How the industry is reacting to Trump's MACRA changes

Industry stakeholders generally praised the Trump administration's proposal to scale back some MACRA requirements, but some groups, such as the American Medical Association (AMA) and the American College of Rheumatology (ACR) raised concerns about how the proposed changes would affect payment calculations.

Background

CMS in June released a proposed rule that would reduce the number of clinicians who would be subject to MACRA's requirements for the 2018 reporting year, which would affect the payments providers will receive in 2020.

Tomorrow: Learn about upcoming changes to hospital inpatient payments in FY 2018

Under MACRA's Quality Payment Program (QPP), which took effect in 2017, eligible professionals can choose from two payment tracks:

  • The Advanced Alternative Payment Model (APM) track, for clinicians who take on a significant portfolio of Advanced APMs, which include risk-based ACO models; or
  • The Merit-based Incentive Payment System (MIPS), for providers who are reimbursed largely through fee-for-service.

CMS in the rule proposed increasing the eligibility threshold for MIPS to providers who bill Medicare Part B for more than $90,000 or who care for more than 200 unique Medicare Part B beneficiaries annually. The eligibility threshold for 2017 was billing at least $30,000 in Medicare Part B revenue or treating more than 100 Medicare Part B beneficiaries annually.

CMS also proposed implementing a MIPS reporting option that would allow eligible hospital-based providers to use results from their hospital's value-based purchasing measures.

CMS under the proposed rule also would extend the option for a 90-day reporting period for MIPS' advancing care information category in 2018, and would allow eligible providers to use 2014 certified electronic health record (EHR) systems without being penalized. CMS said those who use 2015 certified systems could qualify for bonus payments.

In addition, CMS under the proposed rule would give eligible providers the option of creating "virtual groups" in 2018. The option would allow small practices or solo providers that meet the MIPS eligibility requirements to pool their quality data and be evaluated under MIPS as one entity.

CMS also extended the "pick your pace" option, which allows eligible providers to submit partial data and still avoid penalties under the program.

The public comment period for the proposed rule ended Aug. 21.

Stakeholders weigh in

While industry stakeholders generally praised CMS' proposed changes some raised concerns about the methodology for calculating MIPS payment adjustments.

For instance, ACR wrote that it "appreciates many components of the proposed rule," but "continues to be highly concerned about the nature of Medicare Part B payments that are subject to MIPS payment adjustments."

ACR urged "CMS to exclude Part B medication costs from the cost performance category or include both Part D and Part B costs for a fair comparison," writing that the "calculation of resource use (i.e., costs) as currently proposed includes medication costs from Part B, but not Part D, which would result in inaccurate MIPS scoring." Further, ACR wrote that CMS should "increase incentives for physicians to participate in clinical data registries by providing full (Advancing Care Information) credit for participation."

AMA also raised concerns with the proposed methodology for MIPS payment, particularly CMS' plans to establish improvement scoring. AMA wrote, "CMS has not even collected this information yet and seems to be putting the cart before the horse by proposing methodologies for the cost category, which was not scored in 2017, is proposed to remain at zero for 2018, and will be undergoing significant measure modifications over the next few years." The group concluded, "This additional scoring consideration will add complexity to an already complicated program and require physicians to factor in additional considerations when they are just trying to learn the program."

Others were divided on CMS' proposal to raise the eligibility threshold. For instance, the American Medical Group Association wrote that the proposal, which CMS estimated would exclude about two-thirds of Medicare Part B clinicians from MIPS, "undermines MACRA's intent." The group wrote, "Because MIPS is a zero sum game, exempting two-thirds of MIPS eligible clinicians effectively collapses the MIPS Composite Performance Score distribution curve" and "does not meet Congress' goal to transform Medicare into a value-based purchaser of care."

The American Hospital Association (AHA) wrote that it "agrees that CMS' proposal to raise the [eligibility] threshold … would provide needed relief and additional time to transition into the MIPS for small and rural providers." But AHA added that in order for CMS "to provide additional transitional flexibility," the agency should "retain a continuous 90-day reporting period for the quality category for [calendar year] 2018, while allowing groups to report up to a full year if they are ready to do so."

Other groups addressed CMS' proposal for virtual group participation. For instance, the American College of Cardiology (ACC) wrote, "With the timing of the final rule, groups would only have one or two months to navigate and execute this process; it is expected that for the initial performance year, groups may need additional time to understand the virtual group structure and requirements and to discuss this option with their colleagues before electing." ACC recommended that CMS "begin releasing guidance on virtual group reporting as early as possible so groups and solo clinicians have ample time to make an informed decision about this option and consult with those who will be part of their group."

The Association of American Medical Colleges also outlined recommendations for virtual groups, saying CMS should "add a distinct subgroup identifier under MIPS, similar to the identifiers used for virtual groups or for Advanced Payment Models" that "would allow a subset of physicians within a large (tax identification number) to form their own group for reporting and to select measures that are most appropriate for them."

Russell Branzell and Liz Johnson in a comment from the College of Healthcare Information Management Executives praised CMS' "flexibility" in allowing providers to use 2014-certified EHRs without being penalized. "As recently as the start of August we have members reporting that they are not sure when they expect to receive their 2015 Edition CEHRT," they wrote.

However, some groups, including AHA and the American Health Information Management Association, called on CMS to better align the incentives for MIPS' advancing care information requirements and the meaningful use program (Beaulieu, HealthLeaders Media, 8/21; Frieden, MedPage Today, 8/21; Arndt, Modern Healthcare, 8/22).

Register for our webconference on the proposed rule

On August 15, 2017 CMS announced a proposal that would cancel three mandatory bundled payment programs for cardiac and orthopedic episodes and make significant changes to the Comprehensive Care for Joint Replacement (CJR) program.

Join our experts this afternoon at 3 pm ET to learn about CMS's proposed changes to CJR and cancellation of the EPM models.

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