MACRA 2.0 Proposed

Proposed updates to the Medicare Quality Payment Program (QPP) for calendar year 2018 would provide many physicians and other providers welcome relief from several regulatory burdens imposed by the Medicare Access to Care and CHIP Reauthorization Act (MACRA). The updates also would give tens of thousands clinicians new avenues to opt out of the program altogether without penalty.

Most notably, the proposed rule, released June 20, 2017, by the Centers for Medicare & Medicaid Services (CMS), would expand MACRA hardship exemption options and raise the thresholds for mandatory participation — both steps lowering the number of clinicians required to participate in certain MACRA programs.

The rule would raise the mandatory QPP participation threshold – measured in total allowed Part B charges – from $30,000 to $90,000 during the reporting period. Those receiving less than $90,000 in total allowed Part B charges would not have to participate. Similarly, those seeing fewer than 200 Medicare patients during a reporting period could opt out of the QPP. CMS estimates that this proposal alone would excuse some 30 percent of practicing physicians from participating in QPP — that’s in addition to the 35 percent who are already exempt. For the estimated 35 percent of the nation’s clinicians who would remain eligible for the QPP, the CMS proposed rule offers options to relieve several of the program’s most onerous requirements.

One major area of relief applies to small practices, which CMS defines as 15 clinicians or fewer. Those in small practices who still met the new participation thresholds – more than $90,000 in Part B total allowed charges or more than 200 Medicare patients during the reporting period – could declare a hardship exemption for the Advancing Care Information (ACI) category, formerly known as Meaningful Use. Physicians practicing in a rural area or that which is designated as a Health Professional Shortage Area (HPSA) also could opt out of ACI under the newly proposed hardship exemption.

The rule, which takes MACRA into its second year of implementation, would further delay the cost category of the Merit-Based Incentive Payment System (MIPS). Furthermore, clinicians could continue using 2014 Edition Certified Electronic Health Record Technology (CEHRT) for another year, which is especially good news for the many practices feeling pressured to purchase costly required upgrades to the 2015 version. For practices with “decertified” systems, CMS proposes an exemption in 2018 that would be retroactive to the current (2017) reporting year.

Other changes in the proposed second year of the QPP include:

• Bonus points in the MIPS quality category for small practices submitting data on at least one performance category, plus individual bonus points to providers whose patient populations are considered complex as defined by their average Hierarchical Conditions Category;
• New MIPS reporting option giving hospital-based physicians greater flexibility in reporting (they would be able to use their facility’s inpatient value-based scores to calculate their individual scores in cost and quality if they wished);
• MIPS participation avenues for non-affiliated physicians of any specialty to band together to participate as a virtual group in the QPP;
• Use of multiple submission mechanisms even if they were within the same category (for example, measures for the quality category of the QPP could be transmitted via an EHR and via a registry); and
• Addition of exclusions for the summary of care record exchanges and e-prescribing in the ACI category.

The rule still takes steps to move MIPS forward; for example, clinicians would have to submit 12 months or more of data to earn sufficient points in the quality category and avoid penalties. The proposal also continues the three-point floor for each quality measure, with the exception of those that do not meet the data completeness requirements and are not a small practice. It also accords a maximum of only six points for those measures that are “topped out” (compared with a potential of 10 points that can be earned for all other measures).

While the theme of the 2018 proposed rule is clearly “relief,” there are many recommended changes in the 1,058-page proposal. For those physicians who remain eligible, familiarity with what is still a tangled web of rules must be a priority for success in the years ahead.