CY 2022 Quality Payment Program (QPP) Proposed Rule

Executive Summary

The Center for Medicare & Medicaid Services (CMS) for CY 2022 will be focusing on fulfilling requirements of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which includes setting performance thresholds at either the mean or median of the final scores for all MIPS eligible clinicians for the previous performance period.  This could mean greater payment adjustments for clinicians. 

While the majority of the QPP proposed changes are related to formulating the MIPS Value Pathway (MVP) program, there are several other traditional MIPS related updates and changes proposed. While CMS is proposing to delay the implementation of MIPS Value Pathways (MVPs) by 1 year, they make it clear that MVPs are the future of the quality program.  Traditional MIPS reporting policies appear to be stabilizing as CMS begins to transition toward MVPs; however, for those participating in traditional MIPS, higher thresholds may mean that achieving a positive payment adjustment is tougher to reach.

Rule Timeframe

Released: 7/13/2021

Comment period ends: 9/13/2021

Final Rules anticipated: 11/1/2021

Final Rules effective: 1/1/2022

Summary of Proposed Rule

MIPS Value Pathways

Proposed additions to the MVP development criteria

• MVPs will go into effect in 2023, with seven MVP candidates
• MVPs should focus on Promoting Interoperability as a foundation.
• MVPs must include at least one outcome measure that is relevant to the MVP topic so that MVP Participants are measured on outcomes that are meaningful to the care they provide.
• Each MVP that is applicable to more than one clinician specialty should include at least one outcome measure that is relevant to each clinician specialty included.
• In instances when outcome measures are not available, each MVP must include at least one high priority measure that is relevant to the MVP topic, so MVP Participants are measured on high-priority measures that are meaningful to the care they provide.
• Allow the inclusion of outcomes-based administrative claims measures within the quality component of an MVP.
• Each MVP must include at least one high priority measure that is relevant to each clinician specialty included.
• To be included in an MVP, qualified clinical data registry (QCDR) measures must be fully tested.

 Timeline

• CMS is proposing to begin transitioning from traditional MIPS pathways to MVPs in the 2023 MIPS performance year.  This reflects a 1-year delay in the timeline set out in the CY 2021 QPP Final Rule.  Reporting MVPs for performance years 2023-2027 would be voluntary per this proposal.
•   There are seven proposed MVP candidates for the 2023 performance year:
  • Rheumatology
  • Stroke Care and Prevention
  • Heart Disease
  • Chronic Disease Management
  • Emergency Medicine
  • Lower Extremity Joint Repair
  • Anesthesia
• For the 2023 and 2024 performance years, CMS is proposing MVP Participants include individual clinicians, single specialty groups, multispecialty groups, subgroups, and APM entities that are assessed on an MVP for all MIPS performance categories.  There would be no opportunity to volunteer or opt-in.  Participants would be required to register during a specified time.
• Beginning in the 2025 performance year, CMS proposes that multispecialty groups be required to form subgroups in order to report MVPs.
• CMS is soliciting comments on potentially sunsetting traditional MIPS after the end of the 2027 performance and data submissions periods. Any proposal to sunset traditional MIPS would be made in future rulemaking.

Third Party Intermediary Support Requirements

• Require that QCDRs, Qualified Registries, and Health IT vendors support:
  • MVPs relevant to the specialties they support beginning with the 2023 performance year.
  • Subgroup reporting beginning with the 2023 performance year.

Traditional MIPS Program Requirements

MIPS Eligible Clinician Definition

CMS is proposing to revise the definition of a MIPS eligible clinician to include:

• Clinical social workers
• Certified nurse mid-wives

 

Performance Threshold

CMS is proposing to establish the performance threshold using the mean final score from the 2017 performance year/2019 MIPS payment year, which would result in a performance threshold of 75 points for 2022.  The exceptional performance threshold is proposed to be set at 89 points.  This is the final year for the exceptional performance bonus.

Performance Category Weights

For 2022 performance year/2024 payment year, the performance category weights are:

• 30% – Quality
• 30% – Cost
• 15% – Improvement Activities (no change)
• 25% – Promoting Interoperability (no change)

PT, OT, SLP and Audiologists would still be eligible for automatic reweighting resulting in 85% weighting for Quality and 15% for Improvement Activities.  This is unchanged from 2021.

CMS reminds stakeholders that due to the continued PHE, COVID-19, the extreme and uncontrollable circumstances policy will allow for reweighting for performance year 2021.

Complex Patient Bonus

Due to the PHE, CMS is proposing to continue the complex patient bonus for performance year 2021/payment year 2023.  This bonus would be doubled and capped at 10 points and added to the final MIPS score.

For performance year 2022, CMS is looking to revise the complex patient bonus scoring and is seeking comments on the proposed changes outlined in this rule.

