Last week, HHS released a barrage of regulations and guidance under it's various arms. One final rule focused on health IT but the big news centered on CMS' release of the highly anticipated Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) implementation final rule. The announcement differed somewhat from CMS' previous releases. For one, the agency gave interested parties the news in the morning hours as opposed to within the happy/witching hour of 4 p.m. at the end of a working week. Another is the agency teamed up with the U.S. Digital Service team to produce an easy-to-use, informative website detailing the program.
The Medicare program covers about 55 million people, CMS' acting Administrator Andy Slavitt noted on a call for reporters.
MACRA will eliminate the sustainable growth formula and replace it with a .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.
2017 will be a transitional year
While initial reports noted the hefty 2,398 page count (including one from this very publication), the majority of those pages account for responses to comments on the proposed rule (the agency received around 3,800 comments!). CMS is, with the aforementioned website and it's streamlined executive summary, really trying to make the regulation understandable, allow flexibility for physician implementation and push for more patient-centered care.
The rule finalized 2017 as the performance period for the 2019 MIPS payment year as a transition year as part of the development of the program. "For this transition year, for MIPS, the performance threshold will be lowered to a threshold of 3 points. Clinicians who achieve a final score of 70 or higher will be eligible for the exceptional performance adjustment, funded from a pool of $500 million," CMS noted.
A sigh of relief for small providers
The law increased the low-volume threshold to $30,000 in Medicare Part B charges or 100 Medicare patients. About 600,000 clinicians are expected to be affected by the law. Dr. Patrick Conway, deputy administrator for innovation & quality, CMS CMO, said on a call for reporters at the release of the rule that 380,000 clinicians could be exempt from the MIPS program. He added CMS expects 25% of physicians to participate in advanced APMs in 2018 but for the first year expects about 100,000 to participate.
"We think the vast majority of small practices can succeed," Conway said. In addition to increasing the low-volume threshold, HHS noted that $20 million each year for five years will be provided to train and educate Medicare clinicians in small practices of 15 clinicians or less and providers working in underserved areas.
CMS is also allowing MIPS reporting as a group (defined as "a set of clinicians (identified by their NPIs) sharing a common Tax Identification Number, no matter the specialty or practice site"). This could help small providers of similar size to band together to receive a payment adjustment based on the group's performance. Groups must register by June 30, 2017.
CMS listened to administrative burden concerns and focused on flexibility
The agency got out of the office to get real-world takes on how such a sweeping rule could affect the care delivery system. In addition to the written comments, the agency went on listening tours drawing over 100,000 attendees. On the press call, Slavitt noted the changes to the rule were to help physicians focus on delivering care and seeing patients instead of performing administrative tasks. The overwhelming response to the rule was to "make the transition to MACRA as simple and as flexible as possible," Slavitt said.
To that end, providers who feel comfortable can begin on New Year's Day to collect performance data but providers can begin collecting such data anytime between January 1, 2017 and October 2, 2017. Here's the catch: You have to do something in 2017. While providers are offered three different MIPS submission options, no participation will result in a 4% negative payment adjustment in 2019. Performance data is due March 31, 2018.
The agency is allowing providers a "pick-your-pace" method over three data submission options through MIPS or a fourth option to join an Advanced APM:
- "Test" the program by submitting a minimum amount of data – one quality measure, for example – to ensure physicians' systems are working and prepared for broader participation in the next years.
- Submit 90 days of 2017 data, which would allow practices to submit their first performance period for a time later than Jan. 1, 2017 and still qualify for a small positive payment adjustment.
- Submit a full year of 2017 data which could result in a positive payment adjustment.
- Join an Advanced APM, which involves more risk. "If you receive 25% of Medicare payments or see 20% of your Medicare patients through an Advanced APM in 2017, then you earn a 5% incentive payment in 2019," the Quality Payment Program website notes.
More Advanced APM participation opportunities are coming
The agency anticipates the following to be advanced APMs in 2017:
- Comprehensive ESRD Care - Two-sided risk;
- Comprehensive Primary Care Plus (CPC+);
- Next Generation ACO; and
- Medicare Shared Savings Program - Tracks 2 and 3.
CMS intends to broaden APM opportunities for clinicians, including small practices and specialists. For example, a major opportunity being considered for 2018 will be the new Accountable Care Organization Track 1+ model. The agency is also reviewing reopening some existing Advanced APMs for application.
Reduced health IT measures
The "Advancing Care Information" section of MIPS replaces the Meaningful Use program. To mitigate administrative burden, CMS reduced the total number of required measures from 11 in the proposed rule to five in the final rule:
- Security risk analysis;
- Provide patient access;
- Send summary of care; and
- Request/accept summary of care.
In addition to the five required measures, there will be optional measures a provider can report to potentially allow for a higher score. "For the transition year, we will award a bonus score for improvement activities that utilize [certified EHR technology] and for reporting to public health or clinical data registries," the rule stated.
The agency is still open to ideas
Comments will be taken on the final rule for 60 days (the rule is set to be published in the Federal Register on October 19) as CMS begins to implement the law on an iterative basis. "We're not looking to transform the Medicare program in 2017," Slavitt said on the call for reporters. "We're looking to make a long term program successful."