CMS has provided some positive changes to the MACRA Quality Payment Program (QPP). Highlights include relaxed participation requirements and greater technical assistance.

Navigating health reform

Your Health Care Organization’s Quality Journey Starts With MACRA Final Rule

  • 12/19/2016

If you haven’t already jumped into the world of performance-based payment models, here is an opportunity to begin the quality journey. The Medicare Access and CHIP Reauthorization Act (MACRA) final rule was released October 14, 2016, by the Department of Health and Human Services (HHS), and it includes a number of positive changes for providers. By making these changes to the Quality Payment Program (QPP), CMS hopes to shift providers’ risk from reporting to performance.

The final rule is an incredibly complex and detailed document with over 2,200 pages of specifics. The executive summary itself is 24 pages long. While not a substitute for a deep dive into the material, this article provides a short list of highlights comparing the final rule to the proposed rule.

Participation requirements eased for physicians

Participation will be eased for 2017, which has been deemed a transition year. Acting Administrator of CMS Andy Slavitt stated:

In recognition of the wide diversity of physician practices, we intend for the Quality Payment Program to allow physicians to pick their pace of participation for the first performance period that begins January 1, 2017. During 2017, eligible physicians and other clinicians will have multiple options for participation. Choosing one of these options would ensure you do not receive a negative payment adjustment in 2019.

The new participation options include:

  • Test data submission — If an organization submits a minimum amount of 2017 data to Medicare, it will avoid a downward payment adjustment.
  • Partial data submission — If an organization submits 90 days of 2017 data to Medicare, it may earn a neutral or small positive payment adjustment.
  • Full data submission— If an organization submits a full year of 2017 data to Medicare, it may earn a moderate positive payment adjustment.

The size of the payment adjustment will depend on how much data is submitted and the quality results. Choosing not to submit any data in 2017 will result in an automatic 4 percent negative payment adjustment.

New low-volume threshold for small practices

A notable change in the final rule is an increase in the low volume threshold — an increase from $10,000 to $30,000. This is significant because it will afford more small practices an exemption from the Merit Based Incentive Program (MIPS). In 2017, if a small practice has less than or equal to $30,000 in Medicare Part B billing charges or provides care for 100 or fewer Medicare patients in one year, it may be excluded from the new requirements due to low-volume threshold.

Another year to understand how cost is calculated

MACRA has consolidated three Medicare reporting programs under the MIPS pathway of the QPP. Each performance category or pillar carries a weight that will impact a practice’s final score.

Categories 2017 category weight
Quality (PQRS) 60%
Clinical Improvement Activities (*New) 15%
Advancing Care Information (MU) 25%
Cost/Resource Use (Value Modifier) 0% (2017 only)

Under the final rule, the cost category will carry zero weight toward the overall score in 2017, allowing another year for an organization to better understand how cost is calculated. Many practices will see this as welcome relief. Practices should obtain their Quality and Resource Use Reports (QRUR) and Supplemental Reports and use this transition year to try to comprehend the vast amount of data in the reports. This will help practices make decisions regarding specific actions that will improve both the quality of care and the efficiency with which it is provided.

The quality category, which was previously weighted at 50 percent, absorbed the 10 percent shift from cost, with the understanding that this will likely revert back to the original distribution in 2018.

More providers will qualify for APM track

MIPS eligible clinicians may choose to participate in Advanced Alternative Payment Models (APMs). The final rule includes significant changes designed to increase the number of providers who qualify for the APM track. CMS believes APMs represent an important step in moving health care from volume-based to value-based care. Some improvements that will strengthen this program include:

Plans to introduce a new model called Medicare ACO Track 1+ in 2018

Amendments to the financial risk for APM models

Reduced administrative burden

The final rule includes a plan to reduce the administrative burden of participation, which includes the following:

  • An initiative to re-examine clinician reporting requirements. Specifically, the agency said it will synchronize quality measures and practice-specific improvement activities in MIPS so providers aren’t pulled in different directions.
  • $100 million in technical assistance will be available to MIPS eligible clinicians in small practices, rural areas, and practices located in geographic health professional shortage areas (HPSAs). A small practice is described as having 15 or fewer MIPS eligible clinicians. This funding provided over a five-year period ($20 million per year) should be extremely helpful to those organizations.

How we can help

As you consider these highlights and how they might impact your organization, think of participation with MACRA in terms of a treadmill. It’s best to walk on the treadmill before you run, and CMS has set the pace so that you can get on now and walk before the pace picks up. But make no mistake — the final rule is clear that the pace is going to speed up. If you don’t get on now, the pace will be both fast and difficult in the future.

Determining which path is best for your practice is a difficult one. Choosing MIPS or APM is influenced by many different factors, including the degree of financial risk you are prepared to accept. CLA can help you understand your readiness for MACRA, and assist you in the development of a plan to move your practice in the appropriate direction.