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A First Look at the MACRA Final Rule

October 14, 2016
by David Raths
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Required measures in ‘advancing care information’ category of MIPS cut from 11 to 5

Following a brief review of the 2,398-page MACRA Final Rule released Oct. 14, here is a first look at some of the key changes between the proposed and final rule and the rationales CMS offered for its decisions.

• Finalized MIPS Measures. Probably of highest concern to Healthcare Informatics’ readership, CMS scaled back the reporting requirements in the advancing care information performance category of MIPS. CMS cut the number of required measures for full participation in the advancing care information performance category (the former Meaningful Use) from 11 down to five. Clinicians will have to report on these required measures:

• Perform a Security Risk Analysis

• E-Prescribing

• Provide Patient Access to Their Data

• Send Summary of Care via HIE

• Request/Accept Summary of Care

Reporting on all five of these would earn a clinician 50 percent. All of the other advancing care information performance category elements such as using patient-generated health data or enabling “view, download and transmit” by patients are optional and would give up to 10 percent in the overall performance score or a bonus in the case of public health reporting.

CMS noted that commenters had asked it to consider allowing for “use cases” such as the use of certified EHR technology to manage referrals and consultations. The agency said it would consider this possibility in future rule-making. For now, it is offering bonuses for reporting to public health or a clinical data registry.

For full participation in the improvement activities performance category, clinicians can engage in up to four activities, rather than the proposed six activities, to earn the highest possible score of 40.

To address public concerns about the cost performance category, the weighting of the cost performance category has been lowered to zero for the transition year of 2017. (For full participation in the quality performance category, clinicians will report on six quality measures or one specialty-specific or subspecialty-specific measure set.

Information Blocking. CMS reiterated its position on information blocking, saying providers and hospitals participating under the existing MU program are required to demonstrate cooperation with provisions concerning blocking the sharing of information and separately, to demonstrate engagement with activities that support providers with the performance of their certified EHR technology such as cooperation with ONC direct review of certified health information technologies. (ONC just published a final rule around its Health IT Certification program: Enhanced Oversight and Accountability.  Watch Healthcare Informatics for a separate story on that rule.)

Lengthening the On-Ramp. CMS does seem to be trying to make it easy for clinicians to get on the on-ramp with MIPS. Although CMS has designated 2017 as a transitional year, it notes that it envisions 2018 will also be transitional in nature to provide a ramp-up of the program and performance thresholds. It anticipates making new proposals on the parameters of this second transition year in 2017.

Clinicians can report for a full 90-day period or the full year, and maximize their clinicians’ chance to qualify for a positive payment adjustment. Clinicians who are “exceptional performers” in MIPS are eligible for an additional positive adjustment. (Clinicians who achieve a final MIPS score of 70 or higher will be eligible for the exceptional performance adjustment funded from a pool of $500 million.)

Eligible clinicians could also report for less than a full year but for a full 90-day period, and report more than one quality measure, more than one improvement activity, or more than the required measures in the advancing care information performance category in order to avoid a negative MIPS payment adjustment and possibly receive a positive adjustment.

Even if they report one measure in the quality performance category, one in the improvement activities category or report the required measures in the advancing care information category, they can avoid a negative payment adjustment. Only MIPS-eligible clinicians who choose to not report even one measure or activity will receive a full negative 4 percent adjustment.

MIPS-eligible clinicians who participate in Advanced APMs and see a significant portion of their Medicare patients through the Advance APM will qualify for a 5 percent bonus incentive in 2019.

CMS expressed confidence that small practices will participate in MIPS at a rate close to that of other practice sizes, even though they were less likely to participate in PQRS and MU reporting. It noted that $100 million in technical assistance will be available to clinicians in small practices, rural areas through contracts with quality improvement organizations and regional health collaboratives.

• Setting the Low-Volume Threshold for MIPS. CMS estimates that more than half of all clinicians will be excluded from MIPS. The largest excluded cohort, 32.5 percent or over 380,000, will not meet the low-volume threshold, which includes clinicians with $30,000 or less in Medicare Part B allowed charges or less than 100 Medicare patients. (Approximately 5 to 8 percent will be excluded because they are participating in Advanced APMs.)

• What is Medicare ACO Track 1+? The MACRA Final Rule notes that CMS has heard from stakeholders that it should consider offering ACOS an even more gradual transition to performance-based risk.


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