On October 14, 2016, the Centers for Medicare and Medicaid Services (“CMS”) issued its final rule with comment period implementing the Medicare Access and CHIP Reauthorization Act of 2015 (“MACRA”). The rule goes into effect on January 1, 2017, and the results of the rule will financially impact practices in 2019.
The final rule with comment period sets forth two options for eligible clinicians to participate in the Quality Payment Program developed by the rule: (i) the Merit-based Incentive Payment System (“MIPS”); and (ii) Advanced Alternative Payment Models (“Advanced APMs”).
The MIPS will make payment adjustments based on performance in four metrics categories: quality, clinical improvement activities, use of certified electronic health record technology (referred to as “advancing care information”), and cost. In order to achieve the highest possible scores, eligible clinicians should try to submit measures and activities in all three scored performance categories: quality, improvement activities, and advancing care information. The cost performance category score has been reduced to zero percent for 2017.
Under the final rule with comment period, 2017 will be the transition year for participation in the Quality Payment Program. During this period, eligible clinicians will be allowed to pick their pace of participation beginning January 1, 2017. They will have three options for submitting data to the MIPS, and a fourth option to join an Advanced APM, to ensure that they do not receive a negative payment adjustment in 2019.
Under the first option, eligible clinicians can test the program by submitting any data for a full 90-day period, or the full year to maximize their opportunities to qualify for a positive adjustment in 2019, to avoid a negative payment adjustment.
The second option allows eligible clinicians to report for less than the full year, but for at least a 90-day period, and report at least one quality measure, one improvement activity, or more than the required measures in the advancing care information category, in order to avoid a negative payment adjustment in 2019, and to possibly receive a positive adjustment.
Under the third option, eligible clinicians can choose to report on one measure in the quality category; one activity in the improvement activities category; or report the required measures of the advancing care information category in order to avoid a negative MIPS payment adjustment. If eligible clinicians fail to report even one measure or activity, however, they will receive the full four percent negative adjustment.
The fourth option is to participate in an Advanced APM, such as a Medicare Shared Savings Program ACO. Under this option, if a clinician receives a sufficient portion of his/her Medicare payments or sees a sufficient portion of his/her Medicare patients through the Advanced APM, he/she will qualify for a five percent bonus incentive payment in 2019. Although participation in an Advanced APM provides the potential for eligible clinicians to receive a five percent incentive payment and the ability to avoid MIPS altogether, there are very few models that qualify as Advanced APMs, and the ones that do carry a fair amount of financial risk.
Small practices, however, will be excluded from the MACRA requirements in 2017 if they meet the low-volume threshold. To be excluded from the requirements, an eligible clinician must receive less than or equal to $30,000 in Medicare Part B allowed charges, or have less than or equal to 100 Medicare patients. The CMS estimates that this would exclude 32.5% of Medicare clinicians, but only five percent of Medicare Part B spending.
The CMS states that $100 million in technical assistance will be available for practices with fifteen or fewer eligible clinicians, practices in rural areas, and practices located in geographic health professional shortage areas.
Although the CMS has made complying with the Quality Payment Program more flexible for small practices, this flexibility will not likely extend beyond the 2017 transition year. Accordingly, eligible clinicians will likely have to comply with all of the Quality Payment Program requirements in 2018 and beyond.