United States: Top Takeaways From MACRA Proposed Rule

Last Updated: July 20 2017
Article by Katherine Watts

With the proposed changes to the Quality Payment Program (QPP) released Wednesday, the new administration aims to reduce some administrative complexity and extend the flexibility that CMS provided in the initial year of the program, while incentivizing more providers to move into Alternative Payment Models (APMs).

As stated in its fact sheet on the proposed rule, "CMS wants to ensure that there is meaningful measurement and the opportunity for improved patient outcomes while minimizing burden, improving coordination of care for patients, and supporting a pathway to participation in Advanced APMs."

Easing the MIPS Burden

Some of the changes in the proposed rule that would reduce the regulatory burden of participating in the Merit-based Incentive Payment System (MIPS) include:

  • Increase in the low-volume threshold. Currently, physicians with 100 patients or $30,000 in Part B payments are exempt. The proposed rule would increase the threshold to 200 patients or $90,000 in Part B payments.
  • Participation via Virtual Groups. Solo practitioners and physician groups with 10 or fewer eligible clinicians would have the option to band together virtually to participate in MIPS. The ability to pool administrative costs and responsibilities has the potential to make MIPS a much more attractive option for small practices. But as always, the devil is in the details, so stay tuned for more on that option.
  • Bonus points for small practices. Clinicians in practices with 15 or fewer clinicians would receive 5 bonus points on the final score as long as they submit data in at least one performance category in an applicable performance period.
  • Bonus points for complex patients. Up to three bonus points would be added to the final score based on the average Hierarchical Conditions Category (HCC) risk score. CMS has asked for comments on the option of including dual eligibility as a method of adjusting scores—either as an alternative to or in addition to the HCC risk score.

Kicking the Cost Can Down the Road

At least one of the proposed changes—delaying by one year the cost component of the MIPS score—could make it harder for eligible clinicians in the long run. In the proposed rule, the cost category would continue to be weighted at 0% for the 2018 performance year (2020 payment year) and then ramps up quickly to 30% in the 2019 performance year (2021 payment year).

In our view, kicking that particular can down the road could be detrimental for physicians and their practices. Cost control efforts are essential to success in all value-based payment programs, and especially Advanced APMs. So regardless of whether that scoring component is phased in next year or two years from now, providers will be wise to make cost control a priority.

Minor Adjustments to Advanced APM Track

The proposed rule keeps policies regarding Advanced APMs largely unchanged. It extends the revenue-based nominal amount standard through 2020, which requires APM participants to bear total risk of at least 8% of their Medicare Parts A and B revenue.

Medical Home Models are eased more slowly into the nominal amount standard, starting at 2% of the estimated average total Parts A and B revenue in performance year 2018 and increasing to 5% in 2021 and thereafter. The rule also gives more detail about how the All-Payer Combination Option will be implemented, and it reduces the burden for certain APM participants who do not qualify as Qualified Professionals and are therefore subject to MIPS.

Another Step on the Journey to the Triple Aim

This proposed rule just one more step in CMS' journey toward value-based payment for all. By providing this on-ramp to participation in Advanced APMs, the agency is moving our health care system toward lower costs, higher quality and access to care for all.

The proposed rule will be published in the Federal Register on June 30 and CMS is taking comments at https://www.regulations.gov/ through August 21. For more information, contact the agency at QPP@cms.hhs.gov.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

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