MACRA Simplifications for Small Practices

MACRA is finally here and Clinicians are overwhelmed by the changes and complexities in the New Payment Model. CMS has been working with GAO (Government Accountability Office) to understand the unique needs and challenges faced by clinicians in small practices and practices serving the rural or health professional shortage areas. Using the knowledge obtained from GAOs and the feedback from small practices, other stakeholders and public, CMS has come up with various flexibility options and support to ease their burden. CMS defines small practices as those having less than 15 Eligible Clinicians.

1. Increased Low-Volume threshold for Eligibility: Clinicians who bill more than $30,000 to Medicare Part B in a year and see more than 100 Medicare patients a year are eligible for MIPS. Due to this, many small practices would be excluded from MIPS in 2017. Those who are exempted, can still submit quality data to CMS, but they would not be scored or receive payment adjustments. First-time enrollees in Medicare and Qualifying Participants in Advanced APMs are also exempted.
2. Eligibility for Clinicians practicing in RHCs and FQHCs: Eligible Clinicians billing under RHC or FQHC payment methodologies are not subject to MIPS Adjustments. However, Clinicians in RHCs and FQHCs billing under the Physician Fee Schedule are subject to payment adjustments if they meet the low-volume threshold.
3. Clinicians in Critical Access Hospitals: For Eligible Clinicians in CAHs, payment adjustments would apply to the services billed under Medicare Part B and not to the facility payment.
4. Pick your Pace: For the transition year 2017, CMS has a pick your pace which provides options to:
   1. Not participate and receive -4% payment adjustments in 2019.
   2. Submit data for at least one Quality Measure, one Improvement Activity or the required measures under Advancing Care information and get neutral or small positive adjustment.
   3. Submit data for 90 days continuous period and received small payment adjustment.
   4. Submit data for full year and receive moderate payment adjustments.

   Practices that may find difficulty in fulfilling the requirements for a full-year can choose to submit data for either 1 category or 90 days period and avoid negative adjustments.

5. MIPS Performance Threshold: The performance threshold is reduced to three for the transition year 2017, allowing more Clinicians to avoid negative adjustments.
6. Flexibility in Scoring the Performance Categories:
   1. Quality: Individual Clinicians and Groups of less than 16 Clinicians will not be scored on the Hospital Readmission measure. Groups of 16 or more clinicians would not be scored on the Hospital Readmission measure if they do not meet the minimum case volume of 200.  Additionally, floor score of 3 points would be awarded for each submitted quality measure even if it does not meet the minimum case volume of 20, data completeness criteria of 50% patients across all payers or if no benchmark exists for the measure. If Quality is not scored, the weightage would be redistributed as 50% to Improvement Activities and 50% to Advancing Care Information.
   2. Improvement Activities: Groups with 15 or few clinicians, non-patient facing clinicians and those serving in rural or health professional shortage area will receive 20 points on each medium-weighted activity and 40 points on high weighted activity. Individual clinicians who have less than 100 patient facing encounter are defined as non-patient facing clinicians. Groups are considered non-patient facing if more than 75% of NPIs billing under the Group’s TIN are labeled non-patient facing.
   3. Advancing Care Information: Advancing Care Information will be reweighted as 0 for Hospital-based Clinicians, non-patient facing clinicians, NP, PA, CRNAs and CNS. Clinicians can apply to have their ACI weighted to 0 and the 25% assigned to Quality performance category for the following reasons:
      1. Insufficient network connectivity.
      2. Extreme and uncontrollable circumstances.
      3. Lack of control over availability of CHERT.
7. Virtual Groups: Individual Clinicians and small practices comprising of 10 or less clinicians can join to form a virtual group and report to MIPS as a collective entity. Virtual Groups options would be available from the performance year of 2018.
8. Education, Training and Technical Assistance:
   1. Access to free Education Material and webinars posted on https://qpp.cms.gov/resources/education.
   2. Technical Assistance Program: CMS has come up with a 5-year technical assistance program to provide free support to practices with 15 or less clinicians with a goal to provide ground-up support in terms of selection of measures and improvement activities, supporting change management and strategic planning and evaluating the options to join an Advanced APM. Integrated Technical Assistance includes Quality Innovative Networks – Quality Improvement Organizations (QIN-QIOs) (http://qioprogram.org/), Small Underserved and Rural Support (SURS), TCPI (https://innovation.cms.gov/initiatives/Transforming-Clinical-Practices) and APM learning networks (https://innovation.cms.gov/).

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.