When CMS released the Notice of Proposed Rule (NPRM) for the implementation of the Medicare Access and CHIP Reauthorization Act - better known as MACRA – in April of this year, howls of protest could be heard throughout the healthcare landscape.
Critics labeled the proposed rule “too complex, too onerous on small and solo practices, lacking in opportunities for many to participate in alternative payment models, and should be delayed for a full year at least.” Some physicians claimed the rule was an attempt to drive them out of private practice and predictions of mass retirements were rampant.
In the six months after the release of the rule, nearly 4,000 public comments poured into CMS. The agency also collected feedback from over 100,000 physicians at outreach sessions held across the country.
The agency was paying attention. The final rule was released in mid-October and not only offers a series of clarifications, but also significantly softens some of the more aggressive components presented in the original proposed rule.
CMS addressed one of the biggest complaints – that there wasn’t enough time to absorb and comply with the new requirements – by essentially making 2017 a transition year. This gives organizations additional time to figure out what they need to do to implement the mandates of the massive new law.
Here are seven of the key outcomes, changes and clarifications resulting from the release of the final rule.
Establishes the QPP
The two main pathways for healthcare organizations to follow under MACRA - Merit-based Payment System (MIPS) and the Advanced Alternative Payment Model (APMs) - are now collectively referred to as the Quality Payment Program. (QPP). Physicians stressed that they do not separate patients according to domains so CMS decided to focus both the MIPS and APM pathways on quality of care, hence the decision to move them under one umbrella program.
MACRA ended the Sustainable Growth Rate formula that threatened Medicare providers with steep declines in payment over the next 13 years. Instead, QPP aims to provide physicians with new tools and resources to provide better care to patients. Participants in APMs can earn an incentive payment and those who take the MIPS path can earn performance-based payment adjustments.
Sets up the ‘Pick Your Pace’ option
To address the major complaint that there just isn’t enough time to implement between now and January 1, the final rule offers a “pick your pace” option for 2017. Providers can pick one of four options, each with minimum performance thresholds that will avoid payment penalties. The options are:
- Report under MIPS for any 90 day period in 2017. This allows providers not only to avoid a payment penalty, but also gives them an opportunity to receive a positive MIPS payment adjustment.
- Report under MIPS for less than a year, but more than 90 days and report more than one quality measure, more than one improvement activity, or more than the required measures in the advanced care information performance category.
- Report one measure in each MIPS category (other than resource use which is automatically reported) for the entire year.
- Participate in an Advanced APM.
Providers can opt out of all of these options in 2017, but they will receive an automatic four percent negative payment adjustment for the year – to be assessed in 2019.
The final rule technically makes only 2017 a transitional year, but CMS has hinted that 2018 might be transitional as well.
“We envision 2018 to also be transitional in nature to provide a ramp-up of the program and of the performance thresholds. We anticipate making proposals on the parameters of this second transition year through rule-making in 2017.”
The Final Rule raised the minimum threshold on who must participate in the QPP. The annual Medicare A & B charges were raised from $10,000 to $30,000 to reduce the burden on small group and solo providers. The 100 Medicare patient maximum threshold remains in place.
The final rule also mandates the creation of virtual groups which will enable independent doctors to collectively report their data. This will not be in effect until 2018, so these practices will instead be able to use the “pick your pace” option in 2017.
The final rule also clears up some of the confusion regarding “eligible clinicians” under QPP. To begin the program, physicians, physician assistants, nurse practioners, clinical nurse specialists and anesthetists are all eligible. Beginning in 2018, the list expands to include a broader group of clinicians including speech therapists, physical therapists, and occupational therapists.
Provides support for small practices
In addition to increasing thresholds and allowing small practices to report as groups, the final rule provides a number of resources for small practices. MACRA will provide $20 million a year for five years to train and educate Medicare providers in practices of 15 clinicians or less and those located in underserved areas.
Starting in December of 2016, experienced local organizations will offer free specialized help to practices with this funding. CMS is also setting up outreach programs to help small practices get ready for QPP and a long-term program to help small group providers with the Medicare program.
Postpones inclusion of Resource Use category
During 2017, the Resource Use category of MIPS will not be included in the calculation of providers’ composite score. CMS will calculate provider cost under Cost/Resource Use – which replaces the value-based modifier – but will not use the category to calculate payment adjustments.
The thought is that postponing Cost/Resource Use – one of the four MIPS categories outlined in the proposed rule - will ease the transition. It will allow providers to collect more information before being held accountable.
Reduces reporting measures
The final rule maintains the requirement to report on six measures to comply with the Quality category in MIPS, but for 2017, providers will only need to report on one of the six. The category will account for 60 percent of the composite score in 2017 as opposed to the 50 percent stated in the proposed rule.
In the Clinical Improvement Activity category, the final rule reduced the requirement from six to four the number of activities providers must attest to for 2017. Reporting of some EHR activities under the Advancing Care Information Performance (ACIP) category will help fulfill the requirement in 2017.
In the ACIP category, eligible clinicians must report on five EHR use-related measures, down from the 11 in the proposed rule. CMS says that because of the feedback they received, they want to focus this category on the exchange of patient information and the use of technology to support provider goals.
Offers additional support resources
As a result of the volume of feedback that showed a great deal of confusion around the proposed rule, CMS is ramping up support to help providers with the transition.
CMS will continue to collect feedback, but doesn’t anticipate any major changes from the final rule. While the law may still be intimidating, CMS has addressed many of the objections to the rule and made significant changes to make the transition easier. And while there is speculation post-election, even if ACA undergoes change, MACRA is expected to survive.
For more information on readying your organization, feel free to download our road map, Assessing Your Readiness for Value-based Care, 7 Key Areas to Focus On.
 Docs to CMS: MACRA is too complex and should be delayed, by Gregory Twachtman, Family Practice New Digital Network, July 9, 2016.
 MIPS breakdown: 6 must-know parts of the MACRA final rule, by Emily Rappleye, Becker’s Hospital Review, October 18, 2016.
 The MACRA Final Rule: Five Crucial Questions Asked and Answered, by Ron Shinkman, NEJM Catalyst, November 30, 2016.