MACRA Final Rule: What No One Has Yet Told You about MIPS




First, a confession: I was hoping not to have to read all 2,398 pages of the final Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) rules released Oct. 14.

However, I found myself dissatisfied with the summaries issued by the Centers for Medicare & Medicaid Services (CMS) and the early articles being published — they simply left too much unanswered. So I challenged myself to wade through the final rules, and here is what’s most striking to me.

You may have already read about the concessions CMS has made — and there are many — to ease providers onto one of the two MACRA tracks: the Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (APMs). Despite the recent election results and talk of repealing the Affordable Care Act, Washington pundits are in universal agreement that MACRA will survive due to its bipartisan support in both the House and Senate. I believe CMS has done a good job in reducing the reporting requirements and creating multiple paths to ease clinicians into MIPS while still meeting what is required under the statute. However, when one looks at the complicated details of how MIPS will unfold, it can leave your head spinning.

Easing the Transition


First, you will be in MIPS unless you qualify for exemption by being: a qualified participant in an Advanced APM, in your first year of Medicare, or a “low-volume” provider. Know that CMS has no other ability to further exempt solo, small or rural practices from MACRA. Despite there being a 60-day comment period, don’t expect that additional exemptions may magically appear — it would require a change in the statute passed by Congress.

CMS has done the best it can by making the 2017 performance year (which is the 2019 payment year) a “transition year.” This means that it has eased up on the number of measures and activities required overall and even more so on “small practices” (defined as 15 or fewer clinicians), and will allow “at your pace” reporting options that run from a full year, to as little as 90 days, to just one measure or activity to avoid any negative payment adjustments.

Under the revised program, CMS now estimates that penalties will be reduced from the previous estimate of $833 million down to $199 million and “over 90 percent of MIPS-eligible clinicians will receive a positive or neutral MIPS payment adjustment in the transition year, and that at least 80 percent of clinicians in small and solo practices with one-to-nine clinicians will receive a positive or neutral MIPS payment adjustment.”1

Other good news that I haven’t seen pointed out is that CMS has said it intends for the transition process to last at least two years, so additional relief is expected in year two, as well:

“We anticipate that the iterative learning and development period will last longer than the first year, CY2017, of the program as we move towards a steady state; therefore, we envision CY2018 to also be transitional in nature to provide a ramp-up of the program and of the performance thresholds. We anticipate making proposals on the parameters of this second transition year through rule-making in 2017.2

Additionally, CMS has increased the threshold for “low volume” that exempts providers from MIPS from having no more than 100 patients or $10,000 in Medicare Part B payments to having no more than 100 patients or $30,000 in payments. This revision means that 32.5 percent of providers will now be exempt from MIPS, while representing only 5 percent of Medicare Part B payments. This sounds reasonable.

CMS does providers another good turn by planning to calculate and notify providers based on their historical data before the start of a performance period whether or not they’ll be exempt due to “low-volume” for purposes of 2017 reporting.

Sound good so far?


Let’s wade into the details.

If you are in a group as defined by a common Tax ID number (TIN), you must choose to report all MIPS components collectively as a group or all individually. If your TIN selects group reporting, and the group itself is not collectively a “low-volume” provider, then all members of your group must report — even the individual providers who would have been exempt for low volume. So you’re not truly exempt unless your whole group qualifies as exempt or your group decides to individually report.

Another issue: MIPS-eligible clinicians associated with multiple TINs must meet the requirements for each TIN to which they belong, unless they are excluded from MIPS requirements.

Further, if you are a multispecialty group, reporting as a group, all individuals must report on the same measures. Unless specialists within mixed groups individually report, they cannot take advantage of the measures most appropriate to their specialty practice. This may weigh particularly hard on faculty practice plans and other multispecialty practices.

At what moment in time must you decide whether or not to report by group or individually? You do not have to decide until you report in 2018, unless you are counting on reporting quality measures as a group using CMS’ web interface: the Group Practice Reporting Option (GPRO). In this case, you must commit to filing as a group on GPRO by June 30 of the performance year (e.g., June 30, 2017). To keep your options open, you can report on quality instead through a qualified registry or qualified clinical data registry (QCDR). And you may need additional vendors to report your improvement activities and advancing care information. Requirements for third-party submissions are still being finalized.

Still wondering why CMS now projects that 25 percent of providers will already be in Advanced APMS in 2018? Does this make you now consider partnering with others to take a closer look at the Advanced APM option? Stay tuned.


References
1, 2. Centers for Medicare & Medicaid Services. Medicare Program: Merit-based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models. Pages 20, 16.


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