8 Key Facts About MACRA

Leigh Page


October 25, 2016

In This Article

Don't Count on Exemptions

4. It Will Be Hard to Get a MIPS Exemption

There are only three ways to be entirely exempted from MIPS reporting: by participating in an advanced APM, being in your first year of Medicare service, or having a low volume of Medicare patients.

The great majority of these exemptions will be due to low volume. In the proposed rule, CMS estimated that of the projected 336,012 "eligible clinicians" (ECs, in CMS-speak) who would be exempted, 225,615 would be low-volume clinicians.

To be exempted for low volume, clinicians would have to have less than $10,000 in Medicare claims and fewer than 100 Medicare patients. That bar is simply too low for many doctors, says Mark Edney, MD, a Maryland urologist who is on the executive committee of the American Association of Clinical Urologists. In urology, for example, 55%-60% of patients are typically in Medicare, he says.

5. Even Some Physicians Without Patients Will Not Be Exempt

Because clinical measures are mainly about treating patients, the current reporting programs have made accommodations for physicians who don't see patients—pathologists, diagnostic radiologists, nuclear medicine physicians, and many anesthesiologists—but in some cases, these accommodations will end under MIPS, Calamaro says.

On the one hand, the new CPIA category, which was mainly designed for physicians with patients, will make an accommodation to these physicians, called 'non–patient-facing clinicians,'" she says. They'll have to report only two CPIA activities.

On the other hand, things aren't so clear-cut in the MIPS quality category, Calamaro says. Non–patient-facing clinicians have been reporting to PQRS and will continue to do so in the new program, but reporting the cross-cutting measure, which applies to all patient-facing specialties, could be a problem, she says. PQRS informally exempted non–patient-facing physicians from reporting this measure, but it's unclear whether that will continue under MIPS, Calamaro says.

Meanwhile, the MIPS Advancing Care Information program will extend an exemption for most non–patient-facing clinicians under meaningful use, but it appears that interventional radiologists will lose their exemption because they submit surgical codes and would thus be considered patient-facing, Calamaro explains. Some of these physicians, however, may still be able to get a hardship exemption for the new program, she says.

6. Staying Out of MIPS Will Hurt Your Income

Like many physicians, Jean Aycock, MD, a psychiatrist in Raleigh, North Carolina, has stopped reporting PQRS measures and doesn't plan to report for MIPS. "The information CMS wants is irrelevant to patient care and interferes with delivering the best care," she says.

Patrick says she sees a fair number of PQRS dropouts as clients. They ask her to estimate how much it would cost them to comply with reporting, and if the cost exceeds the penalty, they decide to stay out. This is totally legal, because CMS deems measure reporting to be voluntary. But as the maximum penalty rises under MIPS, she says, staying out will become financially more painful.

The breaking point, though, may still be a few years away. Initially, the total MIPS penalty will only be one half the amount of the combined penalties of the three existing programs. That is, the maximum combined penalty for the current programs will be 8% in 2017, but the maximum MIPS penalty in 2019 will only be 4%. Then, however, the MIPS maximum penalty rises to 5% in 2020, 7% in 2021, and 9% in 2022 and afterward.

But there's another, perhaps more significant reason why physicians need to participate, Fulton says. Starting in 2018, CMS plans to post each physician's composite MACRA score and scores for each MIPS category on Physician Compare, the CMS website that lists information on individual physicians.

"If you're a low performer, everyone will know your score," Fulton says. "Not just patients, but also prospective partners and employers." Physicians with a low MACRA score could be less marketable, he says.


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