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UPDATED: CMS releases MACRA final rule, makes 2017 'transition year,' adds 90-day reporting option

Program cements two payment tracks and "pick your pace" approach while setting aside money to support small practices.

Henry Powderly, Editor-in-Chief

The Centers for Medicare and Medicaid Services on Friday released the final version of its physician Quality Payment Program under MACRA, which it said adds flexibility like 90-day reporting to the program to overhaul how physicians are paid under Medicare.

[Read the final rule]

The rule, which garnered more than 4,000 public comments since its proposal in April, cements the two payment tracks already proposed. First, physicians can participate in the Merit-Based Incentive Payment System track, basing payment on clinical performance, practice improvement, reporting and technology use. However, the final rule makes official the "pick your pace provision" that allows providers a slower entry into the model if they are not quite prepared to handle all aspects of the program. To do that, CMS is offering physicians a flexible performance period at the beginning.

Payment tracks

Within MIPS, the federal agency is giving providers three reporting options. One option is Full reporting on all measures for either the full year or a 90-day reporting period. Though that truncated reporting period is something many providers had requested, CMS said those who report for the full year will be eligible for "exceptional performer" adjustments that would drive up their bonuses. Another option is 90-day reporting on some, but not all measures. That means more than one quality measure, more than one improvement activity, or more than the required measures in the advancing care information performance category would be needed in order to avoid penalties, or possibly receive a bonus. Lastly, clinicians can report in 90 days on just one measure to avoid paying any penalties. Failure to do that as a minimum would result in their Medicare payments being cut by 4 percent.

The second major track in MACRA is for physicians who participate in alternative payment models like accountable care organizations. That option ties their payments to savings generated in those models.

[Also: CMS launches Medical Review Reduction program to ease reporting burden for doctors]

According to CMS, most of the comments it received were about more flexibility as well as greater support for small practices. Under the rule, CMS will set aside $20 million a year for five years to help support and train physicians in practices with 15 or fewer doctors.

The agency also said it will make 2017 a transition year, which would mean 2018 payments would not be affected by that year's performance. The law would still go into effect on Jan. 1, 2017.

"We recognize, as described through many insightful comments, that many eligible clinicians face challenges in understanding the requirements and being prepared to participate in the Quality Payment Program in 2017," CMS Acting Administrator Andy Slavitt said in an executive summary of the rule. "As a result, we have decided to finalize transitional policies throughout this final rule with comment period, which will focus the program in its initial years on encouraging participation and educating clinicians, all with the primary goal of placing the patient at the center of the healthcare system. At the same time, we will also increase opportunities to join Advanced APMs, allowing eligible clinicians who chose to do so an opportunity to participate."

At the same time, CMS on Friday unveiled a new website that breaks down many of the components of MACRA in a way it hopes will be easier to understand for clinicians.

The American Medical Association on Friday seemed to support the changes in the final version.

"Our initial review indicates that CMS has been responsive to many of the concerns raised by the AMA, and in the days ahead, the AMA will conduct a comprehensive review of the final rule to ensure that it promotes flexibility and innovation in the delivery of care to help meet the unique needs of all patients," the group said in a statement. "With the flawed Sustainable Growth Rate formula – and its annual threat of steep payment cuts – permanently eliminated, the new law gives many physicians the opportunity to be rewarded for the improvements they make to their practices and for delivering high-quality, high-value care to Medicare patients."

[Also: MACRA reactions light up social media as organizations post early responses to 2,400-page rule]

Since a qualified use of electronic health records is a component under MIPS, CMS said the final rule would sunset the existing EHR Incentive program for physicians.

HIMSS, a healthcare association focused on advancing the industry's use of information technology, applauded the new flexibility in the rule.

"As we dive into the MACRA final rule, HIMSS supports the CMS decision to focus on encouraging participation, educating clinicians and creating a longer glide path in 2017 for clinicians to transition to the Quality Payment Program," said Carla Smith, executive vice president at HIMSS. "We are committed to assisting the healthcare community to ensure all stakeholders can successfully leverage health IT to improve access and quality for patients."   

