MIPS breakdown: 6 must-know parts of the MACRA final rule

Written by Emily Rappleye (Twitter | Google+)  | October 18, 2016 | Print |

The Medicare Access and CHIP Reauthorization Act final rule is here. As industry experts begin to dig into the 2,400-page document released Friday, a few details are emerging that will be critical for providers who plan to practice fee-for-service medicine in 2017.

Physicians, physician assistants, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists who bill more than $30,000 a year or provide care for at least 100 patients under traditional, fee-for-service Medicare will be subject to MACRA's Merit-Based Incentive Payment System beginning Jan. 1.

Becker's caught up with two experts who have already started reading — Tom Lee, PhD, founder and CEO of SA Ignite, and Dan Golder, DDS, principal at Impact Advisors — to determine a few details providers should heed in preparation for MIPS next year.

Here are six takeaways based on the initial findings of Drs. Lee and Golder.

1. Flexibilities provided in the first transition year may continue in 2018. Under the final rule, providers in the MIPS pathway can opt out and not send CMS any data in 2017. Those who opt out will receive an automatic 4 percent negative Medicare payment adjustment in 2019. However, CMS has made it fairly simple to avoid this penalty — by submitting data for just one quality measure or improvement activity.

"This gives those with a penalty avoidance mindset a nice break," Dr. Lee says. "It may be even easier to avoid a penalty than under the existing program."

And while the final rule technically only allows providers to pick their pace for the first year, CMS wrote in the comments section of the final rule, "We anticipate that the iterative learning and development period will last longer than the first year, [calendar year] 2017, of the program as we move towards a steady state; therefore, we envision CY 2018 to also be transitional in nature to provide a ramp-up of the program and of the performance thresholds. We anticipate making proposals on the parameters of this second transition year through rule-making in 2017."

2. During the first year of MIPS, providers will not be evaluated on cost or resource use. Once MIPS is in full swing, payment adjustments will be based on four categories: quality (which replaces the Physician Quality Reporting System), advancing care information (which replaces Meaningful Use), clinical improvement activities, which is a new category, and cost, which replaces the value-based modifier. In 2017, CMS will calculate providers' costs, but will not use the category to determine payment adjustments.

Dr. Lee believes throwing out the cost category in the first year will help ease the transition. "Providers will benefit from having more field experience and learning before becoming accountable," he says. However, Dr. Golder says he thinks it was taken off the table simply to relieve providers' angst. "Cost is the easiest one to get a handle on," Dr. Golder says.

3. Despite flexibilities allowed under the final rule, it is in providers' best interest to participate as much as possible during the transition year — and not just for the practice. While many providers may be tempted to slide by on the bare minimum in 2017, financial incentives will be there for the taking for those who choose to participate fully in MIPS. Full participation requires clinicians to report six measures in the quality category or one specialty-specific measure; report five measures in the advancing care information category; and participate in four improvement activities. The program is scored on a 100-point scale, and those who earn a final score of 70 or higher in 2017 will be eligible to earn an "exceptional performance adjustment" from a pool of $500 million.

"More points and more data means more dollars," Dr. Lee says. "Our preliminary estimates show additional incentives start to build once you get past [a score of ] 70 points — which could become substantially higher than 4 percent," he added, referring to the opportunity to earn additional payments under the exceptional performance adjustment. His team at SA Ignite is working to determine just how much more providers could earn.

4. Quality measure benchmarks will be published this year. As Dr. Lee noted, CMS plans to use historical PQRS data as quality benchmarks for 2017. This is a compromise made by CMS based on public comments. CMS says in the final rule it plans to finalize those benchmarks and publish them ahead of the performance period.

5. Vendors need to prepare, too. CMS is allowing some third party intermediaries to submit data on behalf of clinicians to help alleviate the burden associated with reporting under MIPS. "That's a great feature for providers," says Dr. Golder. But a caveat? It puts pressure on vendors. "They are the ones bearing the real brunt of the development."

6. Small group providers and solo physicians could get squeezed out. In the final rule, CMS made some adjustments to reduce the strain on small group and solo providers, by upping the minimum threshold ($30,000 in Medicare claims or at least 100 patients) and mandating the creation of virtual groups, which will eventually allow independent physicians to band together and collectively report data. However, CMS is not prepared to implement the virtual group option in 2017 and is offering the pick your pace option instead. While the final rule contains more flexibility for small groups and solo providers in MIPS next year, Dr. Golder believes the rule will still put stress on those providers. "Small practices are going to need to start thinking about virtual groups soon because in 2018 they will need to be in those groups, ready to compete with larger practices and hospital-based practices," he says.

Plus, MIPS is required by law to be budget neutral, Dr. Golder points out. This means the groups that pay penalties fund the groups that earn incentives — and large groups will be able to more effectively spread risk and manage high-cost, complex patients. "The worry for small groups is that as we implement MIPS, the successful players will be the large groups," Dr. Golder says. "We will have to see how this sorts itself out," he adds. "CMS does not want to intentionally hurt small practices."

 

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