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MACRA revisited: The final rule

October 19, 2016
The MACRA final rule: "a first-step" in the journey for value-based care, but...
President and CEO

It arrived last Friday, two weeks ahead of schedule and 1,400 pages heftier than the proposed rule it replaced. In just over six months, the MACRA (Medicare Access and CHIP Reauthorization Act of 2015) team held a listening tour, which was attended by more than 100,000 people. They combed through more than 4,000 written public comments. Comments and sentiment synthesized into the final rule that is widely accepted as simpler to understand and easier to begin and navigate.

Acting Centers for Medicaid and Medicare Services (CMS) Administrator Andy Slavitt said, “[MACRA] is a first step of a multi-year journey in which we are particularly focused on allowing clinicians to transition at their own pace.” Understanding that true transformation takes time, CMS established 2017 as a transition year, granting clinicians time to properly prepare while maintaining a focus on their patients and medical practices. For clinicians already engaged with value-based care, MACRA provides attractive rewards and higher rate increases.

Flexible Participation in 2017

While some clinicians are currently engaged in value-based care and largely prepared for MACRA, substantially more are not. The final rule acknowledged this and created four distinct reimbursement paths. For 2017 only, clinicians reporting via MIPS have three clear options:

  1. Do something. Anything. Just don’t ignore MACRA and hope it will go away. Eligible providers who do nothing will receive a -4 percent adjustment to their Medicare reimbursement in 2019. Reporting on a single measure will indicate clinicians are ready to participate in the first full reporting year (2018) and will prevent the negative adjustment.
  2. Do a little bit. Collecting performance data for any single 90-day period between Jan. 1, 2017 and Oct. 2, 2017, will qualify clinicians for a neutral or small upward adjustment.
  3. Do it all. Collecting a full year of performance data will qualify clinicians for a moderate upward adjustment.

Pick your pace in MIPS

Advanced APM track: a 5 percent bonus payment will be earned by clinicians receiving 25 percent of their Medicare payments and seeing 20 percent of their Medicare patients through an advanced APM.

Small Practice Support

Last spring, the proposed rule garnered much attention for its potential harm to small, independent practices. In addition to the flexible reporting requirements, the final rule makes several key accommodations to ease the transition and help alleviate concerns:

  • Increased MIPs eligibility thresholds - In the final rule, providers billing $30,000 or more to Medicare and seeing 100 or more unique Medicare patients per year will be reimbursed via the Quality Reporting Program. This is three times the proposed threshold of $10,000 year. Between the increased threshold and other exemptions (first year of Medicare billing or already in an advanced payment model), CMS anticipates more than half of clinicians in practices of 10 or less will be excluded from MIPS scoring. The American Medical Association predicts the threshold increase will exclude a more conservative 30 percent of otherwise-eligible clinicians compared to the 16 percent exempt under the proposed rule.
    • 600,000 clinicians reimbursed via the Quality Payment Program
    • 70,000 – 120,000 reimbursed via alternative APM track
    • 480,000 – 530,000 reimbursed via MIPs track
    • More than 93 percent of Medicare part B reimbursements will funnel through the Quality Payment Program
  • Financial support and technical training - For each of the next five years, CMS has allotted $5 million for outreach and training for clinicians working in small, rural and underserved areas. These funds will help provide significant technical support and training.
  • Increasing the availability of APMs – CMS has broadened the range of allowable APM models to make participation by clinicians in smaller practices and specialty practices easier. CMS has also changed the cost-based requirement to be practice-based, making it easier for clinicians to qualify for participation.
  • Reducing the time and cost to participate – By simplifying and aligning reporting measures and allowing clinicians to pick their own pace of participation, the barrier to entry is lowered. It will take less time and resources to comply.

Increased APM Participation and Quicker Increases in Bonus Thresholds

CMS estimates that 25 percent, more than 125,000 clinicians, will participate in advanced APMs by 2018. This expected increase is the outcome of several changes:

  • Qualifying more APMs – Increasing the number of allowable APMs makes it easier for small practices and specialists to participate in the APM track now and in the future. For example, the ACO track 1+ model and the oncology and orthopedic bundles are being considered for inclusion in 2018, as is opening participation in existing APM models.
  • Easing the burden of risk – The final rule requires less risk than the proposed rule. It also makes it a little easier for physicians to participate because it allows for risk to be distributed between Medicare and the physician (two-sided risk over one-sided), instead of requiring the physician to bear all the risk.
  • Qualifying APMs for 2017 – The expanded list of qualified APMs for 2017 (to be finalized by Jan. 1, 2017):
    • Comprehensive ESRD Care - Two-sided risk
    • Comprehensive Primary Care Plus (CPC+)
    • Next Generation ACOMedicare
    • Shared Savings Program - Tracks 2 and 3

As participation in the advanced APM track increases, bonuses become harder for each clinician to achieve.

In the proposed rule, the beginning bonus threshold of 25 percent of payments and 20 percent of patients funneling through an advanced APM did not change until 2021, where they increased to 50 and 35 percent respectively. These thresholds remained level until 2023 where they increased to 75 and 50 percent, respectively.

In comparison, the final rule threshold increases are two years faster across the board:

Table 1 Requirements

Technology Requirements

Reporting on technology use has become burdensome and redundant. The MACRA final rule hopes to ease this burden and contains one-third the requirements of Meaningful Use and less than half the requirements of the proposed rule.

The technology requirements in the final rule focus on patient engagement and safety, clinical effectiveness, data security, and the sharing of data (interoperability). The final rule has removed requirements surrounding clinical decision support and computerized physician reporting capabilities. The five “Advancing Care Information” requirements are:

  • Security risk analysis
  • E-prescribing
  • Provide patient access
  • Send summary of care
  • Request and accept summary of care

Bonus points are available for clinicians through optional measures such as reporting to clinical data registries or utilizing EHR technology.

Additional Resources

Healthcare veterans know that change takes time and input from many points of view. Just as the proposed rule improved through the sharing of opinions, the MACRA final rule has a companion 60-day open comment period.

We will continue to digest MACRA and share our opinions. Below are additional resources: