When the 2018 proposed rule for MACRA’s Quality Payment Program dropped Tuesday afternoon, one of the biggest takeaways early on was how the rule added even more flexibilities for smaller physician practices. In fact, says Travis Broome, healthcare policy lead at Aledade, a Bethesda, Md.-based company focused on physician-led accountable care organization development, a quick look at the Centers for Medicare & Medicaid Services (CMS) mission statement on the program shows how focused the agency is in helping smaller practices be successful under MACRA (the Medicare Access and CHIP Reauthorization Act).
“They added a line [about] preserving the independence of the clinical practice to the mission statement of the Quality Payment Program. That was bold because they really don’t mess with those things too often,” says Broome, who works at Aledade with its CEO and co-founder Farzad Mostashari, M.D., former National Coordinator for Health IT.
Indeed, in the last year, there has been significant discussion about MACRA’s potential impact on small practices. In the final rule released last fall, CMS said that it was taking additional steps to aid these practices, including excluding many of them by implementing a low-volume threshold for MIPS (the Merit-based Incentive Payment System) of at least $30,000 in Medicare Part B charges or having less than 100 Medicare patients. In sum, the new policy excluded an estimated 380,000 clinicians for 2017 due to this low-volume threshold.
For 2018, that low-volume threshold was raised significantly, from $30,000 in Medicare Part B charges to $90,000; and from having less than 100 Medicare patients to fewer than 200. The impact of that, Broome says, is not only that 200,000 more clinicians will be excluded from MIPS in 2018, but also that the amount of Medicare spend has been increased by 300 percent—from $30,000 to $90,000—now representing more than 10 percent of the total money that Medicare spends on Part B. As such, Broome fears that this might create “a partition between clinicians who are under the low-volume threshold and who are trying to stay there to ensure they don’t have to do a move to value, and everyone else who has to move to value.” Broome further points out that while CMS did a lot of work early on in making sure specialists were part of MIPS, these low-volume thresholds “might be undoing some of that work,” as many of those people who qualify for those low-volume threshold will be specialists.
To this end, in the proposed rule, CMS has estimated that some 80 percent of qualifying small practice clinicians (15 or fewer) will get either a positive or neutral MIPS payment adjustment in 2018. That might make some stakeholders reflect back to the proposed MACRA rule from last spring which predicted that the overwhelming majority of these small practices would be dinged with Medicare negative payment adjustments. CMS then made modifications for the final rule it released in October, such as excluding many more clinicians from MIPS with low-volume thresholds, a move which seemed to satisfy concerned clinicians.
Broome notes that CMS “got a lot of flak” from Congress for that initial MACRA proposed rule, and as a result, the government has continued to increase the number of exclusions for clinicians in the MIPS track. Some of these include: allowing virtual group reporting for the first time; giving [small practices] five bonus points for participating in MIPS; and giving regulatory relief on the Advancing Care Information category with a hardship exemption. Says Broome, “So with all of this, you can see the situation emerge that that 80 percent number is possible. The pool of people who will be penalized keeps shrinking and the band keeps narrowing over time. That is concerning for the move to value, because if you look at the Value-Based Modifier that we have today, the problem is that everyone winds up in this massive middle area that doesn’t impact anyone. It would be a problem if MIPS ends up replicating that,” he says.
Meanwhile, Anders Gilberg, senior vice president of government affairs with the Englewood, Colo.-based Medical Group Management Association (MGMA), says that while the 80 percent estimation sounds good on the surface, CMS also predicts that 99 percent of practices with 100 or more clinicians are expected to get a positive or neutral MIPS adjustment. “So even with the low- volume threshold going up, CMS’ own predictions are that clinicians in these small practices are much more likely to get penalized than a very large practice who can deal with the complexity with the rule. A 20 percent difference is [meaningful],” says Gilberg.
What’s more, he notes, is that even with these modifications made by CMS, the government’s aggregate estimations predict that $224 million will be taken out of the MIPS payment adjustments in 2020 for practices with 15 or fewer clinicians, while just $10 million will be taken from groups of 100 or more.
What Does the Future Look Like for Small Practices?
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