WASHINGTON -- It's here! The Centers for Medicare & Medicaid Services released the long awaited final MACRA rule on physician payment on Friday morning.
Compared with a previous draft rule issued last April, it eases the reporting burden for clinicians and triples the "low-volume" threshold dollar amount for mandating participation, to practices that bill more than $30,000 in a year or care for more than 100 patients. CMS also announced an interactive website and additional resources and training for small and rural practices.
In April 2015, Congress repealed the loathed Sustainable Growth Rate formula by passing MACRA, the Medicare Access and Chip Reauthorization Act.
The overarching concept of payment reform under MACRA is to shift healthcare away from paying for volume to paying for value -- improving care and outcomes through efficient and smart use of resources -- through a Quality Payment Program (QPP).
"This is a landmark effort to move the healthcare system forward," said Andy Slavitt, acting CMS administrator, on a press call Friday. "But it's also a promise to the millions of taxpayers, including the 10,000 people who turn 65 everyday, to be here when we need it," he said, underscoring the need to build a sustainable Medicare program.
Over the last several months, CMS conducted a listening tour to solicit feedback regarding the MACRA rule. They received nearly 4,000 comment letters regarding and almost 100,000 attendees participated in outreach sessions.
Slavitt synthesized those conversations and letters in a single directive: "Make the transition to MACRA as simple and as flexible as possible."
He explained that CMS responded to this feedback by allowing physicians to choose how quickly they advance into the program through a "pick your pace" format, offering options so that physicians can customize the program to their own specialty and practice.
Slavitt noted that the agency had also cut the number of metrics required for reporting in half.
And announced the launch of a new "one-stop shop portal" at QPP.org.
Slavitt also spoke of a new option in 2018 called "ACO Track One," which is an accountable care organization specifically designed to appeal to small practices, because it involves lower levels of risk and still allow participation in the so-called Advanced Alternative Payment Models -- one of the two tracks included in the QPP, that ultimately yields an annual 5% bonus for participants.
"We are now in the middle of reviewing and opening other popular models in the CMS innovation center [for advanced APM inclusion] to be announced shortly," he said.
Slavitt noted that, as he previously shared, the agency would also be opening episode-based models in orthopedics and cardiology, in addition to oncology and nephrology.
In 2018, Slavitt said he expects about 25% of eligible clinicians to participate in the advanced APMS.
In 2017, he estimated, the agency will pay approximately $1 billion in bonuses for high quality care to clinicians in both QPP channels, on top of the 0.5% positive payment adjustment.
After Slavitt spoke, Patrick Conway, MD, MSc, acting principal deputy administrator and chief medical officer for CMS, described in broad strokes other key changes to the rule such as allowing qualifications in the APM program to be revenue based rather than based on the total cost of care, and investing $20 million to conduct "significant technical support" and outreach to small practices.
"We fully intend to keep the lines of communication open. We want to get this right," said Conway.
One year after SGR repeal, in April 2016, CMS released a draft proposal of the MACRA rule outlining its plans to overhaul physician payment and completely transform reimbursement. The Quality Payment Program CMS introduced in the draft rule offered physicians two pathways for reimbursement: The Merit-based Incentive Program and the advanced Alternative Payment Models. The APM track is the more complex, transformative track. Physicians belonging to and advanced APM will receive a lump-sum 5% incentive payment from 2019 through 2024 and a higher annual payment beginning in 2026.
The eligibility criteria for advanced APMs have been extremely controversial.
The second track, the MIPS, is the pathway any physician who does not qualify as an advanced APM automatically defaults to. The MIPS combines elements of a handful of prior reporting schemes -- the Physician Quality Reporting System, the Value-based Payment Modifier, "Meaningful Use" or the Medicare Electronic Health Record (HER) Incentive Program for Eligible Professionals -- into one unified program that consists of four performance areas:
- Quality
- Cost
- Improvement Activities
- Advanced Care Information
The three prior reporting program will terminate at the end of 2018 with the MIPS programs and policies rolling out in 2019, when MIPS physicians will receive a positive negative or neutral adjustment based on their scores across these four categories in prior years.
According to the QPP website, the “cost category†formerly called “resource use†will be calculated in 2017, however, it will not impact payment adjustments. “In 2018, we will start using the cost category to determine your payment adjustment,†noted the agency.
For reporting purposes, the initial reporting period was slated to begin in January 2017 for all participating clinicians but in response to many clinician groups who felt the window too narrow between the final rule and the reporting, CMS announced a "pick your pace" format, intended to allay some of those fears.
It will be offering four options allowing physicans to dip their toes in the MACRA waters -- submit only a portion of their data in 2017 or for only a portion of the year and avoiding a penalty -- or taking the full plunge -- participating for the full calendar year beginning in January 2017.
CMS fleshed out the details of the four data submission options under the MIPS framework on the call:
- No data and receive a negative 4% payment adjustment
- Minimal data in 2017 -- e.g., one quality measure -- and avoid a negative payment adjustment
- 90 days of 2017 data -- earn a neutral or "small positive payment adjustment"
- Full years's worth of 2017 data -- possibly earn a "moderate positive payment adjustment"
Data must be submitted by March 31, 2018. The first payment adjustments will take effect on Jan. 1, 2019.