A First Look at the MACRA Final Rule

Oct. 17, 2016
Following a brief review of the 2,398-page MACRA Final Rule released Oct. 14, here is a first look at some of the key changes between the proposed and final rule and the rationales CMS offered for its decisions.

Following a brief review of the 2,398-page MACRA Final Rule released Oct. 14, here is a first look at some of the key changes between the proposed and final rule and the rationales CMS offered for its decisions.

• Finalized MIPS Measures. Probably of highest concern to Healthcare Informatics’ readership, CMS scaled back the reporting requirements in the advancing care information performance category of MIPS. CMS cut the number of required measures for full participation in the advancing care information performance category (the former Meaningful Use) from 11 down to five. Clinicians will have to report on these required measures:

• Perform a Security Risk Analysis

• E-Prescribing

• Provide Patient Access to Their Data

• Send Summary of Care via HIE

• Request/Accept Summary of Care

Reporting on all five of these would earn a clinician 50 percent. All of the other advancing care information performance category elements such as using patient-generated health data or enabling “view, download and transmit” by patients are optional and would give up to 10 percent in the overall performance score or a bonus in the case of public health reporting.

CMS noted that commenters had asked it to consider allowing for “use cases” such as the use of certified EHR technology to manage referrals and consultations. The agency said it would consider this possibility in future rule-making. For now, it is offering bonuses for reporting to public health or a clinical data registry.

For full participation in the improvement activities performance category, clinicians can engage in up to four activities, rather than the proposed six activities, to earn the highest possible score of 40.

To address public concerns about the cost performance category, the weighting of the cost performance category has been lowered to zero for the transition year of 2017. (For full participation in the quality performance category, clinicians will report on six quality measures or one specialty-specific or subspecialty-specific measure set.

Information Blocking. CMS reiterated its position on information blocking, saying providers and hospitals participating under the existing MU program are required to demonstrate cooperation with provisions concerning blocking the sharing of information and separately, to demonstrate engagement with activities that support providers with the performance of their certified EHR technology such as cooperation with ONC direct review of certified health information technologies. (ONC just published a final rule around its Health IT Certification program: Enhanced Oversight and Accountability.  Watch Healthcare Informatics for a separate story on that rule.)

Lengthening the On-Ramp. CMS does seem to be trying to make it easy for clinicians to get on the on-ramp with MIPS. Although CMS has designated 2017 as a transitional year, it notes that it envisions 2018 will also be transitional in nature to provide a ramp-up of the program and performance thresholds. It anticipates making new proposals on the parameters of this second transition year in 2017.

Clinicians can report for a full 90-day period or the full year, and maximize their clinicians’ chance to qualify for a positive payment adjustment. Clinicians who are “exceptional performers” in MIPS are eligible for an additional positive adjustment. (Clinicians who achieve a final MIPS score of 70 or higher will be eligible for the exceptional performance adjustment funded from a pool of $500 million.)

Eligible clinicians could also report for less than a full year but for a full 90-day period, and report more than one quality measure, more than one improvement activity, or more than the required measures in the advancing care information performance category in order to avoid a negative MIPS payment adjustment and possibly receive a positive adjustment.

Even if they report one measure in the quality performance category, one in the improvement activities category or report the required measures in the advancing care information category, they can avoid a negative payment adjustment. Only MIPS-eligible clinicians who choose to not report even one measure or activity will receive a full negative 4 percent adjustment.

MIPS-eligible clinicians who participate in Advanced APMs and see a significant portion of their Medicare patients through the Advance APM will qualify for a 5 percent bonus incentive in 2019.

CMS expressed confidence that small practices will participate in MIPS at a rate close to that of other practice sizes, even though they were less likely to participate in PQRS and MU reporting. It noted that $100 million in technical assistance will be available to clinicians in small practices, rural areas through contracts with quality improvement organizations and regional health collaboratives.

• Setting the Low-Volume Threshold for MIPS. CMS estimates that more than half of all clinicians will be excluded from MIPS. The largest excluded cohort, 32.5 percent or over 380,000, will not meet the low-volume threshold, which includes clinicians with $30,000 or less in Medicare Part B allowed charges or less than 100 Medicare patients. (Approximately 5 to 8 percent will be excluded because they are participating in Advanced APMs.)

• What is Medicare ACO Track 1+? The MACRA Final Rule notes that CMS has heard from stakeholders that it should consider offering ACOS an even more gradual transition to performance-based risk.

For 2018, CMS is considering adding a new accountable care organization Track 1+ model that it claims provides more flexibility for clinicians. The Track 1+ Model would test a payment model that incorporates more limited downside risk than is currently present in Tracks 2 or 3 of the Shared Savings Program, but enough financial risk that it would qualify as an Advanced APM. More information will be forthcoming soon, the agency said. This potential Track 1+ Model is envisioned as an on-ramp to Tracks 2 or 3. The model could be open to Track 1 ACOs that are within their current agreement period, initial appllcants to the Shared Savings Program and Track 1 ACOs renewing their agreement that meet model eligible criteria. The model would be voluntary for organizations currently participating in Track 1 or seeking to participate in the Shard Savings Program.

Virtual Groups: MACRA allows solo and small practices to join “virtual groups” to combine their MIPS reporting. Many commenters had asked CMS to allow groups with more than 10 clinicians to participate as virtual groups, even though the statute limits virtual groups to groups of not more than 10 clinicians. CMS notes that it is not implementing virtual groups in the first year of the program, and that it believes it has addressed some of the concerns expressed by clinicians hesitant to participate in the Quality Payment Program. It left the question open and said it would work with stakeholders on how it would structure and implement virtual groups going forward.

• More Providers in APMs. In the final rule, CMS ups its previous estimate of how many clinicians will participate in Advanced Payment Models. (In its acronym-laden jargon, it calls these clinicians Qualifying APM Participants or QPs.) In the proposed rule, CMS estimated that 30,000 to 90,000 clinicians would be QPs in 2017. However, with new Advanced APMs expected to become available in 2017 and 2018, including the Medicare ACO Track 1+, and amendments to reopen applications for or modify current APMs such as the Maryland All-Payer Model and Comprehensive Care for Joint Replacement model, it now anticipates approximately 70,000 QPs in 2017 and 125,000 to 250,000 in 2018. (QPs are excluded from MIPS and receive a 5 percent incentive payment for a year beginning in 2019 through 2024.) CMS also stated that if a clinician participates in several Advanced APMs but does not achieve QP status through participation in any one entity, CMS will assess eligibility based on combined participation in several.

There are many levels of complexity in the Final Rule. Watch the Healthcare Informatics website for more updates and analysis as our editors and industry analysts make sense of all the details.