CMS proposes changes to MACRA Quality Payment Program for 2018

The Center for Medicare and Medicaid Services (CMS) on June 30, 2017, published a proposed rule outlining changes for the 2018 performance year of the Quality Payment Program (QPP) under the Medicare Access and CHIP Reauthorization Act (MACRA). MACRA’s QPP includes the incentive payments for advanced alternative payment models (A-APMs) and the Merit-based Incentive Payment System (MIPS). Performance in 2018 will determine payment adjustments to clinicians that will be applied to their Medicare Part B payments in 2020.

The first performance year began January 1, 2017, for Part B payment adjustments in 2019.

MACRA repealed the sustainable growth rate (SGR) formula for updates to the Medicare Part B Physician Fee Schedule and sets payment updates for all years in the future. Through the QPP, the law is intended to link Medicare payment updates to quality and performance and drive the health care payment system across all payers away from fee-for-service reimbursement models.

Select key provisions of the proposed rule are highlighted below.


  • Low-volume threshold: CMS proposes increasing the low-volume threshold for the 2018 performance year. Under the proposal, clinicians would be exempt from MIPS if their Medicare Part B allowed charges for a performance period do not exceed $90,000 or they treat fewer than 200 Part B beneficiaries. For 2017, the low-volume threshold was set at $30,000 in Part B allowed charges or 100 Part B beneficiaries.
  • 90-day reporting period: The proposed rule would maintain the option for eligible clinicians to report for a period of as little as 90 days under MIPS, rather than a full year.
  • Cost: CMS proposes to maintain the weight of the MIPS cost performance category at 0% of the MIPS composite score for the 2018 performance year, but is requesting feedback on setting the weight at 10%. The MACRA statute does not appear to provide for regulatory flexibility for CMS to generally set the weight of the cost performance category under MIPS below 30% for performance years beginning in 2019. In addition, CMS has proposed to reconsider the list of 10 episodes of care that would be included in the cost performance category that was included in the November 2016 final rule for MIPS and APM incentives. CMS is working to develop a new list of episodes of care.
  • Advancing care information: CMS proposed allowing clinicians to continue to use either the 2014 or 2015 edition of certified electronic health record technology in performance year 2018. The November 2016 final rule called for clinicians to use the 2015 edition.
  • Complex patients: The proposed rule for 2018 proposes applying an adjustment of up to three bonus points for clinicians who treat complex patients. The proposed rule seeks comments on basing the bonus points on average Hierarchical Conditions Category (HCC) risk scores or other methods.
  • Performance threshold: CMS proposes setting the performance threshold at 15 points for the 2018 performance year, meaning that clinicians who score less than 15 points would receive a negative payment adjustment. The performance threshold for 2017 was three points. CMS proposes maintaining the additional performance threshold for exceptional performance at 70 points for 2018.


  • Standard for nominal amount of financial risk: CMS proposes extending the nominal amount standard of 8% of average estimated revenue from Medicare Parts A and B of the participating A-APM entities through performance year 2020. The November 2016 final rule had provided for this standard only for 2017 and 2018 performance years.
  • Physician-focused Payment Model Technical Advisory Committee (PTAC): MACRA created the PTAC to evaluate proposals for new payment models, some of which could be determined to be A-APMs. CMS proposes expanding the scope of proposals PTAC may consider to include models in Medicaid and the Children’s Health Insurance Program (CHIP), in addition to Medicare.
  • All-Payer Combination Option: Notably, CMS provided greater detail on the criteria for the All-Payer Combination option, which will allow clinicians participating in Other Payer Advanced APMs to achieve Qualifying Participant (QP) status under MACRA. The proposed rule provides a timeline for payment models to be determined Other Payer Advanced APMs, notably beginning in January 2018 for state Medicaid programs and April 2018 for Medicare Advantage plans. The proposed rule would provide opportunities for payers, as well as clinicians, to seek to have payment models determined to be Other Payer Advanced APMs.

Next steps

CMS is accepting comments on the proposed rule through August 21, 2017. A final rule is expected in the fall of 2017.


Anne Phelps
Principal | Deloitte Risk and Financial Advisory
US Health Care Regulatory Leader
Deloitte & Touche LLP
Latest conversations from Anne Phelps on Twitter

Daniel Esquibel
Senior Manager | Deloitte Risk and Financial Advisory
Deloitte & Touche LLP

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