What you (still) need to know about the MACRA Final Rule

While the future of the Affordable Care Act and what may replace it now dominate post-election health care debate, the separate Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) marches on under the Final Rule that was released on October 14.

Health care systems would be wise to continue planning for this sea change and MACRA implementation. It is unlikely that we will see big changes in Medicare's value based health care program in the next few years, as MACRA will reduce Medicare outlays.

Among other things, the Medicare Access and CHIP Reauthorization Act of 2015 has steered away from traditional Fee for Service payments once it repealed the Sustainable Growth Rate and incorporated quality measurement into payment. Therefore, revenues are tied to quality, instead of volume. Through MACRA, the Quality Payment Program (QPP) provides two participation methods:

• Advanced APMs: Advanced Alternate Payment Models
• MIPS: Merit-Based Incentive Payment System

The Final Rule (CMS-5517-FC: "Medicare Program; Merit-based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models") aligns prior quality and technology initiatives under one Quality Payment Program umbrella, preserving CMS's commitment to developing a streamlined and flexible program. This will result in financial winners and losers, and the majority of providers, practices, and health systems will be affected. What change from Proposed to Final Rules? CMS loosened the rigor of several specific requirements, which allows providers to ease into the program.

Here's the most important theme: While the Quality Payment Program is a "go," some of the more taxing provisions of the Proposed Rule softened under the Final Rule. Do not misunderstand, the new program creates a seismic shift in the structure of payment: Those eligible who ignore the QPP risk penalties of four percent. However, in 2017, the first performance year, CMS has made it simpler for participants to avert "negative payment adjustments" (read: cuts) in 2019, the first "payment year."

What Defines Eligibility?

Whether a clinician is eligible is determined by two factors:

What Kind of Provider Are You? If you are a physician, physician assistant, nurse practitioner, clinical nurse specialist or CRNA as defined by CMS, you are included.
What Type of Care Do You Provide? If you bill more than $30,000 per year to Medicare, or care for more than 100 Medicare patients, you are included (unless 2017 is your first year participating in Medicare). Remember, eligibility does not require meeting both; it is sufficient to meet either the fee component or volume.

As proposed, MIPS-Eligible Clinicians may submit either as individuals or as Group practices. The rule finalizes NPI/TIN as the identifier for an individual clinician, while the TIN identifies Group Practices. This is the same method used in PQRS. You need to have at least two providers in your TIN, and at least one must be MIPS-eligible to be considered a Group Practice. The June 30 registration deadline (the current PQRS deadline) carries over.

What Are the Essential Requirements?

The essential requirements are variable. One thing that remained consistent between the Proposed and the Final Rules is the program was designed to be flexible. And flexibility normally carries a generous amount of complexity. In effect, the announcement that eligible providers could "Pick Their Pace," complicates the act of pinpointing a set of requirements. In general, providers may succeed either in MIPS or through an APM.

Requirements for Merit-based Incentive Payment System (MIPS)

If participating in MIPS, a provider earns a decile-based (10 levels, not all-or-nothing) composite score based on three categories in 2017 (in later years, Cost is also scored):

A. Quality: Reporting quality measures, a product of the PQRS.
B. Improvement Activities: Formerly CPIA, but new for MIPS.
C. Advancing Care Information: A measurement of whether technology is being used to promote better care from Meaningful Use.

Notice any differences? The second category, Resource Use, has been removed. This was the next step for the Value Modifier (VM), but the added complexity (scoring based on 41 episodes of care) could not sustain the quantity of critical comments about its burdensome complexity, particularly in the new program's first year. The 10 percent of the MIPS score that would have come from Resource Use has been reallocated to Quality. It's worthy to note Resource Use will be back in the scoring composite for the 2018 performance year, with triple the weight in 2019.

Of the remaining categories, there are three ways to avoid penalties:

• Submit Full Data (calendar year): No penalty, potential larger incentive (depending on performance)
• Submit Partial Data (at least 90 days): No penalty, potential small incentive (depending on the amount of data submitted and performance)
• Submit a "Test" (one measure or one activity): No penalty

For ease, we will describe the full requirements to help you see what CMS wants to accomplish. We will provide you the opportunity to evaluate how close you and your practice can approach these targets, for doing more than the minimum provides a benefit.

A: Quality (60 percent of the MIPS Composite Score)

MIPS is an all-payer program, which means that you are no longer limited to Medicare Part B patients for your measure denominators. For some, particularly pediatricians, OB/GYNs, and other specialties with traditionally lower Medicare volume, this means that MIPS will be much more germane to your practice than was PQRS. For those in high volume practices, expect your measure denominators to grow exponentially if you have a large commercial mix.

As proposed, full submission equals at least six measures, including at least one outcome measure (or when no outcome measures is available another type of high priority measure), with denominators calculated from all patients, across all payers. No National Quality Strategy (NQS) Domain is required.

However: The high "data completeness threshold," and the "cross-cutting measure requirement." did NOT make it through the comment period, The reporting requirements call for a "data completeness threshold" of 50 percent only. The 90 percent proposed for Registries and 80 percent proposed for claims-based reporting was reduced back to 50 percent, the same current PQRS required level. In other words, if a reporting sample of 500 patients from a denominator of 1,000 are included, a measure may be considered "complete" and successfully submitted. A cross-cutting measure is no longer required in a step back from PQRS,. You can feel a brief sigh of relief if you were wondering how to collect responses on a cross-cutting measure across all patients.

