MACRA Proposed Rule – Year 2 Key Takeaways

On 21st June 2017, Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would make changes in the second year of the Quality Payment Program as required by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). With the proposed rule, CMS aims to simplify the program, especially for small, independent, and rural practices, while ensuring fiscal sustainability and high-quality care within Medicare.

MACRA Proposed Rule-Year 2 Takeaways

Some of the Key takeaways from the proposed rule for MIPS are:

  • Increasing the low-volume threshold so that more small practices and eligible clinicians in rural and Health Professional Shortage Areas (HPSAs) are exempt from MIPS participation: CMS has increased the low-volume threshold for the performance year 2018. Eligible Clinicians and groups who bill $90,000 or less in Medicare Part B allowed charges or see 200 or less Medicare Part B beneficiaries during the low-volume threshold determination period would be exempted from MIPS. It is estimated that only 37% of MIPS eligible Clinicians and groups would be in MIPS after considering the low-volume threshold and other exclusions. Although a welcome change for many, it is a major setback for those small practices who are ready for MIPS and were looking forward to participating. Starting 2019, CMS proposes to let clinicians opt-in if they exceed 1 of the 2 low-volume thresholds. It is also proposing to add a third component – Number of Part B items and services to determine the low volume threshold.
  • Offering the Virtual Groups participation option: Solo practitioners or groups of 10 or less eligible clinicians who are not excluded from MIPS can form virtual groups with other solo or group of 10 or less eligible clinicians. Those wanting to participate as virtual groups need to make the election by 1st December 2017 and will not be allowed to change later. Since these Clinicians are already eligible as individual or group, we do not foresee any reason for them to form virtual groups and take on an additional burden of aggregating their performance data across several TINs – unless their aggregated score is better than their individual or group score – which is obviously hard to estimate by December 2017.
  • Continuing to allow the use of 2014 Edition CEHRT in 2018 and adding bonus points for those using 2015 Edition CEHRT: With very few EHRs currently certified for 2018, this may seem like a welcome change. However, the 2015 Edition CEHRT is still a requirement for Medicaid EPs and Medicare EH and CAH EHR incentive programs; advanced APMs like CPC+, vendors who were planning their certification in the second half of 2017 would be still going ahead with it.
  • Incorporating the option to use facility-based scoring for facility-based clinicians: Facility-based clinicians i.e. those who have at least 75% of their covered professional services supplied in inpatient hospital settings or emergency department can have their MIPS Quality and Cost Performance Category score calculated from an optional voluntary facility-based scoring mechanism based on the Hospital Value – Based Purchasing Program.
  • Quality Performance Category: Weightage remains at 60% and data completeness criteria at 50%. However, measures that do not meet the data completeness will be given 1 point instead of 3, except for small practices who would continue to receive 3 points. CMS has retained the 3 point floor for measures with benchmarks, measures which do not have benchmarks and that which does not meet the case minimum requirement. CMS proposes to cap the topped out measures at 6 points and remove them from the program in the 4th year they are identified as topped-out.
  • Cost Performance Category: Cost Performance Category continues to be weighted at 0% for 2018 performance year. However, CMS will give the feedback and the Cost Score would be calculated on the Medicare Spending per Beneficiary (MSPB) and total per capita cost measures only. CMS expects to replace the current episode – based cost measures.
  • Improvement Activities Performance Category: No change in scoring. However, CMS is offering more activities (including those that would fetch CEHRT bonus under ACI) to choose from. CMS proposes to include the CPC+ APM model in the definition of certified patient-centered medical home. CMS also proposes a threshold of 50% for the number of practices within a TIN that needs to be recognized as patient-centered medical homes for the TIN to get the full credit for the Improvement Activities performance category.
  • Advancing Care Information Performance Category: Instead of awarding 10% for reporting to Immunization Registry, CMS proposes to award 5% each (up to 10%) for reporting to any Public Health or Clinical Data Registry and additional 5% bonus for reporting to a different registry than those used to earn the performance score. CMS has added a new hardship exception for clinicians in small practices under the Advancing Care Information performance category to reweight their ACI to 0 and reallocate it to Quality. Retroactive to the transition year 2017, CMS proposes to reweight ACI for Ambulatory surgical center (ASC)-based MIPS eligible clinicians to 0 and add an exception for eligible clinicians whose EHR was decertified.
  • Incorporating MIPS performance improvement in scoring quality performance: CMS would award up to 10% points in Quality Performance Category based on the rate of improvement in the current performance period compared to the prior performance period. Similarly, improvement scoring is proposed for Cost Category based on statistically significant changes at the measure However, it will not affect the final score for 2020 payment year, if cost category weight is finalized at 0%.
  • Adding bonus points in the scoring methodology for Caring for complex patients: CMS would award between 1 to 3 bonus points based on the medical complexities of the patients seen by the Eligible Clinician by adding the average Hierarchical Conditions Category (HCC) risk score to the final score.
  • Add bonus points to the Final Score of clinicians in small practices: CMS proposes to adjust the final score of eligible clinicians or groups in small practices by adding 5 points to the final score. How many “takers” remain after the increased low-volume threshold, is yet to see.
  • Performance Threshold: Performance Threshold is increased to 15. Exceptional Performance threshold stays at 70.
  • Performance Period: Performance Period for Quality and Cost would be 12 months, ACI and Improvement activities would be 90 days.
  • Data Submission: The data submission options would remain the same, however CMS proposes flexibility to submit measures and activities through multiple submission mechanisms within a performance category.

