MACRA 2018 Final Rule Considerations: What Could Change from the Proposal? | Rajiv Leventhal | Healthcare Blogs Skip to content Skip to navigation

MACRA 2018 Final Rule Considerations: What Could Change from the Proposal?

October 24, 2017
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A review of what was proposed in June and what industry stakeholders want to see in the final version

The 2018 final rule for MACRA’s Quality Payment Program (QPP) should drop any day now, so this is as good a time as ever to review the proposed rule and see what might change in the finalized version.

Released in June, the Centers for Medicare & Medicaid Services’ (CMS) proposed rule for year two of the QPP, inclusive of two payment paths that eligible Medicare-participating physicians could partake in—MIPS (the Merit-based Incentive Payment System) and the advanced alternative payment model (APM) track—aimed to provide continued relief for physicians, especially smaller practice doctors who many folks believe could struggle to comply to a complex reporting program.

In all, in construction of the 2018 proposed rule, CMS said it engaged more than 100 stakeholder organizations and over 47,000 people since January 1, 2017 to raise awareness, solicit feedback, and help clinicians prepare to participate. Many of those stakeholders will be looking intently to see if those flexibilities changed when the final rule drops, and to see if their comments were heard.

Proposed Flexibilities for Small Practice Docs

In the proposed rule, plans from CMS signaled that many more clinicians will be exempt from MIPS once again, like they were in year one of the QPP, which began in January. The rule proposed increasing clinicians’ low-volume threshold from $30,000 or less in Medicare Part B allowed charges or less than 100 Medicare patients to $90,000 in Part B allowed charges or less than 200 Medicare patients. It was estimated in the 2017 final rule last fall that some 380,000 clinicians fell into this low-volume threshold bucket; now, many more small practice clinicians who don’t have high volumes of Medicare patients—perhaps up to 200,000 more—will be exempt from MIPS in 2018 as well, assuming this proposal sticks.

There has been some debate about whether excusing more clinicians from MIPS for another year is beneficial in the long-term. When the proposed rule was released this summer, I spoke to Travis Broome, healthcare policy lead at Aledade, a Bethesda, Md.-based company focused on physician-led accountable care organization (ACO) development, who pointed out that these exclusions 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 told me 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 point, in its comments on CMS’s proposed changes, Charlotte, N.C.-based Premier Inc. said it opposes the agency’s proposal to increase the low-volume threshold and urges the agency to maintain the current threshold, noting that the increase would significantly reduce the clinicians participating in the value-based payment. Rather, Premier recommends that CMS bring clinicians into the program and ease their reporting requirements. However, many other associations support CMS’ suggestion to increase the low-volume threshold for 2018.

CMS also proposed several more flexibilities for clinicians in the MIPS track for 2018. Some of these included: 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. Healthcare trade associations seem to be in overwhelming support of these year two flexibilities.

Allowing 2014 CEHRT

The American Medical Informatics Association (AMIA), the Healthcare Information and Management Systems Society (HIMSS), and others, were pleased that CMS proposed that providers would continue to be allowed the use 2014 Edition CEHRT (Certified Electronic Health Record Technology), while encouraging the use of 2015 edition CEHRT in year two. But AMIA also said in its comments that it urges CMS to “clearly state its intentions to require 2015 edition CEHRT in 2019 for QPP participation.” Several associations said they want CMS to finalize this proposal that would allow clinicians to use 2014 CEHRT for another year.  

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