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2018 MACRA rule continues pick-your-pace, will exempt even more clinicians (updated)

Under the new 1,058-page rule, more clinicians will benefit from an increased low-volume threshold.

Beth Jones Sanborn, Managing Editor

The Centers for Medicare and Medicaid Services released a proposed revised MACRA rule for 2018 late Tuesday that expands flexibilities of the sweeping change to how physicians are paid.

Under the new 1,058-page rule, more clinicians, especially those from small and rural practices and those who don't treat many Medicare beneficiaries, will benefit from an increased low-volume threshold that will exempt eligible MIPS clinicians with less than $90,000 in allowed charges or less than 200 Part B beneficiaries from having to participate in the program. The threshold in 2017 was $30,000 in allowed charges or 100 beneficiaries, according to the proposed 2018 rule.

"We've heard the concerns that too many quality programs, technology requirements, and measures get between the doctor and the patient," said CMS Administrator Seema Verma. "That's why we're taking a hard look at reducing burdens. By proposing this rule, we aim to improve Medicare by helping doctors and clinicians concentrate on caring for their patients rather than filling out paperwork. CMS will continue to listen and take actionable steps towards alleviating burdens and improving health outcomes for all Americans that we serve."

[Also: Healthcare groups urge CMS to count Medicare Advantage contracts as APMs in MACRA]

Virtual groups will be an available option for participating clinicians in 2018, after various advocacy groups lamented their exclusion in 2017 because the regulations were not fully developed at the time. The groups will allow small practices and groups of 10 or fewer clinicians to band together as one reporting entity regardless of their individual specialties or locations, provided they meet the definition of a MIPS-eligible clinician.

The much applauded "pick your pace" option will also continue in 2018, which allows clinicians to choose the level of their participation. For those clinicians still struggling with making necessary improvements to facilitate reporting, this aspect of the rule brought cheers from all corners as many clinicians feared they would not be ready for MACRA implementation and that getting fully prepared might even take longer than the 2017 performance year.

The proposed rule also allows flexibility for clinicians who are considered hospital-based or have limited face-to-face encounters with patients, and for those doctors fretting changes in what Certified Electronic Health Record Technology is accepted for compliance, the new rule will continue to permit the use of 2014 Edition CEHRT, while encouraging transitioning to the 2015 edition. A bonus will be given to those that use the 2015 edition exclusively.

[Also: MACRA may fuel trend of doctors leaving small practices, defecting to hospital employment]

The proposed rule adds flexibility and additional boosts through revisions to MIPS scoring. The 2018 rule provides a scoring bonus for clinicians that treat complex patients by applying up to three bonus points by adding the average Hierarchical Conditions Category risk score to their final score depending on the complexity of the conditions they treat.

Improvement in MIPS performance will also be rewarded by bonus points, based on the rate of improvement. Up to ten percentage points will be available in the quality performance category.

For small practices, groups with 15 or fewer clinicians, CMS proposed a hardship exemption for the Advancing Care Information performance category, such that the 25 percent weight would be shifted to the Quality category, leaving the ACI category weight at zero. Also, the proposed rule seeks to adjust the final score of any eligible clinician or group who's in a small practice by adding 5 points, provided the clinician or group submits data on at least 1 performance category.  They are seeking comments on whether the small practice bonus should be given to rural practices and clinicians.

Comments on the proposed rule are due by August 21.

[Also: MACRA virtual groups provide more flexibility for physicans, though guidance needed, expert says]

The American Academy of Family Physicians said they will be thoroughly examining the rule, but they see progress on several fronts.

"We're pleased that CMS chose to promulgate rules that are related to virtual groups. This is a solid step forward in leveling the playing field for small practices who--without a mechanism by which they can join other practices for reporting purposes--would be subject to a negative payment adjustment."

The American Hospital Association said the proposed rule continues the incremental, flexible implementation approach called for by hospitals, health systems and the more than 500,000 employed and contracted physicians with whom they partner to deliver care.

"We are encouraged by CMS's proposal for a facility-based clinician reporting option that may promote better alignment and collaboration on efforts to improve quality among hospitals and clinicians," said AHA Executive Vice President Tom Nickels. "We also applaud CMS's proposal to provide much-needed relief from unrealistic, unfunded mandates for EHR capabilities by extending the use of modified stage 2 meaningful use requirements through 2018. We will encourage CMS to provide the same relief to hospitals."

The AHA said it would encourage CMS to provide additional opportunities for clinicians to earn incentives for partnering with hospitals to provide better quality, more efficient care through advanced alternative payment models.

The American Medical Association, which has been critical of the rule, said it was pleased with the administration's changes.

The Administration showed it heard the concerns raised by the AMA on behalf of practicing physicians.

"In proposing these rules, the Administration has taken another step to make sure the promise of MACRA – where physicians are rewarded for improvement and for delivering high-quality, high-value care – will be fulfilled," the group said in a statement. "Patients and physicians will benefit from the new MACRA approach, as flexibility is vital when implementing a wide-ranging reform."

Robert W. Seligson, president of the Physicians Advocacy Institute, also praised the changes made by CMS but said one important goal is to ensure that the final regulation includes appropriate reporting periods for physician practices.

"CMS's proposed rule reflects an understanding of the need to ease the transition for physicians to the quality payment program and reduce MACRA's administrative burden. Ultimately, physicians need to focus on what's most important: providing the highest quality care to their patients," Seligson said. "PAI looks forward to reviewing the proposed rule in more detail and working constructively with CMS to help physician practices of all sizes--especially small and solo practices--be successful across all areas of the quality payment program."

Twitter: @BethJSanborn

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