MACRA 2018 Final Rule Considerations: What Could Change from the Proposal?

Oct. 24, 2017
The 2018 final rule for MACRA’s Quality Payment Program (QPP) should drop any day now, so this is as good a time as ever to review the proposed rule and see what might change in the finalized version.

The 2018 final rule for MACRA’s Quality Payment Program (QPP) should drop any day now, so this is as good a time as ever to review the proposed rule and see what might change in the finalized version.

Released in June, the Centers for Medicare & Medicaid Services’ (CMS) proposed rule for year two of the QPP, inclusive of two payment paths that eligible Medicare-participating physicians could partake in—MIPS (the Merit-based Incentive Payment System) and the advanced alternative payment model (APM) track—aimed to provide continued relief for physicians, especially smaller practice doctors who many folks believe could struggle to comply to a complex reporting program.

In all, in construction of the 2018 proposed rule, CMS said it engaged more than 100 stakeholder organizations and over 47,000 people since January 1, 2017 to raise awareness, solicit feedback, and help clinicians prepare to participate. Many of those stakeholders will be looking intently to see if those flexibilities changed when the final rule drops, and to see if their comments were heard.

Proposed Flexibilities for Small Practice Docs

In the proposed rule, plans from CMS signaled that many more clinicians will be exempt from MIPS once again, like they were in year one of the QPP, which began in January. The rule proposed increasing clinicians’ low-volume threshold from $30,000 or less in Medicare Part B allowed charges or less than 100 Medicare patients to $90,000 in Part B allowed charges or less than 200 Medicare patients. It was estimated in the 2017 final rule last fall that some 380,000 clinicians fell into this low-volume threshold bucket; now, many more small practice clinicians who don’t have high volumes of Medicare patients—perhaps up to 200,000 more—will be exempt from MIPS in 2018 as well, assuming this proposal sticks.

There has been some debate about whether excusing more clinicians from MIPS for another year is beneficial in the long-term. When the proposed rule was released this summer, I spoke to Travis Broome, healthcare policy lead at Aledade, a Bethesda, Md.-based company focused on physician-led accountable care organization (ACO) development, who pointed out that these exclusions might create “a partition between clinicians who are under the low-volume threshold and who are trying to stay there to ensure they don’t have to do a move to value, and everyone else who has to move to value.” Broome further told me that while CMS did a lot of work early on in making sure specialists were part of MIPS, these low-volume thresholds “might be undoing some of that work,” as many of those people who qualify for those low-volume threshold will be specialists.

To this point, in its comments on CMS’s proposed changes, Charlotte, N.C.-based Premier Inc. said it opposes the agency’s proposal to increase the low-volume threshold and urges the agency to maintain the current threshold, noting that the increase would significantly reduce the clinicians participating in the value-based payment. Rather, Premier recommends that CMS bring clinicians into the program and ease their reporting requirements. However, many other associations support CMS’ suggestion to increase the low-volume threshold for 2018.

CMS also proposed several more flexibilities for clinicians in the MIPS track for 2018. Some of these included: allowing virtual group reporting for the first time; giving small practices five bonus points for participating in MIPS; and giving regulatory relief on the Advancing Care Information category with a hardship exemption. Healthcare trade associations seem to be in overwhelming support of these year two flexibilities.

Allowing 2014 CEHRT

The American Medical Informatics Association (AMIA), the Healthcare Information and Management Systems Society (HIMSS), and others, were pleased that CMS proposed that providers would continue to be allowed the use 2014 Edition CEHRT (Certified Electronic Health Record Technology), while encouraging the use of 2015 edition CEHRT in year two. But AMIA also said in its comments that it urges CMS to “clearly state its intentions to require 2015 edition CEHRT in 2019 for QPP participation.” Several associations said they want CMS to finalize this proposal that would allow clinicians to use 2014 CEHRT for another year.  

Cost Category Weighted at 0 Percent

CMS also got feedback on the Resource Use (Cost) category in MIPS, one of four categories of eligible clinician performance, contributing to an annual MIPS final score of up to 100 points. This category was originally slated to not be weighted for 2017 MIPS scores, but would be weighted for 2018 and beyond. But then in the proposed rule for 2018, CMS suggested to keep it at zero percent in 2018, but to go up to 30 percent in future program years (2019 and beyond). Premier said it supports weighting the cost category at zero percent and asks that CMS address the organization’s ongoing concerns with the cost measures, such as risk adjusting for socio-demographic factors. The College of Healthcare Information Management Executives (CHIME) also urged CMS to finalize a weight of 0 percent in 2018 for this category.

Interestingly, several prominent healthcare associations and medical societies, led by the American Medical Association (AMA), recently wrote to the Committee on Energy and Commerce, proposing to continue current MACRA flexibilities for an additional three years, citing the Cost category’s jump to a 30 percent weight in 2019 and beyond as a reason why.

Streamlining Programs

CHIME, meanwhile, said that its single largest concern with the MIPS program is that it is too complex and difficult to navigate and more efforts to streamline it are needed. In its comments to CMS, CHIME wrote, “The overall picture being painted by our members implementing MIPS is that it is extremely complicated and there is a resounding need to further simplify the program…The focus should be on minimizing the complexity within each performance category, providing a straightforward set of measures that must be met by clinicians in each, and working to ensure that MIPS and other reporting programs are harmonized as much as possible.”

CHIME continued, “Many of our members operate in both the hospital and physician practice space and they report that with each passing year, their ability to navigate CMS reporting programs’ policies becomes more complicated. Specifically, they cite the divergence among MIPS, Meaningful Use Medicare hospital policies, Meaningful Use Medicaid provider policies, and specific quality reporting programs as being extremely challenging to manage collectively. More than anything else, they seek simplification and consistency from year to year.”

90-Day Reporting Periods

Another key point following the release of the proposed rule was that CMS maintained a 90-day reporting period for the Advancing Care Information (ACI) and Improvement Activities (IA) categories, but the agency called for a full year of reporting for the Cost and Quality performance categories under MIPS. CHIME noted that adopting a full year performance period under MIPS for quality reporting “will not align it with what CMS has proposed for hospitals.” As such, CHIME and the American Hospital Association (AHA) both feel that this same 90-day reporting for the ACI and IA categories should also be extended to the Quality category in the final rule.

Healthcare Informatics will continue to have plenty more MACRA coverage when the 2018 final rule drops.

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