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Healthcare Associations, Stakeholders Respond to MACRA Finalized Rule with Cautious Hopefulness

October 17, 2016
by Rajiv Leventhal
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Industry leaders discuss how CMS responded to their MACRA concerns

The initial reaction from healthcare stakeholders to the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Final Rule was one of cautious optimism. Indeed, industry leaders seem pleased with how federal officials have responded to their concerns, but also realize that future years of the Quality Payment program could prove challenging for eligible Medicare physicians.

Following the release of the 2,398-page rule on Oct. 14, Healthcare Informatics took a first look at some of the key changes between the proposed and final rule and the rationales that the Centers for Medicare & Medicaid Services (CMS) offered for its decisions. Many of these adjustments were responses to stakeholder feedback, as provider-led associations pushed the government to: reduce burdens, help ease them into the new program, lower risk thresholds for what qualifies as advanced alternative payment models (APMs), and provide plenty more flexibilities so smaller physician practices don’t get penalized for not having the tools or resources to thrive under MACRA.

For the most part, CMS seemed to listen very closely to these concerns, as the agency continues to collect feedback in the 60-day window before the first reporting period kicks in on Jan. 1, 2017.  

Washington, D.C.-based The Advisory Board released a statement applauding the relief that the Final Rule afforded in the first year. “Most—if not all—clinicians should be able to avoid a negative payment adjustment for performance year 2017. CMS proposes three options for providers subject to MIPS [Merit-Based Incentive Payment System] in 2017, the easiest of which providers can meet by reporting a single metric. CMS has also raised the low-volume threshold, exempting more small practices from MIPS,” the statement read.

Indeed, last month, CMS announced flexibilities that will allow eligible Medicare physicians to pick their pace of participation for the first performance period of the program that begins Jan. 1, 2017, aiming to allow physicians to ease into the program if they choose without getting hit with negative payment adjustments right away. These pathways range from sending in only some data into the Quality Payment Program; to sending in more data but for a reduced period of time; to “going all in” for an advanced APM.

Confirmed via the Final Rule, in 2017, only those clinicians on the MIPS track who don’t send in any data will receive a negative 4 percent payment adjustment; all others will receive a neutral or positive payment adjustment. The negative/neutral/positive payment adjustments in MIPS will grow to 9 percent by 2022. To this end, The Advisory Board also expressed satisfaction that providers will not be scored on the “resource use” category in 2017 and can satisfy full-year reporting requirements by reporting for a 90-day period.

Enough Risk?

MACRA’s Quality Payment Program has two tracks for eligible Medicare doctors—the APM track for those participating in what CMS calls an “innovative payment model,” and the MIPS track which is for Medicare Part B providers who will earn a performance-based payment adjustment. For months since the proposed rule was released, a key talking point was what would qualify as an advanced APM, and further, if the prerequisites for these alternative payment models were too aggressive in terms of how the government defined the “nominal risk” financial requirement.

Much of this was cleared up in the Final Rule. For one thing, CMS announced a new advanced APM in 2018—ACO Track 1+, which has lower levels of risk than other accountable care organizations (ACOs). CMS also changed one of the qualifications for participation in advanced APMs to be practice-based as an alternative to total cost-based.

What does this mean? CMS now predicts a much greater push into the APM track from what was previously considered. As Healthcare Informatics’ David Raths noted in this first look at MACRA, in the proposed rule, CMS had estimated that 30,000 to 90,000 clinicians would be qualified APMs in 2017, or less than 10 percent, give or take. However, with new advanced APMs expected to become available in 2017 and 2018, including the Medicare ACO Track 1+, and amendments to reopen applications for or modify current APMs such as the Maryland All-Payer Model, the Oncology Care Model and Comprehensive Care for Joint Replacement Model, the agency now anticipates approximately 70,000 qualifying APM participants in 2017 and 125,000 to 250,000 in 2018, or upwards of 25 percent.

Regarding the Oncology Care Model (OCM) specifically, Brenton Fargnoli, M.D., associate medical director, strategic initiatives at healthcare technology Flatiron Health, and practicing oncology hospitalist, says that the OCM was initially set up was so that downside risk would become an option starting in 2018—but as a response to the MACRA Final Rule considering this model for an advanced APM, downside risk will be an option for participating practices on Jan. 1, 2017. However, by virtue of the requirements, if downside risk is not elected, participants in the OCM would qualify for the MIPS track, notes Fargnoli.

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