CMS’ new proposed rule outlining changes to MACRA for 2018 was hailed as good news for providers, expanding reporting exemptions, loosening EHR standards, and delaying cost-based outcome scoring in the Merit-based Incentive Payment System (MIPS). The move was widely anticipated, as HHS secretary Tom Price has publicly stated his intent to make MACRA more flexible for providers. However, effectively turning 2018 into another transition year calls into question whether MACRA’s original deployment timeline will be delayed even further. The most recent proposed rule also carries some risks for providers unless future years are adjusted accordingly, as it disrupts MACRA’s schedule of gradually increasing mandates and stronger penalties or rewards.
It’s unsurprising that the dramatic changes in MACRA would instill anxiety and uncertainty in many providers. In addition to fundamentally altering the way most providers are reimbursed under Medicare, it also introduces new reporting requirements for quality, clinical process improvements, care costs, and health IT use. CMS addressed some provider concerns by making 2017 a transition year, setting easy reporting targets for providers to avoid reimbursement penalties and weighing the cost category for overall scoring to zero. It also expanded the low-volume threshold, allowing some providers to be exempt from MIPS scoring if they have less than 100 unique Medicare patients per year or $30,000 in annual Medicare Part B charges.
The new proposed rule broadens many of these exemptions. The most significant is the expansion of the low-volume threshold to a minimum $90,000 in total charges and 200 Medicare patients. As a result, the rule would make an additional 136,000 physicians ineligible to participate in MACRA, bringing the estimated total of exempt physicians to roughly 936,000. In all, only 36 percent of physicians would be participate in MIPS in 2018, a figure that seems exceptionally low for the second year of the program, though CMS estimates that these doctors would still represent about 58 percent of all Medicare Part B charges. The large number of exempt physicians could pose problems if many were to outgrow the volume threshold in later years, as it appears they could be immediately subject to the higher penalties and more demanding reporting mandates MACRA imposes as the program matures, whereas current participants could adjust to the increasing requirements gradually. Ineligible providers may need to spend an equivalent amount of time and resources preparing for MACRA as those currently participating in case they lose their exemption.
Physician Groups Exempt from MIPS
Providers may face a similar problem if the cost weight is held at 0 percent for the 2018 reporting year. Originally, cost was supposed to account for 10 percent of a provider’s MIPS score for both 2017 and 2018. Under current guidance, however, the weight is scheduled to jump to 30 percent of the total MIPS score in 2019, with quality dropping to 30 percent from its current 60. Providers may struggle to manage the sudden increase, especially if they did not adequately prepare in 2017 and 2018. Given that cost is widely considered to be the most difficult aspect of clinical care to manage and that CMS’ original intention was increase its weight gradually, it seems likely the agency will make further adjustments to the category to prevent a sudden drop in scores and provider backlash.
Though the proposed rule has been well received by most provider organizations, a few have voiced concerns over the delays to the program. The American Medical Group Association said in a statement that it is worried the rule “delays the transition to value and does not recognize the investment that AMGA members have made in preparing for a value-based health care system.” It suggests that while it lowers certain requirements to accommodate small practices with fewer resources, the proposed rule does not adequately reward providers or medical groups that have made the necessary investments and preparation for MACRA. In addition, care delivery advisor and consultant group Aledade warned that further exemptions could negatively affect the trend towards value-based care as a whole, essentially creating two distinct groups of providers with separate operating models and priorities. The rule does include some provisions to encourage MACRA participation, such as the introduction of “virtual groups,” in which several small practices or individual providers can join together as a single organization for MACRA reporting and scoring purposes. Even so, current trends suggest that MACRA will continue to be rolled out a cautious pace and amended from its original schedule to allow the most time for physicians to prepare.
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