The 2018 QPP Final Rule – Insights into the Future

November 13th, 2017 by

On November 2nd, CMS released the much anticipated 2018 Quality Payment Program (QPP) final rule. While most of what was in the proposed rule ultimately made it into the final rule there was one surprise along with many indicators of what to expect as the QPP continues to mature over the next several years.

1. Cost

The Cost category, accounting for 10% of the 2018 MIPS score, was the biggest surprise and is the most significant difference between the first and second MIPS performance years. In the proposed rule, CMS did shared their concern about the Cost category going from 0% to 30% in 2019, as required by the legislation, and decided it was better to get started in 2018. Only two measures, total per capita cost for all attributed beneficiaries and the Medicare Spending per Beneficiary (MSPB), will be scored in 2018. CMS intends to provide performance feedback on these two measures by July 1, 2018, but organizations do not need to wait until then to start taking action. CMS recently released the 2016 QRUR reports, which contain detailed cost data that should be analyzed to identify areas for improvement during the first half of 2018 prior to the official CMS performance feedback. CMS is currently conducting limited field testing on eight episode-based measures and will expand this testing during 2018. It is expected that the eight episode-based measures, and possibly more, will be added to the Cost category for scoring during the 2019 performance year.

2. APMs

One of the most persistent concerns regarding the QPP has been the limited Advanced APMs options available to clinicians. Large portions of the 2018 final rule are dedicated to the Advanced APM track and what CMS is doing to increase the available options. The most significant portion is focused on other Payer Advanced APMs, which will become part of the Advanced APM track in 2019. Other Payer Advanced APMs are payment models developed and executed by non-Medicare payers, including Medicare Advantage plans. To qualify as other Payer Advanced APMs, the payment models must meet the same criteria for risk (8% total risk), quality measures, and use of Certified EHR Technology (CEHRT), that Medicare APMs must meet. Payment models can be submitted to CMS for review by clinicians, payers, or third party entities in 2018, and CMS will post approved models on their website late in the year. CMS will also develop a demonstration project to test the effects of expanding incentives for clinicians to participate in Medicare Advantage plans that qualify as Advanced APMs. The ultimate goal of the demonstration is to determine if clinicians should qualify for the Advanced APM track, if they only participate in Medicare Advantage plans that meet Advanced APM requirements. The demonstration results would inform the legislative change that would be required to allow this for 2019 or future years.

3. The Performance Threshold

For 2018 the MIPS Performance Threshold (PT) has increased to 15 points, a modest increase over the 2017 PT of 3. 2019 will be a different story. In the 2019 performance year, per the MACRA legislation, the PT must be equal to the mean or median of prior performance periods. In the 2018 Final Rule, CMS estimates that 75% of participants will have scores of 70 or higher. Many 2018 scores that earn a positive payment adjustment will end up below the PT for 2019, resulting in negative payment adjustment for the 2019 performance year. Clinicians and organizations need to be careful not to fall into a false sense of security in 2018 and focus on continual improvement.

CMS is clearly preparing clinicians and the broader healthcare market for a more intensive MIPS program in 2019. This can be seen in the 2018 final rule where CMS states, “a second year to ramp-up the program will continue to help build upon the iterative learning and development of year 1 in preparation for a robust program in year 3.”

For more information on the changes and impacts of the 2018 final rule, listen to our on-demand recording of our ABCs of the QPP webinar where SA Ignite regulatory experts answered the most popular questions that were submitted by registrants. 


Matt Fusan
Director, Customer Experience

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