More than half of physicians could be spared from participating in Medicare’s new value-based payment programs in 2018, thanks to a Centers for Medicare & Medicaid Services proposal exempting some physicians.

The proposed 2018 update to the Quality Payment Program ( QPP ), the payment system created as part of the Medicare Access and CHIP Reauthorization Act ( MACRA ), would increase the low-volume threshold for participation, exempting practices that receive $90,000 or less in Medicare Part B payments or have 200 or fewer Medicare patients would be exempt from participation in either the Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Model (APM) tracks of the QPP.

According to the proposed rule, released June 20, the CMS “estimates that approximately 572,000 eligible clinicians would be required to participate in MIPS in the 2018 MIPS performance period. … After restricting the population of eligible clinician types who are not newly enrolled, the proposed increase in the low-volume threshold is expected to exclude 585,560 clinicians who do not exceed the low-volume threshold.”

The CMS is estimating there will be 554,846 MIPS-eligible clinicians in payment year 2020, and most of them will receive either a positive or neutral payment adjustment because of their participation.

Overall, 96.6% of MIPS-eligible physicians will engage in quality reporting in 2020, with 96.1% receiving either a bonus to their Medicare Part B payments or no adjustment, according to CMS estimates. For all eligible clinicians, 76.8% will receive a bonus payment, with all payment bonuses totaling $673.3 million, while those losing money will see their Medicare payments reduced by $173.3 million. The overall aggregate impact will be a 0.9% increase in Part B payments to clinicians.

However, different practice sizes will have different experiences. For example, practices with 1-15 eligible clinicians (114,424 total eligible clinicians in this group) will see in the aggregate a 0.7% increase, while practices with 16-24 eligible clinicians (22,296) will see a 0.4% increase in the aggregate. Practices of 100 or more clinicians (318,841) stand to see the biggest bump in their Medicare payments, with a 1.4% bonus based on the provisions in the proposal.

Ten percent of practices with 1-15 MIPS-eligible clinicians and 10.9% of practices with 16-24 MIPS-eligible clinicians are estimated to receive a decrease in their Medicare payments based on the proposal, while 0.8% of clinicians in practices of 100 or more are expected to see the penalty.

The increased low-volume threshold would help out a lot of physicians who might otherwise struggle to meet the requirements, but some view it as a penalty against those who have made the investment and are ready to fully transition into the new value-based payment program, particularly the larger health care systems.

According to the MACRA legislation language, the MIPS program will be a budget-neutral program – so, the more practices that are exempt from having to participate, the less money will be available for potential bonuses for those who perform well.

“It compresses the potential reward for those who are ready and ready to do well,” Chet Speed, vice president of public policy at AMGA , said in an interview, adding that the projected 1.4% aggregate bonus payments for large practices and health systems “does not really reflect or reward all the work they have done to get to this point.” AMGA is an association representing large practices and health systems.

Comments on the proposed update to the QPP are due to the CMS by Aug. 21, 2017.