the implementation of 
appropriate technical, administrative, and physical safeguards.
    Security Risk Analysis Measure: Conduct or review a security risk 
analysis in accordance with the requirements in 45 CFR 164.308(a)(1), 
including addressing the security (to include encryption) of ePHI data 
created or maintained by CEHRT in accordance with requirements in 45 
CFR 164.312(a)(2)(iv) and 164.306(d)(3), implement security updates as 
necessary, and correct identified security deficiencies as part of the 
MIPS eligible clinician's risk management process.
    Objective: Electronic Prescribing.
    Objective: Generate and transmit permissible prescriptions 
electronically.
    E-Prescribing Measure: At least one permissible prescription 
written by the MIPS eligible clinician is queried for a drug formulary 
and transmitted electronically using CEHRT.
     Denominator: Number of prescriptions written for drugs 
requiring a prescription to be dispensed other than controlled 
substances during the performance period; or number of prescriptions 
written for drugs requiring a prescription to be dispensed during the 
performance period.
     Numerator: The number of prescriptions in the denominator 
generated, queried for a drug formulary, and transmitted electronically 
using CEHRT.
    Objective: Patient Electronic Access.
    Objective: The MIPS eligible clinician provides patients (or 
patient-authorized representative) with timely electronic access to 
their health information and patient-specific education.
    Provide Patient Access Measure: For at least one unique patient 
seen by the MIPS eligible clinician: (1) The patient (or the patient-
authorized representative) is provided timely access to view online, 
download, and transmit his or her health information; and (2) The MIPS 
eligible clinician ensures the patient's health information is 
available for the patient (or patient-authorized representative) to 
access using any application of their choice that is configured to meet 
the technical specifications of the Application Programing Interface 
(API) in the MIPS eligible clinician's CEHRT.
     Denominator: The number of unique patients seen by the 
MIPS eligible clinician during the performance period.
     Numerator: The number of patients in the denominator (or 
patient authorized representative) who are provided timely access to 
health information to view online, download, and transmit to a third 
party and to access using an application of their choice that is 
configured meet the technical specifications of the API in the MIPS 
eligible clinician's CEHRT.
    Definition of timely--Beginning with the 2018 performance period, 
we are proposing to define ``timely'' as within 4 business days of the 
information being available to the MIPS eligible clinician. This 
definition of timely is the same as we adopted under the EHR Incentive 
Programs (80 FR 62815).
    Patient-Specific Education Measure: The MIPS eligible clinician 
must use clinically relevant information from CEHRT to identify 
patient-specific educational resources and provide electronic access to 
those materials to at least one unique patient seen by the MIPS 
eligible clinician.
     Denominator: The number of unique patients seen by the 
MIPS eligible clinician during the performance period.
     Numerator: The number of patients in the denominator who 
were provided electronic access to patient-specific educational 
resources using clinically relevant information identified from CEHRT 
during the performance period.
    Objective: Coordination of Care Through Patient Engagement.
    Objective: Use CEHRT to engage with patients or their authorized 
representatives about the patient's care.
    View, Download, Transmit (VDT) Measure: During the performance 
period, at least one unique patient (or patient-authorized 
representatives) seen by the MIPS eligible clinician actively engages 
with the EHR made accessible by the MIPS eligible clinician. A MIPS 
eligible clinician may meet the measure by either (1) view, download or 
transmit to a third party their health information; or (2) access their 
health information through the use of an API that can be used by 
applications chosen by the patient and configured to the API in the 
MIPS eligible clinician's CEHRT; or (3) a combination of (1) and (2).
    Proposed change to the View, Download, Transmit (VDT) Measure: 
During the performance period, at least one unique patient (or patient-
authorized representatives) seen by the MIPS eligible clinician 
actively engages with the EHR made accessible by the MIPS eligible 
clinician by either (1) viewing, downloading or transmitting to a third 
party their health information; or (2) accessing their health 
information through the use of an API that can be used by applications 
chosen by the patient and configured to the API in the MIPS eligible 
clinician's CEHRT; or (3) a combination of (1) and (2). We are 
proposing this change because we erroneously described the actions in 
the measure (viewing, downloading or transmitting; or accessing through 
an API) as being taken by the MIPS eligible clinician rather than the 
patient or the patient-authorized representatives. This change would 
align the measure description with the requirements of the numerator 
and denominator. We propose this change would apply beginning with the 
performance period in 2017.
     Denominator: Number of unique patients seen by the MIPS 
eligible clinician during the performance period.
     Numerator: The number of unique patients (or their 
authorized representatives) in the denominator who have viewed online, 
downloaded, or transmitted to a third party the patient's health 
information during the performance period and the number of unique 
patients (or their authorized representatives) in the denominator who 
have accessed their health information through the use of an API during 
the performance period.
    Secure Messaging Measure: For at least one unique patient seen by 
the MIPS eligible clinician during the performance period, a secure 
message was sent using the electronic messaging function of CEHRT to 
the patient (or the patient-authorized representative), or in response 
to a secure message sent by the patient (or the patient-authorized 
representative).
     Denominator: Number of unique patients seen by the MIPS 
eligible clinician during the performance period.
     Numerator: The number of patients in the denominator for 
whom a secure electronic message is sent to the patient (or patient-
authorized representative) or in response to a secure message sent by 
the patient (or patient-authorized representative), during the 
performance period.
    Patient-Generated Health Data Measure: Patient-generated health 
data or data from a non-clinical setting is incorporated into the CEHRT 
for at least one unique patient seen by the MIPS eligible clinician 
during the performance period.
     Denominator: Number of unique patients seen by the MIPS 
eligible clinician during the performance period.
     Numerator: The number of patients in the denominator for 
whom data from non-clinical settings, which may

[[Page 30069]]

include patient-generated health data, is captured through the CEHRT 
into the patient record during the performance period.
    Objective: Health Information Exchange
    Objective: The MIPS eligible clinician provides a summary of care 
record when transitioning or referring their patient to another setting 
of care, receives or retrieves a summary of care record upon the 
receipt of a transition or referral or upon the first patient encounter 
with a new patient, and incorporates summary of care information from 
other health care clinician into their EHR using the functions of 
CEHRT.
    Proposed Change to the Objective: The MIPS eligible clinician 
provides a summary of care record when transitioning or referring their 
patient to another setting of care, receives or retrieves a summary of 
care record upon the receipt of a transition or referral or upon the 
first patient encounter with a new patient, and incorporates summary of 
care information from other health care providers into their EHR using 
the functions of CEHRT.
    We inadvertently used the term ``health care clinician'' and are 
proposing to replace it with the more appropriate term ``health care 
provider''. We are proposing this change would apply beginning with the 
performance period in 2017.
    Send a Summary of Care Measure: For at least one transition of care 
or referral, the MIPS eligible clinician that transitions or refers 
their patient to another setting of care or health care clinician (1) 
creates a summary of care record using CEHRT; and (2) electronically 
exchanges the summary of care record.
    Proposed Change to the Send a Summary of Care Measure: For at least 
one transition of care or referral, the MIPS eligible clinician that 
transitions or refers their patient to another setting of care or 
health care provider (1) creates a summary of care record using CEHRT; 
and (2) electronically exchanges the summary of care record.
    We inadvertently used the term ``health care clinician'' and are 
proposing to replace it with the more appropriate term ``health care 
provider''. We are proposing this change would apply beginning with the 
2017 performance period.
     Denominator: Number of transitions of care and referrals 
during the performance period for which the MIPS eligible clinician was 
the transferring or referring clinician.
     Numerator: The number of transitions of care and referrals 
in the denominator where a summary of care record was created using 
CEHRT and exchanged electronically.
    Request/Accept Summary of Care Measure: For at least one transition 
of care or referral received or patient encounter in which the MIPS 
eligible clinician has never before encountered the patient, the MIPS 
eligible clinician receives or retrieves and incorporates into the 
patient's record an electronic summary of care document.
     Denominator: Number of patient encounters during the 
performance period for which a MIPS eligible clinician was the 
receiving party of a transition or referral or has never before 
encountered the patient and for which an electronic summary of care 
record is available.
     Numerator: Number of patient encounters in the denominator 
where an electronic summary of care record received is incorporated by 
the clinician into the CEHRT.
    Clinical Information Reconciliation Measure: For at least one 
transition of care or referral received or patient encounter in which 
the MIPS eligible clinician has never before encountered the patient, 
the MIPS eligible clinician performs clinical information 
reconciliation. The MIPS eligible clinician must implement clinical 
information reconciliation for the following three clinical information 
sets: (1) Medication. Review of the patient's medication, including the 
name, dosage, frequency, and route of each medication; (2) Medication 
allergy. Review of the patient's known medication allergies; (3) 
Current Problem list. Review of the patient's current and active 
diagnoses.
     Denominator: Number of transitions of care or referrals 
during the performance period for which the MIPS eligible clinician was 
the recipient of the transition or referral or has never before 
encountered the patient.
     Numerator: The number of transitions of care or referrals 
in the denominator where the following three clinical information 
reconciliations were performed: Medication list; medication allergy 
list; and current problem list.
    Objective: Public Health and Clinical Data Registry Reporting.
    Objective: The MIPS eligible clinician is in active engagement with 
a public health agency or clinical data registry to submit electronic 
public health data in a meaningful way using CEHRT, except where 
prohibited, and in accordance with applicable law and practice.
    Immunization Registry Reporting Measure: The MIPS eligible 
clinician is in active engagement with a public health agency to submit 
immunization data and receive immunization forecasts and histories from 
the public health immunization registry/immunization information system 
(IIS).
    We note that the functionality to be bi-directional is part of EHR 
technology certified to the 2015 Edition (80 FR 62554). It means that 
in addition to sending the immunization record to the immunization 
registry, the CEHRT must be able to receive and display a consolidated 
immunization history and forecast.
    Syndromic Surveillance Reporting Measure: The MIPS eligible 
clinician is in active engagement with a public health agency to submit 
syndromic surveillance data from a non-urgent care ambulatory setting 
where the jurisdiction accepts syndromic data from such settings and 
the standards are clearly defined.
    Proposed Change to the Syndromic Surveillance Reporting Measure: 
The MIPS eligible clinician is in active engagement with a public 
health agency to submit syndromic surveillance data. We are proposing 
this change because we inadvertently finalized the measure description 
that we had proposed for Stage 3 of the EHR Incentive Program (80 FR 
82866) and not the measure description that we finalized (80 FR 82970). 
The proposed change aligns with the measure description finalized for 
Stage 3.
    Electronic Case Reporting Measure: The MIPS eligible clinician is 
in active engagement with a public health agency to electronically 
submit case reporting of reportable conditions.
    Public Health Registry Reporting Measure: The MIPS eligible 
clinician is in active engagement with a public health agency to submit 
data to public health registries.
    Clinical Data Registry Reporting Measure: The MIPS eligible 
clinician is in active engagement to submit data to a clinical data 
registry.
    We note that we have split the Specialized Registry Reporting 
Measure that we adopted under the 2017 Advancing Care Information 
Transition Objectives and Measures into two separate measures, Public 
Health Registry and Clinical Data Registry Reporting to better define 
the registries available for reporting. We want to continue to 
encourage those MIPS eligible clinicians who have already started down 
the path of reporting to a specialized registry to continue to engage 
in public health and clinical data registry reporting. Therefore, we 
propose to allow MIPS eligible clinicians and groups to continue to 
count active engagement in electronic

[[Page 30070]]

public health reporting with specialized registries. We propose to 
allow these registries to be counted for purposes of reporting the 
Public Health Registry Reporting Measure or the Clinical Data Registry 
Reporting Measure beginning with the 2018 performance period. A MIPS 
eligible clinician may count a specialized registry if the MIPS 
eligible clinician achieved the phase of active engagement as described 
under ``active engagement option 3: production'' in the 2015 EHR 
Incentive Programs final rule with comment period (80 FR 62862 through 
62865), meaning the clinician has completed testing and validation of 
the electronic submission and is electronically submitting production 
data to the public health agency or clinical data registry.
    As noted previously, to facilitate readers in identifying the 
requirements of CEHRT for the Advancing Care Information Objectives and 
Measures, we are including the following Table 8, which includes the 
2015 Edition and 2014 Edition certification criteria required to meet 
the objectives and measures.

    Table 8--Advancing Care Information Objectives and Measures and Certification Criteria for 2014 and 2015
                                                    Editions
----------------------------------------------------------------------------------------------------------------
             Objective                     Measure                2015 Edition                2014 Edition
----------------------------------------------------------------------------------------------------------------
Protect Patient Health Information  Security Risk          The requirements are a      The requirements are
                                     Analysis.              part of CEHRT specific to   included in the Base EHR
                                                            each certification          Definition.
                                                            criterion.
Electronic Prescribing............  e-Prescribing........  Sec.   170.315(b)(3)        Sec.   170.314(b)(3)
                                                            (Electronic Prescribing).   (Electronic
                                                            Sec.   170.315(a)(10)       Prescribing). Sec.
                                                            (Drug-Formulary and         170.314(a)(10) (Drug-
                                                            Preferred Drug List         Formulary and Preferred
                                                            checks.                     Drug List checks.
Patient Electronic Access.........  Provide Patient        Sec.   170.315(e)(1)        Sec.   170.314(e)(1)
                                     Access.                (View, Download, and        (View, Download, and
                                                            Transmit to 3rd Party).     Transmit to 3rd Party).
                                                            Sec.   170.315(g)(7)
                                                            (Application Access--
                                                            Patient Selection). Sec.
                                                             170.315(g)(8)
                                                            (Application Access--Data
                                                            Category Request). Sec.
                                                            170.315(g)(9)
                                                            (Application Access--All
                                                            Data Request) The three
                                                            criteria combined are the
                                                            ``API'' certification
                                                            criteria.
Patient Electronic Access.........  Patient Specific       Sec.   170.315(a)(13)       Sec.   170.314(a)(13)
                                     Education.             (Patient-specific           (Patient-specific
                                                            Education Resources).       Education Resources).
Coordination of Care Through        View, Download, or     Sec.   170.315(e)(1)        Sec.   170.314(e)(1)
 Patient Engagement.                 Transmit (VDT).        (View, Download, and        (View, Download, and
                                                            Transmit to 3rd Party).     Transmit to 3rd Party).
                                                            Sec.   170.315(g)(7)
                                                            (Application Access--
                                                            Patient Selection). Sec.
                                                             170.315(g)(8)
                                                            (Application Access--Data
                                                            Category Request). Sec.
                                                            170.315(g)(9)
                                                            (Application Access--All
                                                            Data Request) The three
                                                            criteria combined are the
                                                            ``API'' certification
                                                            criteria.
Coordination of Care Through        Secure Messaging.....  Sec.   170.315(e)(2)        Sec.   170.314(e)(3)
 Patient Engagement.                                        (Secure Messaging).         (Secure Messaging).
Coordination of Care Through        Patient-Generated      Sec.   170.315(e)(3)        N/A.
 Patient Engagement.                 Health Data.           (Patient Health
                                                            Information Capture)
                                                            Supports meeting the
                                                            measure, but is NOT
                                                            required to be used to
                                                            meet the measure. The
                                                            certification criterion
                                                            is part of the CEHRT
                                                            definition beginning in
                                                            2018.
Health Information Exchange.......  Send a Summary of      Sec.   170.315(b)(1)        Sec.   170.314(b)(2)
                                     Care.                  (Transitions of Care).      (Transitions of Care-
                                                                                        Create and Transmit
                                                                                        Transition of Care/
                                                                                        Referral Summaries or
                                                                                        Sec.   170.314(b)(8)
                                                                                        (Optional--Transitions
                                                                                        of Care).
Health Information Exchange.......  Request/Accept         Sec.   170.315(b)(1)        Sec.   170.314(b)(1)
                                     Summary of Care.       (Transitions of Care).      (Transitions of Care-
                                                                                        Receive, Display and
                                                                                        Incorporate Transition
                                                                                        of Care/Referral
                                                                                        Summaries or Sec.
                                                                                        170.314(b)(8) (Optional-
                                                                                        Transitions of Care).
Health Information Exchange.......  Clinical Information   Sec.   170.315(b)(2)        Sec.   170.314(b)(4)
                                     Reconciliation.        (Clinical Information       (Clinical Information
                                                            Reconciliation and          Reconciliation or Sec.
                                                            Incorporation).             170.314(b)(9) (Optional--
                                                                                        Clinical Information
                                                                                        Reconciliation and
                                                                                        Incorporation).
Public Health and Clinical Data     Immunization Registry  Sec.   170.315(f)(1)        N/A.
 Registry Reporting.                 Reporting.             (Transmission to
                                                            Immunization Registries).
Public Health and Clinical Data     Syndromic              Sec.   170.315(f)(2)        Sec.   170.314(f)(3)
 Registry Reporting.                 Surveillance           (Transmission to Public     (Transmission to Public
                                     Reporting.             Health Agencies--           Health Agencies--
                                                            Syndromic Surveillance)     Syndromic Surveillance)
                                                            Urgent Care Setting Only.   or Sec.   170.314(f)(7)
                                                                                        (Optional-Ambulatory
                                                                                        Setting Only-
                                                                                        Transmission to Public
                                                                                        Health Agencies--
                                                                                        Syndromic Surveillance).
Public Health and Clinical Data     Electronic Case        Sec.   170.315(f)(5)        N/A.
 Registry Reporting.                 Reporting.             (Transmission to Public
                                                            Health Agencies--
                                                            Electronic Case
                                                            Reporting).

[[Page 30071]]

 
Public Health and Clinical Data     Public Health          EPs may choose one or more  Sec.   170.314(f)(5)
 Registry Reporting.                 Registry Reporting.    of the following: Sec.      (Optional--Ambulatory
                                                            170.315(f)(4)               Setting Only--Cancer
                                                            (Transmission to Cancer     Case Information and
                                                            Registries).                Sec.   170.314(f)(6)
                                                           Sec.   170.315(f)(7)         (Optional--Ambulatory
                                                            (Transmission to Public     Setting Only--
                                                            Health Agencies--Health     Transmission to Cancer
                                                            Care Surveys).              Registries).
Public Health and Clinical Data     Clinical Data          No 2015 Edition health IT   N/A.
 Registry Reporting.                 Registry Reporting.    certification criteria at
                                                            this time.
----------------------------------------------------------------------------------------------------------------

    We are inviting public comment on these proposals.
(b) 2017 and 2018 Advancing Care Information Transition Objectives and 
Measures Specifications

Table 9--Advancing Care Information Performance Category Scoring Methodology for 2018 Advancing Care Information
                                       Transition Objectives and Measures
----------------------------------------------------------------------------------------------------------------
     2018 Advancing Care        2018 Advancing Care      Required/ not
   Information  Transition          Information        required for base    Performance Score       Reporting
          Objective              Transition Measure       score (50%)          (up to 90%)         requirement
----------------------------------------------------------------------------------------------------------------
Protect Patient Health         Security Risk          Required...........  0..................  Yes/No
 Information.                   Analysis.                                                        Statement.
Electronic Prescribing.......  E-Prescribing........  Required...........  0..................  Numerator/
                                                                                                 Denominator.
Patient Electronic Access....  Provide Patient        Required...........  Up to 20...........  Numerator/
                                Access.                                                          Denominator.
                               View, Download, or     Not Required.......  Up to 10...........  Numerator/
                                Transmit (VDT).                                                  Denominator.
Patient-Specific Education...  Patient-Specific       Not Required.......  Up to 10...........  Numerator/
                                Education.                                                       Denominator.
Secure Messaging.............  Secure Messaging.....  Not Required.......  Up to 10...........  Numerator/
                                                                                                 Denominator.
Health Information Exchange..  Health Information     Required...........  Up to 20...........  Numerator/
                                Exchange.                                                        Denominator.
Medication Reconciliation....  Medication             Not Required.......  Up to 10...........  Numerator/
                                Reconciliation.                                                  Denominator.
Public Health Reporting......  Immunization Registry  Not Required.......  0 or 10............  Yes/No
                                Reporting.                                                       Statement.
                               Syndromic              Not Required.......  0 or 5 *...........  Yes/No
                                Surveillance                                                     Statement.
                                Reporting.
                               Specialized Registry   Not Required.......  0 or 5 *...........  Yes/No
                                Reporting.                                                       Statement.
----------------------------------------------------------------------------------------------------------------
                                                 Bonus up to 15%
----------------------------------------------------------------------------------------------------------------
Report to one or more additional public health agencies or clinical data   5 bonus............  Yes/No
 registries beyond those identified for the performance score.                                   Statement.
Report improvement activities using CEHRT................................  10 bonus...........  Yes/No
                                                                                                 Statement.
----------------------------------------------------------------------------------------------------------------
* A MIPS eligible clinician who cannot fulfill the Immunization Registry Reporting measure may earn 5% for each
  public health agency or clinical data registry to which the clinician reports, up to a maximum of 10% under
  the performance score.

    In the CY 2017 Quality Payment Program final rule (81 FR 77229 
through 77237), we finalized the 2017 Advancing Care Information 
Transition Objectives and Measures for MIPS eligible clinicians using 
EHR technology certified to the 2014 Edition. We noted (81 FR 77229 
that these objectives and measures have been adapted from the Modified 
Stage 2 objectives and measures finalized in the 2015 EHR Incentive 
Programs final rule (80 FR 62793 through 62825); however, we did not 
maintain the previously established thresholds for MIPS. For a more 
detailed discussion of the Modified Stage 2 Objectives and Measures, 
including explanatory material and defined terms, we refer readers to 
the 2015 EHR Incentive Programs final rule (80 FR 62793 through 62825). 
We are proposing to make several modifications identified and described 
below to the 2017 Advancing Care Information Transition Objectives and 
Measures for the advancing care information performance category of 
MIPS for the 2017 and 2018 performance periods. These modifications 
would not require changes to EHR technology that has been certified to 
the 2014 Edition.
    We finalized the 2017 Advancing Care Information Transition 
Objectives and Measures only for the 2017 performance period because 
these objectives and measures are for MIPS eligible clinicians using 
EHR technology certified to the 2014 Edition. Because we are proposing 
in section II.C.6.f.(4) to continue to allow the use of EHR technology 
certified to the 2014 Edition in the 2018 performance period, we are 
also proposing to allow MIPS eligible clinicians to report the 
Advancing Care Information Transition Objectives and Measures in 2018.
    Objective: Protect Patient Health Information.
    Objective: Protect electronic protected health information (ePHI) 
created or maintained by the CEHRT through the

[[Page 30072]]

implementation of appropriate technical, administrative, and physical 
safeguards.
    Security Risk Analysis Measure: Conduct or review a security risk 
analysis in accordance with the requirements in 45 CFR 164.308(a)(1), 
including addressing the security (to include encryption) of ePHI data 
created or maintained by CEHRT in accordance with requirements in 45 
CFR 164.312(a)(2)(iv) and 164.306(d)(3), and implement security updates 
as necessary and correct identified security deficiencies as part of 
the MIPS eligible clinician's risk management process.
    Objective: Electronic Prescribing.
    Objective: MIPS eligible clinicians must generate and transmit 
permissible prescriptions electronically.
    E-Prescribing Measure: At least one permissible prescription 
written by the MIPS eligible clinician is queried for a drug formulary 
and transmitted electronically using CEHRT.
     Denominator: Number of prescriptions written for drugs 
requiring a prescription to be dispensed other than controlled 
substances during the performance period; or number of prescriptions 
written for drugs requiring a prescription to be dispensed during the 
performance period.
     Numerator: The number of prescriptions in the denominator 
generated, queried for a drug formulary, and transmitted electronically 
using CEHRT.
    Objective: Patient Electronic Access.
    Objective: The MIPS eligible clinician provides patients (or 
patient-authorized representative) with timely electronic access to 
their health information and patient-specific education.
    Proposed Modification to the Objective: We are proposing to modify 
this objective beginning with the 2017 performance period by removing 
the word ``electronic'' from the description of timely access as it was 
erroneously included in the final rule (81 FR 77228). It was our 
intention to align the objective with the objectives for Patient 
Specific Education and Patient Electronic Access adopted under modified 
Stage 2 in the 2015 EHR Incentive Programs final rule (80 FR 62809 and 
80 FR 62815), which do not include the word ``electronic''. The word 
``electronic'' was also not included in the certification 
specifications for the 2014 Edition, Sec.  170.314(a)(15) (Patient-
specific education resources) and Sec.  170.314(e)(1) (View, download, 
and transmit to third party).
    Provide Patient Access Measure: At least one patient seen by the 
MIPS eligible clinician during the performance period is provided 
timely access to view online, download, and transmit to a third party 
their health information subject to the MIPS eligible clinician's 
discretion to withhold certain information.
     Denominator: The number of unique patients seen by the 
MIPS eligible clinician during the performance period.
     Numerator: The number of patients in the denominator (or 
patient authorized representative) who are provided timely access to 
health information to view online, download, and transmit to a third 
party.
    View, Download, Transmit (VDT) Measure: At least one patient seen 
by the MIPS eligible clinician during the performance period (or 
patient-authorized representative) views, downloads or transmits their 
health information to a third party during the performance period.
     Denominator: Number of unique patients seen by the MIPS 
eligible clinician during the performance period.
     Numerator: The number of unique patients (or their 
authorized representatives) in the denominator who have viewed online, 
downloaded, or transmitted to a third party the patient's health 
information during the performance period.
    Objective: Patient-Specific Education.
    Objective: The MIPS eligible clinician provides patients (or 
patient authorized representative) with timely electronic access to 
their health information and patient-specific education.
    Proposed Change to the Objective: The MIPS eligible clinician uses 
clinically relevant information from CEHRT to identify patient-specific 
educational resources and provide those resources to the patient. We 
inadvertently finalized the description of the Patient Electronic 
Access objective for the Patient-Specific Education Objective, so that 
the Patient-Specific Education Objective had the wrong description. We 
are proposing to correct this error by adopting the description of the 
Patient-Specific Education Objective adopted under modified Stage 2 in 
the 2015 EHR Incentive Programs final rule (80 FR 62809 and 80 FR 
62815). We are proposing this change would apply beginning with the 
performance period in 2017.
    Patient-Specific Education Measure: The MIPS eligible clinician 
must use clinically relevant information from CEHRT to identify 
patient-specific educational resources and provide access to those 
materials to at least one unique patient seen by the MIPS eligible 
clinician.
     Denominator: The number of unique patients seen by the 
MIPS eligible clinician during the performance period.
     Numerator: The number of patients in the denominator who 
were provided access to patient-specific educational resources using 
clinically relevant information identified from CEHRT during the 
performance period.
    Objective: Secure Messaging.
    Objective: Use CEHRT to engage with patients or their authorized 
representatives about the patient's care.
    Secure Messaging Measure: For at least one patient seen by the MIPS 
eligible clinician during the performance period, a secure message was 
sent using the electronic messaging function of CEHRT to the patient 
(or the patient-authorized representative), or in response to a secure 
message sent by the patient (or the patient authorized representative) 
during the performance period.
     Denominator: Number of unique patients seen by the MIPS 
eligible clinician during the performance period.
     Numerator: The number of patients in the denominator for 
whom a secure electronic message is sent to the patient (or patient-
authorized representative) or in response to a secure message sent by 
the patient (or patient-authorized representative), during the 
performance period.
    Objective: Health Information Exchange.
    Objective: The MIPS eligible clinician provides a summary of care 
record when transitioning or referring their patient to another setting 
of care, receives or retrieves a summary of care record upon the 
receipt of a transition or referral or upon the first patient encounter 
with a new patient, and incorporates summary of care information from 
other health care clinicians into their EHR using the functions of 
CEHRT.
    Proposed Change to the Objective: The MIPS eligible clinician 
provides a summary of care record when transitioning or referring their 
patient to another setting of care, receives or retrieves a summary of 
care record upon the receipt of a transition or referral or upon the 
first patient encounter with a new patient, and incorporates summary of 
care information from other health care providers into their EHR using 
the functions of CEHRT.
    We inadvertently used the term ``health care clinician'' and are 
proposing to replace it with the more appropriate term ``health care 
provider''. We are proposing this change would

[[Page 30073]]

apply beginning with the performance period in 2017.
    Health Information Exchange Measure: The MIPS eligible clinician 
that transitions or refers their patient to another setting of care or 
health care clinician (1) uses CEHRT to create a summary of care 
record; and (2) electronically transmits such summary to a receiving 
health care clinician for at least one transition of care or referral.
    Proposed Change to the Measure: The MIPS eligible clinician that 
transitions or refers their patient to another setting of care or 
health care provider (1) uses CEHRT to create a summary of care record; 
and (2) electronically transmits such summary to a receiving health 
care provider for at least one transition of care or referral.
    This change reflects the change proposed to the Health Information 
Exchange objective replacing ``health care clinician'' with ``health 
care provider''. We are proposing this change would apply beginning 
with the performance period in 2017.
     Denominator: Number of transitions of care and referrals 
during the performance period for which the EP was the transferring or 
referring health care clinician.
    Proposed Change to the Denominator: Number of transitions of care 
and referrals during the performance period for which the MIPS eligible 
clinician was the transferring or referring health care provider. This 
change reflects the change proposed to the Health Information Exchange 
Measure replacing ``health care clinician'' with ``health care 
provider''. We also inadvertently referred to the EP in the description 
and are replacing ``EP'' with ``MIPS eligible clinician''. We are 
proposing this change would apply beginning with the performance period 
in 2017.
     Numerator: The number of transitions of care and referrals 
in the denominator where a summary of care record was created using 
CEHRT and exchanged electronically.
Medication Reconciliation
    Objective: Medication Reconciliation.
    Proposed Objective: We are proposing to add a description of the 
Medication Reconciliation Objective beginning with the CY 2017 
performance period, which we inadvertently omitted from the CY 2017 
Quality Payment Program proposed and final rules, as follows:
    Proposed Objective: The MIPS eligible clinician who receives a 
patient from another setting of care or provider of care or believes an 
encounter is relevant performs medication reconciliation. This 
description aligns with the objective adopted for Modified Stage 2 at 
80 FR 62811.
    Medication Reconciliation Measure: The MIPS eligible clinician 
performs medication reconciliation for at least one transition of care 
in which the patient is transitioned into the care of the MIPS eligible 
clinician.
     Denominator: Number of transitions of care or referrals 
during the performance period for which the MIPS eligible clinician was 
the recipient of the transition or referral or has never before 
encountered the patient.
     Numerator: The number of transitions of care or referrals 
in the denominator where the following three clinical information 
reconciliations were performed: Medication list, Medication allergy 
list, and current problem list.
Proposed Modification to the Numerator
    Proposed Numerator: The number of transitions of care or referrals 
in the denominator where medication reconciliation was performed.
    We are proposing to modify the numerator by removing medication 
list, medication allergy list, and current problem list. These three 
criteria were adopted for Stage 3 (80 FR 62862) but not for Modified 
Stage 2 (80 FR 62811). We are proposing this change would apply 
beginning with the performance period in 2017.
    Objective: Public Health Reporting.
    Objective: The MIPS eligible clinician is in active engagement with 
a public health agency or clinical data registry to submit electronic 
public health data in a meaningful way using CEHRT, except where 
prohibited, and in accordance with applicable law and practice.
    Immunization Registry Reporting Measure: The MIPS eligible 
clinician is in active engagement with a public health agency to submit 
immunization data.
    Syndromic Surveillance Reporting Measure: The MIPS eligible 
clinician is in active engagement with a public health agency to submit 
syndromic surveillance data.
    Specialized Registry Reporting Measure: The MIPS eligible clinician 
is in active engagement to submit data to a specialized registry.
    We invite public comments on these proposals.
(c) Exclusions
    We are proposing to add exclusions to the measures associated with 
the Health Information Exchange and Electronic Prescribing objectives 
required for the base score. We propose these exclusions would apply 
beginning with the CY 2017 performance period. In the CY 2017 Quality 
Payment Program final rule (81 FR 77237 through 77238), we did not 
finalize any exclusions for the measures specified for the advancing 
care information performance category as we believe that the MIPS 
exclusion criteria and that the advancing care information performance 
category scoring methodology together accomplish the same end as the 
previously established exclusions for the majority of the advancing 
care information performance category measures. We further noted that 
it was not necessary to finalize the proposed exclusion for the 
Immunization Registry Reporting Measure because MIPS eligible 
clinicians have the flexibility to choose whether to report the measure 
because it is part of the performance score of the advancing care 
information performance category. However, we understand that many MIPS 
eligible clinicians may not achieve a base score because they cannot 
fulfill the measures associated with the Health Information Exchange 
objective in the base score because they seldom refer or transition 
patients, and we believe that the implementation burden of the 
objective is too high to require of those with only a small number of 
referrals or transitions. Similarly, we understand that many MIPS 
eligible clinicians do not often write prescriptions in their practice 
or lack prescribing authority, and thus could not meet the E-
prescribing Measure and would also fail to earn a base score. As this 
was not our intention, we are proposing to establish exclusions for 
these measures, as described below.
    Proposed Exclusion for the E-Prescribing Objective and Measure: In 
the CY 2017 Quality Payment Program final rule (81 FR 28237 through 
28238), we established a policy that MIPS eligible clinicians who write 
fewer than 100 permissible prescriptions in a performance period may 
elect to report their numerator and denominator (if they have at least 
one permissible prescription for the numerator), or they may report a 
null value. This policy has confused MIPS eligible clinicians as a null 
value would appear to indicate a MIPS eligible clinician has failed the 
measure and thus not would not achieve a base score. We are proposing 
to change this policy beginning with the CY 2017 performance period and 
propose to establish an exclusion for the e-Prescribing Measure. MIPS 
eligible clinicians who wish to claim this exclusion would select 
``yes'' to the exclusion and submit a null value for the measure, 
thereby fulfilling the requirement to report this measure as

[[Page 30074]]

part of the base score. It is important that a MIPS eligible clinician 
actually claims the exclusion if they wish to exclude the measure. If a 
MIPS eligible clinician does not claim the exclusion, they would fail 
the measure and not earn a base score or any score in the advancing 
care information performance category.
Advancing Care Information Objective and Measure.
    Objective: Electronic Prescribing.
    Objective: Generate and transmit permissible prescriptions 
electronically.
    E-Prescribing Measure: At least one permissible prescription 
written by the MIPS eligible clinician is queried for a drug formulary 
and transmitted electronically using CEHRT.
     Denominator: Number of prescriptions written for drugs 
requiring a prescription to be dispensed other than controlled 
substances during the performance period; or number of prescriptions 
written for drugs requiring a prescription to be dispensed during the 
performance period.
     Numerator: The number of prescriptions in the denominator 
generated, queried for a drug formulary, and transmitted electronically 
using CEHRT.
    Proposed Exclusion: Any MIPS eligible clinician who writes fewer 
than 100 permissible prescriptions during the performance period.
2017 and 2018 Advancing Care Information Transition Objective and 
Measure
    Objective: Electronic Prescribing.
    Objective: MIPS eligible clinicians must generate and transmit 
permissible prescriptions electronically.
    E-Prescribing Measure: At least one permissible prescription 
written by the MIPS eligible clinician is queried for a drug formulary 
and transmitted electronically using CEHRT.
     Denominator: Number of prescriptions written for drugs 
requiring a prescription to be dispensed other than controlled 
substances during the performance period; or number of prescriptions 
written for drugs requiring a prescription to be dispensed during the 
performance period.
     Numerator: The number of prescriptions in the denominator 
generated, queried for a drug formulary, and transmitted electronically 
using CEHRT.
    Proposed Exclusion: Any MIPS eligible clinician who writes fewer 
than 100 permissible prescriptions during the performance period.
    Proposed Exclusion for the Health Information Exchange Objective 
and Measures: We are proposing to add exclusions for the measures 
associated with the Health Information Exchange Objective. Stakeholders 
have expressed concern through public comments on the CY 2017 Quality 
Payment Program proposed rule and other inquiries to us that some MIPS 
eligible clinicians are unable to meet the measures associated with the 
Health Information Exchange Objective, which are required for the base 
score, because they do not regularly refer or transition patients in 
the normal course of their practice. As we did not intend to 
disadvantage those MIPS eligible clinicians and prevent them from 
earning a base score, we are proposing the exclusions.
Advancing Care Information Objective and Measures
    Objective: Health Information Exchange.
    Objective: The MIPS eligible clinician provides a summary of care 
record when transitioning or referring their patient to another setting 
of care, receives or retrieves a summary of care record upon the 
receipt of a transition or referral or upon the first patient encounter 
with a new patient, and incorporates summary of care information from 
other health care clinician into their EHR using the functions of 
CEHRT.
    We note that we proposed above to replace ``health care clinician'' 
with ``health care provider''.
    Send a Summary of Care Measure: For at least one transition of care 
or referral, the MIPS eligible clinician that transitions or refers 
their patient to another setting of care or health care clinician (1) 
creates a summary of care record using CEHRT; and (2) electronically 
exchanges the summary of care record.
    We note that we proposed above to replace ``health care clinician'' 
with ``health care provider''.
     Denominator: Number of transitions of care and referrals 
during the performance period for which the MIPS eligible clinician was 
the transferring or referring clinician.
     Numerator: The number of transitions of care and referrals 
in the denominator where a summary of care record was created using 
CEHRT and exchanged electronically.
    Proposed Exclusion: Any MIPS eligible clinician who transfers a 
patient to another setting or refers a patient fewer than 100 times 
during the performance period.
    Request/Accept Summary of Care Measure: For at least one transition 
of care or referral received or patient encounter in which the MIPS 
eligible clinician has never before encountered the patient, the MIPS 
eligible clinician receives or retrieves and incorporates into the 
patient's record an electronic summary of care document.
     Denominator: Number of patient encounters during the 
performance period for which a MIPS eligible clinician was the 
receiving party of a transition or referral or has never before 
encountered the patient and for which an electronic summary of care 
record is available.
     Numerator: Number of patient encounters in the denominator 
where an electronic summary of care record received is incorporated by 
the clinician into the CEHRT.
    Proposed Exclusion: Any MIPS eligible clinician who receives 
transitions of care or referrals or has patient encounters in which the 
MIPS eligible clinician has never before encountered the patient fewer 
than 100 times during the performance period.
2017 and 2018 Advancing Care Information Transition Objective and 
Measures
    Objective: Health Information Exchange.
    Objective: The MIPS eligible clinician provides a summary of care 
record when transitioning or referring their patient to another setting 
of care, receives or retrieves a summary of care record upon the 
receipt of a transition or referral or upon the first patient encounter 
with a new patient, and incorporates summary of care information from 
other health care clinicians into their EHR using the functions of 
CEHRT.
    We note that we are proposing above to replace ``health care 
clinician'' with ``health care provider''.
    Health Information Exchange Measure: The MIPS eligible clinician 
that transitions or refers their patient to another setting of care or 
health care clinician (1) uses CEHRT to create a summary of care 
record; and (2) electronically transmits such summary to a receiving 
health care clinician for at least one transition of care or referral.
    We note that we are proposing above to replace ``health care 
clinician'' with ``health care provider''.
     Denominator: Number of transitions of care and referrals 
during the performance period for which the EP was the transferring or 
referring health care clinician.
    We note that we are proposing above to replace ``health care 
clinician'' with ``health care provider''.
     Numerator: The number of transitions of care and referrals 
in the denominator where a summary of care

[[Page 30075]]

record was created using CEHRT and exchanged electronically.
    Proposed Exclusion: Any MIPS eligible clinician who transfers a 
patient to another setting or refers a patient fewer than 100 times 
during the performance period.
    We are inviting public comment on these proposals.
(7) Additional Considerations
(a) 21st Century Cures Act
    As we noted in the CY 2017 Quality Payment Program final rule (81 
FR 77238), section 101(b)(1)(A) of the MACRA amended section 
1848(a)(7)(A) of the Act to sunset the meaningful use payment 
adjustment at the end of CY 2018. Section 1848(a)(7) of the Act 
includes certain statutory exceptions to the meaningful use payment 
adjustment under section 1848(a)(7)(A) of the Act. Specifically, 
section 1848(a)(7)(D) of the Act exempts hospital-based EPs from the 
application of the payment adjustment under section 1848(a)(7)(A) of 
the Act. In addition, section 1848(a)(7)(B) of the Act provides that 
the Secretary may, on a case-by-case basis, exempt an EP from the 
application of the payment adjustment under section 1848(a)(7)(A) of 
the Act if the Secretary determines, subject to annual renewal, that 
compliance with the requirement for being a meaningful EHR user would 
result in a significant hardship, such as in the case of an EP who 
practices in a rural area without sufficient internet access. The last 
sentence of section 1848(a)(7)(B) of the Act also provides that in no 
case may an exemption be granted under subparagraph (B) for more than 5 
years. The MACRA did not maintain these statutory exceptions for the 
advancing care information performance category of the MIPS. Thus, we 
had previously stated that the provisions under sections 1848(a)(7)(B) 
and (D) of the Act are limited to the meaningful use payment adjustment 
under section 1848(a)(7)(A) of the Act and do not apply in the context 
of the MIPS.
    Following the publication of the CY 2017 Quality Payment Program 
final rule, the 21st Century Cures Act (Pub. L. 114-255) was enacted on 
December 13, 2016. Section 4002(b)(1)(B) of the 21st Century Cures Act 
amended section 1848(o)(2)(D) of the Act to state that the provisions 
of sections 1848(a)(7)(B) and (D) of the Act shall apply to assessments 
of MIPS eligible clinicians under section 1848(q) of the Act with 
respect to the performance category described in subsection 
(q)(2)(A)(iv) (the advancing care information performance category) in 
an appropriate manner which may be similar to the manner in which such 
provisions apply with respect to the meaningful use payment adjustment 
made under section 1848(a)(7)(A) of the Act. As a result of this 
legislative change, we believe that the general exceptions described 
under sections 1848(a)(7)(B) and (D) of the Act are applicable under 
the MIPS program. We include below proposals to implement these 
provisions as applied to assessments of MIPS eligible clinicians under 
section 1848(q) of the Act with respect to the advancing care 
information performance category.
(i) MIPS Eligible Clinicians Facing a Significant Hardship
    In the CY 2017 Quality Payment Program final rule (81 FR 77240 
through 77243), we recognized that there may not be sufficient measures 
applicable and available under the advancing care information 
performance category to MIPS eligible clinicians facing a significant 
hardship, such as those who lack sufficient internet connectivity, face 
extreme and uncontrollable circumstances, lack control over the 
availability of CEHRT, or do not have face-to-face interactions with 
patients. We relied on section 1848(q)(5)(F) of the Act to establish a 
final policy to assign a zero percent weighting to the advancing care 
information performance category in the final score if there are not 
sufficient measures and activities applicable and available to MIPS 
eligible clinicians within the categories of significant hardship noted 
above (81 FR 77243). Additionally, under the final policy (81 FR 
77243), we did not impose a limitation on the total number of MIPS 
payment years for which the advancing care information performance 
category could be weighted at zero percent, in contrast with the 5-year 
limitation on significant hardship exceptions under the Medicare EHR 
Incentive Program as required by section 1848(a)(7)(B) of the Act.
    We are not proposing substantive changes to this policy; however, 
as a result of the changes in the law made by the 21st Century Cures 
Act discussed above, we will not rely on section 1848(q)(5)(F) of the 
Act and instead are proposing to use the authority in the last sentence 
of section 1848(o)(2)(D) of the Act for significant hardship exceptions 
under the advancing care information performance category under MIPS. 
Section 1848(o)(2)(D) of the Act, as amended by section 4002(b)(1)(B) 
of the 21st Century Cures Act, states in part that the provisions of 
section 1848(a)(7)(B) of the Act shall apply to assessments of MIPS 
eligible clinicians with respect to the advancing care information 
performance category in an appropriate manner which may be similar to 
the manner in which such provisions apply with respect to the payment 
adjustment made under section 1848(a)(7)(A) of the Act. We would assign 
a zero percent weighting to the advancing care information performance 
category in the MIPS final score for a MIPS payment year for MIPS 
eligible clinicians who successfully demonstrate a significant hardship 
through the application process. We would use the same categories of 
significant hardship and application process as established in the CY 
2017 Quality Payment Program final rule (81 FR 77240-77243). We would 
automatically reweight the advancing care information performance 
category to zero percent for a MIPS eligible clinician who lacks face-
to-face patient interaction and is classified as a non-patient facing 
MIPS eligible clinician without requiring an application. If a MIPS 
eligible clinician submits an application for a significant hardship 
exception or is classified as a non-patient facing MIPS eligible 
clinician, but also reports on the measures specified for the advancing 
care information performance category, they would be scored on the 
advancing care information performance category like all other MIPS 
eligible clinicians, and the category would be given the weighting 
prescribed by section 1848(q)(5)(E) of the Act regardless of the MIPS 
eligible clinician's score.
    We believe this policy would be an appropriate application of the 
provisions of section 1848(a)(7)(B) of the Act to MIPS eligible 
clinicians and is similar to the manner in which those provisions apply 
with respect to the payment adjustment made under section 1848(a)(7)(A) 
of the Act. Under the Medicare EHR Incentive Program an approved 
hardship exception exempted an EP from the payment adjustment. We 
believe that weighting the advancing care information performance 
category to zero percent is similar in effect to an exemption from the 
requirements of that performance category.
    As required under section 1848(a)(7)(B) of the Act, eligible 
professionals were not granted significant hardship exceptions for the 
payment adjustments under the Medicare EHR Incentive Program for more 
than 5 years. We propose not to apply the 5-year limitation under 
section 1848(a)(7)(B) of the Act to significant hardship exceptions for 
the advancing care information performance category under MIPS. We 
believe this proposal is an appropriate application of the provisions 
of section 1848(a)(7)(B)

[[Page 30076]]

of the Act to MIPS eligible clinicians due to our desire to reduce 
clinician burden, promote the greatest level of participation in the 
MIPS program, and maintain consistency with the policies established in 
last year's final rule (81 FR 77243). In the Medicare EHR Incentive 
Program, we received many applications for significant hardship 
exceptions and approved most of them, which we believe indicates many 
eligible professionals were unable to or would have struggled to 
satisfy the requirements of meaningful use. We believe that there will 
be a continued need for significant hardship exceptions in order to 
provide clinicians with the necessary flexibility to participate in the 
MIPS program that best matches their available resources and 
circumstances, which may not change during a 5-year time period. For 
example, a clinician in an area without internet connectivity may 
continue to lack connectivity for more than 5 years. In addition, in 
the CY 2017 Quality Payment Program final rule (81 FR 77242 through 
77243), we noted that we had received comments expressing appreciation 
that CMS moved away from the 5-year limitation to significant hardship 
exceptions.
    We solicit comments on the proposed use of the authority provided 
in the 21st Century Cures Act in section 1848(o)(2)(D) of the Act as it 
relates to application of significant hardship exceptions under MIPS 
and the proposal not to apply a 5-year limit to such exceptions.
(ii) Significant Hardship Exception for MIPS Eligible Clinicians in 
Small Practices
    Section 1848(q)(2)(B)(iii) of the Act requires the Secretary to 
give consideration to the circumstances of small practices (consisting 
of 15 or fewer professionals) and practices located in rural areas and 
geographic HPSAs in establishing improvement activities under MIPS. In 
the CY 2017 Quality Payment Program final rule (81 FR 77187 through 
77188), we finalized that for MIPS eligible clinicians and groups that 
are in small practices or located in rural areas, or geographic health 
professional shortage areas (HPSAs), to achieve full credit under the 
improvement activities category, one high-weighted or two medium-
weighted improvement activities are required.
    While there is no corresponding statutory provision for the 
advancing care information performance category, we believe that 
special consideration should also be available for MIPS eligible 
clinicians located in small practices. Through comments received on the 
CY 2017 Quality Payment Program proposed rule (81 FR 28161-28586), we 
heard many concerns about the impact of MIPS on eligible clinicians in 
small practices. Some commenters stated that there was not a meaningful 
exclusion for small practices that cannot afford the upfront 
investments (including investments in EHR technology) (81 FR 77066). 
Many noted there are still many small practices that have not adopted 
EHRs due to the administrative and financial burden. Some expressed 
concern that small group and solo practices would be driven out of 
business because of the potential negative payment adjustments under 
MIPS (81 FR 77055). A few commenters were concerned about the impact of 
MACRA on small practices and asked CMS to remain sensitive to this 
concern and offer special opportunities for MIPS eligible clinicians in 
areas threatened by access problems (81 FR 77055).
    Based on these concerns, we are proposing a significant hardship 
exception for the advancing care information performance category for 
MIPS eligible clinicians who are in small practices, under the 
authority in section 1848(o)(2)(D) of the Act, as amended by section 
4002(b)(1)(B) of the 21st Century Cures Act (see discussion of the 
statutory authority for significant hardship exceptions in section 
II.C.6.f.(7)(ii). We are proposing that this hardship exception would 
be available to MIPS eligible clinicians in small practices as defined 
under Sec.  414.1305 (15 or fewer clinicians and solo practitioners). 
We are proposing in section II.C.1.e. of this proposed rule, that CMS 
would make eligibility determinations regarding the size of small 
practices for performance periods occurring in 2018 and future years. 
We are proposing to reweight the advancing care information performance 
category to zero percent of the MIPS final score for MIPS eligible 
clinicians who qualify for this hardship exception. We are proposing 
this exception would be available beginning with the 2018 performance 
period and 2020 MIPS payment year. We are proposing a MIPS eligible 
clinician seeking to qualify for this exception would submit an 
application in the form and manner specified by us by December 31st of 
the performance period or a later date specified by us. We are also 
proposing MIPS eligible clinicians seeking this exception must 
demonstrate in the application that there are overwhelming barriers 
that prevent the MIPS eligible clinician from complying with the 
requirements for the advancing care information performance category. 
In accordance with section 1848(a)(7)(B) of the Act, the exception 
would be subject to annual renewal. Under our proposal in section 
II.C.6.f.(7)(a), the 5-year limitation under section 1848(a)(7)(B) of 
the Act would not apply to this significant hardship exception for MIPS 
eligible clinicians in small practices.
    We believe that applying the significant hardship exception in this 
way would be appropriate given the challenges small practices face as 
described by the commenters. In addition, we believe this application 
would be similar to the manner in which the exception applies with 
respect to the payment adjustment made under section 1848(a)(7)(A) of 
the Act because weighting the advancing care information performance 
category to zero percent is similar in effect to an exemption from the 
requirements of that performance category.
    While we would be making this significant hardship exception 
available to small practices in particular, we are considering whether 
other categories or types of clinicians might similarly require an 
exception. We solicit comment on what those categories or types are, 
why such an exception is required, and any data available to support 
the necessity of the exception. We note that supporting data would be 
particularly helpful to our consideration of whether any additional 
exceptions would be appropriate.
    We are seeking comments on these proposals.
(iii) Hospital-Based MIPS Eligible Clinicians
    In the CY 2017 Quality Payment Program final rule (81 FR 77238 
through 77240), we defined a hospital-based MIPS eligible clinician 
under Sec.  414.1305 as a MIPS eligible clinician who furnishes 75 
percent or more of his or her covered professional services in sites of 
service identified by the Place of Service (POS) codes used in the 
HIPAA standard transaction as an inpatient hospital (POS 21), on-campus 
outpatient hospital (POS 22), or emergency room (POS 23) setting, based 
on claims for a period prior to the performance period as specified by 
CMS. We intend to use claims with dates of service between September 1 
of the calendar year 2 years preceding the performance period through 
August 31 of the calendar year preceding the performance period, but in 
the event it is not operationally feasible to use claims from this time 
period, we will use a 12-month period as close as practicable to this 
time period. We discussed our assumption that MIPS eligible clinicians 
who are determined hospital-based do not have

[[Page 30077]]

sufficient advancing care information measures applicable to them, and 
we established a policy to reweight the advancing care information 
performance category to zero percent of the MIPS final score for the 
MIPS payment year in accordance with section 1848(q)(5)(F) of the Act 
(81 FR 77240).
    We are not proposing substantive changes to this policy; however, 
as a result of the changes in the law made by the 21st Century Cures 
Act discussed above, we will not rely on section 1848(q)(5)(F) of the 
Act and instead are proposing to use the authority in the last sentence 
of section 1848(o)(2)(D) of the Act for exceptions for hospital-based 
MIPS eligible clinicians under the advancing care information 
performance category. Section 1848(o)(2)(D) of the Act, as amended by 
section 4002(b)(1)(B) of the 21st Century Cures Act, states in part 
that the provisions of section 1848(a)(7)(D) of the Act shall apply to 
assessments of MIPS eligible clinicians with respect to the advancing 
care information performance category in an appropriate manner which 
may be similar to the manner in which such provisions apply with 
respect to the payment adjustment made under section 1848(a)(7)(A) of 
the Act. We would assign a zero percent weighting to the advancing care 
information performance category in the MIPS final score for a MIPS 
payment year for hospital-based MIPS eligible clinicians as previously 
defined. A hospital-based MIPS eligible clinician would have the option 
to report the advancing care information measures for the performance 
period for the MIPS payment year for which they are determined 
hospital-based. However, if a MIPS eligible clinician who is determined 
hospital-based chooses to report on the advancing care information 
measures, they would be scored on the advancing care information 
performance category like all other MIPS eligible clinicians, and the 
category would be given the weighting prescribed by section 
1848(q)(5)(E) of the Act regardless of their score.
    We believe this policy would be an appropriate application of the 
provisions of section 1848(a)(7)(D) of the Act to MIPS eligible 
clinicians and is similar to the manner in which those provisions apply 
with respect to the payment adjustment made under section 1848(a)(7)(A) 
of the Act. Under the Medicare EHR Incentive Program an approved 
hardship exception exempted an EP from the payment adjustment. We 
believe that weighting the advancing care information performance 
category to zero percent is similar in effect to an exemption from the 
requirements of that performance category.
    We propose to amend Sec.  414.1380(c)(1) and (2) of the regulation 
text to reflect this proposal.
    We request comments on the proposed use of the authority provided 
in the 21st Century Cures Act in section 1848(o)(2)(D) of the Act as it 
relates to hospital-based MIPS eligible clinicians.
(iv) Ambulatory Surgical Center (ASC)--Based MIPS Eligible Clinicians
    Section 16003 of the 21st Century Cures Act amended section 
1848(a)(7)(D) of the Act to provide that no payment adjustment may be 
made under section 1848(a)(7)(A) of the Act for 2017 and 2018 in the 
case of an eligible professional who furnishes substantially all of his 
or her covered professional services in an ambulatory surgical center 
(ASC). Section 1848(a)(7)(D)(iii) of the Act provides that 
determinations of whether an eligible professional is ASC-based may be 
made based on the site of service as defined by the Secretary or an 
attestation, but shall be made without regard to any employment or 
billing arrangement between the eligible professional and any other 
supplier or provider of services. Section 1848(a)(7)(D)(iv) of the Act 
provides that the ASC-based exception shall no longer apply as of the 
first year that begins more than 3 years after the date on which the 
Secretary determines, through notice and comment rulemaking, that CEHRT 
applicable to the ASC setting is available.
    Under section 1848(o)(2)(D) of the Act, as amended by section 
4002(b)(1)(B) of the 21st Century Cures Act, the ASC-based provisions 
of section 1848(a)(7)(D) of the Act shall apply to assessments of MIPS 
eligible clinicians under section 1848(q) of the Act with respect to 
the advancing care information performance category in an appropriate 
manner which may be similar to the manner in which such provisions 
apply with respect to the payment adjustment made under section 
1848(a)(7)(A) of the Act. We believe our proposals set forth below for 
ASC-based MIPS eligible clinicians are an appropriate application of 
the provisions of section 1848(a)(7)(D) of the Act to MIPS eligible 
clinicians. Under the Medicare EHR Incentive Program an approved 
hardship exception exempted an EP from the payment adjustment. We 
believe that weighting the advancing care information performance 
category to zero percent is similar in effect to an exemption from the 
requirements of that performance category.
    To align with our hospital-based MIPS eligible clinician policy, we 
are proposing to define at Sec.  414.1305 an ASC-based MIPS eligible 
clinician as a MIPS eligible clinician who furnishes 75 percent or more 
of his or her covered professional services in sites of service 
identified by the Place of Service (POS) code 24 used in the HIPAA 
standard transaction based on claims for a period prior to the 
performance period as specified by us. We request comments on this 
proposal and solicit comments as to whether other POS codes should be 
used to identify a MIPS eligible clinician's ASC-based status or if an 
alternative methodology should be used. We note that the ASC-based 
determination will be made independent of the hospital-based 
determination.
    To determine a MIPS eligible clinician's ASC-based status, we are 
proposing to use claims with dates of service between September 1 of 
the calendar year 2 years preceding the performance period through 
August 31 of the calendar year preceding the performance period, but in 
the event it is not operationally feasible to use claims from this time 
period, we would use a 12-month period as close as practicable to this 
time period. For example, for the 2018 performance period (2020 MIPS 
payment year), we would use the data available at the end of October 
2017 for Medicare claims with dates of service between September 1, 
2016 through August 31, 2017, to determine whether a MIPS eligible 
clinician is considered ASC-based under our proposed definition. We are 
proposing this timeline to allow us to notify MIPS eligible clinicians 
of their ASC-based status prior to the start of the performance period 
and to align with the hospital-based MIPS eligible clinician 
determination period. For the 2019 MIPS payment year, we would not be 
able to notify MIPS eligible clinicians of their ASC-based status until 
after the final rule is published, which we anticipate would be later 
in 2017. We expect that we would provide this notification through 
QPP.cms.gov.
    For MIPS eligible clinicians who we determine are ASC-based, we 
propose to assign a zero percent weighting to the advancing care 
information performance category in the MIPS final score for the MIPS 
payment year. However, if a MIPS eligible clinician who is determined 
ASC-based chooses to report on the advancing care information measures 
for the performance period for the MIPS payment year for which they are 
determined ASC-based, we propose they would be scored on the advancing 
care information performance category like

