On Thursday, November 1, CMS released the 2019 Medicare Physician Fee Schedule and Quality Payment Program final rule, including important updates to the Merit-Based Incentive Payment System (MIPS). We published our initial thoughts on the rule when it was proposed over the summer here. There is clearly a lot of work ahead for providers preparing for these changes, but overall these updates signal stability for Medicare reimbursement for providers moving into the future as many elements of the program will stay the same.

Caravan Health also submitted formal comments in September on the proposed rule. One big concern was the reduction of levels of reimbursement for complex evaluation and management (E&M) services. We were pleased to see that CMS finalized a more conservative reduction than proposed, maintaining three distinct levels instead of two, and has also delayed implementation of this policy for two years until 2021, allowing further time for improvement. CMS also backed away from a proposal to eliminate same-day payment for multiple E&M visits, which will allow providers to offer greater convenience to patients. We will continue to review the changes, advise our clients, and comment as appropriate.


Changes to MIPS

CMS generally pursued evolutionary rather than revolutionary changes to MIPS this year, with some important policies included alongside generally minor changes. Those major changes include:

Newly Eligible Clinicians: One of the big changes to MIPS is the expansion of MIPS-eligible clinicians, increasing by six the types of providers that may be subject to MIPS reporting and subsequent payment adjustment. Beginning in performance year 2019 physical therapists, occupational therapists, qualified speech language pathologists, qualified audiologists, clinical psychologists, and registered dieticians or nutrition professionals can potentially earn MIPS bonuses. This change will enhance the value of ACO participation for groups of physicians with significant numbers of therapies, audiologists, and other allied health care professionals.
 
Electronic Health Information Sharing: The final rule encourages providers to share electronic health information by making some structural changes to the MIPS Promoting Interoperability category. The total number of reportable measures is reduced but there is more weight on health information exchange between providers and patients. Additionally, beginning in 2019 clinicians must report Promoting Interoperability with 2015 version certified electronic health record technology (CEHRT) - the 2014 transitional measure set will no longer be available. With these policy changes, CMS is signaling a commitment to the MIPS program and positioning health providers for the future. However, providers that have not started upgrading to the 2015 edition will struggle to meet this requirement and could suffer low payments as a result – it's time for them to focus on implementing the upgrade where possible. 

ACO Quality Measures: CMS finalized the reduction in the number of quality measures in the Shared Savings Program. This should lower the reporting burden on ACOs and could be a welcome change to our provider partners. This chart shows the measures that will be added and those that will be retired in 2019.
 
Quality Measure Changes 2018 to 2019

Other Shared Savings Program Changes: CMS also took the opportunity to finalize certain time-sensitive provisions of the Shared Savings Program ACO “Pathways to Success” rule proposed in August 2018. Specifically, CMS outlined the process by which ACOs whose contract would have expired at the end of calendar 2018 may apply for a six-month extension through the next ACO start date of July 1, 2019.  
 

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