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Government Affairs Update
John W. Marshall, Communications Director / Project Manager, Signature Medical Group, Inc.
Practice Advocacy Chairperson, Greater St. Louis MGMA

State Government Issues 


Aside from the two special sessions called by Governor Greitens this year, perhaps the one issue that has affected physician practices around the state this summer is a newly designated category of mid-level provider. State Representative Keith Frederick (R-Rolla) sponsored HB 1842 that passed in 2014. The bill created a new category of licensed professionals - assistant physicians. These are individuals who graduate in good standing from medical school and pass key medical exams, but are not able to ‘match’ with a residency training program. This occurs frequently since about 40,000 doctors apply for 30,000 residency slots each year.

Doctors who will practice in Missouri as assistant physicians will work with a licensed physician in a collaborative practice agreement much like nurse practitioners or PAs do now. The assistant physician will need to practice primary care in one of Missouri’s Health Care Shortage Areas, which won’t be difficult since 110 or 114 Missouri counties are shortage areas for primary care and mental health care.

Numerous additional doctors from around the U.S. could become eligible to treat patients in Missouri’s underserved areas as a result of a planned expansion of a first-in-the-nation law which intends to help lessen the nationwide physician shortage. However, there seems to be quite a bit of consternation on the part of health plans regarding the credentialing for this new category of providers. So, reimbursement appears to be on a case-by-case basis.

(Footnote - Our practice has received numerous inquiries from eligible candidates from both domestic and foreign graduates.)

Federal Issues


Faced with the narrowest of margins for error and a must to garner every vote, Senate Majority Leader Mitch McConnell (R-Ky.) delayed a vote on the bill to keep debate open to replace the Affordable Care Act (Obamacare). That would give Sen. John McCain (R-Ariz.) time to recover from a surgical procedure. But the losses of Senators Mike Lee of Utah and Jerry Moran of Kansas on July 17 sealed the fate of the Senate bill. Then, McConnell made a last effort to bring a “repeal now and replace later” bill to the floor, but it was torpedoed by a trio of Republican senators, including Susan Collins of Maine and Shelley Capitol of West Virginia and Lisa Murkowski of Alaska. “I did not come to Washington to hurt people,” Sen. Capitol said in a statement. “I cannot vote to repeal Obamacare without a replacement plan that addresses my concerns and the needs of West Virginians.” McCain also cast a decisive “no’’ vote for one of the GOP-backed measures.


CMS has just unveiled its 2018 Quality Payment Program (QPP) proposed rule, which contains changes to the Merit-based Incentive Payment System (MIPS), making it the first major proposed rule released by the agency under the Trump administration. The 1,058-page document, now available online for review, shows that CMS remains committed to MACRA, MIPS, and the concept of pay-for-performance even as the Trump administration moves to roll back Obama-era regulations in other industries. The 2018 QPP proposed rule appears to increase flexibility for MIPS reporting and expand the number of exempted providers, reflecting feedback CMS was already processing under the Obama administration. CMS has also adopted a proposal by industry stakeholders to allow MIPS reporting by “virtual groups,” as explained in the analysis below. Here are the key proposals in the rule:

  •  Expansion of the low-volume threshold. Previously, CMS established a “low-volume threshold” to filter out Medicare Part B providers who don’t see enough Medicare patients to warrant their participation in MIPS. The current threshold is either $30,000 in Medicare Part B charges or 100 Medicare patients. Providers who bill less than that amount or see fewer than that number of patients are exempt. The proposed threshold bumps up the dollar amount to $90,000 and doubles the patient threshold to 200 patients.
  •  Virtual reporting groups for small practices. CMS is proposing to create a new reporting option for 2018 called “virtual group reporting.” The proposed rule defines a virtual group as a group comprised of two or more practices with 10 or fewer practitioners each, who combine their performance for the full year reporting period. Interestingly, the proposed rule states that a practice with 10 or fewer practitioners is eligible to participate in MIPS as part of a virtual group if they exceed the low-volume threshold at the group level. Thus a provider who is individually MIPS-exempt can still participate in MIPS and receive bonus payments if his/her group combines their part B patients and charges to exceed the low-volume threshold.
  • Reduced EHR certification requirements. CMS wants to make EHR requirements less onerous for MIPS purposes. For meaningful use reporting under MIPS, the proposed rule would only require EHRs certified under 2014 Edition guidelines instead of the latest 2015 Edition.
  •  Give MIPS bonus points for complex patients. Because this type of bonus did not exist in the original rule, it is being created as a one-time provision for the 2018 reporting year only, though this bonus may be renewed in future years if successful. CMS has been encouraged to adopt risk stratification in the MIPS program. This proposal would add 1-3 points to the MIPS composite score of providers who see “complex” patients. The term “complex” would be defined based on the average Hierarchical Conditions Category (HCC) risk score of patients seen, though CMS may use the number of “dual-eligible” (i.e. individuals who qualify for both Medicare and Medicaid) patients seen as an alternative way to define complex.
  •  Give MIPS bonus points to participating small practices. Similar to the complex patient’s bonus, the small practice bonus would add 5 bonus points to the MIPS score of providers practicing in a small practice. The proposed rule defines a “small practice” as one with 15 or fewer total providers. A virtual group would also qualify as a small practice and receive the bonus for all of its member providers if the group totals 15 or fewer providers.
  •  Continue to calculate MIPS score without Cost component. For the 2017 reporting year, the fourth component of MIPS, the “Cost” category, is not being counted toward providers’ final MIPS scores. The “Quality” category, which stands in for quality reporting, has been weighted upward to 60% to account for Cost being weighted at 0% for 2017. In the proposed rule, CMS would continue this for 2018. In 2019, the Cost category will account for 30% of the MIPS score, as required under MACRA. 

Greater St. Louis MGMA
PO Box 16012, St. Louis, MO 63105