[[Page 30078]]

all other MIPS eligible clinicians, and the performance category would 
be given the weighting prescribed by section 1848(q)(5)(E) of the Act 
regardless of their advancing care information performance category 
score.
    We are proposing these ASC-based policies would apply beginning 
with the 2017 performance period/2019 MIPS payment year.
    We propose to amend Sec.  414.1380(c)(1) and (2) of the regulation 
text to reflect these proposals.
    We request comments on these proposals.
(v) Exception for MIPS Eligible Clinicians Using Decertified EHR 
Technology
    Section 4002(b)(1)(A) of the 21st Century Cures Act amended section 
1848(a)(7)(B) of the Act to provide that the Secretary shall exempt an 
eligible professional from the application of the payment adjustment 
under section 1848(a)(7)(A) of the Act with respect to a year, subject 
to annual renewal, if the Secretary determines that compliance with the 
requirement for being a meaningful EHR user is not possible because the 
CEHRT used by such professional has been decertified under ONC's Health 
IT Certification Program. Section 1848(o)(2)(D) of the Act, as amended 
by section 4002(b)(1)(B) of the 21st Century Cures Act, states in part 
that the provisions of section 1848(a)(7)(B) of the Act shall apply to 
assessments of MIPS eligible clinicians with respect to the advancing 
care information performance category in an appropriate manner which 
may be similar to the manner in which such provisions apply with 
respect to the payment adjustment made under section 1848(a)(7)(A) of 
the Act.
    We are proposing that a MIPS eligible clinician may demonstrate 
through an application process that reporting on the measures specified 
for the advancing care information performance category is not possible 
because the CEHRT used by the MIPS eligible clinician has been 
decertified under ONC's Health IT Certification Program. We are 
proposing that if the MIPS eligible clinician's demonstration is 
successful and an exception is granted, we would assign a zero percent 
weighting to the advancing care information performance category in the 
MIPS final score for the MIPS payment year. In accordance with section 
1848(a)(7)(B) of the Act, the exception would be subject to annual 
renewal, and in no case may a MIPS eligible clinician be granted an 
exception for more than 5 years. We are proposing this exception would 
be available beginning with the CY 2018 performance period and the 2020 
MIPS payment year.
    We are proposing that a MIPS eligible clinician may qualify for 
this exception if their CEHRT was decertified either during the 
performance period for the MIPS payment year or during the calendar 
year preceding the performance period for the MIPS payment year. We 
believe that this timeframe is appropriate because the loss of 
certification may prevent a MIPS eligible clinician from reporting for 
the advancing care information performance category because it will 
require that the MIPS eligible clinician switch to an alternate CEHRT, 
a process that we believe may take up to 2 years. For example, for the 
2020 MIPS payment year, if the MIPS eligible clinician's EHR technology 
was decertified during the CY 2018 performance period or during CY 
2017, the MIPS eligible clinician may qualify for this exception. In 
addition, we are proposing that the MIPS eligible clinician must 
demonstrate in their application and through supporting documentation 
if available that the MIPS eligible clinician made a good faith effort 
to adopt and implement another CEHRT in advance of the performance 
period. We are proposing a MIPS eligible clinician seeking to qualify 
for this exception would submit an application in the form and manner 
specified by us by December 31st of the performance period, or a later 
date specified by us.
    We believe that applying the exception in this way is an 
appropriate application of the provisions of section 1848(a)(7)(B) of 
the Act to MIPS eligible clinicians given that weighting the advancing 
care information performance category to zero percent is similar in 
effect to an exemption from the requirements of that performance 
category. Under the Medicare EHR Incentive Program an approved hardship 
exception exempted an EP from the payment adjustment. We believe that 
weighting the advancing care information performance category to zero 
percent is similar in effect to an exemption from the requirements of 
that performance category.
    The ONC Health IT Certification Program: Enhanced Oversight and 
Accountability final rule (``EOA final rule'') (81 FR 72404), effective 
December 19, 2016, created a regulatory framework for the ONC's direct 
review of health information technology (health IT) certified under the 
ONC Health IT Certification Program, including, when necessary, 
requiring the correction of non-conformities found in health IT 
certified under the Program and/or terminating certifications issued to 
certified health IT. Prior to the EOA final rule, ONC-Authorized 
Certification Bodies (ONC-ACBs) had the only authority to terminate or 
revoke certification of health IT under the program, which they used on 
previous occasions. On September 23, 2015, we posted an FAQ discussing 
the requirements for using a decertified CEHRT.\3\
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    \3\ https://questions.cms.gov/faq.php?isDept=0&search=decertify&searchType=keyword&submitSearch=1&id=5005.
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    Once all administrative processes, if any, are complete, then 
notice of a ``termination of certification'' is listed on the of the 
Certified Health IT Product List (CPHL) Web page.\4\ As appropriate, 
ONC will also publicize the termination of certification of health IT 
through other communication channels (for example, ONC list serv(s)). 
Further, when ONC terminates the certification of a health IT product, 
the health IT developer is required to notify all potentially affected 
customers in a timely manner.
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    \4\ The list is available at https://chpl.healthit.gov/#/decertifications/products.
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    We further note that in comparison to termination actions taken by 
ONC and ONC-ACBs, a health IT developer may voluntarily withdraw a 
certification that is in good standing under the ONC Health IT 
Certification Program. A voluntary withdrawal may be the result of the 
health IT developer going out of business, the developer no longer 
supporting the product, or for other reasons that are not in response 
to ONC-ACB surveillance, ONC direct review, or a finding of non-
conformity by ONC or an ONC-ACB.\5\ In such instances, ONC will list 
these products on the ``Inactive Certificates'' \6\ Web page of the 
CHPL.
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    \5\ For further descriptions of certification statuses, please 
consult the CHPL Public User Guide.
    \6\ The ``Inactive Certificates'' Web page is available at 
https://chpl.healthit.gov/#/decertifications/inactive.
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    We propose to amend Sec.  414.1380(c)(1) and (2) of the regulation 
text to reflect these proposals. We are seeking comments on these 
proposals.
(b) Hospital-Based MIPS Eligible Clinicians
    In the CY 2017 Quality Payment Program final rule (81 FR 77238 
through 77240, we defined a hospital-based MIPS eligible clinician as a 
MIPS eligible clinician who furnishes 75 percent or more of his or her 
covered professional services in sites of services identified by the 
Place of Service (POS) codes used in the HIPAA standard transaction as 
an inpatient hospital (POS 21), on campus outpatient hospital

[[Page 30079]]

(POS 22) or emergency room (POS 23) setting, based on claims for a 
period prior to the performance period as specified by CMS.
    We are proposing to modify our policy to include covered 
professional services furnished by MIPS eligible clinicians in an off-
campus-outpatient hospital (POS 19) in the definition of hospital-based 
MIPS eligible clinician. POS 19 was developed in 2015 in order to 
capture the numerous physicians that are paid for a portion of their 
services in an ``off campus-outpatient hospital'' versus an on campus-
outpatient hospital, (POS 22). We also believe that these MIPS eligible 
clinicians would not typically have control of the development and 
maintenance of their EHR systems, just like those who bill using POS 
22. We propose to add POS 19 to our existing definition of a hospital-
based MIPS eligible clinician beginning with the performance period in 
2018.
    We invite comment on this proposal.
(c) Nurse Practitioners, Physician Assistants, Clinical Nurse 
Specialists, and Certified Registered Nurse Anesthetists
    In the CY 2017 Quality Payment Program final rule (81 FR 77243-
77244), we discussed our belief that certain types of MIPS eligible 
clinicians (NPs, PAs, CNSs, and CRNAs) may lack experience with the 
adoption and use of CEHRT. Because many of these non-physician 
clinicians are not eligible to participate in the Medicare or Medicaid 
EHR Incentive Program, we stated that we have little evidence as to 
whether there are sufficient measures applicable and available to these 
types of MIPS eligible clinicians under the advancing care information 
performance category. We established a policy under section 
1848(q)(5)(F) of the Act to assign a weight of zero to the advancing 
care information performance category in the MIPS final score if there 
are not sufficient measures applicable and available to NPs, PAs, 
CRNAs, and CNSs. We will assign a weight of zero only in the event that 
an NP, PA, CRNA, or CNS does not submit any data for any of the 
measures specified for the advancing care information performance 
category. We encouraged all NPs, PAs, CRNAs, and CNSs to report on 
these measures to the extent they are applicable and available, 
however, we understand that some NPs, PAs, CRNAs, and CNSs may choose 
to accept a weight of zero for this performance category if they are 
unable to fully report the advancing care information measures. These 
MIPS eligible clinicians may choose to submit advancing care 
information measures should they determine that these measures are 
applicable and available to them; however, we noted that if they choose 
to report, they will be scored on the advancing care information 
performance category like all other MIPS eligible clinicians and the 
performance category will be given the weighting prescribed by section 
1848(q)(5)(E) of the Act regardless of their advancing care information 
performance category score.
    We stated that this approach is appropriate for the first MIPS 
performance period based on the payment consequences associated with 
reporting, the fact that many of these types of MIPS eligible 
clinicians may lack experience with EHR use, and our current 
uncertainty as to whether we have adopted sufficient measures that are 
applicable and available to these types of MIPS eligible clinicians. We 
noted that we would use the first MIPS performance period to further 
evaluate the participation of these MIPS eligible clinicians in the 
advancing care information performance category and would consider for 
subsequent years whether the measures specified for this category are 
applicable and available to these MIPS eligible clinicians. At this 
time we have no additional information because the first MIPS 
performance period is currently underway, and thus we propose the same 
policy for NPs, PAs, CRNAs, and CNSs for the 2018 performance period as 
well. We still intend to evaluate the participation of these MIPS 
eligible clinicians in the advancing care information performance 
category for 2017 and expect to adopt measures applicable and available 
to them in subsequent years.
    We are seeking comment on how the advancing care information 
performance category could be applied to NPs, PAs, CRNAs, and CNSs in 
future years of MIPS, and the types of measures that would be 
applicable and available to these types of MIPS eligible clinicians. In 
addition, through the Call for Measures Process we are seeking new 
measures that may be more broadly applicable to these additional types 
of MIPS eligible clinicians in future program years. For more 
information on the Call for Measures, see https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/CallForMeasures.html.
    We are inviting public comment on these proposals.
(d) Scoring for MIPS Eligible Clinicians in Group Practices
    In any of the situations described in the sections above, we would 
assign a zero percent weighting to the advancing care information 
performance category in the MIPS final score for the MIPS payment year 
if the MIPS eligible clinician meets certain specified requirements for 
this weighting. We noted that these MIPS eligible clinicians may choose 
to submit advancing care information measures; however, if they choose 
to report, they will be scored on the advancing care information 
performance category like all other MIPS eligible clinicians and the 
performance category will be given the weighting prescribed by section 
1848(q)(5)(E) of the Act regardless of their advancing care information 
performance category score. This policy includes MIPS eligible 
clinicians choosing to report as part of a group practice or part of a 
virtual group.
    Group practices as defined at Sec.  414.1310(e)(1) are required to 
aggregate their performance data across the TIN in order for their 
performance to be assessed as a group (81 FR 77058). Additionally, 
groups that elect to have their performance assessed as a group will be 
assessed as a group across all four MIPS performance categories. By 
reporting as part of a group practice, MIPS eligible clinicians are 
subscribing to the data reporting and scoring requirements of the group 
practice. We note that the data submission criteria for groups 
reporting advancing care information performance category described in 
the CY 2017 Quality Payment Program final rule (81 FR 77215) state that 
group data should be aggregated for all MIPS eligible clinicians within 
the group practice. This includes those MIPS eligible clinicians who 
may qualify for a zero percent weighting of the advancing care 
information performance category due to the circumstances as described 
above, such as a significant hardship or other type of exception, 
hospital-based or ASC-based status, or certain types of non-physician 
practitioners (NPs, PAs, CNSs, and CRNAs). If these MIPS eligible 
clinicians report as part of a group practice or virtual group, they 
will be scored on the advancing care information performance category 
like all other MIPS eligible clinicians and the performance category 
will be given the weighting prescribed by section 1848(q)(5)(E) of the 
Act regardless of the group practice's advancing care information 
performance category score.

[[Page 30080]]

(e) Timeline for Submission of Reweighting Applications
    In the CY 2017 Quality Payment Program final rule (81 FR77240-
77243), we established the timeline for the submission of applications 
to reweight the advancing care information performance category in the 
MIPS final score to align with the data submission timeline for MIPS. 
We established that all applications for reweighting the advancing care 
information performance category be submitted by the MIPS eligible 
clinician or designated group representative in the form and manner 
specified by us. All applications may be submitted on a rolling basis, 
but must be received by us no later than the close of the submission 
period for the relevant performance period, or a later date specified 
by us. An application would need to be submitted annually to be 
considered for reweighting each year.
    The Quality Payment Program Exception Application will be used to 
apply for the following exceptions: Insufficient Internet Connectivity; 
Extreme and Uncontrollable Circumstances; Lack of Control over the 
Availability of CEHRT; Decertification of CEHRT; and Small Practice.
    We are proposing to change the submission deadline for the 
application as we believe that aligning the data submission deadline 
with the reweighting application deadline could disadvantages MIPS 
eligible clinicians. We are proposing to change the submission deadline 
for the CY 2017 performance period to December 31, 2017, or a later 
date specified by us. We believe this change would help MIPS eligible 
clinicians by allowing them to learn whether their application is 
approved prior to the data submission deadline for the CY 2017 
performance period, March 31, 2018. We plan to have the application 
available in mid-2017. We encourage MIPS eligible clinicians to apply 
early as we expect to process the applications on a rolling basis. We 
note that if a MIPS eligible clinician submits data for the advancing 
care information category after an application has been submitted, the 
data would be scored, the application would be considered voided and 
the advancing care information performance category would not be 
reweighted.
    We further propose that the submission deadline for the 2018 
performance period will be December 31, 2018, or a later date as 
specified by us. We believe this would help MIPS eligible clinicians by 
allowing them to learn whether their application is approved prior to 
the data submission deadline for the CY 2018 performance period, March 
31, 2019.
    We request comments on these proposals.
g. APM Scoring Standard for MIPS Eligible Clinicians in MIPS APMs
(1) Overview
    Under section 1848(q)(1)(C)(ii)(1) of the Act, Qualifying APM 
Participants (QPs) are not MIPS eligible clinicians and are thus 
excluded from MIPS reporting requirements and payment adjustments. 
Similarly, under section 1848(q)(1)(c)(ii)(II) of the Act, Partial 
Qualifying APM Participants (Partial QPs) are also not MIPS eligible 
clinicians unless they opt to report and be scored under MIPS. All 
other eligible clinicians, including those participating in MIPS APMs, 
are MIPS eligible clinicians and subject to MIPS reporting requirements 
and payment adjustments unless they are excluded on another basis such 
as being newly enrolled in Medicare or not exceeding the low volume 
threshold.
    In the CY 2017 Quality Payment Program final rule (81 FR 77246-
77269, 77543), we finalized the APM scoring standard, which is designed 
to reduce reporting burden for participants in certain APMs by 
minimizing the need for them to make duplicative data submissions for 
both MIPS and their respective APMs. We also sought to ensure that 
eligible clinicians in APM Entities that participate in certain types 
of APMs that assess their participants on quality and cost are assessed 
as consistently as possible across MIPS and their respective APMs. 
Given that many APMs already assess their participants on cost and 
quality of care and require engagement in certain improvement 
activities, we believe that without the APM scoring standard, 
misalignments could be quite common between the evaluation of 
performance under the terms of the APM and evaluation of performance on 
measures and activities under MIPS.
    In the CY 2017 Quality Payment Program final rule (81 FR 77249), we 
identified the types of APMs for which the APM scoring standard would 
apply as MIPS APMs. We finalized that to be a MIPS APM, an APM must 
satisfy the following criteria: (1) APM Entities participate in the APM 
under an agreement with CMS or by law or regulation; (2) the APM 
requires that APM Entities include at least one MIPS eligible clinician 
on a Participation List; and (3) the APM bases payment incentives on 
performance (either at the APM Entity or eligible clinician level) on 
cost/utilization and quality measures. We specified that we will post 
the list of MIPS APMs prior to the first day of the MIPS performance 
year for each year (81 FR 77250). We finalized in the regulation at 
Sec.  414.1370(b) that for a new APM to be a MIPS APM, its first 
performance year must start on or before the first day of the MIPS 
performance year. A list of MIPS APMs is available at www.qpp.cms.gov.
    We established in the regulation at Sec.  414.1370(c) that the MIPS 
performance year under Sec.  414.1320 of the regulations applies for 
the APM scoring standard.
    We finalized that under section Sec.  414.1370(f) of our 
regulations on the APM scoring standard, MIPS eligible clinicians will 
be scored at the APM Entity group level and each eligible clinician 
will receive the APM Entity group's final score. The MIPS payment 
adjustment is applied at the TIN/NPI level for each of the MIPS 
eligible clinicians in the APM Entity. The MIPS final score is 
comprised of the four MIPS performance category scores, as described in 
our regulation at Sec.  414.1370(g): quality, cost, improvement 
activities, and advancing care information. Both the Medicare Shared 
Savings Program and Next Generation ACO Model are MIPS APMs for the CY 
2017 performance year. For these two MIPS APMs, in accordance with our 
regulation at Sec.  414.1370(h), the MIPS performance category scores 
are weighted as follows: Quality at 50 percent; cost at zero percent; 
improvement activities at 20 percent; and advancing care information at 
30 percent of the final score. For all other MIPS APMs for the CY 2017 
performance year, quality and cost are each weighted at zero percent, 
improvement activities at 25 percent, and advancing care information at 
75 percent of the final score.
    As explained in the following sections, we propose to: Add an APM 
participant assessment date for full TIN APMs; add the CAHPS for ACOs 
survey to the Shared Savings Program and Next Generation ACO quality 
measures included for scoring under the MIPS APM quality performance 
category; define Other MIPS APMs; and add scoring for quality 
improvement to the MIPS APM quality performance category for MIPS APMs 
beginning in 2018. We also propose a Quality Payment Program 2018 
performance year quality scoring methodology for Other MIPS APMs, and 
describe the scoring methodology for quality improvement for Other MIPS 
APMs as applicable.
    In reviewing these proposals, we remind readers that the APM 
scoring

[[Page 30081]]

standard is built upon the generally applicable MIPS scoring standard, 
but provides for special policies to address the unique circumstances 
of MIPS eligible clinicians who are in APM Entities participating in 
MIPS APMs. For the cost, improvement activities, and advancing care 
information performance categories, unless a separate policy has been 
established or is being proposed for the APM scoring standard, the 
generally applicable MIPS policies would be applicable. Additionally, 
unless we include a proposal to adopt a unique policy for the APM 
scoring standard, we propose to adopt the same generally applicable 
MIPS policies proposed elsewhere in this proposed rule, and would treat 
the APM Entity group as the group for purposes of MIPS. For the quality 
performance category, however, the APM scoring standard we propose is 
presented as a separate, unique standard, and therefore generally 
applicable MIPS policies would not be applied to the quality 
performance category under the APM scoring standard unless specifically 
stated. We seek comment on whether there may be potential conflicts or 
inconsistencies between the generally applicable MIPS policies and 
those under the APM scoring standard, particularly where these could 
impact our goals to reduce duplicative and potentially incongruous 
reporting requirements and performance evaluations that could undermine 
our ability to test or evaluate MIPS APMs, or whether certain generally 
applicable MIPS policies should be made explicitly applicable to the 
APM scoring standard.
(2) Assessment Dates for Inclusion of MIPS Eligible Clinicians in APM 
Entity Groups Under the APM Scoring Standard
    In the CY 2017 Quality Payment Program final rule, we specified in 
the regulation at Sec.  414.1370(e) that the APM Entity group for 
purposes of scoring under the APM scoring standard is determined in the 
manner prescribed at Sec.  414.1425(b)(1), which provides that eligible 
clinicians who are on a Participation List on at least one of three 
dates (March 31, June 30, and August 31) would be considered part of 
the APM Entity group. Under these regulations, MIPS eligible clinicians 
who are not on a Participation List on one of these three assessment 
dates are not scored under the APM scoring standard. Instead, they 
would need to submit data to MIPS through one of the MIPS data 
submission mechanisms and their performance would be assessed either as 
individual MIPS eligible clinicians or as a group according to the 
generally applicable MIPS reporting and scoring criteria.
    We will continue to use the three assessment dates of March 31, 
June 30, and August 31 to identify MIPS eligible clinicians who are on 
an APM Entity's Participation List and determine the APM Entity group 
that is used for purposes of the APM scoring standard. Beginning in the 
2018 performance year, we propose to add a fourth assessment date of 
December 31 to identify those MIPS eligible clinicians who participate 
in a full TIN APM. We propose to define full TIN APM at Sec.  414.1305 
to mean an APM where participation is determined at the TIN level, and 
all eligible clinicians who have assigned their billing rights to a 
participating TIN are therefore participating in the APM. An example of 
a full TIN APM is the Shared Savings Program which requires all 
individuals and entities that have reassigned their right to receive 
Medicare payment to the TIN of an ACO participant to participate in the 
ACO and comply with the requirements of the Shared Savings Program.
    If an eligible clinician elects to reassign their billing rights to 
a TIN participating in a full TIN APM, the eligible clinician is 
necessarily participating in the full TIN APM. We propose to add this 
fourth date of December 31 only for eligible clinicians in a full TIN 
APM, and only for purposes of applying the APM scoring standard. We are 
not proposing to use this additional assessment date of December 31 for 
purposes of QP determinations. Therefore, we propose to amend Sec.  
414.1370(e) to identify the four assessment dates that would be used to 
identify the APM Entity group for purposes of the APM scoring standard, 
and to specify that the December 31 date would be used only to identify 
eligible clinicians on the APM Entity's Participation List for a MIPS 
APM that is a full TIN APM in order to add them to the APM Entity group 
that is scored under the APM scoring standard.
    We propose to use this fourth assessment date of December 31 to 
extend the APM scoring standard to only those MIPS eligible clinicians 
participating in MIPS APMs that are full TIN APMs, ensuring that an 
eligible clinician who joins the full TIN APM late in the performance 
year would be scored under the APM scoring standard. We considered 
proposing to use the fourth assessment date more broadly for all MIPS 
APMs. However, we believe that this approach would have allowed MIPS 
eligible clinicians to inappropriately leverage the fourth assessment 
date to avoid reporting and scoring under the generally applicable MIPS 
scoring standard when they were part of the MIPS APM for only a very 
limited portion of the performance year. That is, for MIPS APMs that 
allow split TIN participation, it would be possible for eligible 
clinicians to briefly join a MIPS APM principally in order to benefit 
from the APM scoring standard, despite having limited opportunity to 
contribute to the APM Entity's performance in the MIPS APM. In 
contrast, we believe MIPS eligible clinicians would be less likely to 
join a full TIN APM principally to avail themselves of the APM scoring 
standard, since doing so would require either that the entire TIN join 
the MIPS APM or the administratively burdensome act of the eligible 
clinician reassigning their billing rights to the TIN of an entity 
participating in the full TIN APM.
    We will continue to use only the three dates of March 31, June 30, 
and August 31 to determine, based on Participation Lists, the MIPS 
eligible clinicians who participate in MIPS APMs that are not full TIN 
APMs. We seek comment on the proposed addition of the fourth date of 
December 31 to assess Participation Lists to identify MIPS eligible 
clinicians who participate in MIPS APMs that are full TIN APMs for 
purposes of the APM scoring standard.
(3) Calculating MIPS APM Performance Category Scores
    In the CY 2017 Quality Payment Program final rule, we established a 
scoring standard for MIPS eligible clinicians participating in MIPS 
APMs to reduce participant reporting burden by reducing the need for 
eligible clinicians participating in these types of APMs to make 
duplicative data submissions for both MIPS and their respective APMs 
(81 FR 77246 through 77271). In accordance with section 
1848(q)(1)(D)(i) of the Act, we proposed to assess the performance of a 
group of MIPS eligible clinicians in an APM Entity that participates in 
one or more MIPS APMs based on their collective performance as an APM 
Entity group, as defined at Sec.  414.1305.
    In addition to reducing reporting burden, we sought to ensure that 
eligible clinicians in MIPS APMs are not assessed in multiple ways on 
the same performance activities. Depending on the terms of the 
particular MIPS APM, we believe that misalignments could be common 
between the evaluation of performance on quality and cost under MIPS 
versus under the terms of the APM. We believe requiring eligible 
clinicians in MIPS APMs to submit data, be scored on measures, and be 
subject

[[Page 30082]]

to payment adjustments that are not aligned between MIPS and an APM 
could potentially undermine the validity of testing or performance 
evaluation under the APM. We also believe imposition of MIPS reporting 
requirements would result in reporting activity that provides little or 
no added value to the assessment of eligible clinicians, and could 
confuse eligible clinicians as to which CMS incentives should take 
priority over others in designing and implementing care improvement 
activities.
(a) Cost Performance Category
    In the CY 2017 Quality Payment Program final rule, for MIPS 
eligible clinicians participating in MIPS APMs, we used our authority 
to waive requirements under the Medicare statute to reduce the scoring 
weight for the cost performance category to zero (81 FR 77258, 77262, 
and 77266). We did this for MIPS APMs authorized under section 1115A of 
the Act using our authority under section 1115A(d)(1) of the Act to 
waive the requirement under section 1848(q)(5)(E)(i)(II) of the Act 
that specifies the scoring weight for the cost performance category. 
Having reduced the cost performance category weight to zero, we further 
used our authority under section 1115A(d)(1) of the Act to waive the 
requirements under sections 1848(q)(2)(B)(ii) and 1848(q)(2)(A)(ii) of 
the Act to specify and use, respectively, cost measures in calculating 
the MIPS final score for MIPS eligible clinicians participating in 
Other MIPS APMs (81 FR 77261 through 77262 and 77265 through 77266). 
Similarly, for MIPS eligible clinicians participating in the Medicare 
Shared Savings Program, we used our authority under section 1899(f) of 
the Act to waive the same requirements of section 1848 of the Act for 
the MIPS cost performance category (81 FR 77257 through 77258). We 
finalized this policy because: (1) APM Entity groups are already 
subject to cost and utilization performance assessment under the MIPS 
APMs; (2) MIPS APMs usually measure cost in terms of total cost of 
care, which is a broader accountability standard that inherently 
encompasses the purpose of the claims-based measures that have 
relatively narrow clinical scopes, and MIPS APMs that do not measure 
cost in terms of total cost of care may depart entirely from MIPS 
measures; and (3) the beneficiary attribution methodologies differ for 
measuring cost under APMs and MIPS, leading to an unpredictable degree 
of overlap (for eligible clinicians and for CMS) between the sets of 
beneficiaries for which eligible clinicians would be responsible that 
would vary based on the unique APM Entity characteristics such as which 
and how many eligible clinicians comprise an APM Entity group. We 
believe that with an APM Entity's finite resources for engaging in 
efforts to improve quality and lower costs for a specified beneficiary 
population, measurement of the population identified through the APM 
must take priority in order to ensure that the goals and the model 
evaluation associated with the APM are as clear and free of confounding 
factors as possible. The potential for different, conflicting results 
across APMs and MIPS assessments may create uncertainty for MIPS 
eligible clinicians who are attempting to strategically transform their 
respective practices and succeed under the terms of the APM. We are not 
proposing changes to these policies.
    We welcome comment on our proposal to continue to waive the 
weighting of the cost performance category for the 2020 payment year 
forward.
(i) Measuring Improvement in the Cost Performance Category
    In setting performance standards with respect to measures and 
activities in each MIPS performance category, section 1848(q)(3)(B) of 
the Act requires us to consider, historical performance standards, 
improvement, and the opportunity for continued improvement. Section 
1848(q)(5)(D)(i)(I) requires us to introduce the measurement of 
improvement into performance scores in the cost performance category 
for MIPS eligible clinicians for the 2020 MIPS Payment Year if data 
sufficient to measure improvement are available. Section 
1848(q)(5)(D)(i)(II) permits us to take into account improvement in the 
case of performance scores in other performance categories. Given that 
we have in effect waivers of the scoring weight for the cost 
performance category, and of the requirement to specify and use cost 
measures in calculating the MIPS final score for MIPS eligible 
clinicians participating in MIPS APMs, and for the same reasons that we 
initially waived those requirements, we propose to use our authority 
under section 1115A(d)(1) of the Act for MIPS APMs authorized under 
section 1115A of the Act and under section 1899(f) of the Act for MIPS 
APMs under the Medicare Shared Savings Program, to waive the 
requirement under section 1848(q)(5)(D)(i)(I) of the Act to take 
improvement into account for performance scores in the cost performance 
category beginning with the 2018 MIPS performance year.
    We seek comment on this proposal.
(b) Quality Performance Category
(i) Web Interface Reporters: Shared Savings Program and Next Generation 
ACO Model
(A) Quality Measures
    We finalized in the CY 2017 Quality Payment Program final rule that 
under the APM scoring standard, participants in the Shared Savings 
Program and Next Generation ACO Model would be assessed for the 
purposes of generating a MIPS APM quality performance category score 
based exclusively on quality measures submitted using the CMS Web 
Interface (81 FR 77256 and 77261). In the CY 2017 Quality Payment 
Program final rule, we recognized that ACOs in both the Shared Savings 
Program and Next Generation ACO Model use the CMS Web Interface to 
submit data on quality measures, and that the measures they would 
report were also MIPS measures for 2017. For the Shared Savings Program 
and the Next Generation ACO Model, we finalized a policy to use quality 
measures and data submitted by the participant ACOs to the CMS Web 
Interface (as required under the rules for these initiatives) and MIPS 
benchmarks for these measures to score quality for MIPS eligible 
clinicians in these MIPS APMs at the APM Entity level (81 FR 77256, 
77261). For these MIPS APMs, which we refer to as Web Interface 
reporters going forward, we established that quality performance data 
that are not submitted to the CMS Web Interface, for example the CAHPS 
for ACOs survey and claims-based measures, will not be included in the 
MIPS APM quality performance category score for 2017.
(aa) Addition of New Measures
    For the Shared Savings Program and Next Generation ACO Model, we 
propose to score the CAHPS for ACOs survey, in addition to the CMS Web 
Interface measures that are used to calculate the MIPS APM quality 
performance category score for the Shared Savings Program and Next 
Generation ACO Model, beginning in the 2018 performance year. The CAHPS 
for ACOs survey is already required in the Shared Savings Program and 
Next Generation ACO Model, and including the CAHPS for ACOs survey 
would better align the measures on which participants in these MIPS 
APMs are assessed under the APM scoring standard with the measures used 
to

[[Page 30083]]

assess participants' quality performance under the APM.
    We did not initially propose to include the CAHPS for ACOs survey 
as part of the MIPS APM quality performance category scoring for the 
Shared Savings Program and Next Generation ACO Model because we 
believed that the CAHPS for ACOs survey would not be collected and 
scored in time to produce a MIPS quality performance category score. 
However, operational efficiencies have recently been introduced that 
have made it possible to score the CAHPS for ACOs survey on the same 
timeline as the CAHPS for MIPS survey. Under our proposal, the CAHPS 
for ACOs survey would be added to the total number of quality 
performance category measures available for scoring in these MIPS APMs.
    While the CAHPS for ACOs survey is new to MIPS APM scoring, the CG-
CAHPS survey upon which it is based is also the basis for the CAHPS for 
MIPS survey, which was included on the MIPS final list for the 2017 
performance year. For a further discussion of the CAHPS for ACOs 
survey, and the way it will be scored, we refer readers to 
II.C.6.b.(3)(a)(ii) of this proposed rule, which describes the 
identical CAHPS for MIPS survey and its scoring method that will be 
used for MIPS in the 2018 performance year. We note that although each 
question in the CAHPS for ACOs survey can also be found in the CAHPS 
for MIPS survey, the CAHPS for ACOs survey will have one fewer survey 
question the SSM entitled ``Between Visit Communication'', which has 
never been a scored measure with the Medicare Shared Savings Program 
CAHPS for ACOs Survey and which we believe to be inappropriate for use 
by ACOs.

       Table 10--Web Interface Reporters: Shared Savings Program and Next Generation ACO Model New Measure
----------------------------------------------------------------------------------------------------------------
                                 NQF/quality        National
         Measure name             number (if        quality            Measure description       Primary measure
                                 applicable)    strategy domain                                       steward
----------------------------------------------------------------------------------------------------------------
CAHPS for ACOs...............  N/A............  Patient/         Consumer Assessment of          Agency for
                                                 Caregiver        Healthcare Providers and        Healthcare
                                                 Experience.      Systems (CAHPS) surveys for     Research and
                                                                  Accountable Care                Quality (AHRQ)
                                                                  Organizations (ACOs) in the
                                                                  Medicare Shared Savings
                                                                  Program (SSP) and Next
                                                                  Generation ACOs ask consumers
                                                                  about their experiences with
                                                                  health care. The CAHPS for
                                                                  ACOs Survey is collected from
                                                                  a sample of beneficiaries who
                                                                  get the majority of their
                                                                  care from an ACO, and the
                                                                  questions address care
                                                                  received from a named
                                                                  clinician within the ACO.
                                                                 Survey measures include:
                                                                    --Getting Timely Care,
                                                                     Appointments, and
                                                                     Information.
                                                                    --How Well Your Providers
                                                                     Communicate.
                                                                    --Patients' Rating of
                                                                     Providers.
                                                                    --Access to Specialists....
                                                                    --Health Promotion and
                                                                     Education.
                                                                    --Shared Decision Making...
                                                                    --Health Status/Functional
                                                                     Status.
                                                                    --Stewardship of Patient
                                                                     Resources.
----------------------------------------------------------------------------------------------------------------

(B) Calculating Quality Scores
    We refer readers to section II.C.7.a.(1)(h)(ii) of this proposed 
rule for our summary of finalized policies and proposed changes related 
to calculating the MIPS quality performance category percent score for 
MIPS eligible clinicians, including APM Entity groups reporting through 
the CMS Web Interface. Those policies and proposed changes in section 
II.C.7.a.(1)(h)(ii) of this proposed rule would apply in the same 
manner under the APM scoring standard except as otherwise noted in this 
section of the proposed rule. However, we propose not to subject MIPS 
APM Web Interface reporters to a 3 point floor because we do not 
believe it is necessary to apply this transition year policy to 
eligible clinicians participating in previously established MIPS APMs.
(C) Incentives to Report High Priority Measures
    In the CY 2017 Quality Payment Program final rule, we finalized 
that for CMS Web Interface reporters, we will apply bonus points based 
on the finalized set of measures reportable through the CMS Web 
Interface. (81 FR 77291 through 77294). We will assign two bonus points 
for reporting two or more outcome or patient experience measures and 
one bonus point for reporting any other high priority measure, beyond 
the first high priority measure. We note that in addition to the 
measures required by the APM to be submitted through the CMS Web 
Interface, APM Entities in the Shared Savings Program and Next 
Generation ACO Models must also report the CAHPS for ACOs survey and we 
propose that beginning for the 2020 payment year forward they may 
receive bonus points under the APM scoring standard for submitting that 
measure. Participants in MIPS APMs, like all MIPS eligible clinicians, 
are also subject to the 10 percent cap on bonus points for reporting 
high priority measures. APM Entities reporting through the CMS Web 
Interface will only receive bonus points if they submit a high priority 
measure with a performance rate that is greater than zero, provided 
that the measure meets the case minimum requirements.
(D) Scoring Quality Improvement
    Beginning in the CY 2018 performance year, section 
1848(q)(5)(D)(i)(I) of the Act requires us to score improvement for the 
MIPS quality performance category for MIPS eligible clinicians, 
including those participating in MIPS APMs, if data sufficient to 
measure quality improvement are available. We propose to calculate the 
quality improvement score using the methodology described in section 
II.C.7.a.(1)(i) for scoring quality improvement for eligible clinicians 
submitting quality measures via the CMS Web Interface. We believe 
aligning the scoring methodology used for all CMS Web Interface 
submissions will minimize confusion among MIPS eligible clinicians 
receiving a MIPS score, including those participating in MIPS APMs.
(E) Total Quality Performance Category Score for CMS Web Interface 
Reporters
    We propose to calculate the total quality percent score for MIPS 
eligible clinicians using the CMS Web Interface according to the 
methodology described

[[Page 30084]]

in section II.C.7.a.(1)(h)(2) of this proposed rule.
    We seek comment on our proposed quality performance category 
scoring methodology for CMS Web Interface reporters.
(ii) Other MIPS APMs
    We propose to define the term Other MIPS APM at Sec.  414.1305 as a 
MIPS APM that does not require reporting through the CMS Web Interface. 
We propose to add this definition as we believe it will be useful in 
discussing our policies for the APM scoring standard. In the 2018 MIPS 
performance period, Other MIPS APMs will include the Comprehensive ESRD 
Care Model, the Comprehensive Primary Care Plus Model (CPC+), and the 
Oncology Care Model.
(A) Quality Measures
    In the CY 2017 Quality Payment Program final rule, we explained 
that current MIPS APMs have requirements regarding the number of 
quality measures, measure specifications, as well as the measure 
reporting method(s) and frequency of reporting, and have an established 
mechanism for submission of these measures to us within the structure 
of the specific MIPS APM. We explained that operational considerations 
and constraints interfered with our ability to use the quality measure 
data from some MIPS APMs for the purpose of satisfying MIPS data 
submission requirements for the quality performance category for the 
first performance year. We concluded that there was insufficient time 
to adequately implement changes to the current MIPS APM quality measure 
data collection timelines and infrastructure in the first performance 
year to conduct a smooth hand-off to the MIPS system that would enable 
use of APM quality measure data to satisfy the MIPS quality performance 
category requirements in the first MIPS performance year (81 FR 77264). 
Out of concern that subjecting MIPS eligible clinicians who participate 
in MIPS APMs to multiple, potentially duplicative or inconsistent 
performance assessments could undermine the validity of testing or 
performance evaluation under the MIPS APMs; and that there was 
insufficient time to make adjustments in operationally complex systems 
and processes related to the alignment, submission and collection of 
APM quality measures for purposes of MIPS, we used our authority under 
section 1115A(d)(1) to waive certain requirements of section 1848(q).
    We finalized that for the first MIPS performance year only, for 
MIPS eligible clinicians participating in APM Entities in Other MIPS 
APMs, the weight for the quality performance category is zero (81 FR 
77268). To avoid risking adverse operational or program evaluation 
consequences for MIPS APMs while we worked toward incorporating MIPS 
APM quality measures into scoring for future performance years, we used 
the authority provided by section 1115A(d)(1) of the Act to waive the 
quality performance category weight required under section 
1848(q)(5)(E)(i)(I) of the Act, and we indicated that with the 
reduction of the quality performance category weight to zero, it was 
unnecessary to establish for MIPS APMs a final list of quality measures 
as required under section 1848(q)(2)(D) of the Act or to specify and 
use quality measures in determining the MIPS final score for these MIPS 
eligible clinicians. As such, we further waived the requirements under 
sections 1848(q)(2)(D), 1848(q)(2)(B)(i) and 1848(q)(2)(A)(i) of the 
Act to establish a final list of quality measures (using certain 
criteria and processes); and to specify and use, respectively, quality 
measures in calculating the MIPS final score for the first MIPS 
performance year.
    In the CY 2017 Quality Payment Program final rule, we anticipated 
that beginning with the second MIPS performance year, the APM quality 
measure data submitted to us during the MIPS performance year would be 
used to derive a MIPS quality performance score for APM Entities in all 
MIPS APMs.
    We also anticipated that it may be necessary to propose policies 
and waivers of requirements of the statute, such as section 
1848(q)(2)(D) of the Act, to enable the use of non-MIPS quality 
measures in the quality performance category score. We anticipated that 
by the second performance year we would have had sufficient time to 
resolve operational constraints related to use of separate quality 
measure systems and to adjust quality measure data submission 
timelines. Accordingly, we stated our intention to, in future 
rulemaking, use our section 1115A(d)(1) waiver authority to establish 
that the quality measures and data that are used to evaluate 
performance for APM Entities in MIPS APMs would be used to calculate a 
MIPS quality performance score under the APM scoring standard.
    We have since designed the means to overcome the operational 
constraints that prevented us from scoring quality under the APM 
scoring standard in the first performance year, and we propose to adopt 
quality measures for use under the APM scoring standard, and begin 
collecting MIPS APM quality measure performance data in order to 
generate a MIPS quality performance category score for APM Entities 
participating in MIPS APMs beginning with the 2018 performance year.
(aa) APM Measures for MIPS
    In the CY 2017 Quality Payment Program final rule, we explained the 
concerns that led us to express our intent to use the quality measures 
and data that apply in the MIPS APM for purposes of the APM scoring 
standard, including concerns about the application of multiple, 
potentially duplicative or inconsistent performance assessments that 
could negatively impact our ability to evaluate MIPS APMs (81 FR 
77246). Additionally, the quality and cost/utilization measures that 
are used to calculate performance-based payments in MIPS APMs may vary 
from one MIPS APM to another. Factors such as the type and quantity of 
measures required, the MIPS APM's particular measure specifications, 
how frequently the measures must be reported, and the mechanisms used 
to collect or submit the measures all add to the diversity in the 
quality and cost/utilization measures used to evaluate performance 
among MIPS APMs. Given these concerns and the differences between and 
among the quality measures used to evaluate performance within MIPS 
APMs as opposed to those used more generally under MIPS, we propose to 
use our authority under section 1115A(d)(1) of the Act to waive 
requirements under section 1848(q)(2)(D) of the Act, which requires the 
Secretary to use certain criteria and processes to establish an annual 
MIPS final list of quality measures from which all MIPS eligible 
clinicians may choose measures for purposes of assessment, and instead 
to establish a MIPS APM quality measure list for purposes of the APM 
scoring standard. The MIPS APM quality measure list would be adopted as 
the final list of MIPS quality measures under the APM scoring standard, 
and would reflect the quality measures that are used to evaluate 
performance on quality within each MIPS APM.
    The MIPS APM quality measure list we propose in Table 13, would 
define distinct measure sets for participants in each MIPS APM for 
purposes of the APM scoring standard, based on the measures that are 
used by the APM, and for which data will be collected by the close of 
the MIPS submission period. The measure sets on the MIPS APM measure 
list would represent all possible measures which may contribute to an 
APM Entity's MIPS score for the MIPS quality performance

[[Page 30085]]

category, and may include measures that are the same as or similar to 
those used by MIPS. However, measures may ultimately not be used for 
scoring if a measure's data becomes inappropriate or unavailable for 
scoring; for example, if a measure's clinical guidelines are changed or 
the measure is otherwise modified by the APM during the performance 
year, the data collected during that performance year would not be 
uniform, and as such may be rendered unusable for purposes of the APM 
scoring standard (See Tables 14, 15, and 16).
(B) Measure Requirements for Other MIPS APMs
    Because the quality measure sets for each Other MIPS APM are 
unique, we propose to calculate the MIPS quality performance category 
score using APM-specific quality measures. For purposes of the APM 
scoring standard, we will score only measures that: (1) Are tied to 
payment as described under the terms of the APM, (2) are available for 
scoring near the close of the MIPS submission period, (3) have a 
minimum of 20 cases available for reporting, and (4) have an available 
benchmark. We discuss each of these requirements for Other MIPS APM 
quality measures below.
(aa) Tied to Payment
    For purposes of the APM scoring standard, we will consider a 
measure to be tied to payment if an APM Entity group will receive a 
payment adjustment or other incentive payment under the terms of the 
APM, based on the APM Entity's performance on the measure.
(bb) Available for Scoring
    Some MIPS APM quality measure results are not available until late 
in the calendar year subsequent to the MIPS performance year, which 
would prevent us from including them in the MIPS APM quality 
performance category score due to the larger programmatic timelines for 
providing MIPS eligible clinician performance feedback by July and 
issuing budget-neutral MIPS payment adjustments. Consequently, we 
propose to only use the MIPS APM quality measure data that are 
submitted by the close of the MIPS submission period and are available 
for scoring in time for inclusion to calculate a MIPS quality 
performance category score. Measures are to be submitted according to 
requirements under the terms of the APM; the measure data will then be 
aggregated and prepared for submission to MIPS for the purpose of 
creating a MIPS quality performance category score.
    We believe using the Other MIPS APMs' quality measure data that 
have been submitted no later than the close of the MIPS submission 
period and have been processed and made available to MIPS for scoring 
in time to calculate a MIPS quality performance category score is 
consistent with our intent to decrease duplicative reporting for MIPS 
eligible clinicians who would otherwise need to report quality measures 
to both MIPS and their APM. Going forward, these are the measures to 
which we are referring when we limit scoring to measures that are 
available near the close of the MIPS submission period.
(cc) 20 Case Minimum
    We also believe that a 20 case minimum, in alignment with the one 
finalized generally under MIPS in the CY 2017 Quality Payment Program 
final rule (81 FR 77288), is necessary to ensure the reliability of the 
measure data submitted, as explained the CY 2017 Quality Payment 
Program final rule.
    As under the general policy for MIPS, when an APM Entity reports a 
quality measure that includes less than 20 cases, that measure would 
receive a null score for that measure's achievement points, and the 
measure would be removed from both the numerator and the denominator of 
the MIPS quality performance category percentage. We propose to apply 
this policy under the APM scoring standard.
(dd) Available Benchmark
    An APM Entity's score on each quality measure would be calculated 
in part by comparing the APM Entity's performance on the measure with a 
benchmark performance score. Therefore, we would need all scored 
measures to have a benchmark available by the time that the MIPS 
quality performance category score is calculated, in order to make that 
comparison.
    We propose that, for the APM scoring standard, the benchmark score 
used for a quality measure would be the benchmark used in the MIPS APM 
for calculation of the performance based payments, where such a 
benchmark is available. If the APM does not produce a benchmark score 
for a reportable measure that is included on the APM measures list, we 
would use the benchmark score for the measure that is used for the MIPS 
quality performance category generally (outside of the APM scoring 
standard) for that performance year, provided the measure 
specifications for the measure are the same under both the MIPS final 
list and the APM measures list. If neither the APM nor MIPS has a 
benchmark available for a reported measure, the APM Entity that 
reported that measure would receive a null score for that measure's 
achievement points, and the measure would be removed from both the 
numerator and the denominator of the quality performance category 
percentage.
(C) Calculating the Quality Performance Category Percent Score
    Eligible clinicians who participate in Other MIPS APMs are subject 
to specific quality measure reporting requirements within these APMs. 
To best align with APM design and objectives, we propose that the 
minimum number of required measures to be reported for the APM scoring 
standard would be the minimum number of quality measures that are 
required by the MIPS APM and are collected and available in time to be 
included in the calculation for the APM Entity score under the APM 
scoring standard. For example, if an Other MIPS APM requires 
participating APM Entities to report nine of 14 quality measures by a 
specific date and the APM Entity misses the MIPS submission deadline, 
then for the purposes of calculating an APM Entity quality performance 
category score, the APM Entity would receive a zero for those measures. 
An APM Entity that does not submit any APM quality measures by the MIPS 
submission deadline would receive a zero for its MIPS APM quality 
performance category percent score for the performance year.
    We propose that if an APM Entity submits some, but not all of the 
measures required by the MIPS APM by the close of the MIPS submission 
period, the APM Entity would receive points for the measures that were 
submitted, but would receive a score of zero for each remaining measure 
between the number of measures reported and the number of measures 
required by the APM that were available for scoring.
    For example, if an APM Entity in the above hypothetical MIPS APM 
submits quality performance data on three of the APM's measures, 
instead of the required nine, the APM Entity would receive quality 
points in the APM scoring standard quality performance category percent 
score for the three measures it submitted, but would receive zero 
points for each of the six remaining measures that were required under 
the terms of the MIPS APM. On the other hand, if an APM Entity reports 
on more than the minimum number of measures required to be reported 
under the MIPS APM and the measures meet the other

[[Page 30086]]

criteria for scoring, only the measures with the highest scores, up to 
the number of measures required to be reported under the MIPS APM, 
would be counted; however, any bonus points earned by reporting on 
measures beyond the minimum number of required measures would be 
awarded.
    If a measure is reported but fails to meet the 20 case minimum or 
does not have a benchmark available, there would be a null score for 
that measure, and it would be removed from both the numerator and the 
denominator, so as not to negatively affect the APM Entity's quality 
performance category score.
    We propose to assign bonus points for reporting high priority 
measures or measures with end-to-end CEHRT reporting as described for 
general MIPS scoring in the CY 2017 Quality Payment Program final rule 
(81 FR 77297 through 77299).
(aa) Quality Measure Benchmarks
    An APM Entity's MIPS quality measure score will be calculated by 
comparing the APM Entity's performance on a given measure with a 
benchmark performance score. We propose that the benchmark score used 
for a quality measure would be the benchmark used by the MIPS APM for 
calculation of the performance based payments within the APM, if 
possible, in order to best align the measure performance outcomes 
between the APM and MIPS programs. If the MIPS APM does not produce a 
benchmark score for a reportable measure that will be available at the 
close of the MIPS submission period, the benchmark score for the 
measure that is used for the MIPS quality performance category 
generally for that performance year would be used, provided the measure 
specifications are the same for both. If neither the APM nor MIPS has a 
benchmark available for a reported measure, the APM Entity that 
reported that measure will receive a null score for that measure's 
achievement points, and the measure will be removed from both the 
numerator and the denominator of the quality performance category 
percentage.
    We are proposing that for measures that are pay for reporting or 
which do not measure performance on a continuum of performance, we will 
consider these measures to be lacking a benchmark and they will be 
treated as such. For example, if a model only requires that an APM 
Entity must surpass a threshold and does not measure APM Entities on 
performance beyond surpassing a threshold, we would not consider such a 
measure to measure performance on a continuum.
    We propose to score quality measure performance under the APM 
scoring standard using a percentile distribution, separated by decile 
categories, as described in the finalized MIPS quality scoring 
methodology (81 FR 77282 through 77284). For each benchmark, we will 
calculate the decile breaks for measure performance and assign points 
based on the benchmark decile range into which the APM Entity's measure 
performance falls.
    We propose to use a graduated points-assignment approach, where a 
measure is assigned a continuum of points out to one decimal place, 
based on its place in the decile. For example, a raw score of 55 
percent would fall within the sixth decile of 41.0 percent to 61.9 
percent and would receive between 6.0 and 6.9 points.
    We seek comment on this proposed method.

                 Table 11--Benchmark Decile Distribution
------------------------------------------------------------------------
                                                             Graduated
         Sample benchmark decile          Sample quality   points  (with
                                            measure (%)      no floor)
------------------------------------------------------------------------
Example Benchmark Decile 1..............           0-9.9         1.0-1.9
Example Benchmark Decile 2..............       10.0-17.9         2.0-2.9
Example Benchmark Decile 3..............       18.0-22.9         3.0-3.9
Example Benchmark Decile 4..............       23.0-35.9         4.0-4.9
Example Benchmark Decile 5..............       36.0-40.9         5.0-5.9
Example Benchmark Decile 6..............       41.0-61.9         6.0-6.9
Example Benchmark Decile 7..............       62.0-68.9         7.0-7.9
Example Benchmark Decile 8..............       69.0-78.9         8.0-8.9
Example Benchmark Decile 9..............       79.0-84.9         9.0-9.9
Example Benchmark Decile 10.............        85.0-100            10.0
------------------------------------------------------------------------

(bb) Assigning Quality Measure Points Based on Achievement
    For the APM scoring standard quality performance category, we 
propose that each APM Entity that reports on quality measures would 
receive between 1 and 10 achievement points for each measure reported 
that can be reliably scored against a benchmark, up to the number of 
measures that are required to be reported by the APM. Because measures 
that lack benchmarks or 20 reported cases are removed from the 
numerator and denominator of the quality performance category 
percentage, it is unnecessary to include a point-floor for scoring of 
Other MIPS APMs. Similarly, because the quality measures reported by 
the MIPS APM for MIPS eligible clinicians under the APM scoring 
standard are required to be submitted to the APM under the terms of 
participation in the APM, and the MIPS eligible clinicians do not 
select their APM measures, there will be no cap on topped out measures 
for MIPS APM participants being scored under the APM scoring standard, 
which differs from the policy for other MIPS eligible clinicians 
proposed at section II.C.7.a.(2)(c) of this proposed rule.
    Beginning in the 2018 MIPS performance year, we propose that APM 
Entities in MIPS APMs, like other MIPS eligible clinicians, would be 
eligible to receive bonus points for the MIPS quality performance 
category for reporting on high priority measures or measures submitted 
via CEHRT (for example, end-to-end submission) according to the 
criteria described in section II.C.7.a.(1) of this proposed rule. For 
each Other MIPS APM, we propose to identify whether any of their 
available measures meets the criteria to receive a bonus, and add the 
bonus points to the quality achievement points. Further, we propose 
that the total number of awarded bonus points may not exceed 10 percent 
of the APM Entity's total available achievement points for the MIPS 
quality performance category score.
    To generate the APM Entity's quality performance category 
percentage, achievement points would be added to any applicable bonus 
points, and then divided by the total number of available achievement 
points, with a cap of 100

[[Page 30087]]

percent. For more detail on the MIPS quality performance category 
percentage score calculation, we refer readers to section II.C.7.a.(1) 
of this proposed rule.
    Under the APM scoring standard for Other MIPS APMs, the number of 
available achievement points would be the number of measures required 
under the terms of the APM and available for scoring multiplied by ten. 
If, however, an APM Entity reports on a required measure that fails the 
20 case minimum requirement, or which has no available benchmark for 
that performance year, the measure would receive a null score and all 
points from that measure would be removed from both the numerator and 
the denominator.
    For example, if an APM Entity reports on four out of four measures 
required to be reported by the MIPS APM, and receives an achievement 
score of five on each and no bonus points, the APM Entity's quality 
performance category percentage would be [(5 points x 4 measures) + 0 
bonus points]/(4 measures x 10 max available points), or 50 percent. 
If, however, one of those measures failed the 20 case minimum 
requirement or had no benchmark available, that measure would have a 
null value and would be removed from both the numerator and denominator 
to create a quality performance category percentage of [(5 points x 3 
measures) + 0 bonus points]/(3measures x 10 max available points), or 
50 percent.
    If an APM Entity fails to meet the 20 case minimum on all available 
APM measures, that APM Entity would have its quality performance 
category score reweighted to zero, as described below.
    We request comment on the above proposals for calculating the 
quality category percent score.
(D) Quality Improvement Scoring
    Beginning in the 2018 performance year, we propose to score 
improvement as well as achievement in the quality performance category.
    For the APM scoring standard, we propose that the quality 
improvement percentage points would be awarded based on the following 
formula:

Quality Improvement Score = (Absolute Improvement/Previous Year Quality 
Performance Category Percent Score Prior to Bonus Points)/10

    For a more detailed discussion of improvement scoring for the 
quality performance category under the APM scoring standard, we refer 
readers to the discussion on calculating improvement at the quality 
performance category level for MIPS at section II.C.7.a.(1)(i) of this 
proposed rule.
(E) Calculating Total Quality Performance Category Score
    We propose that the APM Entity's total quality performance category 
score would be equal to [(achievement points + bonus points)/total 
available achievement points] + quality improvement score. The APM 
Entity's total quality performance category score may not exceed 100 
percent. We request comment on the above proposed quality scoring 
methodology.
    We seek comment on the proposed quality performance category 
scoring methodology for APM Entities participating in Other MIPS APMs.
(c) Improvement Activities Performance Category
    As finalized in the CY 2017 Quality Payment Program final rule, for 
all MIPS APMs we will assign the same improvement activities score to 
each APM Entity based on the activities involved in participation in a 
MIPS APM. APM Entities will receive a minimum of one half of the total 
possible points. This policy is in accordance with section 
1848(q)(5)(C)(ii) of the Act. In the event that the assigned score does 
not represent the maximum improvement activities score, the APM Entity 
group will have the opportunity to report additional improvement 
activities to add points to the APM Entity level score.
(d) Advancing Care Information Performance Category
    In the CY 2017 Quality Payment Program final rule, we finalized our 
policy to attribute one score to each MIPS eligible clinician in an APM 
Entity group by looking for both individual and group TIN level data 
submitted for a MIPS eligible clinician, and using the highest 
available score (81 FR 77268). We will then use these scores to create 
an APM Entity's score based on the average of the highest scores 
available for all MIPS eligible clinicians in the APM Entity group. If 
an individual or TIN did not report on the advancing care information 
performance category, they will contribute a zero to the APM Entity's 
aggregate score. Each MIPS eligible clinician in an APM Entity group 
will receive one score, weighted equally with the scores of every other 
MIPS eligible clinician in the APM Entity group, and we will use these 
to calculate a single APM Entity-level advancing care information 
performance category score.
    We refer readers to section II.C.6.f.(6) of this proposed rule for 
our summary of proposed changes related to scoring the advancing care 
information performance category.
(i) Special Circumstances
    As described in the CY 2017 Quality Payment Program final rule (81 
FR 77238-77245), under the generally applicable MIPS scoring standard, 
we will assign a weight of zero percent to the advancing care 
information performance category in the final score for MIPS eligible 
clinicians who meet specific criteria: hospital-based MIPS eligible 
clinicians, MIPS eligible clinicians who are facing a significant 
hardship, and certain types of non-physician practitioners (NPs, PAs, 
CRNAs, CNSs) who are MIPS eligible clinicians. In section II.C.7.a.(6) 
of this proposed rule, we are also proposing to include in this 
weighting policy ASC-based MIPS eligible clinicians and MIPS eligible 
clinicians who are using decertified EHR technology.
    Under the APM scoring standard, we propose that if a MIPS eligible 
clinician who qualifies for a zero percent weighting of the advancing 
care information performance category in the final score is part of a 
TIN that includes one or more MIPS eligible clinicians who do not 
qualify for a zero percent weighting, we would not apply the zero 
percent weighting to the qualifying MIPS eligible clinician, and the 
TIN would still be required to report on behalf of the group, although 
the TIN would not need to report data for the qualifying MIPS eligible 
clinician. All MIPS eligible clinicians in the TIN would count towards 
the TIN's weight when calculating an aggregated APM Entity score for 
the advancing care information performance category.
    If, however, the MIPS eligible clinician is a solo practitioner and 
qualifies for a zero percent weighting, or if all MIPS eligible 
clinicians in a TIN qualify for the zero percent weighting, the TIN 
would not be required to report on the advancing care information 
performance category, and if the TIN chooses not to report that TIN 
would be assigned a weight of 0 when calculating the APM Entity's 
advancing care information performance category score.
    If advancing care information data are reported by one or more TINs 
in an APM Entity, an advancing care information performance category 
score will be calculated for, and will be applicable to, all MIPS 
eligible clinicians in the APM Entity group. If all MIPS eligible 
clinicians in all TINs in an APM Entity group qualify for a zero 
percent weighting of have the advancing care information performance 
category, or in the case of a solo practitioner who comprises an entire

[[Page 30088]]

APM Entity and qualifies for zero percent weighting, the advancing care 
information performance category would be weighted at zero percent of 
the final score, and the advancing care information performance 
category's weight would be redistributed to the quality performance 
category.
(4) Calculating Total APM Entity Score
(a) Performance Category Weighting
    As discussed in section II.C.6.g.(3)(a) of this proposed rule, we 
propose to continue to use our authority to waive sections 
1848(q)(2)(B)(ii) and 1848(q)(2)(A)(ii) of the Act to specify and use, 
respectively, cost measures; and to maintain the cost performance 
category weight of zero under the APM scoring standard for the 2018 
performance period and subsequent MIPS performance periods. Because the 
cost performance category would be reweighted to zero that weight would 
need to be redistributed to other performance categories. We propose to 
use our authority under section 1115A(d)(1) to waive requirements under 
sections 1848(q)(5)(E)(i)(I)(bb), 1848(q)(5)(E)(i)(III) and 
1848(q)(5)(E)(i)(IV) of the Act that prescribe the weights, 
respectively, for the quality, improvement activities, and ACI 
performance categories. We propose to weight the quality performance 
category score to 50 percent, the improvement activities performance 
category to 20 percent, and the advancing care information performance 
category to 30 percent of the final score for all APM Entities in Other 
MIPS APMs. We propose these weights to align the Other MIPS APM 
performance category weights with those assigned to the Web Interface 
reporters, which we adopted as explained in the CY 2017 Quality Payment 
Program final rule at 81 FR 77262 through 77263. We believe it is 
appropriate to align the performance category weights for APM Entities 
in MIPS APMs that require reporting through the Web Interface with 
those in Other MIPS APMs. By aligning the performance category weights 
among all MIPS APMs, we would create greater scoring parity among the 
MIPS eligible clinicians in MIPS APMs who are being scored under the 
APM scoring standard. These proposals are summarized in Table 12.

