Practice Notes

4 takeaways from CMS Administrator Slavitt's MACRA update

Andy Slavitt, Acting Administrator at the Centers for Medicare and Medicaid (CMS), recently responded to the public conversation over implementation of the Medicare and Chip Reauthorization Act of 2015 (MACRA). Recognizing the wide variety of physician practice settings, and implicitly acknowledging corresponding variety in preparedness, Slavitt used the post to announce added flexibility for providers during the first year of MACRA performance reporting, slated to begin January 1, 2017.

MIPS reporting and performance still crucial to Medicare success

Perhaps the strongest statement we read in the announcement was Slavitt's framing of the "Pick Your Pace" program in terms of only the first performance year of the Quality Payment Program. In fact, Slavitt referenced the "first year" or "first performance period" on four separate occasions as he detailed the proposal. The implication here is that future performance periods, from 2018 and on, may likely go forward unchanged from the proposed rule that was released on April 27th.

Those of you following our reporting on MACRA will know that the original proposal carries sharp risks for providers wherein every physician will be required to report on a variety of metrics across four performance categories including quality, cost, clinical improvement activities, and electronic health records use. Performance scores correlate to positive or negative payment adjustments for every provider in the MIPS track of the program, and poor performance or failure to report is set to produce a negative payment adjustment as large as 4% in 2018 and 9% by 2022.

With this announcement of flexibility for the first year, Slavitt and CMS appear to be confirming that stakes are likely to remain high for hundreds of thousands of providers heading into 2018. Although flexible measures during 2017 make for some additional prep time for some, urgency remains high to understand MIPS requirements, set a strategy for reporting, and improve performance across all categories.

Non-reporters still at risk for negative adjustments in 2017

Three of the four "options" Slavitt describes for 2017 MACRA participation correspond to providers in the Merit-Based Incentive Program, or MIPS track. Each of those options clearly demands some measure of performance reporting. The first option makes it possible to avoid negative adjustments entirely by submitting "some" data to the Quality Payment Program, but does not specify how much or what kind of data will be required.

We'll be looking closely when the final rule is announced later this fall, but for now it appears that 2017 non-reporters will not be excused from 2019 penalties. The conservative interpretation would be to continue preparing at the best possible speed to report data in all four performance categories.

Strong performers may see reduced payment adjustments in 2019

Slavitt says nothing about the levels of positive payment adjustments available for those groups who elect under Options 2 and 3 to participate in the Quality Payment Program for part or all of 2017. However, it is a legal requirement of the underlying law that the Payment Program be budget neutral.

It is unclear how CMS proposes to relieve so many practices of the burden of possible negative adjustments without also reducing corresponding levels of positive adjustments available. There is some additional money that CMS can deploy to reward the highest performers, but that seems unlikely to alter the basic math. We'll be watching closely for these details in the final rule as well.

Despite rumors, no confirmed changes to the APM track

The fourth option Slavitt discusses explicitly mentions participation in the Advanced Alternative Payment Model (APM) payment track. Although he doesn't say too much about it, Slavitt's comments line up perfectly with the APM track as announced in the proposed rule.

That's not to say there haven't been updates since April on this front. Earlier this fall, CMS proposed changes to the Comprehensive Care for Joint Replacement (CJR) payment model to incorporate EHR use requirements and permit its inclusion in the list of qualifying Advanced Alternative Payment Models. There has been a lot of discussion about whether CMS would make the APM Track easier to access by expanding the list of qualifying payment models, but Slavitt's blog post provides no indication that that will occur. However, it also fails to rule the possibility out.

Rest assured that we'll be tracking that possibility and looking for answers to fill all the gaps in Mr. Slavitt's announcement when the final rule is released. The agency has a self-imposed deadline of November 1 to get it out, and we're expecting to see it any day across the next six weeks.

In the meantime, we recommend that you keep pressing to assess your readiness, prepare your reporting strategy, and develop an action plan to improve your performance for 2017 and beyond in the four performance categories spelled out in the proposed rule. If you need help with any of these steps, please feel free to reach out to me or to anyone on our team to share the resources available to you.


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