CMS Final Rule on MACRA Reform Eases Pressure

Andy Slavitt

The Final Rule from CMS on the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), issued Friday, October 14, eases the pressure on small, rural practices to meet reporting and performance standards and explains more about the intentions behind the recently announced 2017 transition year, which is intended to make it easier for all practices to gradually move away from fee-for-service style billing.

The rule provides for guidance and financial support for smaller practices, expands the definition of Alternative Payment Models (APMs), lowers performance standards to make it easier to earn financial incentives, and simplifies prior “all or nothing” requirements for the use of electronic health record technology.

The final rule and its adjustments represent a nod to the 4000 comments received by CMS in response to the Merit-based Incentive System (MIPS) of payments and penalties and the APM plan, designed to serve as different tracks toward value reform in medical practice. “The hope is that by lowering the barriers to participation at the outset, we can set the foundation for a program that supports long-term, high-quality patient care through feedback and open communication between CMS and other stakeholders,” CMS said in its executive summary of the Final Rule.

Earlier this summer, CMS Acting Administrator Andy Slavitt preannounced several different ways under MACRA that physician practices could transition slowly toward the MIPS and APM programs that CMS wants to make the standard for physician payment and patient treatment. “We recognize, as described through many insightful comments, that many eligible clinicians face challenges in understanding the requirements and being prepared to participate in the Quality Payment Program (QPP) in 2017,” CMS said in reference to the MACRA program that encompasses MIPS and APMs.

Whereas many practices have expressed nervousness about meeting the reporting requirements under MIPS, CMS stated that its experience with the Physician Quality Reporting System has proved otherwise. “Historical evidence has shown that clinical practices of all sizes can successfully submit data, including over 110,000 solo and small practices with 15 or fewer clinicians who participated in PQRS in 2015.”

CMS said many small practices would be excluded from the new requirements due to a low volume threshold of $30,000 or less in Medicare Part B charges or under 100 Medicare patients, although physician groups had called for a higher cutoff to allow more practices not to participate in 2017. “We considered this option, but determined that it was inconsistent with the statutory MIPS exclusion based on the low-volume threshold,” CMS stated. “We anticipate that more clinicians will be determined to be eligible to participate in the program in future years.”

MACRA also allows for small practices to pool financial risk and join as “virtual groups” in order to combine their MIPS reporting. CMS said virtual groups won’t be allowed in 2017 and that it wants to be sure that this system will be workable before implementation.

The public payer said $100 million in technical assistance would be made available to MIPS-eligible clinicians in small practices, rural areas, and geographic areas where physician numbers are insufficient.

Whereas oncology professionals have contended the bar is set too high for participation in Advanced APMs, CMS said the Final Rule carefully defines these models of care and allows for non-CMS or “other payer Advanced APMs.”

“We are completing an initial set of Advanced APM determinations that we will release as soon as possible but no later than January 1, 2017,” CMS said.

The Final Rule drew cautious praise from the Community Oncology Alliance (COA), which represents independent oncology practices across the country, and said it remains concerned about how CMS’s Oncology Care Model (OCM) fits into the MACRA program.

“Based on an initial review, it appears that CMS heard some of COA’s concerns but certainly not all. They have lessened some of the requirements and extended their implementation time,” COA wrote in a statement. “Additionally, it appears that OCM practices must still select the OCM two-sided risk model on or after January 1, 2017, if they are to be exempt from MIPS. The question becomes who, if any, of the 195 OCM teams will feel comfortable making such a decision by the new year. We believe there is far too much to know and understand about the OCM by then.”

Meanwhile, ASCO said the flexibility encompassed by the Final Rule was heartening. “We are particularly encouraged that CMS has introduced a QPP transitional period for 2017 and has included the general oncology specialty measure set in the final rule after removing it from the proposed rule. We are also very pleased to see special considerations being given to small and rural practices, which will help ensure that care for vulnerable patients with cancer will not be disrupted during this period of transition,” the group said in a statement. “ASCO commends CMS for listening and responding to the feedback it received from across the medical community, and for making substantive changes that will reduce reporting burden and facilitate transition to alternative payment models. We will closely review the details of the final rule and offer a detailed analysis of the rule for our members."

Not only are practices going to be allowed to choose the pace at which they participate in MIPS over 2017, but CMS announced Friday that the performance threshold would be lowered so that physicians could qualify for “exceptional performance adjustment” payments with lower final scores. However, standards will be raised as CMS determines practices are ready. “These transition year policies for CY 2017 will encourage participation by clinicians and will provide a ramp-up period for clinicians to prepare for higher performance thresholds in the second year of the program,” CMS stated.