Medical Societies Praise Draft MACRA Rules for 'Flexibility'

Ken Terry

June 21, 2017

Initial industry reaction to the Centers for Medicare and Medicaid Services' (CMS) proposed 2018 rule released yesterday for the Quality Payment Program (QPP) was largely positive.

David O. Barbe, MD, president of the American Medical Association, said that the proposed rule showed that CMS had paid attention to the concerns of practicing physicians with regard to the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA).

"CMS is proposing a number of policies to help physicians avoid penalties under the Quality Payment Program," Dr Barbe said in a news release. "In particular, it is suggesting several actions to assist small practices."

Among the steps CMS took in this regard, the most important was to exclude from the Merit-Based Incentive Payment System (MIPS) eligible clinicians and groups that have Medicare Part B-allowed charges of $90,000 or less or that care for 200 or fewer Medicare Part B beneficiaries. According to the proposed rule, this will exclude about 134,000 additional clinicians from MIPS.

Moreover, CMS said, the new threshold will especially benefit small practices, which represent about 35% of all clinicians billing Part B services. Applying the 2017 criterion for participation, 27% of those eligible for MIPS would have come from small practices; with the latest threshold, that drops to 22%.

Other provisions in the proposed rule that will be helpful to small practices include offering them the option to participate in "virtual groups" for reporting purposes, continuing to allow the use of 2014-edition certified electronic health records (EHRs) alongside 2015-edition EHRs, adding a new hardship exception for clinicians in small practices under the Advancing Care Information category of MIPS, and giving them bonus points on their total score.

The American Medical Group Association (AMGA), which includes large groups, praised CMS' solicitude to small practices. However, AMGA said in a statement, it is concerned that the proposed rule will slow down the move to value-based reimbursement and that it doesn't recognize the investment that AMGA members have made in preparing for a value-based healthcare system.

"If CMS wants to transition to value-based payment for care, the program needs to be fully implemented," said Chester A. Speed, JD, LLM, AMGA's vice president of public policy. "We recommend that CMS revise its proposal to fully incentivize high performers in the Medicare program."

New Options Benefit Hospital-Employed Doctors

The American Hospital Association (AHA) applauded the QPP proposed rule, which affects hospital-employed physicians as well as the doctors with whom many hospitals have partnered in alternative payment models (APMs) such as accountable care organizations. The AHA especially liked the details in the rule about the "all-payer option," which, starting in 2019, will allow clinicians to qualify for advanced APM incentives based on combined participation in alternative payment arrangements with Medicare and non-Medicare payers (including Medicare Advantage, Medicaid, and private payers).

Additionally, the AHA praised the facility-based clinical reporting option in the proposed rule. This option will allow physicians who work primarily in hospitals and emergency departments to use a facility-based scoring mechanism based on CMS' Hospital Value-Based Purchasing Program. This approach will convert a hospital's total performance score into MIPS quality and cost scores for individual clinicians.

"Today's proposed rule continues the incremental, flexible implementation approach called for by hospitals, health systems and the more than 500,000 employed and contracted physicians with whom they partner to deliver care," AHA Executive Vice President Tom Nickels said in a statement. "We are encouraged by CMS' proposal for a facility-based clinician reporting option that may promote better alignment and collaboration on efforts to improve quality among hospitals and clinicians."

CMS's decision to allow the use of 2014-edition or 2015-edition certified EHRs next year and give bonus points to clinicians who use the latter products drew praise from the HIMSS EHR Association (EHRA). The association's members, who include most of the major EHR developers, have been laboring to rewrite their software to meet the 2015-edition criteria.

"We're pleased that CMS is encouraging providers to use the 2015 Edition through incentive opportunities, as part of its several proposals to increase flexibility for clinicians," said Sasha TerMaat, EHRA chair, and director of EHR manufacturer Epic. "EHR developers have invested heavily in developing and rolling out 2015 Edition technology, which when widely adopted will offer enhanced interoperability and usability improvements."

Changes in MIPS Scoring

For MIPS participants, the QPP proposed rule makes some relatively minor changes in performance scoring from the 2017 final rule. Quality measures will form 60% of the total score in the 2019 and 2020 payment years and 30% in 2021; under the 2017 regulations, they would form only 50% of the score in 2020. CMS also proposes to increase the data completeness threshold, currently 50% for most submission mechanisms, to 60% in 2019. Starting in 2018, clinicians can also get up to six points for using six "topped out" measures that most clinicians are already doing well on.

The cost of care will not be counted in the 2019 payment year, based on 2017 performance. Under the current rule, it would form 10% of the score in the 2020 payment year, and 30% in 2021 and beyond. The proposed rule would continue to exclude cost in calculating clinicians' scores for the 2020 payment year, but CMS says it is "soliciting feedback on keeping the weight at 10%."

In both the quality and cost categories, CMS will begin rewarding improved performance for an individual clinician or group for a current performance year compared with the prior performance period. For quality, improvement scoring will be based on the rate of improvement so that higher improvement results in more points. Clinicians can garner up to 10 points in the quality category by improving their performance.

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