9 major takeaways from the 2018 MACRA proposed rule
CMS under President Donald Trump is still committing to the Quality Payment Program while allowing for more flexibility for clinicians. But will it really alleviate administrative burden?
It certainly was a busy few days in Washington for the healthcare sector last week. The Senate revealed the discussion draft of their healthcare reform plan, hoping to come to a vote sometime this week. But in case you missed it, the CMS unveiled another highly-anticipated federal document last week: the 2018 Quality Payment Program (QPP) proposed rule.
In 1,058 pages full of dense legislative language, the agency laid out the ground rules for the second year of MACRA, the rule QPP implements. At the rule's announcement, the CMS messaged it was allowing flexibility for the rule by proposing the exemption of small providers participating in the program. The agency believes the move will exclude about 134,000 clinicians from the program, adding to the already 800,000 clinicians exempted from MACRA's Merit-based Incentive Payment System (MIPS).
The exemptions are on brand for the agency under the helm of HHS Secretary Tom Price. His appointment signaled the agency would work toward reducing administrative burden for physicians, including easing MACRA requirements. However, it will be important to watch whether the final rule continues to trend to value-based care. In addition, given the complexity and sweeping nature of QPP/MACRA, it is yet to be seen whether the rule changes will actually alleviate administrative burden.
After having some time to digest the final rule and reactions, here are the most important takeaways from the proposed rule:
1. Only 36% of clinicians will be eligible for MIPS after all exclusions, but they make up 58% of Medicare Part B charges
MACRA/QPP is a massive piece of legislation. At it's core, MACRA will eliminate the sustainable growth rate formula and replace it with a 0.5% annual rate increase through 2019, after which physicians are encouraged to shift to one of two Quality Payment Programs: 1) Merit-Based Incentive Payment System (MIPS) or 2): Alternative Payment Model (APM).
MIPS sunsets and packages up Meaningful Use, the Physician Quality Reporting System and the Value-Based Payment Modifier where physicians will receive payment adjustments based on quality (via both evidence-based standards and practice-based improvement activities), cost and use of certified EHR technology use.
The main message CMS put forth in the proposed rule's announcement was the allowing for greater flexibility for the program participation for physicians. This is not all that different from the agency's stance during President Barack Obama's tenure. Former CMS Administrator Andy Slavitt and CMS staff went on listening tours and reviewed thousands of written comments for the rule's first performance year. Last fall, Slavitt said, the largest response was to "make the transition to MACRA as simple and as flexible as possible."
For the second year of the program, CMS is increasing the low-volume threshold to $90,000 or less in Medicare Part B charges or 200 or fewer Medicare patients annually. The original threshold was $30,000 in Medicare Part B charges or 100 Medicare patients.
The continued exemptions do dwindle the number of eligible clinicians to 36%. However, as Table 85 on page 721 of the document shows, that 36% makes up 58% of Part B charges remaining after exclusion:
2. Hospital-based physicians can now report at a facility level
Hospital-based clinicians in the 2018 MIPS performance period now have an opportunity to be assessed on quality and cost in the context of the facilities where they work. Such clinicians can submit their facility's inpatient value-based score to help calculate an individual score.
Aledade's Travis Broome told Healthcare Dive that such a move could be a big win for administrative simplification. "Before, there was no recognition or special category for physicians who work in facilities such as a hospital," Broome said.
3. CMS introduces virtual reporting groups for next year
Another new reporting option for the 2018 performance year is the ability for smaller practices to report as a virtual group. The proposed rule defines a virtual group as a combination of a solo practitioners or a group with 10 or fewer eligible clinicians banding together with at least one other solo practitioner or group for a performance period of a year. A written agreement amongst the group participants must be submitted to CMS by December 1 prior to the start of the applicable performance period.
Virtual groups are largely seen as a means for smaller practices or solo clinicians to dip their toes into taking on more risk to advance their move to value-based care. Broome was pleased to see the addition of virtual group reporting in the proposed rule as he sees it as a tailored accountable care organization designed to do well on MIPS.
One important caveat regarding virtual groups: Participants will be assessed as a group on all MIPS categories, not cherry-picked program options.
Broome is hopeful the minimal amount of formation requirements the agency set forth will lead to innovation as virtual groups band together.
4. CMS is easing up on EHR technology requirements for MIPS' Advancing Care Information program — but gives an incentive to ramp up technology efforts
MIPS' Advancing Care Information (ACI) portion is the section that phases out the Meaningful Use (MU) program, which spurred the adoption of EHRs among physicians and health systems. The MU program had it's fair share of pushback from physicians. Many felt forced to adopt technology they weren't happy with when EHRs first entered the market, before the federal government incentivized their adoption. The ACI program sought to reduce many of MU's requirements.
