CMS Seeks to Make MACRA Manageable for Small Practices

CMS foresees a world where nine out of 10 small practices will participate in the Medicare Access and CHIP Reauthorization (MACRA) program, which determines how Medicare physicians are reimbursed.

For those small practices thinking they can escape the program, CMS isn't buying it. "As we build the program, our goal is to achieve a 90 percent participation rate by all clinicians. That includes small practices as well," Jean Moody-Williams, deputy director of the center for clinical standards and quality at CMS said at this year's Healthcare Information and Management Systems Society (HIMSS) conference, held in Orlando. Moody-Williams presented in a session on how small, rural, and underserved practices can adhere to the quality payment program.

Those numbers didn't come out of thin air. Moody-Williams said these aspirational projections are based on historical data from the Value-based Modifier, Meaningful Use, and Physician Quality Reporting System  programs. They're also based on the "customized support" that CMS has set out to provide small practices, which MACRA defines as any practice with 15 clinicians or under.

An example of this support, she outlined at HIMSS, is CMS giving small practices "easier access" to successfully meet MACRA-related goals in the Merit-based Incentive Payment System (MIPS).  For instance, CMS' "pick your own pace" onramp to year one of MACRA reporting allows for practices to submit one quality measure or one improvement activity or minimum participation in the advancing care information (ACI) portion of MIPS. By doing so, the practices will avoid any negative payment adjustments related to MIPS. If they do nothing, practices will be hit with a 4-percent pay penalty.

Moody-Williams encourages small practices to go this route and avoid a negative payment. "Use that time to assess where you are going to go as a small practice and how you're going to participate," she says.      

Not only has CMS provided this flexibility for all practices, but smaller groups will have fewer reporting requirements in ACI, Improvement Activities (IA), and Quality categories. For example, large-practice clinicians need to report at least three medium-weighted activities to receive full credit for IA. Small practices only have to report two.

CMS is also aiming to make the other MACRA pathway, Advanced Alternative Payment Models (APMs), easier for small practices to join, says Moody-Williams. Some of the available APMs, in which participation would garner practices a 5-percent payment bonus, were created with small practices in mind, she said. "The Comprehensive Primary Care Plus (CPC+) Model is particularly attractive to some of the small practices," she said. "It's the advanced medical home model. It's based on the special financial risk and nominal amount standards for the medical home."

In the regions where its available, CPC+ has two tracks to accommodate a diversity of practices, CMS says.  Another APM-approved model, Medicare ACO Track 1+ Model was designed to help small practices transition to performance-based risk, Moody-Williams said.

Resources and Virtual Groups

CMS recently announced it is providing funding that will amount to $100 million over five years to selected organizations who provide on-the-ground technical training to small practices. The training will include helping practices decide which MIPS measures they should report, how to optimize their health IT systems to adhere to the payment program requirements, and evaluate their options for joining an Advanced APM. This is the other part of CMS' efforts to ensure 90 percent of small practices are involved with the MACRA program.

"We're ready to start giving this help out. It adds to the layer of assistance that is already available in a number of mechanisms," Moody-Williams. The additional mechanisms that she is referring to come in the form of educational webinars and podcasts, a staffed quality payment service center, integrated technical assistance initiatives, the CMS website, and more.

"We have established a goal at CMS that all eligible clinicians, for MIPS and APMs, 100 percent of them, have access to technical assistance, should they choose to use it. With this [$100 million] contract, I think we have that," she said, adding the contract covers the entire country by providing funding to resources in each region.

A future resource, not yet available, to help small practices adhere to MIPS, will be virtual groups. CMS is currently in the rulemaking process around virtual groups, which will allow 10 or fewer small practices (or solo physicians) to join up and report on MIPS requirements as a single entity. They'll be scored on combined performance and available in 2018.

While the details are not yet ironed out on virtual groups, Moody-Williams did lay out some of the provisions of the MACRA law. She said virtual groups may be based on appropriate classifications, such as location and specialty; that virtual groups must elect to participate as an entity prior to the performance year; and they have to create a formal written agreement.

During the HIMSS session, Moody-Williams said the biggest challenge CMS was facing currently was simply making physicians aware of the program. Part of CMS' ongoing efforts are to spread the word.

"There are more than 100 people in this room. If you would all find 20 small-practice clinicians to tell about this program, it would be helpful. The only way to get the word out is word of mouth," she said.