Medicare Urged to Open Quality Reporting to All Doctors

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By Mindy Yochelson

Doctors in small practices should be allowed to participate fully in Medicare’s quality reporting program next year, physician groups are telling the Medicare agency.

Some warn that excluding small doctors from the quality program could result in paltry payments for good performers and offer little incentive for nonparticipants to improve performance. The groups were commenting on a proposal for the second year of Medicare’s doctor quality payment program. Comments to the Centers for Medicare & Medicaid Services were due Aug. 21.

The law generally requires that eligible doctors who don’t participate in alternative payment models report quality measures under a reporting program known as the Merit-Based Incentive Payment System (MIPS). Results can raise or lower Medicare reimbursements to doctors based on their score.

Medicare proposed in June to raise the 2018 exclusion limits for low-volume providers. In 2017, doctors with $30,000 or less in Medicare charges or who provide care to 100 or fewer beneficiaries during a performance period don’t have to report under MIPS.

Medicare’s proposal for 2018, released June 20, would lift the thresholds to exclude those billing $90,000 or less or treating 200 or fewer beneficiaries. The number of doctors excluded from MIPS based on size is estimated to jump to 586,000 in 2018 from 384,000.

Let Us In

When the proposal was released, doctor groups for the most part said they were relieved. The higher limits would ease the administrative burden on small practices and help them avoid penalties, they said.

Many are now telling CMS that small practices and solo practitioners should be allowed to participate if they want and be subject to the same rewards and penalties as those in larger groups.

But the Centers for Medicare & Medicaid Services was clear in its proposed rule. Ineligible doctors “in no case” may get an increase or decrease, regardless if they voluntarily send in performance measures.

The American College of Physicians and AMGA were among those that strongly recommended that smaller groups that want to be part of the program be scored like others.

Individual doctors or groups that fall below either the monetary minimum or the patient limit or both should not only be able to voluntarily participate but be scored under MIPS, AMGA, which represents large health systems, said.

Some of these clinicians may be participating this year and would be frustrated if turned away in 2018, the ACP, which represents internists, said.

Doctors have yet to submit measures under MIPS for this first year, Premier, the health-care alliance, said. At least wait until there’s evidence that additional exclusions are needed, Premier told the CMS.

Regardless, doctors in small practices that want to should be able to fully opt in and receive payment adjustments, the health-care alliance said.

Negative Ramifications

One of the problems with the shrinking participation group is that MIPS is a “zero sum game,” AMGA said. MIPS adjustments have to be budget neutral in that those professionals being rewarded with extra money are paid out of the penalty pool.

However, the penalty pool is small because few of the high-volume practices are being subject to cuts. Under the CMS’s lenient performance measure scoring system, nearly all clinicians will receive a positive payment adjustment in 2018. With many of the smaller practices—which are more likely to get payment cuts—excluded from MIPS, there’s not much in bonuses for the higher-scoring clinicians.

With the shallow pool of money spread across a significant number of positive scorers, the average reward is expected at about 1 percent.

Beyond the Dollars

Further, the impact of more doctor exclusions can go beyond the immediate dollar signs of bonuses and penalties. Excluding professionals and small groups from receiving a score can lead to their complacency, AMGA said.

Leaving them out “poses a risk of stalling these exempted practices in making progress,” ACP said.

“These clinicians would neither get performance feedback reports, nor would their performance be available on Physician Compare,” Premier said.

The Federation of American Hospitals warned this could lead to a two-tiered system in which one tier would consist of those “actively engaged and moving forward with MIPS,” and the other of those making efforts to avoid inclusion or with limited participation.

Future Inclusion?

The CMS indicated in the proposal that it’s considering easing up in the future on its prohibition of equal MIPS participation for smaller practices. The agency asked for comments about whether meeting just one of the two limits—either the allowed charges or the number of beneficiaries—should allow for full participation.

However, the earliest this would happen is 2019, the CMS said.

The American College of Emergency Physicians and other groups urged earlier implementation. Doing so would “provide some of these clinicians with an opportunity to engage in quality reporting and qualify for positive payment adjustments,” ACEP said.

Nonetheless, ACEP said it supports the proposal to shield more small practices from reporting requirements next year.

The additional exclusions are appropriate for those having trouble reporting, Laura Wooster, the group’s associate executive director for public affairs, told Bloomberg BNA Aug. 24.

Doctors who legitimately have difficulty keeping up because they lack resources and can’t compete against larger groups should be excluded, she said. Penalizing them would make matters worse if they need to make investments toward improvement, she said.

To contact the reporter on this story: Mindy Yochelson in Washington at

To contact the editor responsible for this story: Kendra Casey Plank at

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