Performance Category Proposals

Quality

• CMS is proposing to maintain the data completeness criteria threshold at 70% for 2022 and increase it to 80% beginning with the 2023 performance year.  They also are clarifying language to state that for Part B Claims reporting, 70% data completeness is for Medicare Part B payers only (for 2022).  Other reporting types must report on all payers.
• Case minimum to be maintained at 20 cases for 2022, but CMS is proposing to move to measure-specific case minimums.
• Assigning Quality Measure Achievement points proposals:
• Update quality measure scoring to remove end-to-end electronic reporting and high-priority measure bonus points.
• For benchmarked measures, CMS removes the 3-point floor for scoring.  Measures will be scored from 1-10 points.  Measures without a benchmark will be assigned zero points.  There are some exceptions to scoring for small practices.
• Maintain a 5-point floor for new measures in the program for their first 2 years (5-10 points).  They would be assigned as Class 4 measures.
• Topped out measures could receive a maximum of 7 points.
• There is a proposal to use performance period benchmarks, or a different baseline period, such as calendar year 2019, for scoring quality measures in the 2022 performance period.  CMS is analyzing the 2020 performance period data to determine if it can be used for 2022 benchmarking.
• Extend the CMS Web Interface as a quality reporting option for registered groups, virtual groups, or other APM Entities for the 2022 performance period.
• Quality Measure and Specialty Measure Set Changes
• There are 195 Quality Measures proposed for 2022.  CMS has proposed adding five new quality measures with two of these being administrative claims measures.
• A request for information is made regarding one potential new measure: COVID-19 Vaccination by Clinicians.
• Modifications to existing measure sets are proposed.  This includes changes to the PT/OT Specialty Set to remove measure 154.  CMS also proposes to remove measure 050 which is not currently included in the PT/OT Specialty Set but may be added if it is maintained in the list of measures.  There are no changes proposed to the Speech Specialty set.
• There are 19 Quality Measures proposed for removal from the MIPS program.  Measure 154 is included in the list for removal. 
• Substantive changes to 84 measures are outlined.  This includes three FOTO measures (217, 219, 478) and five other measures commonly used by therapists (128,143, 182, 226, 281).

Improvement Activities

• No scoring changes are proposed for the Improvement Activities category for 2022.
• CMS is proposing 7 new improvement activities, 3 of which are related to promoting health equity.
• There are 15 current improvement activities with proposed modification.  Eleven address health equity.  Included on the list of proposed modifications is:
• IA_BE_6 – Collection of and follow-up on patient experience and satisfaction data on beneficiary engagement
• Proposing to remove 6 previously adopted improvement activities.  This includes:
• IA_BE_13 – Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms

Promoting Interoperability

• No changes are proposed to the reporting period.
• CMS is proposing to apply automatic reweighting to small practices. This means they would no longer be required to apply for hardship exceptions and reweighting.
• Proposed revisions to reporting requirements:
• Added requirement in the Provide Patients Electronic Access to Their Health Information measure that patients have access to their health information indefinitely, for encounters on or after January 1, 2016.
• Require MIPS eligible clinicians to attest to conducting an annual assessment of the High-Priority Guide of the Safety Assurance Factors for EHR Resilience Guides (SAFER Guides) beginning with the CY 2022 performance period.

Cost

• There are five new cost measures proposed for performance year 2022 which includes new episode-based measures.

• CMS is proposing scoring flexibilities beginning in 2022.

Care Compare (Public Reporting)

• MVPs and subgroups would be subject to public reporting.  Due to the delay in MVP implementation, reporting is also proposed to be delayed.
• CMS is proposing to add the following affiliations to providers on Care Compare:
• Long-Term Care Hospitals
• Inpatient Rehabilitation Facilities
• Inpatient Psychiatric Facilities
• Skilled Nursing Facilities
• Home Health Agencies
• Hospice
• End-Stage Renal Disease (ESRD) Facilities

MIPS APM Performance Pathway (APP) Proposals

• Extend reporting via the CMS Web Interface under the MIPS APP for Shared Savings Programs accountable care organizations (ACOs) through 2023.
• Updates to measures are proposed
• Allow MIPS eligible clinicians to report the MIPS APP as a subgroup beginning in 2023

MIPS Advanced Alternative Payment Models (APMs) Proposals

• Include arrangements for identifying TINs where a qualifying APM participant’s original TIN is no longer active.

FHIR API Adoption and Digital Quality Measures (dQMs)

CMS is requesting information and seeking comments on use of FHIR HL7 to support the Promoting Interoperability category of MIPS. 

CMS continues to move toward adopting digital quality measures across all quality reporting and value-based purchasing programs by 2025.  They are currently working to move eCQMs to dQMs using FHIR HL7. 

Data Validation Audit and Targeted Audit

CMS clarifies that no changes can be made to the data validation plan once it is approved, unless those changes are approved by CMS.

QCDR Measures

In order to determine whether a QCDR measure may be finalized within an MVP, CMS require QCDR measure testing data for review by the end of the self-nomination period. CMS will request that QCDRs share testing data for their fully tested QCDR measures at the time of MVP candidate submission –  which may be prior to the September 1st deadline. CMS will not finalize the inclusion of the QCDR measure within an MVP without the testing data.

References and Resources

QPP Fact Sheet

Pre-published Proposed Rule

Quality Payment Program Website