     Table 12--APM Scoring Standard Performance Category Weights--Beginning for the 2018 Performance Period
----------------------------------------------------------------------------------------------------------------
                                                                                                    Performance
      MIPS performance category           APM entity submission      Performance category score      category
                                               requirement                                          weight  (%)
----------------------------------------------------------------------------------------------------------------
Quality.............................  The APM Entity will be        CMS will assign the same                  50
                                       required to submit quality    quality category
                                       measures to CMS as required   performance score to each
                                       by the MIPS APM. Measures     TIN/NPI in an APM Entity
                                       available at the close of     group based on the APM
                                       the MIPS submission period    Entity's total quality
                                       will be used to calculate     score, derived from
                                       the MIPS quality              available APM quality
                                       performance category score.   measures.
                                       If the APM Entity does not
                                       submit any APM required
                                       measures by the MIPS
                                       submission deadline, the
                                       APM Entity will be assigned
                                       a zero.
Cost................................  The APM Entity group will     N/A.........................               0
                                       not be assessed on cost
                                       under MIPS.
Improvement Activities..............  MIPS eligible clinicians do   CMS will assign the same                  20
                                       not need to report            improvement activities
                                       improvement activities        score to each APM Entity
                                       data; if the CMS-assigned     based on the activities
                                       improvement activities        involved in participation
                                       score is below the maximum    in the MIPS APM. APM
                                       improvement activities        Entities will receive a
                                       score APM Entities will       minimum of one half of the
                                       have the opportunity to       total possible points. In
                                       submit additional             the event that the assigned
                                       improvement activities to     score does not represent
                                       raise the APM Entity          the maximum improvement
                                       improvement activity score.   activities score, the APM
                                                                     Entity will have the
                                                                     opportunity to report
                                                                     additional improvement
                                                                     activities to add points to
                                                                     the APM Entity level score.
Advancing Care Information..........  Each MIPS eligible clinician  We will attribute the same                30
                                       in the APM Entity group is    score to each MIPS eligible
                                       required to report            clinician in the APM Entity
                                       advancing care information    group. This score will be
                                       to MIPS through either        the highest score
                                       group TIN or individual       attributable to the TIN/NPI
                                       reporting.                    combination of each MIPS
                                                                     eligible clinician, which
                                                                     may be derived from either
                                                                     group or individual
                                                                     reporting. The scores
                                                                     attributed to each MIPS
                                                                     eligible clinicians will be
                                                                     averaged for a single APM
                                                                     Entity score.
----------------------------------------------------------------------------------------------------------------

    It is possible that there could be instances where an Other MIPS 
APM has no measures available to score for the quality performance 
category for a MIPS performance period; for example, it is possible 
that none of the Other MIPS APM's measures would be available for 
calculating a quality performance category score by or shortly after 
the close of the MIPS submission period because the measures were 
removed due to changes in clinical practice guidelines. In addition, as 
explained in section II.C.6.g.(3)(d)(i) of this proposed rule, the MIPS 
eligible clinicians in an APM Entity may qualify for a zero percent 
weighting for the advancing care information performance category. In 
such instances, under the APM scoring standard, we propose to reweight 
the affected performance category to zero, in accordance with section 
1848(q)(5)(F) of the Act.
    If the quality performance category is reweighted to zero, we 
propose to reweight the improvement activities and advancing care 
information performance categories to 25 and 75 percent, respectively. 
If the advancing care information performance category is reweighted to 
zero, the quality performance category weight would be

[[Page 30089]]

increased to 80 percent. These proposals are summarized in Table 13.

   Table 13--APM Scoring Standard Performance Category Weights for Other MIPS APMs With Performance Categories
                            Weighted to 0--Beginning for the 2018 Performance Period
----------------------------------------------------------------------------------------------------------------
                                                                                                    Performance
                                                                                    Performance      category
                                  APM entity submission    Performance category      category       weight (no
   MIPS performance category           requirement                 score            weight (no    advancing care
                                                                                   quality) (%)    information)
                                                                                                        (%)
----------------------------------------------------------------------------------------------------------------
Quality........................  The APM Entity would     CMS will assign the                  0              80
                                  not be assessed on       same quality category
                                  quality under MIPS if    performance score to
                                  no quality data are      each TIN/NPI in an
                                  available at the close   APM Entity group
                                  of the MIPS submission   based on the APM
                                  period. The APM Entity   Entity's total
                                  will submit quality      quality score,
                                  measures to CMS as       derived from
                                  required by the MIPS     available APM quality
                                  APM.                     measures.
Cost...........................  The APM Entity group     N/A...................               0               0
                                  will not be assessed
                                  on cost under MIPS.
Improvement Activities.........  MIPS eligible            CMS will assign the                 25              20
                                  clinicians do not need   same improvement
                                  to report improvement    activities score to
                                  activities data unless   each APM Entity group
                                  the CMS-assigned         based on the
                                  improvement activities   activities involved
                                  scores is below the      in participation in
                                  maximum improvement      the MIPS APM.
                                  activities score.       APM Entities will
                                                           receive a minimum of
                                                           one half of the total
                                                           possible points. In
                                                           the event that the
                                                           assigned score does
                                                           not represent the
                                                           maximum improvement
                                                           activities score, the
                                                           APM Entity will have
                                                           the opportunity to
                                                           report additional
                                                           improvement
                                                           activities to add
                                                           points to the APM
                                                           Entity level score.
Advancing Care Information.....  Each MIPS eligible       We will attribute the               75               0
                                  clinician in the APM     same score to each
                                  Entity group reports     MIPS eligible
                                  advancing care           clinician in the APM
                                  information to MIPS      Entity group. This
                                  through either group     score will be the
                                  TIN or individual        highest score
                                  reporting.               attributable to the
                                                           TIN/NPI combination
                                                           of each MIPS eligible
                                                           clinician, which may
                                                           be derived from
                                                           either group or
                                                           individual reporting.
                                                           The scores attributed
                                                           to each MIPS eligible
                                                           clinicians will be
                                                           averaged for a single
                                                           APM Entity score.
----------------------------------------------------------------------------------------------------------------

    We seek comment on the proposed reweighting for APM Entities 
participating in MIPS APMs.
(b) Risk Factor Score
    Section 1848(q)(1)(G) of the Act requires us to consider risk 
factors in our scoring methodology. Specifically, that section provides 
that the Secretary, on an ongoing basis, shall, as the Secretary 
determines appropriate and based on individuals' health status and 
other risk factors, assess appropriate adjustments to quality measures, 
cost measures, and other measures used under MIPS and assess and 
implement appropriate adjustments to payment adjustments, final scores, 
scores for performance categories, or scores for measures or activities 
under the MIPS.
    We refer readers to II.C.7.b.(1) of this proposed rule for a 
description of the risk factor adjustment and its application to APM 
Entities.
(c) Small Practice Bonus
    We believe an adjustment for eligible clinicians in small practices 
(referred to herein as the small practice bonus) is appropriate to 
recognize barriers faced by small practices, such as unique challenges 
related to financial and other resources, environmental factors, and 
access to health information technology, and to incentivize eligible 
clinicians in small practices to participate in the Quality Payment 
Program and to overcome any performance discrepancy due to practice 
size.
    We refer readers to section II.C.7.b.(2) of this proposed rule for 
a discussion of the small practice adjustment and its application to 
APM Entities.
(d) Final Score Methodology
    In the CY 2017 Quality Payment Program final rule, we finalized the 
methodology for calculating a final score of 0-100 based on the four 
performance categories (81 FR 77320). We refer readers to section 
II.C.7.c. of this proposed rule for a discussion of the changes we are 
proposing for the final score methodology.
(5) MIPS APM Performance Feedback
    In the CY 2017 Quality Payment Program final rule (81 FR 77270), we 
finalized that all MIPS eligible clinicians scored under the APM 
scoring standard will receive performance feedback as specified under 
section 1848(q)(12) of the Act on the quality and cost performance 
categories to the extent applicable, based on data collected in the 
September 2016 QRUR, unless they did not have data included in the 
September 2016 QRUR. Those eligible clinicians without data included in 
the September 2016 QRUR will not receive any performance feedback until 
performance data is available for feedback.
    Beginning with the 2018 performance year, we propose that MIPS 
eligible clinicians whose MIPS payment adjustment is based on their 
score under the APM scoring standard will receive performance feedback 
as specified

[[Page 30090]]

under section 1848(q)(12) of the Act for the quality, advancing care 
information, and improvement activities performance categories to the 
extent data are available for the MIPS performance year. Further, we 
propose that in cases where performance data are not available for a 
MIPS APM performance category because the MIPS APM performance category 
has been weighted to zero for that performance year, we would not 
provide performance feedback on that MIPS performance category.
    We believe that with an APM Entity's finite resources for engaging 
in efforts to improve quality and lower costs for a specified 
beneficiary population, the incentives of the APM must take priority 
over those offered by MIPS in order to ensure that the goals and 
evaluation associated with the APM are as clear and free of confounding 
factors as possible. The potential for different, conflicting messages 
in performance feedback provided by the APMs and that provided by MIPS 
may create uncertainty for MIPS eligible clinicians who are attempting 
to strategically transform their respective practices and succeed under 
the terms of the APM. Accordingly, under section 1115A(d)(1) and 
section 1899(f), for all performance years we propose to waive--for 
MIPS eligible clinicians participating in MIPS APMs--the requirement 
under section 1848(q)(12)(A)(i)(I) of the Act to provide performance 
feedback for the cost performance category.
    We request comment on these proposals to waive requirements for 
performance feedback on the cost performance category indefinitely, and 
for the other performance categories in years for which the weight for 
those categories has been reweighted to zero.
(6) Summary of Proposals
    In summary, we have proposed the following in this section:
     We propose to amend the regulation at Sec.  414.1370(e) to 
identify the four assessment dates that would be used to identify the 
APM Entity group for purposes of the APM scoring standard, and to 
specify that the December 31 date will be used only to identify 
eligible clinicians on the APM Entity's Participation List for a MIPS 
APM that is a full TIN APM in order to add them to the APM Entity group 
that is scored under the APM scoring standard. We propose to use this 
fourth assessment date of December 31 to extend the APM scoring 
standard to only those MIPS eligible clinicians participating in MIPS 
APMs that are full TIN APMs, ensuring that an eligible clinician who 
joins the full TIN APM late in the performance year would be scored 
under the APM scoring standard.
     We propose to continue to weight the cost performance 
category under the APM scoring standard for Web Interface reporters at 
zero percent for the 2020 payment year forward.
     Aligned with our proposal to weight the cost performance 
category at zero percent, we propose not to take improvement into 
account for performance scores in the cost performance category for Web 
Interface reporters beginning with the 2020 MIPS Payment Year.
     We propose to score the CAHPS for ACOs survey, in addition 
to the CMS Web Interface measures that are used to calculate the MIPS 
APM quality performance category score for Web Interface reporters 
including the Shared Savings Program and Next Generation ACO Model), 
beginning in the 2018 performance year.
     We propose that, beginning for the 2018 performance year, 
eligible clinicians in MIPS APMs that are Web Interface reporters may 
receive bonus points under the APM scoring standard for submitting the 
CAHPS for ACOs survey.
     We propose to calculate the quality improvement score for 
MIPS eligible clinicians submitting quality measures via the CMS Web 
Interface using the methodology described in section II.C.7.a.(1)(i).
     We propose to calculate the total quality percent score 
for MIPS eligible clinicians using the CMS Web Interface according to 
the methodology described in section II.C.7.a.(1)(h)(2) of this 
proposed rule.
     We propose to establish a separate MIPS final list of 
quality measures for each Other MIPS APM that would be the quality 
measure list used for purposes of the APM scoring standard.
     We propose to calculate the MIPS quality performance 
category score for Other MIPS APMs using MIPS APM-specific quality 
measures. For purposes of the APM scoring standard, we would score only 
measures that: (1) Are tied to payment as described under the terms of 
the APM, (2) are available for scoring near the close of the MIPS 
submission period, (3) have a minimum of 20 cases available for 
reporting, and (4) have an available benchmark.
     We propose to only use the MIPS APM quality measure data 
that are submitted by the close of the MIPS submission period and are 
available for scoring in time for inclusion to calculate a MIPS quality 
performance category score.
     We propose that, for the APM scoring standard, the 
benchmark score used for a quality measure would be the benchmark used 
in the MIPS APM for calculation of the performance based payments, 
where such a benchmark is available. If the APM does not produce a 
benchmark score for a reportable measure that is included on the APM 
measures list, we would use the benchmark score for the measure that is 
used for the MIPS quality performance category generally (outside of 
the APM scoring standard) for that performance year, provided the 
measure specifications for the measure are the same under both the MIPS 
final list and the APM measures list.
     We propose that the minimum number of quality measures 
required to be reported for the APM scoring standard would be the 
minimum number of quality measures that are required within the MIPS 
APM and are collected and available in time to be included in the 
calculation for the APM Entity score under the APM scoring standard. We 
propose that if an APM Entity submits some, but not all of the measures 
required by the MIPS APM by the close of the MIPS submission period, 
the APM Entity would receive points for the measures that were 
submitted, but would receive a score of zero for each remaining measure 
between the number of measures reported and the number of measures 
required by the APM that were available for scoring.
     We propose that the benchmark score used for a quality 
measure would be the benchmark used by the MIPS APM for calculation of 
the performance based payments within the APM, if possible, in order to 
best align the measure performance outcomes between the two programs. 
We are proposing that for measures that are pay for reporting or which 
do not measure performance on a continuum of performance, we will 
consider these measures to be lacking a benchmark and they will be 
treated as such.
     We propose to score quality measure performance under the 
APM scoring standard using a percentile distribution, separated by 
decile categories, as described in the finalized MIPS quality scoring 
methodology. We propose to use a graduated points-assignment approach, 
where a measure is assigned a continuum of points out to one decimal 
place, based on its place in the decile.
     We propose that each APM Entity that reports on quality 
measures would receive between 1 and 10 achievement points for each 
measure reported that can be reliably scored against a benchmark, up to 
the number of

[[Page 30091]]

measures that are required to be reported by the APM.
     We propose that APM Entities in MIPS APMs, like other MIPS 
eligible clinicians, would be eligible to receive bonus points for the 
MIPS quality performance category for reporting on high priority 
measures or measures submitted via CEHRT. For each Other MIPS APM, we 
propose to identify whether any of their available measures meets the 
criteria to receive a bonus, and add the bonus points to the quality 
achievement points.
     Beginning in the 2018 performance year, we propose to 
score improvement as well as achievement in the quality performance 
category. For the APM scoring standard, we propose that the improvement 
percentage points would be awarded based on the following formula:

Quality Improvement Score = (Absolute Improvement/Previous Year Quality 
Performance Category Percent Score Prior to Bonus Points)/10.

     We propose that the APM Entity's total quality performance 
category score would be equal to [(achievement points + bonus points)/
total available achievement points] + quality improvement score.
     Under the APM scoring standard, we propose that if a MIPS 
eligible clinician who qualifies for a zero percent weighting of the 
advancing care information performance category in the final score is 
part of a TIN that includes one or more MIPS eligible clinicians who do 
not qualify for a zero percent weighting, we would not apply the zero 
percent weighting to the qualifying MIPS eligible clinician, and the 
TIN would still be required to report on behalf of the group, although 
the TIN would not need to report data for the qualifying MIPS eligible 
clinician.
     We propose to maintain the cost performance category 
weight of zero for Other MIPS APMs under the APM scoring standard for 
the 2020 MIPS payment year and subsequent MIPS payment years. Because 
the cost performance category would be reweighted to zero that weight 
would need to be redistributed to other performance categories. We 
propose to align the Other MIPS APM performance category weights with 
those proposed for Web Interface reporters and weight the quality 
performance category to 50 percent, the improvement activities 
performance category to 20 percent, and the advancing care information 
performance category to 30 percent of the APM Entity final score.
     It is possible that none of the Other MIPS APM's measures 
would be available for calculating a quality performance category score 
by or shortly after the close of the MIPS submission period, for 
example, due to changes in clinical practice guidelines. In addition, 
the MIPS eligible clinicians in an APM Entity may qualify for a zero 
percent weighting for the advancing care information performance 
category. In such instances, under the APM scoring standard, we propose 
to reweight the affected performance category to zero.
     Beginning with the 2018 performance year, we propose that 
MIPS eligible clinicians whose MIPS payment adjustment is based on 
their score under the APM scoring standard will receive performance 
feedback as specified under section 1848(q)(12) of the Act for the 
quality, advancing care information, and improvement activities 
performance categories to the extent data are available for the MIPS 
performance year. Further, we propose that in cases where the MIPS APM 
performance category has been weighted to zero for that performance 
year, we would not provide performance feedback on that MIPS 
performance category.
    The following tables represent the measures being introduced for 
notice and comment, and would serve as the measure set used by 
participants in the identified MIPS APMs in order to create a MIPS 
score under the APM scoring standard, as described in section 
II.C.6.g.(3)(b)(ii)(A) of this proposed rule. Once this list is 
finalized, no measures may be added to this list.

                              Table 14--MIPS APM Measures List--Oncology Care Model
----------------------------------------------------------------------------------------------------------------
                                    NQF/Quality
          Measure name              number  (if      National quality    Measure description    Primary measure
                                    applicable)      strategy  domain                               steward
----------------------------------------------------------------------------------------------------------------
Risk-adjusted proportion of      NA...............  Effective          Percentage of OCM-      NA
 patients with all-cause                             Clinical Care.     attributed FFS
 hospital admissions within the                                         beneficiaries who
 6-month episode.                                                       were had an acute-
                                                                        care hospital stay
                                                                        during the
                                                                        measurement period.
Risk-adjusted proportion of      NA...............  Effective          Percentage of OCM-      .................
 patients with all-cause ED                          Clinical Care.     attributed FFS
 visits or observation stays                                            beneficiaries who had
 that did not result in a                                               an ER visit that did
 hospital admission within the                                          not result in a
 6-month episode.                                                       hospital stay during
                                                                        the measurement
                                                                        period.
Proportion of patients who died  NA...............  Effective          Percentage of OCM-      NA
 who were admitted to hospice                        Clinical Care.     attributed FFS
 for 3 days or more.                                                    beneficiaries who
                                                                        died and spent at
                                                                        least 3 days in
                                                                        hospice during the
                                                                        measurement time
                                                                        period.
Oncology: Medical and            0384/143.........  Person and         Percentage of patient   Physician
 Radiation--Pain Intensity                           Caregiver          visits, regardless of   Consortium for
 Quantified.                                         Centered           patient age, with a     Performance
                                                     Experience.        diagnosis of cancer     Improvement
                                                                        currently receiving     Foundations
                                                                        chemotherapy or         (PCPI).
                                                                        radiation therapy in
                                                                        which pain intensity
                                                                        is quantified.
Oncology: Medical and            0383/144.........  Person and         Percentage of visits    American Society
 Radiation--Plan of Care for                         Caregiver          for patients,           of Clinical
 Pain.                                               Centered           regardless of age,      Oncology.
                                                     Experience.        with a diagnosis of
                                                                        cancer currently
                                                                        receiving
                                                                        chemotherapy or
                                                                        radiation therapy who
                                                                        report having pain
                                                                        with a documented
                                                                        plan of care to
                                                                        address pain.
Preventive Care and Screening:   0418/134.........  Community/         Percentage of patients  Centers for
 Screening for Depression and                        Population         aged 12 and older       Medicare &
 Follow-Up Plan.                                     Health.            screened for            Medicaid
                                                                        depression on the       Services.
                                                                        date of the encounter
                                                                        using an age
                                                                        appropriate
                                                                        standardized
                                                                        depression screening
                                                                        tool AND if positive,
                                                                        a follow-up plan is
                                                                        documented on the
                                                                        date of the positive
                                                                        screen.

[[Page 30092]]

 
Patient-Reported Experience of   NA...............  Person and         Summary/Survey          NA
 Care.                                               Caregiver          Measures may include:
                                                     Centered          --Overall measure of
                                                     Experience.        patient experience.
                                                                       --Exchanging
                                                                        Information with
                                                                        Patients.
                                                                       --Access..............
                                                                       --Shared Decision
                                                                        Making.
                                                                       --Enabling Self-
                                                                        Management.
                                                                       --Affective
                                                                        Communication.
Prostate Cancer: Adjuvant        0390/104.........  Effective          Percentage of           American
 Hormonal Therapy for High or                        Clinical Care.     patients, regardless    Urological
 Very High Risk Prostate Cancer.                                        of age, with a          Association
                                                                        diagnosis of prostate   Education and
                                                                        cancer at high or       Research.
                                                                        very high risk of
                                                                        recurrence receiving
                                                                        external beam and
                                                                        radiotherapy to the
                                                                        prostate who were
                                                                        prescribed adjuvant
                                                                        hormonal therapy
                                                                        (GnRH [gonadotropin
                                                                        releasing hormone]
                                                                        agonist or
                                                                        antagonist).
Adjuvant chemotherapy is         0223.............  Communication and  Percentage of patients  Commission on
 recommended or administered                         Care               under the age of 80     Cancer, American
 within 4 months (120 days) of                       Coordination.      with AJCC III (lymph    College of
 diagnosis to patients under                                            node positive) colon    Surgeons.
 the age of 80 with AJCC III                                            cancer for whom
 (lymph node positive) colon                                            adjuvant chemotherapy
 cancer.                                                                is recommended and
                                                                        not received or
                                                                        administered within 4
                                                                        months (120 days) of
                                                                        diagnosis.
Combination chemotherapy is      0559.............  Communication and  Percentage of female    Commission on
 recommended or administered                         Care               patients, age >18 at    Cancer, American
 within 4 months (120 days) of                       Coordination.      diagnosis, who have     College of
 diagnosis for women under 70                                           their first diagnosis   Surgeons.
 with AJCC T1cN0M0, or Stage                                            of breast cancer
 IB--III hormone receptor                                               (epithelial
 negative breast cancer.                                                malignancy), at AJCC
                                                                        stage T1cN0M0 (tumor
                                                                        greater than 1 cm),
                                                                        or Stage IB--III,
                                                                        whose primary tumor
                                                                        is progesterone and
                                                                        estrogen receptor
                                                                        negative recommended
                                                                        for multiagent
                                                                        chemotherapy
                                                                        (recommended or
                                                                        administered) within
                                                                        4 months (120 days)
                                                                        of diagnosis.
Trastuzumab administered to      1858/450.........  Efficiency and     Proportion of female    American Society
 patients with AJCC stage I                          Cost Reduction.    patients (aged 18       of Clinical
 (T1c)--III and human epidermal                                         years and older) with   Oncology.
 growth factor receptor 2                                               AJCC stage I (Tlc)--
 (HER2) positive breast cancer                                          Ill, human epidermal
 who receive adjuvant                                                   growth factor
 chemotherapy.                                                          receptor 2 (HER2)
                                                                        positive breast
                                                                        cancer receiving
                                                                        adjuvant chemotherapy.
Breast Cancer: Hormonal Therapy  0387.............  Communication and  Percentage of female    AMA-convened
 for Stage I (T1b)--IIIC                             Care               patients aged 18        Physician
 Estrogen Receptor/Progesterone                      Coordination.      years and older with    Consortium for
 Receptor (ER/PR) Positive                                              Stage I (T1b) through   Performance
 Breast Cancer.                                                         IIIC, ER or PR          Improvement.
                                                                        positive breast
                                                                        cancer who were
                                                                        prescribed tamoxifen
                                                                        or aromatase
                                                                        inhibitor (AI) during
                                                                        the 12-month
                                                                        reporting period.
Documentation of Current         0419/130.........  Patient Safety...  Percentage of visits    Centers for
 Medications in the Medical                                             for patients aged 18    Medicare &
 Record.                                                                years and older for     Medicaid
                                                                        which the eligible      Services.
                                                                        clinician attests to
                                                                        documenting a list of
                                                                        current medications
                                                                        using all immediate
                                                                        resources available
                                                                        on the date of the
                                                                        encounter. This list
                                                                        must include ALL
                                                                        known prescriptions,
                                                                        over-the counters,
                                                                        herbals, and vitamin/
                                                                        mineral/dietary AND
                                                                        must contain the
                                                                        medications' name,
                                                                        dosage, frequency and
                                                                        route of
                                                                        administration.
----------------------------------------------------------------------------------------------------------------


                            Table 15--MIPS APM Measures List--Comprehensive ESRD Care
----------------------------------------------------------------------------------------------------------------
                                    NQF/Quality
          Measure name              number  (if      National quality    Measure description    Primary measure
                                    applicable)      strategy  domain                               steward
----------------------------------------------------------------------------------------------------------------
ESCO Standardized Mortality      0101/154.........  Patient Safety...  Falls: Risk             National
 Ratio.                                                                 Assessment:             Committee for
                                                                        Percentage of           Quality
                                                                        patients aged 65        Assurance.
                                                                        years and older with
                                                                        a history of falIs
                                                                        who had a risk
                                                                        assessment for falls
                                                                        completed within for
                                                                        Quality 12 months.
Falls: Screening, Risk           0101/154.........  Communication and  Falls: Risk             National
 Assessment and Plan of Care to                      Coordination.      Assessment:             Committee for
 Prevent Future Falls.                                                  Percentage of           Quality
                                                                        patients aged 65        Assurance.
                                                                        years and older with
                                                                        a history of falIs
                                                                        who had a risk
                                                                        assessment for falls
                                                                        completed within for
                                                                        Quality 12 months.
Advance Care Plan..............  0326/47..........  Patient Safety...  Percentage of patients  National
                                                                        aged 65 years and       Committee for
                                                                        older who have an       Quality
                                                                        advance care plan or    Assurance.
                                                                        surrogate decision
                                                                        maker documented in
                                                                        the medical record or
                                                                        documentation in the
                                                                        medical record that
                                                                        an advance care plan
                                                                        was discussed but the
                                                                        patient did not wish
                                                                        or was not able to
                                                                        name a surrogate
                                                                        decision maker or
                                                                        provide an advance
                                                                        care plan.

[[Page 30093]]

 
ICH-CAHPS: Nephrologists'        0258.............  Person and         Summary/Survey          Agency for
 Communication and Caring.                           Caregiver          Measures may include:   Healthcare
                                                     Centered          --Getting timely care,   Research and
                                                     Experience and     appointments, and       Quality.
                                                     Outcome.           information.
                                                                       --How well providers
                                                                        communicate.
                                                                       --Patients' rating of
                                                                        provider.
                                                                       --Access to
                                                                        specialists.
                                                                       --Health promotion and
                                                                        education.
                                                                       --Shared decision-
                                                                        making.
                                                                       --Health status and
                                                                        functional status.
                                                                       --Courteous and
                                                                        helpful office staff.
                                                                       --Care coordination...
                                                                       --Between visit
                                                                        communication.
                                                                       --Helping you to take
                                                                        medications as
                                                                        directed, and.
                                                                       --Stewardship of
                                                                        patient resources.
ICH-CAHPS: ICH-CAHPS: Rating of  0258.............  Person and         Comparison of services  Agency for
 Dialysis Center.                                    Caregiver          and quality of care     Healthcare
                                                     Centered           that dialysis           Research and
                                                     Experience and     facilities provide      Quality.
                                                     Outcome.           from the perspective
                                                                        of ESRD patients
                                                                        receiving in-center
                                                                        hemodialysis care.
                                                                        Patients will assess
                                                                        their dialysis
                                                                        providers, including
                                                                        nephrologists and
                                                                        medical and non-
                                                                        medical staff, the
                                                                        quality of dialysis
                                                                        care they receive,
                                                                        and information
                                                                        sharing about their
                                                                        disease.
ICH-CAHPS: Quality of Dialysis   0258.............  .................  Comparison of services  Agency for
 Center Care and Operations.                                            and quality of care     Healthcare
                                                                        that dialysis           Research and
                                                                        facilities provide      Quality.
                                                                        from the perspective
                                                                        of ESRD patients
                                                                        receiving in-center
                                                                        hemodialysis care.
                                                                        Patients will assess
                                                                        their dialysis
                                                                        providers, including
                                                                        nephrologists and
                                                                        medical and non-
                                                                        medical staff, the
                                                                        quality of dialysis
                                                                        care they receive,
                                                                        and information
                                                                        sharing about their
                                                                        disease.
ICH-CAHPS: Providing             0258.............  .................  Comparison of services  Agency for
 Information to Patients.                                               and quality of care     Healthcare
                                                                        that dialysis           Research and
                                                                        facilities provide      Quality.
                                                                        from the perspective
                                                                        of ESRD patients
                                                                        receiving in-center
                                                                        hemodialysis care.
                                                                        Patients will assess
                                                                        their dialysis
                                                                        providers, including
                                                                        nephrologists and
                                                                        medical and non-
                                                                        medical staff, the
                                                                        quality of dialysis
                                                                        care they receive,
                                                                        and information
                                                                        sharing about their
                                                                        disease.
ICH-CAHPS: Rating of Kidney      0258.............  .................  Comparison of services  Agency for
 Doctors.                                                               and quality of care     Healthcare
                                                                        that dialysis           Research and
                                                                        facilities provide      Quality.
                                                                        from the perspective
                                                                        of ESRD patients
                                                                        receiving in-center
                                                                        hemodialysis care.
                                                                        Patients will assess
                                                                        their dialysis
                                                                        providers, including
                                                                        nephrologists and
                                                                        medical and non-
                                                                        medical staff, the
                                                                        quality of dialysis
                                                                        care they receive,
                                                                        and information
                                                                        sharing about their
                                                                        disease.
ICH-CAHPS: Rating of Dialysis    0258.............  .................  Comparison of services  Agency for
 Center Staff.                                                          and quality of care     Healthcare
ICH-CAHPS: Rating of Dialysis                                           that dialysis           Research and
 Center.                                                                facilities provide      Quality.
                                                                        from the perspective
                                                                        of ESRD patients
                                                                        receiving in-center
                                                                        hemodialysis care.
                                                                        Patients will assess
                                                                        their dialysis
                                                                        providers, including
                                                                        nephrologists and
                                                                        medical and non-
                                                                        medical staff, the
                                                                        quality of dialysis
                                                                        care they receive,
                                                                        and information
                                                                        sharing about their
                                                                        disease.
Medication Reconciliation Post   0554.............  Communication and  The percentage of       National
 Discharge.                                          Care               discharges from any     Committee for
                                                     Coordination.      inpatient facility      Quality
                                                                        (e.g. hospital,         Assurance.
                                                                        skilled nursing
                                                                        facility, or
                                                                        rehabilitation
                                                                        facility) for
                                                                        patients 18 years of
                                                                        age and older seen
                                                                        within 30 days
                                                                        following the
                                                                        discharge in the
                                                                        office by the
                                                                        physicians,
                                                                        prescribing
                                                                        practitioner,
                                                                        registered nurse, or
                                                                        clinical pharmacist
                                                                        providing on-going
                                                                        care for whom the
                                                                        discharge medication
                                                                        list was reconciled
                                                                        with the current
                                                                        medication list in
                                                                        the outpatient
                                                                        medical record. This
                                                                        measure is reported
                                                                        as three rates
                                                                        stratified by age
                                                                        group:
                                                                           Reporting
                                                                           Criteria 1: 18-64
                                                                           years of age.
                                                                           Reporting
                                                                           Criteria 2: 65
                                                                           years and older.
                                                                           Total
                                                                           Rate: All patients
                                                                           18 years of age
                                                                           and Older.
Diabetes Care: Eye Exam........  0055/117.........  Effective          Percentage of patients  National
                                                     Clinical Care.     18-75 years of age      Committee for
                                                                        with diabetes who had   Quality
                                                                        a retinal or dilated    Assurance.
                                                                        eye exam by an eye
                                                                        care professional
                                                                        during the
                                                                        measurement period or
                                                                        a negative retinal
                                                                        exam (no evidence of
                                                                        retinopathy) in the
                                                                        12 months prior to
                                                                        the measurement
                                                                        period.
Diabetes Care: Foot Exam.......  0056/163.........  Effective          Percentage of patients  National
                                                     Clinical Care.     18-75 years of age      Committee for
                                                                        with diabetes (type 1   Quality
                                                                        and type 2) who         Assurance.
                                                                        received a foot exam
                                                                        (visual inspection
                                                                        and sensory exam with
                                                                        mono filament and a
                                                                        pulse exam) during
                                                                        the previous
                                                                        measurement year.
Influenza Immunization for the   0041/110, 0226...  Community/         Percentage of patients  Kidney Care
 ESRD Population.                                    Population         aged 6 months and       Quality Alliance
                                                     Health.            older seen for a        (KCQA).
                                                                        visit between October
                                                                        1 and March 31 who
                                                                        received an influenza
                                                                        immunization OR who
                                                                        reported previous
                                                                        receipt of an
                                                                        influenza
                                                                        immunization.
Pneumococcal Vaccination Status  0043/111.........  Community/         Percentage of patients  National
                                                     Population         65 years of age and     Committee for
                                                     Health.            older who have ever     Quality
                                                                        received a              Assurance.
                                                                        pneumococcal vaccine.

[[Page 30094]]

 
Screening for Clinical           0418/134.........  Community/         Percentage of patients  Centers for
 Depression and Follow-Up Plan.                      Population         aged 12 and older       Medicare and
                                                     Health.            screened for            Medicaid
                                                                        depression on the       Services.
                                                                        date of the encounter
                                                                        and using an age
                                                                        appropriate
                                                                        standardized
                                                                        depression screening
                                                                        tool AND if positive,
                                                                        a follow-up plan is
                                                                        documented on the
                                                                        date of the positive
                                                                        screen.
Tobacco Use: Screening and       0028/226.........  Community/         Percentage of patients  Physician
 Cessation Intervention.                             Population         aged 18 years and       Consortium for
                                                     Health.            older who were          Performance
                                                                        screened for tobacco    Improvement
                                                                        use one or more times   Foundations
                                                                        within 24 months AND    (PCPI).
                                                                        who received
                                                                        cessation counseling
                                                                        intervention if
                                                                        identified as a
                                                                        tobacco user.
----------------------------------------------------------------------------------------------------------------


                    Table 16--MIPS APM Measures List--Comprehensive Primary Care Plus (CPC+)
----------------------------------------------------------------------------------------------------------------
                                    NQF/Quality
          Measure name               number (if      National quality    Measure description    Primary measure
                                    applicable)      strategy  domain                               steward
----------------------------------------------------------------------------------------------------------------
Depression Remission at Twelve   0710/370.........  Effective          Patients age 18 and     Minnesota
 Months.                                             Clinical Care.     older with major        Community
                                                                        depression or           Measurement
                                                                        dysthymia and an
                                                                        initial Patient
                                                                        Health Questionnaire
                                                                        (PHQ-9) score greater
                                                                        than nine who
                                                                        demonstrate remission
                                                                        at twelve months (+/-
                                                                        30 days after an
                                                                        index visit) defined
                                                                        as a PHQ-9 score less
                                                                        than five. This
                                                                        measure applies to
                                                                        both patients with
                                                                        newly diagnosed and
                                                                        existing depression
                                                                        whose current PHQ-9
                                                                        score indicates a
                                                                        need for treatment.
Controlling High Blood Pressure  0018/236.........  Effective          Percentage of patients  National
                                                     Clinical Care.     18-85 years of age      Committee for
                                                                        who had a diagnosis     Quality
                                                                        of hypertension and     Assurance
                                                                        whose blood pressure
                                                                        was adequately
                                                                        controlled (<140/90
                                                                        mmHg) during the
                                                                        measurement period.
Diabetes: Eye Exam.............  0055/117.........  Effective          Percentage of patients  National
                                                     Clinical Care.     18-75 years of age      Committee for
                                                                        with diabetes who had   Quality
                                                                        a retinal or dilated    Assurance
                                                                        eye exam by an eye
                                                                        care professional
                                                                        during the
                                                                        measurement period or
                                                                        a negative retinal
                                                                        exam (no evidence of
                                                                        retinopathy) in the
                                                                        12 months prior to
                                                                        the measurement
                                                                        period.
Diabetes: Hemoglobin A1c         0059/001.........  Effective          Percentage of patients  National
 (HbA1c) Poor Control (>9%).                         Clinical Care.     18-75 years of age      Committee for
                                                                        with diabetes who had   Quality
                                                                        hemoglobin A1c >9.0%    Assurance
                                                                        during the
                                                                        measurement period.
Use of High-Risk Medications in  0022/238.........  Patient Safety...  Percentage of patients  National
 the Elderly.                                                           66 years of age and     Committee for
                                                                        older who were          Quality
                                                                        ordered high-risk       Assurance
                                                                        medications. Two
                                                                        rates are reported.
                                                                          a. Percentage of
                                                                           patients who were
                                                                           ordered at least
                                                                           one high-risk
                                                                           medication.
                                                                          b. Percentage of
                                                                           patients who were
                                                                           ordered at least
                                                                           two different high-
                                                                           risk medications.
Dementia: Cognitive Assessment.  NA/281...........  Effective          Percentage of           Physician
                                                     Clinical Care.     patients, regardless    Consortium for
                                                                        of age, with a          Performance
                                                                        diagnosis of dementia   Improvement
                                                                        for whom an             Foundation
                                                                        assessment of           (PCPI)
                                                                        cognition is
                                                                        performed and the
                                                                        results reviewed at
                                                                        least once within a
                                                                        12-month period.
Falls: Screening for Future      0101/318.........  Patient Safety...  Percentage of patients  National
 Fall Risk.                                                             65 years of age and     Committee for
                                                                        older who were          Quality
                                                                        screened for future     Assurance
                                                                        fall risk at least
                                                                        once during the
                                                                        measurement period.
Initiation and Engagement of     0004/305.........  Effective          Percentage of patients  National
 Alcohol and Other Drug                              Clinical Care.     13 years of age and     Committee for
 Dependence Treatment.                                                  older with a new        Quality
                                                                        episode of alcohol      Assurance
                                                                        and other drug (AOD)
                                                                        dependence who
                                                                        received the
                                                                        following. Two rates
                                                                        are reported.
                                                                       a. Percentage of
                                                                        patients who
                                                                        initiated treatment
                                                                        within 14 days of the
                                                                        diagnosis.
                                                                          b. Percentage of
                                                                           patients who
                                                                           initiated
                                                                           treatment and who
                                                                           had two or more
                                                                           additional
                                                                           services with an
                                                                           AOD diagnosis
                                                                           within 30 days of
                                                                           the initiation
                                                                           visit.
Closing the Referral Loop:       NA/374...........  Communication and  Percentage of Patients  Centers for
 Receipt of Specialist Report.                       Care               with referrals,         Medicare and
                                                     Coordination.      regardless of age,      Medicaid
                                                                        for which the           Services
                                                                        referring provider
                                                                        receives a report
                                                                        from the provider to
                                                                        whom the patient was
                                                                        referred.
Cervical Cancer Screening......  0032/309.........  Effective          Percentage of women 21- National
                                                     Clinical Care.     64 years of age, who    Committee for
                                                                        were screened for       Quality
                                                                        cervical cancer using   Assurance
                                                                        either of the
                                                                        following criteria.
                                                                           Women age
                                                                           21-64 who had
                                                                           cervical cytology
                                                                           performed every 3
                                                                           years.
                                                                           Women age
                                                                           30-64 who had
                                                                           cervical cytology/
                                                                           human
                                                                           papillomavirus
                                                                           (HPV) co-testing
                                                                           performed every 5
                                                                           years.
Colorectal Cancer Screening....  0034/113.........  Effective          Percentage of           National
                                                     Clinical Care.     patients, 50-75 years   Committee for
                                                                        of age who had          Quality
                                                                        appropriate screening   Assurance
                                                                        for colorectal cancer.
Preventive Care and Screening:   0028/226.........  Community/         Percentage of patients  Physician
 Tobacco Use: Screening and                          Population         aged 18 years and       Consortium for
 Cessation Intervention.                             Health.            older who were          Performance
                                                                        screened for tobacco    Improvement
                                                                        use one or more times   Foundations
                                                                        within 24 months AND    (PCPI)
                                                                        who received
                                                                        cessation counseling
                                                                        intervention if
                                                                        identified as a
                                                                        tobacco user.

[[Page 30095]]

 
Breast Cancer Screening........  2372/112.........  Effective          Percentage of women 50- National
                                                     Clinical Care.     74 years of age who     Committee for
                                                                        had a mammogram to      Quality
                                                                        screen for breast       Assurance
                                                                        cancer.
Preventive Care and Screening:   0041/110.........  Community/         Percentage of patients  PCPI(R)
 Influenza Immunization.                             Population         aged 6 months and       Foundation
                                                     Health.            older seen for a        (PCPI[R])
                                                                        visit between October
                                                                        1 and March 31 who
                                                                        received an influenza
                                                                        immunization OR who
                                                                        reported previous
                                                                        receipt of an
                                                                        influenza
                                                                        immunization.
Pneumonia Vaccination Status     0043/111.........  Community/         Percentage of patients  National
 for Older Adults.                                   Population         65 years of age and     Committee for
                                                     Health.            older who have ever     Quality
                                                                        received a              Assurance
                                                                        pneumococcal vaccine.
Diabetes: Medical Attention for  0062/119.........  Effective          The percentage of       National
 Nephropathy.                                        Clinical Care.     patients 18-75 years    Committee for
                                                                        of age with diabetes    Quality
                                                                        who had a nephropathy   Assurance
                                                                        screening test or
                                                                        evidence of
                                                                        nephropathy during
                                                                        the measurement
                                                                        period.
Ischemic Vascular Disease        0068/204.........  Effective          Percentage of patients  National
 (IVD): Use of Aspirin or                            Clinical Care.     18 years of age and     Committee
 Another.                                                               older who were          Quality
                                                                        diagnosed with acute    Assurance
                                                                        myocardial infarction
                                                                        (AMI), coronary
                                                                        artery bypass graft
                                                                        (CABG) or
                                                                        percutaneous coronary
                                                                        interventions (PCI)
                                                                        in the 12 months
                                                                        prior to the
                                                                        measurement period,
                                                                        or who had an active
                                                                        diagnosis of ischemic
                                                                        vascular disease
                                                                        (IVD) during the
                                                                        measurement period,
                                                                        and who had
                                                                        documentation of use
                                                                        of aspirin or another
                                                                        antiplatelet during
                                                                        the measurement
                                                                        period.
Hypertension: Improvement in     NA/373...........  Effective          Percentage of patients  Centers for
 Blood Pressure.                                     Clinical Care.     aged 18-85 years of     Medicare &
                                                                        age with a diagnosis    Medicaid
                                                                        of hypertension whose   Services (CMS)
                                                                        blood pressure
                                                                        improved during the
                                                                        measurement period.
Preventive Care and Screening:   0418/134.........  Community/         Percentage of patients  Centers for
 Screening for Depression and                        Population         aged 12 years and       Medicare &
 Follow-Up Plan.                                     Health.            older screened for      Medicaid
                                                                        depression on the       Services (CMS)
                                                                        date of the encounter
                                                                        using an age
                                                                        appropriate
                                                                        standardized
                                                                        depression screening
                                                                        tool AND if positive,
                                                                        a follow-up plan is
                                                                        documented on the
                                                                        date of the positive
                                                                        screen.
Diabetes: Foot Exam............  0056/163.........  Effective          The percentage of       National
                                                     Clinical Care.     patients 18-75 years    Committee for
                                                                        of age with diabetes    Quality
                                                                        (type 1 and type 2)     Assurance
                                                                        who received a foot
                                                                        exam (visual
                                                                        inspection and
                                                                        sensory exam with
                                                                        mono filament and a
                                                                        pulse exam) during
                                                                        the measurement year.
Statin Therapy for the           NA/438...........  Not provided in    Percentage of the       Quality Insights
 Prevention and Treatment of                         the measure.       following patients--
 Cardiovascular Disease.                                                all considered at
                                                                        high risk of
                                                                        cardiovascular
                                                                        events--who were
                                                                        prescribed or were on
                                                                        statin therapy during
                                                                        the measurement
                                                                        period:
                                                                       * Adults aged >=21
                                                                        years who were
                                                                        previously diagnosed
                                                                        with or currently
                                                                        have an active
                                                                        diagnosis of clinical
                                                                        atherosclerotic
                                                                        cardiovascular
                                                                        disease (ASCVD); OR.
                                                                       * Adults aged >=21
                                                                        years who have ever
                                                                        had a fasting or
                                                                        direct low-density
                                                                        lipoprotein
                                                                        cholesterol (LDL-C)
                                                                        level >=190 mg/dL or
                                                                        were previously
                                                                        diagnosed with or
                                                                        currently have an
                                                                        active diagnosis of
                                                                        familial or pure
                                                                        hypercholesterolemia;
                                                                        OR
                                                                          * Adults aged 40-75
                                                                           years with a
                                                                           diagnosis of
                                                                           diabetes with a
                                                                           fasting or direct
                                                                           LDL-C level of 70-
                                                                           189 mg/dL.
Inpatient Hospital Utilization   NA...............  .................  For members 18 years    National
 (IHU).                                                                 of age and older, the   Committee for
                                                                        risk-adjusted ratio     Quality
                                                                        of observed to          Assurance
                                                                        expected acute
                                                                        inpatient discharges
                                                                        during the
                                                                        measurement year
                                                                        reported by Surgery,
                                                                        Medicine, and Total.
Emergency Department             NA...............  .................  For members 18 years    National
 Utilization (EDU).                                                     of age and older, the   Committee for
                                                                        risk-adjusted ratio     Quality
                                                                        of observed to          Assurance
                                                                        expected emergency
                                                                        department (ED)
                                                                        visits during the
                                                                        measurement year.
Preventive Care and Screening:   0421.............  Community/         Percentage of patients  Centers for
 Body Mass Index (BMI)                               Population         aged 18 years and       Medicare &
 Screening and Follow-Up Plan.                       Health.            older with a BMI        Medicaid
                                                                        documented during the   Services (CMS)
                                                                        current encounter or
                                                                        during the previous
                                                                        six months AND with a
                                                                        BMI outside of normal
                                                                        parameters, a follow-
                                                                        up plan is documented
                                                                        during the encounter
                                                                        or during the
                                                                        previous six months
                                                                        of the current
                                                                        encounter. Normal
                                                                        Parameters: Age 18
                                                                        years and older BMI
                                                                        [gteqt]18.5 and <25
                                                                        kg/m2.
CAHPS..........................  CPC+ specific;     .................  CG-CAHPS Survey 3.0...  AHRQ
                                  different than
                                  CAHPS for MIPS.
----------------------------------------------------------------------------------------------------------------

7. MIPS Final Score Methodology
    For the 2020 MIPS payment year, we intend to build on the scoring 
methodology we finalized for the transition year, which allows for 
accountability and alignment across the performance categories and 
minimizes burden on MIPS eligible clinicians, while continuing to 
prepare MIPS eligible clinicians for the performance threshold required 
for the 2021 MIPS payment year. Our rationale for our scoring 
methodology continues to be grounded in the understanding that the MIPS 
scoring system has many components and numerous moving parts.
    As we continue to move forward in implementing the MIPS program, we 
strive to balance the statutory requirements and programmatic goals

[[Page 30096]]

with the ease of use, stability, and meaningfulness for MIPS eligible 
clinicians, while also emphasizing simplicity and scoring that is 
understandable for MIPS eligible clinicians. In this section, we 
propose refinements to the performance standards, the methodology for 
determining a score for each of the four performance categories (the 
``performance category score''), and the methodology for determining a 
final score based on the performance category scores.
    We intend to continue the transition of MIPS by proposing the 
following policies:
     Continuation of many transition year scoring policies in 
the quality performance category, with an adjustment to the number of 
achievement points available for measures that fail to meet the data 
completeness criteria, to encourage MIPS eligible clinician to meet 
data completeness while providing an exception for small practices;
     An improvement scoring methodology that rewards MIPS 
eligible clinicians who improve their performance in the quality and 
cost performance categories;
     A new scoring option for the quality and cost performance 
categories that allows facility-based MIPS eligible clinicians to be 
scored based on their facility's performance;
     Special considerations for MIPS eligible clinicians in 
small practices or those who care for complex patients; and
     Policies that allow multiple pathways for MIPS eligible 
clinicians to receive a neutral to positive MIPS payment adjustment.
    We believe these sets of proposed policies will help clinicians 
smoothly transition from the transition year to the 2021 MIPS payment 
year, for which the performance threshold (which represents the final 
score that would earn a neutral MIPS adjustment) will be either the 
mean or median (as selected by the Secretary) of the MIPS final scores 
for all MIPS eligible clinicians from a previous period specified by 
the Secretary.
    Unless otherwise noted, for purposes of this section II.C.7. on 
scoring, the term ``MIPS eligible clinician'' will refer to MIPS 
eligible clinicians that submit data and are scored at either the 
individual- or group-level, including virtual groups, but will not 
refer to MIPS eligible clinicians who elect facility-based scoring. The 
scoring rules for facility-based measurement are discussed in section 
II.C.7.a.(4). of this proposed rule. We also note that the APM scoring 
standard applies to APM Entities in MIPS APMs, and those policies take 
precedence where applicable; however, where those policies do not 
apply, scoring for MIPS eligible clinicians as described in this 
section II.C.7. on scoring will apply. We refer readers to section 
II.C.6.g. of this proposed rule for additional information about the 
APM scoring standard.
a. Converting Measures and Activities Into Performance Category Scores
(1) Policies That Apply Across Multiple Performance Categories
    The detailed policies and proposals for scoring the four 
performance categories are described in detail in section II.C.7.a. of 
this proposed rule. However, as the four performance categories 
collectively create a single MIPS final score, there are several 
policies that apply across categories, which we discuss in section 
II.C.7.a.(1) of this proposed rule.
(a) Performance Standards
    In accordance with section 1848(q)(3) of the Act, in the CY 2017 
Quality Payment Program final rule, we finalized performance standards 
for the four performance categories. We refer readers to the CY 2017 
Quality Payment Program final rule for a description of the performance 
standards against which measures and activities in the four performance 
categories are scored (81 FR 77271 through 77272).
    As discussed in section II.C.7.a.(1)(b)(i) of this proposed rule, 
we are proposing to add an improvement scoring standard to the quality 
and cost performance categories starting for the 2020 MIPS payment 
year.
(b) Policies Related to Scoring Improvement
(i) Background
    In accordance with section 1848(q)(5)(D)(i) of the Act, beginning 
with the 2020 MIPS payment year, if data sufficient to measure 
improvement are available, the final score methodology shall take into 
account improvement of the MIPS eligible clinician in calculating the 
performance score for the quality and cost performance categories and 
may take into account improvement for the improvement activities and 
advancing care information performance categories. In addition, section 
1848(q)(3)(B) of the Act provides that the Secretary, in establishing 
performance standards for measures and activities for the MIPS 
performance categories, shall consider: Historical performance 
standards; improvement; and the opportunity for continued improvement. 
Section 1848(q)(5)(D)(ii) of the Act also provides that achievement may 
be weighted higher than improvement.
    In the CY 2017 Quality Payment Program final rule, we summarized 
public comments received on the proposed rule regarding potential ways 
to incorporate improvement into the scoring methodology moving forward, 
including approaches based on methodologies used in the Hospital VBP 
Program, the Shared Savings Program, and Medicare Advantage 5-star 
Ratings Program (81 FR 77306 through 77308). We did not finalize a 
policy at that time on this topic and indicated we would take comments 
into account in developing a proposal for future rulemaking.
    When considering the applicability of these programs to MIPS, we 
looked at the approach that was used to measure improvement for each of 
the programs and how improvement was incorporated into the overall 
scoring system. An approach that focuses on measure-level comparison 
enables a more granular assessment of improvement because performance 
on a specific measure can be considered and compared from year to year. 
All options that we considered last year use a standard set of measures 
that do not provide for choice of measures to assess performance; 
therefore, they are better structured to compare changes in performance 
based on the same measure from year to year. The aforementioned 
programs do not use a category-level approach; however, we believe that 
a category-level approach would provide a broader perspective, 
particularly in the absence of a standard set of measures, because it 
would allow for a more flexible approach that enables MIPS eligible 
clinicians to select measures and data submission mechanisms that can 
change from year to year and be more appropriate to their practice in a 
given year.
    We believe that both approaches are viable options for measuring 
improvement. Accordingly, we believe that an appropriate approach for 
measuring improvement for the quality performance category and the cost 
performance category should consider the unique characteristics of each 
performance category rather than necessarily applying a uniform 
approach across both performance categories. For the quality 
performance category, clinicians are offered a variety of different 
measures which can be submitted by different mechanisms, rather than a 
standard set of measures or a single data submission mechanism.

