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MACRA Flexibility: Set Your Own Pace in 2017

September 21, 2016

The clinician community breathed at least a partial sigh of relief last week.  The Centers for Medicare and Medicaid Services (CMS) announced that clinicians would not suffer financial penalties in 2019 based on their performance in 2017 under the new Quality Payment Program (QPP) that implements the Medicare Access and CHIP Reauthorization Act (MACRA).

Still, the message is clear:  CMS intends for all eligible clinicians to participate in the QPP as the way to avoid negative payment adjustments down the road.  It is simply providing some leeway and choices in the pace with which clinicians make the transition during the program’s first year.  

The only clinicians who will not have to report something in 2017 to avoid penalties (exacted in 2019) are brand-new ones, those with fewer than 100 patients or less than $10,000 in billings, or those in an advanced Alternative Payment Model (APM).  As Harold Miller, president and CEO of the Center for Healthcare Quality and Payment Reform says in HealthLeaders, “This is not delaying implementation of MACRA, it’s actually creating a less problematic starting point for the measurement that will go into determining what happens to physicians in 2019.”

It’s a lot to juggle, but here is the message:  If you have been participating in the Qualified Clinical Data Registry (QCDR) in 2016, which will determine payments in 2018, continue with what you are doing for the remainder of the calendar year.  But prepare for MACRA in 2017, which will determine payments in 2019.  Also, keep in mind that the final rule could contain significant changes when it is issued in November 2016. 

The announcement from CMS comes in response to widespread concerns from clinicians and medical associations about MACRA’s proposed aggressive timeframe, complexity, stringent reporting requirements and failure to consider the special needs of practices with fewer resources, including physicians in rural communities.  In a September 8, 2016 blog post, CMS Acting Administrator Andy Slavitt outlined four options for clinicians that will ease the transition by allowing them to “pick their pace for participation” during the first reporting period that begins on January 1, 2017.

All four options enable clinicians to avoid penalties in the first year as they move to a reimbursement model based on value and quality; some offer an opportunity for positive payment adjustments.  The point is that these choices give providers an opportunity to start relatively slowly or move ahead more ambitiously, based on how far along they are in preparing for MACRA.

How Fast Do You Want to Go?

Everyone is on the same journey; it’s up to you and your practice to decide how quickly you want to start off on the trek.  Be aware, however, that clinicians and practices will have to wait until CMS provides more information (which it has promised to do when it issues the final rule in November) to make a final decision on which path to take in 2017.  Though details are forthcoming, the four options are: 

  1. For clinicians participating in the Merit-Based Incentive Payment System (MIPS):  Report “some” information to the QPP that includes data collected after January 1, 2017.  This option would allow you to test the water, assess how well your system is working and gear up for more extensive participation in 2018 and 2019 as details about the QPP unfold. 
  2. Report complete data for a reduced period in 2017.  This option would enable you to report for part of the calendar year (not necessarily beginning January 1, 2017) on quality measures, use of technology and performance improvement activities, and not only avoid a penalty, but also potentially earn a partial positive payment adjustment in 2019.
  3. Report for the entire calendar year.  If you are ready to go, you can report quality measures, technology use and improvement activities for the full year, and potentially receive a modest payment increase.  According to CMS, this is not out of the realm of possibility; practices of all sizes have already attempted and succeeded in submitting a full year’s worth of quality data.  If you are confident about your system and procedures, you might want to move ahead with this option and aim for the bonus. 
  4. Participate in an advanced APM.  The proposed rule allows clinicians to participate in an advanced APM, such as Medicare Shared Savings Track 2 or 3 in 2017.  Practices that receive enough of their Medicare payments through an advanced APM would quality for a five percent payment incentive in 2019. 

Our assessment is that most MMGS clients probably will want to consider option 2, full reporting on all measures for part of the year, or option 3, full reporting on all measures for the entire year. 

One of the more frustrating aspects of deciding which path to take is the fact that CMS quality measures will not be decided until the second quarter of 2017.  This means that practices will not have quality data on approved CMS measures for the entire first quarter of 2017. 

Still, CMS’s decision to give clinicians a bit more breathing room with regard to MACRA implementation bodes well for the QPP.  In summarizing the extensive feedback CMS received from physicians in response to the proposed rule, introduced this past April, Slavitt notes that “the clinician community wants a system that begins and ends with what’s right for the patient.  We heard from physicians and other clinicians on how technology can help with patient care and how excessive reporting can distract from patient care; how new programs like medical homes can be encouraged; and the unique issues facing small and rural non-hospital-based physicians.”

Overall, the clinician community is pleased with CMS’s responsiveness to its concerns.  "By adopting this thoughtful and flexible approach, the Administration is encouraging a successful transition to the new law by offering physicians options for participating in MACRA,” says Andrew Gurman, MD, president of the American Medical Association.  “This approach better reflects the diversity of medical practices throughout the country.  The AMA believes the actions that the Administration announced today will help give physicians a fair shot in the first year of MACRA implementation. This is the flexibility that physicians were seeking all along, and we are looking forward to working with Acting Administrator Slavitt and the administration on other efforts to get MACRA off to a successful start."

MACRA Basics Revisited

As discussed in our May 15, 2016 eAlert, MACRA and the Medicare Payment Reform Juggernaut, MACRA provides two tracks for participating clinicians:  MIPS and advanced APMs, which include accountable care organizations, bundled payment models and other structures that tie clinician reimbursements to patient outcomes.  The goal of MIPS is to prepare clinicians for participation in an advanced APM.  The vast majority of clinicians will participate in MIPS in the first year.  Only about four to 11 percent of clinicians currently qualify for participation in advanced APMs, according to a Brookings Institution report, How the Money Flows Under MACRA.

Participants in MIPS will receive a composite scored based on their performance in four areas:

  1. Quality (50 percent of score in year 1, 30 percent of score in year 3):  Clinicians would report at least six measures versus the nine measures under the Physician Quality Reporting System (PQRS).  These measures will be included in the final rule.  MIPS eligible clinicians may select their quality measures from a list of all measures or from a list of measures specific to their specialty. 
  2. Cost (10 percent, 30 percent):  Cost is measured on a claims basis; thus, no reporting is necessary.
  3. Clinical practice improvement activity (15 percent, 15 percent):  This new category consists of process improvement activities in nine areas, each of which is scored on an “all or nothing” basis.  These include activities such as care coordination, patient safety and beneficiary engagement, such as the creation of care plans for patients with complex medical needs.  Clinicians can choose to report on activities that reflect their practices’ goals.  Since clinical practice improvement activities were not a part of the PQRS, we recommend reviewing this list to see which activities you are already doing or planning to implement.  
  4. Advancing care information (25 percent, 25 percent):  This category replaces the Meaningful Use Electronic Health Record Incentive Program.  Clinicians would report measures that show how they use EHRs in their daily practice with an emphasis on interoperability and health information exchange. 

The 100-point composite score across these four categories is used to determine a positive or negative payment adjustment.  The criteria for determining incentive payments or penalties will be adjusted each year based on the country’s performance as a whole.  The better the performance, the lower the incentive, because the program will remain budget neutral.

For More Information

CMS provides extensive MACRA resources including fact sheets and links to webinars.

An excellent infographic and introduction to MACRA can be found here.

For more information, also see the Medscape article MACRA for Busy Docs:  12 Things to Know.

We are monitoring this issue closely and will keep you informed of new developments as they arise.  If you have any questions, please contact your MiraMed client service executive.

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