For the program's second year, CMS is proposing that MIPS eligible clinicians may continue to use EHR technology certified to the 2014 Edition for 2018's performance in the ACI calculations. This is great news, as Beth Israel Deaconess Memorial Center CIO Dr. John Halamka noted on a webinar last week, because not many EHR vendors have products certified for the 2015 Edition that Stage 3 of MU requires. "These things are not a sign of laziness, they're a sign of reality," Halamka said on the webinar. "Products are just now being certified and coming into the market."
But, if a clinician is able to get their hands on and implement a certified 2015 Edition product, then CMS is proposing a bonus of 10 percentage points under the ACI category for 2018's performance period.
The proposed rule did not address 2015 Edition timelines for hospitals. The agency could address this in August when it is set to finalize the 2018 Medicare Inpatient Prospective Payment Systems rule (the proposed rule was released in April).
5. Physicians could receive MIPS bonus points for complex patients
The agency is proposing a one-time special consideration for MIPS eligible clinicians who care for complex patients in 2018's performance period (2020 MIPS payment year).
Physicians who care for sicker patients don't want their scores to be hurt for conditions that are out of their control. CMS recognized this and wishes to "protect access to care for complex patients and provide them with excellent care."
The agency proposed that complex patient bonus points will not exceed three percentage points.
6. Clinicians need to pay attention to cost controls despite MIPS not measuring them next year
For next year's performance period, MIPS scoring is weighted as follows:
- Quality: 60%
- Cost: 0%
- ACI: 25%
- Improvement Activities: 15%
The agency was supposed to "gradually increase" the cost scoring beginning in 2018 to 30%. While still weighted at 0% next year, MIPS scoring ramps up the category's weight to the full legally mandated 30% in performance period 2019.
Thus, despite having flexibility in the cost category this year, clinicians need to still be working toward advancing their cost efforts as the sharp increase to 30% will likely be a "rude awakening" for many, Naomi Levinthal, practice manager for Advisory Board Company's Health Care IT Advisor and Quality Reporting Roundtable, told Healthcare Dive.
7. Advanced APM participants are expected to double
Experts expect most eligible clinicians to seed into the MIPS track in the early years of the QPP program. However, with the availability of the Medicare Track 1+, Next Generation ACO and Comprehensive Primary Care Plus programs allowing new entryways to Advanced APMs, CMS estimates Advanced APM participants to double from 70,000-120,000 clinicians to 180,000-245,000 clinicians.
8. The document is a look into CMS' thinking on regulation and how it affects clinicians' businesses...
The 2018 QPP proposed rule is the first look at how a CMS under President Donald Trump views MACRA/QPP. For the most part, the document continues on the path toward value-based care. The MACRA legislation was a bipartisan document, after all.
A Trump CMS takes the previous administration's tendency toward provider flexibility over MACRA and ups the dial a little bit. Secretary Price is known for wanting to ease administrative burdens for providers and this document mirrors that.
“We’ve heard the concerns that too many quality programs, technology requirements and measures get between the doctor and the patient,” said CMS Administrator Seema Verma on the rule's arrival. “By proposing this rule, we aim to improve Medicare by helping doctors and clinicians concentrate on caring for their patients rather than filling out paperwork.”
The program may continue to change depending on how the administration views the goal of quality-based payments. "[W]e expect the Quality Payment Program to evolve over multiple years in order to achieve our national goals," the rule stated.
9. ...but will it really help?
While the new reporting flexibility in the proposed rule was lauded by major stakeholder organizations such as the American Medical Association and HIMSS, some believe there is a disconnect between regulation and the reality of practice in some areas.
For example, Levinthal told Healthcare Dive that clinicians shouldn't have to read 600 pages of a rule to understand it. In addition, she said the possibility of currently proposing two different CEHRT requirements for hospitals and employed clinicians could result in a situation where chasing two different sets of requirements could cause confusion. "We hope CMS makes that aligned because I think it'll be difficult to manage two sets of upgrade timelines," she said. "Otherwise, it'll be an interesting year."
Some have questioned whether the flexibility will adversely effect the trend toward value-based care. “If CMS wants to transition to value-based payment for care, the program needs to be fully implemented,” Chester Speed, VP of public policy at the American Medical Group Association, said upon the rule's release. “We recommend that CMS revise its proposal to fully incentivize high performers in the Medicare program.”
Broome points to Table 85 as being a key object to watch in the final rule. After exclusions, 65% of Medicare Part B charges remain in MIPS, a number he believes needs to be raised overtime. "If those numbers start going down, that would be concerning," he said, indicating the trend toward value-based care may not be a large focus for CMS.
There is a bit of nuance where some of the missing percentage is due to Advanced APM participation which is positive in the move to value-based care, Broome said, adding, "That isn't a bad number but it needs to go up not down if we are going to continue the trend toward value-based care."
- Healthcare Dive CMS proposal exempts another 134K from MACRA
- Healthcare Dive More than 800K physicians get MACRA reporting reprieve for 2017
- CMS Draft Rule
- Healthcare Dive MACRA: What healthcare leaders need to know
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