2021 Medicare Physician Fee Schedule Quality Payment Program Summary: Emergency Medicine

September 4, 2020

On August 3, 2020, the Centers for Medicare and Medicaid Services (CMS) released its CY 2021 Medicare Physician Fee Schedule (MPFS) proposed rule, which includes changes to Medicare Part B payment and other policies, as well the Quality Payment Program (QPP).
CMS is not proposing any significant changes to the QPP due to the public health emergency (PHE) still in effect. The following is a summary of the significant provisions contained in the QPP portion of the Proposed Rule.

2020 MIPS Provisions
Policies that would Impact the 2020 Reporting Year:

• For 2020 only, CMS is doubling the complex patient bonus from five (5) points to a maximum of ten (10) points added to the overall MIPS performance score to account for additional complexities due to the COVID-19 pandemic.
• 2020 Reporting Exemptions Due to COVID-19: As described here, CMS is granting hardship exemptions on a case-by-case basis due to COVID-19.
  • It is therefore possible for an ED clinician or group to request to be exempted from all four performance categories in 2020. If clinicians submit a hardship exception application for all four MIPS performance categories, and their application is approved, they will be held harmless from a payment adjustment in 2022—meaning that they will not be eligible for a bonus or potentially face a penalty based on their MIPS performance in 2020.
  • This is not a proposal, but rather an official self-executing administrative policy.
• For performance year 2020, all ACOs are affected by the PHE and the MSSP extreme and uncontrollable circumstances policy applies.

2021 Quality Payment Program Proposals
MIPS Value Pathways
In the 2020 MPFS, CMS finalized the concept of MIPS Value Pathways (MVP) with the intention of beginning to introduce MVPs in the 2021 PFS.

• MVPs are templates for how to participate in MIPS.
• CMS is not introducing any MVPs in the 2021 PFS and they will not be available for reporting until CY 2022 or later.

Proposed MIPS Performance Thresholds and Category Weights

• Performance Threshold to avoid a penalty of up to -9% and attain a 0% Payment Adjustment: 50 points (up from 45 points in 2020).
• Exceptional Performance Threshold remains at 85 points (same as 2020) to be eligible for the$500 million pool.
• As required by statute, the maximum negative payment adjustment in 2023 (based on performance in 2021) is -9%, and the positive payment adjustment can be up to 9% (before any exceptional performance bonus).
  • Since MIPS is a budget neutral program, the size of the positive payment adjustments is ultimately controlled by the amount of money available through the pool of negative payment adjustments. In other words, the 9% positive payment adjustment can be scaled up or down (capped at a factor of + 3%).
  • Likewise, the exceptional performance bonus is capped at $500 million across all eligible Medicare providers, so the more providers who quality for the bonus, the smaller it is. In the first three years of the program, most clinicians qualified for a positive payment adjustment, so the size of the adjustment was relatively small.
  • For example, if a clinician received a perfect score of 100 in 2019, the clinician would only receive a positive adjustment of 1.79%in 2021 (much less than the 7% permissible under law) and up slightly from the 1.68% in 2020.

2021 Performance Year (PY) Category Weights

• Quality: 40% (5% decrease from PY 2020)
• Cost: 20% (5% increase from PY 2020)
• PI: 25% (no change from PY 2020)
  • For Non-patient Facing Groups (NPF) the PI category will again be reweighted to Quality.
• IA: 15% (no change from PY 2020)

By law, the Cost and Quality performance categories must become equally weighted at 30% by the 2022 performance period.

2021 Performance Period Scoring
Due to the COVID-19 public health emergency (PHE) declared by the Secretary of DHHS, 2021 performance period benchmarks will be used to score Quality Measures. CMS is concerned that there will not be a representative sample of historic data from 2019, which could skew benchmarks.

• Typically, CMS uses historical benchmarks to score quality measures based on performance data gathered two years before the performance year.
• This means that groups will not be able to review measure benchmarks in advance of reporting them.
• Since CMS is proposing to use performance period benchmarks for 2021, not historical benchmarks, the scoring policy for topped-out measures must be updated.
  • The seven (7) measure achievement point cap will be applied only if the measure is identified as topped out, based on the established benchmarks for both the 2020 and 2021 performance periods.
  • Existing measure specifications will be updated to include telehealth services that are directly applicable to existing episode-based cost measures and the TPCC measure.

Quality Performance Category
CMS is proposing a total of 206 quality measures for the 2021 performance period. This includes substantive changes to 112 existing MIPS quality measures, changes to specialty sets (including adding one measure and removing one measure from the emergency medicine specialty set), the removal of 14 quality measures, and the addition of two new administrative claims outcome quality measures.

Emergency Medicine Measure Changes:

• CMS is proposing to add one measure to the Emergency Medicine Specialty Set: Measure #418: Osteoporosis Management in Women Who Had a Fracture;
• CMS is proposing to remove one measure from the Emergency Medicine Specialty Set due to its topped-out status: Measure #333: Adult Sinusitis: CT for Acute Sinusitis (Overuse)

Due to the COVID-19 pandemic, CMS is proposing to change how it establishes quality benchmarks. Since CMS held clinicians harmless if they were unable to report data from 2019, CMS believes that 2019 data may be unreliable. Therefore, CMS intends to develop performance period benchmarks for the CY 2021 MIPS performance period using the data submitted during the CY 2021 performance period rather than the baseline period historic data (2019 data).

Cost Category

• The Cost Category is updated to existing measure specifications.
• This includes telehealth services that are directly applicable to existing episode-based cost measures and the TPCC measure.

Qualified Clinical Data Registries (QCDRs)
QCDRs are third-party intermediaries that help clinicians report under MIPS. ACEP has its own QCDR called the Clinical Emergency Data Registry (CEDR). CMS has separate policies governing QCDRs and the approval of QCDR measures.

Due to the COVID-19 pandemic, CMS has delayed two new requirements finalized in last year’s rule:

• The QCDR measure testing requirement is delayed until the 2022 performance period; and
• The QCDR measure data collection requirement is delayed until the 2022 performance period. QCDRs are required to collect data on a QCDR measure prior to submitting the QCDR measure for CMS consideration during the self-nomination period.
• In the rule, CMS is proposing to allow QCDRs to develop measures that can be used in MVPs, if the measures are fully tested at the clinician level prior to being submitted for consideration. This is a significant proposal, as previously, it was unclear what role QCDRs could play in MVPs.

CMS is also proposing that QCDRs conduct data validation audits, with specific obligations, on an annual basis.

APM Performance Pathway (APP)

CMS proposes a new APM Performance Pathway (APP) in 2021. This new Pathway would be complementary to MVPs. The APP would be available only to participants in MIPS APMs and may be reported by the individual eligible clinician, group (TIN), or APM Entity.

• In the APP, Cost would be weighted at 0%; IA would automatically get full credit; PI would be reported and scored at the individual or group level, as is required for the rest of MIPS.
• Quality will be composed of six (6) measures that are specifically focused on population health and widely available to all MIPS APM participants.

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