How New Rules for 2018 Will Impact Clinical Pathways

These clinical measures would include avoidable admissions, emergency department visits, and readmissions. Patient experience would include the ability to receive care and communicate concerns, and value would be based on factors such as spending per beneficiary after a hospitalization. 

The reason for MedPAC’s recommendation is based on the fact that MIPS as it is currently positioned would produce a significant administrative burden on clinicians because of its complexity. CMS has estimated this administrative burden to be over $1 billion. CMS has stated that increasing the program’s flexibility and options has only increased the complexity.

Beyond the administrative burden, the other issue is the foundation of MIPS has not proven true. MIPS measures have not been proven to be associated with high-value care. Furthermore, many physicians will not understand what they need to do to improve their score, since they’re already performing at a high level. The current system is structured to maximize clinician scores, with a limited ability to detect performance issues as described by MedPAC. How this plays out will impact clinical pathways, which often use MIPS measures as a foundation. 



The list of issues facing HHS is enormous, and one additional issue that should be considered of great importance is biosimilars. CMS recently announced a shift in how it will reimburse for biosimilars under Medicare Part B.7 Prior to this rule change, biosimilars substituted for a common reference product were grouped under the same Healthcare Common Procedure Coding System (HCPCS) code, meaning biosimilars were grouped into the same payment calculation for determining a single ASP payment limit.  Under the policy, which takes effect on January 1, 2018, all approved biosimilars will get their own HCPCS codes. Separate codes means that clinical pathways can more easily call out biosimilars based on their unique indications and price.


Much is set to happen in 2018, including a leadership change within HHS and continued interest around CMS and MIPS programs. It is clear that clinical pathways will need to remain abreast of these changes to assure that their users are best positioned for optimum clinical and financial outcomes. 


1. 340B Drug Pricing Program. Health Resources & Services Administration website. Accessed November 29, 2017. 

2. Hepworth AJ, Shankar A. Proposed rule would slash Medicare payments for 340B Drugs. Health Care Law Today website. Published July 20, 2017. Accessed November 29, 2017.

3. Hospital groups file lawsuit to stop significant payment cuts for 340B hospitals. American Hospital Association website. Accessed November 29, 2017.

4. CMS finalizes policies that lower out-of-pocket drug costs and increase access to high-quality care. Centers for Medicare and Medicaid Services website. Published November 1, 2017. Accessed November 29, 2017.

5. MIPS overview. Quality Payment Program website. Accessed November 29, 2017.

6. Dickson V. MedPAC urges repealing MIPS. Modern Healthcare website. Published October 5, 2017. Accessed November 29, 2017.

7. Brennan Z. CMS shifts coding and payment policy for biosimilars under Medicare Part B. Regulatory Affairs Professionals Society website. Published November 2, 2017. Accessed November 29, 2017.

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