The 2018 Quality Payment Program proposed rule eases the burden on small and rural practices compared to the 2017 rule, more or less responding to criticism of the 2017 rule’s high expectations on practices.

While the 2018 proposed rule keeps the 2017 rule’s positive changes to the non-patient-facing threshold (increasing from 25 to 100), the overall implications are a mixed bag for imaging, according to Gregory Nicola, MD, vice president of the Hackensack Radiology group and Chair of the American College of Radiology’s (ACR’s) MACRA Committee.

“Overall we were pleased that Medicare moved the dial last year, but they didn’t accept our recommendations that only evaluation of management services be included on the patient-facing encounter list,” he said. “They went ahead and finalized Zero-day global and surgical codes on the that list, that put some practices in jeopardy.”

On the other hand, changes to Advancing Care Information activities may pay dividends for imaging. CMS expanded the exclusions for hospital-based practices to include off-campus sites of service—not an uncommon setup for radiology.

“I’ve already spoken to a couple practices that were going to have to do ACI exclusions this year but won’t in the next performance period because it’s now included in the exemption,” said Nicola. “That helped quite a few practices.”

A new participation option called Virtual Groups allows small practices of 10 or fewer clinicians to form reporting groups with other practices across the country. This could benefit radiologists, said Nicola, especially due to an odd quirk in how CMS worded this years’ rule: they didn’t limit the number of taxpayer IDs in a group.

“Theoretically you could have all the small practices in the country join together, which would be very interesting,” he said. “Medicare made a comment that they would look to see if large portions of specialties were included in groups and place a cap on the number of taxpayer IDs in a group, but they decided not to place a cap this year.”

CMS also raised the low-volume threshold to $90,000 billed to Medicare, potentially excluding some types of radiologists who don’t see many Medicare beneficiaries­—pediatric radiologist chief among them, said Nicola.

Overall, the Virtual Groups option and preserving the 100-encounter patient-facing threshold means this 2018 proposed rule should be beneficial for imaging, but especially useful to smaller practices.

“Medicare is continuing a fairly abrupt transition, listening to small and rural practices and clinics across the country to make a program that’s easier to do than past performance programs,” said Nicola. “I think that started in the 2017 proposed rule and I think it continues with this rule.”