MACRA Final Rule Released, Small Practices Given Support

Welcome to Practice Rounds, our new weekly column exploring what's being covered in the larger world of healthcare. This week's Practice Rounds will focus entirely on the release of the MACRA final rule.

CMS Drops MACRA Final Rule

This week, CMS released the nearly 2,400-page final rule for implementing the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA). In the press release announcing the rule, the government included emphasis on supporting small and independent practices. The rule will start to take place next year, with the results having an impact on practices financially in 2019. It gives physicians the option of two pathways: the Merit-based Incentive Payment System (MIPS), which will include most physicians and Advanced Alternative Payment Models (APMs), which will include 5 percent to 8 percent of physicians.

Earlier this year, CMS announced changes to the first-year reporting requirements, including flexibility that will make it easier for practices to avoid penalties in 2019. The "pick your pace" aspect of the program gives providers the ability to simply submit some data to the quality payment program - there is no threshold - and they will avoid a negative payout in 2019. As part of today's announcement, CMS indicated that because of this flexibility, 90 percent of all MIPS eligible clinicians will receive a positive or neutral MIPS payment adjustment in the first year. Specifically, CMS says that 80 percent of small practices with one to nine physicians will receive a positive or neutral payment adjustment.

Also, CMS expanded the number of physicians that could be exempt from MACRA in year one, saying anyone that has a low volume of Medicare patients won't have to report. Low volume was defined by CMS as clinicians with less than or equal to $30,000 in allowed Medicare charges or less than or equal to 100 Medicare patients (it was $10,000 in the proposed rule). The agency says that this will mean 32.5 percent of clinicians billing Medicare Part B will be exempt from MACRA.

As part of today's announcement, CMS revealed it has set aside $20 million to train and educate Medicare-eligible physicians in practices of 15 clinicians or fewer working in underserved areas on MACRA. Also, CMS says it will conduct outreach to these small practices to help them prepare for the transition.

In the various areas that comprise the MIPS pathway, such as the improvement category, small practices also will be graded on a scale. For example, while normal-sized practices are required to conduct six medium-weighted improvement activities or three high-weighted activities, small practices are required to conduct only one high-weighted activity or two medium-weighted activities.

Within the final rule itself, CMS acknowledges that concern for small practices was one of the most prominent themes in the feedback it received on the proposed rule from stakeholders. Recently, Republican Congressional Lawmakers sent a letter of concern to CMS Administrator Andy Slavitt expressing concern over what the MACRA rule would do to small practices.

CMS has made assisting small practices an emphasis in the release of this final rule. However, some are skeptical that the rule is all that helpful after the transition year. Halee-Fischer Wright, physician and president of the Medical Group Management Association, said in a statement, "It’s disappointing that flexibility provided for quality reporting in 2017 largely disappears in 2018 and beyond. CMS missed an opportunity to close the two-year gap between the measurement and payment periods, which would facilitate improved patient care by providing actionable feedback to physicians and more timely incentives."

Physicians Practice will have continuing coverage of these developments.