[[Page 30097]]

For the cost performance category, however, clinicians are scored on 
the same set of cost measures to the extent each measure is applicable 
and available to them; clinicians cannot choose which cost measures 
they will be scored on. In addition, all of the cost measures are 
derived from administrative claims data with no additional submission 
required by the clinician.
    When considering the applicability of these programs to MIPS, we 
also considered how scoring improvement is incorporated into the 
overall scoring system, including when only achievement or improvement 
is incorporated into a final score or when improvement and achievement 
are both incorporated into a final score.
    We considered whether we could adapt the Hospital VBP Program's 
general approach for assessing improvement to MIPS and note that many 
commenters, in response to the CY 2017 Quality Payment Program proposed 
rule, recommended this methodology for MIPS because it is familiar to 
the health care community. However, we decided that the Hospital VBP 
Program's improvement scoring methodology, which compares changes in 
performance based on the same measure from year to year, is not fully 
translatable to MIPS for the quality performance category and the cost 
performance category. The scoring methodology used to assess 
achievement in the Hospital VBP Program, as required by section 
1886(o)(5)(B)(ii) of the Act, does not reward points for achievement in 
the same method as MIPS, because hospitals that fall below the 
achievement threshold (the median performance during the benchmark 
period) are not awarded achievement points. We refer readers to the 
Hospital Inpatient VBP Program Final Rule (76 FR 26516 through 26525) 
for additional discussion of the Hospital VBP Program's scoring 
methodology. In addition, the Hospital VBP Program requires the use of 
either the achievement score or the improvement points, but not both, 
for the Program's performance scoring calculation. Adopting the 
Hospital VBP Program method for MIPS would require significant changes 
to the scoring methodology used for the quality and cost performance 
categories. For the quality performance category, there are a wide 
variety of measures available in MIPS, and clinicians have flexibility 
in selecting measures and submission mechanisms, with the potential for 
clinicians to select different measures from year to year, which would 
affect our ability to capture performance changes at the measure level.
    We continue to believe that flexibility for clinicians to select 
meaningful measures is appropriate for MIPS, especially for the quality 
performance category. The Hospital VBP Program methodology, which 
relies on consistent measures from year to year in order to track 
improvement, would limit our ability to measure improvement in MIPS.
    We also considered adopting the Shared Savings Program's approach 
for assessing improvement, where participants can receive bonus points 
for improving on quality measures over time. The Shared Savings Program 
methodology could be adopted without an underlying change to the 
scoring of achievement in the quality and cost performance categories 
with an approach that considers both achievement and improvement in its 
overall scoring calculation and would align MIPS and the Shared Savings 
Program. However, we believe that the Shared Savings Program's 
improvement methodology would not be appropriate for the MIPS quality 
performance category because we are again concerned about the wide 
variety of quality measures available in MIPS and the flexibility 
clinicians have in selecting measures and submission mechanisms that 
could affect our ability to capture performance changes at the measure 
level. We seek to balance a system that allows for meaningful 
measurement to clinicians and accommodates the various practice types 
by allowing for a choice of measures and submission mechanisms that may 
differ from year to year for the quality performance category. However, 
as we discuss in section II.C.7.a.(3)(a) of this proposed rule, we do 
believe the Shared Savings Program measure level methodology could be 
translated for cost measures in the cost performance category.
    Finally, we also considered adopting the Medicare Advantage 
Program's 5-Star Rating approach for assessing improvement, where 
Medicare Advantage contracts are rated on quality and performance 
measures. Under this approach, we would identify an overall 
``improvement measure score'' by comparing the underlying numeric data 
for measures from the prior year with the data from measures for the 
performance period. To obtain an ``improvement measure score'' MIPS 
eligible clinicians would need to have data for both years in at least 
half of the required measures for the quality performance category (81 
FR 77307). We are again concerned that the wide variety of measures 
available in MIPS and the flexibility clinicians have in selecting 
different measures and submission mechanisms from year to year could 
affect our ability to capture performance changes at the measure level, 
particularly for the quality performance category. Accordingly, we do 
not believe this is an appropriate approach for the quality performance 
category. Although this approach could be considered for the cost 
performance category, we believe that the Shared Savings Program is 
more analogous to MIPS and that the improvement methodology used in 
that program is one with which more stakeholders in MIPS would be 
familiar.
    After taking all of this into consideration, we are proposing two 
different approaches for scoring improvement from year to year. As 
described in section II.C.7.a.(2)(i)(i) of this proposed rule, we are 
proposing to measure improvement at the performance category level for 
the quality performance category score. Because clinicians can elect 
the submission mechanisms and quality measures that are most meaningful 
to their practice, and these choices can change from year to year, we 
want a flexible methodology that allows for improvement scoring even 
when the quality measures change. This is particularly important as we 
encourage MIPS eligible clinicians to move away from topped out 
measures and toward more outcome measures. We do not want the 
flexibility that is offered to MIPS eligible clinicians in the quality 
performance category to limit clinicians' ability to move towards 
outcome measures, or limit our ability to measure improvement. Our 
proposal for taking improvement into account as part of the quality 
performance category score is addressed in detail in sections 
II.C.7.a.(2)(i) through II.C.7.a.(2)(j) of this proposed rule.
    We believe that there is reason to adopt a different methodology 
for scoring improvement for the cost performance category from that 
used for the quality performance category. In contrast to the quality 
performance category, for the cost performance category, MIPS eligible 
clinicians do not have a choice in measures or submission mechanisms; 
rather, all MIPS eligible clinicians are assessed on all measures based 
on the availability and applicability of the measure to their practice, 
and all measures are derived from administrative claims data. 
Therefore, for the cost performance category, we propose in section 
II.C.7.a.(3)(a)(i) of this proposed rule to measure improvement at the 
measure

[[Page 30098]]

level. We also note, that while we are statutorily required to measure 
improvement for the cost performance category beginning with the second 
MIPS payment year if data sufficient to measure improvement is 
available, we are also proposing at II.C.6.d.(2) of this proposed rule 
to weight the cost performance category at zero percent for the 2018 
MIPS performance period/2020 MIPS payment year. Therefore, the 
improvement score for the cost performance category would not affect 
the MIPS final score for the 2018 MIPS performance period/2020 MIPS 
payment year and would be for informational purposes only.
    We are not proposing to score improvement in the improvement 
activities performance category or the advancing care information 
performance category at this time, though we may address improvement 
scoring for these performance categories in future rulemaking.
    We propose to amend Sec.  414.1380(a)(1)(i) to add that improvement 
scoring is available for performance in the quality performance 
category and for the cost performance category at Sec.  
414.1380(a)(1)(ii) beginning with the 2020 MIPS payment year.
    We invite public comment on our proposals to score improvement for 
the quality and cost performance categories starting with the 2020 MIPS 
payment year.
(ii) Data Sufficiency Standard To Measure Improvement
    Section 1848(q)(5)(D)(i) of the Act requires us to measure 
improvement for the quality and cost performance categories of MIPS if 
data sufficient to measure improvement are available, which we 
interpret to mean that we would measure improvement when we can 
identify data from a current performance period that can be compared to 
data from a prior performance period or data that compares performance 
from year to year. In section II.C.7.a.(2)(i)(ii) of this proposed 
rule, we propose for the quality performance category that we would 
measure improvement when data are available because there is a 
performance category score for the prior performance period. In section 
II.C.7.a.(3)(a)(i) of this proposed rule, we propose for the cost 
performance category that we would measure improvement when data are 
available which is when there is sufficient case volume to provide 
measurable data on measures in subsequent years with the same 
identifier. We refer readers to the noted sections for details on these 
proposals.
(c) Scoring Flexibility for ICD-10 Measure Specification Changes During 
the Performance Period
    The quality and cost performance categories rely on measures that 
use detailed measure specifications that include ICD-10-CM/PCS (``ICD-
10'') code sets. We annually issue new ICD-10 coding updates, which are 
effective from October 1, through September 30 (https://www.cms.gov/Medicare/Coding/ICD10/ICD10OmbudsmanandICD10CoordinationCenterICC.html). As part of this 
update, codes are added as well as removed from the ICD-10 code set.
    To provide scoring flexibility for MIPS eligible clinicians and 
groups for measures impacted by ICD-10 coding changes in the final 
quarter of the Quality Payment Program performance period--which may 
render the measures no longer comparable to the historical benchmark--
we propose at Sec.  414.1380(b)(1)(xviii) and Sec.  414.1320(c)(2) to 
provide that we will assess performance on measures considered 
significantly impacted by ICD-10 updates based only on the first 9 
months of the 12-month performance period (for example, January 1, 2018 
through September 30, 2018, for the 2018 MIPS performance period). We 
believe it would be appropriate to assess performance for significantly 
impacted measures based on the first 9 months of the performance 
period, rather than the full 12 months, because the indicated 
performance for the last quarter could be affected by the coding 
changes rather than actual differences in performance. Performance on 
measures that are not significantly impacted by changes to ICD-10 codes 
would continue to be assessed on the full 12-month performance period 
(January 1 through December 31).
    Any measure that relies on an ICD-10 code which is added, modified, 
or removed, such as in the measure numerator, denominator, exclusions, 
or exceptions, could have an impact on the indicated performance on the 
measure, although the impact may not always be significant. We propose 
an annual review process to analyze the measures that have a code 
impact and assess the subset of measures significantly impacted by ICD-
10 coding changes during the performance period. Depending on the data 
available, we anticipate that our determination as to whether a measure 
is significantly impacted by ICD-10 coding changes would include these 
factors: A more than 10 percent change in codes in the measure 
numerator, denominator, exclusions, and exceptions; guideline changes 
or new products or procedures reflected in ICD-10 code changes; and 
feedback on a measure received from measure developers and stewards. We 
considered an approach where we would consider any change in ICD-10 
coding to impact performance on a measure and thus only rely on the 
first 9 months of the 12-month performance period for such measures. 
However, we believe such an approach would be too broad and truncate 
measurement for too many measures where performance may not be 
significantly affected. We believe that our proposed approach ensures 
the measures on which individual MIPS eligible clinicians and groups 
will have their performance assessed are accurate for the performance 
period and are consistent with the benchmark set for the performance 
period.
    We propose to publish on the CMS Web site which measures are 
significantly impacted by ICD-10 coding changes and would require the 
9-month assessment. We propose to publish this information by October 
1st of the performance period if technically feasible, but by no later 
than the beginning of the data submission period, which is January 1, 
2019 for the 2018 performance period.
    We request comment on the proposal to address ICD-10 measures 
specification changes during the performance period by relying on the 
first 9 months of the 12-month performance period. We also request 
comment on potential alternate approaches to address measures that are 
significantly impacted due to ICD-10 changes during the performance 
period, including the factors we might use to determine whether a 
measure is significantly impacted.
(2) Scoring the Quality Performance Category for Data Submission via 
Claims, Data Submissions via EHR, Third Party Data Submission Options, 
CMS Web Interface, and Administrative Claims
    Many comments submitted in response to the CY 2017 Quality Payment 
Program final rule requested additional clarification on our finalized 
scoring methodology for the 2019 MIPS payment year. To provide further 
clarity to MIPS eligible clinicians about the transition year scoring 
policies, before describing our proposed scoring policies for the 2020 
MIPS payment year, we provide a summary of the scoring policies 
finalized in the CY 2017 Quality Payment Program final rule along with 
examples of how they apply under several scenarios.
    In the CY 2017 Quality Payment Program final rule (81 FR 77286 
through

[[Page 30099]]

77287), we finalized that the quality performance category would be 
scored by assigning achievement points to each submitted measure, which 
we refer to in this section of the proposed rule as ``measure 
achievement points'' and we propose to amend various paragraphs in 
Sec.  414.1380(b)(1) to use this term in place of ``achievement 
points''. MIPS eligible clinicians can also earn bonus points for 
certain measures (81 FR 77293 through 77294; 81 FR 77297 through 
77299), which we refer to as ``measure bonus points'', and we propose 
to amend Sec.  414.1380(b)(1)(xiii) (which we propose to redesignate as 
Sec.  414.1380(b)(1)(xiv) in this proposed rule),\7\ Sec.  
414.1380(b)(1)(xiv) (which we propose to redesignate as Sec.  
414.1380(b)(1)(xv) in this proposed rule), and Sec.  414.1380(b)(1)(xv) 
(which we propose to redesignate as Sec.  414.1380(b)(1)(xvii) in this 
proposed rule) to use this term in place of ``bonus points''. The 
measure achievement points assigned to each measure would be added with 
any measure bonus points and then divided by the total possible points 
(Sec.  414.1380(b)(1)(xv) (which we propose to redesignate as Sec.  
414.1380(b)(1)(xvii)). In this section of the proposed rule we refer to 
the total possible points as ``total available measure achievement 
points'', and we propose to amend Sec.  414.1380(b)(1)(xv) to use this 
term in place of ``total possible points''. We also propose to amend 
these terms in Sec.  414.1380(b)(1)(xiii)(D) (which we propose to 
redesignate as Sec.  414.1380(b)(1)(xiv)(D) in this proposed rule), and 
Sec.  414.1380(b)(1)(xiv) (which we propose to redesignate as Sec.  
414.1380(b)(1)(xv) in this proposed rule).
---------------------------------------------------------------------------

    \7\ In section II.C.7.a.(2)(c) of this proposed rule, we propose 
a new provision to be codified at Sec.  414.1380(b)(1)(xiii), and in 
section II.C.7.a.(2)(i) of this proposed rule, we propose a new 
provision to be codified at Sec.  414.1380(b)(1)(xvi). As a result, 
we propose as well that the remaining paragraphs be redesignated in 
order following the new provisions.
---------------------------------------------------------------------------

    This resulting quality performance category score is a fraction 
from zero to 1, which can be formatted as a percent; therefore, for 
this section, we will present the quality performance category score as 
a percent and refer to it as ``quality performance category percent 
score.'' We also propose to amend Sec.  414.1380(b)(1)(xv) (which we 
propose to redesignate as Sec.  414.1380(b)(1)(xvii) in this proposed 
rule) to use this term in place of ``quality performance category 
score''. Thus, the formula for the quality performance category percent 
score that we will use in this section is as follows:

(total measure achievement points + total measure bonus points)/total 
available measure achievement points = quality performance category 
percent score.

    In the CY 2017 Quality Payment Program final rule, we finalized 
that for the quality performance category, an individual MIPS eligible 
clinician or group that submits data on quality measures via EHR, QCDR, 
qualified registry, claims, or a CMS-approved survey vendor for the 
CAHPS for MIPS survey will be assigned measure achievement points for 6 
measures (1 outcome or, if an outcome measure is not available, other 
high priority measure and the next 5 highest scoring measures) as 
available and applicable, and will receive applicable measure bonus 
points for all measures submitted that meet the bonus criteria (81 FR 
77282 through 77301).
    In addition, for groups of 16 or more clinicians who meet the case 
minimum of 200, we will also automatically score the administrative 
claims-based all-cause hospital readmission measure as a seventh 
measure (81 FR 77287). For individual MIPS eligible clinicians and 
groups for whom the readmission measure does not apply, the denominator 
is generally 60 (10 available measure achievement points multiplied by 
6 available measures). For groups for whom the readmission measure 
applies, the denominator is generally 70 points.
    If we determined that a MIPS eligible clinician has fewer than 6 
measures available and applicable, we will score only the number of 
measures that are available and adjust the denominator accordingly to 
the total available measure achievement points (81 FR 77291). We refer 
readers to section II.C.7.a.(2)(e) of this proposed rule, for a 
description of the validation process to determine measure 
availability.
    For the 2019 MIPS payment year, a MIPS eligible clinician that 
submits quality measure data via claims, EHR, or third party data 
submission options (that is, QCDR, qualified registry, EHR, or CMS-
approved survey vendor for the CAHPS for MIPS survey), can earn between 
3 and 10 measure achievement points for quality measures submitted for 
the performance period of greater than or equal to 90 continuous days 
during CY 2017. A MIPS eligible clinician can earn measure bonus points 
(subject to a cap) if they submit additional high priority measures 
with a performance rate that is greater than zero, and that meet the 
case minimum and data completeness requirements, or submit a measure 
using an end-to-end electronic pathway. An individual MIPS eligible 
clinician that has 6 or more quality measures available and applicable 
will have 60 total available measure achievement points. For example, 
as shown in Table 17, if an individual MIPS eligible clinician submits 
7 measures, including one required outcome measure and 2 additional 
high priority measures, the MIPS eligible clinician will be assigned 
points based on achievement for the required outcome measure and the 
next 5 measures with the highest number of measure achievement points. 
In this example, the second high priority measure has the lowest number 
of measure achievement points and therefore is not included in the 
total measure achievement points calculated (81 FR 77300), but the MIPS 
eligible clinician will still receive a bonus point for submitting a 
high priority measure (81 FR 77291 through 77294). We note that in the 
CY 2017 Quality Payment Program proposed rule, we proposed that bonus 
points would be available for high priority measures that are not 
scored (not included in the top 6 measures for the quality performance 
category score) as long as the measure has the required case minimum, 
data completeness, and has a performance rate greater than zero, 
because we believed these qualities would allow us to include the 
measure in future benchmark development (81 FR 28255). Although we 
received public comments on this policy, responded to those comments, 
and reiterated this proposal in the CY 2017 Quality Payment Program 
final rule (81 FR 77292), we would like to clarify that our policy to 
assign measure bonus points for high priority measures, even if the 
measure's achievement points are not included in the total measure 
achievement points for calculating the quality performance category 
percent score, as long as the measure has the required case minimum, 
data completeness, and has a performance rate greater than zero, 
applies beginning with the transition year. We propose to amend Sec.  
414.1380(b)(1)(xiii)(A) (which we propose to redesignate as Sec.  
414.1380(b)(1)(xiv)(A)) to state that measure bonus points may be 
included in the calculation of the quality performance category percent 
score regardless of whether the measure is included in the calculation 
of the total measure achievement points. We also propose a technical 
correction to the second sentence of that paragraph to state that to 
qualify for measure bonus points, each measure must be reported with 
sufficient case volume to meet the required case minimum, meet the 
required data completeness criteria, and

[[Page 30100]]

not have a zero percent performance rate.

    Table 17--Example Calculation of the Quality Performance Category Percent Score for an Individual for the
                                                 Transition Year
----------------------------------------------------------------------------------------------------------------
                                                                             Total
                                                                           available
                                   Measure achievement   Measure bonus      measure       Performance category
                                          points           points *       achievement         percent score
                                                                            points
----------------------------------------------------------------------------------------------------------------
Measure 1 (Outcome--required)....  3..................             n/a              10  (measure achievement
Measure 2........................  6..................             n/a              10   points from 6 measures
                                                                                         + measure bonus points)/
                                                                                         total available measure
                                                                                         achievement points.
Measure 3........................  6..................             n/a              10
Measure 4........................  6..................             n/a              10
Measure 5........................  6..................             n/a              10
Measure 6 (High priority)........  4..................               1              10
Measure 7 (High priority)........  3 (not included for               1             n/a  ........................
                                    achievement).
                                  ------------------------------------------------------------------------------
    Total........................  31.................               2              60  (31+2)/60 = 55%
----------------------------------------------------------------------------------------------------------------
* Assumes the measures meet the required case minimum, data completeness, and has performance greater than zero.
  Assumes no bonus points for end-to-end electronic submission. This example does not apply to CMS Web Interface
  Reporters because individuals are not able to submit data via that mechanism.

    A group of 16 or more clinicians will also be automatically scored 
on the hospital readmission measure if they meet the case minimum. 
Table 18 illustrates an example of a group that submitted the 6 
required quality measures, including an additional high priority 
measure, and received 3 measure achievement points for each submitted 
measure and the all-cause readmission measure.

    Table 18--Example Calculation of the Quality Performance Category Percent Score for a Group of 16 or More
                       Clinicians, Non-CMS Web Interface Reporter for the Transition Year
----------------------------------------------------------------------------------------------------------------
                                                                          Total
                                         Measure                        available
                                       achievement    Measure bonus      measure         Performance category
                                         points         points *       achievement          percent score
                                                                         points
----------------------------------------------------------------------------------------------------------------
Measure 1 (Outcome--required)......               3             n/a              10  (measure achievement points
                                                                                      from 7 measures + measure
                                                                                      bonus points)/total
                                                                                      available measure
                                                                                      achievement points.
Measure 2 (High priority)..........               3               1              10
Measure 3..........................               3             n/a              10
Measure 4..........................               3             n/a              10
Measure 5..........................               3             n/a              10
Measure 6..........................               3             n/a              10
Measure 7--(readmission measure                   3             n/a              10
 with 200+ cases).
                                    ----------------------------------------------------------------------------
    Total..........................              21               1              70  (21+1)/70 = 31.4%
----------------------------------------------------------------------------------------------------------------
* Assumes the measures meet the required case minimum, data completeness, and has performance greater than zero.
  Assumes no bonus points for end-to-end electronic submission.

    In the CY 2017 Quality Payment Program final rule, we also 
finalized scoring policies specific to groups of 25 or more that submit 
their quality performance measures using the CMS Web Interface (81 FR 
77278 through 77306).
    Although we are not proposing to change the basic scoring system 
that we finalized in the CY 2017 Quality Payment Program final rule for 
the 2020 MIPS payment year, we are proposing several modifications to 
scoring the quality performance category, including adjusting scoring 
for measures that do not meet the data completeness criteria, adding a 
method for scoring measures submitted via multiple mechanisms, adding a 
method for scoring selected topped out measures, and adding a method 
for scoring improvement. We also note that in section II.C.7.a.(4) of 
this proposed rule, we are also proposing an additional option for 
facility-based scoring for the quality performance category.
(a) Quality Measure Benchmarks
    We are not proposing to change the policies on benchmarking 
finalized in the CY 2017 Quality Payment Program final rule and 
codified at paragraphs (b)(1)(i) through (iii) of Sec.  414.1380; 
however, we are proposing a technical correction to paragraphs (i) and 
(ii) to clarify that measure benchmark data are separated into decile 
categories based on percentile distribution, and that, other than using 
performance period data, performance period benchmarks are created in 
the same manner as historical benchmarks using decile categories based 
on a percentile distribution and that each benchmark must have a 
minimum of 20 individual clinicians or groups who reported on the 
measure meeting the data completeness requirement and case minimum case 
size criteria and performance greater than zero. We refer

[[Page 30101]]

readers to the discussion at 81 FR 77282 for more details on that 
policy.
    We note that in section II.C.2.c. of this proposed rule, we are 
proposing to increase the low-volume threshold which, because we 
include MIPS eligible clinicians and comparable APMs that meet our 
benchmark criteria in our measure benchmarks, could have an impact on 
our MIPS benchmarks, specifically by reducing the number of individual 
eligible clinicians and groups that meet the definition of a MIPS 
eligible clinician and contribute to our benchmarks. Therefore, we seek 
feedback on whether we should broaden the criteria for creating our 
MIPS benchmarks to include PQRS and any data from MIPS, including 
voluntary reporters, that meet our benchmark performance, case minimum 
and data completeness criteria when creating our benchmarks.
    In the CY 2017 Quality Payment Program final rule, we did not 
stratify benchmarks by practice characteristics, such as practice size, 
because we did not believe there was a compelling rationale for such an 
approach, and we believed that stratifying could have unintended 
negative consequences for the stability of the benchmarks, equity 
across practices, and quality of care for beneficiaries (81 FR 77282). 
However, we sought comment on any rationales for or against stratifying 
by practice size we may not have considered. We note that we do create 
separate benchmarks for each of the following submission mechanisms: 
EHR submission options; QCDR and qualified registry submission options; 
claims submission options; CMS Web Interface submission options; CMS-
approved survey vendor for CAHPS for MIPS submission options; and 
administrative claims submission options (for measures derived from 
claims data, such as the all-cause hospital readmission measure) (81 FR 
77282).
    Several commenters who responded to our solicitation of comment in 
the final rule supported stratifying measure benchmarks by practice 
size because the commenters believed it would help small practices, 
which have limited resources compared to larger practices, and because 
quality measures may have characteristics that are less favorable to 
small groups. One commenter recommended that we stratify by practice 
size during the 5 years in which technical assistance is available. One 
commenter recommended that we develop criteria for determining when a 
benchmark should be stratified by group size, and another commenter 
recommended if we do not stratify benchmarks by practice size, we 
adjust MIPS payment adjustments for practice size. Several commenters 
recommended that we stratify benchmarks beyond practice size and 
include adjustments for disease severity and socioeconomic status of 
patients, specialty or sub-specialty, geographic region, and/or site of 
service. One commenter specifically suggested that we use peer 
comparison groups when establishing measure benchmarks.
    After consideration of the comments we received, we are not 
proposing to change our policies related to stratifying benchmarks by 
practice size for the 2020 MIPS payment year. For many measures, the 
benchmarks may not need stratification as they are only meaningful to 
certain specialties and only expected to be submitted by those certain 
specialists. We would like to further clarify that in the majority of 
instances our current benchmarking approach only compares like 
clinicians to like clinicians. We continue to believe that stratifying 
by practice size could have unintended negative consequences for the 
stability of the benchmarks, equity across practices, and quality of 
care for beneficiaries. However, we seek comment on methods by which we 
could stratify benchmarks, while maintaining reliability and stability 
of the benchmarks, to use in developing future rulemaking for future 
performance and payment years. Specifically, we seek comment on methods 
for stratifying benchmarks by specialty or by place of service. We also 
request comment on specific criteria to consider for stratifying 
measures, such as how we should stratify submissions by multi-specialty 
practices or by practices that operate in multiple places of service.
(b) Assigning Points Based on Achievement
    In the CY 2017 Quality Payment Program final rule, we finalized at 
Sec.  414.1380(b)(1) that a MIPS quality measure must have a measure 
benchmark to be scored based on performance. MIPS quality measures that 
do not have a benchmark (for example, because fewer than 20 MIPS 
eligible clinicians or groups submitted data that met our criteria to 
create a reliable benchmark) will not be scored based on performance 
(81 FR 77286). We are not proposing any changes to this policy, but we 
are proposing a technical correction to the regulatory text at Sec.  
414.1380(b)(1) to delete the term ``MIPS'' before ``quality measure'' 
in third sentence of that paragraph and to delete the term MIPS before 
``quality measures'' in the fourth sentence of that paragraph because 
this policy applies to all quality measures, including the measures 
finalized for the MIPS program and the quality measures submitted 
through a QCDR that have been approved for MIPS.
    We are also not proposing to change the policies to score quality 
measure performance using a percentile distribution, separated by 
decile categories and assign partial points based on the percentile 
distribution finalized in the CY 2017 Quality Payment Program final 
rule and codified at paragraphs (b)(1)(ix), (x), and (xi) of Sec.  
414.1380; however, we propose a technical correction to paragraph (ix) 
to clarify that measures are scored against measure benchmarks. We 
refer readers to the discussion at 81 FR 77286 for more details on 
those policies.
    For illustration, Table 19 provides an example of assigning points 
for performance based on benchmarks using a percentile distribution, 
separated by decile categories. The example is of the benchmarks for 
Measure 130 Documentation of Current Medications in the Medical Record, 
which is based on our 2015 benchmark file for the 2017 MIPS performance 
period.

        Table 19--Example of Assigning Points for Performance Based on a Benchmark, Separated by Deciles
----------------------------------------------------------------------------------------------------------------
                                                          Measure ID #130 (documentation of current medications
                                                                         in the medical record) *
                                                        --------------------------------------------------------
                  Submission mechanism                         Claims
                                                            performance      EHR performance     Registry/QCDR
                                                             benchmark          benchmark          benchmark
----------------------------------------------------------------------------------------------------------------
Decile 1 or 2 (3 points)...............................             <96.11             <76.59             <61.27
Decile 3 (3.0-3.9 points)..............................        96.11-98.73        76.59-87.88        61.27-82.11
Decile 4 (4.0-4.9 points)..............................        98.74-99.64        87.89-92.73        82.12-91.71
Decile 5 (5.0-5.9 points)..............................        99.65-99.99        92.74-95.35        91.72-96.86

[[Page 30102]]

 
Decile 6 (6.0-6.9 points)..............................                 --       95.36 -97.08        96.87-99.30
Decile 7 (7.0-7.9 points)..............................                 --        97.09-98.27       99.31 -99.99
Decile 8 (8.0-8.9 points)..............................                 --        98.28-99.12                 --
Decile 9 (9.0-9.9 points)..............................                 --        99.13-99.75                 --
Decile 10 (10 points)..................................                100           >= 99.76                100
----------------------------------------------------------------------------------------------------------------
* Based on our historical benchmark file for the 2017 MIPS performance period.

    In Table 19, the cells with ``--'' represent where there is a 
cluster at the top of benchmark distribution. For example, for the 
claims benchmark, over 50 percent of the MIPS eligible clinicians 
submitting that measure had a performance rate of 100 percent based on 
2015 PQRS data. Because of the cluster, clinicians who are at the 6, 7, 
8, and 9th decile all would have performance rates of 100 percent and 
would all receive a score of 10 points, indicated by dashes for those 
deciles. Based on this clustered distribution, those clinicians with 
performance of 99.99 percent fall into decile 5 and receive points in 
the range from 5.0 to 5.9 points. For this measure, the benchmark for 
each submission mechanism is topped out.
    We note that for quality measures for which baseline period data is 
available, we will publish the numerical baseline period benchmarks 
with deciles prior to the start of the performance period (or as soon 
as possible thereafter) (81 FR 77282). For quality measures for which 
there is no comparable data from the baseline period, we will publish 
the numerical performance period benchmarks after the end of the 
performance period (81 FR 77282). We will also publish further 
explanation of how we calculate partial points at qpp.cms.gov.
(i) Floor for Scored Quality Measures
    For the 2017 MIPS performance period, we also finalized at Sec.  
414.1380(b)(1) a global 3-point floor for each scored quality measure, 
as well as for the hospital readmission measure (if applicable), such 
that MIPS eligible clinicians would receive between 3 and 10 measure 
achievement points for each submitted measure that can be reliably 
scored against a benchmark, which requires meeting the case minimum and 
data completeness requirements (81 FR 77286 through 77287). Likewise, 
for measures without a benchmark based on the baseline period, we 
stated that we would continue to assign between 3 and 10 measure 
achievement points for performance years after the first transition 
year because it would help to ensure that the MIPS eligible clinicians 
are protected from a poor performance score that they would not be able 
to anticipate (81 FR 77282; 81 FR 77287). For measures with benchmarks 
based on the baseline period, we stated the 3-point floor was for the 
transition year and that we would revisit the 3-point floor in future 
years (81 FR 77286 through 77287).
    For the 2018 MIPS performance period, we propose to again apply a 
3-point floor for each measure that can be reliably scored against a 
benchmark based on the baseline period, and to amend Sec.  
414.1380(b)(1) accordingly. We refer readers to section 
II.C.7.a.(2)(h)(ii) of this rule, for our proposal to score measures in 
the CMS Web Interface for the Quality Payment Program for which 
performance is below the 30th percentile. We will revisit the 3-point 
floor for such measures again in future rulemaking.
    We invite public comment on this proposal to again apply this 3-
point floor for quality measures that can be reliably scored against a 
baseline benchmark in the 2018 MIPS performance period.
(ii) Additional Policies for the CAHPS for MIPS Measure Score
    In the CY 2017 Quality Payment Program final rule, we finalized a 
policy for the CAHPS for MIPS measure, such that each Summary Survey 
Measure (SSM) will have an individual benchmark, that we will score 
each SSM individually and compare it against the benchmark to establish 
the number of points, and the CAHPS score will be the average number of 
points across SSMs (81 FR 77284).
    As described in section II.C.6.b.(3)(a)(iii) of this proposed rule, 
we are proposing to remove two SSMs from the CAHPS for MIPS survey, 
which would result in the collection of 10 SSMs in the CAHPS for MIPS 
survey. Eight of those 10 SSMs have had high reliability for scoring in 
prior years, or reliability is expected to improve for the revised 
version of the measure, and they also represent elements of patient 
experience for which we can measure the effect one practice has 
compared to other practices participating in MIPS. The ``Health Status 
and Functional Status'' SSM, however, assesses underlying 
characteristics of a group's patient population characteristics and is 
less of a reflection of patient experience of care with the group. 
Moreover, to the extent that health and functional status reflects 
experience with the practice, case-mix adjustment is not sufficient to 
separate how much of the score is due to patient experience versus due 
to aspects of the underlying health of patients. The ``Access to 
Specialists'' SSM has low reliability; historically it has had small 
sample sizes, and therefore, the majority of groups do not achieve 
adequate reliability, which means there is limited ability to 
distinguish between practices' performance.
    For these reasons, we propose not to score the ``Health Status and 
Functional Status'' SSM and the ``Access to Specialists'' SSM beginning 
with the 2018 MIPS performance period. Despite not being suitable for 
scoring, both SSMs provide important information about patient care. 
Qualitative work suggests that ``Access to Specialists'' is a critical 
issue for Medicare FFS beneficiaries. The survey is also a useful tool 
for assessing beneficiaries' self-reported health status and functional 
status, even if this measure is not used for scoring practices' care 
experiences. Therefore, we believe that continued collection of the 
data for these two SSMs is appropriate even though we do not propose to 
score them.
    Other than these two SSMs, we propose to score the remaining 8 SSMs 
because they have had high reliability for scoring in prior years, or 
reliability is expected to improve for the revised version of the 
measure, and they also

[[Page 30103]]

represent elements of patient experience for which we can measure the 
effect one practice has compared to other practices participating in 
MIPS. Table 20 summarizes the proposed SSMs included in the CAHPS for 
MIPS survey and illustrates application of our proposal to score only 8 
measures.

                                Table 20--Proposed SSM for CAHPS for MIPS Scoring
----------------------------------------------------------------------------------------------------------------
                                                         Proposed for inclusion in    Proposed for inclusion in
                Summary survey measure                  the CAHPS for MIPS survey?     CAHPS for MIPS scoring?
----------------------------------------------------------------------------------------------------------------
Getting Timely Care, Appointments, and Information...  Yes.........................  Yes.
How Well Providers Communicate.......................  Yes.........................  Yes.
Patient's Rating of Provider.........................  Yes.........................  Yes.
Health Promotion & Education.........................  Yes.........................  Yes.
Shared Decision Making...............................  Yes.........................  Yes.
Stewardship of Patient Resources.....................  Yes.........................  Yes.
Courteous and Helpful Office Staff...................  Yes.........................  Yes.
Care Coordination....................................  Yes.........................  Yes.
Health Status and Functional Status..................  Yes.........................  No.
Access to Specialists................................  Yes.........................  No.
----------------------------------------------------------------------------------------------------------------

    We invite comment on our proposal not to score the ``Health Status 
and Functional Status'' and ``Access to Specialists'' SSMs beginning 
with the 2018 MIPS performance period.
    We note that in section II.C.6.g.(3)(b)(i)(A) of this proposed 
rule, we are proposing to add the CAHPS for ACOs survey as an available 
measure for calculating the MIPS APM score for the Shared Savings 
Program and Next Generation ACO Model. We refer readers participating 
in ACOs to section II.C.6.g.(3)(b) of this proposed rule for the CAHPS 
for ACOs scoring methodology.
(c) Identifying and Assigning Measure Achievement Points for Topped Out 
Measures
    Section 1848(q)(3)(B) of the Act requires that, in establishing 
performance standards with respect to measures and activities, we 
consider, among other things, the opportunity for continued 
improvement. We finalized in the CY 2017 Quality Payment Program final 
rule that we would identify topped out process measures as those with a 
median performance rate of 95 percent or higher (81 FR 77286). For non-
process measures we finalized a topped out definition similar to the 
definition used in the Hospital VBP Program: Truncated Coefficient of 
Variation is less than 0.10 and the 75th and 90th percentiles are 
within 2 standard errors (81 FR 77286). When a measure is topped out, a 
large majority of clinicians submitting the measure performs at or very 
near the top of the distribution; therefore, there is little or no room 
for the majority of MIPS eligible clinicians who submit the measure to 
improve. We understand that every measure we have identified as topped 
out may offer room for improvement for some MIPS eligible clinicians; 
however, we believe asking clinicians to submit measures that we have 
identified as topped out and measures for which they already excel is 
an unnecessary burden that does not add value or improve beneficiary 
outcomes.
    Based on 2015 historic benchmark data,\8\ approximately 45 percent 
of the quality measure benchmarks currently meet the definition of 
topped out, with some submission mechanisms having a higher percent of 
topped out measures than others. Approximately 70 percent of claims 
measures are topped out, 10 percent of EHR measures are topped out, and 
45 percent of registry/QCDR measures are topped out.
---------------------------------------------------------------------------

    \8\ The topped out determination is calculated on historic 
performance data and the percentage of topped out measures may 
change when evaluated for the most applicable annual period.
---------------------------------------------------------------------------

    In the CY 2017 Quality Payment Program final rule, we finalized 
that for the 2019 MIPS payment year, we would score topped out quality 
measures in the same manner as other measures (81 FR 77286). We 
finalized that we would not modify the benchmark methodology for topped 
out measures for the first year that the measure has been identified as 
topped out, but that we would modify the benchmark methodology for 
topped out measures beginning with the 2020 MIPS payment year, provided 
that it is the second year the measure has been identified as topped 
out. As described in detail later in this section, we are proposing a 
phased in approach to apply special scoring to topped out measures, 
beginning with the 2018 MIPS performance period (2020 MIPS payment 
year), rather than modifying the benchmark methodology for topped out 
measures as indicated in the CY 2017 Quality Payment Program final 
rule.
    In the CY 2017 Quality Payment Program final rule, we sought 
comment on how topped out measures should be scored provided that it is 
the second year the measure has been identified as topped out (81 FR 
77286). We suggested three possible options: (1) Score the measures 
using a mid-cluster approach; (2) remove topped out measures; or (3) 
apply a flat percentage in building the benchmarks for topped out 
measures. Flat percentages assign points based directly on the 
percentage of performance rather than by a percentile distribution by 
decile. Flat-rate would provide high scores to virtually all clinicians 
submitting the measure because performance rates tend to be high. 
Cluster-based benchmarks for topped out measures are based on a 
percentile distribution, but because many submitters are clustered at 
the top of performance, there can be large drops in points assigned for 
relatively small differences in performance. The current top of the 
cluster approach can result in many clinicians receiving 10 points. A 
mid-cluster approach would limit the maximum number of points a topped 
out measure can achieve based on how clustered the score are, and could 
still result in large drops, although less than with the top of the 
cluster approach, in points assigned for relatively small differences 
in performance. We also noted in the CY 2017 Quality Payment Program 
final rule that we anticipate removing topped out measures over time 
and sought comment on what point in time we should remove topped out 
measures from MIPS (81 FR 77286). The comments and our proposed policy 
for removing topped out measures are described in section II.C.6.c.(2) 
of this proposed rule.
    In response to our request for comment in the CY 2017 Quality 
Payment Program final rule, a few

[[Page 30104]]

commenters believed that we should not score topped out measures 
differently from other measures because commenters believed changing 
the scoring could reduce quality, add complexity to the program, and 
reduce incentives to participate in MIPS. Several commenters 
recommended that if we do score topped out measures differently, we use 
flat percentages rather than cluster-based benchmarks, with a few 
commenters noting that using flat percentages could help ensure those 
with high performance on a measure are not penalized as low performers 
and another noting that allowing high scorers to earn maximum or near 
maximum points is similar to the approach in the Shared Savings 
Program. A few commenters recommended that we publish information about 
topped out and potentially topped out measures prior to the performance 
period to allow clinicians time to adjust their reporting strategies, 
with one commenter noting that improvement may be rewarded in addition 
to achievement. One commenter recommended pushing back the baseline 
performance period for identifying topped out measures to the 2018 MIPS 
performance period because in the transition year it is unclear how 
many eligible clinicians will be reporting at different times and for 
what period they will report.
    As described in section II.C.6.c.(2) of this proposed rule, we are 
proposing a lifecycle for topped out measures by which, after a measure 
benchmark is identified as topped out in the published benchmark for 2 
years, in the third consecutive year it is identified as topped out it 
will be considered for removal through notice-and-comment rulemaking or 
the QCDR approval process and may be removed from the benchmark list in 
the fourth year, subject to the phased in approach described in section 
II.C.6.c.(2) of this proposed rule.
    As part of the lifecycle for topped out measures, we also propose 
in this section II.C.7.a.(2)(c) of this proposed rule, a method to 
phase in special scoring for topped out measure benchmarks starting 
with the 2018 MIPS performance period, provided that is the second 
consecutive year the measure benchmark is identified as topped out in 
the benchmarks published for the performance period. This special 
scoring would not apply to measures in the CMS Web Interface, as 
explained later in this section. The phased-in approach described in 
this section represents our first step in methodically implementing 
special scoring for topped out measures.
    We are not proposing to remove topped out measures for the 2018 
MIPS performance period because we recognize that there are currently a 
large number of topped out measures and removing them may impact the 
ability of some MIPS eligible clinicians to submit 6 measures and may 
impact some specialties more than others. We note, however, that as 
described in section II.C.6.c.(2) of this proposed rule, we are 
proposing a timeline for removing topped out measures in future years. 
We believe this provides MIPS eligible clinicians the ability to 
anticipate and plan for the removal of specific topped out measures, 
while providing measure developers time to develop new measures.
    We note that because we create a separate benchmark for each 
submission mechanism available for a measure, a benchmark for one 
submission mechanism for the measure may be identified as topped out 
while another submission mechanism's benchmark may not be topped out. 
The topped out designation and special scoring apply only to the 
specific benchmark that is topped out, not necessarily every benchmark 
for a measure. For example, the benchmark for the claims submission 
mechanism may be topped out for a measure, but the benchmark for the 
EHR submission mechanisms for that same measure may not be topped out. 
In this case, the topped out scoring would only apply to measures 
submitted via the claims submission mechanism, which has the topped out 
benchmark. We also describe in section II.C.6.c.(2) of this proposed 
rule that, similarly, only the submission mechanism that is topped out 
for the measure would be removed.
    We propose to cap the score of topped out measures at 6 measure 
achievement points. We are proposing a 6-point cap for multiple 
reasons. First, we believe applying a cap to the current method of 
scoring a measure against a benchmark is a simple approach that can 
easily be predicted by clinicians. Second, the cap will create 
incentives for clinicians to submit other measures for which they can 
improve and earn future improvement points. Third, considering our 
proposed topped out measure lifecycle, we believe this cap would only 
be used for a few years and the simplicity of a cap on the current 
benchmarks would outweigh the cluster-based options or applying a cap 
on benchmarks based on flat-percentage, which are more complicated. The 
rationale for a 6-point cap is that 6 points is the median score for 
any measure as it represents the start of the 6th decile for 
performance and represents the spot between the bottom 5 deciles and 
start of the top 5 deciles.
    We believe this proposed capped scoring methodology will 
incentivize MIPS eligible clinicians to begin submitting non-topped out 
measures without performing below the median score. This methodology 
also would not impact scoring for those MIPS eligible clinicians that 
do not perform near the top of the measure and therefore have 
significant room to improve on the measure. We may also consider 
lowering the cap below 6 points in future years, especially if we 
remove the 3-point floor for performance in future years.
    We note that although we are proposing a new methodology for 
assigning measure achievement points for topped out measures, we are 
not changing the policy for awarding measure bonus points for topped 
out measures. Topped out measures will still be eligible for measure 
bonus points if they meet the required criteria. We refer readers to 
sections II.C.7.a.(2)(f) and II.C.7.a.(2)(g) of this proposed rule for 
more information about measure bonus points.
    We request comments on our proposal to score topped out measures 
differently by applying a 6-point cap, provided it is the second 
consecutive year the measure is identified as topped out. Specifically, 
we seek feedback on whether 6 points is the appropriate cap or whether 
we should consider another value. We also seek comment on other 
possible options for scoring topped out measures that would meet our 
policy goals to encourage clinicians to begin to submit measures that 
are not topped out while also providing stability for MIPS eligible 
clinicians.
    While we believe it is important to score topped out measures 
differently because they could have a disproportionate impact on the 
scores for certain MIPS eligible clinicians and topped out measures 
provide little room for improvement for the majority of MIPS eligible 
clinicians who submit them, we also recognize that numerous measure 
benchmarks are currently identified as topped out and special scoring 
for topped out measures could impact some specialties more than others. 
Therefore, we considered ways to phase in special scoring for topped 
out measures in a way that will begin to apply special scoring, but 
would not overwhelm any one specialty and would also provide additional 
time to evaluate the impact of topped out measures before implementing 
it for all topped out measures, while also beginning to encourage 
submission of measures that are not topped out.

[[Page 30105]]

    We believe the best way to accomplish this is by applying special 
topped out scoring to a select number of measures for the 2018 
performance period and to then apply the special topped out scoring to 
all topped out measures for the 2019 performance period, provided it is 
the second consecutive year the measure is topped out. We believe this 
approach allows us time to further evaluate the impact of topped out 
measures and allows for a methodical way to phase in topped out 
scoring.
    We identified measures we believe should be scored with the special 
topped out scoring for the 2018 performance period by using the 
following set criteria, which are only intended as a way to phase in 
our topped-out measure policy for selected measures and are not 
intended to be criteria for use in future policies:
     Measure is topped out and there is no difference in 
performance between decile 3 through decile 10. We applied this 
limitation because, based on historical data, there is no room for 
improvement for over 80 percent of MIPS eligible clinicians that 
reported on these measures.
     Process measures only because we want to continue to 
encourage reporting on high priority outcome measures, and the small 
subset of structure measures was confined to only three specialties.
     MIPS measures only (which does not include measures that 
can only be reported through a QCDR) given that QCDR measures go 
through a separate process for approval and because we want to 
encourage use of QCDRs required by section 1848(q)(1)(E) of the Act.
     Measure is topped out for all mechanisms by which the 
measure can be submitted. Because we create a separate benchmark for 
each submission mechanism available for a measure, a benchmark for one 
submission mechanism for the measure may be identified as topped out 
while another submission mechanism's benchmark may not be topped out. 
For example, the benchmark for the claims submission mechanism may be 
topped out for a measure, but the benchmark for the EHR submission 
mechanisms for that same measure may not be topped out. We decided to 
limit our criteria to only measures that were topped out for all 
measures for simplicity and to avoid confusion about what scoring is 
applied to a measure.
     Measure is in a specialty set with at least 10 measures, 
because 2 measures in the pathology specialty set, which only has 8 
measures total would have been included.
    Applying these criteria results in the 6 measures as listed in 
Table 21.

         Table 21--Topped Out Measures Proposed for Special Scoring for the 2018 MIPS Performance Period
----------------------------------------------------------------------------------------------------------------
                                                                       Topped out for all
         Measure name             Measure ID        Measure type           submission          Specialty set
                                                                           mechanisms
----------------------------------------------------------------------------------------------------------------
Perioperative Care: Selection               21  Process.............  Yes................  General Surgery,
 of Prophylactic Antibiotic--                                                               Orthopedic Surgery,
 First OR Second Generation                                                                 Otolaryngology,
 Cephalosporin.                                                                             Thoracic Surgery,
                                                                                            Plastic Surgery.
Melanoma: Overutilization of               224  Process.............  Yes................  Dermatology.
 Imaging Studies in Melanoma.
Perioperative Care: Venous                  23  Process.............  Yes................  General Surgery,
 Thromboembolism (VTE)                                                                      Orthopedic Surgery,
 Prophylaxis (When Indicated                                                                Otolaryngology,
 in ALL Patients).                                                                          Thoracic Surgery,
                                                                                            Plastic Surgery.
Image Confirmation of                      262  Process.............  Yes................  n/a.
 Successful Excision of Image--
 Localized Breast Lesion.
Optimizing Patient Exposure to             359  Process.............  Yes................  Diagnostic Radiology.
 Ionizing Radiation:
 Utilization of a Standardized
 Nomenclature for Computerized
 Tomography (CT) Imaging
 Description.
Chronic Obstructive Pulmonary               52  Process.............  Yes................  n/a.
 Disease (COPD): Inhaled
 Bronchodilator Therapy.
----------------------------------------------------------------------------------------------------------------

    We propose to apply the special topped out scoring method that we 
finalize for the 2018 performance period to only the 6 measures in 
Table 21 for the 2018 performance period, provided they are again 
identified as topped out in the benchmarks for the 2018 performance 
period. If these measures are not identified as topped out in the 
benchmarks published for the 2018 performance period, they will not be 
scored differently because they would not be topped out for a second 
consecutive year.
    We seek comment on our proposal to apply special topped out scoring 
only to the 6 measures identified in Table 21 for the 2018 performance 
period.
    Starting with the 2019 performance period, we propose to apply the 
special topped out scoring method to all topped out measures, provided 
it is the second (or more) consecutive year the measure is identified 
as topped out. We seek comment on our proposal to apply special topped 
out scoring to all topped out measures, provided it is the second (or 
more) consecutive year the measure is identified as topped out.
    We illustrate the lifecycle for scoring and removing topped out 
measures based on our proposals as follows:
     Year 1: Measure benchmarks are identified as topped out, 
which in this example would be in the benchmarks published for the 2017 
MIPS performance period.
     Year 2: Measure benchmarks are identified as topped out, 
which in this example would be in the benchmarks published for the 2018 
MIPS performance period. Measures identified in Table 21 have special 
scoring applied, provided they are identified as topped out for the 
2018 MIPS performance period, meaning it is the second consecutive year 
they are identified as topped out.
     Year 3: Measure benchmarks are identified as topped out in 
the benchmarks published for the 2019 MIPS performance period. All 
measure benchmarks identified as topped out for the second (or more) 
consecutive year have special scoring applied for the 2019 MIPS 
performance period. In Year 3 we would also consider removal of the 
select set of topped out measures identified in Table 21, through 
notice and comment rulemaking, provided they are identified as topped 
out during the previous two (or more) consecutive

[[Page 30106]]

years. In our example, Year 3 would be the 2019 performance period.
     Year 4: Measure benchmarks are identified as topped out in 
the benchmarks published for the 2020 MIPS performance period. Measure 
benchmarks identified as topped out for a second (or more) consecutive 
year continue to have special scoring applied. Topped out measures 
finalized for removal for the 2020 MIPS performance period are no 
longer available for reporting.
    An example of applying the proposed scoring cap compared to scoring 
applied for the 2017 MIPS performance period is provided in Table 22.

       Table 22--Proposed Scoring for Topped Out Measures* Starting in the CY 2018 MIPS Performance Period Compared to the Transition Year Scoring
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                                          Quality Cate-
        Scoring policy             Measure 1         Measure 2         Measure 3         Measure 4     Measure 5  (not  Measure 6  (not    gory Percent
                                 (topped out)      (topped out)      (topped out)      (topped out)      topped out)      topped out)        Score *
--------------------------------------------------------------------------------------------------------------------------------------------------------
2017 MIPS performance period   10 measure        10 measure        10 measure        4 measure         10 measure       5 measure        49/60 = 81.67%.
 Scoring.                       achievement       achievement       achievement       achievement       achievement      achievement
                                points.           points.           points.           points (did not   points.          points.
                                                                                      get max score).
Proposed Capped Scoring        6 measure         6 measure         6 measure         4 measure         10 measure       5 measure        37/60 = 61.67%.
 applied.                       achievement       achievement       achievement       achievement       achievement      achievement
                                points.           points.           points.           points.           points.          points.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Notes........................  Topped out measures scored with 6-point measure achievement point cap.
                                Cap does not impact score if the MIPS eligible clinician's score is
                                below the cap.
                               Still possible to earn maximum
                                measure achievement points on the
                                non-topped out measures.
--------------------------------------------------------------------------------------------------------------------------------------------------------
* This example would only apply to the 6 measures identified in Table 21 for the CY 2018 MIPS Performance Period. This example also excludes bonus
  points and improvement scoring proposed in section II.C.7.a.(2)(i) of this proposed rule.

    Together the proposed policies for phasing in capped scoring and 
removing topped out measures are intended to provide an incentive for 
MIPS eligible clinicians to begin to submit measures that are not 
topped out while also providing stability by allowing MIPS eligible 
clinicians who have few alternative measures to continue to receive 
standard scoring for most topped out measures for an additional year, 
and not perform below the median score for those 6 measures that 
receive special scoring. It also provides MIPS eligible clinicians the 
ability to anticipate and plan for the removal of specific topped out 
measures, while providing measure developers time to develop new 
measures.
    We propose to add a new paragraph at Sec.  414.1380(b)(1)(xiii) to 
codify our proposal for the lifecycle for removing topped out measures.
    We also propose to add at Sec.  414.1380(b)(1)(xiii)(A) that for 
the 2018 MIPS performance period, the 6 measures identified in Table 21 
will receive a maximum of 6 measure achievement points, provided that 
the measure benchmarks are identified as topped out again in the 
benchmarks published for the 2018 MIPS performance period. We also 
propose to add at Sec.  414.1380(b)(1)(xiii)(B) that beginning with the 
2019 MIPS performance period, measure benchmarks, except for measures 
in the CMS Web Interface, that are identified as topped out for two 2 
or more consecutive years will receive a maximum of 6 measure 
achievement points in the second consecutive year it is identified as 
topped out, and beyond. We specifically seek comment on whether the 
proposed policy to cap the score of topped out measures beginning with 
the 2019 performance period should apply to SSMs in the CAHPS for MIPS 
survey measure or whether there is another alternative policy that 
could be applied for the CAHPS for MIPS survey measure due to high, 
unvarying performance within the SSM. We note that we would like to 
encourage groups to report the CAHPS for MIPS survey as it incorporates 
beneficiary feedback.
    We stated in the CY 2017 Quality Payment Program final rule that we 
do not believe it would be appropriate to remove topped out measures 
from the CMS Web Interface for the Quality Payment Program because the 
CMS Web Interface measures are used in MIPS and in APMs such as the 
Shared Savings Program and because we have aligned policies, where 
possible, with the Shared Savings Program, such as using the Shared 
Savings Program benchmarks for the CMS Web Interface measures (81 FR 
77285). In the CY 2017 Quality Payment Program final rule, we also 
finalized that MIPS eligible clinicians submitting via the CMS Web 
Interface must submit all measures included in the CMS Web Interface 
(81 FR 77116). Thus, if a CMS Web Interface measure is topped out, the 
CMS Web Interface submitter cannot select other measures. Because of 
the lack of ability to select measures, we are not proposing to apply a 
special scoring adjustment to topped out measures for CMS Web Interface 
for the Quality Payment Program.
    Additionally, because the Shared Savings Program incorporates a 
methodology for measures with high performance into the benchmark, we 
do not believe capping benchmarks from the CMS Web Interface for the 
Quality Payment Program is appropriate. We finalized in the CY 2017 
Quality Payment Program final rule at Sec.  414.1380(b)(1)(ii)(A) to 
use benchmarks from the corresponding reporting year of the Shared 
Savings Program. The Shared Savings Program adjusts some benchmarks to 
a flat percentage when the 60th percentile is equal to or greater than 
80.00 percent for individual measures (78 FR 74759 through 74763), and, 
for other measures, benchmarks are set using flat percentages when the 
90th percentile for a measure are equal to or greater than 95.00 
percent (79 FR 67925). Thus, we are not proposing to apply the topped 
out measure cap to measures in the CMS Web Interface for the Quality 
Payment Program.
    We seek comment on this proposal not to apply the topped out 
measure cap to measures in the CMS Web Interface for the Quality 
Payment Program.
(d) Case Minimum Requirements and Measure Reliability and Validity
    To help ensure reliable measurement, in the CY 2017 Quality Payment 
Program final rule (81 FR 77288), we finalized a 20-case minimum for 
all quality measures except the all-cause hospital readmission measure. 
For the all-cause hospital readmission measure, we finalized in the CY 
2017 Quality Payment Program final rule a 200-case minimum and 
finalized to apply the all-cause hospital readmission measure only to 
groups of 16 or more clinicians that meet the 200-case minimum 
requirement (81 FR 77288).

[[Page 30107]]

    We are not proposing any changes to these policies.
    For the 2019 MIPS payment year, we finalized in the CY 2017 Quality 
Payment Program final rule that if the measure is submitted but is 
unable to be scored because it does not meet the required case minimum, 
does not have a benchmark, or does not meet the data completeness 
requirement, the measure would receive a score of 3 points (81 FR 77288 
through 77289). We identified two classes of measures for the 
transition year. Class \9\ 1 measures are measures that can be scored 
based on performance because they have a benchmark, meet the case 
minimum requirement, and meet the data completeness standard. We 
finalized that Class 1 measures would receive 3 to 10 points based on 
performance compared to the benchmark (81 FR 77289). Class 2 measures 
are measures that cannot be scored based on performance because they do 
not have a benchmark, do not have at least 20 cases, or the submitted 
measure does not meet data completeness criteria. We finalized that 
Class 2 measures, which do not include measures submitted with the CMS 
Web Interface or administrative claims-based measures, receive 3 points 
(81 FR 77289).
---------------------------------------------------------------------------

    \9\ References to ``Classes'' of measures in this section 
II.C.7.a.(2)(d) are intended only to characterize the measures for 
ease of discussion.
---------------------------------------------------------------------------

    We propose to maintain the policy to assign 3 points for measures 
that are submitted but do not meet the required case minimum or does 
not have a benchmark for the 2020 MIPS payment year and amend Sec.  
414.1380(b)(1)(vii) accordingly.
    We also propose a change to the policy for scoring measures that do 
not meet the data completeness requirement for the 2020 MIPS payment 
year.
    To encourage complete reporting, we are proposing that in the 2020 
MIPS payment year, measures that do not meet data completeness 
standards will receive 1 point instead of the 3 points that were 
awarded in the 2019 MIPS payment year. We propose lowering the point 
floor to 1 for measures that do not meet data completeness standards 
for several reasons. First, we want to encourage complete reporting 
because data completeness is needed to reliably measure quality. 
Second, unlike case minimum and availability of a benchmark, data 
completeness is within the direct control of the MIPS eligible 
clinician. In the future, we intend that measures that do not meet the 
completeness criteria will receive zero points; however, we believe 
that during the second year of transitioning to MIPS, clinicians should 
continue to receive at least 1 measure achievement point for any 
submitted measure, even if the measure does not meet the data 
completeness standards.
    We are concerned, however, that data completeness may be harder to 
achieve for small practices. For example, small practices tend to have 
small case volume and missing one or two cases could cause the MIPS 
eligible clinician to miss the data completeness standard as each case 
may represent multiple percentage points for data completeness. For 
example, for a small practice with only 20 cases for a measure, each 
case is worth 5 percentage points, and if they miss reporting just 11 
or more cases, they would fail to meet the data completeness threshold, 
whereas for a practice with 200 cases, each case is worth 0.5 
percentage points towards data completeness and the practice would have 
to miss more than 100 cases to fail to meet the data completeness 
criteria. Applying 1 point for missing data completeness based on 
missing a relatively small number of cases could disadvantage these 
clinicians, who may have additional burdens for reporting in MIPS, 
although we also recognize that failing to report on 10 or more 
patients is undesirable. In addition, we know that many small practices 
may have less experience with submitting quality performance category 
data and may not yet have systems in place to ensure they can meet the 
data completeness criteria. Thus, we are also proposing an exception to 
the proposed policy for measures submitted by small practices, as 
defined in Sec.  414.1305. We propose that these clinicians would 
continue to receive 3 points for measures that do not meet data 
completeness.
    Therefore, we propose to revise Class 2 measures to include only 
measures that cannot be scored based on performance because they do not 
have a benchmark or do not have at least 20 cases. We also propose to 
create Class 3 measures, which are measures that do not meet the data 
completeness requirement. We propose that the revised Class 2 measure 
would continue to receive 3 points. The proposed Class 3 measures would 
receive 1 point, except if the measure is submitted by a small practice 
in which case the Class 3 measure would receive 3 points. However, 
consistent with the policy finalized in the CY 2017 Quality Payment 
Program final rule, these policies for Class 2 and Class 3 measures 
would not apply to measures submitted with the CMS Web Interface or 
administrative claims-based measures. A summary of the proposals is 
provided in Table 23.