Small practice support

Early reactions on social media Friday suggest that many in the industry feel CMS listened when it came to the concerns of small practices. In addition to the transition year and funds set aside to support training, the final rule added a few other provisions to help these healthcare providers.

"For 2017, many small practices will be excluded from new requirements due to the low-volume threshold, which has been set at less than or equal to $30,000 in Medicare Part B allowed charges or less than or equal to 100 Medicare patients, representing 32.5 percent of pre-exclusion Medicare clinicians but only 5 percent of Medicare Part B spending," the agency said.

Also, the rule establishes options for solo practitioners or small group practices to form "virtual groups" with other practices of no more than 10 clinicians to combine their MIPS reporting. However, that option will only be available after the 2017 transition year.

"CMS wants to make sure the virtual group technology is meaningful and simple to use for clinicians, and we look forward to stakeholder engagement on how to structure and implement virtual groups in future years of the program," CMS said.

However, the Medical Group Management Association, an advocacy organization for physician practices, said the final rule still puts a lot of pressure on clinicians, suggesting that a single transition year may not be enough.

"It's disappointing that flexibility provided for quality reporting in 2017 largely disappears in 2018 and beyond," the group said in a statement. "The Centers for Medicare and Medicaid Services missed an opportunity to close the two-year gap between the measurement and payment periods, which would facilitate improved patient care by providing actionable feedback to physicians and more timely incentives. The sheer magnitude of a 2,400-page regulation and its impact on physician practices can't be ignored."

Expanding alternative payment models

Another change CMS made in the final rule gives physicians more options if they want to participate in the Alternative Payment Model track. On one hand, physicians could participate in Advanced APMs. The only criteria is that the APMs use certified electronic health record technology, that payments are tied to quality measures that align with MIPS measures and that they bear some downside risk for reimbursement. CMS said it is expanding the number of APMs that will qualify under the rule. In a conference call Friday, CMS said it is currently "retrofitting" APMs so that they would qualify under MACRA. It also plans to create new APMs. That would include a new ACO +1 model that, unlike Track 1 of the Medicare Shared Savings ACO program, includes some limited downside risk.

CMS also said physicians can participate in Other Payer Advanced APMs, which are value-based models run on the payer side. Again, those programs need to include EHR use, be based on quality and place downside risk on the physician tied to spending.

Technology is key

The final rule would officially replace the meaningful use program for eligible professionals, but it still places heavy importance on the use of technology such as certified electronic health records. However, CMS said it softened the requirements compared to the proposed rule. While the final version of MACRA keeps the original alignment of technology guidelines with certain performance categories, the final rule mandates fewer measures that physicians absolutely must demonstrate.

"We are reducing the total number of required measures from eleven in the proposed rule to only five in our final policy. All other measures would be optional for reporting," CMS said. However, physicians that report on more than the required measures could earn bonuses. 

Those five measure are performing a security risk analysis, E-prescribing, providing patient access to their data, sending a summary of care through a health information exchange and requesting or accepting a summary of care.

But while EHR remains critical in MACRA, CMS chose not to include more technology measures tied to telemedicine such as virtual visits and remote monitoring. CMS said Medicare's definition of telemedicine that requires virtual visits to be live in real time limited them from adding those measures. Overall, CMS said seven of its practice improvement measures were in some way related to telemedicine.

CMS also chose not to include using EHRs for managing referrals or consultations, or other practice-based ways EHRs are used in workflows, in its advancing care information performance category.

"However, for the 2017 transition year, we will award bonus points for improvement activities that utilize CEHRT and for reporting to a public health or clinical data registry, reflecting the belief that the advancing care information performance category should align with the other performance categories to achieve the unified goal of quality improvement." 

This story will be updated.

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