Expert Commentary: Nathan Bays on MACRA in 2018

Last week the Centers for Medicare and Medicaid Services (“CMS”) released the 2018 proposed rule for the Medicare Access and CHIP Reauthorization Act (“MACRA”) Quality Payment Program (“QPP”). As proposed, the QPP will bring several changes to clinicians in the 2018 performance year, with implications for reporting and clinical practice in the year ahead. However, the underpinnings of MACRA remain the same: high-performers will be rewarded, effective reporting will remain key to success, and clinicians will need to enhance their focus on care coordination and clinical process.

Key Takeaways for Clinical Practitioners

While the MACRA proposed rule contains substantial guidance for clinicians—1058 pages worth! —there are a handful of items that will drive the structure of the program in 2018. Several of those include:

MIPS Performance Thresholds Rise, But More Opportunities Exist for Clinicians to Improve Their Score. In the Merit-based Incentive Program (“MIPS”) track—which is the MACRA QPP track that will govern the reporting requirements and reimbursement for clinicians who practice predominantly in fee-for-service models—clinicians will need to receive at least 15 points in the 2018 performance year to avoid a negative payment adjustment in 2020. The additional performance threshold—an additional $500 million pool to be allocated to high performers—will remain at 70 points in 2018. At the same time, clinicians will be able to receive additional performance points for the following:

  • Caring for patients with complex conditions
  • The exclusive use of 2015 edition EHR systems
  • Small practices, defined as those with 15 or fewer clinicians

Additionally, a significant hardship exception has been created for MIPS eligible clinicians in small practice.

More Clinicians Will Be Exempted From MIPS, But Most Likely Not Mid-Size and Large Groups. The 2018 rule raises the low-volume threshold exemption from $30k to $90k, or fewer than 200 beneficiaries (up from 100). These exemptions are projected to exclude an additional 134k clinicians from MIPS in the 2018 performance year. With these additional exclusions, 65% of Medicare Part B payments will be captured in the MIPS program, down from 72.2% in the 2017 performance year. While these changes will exempt more clinicians, don’t forget that the $90k is calculated at the Taxpayer Identification Number (“TIN”) level, which means that most groups of any substantive size will not be able to meet the exclusions.

Guidance for the All-Payer Combination Alternative Payment Model (“APM”) Option. Clinicians who predominantly practice through downside risk-bearing models will be in the ‘Advanced APM Track.’ Beginning in the 2019 performance year, clinicians will be able to combine revenue that flows through their Medicare Advanced APM with revenue that flows through arrangements with commercial payers, referred to as the ‘All-Payer Combination APM.’ It is expected many clinicians will seek to take advantage of the opportunities—both financial and structural—of being in the Advanced APM Track, so early guidance on how clinicians can participate in 2019 via the All-Payer Combination APM with commercial payers is important for contracting purposes.

Strategic Implications of the Proposed Rule

So, what does the 2018 proposed rule mean for clinicians? Here are a few strategic implications:

Quality. The 2018 MIPS Quality Domain reporting period is 12 months, as opposed to the 3 month period in 2017. Tracking and reporting quality will be critical to scoring well in MIPS in 2018, as the Quality domain retains a 60 percent weighting (50 percent for MIPS APM participants).

Large and mid-size practices competing for dollars. With the additional exclusion of small practices—which would likely be lower scorers—mid-size and large practices will be ‘competing’ against each other in the MIPS track, further enhancing the need to ensure performance and reporting in the three relevant domains (Quality, Improvement Activities, and Advancing Care Information).

Prepare for Cost. As in 2017, CMS proposed to weight the Cost performance domain at 0 percent in 2019. That said, without a legislative change, the domain will jump to a 30 percent weighting in 2020 (i.e., CMS cannot arbitrarily weight this at 0 beyond 2018). Clinicians should begin to analyze their referral patterns and sites of service cost in anticipation of Cost being an influential component of the MIPS score in performance year 2019.

Advanced APM Contracting. Ensure your contracts with payers reflect the guidance for the All-Payer Combination Advanced APM. Clinicians will need to ensure that payer relationships are structured to allow clinicians to use revenue that flows through applicable Advanced APMs with commercial payers toward Advanced APM track eligibility beginning in 2019.

What’s Next

The proposed rule will remain open for comments through August 21, which means that anyone—physicians, nurse practitioners, hospital administrators, and average citizens have an opportunity to provide feedback to CMS on the positives and negatives of the 2018 proposed rule. CMS will then publish the 2018 final rule no later than October 31, with the changes going into effect January 1 for the 2018 performance year.


Further reading:
At long last: The documentation you need for Improvement Activity audits
Quick-Look Comparison: MIPS 2017 vs. 2018 requirements

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