                  Table 23--Quality Performance Category: Scoring Measures Based on Performance
----------------------------------------------------------------------------------------------------------------
                                              Scoring rules in 2017   Description proposed    Proposed for 2018
     Measure type          Description in        MIPS performance        for 2018 MIPS        MIPS performance
                          transition year             period           performance period          period
----------------------------------------------------------------------------------------------------------------
Class 1..............  Measures that can be   3 to 10 points based   Same as transition     Same as transition
                        scored based on        on performance         year.                  year.
                        performance.           compared to the                              3 to 10 points based
                        Measures that were     benchmark.                                    on performance
                        submitted or                                                         compared to the
                        calculated that met                                                  benchmark.
                        the following
                        criteria:
                          (1) The measure
                           has a benchmark;.
                          (2) Has at least
                           20 cases; and.
                          (3) Meets the data
                           completeness
                           standard
                           (generally 50
                           percent.).

[[Page 30108]]

 
Class 2..............  Measures that cannot   3 points.............  Measures that were     3 points
                        be scored based on    * This Class 2          submitted and meet    *This Class 2
                        performance.           measure policy does    data completeness,     measure policy
                        Measures that were     not apply to CMS Web   but does not have      would not apply to
                        submitted, but fail    Interface measures     one or both of the     CMS Web Interface
                        to meet one of the     and administrative     following:             measures and
                        Class 1 criteria.      claims based          (1) a benchmark......   administrative
                        The measure either     measures.             (2) at least 20 cases   claims based
                                                                                             measures.
                          (1) does not have
                           a benchmark,.
                          (2) does not have
                           at least 20
                           cases, or.
                          (3) does not meet
                           data completeness
                           criteria..
Class 3..............  n/a..................  n/a..................  Measures that were     1 point except for
                                                                      submitted, but do      small practices,
                                                                      not meet data          which would receive
                                                                      completeness           3 points.
                                                                      criteria, regardless  *This Class 3
                                                                      of whether they have   measure policy
                                                                      a benchmark or meet    would not apply to
                                                                      the case minimum.      CMS Web Interface
                                                                                             measures and
                                                                                             administrative
                                                                                             claims based
                                                                                             measures.
----------------------------------------------------------------------------------------------------------------

    We propose to amend Sec.  414.1380(b)(1)(vii) to assign 3 points 
for measures that do not meet the case minimum or do not have a 
benchmark in the 2020 MIPS payment year, and to assign 1 point for 
measures that do not meet data completeness requirements, unless the 
measure is submitted by a small practice, in which case it would 
receive 3 points.
    We invite comment on our proposal to assign 1 point to measures 
that do not meet data completeness criteria, with an exception for 
measures submitted by small practices.
    We are not proposing to change the methodology we use to score 
measures submitted via the CMS Web Interface that do not meet the case 
minimum, do not have a benchmark, or do not meet the data completeness 
requirement finalized in the CY 2017 Quality Payment Program final rule 
and codified at paragraph (b)(1)(viii) of Sec.  414.1380. However, we 
note that as described in section II.C.7.a.(2)(h)(ii) of this proposed 
rule, we are proposing to add that CMS Web Interface measures with a 
benchmark that are redesignated from pay for performance to pay for 
reporting by the Shared Savings Program will not be scored. We refer 
readers to the discussion at 81 FR 77288 for more details on our 
previously finalized policy.
    We are also not proposing any changes to the policy to not include 
administrative claims measures in the quality performance category 
percent score if the case minimum is not met or if the measure does not 
have a benchmark finalized in the CY 2017 Quality Payment Program final 
rule and codified at paragraph (b)(1)(viii) of Sec.  414.1380. We refer 
readers to the discussion at 81 FR 77288 for more details on that 
policy.
    To clarify the exclusion of measures submitted via the CMS Web 
Interface and based on administrative claims from the policy changes 
proposed to be codified at paragraph (b)(1)(vii) previously, we are 
amending paragraph (b)(1)(vii) to make it subject to paragraph 
(b)(1)(viii), which codifies the exclusion.
(e) Scoring for MIPS Eligible Clinician That Do Not Meet Quality 
Performance Category Criteria
    In the CY 2017 Quality Payment Program final rule, we finalized 
that MIPS eligible clinicians who fail to submit a measure that is 
required to satisfy the quality performance category submission 
criteria would receive zero points for that measure (81 FR 77291). For 
each required measure that is not submitted, a MIPS eligible clinician 
would receive zero points out of 10. For example, if a MIPS eligible 
clinician had 6 measures available and applicable but submitted only 4 
measures, the MIPS eligible clinician would be assigned zero out of 10 
measure achievement points for the 2 missing measures, which would be 
calculated into their performance category percent score.
    We are not proposing any changes to the policy to assign zero 
points for failing to submit a measure that is required in this 
proposed rule.
    In the CY 2017 Quality Payment Program final rule, we also 
finalized implementation of a validation process for claims and 
registry submissions to validate whether MIPS eligible clinicians have 
6 applicable and available measures, whether an outcome measure is 
available or whether another high priority measure is available if an 
outcome measure is not available (81 FR 77290 through 77291).
    We are not proposing any changes to apply a process to validate 
whether MIPS eligible clinicians that submit measures via claims and 
registry submissions have measures available and applicable. As stated 
in the CY 2017 Quality Payment Program final rule (81 FR 77290), we did 
not intend to establish a validation process for QCDRs because we 
expect that MIPS eligible clinicians that enroll in QCDRs will have 
sufficient meaningful measures to meet the quality performance category 
criteria (81 FR 77290 through 77291). We do not propose any changes to 
this policy.
    We also stated that if a MIPS eligible clinician did not have 6 
measures relevant within their EHR to meet the full specialty set 
requirements or meet the requirement to submit 6 measures, the MIPS 
eligible clinician should select a different submission mechanism to 
meet the quality performance category requirements and should work with 
their EHR vendors to incorporate applicable measures as feasible (81 FR 
77290 through 77291). Under our proposals in section II.C.6.a.(1) of 
this proposed rule to allow measures to be submitted and scored via 
multiple mechanisms within a performance category, we anticipate that 
MIPS

[[Page 30109]]

eligible clinicians that submit fewer than 6 measures via EHR will have 
sufficient additional measures available via a combination of 
submission mechanisms to submit the measures required to meet the 
quality performance category criteria. For example, the MIPS eligible 
clinician could submit 2 measures via EHR and supplement that with 4 
measures via QCDR or registry.
    Therefore, given our proposal to score multiple mechanisms, if a 
MIPS eligible clinician submits any quality measures via EHR or QCDR, 
we would not conduct a validation process because we expect these MIPS 
eligible clinicians to have sufficient measures available to meet the 
quality performance category requirements.
    Given our proposal in section II.C.7.a.(2)(h) of this proposed rule 
to score measures submitted via multiple mechanisms, we propose to 
validate the availability and applicability of measures only if a MIPS 
eligible clinician submits via claims submission options only, registry 
submission options only, or a combination of claims and registry 
submission options. In these cases, we propose that we will apply the 
validation process to determine if other measures are available and 
applicable broadly across claims and registry submission options. We 
will not check if there are measures available via EHR or QCDR 
submission options for these reporters. We note that groups cannot 
report via claims and therefore groups and virtual groups will only 
have validation applied across registries. We would validate the 
availability and applicability of a measure through a clinically 
related measure analysis based on patient type, procedure, or clinical 
action associated with the measure specifications. For us to recognize 
fewer than 6 measures, an individual MIPS eligible clinician must 
submit exclusively using claims or qualified registries or a 
combination of the two, and a group or virtual group must submit 
exclusively using qualified registries. Given our proposal in section 
II.C.7.a.(2)(h) of this proposed rule to score measures submitted via 
multiple mechanisms, validation will be conducted first by applying the 
clinically related measure analysis for the individual measure and 
then, to the extent technically feasible, validation will be applied to 
check for available measures available via both claims and registries.
    We recognize that in extremely rare instances there may be a MIPS 
eligible clinician who may not have available and applicable quality 
measures. For example, a subspecialist who focuses on a very targeted 
clinical area may not have any measures available. However, in many 
cases, the clinician may be part of a broader group or would have the 
ability to select some of the cross-cutting measures that are 
available. Given the wide array of submission options, including QCDRs 
which have the flexibility to develop additional measures, we believe 
this scenario should be extremely rare. If we are not able to score the 
quality performance category, we may reweight their score according to 
the reweighting policies described in section II.C.7.b.(3)(b) and 
II.C.7.b.(3)(d) of this proposed rule. We note that we anticipate this 
will be a rare circumstance given our proposals to allow measures to be 
submitted and scored via multiple mechanisms within a performance 
category and to allow facility-based measurement for the quality 
performance category.
(f) Incentives To Report High Priority Measures
    In the CY 2017 Quality Payment Program final rule, we finalized 
that we would award 2 bonus points for each outcome or patient 
experience measure and 1 bonus point for each additional high priority 
measure that is reported in addition to the 1 high priority measure 
that is already required to be reported under the quality performance 
category submission criteria, provided the measure has a performance 
rate greater than zero, and the measure meets the case minimum and data 
completeness requirements (81 FR 77293). High priority measures were 
defined as outcome, appropriate use, patient safety, efficiency, 
patient experience and care coordination measures, as identified in 
Tables A and E in the Appendix of the CY 2017 Quality Payment Program 
final rule (81 FR 77558 and 77686). We also finalized that we will 
apply measure bonus points for the CMS Web Interface for the Quality 
Payment Program based on the finalized set of measures reportable 
through that submission mechanism (81 FR 77293). We note that in 
addition to the 14 required measures, CMS Web Interface reporters may 
also report the CAHPS for MIPS survey and receive measure bonus points 
for submitting that measure.
    We are not proposing any changes to these policies for awarding 
measure bonus points for reporting high priority measures in this 
proposed rule.
    In the CY 2017 Quality Payment Program final rule, we finalized a 
cap on high priority measure bonus points at 10 percent of the 
denominator (total possible measure achievement points the MIPS 
eligible clinician could receive in the quality performance category) 
of the quality performance category for the first 2 years of MIPS (81 
FR 77294). Groups that submit via the CMS Web Interface for the Quality 
Payment Program are also subject to the 10 percent cap on high priority 
measure bonus points. We are not proposing any changes to the cap on 
measure bonus points for reporting high priority measures, which is 
codified at Sec.  414.1380(b)(1)(xiv)(D) \10\, in this proposed rule.
---------------------------------------------------------------------------

    \10\ Redesignated from Sec.  414.1380(b)(1)(xiii)(D).
---------------------------------------------------------------------------

(g) Incentives to Use CEHRT To Support Quality Performance Category 
Submissions
    Section 1848(q)(5)(B)(ii) of the Act outlines specific scoring 
rules to encourage the use of CEHRT under the quality performance 
category. For more of the statutory background and description of the 
proposed and finalized policies, we refer readers to the CY 2017 
Quality Payment Program final rule (81 FR 77294 through 77299).
    In the CY 2017 Quality Payment Program final rule at Sec.  
414.1380(b)(1)(xiv), we codified that 1 bonus point is available for 
each quality measure submitted with end-to-end electronic reporting, 
under certain criteria described below (81 FR 77297). We also finalized 
a policy capping the number of bonus points available for electronic 
end-to-end reporting at 10 percent of the denominator of the quality 
performance category percent score, for the first 2 years of the 
program (81 FR 77297). For example, when the denominator is 60, the 
number of measure bonus points will be capped at 6 points. We also 
finalized that the CEHRT bonus would be available to all submission 
mechanisms except claims submissions. Specifically, MIPS eligible 
clinicians who report via qualified registries, QCDRs, EHR submission 
mechanisms, or the CMS Web Interface for the Quality Payment Program, 
in a manner that meets the end-to-end reporting requirements, may 
receive 1 bonus point for each reported measure with a cap as described 
(81 FR 77297).
    We are not proposing changes to these policies related to bonus 
points for using CEHRT for end-to-end reporting in this proposed rule. 
However, we are seeking comment on the use of health IT in quality 
measurement and how HHS can encourage the use of certified EHR 
technology in quality measurement as established in the statute. What 
other incentives within this category for reporting in an end-to-end 
manner could be leveraged to incentivize more clinicians to report 
electronically? What format should these incentives take? For

[[Page 30110]]

example, should clinicians who report all of their quality performance 
category data in an end-to-end manner receive additional bonus points 
than those who report only partial electronic data? Are there other 
ways that HHS should incentivize providers to report electronic quality 
data beyond what is currently employed? We welcome public comment on 
these questions.
(h) Calculating Total Measure Achievement and Measure Bonus Points
    In section II.C.7.a.(2)(i) of this proposed rule, we are proposing 
a new methodology to reward improvement based on achievement, from 1 
year to another, which requires modifying the calculation of the 
quality performance category percent score. In this section 
II.C.7.a.(2)(h) of the proposed rule, we are summarizing the policies 
for calculating the total measure achievement points and total measure 
bonus points, prior to scoring improvement and the final quality 
performance category percent score. We note that we will refer to 
policies finalized in the CY 2017 Quality Payment Program final rule 
that apply to the quality performance category score, which is referred 
to as the quality performance category percent score in this proposed 
rule, in this section. We are also proposing some refinements to 
address the ability for MIPS eligible clinicians to submit quality data 
via multiple submission mechanisms.
(i) Calculating Total Measure Achievement and Measure Bonus Points for 
Non-CMS Web Interface Reporters
    In the CY 2017 Quality Payment Program final rule (81 FR 77300), we 
finalized that if a MIPS eligible clinician elects to report more than 
the minimum number of measures to meet the MIPS quality performance 
category criteria, then we will only include the scores for the 
measures with the highest number of assigned points, once the first 
outcome measure is scored, or if an outcome measure is not available, 
once another high priority measure is scored. We are not proposing any 
changes to the policy to score the measures with the highest number of 
assigned points in this proposed rule; however, we are proposing 
refinements to account for measures being submitted across multiple 
submission mechanisms.
    In the CY 2017 Quality Payment Program final rule, we sought 
comment on whether to score measures submitted across multiple 
submission mechanisms (81 FR 77275). As described in section 
II.C.6.a.(1) of this proposed rule, we are proposing that MIPS eligible 
clinicians be able to submit measures within a performance category via 
multiple submission mechanisms. In the CY 2017 Quality Payment Program 
final rule, we also sought comment on what approach we should use to 
combine the scores for quality measures from multiple submission 
mechanisms into a single aggregate score for the quality performance 
category (81 FR 77275). Examples of possible scoring options were a 
weighted average score on quality measures submitted through two or 
more different mechanisms or taking the highest scores for any 
submitted measure regardless of how the measure is submitted. A few 
comments received in response to the CY 2017 Quality Payment Program 
final rule did not support developing different weights for different 
submission methods. One commenter recommended that we take the highest 
score for any submitted measure, regardless of submission mechanisms, 
or alternatively, calculate independent scores that would each 
contribute equally to the final score.
    After consideration of the comments we received, we are proposing, 
beginning with the 2018 MIPS performance period, a method to score 
quality measures if a MIPS eligible clinician submits measures via more 
than one of the following submission mechanisms: Claims, qualified 
registry, EHR or QCDR submission options. We believe that allowing MIPS 
eligible clinicians to be scored across these data submission 
mechanisms in the quality performance category will provide additional 
options for MIPS eligible clinicians to report the measures required to 
meet the quality performance category criteria, and encourage MIPS 
eligible clinicians to begin using electronic submission mechanisms, 
even if they may not have 6 measures to report via a single electronic 
submission mechanism alone. We note that we also continue to score the 
CMS-approved survey vendor for CAHPS for MIPS submission options in 
conjunction with other submission mechanisms (81 FR 77275) as noted in 
Table 24.
    We propose to score measures across multiple mechanisms using the 
following rules:
     As with the rest of MIPS, we will only score measures 
within a single identifier. For example, as codified in Sec.  
414.1310(e), eligible clinicians and MIPS eligible clinicians within a 
group aggregate their performance data across the TIN in order for 
their performance to be assessed as a group. Therefore, measures can 
only be scored across multiple mechanisms if reported by the same 
individual MIPS eligible clinician, group, virtual group or APM Entity, 
as described in Table 24.
     We do not propose to aggregate measure results across 
different submitters to create a single score for an individual measure 
(for example, we are not going to aggregate scores from different TINs 
within a virtual group TIN to create a single virtual group score for 
the measures; rather, virtual groups must perform that aggregation 
across TINs prior to data submission to CMS). Virtual groups are 
treated like other groups and must report all of their measures at the 
virtual group level, for the measures to be scored. Data completeness 
and all the other criteria will be evaluated at the virtual group 
level. Then the same rules apply for selecting which measures are used 
for scoring. In other words, if a virtual group representative submits 
some measures via a qualified registry and other measures via EHR, but 
an individual TIN within the virtual group also submits measures, we 
will only use the scores from the measures that were submitted at the 
virtual group level, because the TIN submission does not use the 
virtual group identifier. This is consistent with our other scoring 
principles, where, for virtual groups, all quality measures are scored 
at the virtual group level.
     Separately, as also described in Table 24, because CMS Web 
Interface and facility-based measurement each have a comprehensive set 
of measures that meet the proposed MIPS submission requirements, we do 
not propose to combine CMS Web Interface measures or facility-based 
measurement with other group submission mechanisms (other than CAHPS 
for MIPS, which can be submitted in conjunction with the CMS Web 
Interface). We refer readers to section II.C.7.a.(2)(h)(ii) of this 
proposed rule for discussion of calculating the total measure 
achievement and measure bonus points for CMS Web Interface reporters 
and to section II.C.7.a.(4) of this proposed rule for a description of 
our proposed policies on facility-based measurement. We list these 
submission mechanisms in Table 24, to illustrate that CMS Web Interface 
submissions and facility-based measurement cannot be combined with 
other submission options, except that the CAHPS for MIPS survey can be 
combined with CMS Web Interface, as described in section 
II.C.7.a.(2)(h)(ii) of this proposed rule.

[[Page 30111]]



   Table 24--Scoring Allowed Across Multiple Mechanisms by Submission
                                Mechanism
        [Determined by MIPS identifier and submission mechanism]
------------------------------------------------------------------------
                                           When can quality measures be
     MIPS identifier and submission           scored across multiple
               mechanisms                          mechanisms?
------------------------------------------------------------------------
Individual eligible clinician reporting  Can combine claims, EHR, QCDR,
 via claims, EHR, QCDR, and registry      and registry.
 submission options.
Group reporting via EHR, QCDR,           Can combine EHR, QCDR,
 registry, and the CAHPS for MIPS         registry, and CAHPS for MIPS
 survey.                                  survey.
Virtual group reporting via EHR, QCDR,   Can combine EHR, QCDR,
 registry, and the CAHPS for MIPS         registry, and CAHPS for MIPS
 survey.                                  survey.
Group reporting via CMS Web Interface..  Cannot be combined with other
                                          submission mechanisms, except
                                          for the CAHPS for MIPS survey.
Virtual group reporting via CMS Web      Cannot be combined with other
 Interface.                               submission mechanisms, except
                                          for the CAHPS for MIPS survey.
Individual or group reporting facility-  Cannot be combined with other
 based measures.                          submission mechanisms.
MIPS APMs reporting Web Interface or     MIPS APMs are subject to
 other quality measures.                  separate scoring standards and
                                          cannot be combined with other
                                          submission mechanisms.
------------------------------------------------------------------------

     If a MIPS eligible clinician submits the same measure via 
2 different submission mechanisms, we will score each mechanism by 
which the measure is submitted for achievement and take the highest 
measure achievement points of the 2 mechanisms.
     Measure bonus points for high priority measures would be 
added for all measures submitted via all the different submission 
mechanisms available, even if more than 6 measures are submitted, but 
high priority measure bonus points are only available once for each 
unique measure (as noted by the measure number) that meets the criteria 
for earning the bonus point. For example, if a MIPS eligible clinician 
submits 8 measures--6 process and 2 outcome--and both outcome measures 
meet the criteria for a high priority bonus (meeting the required data 
completeness, case minimum, and has a performance rate greater than 
zero), the outcome measure with the highest measure achievement points 
would be scored as the required outcome measure and then the measures 
with the next 5 highest measure achievement points will contribute to 
the final quality score. This could include the second outcome measure 
but does not have to. Even if the measure achievement points for the 
second outcome measure are not part of the quality performance category 
percent score, measure bonus points would still be available for 
submitting a second outcome measure and meeting the requirement for the 
high priority measure bonus points. The rationale for providing measure 
bonus points for measures that do not contribute measure achievement 
points to the quality performance category percent score is that it 
would help create better benchmarks for outcome and other high priority 
measures by encouraging clinicians to report them even if they may not 
have high performance on the measure. We also want to encourage MIPS 
eligible clinicians to submit to us all of their available MIPS data, 
not only the data that they or their intermediary deem to be their best 
data. We believe it will be in the best interest of all MIPS eligible 
clinicians that we determine which measures will result in the 
clinician receiving the highest MIPS score. If the same measure is 
submitted through multiple submission mechanisms, we would apply the 
bonus points only once to the measure. We propose to amend Sec.  
414.1380(b)(1)(xiv) (as redesignated from Sec.  414.1380(b)(1)(xiii)) 
to add paragraph (b)(1)(xiv)(E) that if the same high priority measure 
is submitted via two or more submission mechanisms, as determined using 
the measure ID, the measure will receive high priority measure bonus 
points only once for the measure. The total measure bonus points for 
high-priority measures would still be capped at 10 percent of the total 
possible measure achievement points.
     Measure bonus points that are available for the use of 
end-to-end electronic reporting would be calculated for all submitted 
measures across all submission mechanisms, including measures that 
cannot be reliably scored against a benchmark. If the same measure is 
submitted through multiple submission mechanisms, then we would apply 
the bonus points only once to the measure. For example, if the same 
measure is submitted using end-to-end reporting via both a QCDR and EHR 
reporting mechanism, the measure would only get a measure bonus point 
one time. We propose to amend Sec.  414.1380(b)(1)(xv) (as 
redesignated) to add that if the same measure is submitted via two or 
more submission mechanisms, as determined using the measure ID, the 
measure will receive measure bonus points only once for the measure. 
The total measure bonus points for end-to-end electronic reporting 
would still be capped at 10 percent of the total available measure 
achievement points.
    Although we provide a policy to account for scoring in those 
circumstances when the same measure is submitted via multiple 
mechanisms, we anticipate that this will be a rare circumstance and do 
not encourage clinicians to submit the same measure via multiple 
mechanisms. Table 25 illustrates how we would assign total measure 
achievement points and total measure bonus points across multiple 
submission mechanisms under our proposal. In this example, a MIPS 
eligible clinician elects to submit quality data via 3 submission 
mechanisms: 3 Measures via registry, 4 measures via claims, and 5 
measures via EHR. The 3 registry measures are also submitted via claims 
(as noted by the same measure letter in this example). The EHR measures 
do not overlap with either the registry or claims measures. In this 
example, we assign measure achievement and bonus points for each 
measure. If the same measure (as determined by measure ID) is 
submitted, then we use the highest achievement points for that measure. 
For the bonus points, we assess which of the outcome measures meets the 
outcome measure requirement and then we identify any other unique 
measures that qualify for the high priority bonus. We also identify the 
unique measures that qualify for end-to-end electronic reporting bonus.

[[Page 30112]]



    Table 25--Example of Assigning Total Measure Achievement and Bonus Points for an Individual MIPS Eligible
                      Clinician That Submits Measures Across Multiple Submission Mechanisms
----------------------------------------------------------------------------------------------------------------
                                                                              High priority      Incentive for
                                   Measure achievement   6 Scored measures    measure bonus      CEHRT measure
                                         points                                   points          bonus points
----------------------------------------------------------------------------------------------------------------
Registry
----------------------------------------------------------------------------------------------------------------
Measure A (Outcome)............  7.1...................  7.1 (Outcome       (required outcome
                                                          measure with       measure does not
                                                          highest            receive bonus
                                                          achievement        points).
                                                          points).
Measure B......................  6.2 (points not
                                  considered because it
                                  is lower than the 8.2
                                  points for the same
                                  claims measure).
Measure C (high priority         5.1 (points not         .................  1
 patient safety measure that      considered because it
 meets requirements for           is lower than the 6.0
 additional bonus points).        points for the same
                                  claims measure).
----------------------------------------------------------------------------------------------------------------
Claims
----------------------------------------------------------------------------------------------------------------
Measure A (Outcome)............  4.1 (points not         .................  No bonus points
                                  considered because it                      because the
                                  is lower than the 7.1                      registry
                                  points for the same                        submission of
                                  measure submitted via                      the same measure
                                  a registry).                               satisfies
                                                                             requirement for
                                                                             outcome measure.
Measure B......................  8.2...................  8.2
Measure C (High priority         6.0...................  6.0..............  No bonus (Bonus
 patient safety measure that                                                 applied to the
 meets requirements for                                                      registry
 additional bonus points).                                                   measure).
Measure D (outcome measure <50%  1.0...................  1.0..............  (no high priority
 of data submitted).                                                         bonus points
                                                                             because below
                                                                             data
                                                                             completeness).
----------------------------------------------------------------------------------------------------------------
     EHR (using end-to-end)                                                                      Reporting that
                                                                                                   meets CEHRT
                                                                                                   bonus point
                                                                                                    criteria
----------------------------------------------------------------------------------------------------------------
Measure E......................  5.1...................  5.1..............  .................  1
Measure F......................  5.0...................  5.0..............  .................  1
Measure G......................  4.1...................  .................  .................  1
Measure H......................  4.2...................  4.2..............  .................  1
Measure I (high priority         3.0...................  .................  (no high priority  1
 patient safety measure that is                                              bonus points
 below case minimum).                                                        because below
                                                                             case minimum).
                                 35.6..................  1 (below 10%       5 (below 10% cap)
                                                          cap\1\).
                                                        --------------------------------------------------------
Quality Performance Category     ......................                 (35.6 + 1 + 5)/60 = 69.33%
 Percent Score Prior to
 Improvement Scoring.
----------------------------------------------------------------------------------------------------------------
\1\ In this example the cap would be 6 points, which is 10 percent of the total available measure achievement
  points of 60.

    We propose to amend Sec.  414.1380(b)(1)(xii) to add paragraph (A) 
to state that if a MIPS eligible clinician submits measures via claims, 
qualified registry, EHR, or QCDR submission options, and submits more 
than the required number of measures, they are scored on the required 
measures with the highest assigned measure achievement points. MIPS 
eligible clinicians that report a measure via more than 1 submission 
mechanism can be scored on only 1 submission mechanism, which will be 
the submission mechanism with the highest measure achievement points. 
Groups that submit via these submission mechanisms may also submit and 
be scored on CMS-approved survey vendor for CAHPS for MIPS submission 
mechanisms.
    We invite comments on our proposal to calculate the total measure 
achievement points by using the measures with the 6 highest measure 
achievement points across multiple submission mechanisms. We invite 
comments on our proposal that if the same measure is submitted via 2 or 
more mechanisms, we will only take the one with the highest measure 
achievement points. We invite comments on our proposal to assign high 
priority measure bonus points to all measures, with performance greater 
than zero, that meet case minimums, and that meet data completeness 
requirements, regardless of submission mechanism and to assign measure

[[Page 30113]]

bonus points for each unique measure submitted using end-to-end 
electronic reporting. We invite comments on our proposal that if the 
same measure is submitted using 2 different mechanisms, the measure 
will receive measure bonus points once.
    We are not proposing any changes to our policy that if a MIPS 
eligible clinician does not have any scored measures, then a quality 
performance category percent score will not be calculated as finalized 
in the CY 2017 Quality Payment Program final rule at 81 FR 77300. We 
refer readers to the discussion at 81 FR 77299 through 77300 for more 
details on that policy. As stated in section II.C.7.a.(2)(e) of this 
proposed rule, we anticipate that it will be only in rare case that a 
MIPS eligible clinician does not have any scored measures and a quality 
performance category percent score cannot be calculated.
(ii) Calculating Total Measure Achievement and Measure Bonus Points for 
CMS Web Interface Reporters
    In the CY 2017 Quality Payment Program final rule, we finalized 
that CMS Web Interface reporters are required to report 14 measures, 13 
individual measures, and a 2-component measure for diabetes (81 FR 
77302 through 77305). We note that for the transition year, 3 measures 
did not have a benchmark in the Shared Savings Program. Therefore, for 
the transition year, CMS Web Interface reporters are scored on 11 of 
the total 14 required measures, provided that they report all 14 
required measures.
    In the CY 2017 Quality Payment Program final rule, we finalized a 
global floor of 3 points for all CMS Web Interface measures submitted 
in the transition year, even with measures at zero percent performance 
rate, provided that these measures have met the data completeness 
criteria, have a benchmark and meet the case minimum requirements (82 
FR 77305). Therefore, measures with performance below the 30th 
percentile will be assigned a value of 3 points during the transition 
year to be consistent with the floor established for other measures and 
because the Shared Savings Program does not publish benchmarks below 
the 30th percentile (82 FR 77305). We stated that we will reassess 
scoring for measures below the 30th percentile in future years.
    We propose to continue to assign 3 points for measures with 
performance below the 30th percentile, provided the measure meets data 
completeness, has a benchmark, and meets the case minimum requirements 
for the 2018 MIPS performance year; we make this proposal in order to 
continue to align with the 3-point floor for other measures and because 
the Shared Savings Program does not publish benchmarks with values 
below the 30th percentile. We will reassess this policy again next year 
through rulemaking.
    We are not proposing any changes to our previously finalized policy 
to exclude from scoring CMS Web Interface measures that are submitted 
but that do not meet the case minimum requirement or that lack a 
benchmark, or to our policy that measures that are not submitted and 
measures submitted below the data completeness requirements will 
receive a zero score (82 FR 77305). However, to further increase 
alignment with the Shared Savings Program, we propose to also exclude 
CMS Web Interface measures from scoring if the measure is redesignated 
from pay for performance to pay for reporting for all Shared Savings 
Program ACOs, although we will recognize the measure was submitted. 
While the Shared Savings Program designates measures that are pay for 
performance in advance of the reporting year, the Shared Savings 
Program may redesignate a measure as pay for reporting under certain 
circumstances (see 42 CFR 425.502(a)(5)). Therefore, we propose to 
amend Sec.  414.1380(b)(1)(viii) to add that CMS Web Interface measures 
that have a measure benchmark but are redesignated as pay for reporting 
for all Shared Savings Program ACOs by the Shared Savings Program will 
not be scored, as long as the data completeness requirement is met.
    We invite comment on our proposal to not score CMS Web Interface 
measures redesignated as pay for reporting by the Shared Savings 
Program.
    We also note that, while we did not state explicitly in the CY 2017 
Quality Payment Program final rule, groups that choose to report 
quality measures via the CMS Web Interface may, in addition to the 14 
required measures, also submit the CAHPS for MIPS survey in the quality 
performance category (81 FR 77094 through 77095; 81 FR 77292). If they 
do so, they can receive bonus points for submitting this high priority 
measure and will be scored on it as an additional measure. Therefore, 
we propose to amend Sec.  414.1380(b)(1)(xii) to add paragraph (B) to 
state that groups that submit measures via the CMS Web Interface may 
also submit and be scored on CMS-approved survey vendor for CAHPS for 
MIPS submission options.
    In addition, groups of 16 or more eligible clinicians that meet the 
case minimum for administrative claims measures will automatically be 
scored on the all-cause hospital readmission measure and have that 
measure score included in their quality category performance percent 
score.
    We are not proposing any changes to calculating the total measure 
achievement points and measure bonus points for CMS Web Interface 
measures in this proposed rule, although we are proposing to add 
improvement to the quality performance category percent score for such 
submissions (as well as other submission mechanisms) in section 
II.C.7.a.(2)(j) of this proposed rule.
(i) Scoring Improvement for the MIPS Quality Performance Category 
Percent Score
(i) Calculating Improvement at the Quality Performance Category Level
    In the CY 2017 Quality Payment Program final rule, we noted that we 
consider achievement to mean how a MIPS eligible clinician performs 
relative to performance standards, and improvement to mean how a MIPS 
eligible clinician performs compared to the MIPS eligible clinician's 
own previous performance on measures and activities in the performance 
category (81 FR 77274). We also solicited public comments in the CY 
2017 Quality Payment Program proposed rule on potential ways to 
incorporate improvement in the scoring methodology. In section 
II.C.7.a.(1)(b)(i) of this proposed rule, we explain why we believe 
that the options set forth in the CY 2017 Quality Payment Program 
proposed rule, including the Hospital VBP Program, the Shared Savings 
Program, and Medicare Advantage 5-star Ratings Program, were not fully 
translatable to MIPS. Beginning with the 2018 MIPS performance period, 
we propose here to score improvement as well as achievement in the 
quality performance category level when data is sufficient. We believe 
that scoring improvement at the performance category level, rather than 
measuring improvement at the measure level, for the quality performance 
category would allow improvement to be available to the broadest number 
of MIPS eligible clinicians because we are connecting performance to 
previous MIPS quality performance as a whole rather than changes in 
performance for individual measures. Just as we believe it is important 
for a MIPS eligible clinician to have the flexibility to choose 
measures that are meaningful to their practice, we want them to be able 
to adopt new measures without concern

[[Page 30114]]

about losing the ability to be measured on improvement. In addition, we 
are encouraging MIPS eligible clinicians to select more outcome 
measures and to move away from topped out measures. We do not want to 
remove the opportunity to score improvement from those who select 
different measures between performance periods for the quality 
performance category; therefore, we are proposing to measure 
improvement at the category level which can be calculated with 
different measures.
    We propose at Sec.  414.1380(b)(1)(xvi)(E) to define an improvement 
percent score to mean the score that represents improvement for the 
purposes of calculating the quality performance category percent score. 
We also propose at Sec.  414.1380(b)(1)(xvi)(C) that an improvement 
percent score would be assessed at the quality performance category 
level and included in the calculation of the quality performance 
category percent score. When we evaluated different improvement scoring 
options, we saw two general methods for incorporating improvement. One 
method measures both achievement and improvement and takes the higher 
of the two scores for each measure that is compared. The Hospital VBP 
Program incorporates such a methodology. The second method is to 
calculate an achievement score and then add an improvement score if 
improvement is measured. The Shared Savings Program utilizes a similar 
methodology for measuring improvement. For the quality performance 
category, we are proposing to calculate improvement at the category 
level and believe adding improvement to an existing achievement percent 
score would be the most straight-forward and simple way to incorporate 
improvement. For the purpose of improvement scoring methodology, the 
term ``quality performance category achievement percent score'' means 
the total measure achievement points divided by the total possible 
available measure achievement points, without consideration of bonus 
points or improvement adjustments and is discussed in section 
II.C.7.a.(2)(i)(iv) of this proposed rule.
    Consistent with bonuses available in the quality performance 
category, we propose at Sec.  414.1380(b)(1)(xvi)(B) that the 
improvement percent score may not total more than 10 percentage points.
    We invite public comments on these proposals.
(ii) Data Sufficiency Standard To Measure Improvement for Quality 
Performance Category
    Section 1848(q)(5)(D)(i) of the Act stipulates that beginning with 
the second year to which the MIPS applies, if data sufficient to 
measure improvement is available then we shall measure improvement for 
the quality performance category. Measuring improvement requires a 
direct comparison of data from one Quality Payment Program year to 
another. Starting with the 2020 MIPS payment year, we propose that a 
MIPS eligible clinician's data would be sufficient to score improvement 
in the quality performance category if the MIPS eligible clinician had 
a comparable quality performance category achievement percent score for 
the MIPS performance period immediately prior to the current MIPS 
performance period; we explain our proposal to identify how we will 
identify ``comparable'' quality performance category achievement 
percent scores below. We believe that this approach would allow 
improvement to be broadly available to MIPS eligible clinicians and 
encourage continued participation in the MIPS program. Moreover, this 
approach would encourage MIPS eligible clinicians to focus on efforts 
to improve the quality of care delivered. We note that, by measuring 
improvement based only on the overall quality performance category 
achievement percent score, some MIPS eligible clinicians and groups may 
generate an improvement score simply by switching to measures on which 
they perform more highly, rather than actually improving at the same 
measures. We will monitor how frequently improvement is due to actual 
improvement versus potentially perceived improvement by switching 
measures and will address through future rulemaking, as needed. We also 
solicit comment on whether we should require some level of year to year 
consistency when scoring improvement.
    We propose that ``comparability'' of quality performance category 
achievement percent scores would be established by looking first at the 
submitter of the data. As discussed in more detail in section 
II.C.7.a.(2)(i)(i) of this proposed rule, we are comparing results at 
the category, rather than the performance measure level because we 
believe that the performance category score from 1 year is comparable 
to the performance category score from the prior year, even if the 
measures in the performance category have changed from year to year.
    We propose to compare results from an identifier when we receive 
submissions with that same identifier (either TIN/NPI for individual, 
or TIN for group, APM entity, or virtual group identifier) for two 
consecutive performance periods. However, if we do not have the same 
identifier for two consecutive performance periods, we propose a 
methodology to create a comparable performance category score that can 
be used for improvement measurement. Just as we do not want to remove 
the opportunity to earn an improvement score from those who elect new 
measures between performance periods for the quality performance 
category, we also do not want to restrict improvement for those MIPS 
eligible clinicians who elect to participate in MIPS using a different 
identifier.
    There are times when submissions from a particular individual 
clinician or group of clinicians use different identifiers between 2 
years. For example, a group of 20 MIPS eligible clinicians could choose 
to submit as a group (using their TIN identifier) for the current 
performance period. If the group also submitted as a group for the 
previous year's performance period, we would simply compare the group 
scores associated with the previous performance period to the current 
performance period (following the methodology explained in section 
II.C.7.a.(2)(i)(iv) of this proposed rule). However, if the group 
members had previously elected to submit to MIPS as individual 
clinicians, we would not have a group score at the TIN level from the 
previous performance period to which to compare the current performance 
period.
    In circumstances where we do not have the same identifier for two 
consecutive performance periods, we propose to identify a comparable 
score for individual submissions or calculate a comparable score for 
group, virtual group, and APM entity submissions. For individual 
submissions, if we do not have a quality performance category 
achievement percent score for the same individual identifier in the 
immediately prior period, then we propose to apply the hierarchy logic 
that is described in section II.C.8.a.(2) of this proposed rule to 
identify the quality performance category achievement score associated 
with the final score that would be applied to the TIN/NPI for payment 
purposes. For example, if there is no historical score for the TIN/NPI, 
but there is a TIN score (because in the previous period the TIN 
submitted as a group), then we would use the quality performance 
category achievement

[[Page 30115]]

percent score associated with the TIN's prior performance. If the NPI 
had changed TINs and there was no historical score for the same TIN/
NPI, then we would take the highest prior score associated with the 
NPI.
    When we do not have a comparable TIN group, virtual group, or APM 
Entity score, we propose to calculate a score based on the individual 
TIN/NPIs in the practice for the current performance period. For 
example, in a group of 20 clinicians that previously participated in 
MIPS as individuals, but now want to participate as a group, we would 
not have a comparable TIN score to use for scoring improvement. We 
believe however it is still important to provide to the MIPS eligible 
clinicians the improvement points they have earned. Similarly, in cases 
where a group of clinicians previously participated in MIPS as 
individuals, but now participates as a new TIN, or a new virtual group, 
or a new APM Entity submitting data in the performance period, we would 
not have a comparable TIN, virtual group, or APM Entity score to use 
for scoring improvement. Therefore, we propose to calculate a score by 
taking the average of the individual quality performance category 
achievement scores for the MIPS eligible clinicians that were in the 
group for the current performance period. If we have more than one 
quality performance category achievement percent score for the same 
individual identifier in the immediately prior period, then we propose 
to apply the hierarchy logic that is described in section II.C.8.a.(2) 
of this proposed rule to identify the quality performance category 
score associated with the final score that would be applied to the TIN/
NPI for payment purposes. We would exclude any TIN/NPI's that did not 
have a final score because they were not eligible for MIPS. We would 
include quality performance category achievement percent scores of zero 
in the average.
    There are instances where we would not be able to measure 
improvement due to lack of sufficient data. For example, if the MIPS 
eligible clinicians did not participate in MIPS in the previous 
performance period because they were not eligible for MIPS, we could 
not calculate improvement because we would not have a previous quality 
performance category achievement percent score.
    Table 26 summarizes the different cases when a group or individual 
would be eligible for improvement scoring under this proposal.

                             Table 26--Eligibility for Improvement Scoring Examples
----------------------------------------------------------------------------------------------------------------
                                                        Prior MIPS
                                                       performance
                                    Current MIPS    period identifier     Eligible for
            Scenario                performance        (with score        improvement       Data comparability
                                 period identifier    greater  than         scoring
                                                          zero)
----------------------------------------------------------------------------------------------------------------
No change in identifier........  Individual (TIN A/ Individual (TIN A/ Yes..............  Current individual
                                  NPI 1).            NPI 1).                               score is compared to
                                                                                           individual score from
                                                                                           prior performance
                                                                                           period.
No change in identifier........  Group (TIN A)....  Group (TIN A)....  Yes..............  Current group score is
                                                                                           compared to group
                                                                                           score from prior
                                                                                           performance period.
Individual is with same group,   Individual (TIN A/ Group (TIN A)....  Yes..............  Current individual
 but selects to submit as an      NPI 1).                                                  score is compared to
 individual whereas previously                                                             the group score
 the group submitted as a group.                                                           associated with the
                                                                                           TIN/NPI from the
                                                                                           prior performance
                                                                                           period.
Individual changes practices,    Individual (TIN B/ Individual (TIN A/ Yes..............  Current individual
 but submitted to MIPS            NPI).              NPI).                                 score is compared to
 previously as an individual.                                                              the individual score
                                                                                           from the prior
                                                                                           performance period.
Individual changes practices     Individual (TIN C/ Group (TIN A/      Yes..............  Current individual
 and has multiple scores in       NPI).              NPI); Individual                      score is compared to
 prior performance period.                           (TIN B/NPI).                          highest score from
                                                                                           the prior performance
                                                                                           period.
Group does not have a previous   Group (TIN A)....  Individual scores  Yes..............  The current group
 group score from prior                              (TIN A/NPI 1,                         score is compared to
 performance period.                                 TIN A/NPI 2, TIN                      the average of the
                                                     A/NPI 3, etc.).                       scores from the prior
                                                                                           performance period of
                                                                                           individuals who
                                                                                           comprise the current
                                                                                           group.
Virtual group does not have      Virtual Group      Individuals (TIN   Yes..............  The current group
 previous group score from        (Virtual Group     A/NPI 1, TIN A/                       score is compared to
 prior performance period.        Identifier A)      NPI 2, TIN B/NPI                      the average of the
                                  (Assume virtual    1, TIN B/NPI 2).                      scores from the prior
                                  group has 2 TINs                                         performance period of
                                  with 2                                                   individuals who
                                  clinicians.).                                            comprise the current
                                                                                           group.
Individual does not have a       Individual (TIN A/ Individual was     No...............  The individual quality
 quality performance category     NPI 1).            not eligible for                      performance category
 achievement score for the                           MIPS and did not                      score is missing for
 prior performance period.                           voluntarily                           the prior performance
                                                     submit any                            period and not
                                                     quality measures                      eligible for
                                                     to MIPS.                              improvement scoring.
----------------------------------------------------------------------------------------------------------------

    We propose at Sec.  414.1380(b)(1)(xvi)(A) to state that 
improvement scoring is available when the data sufficiency standard is 
met, which means when data are available and a MIPS eligible clinician 
or group has a quality performance category achievement percent score 
for the previous performance period. We also propose at Sec.  
414.1380(b)(1)(xvi)(A)(1) that data must be comparable to meet the 
requirement of data sufficiency,

[[Page 30116]]

which means that the quality performance category achievement percent 
score is available for the current performance period and the previous 
performance period and, therefore, quality performance category 
achievement percent scores can be compared. We also propose at Sec.  
414.1380(b)(1)(xvi)(A)(2) that quality performance category achievement 
percent scores are comparable when submissions are received from the 
same identifier for two consecutive performance periods. We also 
propose an exception at Sec.  414.1380(b)(1)(xvi)(A)(3) that if the 
identifier is not the same for 2 consecutive performance periods, then 
for individual submissions, the comparable quality performance category 
achievement percent score is the quality performance category 
achievement percent score associated with the final score from the 
prior performance period that will be used for payment. For group, 
virtual group, and APM entity submissions, the comparable quality 
performance category achievement percent score is the average of the 
quality performance category achievement percent score associated with 
the final score from the prior performance period that will be used for 
payment for each of the individuals in the group. As noted above, these 
proposals are designed to offer improvement scoring to all MIPS 
eligible clinicians with sufficient data in the prior MIPS performance 
period. We invite public comments on our proposals as they relate to 
data sufficiency for improvement scoring.
    We also seek comment on an alternative to this proposal: Whether we 
should restrict improvement to those who submit quality performance 
data using the same identifier for two consecutive MIPS performance 
periods. We believe this option would be simpler to apply, communicate 
and understand than our proposal is, but this alternative could have 
the unintended consequence of not allowing improvement scoring for 
certain MIPS eligible clinicians, groups, virtual groups and APM 
entities.
(iii) Additional Requirement for Full Participation To Measure 
Improvement for Quality Performance Category
    To receive a quality performance category improvement percent score 
greater than zero, we are also proposing that MIPS eligible clinicians 
must fully participate, which we propose in Sec.  
414.1380(b)(1)(xvi)(F) to mean compliance with Sec.  414.1330 and Sec.  
414.1340, in the current performance year. Compliance with those 
referenced regulations entails the submission of all required measures, 
including meeting data completeness, for the quality performance 
category for the current performance period. For example, for MIPS 
eligible clinicians submitting via QCDR, full participation would 
generally mean submitting 6 measures including 1 outcome measure if an 
outcome measure is available or 1 high priority measure if an outcome 
measure is not available, and meeting the 50 percent data completeness 
criteria for each of the 6 measures.
    We believe that improvement is most meaningful and valid when we 
have a full set of quality measures. A comparison of data resulting 
from full participation of a MIPS eligible clinician from 1 year to 
another enables a more accurate assessment of improvement because the 
performance being compared is based on the applicable and available 
measures for the performance periods and not from changes in 
participation. While we are not requiring full participation for both 
performance periods, requiring full participation for the current 
performance period means that any future improvement scores for a 
clinician or group would be derived solely from changes in performance 
and not because the clinician or group submitted more measures. We 
propose at Sec.  414.1380(b)(1)(xvi)(C)(5) that the quality improvement 
percent score is zero if the clinician did not fully participate in the 
quality performance category for the current performance period.
    Because we want to award improvement for net increases in 
performance and not just improved participation in MIPS, we want to 
measure improvement above a floor for the 2018 MIPS performance period, 
to account for our transition year policies. We considered that MIPS 
eligible clinicians who chose the ``test'' option of the ``pick your 
pace'' approach for the transition year may not have submitted all the 
required measures and, as a result, may have a relatively low quality 
performance category achievement score for the 2017 MIPS performance 
period. Due to the transition year policy to award at least 3 measure 
achievement points for any submitted measure via claims, EHR, QCDR, 
qualified registry, and CMS-approved survey vendor for CAHPS for MIPS, 
and the 3-point floor for the all-cause readmission measure (if the 
measure applies), a MIPS eligible clinician that submitted some data 
via these mechanisms on the required number of measures would 
automatically have a quality performance category achievement score of 
at least 30 percent because they would receive at least 3 of 10 
possible measure achievement points for each required measure. For 
example, if a solo practitioner submitted 6 measures and received 3 
points for each measure, then the solo practitioner would have 18 
measure achievement points out of a possible 60 total possible measure 
achievement points (3 measure achievement points x 6 measures). The 
quality performance category achievement percent score is 18/60 which 
equals 30 percent. For groups with 16 or more clinicians that submitted 
6 measures and receive 3 measure achievement points for each submitted 
measure as well as the all-cause hospital readmission measure, then the 
group would have 21 measure achievement points out of 70 total possible 
measure achievement points or a quality performance category 
achievement percent score of 21/70 which equals 30 percent (3 measure 
achievement points x 7 measures). For the CMS Web Interface submission 
option, MIPS eligible clinicians that fully participate by submitting 
and meeting data completeness for all measures, would also be able to 
achieve a quality performance category achievement percent score of at 
least 30 percent, as each scored measure would receive 3 measure 
achievement points out of 10 possible measure achievement points.
    Therefore, we propose at Sec.  414.1380(b)(1)(xvi)(C)(4) that if a 
MIPS eligible clinician has a previous year quality performance 
category score less than or equal to 30 percent, we would compare 2018 
performance to an assumed 2017 quality performance category achievement 
percent score of 30 percent. In effect, for the MIPS 2018 performance 
period, improvement would be measured only if the clinician's 2018 
quality performance category achievement percent score for the quality 
performance category exceeds 30 percent. We believe this approach 
appropriately recognizes the participation of MIPS eligible clinicians 
who participated in the transition year and accounts for MIPS eligible 
clinicians who participated minimally and may otherwise be awarded for 
an increase in participation rather than an increase in achievement 
performance.
    We invite public comment on these proposals.
(iv) Measuring Improvement Based on Changes in Achievement
    To calculate improvement with a focus on quality performance, we 
are proposing to focus on improvement based on achievement performance 
and would not consider measure bonus

[[Page 30117]]

points in our improvement algorithm. Bonus points may be awarded for 
reasons not directly related to performance such as the use of end-to-
end electronic reporting. We believe that improvement points should be 
awarded based on improvement related to achievement. Accordingly, we 
are proposing to use an individual MIPS eligible clinician's or group's 
total measure achievement points from the prior MIPS performance period 
without the bonus points the individual MIPS eligible clinician or 
group may have received, to calculate improvement. Therefore, to 
measure improvement at the quality performance category level, we will 
use the quality performance category achievement percent score 
excluding measure bonus points (and any improvement score) for the 
applicable years. We propose at Sec.  414.1380(b)(1)(xvi)(D) to call 
this score, which is based on achievement only, the ``quality 
performance category achievement percent score'' which is calculated 
using the following formula:

Quality performance category achievement percent score = total measure 
achievement points/total available measure achievement points.

    Table 27 illustrates how the quality performance category 
achievement percent score is calculated. For simplicity, we assume the 
MIPS eligible clinician received 6 measure achievement points for each 
of the submitted 6 required measures in the current performance period, 
which equals 36 total measure achievement points. This is compared to 
the previous performance period when the MIPS eligible clinician 
received only 5 measure achievement points per measure, for 30 total 
measure achievement points. The quality performance category 
achievement percent score is represented in line 2. For improvement, 
performance in the current 2018 MIPS performance period (60 percent) is 
compared to the performance category achievement percent score in the 
2017 MIPS performance period (50 percent).

Table 27--Comparison of Quality Performance Category Achievement Percent
                                 Scores
------------------------------------------------------------------------
                                  Current MIPS          Previous MIPS
                               performance period    performance period
------------------------------------------------------------------------
(1) Total Measure             6 measure             5 measure
 Achievement Points.           achievement points    achievement points
                               x 6 measures = 36     x 6 measures = 30
                               total measure         total measure
                               achievement points.   achievement points.
(2) Quality Performance       36/60 = 60 percent..  30/60 = 50 percent.
 Category Achievement
 Percent Score (measure
 achievement points/60 for
 this example).
------------------------------------------------------------------------

    The current MIPS performance period quality performance category 
achievement percent score is compared to the previous performance 
period quality performance category achievement percent score. If the 
current score is higher, the MIPS eligible clinician may qualify for an 
improvement percent score to be added into the quality performance 
category percent score for the current performance year.
    We propose to amend the regulatory text at Sec.  
414.1380(b)(1)(xvi) to state that improvement scoring is available to 
MIPS eligible clinicians and groups that demonstrate improvement in 
performance in the current MIPS performance period compared to the 
performance in the previous MIPS performance period, based on 
achievement. Bonus points or improvement percent score adjustments made 
to the category score in the prior or current performance period are 
not taken into account when determining whether an improvement has 
occurred or the size of any improvement percent score.
    We invite public comment on our proposal to award improvement based 
on changes in the quality performance category achievement percent 
score.
(v) Improvement Scoring Methodology for the Quality Performance 
Category
    We believe the improvement scoring methodology that we are 
proposing for the quality performance category recognizes the rate of 
increase in quality performance category scores of MIPS eligible 
clinicians from one performance period to another performance period so 
that a higher rate of improvement results in a higher improvement 
percent score. We believe this is particularly true for those 
clinicians with lower performance who will be incentivized to begin 
improving with the opportunity to increase their improvement 
significantly and achieve a higher improvement percent score.
    We propose to award an ``improvement percent score'' based on the 
following formula:

Improvement percent score = (increase in quality performance category 
achievement percent score from prior performance period to current 
performance period/prior year quality performance category achievement 
percent score) * 10 percent.

    Using the example from Table 27, the quality performance category 
achievement percent score for the current performance period is 60 
percent, and the previous performance period achievement percent score 
is 50 percent. The increase in achievement is 10 percentage points (60 
percent--50 percent). Therefore, the improvement percent score is 10 
percent (increase in achievement)/50 percent (previous performance 
period achievement percent score) * 10 percent = 2 percentage points. 
Another way to explain the logic is a 20 percent rate of improvement 
for achievement (for example increasing the achievement percent score 
10 percentage points which is 20 percent higher than the original 50 
percent achievement percent score) is worth a 2 percentage point 
increase to the quality performance category achievement percent score.
    We believe that this improvement scoring methodology provides an 
easily explained and applied approach that is consistent for all MIPS 
eligible clinicians. Additionally, it provides additional incentives 
for MIPS eligible clinicians who are lower performers to improve 
performance. We believe that providing larger incentives for MIPS 
eligible clinicians with lower quality performance category scores to 
improve will not only increase the quality performance category scores 
but also will have the greatest impact on improving quality for 
beneficiaries.
    We also propose that the improvement percent score cannot be 
negative (that is, lower than zero percentage points). The improvement 
percent score would be zero for those who do not have sufficient data 
or who are not eligible under our proposal for improvement points. For 
example, as noted in section II.C.7.a.(2)(i)(ii) of this proposed rule, 
a MIPS eligible clinician would not be eligible for improvement if the 
clinician was not eligible for MIPS

[[Page 30118]]

in the prior performance period and did not have a quality performance 
category achievement percent score. We are also proposing to cap the 
size of the improvement award at 10 percentage points, which we believe 
appropriately rewards improvement and does not outweigh percentage 
points available through achievement. In effect, 10 percentage points 
under our proposed formula would represent 100 percent improvement--or 
doubling of achievement measure points--over the immediately preceding 
period. For the reasons stated, we anticipate that this amount will 
encourage participation by individual MIPS eligible clinicians and 
groups and will provide an appropriate recognition and award for the 
largest increases in performance improvement.
    Table 28 illustrates examples of the proposed improvement percent 
scoring methodology, which is based on rate of increase in quality 
performance category achievement percent scores.

