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6 things imaging leaders need to know about the MACRA proposed rule

June 30, 2017

    On June 20, the Centers for Medicare and Medicaid Services (CMS) released proposed changes to MACRA's Quality Payment Program (QPP) for 2018.

    QPP—which CMS phased in this year—more closely ties physician payment to performance and establishes new rules for reporting. It requires eligible professionals to participate in one of two payment tracks: Merit-based Incentive Payment System (MIPS) or Advance Alternative Payment Models (APMs). The MIPS track consolidates and replaces previous physician reporting programs, while the APM track rewards providers taking on greater downside risk.

    To save our members time, we analyzed the 1,058-page rule and distilled six key takeaways from imaging leaders and radiologists.

    1. Quality is still king, but costs loom

    By far the biggest news for imaging leaders to know is the re-weighting of the MIPS performance categories for the 2018 reporting year. Most notably, CMS proposed for the quality category to continue to be weighted at 60%, and for the cost category to be weighted at 0%.

    In previous rules, CMS said it intended to gradually re-weight the quality and cost categories until they reach the category weights required by law in 2019. However, in its latest rule CMS now proposes to maintain several 2017 performance year flexibilities—namely excluding cost metrics from performance calculations—to ease clinicians into MIPS requirements for a year.

    Despite that leniency, clinicians should continue to prioritize cost control efforts as CMS is required by law to weight the cost category at 30% in 2019. Providers who ignore costs in 2018 will be faced with a steep incline in cost reporting next year.

    2. Reporting requirements expected to tighten

    For 2019 and beyond, CMS proposes to extend the reporting period for the Quality and Cost categories to one full calendar year, as opposed to the current 90 days. For the Improvement Activities and Advancing Care Information categories, CMS has proposed to keep the performance period for at 90 days.

    For all four metrics, payment would continue to be based on performance two years prior. For example, cost and quality payment in 2020 would be based on performance across 2018. Similarly, 2020 payments for the Improvement Activities and Advancing Care Information categories would be based on a 90-day period in 2018.

    3. No proposed changes to non-patient-facing definition

    CMS proposes to keep the non-patient facing definition as is, but for the first time it would extend the definition to virtual groups. Here's a refresher on the definitions for both sets of physicians under MIPS:

    • Non-patient-facing MIPS-eligible clinician: An individual who bills 100 or fewer patient-facing encounters annually.
    • Non-patient-facing MIPS-eligible group: A group in which at least 75% of eligible providers are designated as non-patient-facing clinicians.

    To determine which providers qualify for non-patient-facing status, CMS would use Medicare claims from two 12-month time periods, with the first beginning Sept. 1, two years prior to the performance year. Providers and groups would only be deemed patient facing if they exceed the thresholds for two consecutive assessment periods.

    For more information on non-patient facing encounter codes and how they related to radiology, check out this blog post.

    4. APM expansion, small group exemptions are likely to make MIPS more competitive

    CMS has been taking steps to increase the number of clinicians eligible for the APM track, including by increasing qualifying models such as the new Medicare Track 1+ program and reopening applications for the Next Generation ACO program and CPC+. CMS estimates that the number of clinicians in the APM track will double from an expected 70,000 to 120,000 clinicians in 2017 to 180,000 to 245,000 in the 2018 performance year.

    Additionally, CMS has proposed increasing the low-volume threshold for MIPS eligibility, so that a greater number of small and rural practices would be exempt from participation.  Previously, groups with less than $30,000 in Medicare Part B allowed charges or less than 100 Part B beneficiaries were exempt. Under the proposed rule, CMS would expand exemption to organizations with less $90,000 in Part B charges or less than 200 beneficiaries.

    The increase in APM track participants, combined with an increase in clinicians exempt from QPP, would mean fewer providers in the MIPS track. And since MIPS provider performance is compared to peers, fewer providers would mean the MIPS track would likely be far more competitive in the years to come.

    5. CDS use would be added as a bonus for Advancing Care Information category

    CMS has proposed 11 new improvement activities that would be eligible for a 10% bonus in the advancing care improvement category (ACI) beginning in 2018. Arguably the most notable metric for imaging leaders revolves around clinical decision support (CDS); namely, CMS proposes to offer an ACI bonus to MIPS eligible clinicians who attest to using appropriate use criteria (AUC) through a qualified CDS mechanism for all advanced diagnostic imaging services.

    This bonus might help secure ordering provider buy-in for CDS, which is required for outpatient advanced imaging in 2018 for Medicare reimbursement. Information about requirements for CDS implementation will be released in the Medicare Physician Fee Schedule proposed rule, which has not yet been released for 2018.

    6. Facility-based providers would be given new reporting options under MIPS

    To further evaluate clinicians in the context of their environment, CMS is proposing to give facility-based providers a new reporting option under MIPS. The rule would allow hospital-based clinicians to submit their facility's inpatient value-based purchasing score to better calculate an individual score for the cost and quality categories of MIPS. For the upcoming year, CMS is proposing to limit this opportunity to clinicians who primarily practice in the hospital setting; however, CMS hopes to expand the facility based measurement program to other value-based payment programs in the future.

    This would impact radiologists who primarily read images for hospital-based patients. But it would also require hospitals and radiologists to share relevant data for reporting.

    Join us to learn more key insights and action items from the MACRA proposal

    On July 11 at 3 p.m. ET, our experts will give an overview of the most important implications of the proposed rule; review key changes to the MIPS and APM tracks for the 2018 performance year; and provide guidance on navigating the transition to risk-based payment and the evolution of hospital-physician alignment.

    You won't want to miss this webconference—so register now to secure your spot.

    Register Now


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