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MACRA Final Rule Expected Soon: What are the Considerations?

October 10, 2016
by Rajiv Leventhal
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Plenty still to be decided as MACRA final rule could come any day

With rumors swirling that the Medicare Access and CHIP Reauthorization Act (MACRA) final rule could drop from the Centers for Medicare & Medicaid Services (CMS) sooner rather than later (a source close to Washington D.C. has told Healthcare Informatics that the rule could come down as early as Oct. 11 and probably no later than next week), now is a good time to take a look back at what was proposed and what key elements might be changed.

As the industry knows already, CMS last month announced flexibilities that will allow eligible Medicare physicians to pick their pace of participation for the first performance period of the outcomes-based program that begins Jan. 1, 2017. CMS Acting Administrator, Andy Slavitt said in a blog post announcing the program flexibilities that providers will have four pathways to choose from for the first year of MACRA in 2017.

These pathways range from sending in only some data to MACRA’s Quality Payment Program, which includes two paths—the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs); to sending in more data but for a reduced period of time; to “going all in” as is. The idea, CMS said, is to allow doctors to choose their pace for easing into a brand new physician payment program full of complexities, while at the same time avoiding negative payment adjustments in 2019. But even with these flexibilities in place, there is more to consider regarding what might change from the 962-page proposal to the final rule.

Timing—Given the four paths that participating providers could choose from, there are different timelines in place for program involvement in 2017. As reported in a story last month from Healthcare Informatics, policy experts noted that physicians do not have to start reporting right away on Jan. 1 if they choose the either of two pathways that allow them to “submit some data to the Quality Payment Program, including data from after Jan. 1, 2017,” or “submit Quality Payment Program information for a reduced number of days.” Essentially speaking, this is a “delay” without using the word. But, as Tom Lee, Ph.D., founder and CEO of Chicago-based consulting and software firm SA Ignite, said in that same story, “For ‘incentive seekers,’ the true start date for MACRA is indeed Jan. 1, 2017.” Indeed, while physicians and healthcare associations have asked for a delay to MACRA since the release of the proposed rule, most of the timeframe questions have likely been put to bed with CMS’ announcement last month.

Concern for small practices—There has been no shortage of conversation about solo and small practices’ ability to thrive, and even survive, under MACRA’s rules. A Black Book survey from June revealed that two-thirds of high Medicare-volume small practices said they foresee the end of their independence due to the physician payment changes that will take place under MACRA. In a projection of what’s to come regarding payment adjustments, CMS estimated itself in the proposed rule that 87 percent of eligible solo practitioners and 70 percent of practices with two to nine physicians could get hit with a negative payment adjustment early on in the program. In terms of dollars, these negative hits could be in the range of $100 million to $300 million.

So what could be done to help these types of practices? During a Congressional hearing in May, Slavitt provided further detail on how CMS plans to help out smaller practices, noting that if they are already participating in clinical data registries, for example, that can be used for MIPS rather than requiring physicians to send information in again. Also, he said, “Small practices can report in groups in many categories where they weren’t able to before, and others won’t have to report at all if they don’t meet the minimum Medicare threshold for patients.” In another hearing in June, Slavitt said that the creation of virtual groups is something the agency has received significant feedback on, although that wouldn't take place until 2018.

Nominal risk—The MACRA proposed rule calls for the streamlining of various quality reporting programs into a single framework. It does this by guiding providers down one of two paths—MIPS or APMs. Most policy folks expect the overwhelming majority (90 percent or more) of eligible doctors to choose the MIPS path as the two-sided risk models as part of the advanced APM track are very aggressive for many. Simply put, the APM path is a huge gamble for many organizations who are not set up well to be in danger of losing money as a result of poor quality performance.