Brief Your CEO: Let the C-Suite Know About the Key MACRA Changes on the Table

Ordering physicians aren’t just your clients but your business lifeline. So when major changes to physician reimbursements are in the works, you need to be on top of them. And when it comes to physician reimbursements, it doesn’t get much bigger than MACRA, the Medicare Access and CHIP Reauthorization Act of 2015. "MACRA is the biggest change in how physicians are paid … since the creation of DRGs," according to a pathologist who sits on the board of governors for the College of American Pathologists. So you need to be aware that on June 30, the CMS issued a Proposed Rule addressing a key part of implementation: the Quality Payment Program (QPP) for 2018, the second Performance Year. Here’s a quick analysis of the Proposed Rule that you can use to prepare a briefing for your lab’s CEO or CFO.

MA CRA, 101
Start out with an overview of what MACRA is all about. Explain that the MACRA system, which won’t be fully in place until 2019 at the earliest, eliminates the old sustainable growth rate formula in favor of the QPP system. There are 2 QPP tracks.

The first is the Merit-Based Incentive Payment System (MIPS), in which value of Part B physician services is based on 4 performance categories:

  • Quality—physicians must report on 6 measures;
  • Advancing Care Information—providers can select "customizable measures" for reporting day-to-day use of technology and demonstrate interoperability;
  • Clinical Practice Improvement Activities—such as care coordination and patient safety;
  • Cost—based not on physician reporting but on Medicare claims data that use "40 episode-specific measures."

2. Advanced APMs
The second track is incentive payments for participating in certain Advanced Alternative Payment Models (APMs). Providers who participate in Advanced APMs are exempt from MIPS reporting.

The 5 Proposed MIPS Changes
Let your CEO know that the Proposed Rule includes changes to both tracks for the 2018 Performance Year and provide a summary for each one. Start with the 5 key MIPS changes:

1. Raising the Low-Volume Threshold
The first key MIPS change involves a significant hike in the 2018 threshold:

  • 2017 Threshold: $30,000 in Medicare Part B allowed charges or less than or equal to 100 Medicare patients;
  • Proposed 2018 Threshold: $90,000 in Medicare Part B allowed charges or less than or equal to 200 Medicare patients;

The impact of this increase: More physicians would be exempt from participating in MIPS in 2018. Physicians who fall below the low-volume threshold would be allowed to opt-in to MIPS starting in the 2019 Performance Year.

2. New Virtual Groups Requirement
The second and perhaps most troubling proposed MIPS change is the new requirement that disparate providers who don’t belong to a medical group form virtual groups for purposes of aggregating and reporting their MIPS data. Physicians will have to submit a written agreement among members of the virtual group to CMS by December 1, 2018.

Sticking point: Explain that physicians may have a hard time meeting that deadline. Public comments on the Proposed Rule are scheduled to close on August 21. And based on what it did last year, the CMS will likely issue a Final Rule in November. That may not be enough time for disparate providers to get together and conclude a virtual agreement for the 2018 Performance Year to submit to CMS by December 1, 2108.

3. Allow for Continued Use of 2014 CEHRT
Let the CEO know that the Proposed Rule would allow providers to continue using a 2014 Certified Electronic Health Record Technology in 2018; but providers who implement a 2015 edition product may qualify for a bonus.

4. Cost Performance of Zero Percent
Under the Proposed Rule, the cost performance category of the MIPS score for the 2018 Performance Year would be set at zero percent to give CMS more time to develop and provide feedback to providers on episode-based measures.

5. Facility-Based Performance Evaluation
Explain that the Proposed Rule establishes a method to assess the quality and cost performance of individual providers who carry out their primary responsibilities in a health care facility based on the facility’s performance.

The 2 Proposed Advanced APM Changes
Let your CEO know that the Proposed Rule includes changes to both tracks for the 2018 Performance Year and provide a summary for each one. Start with the 5 key MIPS changes:

1. New Qualified Advanced APM (QP) Determination Process
First, explain that under the Proposed Rule, CMS would be permitted to make determinations of a Qualifying APM Participant (QP), i.e., eligible provider participating in an Advanced APM to a sufficient degree for Advanced APMs that start or end during the QPP performance year and which operate continuously for at least 60 days. In those circumstances, CMS will use only data from Advanced APMs where they operated within the QPP performance year to make QP determinations.

CMS is also asking for comments on a proposal that would allow QPs to receive participation credit for Medicare Advantage as part of the Medicare Option rather than the All-Payer Combination Option. Under current rules, providers looking to become QPs have only 2 scoring options based on their participation in Advanced APMs: the Medicare Option (only Medicare as the payer) and/or All-Payer Combination Option (payers other than Medicare).

2. New Other Payer Advanced APM Determination Process
The Proposed Rule would also establish a process allowing payers to request that CMS make a determination about whether a payer’s program meets Advanced APM status starting before the 2019 Performance Year. Payers eligible to request such determinations include, among others, Medicaid, Medicare Advantage, Programs of All Inclusive Care for the Elderly plans and Medicare-Medicaid plans.


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