CMS released the MACRA Final Rule on October 14th and proved they listened to many of the 4000 official comments submitted in response to the proposed regulations published in April. The result is a very different program than originally proposed – at least for the first two years. So what’s new in the Final Rule? Lots. Let’s start with the MIPS pathway.

Participation Options – CMS filled in the details of the expanded participation options announced on September 8th. Merely submitting one piece of data for at least half of eligible patients during a 90-day window in 2017 allows clinicians to avoid a penalty. With a CMS reported 87% PQRS physician participation rate, most physicians can avoid a 2019 payment penalty by pretty much just continuing what they are doing. Unfortunately, the CMS reported participation rate for solo and small physician practices is much lower at 58%. Submitting more data offers greater opportunity for increased reimbursement in 2019.

Although the absolute details for the 2018 performance period will be promulgated during the coming year, CMS anticipates requiring full Quality measure reporting for the entire calendar year but continuing the 90-day minimum reporting intervals for Improvement Activities and Advancing Care Information. CMS cites the newness of the additional Improvement Activities reporting requirement and the required full transition to 2015 CEHRT as the underlying reasons for a shorter reporting interval for these performance categories.

By 2019 (Year 3), the full program should be in place as legislated.

Low Volume Definition – CMS increased the eligible clinician low volume exclusion threshold from the originally proposed $10,000 in claims to $30,000. The definition of non-patient facing providers expanded to allow groups with > 75% of their individual members meeting the non-patient facing criteria to be considered non-patient facing and increased the determination interval to a two-year period. When combined with the exclusion of first-year Medicare participants and the Advanced APM QPs, CMS estimates that 53-57% of Medicare clinicians will be excluded from MIPS participation in 2017.

Performance Threshold – CMS established a 2017 payment adjustment performance threshold of 3 points to minimize the risk of penalties in the program’s first year. This is one reason that merely submitting one piece of data for at least half of eligible patients during a 90-day window allows clinicians to avoid a payment penalty in 2019. Only those eligible clinicians that do not submit any data at all in 2017 will be subject to a payment penalty in 2019.

Performance Category Weights – The Cost category (formerly Resource Use) will have a weight of 0% in 2017. CMS will evaluate and provide feedback to eligible clinicians for this performance category but will not include this category in the eligible clinician final score (formerly the Composite Performance Score). The anticipated 10% weighting will shift to the Quality performance category, making Quality worth 60% of the final score. The other category weights remain unchanged with Advancing Care Information comprising 25% of the final score and Improvement Activities (formerly Clinical Practice Improvement Activity) contributing 15%.

Quality Performance Category Scoring – Significant changes in this category include

  • Eliminating the requirement to report a cross cutting measure;
  • Providing performance feedback but not scoring the population-based measures for the Acute Conditions Composite (AHRQ – Pneumonia, UTI, Dehydration) and
  • Chronic Conditions Composite (AHRQ – DM, COPD/Asthma, HF);
    • The All-cause hospital readmissions measure will be scored for groups of >15 clinicians that have at least 200 qualifying cases.
  • Assigning a minimum score of 3 points for any submitted measure during 2017 regardless of actual performance (usual range 1-10 based on benchmark decile comparison and 0 if not reported) – even in the case minimum is not met (which is another reason that submitting any data will result in penalty avoidance); and
  • Requiring that data be submitted for only 50% of all patients for measure reporting rather than the proposed 90%. o This threshold is consistent with the PQRS threshold (though it applies to all payers now, not just Medicare) and will likely increase to 60% in 2018.
  • Cost Performance Category Scoring – As mentioned, this category will not contribute to the 2017 final score but performance feedback will be provided. The category weight will be 10% in 2018 and the full 30% legislated for 2019.

Advancing Care Information Performance Category Scoring – Significant changes in this category include

  • Decreasing the number of required elements in the base scoring section;
  • Moving the Immunization Registry reporting measure from the required base portion to the performance portion of the scoring methodology; and
  • Changing the bonus structure.
    • Can now receive a 5% bonus for reporting to a registry other than an immunization registry (rather than 1 point), and
    • Can receive a 10% bonus for attesting to using CEHRT to complete at least one of the specifically designated Improvement Activities

Improvement Activities Performance Category Scoring – Significant changes in this category include

  • Decreasing the required point total for achieving the maximum possible score from 60 points to 40 (and 20 for special consideration groups like small practices, rural locations, non-patient facing providers);
  • Expanding the organizations qualified to designate patient centered medical home status; and
  • Altering the assigned minimum of half credit for APM participation to an assigned CMS scored APM model specific credit that may result in more than half credit.
    • The APM could submit additional activities to achieve the maximum category score.

Payment Adjustment Factor – As mentioned above, CMS set the 2017 performance threshold at a final score of 3 points. This results in avoidance of 2019 reimbursement penalties by reporting at least one piece of Quality or Improvement Activity data or meeting the base requirements of the Advancing Care Information category. By setting this threshold, CMS estimates that >90 percent of MIPS eligible clinicians will receive a positive or neutral MIPS payment adjustment in 2019 and > 80 percent of clinicians in small (2-9) and solo practices will receive a positive or neutral MIPS payment adjustment in 2019 based on historic reporting tendencies. Since positive payments must be offset by negative payments, the scaling factor applied to positive payments is likely to be less than 1, so the percentages of positive adjustments will likely be significantly less than the maximum potential of 4%.

Additional MIPS Payment Adjustment Factor – CMS established the performance threshold that recognizes exceptional performance at 70 points for 2017 based on historical PQRS performance experience. Recall that the payment adjustment related to exceptional performance will not exceed 10% for any applicable eligible clinician with an aggregate payment of $500 million awarded each year from 2019 to 2024.

The Advanced APM path also experienced some significant changes – although the qualifying APMs themselves did not change (MSSP Track 1 still not included).

Qualifying APM Participant (QP) Determinations – The first significant change in this area is that QP determinations will occur at the APM Entity level (e.g., the ACO) rather than for each individual eligible clinician in the APM Entity. The QP designation will thereafter be conferred to each eligible clinician on the APM Entity Participation List. This change makes it more likely that individual eligible clinicians will attain QP status.

The second significant change in this area is that QP determinations will be made three times during the year with data evaluated March 31st, June 30th, and August 31st rather than just once for the entire year. Once determined to be a QP for any evaluation interval, the designation persists for that year regardless of individual performance in subsequent evaluation periods that year – unless the APM Entity withdraws from the qualifying APM model or if integrity issues arise. This process also enhances the opportunity to attain QP status.

MIPS Participation Decision for Partial QPs – APM Entities will know their QP status by the end of the calendar year. Those designated as Partial QPs can make the decision to participate in MIPS at that time – rather than prospectively making that determination before actually knowing their status or their performance on the pertinent measures. Recall that Partial QPs do not experience payment adjustments – positive or negative. Permitting participation in MIPS introduces the possibility of positive payment adjustments.

So what should we do with the changes introduced in the Final Rule? That is the topic of another article.

Terrence R. McWilliams, MD, FAAFP

Chief Clinical Officer and Managing Director, Employed Provider Networks