In this week’s episode, Dr. Dan Mingle provides his thoughts and takeaways from the 2024 Proposed Rule.

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Question One: Importance of the Proposed Rule

Kyle asks: “Dr. Mingle, how important is it to pay attention to the Proposed Rule?”

The Proposed Rule is important, but it’s not as essential to pay attention to as the Final Rule.

Everyone is busy. And the Final Rule, annually, is the one that sets the new rule in regulatory concrete. So if you are only going to invest in one, invest your time in the Final Rule.

There are two reasons to pay careful attention to the Proposed Rule: the opportunity to comment and to prepare for future changes.

On the opportunity to comment:

• Medicare will accept comments on the proposals until 5 PM EDT on 9/11/2023
• You can submit a comment on the Regulations.gov website, and refer to file code CMS-1784-P
• Your comments make a difference:
  • Medicare reads the comments and considers all of the feedback when finalizing the rules
  • Medicare encourages unique comments, and “campaigns” are discouraged

I think it is true that a single well-reasoned, well-explained comment has a great chance of success. However, I’d be surprised if they weren’t responsive to the “weight” of many specific comments.

On preparing for future changes:

• The Proposed Rule is a warning of the changes that CMS may finalize in early November, less than two months before they go into effect.
• Sometimes, it makes sense to be building infrastructure in preparation for those changes that are likely.

And the predictive value of the Proposed Rule is enhanced by knowledge and experience of:

• The annual rulemaking cycle
• The relationship between legislation and regulation
• Each rule’s relationship to Medicare strategy
• And simply the observation that I’ve never seen a Final Rule that is more restrictive than the proposal

Question Two: Proposed Changes to MIPS

Kyle asks: “What do you think are the most important proposals for MIPS participants in the 2024 Proposed Rule?”

There are really just two things, I think, that might be a surprise.

First, CMS proposes to increase the MIPS Performance Threshold to 82.

That’s an increase of 7 points from the 2023 threshold of 75.

That significant, especially considering 82 represents average scores across the three Performance Years 2017, 2018, and 2019.

Those averages were generated in the first years of MIPS when:

• Requirements were easier
• More bonus points were available
• And Cost measures were not factored in

On the good side, it should mean a higher potential incentive for those above the threshold.

Second, CMS proposes to increase the Promoting Interoperability Performance Period to 180 days (up from 90 days).

I expect this will have little impact on most MIPS participants. It will primarily be a consideration when changing or upgrading EHR systems. In those cases, you will probably find leniency when requesting Hardship Exceptions.

Question Three: MIPS Value Pathways (MVPs) in the 2024 Proposed Rule

Kyle asks: “MVPs just became available for the 2023 Performance Year, with a target to sunset traditional MIPS and require MVPs as early as the 2028 Performance Year. What’s newly proposed for MVPs?”

There is not much that’s concrete other than what you would expect.

There are no proposed updates to the project timeline. A 2028 sunset of traditional MIPS and total reliance on MVPs is still the target.

There are proposed tweaks to the first twelve MVPs and five more proposed for introduction.

Of most significant import is the implication in CMS’s embedded Request For Information (RFI):

• CMS wants our input on how to use MVPs to define specialist roles in our ACOs
• In the 2024 Proposed Rule, Medicare reiterates that they want all Medicare beneficiaries in an accountable care setting by 2030. The 2028 proposed switchover from traditional MIPS to MVPs suggests to me that MVPs are expected to help the nation cross that final gap of accountability
• Making this RFI in this Proposed Rule is a clear indication of intent and a strong signal that it will show up in rulemaking soon

Question Four: MSSP in the 2024 Proposed Rule

Kyle: “What issues do you think are most important for Medicare Shared Savings Program (MSSP) participants?”

I think the proposed changes to the MSSP quality reporting workflow will have the most significant impact from the Proposed Rule.

Despite heavy lobbying by the National Association of Accountable Care Organizations (NAACOs) and individual ACOs, CMS stubbornly refuses to postpone the 2025 scheduled sunset of the Web Interface for quality reporting.

Instead, they propose to offer a new quality measure collection type called Medicare CQMs. It’s the same 3-measure APP measure set: HbA1c, blood pressure control, and depression screening.

The proposed Medicare CQMs:

• Will use the numerator specs and collection dynamics of the existing MIPS CQMs (requiring a registry vendor to submit)
• But, the denominator will be limited to Medicare patients.
  • This limitation is similar to what we experienced in PQRS, with a slight difference:
    • Medicare CQMs will limit reporting to Medicare patients seen by primary care providers of the ACO
    • Not just attributed patients but all patients seen

Overall, this is intended to reduce the burden on practices and to be a temporary measure type as ACOs transition to all-patient, all-payer reporting.

CMS intends to provide a list of Medicare patients early in the first quarter of every year, but this list will be incomplete. Typically, there is a quarter lag between claims generation and list preparation, so the list will only include patient experiences through the year’s third quarter.

Another main point to pay attention to for MSSP participants is the proposal to change the CEHRT requirement for Advanced APM participants from 75% to 100%.

Finally, CMS has proposed requiring all APM participants to submit MIPS Promoting Interoperability and have a MIPS PI score.

• All reporting methods are open for this proposal: individual, practice-level, and APM-level reporting.
• And you can still qualify for an exclusion like the Small Practice Exclusion or Non-Patient Facing exclusion.

Send us your value-based care questions!

If you’d like to ask a question about the APP transition, MIPS, ACO quality reporting, or any other Alternative Payment Model, you can reach out to us in three ways:

You can leave your questions in a YouTube comment under any episode of Ask Dr. Mingle.

On LinkedIn, leave your questions in a comment on any of our posts.

And you can reach out directly by sending an email to hello@minglehealth.com.

Want to learn more about MIPS Value Pathways?

MIPS Value Pathways (MVPs) are the newest reporting option implemented by CMS for MIPS-eligible clinicians to fulfill their reporting requirements. Download our latest PDF guide to increase your understanding of MIPS Value Pathways in 2023.

Access the Guide