BREAKING: MACRA Final Rule Released

Oct. 17, 2016
The Department of Health & Human Services (HHS) has finalized the highly-anticipated Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Final Rule.

The Department of Health & Human Services (HHS) has finalized the highly-anticipated Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Final Rule, in which eligible Medicare physicians will be paid for the quality of care they deliver, via the government’s Quality Payment Program, which replaces the Sustainable Growth Rate (SGR) for physician reimbursement.

The Final Rule, released publicly on Oct. 14, and nearly 2,400 pages in length, aims to create a more modern, patient-centered Medicare program by promoting quality patient care while controlling escalating costs through the Merit-Based Incentive Payment System (MIPS) and incentive payments for Advanced Alternative Payment Models (Advanced APMs), according to a blog post from Andy Slavitt, Centers for Medicare & Medicaid Services (CMS) Acting Administrator.

The MIPS path is designed for providers in traditional, fee-for-service Medicare, and who can thus ease their way in. The advanced APM track is designed for providers who are participating in specific value-based care models already.

“Today, we’re proud to put into action Congress’s bipartisan vision of a Medicare program that rewards clinicians for delivering quality care to their patients,” HHS Secretary Sylvia M. Burwell said in a statement. “Designed with input from thousands of clinicians and patients across the country, the new Quality Payment Program will strengthen our health care system for patients, clinicians and the American taxpayer.”

According to an HHS press release, the Final Rule is “informed by a months-long listening tour with nearly 100,000 attendees and nearly 4,000 public comments. A common theme in the input HHS received was the need for flexibility, simplicity, and support for small practices. And that’s what this final policy aims to provide.”

Last month, federal officials announced flexibilities that will allow eligible Medicare physicians to pick their pace of participation for the first performance period of the outcomes-based program that begins Jan. 1, 2017 that aim to allow physicians to ease into the program without getting hit with negative payment adjustments right away.

In the blog post, Slavitt said that “Other than a 0.5 percent fee schedule update in 2017 and 2018, there are very few changes when the program first begins in 2017. If you already participate in an advanced APM, your participation stays the same. If you aren’t in an advanced APM, but are interested, more options are becoming available. If you participate in the standard Medicare quality reporting and Electronic Health Records (EHR) incentive programs, you will find MIPS simpler. And, if you see Medicare patients, but have never participated in a Medicare quality program, there are paths to choose from to get started. The first couple of years are aimed at getting physicians gradually more experienced with the program and vendors more capable of supporting physicians. We have finalized this policy with a comment period so that we can continue to improve the program based on your feedback.”

More specifically, in the MIPS track, payment adjustments in the first year will be neutral, positive or negative up to 4 percent. This will grow to 9 percent by 2022. So essentially, as long as eligible physicians report to some measure or activity in 2017, they will not be dinged with a 4 percent payment penalty. For the APM track, clinicians who receive 25 percent of Medicare payments or see 20 percent of their Medicare patients through an advanced APM in 2017, then they earn a 5 percent incentive payment in 2019.

CMS officials also said the agency intends to broaden opportunities for clinicians, including small practices and specialties, to participate in these kinds of initiatives. For example, according to the HHS press release, a major opportunity being considered for 2018 will be the new accountable care organization (ACO) Track 1+ model that provides more flexibility for clinicians, with lower levels of risk than other ACOs. CMS is also reviewing reopening some existing advanced APMs for application to allow more clinicians to join these types of initiatives. In 2018, CMS expects about 25 percent of eligible clinicians will be a part of the second path of advanced alternative payment models.

And, according to Slavitt’s blog post, specifically for specialists, in addition to oncology and nephrology, the agency recently proposed allowing participants in new cardiac and orthopedic bundled payment models the possibility to qualify as advanced APMs beginning in 2018.

Help for Small Practices

There has been no shortage of conversation about solo and small practices’ ability to thrive, and even survive, under MACRA’s rules. A Black Book survey from June revealed that two-thirds of high Medicare-volume small practices said they foresee the end of their independence due to the physician payment changes that will take place under MACRA.

In today’s announcement, federal officials said MACRA provides $20 million each year for five years to train and educate Medicare clinicians in small practices of 15 clinicians or fewer and those working in underserved areas. Beginning December 2016, local, experienced organizations will offer free, on-the-ground, specialized help to small practices using this funding.

What’s more, Slavitt said that CMS is taking additional steps to aid small practices, including: reducing the time and cost to participate, excluding more small practices (the new policy will exclude an estimated 380,000 clinicians), increasing the availability of advanced APMs to small practices, allowing practices to begin participation at their own pace, changing one of the qualifications for participation in Advanced APMs to be practice-based as an alternative to total cost-based. “Due to these changes, we estimate that small physicians will have the same level of participation as that of other practice sizes,” the blog post read. Indeed, those practices which fall below the requirements of at least $30,000 Medicare Part B charges or 100 Medicare patients are exempt from participating in 2017.

A One-Stop-MACRA-Shop

In his blog, Slavitt noted that much of stakeholder feedback centered on simplified scoring, better feedback, and clear rules. To this end, the government says it is simplifying requirements for the two quality components of the program—the quality measures and practice-specific improvement activities. They are also moving to align the measurement of certified EHR technology with the improvement activities. The statement read, “This will begin 2017 with a portion of the Advancing Care Information measures; we intend to align more of these measures with quality in later years, to further ensure that certified EHRs are being used to support high-quality care. We also narrowed the focus to those measures that support hospitals and physicians safely and securely exchanging information, and we expect both registries and certified EHRs to move to make reporting more ‘push button,’ making such reporting easier for clinicians.”

Finally, CMS is rolling out the new Quality Payment Program website, which will explain the new program and help clinicians identify the measures and activities most meaningful to their practice or specialty.

Federal officials have said that the rule will have a 60-day comment period where more changes could be made. Healthcare Informatics will have more coverage as this story continues to unfold.