The Reading Room

What imaging leaders and radiologists need to know about the MACRA final rule

by Pooja Desai and Erin Lane

Last Friday, CMS released the highly anticipated final rule for the Quality Payment Program portion of MACRA (Medicare Access and CHIP Reauthorization Act). To save you time, we read the 2,400-page rule and distilled the five biggest takeaways for radiologists and imaging leaders.

As a brief reminder, the MACRA legislation permanently replaced the Sustainable Growth Rate formula and established two new tracks for physician payment.

1. Expect to fall in the MIPS track

The final rule confirmed that providers will have to take on significant downside risk to qualify for the APM track under MACRA. As a result, the vast majority of radiologists will fall into the MIPS track, which replaces several current quality reporting programs.

Providers in the MIPS track will report measures across four categories, and performance will be aggregated into a MIPS composite performance score (CPS) to determine payment adjustments. Under the newly released final rule, the four categories will be weighted as follows in 2017 and 2018:

Four categories that determine MIPS score

Four categories that determine MIPS score

Starting with performance year 2018, the cost performance category will gradually increase—accounting for 10% of the score in 2018 and 30% in 2019.

2. Determine if your providers will be non-patient-facing under revised definitions

A major concern for radiologists emerging from the initial MACRA proposal was that MIPS performance metrics may not take into account their unique needs as non-patient-facing clinicians. Under the proposed rule, any clinician or group that performed at least 25 patient-facing services per year would be deemed patient-facing, and therefore be subject to all four of the scoring categories under MIPS.

In the final rule, CMS revised the non-patient-facing definition for both providers and groups:

  • Non-patient-facing MIPS-eligible clinician: An individual who bills 100 or fewer patient-facing encounters annually. CMS has yet to publish a list of patient-facing encounters, but this list is expected to include general office visits, outpatient visits, and procedures.
  • 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 will use Medicare claims from two twelve-month time periods, with the first beginning September 1 two years prior to the performance year. Providers and groups will only be deemed patient-facing if they exceed the revised thresholds for two consecutive assessment periods.

The timeline below outlines the assessments periods for the 2017 performance year:

Non-patient-facing determination timeline for the 2017 performance year (PY)

For non-patient-facing clinicians and groups, MIPS reporting requirements and performance categories are weighted differently than for patient-facing peers. Most notably, the cost category is weighted at zero, placing a greater emphasis on quality.

MIPS performance metrics and reporting requirements

  Quality Cost/Resource Use Clinical Practice Improvement Advancing Care Information
Patient Facing Six measures including one outcomes measure, or one specialty measure set Based on claims, so no reporting; includes 10 episode-based costs and total costs per beneficiary Four medium-weighted or two high-weighted measures Five required measures
Non-Patient Facing Same as patient-facing requirements if possible; if not, as many as possible Category weighted at zero Two medium-weighted or one high-weighted measure When enough measures are not applicable or available, category weighted at zero

3. Use the transition year 2017 to set yourself up for future success

To ease providers into the new program, CMS has identified 2017 as a transition year. This means that in 2017, reporting requirements will differ from subsequent years in two key ways.

First, the agency will weight cost performance at zero, shifting the weight to the quality category.

Additionally, providers will have three options for reporting in 2017:

  • Full metric set across all categories. Report the required MIPS metrics for a period of at least 90 days to be eligible for a moderate positive payment adjustment.
  • One metric in each category. Report on at least one required MIPS metric in each category for a period of at least 90 days to be eligible for a small positive payment adjustment.
  • One metric in any category. Report one metric in any category for any period of time to avoid facing a MIPS penalty.

As a result of these flexible reporting options in 2017, only non-reporting providers will incur a penalty in 2019. While this may seem like good news, under MIPS’ budget neutral payment adjustments, fewer penalties also means fewer and smaller bonuses for high performers.

Despite new flexibility, providers should not consider 2017 a year off. Instead, we recommend reporting on all possible metrics. Providers who take this leap early will receive performance feedback, which will allow them to choose higher-scoring metrics in the future and thereby position them for long-term success.

4. Focus on quality performance

While the MIPS score is based on four categories, quality performance will constitute up to 85% of the CPS for many non-patient-facing radiologists. Regardless of patient-facing status, quality will be at least 60% of providers total score in 2017—by far the largest category.

While radiologists only need to submit one quality measure in the transition year to avoid a penalty, in future years patient-facing providers will be evaluated on:

  • Submission of up to six selected measures, one of which must be an outcome measure
  • One population-based measure calculated from claims data (All-Cause Readmissions)

See chart above for non-patient facing requirements.

In contrast to ACI and Improvement Activities categories, where providers simply demonstrate they meet requirements to score points, quality (and cost) scores are based on relative provider performance compared to peers. This means that simply reporting on quality does not guarantee strong performance. Potentially fierce competition, in addition to the heavy weight placed on this category, makes quality a critical performance area of focus for providers.

This elevates the usefulness of a Qualified Clinical Data Registries (QCDR) over other methods of quality reporting. QCDRs expand the quality metric set, including high-priority measures eligible for more bonus points, giving radiologists the opportunity to report on more, and more unique quality metrics, where competition is likely to be thinner.

Additionally, using a QCDR can help fulfills a CPIA requirement and streamlines reporting since QCDRs can be used to report across the quality, ACI, and Clinical Practice Improvement Activities categories of MIPS.

5. Understand that the APM track is more accessible than previously anticipated

For all providers, some of the biggest news coming out of the final rule is the revised qualification requirements for the APM track. CMS estimates that as many as one quarter of all eligible clinicians—up from the originally estimated 4-12%—could qualify for the APM track in 2020 based on their contract mix in 2018.

There are two key changes that make the APM track more accessible:

  • Loosening the financial risk criteria: including reducing the at-risk revenue-based standard to 8% and reducing maximum possible loss to 3% of spending target.
  • Adding new APM-eligible payment models for 2018, including a MSSP ACO Track 1+ model and new bundled payment programs.

While we still believe that the majority of radiologists will fall into the MIPS track, the final rule makes the APM track seem more accessible than before.

As more alternative payment models qualify for the APM track, more providers may pursue those models. As a result, radiologists are likely to find themselves in markets with greater provider risk.

Whether they participate in or simply partner with APM entities such as ACOs, radiologists will need to focus on positioning themselves as strong partners to risk-bearing entities in order to secure market share and remain the imaging provider of choice.

Other notable modifications to the quality payment program

  • The threshold for low-volume providers has been increased, allowing many small practices to be excluded from new requirements. MACRA has modified the low-volume threshold to be either less than or equal to 30,000 in Medicare charges or 100 or fewer Medicare patients.
  • Small practices, consisting of up to 10 clinicians, may join “virtual groups” that combine their MIPS reporting in future years. While not available in 2017, CMS plans to use this transition year to implement a virtual group program.
  • 2018 has been identified as an additional transition year. The agency will continue to ease into MIPS in 2018. As a result, clinicians can expect to see more modifications to QPP in the future.

To understand how MACRA will impact providers outside of radiology, read our colleagues’ recent blog post for medical groups.

Ready to brief your board on next steps?

Before you meet with your executive team, make sure to download our executive briefing on the strategic implications of MACRA—so you can answer questions about the upcoming changes.