The rule also proposes the following modifications to APMs:

  • Extending the revenue-based nominal amount standard, which was previously finalized through the performance year 2018, for two additional years (through the performance year 2020). This standard permits an APM to meet the financial risk criterion to qualify as an Advanced APM if participants are required to bear the total risk of at least 8% of their Medicare Parts A and B revenue.
  • Exempt Round 1 participants in the Comprehensive Primary Care Plus Model (CPC+) from the requirement that the medical home standard applies only to APM Entities with fewer than 50 clinicians in their parent organization.
  • Modifying the nominal amount standard for Medical Home Models so that the required amount of total risk increases gradually. For the performance year 2018, it is adjusted to 2% of the estimated average total Medicare Parts A and B revenues of all providers and suppliers in participating APM Entities.
  • Giving more details about how the All-Payer Combination Option will be implemented. This option allows clinicians to become Qualifying APM Participants (QPs) through a combination of Medicare participation in Advanced APMs and participation in Other Payer Advanced APMs. This option will be available beginning in the performance year 2019.
  • Giving more detail on how eligible clinicians participating in selected APMs will be assessed under the APM scoring standard. In 2017, there were different scoring standards for ACO and other MIPS APMs. For 2018, CMS proposes to align weightage against all MIPS APM and access all MIPS APM on Quality.

The proposed rule is open for comments until 21st August 2017. You can submit your comments https://www.regulations.gov/. The proposed rule (CMS-5522-P) can be downloaded from the Federal Register at: https://www.federalregister.gov/documents/2017/06/30/2017-13010/medicare-program-cy-2018-updates-to-the-quality-payment-program. CMS has also published a factsheet of the proposed rule at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Proposed-rule-fact-sheet.pdf

In the quest to simplify things for small, independent, and rural practices who are not yet ready, it may seem that CMS is taking regressive steps instead of progressive one towards the program. It was anticipated that CMS might be including more number of smaller practices in QPP by decreasing low-volume threshold and also giving them more opportunities by increasing the flexibilities and granting additional bonuses. However, if the proposed low-volume threshold is here to stay, many smaller practices may be left out. Even if the proposed rule has significant deviations from the plans laid out for 2018 in the previous final rule, the backbone of the program is the same. Core elements of the program, such as performance categories and the structure of the program remains unchanged. It also proposes continued program advancements, such as increasing reporting requirements, as expected. Even though it might seem that you are done with QPP, do not hit the brake pedal on MIPS. Rather it is an opportunity for you to explore other advanced APM opportunities or take the time in setting up the systems to succeed in the program as it expands in the future.


About the Author:

Arnaz Bharucha is the R&D Lead for Quality Improvement and Senior Software Architect with over 17 years of experience in designing and supporting healthcare IT products for Electronic Health Record, Quality Reporting for MIPS, Meaningful Use, PQRS, PCMH, DOQ-IT etc., and professional & institutional medical billing systems. She has shouldered key responsibilities of understanding the US Healthcare industry standards, designing iPatientCare suite of products in compliance with the ONC’s Meaningful Use, designing and implementing interoperability and other healthcare Quality Reporting initiatives requirements. Under her leadership, iPatientCare has been a Qualified Registry for submitting quality measures to CMS since 2014.

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