There are more than 270 MIPS measures available, not counting those that a QCDR will be able to develop and report on your behalf. In addition to the freedom to select which measures you want to report (unless you report as a group through the CMS Web Interface), you have choices for how you want to report. Groups and individuals may submit via QCDRs, Qualified Registries, or EHRs. For those who do not want a partner in this process, you may submit via Part B claims (if an individual) and through the CMS Web Interface if in a registered Group Practice.

B: Improvement Activities (15 percent of the MIPS Composite Score)

Formerly CPIA, this requirement is similarly structured to what was proposed, but the amount required amount that constitutes a "full" submission has decreased. Still weighted as "high" and "medium," and 20 points are still assigned to the former for Improvement Activities, while 10 remain the value for the latter. However, to earn the full score in this section, only 40 points are now required instead of 60. You are only required to earn 20 points ff you have 15 or fewer providers in your practice.

Improvement Activities must encompass a 90-day period, which reduces burden for practices, while dovetailing with the "partial" submission requirements. Those in MIPS APMs earn half of their points automatically, and those in certified Patient-Centered Medical Homes continue to earn full credit.

When it comes to submission there are no changes from the Proposed Rule to the Final Rule. QCDRs, Qualified Registries and EHRs remain options, and providers will also have the ability to attest, or submit data through administrative claims (if feasible).

C: Advancing Care Information (25 percent of the MIPS Composite Score)

Meaningful Use may be sunsetting at the end of 2016, but Advancing Care Information serves to remind everyone that Medicare will continue to value Health Information Technology (HIT) in its quality initiatives, and score it accordingly. The requirements for earning the "base" (50 percent) of this component may be earned by submitting information on five measures formerly included in Meaningful Use, with plenty of provider options to fulfill the remaining 50 percent, including Public Health and Clinical Data Registry Reporting.

Noteworthy here is that certain Improvement Activities may serve double-duty with Advancing Care Information categories. Furthermore, eCQMs are not included in this section; all quality measures are scored in the Quality section. Both of these examples illustrate CMS's goal of aligning programs—recognition that repeating the same tasks represents the same inefficiency that they penalize when calculating cost composites and benchmarks.

Requirements for Advanced Alternate Payment Models (APMs)

The rule retains the option for providers who choose not to participate in MIPS to be successful via participation in an Advanced Alternate Payment Model (APM). The three standards proposed for qualifying as an Advanced APM are unchanged from the proposal. An APM must meet all of the following:

• The majority of participants use Certified EHR Technology (CEHRT).
• Report on "MIPS-comparable" quality metrics.
• Participants must bear a risk standard considered "more than nominal."

Even though each component has been retained, CMS has made a focused effort to encourage APM participation by simplifying and reducing the "nominal risk" standards and offering new options. Instead of requiring APMs to bear a risk of four percent of all expected expenditures, CMS is only requiring three percent. Depending on the program, that one percent difference can represent millions of dollars, and determine for some whether they jump in or sit back. In addition to this benchmark-based standard, CMS has also added a revenue-based standard, wherein risk may be limited to eight percent of estimated Medicare Part A and B reimbursements for the entities in the APM. To reduce confusion, CMS has eliminated "marginal loss rate" (the level at which an APM must pay back excess spending over benchmark).

Once again, be forewarned that being involved in a program that changes the nature in which payment is earned and delivered does not mean that you are in an Advanced APM if you're considering participating in an APM,. Some may fall between the two tracks (MIPS APMs), while others may not count at all. Only a select few programs have been identified as meeting these standards and counting towards QPP credit:

• Medicare Shared Savings Program (Tracks 2 and 3);
• Next Generation ACO Model.
• Comprehensive ESRD Model (two-sided risk arrangements);
• Oncology Care Model (two-sided risk);
• Comprehensive Primary Care Plus (CPC+);

CMS notes that this list is subject to change, and that a final listing will be published before the end of 2016.

Looking Ahead

Financially, those who do not submit any data in MIPS 2017 will lose four percent in 2019. Loss in an ACO depends on the agreements signed, and the level of excess compared to benchmarks. Each participant group has the ability to earn incentive payments. In each case, it depends on your performance compared to peers and/or benchmarks, but MIPS also will factor in the amount of data you submit. As is the case today, results will be publicly visible. In terms of prestige, pride and future revenues, this should not be ignored.

In future years, expect to see that these eased requirements aren't gifts—they are loans, to be paid back with interest. The requirements will be strengthened, and mere fulfillment will not be suffice to avoid penalties. Increased flexibility will continue, as practices may link themselves together as "Virtual Groups."

Although not quite the bombshell presented at the proposal stage, the Final Rule clearly marks a new chapter (perhaps a new volume) in the ongoing saga of our health care delivery system. Health Information Technology ties it together: All patients are counted and there are mandatory provisions for establishing activities to provide better care.

For those who are ready to take the next step, there is freedom to choose to participate in Advanced Alternative Payment Models. For those in smaller groups who believed that the program would not be feasible, CMS has earmarked $20 million over the next five years to help you succeed. Yes, some of the specifics have been slightly softened between Proposal and Approval, but to see this as a CMS retreat ignores the magnitude of what has changed. We will all be learning this together, and we look forward to bringing you new insights, stories and lessons as we continue to push towards Value-Based Care.

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

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