Key Quality Payment Program Changes in 2022 PFS Proposed Rule


CMS introduced the first seven MIPS value pathways and other updates to the Quality Payment Program as part of the Medicare Physician Fee Schedule proposed rule.

If finalized, the Quality Payment Program (QPP) will undergo significant policy changes under the Medicare Physician Fee Schedule (PFS) proposed rule. Most notably, the rule introduced the first seven Merit-Based Incentive Payment System (MIPS) value pathways (MVPs), which will be used to streamline MIPS reporting requirements in the future.

The QPP began in 2017 as a value-based payment model that rewards clinicians for delivering high-quality care and reduces payments for clinicians who fail to meet performance standards. It replaced the flawed sustainable growth rate (SGR) model which was repealed under the Medicare Access and CHIP Reauthorization Act (MACRA).

Clinicians can participate in the QPP through either MIPS or advanced alternative payment models (APMs), but most of the proposed updates for CY 2022 focus on MIPS.

There are currently three reporting frameworks available to MIPS eligible clinicians depending on individual needs and eligibility: traditional MIPS, MIPS Value Pathways, and the alternative payment model (APM) performance pathway (APP).

MVPs were CMS’s answer to grievances from clinicians about confusing quality measures that led some physicians to call on Congress to repeal MIPS in 2018. With the addition of MVPs, clinicians will be able to report only on measures that apply to their specialty.

Under the CY 2022 Physician Fee Schedule Notice of Proposed Rule Making (NPRM), CMS has proposed seven MVPs for the 2023 performance year to align with the following clinical areas: rheumatology, heart disease, stroke care and prevention, lower extremity joint repair, anesthesia, emergency medicine, and chronic disease management.

“We recognize that there are many types of MVPs we need to develop, and that the traditional MIPS framework is needed until we have a sufficient number of MVPs available,” a CMS QPP overview fact sheet on the proposed rule explained.

“Through the MVP development work, we’ll gradually implement MVPs for more specialties and subspecialties that participate in the program.”

CMS is now requesting public comment on potentially phasing out traditional MIPS after the 2027 performance year and simultaneously mandating MVP participation for all MIPS clinicians.

CMS also proposed the establishment of subgroup reporting to satisfy stakeholder requests for more comprehensive data reporting from MIPS. For the first few years, subgroup reporting will be limited to clinicians reporting under MVPs or APP.

In addition to the MVPs, CMS plans to increase the MIPS performance threshold for the CY 2022 performance year from 60 to 75 points, revise reporting requirements for promoting interoperability, and receive feedback on how the QPP can advance health equity efforts.

The rule includes tweaks to existing MIPS performance categories, including five new episode-based cost measures under the cost performance category and three new health equity measures under the improvement activities performance category.

The proposed changes will also enable clinical social workers and certified nurse midwives to become MIPS eligible clinician types starting in the 2022 performance year. Additionally, CMS proposed implementing a recent statutory change that allows physician assistants (PAs) to bill Medicare directly and subsequently reduce administrative burden.


MIPS and its value drivers have received mixed feedback since its 2017 implementation. One survey showed that physicians appreciate the improvements in process quality that MIPS afforded more than the actual clinical outcomes it may have led to.

In response to the proposed rule, the AHA explained that it remains “concerned about the feasibility of the Merit-Based Incentive Payment System (MIPS) Value Pathways, and believe much work remains to ensure they result in fair, equitable performance comparisons across MIPS clinicians and groups.”

Other industry groups have spoken up about general concerns regarding the Medicare Physician Fee Schedule proposed rule. One of the rule’s main goals is to decrease the physician Medicare reimbursement conversion factor by over a dollar.

The MGMA and the Surgical Care Coalition both expressed concerns about the impact of the conversion factor reduction because it does not keep up with inflation and could harm patients and physicians.

Although MVPs were offered as a solution to previous inconsistent reporting measures, many are still skeptical of the usefulness and accuracy of self-reported quality measures. When it was first enacted in 2017, clinicians were troubled by the quality reporting flexibilities that MIPS allowed.

With a multitude of quality measures to choose from under the old model, clinicians could theoretically pick and choose only measures with favorable outcomes. In addition, the quantity of quality measures did not allow for meaningful data analysis. MVPs intend to streamline this process and mitigate confusion.

CMS is giving clinicians a buffer period to learn about and adjust to the new rules. But the rapidly changing policies are bound to add confusion and administrative burden to physicians and practices as they navigate the new requirements.

Along with significant changes to the QPP, the Medicare Physician Fee Schedule proposed rule also aims to expand telehealth capabilities by allowing physicians to be reimbursed for behavioral health services provided via phone calls and video appointments. Comments on the proposed rule are due to CMS by September 13th.

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