10 takeaways on the MACRA proposed rule

CMS on Tuesday released its 2018 proposed rule to implement MACRA's Quality Payment Program (QPP).

The agency is accepting comments on the proposal through August 21, and we expect a final rule to be released in the fall.

We're still analyzing the 1,058-page proposal, and will have more key insights and action items to share in our upcoming webconference on July 11 at 3 p.m. ET. (Register now to secure your spot).

Here are our 10 early takeaways:

1. Two overall trends are clear: Payment and delivery system reforms are moving ahead, and the administration wants to reduce the regulatory burden of MACRA on providers. This was the new administration's first time to put their stamp on MACRA's QPP and they largely left the structure the same—and in fact gave clinicians more ways to succeed in the program, while also offering significant flexibility to providers.
2. About 134,000 more clinicians—mostly those who work in small practices and those that practice in rural regions and Health Professional Shortage Areas—would be exempt from participating in the QPP altogether. CMS in 2017 allowed providers to be exempt if they had less than $30,000 in Medicare Part B revenue or saw fewer than 100 Medicare Part B patients per year. The agency is now proposing that physician practices making less than $90,000 or caring for less than 200 Medicare patients would not have to participate in the program.
3. The agency would also ease Merit-Based Incentive Payment System (MIPS) burdens by offering bonus points to small practices as well as practices that treat a large share of complex patients. Small practices (those with 15 or fewer clinicians) would have to submit data on at least one performance category to earn five additional points to their final score. CMS could award providers one to three bonus points if their patient population is deemed particularly complex, as measured by Hierarchical Conditions Category (HCC) risk scores.
4. Facility-based providers would be given a new reporting option for the MIPS program. The rule would allow hospital-based clinicians to submit their facility's inpatient value-based purchasing score to be used to calculate an individual score for the cost and quality categories of MIPS.
5. CMS estimates substantially more providers would qualify for the Advanced Alternative Payment Model (APM) track for 2018 than 2017. With the inclusion of the new Medicare Track 1+ program as a qualifying APM and the reopening of applications for the Next Generation ACO program and Comprehensive Primary Care Plus (CPC+) program, CMS estimates that the number of clinicians in the APM track would double from an expected 70,000 to 120,000 clinicians in 2017 to 180,000 to 245,000 in the 2018 performance year. The increase in APM track participants, combined with an increase in clinicians exempt from QPP, would make MIPS far more competitive.
6. CMS doesn't plan to change the APM qualification criterion. CMS proposes to maintain the existing APM qualification criteria through the 2019 and 2020 performance years. Risk-based programs eligible for the APM track would still require a revenue-based nominal amount standard at 8% of the estimated average total Parts A and B revenue of eligible clinicians.
7. CMS is proposing to maintain several 2017 performance year flexibilities that ease clinicians into MIPS requirements for another year. Most notably, the agency would delay required performance in the cost category for the second year in a row. Clinicians would also be allowed to continue use of 2014 Edition Certified Electronic Health Record Technology (CEHRT) rather than be required to upgrade to 2015 Edition technology.
8. However, providers should continue to prioritize cost control efforts. By law, CMS is required to weigh the cost category at 30% by the 2019 performance year, so the on-ramp will be much steeper if providers ignore these measures for another year.
9. The proposed rule would create new avenues for solo practitioners to participate (and succeed) under MIPS. Secretary Price is a vocal proponent of easing the burden of regulatory requirements on independent physicians and the proposed rule reflects that view. The proposal would allow a solo practitioner to form a virtual group with other small groups to qualify for MIPS participation.
10. The rule proposes to raise the bar just slightly in order to earn full points in the quality category and avoid payment penalties overall in MIPS. Clinicians would be expected to submit at least 12 months of data in the quality category rather than choose a 90-day performance period. Additionally, in order to avoid a payment penalty in 2019, clinicians have to earn three points across the three MIPS categories. CMS is proposing to raise that threshold to 15 total points for the 2018 performance year. CMS is proposing to raise that threshold to 15 total points for the 2018 performance year, which is a fairly low bar to clear and may dilute bonuses for high performers.