  Table 28--Improvement Scoring Examples Based on Rate of Increase in Quality Performance Category Achievement
                                                 Percent Scores
----------------------------------------------------------------------------------------------------------------
                               Year 1 quality  Year 2 quality
                                performance      performance
                                  category        category       Increase in        Rate of        Improvement
                                achievement      achievement     achievement      improvement     percent score
                               percent score    percent score
----------------------------------------------------------------------------------------------------------------
Individual Eligible           5% (Will                     50  20% Because the  20%/30%= 0.67..  0.67*10% = 6.7%
 Clinician #1 (Pick your       substitute 30%                   year 1 score                      No cap needed.
 Pace Test Option).            which is the                     is below 30%,
                               lowest score a                   we measure
                               clinician can                    improvement
                               achieve with                     above 30%.
                               complete
                               reporting in
                               year 1.).
Individual Eligible           60%............              66  6%.............  6%/60%= 0.10...  0.10*10% = 1.0%
 Clinician #2.                                                                                    No cap needed.
Individual Eligible           90%............              93  3%.............  3%/90%= 0.033..  0.033*10% =
 Clinician #3.                                                                                    0.3% No cap
                                                                                                  needed.
Individual Eligible           30%............              70  40%............  40%/30%=1.33...  1.33*10%=13.3%
 Clinician #4.                                                                                    Apply cap at
                                                                                                  10%.
----------------------------------------------------------------------------------------------------------------

    We also considered an alternative to measuring the rate of 
improvement. The alternative would use band levels to determine the 
improvement points for MIPS eligible clinicians who qualify for 
improvement points. Under the band level methodology, a MIPS eligible 
clinician's improvement points would be determined by an improvement in 
the quality performance category achievement percent score from 1 year 
to the next year to determine improvement in the same manner as set 
forth in the rate of improvement methodology. However, for the band 
level methodology, an improvement percent score would then be assigned 
by taking into account a portion (50, 75 or 100 percent) of the 
improvement in achievement, based on the clinician's performance 
category achievement percent score for the prior year. Bands would be 
set for category achievement percent scores, with increases from lower 
category achievement scores earning a larger portion (percentage) of 
the improvement points. Under this alternative, simple improvement 
percentage points for improvement are awarded to MIPS eligible 
clinicians whose category scores improved across years according to the 
band level, up to a maximum of 10 percent of the total score.
    In Table 29, we illustrate the band levels we considered as part of 
this alternative proposal. The chart depicts the band level and the 
improvement points allotted for the increases in improvement scores 
that fall within the transition year score range.

  Table 29--Band Level and Improvement Points Allotted for Determining
                       Improvement Percent Scores
------------------------------------------------------------------------
                                            % Credit for each percent
      Transition year score range            increase in achievement
------------------------------------------------------------------------
1-50...................................  100% of increase in
                                          achievement.
51-75..................................  75% of increase in achievement.
75-100.................................  50% of increase in achievement.
------------------------------------------------------------------------

    Table 30 illustrates examples of the improvement scoring 
methodology based on band levels. Generally, this methodology would 
generate a higher improvement percent score for clinicians; however, we 
believe the policy we proposed would provide a score that better 
represents true improvement at the performance category level, rather 
than comparing simple increases in performance category scores.

[[Page 30119]]



                   Table 30--Examples of Improvement Scoring Methodology Based on Band Levels
----------------------------------------------------------------------------------------------------------------
                                Year 1 quality  Year 2 quality
                                 performance      performance                       Band for       Improvement
                                   category        category       Increase in      improvement    percent score
                                 achievement      achievement     achievement      adjustment    (after applying
                                percent score    percent score                                       the cap)
----------------------------------------------------------------------------------------------------------------
Individual Eligible Clinician  5% (Will                    50%  20% Because the            100%  20%*100%= 20%
 #1 (Pick your Pace Test        substitute 30%                   year 1 score                     which is
 Option).                       which is the                     is below 30%,                    capped at 10%.
                                lowest score a                   we measure
                                clinician can                    improvement
                                achieve with                     above 30%.
                                complete
                                reporting in
                                year 1.)
Individual Eligible Clinician  60%............             66%  6%.............             75%  6%*75%= 4.5% No
 #2.                                                                                              cap needed
Individual Eligible Clinician  90%............             93%  3%.............             50%  3%*50%= 1.5% No
 #3.                                                                                              cap needed
----------------------------------------------------------------------------------------------------------------

    In addition, we considered another alternative that would adopt the 
improvement scoring methodology of the Shared Savings Program\11\ for 
CMS Web Interface submissions in the quality performance category, but 
decided to not adopt this approach. Under the Shared Savings Program 
approach, eligible clinicians and groups that submit through the CMS 
Web Interface would have been required to submit on the same set of 
quality measures, and we would have awarded improvement for all 
eligible clinicians or groups who submitted complete data in the prior 
year. As Shared Savings Program and Next Generation ACOs report using 
the CMS Web Interface, using the same improvement score approach would 
align MIPS with these other programs. We believed it could be 
beneficial to align improvement between the programs because it would 
align incentives for those who participate in the Shared Savings 
Program or ACOs. The Shared Savings Program approach would test each 
measure for statistically significant improvement or statistically 
significant decline. We would sum the number of measures with a 
statistically significant improvement and subtract the number of 
measures with a statistically significant decline to determine the Net 
Improvement. We would next divide the Net Improvement in each domain by 
the number of eligible measures in the domain to calculate the 
Improvement Score. We would cap the number of possible improvement 
percentage points at 10.
---------------------------------------------------------------------------

    \11\ For additional information on the Shared Savings Program's 
scoring methodology, we refer readers to the Quality Measurement 
Methodology and Resources, September 2016, Version 1 and the 
Medicare Shared Savings Program Quality Measure Benchmarks for the 
2016 and 2017 Reporting Years (available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/MSSP-QM-Benchmarks-2016.pdf.)
---------------------------------------------------------------------------

    We considered the Shared Savings Program methodology because it 
would promote alignment with ACOs. We ultimately decided not to adopt 
this scoring methodology because we believe having a single performance 
category level approach for all quality performance category scores 
encourages a uniformity in our approach to improvement scoring and 
simplifies the scoring rules for MIPS eligible clinicians. It also 
allows us greater flexibility to compare performance scores across the 
diverse submission mechanisms, which makes improvement scoring more 
broadly available to eligible clinicians and groups that elect 
different ways of participating in MIPS.
    We propose to add regulatory text at Sec.  
414.1380(b)(1)(xvi)(C)(3) to state that an improvement percent score 
cannot be negative (that is, lower than zero percentage points). We 
also propose to add regulatory text at Sec.  414.1380(b)(1)(xvi)(C)(1) 
to state that improvement scoring is awarded based on the rate of 
increase in the quality performance category achievement percent score 
of individual MIPS eligible clinicians or groups from the current MIPS 
performance period compared to the score in the year immediately prior 
to the current MIPS performance period. We also propose to add 
regulatory text at Sec.  414.1380(b)(1)(xvi)(C)(2) to state that an 
improvement percent score is calculated by dividing the increase in the 
quality performance category achievement percent score of an individual 
MIPS eligible clinician or group, which is calculated by comparing the 
quality performance category achievement percent score the current MIPS 
performance period to the quality performance category achievement 
percent score from the MIPS performance period in the year immediately 
prior to the current MIPS performance period, by the prior year quality 
performance category achievement percent score, and multiplying by 10 
percent.
    We invite public comments on our proposal to calculate improvement 
scoring using a methodology that awards improvement points based on the 
rate of improvement and, alternatively, on rewarding improvement at the 
band level or using the Shared Saving Program approach for CMS Web 
Interface submissions.
(j) Calculating the Quality Performance Category Percent Score 
Including Improvement
    In the CY 2017 Quality Payment Program final rule, we finalized at 
Sec.  414.1380(b)(1)(xv) that the quality performance category score is 
the sum of all points assigned for the measures required for the 
quality performance category criteria plus bonus points, divided by the 
sum of total possible points (81 FR 77300). Using the terminology 
proposed in section II.C.7.a.(2) of this proposed rule, this formula 
can be represented as:

Quality performance category percent score = (total measure achievement 
points + measure bonus points)/total available measure achievement 
points.

    We propose to incorporate the improvement percent score, which is 
proposed in section II.C.7.a.(2)(i)(i) of this proposed rule, into the 
quality performance category percent score. We propose to amend Sec.  
414.1380(b)(1)(xv) (redesignated as Sec.  414.1380(b)(1)(xvii)) to add 
the improvement percent score (as calculated pursuant to proposed 
paragraph (b)(1)(xvi)(A) through (F)) to the quality performance score. 
We also propose to amend Sec.  414.1380(b)(1)(xv) (redesignated as 
Sec.  414.1380(b)(1)(xvii)) to amend the text that states the quality 
performance category percent score cannot exceed the total possible 
points for the quality performance category to clarify that the total 
possible points for

[[Page 30120]]

the quality performance category cannot exceed 100 percentage points. 
Thus, the calculation for the proposed quality performance category 
percent score including improvement, can be summarized in the following 
formula:

Quality performance category percent score = ([total measure 
achievement points + measure bonus points]/total available measure 
achievement points) + improvement percent score, not to exceed 100 
percent.

    This same formula and logic will be applied for both CMS Web 
Interface and Non-CMS Web Interface reporters.
    Table 31 illustrates an example of calculating the quality 
performance category percent score including improvement for a non-CMS 
Web Interface reporter. In this example, an individual MIPS eligible 
clinician received measure achievement points for their 6 required 
measures, and received 6 measure bonus points. Because this is an 
individual clinician and the administrative claims based measure is not 
applicable, the total available measure achievement points for this 
clinician is 60. The improvement percent score would be calculated 
based on the proposal in section II.C.7.a.(2)(i) of this proposed rule; 
Table 31 does not illustrate the underlying calculations for the 
improvement percent score. To calculate the quality performance 
category percent score, the total measures achievement points would be 
summed with the total measure bonus points and then divided by the 
total available measure achievement points. The improvement percent 
score would be added to that calculation. The resulting quality 
performance category percent score cannot exceed 100 percentage points.

                            Table 31--Example of Scoring the Quality Performance Category Percent Score Including Improvement
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                       Total
                                   Total measure                     available                                  Improvement
                                    achievement    Total measure      measure        Calculation prior to      percent score      Quality performance
                                      points       bonus points     achievement           improvement               (%)         category percent score
                                                                      points
--------------------------------------------------------------------------------------------------------------------------------------------------------
Individual Eligible Clinician...            35.6               6              60  (35.6 + 6)/60 = 69.33%....             1.9  69.33% + 1.9% = 71.23%
Individual Eligible Clinician               35.6               6              60  (35.6 + 6)/60 = 69.33%....               0  69.33% + 0% = 69.33%
 (did not submit in Year 1).
Individual Eligible Clinician                 50               6              60  (50 + 6)/60 = 93.33%......              10  93.33% + 10% = 103.33%,
 (with maximum improvement).                                                                                                   which is capped at 100%
--------------------------------------------------------------------------------------------------------------------------------------------------------

    We note that the quality performance category percent score is then 
multiplied by the performance category weight for calculating the final 
score.
    We invite public comment on this overall methodology and formula 
for calculating the quality performance category percent score.
(3) Scoring the Cost Performance Category
    We score the cost performance category using a methodology that is 
generally consistent with the methodology used for the quality 
performance category. In the CY 2017 Quality Payment Program final rule 
(81 FR 77309), we codified at Sec.  414.1380(b)(2) that a MIPS eligible 
clinician receives 1 to 10 achievement points for each cost measure 
attributed to the MIPS eligible clinician based on the MIPS eligible 
clinician's performance compared to the measure benchmark. We establish 
a single benchmark for each cost measure and base those benchmarks on 
the performance period (81 FR 77309). Because we base the benchmarks on 
the performance period, we will not be able to publish the actual 
numerical benchmarks in advance of the performance period (81 FR 
77309). We develop a benchmark for a cost measure only if at least 20 
groups (for those MIPS eligible clinicians participating in MIPS as a 
group practice) or TIN/NPI combinations (for those MIPS eligible 
clinicians participating in MIPS as an individual) can be attributed 
the case minimum for the measure (81 FR 77309). If a benchmark is not 
developed, the cost measure is not scored or included in the 
performance category (81 FR 77309). For each set of benchmarks, we 
calculate the decile breaks based on cost measure performance during 
the performance period and assign 1 to 10 achievement points for each 
measure based on which benchmark decile range the MIPS eligible 
clinician's performance on the measure is between (81 FR 77309 through 
77310). We also codified at Sec.  414.1380(b)(2)(iii) that a MIPS 
eligible clinician's cost performance category score is the equally-
weighted average of all scored cost measures (81 FR 77311).
    In the CY 2017 Quality Payment Program final rule (81 FR 77311), we 
adopted a final policy to not calculate a cost performance category 
score if a MIPS eligible clinician or group is not attributed any cost 
measures because the MIPS eligible clinician or group has not met the 
case minimum requirements for any of the cost measures or a benchmark 
has not been created for any of the cost measures that would otherwise 
be attributed to the clinician or group. We inadvertently failed to 
include this policy in the regulation text and are proposing to codify 
it under Sec.  414.1380(b)(2)(v).
    For more of the statutory background and descriptions of our 
current policies for the cost performance category, we refer readers to 
the CY 2017 Quality Payment Program final rule (81 FR 77308 through 
77311).
    In section II.C.7.a.(3)(a) of this proposed rule, we propose to add 
improvement scoring to the cost performance category scoring 
methodology starting with the 2020 MIPS payment year. We do not propose 
any changes to the methodology for scoring achievement in the cost 
performance category for the 2020 MIPS payment year other than the 
method used for facility-based measurement described in II.C.7.a.(4) of 
this proposed rule. We are proposing a change in terminology to refer 
to the ``cost performance category percent score in order to be 
consistent with the terminology used in the quality performance 
category. In section II.C.7.a.(2) of this proposed rule, we propose to 
calculate a ``quality performance category percent score'' which is 
reflective of performance in the quality performance category based on 
dividing the sum of total measure achievement points and bonus points 
by the total available measure achievement points. We propose to revise 
Sec.  414.1380(b)(2)(iii) to provide that a

[[Page 30121]]

MIPS eligible clinician's cost performance category percent score is 
the sum of the following, not to exceed 100 percent: The total number 
of achievement points earned by the MIPS eligible clinician divided by 
the total number of available achievement points (which can be 
expressed as a percentage); and the cost improvement score. This 
terminology change to refer to the score as a percentage is consistent 
with the change in section II.C.7.a.(2) for the quality performance 
category. We discuss our proposals for improvement scoring in the cost 
performance category in section II.C.7.b.3.(a) of this proposed rule.
(a) Measuring Improvement
(i) Calculating Improvement at the Cost Measure Level
    In section II.C.7.a.(1)(b) of this proposed rule, we propose to 
make available to MIPS eligible clinicians and groups a method of 
measuring improvement in the quality and cost performance categories. 
In section II.C.7.a.(2)(i) of this proposed rule, for the quality 
performance category, we propose to assess improvement on the basis of 
the score at the performance category level. For the cost performance 
category, similar to the quality performance category, we propose at 
Sec.  414.1380(b)(2)(iv) that improvement scoring is available to MIPS 
eligible clinicians and groups that demonstrate improvement in 
performance in the current MIPS performance period compared to their 
performance in the immediately preceding MIPS performance period (for 
example, demonstrating improvement in the 2018 MIPS performance period 
over the 2017 MIPS performance period).
    In section II.C.7.a.(2)(i) of this proposed rule, we note the 
various challenges associated with attempting to measure improvement in 
the quality performance category at the measure level, given the many 
opportunities available to clinicians to select which measures to 
report. The cost performance category is not subject to this same issue 
of measure selection. Cost measures are calculated based on Medicare 
administrative claims data maintained by CMS, without any additional 
data input from or reporting by clinicians, and MIPS eligible 
clinicians are not given the opportunity to select which cost measures 
apply to them. We believe that there are advantages to measuring cost 
improvement at the measure level. Principally, MIPS eligible clinicians 
could see their performance on each cost measure and better understand 
how practice improvement changes can drive changes for each specific 
cost measure. Additionally, as discussed in section II.C.7.a.(1)(b)(i) 
of this proposed rule, other Medicare value-based purchasing programs 
generally assess performance improvement at the measure level. 
Therefore, we propose at section Sec.  414.1380(b)(2)(iv)(A) to measure 
cost improvement at the measure level for the cost performance 
category.
    As described in section II.C.7.a.(1)(b)(ii) of this proposed rule, 
we believe that we would have data sufficient to measure improvement 
when we can measure performance in the current performance period 
compared to the prior performance period. Due to the differences in our 
proposals for measuring improvement for the quality and cost 
performance categories, such as measuring improvement at the measure 
level versus the performance category level, we are proposing a 
different data sufficiency standard for the cost performance category 
than for the quality performance category, which is proposed in section 
II.C.7.a.(2)(i)(ii) of this proposed rule. First, for data sufficient 
to measure improvement to be available for the cost performance 
category, the same cost measure(s) would need to be specified for the 
cost performance category for 2 consecutive performance periods. For 
the 2020 MIPS payment year, only 2 cost measures, the MSPB measure and 
the total per capita cost measure, would be eligible for improvement 
scoring. For a measure to be scored in either performance period, a 
MIPS eligible clinician would need to have a sufficient number of 
attributed cases to meet or exceed the case minimum for the measure.
    In addition, a clinician would have to report for MIPS using the 
same identifier (TIN/NPI combination for individuals, TIN for groups, 
or virtual group identifiers for virtual groups) and be scored on the 
same measure(s) for 2 consecutive performance periods. We wish to 
encourage action on the part of clinicians in reviewing and 
understanding their contribution to patient costs. For example, a 
clinician who is shown to have lower performance on the MSPB measure 
could focus on the efficient use of post-acute care and be able to see 
that improvement reflected in the cost improvement score in future 
years. This review could highlight opportunities for better stewardship 
of healthcare costs such as better recognition of unnecessary costs 
related to common ordering practices. For these reasons, we believe 
that improvement should be evaluated only when there is a consistent 
identifier.
    Therefore, for the cost performance category, we are proposing at 
Sec.  414.1380(b)(2)(iv)(B) that we would calculate a cost improvement 
score only when data sufficient to measure improvement is available. We 
are proposing that sufficient data would be available when a MIPS 
eligible clinician participates in MIPS using the same identifier in 2 
consecutive performance periods and is scored on the same cost 
measure(s) for 2 consecutive performance periods (for example, in the 
2017 MIPS performance period and the 2018 MIPS performance period). If 
the cost improvement score cannot be calculated because sufficient data 
is not available, we are proposing to assign a cost improvement score 
of zero percentage points. While the total available cost improvement 
score would be limited at first because only 2 cost measures would be 
included in both the first and second performance periods of the 
program (total per capita cost and MSPB), more opportunities for 
improvement scoring would be available in the future as additional cost 
measures, including episode-based measures, are added in future 
rulemaking. MIPS eligible clinicians would be able to review their 
performance feedback and make improvements compared to the score in 
their previous feedback.
    We invite public comments on these proposals.
(ii) Improvement Scoring Methodology
    In section II.C.7.a.(1)(b)(i) of this proposed rule, we discuss a 
number of different programs and how they measure improvement at the 
category or measure level as part of their scoring systems. For 
example, the Hospital Value-Based Purchasing (VBP) Program awards 
either measure improvement or measure achievement, but not both. In the 
proposed method for the quality performance category, we compare the 
overall rate of achievement on all the underlying measures in the 
quality performance category and measure a rate of overall improvement 
to calculate an improvement percent score. We then add the improvement 
percent score after taking into account measure achievement points and 
measure bonus points as described in proposed Sec.  
414.1380(b)(1)(xvii). In reviewing the methodologies that are specified 
in section II.C.7.a.(1)(b)(i) of this proposed rule that include 
consideration of improvement at the measure level, we noted that the 
methodology used in the Shared Savings Program would best reward 
achievement and improvement

[[Page 30122]]

for the cost performance category because this program includes 
measures for clinicians, the methodology is straightforward, and it 
only recognizes significant improvement. We propose to quantify 
improvement in the cost performance category by comparing the number of 
cost measures with significant improvement in performance and the 
number of cost measures with significant declines in performance. We 
propose at Sec.  414.1380(b)(2)(iv)(C) to determine the cost 
improvement score by subtracting the number of cost measures with 
significant declines from the number of cost measures with significant 
improvement, and then dividing the result by the number of cost 
measures for which the MIPS eligible clinician or group was scored in 
both performance periods, and then multiplying the result by the 
maximum cost improvement score. For the 2020 MIPS payment year, 
improvement scoring would be possible for the total per capita cost 
measure and the MSPB measure as those 2 measures would be available for 
2 consecutive performance periods under our proposals in section 
II.C.6.d.(3)(a). As in our proposed quality improvement methodology, we 
propose at Sec.  414.1380(b)(2)(iv)(D) that the cost improvement score 
could not be lower than zero, and therefore, could only be positive.
    We propose to determine whether there was a significant improvement 
or decline in performance between the 2 performance periods by applying 
a common standard statistical test, a t-test, as is used in the Shared 
Savings Program (79 FR 67930 through 67931). The t-test's statistical 
significance and the t-test's effect size are the 2 primary outputs of 
the t-test. Statistical significance indicates whether the difference 
between sample averages is likely to represent an actual difference 
between populations and the effect size indicates whether that 
difference is large enough to be practically meaningful. Statistical 
significance testing in this case assesses how unlikely it is that 
differences as large as those observed would be due to chance when the 
performance is actually the same. The test recognizes and appropriately 
adjusts measures at both high and low levels of performance for 
statistically significant levels of change. However, as an alternative, 
we welcome public comments on whether we should consider instead 
adopting an improvement scoring methodology that measures improvement 
in the cost performance category the same way we propose to do in the 
quality performance category; that is, using the rate of improvement 
and without requiring statistical significance. We refer readers to 
section II.C.7.a.(2)(i) of this proposed rule for our proposal related 
to measuring improvement in the quality performance category.
    Section 1848(q)(5)(D)(ii) of the Act specifies that the Secretary 
may assign a higher scoring weight under subparagraph (F) with respect 
to the achievement of a MIPS eligible clinician than with respect to 
any improvement of such clinician with respect to a measure, activity, 
or category described in paragraph (2). We believe that there are many 
opportunities for clinicians to actively work on improving their 
performance on cost measures, through more active care management or 
reductions in certain services. However, we recognize that most 
clinicians are still learning about their opportunities in cost 
measurement. We aim to continue to educate clinicians about 
opportunities in cost measurement and continue to develop opportunities 
for robust feedback and measures that better recognize the role of 
clinicians. Since MIPS is still in its beginning years and we 
understand that clinicians are working hard to understand how we 
measure costs for purposes of the cost performance category, as well as 
how we score their performance in all other aspects of the program, we 
believe improvement scoring in the cost performance category should be 
limited to avoid creating additional confusion. Based on these 
considerations, we propose in section II.C.6.d.(2) of this proposed 
rule to weight the cost performance category at zero percent for the 
2020 MIPS payment year/2018 MIPS performance period. With the entire 
cost performance category proposed to be weighted at zero percent, we 
believe that the focus of clinicians should be on achievement as 
opposed to improvement, and therefore we propose at Sec.  
414.1380(b)(2)(iv)(E) that although improvement would be measured 
according to the method described above, the maximum cost improvement 
score for the 2020 MIPS payment year would be zero percentage points. 
Section 1848(q)(5)(D)(ii) of the Act provides discretion for the 
Secretary to assign a higher scoring weight under subparagraph (F), 
which refers to section 1848(q)(5)(F) of the Act, with respect to 
achievement than with respect to improvement. Section 1848(q)(5)(F) of 
the Act provides if there are not sufficient measures and activities 
applicable and available to each type of MIPS eligible clinician, the 
Secretary shall assign different scoring weights (including a weight of 
zero) for measures, activities, and/or performance categories. When 
read together, we interpret sections 1848(q)(5)(D)(ii) and 
1848(q)(5)(F) of the Act to provide discretion to the Secretary to 
assign a scoring weight of zero for improvement on the measures 
specified for the cost performance category. Under the improvement 
scoring methodology we have proposed, we believe a maximum cost 
improvement score of zero would be effectively the same as a scoring 
weight of zero. As a result of our proposal, the cost improvement score 
would not contribute to the cost performance category percent score 
calculated for the 2020 MIPS payment year. In other words, we would 
calculate a cost improvement score, but the cost improvement score 
would not contribute any points to the cost performance category 
percent score for the 2020 MIPS payment year.
    In section II.C.6.d.(2) of this proposed rule, we consider an 
alternative to make no changes to the previously finalized weight of 10 
percent for the cost performance category for the 2020 MIPS payment 
year. If we finalize this alternative, we believe that improvement 
should be given weight towards the cost performance category percent 
score, but it should still be limited. Therefore, we propose that if we 
maintain a weight of 10 percent for the cost performance category for 
the 2020 MIPS payment year, the maximum cost improvement score 
available in the cost performance category would be 1 percentage point 
out of 100 percentage points available for the cost performance 
category percent score. If a clinician were measured on only one 
measure consistently from one performance period to the next and met 
the requirements for improvement, the clinician would receive one 
improvement percentage point in the cost performance category percent 
score. If a clinician were measured on 2 measures consistently, 
improved significantly on one, and did not show significant improvement 
on the other (as measured by the t-test method described above), the 
clinician would receive 0.5 improvement percentage points.
    We invite comments on these proposals as well as alternative ways 
to measure changes in statistical significance for the cost measure.
(b) Calculating the Cost Performance Category Percent Score With 
Achievement and Improvement
    In section II.C.7.a.(1)(b) of this proposed rule, we evaluated 
different improvement scoring options used in other CMS programs. In 
those programs, we saw 2 general methods for

[[Page 30123]]

incorporating improvement. One method measures both achievement and 
improvement and takes the higher of the 2 scores for each measure that 
is compared. The Hospital VBP Program incorporates such a methodology. 
The second method is to calculate an achievement score and then add an 
improvement score if improvement is measured. The Shared Savings 
Program utilizes a similar methodology for measuring improvement. For 
the cost performance category, we are proposing to evaluate improvement 
at the measure level, unlike the quality performance category where we 
are proposing to evaluate improvement at the performance category 
level. For both the quality performance category and the cost 
performance category, we are proposing to add improvement to an 
existing category percent score. We believe this is the most straight-
forward and simple way to incorporate improvement. It is also 
consistent with other Medicare programs that reward improvement.
    As noted in section II.7.b.(3) of this proposed rule, we have 
proposed a change in terminology to express the cost performance 
category percent score as a percentage. We propose to revise Sec.  
414.1380(b)(2)(iii) to provide that a MIPS eligible clinician's cost 
performance category percent score is the sum of the following, not to 
exceed 100 percent: The total number of achievement points earned by 
the MIPS eligible clinician divided by the total number of available 
achievement points (which can be expressed as a percentage); and the 
cost improvement score. With these two proposed changes, the formula 
would be (Cost Achievement Points/Available Cost Achievement Points) + 
(Cost Improvement Score) = (Cost Performance Category Percent Score).
    We invite public comments on these proposals.
    In Table 32, we provide an example of cost performance category 
percent scores along with the determination of improvement or decline. 
For illustrative purposes, we are using the alternative proposal of a 
maximum cost improvement score of 1. This example is for group 
reporting where the group is measured on both the total per capita cost 
measure and the MSPB measure for 2 consecutive performance periods.

           Table 32--Example of Assessing Achievement and Improvement in the Cost Performance Category
----------------------------------------------------------------------------------------------------------------
                                                                                    Significant     Significant
                                                      Measure     Total possible    improvement    decline from
                     Measure                        achievement       measure       from prior         prior
                                                   points earned    achievement     performance     performance
                                                   by the group       points          period          period
----------------------------------------------------------------------------------------------------------------
Total per Capita Cost Measure...................             8.2              10             Yes              No
MSPB Measure....................................             6.4              10              No              No
----------------------------------------------------------------------------------------------------------------

    In this example, there are 20 total possible measure achievement 
points and 14.6 measure achievement points earned by the group, and the 
group improved on one measure but not the other, with both measures 
being scored in each performance period. The cost improvement score 
would be determined as follows: ((1 measure with significant 
improvement-zero measures with significant decline)/2 measures) * 1 
percentage point = 0.5 percentage points. Under the proposed revised 
formula, the cost performance category percent score would be (14.6/20) 
+ 0.5% = 73.5%.
    As discussed in section II.C.7.b.(2) of this proposed rule, in 
determining the MIPS final score, the cost performance category percent 
score is multiplied by the cost performance category weight. For the 
2020 MIPS payment year, if we finalize the cost performance category 
weight of zero percent, then the cost performance category percent 
score will not contribute to the final score.
(4) Facility-Based Measures Scoring Option for the 2020 MIPS Payment 
Year for the Quality and Cost Performance Categories
(a) Background
    Section 1848(q)(2)(C)(ii) of the Act provides that the Secretary 
may use measures used for payment systems other than for physicians, 
such as measures for inpatient hospitals, for purposes of the quality 
and cost performance categories. However, the Secretary may not use 
measures for hospital outpatient departments, except in the case of 
items and services furnished by emergency physicians, radiologists, and 
anesthesiologists. In the MIPS and APMs RFI (80 FR 59108), we sought 
comment on how we could best use this authority. We refer readers to 
the CY 2017 Quality Payment Program final rule (81 FR 77127) for a 
summary of these comments.
    As noted in the CY 2017 Quality Payment Program proposed rule (81 
FR 28192), we considered an option for facility-based MIPS eligible 
clinicians to elect to use their institution's performance rates as a 
proxy for the MIPS eligible clinician's quality score. However, we did 
not propose an option for the transition year of MIPS because there 
were several operational considerations that we believed needed to be 
addressed before this option could be implemented. We requested 
comments on the following issues: (1) Whether we should attribute a 
facility's performance to a MIPS eligible clinician for purposes of the 
quality and cost performance categories and under what conditions such 
attribution would be appropriate and representative of the MIPS 
eligible clinician's performance; (2) possible criteria for attributing 
a facility's performance to a MIPS eligible clinician for purposes of 
the quality and cost performance categories; (3) the specific measures 
and settings for which we can use the facility's quality and cost data 
as a proxy for the MIPS eligible clinician's quality and cost 
performance categories; and (4) if attribution should be automatic or 
if an individual MIPS eligible clinician or group should elect for it 
to be done and choose the facilities through a registration process.
    As noted in the CY 2017 Quality Payment Program final rule (81 FR 
77127 through 77130), the majority of the comments we received 
supported attributing a facility's performance to a MIPS eligible 
clinician for purposes of the quality and cost performance categories. 
Some commenters opposed using a facility's quality and cost performance 
as a proxy for MIPS eligible clinicians. Many of these commenters 
expressed the view that facility scores do not represent the individual 
MIPS eligible clinician's performance. In addition, we received 
suggestions on how we should attribute a facility's performance to a 
MIPS eligible clinician, as well as comments suggesting that 
attribution should be voluntary and that the facility's measures should 
be relevant to the MIPS eligible clinician. A full discussion of the 
comments we received

[[Page 30124]]

and our responses can be found in the CY 2017 Quality Payment Program 
final rule (81 FR 77127 through 77130).
    In addition, we have received ongoing feedback from various 
stakeholder associations and individuals regarding facility-based 
measurement for MIPS eligible clinicians, which included: Support for 
MIPS eligible clinicians being able to choose to be assessed in this 
manner; several groups' preference that value-based purchasing and 
quality reporting program measure data be used for facility-based 
scoring; support for a ``hybrid'' approach where MIPS eligible 
clinicians could select both clinician-based measures and facility-
based measures for purposes of MIPS scoring; and a suggested 2-year 
pilot program before expanding facility-based scoring more broadly with 
an emphasis on no negative impact on those who are measured in this 
fashion. We took this feedback, as well as the comments discussed in 
the CY 2017 Quality Payment Program final rule, into consideration when 
developing proposals for the application of facility-based measures.
(b) Facility-Based Measurement
    We believe that facility-based measurement is intended to reduce 
reporting burden on facility-based MIPS eligible clinicians by 
leveraging existing quality data sources and value-based purchasing 
experiences and aligning incentives between facilities and the MIPS 
eligible clinicians who provide services there. In addition, we believe 
that facility-based MIPS eligible clinicians contribute substantively 
to their respective facilities' performance on facility-based measures 
of quality and cost, and that their performance may be better reflected 
by their facilities' performance on such measures.
    Medicare operates both pay-for-reporting programs and pay-for-
performance programs. Pay-for-reporting programs incentivize the act of 
reporting data on quality and/or other measures and activities, 
typically by applying a downward payment adjustment to facilities or 
clinicians, as applicable, that fail to submit data as required by the 
Secretary. This type of program does not adjust payments based on 
performance. In contrast, pay-for-performance programs, such as VBP 
programs, score facilities or clinicians, as applicable, on their 
performance on specified quality and/or other measures and activities 
and adjust payments based on that performance. Pay-for-performance 
programs, such as VBP programs, are more analogous to MIPS given its 
focus on performance and not just reporting. For this reason, we 
believe that facility-based measurement under MIPS should be based on 
pay-for-performance programs rather than pay-for-reporting programs.
    Many Medicare payment systems include a pay-for-performance 
program, such as the Hospital VBP Program, the Skilled Nursing Facility 
VBP Program (SNF VBP), the End Stage Renal Disease Quality Incentive 
Program (ESRD QIP), and the Home Health Value-Based Purchasing Program 
(HHVBP). We believe that clinicians play a role in contributing to 
quality performance in all of these programs. However, we believe that 
a larger and more diverse group of clinicians contributes to quality in 
the inpatient hospital setting than in other settings in which we might 
begin to implement this measurement option. In addition, the inpatient 
hospital setting has a mature value-based purchasing program, first 
established to adjust payment for hospitals in FY 2013 (76 FR 26489). 
Therefore, we believe it is appropriate to implement this scoring 
option in a limited fashion in the first year of incorporating 
additional facility-based measures under MIPS by focusing on inpatient 
hospital measures that are used for certain pay-for-performance 
programs as facility-based measures.
    The inpatient hospital setting includes three distinct pay-for-
performance programs: The Hospital VBP Program, the Hospital 
Readmissions Reduction Program (HRRP), and the Hospital-Acquired 
Condition Reduction Program (HACRP). We believe that the Hospital VBP 
Program is most analogous to the MIPS program at this time because the 
Hospital VBP Program compares facilities on a series of different 
measures that intend to capture the breadth of care provided in a 
facility. In contrast, the HACRP and HRRP each focus on a single type 
of outcome for patients treated in a hospital (safety and readmissions, 
respectively), though we note that these outcomes are critically 
important to health care improvement. The payment adjustments 
associated with those 2 programs are intended to provide negative 
adjustments for poor performance but do not similarly reward high 
performance. In contrast, the Hospital VBP Program compares performance 
among hospitals and rewards high performers and provides negative 
adjustments to poor performers.
    We also considered program timing when determining what Hospital 
VBP Program year to use for facility-based measurement for the 2020 
MIPS payment year. Quality measurement for the FY 2019 Hospital VBP 
Program's performance period will be concluded by December 31, 2017 (we 
refer readers to the finalized FY 2019 performance periods in the FY 
2017 Inpatient Prospective Payment System/Long-Term Care Hospital 
Prospective Payment System Final Rule, 81 FR 57002), and the Hospital 
VBP Program scoring reports (referred to as the Percentage Payment 
Summary Reports) will be provided to participating hospitals not later 
than 60 days prior to the beginning of FY 2019, pursuant to the 
Hospital VBP Program's statutory requirement at section 1886(o)(8) of 
the Act. We further note that hospitals must meet case and measure 
minimums during the performance period to receive a Total Performance 
Score under that Program. We discuss eligibility for facility-based 
measurement in section II.C.7.b.(4)(c) of this proposed rule, and we 
note that the determination of the applicable hospital will be made on 
the basis of a period that overlaps with the applicable Hospital VBP 
Program performance period. Although Hospital VBP Program measures have 
different measurement periods, the FY 2019 measures all overlap from 
January to June in 2017, which also overlaps with our first 12-month 
period to determine MIPS eligibility.
    We believe that MIPS eligible clinicians electing the facility-
based measurement option under MIPS should be able to consider as much 
information as possible when making that decision, including how their 
attributed hospital performed in the Hospital VBP Program because an 
individual clinician is a part of the clinical team in the hospital, 
rather than the sole clinician responsible for care as tracked by 
quality measures. Therefore, we concluded that we should be as 
transparent as possible with MIPS eligible clinicians about their 
potential facility-based scores before they begin data submission for 
the MIPS performance period since this policy option is intended to 
minimize reporting burdens on clinicians that are already participating 
in quality improvement efforts through other CMS programs. We expect 
that MIPS eligible clinicians that would consider facility-based 
scoring would generally be aware of their hospital's performance on its 
quality measures, but believe that providing this information directly 
to clinicians ensures that such clinicians are fully aware of the 
implications of their scoring elections under MIPS. However, we note 
that this policy could conceivably place non-facility-based MIPS 
eligible clinicians at a competitive

[[Page 30125]]

disadvantage since they would not have any means by which to ascertain 
their MIPS measure scores in advance. We view that compromise as a 
necessity to maximize transparency, and we request comment on whether 
this notification in advance of the conclusion of the MIPS performance 
period is appropriate, or if we should consider notifying facility-
based clinicians later in the MIPS performance period or even after its 
conclusion. Notification after the MIPS performance period would 
prevent facility-based clinicians from being able to compare their 
expected MIPS performance category scores under the facility-based 
measurement option with their expected scores under the options 
available to all MIPS eligible clinicians and pick the higher of the 
two. Since higher performance category scores may result in a higher 
final score and a higher MIPS payment adjustment, there is a 
substantial incentive for a clinician to undertake this comparison, a 
comparison unavailable to non-facility-based peers.
    The performance periods proposed in section II.C.5. of this 
proposed rule for the 2020 MIPS payment year occur in 2018, with data 
submission for most mechanisms starting in January 2019. To provide 
potential facility-based scores to clinicians by the time the data 
submission period for the 2018 MIPS performance period begins assuming 
that timeframe is operationally feasible), we believe that the FY 2019 
program year of the Hospital VBP Program, as well as the corresponding 
performance periods, is the most appropriate program year to use for 
purposes of facility-based measurement under the quality and cost 
performance categories for the 2020 MIPS payment year. However, we note 
also that Hospital VBP performance periods can run for periods as long 
as 36 months, and for some FY 2019 Hospital VBP Program measures, the 
performance period begins in 2014. We request comment on whether this 
lengthy performance period duration should override our desire to 
include all Hospital VBP Program measures as discussed further below. 
We propose at Sec.  414.1380(e)(6)(iii) that the performance period for 
facility-based measurement is the performance period for the measures 
for the measures adopted under the value-based purchasing program of 
the facility of the year specified.
    We considered whether we should include the entire set of Hospital 
VBP Program measures for purposes of facility-based measurement under 
MIPS or attempt to differentiate those which may be more influenced by 
clinicians' contribution to quality performance than others. However, 
we believe that clinicians have a broad and important role as part of 
the healthcare team at a hospital and that attempting to differentiate 
certain measures undermines the team-based approach of facility-based 
measurement. We propose at Sec.  414.1380(e)(6)(i) that the quality and 
cost measures are those adopted under the value-based purchasing 
program of the facility program for the year specified.
    Therefore, we propose for the 2020 MIPS payment year to include all 
the measures adopted for the FY 2019 Hospital VBP Program on the MIPS 
list of quality measures and cost measures. Under this proposal, we 
consider the FY 2019 Hospital VBP Program measures to meet the 
definition of additional system-based measures provided in section 
1848(q)(2)(C)(ii) of the Act, and we propose at Sec.  414.1380(e)(1)(i) 
that facility-based measures available for the 2018 MIPS performance 
period are the measures adopted for the FY 2019 Hospital VBP Program 
year authorized by section 1886(o) of the Act and codified in our 
regulations at Sec. Sec.  412.160 through 412.167. Measures in the FY 
2019 Hospital VBP Program have different performance periods as noted 
in Table 33.
    We request comments on these proposals. We also request comments on 
what other programs, if any, we should consider including for purposes 
of facility-based measurement under MIPS in future program years.
(c) Facility-Based Measurement Applicability
(i) General
    The percentage of professional time a clinician spends working in a 
hospital varies considerably. Some clinicians may provide services in 
the hospital regularly, but also treat patients extensively in an 
outpatient office or another environment. Other clinicians may practice 
exclusively within a hospital. Recognizing the various levels of 
presence of different clinicians within a hospital environment, we seek 
to limit the potential applicability of facility-based measurement to 
those MIPS eligible clinicians with a significant presence in the 
hospital.
    In the CY 2017 Quality Payment Program final rule (81 FR 77238 
through 77240), we adopted a definition of ``hospital-based MIPS 
eligible clinician'' under Sec.  414.1305 for purposes of the advancing 
care information performance category. Section 414.1305 defines a 
hospital-based MIPS eligible clinician as a MIPS eligible clinician who 
furnishes 75 percent or more of his or her covered professional 
services in sites of service identified by the POS codes used in the 
HIPAA standard transaction as an inpatient hospital, on-campus 
outpatient hospital, or emergency room setting, based on claims for a 
period prior to the performance period as specified by CMS. We 
considered whether we should simply use this definition to determine 
eligibility for facility-based measurement under MIPS. However, we are 
concerned that this definition could include many clinicians that have 
limited or no presence in the inpatient hospital setting. We have noted 
that hospital-based clinicians may not have control over important 
aspects of the certified EHR technology that is available in the 
hospital setting (81 FR 77238). In that regard, there is little 
difference between outpatient and inpatient hospital settings. But we 
are proposing to determine a MIPS eligible clinician's quality 
performance category score and cost performance category score based on 
a hospital's Hospital VBP performance, which is based on inpatient 
services. Section 1848(q)(2)(C)(ii) of the Act limits our ability to 
incorporate measures used for hospital outpatient departments. Our 
proposal at section II.C.6.f.(7)(a)(i) of this proposed rule to expand 
the definition of a hospital-based MIPS eligible clinician for the 
advancing care information performance category to include clinicians 
who practice primarily in off-campus outpatient hospitals could include 
clinicians that practice many miles away from the hospital in practices 
which are owned by the hospital, but do not substantially contribute to 
the hospital's Hospital VBP Program performance. As we discuss further 
in this section, the measures used in the Hospital VBP Program are 
focused on care provided in the inpatient setting. We do not believe it 
is appropriate for a MIPS eligible clinician to use a hospital's 
Hospital VBP Program performance for MIPS scoring if they did not 
provide services in that setting.
    Therefore, we believe establishing a different definition for 
purposes of facility-based measurement is necessary to implement this 
option. We also note that, since we are seeking comments above on other 
programs to consider including for purposes of facility-based 
measurement in future years, we believe establishing a separate 
definition that could be expanded as needed for this purpose is 
appropriate. We propose at Sec.  414.1380(e)(2) that a MIPS eligible 
clinician is eligible for facility-based

[[Page 30126]]

measurement under MIPS if they are determined facility-based as an 
individual. We propose at Sec.  414.1380(e)(2)(i) that a MIPS eligible 
clinician is considered facility-based as an individual if the MIPS 
eligible clinician furnishes 75 percent or more of their covered 
professional services (as defined in section 1848(k)(3)(A) of the Act) 
in sites of service identified by the POS codes used in the HIPAA 
standard transaction as an inpatient hospital, as identified by POS 
code 21, or an emergency room, as identified by POS code 23, based on 
claims for a period prior to the performance period as specified by 
CMS. We understand that the services of some clinicians who practice 
solely in the hospital are billed using place of service codes such as 
code 22, reflecting an on-campus outpatient hospital for patients who 
are in observation status. Because there are limits on the length of 
time a Medicare patient may be seen under observation status, we 
believe that these clinicians would still furnish 75 percent or more of 
their covered professional services using POS code 21, but seek comment 
on whether a lower or higher threshold of inpatient services would be 
appropriate. We do not propose to include POS code 22 in determining 
whether a clinician is facility-based because many clinicians who bill 
for services using this POS code may work on a hospital campus but in a 
capacity that has little to do with the inpatient care in the hospital. 
In contrast, we believe those who provide services in the emergency 
room or the inpatient hospital clearly contribute to patient care that 
is captured as part of the Hospital VBP Program because many patients 
who are admitted are admitted through the emergency room. We seek 
comments on whether POS 22 should be included in determining if a 
clinician is facility-based and how we might distinguish those 
clinicians who contribute to inpatient care from those who do not. We 
note that the inclusion of any POS code in our definition is pending 
technical feasibility to link a clinician to a facility under the 
method described in section II.C.7.b.(4)(d) of this proposed rule.
    We note that this more limited definition would mean that a 
clinician who is determined to be facility-based likely would also be 
determined to be hospital-based for purposes of the advancing care 
information performance category, because this proposed definition of 
facility-based is narrower than the hospital-based definition 
established for that purpose. Clinicians would be determined to be 
facility-based through an evaluation of covered professional services 
between September 1 of the calendar year 2 years preceding the 
performance period through August 31 of the calendar year preceding the 
performance period with a 30-day claims run out. For example, for the 
2020 MIPS payment year, where we have adopted a performance period of 
CY 2018 for the quality and cost performance categories, we would use 
the data available at the end of October 2017 to determine whether a 
MIPS eligible clinician is considered facility-based by our definition. 
At that time, those data would include Medicare claims with dates of 
service between September 1, 2016 and August 31, 2017. In the event 
that it is not operationally feasible to use claims from this exact 
time period, we would use a 12-month period as close as practicable to 
September 1 of the calendar year 2 years preceding the performance 
period and August 31 of the calendar year preceding the performance 
period. This determination would allow clinicians to be made aware of 
their eligibility for facility-based measurement near the beginning of 
the MIPS performance period. We believe that this definition allows us 
to identify MIPS eligible clinicians who are significant contributors 
to facilities' care for Medicare beneficiaries and other patients for 
purposes of facility-based measurement.
    We also recognize that in addition to the variation in the 
percentage of time a clinician is present in the hospital, there is 
also great variability in the types of services that clinicians 
perform. Some may be responsible for overall management of patients 
throughout their stay, others may perform a procedure, and others may 
serve a role in supporting diagnostics. We considered whether certain 
clinicians should be identified as eligible for this facility-based 
measurement option based on characteristics in addition to their 
percentage of covered professional services furnished in the inpatient 
hospital or emergency room setting, such as by requiring a certain 
specialty such as hospital medicine or by limiting eligibility to those 
who served in patient-facing roles. However, we believe that all MIPS 
eligible clinicians with a significant presence in the facility play a 
role in the overall performance of a facility, and therefore, are not 
proposing at this time to further limit this option based on 
characteristics other than the percentage of covered professional 
services furnished in an inpatient hospital or emergency room setting. 
Additionally, we believe that allowing facility-based MIPS eligible 
clinicians the most flexibility possible, while still being able to 
accurately measure the value of care those clinicians provide, as we 
continue implementation of the Quality Payment Program is paramount in 
ensuring that clinicians understand the program and its effects on the 
care they provide.
    We request comments on this proposal.
(ii) Facility-Based Measurement Group Participation
    We are also proposing at Sec.  414.1380(e)(2) that a MIPS eligible 
clinician is eligible for facility-based measurement under MIPS if they 
are determined facility-based as part of a group. We are proposing at 
Sec.  414.1380(e)(2)(ii) that a facility-based group is a group in 
which 75 percent or more of the MIPS eligible clinician NPIs billing 
under the group's TIN are eligible for facility-based measurement as 
individuals as defined in Sec.  414.1380(e)(2)(i). We also considered 
an alternative proposal in which a facility-based group would be a 
group where the TIN overall furnishes 75 percent or more of its covered 
professional services (as defined in section 1848(k)(3)(A) of the Act) 
in sites of service identified by the POS codes used in the HIPAA 
standard transaction as an inpatient hospital, as identified by POS 
code 21, or the emergency room, as identified by POS code 23, based on 
claims for a period prior to the performance period as specified by 
CMS. Groups would be determined to be facility-based through an 
evaluation of covered professional services between September 1 of the 
calendar year 2 years preceding the performance period through August 
31 of the calendar year preceding the performance period with a 30 day 
claims run out period (or if not operationally feasible to use claims 
from this exact time period, a 12-month period as close as practicable 
to September 1 of the calendar year 2 years preceding the performance 
period and August 31 of the calendar year preceding the performance 
period).
    We request comments on our proposal and alternative proposal.
(d) Facility Attribution for Facility-Based Measurement
    Many MIPS eligible clinicians provide services at more than one 
hospital, so we must develop a method to identify which hospital's 
scores should be associated with that MIPS eligible clinician under 
this facility-based measurement option. We considered

[[Page 30127]]

whether a clinician should be required to identify for us the hospital 
with which they were affiliated, but felt that such a requirement would 
add unnecessary administrative burden in a process that we believe was 
intended to reduce burden. We also considered whether we could combine 
scores from multiple hospitals, but believe that such a combination 
would reduce the alignment between a single hospital and a clinician or 
group and could be confusing for participants. We believe we must 
establish a reasonable threshold for a MIPS eligible clinician's 
participation in clinical care at a given facility to allow that MIPS 
eligible clinician to be scored using that facility's measures. We do 
not believe it to be appropriate to allow MIPS eligible clinicians to 
claim credit for facilities' measures if the MIPS eligible clinician 
does not participate meaningfully in the care provided at a given 
facility.
    Therefore, we propose at Sec.  414.1380(e)(5) that MIPS eligible 
clinicians who elect facility-based measurement would receive scores 
derived from the value-based purchasing score (using the methodology 
described in section II.B.7.b.4 of this proposed rule) for the facility 
at which they provided services for the most Medicare beneficiaries 
during the period of September 1 of the calendar year 2 years preceding 
the performance period through August 31 of the calendar year preceding 
the performance period with a 30 day claims run out. This mirrors our 
period of determining if a clinician is eligible for facility-based 
measurement and also overlaps with parts of the performance period for 
the applicable Hospital VBP program measures. For the first year, the 
value-based purchasing score for the facility is the FY 2019 Hospital 
VBP Program's Total Performance Score. In cases in which there was an 
equal number of Medicare beneficiaries treated at more than one 
facility, we propose to use the value-based purchasing score from the 
facility with the highest score.
(e) Election of Facility-Based Measurement
    Stakeholders have expressed a strong preference that facility-based 
measurement be a voluntary process, and we agree with this preference 
considering our general goal in making MIPS as flexible as possible. 
Therefore, we propose at Sec.  414.1380(e)(3) that individual MIPS 
eligible clinicians or groups who wish to have their quality and cost 
performance category scores determined based on a facility's 
performance must elect to do so. We propose that those clinicians or 
groups who are eligible for and wish to elect facility-based 
measurement would be required to submit their election during the data 
submission period as determined at Sec.  414.1325(f) through the 
attestation submission mechanism established for the improvement 
activities and advancing care information performance categories. If 
technically feasible, we would let the MIPS eligible clinician know 
that they were eligible for facility-based measurement prior to the 
submission period, so that MIPS eligible clinicians would be informed 
if this option is available to them.
    We also considered an alternative approach of not requiring an 
election process but instead automatically applying facility-based 
measurement to MIPS eligible clinicians and groups who are eligible for 
facility-based measurement, if technically feasible. Under this 
approach, we would calculate a MIPS eligible clinician's facility-based 
measurement score based on the hospital's (as identified using the 
process described in section II.C.6.b. of this proposed rule) 
performance using the methodology described in section II.C.7.a.2.b. of 
this proposed rule, and automatically use that facility-based 
measurement score for the quality and cost performance category scores 
if the facility-based measurement score is higher than the quality and 
cost performance category scores as determined based on data submitted 
by the MIPS eligible clinician through any available reporting 
mechanism. This facility-based measurement score would be calculated 
even if an individual MIPS eligible clinician or group did not submit 
any data for the quality performance category. This option would reduce 
burden for MIPS eligible clinicians by not requiring them to elect 
facility-based measurement, but is contrary to stakeholders' request 
for a voluntary policy. Additionally, under this option, our 
considerations about Hospital VBP Program timing would be less 
applicable. That is, we explained our rationale for specifying the FY 
2019 Hospital VBP Program above, in part to ensure that MIPS eligible 
clinicians are informed about their potential facility-based scores 
prior to the conclusion of the MIPS performance period. However, under 
an automatic process, we could consider automatically using other 
Hospital VBP Program years' scores. For example, we could apply FY 2020 
Hospital VBP Program scores instead of FY 2019. We intend in general to 
align Hospital VBP and MIPS performance periods when feasible, and the 
timing considerations we described above led us to conclude that FY 
2019 was the most appropriate Hospital VBP Program year for the first 
year of the facility-based measurement option under MIPS, and selecting 
other years would result in further divergence between the MIPS 
performance period and the Hospital VBP Program's performance periods. 
We are also concerned that a method that does not require active 
selection may result in MIPS eligible clinicians being scored on 
measures at a facility and being unaware that such scoring is taking 
place. We are also concerned that such a method could provide an 
advantage to those facility-based clinicians who do not submit quality 
measures in comparison to those who work in other environments. We also 
note that this option may not be technically feasible for us to 
implement for the 2018 MIPS performance period.
    We invite comments on this proposal and alternate proposal.
(e) Facility-Based Measures
    For the FY 2019 program year, the Hospital VBP Program has adopted 
13 quality and efficiency measures. The Hospital VBP Program currently 
includes 4 domains: Person and community engagement, clinical care, 
safety, and efficiency and cost reduction. These domains align with 
many MIPS high priority measures (outcome, appropriate use, patient 
safety, efficiency, patient experience, and care coordination measures) 
in the quality performance category and the efficiency and cost 
reduction domain closely aligns with our cost performance category. We 
believe this set of measures covering 4 domains and composed primarily 
of measures that would be considered high priority under the MIPS 
quality performance category capture a broad picture of hospital-based 
care. For example, the HCAHPS survey under the Hospital VBP Program is 
a patient experience measure, which would make it a high-priority 
measure under MIPS. Additionally, the Hospital VBP Program has adopted 
several measures of clinical outcomes in the form of 30-day mortality 
measures, and clinical outcomes are a high-priority topic for MIPS. The 
Hospital VBP Program includes several measures in a Safety domain, 
which meets our definition of patient safety measures as high-priority. 
Therefore, we propose that facility-based individual MIPS eligible 
clinicians or groups that are attributed to a hospital would be scored 
on all the measures on which the hospital is scored for the Hospital 
VBP Program via the Hospital VBP Program's Total

[[Page 30128]]

Performance Score (TPS) scoring methodology.
    The Hospital VBP Program's FY 2019 measures, and their associated 
performance periods, have been reproduced in Table 33 (see 81 FR 56985 
and 57002).

                                 Table 33--FY 2019 Hospital VBP Program Measures
----------------------------------------------------------------------------------------------------------------
             Short name                    Domain/measure name             NQF No.          Performance period
----------------------------------------------------------------------------------------------------------------
                                     Person and Community Engagement Domain
----------------------------------------------------------------------------------------------------------------
HCAHPS..............................  Hospital Consumer Assessment   0166 (0228)          CY 2017
                                       of Healthcare Providers and
                                       Systems (HCAHPS) (including
                                       Care Transition Measure).
----------------------------------------------------------------------------------------------------------------
                                              Clinical Care Domain
----------------------------------------------------------------------------------------------------------------
MORT-30-AMI.........................  Hospital 30-Day, All-Cause,    0230                 July 1, 2014--June 30,
                                       Risk-Standardized Mortality                         2017
                                       Rate (RSMR) Following Acute
                                       Myocardial Infarction (AMI)
                                       Hospitalization.
MORT-30-HF..........................  Hospital 30-Day, All-Cause,    0229                 July 1, 2014--June 30,
                                       Risk-Standardized Mortality                         2017
                                       Rate (RSMR) Following Heart
                                       Failure (HF) Hospitalization.
MORT-30-PN..........................  Hospital 30-Day, All-Cause,    0468                 July 1, 2014--June 30,
                                       Risk-Standardized Mortality                         2017
                                       Rate (RSMR) Following
                                       Pneumonia Hospitalization.
THA/TKA.............................  Hospital-Level Risk-           1550                 January 1, 2015--June
                                       Standardized Complication                           30, 2017
                                       Rate (RSCR) Following
                                       Elective Primary Total Hip
                                       Arthroplasty (THA) and/or
                                       Total Knee Arthroplasty
                                       (TKA).
----------------------------------------------------------------------------------------------------------------
                                                  Safety Domain
----------------------------------------------------------------------------------------------------------------
CAUTI...............................  National Healthcare Safety     0138                 CY 2017
                                       Network (NHSN) Catheter-
                                       Associated Urinary Tract
                                       Infection (CAUTI) Outcome
                                       Measure.
CLABSI..............................  National Healthcare Safety     0139                 CY 2017
                                       Network (NHSN) Central Line-
                                       Associated Bloodstream
                                       Infection (CLABSI) Outcome
                                       Measure.
Colon and Abdominal Hysterectomy SSI  American College of Surgeons-- 0753                 CY 2017
                                       Centers for Disease Control
                                       and Prevention (ACS-CDC)
                                       Harmonized Procedure
                                       Specific Surgical Site
                                       Infection (SSI) Outcome
                                       Measure.
MRSA Bacteremia.....................  National Healthcare Safety     1716                 CY 2017
                                       Network (NHSN) Facility-wide
                                       Inpatient Hospital-onset
                                       Methicillin-resistant
                                       Staphylococcus aureus (MRSA)
                                       Bacteremia Outcome Measure.
CDI.................................  National Healthcare Safety     1717                 CY 2017
                                       Network (NHSN) Facility-wide
                                       Inpatient Hospital-onset
                                       Clostridium difficile
                                       Infection (CDI) Outcome
                                       Measure.
PSI-90*.............................  Patient Safety for Selected    0531                 July 1, 2015--June 30
                                       Indicators (Composite                               2017
                                       Measure).
PC-01...............................  Elective Delivery............  0469                 CY 2017
----------------------------------------------------------------------------------------------------------------
                                      Efficiency and Cost Reduction Domain
----------------------------------------------------------------------------------------------------------------
MSPB................................  Payment-Standardized Medicare  2158                 CY 2017
                                       Spending Per Beneficiary
                                       (MSPB).
----------------------------------------------------------------------------------------------------------------
* PSI-90 has been proposed in the FY 2018 IPPS/LTCH PPS proposed rule for removal beginning with the FY 2019
  program year.

