10 Takeaways from the 2018 MACRA Proposed Rule

This week, CMS released the proposed rule which outlines the 2018 performance year requirements of its Quality Payment Program (QPP), under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

For small practices, it should be seen as a major win, early observers of the rule say. CMS created a number of flexibilities in the QPP that will allow practices with 1 to 15 physicians (its definition of small) to either skip participation altogether or have an easier time adhering to the guidelines.

The American Medical Association (AMA) praised the rule shortly after it was released.

"In proposing these rules, [CMS] has taken another step to make sure the promise of MACRA – where physicians are rewarded for improvement and for delivering high-quality, high-value care – will be fulfilled. Patients and physicians will benefit from the new MACRA approach, as flexibility is vital when implementing a wide-ranging reform," AMA President David Barbe, MD, said in a statement.

MACRA's Merit-based Incentive Payment System (MIPS) aims to either reward or penalize Medicare physicians based on how they perform in four categories: Quality, Cost, Improvement Activities, and Advancing Care Information (ACI). MACRA also includes an option for involvement in an advanced alternative payment model (APM), which includes a 5-percent payment bonus for eligible clinicians.

Here are some of the flexibilities offered by CMS in this proposed rule, along with the other major takeaways for practices:

1. Low-Exemption Threshold Increased

While CMS seemingly* didn't continue its "pick-your-pace" method of flexibility from the current performance year, which allowed practices to submit a minimum amount in order to not receive any penalties, it did increase the low-exemption threshold. Originally, the threshold to skip MIPS was if practices had fewer than $30,000 in Medicare Part B allowed charges or fewer than 100 Part B beneficiaries. That number was upped to $90,000 in Part B allowed charges or fewer than 200 Part B beneficiaries.

*Editor's Note: A CMS spokesperson confirmed to Physicians Practice that it's continuing to propose flexibilities, similar to the "pick-your-pace" method of flexibility from year but not the exact same one. In year one, eligible clinicians could submit one quality measure, minimum ACI requirements, or one improvement activity, and not receive a penalty. In year two, they have to complete one category (ACI, Improvement Activities, or Quality), in order to avoid penalty. The performance threshold goes from 3 points in year one to 15 points in year two.

"Clinicians that are not ready to participate in the 3 (of 4) categories, with the increase performance period proposals,  could still do well in the program overall by focusing on the performance category that is most important to them," the spokesperson wrote in an email.

2. Optimism Abounds

The end of the 1058-page rule includes impact analysis, where there is a lot more optimism on how practices will fare than last year. For the 2017 proposed rule, CMS predicted that approximately only 13 percent of solo docs and 30 percent of small practices (2-9 clinicians) would receive a positive payment adjustment under MIPS. With the added flexibilities for the 2018 reporting period, it's predicting that 80 percent of small practices will receive a positive or neutral payment adjustment. Moreover, CMS predicts 90 percent of eligible practices (those that do not meet the exemption), will participate.

"Our assumption of 90 percent average participation for the categories of practices with 1-15 clinicians reflects our belief that small and solo practices will respond to the finalized policies and this proposed rule's flexibility, reduced data submission burden, financial incentives, and the  support they will receive through technical assistance by participating at a rate close to that of other practice sizes, enhancing  the existing upward trend  in  quality data submission rates," CMS writes on page 729 of the rule.

3.  Is Anyone Left?

As many on Twitter and elsewhere in the healthcare policy landscape noted, this higher level of exemption begets the question: Who is left to actually participate in this program?

CMS estimated that 64 percent of Part B physicians are exempt from MIPS in 2018, on page 721 of the 1,058-page rule. However, this number may actually be higher. A month ago, CMS estimated that two-thirds of physicians would be exempt from this year's performance period, with its exemption threshold of less than $30,000 in Part B allowed charges and 100 Part B beneficiaries. If the exemption threshold is higher in 2018, as proposed, it's very possible that an even higher percentage of clinicians will be exempt from MIPS and MACRA. Also, for the 2019 performance period, CMS is allowing those that exceed one or two low-volume exemption thresholds to opt in.

4. Virtual Groups in Place

After sitting out the first year of MACRA and MIPS, CMS has proposed virtual group participation in 2018. This would allow solo docs and groups of 10 or fewer eligible clinicians to team up "virtually" and submit its MIPS measures as one entity. The virtual group can be any combo of eligible practitioners, regardless of specialty and practice location, as long as each member meets the definition of a MIPS eligible clinician. Virtual groups, CMS says, need to make their election as a unit prior to the 2018 performance period. Media reports indicate, however, the virtual group option may take a while to get off the ground. CMS is anticipating just 16 virtual groups for next year.

5. Participation Awards for Small Practices

In its effort to cater to small practices, CMS is proposing that practices with 15 or fewer eligible clinicians get an extra 5 points to their final score as long as the eligible clinician or group submits data on at least one performance category in an applicable performance period. In essence, just for participating in MIPS, small practices get an extra five points tacked onto their final score.

6. Category Percentages Remain

Just like for the current performance period, the MIPS categories will be weighted as follows: Quality – 60 percent; Improvement Activities – 15 percent; ACI – 25 percent; and Cost – 0 percent. Along with the 5-point bonus for small practices, those who care for complex patients will get an extra three points tacked onto their final score. Practices who meet certain exclusions for ACI will have their score reweighted based on Quality. Out of 100 points, CMS is looking for a total of 70 based on how practices measure up to the three categories (with Cost being exempted this year).

7. Full-Year Reporting for Quality

For ACI and Improvement Activities, practices have to submit 90-days minimum for a performance period. For Quality, they have to submit the full-year reporting period. This differs from the current year, where it's 90-days for all three.

8. Favorable Tech Requirements

Another area where CMS is aiming to assist physicians is in the tech requirements for the ACI category. Originally, practices participating i

n MIPS were supposed to use 2015 certified EHR technology for 2018 reporting. However, similar to the 2017 performance period, CMS is allowing them to use 2014 certified EHR technology for next year's reporting period.  Practices that use the 2015 certification get a bonus for using it, rather than relying on old technology.

Also, for Advancing Care Information, CMS is offering more hardship exemption options for small practices, who if they quality for these exemptions, can skip this category altogether. CMS is allowing clinicians to skip immunization registry reporting and to receive bonus points for additional registry reporting.

This won the approval of the Medical Group Management Association's vice president of government affairs, Anders Gilberg, who said it was a win for MGMA.

9. Improvement Activities/Quality Changes

The other two categories that eligible clinicians have to worry about for the 2018 reporting period don't have as many changes as Advancing Care Information. There is an uptick in how much Quality data needs to be reported for that measure to be counted against a clinician's overall Quality Score. It was 50 percent of the measure in 2017, CMS is proposing that go up to 60 percent in 2018.

For Improvement Activities, CMS proposed more activities that eligible clinicians can choose. Small practices still only have to choose two medium or one high-weighted activity to reach the highest score. Practices with more than 15 eligible clinicians have to submit either four medium or two high-weight activities.

10.  Required Risk Stays the Same

Another carryover from 2017 to 2018 was the amount of risk-based revenue eligible clinicians needed to have to qualify for the APM pathway and its automatic 5-percent payment incentive. The nominal risk requirement will not only be 8 percent for next year's reporting period, but CMS is proposing that this be extended to 2019 as well. For practices participating in an eligible Medicare medical home model, the risk needed to quality for 2 percent of revenue in 2018, 3 percent in 2019, 4 percent in 2020, and 5 percent in 2021 and each year after.