At the Helm

10 takeaways on the 2018 MACRA final rule

by Tony Panjamapirom, PhD and Rob Lazerow

CMS on Nov. 2 released the 2018 final rule with comment period to implement the second year of MACRA's Quality Payment Program (QPP). Public can submit comment through January 1, 2018.

We've thoroughly analyzed the 1,653-page rule and presented comprehensive insights and action items to in our on-demand webconferences. Watch them now to:

In the meantime, here are 10 initial takeaways from our experts:

  1. Two overall trends are clear: Payment reform continues apace, and the administration wants to reduce the regulatory burden of MACRA on providers. The 2018 rule was the Trump administration's first opportunity to put their stamp on MACRA's QPP, and they largely left the structure the same. The final rule gives clinicians more ways to succeed in the program, while also offering flexibility to providers, especially solo practitioners and small practices.

  2. The final rule reduces the number of clinicians subject to the Merit-Based Incentive Payment System (MIPS) track in 2018 to approximately 622,000. In 2017, CMS exempted providers that had less than $30,000 in Medicare Part B revenue or saw fewer than 100 Medicare Part B patients per year. For 2018, the agency will exempt providers and groups with less than $90,000 in Medicare Part B allowed charges or that care for less than 200 Medicare Part B patients, excluding about 123,000 more clinicians from MIPS. These clinicians—mostly those who work in small practices and those that practice in rural regions and Health Professional Shortage Areas—would be exempt from participating in the QPP altogether.

  3. CMS is also easing MIPS burdens by offering bonus points to small practices and groups that treat a large share of complex patients. Small practices (those with 15 or fewer clinicians) can earn five additional points to their MIPS final score if they submit data on at least one performance category. Additionally, CMS will award providers up to five bonus points if their patient population is deemed particularly complex, as measured by a combination of Hierarchical Conditions Category (HCC) risk scores and the number of dually eligible patients treated.

  4. CMS maintains for another year several 2017 performance year flexibilities intended to ease clinicians into MIPS requirements. Most notably, clinicians are allowed to continue using 2014 Edition Certified Electronic Health Record Technology (CEHRT), rather than upgrading to 2015 Edition technology, to report the Advancing Care Information (ACI) transition measures (i.e., Modified-Stage 2 equivalent measure set). Clinicians that exclusively use 2015 CEHRT to report the ACI objectives and measures (i.e., Stage 3 equivalent measure set) could be eligible for 10% bonus score.

  5. However, providers must prioritize their Quality performance improvement and Cost control efforts in 2018. Next year, CMS will quadruple the reporting period for the Quality performance category to a full calendar year and increase the data completeness requirements to 60% for EHR, registry, and claims-based submission methods. Notably, CMS will begin to assess providers on Cost measures in 2018—a significant change from the proposed rule, which initially delayed the cost measures entirely until 2019. The Cost category will be weighted at 10% of the MIPS final score in 2018 and will increase to 30% in 2019. Collectively, we believe that Quality and Cost performance will likely become a key determinant of high-performing providers.

  6. The rule creates new avenues for solo practitioners and small practices to participate and succeed under MIPS—but time is of the essence. The Trump administration supports easing the burden of regulatory requirements, and the QPP final rule reflects that principle. Solo practitioners and small practices can form a virtual group without specialty or location limitations to participate in MIPS together. Those interested in the virtual group option should review the Virtual Groups Toolkit. The virtual group electronic submission deadline is December 1, 2017 for the 2018 performance year. Providers considering this new option for 2018 must act quickly.

  7. The final rule raises the performance bar to avoid payment penalties in MIPS slightly overall. In order to avoid a payment penalty in 2019, clinicians need to earn three points across the three MIPS categories in 2017. For payment adjustments in 2020, CMS is raising that threshold to 15 total points for the 2018 performance year. This is still a fairly low bar to clear and may dilute bonuses in 2020 for high performers.

  8. CMS estimates substantially more providers will qualify for the Advanced Alternative Payment Model (APM) track in 2018 than 2017. With the inclusion of the new Medicare Share Savings Program (MSSP) Track 1+ as a qualifying Advanced APM and the reopening of applications for the Next Generation ACO Model and Comprehensive Primary Care Plus (CPC+) program, 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 185,000 to 250,000 in the 2018 performance year. The increase in APM track participants, combined with an increase in clinicians exempt from QPP, would make MIPS far more competitive.

  9. CMS isn't changing the Advanced APM qualification criteria. CMS will maintain the existing Advanced APM qualification criteria through the 2019 and 2020 performance years. Risk-based programs eligible for the Advanced APM track still will require a revenue-based nominal amount standard at 8% of the estimated average total Parts A and B revenue of eligible clinicians. For guidance on how to effectively evaluate risk-based payment models, don't miss our new Medicare Risk Strategy research.

  10. Providers in areas affected by natural disasters during 2017 will receive a neutral payment adjustment in 2019. CMS adopted a policy to account for the recent hurricanes and other natural disasters during 2017. Per an interim final rule, providers in impacted regions are not required to submit 2017 MIPS data, and they can automatically avoid the 2019 penalty. Alternatively, they may choose to submit 2017 MIPS data to receive a MIPS score and MIPS payment adjustment based on category-by-category performance similar to other eligible clinicians.

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