    We note that the Patient Safety Composite Measure (PSI-90) was 
proposed for removal beginning with the FY 2019 measure set in the FY 
2018 IPPS/LTCH proposed rule (82 FR 19970) due to issues with 
calculating the measure score. If the proposal to remove that measure 
from the hospital measure set is finalized, we would remove the measure 
from the list of those adopted for facility-based measurement in the 
MIPS program.
    We propose at Sec.  414.1380(e)(4) that there are no data 
submission requirements for the facility-based measures used to assess 
performance in the quality and cost performance categories, other than 
electing the option through attestation as proposed in section 
II.C.7.a.(4)(e). We also refer readers to section II.C.7. of this 
proposed rule for further details on how we will incorporate scoring 
for facility-based measurements into MIPS.
(f) Scoring Facility-Based Measurement
(i) Hospital VBP Program Scoring
    As we discuss above in subsection (b), we believe that the Hospital 
VBP Program represents the most appropriate value-based purchasing 
program with which to begin implementation of the facility-based 
measurement option under MIPS.
    Section 1886(o) of the Act, as added by section 3001(a)(1) of the 
Affordable Care Act, requires the Secretary to establish a hospital 
value-based purchasing program (the Hospital VBP Program) under which 
value-based incentive payments are made in a fiscal year to hospitals 
that meet performance standards established for a performance period 
for such fiscal year. These value-based incentive payments are funded 
through a reduction to participating hospitals' base-operating DRG 
payment amounts, with the amount of the reduction specified by statute. 
For the FY 2019 program year, that reduction will be equal to 2 
percent. Participating hospitals then receive value-based incentive 
payments depending on their performance on measures adopted

[[Page 30129]]

under the Program. For more detail on the statutory background and 
history of the Hospital VBP Program's implementation, we refer readers 
to 81 FR 56979.
    As noted previously, the FY 2019 Hospital VBP Program will score 
participating hospitals on 13 measures covering 4 domains of care, 
although as discussed in the FY 2018 IPPS/LTCH proposed rule (82 FR 
19970), we have proposed to remove the PSI 90 Patient Safety Composite 
measure from the FY 2019 measure set. For each of the measures, 
performance standards are established for the applicable fiscal year 
that include levels of achievement and improvement. For the FY 2019 
program year, the achievement threshold and benchmark are calculated 
using baseline period data with respect to that fiscal year, with the 
achievement threshold for each of these measures being the median of 
hospital performance on the measure during the baseline period and the 
benchmark for each of these measures being the arithmetic mean of the 
top decile of hospital performance during the baseline period. The 
achievement threshold and benchmark for the MSPB measure are calculated 
using the same methodology, except that we use performance period data 
instead of baseline period data in our calculations. We then calculate 
hospital performance on each measure during the performance period for 
which they have sufficient data and calculate a measure score based on 
that performance as compared with the performance standards that apply 
to the measure. For achievement scoring, those hospitals that perform 
below (or above in the case of measures for which a lower rate is 
better) the level of the achievement threshold are not awarded any 
achievement points. Those that perform between the level of the 
achievement threshold and the benchmark are awarded points based on the 
relative performance of the hospital, according to formulas specified 
by the Hospital VBP Program (see the Hospital Inpatient VBP Program 
final rule, 76 FR 26518 through 26519). Those hospitals whose 
performance meets or exceeds the benchmark are awarded 10 achievement 
points for the measure. Hospitals are also provided the opportunity to 
receive improvement points based on their improvement between the 
baseline period for the measure and the performance period. A hospital 
is awarded between 0 and 10 points for achievement and 0 and 9 points 
for improvement, and is awarded the higher of the 2 scores for each 
individual measure. There are no floors established for scoring and no 
bonus points are available in this scoring system.
    Points awarded for measures within each domain are summed to reach 
the unweighted domain score. We note for the person and community 
engagement domain only, the domain score consists of a base score and a 
consistency score. The base score is based on the greater of 
improvement or achievement points for each of the 8 HCAHPS survey 
dimensions. Consistency points are awarded based on a hospital's lowest 
HCAHPS dimension score during the performance period relative to 
national hospital scores on that dimension during the baseline period. 
The domain scores are then weighted according to domain weights 
specified each Program year, then summed to reach the Total Performance 
Score, which is converted to a value-based incentive payment percentage 
that is used to adjust payments to each hospital for inpatient services 
furnished during the applicable program year. For the FY 2019 program 
year, all 4 domains will be weighted equally. We refer readers to 81 FR 
57005 and 81 FR 79857 through 79858 for additional information on the 
Hospital VBP Program's performance standards, as well as the QualityNet 
Web site for certain technical updates to the performance standards.
(ii) Applying Hospital VBP Program Scoring to the MIPS Quality and Cost 
Performance Categories
    We considered several methods to incorporate facility-based 
measures into scoring for the 2020 MIPS payment year, including 
selecting hospitals' measure scores, domain scores, and the Hospital 
VBP Program Total Performance Scores to form the basis for the cost and 
quality performance category scores for individual MIPS eligible 
clinicians and groups that are eligible to participate in facility-
based measurement. Although each of these approaches may have merit, we 
have proposed the option that we believe provides the fairest 
comparison between performance in the 2 programs and will best allow us 
to expand the opportunity to other programs in the future.
    Unlike MIPS, the Hospital VBP Program does not have performance 
categories. There are instead four domains of measures. We considered 
whether we should try to identify certain domains or measures that were 
more closely aligned with those identified in the quality performance 
category or the cost performance category. We also considered whether 
we should limit the application of facility-based measurement to the 
quality performance category and calculate the cost performance 
category score as we do for other clinicians. However, we believe that 
value-based purchasing programs are generally constructed to assess an 
overall picture of the care provided by the facility, taking into 
account both the costs and the quality of care provided. Given our 
focus on alignment between quality and cost, we also do not believe it 
is appropriate to measure quality on one unit (a hospital) and cost on 
another (such as an individual clinician or TIN). Therefore, we propose 
at Sec.  414.1380(e) that facility-based scoring is available for the 
quality and cost performance categories and that the facility-based 
measurement scoring standard is the MIPS scoring methodology applicable 
for those who meet facility-based eligibility requirements and who 
elect facility-based measurement.
(iii) Benchmarking Facility-Based Measures
    Measures in the MIPS quality performance category are benchmarked 
to historical performance on the basis of performance during the 12-
month calendar year that is 2 years prior to the performance period for 
the MIPS payment year. If a historical benchmark cannot be established, 
a benchmark is calculated during the performance period. In the cost 
performance category, benchmarks are established during the performance 
period because changes in payment policies year to year can make it 
challenging to compare performance on cost measure year to year. 
Although we propose a different performance period for MIPS eligible 
clinicians in facility-based measurement, the baseline period used for 
creating MIPS benchmarks is generally consistent with this approach. We 
note that the Hospital VBP Program uses measures for the same fiscal 
year even if those measures do not have the same performance period 
length, but the baseline period closes well before the performance 
period. The MSPB is benchmarked in a manner that is similar to measures 
in the MIPS cost performance category. The MSPB only uses a historical 
baseline period for improvement scoring and bases its achievement 
threshold and benchmark solely on the performance period (81 FR 57002). 
We propose at Sec.  414.1380(e)(6)(ii) that the benchmarks for 
facility-based measurement are those that are adopted under the value-
based purchasing program of the facility for the year specified.

[[Page 30130]]

(iv) Assigning MIPS Performance Category Scores Based on Hospital VBP 
Performance
    Performance measurement in the Hospital VBP Program and MIPS is 
quite different in part due to the design and the maturity of the 
programs. As noted above, the Hospital VBP Program only assigns 
achievement points to a hospital for its performance on a measure if 
the hospital's performance during the performance period meets or 
exceeds the median of hospital performance on that measure during the 
applicable baseline period, whereas MIPS assigns achievement points to 
all measures that meet the required data completeness and case 
minimums. In addition, the Hospital VBP Program has removed many 
process measures and topped out measures since its first program year 
(FY 2013), while both process and topped out measures are available in 
MIPS. With respect to the FY 2017 program year, for example, the median 
Total Performance Score for a hospital in Hospital VBP was 33.88 out of 
100 possible points. If we were to simply assign the Hospital VBP Total 
Performance Score for a hospital to a clinician, the performance of 
those MIPS eligible clinicians electing facility-based measurement 
would likely be lower than most who participated in the MIPS program, 
particularly in the quality performance category.
    We believe that we should recognize relative performance in the 
facility programs that reflects their different designs. Therefore, we 
propose at Sec.  414.1380(e)(6)(iv) that the quality performance 
category score for facility-based measurement is reached by determining 
the percentile performance of the facility determined in the value-
based purchasing program for the specified year as described under 
Sec.  414.1380(e)(5) and awarding a score associated with that same 
percentile performance in the MIPS quality performance category score 
for those clinicians who are not scored using facility-based 
measurement. We also propose at Sec.  414.1380(e)(6)(v) that the cost 
performance category score for facility-based measurement is 
established by determining the percentile performance of the facility 
determined in the value-based purchasing program for the specified year 
as described in Sec.  414.1380(e)(5) and awarding the number of points 
associated with that same percentile performance in the MIPS cost 
performance category score for those clinicians who are not scored 
using facility-based measurement. For example, if the median Hospital 
VBP Program Total Performance Score was 35 out of 100 possible points 
and the median quality performance category percent score in MIPS was 
75 percent and the median cost performance category score was 50 
percent, then a clinician or group that is evaluated based on a 
hospital that received an Hospital VBP Program Total Performance Score 
of 35 points would receive a score of 75 percent for the quality 
performance category and 50 percent for the cost performance category. 
The percentile distribution for both the Hospital VBP Program and MIPS 
would be based on the distribution during the applicable performance 
periods for each of the programs and not on a previous benchmark year.
    We believe this proposal offers a fairer comparison of the 
performance among participants in MIPS and the Hospital VBP Program 
compared to other options we considered and provides an objective means 
to normalize differences in measured performance between the programs. 
In addition, we believe this method will make it simpler to apply the 
concept of facility-based measurement to additional programs in the 
future.
    We welcome public comments on this proposal.
(v) Scoring Improvement for Facility-Based Measurement
    The Hospital VBP Program includes a methodology for recognizing 
improvement on individual measures which is then incorporated into the 
total performance score for each participating hospital. A hospital's 
performance on a measure is compared to a national benchmark as well as 
its own performance from a corresponding baseline period.
    In this proposed rule, we have proposed to consider improvement in 
the quality and cost performance categories. In section II.C.7.a.(2)(i) 
of this proposed rule, we propose to measure improvement in the quality 
performance category based on improved achievement for the performance 
category percent score and award improvement even if, under certain 
circumstances, a clinician moves from one identifier to another from 1 
year to the next. For those who may be measured under facility-based 
measurement, improvement is already captured in the scoring method used 
by the Hospital VBP Program, so we do not believe it is appropriate to 
separately measure improvement using the proposed MIPS methodology. 
Although the improvement methodology is not identical, a hospital that 
demonstrated improvement in the individual measures would in turn 
receive a higher score through the Hospital VBP Program methodology, so 
that improvement is reflected in the underlying Hospital VBP Program 
measurement. In addition, improvement is already captured in the 
distribution of MIPS performance scores that is used to translate 
Hospital VBP Total Performance Score into a MIPS quality performance 
category score. Therefore, we are not proposing any additional 
improvement scoring for facility-based measurement for either the 
quality or cost performance category.
    Because we intend to allow clinicians the flexibility to elect 
facility-based measurement on an annual basis, some clinicians may be 
measured through facility-based measurement in 1 year and through 
another MIPS method in the next. Because the first MIPS performance 
period in which a clinician could switch from facility-based 
measurement to another MIPS method would be in 2019, we seek comment on 
how to assess improvement for those that switch from facility-based 
scoring to another MIPS method. We request comment on whether it is 
appropriate to include measurement of improvement in the MIPS quality 
performance category for facility-based measured clinicians and groups 
given that the Hospital VBP Program already takes improvement into 
account in its scoring methodology.
    In section II.C.7.a.(3)(a) of this proposed rule, we discuss our 
proposal to measure improvement in the cost performance category at the 
measure level. We propose that clinicians under facility-based 
measurement would not be eligible for a cost improvement score in the 
cost performance category. As in the quality performance category, we 
believe that a clinician participating in facility-based measurement in 
subsequent years would already have improvement recognized as part of 
the Hospital VBP Program methodology and should therefore not be given 
additional credit. In addition, because we propose to limit measurement 
of improvement to those MIPS eligible clinicians that participate in 
MIPS using the same identifier and are scored on the same cost 
measure(s) in 2 consecutive performance periods, those MIPS eligible 
clinicians who elect facility-based measurement would not be eligible 
for a cost improvement score in the cost performance category under our 
proposed methodology because they would not be scored on the same cost 
measure(s) for 2 consecutive performance periods.

[[Page 30131]]

    We invite comments on these proposals.
(vi) Bonus Points for Facility-Based Measurement
    MIPS eligible clinicians that report on quality measures are 
eligible for bonus points for the reporting of additional outcome and 
high priority measures beyond the one that is required. 2 bonus points 
are awarded for each additional outcome or patient experience measure, 
and one bonus point is awarded for each additional other high priority 
measure. These bonus points are intended to encourage the use of 
measures that are more impactful on patients and better reflect the 
overall goals of the MIPS program. Many of the measures in the Hospital 
VBP Program meet the criteria that we have adopted for high-priority 
measures. We support measurement that takes clinicians' focus away from 
clinical process measures; however, our proposed scoring method 
described above is based on a percentile distribution of scores within 
the quality and cost performance categories that already accounts for 
bonus points. For this reason, we are not proposing to calculate 
additional high priority bonus points for facility-based measurement.
    We note that clinicians have an additional opportunity to receive 
bonus points in the quality performance category score for using end-
to-end electronic submission of quality measures. The Hospital VBP 
Program does not capture whether or not measures are reported using 
end-to-end electronic reporting. In addition, our proposed facility-
based scoring method described above is based on a percentile 
distribution of scores within the quality and cost performance 
categories that already accounts for bonus points. For this reason, we 
are not proposing to calculate additional end-to-end electronic 
reporting bonus points for facility-based measurement.
    We welcome public comments on our approach.
(vii) Special Rules for Facility-Based Measurement
    Some hospitals do not receive a Total Performance Score in a given 
year in the Hospital VBP Program, whether due to insufficient quality 
measure data, failure to meet requirements under the Hospital Inpatient 
Quality Reporting Program, or other reasons. In these cases, we would 
be unable to calculate a facility-based score based on the hospital's 
performance, and facility-based clinicians would be required to 
participate in MIPS via another method. Most hospitals which do not 
receive a Total Performance Score in the Hospital VBP Program are 
routinely excluded, such as hospitals in Maryland. In such cases, 
facility-based clinicians would know well in advance that the hospital 
would not receive a Total Performance Score, and that they would need 
to participate in MIPS through another method. However, we are 
concerned that some facility-based clinicians may provide services in 
hospitals which they expect will receive a Total Performance Score but 
do not due to various rare circumstances such as natural disasters. In 
section II.C.7.b.(3)(c) of this proposed rule, we propose a process for 
requesting a reweighting assessment for the quality, cost and 
improvement activities performance categories due to extreme and 
uncontrollable circumstances, such as natural disasters. We propose 
that MIPS eligible clinicians who are facility-based and affected by 
extreme and uncontrollable circumstances, such as natural disasters, 
may apply for reweighting.
    In addition, we note that hospitals may submit correction requests 
to their Total Performance Scores calculated under the Hospital VBP 
Program, and may also appeal the calculations of their Total 
Performance Scores, subject to Hospital VBP Program requirements 
established in prior rulemaking. We intend to use the final Hospital 
VBP Total Performance Score for the facility-based measurement option 
under MIPS. In the event that a hospital obtains a successful 
correction or appeal of its Total Performance Score, we would update 
MIPS eligible clinicians' quality and cost performance category scores 
accordingly, as long as the update could be made prior to the 
application of the MIPS payment adjustment for the relevant MIPS 
payment year. We welcome public comments on whether a different 
deadline should be considered.
    Additionally, although we wish to tie the hospital and clinician 
performance as closely together as possible for purposes of the 
facility-based scoring policy, we do not wish to disadvantage those 
clinicians and groups that select this measurement method. In section 
II.C.7.a.(2) of this proposed rule, we propose to retain a policy 
equivalent to the 3-point floor for all measures with complete data in 
the quality performance category scored against a benchmark in the 2020 
MIPS payment year. However, the Hospital VBP Program does not have a 
corresponding scoring floor. Therefore, we propose to adopt a floor on 
the Hospital VBP Program Total Performance Score for purposes of 
facility-based measurement under MIPS so that any score in the quality 
performance category, once translated into the percentile distribution 
described above, that would result in a score of below 30 percent would 
be reset to a score of 30 percent in the quality performance category. 
We believe that this adjustment is important to maintain consistency 
with our other policies. There is no similar floor established for 
measures in the cost performance category under MIPS, so we do not 
propose any floor for the cost performance category for facility-based 
measurement.
    Some MIPS eligible clinicians who select facility-based measurement 
could have sufficient numbers of attributed patients to meet the case 
minimums for the cost measures established under MIPS. Although there 
is no additional data reporting for cost measures, we believe that, to 
facilitate the relationship between cost and quality measures, they 
should be evaluated covering the same population as opposed to 
comparing a hospital population and a population attributed to an 
individual clinician or group. In addition, we believe that including 
additional cost measures in the cost performance category score for 
MIPS eligible clinicians who elect facility-based measurement would 
reduce the alignment of incentives between the hospital and the 
clinician. Thus, we are proposing at Sec.  414.1380(e)(6)(v)(A) that 
MIPS eligible clinicians who elect facility-based measurement would not 
be scored on other cost measures specified for the cost performance 
category, even if they meet the case minimum for a cost measure.
    If a clinician or a group elects facility-based measurement but 
also submits quality data through another MIPS mechanism, we propose to 
use the higher of the two scores for the quality performance category 
and base the score of the cost performance category on the same method 
(that is, if the facility-based quality performance category score is 
higher, facility-based measurement is used for quality and cost). Since 
this policy may result in a higher final score, it may provide 
facility-based clinicians with a substantial incentive to elect 
facility-based measurement, whether or not the clinician believes such 
measures are the most accurate or useful measures of that clinician's 
performance. Therefore, this policy may create an unfair advantage for 
facility-based clinicians over non-facility-based clinicians, since 
non-facility-based clinicians would not have the opportunity to use the 
higher of two scores. Therefore, we seek comment on whether this 
proposal to use the higher score is the best approach to score the 
performance of facility-based clinicians

[[Page 30132]]

in comparison to their non-facility-based peers.
(5) Scoring the Improvement Activities Performance Category
    Section 1848(q)(5)(C) of the Act specifies scoring rules for the 
improvement activities performance category. For more of the statutory 
background and description of the proposed and finalized policies, we 
refer readers to the CY 2017 Quality Payment Program final rule (81 FR 
77311 through 77319). We have also codified certain requirements for 
the improvement activities performance category at Sec.  
414.1380(b)(3). Based on these criteria, we finalized at Sec.  
414.1380(b)(3) in the CY 2017 Quality Payment Program final rule the 
scoring methodology for this category, which assigns points based on 
certified patient-centered medical home participation or comparable 
specialty practice participation, APM participation, and the 
improvement activities reported by the MIPS eligible clinician (81 FR 
77312). A MIPS eligible clinician's performance will be evaluated by 
comparing the reported improvement activities to the highest possible 
score (40 points). We are not proposing any changes to the scoring of 
the improvement activities performance category in this proposed rule.
(a) Assigning Points to Reported Improvement Activities
    We will assign points for each reported improvement activity within 
2 categories: Medium-weighted and high-weighted activities. Each 
medium-weighted activity is worth 10 points toward the total category 
score of 40 points, and each high-weighted activity is worth 20 points 
toward the total category score of 40 points. These points are doubled 
for small practices, practices in rural areas, or practices located in 
geographic HPSAs, and non-patient facing MIPS eligible clinicians. We 
refer readers to Sec.  414.1380(b)(3) and the CY 2017 Quality Payment 
Program final rule (81 FR 78312) for further detail on improvement 
activities scoring.
    Activities will be weighted as high based on the extent to which 
they align with activities that support the certified patient-centered 
medical home, since that is consistent with the standard under section 
1848(q)(5)(C)(i) of the Act for achieving the highest potential score 
for the improvement activities performance category, as well as with 
our priorities for transforming clinical practice (81 FR 77311). 
Additionally, activities that require performance of multiple actions, 
such as participation in the Transforming Clinical Practice Initiative 
(TCPI), participation in a MIPS eligible clinician's state Medicaid 
program, or an activity identified as a public health priority (such as 
emphasis on anticoagulation management or utilization of prescription 
drug monitoring programs) are justifiably weighted as high (81 FR 77311 
through 77312).
    We refer readers to Table 26 of the CY 2017 Quality Payment Program 
final rule for a summary of the previously finalized improvement 
activities that are weighted as high (81 FR 77312 through 77313), and 
we refer readers to Table H of the same final rule, for a list of all 
the previously finalized improvement activities, both medium- and high-
weighted (81 FR 77817 through 77831). Please refer to Table F and Table 
G in the appendices of this proposed rule for proposed additions and 
changes to the Improvement Activities Inventory for the 2020 MIPS 
payment year and future years. Activities included in these proposed 
tables would apply for the 2020 MIPS payment year and future years 
unless further modified via notice and comment rulemaking. Consistent 
with our unified scoring system principles, we finalized in the CY 2017 
Quality Payment Program final rule that MIPS eligible clinicians will 
know in advance how many potential points they could receive for each 
improvement activity (81 FR 77311 through 77319).
(b) Improvement Activities Performance Category Highest Potential Score
    At Sec.  414.1380(b)(3), we finalized that we will require a total 
of 40 points to receive the highest score for the improvement 
activities performance category (81 FR 77315). For more of the 
statutory background and description of the proposed and finalized 
policies, we refer readers to the CY 2017 Quality Payment Program final 
rule (81 FR 77314 through 77315).
    For small practices, practices in rural areas and geographic HPSA 
practices and non-patient facing MIPS eligible clinicians, the weight 
for any activity selected is doubled so that these practices and 
eligible clinicians only need to select one high- or two medium-
weighted activities to achieve the highest score of 40 points (81 FR 
77312).
    In accordance with section 1848(q)(5)(C)(ii) of the Act, we 
codified at Sec.  414.1380(b)(3)(ix) that individual MIPS eligible 
clinicians or groups who are participating in an APM (as defined in 
section 1833(z)(3)(C) of the Act) for a performance period will 
automatically earn at least one half of the highest potential score for 
the improvement activities performance category for the performance 
period. In addition, MIPS eligible clinicians that are participating in 
MIPS APMs will be assigned an improvement activity score, which may be 
higher than one half of the highest potential score. This assignment is 
based on the extent to which the requirements of the specific model 
meet the list of activities in the Improvement Activities Inventory. 
For a further description of improvement activities and the APM scoring 
standard for MIPS, we refer readers to the CY 2017 Quality Payment 
Program final rule (81 FR 77246). For all other individual MIPS 
eligible clinicians or groups, we refer readers to the scoring 
requirements for individual MIPS eligible clinicians and groups in the 
CY 2017 Quality Payment Program final rule (81 FR 77270). An individual 
MIPS eligible clinician or group is not required to perform activities 
in each improvement activities subcategory or participate in an APM to 
achieve the highest potential score in accordance with section 
1848(q)(5)(C)(iii) of the Act (81 FR 77178).
    In the CY 2017 Quality Payment Program final rule, we also 
finalized that individual MIPS eligible clinicians and groups that 
successfully participate and submit data to fulfill the requirements 
for the CMS Study on Improvement Activities and Measurement will 
receive the highest score for the improvement activities performance 
category (81 FR 77315). We refer readers to section II.C.6.e.(7) of 
this proposed rule for further detail on this study.
(c) Points for Certified Patient-Centered Medical Home or Comparable 
Specialty Practice
    Section 1848(q)(5)(C)(i) of the Act specifies that a MIPS eligible 
clinician who is in a practice that is certified as a patient-centered 
medical home or comparable specialty practice for a performance period, 
as determined by the Secretary, must be given the highest potential 
score for the improvement activities performance category for the 
performance period. Accordingly, at Sec.  414.1380(b)(3)(iv), we 
specify that a MIPS eligible clinician who is in a practice that is 
certified as a patient-centered medical home, including a Medicaid 
Medical Home, Medical Home Model, or comparable specialty practice, 
will receive the highest potential score for the improvement activities 
performance category (81 FR 77196 through 77180).
    We are not proposing any changes to the scoring of the patient-
centered medical home or comparable specialty

[[Page 30133]]

practice; although we are proposing a change to how groups qualify for 
this activity. We refer readers to section II.C.6.e. of this proposed 
rule for a discussion of the requirements for certified patient-
centered medical home practices or comparable specialty practices.
(d) Calculating the Improvement Activities Performance Category Score
    In the CY 2017 Quality Payment Program final rule (81 FR 77318), we 
finalized that individual MIPS eligible clinicians and groups must earn 
a total of 40 points to receive the highest score for the improvement 
activities performance category. To determine the improvement 
activities performance category score, we sum the points for all of a 
MIPS eligible clinician's reported activities and divide by the 
improvement activities performance category highest potential score of 
40. A perfect score will be 40 points divided by 40 possible points, 
which equals 100 percent. If MIPS eligible clinicians have more than 40 
improvement activities points we will cap the resulting improvement 
activities performance category score at 100 percent.
    Section 1848(q)(2)(B)(iii) of the Act requires the Secretary to 
give consideration to the circumstances of small practices and 
practices located in rural areas and in geographic HPSAs (as designated 
under section 332(a)(1)(A) of the PHS Act) in defining activities. 
Section 1848(q)(2)(C)(iv) of the Act also requires the Secretary to 
give consideration to non-patient facing MIPS eligible clinicians. 
Further, section 1848(q)(5)(F) of the Act allows the Secretary to 
assign different scoring weights for measures, activities, and 
performance categories, if there are not sufficient measures and 
activities applicable and available to each type of eligible clinician.
    Accordingly, we finalized that the following scoring applies to 
MIPS eligible clinicians who are a non-patient facing MIPS eligible 
clinician, a small practice (consisting of 15 or fewer professionals), 
a practice located in a rural area, or practice in a geographic HPSA or 
any combination thereof:
     Reporting of one medium-weighted activity will result in 
20 points or one-half of the highest score.
     Reporting of two medium-weighted activities will result in 
40 points or the highest score.
     Reporting of one high-weighted activity will result in 40 
points or the highest score.
    The following scoring applies to MIPS eligible clinicians who are 
not a non-patient facing clinician, a small practice, a practice 
located in a rural area, or a practice in a geographic HPSA:
     Reporting of one medium-weighted activity will result in 
10 points which is one-fourth of the highest score.
     Reporting of two medium-weighted activities will result in 
20 points which is one-half of the highest score.
     Reporting of three medium-weighted activities will result 
in 30 points which is three-fourths of the highest score.
     Reporting of four medium-weighted activities will result 
in 40 points which is the highest score.
     Reporting of one high-weighted activity will result in 20 
points which is one-half of the highest score.
     Reporting of two high-weighted activities will result in 
40 points which is the highest score.
     Reporting of a combination of medium-weighted and high-
weighted activities where the total number of points achieved are 
calculated based on the number of activities selected and the weighting 
assigned to that activity (number of medium-weighted activities 
selected x 10 points + number of high-weighted activities selected x 20 
points) (81 FR 78318).
    We also finalized in the CY 2017 Quality Payment Program final rule 
that certain activities in the improvement activities performance 
category will also qualify for a bonus under the advancing care 
information performance category (81 FR 78318). This bonus will be 
calculated under the advancing care information performance category 
and not under the improvement activities performance category. We refer 
readers to section II.C.6.f.5.(d) of this proposed rule for further 
details. For more information about our finalized improvement 
activities scoring policies and for several sample scoring charts, we 
refer readers to the CY 2017 Quality Payment Program final rule (81 FR 
78319). Finally, in that same final rule, we codified at Sec.  
414.1380(b)(3)(ix) that MIPS eligible clinicians participating in APMs 
that are not certified patient-centered medical homes will 
automatically earn a minimum score of one-half of the highest potential 
score for the performance category, as required by section 
1848(q)(5)(C)(ii) of the Act. For any other MIPS eligible clinician who 
does not report at least one activity, including a MIPS eligible 
clinician who does not identify to us that they are participating in a 
certified patient-centered medical home or comparable specialty 
practice, we will calculate a score of zero points (81 FR 77319).
(e) Self-Identification Policy for MIPS Eligible Clinicians
    We also noted in the CY 2017 Quality Payment Program final rule (81 
FR 77319), that individual MIPS eligible clinicians or groups 
participating in APMs would not be required to self-identify as 
participating in an APM, but that all MIPS eligible clinicians would be 
required to self-identify if they were part of a certified patient-
centered medical home or comparable specialty practice, a non-patient 
facing MIPS eligible clinician, a small practice, a practice located in 
a rural area, or a practice in a geographic HPSA or any combination 
thereof, and that we would validate these self-identifications as 
appropriate. However, beginning with the 2018 MIPS performance period, 
we are proposing to no longer require these self-identifications for a 
non-patient facing MIPS eligible clinician, a small practice, a 
practice located in a rural area, or a practice in a geographic HPSA or 
any combination thereof because it is technically feasible for us to 
identify these MIPS eligible clinicians during attestation to the 
performance of improvement activities following the performance period. 
We define these MIPS eligible clinicians in the CY 2017 Quality Payment 
Program final rule (81 FR 77540), and they are discussed in this 
proposed rule in section II.C.1. of this proposed rule. However, MIPS 
eligible clinicians that are part of a certified patient-centered 
medical home or comparable specialty practice are still required to 
self-identify for the 2018 MIPS performance period, and we will 
validate these self-identifications as appropriate. We refer readers to 
section II.C.6.e.3.(c) of this proposed rule for the criteria for 
recognition as a certified patient-centered medical home or comparable 
specialty practice.
(6) Scoring the Advancing Care Information Performance Category
    We refer readers to section II.C.6.f. of this proposed rule with 
comment period, where we discuss scoring the advancing care information 
performance category.
b. Calculating the Final Score
    For a description of the statutory basis and our policies for 
calculating the final score for MIPS eligible clinicians, we refer 
readers to the discussion in the CY 2017 Quality Payment Program final 
rule (81 FR 77319 through 77329) and Sec.  414.1380. In this proposed 
rule, we propose to add a complex patient scoring bonus and add a small 
practice bonus to the final score. In addition, we review the final 
score calculation for the

[[Page 30134]]

2020 MIPS payment year and propose refinements to the reweighting 
policies.
(1) Accounting for Risk Factors
    Section 1848(q)(1)(G) of the Act requires us to consider risk 
factors in our scoring methodology. Specifically, that section provides 
that the Secretary, on an ongoing basis, shall, as the Secretary 
determines appropriate and based on individuals' health status and 
other risk factors, assess appropriate adjustments to quality measures, 
cost measures, and other measures used under MIPS and assess and 
implement appropriate adjustments to payment adjustments, final scores, 
scores for performance categories, or scores for measures or activities 
under the MIPS. In doing this, the Secretary is required to take into 
account the relevant studies conducted under section 2(d) of the 
Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 
and, as appropriate, other information, including information collected 
before completion of such studies and recommendations. We refer readers 
to our discussion of risk factors for the transition year of MIPS (81 
FR 77320 through 77321).
    In this section, we summarize our efforts related to social risk 
and the relevant studies conducted under section 2(d) of the IMPACT Act 
of 2014. We also propose some short-term adjustments to address patient 
complexity.
(a) Considerations for Social Risk
    We understand that social risk factors such as income, education, 
race and ethnicity, employment, disability, community resources, and 
social support (certain factors of which are also sometimes referred to 
as socioeconomic status (SES) factors or socio-demographic status (SDS) 
factors) play a major role in health. One of our core objectives is to 
improve beneficiary outcomes, including reducing health disparities, 
and we want to ensure that all beneficiaries, including those with 
social risk factors, receive high quality care. In addition, we seek to 
ensure that the quality of care furnished by providers and suppliers is 
assessed as fairly as possible under our programs while ensuring that 
beneficiaries have adequate access to excellent care.
    We have been reviewing reports prepared by the Office of the 
Assistant Secretary for Planning and Evaluation (ASPE) and the National 
Academies of Sciences, Engineering, and Medicine on the issue of 
accounting for social risk factors in CMS' value-based purchasing and 
quality reporting programs, and considering options on how to address 
the issue in these programs. On December 21, 2016, ASPE submitted the 
first of several Reports to Congress on a study it was required to 
conduct under section 2(d) of the IMPACT Act of 2014. The first study 
analyzed the effects of certain social risk factors in Medicare 
beneficiaries on quality measures and measures of resource use used in 
one or more of nine Medicare value-based purchasing programs.\12\ The 
report also included considerations for strategies to account for 
social risk factors in these programs. A second report due October 2019 
will expand on these initial analyses, supplemented with non-Medicare 
datasets to measure social risk factors. In a January 10, 2017 report 
released by the National Academies of Sciences, Engineering, and 
Medicine, that body provided various potential methods for accounting 
for social risk factors, including stratified public reporting.\13\
---------------------------------------------------------------------------

    \12\ Office of the Assistant Secretary for Planning and 
Evaluation. 2016. Report to Congress: Social Risk Factors and 
Performance Under Medicare's Value-Based Purchasing Programs. 
Available at https://aspe.hhs.gov/pdf-report/report-congress-social-risk-factors-and-performance-under-medicares-value-based-purchasing-programs.
    \13\ National Academies of Sciences, Engineering, and Medicine. 
2017. Accounting for social risk factors in Medicare payment. 
Washington, DC: The National Academies Press.
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    As noted in the FY 2017 IPPS/LTCH PPS final rule (81 FR 56974), the 
NQF has undertaken a 2-year trial period in which certain new measures 
and measures undergoing maintenance, and measures endorsed with the 
condition that they enter the trial period can be assessed to determine 
whether risk adjustment for selected social risk factors is appropriate 
for these measures. This trial entails temporarily allowing inclusion 
of social risk factors in the risk-adjustment approach for these 
measures. At the conclusion of the trial, NQF will issue 
recommendations on the future inclusion of social risk factors in risk 
adjustment for these quality measures, and we will closely review its 
findings.
    As we continue to consider the analyses and recommendations from 
these and any future reports, and await the results of the NQF trial on 
risk adjustment for quality measures, we are continuing in this 
proposed rule to work with stakeholders in this process. As we have 
previously communicated, we are concerned about holding providers to 
different standards for the outcomes of their patients with social risk 
factors because we do not want to mask potential disparities or 
minimize incentives to improve the outcomes for disadvantaged 
populations. Keeping this concern in mind, while we sought input on 
this topic previously, we continue to seek public comment on whether we 
should account for social risk factors in the MIPS, and if so, what 
method or combination of methods would be most appropriate for 
accounting for social risk factors in the MIPS. Examples of methods 
include: Adjustment of MIPS eligible clinician scores (for example, 
stratifying the scores of MIPS eligible clinicians based on the 
proportion of their patients who are dual eligible); confidential 
reporting of stratified measure rates to MIPS eligible clinicians; 
public reporting of stratified measure results; risk adjustment of a 
particular measure as appropriate based on data and evidence; and 
redesigning payment incentives (for instance, rewarding improvement for 
clinicians caring for patients with social risk factors or 
incentivizing clinicians to achieve health equity). We are seeking 
comments on whether any of these methods should be considered, and if 
so, which of these methods or combination of methods would best account 
for social risk factors in MIPS, if any.
    In addition, we are seeking public comment on which social risk 
factors might be most appropriate for stratifying measure scores and/or 
potential risk adjustment of a particular measure. Examples of social 
risk factors include, but are not limited to the following: Dual 
eligibility/low-income subsidy; race and ethnicity; and geographic area 
of residence. We are seeking comment on which of these factors, 
including current data sources where this information would be 
available, could be used alone or in combination, and whether other 
data should be collected to better capture the effects of social risk. 
We will take commenters' input into consideration as we continue to 
assess the appropriateness and feasibility of accounting for social 
risk factors in MIPS. We note that any such changes would be proposed 
through future notice and comment rulemaking.
    We look forward to working with stakeholders as we consider the 
issue of accounting for social risk factors and reducing health 
disparities in CMS programs. Of note, implementing any of the above 
methods would be taken into consideration in the context of how this 
and other CMS programs operate (for example, data submission methods, 
availability of data, statistical considerations relating to 
reliability of data calculations, among others), we also welcome 
comment on operational considerations. CMS is committed to ensuring 
that its beneficiaries have access to and receive excellent care, and 
that the quality of care furnished by

[[Page 30135]]

providers and suppliers is assessed fairly in CMS programs.
(b) Complex Patient Bonus
    While we work with stakeholders on these issues as we have 
described, we are proposing, under the authority within section 
1848(q)(1)(G) of the Act, which allows us to assess and implement 
appropriate adjustments to payment adjustments, MIPS final scores, 
scores for performance categories, or scores for measures or activities 
under MIPS, to implement a short-term strategy for the Quality Payment 
Program to address the impact patient complexity may have on final 
scores. The overall goal when considering a bonus for complex patients 
is two-fold: (1) To protect access to care for complex patients and 
provide them with excellent care; and (2) to avoid placing MIPS 
eligible clinicians who care for complex patients at a potential 
disadvantage while we review the completed studies and research to 
address the underlying issues. We used the term ``patient complexity'' 
to take into account a multitude of factors that describe and have an 
impact on patient health outcomes; such factors include the health 
status and medical conditions of patients, as well as social risk 
factors. We believe that as the number and intensity of these factors 
increase for a single patient, the patient may require more services, 
more clinician focus, and more resources in order to achieve health 
outcomes that are similar to those who have fewer factors. In 
developing the policy for the complex patient bonus, we assessed 
whether there was a MIPS performance discrepancy by patient complexity 
using two well-established indicators in the Medicare program. Our 
proposal is intended to address any discrepancy, without masking 
performance. Because this bonus is intended to be a short-term 
strategy, we are proposing the bonus only for the 2018 MIPS performance 
period (2020 MIPS payment year) and will assess on an annual basis 
whether to continue the bonus and how the bonus should be structured.
    When considering approaches for a complex patient bonus, we 
reviewed evidence to identify how indicators of patient complexity have 
an impact on performance under MIPS as well as availability of data to 
implement the bonus. Specifically, we identified two potential 
indicators for complexity: Medical complexity as measured through 
Hierarchical Condition Category (HCC) risk scores, and social risk as 
measured through the proportion of patients with dual eligible status. 
We identified these indicators because they are common indicators of 
patient complexity in the Medicare program and the data is readily 
available. As discussed below, both of these indicators have been used 
in Medicare programs to account for risk and both data elements are 
already publicly available for individual NPIs in the Medicare 
Physician and Other Supplier Public Use File (referred to as the 
Physician and Other Supplier PUF) (https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/medicare-provider-charge-data/physician-and-other-supplier.html). While we 
recognize that these indicators are interrelated (as dual eligible 
status is one of the factors included in calculation of HCC risk 
scores), we intend for the sake of simplicity to implement one of these 
indicators for the 2020 MIPS payment year.
    We believe that average HCC risk scores are a valid proxy for 
medical complexity that have been used by other CMS programs. The HCC 
model was developed by CMS as a risk-adjustment model that uses 
hierarchical condition categories to assign risk scores to Medicare 
beneficiaries. Those scores estimate how Medicare beneficiaries' FFS 
spending will compare to the overall average for the entire Medicare 
population. According to the Physician and Other Supplier PUF 
methodological overview, published in January of 2017,\14\ the average 
risk score is set at 1.08; beneficiaries with scores greater than that 
are expected to have above-average spending, and vice versa. Risk 
scores are based on a beneficiary's age and sex; whether the 
beneficiary is eligible for Medicaid, first qualified for Medicare on 
the basis of disability, or lives in an institution (usually a nursing 
home); and the beneficiary's diagnoses from the previous year. The HCC 
model was designed for risk adjustment on larger populations, such as 
the enrollees in an MA plan, and generates more accurate results when 
used to compare groups of beneficiaries rather than individuals. For 
more information on the HCC risk score, see: https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors.html.
---------------------------------------------------------------------------

    \14\ https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Downloads/Medicare-Physician-and-Other-Supplier-PUF-Methodology.pdf.
---------------------------------------------------------------------------

    HCC risk scores have been used in the VM to apply an additional 
upward payment adjustment of +1.0x for clinicians whose attributed 
patient population has an average risk score that is in the top 25 
percent of all beneficiary risk scores (77 FR 69325 through 69326). CMS 
proposes and announces changes to the HCC risk adjustment model as part 
of the announcement of payment policies for Medicare Advantage plans 
under section 1853 of the Act; the proposals and announcements are 
posted at https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Announcements-and-Documents.html.
    A mean HCC risk score for a MIPS eligible clinician can be 
calculated by averaging the HCC risk scores for the beneficiaries cared 
for by the clinician. In considering options for a complex patient 
bonus, we explored the use of average HCC risk scores while recognizing 
that ``complexity'' is one of several drivers of that metric. We 
believe that using the HCC risk score as a proxy for patient complexity 
is a helpful starting point, and will explore methods for further 
distinguishing complexity from other reasons a clinician could receive 
a high average HCC risk score.
    In addition to medical complexity, patient complexity includes 
social risk factors, and we considered identifying patients dually 
eligible for Medicare and Medicaid, which we believe is a proxy for 
social risk factors. A ratio of beneficiaries seen by a MIPS eligible 
clinician who are dual eligible can be calculated using claims data 
based on the proportion of unique patients who are dually eligible for 
Medicare and full- and partial-benefit Medicaid (referred to herein as 
``dual eligible status'') seen by the MIPS eligible clinician during 
the performance year among all unique Medicare beneficiaries seen 
during the performance year. Dual eligible Medicare beneficiaries are 
qualified to receive Medicare and Medicaid benefits. In the Physician 
and Other Supplier PUF, beneficiaries are classified as Medicare and 
Medicaid entitlement if in any month in the given calendar year they 
were receiving full or partial Medicaid benefits.\15\ Dual eligibility 
has been used in the Medicare Advantage 5-star methodology \16\ and 
stratification by proportion of dual eligibility status is proposed for 
the Hospital Readmissions Reduction Program (82 FR 19959 through 
19961).
---------------------------------------------------------------------------

    \15\ https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Downloads/Medicare-Physician-and-Other-Supplier-PUF-Methodology.pdf.
    \16\ Centers for Medicare & Medicaid Services. Medicare 2017 
Part C & D Star Rating Technical Notes. Available at https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/Downloads/2017-Part-C-and-D-Medicare-Star-Ratings-Data-v04-04-2017-.zip.

---------------------------------------------------------------------------

[[Page 30136]]

    We evaluated both indicators (average HCC risk score and proportion 
dual eligible status) using the 2015 Physician and Other Supplier PUF. 
We incorporated these factors into our scoring model that uses 
historical PQRS data to simulate scores for MIPS eligible clinicians 
including estimates for the quality, advancing care information, and 
improvement activities performance categories, and the small practice 
bonus that is proposed in section II.C.7.b.(1)(c) of this proposed 
rule. The scoring model is described in more detail in the regulatory 
impact analysis in section V.C. of this proposed rule. For HCC, we 
merged the average HCC risk score by NPI with each TIN/NPI in our 
population. We calculated a dual eligible ratio by taking a proportion 
of dual eligible beneficiaries and divided by total beneficiaries for 
each NPI. We created group level scores by taking an average of NPI 
scores weighted by the number of beneficiaries. We divided clinicians 
and groups into quartiles based on average HCC risk score and percent 
of duals. To assess whether there was a difference in MIPS simulated 
scores by these two variables, we analyzed the effect of average HCC 
risk score and dual eligible ratio separately for groups and 
individuals. When looking at individuals, we focused on individuals 
that reported 6 or more measures (removing individuals who reported no 
measures or who reported less than 6 measures). We restricted our 
analysis to individuals who reported 6 or more measures because we 
wanted to look at differences in performance for those who reported the 
required 6 measures, rather than differences in scores due to 
incomplete reporting.
    We observed modest correlation between these two indicators. Using 
the Physician and Other Supplier PUF (after restricting to those 
clinicians that we estimate to be MIPS eligible in our scoring model 
described in section V.C of this proposed rule), the correlation 
coefficient for these two factors is 0.487 (some correlation is 
expected due to the inclusion of dual eligible status in the HCC risk 
model). The correlation between average HCC risk scores and proportion 
of patients with dual eligible status indicates that while there is 
overlap between these two indicators, they cannot be used 
interchangeably.
    We also assessed the correlation of these indicators with MIPS 
final scores based on performance and the small practice bonus for MIPS 
eligible clinicians, as well as variations by practice size, submission 
mechanism, and specialty. Average MIPS simulated scores (prior to any 
complex patient bonus) varied from 82.73 (fourth HCC quartile, highest 
risk) to 87.14 (first HCC quartile, lowest risk) for group reporters, 
and from 82.36 (fourth HCC quartile, highest risk) to 86.39 (first HCC 
quartile, lowest risk) for individual reporters who reported 6 or more 
measures (see Table 34). When reviewing average HCC risk scores by 
practice size, we found that MIPS eligible clinicians in larger 
practices had slightly higher risk scores than those in small practices 
(average HCC risk score of 1.82 for practices with 100 or more 
clinicians, compared with 1.61 for practices with 1-15 clinicians) (see 
Table 35) and that the average HCC risk score varied by specialty, with 
nephrology having the highest average HCC risk score (3.05) and 
dermatology having the lowest (1.24). The average HCC risk score for 
family medicine was 1.58 (see Table 36).
    We also ranked MIPS eligible clinicians by proportion of patients 
with dual eligibility (see Table 34). Performance for MIPS eligible 
clinicians ranged from 82.35 in the fourth dual quartile (highest 
proportion dual eligible patients) to 89.49 in the second dual quartile 
(second lowest proportion dual eligible patients) for group reporters. 
Performance for MIPS eligible clinicians reporting individually who 
reported 6 or more measures ranged from 83.08 in the fourth dual 
quartile (highest proportion dual eligible patients) to 86.80 in the 
first dual quartile (lowest proportion dual eligible patients).

 Table 34--MIPS Simulated Score * by HCC Risk Quartile and Dual Eligible
                             Ratio Quartile
------------------------------------------------------------------------
                                            Individuals
                                              with 6+          Group
                                            measures **
------------------------------------------------------------------------
HCC Quartile
    Quartile 1--Lowest Average HCC Risk            86.39           87.14
     Score..............................
    Quartile 2..........................           84.89           88.41
    Quartile 3..........................           83.31           86.76
    Quartile 4--Highest Average HCC Risk           82.36           82.73
     Score..............................
Dual Eligible Ratio
    Quartile 1--Lowest Proportion of               86.80           88.03
     Dual Status........................
    Quartile 2..........................           83.76           89.49
    Quartile 3..........................           82.63           85.39
    Quartile 4--Highest Proportion of              83.08           82.35
     Dual Status........................
------------------------------------------------------------------------
* The simulated score includes estimated quality, advancing care
  information, and improvement activities performance categories without
  complex patient bonus. Simulated score does include small practice
  bonus proposed in II.C.7.b.(1)(c) of this proposed rule.
** We restricted this column to individuals who reported 6 or more
  measures to assess differences in performance for those who reported
  the required 6 measures and to not consider changes due to incomplete
  reporting.


  Table 35--Average HCC Risk Score and Dual Eligible Ratio by Practice
                                  Size
------------------------------------------------------------------------
                                            Average HCC    Dual eligible
              Practice size                 risk score      ratio  (%)
------------------------------------------------------------------------
1-15 clinicians.........................            1.61           24.90
16-24 clinicians........................            1.70           26.20
25-99 clinicians........................            1.72           27.50
100 or more clinicians..................            1.82           26.90
    Total...............................            1.75           26.60
------------------------------------------------------------------------


[[Page 30137]]


  Table 36--Average HCC Risk Score and Dual Eligible Ratio by Specialty
------------------------------------------------------------------------
                                           Average  HCC    Dual eligible
               Specialty *                  risk score       ratio (%)
------------------------------------------------------------------------
Total...................................            1.75           26.60
Addiction Medicine......................            1.77           37.00
Allergy/Immunology......................            1.38           19.70
Anesthesiology..........................            1.78           26.00
Anesthesiology Assistant................            1.94           26.50
Cardiac Electrophysiology...............            1.85           23.20
Cardiac Surgery.........................            1.93           25.10
Cardiovascular Disease (Cardiology).....            1.85           25.30
Certified Clinical Nurse Specialist.....            1.78           31.20
Certified Registered Nurse Anesthetist              1.77           25.50
 (CRNA).................................
Chiropractic............................            1.27           19.10
Clinic or Group Practice................            1.57           30.60
Colorectal Surgery (Proctology).........            1.70           22.10
Critical Care (Intensivists)............            2.06           28.50
Dermatology.............................            1.24           11.90
Diagnostic Radiology....................            1.78           26.50
Emergency Medicine......................            1.94           34.10
Endocrinology...........................            1.78           24.70
Family Medicine *.......................            1.58           25.80
Gastroenterology........................            1.70           24.20
General Practice........................            1.60           35.80
General Surgery.........................            1.83           27.10
Geriatric Medicine......................            1.93           29.60
Geriatric Psychiatry....................            1.92           39.30
Gynecological Oncology..................            1.76           24.20
Hand Surgery............................            1.39           17.80
Hematology..............................            1.95           25.80
Hematology-Oncology.....................            1.92           24.90
Hospice and Palliative Care.............            1.93           26.90
Infectious Disease......................            2.35           31.60
Internal Medicine.......................            1.84           28.10
Interventional Cardiology...............            1.79           22.90
Interventional Pain Management..........            1.50           26.90
Interventional Radiology................            2.18           28.80
Maxillofacial Surgery...................            1.90           30.20
Medical Oncology........................            1.94           23.50
Nephrology..............................            3.05           33.00
Neurology...............................            1.79           27.40
Neuropsychiatry.........................            1.76           30.30
Neurosurgery............................            1.68           24.70
Nuclear Medicine........................            1.91           26.10
Nurse Practitioner......................            1.78           28.60
Obstetrics & Gynecology.................            1.63           26.20
Ophthalmology...........................            1.37           18.70
Optometry...............................            1.33           24.80
Oral Surgery (Dentist only).............            1.82           29.20
Orthopedic Surgery......................            1.44           20.50
Osteopathic Manipulative Medicine.......            1.62           29.70
Otolaryngology..........................            1.50           21.10
Pain Management.........................            1.57           29.50
Pathology...............................            1.71           23.70
Pediatric Medicine......................            1.95           31.10
Peripheral Vascular Disease.............            1.83           23.10
Physical Medicine and Rehabilitation....            1.76           27.00
Physician Assistant.....................            1.69           26.40
Physician, Sleep Medicine...............            1.70           23.20
Plastic and Reconstructive Surgery......            1.74           23.60
Podiatry................................            1.72           27.70
Preventive Medicine.....................            1.80           27.60
Psychiatry..............................            1.80           39.50
Pulmonary Disease.......................            2.00           27.20
Radiation Oncology......................            1.79           22.20
Rheumatology............................            1.65           23.40
Sports Medicine.........................            1.54           22.70
Surgical Oncology.......................            1.92           25.10
Thoracic Surgery........................            1.94           26.30
Urology.................................            1.56           20.30
Vascular Surgery........................            2.22           26.80
------------------------------------------------------------------------
* Specialty descriptions as self-reported on Part B claims. Note that
  all categories are mutually exclusive, including General Practice and
  Family Practice. `Family Medicine' is used here for physicians listed
  as `Family Practice' in Part B claims.


