The proposed revisions to the 2018 are out, and as with the debut of the law itself, most groups are happy to see MACRA legislation move forward. In the latest round of comments, organizations expressed their appreciation for the overall shift towards reducing the reporting burden on clinicians and increasing flexibility within various aspects of the new rule, including the revised low-volume threshold for clinicians who treat fewer Medicare patients, the implementation of the facility-based measurement option and flexibility that allows clinicians to use 2014 or 2015 edition EHRs for the 2018 performance year.
The new low-volume threshold
For 2018, clinicians who treat fewer than 200 Medicare Part B beneficiaries or bill less than $90,000 in Part B allowed charges will be exempt from having to participate in the Merit-based Incentive Payment System. It's an increase of $60,000 in allowable charges and a doubling in the number of Medicare beneficiaries over the threshold for 2017 reporting. The adjustment opens the door for many more clinicians to be exempt from MIPS participation and it's pretty close to the top of many groups lists of things they were happy to see proposed for 2018.
The American Hospital Association said the new threshold would provide needed relief and additional time for small and rural providers to transition into MIPS for small and rural providers. The American Medical Association also voiced support for the change, and stressed that CMS should notify ECs as soon as possible whether they qualify for the exemption. The Medical Group Management Association wants to see the proposal finalized and want to see it refined even further.
"CMS should mirror its own policy for non-patient facing eligible clinicians (ECs) and scale the low-volume threshold to the group practice level, exempting a group from MIPS if 75 percent or more of its ECs individually fall below the low-volume threshold or the group's average Medicare allowed charges or Medicare patient population falls below the threshold."
The facility-based measurement option
New for 2018, this option will allow a facility-based clinician for whom 75 percent of their professional services are rendered in an inpatient hospital setting or emergency department to to submit their facility's inpatient value-based purchasing score to better calculate an individual score for the cost and quality categories of MIPS.
The AHA applauded the option and expressed support for "nearly all" of the new policy, saying it will help clinicians and hospitals streamline processes and cut down on the data collection burden. However, the group asked CMS to provide even more flexibility for group practices, help hospitals to work with the clinicians who choose the option, and consider opening the option up to more facility types in the future.
The AMA also supported the policy, but asked that CMS reduce the 30 percent floor in the quality category to "better align program requirements for both facility and non-facility physicians."
The provision that eligible clinicians can use 2014 or 2015 certified EHR technology met with widespread support. MGMA wants to see the policy finalized and extended through 2020.
The American Academy of Family Physicians also trumpeted support for this, especially in light of the plight of small practices who have limited resources, both financial and staff, for MACRA implementation.
"Some noted switching to 2015 edition CEHRT is cost prohibitive for small practices. It is noted that ONC is working with health IT developers to analyze and monitor the status of developer readiness for 2015 edition CEHRT. While several analyses indicated progress was on track, both stakeholder feedback and market trend factor analysis strongly indicated a slower, more measured approach is required," the AAFP said in its official comments.
Along with their stated support for the CEHRT flexibility, the AMA urged CMS to look at related improvements within the ACI category, including the addition of flexibility within the base score, reducing information blocking attestation requirements and making it possible for physicians to score ACI credit by using CEHRT to participate in a Qualified Clinical Data Registry.
Reporting periods and other fine tuning
While the AHA professed appreciation for the proposals for additional flexibility, including a 90-day reporting period for the ACI category in 2018 and 2019, they also want CMS to retain a continuous 90-day reporting period for the quality category in 2018, rather than requiring a full year of data as proposed.
The group agreed a longer data collection period could produce more reliable performance data, but stressed that during the transition into MACRA, clinicians should have the "utmost flexibility." They are also calling for a 90-day reporting period for 2019 as well.
"We are concerned that a requirement to report a full year of data might make it more likely for clinicians to experience a penalty. Retaining the 90-day reporting period adopted for CY 2017 would afford additional time to plan and prepare for data collection. Furthermore, this approach would not preclude those clinicians that are prepared to submit a full year of data to do so."
The AMA also expressed concern over the proposed full calendar year of reporting, echoing the notion that it would mean significant administrative burden. Having different reporting periods for different categories was also a sticking point for the group, saying it adds complexity and confusion to a law that already is weighing on providers who must comply.
Right now, the proposal states that quality and cost categories require a full year of reporting while the improvement activities and advancing care information categories allow 90 days.
The AMA is asking CMS maintain a permanent 90-day reporting period for the ACI category. "Our members have expressed a desire for both simplicity and stability in the QPP. We also want to encourage physicians to focus on the use of their health IT tools rather than solely reporting on measures. A shorter reporting period enables physicians to adopt innovative uses of technology and permits flexibility to test new health IT solutions."
The AAFP is also on board with sticking with a shorter reporting period, saying in their official comments that they are concerned that CMS should not require a full year of quality reporting for the 2018 performance year. "We encourage CMS to continue to allow 90-day reporting periods for the quality, ACI, and improvement activities performance categories in the MIPS 2018 performance period."
MGMA is also looking for a permanent reporting period for the quality and ACI reporting periods of any 90 consecutive days "using sampling and attestation methodologies that ensure statistical validity." They said doing so would yield a number of improvements, especially reducing the reporting burden for participating ECs. They also recommended aligning the reporting period across MIPS categories, and shrinking the problematic two-year lag between performance and payment.
"Establishing a 90-day reporting floor would also give CMS an opportunity to set benchmarks based on more current data, rather than from four years prior to the payment year."
Reweighting the cost category
Weighting of the QPP performance categories is a multifaceted issue, as some categories may present more challenges than others when it comes to measuring and reporting. The cost category seems to be one that has drawn ire from several groups who think it should not weigh into the final MIPS score at all. The AMA voiced strong support for CMS' proposal to maintain the cost category weight at zero for the 2018 performance period, saying they believe CMS needs additional time to "develop, test, and refine new episode-based cost measures before including them in the MIPS program.
The AAFP and MGMA also want to see the cost category weighted at zero. "We strongly urge CMS to continue a gradual introduction of cost into the MIPS final score and increase it to 10 percent beginning with the 2019 performance period."
MGMA said they want the cost category weighted at zero until "CMS has extensively tested the new episode-based measures, reformed the patient attribution methodology, and implemented key aspects of this category, including patient relationship codes and risk adjustment recommendations from a forthcoming congressionally-mandated report."
Other standout concerns
MGMA is calling for quarterly feedback from CMS for MACRA participants such that adjustments that could positively impact performance can be made more often throughout the year. The lack of real-time or actionable feedback is a significant concern, said Jennifer McLaughlin, senior associate director of government affairs from MGMA. She said congress recommended feedback on quarterly basis, but right now it is slated to happen annually.
"They are already looking at 2018 and have no indication from CMS on how this is all really working. There is a disconnect between what groups are reporting and lack of feedback. It positions this as more of a compliance program than a quality program," she said.
Also, the AAFP reiterated their "steadfast opposition" the entire MIPS APM category, saying the category was created outside of the statutory requirements and introduces unneeded complexity to an already complex program. They argued that eligible clinicians might intentionally remain in MIPS APMs, given the scoring advantage they have been given, instead of progressing towards advanced APMs.
"We urge CMS to closely monitor participants who may be intentionally avoiding the progression to AAPMs," they said.
They also slammed a proposal for 2018 that would allow doctors to submit data for measures through multiple submission mechanisms within a single MIPS category, as this too would add complexity for the participant, even under the guise of yielding a better score, and would also complicate the processing of MIPS data. "CMS should consider withholding this portion of the proposed rule until they can demonstrate the ability to receive data and send feedback in a timely and accurate fashion," the AAFP said.