Medicare Reimbursement: CMS Proposes MACRA Physician Performance Requirements for 2018

On June 30, CMS issued a Proposed Rule addressing a key part of Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) implementation: the Quality Payment Program (QPP) for 2018, the second Performance Year. Here’s a quick overview of the Proposed Rule.

MACRA, 101
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.”

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

The 5 Proposed MIPS Changes
The Proposed Rule includes changes to both tracks for the 2018 Performance Year. The 5 key MIPS changes:

1. Raising the Low-Volume 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;

• Impact: More physicians would be exempt from participating in MIPS in 2018. Physicians who fall below the low-volume threshold will be allowed to opt-in to MIPS starting in the 2019 Performance Year.

2. New Virtual Groups Requirement
Disparate providers who don’t belong to a medical group must 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.

3. Allow for Continued Use of 2014 CEHRT
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
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
The Proposed Rule also includes changes to the APM track.

1. New Qualified Advanced APM (QP) Determination Process
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 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.

Takeaway: Public comments on the Proposed Rule close on August 21, 2017 and, based on what happened last year, CMS will likely issue a final rule in November. That could prove too narrow a window for some of the Program Year 2018 deadlines, most notably the requirement that virtual groups submit an agreement among group members to CMS by December 1, 2108.