[[Page 30138]]

    Based on our assessment of these two indicators, we generally see 
high average simulated scores \17\ that are above 80 points for each 
quartile based on average HCC risk score or proportion of dual status 
patients (see Table 34). As discussed in II.C.8.d. of this proposed 
rule, 70 points is the proposed additional performance threshold at 
which MIPS eligible clinicians can receive the additional adjustment 
factor for exceptional performance. However, even though the simulated 
scores are high, we also generally see a very modest decrease in 
simulated scores of 4.0 points (for individuals who report 6 or more 
measures) and 4.4 points (for groups) from the top quartile to the 
bottom quartile for the average patient HCC risk score and from 3.7 
(for individuals who report 6 or more measures) and 5.7 points (for 
groups) from the top quartile to the bottom quartile for dual eligible 
ratio. While we are transitioning into MIPS and evolving our scoring 
policies, we want to ensure safeguards and access for these vulnerable 
patients; therefore, we are proposing to apply a small complex patient 
bonus to final scores used for the 2020 MIPS payment year. As we stated 
earlier, we intend to start with one dimension of patient complexity 
for simplicity. For the 2020 MIPS payment year, we are proposing a 
complex patient bonus based on the average HCC risk score because this 
is the indicator that clinicians are familiar with from the VM.
---------------------------------------------------------------------------

    \17\ Scores are simulated prior to any complex patient bonus.
---------------------------------------------------------------------------

    We propose at Sec.  414.1380(c)(3) to add a complex patient bonus 
to the final score for the 2020 MIPS payment year for MIPS eligible 
clinicians that submit data (as explained below) for at least one 
performance category. We propose at Sec.  414.1380(c)(3)(i) to 
calculate an average HCC risk score, using the model adopted under 
section 1853 of the Act for Medicare Advantage risk adjustment 
purposes, for each MIPS eligible clinician or group, and to use that 
average HCC risk score as the complex patient bonus. We would calculate 
the average HCC risk score for a MIPS eligible clinician or group by 
averaging HCC risk scores for beneficiaries cared for by the MIPS 
eligible clinician or clinicians in the group during the second 12-
month segment of the eligibility period, which spans from the last 4 
months of a calendar year 1 year prior to the performance period 
followed by the first 8 months of the performance period in the next 
calendar year (September 1, 2017 to August 31, 2018 for the 2018 MIPS 
performance period) as described in section II.C.3.c. of this proposed 
rule. We propose the second 12-month segment of the eligibility period 
to align with other MIPS policies and to ensure we have sufficient time 
to determine the necessary calculations. The second period 12-month 
segment overlaps 8-months with the MIPS performance period which means 
that many of the patients in our complex patient bonus would have been 
cared for by the clinician, group, virtual group or APM Entity during 
the MIPS performance period.
    HCC risk scores for beneficiaries would be calculated based on the 
calendar year immediately prior to the performance period. For the 2018 
MIPS performance period, the HCC risk scores would be calculated based 
on beneficiary services from the 2017 calendar year. We chose this 
approach because CMS uses prior year diagnoses to set Medicare 
Advantage rates prospectively every year and has employed this approach 
in the VM (77 FR 69317-8). Additionally, this approach mitigates the 
risk of ``upcoding'' to get higher expected costs, which could happen 
if concurrent risk adjustments were incorporated. We realize using the 
2017 calendar year to assess beneficiary HCC risk scores overlaps by 4-
months with the 12-month data period to identify beneficiaries (which 
is September 1, 2017 to August 31, 2018 for the 2018 MIPS performance 
period); however, we annually calculate the beneficiary HCC risk score 
and use it for multiple purposes (like the Physician and Other Supplier 
PUF).
    For MIPS APMs and virtual groups, we propose at Sec.  
414.1380(c)(3)(ii) to use the beneficiary weighted average HCC risk 
score for all MIPS eligible clinicians, and if technically feasible, 
TINs for models and virtual groups which rely on complete TIN 
participation, within the APM Entity or virtual group, respectively, as 
the complex patient bonus. We would calculate the weighted average by 
taking the sum of the individual clinician's (or TIN's as appropriate) 
average HCC risk score multiplied by the number of unique beneficiaries 
cared for by the clinician and then divide by the sum of the 
beneficiaries cared for by each individual clinician (or TIN as 
appropriate) in the APM Entity or virtual group.
    We propose at Sec.  414.1380(c)(3)(iii) that the complex patient 
bonus cannot exceed 3 points. This value was selected because the 
differences in performance we observed between simulated scores between 
the first and fourth quartiles of average HCC risk scores was 
approximately 4 points for individuals and approximately 5 points for 
groups. We considered whether we should apply a set number of points to 
those in a specific quartile (for example, for the highest risk 
quartile only), but did not want to restrict the bonus to only certain 
MIPS eligible clinicians. Rather than assign points based on quartile, 
we believed that adding the average HCC risk score directly to the 
final score would achieve our goal of accounting for patient complexity 
without masking low performance and does provide a modest effect on the 
final score. The 95th percentile of HCC values for individual 
clinicians was 2.91 which we rounded to 3 for simplicity. We believe 
applying this bonus to the final score is appropriate because caring 
for complex and vulnerable patients can affect all aspects of a 
practice and not just specific performance categories. It may also 
create a small incentive to provide access to complex patients.
    Finally, we propose that the MIPS eligible clinician, group, 
virtual group or APM Entity must submit data on at least one measure or 
activity in a performance category during the performance period to 
receive the complex patient bonus. Under this proposal, MIPS eligible 
clinicians would not need to meet submissions requirements for the 
quality performance category in order to receive the bonus (they could 
instead submit improvement activities or advancing care information 
measures only or submit fewer than the required number of measures for 
the quality performance category).
    Based on our data analysis, we estimate that this bonus on average 
would range from 1.16 points in the first quartile based on HCC risk 
scores to 2.49 points in the fourth quartile for individual reporters 
submitting 6 or more measures, and 1.26 points in the first quartile to 
2.23 points in the fourth quartile for group reporters. For example, a 
MIPS eligible clinician with a final score of 55.11 with an average HCC 
risk score of 2.01 would receive a final score of 57.12. We propose in 
section II.C.7.b.(2) of this proposed rule that if the result of the 
calculation is greater than 100 points, then the final score would be 
capped at 100 points.
    We also seek comment on an alternative complex patient bonus 
methodology, similarly for the 2020 MIPS payment year only. Under the 
alternative, we would apply a complex patient bonus based on a ratio of 
patients who are dual eligible, because we believe that dual eligible 
status is a common indicator of social risk for

[[Page 30139]]

which we currently have data available. We believe the advantage of 
this option is its relative simplicity and that it creates a direct 
incentive to care for dual eligible patients, who are often medically 
complex and have concurrent social risk factors. In addition, whereas 
the HCC risk scores rely on the diagnoses a beneficiary receives which 
could be impacted by variations in coding practices among clinicians, 
the dual eligibility ratio is not impacted by variations in coding 
practices. For this alternative option, we would calculate a dual 
eligible ratio (including both full and partial Medicaid beneficiaries) 
for each MIPS eligible clinician based on the proportion of unique 
patients who have dual eligible status seen by the MIPS eligible 
clinician among all unique patients seen during the second 12-month 
segment of the eligibility period, which spans from the last 4 months 
of a calendar year 1 year prior to the performance period followed by 
the first 8 months of the performance period.
    For MIPS APMs and virtual groups, we would use the average dual 
eligible patient ratio for all MIPS eligible clinicians, and if 
technically feasible, TINs for models and virtual groups which rely on 
complete TIN participation, within the APM entity or virtual group, 
respectively.
    Under this alternative option, we would identify dual eligible 
status (numerator of the ratio) using data on dual-eligibility status 
sourced from the state Medicare Modernization Act (MMA) files, which 
are files each state submits to CMS with monthly Medicaid eligibility 
information. We would use dual-eligibility status data from the state 
MMA files because it is the best available data for identifying dual 
eligible beneficiaries. Under this alternative option, an individual 
would be counted as a full-benefit or partial-benefit dual patient if 
the beneficiary was identified as a full-benefit or partial-benefit 
dual in the state MMA files at the conclusion of the second 12-month 
segment of the eligibility determination period.
    We would define the proportion of full benefit or partial dual 
eligible beneficiaries as the proportion of dual eligible patients 
among all unique Medicare patients seen by the MIPS eligible clinician 
or group during the second 12-month segment of the eligibility period 
which spans from the last 4 months of a calendar year prior to the 
performance period followed by the first 8 months of the performance 
period in the next calendar year (September 1, 2017 to August 31, 2018 
for the 2018 MIPS performance period) as described in section II.C.3.c. 
of this proposed rule, to identify MIPS eligible clinicians for 
calculation of the complex patient bonus. This date range aligns with 
the second low-volume threshold determination and also represents care 
provided during the performance period.
    We would propose to multiply the dual eligible ratio by 5 points to 
calculate a complex patient bonus for each MIPS eligible clinician. For 
example, a MIPS eligible clinician who sees 400 patients with dual 
eligible status out of 1000 total Medicare patients seen during the 
second 12-month segment of the eligibility period would have a complex 
patient ratio of 0.4, which would be multiplied by 5 points for a 
complex patient bonus of 2 points toward the final score. We believe 
this approach is simple to explain and would be available to all 
clinicians who care for dual eligible beneficiaries. We also believe a 
complex patient bonus ranging from 1 to 5 points (with most MIPS 
eligible clinicians receiving a bonus between 1 and 3 points) is 
appropriate because, in our analysis, we estimated differences in 
performance between the 1st and 4th quartiles of dual eligible ratios 
to be approximately 3 points for individuals and approximately 6 points 
for groups. A bonus of less than 5 points would help to mitigate the 
impact of caring for patients with social risk factors while not 
masking poor performance. Using this approach, we estimate that the 
bonus would range from 0.45 (first dual quartile) to 2.42 (fourth dual 
quartile) for individual reporters, and from 0.63 (first dual quartile) 
to 2.19 (fourth dual quartile) for group reporters. Under this 
alternative option, we would also include the complex patient bonus in 
the calculation of the final score. Again, we propose in section 
II.C.7.b.(2) of this proposed rule that if the result of the 
calculation is greater than 100 points, then the final score would be 
capped at 100 points. We seek comments on our proposed bonus for 
complex patients based on average HCC risk scores, and our alternative 
option using a ratio of dual eligible patients in lieu of average HCC 
risk scores. We reiterate that the complex patient bonus is intended to 
be a short-term solution, which we plan to revisit on an annual basis, 
to incentivize clinicians to care for patients with medical complexity. 
We may consider alternate adjustments in future years after methods 
that more fully account for patient complexity in MIPS have been 
developed. We also seek comments on alternative methods to construct a 
complex patient bonus.
(c) Small Practice Bonus for the 2020 MIPS Payment Year
    Eligible clinicians and groups who work in small practices are a 
crucial part of the health care system. The Quality Payment Program 
provides options designed to make it easier for these MIPS eligible 
clinicians and groups to report on performance and quality and 
participate in advanced alternative payment models for incentives. We 
have heard directly from clinicians in small practices that they face 
unique challenges related to financial and other resources, 
environmental factors, and access to health information technology. We 
heard from many commenters that the Quality Payment Program advantages 
large organizations because such organizations have more resources 
invested in the infrastructure required to track and report measures to 
MIPS. Based on our scoring model, which is described in the regulatory 
impact analysis in section V.C. of this proposed rule, practices with 
more than 100 clinicians may perform better in the Quality Payment 
Program, on average compared to smaller practices. We believe this 
trend is due primarily to two factors: Participation rates and 
submission mechanism. Based on the most recent PQRS data available, 
practices with 100 or more MIPS eligible clinicians have participated 
in the PQRS at a higher rate than small practices (99.4 percent 
compared to 69.7 percent, respectively). As we indicate in our 
regulatory impact analysis in section V.C. of this proposed rule, we 
believe participation rates based only on historic 2015 quality data 
submitted under PQRS significantly underestimate the expected 
participation in MIPS particularly for small practices. Therefore, we 
have modeled the regulatory impact analysis using minimum participation 
assumptions of 80 percent and 90 percent participation for each 
practice size category (1-15 clinicians, 16-24 clinicians, 25-99 
clinicians, and 100 or more clinicians). However, even with these 
enhanced participation assumptions, MIPS eligible clinicians in small 
practices would have lower participation than MIPS eligible clinicians 
in larger practices as 80 or 90 percent participation is still much 
lower than the 99.4 percent participation for MIPS eligible clinicians 
in practices with 100 or more clinicians.
    In addition, practices with 100 or more MIPS eligible clinicians 
are more likely to report as a group, rather than individually, which 
reduces burden to individuals within those practices due

[[Page 30140]]

to the unified nature of group reporting. Specifically, 63.1 percent of 
practices with 100 or more MIPS eligible clinicians are reporting via 
CMS Web Interface (either through the Shared Savings Program or as a 
group practice) compared to 20.5 percent of small practices (the CMS 
Web Interface reporting mechanism is only available to small practices 
participating in the Shared Saving Program or Next Generation ACO 
Model.) \18\
---------------------------------------------------------------------------

    \18\ Groups must have at least 25 clinicians to participate in 
Web Interface.
---------------------------------------------------------------------------

    These two factors have financial implications based on the MIPS 
scoring model described in section V.C. of this proposed rule. Looking 
at the combined impact performance, we see consistent trends for small 
practices in various scenarios. A combined impact of performance 
measurement looks at the aggregate net percent change (the combined 
impact of MIPS negative and positive adjustments in the final score). 
In analyzing the combined impact performance, we see MIPS eligible 
clinicians in small practices consistently have a lower combined impact 
performance than larger practices based on actual historical data and 
after we apply the 80 and 90 percent participation assumptions.
    Due to these challenges, we believe an adjustment to the final 
score for MIPS eligible clinicians in small practices (referred to 
herein as the ``small practice bonus'') is appropriate to recognize 
these barriers and to incentivize MIPS eligible clinicians in small 
practices to participate in the Quality Payment Program and to overcome 
any performance discrepancy due to practice size. To receive the small 
practice bonus, we propose that the MIPS eligible clinician must 
participate in the program by submitting data on at least one 
performance category in the 2018 MIPS performance period. Therefore, 
MIPS eligible clinicians would not need to meet submission requirements 
for the quality performance category in order to receive the bonus 
(they could instead submit improvement activities or advancing care 
information measures only or submit fewer than the required number of 
measures for the quality performance category). Additionally, we 
propose that group practices, virtual groups, or APM Entities that 
consist of a total of 15 or fewer clinicians may receive the small 
practice bonus.
    We propose at Sec.  414.1380(c)(4) to add a small practice bonus of 
five points to the final score for MIPS eligible clinicians who 
participate in MIPS for the 2018 MIPS performance period and are in 
small practices or virtual groups or APM entities with 15 or fewer 
clinicians (the entire virtual group or APM entity combined must 
include 15 or fewer clinicians to qualify for the bonus). We believe a 
bonus of 5 points is appropriate to acknowledge the challenges small 
practices face in participating in MIPS, and to help them achieve the 
performance threshold proposed at section II.C.8.c. of this proposed 
rule at 15 points for the 2020 MIPS payment year, as this bonus 
represents one-third of the total points needed to meet or exceed the 
performance threshold and receive a neutral to positive payment 
adjustment. With a small practice bonus of 5 points, small practices 
could achieve this performance threshold by reporting 2 quality 
measures or 1 quality measure and 1 improvement activity.\19\ We 
believe that a higher bonus (for example, a bonus that would meet or 
exceed the performance threshold) is not ideal because it might 
discourage small practices from actively participating in MIPS or could 
mask poor performance. We propose in section II.C.7.b.(2) of this 
proposed rule that if the result of the calculation is greater than 100 
points, then the final score would be capped at 100 points.
---------------------------------------------------------------------------

    \19\ Assuming the small practice did not submit advancing care 
information and applied for the hardship exception and had the 
advancing care information performance category weight redistributed 
to quality, the small practice would have a final score with 85 
percent weight from the quality performance category score and 15 
percent from improvement activities. With the proposed scoring for 
small practices, submitting one measure one time would provide at 
least 3 measure achievement points out of 60 total available measure 
points. With 85 percent quality performance category weight, each 
quality measure would be worth at least 4.25 point towards the final 
score. ((3/60) x 85% x 100= 4.25 points). For improvement 
activities, each medium weighted activity is worth 20 out of 40 
possible points which translates to 7.5 points to the file score. 
(20/40) x 15% x 100 = 7.5 points).
---------------------------------------------------------------------------

    This bonus is intended to be a short-term strategy to help small 
practices transition to MIPS, therefore, we are proposing the bonus 
only for the 2018 MIPS performance period (2020 MIPS payment year) and 
will assess on an annual basis whether to continue the bonus and how 
the bonus should be structured.
    We are inviting public comment on our proposal to apply a small 
practice bonus for the 2020 MIPS payment year.
    We also considered applying a bonus for MIPS eligible clinicians 
that practice in either a small practice or a rural area. However, on 
average, we saw less than a one point difference between scores for 
MIPS eligible clinicians who practice in rural areas and those who do 
not. Therefore, we are not proposing to extend the final score bonus to 
those who practice in a rural area, but plan to continue to monitor the 
Quality Payment Program's impacts on the performance of those who 
practice in rural areas. We also seek comment on the application of a 
rural bonus in the future, including available evidence demonstrating 
differences in clinician performance based on rural status. If we 
implement a bonus for practices located in rural areas, we would use 
the definition for rural specified in section II.C.1. of this proposed 
rule for individuals and groups (including virtual groups).
(2) Final Score Calculation
    With the proposed addition of the complex patient and small 
practice bonuses, we propose to use the formula at Sec.  414.1380(c) to 
calculate the final score for all MIPS eligible clinicians, groups, 
virtual groups, and MIPS APMs starting with the 2020 MIPS payment year.
    We propose to revise the final score calculation at Sec.  
414.1380(c) to reflect this updated formula. We also propose to revise 
the policy finalized in the CY 2017 Quality Payment Program final rule 
to assign MIPS eligible clinicians with only 1 scored performance 
category a final score that is equal to the performance threshold (81 
FR 77326 through 77328) (we note that we inadvertently failed to codify 
this policy in Sec.  414.1380(c)). We are proposing this revision to 
the policy to account for our proposal in section II.C.7.b.(3)(c) of 
this proposed rule for extreme and uncontrollable circumstances which, 
if finalized, could result in a scenario where a MIPS eligible 
clinician is not scored on any performance categories. To reflect this 
proposal, we propose to add to Sec.  414.1380(c) that a MIPS eligible 
clinician with fewer than 2 performance category scores would receive a 
final score equal to the performance threshold.
    With the proposed addition of the complex patient and small 
practice bonuses, we also propose to strike the following phrase from 
the final score definition at Sec.  414.1305: ``The final score is the 
sum of each of the products of each performance category score and each 
performance category's assigned weight, multiplied by 100.'' We believe 
this portion of the definition would be incorrect and redundant of the 
proposed revised regulation at Sec.  414.1380(c).
    We invite public comment on the proposed final score methodology 
and associated revisions to regulation text.

[[Page 30141]]

(3) Final Score Performance Category Weights
(a) General Weights
    Section 1848(q)(5)(E)(i) of the Act specifies weights for the 
performance categories included in the MIPS final score: In general, 30 
percent for the quality performance category, 30 percent for the cost 
performance category, 25 percent for the advancing care information 
performance category, and 15 percent for the improvement activities 
performance category. However, that section also specifies different 
weightings for the quality and cost performance categories for the 
first and second years for which the MIPS applies to payments. Section 
1848(q)(5)(E)(i)(II)(bb) of the Act specifies that for the transition 
year, not more than 10 percent of the final score will be based on the 
cost performance category, and for the 2020 MIPS payment year, not more 
than 15 percent will be based on the cost performance category. Under 
section 1848(q)(5)(E)(i)(I)(bb) of the Act, the weight of the quality 
performance category for each of the first 2 years will increase by the 
difference of 30 percent minus the weight specified for the cost 
performance category for the year.
    In the CY 2017 Quality Payment Program final rule, we established 
the weights of the cost performance category as 10 percent of the final 
score (81 FR 77166) and the quality performance category as 50 percent 
of the final score (81 FR 77100) for the 2020 MIPS payment year. 
However, we are proposing in section II.C.6.d. of this proposed rule to 
change the weight of the cost performance category to zero percent and 
in section II.C.6.b. of this proposed rule to change the weight of the 
quality performance category to 60 percent for the 2020 MIPS payment 
year. We refer readers to sections II.C.6.b. and II.C.6.d. of this 
proposed rule for further information on the policies related to the 
weight of the quality and cost performance categories, including our 
rationale for our proposed weighting for each category.
    As specified in section 1848(q)(5)(E)(i) of the Act, the weights 
for the other performance categories are 25 percent for the advancing 
care information performance category and 15 percent for the 
improvement activities performance category. Section 1848(q)(5)(E)(ii) 
of the Act provides that in any year in which the Secretary estimates 
that the proportion of eligible professionals (as defined in section 
1848(o)(5) of the Act) who are meaningful EHR users (as determined in 
section 1848(o)(2) of the Act) is 75 percent or greater, the Secretary 
may reduce the applicable percentage weight of the advancing care 
information performance category in the final score, but not below 15 
percent. For more on our policies concerning section 1848(q)(5)(E)(ii) 
of the Act and a review of our proposal for reweighting the advancing 
care information performance category in the event that the proportion 
of MIPS eligible clinicians who are meaningful EHR users is 75 percent 
or greater starting with the 2019 MIPS performance period, we refer 
readers to section II.C.6.f.(5) of this proposed rule.
    Table 37 summarizes the weights specified for each performance 
category under section 1848(q)(5)(E)(i) of the Act and in accordance 
with our policies in the CY 2017 Quality Payment Program final rule as 
codified at Sec. Sec.  414.1380(c)(1), 414.1330(b), 414.1350(b), 
414.1355(b), and 414.1375(a), and with our proposals in section II.C.6. 
of this proposed rule.

                     Table 37--Finalized and Proposed Weights by MIPS Performance Category *
----------------------------------------------------------------------------------------------------------------
                                                                           2020 MIPS payment   2021 MIPS payment
                Performance category                    Transition year     year (proposed)     year and beyond
                                                          (final) (%)             (%)             (final) (%)
----------------------------------------------------------------------------------------------------------------
Quality.............................................                  60                  60                  30
Cost................................................                   0                   0                  30
Improvement Activities..............................                  15                  15                  15
Advancing Care Information**........................                  25                  25                  25
----------------------------------------------------------------------------------------------------------------
* In sections II.C.6.b. and II.C.6.c., we propose to maintain the same weights from the transition year for the
  2020 MIPS payment year for quality and cost (60 percent and zero percent, respectively).
**[hairsp]As described in section II.C.6.f. of this proposed rule, the weight for advancing care information
  could decrease (not below 15 percent) starting with the 2021 MIPS payment year if the Secretary estimates that
  the proportion of physicians who are meaningful EHR users is 75 percent or greater.

(b) Flexibility for Weighting Performance Categories
    Under section 1848(q)(5)(F) of the Act, if there are not sufficient 
measures and activities applicable and available to each type of MIPS 
eligible clinician involved, the Secretary shall assign different 
scoring weights (including a weight of zero) for each performance 
category based on the extent to which the category is applicable and 
for each measure and activity based on the extent to which the measure 
or activity is applicable and available to the type of MIPS eligible 
clinician involved. For the 2020 MIPS payment year, we propose to 
assign a scoring weight of zero percent to a performance category and 
redistribute its weight to the other performance categories in the 
following scenarios.
    For the quality performance category, we propose that having 
sufficient measures applicable and available means that we can 
calculate a quality performance category percent score for the MIPS 
eligible clinician because at least one quality measure is applicable 
and available to the MIPS eligible clinician. Based on the volume of 
measures available to MIPS eligible clinicians via the multiple 
submission mechanisms, we generally believe there will be at least one 
quality measure applicable and available to every MIPS eligible 
clinician. Given that we generally believe there will be at least one 
quality measure applicable and available to every MIPS eligible 
clinician, if we receive no quality performance category submission 
from a MIPS eligible clinician, the MIPS eligible clinician generally 
will receive a performance category score of zero (or slightly above 
zero if the all-cause hospital readmission measure applies because the 
clinician submits data for a performance category other than the 
quality performance category).\20\

[[Page 30142]]

However, as described in section II.C.7.a.(2)(e) of this proposed rule, 
there may be rare instances that we believe could affect only a very 
limited subset of MIPS eligible clinicians (as well as groups and 
virtual groups) that may have no quality measures available and 
applicable and for whom we receive no quality performance category 
submission (and for whom the all-cause hospital readmission measure 
does not apply). In those instances, we would not be able to calculate 
a quality performance category percent score.
---------------------------------------------------------------------------

    \20\ As discussed in the CY 2017 Quality Payment Program final 
rule (81 FR 77300), groups of 16 or more eligible clinicians that 
meet the applicable case minimum requirement are automatically 
scored on the all-cause readmission measure, even if they do not 
submit any other data under the quality performance category, 
provided that they submit data under one of the other performance 
categories. If such groups do not submit data under any performance 
category, the readmission measure is not scored.
---------------------------------------------------------------------------

    The proposed quality performance category scoring policies for the 
2020 MIPS payment year continue many of the special scoring policies 
from the transition year which would enable us to determine a quality 
performance category percent score whenever a MIPS eligible clinician 
has submitted at least 1 quality measure. In addition, MIPS eligible 
clinicians that do not submit quality measures when they have them 
available and applicable would receive a quality performance category 
percent score of zero percent. It is only in the rare scenarios when we 
determine that a MIPS eligible clinician does not have any relevant 
quality measures available to report or the MIPS eligible clinician is 
approved for reweighting the quality performance category based on 
extreme and uncontrollable circumstances as proposed in section 
II.C.7.b.(3)(c) of this proposed rule, that we would reweight the 
quality performance category. Therefore, we continue to believe that we 
will not be able to calculate a score for the quality performance 
category only in the rare scenarios when a MIPS eligible clinician does 
not have any relevant quality measures available to report.
    For the cost performance category, we continue to believe that 
having sufficient measures applicable and available means that we can 
reliably calculate a score for the cost measures that adequately 
captures and reflects the performance of a MIPS eligible clinician, and 
that MIPS eligible clinicians who are not attributed enough cases to be 
reliably measured should not be scored for the cost performance 
category (81 FR 77322 through 77323). We established a policy that if a 
MIPS eligible clinician is not attributed a sufficient number of cases 
for a measure (in other words, has not met the required case minimum 
for the measure), or if a measure does not have a benchmark, then the 
measure will not be scored for that clinician (81 FR 77323). If we do 
not score any cost measures for a MIPS eligible clinician in accordance 
with this policy, then the clinician would not receive a cost 
performance category percent score. Because we have proposed in section 
II.C.6.d. of this proposed rule to set the weight of the cost 
performance category to zero percent of the final score for the 2020 
MIPS payment year, we are not proposing to redistribute the weight of 
the cost performance category to any other performance categories for 
the 2020 MIPS payment year. In the event we do not finalize this 
proposal, we are proposing to redistribute the weight of the cost 
performance category as described in section II.C.7.b.(3)(d) of this 
proposed rule.
    For the improvement activities performance category, we believe 
that all MIPS eligible clinicians will have sufficient activities 
applicable and available; however, as discussed in section 
II.C.7.b.(3)(c) of this proposed rule, we believe there are limited 
extreme and uncontrollable circumstances, such as natural disasters, 
where a clinician is unable to report improvement activities. Barring 
these circumstances, we are not proposing any changes that would affect 
our ability to calculate an improvement activities performance category 
score.
    We refer readers to section II.C.6.f. of this proposed rule for a 
detailed discussion of our proposals and policies under which we would 
not score the advancing care information performance category and would 
assign a weight of zero percent to that category for a MIPS eligible 
clinician.
    We invite public comment on our interpretation of sufficient 
measures available and applicable in the performance categories.
(c) Extreme and Uncontrollable Circumstances
    In the CY 2017 Quality Payment Program final rule (81 FR 77241 
through 77243), we discussed our belief that extreme and uncontrollable 
circumstances, such as a natural disaster in which an EHR or practice 
location is destroyed, can happen at any time and are outside a MIPS 
eligible clinician's control. We stated that if a MIPS eligible 
clinician's CEHRT is unavailable as a result of such circumstances, 
then the measures specified for the advancing care information 
performance category may not be available for the MIPS eligible 
clinician to report. We established a policy allowing a MIPS eligible 
clinician affected by extreme and uncontrollable circumstances to 
submit an application to us to be considered for reweighting of the 
advancing care information performance category under section 
1848(q)(5)(F) of the Act. Although we are proposing in section 
II.C.6.f. of this proposed rule to use the authority in the last 
sentence of section 1848(o)(2)(D) of the Act, as amended by section 
4002(b)(1)(B) of the 21st Century Cures Act, as the authority for this 
policy, rather than section 1848(q)(5)(F) of the Act, we continue to 
believe that extreme and uncontrollable circumstances could affect the 
availability of a MIPS eligible clinician's CEHRT and the measures 
specified for the advancing care information performance category.
    While we did not propose or finalize a similar reweighting policy 
for other performance categories in the transition year, we believe a 
similar reweighting policy may be appropriate for the quality, cost, 
and improvement activities performance categories beginning with the 
2020 MIPS payment year. For these performance categories, we propose to 
define ``extreme and uncontrollable circumstances'' as rare (that is, 
highly unlikely to occur in a given year) events entirely outside the 
control of the clinician and of the facility in which the clinician 
practices that cause the MIPS eligible clinician to not be able to 
collect information that the clinician would submit for a performance 
category or to submit information that would be used to score a 
performance category for an extended period of time (for example, 3 
months could be considered an extended period of time with regard to 
information a clinician would collect for the quality performance 
category). For example, a tornado or fire destroying the only facility 
in which a clinician practices likely would be considered an ``extreme 
and uncontrollable circumstance;'' however, neither the inability to 
renew a lease--even a long or extended lease--nor a facility being 
found not compliant with federal, state, or local building codes or 
other requirements would be considered ``extreme and uncontrollable 
circumstances.'' We propose that we would review both the circumstances 
and the timing independently to assess the availability and 
applicability of measures and activities independently for each 
performance category. For example, in 2018 the performance period for 
improvement activities is only 90 days, whereas it is 12 months for the 
quality performance category, so an issue lasting 3 months may have 
more impact on the availability of measures for the quality performance 
category than for the improvement activities performance category, 
because

[[Page 30143]]

the MIPS eligible clinician, conceivably, could participate in 
improvement activities for a different 90-day period.
    We believe that extreme and uncontrollable circumstances, such as 
natural disasters, may affect a clinician's ability to access or submit 
quality measures via all submission mechanisms (effectively rendering 
the measures unavailable to the clinician) as well as the availability 
of numerous improvement activities. In addition, damage to a facility 
where care is provided due to a natural disaster, such as a hurricane, 
could result in practice management and clinical systems that are used 
for the collection or submission of data to be down, thus impacting a 
clinician's ability to submit necessary information via Qualified 
Registry, QCDR, CMS Web Interface, or claims. This policy would not 
include issues that third party intermediaries, such as EHRs, Qualified 
Registries, or QCDRs, might have submitting information to MIPS on 
behalf of a MIPS eligible clinician. Instead, this policy is geared 
towards events, such as natural disasters, that affect the MIPS 
eligible clinician's ability to submit data to the third party 
intermediary, which in turn, could affect the ability of the clinician 
(or the third party intermediary acting on their behalf) to 
successfully submit measures and activities to MIPS.
    We also propose to use this policy for measures which we derive 
from claims data, such as the all-cause hospital readmission measure 
and the cost measures. Other programs, such as the Hospital VBP 
Program, allow hospitals to submit exception applications when ``a 
hospital is able to continue to report data on measures . . . but can 
demonstrate that its Hospital VBP Program measure rates are negatively 
impacted as a result of a natural disaster or other extraordinary 
circumstance and, as a result, the hospital receives a lower value-
based incentive payment'' (78 FR 50705). For the Hospital VBP Program, 
we ``interpret[ed] the minimum numbers of cases and measures 
requirement in the Act to enable us to not score . . . all applicable 
quality measure data from a performance period and, thus, exclude the 
hospital from the Hospital VBP Program for a fiscal year during which 
the hospital has experienced a disaster or other extraordinary 
circumstance'' (78 FR 50705). Hospitals that request and are granted an 
exception are exempted from the Program entirely for the applicable 
year.
    For the 2020 MIPS payment year, we would score quality measures and 
assign points even for those clinicians who do not meet the case 
minimums for the quality measures they submit. However, we established 
a policy not to score a cost measure unless a MIPS eligible clinician 
has met the required case minimum for the measure (81 FR 77323), and 
not to score administrative claims measures, such as the all-cause 
hospital readmission measure, if they cannot be reliably scored against 
a benchmark (81 FR 77288 through 77289). Even if the required case 
minimums have been met and we are able to reliably calculate scores for 
the measures that are derived from claims, we believe a MIPS eligible 
clinician's performance on those measures could be adversely impacted 
by a natural disaster or other extraordinary circumstance, similar to 
the issues we identified for the Hospital VBP Program. For example, the 
claims data used to calculate the cost measures or the all-cause 
hospital readmission measure could be significantly affected if a 
natural disaster caused wide-spread injury or health problems for the 
community, which could not have been prevented by high-value 
healthcare. In such cases, we believe that the measures are available 
to the clinician, but are likely not applicable, because the extreme 
and uncontrollable circumstance has disrupted practice and measurement 
processes. Therefore, we believe an approach similar to Hospital VBP 
Program is warranted under MIPS, and we are proposing that we would 
exempt a MIPS eligible clinician from all quality and cost measures 
calculated from administrative claims data if the clinician is granted 
an exception for the respective performance categories based on extreme 
and uncontrollable circumstances.
    Beginning with the 2020 MIPS payment year, we propose that we would 
reweight the quality, cost, and/or improvement activities performance 
categories if a MIPS eligible clinician, group, or virtual group's 
request for a reweighting assessment based on extreme and 
uncontrollable circumstances is granted. We propose that MIPS eligible 
clinicians could request a reweighting assessment if they believe 
extreme and uncontrollable circumstances affect the availability and 
applicability of measures for the quality, cost, and improvement 
activities performance categories. To the extent possible, we would 
seek to align the requirements for submitting a reweighting assessment 
for extreme and uncontrollable circumstances with the requirements for 
requesting a significant hardship exception for the advancing care 
information performance category. For example, we propose to adopt the 
same deadline (December 31, 2018 for the 2018 MIPS performance period) 
for submission of a reweighting assessment (see section II.C.6.f. of 
this proposed rule), and we would encourage the requests to be 
submitted on a rolling basis. We propose the reweighting assessment 
must include the nature of the extreme and uncontrollable circumstance, 
including the type of event, date of the event, and length of time over 
which the event took place, performance categories impacted, and other 
pertinent details that impacted the ability to report on measures or 
activities to be considered for reweighting of the quality, cost, or 
improvement activities performance categories (for example, information 
detailing how exactly the event impacted availability and applicability 
of measures). If we finalize the policy to allow reweighting based on 
extreme and uncontrollable circumstances beginning with the 2020 MIPS 
payment year, we would specify the form and manner in which these 
reweighting applications must be submitted outside of the rulemaking 
process after the final rule is published.
    For virtual groups, we propose to ask the virtual group to submit a 
reweighting assessment for extreme and uncontrollable circumstances 
similar to groups, and we would evaluate whether sufficient measures 
and activities are applicable and available to the majority of TINs in 
the virtual group. We are proposing that a majority of TINs in the 
virtual group would need to be impacted before we grant an exception. 
We still find it important to measure the performance of virtual group 
members unaffected by an extreme and uncontrollable circumstance even 
if some of the virtual group's TINs are affected.
    We also seek comment on what additional factors we should consider 
for virtual groups. This reweighting assessment due to extreme and 
uncontrollable circumstances for the quality, cost, and improvement 
activities would not be available to APM Entities in the APM scoring 
standard for the following reasons. First, all MIPS eligible clinicians 
scored under the APM scoring standard will automatically receive an 
improvement activities category score based on the terms of their 
participation in a MIPS APM and need not report anything for this 
performance category. Second, the cost performance category has no 
weight under the APM scoring standard. Finally, for the quality 
performance category, each MIPS APM has its own rules related to 
quality measures and we believe any decisions related to

[[Page 30144]]

availability and applicability of measures should reside within the 
model. As noted in II.C.6.g.(2)(d) of this proposed rule, MIPS APM 
entities would be able to request reweighting of the advancing care 
information performance category.
    If we finalize these proposals for reweighting the quality, cost, 
and improvement activities performance categories based on extreme and 
uncontrollable circumstances, then it would be possible that one or 
more of these performance categories would not be scored and would be 
weighted at zero percent of the final score for a MIPS eligible 
clinician. We propose to assign a final score equal to the performance 
threshold if fewer than two performance categories are scored for a 
MIPS eligible clinician. This is consistent with our policy finalized 
in the CY 2017 Quality Payment Program final rule that because the 
final score is a composite score, we believe the intention of section 
1848(q)(5) of the Act is for MIPS eligible clinicians to be scored 
based on multiple performance categories (81 FR 77326 through 77328).
    We request comment on our extreme and uncontrollable circumstances 
proposals. We also seek comment on the types of the extreme and 
uncontrollable circumstances we should consider for this policy given 
the general parameters we describe in this section.
(d) Redistributing Performance Category Weights
    In the CY 2017 Quality Payment Program final rule, we codified at 
Sec.  414.1380(c)(2) that we will assign different scoring weights for 
the performance categories if we determine there are not sufficient 
measures and activities applicable and available to MIPS eligible 
clinicians (81 FR 77327). We also finalized a policy to assign MIPS 
eligible clinicians with only one scored performance category a final 
score that is equal to the performance threshold, which means the 
clinician would receive a MIPS payment adjustment factor of zero 
percent for the year (81 FR 77326 through 77328). We are proposing in 
section II.C.7.b.(2) of this proposed rule to refine this policy such 
that a MIPS eligible clinician with fewer than 2 performance category 
scores would receive a final score equal to the performance threshold. 
This refinement is to account for our proposal in section 
II.C.7.b.(3)(c) of this proposed rule for extreme and uncontrollable 
circumstances which, if finalized, could result in a scenario where a 
MIPS eligible clinician is not scored on any performance categories. We 
refer readers to the CY 2017 Quality Payment Program final rule for a 
description of our policies for redistributing the weights of the 
performance categories (81 FR 77325 through 77329). For the 2020 MIPS 
payment year, we propose to redistribute the weights of the performance 
categories in a manner that is similar to the transition year. However, 
we are also proposing new scoring policies to incorporate our proposals 
for extreme and uncontrollable circumstances.
    In section II.C.6.f. of this proposed rule, we are proposing to use 
the authority in the last sentence of section 1848(o)(2)(D) of the Act, 
as amended by section 4002(b)(1)(B) of the 21st Century Cures Act, as 
the authority for certain policies under which we would assign a 
scoring weight of zero percent for the advancing care information 
performance category, and to amend Sec.  414.1380(c)(2) to reflect our 
proposals. We are not, however, proposing substantive changes to the 
policy established in the CY 2017 Quality Payment Program final rule to 
redistribute the weight of the advancing care information performance 
category to the other performance categories for the transition year 
(81 FR 77325 through 77329).
    For the 2020 MIPS payment year, if we assign a weight of zero 
percent for the advancing care information performance category for a 
MIPS eligible clinician, we propose to continue our policy from the 
transition year and redistribute the weight of the advancing care 
information performance category to the quality performance category 
(assuming the quality performance category does not qualify for 
reweighting). We believe redistributing the weight of the advancing 
care information performance category to the quality performance 
category (rather than redistributing to both the quality and 
improvement activities performance categories) is appropriate because 
MIPS eligible clinicians have more experience reporting quality 
measures through the PQRS program, and measurement in this performance 
category is more mature.
    If we do not finalize our proposal at section II.C.6.d. of this 
proposed rule to weight the cost performance category at zero percent 
(which means the weight of the cost performance category is greater 
than zero percent), then we propose to not redistribute the weight of 
any other performance categories to the cost performance category. We 
believe this is consistent with our policy of introducing cost 
measurement in a deliberate fashion and recognition that clinicians are 
more familiar with other elements of MIPS. In the rare and unlikely 
scenario where a MIPS eligible clinician qualifies for reweighting of 
the quality performance category percent score (because there are not 
sufficient quality measures applicable and available to the clinician 
or the clinician is facing extreme and uncontrollable circumstances) 
and the MIPS eligible clinician is eligible to have the advancing care 
information performance category reweighted to zero and the MIPS 
eligible clinician has sufficient cost measures applicable and 
available to have a cost performance category percent score that is not 
reweighted, then we would redistribute the weight of the quality and 
advancing care information performance categories to the improvement 
activities performance category and would not redistribute the weight 
to the cost performance category. If we finalize the cost performance 
category weight at zero percent for the 2020 MIPS payment year, then we 
would set the final score at the performance threshold because the 
final score would be based on improvement activities which would not be 
a composite of two or more performance category scores.
    For the 2020 MIPS payment year, if we do not finalize the proposal 
to set the cost performance category a zero percent weight, and if a 
MIPS eligible clinician does not receive a cost performance category 
percent score because there are not sufficient cost measures applicable 
and available to the clinician or the clinician is facing extreme and 
uncontrollable circumstances, we propose to redistribute the weight of 
the cost performance category to the quality performance category. In 
the rare scenarios where a MIPS eligible clinician does not receive a 
quality performance category percent score because there are not 
sufficient quality measures applicable and available to the clinician 
or the clinician is facing extreme and uncontrollable circumstances, we 
propose to redistribute the weight of the cost performance category 
equally to the remaining performance categories that are not 
reweighted.
    In the rare event a MIPS eligible clinician is not scored on at 
least one measure in the quality performance category because there are 
not sufficient measures applicable and available or the clinician is 
facing extreme and uncontrollable circumstances, we propose for the 
2020 MIPS payment year to continue our policy from the transition year 
and redistribute the 60 percent weight of the quality performance 
category so that the performance category weights are 50

[[Page 30145]]

percent for the advancing care information performance category and 50 
percent for the improvement activities performance category (assuming 
these performance categories do not qualify for reweighting). While 
clinicians have more experience reporting advancing care information 
measures, we believe equal weighting to both the improvement activities 
and advancing care information is appropriate for simplicity. 
Additionally, in the absence of quality measures, we believe increasing 
the relative weight of the improvement activities performance category 
is appropriate because both improvement activities and advancing care 
information have elements of quality and care improvement which are 
important to emphasize. Should the cost performance category have 
available and applicable measures and the cost performance category 
weight is not zero, but either the improvement activities or advancing 
care information performance category is reweighted to zero percent, 
then we would redistribute the weight of the quality performance 
category to the remaining performance category that is not weighted at 
zero percent. We would not redistribute the weight to the cost 
performance category.
    We believe that all MIPS eligible clinicians will have sufficient 
improvement activities applicable and available. It is possible that a 
MIPS eligible clinician might face extreme and uncontrollable 
circumstances that render the improvement activities not applicable or 
available to the clinician; however, in that scenario, we believe it is 
likely that the measures specified for the other performance categories 
also would not be applicable or available to the clinician based on the 
circumstances. In the rare event that the improvement activities 
performance category would qualify for reweighting based on extreme and 
uncontrollable circumstances, and the other performance categories 
would not also qualify for reweighting, we propose to redistribute the 
improvement activities performance category weight to the quality 
performance category consistent with the redistribution policies for 
the cost and advancing care information performance categories. Should 
the cost performance category have available and applicable measures 
and the cost performance category weight is not finalized at zero 
percent, and the quality performance category is reweighted to zero 
percent, then we would redistribute the weight of the improvement 
activities performance category to the advancing care information 
performance category.
    Table 38 summarizes the potential reweighting scenarios based on 
our proposals for the 2020 MIPS payment year should the cost 
performance category be weighted at zero percent.

   Table 38--Proposed Performance Category Redistribution Policies for the 2020 MIPS Payment Year if the Cost
                                   Performance Category Weight Is Zero Percent
----------------------------------------------------------------------------------------------------------------
                                                                     Reweight                        Reweight
                                                                  scenario if no     Reweight     scenario if no
                                                   Weighting for  advancing care  scenario if no    improvement
              Performance category                 the 2020 MIPS    information       quality       activities
                                                   payment year     performance     performance     performance
                                                        (%)       category score     category     category score
                                                                        (%)        percent score        (%)
----------------------------------------------------------------------------------------------------------------
Quality.........................................              60              85               0              75
Cost............................................               0               0               0               0
Improvement Activities..........................              15              15              50               0
Advancing Care Information......................              25               0              50              25
----------------------------------------------------------------------------------------------------------------

    In response to our final policy to redistribute the advancing care 
information performance category weight solely to the quality 
performance category in the CY 2017 Quality Payment Program final rule 
(81 FR 77327), we received some comments expressing concern that this 
would place undue emphasis on the quality performance category. 
Commenters expressed the belief that this policy would particularly 
affect non-patient facing MIPS eligible clinicians who have limited 
available measures, and would limit the ability to fairly compare 
different specialties that are reweighted differently. One reason for 
the discrepancy is that MIPS eligible clinicians that submit data to 
the advancing care information performance category can readily achieve 
a base score of 50 percent if they meet the requirements for the base 
score measures, whereas the quality performance category does not start 
at the same base. Commenters also expressed the belief that specialties 
with few quality measures available to them will be unfairly impacted 
by this reweighting policy, by putting a disproportionate weight on 
just a few quality measures. Commenters suggested we redistribute the 
weight of the advancing care information performance category to the 
improvement activities performance category because the improvement 
activities performance category allows for the most flexibility. One 
commenter recommended redistributing the weight of the advancing care 
information performance category to both the quality and improvement 
activities performance categories.
    We continue to have concerns about increasing the weight of the 
improvement activities performance category, given that this 
performance category is based on attestation only and is not connected 
to a predecessor CMS program like the other MIPS performance 
categories. However, based on the comments we received, we considered 
an alternative approach for the 2020 MIPS payment year to redistribute 
the weight of the advancing care information performance category to 
the quality and improvement activities performance categories, to 
minimize the impact of the quality performance category on the final 
score. For this approach, we would redistribute 15 percent to the 
quality performance category (60 percent + 15 percent = 75 percent) and 
10 percent to the improvement activities performance category (15 
percent + 10 percent = 25 percent). We considered redistributing the 
weight of the advancing care information performance category equally 
to the quality and improvement activities performance categories. 
However, for simplicity, we wanted to redistribute the weights in 
increments of 5 points. Because MIPS eligible clinicians have more 
experience reporting quality measures and because these measures are 
more mature, under

[[Page 30146]]

this alternative option, we would redistribute slightly more to the 
quality performance category (15 percent vs. 10 percent). Should the 
cost performance category have available and applicable measures and 
the cost performance category weight is not finalized at zero percent 
and the quality performance category is reweighted to zero percent, 
then we would redistribute the weight of the advancing care information 
performance category to the improvement activities performance 
category. This alternative approach, assuming the cost performance 
category weight is zero percent is detailed in Table 39.

     Table 39--Alternative Option for Reweighting the Advancing Care
 Information Performance Category for the 2020 MIPS Payment Year if the
            Cost Performance Category Weight Is Zero Percent
------------------------------------------------------------------------
                                                             Reweight
                                                          scenario if no
                                         Weighting for    advancing care
         Performance category            the 2020 MIPS     information
                                          payment year     performance
                                              (%)         category score
                                                               (%)
------------------------------------------------------------------------
Quality...............................               60               75
Cost..................................                0                0
Improvement Activities................               15               25
Advancing Care Information............               25                0
------------------------------------------------------------------------

    We invite comments on our proposal for weighting the performance 
categories for the 2020 MIPS payment year and our alternative option 
for reweighting the advancing care information performance category.
8. MIPS Payment Adjustments
a. Payment Adjustment Identifier and Final Score Used in Payment 
Adjustment Calculation
(1) Payment Adjustment Identifier
    For purposes of applying the MIPS payment adjustment under section 
1848(q)(6)(E) of the Act, we finalized a policy in the CY 2017 Quality 
Payment Program final rule to use a single identifier, TIN/NPI, for all 
MIPS eligible clinicians, regardless of whether the TIN/NPI was 
measured as an individual, group or APM Entity group (81 FR 77329 
through 77330). In other words, a TIN/NPI may receive a final score 
based on individual, group, or APM Entity group performance, but the 
MIPS payment adjustment would be applied at the TIN/NPI level.
    We are not proposing any changes to the MIPS payment adjustment 
identifier.
(2) Final Score Used in Payment Adjustment Calculation
    In CY 2017 Quality Payment Program final rule (81 FR 77330 through 
77332), we finalized a policy to use a TIN/NPI's historical performance 
from the performance period associated with the MIPS payment 
adjustment. We also proposed the following policies, and, although we 
received public comments on them and responded to those comments, we 
inadvertently failed to state that we were finalizing these policies, 
although it was our intention to do so. Thus, we clarify that the 
following final policies apply beginning with the transition year. For 
groups submitting data using the TIN identifier, we will apply the 
group final score to all the TIN/NPI combinations that bill under that 
TIN during the performance period. For individual MIPS eligible 
clinicians submitting data using TIN/NPI, we will use the final score 
associated with the TIN/NPI that is used during the performance period. 
For eligible clinicians in MIPS APMs, we will assign the APM Entity 
group's final score to all the APM Entity Participant Identifiers that 
are associated with the APM Entity. For eligible clinicians that 
participate in APMs for which the APM scoring standard does not apply, 
we will assign a final score using either the individual or group data 
submission assignments.
    In the case where a MIPS eligible clinician starts working in a new 
practice or otherwise establishes a new TIN that did not exist during 
the performance period, there would be no corresponding historical 
performance information or final score for the new TIN/NPI. In cases 
where there is no final score associated with a TIN/NPI from the 
performance period, we will use the NPI's performance for the TIN(s) 
the NPI was billing under during the performance period. If the MIPS 
eligible clinician has only one final score associated with the NPI 
from the performance period, then we will use that final score. In the 
event that an NPI bills under multiple TINs in the performance period 
and bills under a new TIN in the MIPS payment year, we finalized a 
policy of taking the highest final score associated with that NPI in 
the performance period (81 FR 77332).
    In some cases, a TIN/NPI could have more than one final score 
associated with it from the performance period, if the MIPS eligible 
clinician submitted duplicative data sets. In this situation, the MIPS 
eligible clinician has not changed practices; rather, for example, a 
MIPS eligible clinician has a final score for an APM Entity and a final 
score for a group TIN. If a MIPS eligible clinician has multiple final 
scores, the following hierarchy will apply. If a MIPS eligible 
clinician is a participant in MIPS APM, then the APM Entity final score 
would be used instead of any other final score. If a MIPS eligible 
clinician has more than one APM Entity final score, we will apply the 
highest APM Entity final score to the MIPS eligible clinician. If a 
MIPS eligible clinician reports as a group and as an individual and not 
as an APM Entity, we will calculate a final score for the group and 
individual identifier and use the highest final score for the TIN/NPI 
(81 FR 77332).
    For a further description of our policies, we refer readers to the 
CY 2017 Quality Payment Program final rule (81 FR 77330 through 77332).
    In addition to the above policies from the CY 2017 Quality Payment 
Program final rule, beginning with the 2020 MIPS payment year, we are 
proposing to modify the policies to address the addition of virtual 
groups. Section 1848(q)(5)(I)(i) of the Act provides that MIPS eligible 
clinicians electing to be a virtual group must: (1) Have their 
performance assessed for the quality and cost performance categories in 
a manner that applies the combined performance of all the MIPS eligible 
clinicians in the virtual group to each MIPS eligible clinician in the 
virtual group for the applicable performance period; and (2) be scored 
for the quality

[[Page 30147]]

and cost performance categories based on such assessment. Therefore, 
when identifying a final score for payment adjustments, we must 
prioritize a virtual group final score over other final scores such as 
individual and group scores. Because we also wish to encourage movement 
towards APMs, we will prioritize using the APM Entity final score over 
any other score for a TIN/NPI, including a TIN/NPI that is in a virtual 
group. If a TIN/NPI is in both a virtual group and a MIPS APM, we 
propose to use the waiver authority for Innovation Center models under 
section 1115A(d)(1) of the Act and the Shared Savings Program waiver 
authority under section 1899(f) of the Act to waive section 
1848(q)(5)(I)(i)(I) and (II) of the Act. As discussed in section 
II.C.4.h. of this proposed rule, the use of waiver authority is to 
avoid creating competing incentives between MIPS and the APM. We want 
MIPS eligible clinicians to focus on the requirements of the APM to 
ensure that the models produce valid results that are not confounded by 
the incentives created by MIPS.
    We also propose to modify our hierarchy to state that if a MIPS 
eligible clinician is not in an APM Entity and is in a virtual group, 
the MIPS eligible clinician would receive the virtual group final score 
over any other final score. Our policies remain unchanged for TIN/NPIs 
who are not in an APM Entity or virtual group.
    We invite public comment on our proposals.
    Table 40 illustrates the previously finalized and newly proposed 
policies for determining which final score to use when more than one 
final score is associated with a TIN/NPI.

  Table 40--Hierarchy for Final Score When More Than One Final Score Is
                        Associated With a TIN/NPI
------------------------------------------------------------------------
                                          Final score used to determine
                Example                        payment adjustments
------------------------------------------------------------------------
TIN/NPI has more than one APM Entity     The highest of the APM Entity
 final score.                             final scores.
TIN/NPI has an APM Entity final score    APM Entity final score.
 that is not a virtual group score and
 also has a group final score.
TIN/NPI has an APM Entity final score    APM Entity final score.
 and also has a virtual group score.
TIN/NPI has a virtual group score and    Virtual group score.
 an individual final score.
TIN/NPI has a group final score and an   The highest of the group or
 individual final score, but no APM       individual final score.
 Entity final score and is not in a
 virtual group.
------------------------------------------------------------------------

    Table 41 illustrates the previously finalized policies that apply 
if there is no final score associated with a TIN/NPI from the 
performance period, such as when a MIPS eligible clinician starts 
working in a new practice or otherwise establishes a new TIN.

           Table 41--No Final Score Associated With a TIN/NPI
------------------------------------------------------------------------
                                                           Final score
                         Performance    TIN/NPI billing      used to
    MIPS eligible        period final   in MIPS payment     determine
  clinician  (NPI 1)        score        year  (yes/no)      payment
                                                           adjustments
------------------------------------------------------------------------
TIN A/NPI 1..........  90.............  Yes (NPI 1 is    90 (Final score
                                         still billing    for TIN A/NPI
                                         under TIN A in   1 from the
                                         the MIPS         performance
                                         payment year).   period).
TIN B/NPI 1..........  70.............  No (NPI 1 has    n/a (no claims
                                         left TIN B and   are billed
                                         no longer        under TIN B/
                                         bills under      NPI 1).
                                         TIN B in the
                                         MIPS payment
                                         year).
TIN C/NPI 1..........  n/a (NPI 1 was   Yes (NPI 1 has   90 (No final
                        not part of      joined TIN C     score for TIN
                        TIN C during     and is billing   C/NPI 1, so
                        the              under TIN C in   use the
                        performance      the MIPS         highest final
                        period).         payment year).   score
                                                          associated
                                                          with NPI 1
                                                          from the
                                                          performance
                                                          period).
------------------------------------------------------------------------

b. MIPS Payment Adjustment Factors
    For a description of the statutory background and further 
description of our policies, we refer readers to the CY 2017 Quality 
Payment Program final rule (81 FR 77332 through 77333).
    We are not proposing any changes to these policies.
c. Establishing the Performance Threshold
    Under section 1848(q)(6)(D)(i) of the Act, for each year of the 
MIPS, the Secretary shall compute a performance threshold with respect 
to which the final scores of MIPS eligible clinicians are compared for 
purposes of determining the MIPS payment adjustment factors under 
section 1848(q)(6)(A) of the Act for a year. The performance threshold 
for a year must be either the mean or median (as selected by the 
Secretary, and which may be reassessed every 3 years) of the final 
scores for all MIPS eligible clinicians for a prior period specified by 
the Secretary. Section 1848(q)(6)(D)(iii) of the Act outlines a special 
rule for the initial 2 years of MIPS, which requires the Secretary, 
prior to the performance period for such years, to establish a 
performance threshold for purposes of determining the MIPS payment 
adjustment factors under section 1848(q)(6)(A) of the Act and an 
additional performance threshold for purposes of determining the 
additional MIPS payment adjustment factors under section 1848(q)(6)(C) 
of the Act, each of which shall be based on a period prior to the 
performance period and take into account data available for performance 
on measures and activities that may be used under the performance 
categories and other factors determined appropriate by the Secretary. 
We codified the term performance threshold at Sec.  414.1305 as the 
numerical threshold for a MIPS payment year against which the final 
scores of MIPS eligible clinicians are compared to determine the MIPS 
payment adjustment factors. We codified at Sec.  414.1405(b) that a 
performance threshold will be specified for each MIPS payment year. We 
refer readers to the CY 2017 Quality Payment Program final rule for 
further discussion

[[Page 30148]]

of the performance threshold (81 FR 77333 through 77338). In accordance 
with the special rule set forth in section 1848(q)(6)(D)(iii) of the 
Act, we finalized a performance threshold of 3 points for the 
transition year (81 FR 77334 through 77338).
    Our goal was to encourage participation and provide an opportunity 
for MIPS eligible clinicians to become familiar with the MIPS Program. 
We determined that it would have been inappropriate to set a 
performance threshold that would result in downward adjustments to 
payments for many clinicians who may not have had time to prepare 
adequately to succeed under MIPS. By providing a pathway for many 
clinicians to succeed under MIPS, we believed that we would encourage 
early participation in the program, which may enable more robust and 
thorough engagement with the program over time. We set the performance 
threshold at a low number to provide MIPS eligible clinicians an 
opportunity to achieve a minimum level of success under the program, 
while gaining experience with reporting on the measures and activities 
and becoming familiar with other program policies and requirements. We 
believed if we set the threshold too high, using a new formula that is 
unfamiliar and confusing to clinicians, many could be discouraged from 
participating in the first year of the program, which may lead to lower 
participation rates in future years. Additionally, we believed this 
flexibility is particularly important to reduce the burden for MIPS 
eligible clinicians in small or solo practices. We believed that active 
participation of MIPS eligible clinicians in MIPS will improve the 
overall quality, cost, and care coordination of services provided to 
Medicare beneficiaries. In accordance with section 1848(q)(6)(D)(iii) 
of the Act, we took into account available data regarding performance 
on measures and activities, as well as other factors we determined 
appropriate. We refer readers to 81 FR 77333 through 77338 for details 
on our analysis. We also stated our intent to increase the performance 
threshold in the 2020 MIPS payment year, and that, beginning in the 
2021 MIPS payment year, we will use the mean or median final score from 
a prior period as required by section 1848(q)(6)(D)(i) of the Act (81 
FR 77338).
    For the 2020 MIPS payment year, we again want to use the 
flexibility provided in section 1848(q)(6)(D)(iii) to help transition 
MIPS eligible clinicians to the 2021 MIPS payment year, when the 
performance threshold will be the mean or median of the final scores 
for all MIPS eligible clinicians from a prior period. We want to 
encourage continued participation and the collection of meaningful data 
by MIPS eligible clinicians. A higher performance threshold would help 
MIPS eligible clinicians strive to achieve more complete reporting and 
better performance and prepare MIPS eligible clinicians for the 2021 
MIPS payment year. However, a performance threshold set too high could 
also create a performance barrier, particularly for MIPS eligible 
clinicians who did not previously participate in PQRS or the EHR 
Incentive Programs. We have heard from stakeholders requesting that we 
continue a low performance threshold and from stakeholders requesting 
that we ramp up the performance threshold to help MIPS eligible 
clinicians prepare for the 2021 MIPS payment year and to meaningfully 
incentivize higher performance. Given our desire to provide a 
meaningful ramp between the transition year's 3-point performance 
threshold and the 2021 MIPS payment year performance threshold using 
the mean or median of the final scores for all MIPS eligible clinicians 
for a prior period, we are proposing to set the performance threshold 
at 15 points for the 2020 MIPS payment year.
    We propose a performance threshold of 15 points because it 
represents a meaningful increase in performance threshold, compared to 
3 points in the transition year, while maintaining flexibility for MIPS 
eligible clinicians in the pathways available to achieve this 
performance threshold. For example, submitting the maximum number of 
improvement activities could qualify for a score for 15 points (40 out 
40 possible points for the improvement activity which is worth 15 
percent of the final score). The performance threshold could also be 
met by full participation in the quality performance category: By 
submitting all required measures with the necessary data completeness, 
MIPS eligible clinicians would earn at least a quality performance 
category percent score of 30 percent (which is 3 measure achievement 
points out of 10 measure points for each required measure).
    If the quality performance category is weighted at 60 percent, then 
the quality performance category would be 30 percent x 60 percent x 100 
which equals 18 points toward the final score and exceeds the 
performance threshold. Finally, a MIPS eligible clinician could achieve 
a final score of 15 points through an advancing care information 
performance category score of 60 percent or higher (60 percent 
advancing care information performance category score x 25 percent for 
the advancing care information performance category weight x 100 equals 
15 points towards the final score). We refer readers to section 
II.C.8.g.(2) of this proposed rule for complete examples of how MIPS 
eligible clinician could exceed the performance threshold. We believe 
the proposed performance threshold would mitigate concerns from MIPS 
eligible clinicians about participating in the program for the second 
year. However, we remain concerned that moving from a performance 
threshold of 15 points for the 2020 MIPS payment year to a performance 
threshold of the mean or median of the final scores for all MIPS 
eligible clinicians for a prior period for the 2021 MIPS payment year 
may be a steep jump.
    By the 2021 MIPS payment year, MIPS eligible clinicians would 
likely need to submit most of the required information and perform well 
on the measures and activities to receive a positive MIPS payment 
adjustment. Therefore, we also seek comment on setting the performance 
threshold either lower or higher than the proposed 15 points for the 
2020 MIPS payment year. A performance threshold lower than the proposed 
15 points for the 2020 MIPS payment year presents the potential for a 
significant increase in the final score a MIPS eligible clinician must 
earn to meet the performance threshold in the 2021 MIPS payment ye