MACRA: Ready Or Not, The Final Rule Is Here!

CMS posted the final version (2398 pages) of its physician Quality Payment Program under MACRA on Friday October 14, 2016.  CMS MACRA final rule makes 2017 a “transition” year.

The agency stated, “MACRA adds flexibility to the program to overhaul how physicians are paid under Medicare”.

The rule garnered more than 4,000 public comments since the proposal in April 2016.    It cements the two payment tracks already proposed. First, physicians can participate in the Merit-Based Incentive Payment System track, which based payment of clinic performance, practice improvement, reporting and technology use. However, the final rule makes official the "pick your pace provision" that allows providers a slower entry into the model if they are not quite prepared to handle all aspects of the program. To do that, CMS announced changes to the first year reporting period, including flexibility making it easier for Practices to avoid penalties in 2019.

The second track is for physicians who participate in alternative payment models like ACO’s (accountable care organizations) that will tie their payments to savings generated in the ACO models.

According to CMS, most of the public comments received called for more flexibility as well as greater support for small practices. Under the rule, CMS will set aside $20 million a year for five years to help support and train physicians in practices with 15 or fewer doctors.

CMS also stated, 2017 will be a transition year, which would mean 2018 payments would not be affected by that year's performance.  The “pick your pace” aspect of the program gives providers the ability to simply submit “some data” to the quality payment program with no threshold and they will avoid a negative payout in 2019.  The flexibility will allow 90% of all MIPS eligible clinicians to receive a positive or neutral MIPS payment in the first year. 

In the Press Release announcing the rule, the government emphasized supporting small and independent practices.  The rule will begin next year with the results having an impact on practices financially in 2019.

CMS expanded the number of Physicians that could be exempt from MACRA in the first year. Anyone who has a low volume of Medicare patients won’t have to report.  Low volume was defined as clinicians with less than $30,000 in allowed Medicare charges or less than or equal to 100 Medicare patients. 

In various areas that comprise the MIPS pathway, such as improvement category, small practices will be graded on a scale.  While normal sized practices are required to conduct six medium-weighted improvement activities or three high-weighted activities, small practices will be required to conduct only one high-weighted activity or two medium-weighted activities.

In today’s announcement, CMS revealed they have set aside $20 million to train and educate Medicare-eligible physicians in practices of 15 clinicians or few working in underserved areas on MACRA.  They will conduct an outreach to small practices to help them prepare for the transition.

CMS changed data submission methods from Measures Group to “Registry Only” for a number of measures.

As an example: American College of Radiology
Measure Description: Percentage of Final Reports for computed tomography (CT) studies of the thorax for patients aged 18 years and older with documented follow-up recommendations for incidentally detected pulmonary nodules (follow-up CT imaging studies needed or no follow-up is needed) based on nodule size AND patient risk factors.
NQS:  Communication and Care Coordination 
Reference MACRA Rule page #2377

Where can you go for help with the Quality Payment Program?

This new website will explain the new program and help clinicians easily identify the measures and activities most meaningful to the practice or specialty. The tool allows clinicians and practice managers to browse and explore the program options that best fit their practice

CMS has organizations on the ground to provide help to clinicians who are eligible for the Quality Payment Program:

TCPI -Transforming Clinical Practice Initiative (TCPI)  -  Designed to support more than 140,000 clinician practices over the next 4 years in further developing the comprehensive quality improvement strategies.  TCPI will have the advantage of learning about MIPS and how to move toward participating in Advanced APMs.

QIN-QIOs-Quality Innovation Network (QIN) - Quality Improvement Organizations (QIO):  The Programs bring Medicare beneficiaries, providers, and communities together tin data-driven initiatives that increase patient safety, make communities healthier, better coordinate post-hospital care, and improve clinical quality

APM – Alterative Payment Model – Can help you find specialized information about what you need to do to be successful in the Advanced APM track.  They can help you understand the special benefits through your APM that will help you be successful in MIPS.

What can you do now:

1.    QRUR – Quality and Resource Use Reports – Every group practice and solo practitioner nationwide can pull their QRUR reports by their Medicare-enrolled Taxpayer Identification Number (TIN).

Understand your QRUR Report and know how you performed in 2015 on the quality and cost measures used to calculate the 2017 Value Modifier.  The QRUR shows how the Value Modifier will apply to physician payments under the Medicare Physician Fee Schedule (MPFS).  CMS has links on the website on how to obtain a QRUR.

For solo practitioners and physicians in groups with 2 or more EP’s that are subject to the 2017 Value Modifier, CMS established an informal review period to request a correction of a perceived error in their 2017 Value Modifier calculation.  The information review period for the 2017 Value Modifier began September 26, 2016 and will close November 30, 2016.

The CMS website for QRUR’s provides tips on how to use the 2015  Annual QRUR and accompanying tables to understand your performance and to improve quality of care, streamline resource use, and identify care coordination opportunities for beneficiaries.

2.    For more information about the initiative, go to:

3.    For providers, the key takeaways are:

• Consider your patient population. Are they educated, do they have a high utilization of prescription pain medications, and can these two issues lead to lower patient satisfaction scores and, also, have an effect on the proposed group practice reporting option (“GPRO”)?

• Look to see how long you need to be enrolled in Medicare to qualify as an APM participant.

• Make a chart of the different options available and the “pros and cons” of participating in each one.

Sources of Information:

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