MACRA: The Journey Continues
As 2017 came to a close, the Centers for Medicare and Medicaid Services (CMS) released its rules for the second year of the Quality Payment Program (QPP), a payment incentive program that rewards value and outcomes for physicians who participate in the Merit-based Incentive Payment System (MIPS).
MIPS-eligible physician who participated at any level with data collection throughout 2017 in the “Pick Your Pace” models, have until March 31, 2018 to submit 2017 data for a payment adjustment in 2019. CAP is committed to provide resources to help our members navigate the continual changes and adjustments still taking shape, especially as we move through 2018 and into 2019, when CMS expects the finality of rulemaking for the QPP and MIPS.
Of significance in the 2018 Final Rule is an increased focus on the protection of small, independent practices. These are a few items to that effect--
- In 2018, many more small practices will be excluded from MIPS compliance due to modified low-volume thresholds. The new low-volume threshold has been set at less than or equal to $90,000 in Medicare Part B allowed charges or less than or equal to 200 Medicare patients.
- 2018 also introduced Virtual Groups. This option gives solo practitioners and groups of 10 or fewer eligible clinicians the option to come together “virtually” to participate in MIPS for a performance period of a year.
- The addition of five bonus points to the final score of small practices.
- CMS will continue funding the community-based organizations awarded in 2017 that have been providing hands-on technical assistance free of charge to help support and train physicians in practices with 15 or fewer clinicians to achieve greater success with QPP/MIPS compliance. The organization serving California physicians is the Health Services Advisory Group (HSAG).
Latest Updates from the Centers for Medicare & Medicaid Services:
- Quality Payment Program – Dedicated CMS site providing detailed information on QPP requirements, quality measures and important dates in 2018.
- MIPS Participation Status Tool – The CMS Quality Payment Program website has released an interactive tool that allows you to determine if you should participate in MIPS in 2018.
- CMS authorized physicians affected by California fires will be granted automatic MIPS exceptions. Under this policy, physicians affected by the Northern and Southern California wildfires will automatically receive a neutral MIPS payment adjustment, unless they submit data for any of the MIPS performance categories by the 2017 submission deadline on March 31, 2018. https://www.cms.gov/About-CMS/Agency-Information/Emergency/Wildfires.html
- Final Rule Overview Fact Sheet for the Quality Payment Program in 2018 (Year 2)
- Quality Payment Program Resource Library
- CMS also posted a new Enterprise Identity Data Management (EIDM) User Guide, which details how to create an EIDM account and/or ‘Physician Quality and Value Program’ role to submit or access Quality Payment Program data.
What is the Medicare Access and CHIP Reauthorization Act (MACRA)?
MACRA is legislation passed in 2015 by Congress. MACRA eliminates the sustainable growth rate, but preserves fee-for-service payments. MACRA consolidates several quality-reporting programs into a single system, the Quality Payment Program (QPP). This system has two tracks:
- the Merit-Based Incentive Payment System (MIPS)
- the Advanced Alternative Payment Model (AAPM).
Under MACRA, physicians can choose to participate in either of the two tracks. Based on their 2017 performance in MIPS or an APM, physicians will receive positive or negative Medicare payment adjustments beginning in 2019.
What track will most clinicians fall into?
Based on CMS calculations, 83 to 90 percent of eligible clinicians will fall into the MIPS track in 2017, while only 10 to 17 percent of clinicians will fall into the Advanced APM track.
How will MACRA impact my Medicare payments?
Under MACRA, all physicians will receive a 0.5 percent update to the annual conversion factor (before sequestration or adjustments due to impacts from budget neutrality factors) from 2016 through 2019. For 2020 to 2025, no update is guaranteed. Physician updates will be based on performance in either the MIPS or the APM track. Physicians will then receive that track’s associated bonus or penalties.
What are the exemptions from MIPS?
For the CY 2017 performance year, there are only three exemptions from MIPS for clinicians who otherwise meet the eligibility requirements above:
- Clinicians in their first year of Medicare Part B participation
- Clinicians billing Medicare Part B up to $30,000 in allowed charges or providing care for up to 100 Part B patients in one year
- Clinicians in entities sufficiently participating in an Advanced APM
Is there any relief for solo, small, and rural practices?
The final rule, as noted above, exempts from reporting requirements for 2017 practices with $30,000 or less in Medicare Part B charges or 100 Medicare patients or fewer, or who will be in their first year of Medicare participation. The earlier version of the rule set the exemption threshold for Medicare charges at $10,000 or less and 100 or fewer patients.
Most small practices are expected to choose the MIPS track, and the final rule allows for more choices in how they report their data in 2017. They can either submit a minimum amount of information, such as an individual quality performance measure or clinical improvement activity; data covering 90 days or more and more than one quality measure or improvement activity; or a full year of data. The final rule also reduces by about half the number of required reporting measures. There are additional reduced reporting requirements for small, rural, and health professional shortage area clinicians across several of the MIPS categories.
If I am in an alternative payment model (such as an ACO), do I still have to participate in MIPS?
Only APM participants who successfully participate in an advanced APM, assuming they meet the required thresholds, will be exempt from MIPS. The majority of physicians will only be eligible for MIPS. This includes many APM participants.
You must participate in MIPS if your APM does not qualify as an advanced APM. You must participate in MIPS if you cannot meet the thresholds for advanced APM participation. However, participation in an APM may help you meet some of the MIPS reporting requirements. These requirements include quality reporting and clinical practice improvement.
What if I am choosing to not participate in MIPS or an APM?
Some physicians — for example, those planning to retire in the near future — may choose not to participate in MIPS or an APM. These physicians can continue to see Medicare patients. They will receive fee-for-service-based payment for treating these patients. However, they will also experience reduction in their Medicare payments two years later. These payments will be reduced by the amount of the maximum MIPS penalty. In 2019, the maximum penalty will be four percent. It will increase to nine percent in 2021.
Is there a group reporting option for MIPS?
Yes. If a practice reports at the group level for one MIPS category, it must do so for all four categories of the program.
Should we report at the individual clinician or group practice level?
While each practice is different, there may be benefits to reporting for MIPS at the group practice level (TIN) if there are multiple eligible clinicians in the practice. There is no registration process for practices that wish to report at the group level. If you participate as a group or individual, you must do so for all categories. You cannot report at different levels for each category.
Without an EHR, is it possible to participate in MIPS?
Clinicians without an EHR can still participate in MIPS, but will not be eligible for any of the points under the Advancing Care Information (ACI) performance category. This will negatively affect the clinician’s total composite score. If you do well on the quality and clinical practice improvement activity categories, you could potentially earn a score high enough to be eligible to earn a bonus.
Should those of us without EHR apply for a hardship exemption?
Yes. Under MIPS, hardship exemptions are available for MIPS-eligible clinicians who cannot comply with the advancing care information category because of a significant hardship. CMS will announce the application process at a later date.
Will MIPS performance data be made available publicly?
Yes. CMS will publish clinician and group performance on either the Physician Compare website or CMS downloadable database. CMS will allow a 30-day preview period in advance of the publication of any data on Physician Compare to allow clinicians to review and submit corrections before information is made public.
What if my question was not answered?
Please submit your question and we will send you more information.